Managing depression via the Internet : self-report measures, treatment & relapse prevention

Cognitive behaviour therapy (CBT) is an effective treatment for depression but access is limited. One way of increasing access is to offer CBT via the Internet. In Study I, guided Internet-based CBT was found to have a large effect on depressive symptoms compared to taking part in an online discussion group. Approximately two hours were spent on guiding each patient and the large effect found differs from previous studies that showed smaller effects, probably due to lack of guidance. The intervention had no effect on the participants’ quality of life but significantly decreased their level of anxiety. Internet-based versions of self-report measures can be more practical and efficient than paper versions. However, before implementation, evidence of psychometrical equivalence to the paper versions should be available. This was tested in Studies II and III for the Montgomery-Åsberg Depression Rating Scale – Self-rated (MADRS-S) and the Beck Depression Inventory – Second Edition (BDI-II). When the full scales were investigated, equivalent psychometric properties were found in the two versions of the MADRS-S and BDI-II. However, in the Internet-version of the BDI-II, a lower score was found for the question about suicidality and the difference was statistically significant. Although the difference was small, this indicates that suicidality might be underestimated when using the Internet-based BDI-II. As the long-term prognosis after treatment for depression is poor, in Study IV we investigated the possibility of delivering CBT-based relapse prevention via the Internet. The results revealed that fewer participants in the intervention group experienced a relapse compared to the control group and that the time spent on guiding each participant was approximately 2.5 hours. A trend towards a higher remission rate was found in the CBT group at the six-month follow-up and a reduction of depressive symptoms was associated with a lowered risk of relapse. CBT-based relapse prevention via the Internet can potentially be made available to large numbers of patients, thus improving their prognosis. The Internet increases the possibilities for health care providers in the management of depression

Managing depression via the Internet : self-report measures, treatment & relapse prevention

Cognitive behaviour therapy (CBT) is an effective treatment for depression but access is limited. One way of increasing access is to offer CBT via the Internet. In Study I, guided Internet-based CBT was found to have a large effect on depressive symptoms compared to taking part in an online discussion group. Approximately two hours were spent on guiding each patient and the large effect found differs from previous studies that showed smaller effects, probably due to lack of guidance. The intervention had no effect on the participants’ quality of life but significantly decreased their level of anxiety. Internet-based versions of self-report measures can be more practical and efficient than paper versions. However, before implementation, evidence of psychometrical equivalence to the paper versions should be available. This was tested in Studies II and III for the Montgomery-Åsberg Depression Rating Scale – Self-rated (MADRS-S) and the Beck Depression Inventory – Second Edition (BDI-II). When the full scales were investigated, equivalent psychometric properties were found in the two versions of the MADRS-S and BDI-II. However, in the Internet-version of the BDI-II, a lower score was found for the question about suicidality and the difference was statistically significant. Although the difference was small, this indicates that suicidality might be underestimated when using the Internet-based BDI-II. As the long-term prognosis after treatment for depression is poor, in Study IV we investigated the possibility of delivering CBT-based relapse prevention via the Internet. The results revealed that fewer participants in the intervention group experienced a relapse compared to the control group and that the time spent on guiding each participant was approximately 2.5 hours. A trend towards a higher remission rate was found in the CBT group at the six-month follow-up and a reduction of depressive symptoms was associated with a lowered risk of relapse. CBT-based relapse prevention via the Internet can potentially be made available to large numbers of patients, thus improving their prognosis. The Internet increases the possibilities for health care providers in the management of depression

An internet-based behavioral intervention for adults with autism spectrum disorder – A randomized controlled trial and feasibility study

Background: The increased prevalence of Autism Spectrum Disorder (ASD) diagnoses in combination with psychiatric comorbidity, has led to an increased need for effective interventions. The evidence for internet-based interventions for several mental health problems is established but has not been evaluated for adults with ASD. Objective: The aim of this randomized controlled trial is to evaluate the feasibility and effects of an internet-based intervention targeting quality of life and psychiatric symptoms (depression and anxiety) in adults with ASD. Methods: 84 participants were randomly allocated to intervention (n = 42) or control (n = 42). The 18-week internet-based intervention covered a range of themes related to difficulties common in ASD, and exercises based on cognitive behavioral strategies. Participants were provided with individual feedback following each module and were invited to regular chat sessions with peer participants. The primary outcomes were subjective quality of life and sense of coherence, and secondary outcomes were symptoms of depression and anxiety. All outcomes were measured at five occasions and analysed with linear mixed effect models. Participant satisfaction and adherence was also analysed. Results: Participant satisfaction and adherence was satisfactory but no significant interaction between group and time was found for any outcome measure. Autistic traits were negatively related to quality of life and sense of coherence and positively related to anxiety and depressive symptoms. Conclusions: This internet-based intervention showed feasibility regarding adherence and participant satisfaction. However, no significant effects on quality of life, sense of coherence or psychiatric symptoms were found, likely due to limitations in the design and methodology of this specific trial in combination to the heterogeneity of the group. Individuals with ASD may require interventions that are flexible and individually tailored in regard to both format, content and therapeutic support. The current trial provides useful information and suggestions for the future research on internet-based interventions for ASD

Are quantity and content of psychiatric interventions associated with suicide? : A case-control study of a Swedish sample

Background Research is required to identify those psychiatric interventions with a protective effect against suicide. The overarching aim of the current study was to examine whether completed suicide in psychiatric patients in a Swedish population was associated with the quantity and nature of previous medical and psychosocial treatment interventions. Methods This retrospective case-control study (n = 308) compared a group of deceased psychiatric patients with matched controls. For every case of suicide, a control was found within psychiatry that matched according to sex, age, and primary psychiatric diagnosis. A stepwise forward logistic regression model with suicide as the dependent outcome variable was used. Results Receiving pharmacotherapy combined with psychotherapy [OR: 0.44 (95% CI: 0.226-0.876), p = 0.019] and a higher number of outpatient visits in psychiatry [OR: 0.99 (95% CI: 0.982-0.999), p = 0.028] were negatively associated with suicide. These associations were still significant after controlling for previous serious suicide attempts and somatic comorbidity. Conclusions Frequent visits and pharmacotherapy combined with psychotherapy seem to be important for preventing suicide in psychiatric patients. The reasons for not receiving such therapy are important issues for further study

Increasing accessibility to iCBT for depression : A randomised controlled trial of condensed versus standard length treatment

Background: Research show that internet-based CBT (iCBT) is an effective treatment for depression. However, little is known about how length of treatment text material affect outcomes. Accessibility to treatment would improve if treatment could be presented with less text, especially for patients with ADHD symptoms and lower reading speed.Objective: The aim of this study was to test the hypothesis that a Condensed treatment would be non-inferior to a Full-length treatment. We further hypothesized that a Condensed treatment would be extra helpful for participants with a low reading speed and more ADHD symptoms. Method: A single-blind randomised controlled trial was conducted (N = 267) comparing two versions of guided iCBT for depression; Full-length (60 000 words) and Condensed (30 000 words). Estimated between-group effect sizes and their confidence intervals were compared to a pre-determined non-inferiority margin (Cohen’s d = 0.4). Moderation analyses of reading speed and ADHD symptoms were conducted, as well as comparisons of treatment engagement and knowledge acquisition. Results: The Condensed version of iCBT was non-inferior at endpoint for depressive symptoms, anxiety symptoms, and quality of life compared to the Full-length version. There was a significant interaction effect between reading speed and treatment version. No significant differences between the treatment versions were found on measures of treatment engagement or knowledge acquisition. Conclusion: A condensed version of iCBT for depression can be used with non-inferior results. A condensed treatment might be extra helpful for patients with lower reading speed. Given a high degree of missing data, these results need to be replicated

Internet delivered transdiagnostic treatment with telephone support for pain patients with emotional comorbidity: a replicated single case study

In pain patients, comorbid emotional problems have been linked to negative outcomes, including suboptimal treatment gains. Developing parsimonious and accessible treatment options is therefore important. The overarching aim of this study was to test an internet delivered therapist guided transdiagnostic treatment with telephone support. An adapted version of the Unified Protocol for Transdiagnostic Treatments of Emotional Disorders was used as an intervention for pain patients with residual pain problems and comorbid emotional problems after having received a multimodal pain rehabilitation. The study used a replicated AB single case experimental design (N = 5; 3 females). Outcome measures were depressive and general anxiety symptoms, pain intensity, pain coping problems, and diagnostic status. Feasibility measures (completion and compliance) and patient satisfaction were also assessed. Scores on Nonoverlap of All Pairs (NAP) indicate a decrease of anxiety for three participants and a decrease of depression for four participants. Decreases were small and did not always reach statistical significance. Also, Tau-U scores could only confirm a reliable trend for one participant. Two out of four patients who were diagnosed with psychiatric disorders before treatment did no longer fulfill diagnostic criteria posttreatment. No improvements could be seen on pain problems. The treatment was feasible and patient satisfaction was high. Hence, while an internet delivered transdiagnostic treatment with telephone support may be a feasible and accepted secondary intervention for pain patients with comorbid emotional problems, the effects are unclear. The gap between high patient satisfaction and small changes in symptomatology should be explored further

Increasing the accessibility to internet-based cognitive behavioural therapy for depression: A single-blind randomized controlled trial of condensed versus full-text versions

Background: Research shows that internet-based cognitive behavioural therapy (iCBT) is an effective treatment for depression. However, little is known about how the length of the text material in iCBT affects outcomes. Objective: The aim of this study was to test whether a condensed iCBT version for depression would be non-inferior to the existing full-text version in reducing depressive symptoms at post-treatment. We also wanted to test non-inferiority for secondary outcomes and explore reading speed and ADHD symptoms as potential moderators. Method: A single-blind randomized controlled trial was conducted (N = 267) comparing two versions of guided iCBT for depression; full-text (around 60,000 words) and condensed (around 30,000 words, with the option to listen to the text). Estimated between-group effect sizes and their confidence intervals for depression, anxiety and quality of life, were compared to a pre-determined non-inferiority margin (ES = 0.4). Moderation analyses of reading speed and ADHD symptoms were conducted. Results: The condensed version of iCBT was non-inferior to the full-text version on post-treatment measures for depressive symptoms (95 % CI = −0.42–0.24), anxiety symptoms (95 % CI = −0.24–0.32), and quality of life (95 % CI = −0.09–0.49). Non-inferiority was inconclusive for depressive symptoms at the one-year follow-up (95 % CI = −0.60–0.47). There was no significant moderation effects of reading speed (p = 0.06) or ADHD symptoms (p = 0.11) on depressive symptoms. Conclusion: These results indicate that a condensed version of iCBT for depression is as effective at treating depression as the full-text version. By shortening texts, iCBT may be made available to more people. Due to unequal dropout rates between the groups, these results are preliminary and need to be replicated

Increasing accessibility to iCBT for depression : A randomised controlled trial of condensed versus standard length treatment

Background: Research show that internet-based CBT (iCBT) is an effective treatment for depression. However, little is known about how length of treatment text material affect outcomes. Accessibility to treatment would improve if treatment could be presented with less text, especially for patients with ADHD symptoms and lower reading speed.Objective: The aim of this study was to test the hypothesis that a Condensed treatment would be non-inferior to a Full-length treatment. We further hypothesized that a Condensed treatment would be extra helpful for participants with a low reading speed and more ADHD symptoms. Method: A single-blind randomised controlled trial was conducted (N = 267) comparing two versions of guided iCBT for depression; Full-length (60 000 words) and Condensed (30 000 words). Estimated between-group effect sizes and their confidence intervals were compared to a pre-determined non-inferiority margin (Cohen’s d = 0.4). Moderation analyses of reading speed and ADHD symptoms were conducted, as well as comparisons of treatment engagement and knowledge acquisition. Results: The Condensed version of iCBT was non-inferior at endpoint for depressive symptoms, anxiety symptoms, and quality of life compared to the Full-length version. There was a significant interaction effect between reading speed and treatment version. No significant differences between the treatment versions were found on measures of treatment engagement or knowledge acquisition. Conclusion: A condensed version of iCBT for depression can be used with non-inferior results. A condensed treatment might be extra helpful for patients with lower reading speed. Given a high degree of missing data, these results need to be replicated