Actualising therapy 2.0: enhancing engagement with computerised cognitive behavioural therapy for common mental health disorders

Computerised cognitive behavioural therapy (CCBT) is a clinically effective method of delivering CBT which may help address the under – treatment of common mental health disorders (CMHDs) in the population. However, concerns regarding acceptability, attrition rates and the therapeutic alliance are obstacles to widespread population dissemination. This thesis aimed to address these implementation issues by applying concepts from human – computer interaction (HCI) and attachment theory to the field of CCBT. Chapter 1 presents a meta – analysis investigating the effectiveness of CCBT for CMHDs and moderators of this effect. Chapter 2 presents a systematic review and analysis conducted to examine predictors of CCBT engagement. A process – based model of engagement with CCBT developed from the findings of this review is also presented. Adult attachment is known to influence engagement and alliance in face to face therapies, but research has not explored whether these relationships are mirrored in CCBT. Four empirical studies intended to address this question. Study 1 used a student population based survey to explore the acceptability of CCBT in a student population and the associations with adult attachment. Results demonstrated adult attachment was not associated with acceptability of CCBT. Study 2a utilised an open trial of a supported CCBT program to investigate whether adult attachment would predict engagement and alliance in vivo. Results showed attachment did not predict these outcomes. Study 2b utilised an open trial with a non – supported online CCBT program. Results indicated attachment security was positively associated with program engagement and alliance. It is proposed a combination of attachment system activation and perceiving computers as social actors account for these findings. Study 3 used a randomised, experimental paradigm to test the benefits of security priming in CCBT. Security priming produced higher levels of program engagement and better working alliance compared to neutral primes. Furthermore these effects were not moderated by dispositional attachment styles. These results demonstrate something so uniquely human, dispositional attachment orientations, founded on the intimate bonds we form in infancy and in adulthood , extend their influence into the experience of unguided CCBT, a solely human – computer interaction. Unguided – CCBT, a highly cost effective intervention with the potential for considerable public health impact, may benefit from incorporating security priming techniques in program designs to maximise engagement and alliance. Engagement and alliance is attainable in CCBT and paying attention to the attachment styles of program users may present a distinctive opportunity to overcome these implementation barriers

Acceptability, Use, and Safety of a Mobile Phone App (BlueIce) for Young People Who Self-Harm: Qualitative Study of Service Users’ Experience

Background: Self-harm is common among adolescents and is associated with a number of negative psychosocial outcomes including a higher risk of suicide. Recent reviews highlight the lack of research into specific interventions for children and young people who self-harm. Developing innovative interventions that are coproduced with individuals with lived experience and that reduce self-harm are key challenges for self-harm prevention. Objective: The aim of this study was to explore the acceptability, use, and safety of BlueIce, a mobile phone app for young people who self-harm and who are attending child and adolescent mental health services (CAMHS). Methods: This study is part of a mixed methods phase 1 trial of BlueIce. Young people aged 12-17 years attending specialist CAMHS were recruited. Clinicians were invited to refer young people who were self-harming or who had a history of self-harm. On consent being obtained and baseline measures taken, participants used BlueIce as an adjunct to usual care for an initial familiarization period of 2 weeks. If after this time they wanted to continue, they used BlueIce for a further 10 weeks. Semistructured interviews were conducted at postfamiliarization (2 weeks after using BlueIce) and postuse (12 weeks after using BlueIce) to assess the acceptability, use, and safety of BlueIce. We undertook a qualitative analysis using a deductive approach, and then an inductive approach, to investigate common themes. Results: Postfamiliarization interviews were conducted with 40 participants. Of these, 37 participants elected to use BlueIce, with postuse interviews being conducted with 33 participants. Following 6 key themes emerged from the data: (1) appraisal of BlueIce, (2) usability of BlueIce, (3) safety, (4) benefits of BlueIce, (5) agency and control, and (6) BlueIce less helpful. The participants reported that BlueIce was accessible, easy to use, and convenient. Many highlighted the mood diary and mood lifter sections as particularly helpful in offering a way to track their moods and offering new strategies to manage their thoughts to self-harm. No adverse effects were reported. For those who did not find BlueIce helpful, issues around motivation to stop self-harming impeded their ability to use the app. Conclusions: BlueIce was judged to be a helpful and safe way of supporting adolescents to manage thoughts of self-harming. Adolescents reported numerous benefits of using BlueIce, and all would recommend the app to other young people who were struggling with self-harm. These preliminary findings are encouraging and provide initial support for the acceptability of BlueIce as a self-help intervention used in conjunction with the traditional face-to-face therapy

Safety, Acceptability, and Use of a Smartphone App, BlueIce, for Young People Who Self-Harm: Protocol for an Open Phase I Trial

Background: Up to 18% of adolescents will engage in an act of self-harm before young adulthood, with the majority of acts occurring in private. Mobile apps may offer a way of providing support for young people at times of distress to prevent self-harm. Objective: This is a proof-of-concept study designed to explore the safety, acceptability, feasibility, and usability of a smartphone app, BlueIce, with young people who are self-harming. Methods: In this phase I open trial we will evaluate BlueIce, a smartphone app developed and coproduced with young people with lived experience of self-harm. BlueIce includes a mood-monitoring diary, selection of mood-lifting techniques based on cognitive behavior therapy and dialectical behavior therapy, and direct access to emergency telephone numbers. We will recruit young people (n=50) attending specialist child and adolescent mental health services with a current or past history of self-harm to trial BlueIce as an adjunct to their usual care. Questionnaires and interviews will be completed at baseline, postfamiliarization (2 weeks), and at follow-up (12 weeks after baseline) to assess safety, app use, and acceptability. Interviews will be undertaken with clinicians to assess the feasibility of BlueIce within a clinical setting. Results: Recruitment occurred between May and November 2016. The recruitment target  was 50, and by the beginning of November 54 young people had been referred.  Conclusions: This study is the first to evaluate an app specifically developed with young people for young people (under the age of 18 years) who self-harm. It will determine whether BlueIce is acceptable, how often it is used, and whether it is safe and does not have any unintentional adverse effects. This information will determine whether a feasibility trial to test recruitment, randomization, retention, and appropriate outcome measures should be pursued

Mental Health Mobile Apps for Preadolescents and Adolescents:A Systematic Review

Background: There are an increasing number of mobile apps available for adolescents with mental health problems and an increasing interest in assimilating mobile health (mHealth) into mental health services. Despite the growing number of apps available, the evidence base for their efficacy is unclear. Objective: This review aimed to systematically appraise the available research evidence on the efficacy and acceptability of mobile apps for mental health in children and adolescents younger than 18 years.  Methods: The following were systematically searched for relevant publications between January 2008 and July 2016: APA PsychNet, ACM Digital Library, Cochrane Library, Community Care Inform-Children, EMBASE, Google Scholar, PubMed, Scopus, Social Policy and Practice, Web of Science, Journal of Medical Internet Research, Cyberpsychology, Behavior and Social Networking, and OpenGrey. Abstracts were included if they described mental health apps (targeting depression, bipolar disorder, anxiety disorders, self-harm, suicide prevention, conduct disorder, eating disorders and body image issues, schizophrenia, psychosis, and insomnia) for mobile devices and for use by adolescents younger than 18 years.  Results: A total of 24 publications met the inclusion criteria. These described 15 apps, two of which were available to download. Two small randomized trials and one case study failed to demonstrate a significant effect of three apps on intended mental health outcomes. Articles that analyzed the content of six apps for children and adolescents that were available to download established that none had undergone any research evaluation. Feasibility outcomes suggest acceptability of apps was good and app usage was moderate.  Conclusions: Overall, there is currently insufficient research evidence to support the effectiveness of apps for children, preadolescents, and adolescents with mental health problems. Given the number and pace at which mHealth apps are being released on app stores, methodologically robust research studies evaluating their safety, efficacy, and effectiveness is promptly needed

A Smartphone App (BlueIce) for Young People Who Self-Harm:Open Phase 1 Pre-Post Trial

Background: Recent years have seen a significant increase in the availability of smartphone apps for mental health problems. Despite their proliferation, few apps have been specifically developed for young people, and almost none have been subject to any form of evaluation.  Objective: This study aimed to undertake a preliminary evaluation of a smartphone app (BlueIce), coproduced with young people and designed to help young people manage distress and urges to self-harm. We aimed to assess the acceptability, safety, and use of BlueIce and to explore the effects on the primary outcome of self-harm and the secondary outcomes of psychological functioning.  Methods: We undertook an open trial where we recruited young people aged 12 to 17 years attending specialist child and adolescent mental health services (CAMHS) who were currently self-harming or had a history of self-harm. Eligible participants were assessed at baseline and then given BlueIce. They were assessed 2 weeks later (post familiarization) and again at 12 weeks (post use). A behavior-screening questionnaire (Strengths and Difficulties Questionnaire) was completed along with standardized measures of depression (Mood and Feelings Questionnaire or MFQ) and anxiety (Revised Child Anxiety and Depression Scale or RCADS), taking into account self-reports of self-harm, app helpfulness, and safety.  Results: All core CAMHS professional groups referred at least 1 young person. Out of 40 young people recruited, 37 (93%) elected to use BlueIce after familiarization, with 29 out of 33 (88%) wanting to keep it at the end of the study. No young person called the emergency numbers during the 12-week trial, and no one was withdrawn by his or her clinician due to increased risk of suicide. Almost three-quarters (73%) of those who had recently self-harmed reported reductions in self-harm after using BlueIce for 12 weeks. There was a statistically significant mean difference of 4.91 (t31=2.11; P=.04; 95% CI 0.17-9.64) on postuse symptoms of depression (MFQ) and 13.53 on symptoms of anxiety (RCADS) (t30=3.76; P=.001; 95% CI 6.17-20.90), which was evident across all anxiety subscales. Ratings of app acceptability and usefulness were high.  Conclusions: Our study has a number of methodological limitations, particularly the absence of a comparison group and a prospective way of assessing self-harm. Nonetheless, our findings are encouraging and suggest that BlueIce, used alongside a traditional CAMHS face-to-face intervention, can help young people manage their emotional distress and urges to self-harm

Innovations in Practice: Avatar‐based virtual reality in CAMHS talking therapy: two exploratory case studies

BackgroundAvatar‐based virtual reality therapy is an emerging digital technology that can be used to assist the treatment of common mental health problems. This may be particularly appealing to young people who are highly familiar with digital technologies and may provide a medium to facilitate communication within face‐to‐face therapy.MethodWe present two case summaries of young people who used ProReal, who had difficulties engaging in talking therapies. ProReal is a software package providing avatar‐based virtual reality therapy, used as part of talking psychological therapies provided within a CAMHS outpatient clinic. Young people completed pre and postuse routine outcome measures and took part in qualitative interviews assessing their experience of ProReal.ResultsOutcome measures showed a reduction over time. The two young people felt ProReal was highly accessible, with both young people positively describing how ProReal helped them externalize their inner worlds to help them to reappraise their thoughts, feelings and experiences. They also reported ProReal being a helpful tool to facilitate communication with the clinician.ConclusionThese case summaries demonstrate how ProReal can be readily integrated into clinical practice and how it can facilitate communication and therapy with young people who find it difficult to express themselves

The ‘long-term’ effects of universal school-based anxiety prevention trials:A systematic review

Objective Previous reviews demonstrate that universal school-based anxiety prevention programs are generally effective in the short-term, but have not yet provided a clear evaluation of the longer-term effects. This review focuses exclusively on randomized controlled trials (RCTs) of universal school-based anxiety prevention programs that included a follow-up at 12-months or beyond. Method In total, 359 references from previous reviews in the field were screened; PubMed and PsychInfo were also systematically searched. Eight studies met criteria (each based on cognitive-behavioural principles) comprising 7522 children aged nine-18 years. Risk of bias in most studies was high, thus a formal meta-analysis was not conducted. Results Three of the eight studies reported greater reductions in anxiety symptomology in the prevention group compared to the control group at post-intervention (immediate effect), and each of these studies also reported maintenance of this effect at 12-month follow-up. Two further studies reported a ‘delayed’ effect at 12-month follow-up. Each of these five studies was evaluating the FRIENDS program, and estimated effect sizes at 12-months follow-up varied from 0.2 to 0.69 (Hedges g). The final three studies reported no immediate or long-term effects. Conclusions The findings from this review suggest that the effects of some universally delivered school-based anxiety prevention trials can last up to 12-months, but this may depend on various factors (including program-type). It was not possible to draw firm conclusions regarding the influence of delivery mode (teacher versus health professional), parent sessions or child booster sessions. Further high quality RCTs with long-term follow-up periods are needed