Optimizing internet-delivered cognitive behaviour therapy for alcohol misuse—a randomized factorial trial examining effects of a pre-treatment assessment interview and guidance

Background: Internet-delivered cognitive behavioral therapy (ICBT) for alcohol misuse has potential to radically improve access to evidence-based care, and there is a need to investigate ways to optimize its delivery in clinical settings. Guidance from a clinician has previously been shown to improve drinking outcomes in ICBT, and some studies suggest that pre-treatment assessments may contribute in initiating early change. The objective of this study was to investigate the added and combined effects of a pre-treatment assessment interview and guidance on the outcomes of ICBT for alcohol misuse delivered in an online therapy clinic. Methods: A 2X2 factorial randomized controlled trial was conducted where participants received access to an 8-week ICBT program, and either a pre-treatment assessment interview (Factor 1), guidance (Factor 2), a combination of these, or neither of these. Participants were 270 individuals (66.8% female, mean age = 46.5) scoring 8 or more on the Alcohol Use Disorders Identification Test and consuming 14 standard drinks or more in the preceding week. Primary outcomes were number of drinks consumed and number of heavy drinking days during the preceding week, 3 months post-treatment. Results: Large within-group effects were found in terms of alcohol reductions (dw ≥ 0.82, p < 0.001), but neither of the factors significantly improved drinking outcomes. Guidance was associated with greater adherence (i.e. completed modules). Conclusions: Neither a pre-treatment assessment interview nor guidance from a clinician appears to improve drinking outcomes resulting from internet-delivered cognitive behaviour therapy for alcohol misuse when delivered in a routine online therapy clinic. Trial registration: NCT03984786. Registered 13 June 2019, https://clinicaltrials.gov/ct2/show/NCT03984786. Keywords: Alcohol; Assessment reactivity; Cognitive behavior therapy; Guidance; Internet; Treatmen

Examining differential responses to the Take Care of Me trial: A latent class and moderation analysis

Given prevalent alcohol misuse-emotional comorbidities among young adults, we developed an internet-based integrated treatment called Take Care of Me. Although the treatment had an impact on several secondary outcomes, effects were not observed for the primary outcome. Therefore, the goal of the current study was to examine heterogeneity in treatment responses. The initial RCT randomized participants to either a treatment or psychoeducational control condition. We conducted an exploratory latent class analysis to distinguish individuals based on pre-treatment risk and then used moderated regressions to examine differential treatment responses based on class membership. We found evidence for three distinct groups. Most participants fell in the “low severity” group (n = 123), followed by the “moderate severity” group (n = 57) who had a higher likelihood of endorsing a previous mental health diagnosis and treatment and higher symptom severity than the low group. The “high severity” group (n = 42) endorsed a family history of alcoholism, and the highest symptom severity and executive dysfunction. Moderated regressions revealed significant class differences in treatment responses. In the treatment condition, high severity (relative to low) participants reported higher alcohol consumption and hazardous drinking and lower quality of life at follow-up, whereas moderate severity (relative to low) individuals had lower alcohol consumption at follow-up, and lower hazardous drinking at end-of-treatment. No class differences were found for participants in the control group. Higher risk individuals in the treatment condition had poorer responses to the program. Tailoring interventions to severity may be important to examine in future research

Efficacy of a novel online integrated treatment for problem gambling and tobacco smoking: Results of a randomized controlled trial

Background and aimsProblem gambling and tobacco use are highly comorbid among adults. However, there are few treatment frameworks that target both gambling and tobacco use simultaneously (i.e., an integrated approach), while also being accessible and evidence-based. The aim of this two-arm open label RCT was to examine the efficacy of an integrated online treatment for problem gambling and tobacco use.MethodsA sample of 209 participants (M$_{age}$ = 37.66, SD = 13.81; 62.2% female) from North America were randomized into one of two treatment conditions (integrated [n = 91] or gambling only [n = 118]) that lasted for eight weeks and consisted of seven online modules. Participants completed assessments at baseline, after treatment completion, and at 24-week follow-up.ResultsWhile a priori planned generalized linear mixed models showed no condition differences on primary (gambling days, money spent, time spent) and secondary outcomes, both conditions did appear to significantly reduce problem gambling and smoking behaviours over time. Post hoc analyses showed that reductions in smoking and gambling craving were correlated with reductions in days spent gambling, as well as with gambling disorder symptoms. Relatively high (versus low) nicotine replacement therapy use was associated with greater reductions in gambling behaviours in the integrated treatment condition.Discussion and conclusionsWhile our open label RCT does not support a clear benefit of integrated treatment, findings suggest that changes in smoking and gambling were correlated over time, regardless of treatment condition, suggesting that more research on mechanisms of smoking outcomes in the context of gambling treatment may be relevant

Feasibility of trial procedures for a randomised controlled trial of a community based group exercise intervention for falls prevention for visually impaired older people: the VIOLET study

Background Visually impaired older people (VIOP) have a higher risk of falling than their sighted peers, and are likely to avoid physical activity. The aim was to adapt the existing Falls Management Exercise (FaME) programme for VIOP, delivered in the community, and to investigate the feasibility of conducting a definitive randomised controlled trial (RCT) of this adapted intervention. Methods Two-centre randomised mixed methods pilot trial and economic evaluation of the adapted group-based FaME programme for VIOP versus usual care. A one hour exercise programme ran weekly over 12 weeks at the study sites (Newcastle and Glasgow), delivered by third sector (voluntary and community) organisations. Participants were advised to exercise at home for an additional two hours over the week. Those randomised to the usual activities group received no intervention. Outcome measures were completed at baseline, 12 and 24 weeks. The potential primary outcome was the Short Form Falls Efficacy Scale – International (SFES-I). Participants’ adherence was assessed by reviewing attendance records and self-reported compliance to the home exercises. Adherence with the course content (fidelity) by instructors was assessed by a researcher. Adverse events were collected in a weekly phone call. Results Eighteen participants, drawn from community-living VIOP were screened; 68 met the inclusion criteria; 64 participants were randomised with 33 allocated to the intervention and 31 to the usual activities arm. 94% of participants provided data at the 12 week visit and 92% at 24 weeks. Adherence was high. The intervention was found to be safe with 76% attending nine or more classes. Median time for home exercise was 50 min per week. There was little or no evidence that fear of falling, balance and falls risk, physical activity, emotional, attitudinal or quality of life outcomes differed between trial arms at follow-up. Conclusions The intervention, FaME, was implemented successfully for VIOP and all progression criteria for a main trial were met. The lack of difference between groups on fear of falling was unsurprising given it was a pilot study but there may have been other contributory factors including suboptimal exercise dose and apparent low risk of falls in participants. These issues need addressing for a future trial

Appearance-based information about coping with pain: Valid or biased?

Previous research led to the conclusion that patient characteristics such as physical attractiveness and non-verbal expressiveness affected judgements of patient pain and distress. This study investigated whether this represents an intrusive bias or whether there indeed are psychological differences between physically attractive vs physically unattractive and expressive vs inexpressive pain patients. The findings led to the conclusion that both variables are related to the types of coping strategies pain patients use. Specifically, physically attractive and nonverbally expressive patients were found to be less likely to utilize passive coping strategies. Coping style also was found to be related to demographic characteristics of the patients. Theoretical reasons for the identified relationships are discussed as are the implications of these findings for the assessment of pain.physical attractiveness pain non-verbal expressiveness

Advances in digital CBT : where are we now, and where next?

Digital CBT refers to the use of digital tools, platforms or devices to deliver or enhance cognitive behavioural therapy assessment, formulation, treatment, training and supervision. The 'Advances in Digital CBT' special issue aimed to document examples of innovative digital CBT practice in this rapidly developing field. In this paper, we have briefly summarised and synthesised the advances demonstrated in this group of articles. These include developments in our understanding of mental health apps, the use of digital tools as an adjunct to therapy, the effectiveness of remotely delivered CBT in routine clinical practice, our understanding of user experiences and involvement, and in digital CBT research methods. We consider the extent of current knowledge in these areas and identify where gaps in evidence lie and how the field could be taken forward to address these. Lastly, we reflect on the broader digital CBT picture and offer our suggestions of six key directions for future research: using robust study designs to evaluate and optimise digital tools; translating and culturally adapting digital tools and practices; understanding and addressing digital exclusion; exploring, reporting and addressing possible negative effects; improving user involvement in design and evaluation; and addressing the implementation gap for digital tools. We suggest that further advances in these areas would be of particular benefit to the digital CBT field

A qualitative examination of psychology graduate students' experiences with guided Internet-delivered cognitive behaviour therapy

Guided Internet-delivered cognitive behaviour therapy (ICBT) is efficacious for the treatment of a variety of clinical disorders (Spek et al., 2007), yet minimal research has investigated training students in guided ICBT. To contribute to the training literature, through qualitative interviews, this study explored how ICBT was perceived by student therapists (n = 12) trained in guided ICBT. Additionally, facilitators and challenges encountered by students learning guided ICBT were examined. Qualitative analysis revealed that students perceived training to enhance their professional skills in guided ICBT such as how to gain informed consent, address emergencies, and facilitate communication over the Internet. Students described guided ICBT as beneficial for novice therapists learning cognitive behavior therapy as asynchronous communication allowed them to reflect on their clinical emails and seek supervision. Further, students perceived guided ICBT as an important skill for future practice and an avenue to improve patient access to mental health care. Specific facilitators of learning guided ICBT included having access to formal and peer supervision as well as technical assistance, ICBT modules, a functional web application, and detailed policies and procedures for the practice of guided ICBT. Challenges in delivering guided ICBT were also identified by participants such as finding time to learn the approach given other academic commitments, working with non-responsive clients, addressing multiple complex topics over email, and communicating through asynchronous emails. Based on the feedback collected from participants, recommendations for training in guided ICBT are offered along with future research directions

Understanding health behavior: An integrated model for social marketers

Many effective social marketing campaigns seek to change health-related beha-vior by utilizing various health-protective behavioral theories. In this article, we review and integrate three such theories: protection motivation theory (PMT), the extended parallel process model (EPPM), and the transtheoretical model (TTM). We highlight how EPPM and TTM can be used to refine PMT by add-ing insight into the decision-making process involved when consumers consider whether or not to follow a particular recommended health behavior. Specifically, the development of an integrated PMT model can provide insight into the char-acteristics of people more or less likely to change, what happens when persuasion fails, and what can be done to increase persuasion. Developing an integrated PMT model opens new avenues of research that have the potential to increase our understanding of behavior and assist in creating more persuasive social marketing campaigns

Exploring client messages in a therapist-guided internet intervention for alcohol use disorders – A content analysis

Background: There is a growing interest in offering therapist-guided internet interventions for alcohol use disorders (AUD) in regular addiction services. Elucidating the therapeutic processes during these interventions may help improve clinical delivery. The aim of this paper was to investigate written messages from client to therapist in a therapist-guided internet intervention for AUD. Methods: Data was extracted from the therapist-guided arm (n = 57) of a randomized trial of internet interventions for AUD. Qualitative content analysis was used to identify distinct categories of client behaviors in written messages to therapists. Coding was deductive (applying categories from past literature) as well as inductive (identifying new categories from the data). Subsequently, exploratory correlational and regression analyses were conducted to investigate whether identified client behaviors predicted module completion and drinking outcomes. Also, client questions posed in messages to therapists were categorized separately. Results: Eleven distinct behavior categories were identified, of which the two most common were alliance (26.6% of total categorizations) and identifying patterns and problem behaviors (22.8%). Confrontational alliance rupture was the least common category (0.4%). One new behavior category was identified inductively – alcohol-related setback (4.1%). In the exploratory analyses, no categories consistently predicted module completion or drinking outcomes. Client questions were most commonly posed to improve understanding or use of program content or skills. Discussion: The behavior categories, although not predictive of module completion or outcomes, may be of use for therapists, treatment developers and health care providers as a tool for understanding therapeutic processes in internet interventions for AUD