Mechanisms of change in internet- and mobile-based interventions for adult anxiety disorders: A systematic review and meta-analysis protocol

Systematic Review and Meta-Analysi

Mechanisms of change in digital interventions for depression: Protocol for an individual participant data meta-analysis

Digital interventions for depression might have the potential to extend and augment evidence-based treatements for this common mental disorder. Although the efficacy of digital interventions for depressive disorders is well established (Karyotaki et al., 2017; Karyotaki et al., 2018; Karyotaki et al., 2021; Königbauer et al., 2017; Reins et al., 2020), comprehensive and integrated knowledge about their mechanisms of change is largely pending. Precise information on the mediators and mechanisms of change in these interventions is crucial, in order to advance intervention development and clinical practice, contributing to more effective interventions and improved treatment outcomes (Domhardt, Cuijpers et al., 2021; Domhardt, Steubl et al., 2021). The project "Mechanisms of change in internet- and mobile-based interventions for depression: A systematic review and meta-analysis of individual participant data (howIMIwork)" is funded by the German Federal Ministry of Education and Research (BMBF; Grant Identification FKZ 01KG1802). References: Domhardt, M., Cuijpers, P., Ebert, D. D., & Baumeister, H. (2021). More Light? Opportunities and Pitfalls in Digitalized Psychotherapy Process Research. Frontiers in Psychology, 12, 544129. https://doi.org/10.3389/fpsyg.2021.544129 Domhardt, M., Steubl, L., Boettcher, J., Buntrock, C., Karyotaki, E., Ebert, D. D., Cuijpers, P., & Baumeister, H. (2021). Mediators and mechanisms of change in internet- and mobile-based interventions for depression: A systematic review. Clinical Psychology Review, 83, 101953. https://doi.org/10.1016/j.cpr.2020.101953 Karyotaki, E., Riper, H., Twisk, J., Hoogendoorn, A., Kleiboer, A., Mira, A., Mackinnon, A., Meyer, B., Botella, C., Littlewood, E., Andersson, G., Christensen, H., Klein, J. P., Schroder, J., Breton-Lopez, J., Scheider, J., Griffiths, K., Farrer, L., Huibers, M. J., . . . Cuijpers, P. (2017). Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry, 74(4), 351–359. https://doi.org/10.1001/jamapsychiatry.2017.0044 Karyotaki, E., Ebert, D. D., Donkin, L., Riper, H., Twisk, J., Burger, S., Rozental, A., Lange, A., Williams, A. D., Zarski, A. C., Geraedts, A., van Straten, A., Kleiboer, A., Meyer, B., Ünlü Ince, B. B., Buntrock, C., Lehr, D., Snoek, F. J., Andrews, G., . . . Cuijpers, P. (2018). Do guided internet-based interventions result in clinically relevant changes for patients with depression? An individual participant data meta-analysis. Clinical Psychology Review, 63, 80–92. https://doi.org/10.1016/j.cpr.2018.06.007 Karyotaki, E., Efthimiou, O., Miguel, C., Bermpohl, F. M. G., Furukawa, T. A., Cuijpers, P., Riper, H., Patel, V., Mira, A., Gemmil, A. W., Yeung, A. S., Lange, A., Williams, A. D., Mackinnon, A., Geraedts, A., van Straten, A., Meyer, B., Björkelund, C., Knaevelsrud, C., . . . Forsell, Y. (2021). Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry, 78(4), 361–371. https://doi.org/10.1001/jamapsychiatry.2020.4364 Königbauer, J., Letsch, J., Doebler, P., Ebert, D. D., & Baumeister, H. (2017). Internet- and mobile-based depression interventions for people with diagnosed depression: A systematic review and meta-analysis. Journal of Affective Disorders, 223, 28–40. https://doi.org/10.1016/j.jad.2017.07.021 Reins, J. A., Buntrock, C., Zimmermann, J., Grund, S., Harrer, M., Lehr, D., Baumeister, H., Weisel, K., Domhardt, M., Imamura, K., Kawakami, N., Spek, V., Nobis, S., Snoek, F., Cuijpers, P., Klein, J. P., Moritz, S., & Ebert, D. D. (2020). Efficacy and Moderators of Internet-Based Interventions in Adults with Subthreshold Depression: An Individual Participant Data Meta-Analysis of Randomized Controlled Trials. Psychotherapy and Psychosomatics, 1–13. https://doi.org/10.1159/00050781

Mechanisms of change in Internet- and mobile-based interventions for PTSD: a systematic review and meta-analysis

Background: While Internet- and mobile-based interventions (IMIs) are potential options to increase the access to evidence-based therapies for post-traumatic stress disorder (PTSD), comprehensive knowledge on their working mechanisms is still scarce. Objective: We aimed to evaluate studies investigating the efficacy and mechanisms of change in IMIs for adults with PTSD. Method: In this systematic review and meta-analysis (PROSPERO CRD42019130314), five databases were consulted to identify relevant studies, complemented by forward (i.e. citation search) and backward (i.e. review of reference lists from included studies) searches. Randomized controlled trials (RCTs) investigating the efficacy of IMIs compared to active controls, as well as component and mediation studies were included. Two independent reviewers extracted the data and assessed the risk of bias and requirements for process research. Random-effects meta-analyses on PTSD symptom severity as primary outcome were conducted and further information was synthesized qualitatively. Results: In total, 33 RCTs were included (N = 5421). The meta-analysis comparing IMIs to non-bonafide active controls yielded a significant standardized mean difference (SMD) of −0.36 (95%CI −0.53 to −0.19) favouring IMIs. Although meta-analytic pooling was not possible for the component and mediation studies, evidence suggests no differential effects regarding PTSD symptom reduction between different levels of support and personalization and between different types of exposure. Moreover, mediation studies revealed significant intervening variable effects for self-efficacy beliefs, perceived physical impairment, social acknowledgement, and trauma disclosure. Conclusions: Results indicate that IMIs for PTSD are superior to active controls. Furthermore, findings may contribute to the development of new interventions by outlining important directions for future research (e.g. regarding requirements for process research) and highlighting potential mechanisms of change (i.e. self-efficacy, perceived physical impairment, social acknowledgement, and trauma disclosure)

More Light? Opportunities and Pitfalls in Digitalized Psychotherapy Process Research

While the evidence on the effectiveness of different psychotherapies is often strong, it is not settled whereby and how these therapies work. Knowledge on the causal factors and change mechanisms is of high clinical and public relevance, as it contributes to the empirically informed advancement of psychotherapeutic interventions. Here, digitalized research approaches might possess the potential to generate new insights into human behavior change, contributing to augmented interventions and mental healthcare practices with better treatment outcomes. In this perspective article, we describe recent findings of research into change mechanisms that were only feasible with digital tools and outline important future directions for this rather novel branch of research. Furthermore, we indicate several challenges and pitfalls that are to be solved, in order to advance digitalized psychotherapy process research, both methodologically and technologically

Can You Sleep? – Effect of Retrospective Recall of Child Maltreatment on Sleep Parameters and the Mediating Role of Psychological Distress Among Students of Two German Universities

Purpose: Child maltreatment may be linked with long-term sleeping disorders and limited coping with stress. Yet, the potential relationships are only marginally studied. Patients and Methods: Based on a sample of young adults (n = 312) this study aims at exploring the effects of child maltreatment and the experience of threat to personal safety and life in childhood on sleep disturbances in early adulthood. Data were collected at the two study sites, Ulm University and Bielefeld University, by an online survey. For both risk factors, child maltreatment and the experience of threat to personal safety and life in childhood, a direct impact on sleep disturbances and an indirect path via psychological distress were tested using Structural Equation Modelling (SEM). Results: In these models, the direct path to sleep disturbances turned out to be significant for the experience of threat to personal safety and life (Path C: b = 0.18, p = 0.013), but not for child maltreatment (Path C: b = 0.05, p = 0.491). However, the current level of psychological distress was found to have a mediating effect on sleep disturbances for both risk factors, thereby confirming indirect significant effects. Conclusion: Considering that the etiological pathway of child maltreatment on sleeping disturbances is mediated via psychological distress, this provides a venue to test in future research whether stress reduction interventions can reduce the negative consequences of child maltreatment on sleep disorders

Mechanisms of Change in Digital Health Interventions for Mental Disorders in Youth: Systematic Review

BackgroundDigital health interventions (DHIs) are efficacious for several mental disorders in youth; however, integrated, evidence-based knowledge about the mechanisms of change in these interventions is lacking. ObjectiveThis systematic review aims to comprehensively evaluate studies on mediators and mechanisms of change in different DHIs for common mental disorders in children and adolescents. MethodsA systematic literature search of the electronic databases Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PsycINFO was conducted, complemented by backward and forward searches. Two independent reviewers selected studies for inclusion, extracted the data, and rated the methodological quality of eligible studies (ie, risk of bias and 8 quality criteria for process research). ResultsA total of 25 studies that have evaluated 39 potential mediators were included in this review. Cognitive mediators were the largest group of examined intervening variables, followed by a broad range of emotional and affective, interpersonal, parenting behavior, and other mediators. The mediator categories with the highest percentages of significant intervening variables were the groups of affective mediators (4/4, 100%) and combined cognitive mediators (13/19, 68%). Although more than three-quarters of the eligible studies met 5 or more quality criteria, causal conclusions have been widely precluded. ConclusionsThe findings of this review might guide the empirically informed advancement of DHIs, contributing to improved intervention outcomes, and the discussion of methodological recommendations for process research might facilitate mediation studies with more pertinent designs, allowing for conclusions with higher causal certainty in the future

Therapeutic processes in digital interventions for anxiety: A systematic review and meta-analytic structural equation modeling of randomized controlled trials

Domhardt M, Nowak H, Engler S, et al. Therapeutic processes in digital interventions for anxiety: A systematic review and meta-analytic structural equation modeling of randomized controlled trials. Clinical psychology review. 2021;90: 102084.While the efficacy of Internet- and mobile-based interventions (IMIs) for treating anxiety disorders is well established, there is no comprehensive overview about the underlying therapeutic processes so far. Thus, this systematic review and meta-analysis evaluated research on mediators and mechanisms of change in IMIs for adult anxiety disorders (PROSPERO: CRD42020185545). A systematic literature search was performed in five databases (i.e., CENTRAL, Embase, MEDLINE, PsycINFO and ClinicalTrials.gov). Two reviewers independently screened studies for inclusion, assessed the risk of bias and adherence to quality criteria for process research. Overall, 26 studies (N=6042) investigating 64 mediators were included. Samples consisted predominantly of participants with clinically relevant symptoms of generalized anxiety disorder and severe health anxiety, as well as of participants with non-clinically relevant anxiety symptoms. The largest group of examined mediators (45%) were cognitive variables, evincing also the second highest proportion of significance (19/29); followed in numbers by skills (examined: 22%; significant: 10/14) and a wide range of other (19%; 7/12), emotional/affective (11%; 2/7) and behavioral mediators (3%; 1/2). Meta-analytical synthesis of mediators, limited by a small number of eligible studies, was conducted by deploying a two-stage structural equation modeling approach, resulting in a significant indirect effect for negative thinking (k=3 studies) and non-significant indirect effects for combined cognitive variables, both in clinical (k=5) and non-clinical samples (k=3). The findings of this review might further the understanding on presumed change mechanisms in IMIs for anxiety, informing intervention development and the concurrent optimization of outcomes. Furthermore, by reviewing eligible mediation studies, we discuss methodological implications and recommendations for future process research, striving for causally robust findings. Future studies should investigate a broader range of variables as potential mediators, as well as to develop and apply original (digital) process and engagement measures to gather qualitative and high-resolution data on therapeutic processes. Copyright © 2021 Elsevier Ltd. All rights reserved

Acceptance and commitment therapy for chronic pain : protocol of a systematic review and individual participant data meta-analysis

Background: Acceptance and commitment therapy (ACT) can be effective in treating chronic pain. Despite evidence supporting the effectiveness of ACT, uncertainties remain regarding which subgroups in the chronic pain population are likely to benefit most and least. This protocol describes the application for two meta-analytic approaches, one at the level of individual participant data and the other at the level of aggregated data, from randomized controlled trials of ACT for chronic pain (ACT-CP-MA). Methods: We will systematically conduct literature searches in CENTRAL, MEDLINE, EMBASE, PsycINFO, and trial registers. Two reviewers will independently select studies for inclusion and data extraction. ACT-CP-MA will include randomized controlled trials with ACT for chronic pain compared to control conditions for adults (>= 18 years) with chronic pain (>= 3 months). We will invite the authors of all eligible trials to share individual participant data. Outcomes will include standardized measures of pain interference, pain intensity, depression, anxiety, health-related quality of life, participants' rating of overall improvement, and ACT-related process variables. Using the Cochrane Collaboration's tool and GRADE, reviewers will independently check for risk of bias, quality of evidence, and strength of recommendations. In the individual participant data meta-analysis, we will use a one-step approach where participants are clustered with studies and data from all studies are modeled simultaneously. For analyses, we will use mixed-effects models. Additionally, we will employ a meta-analysis with aggregate data and compare the results of both meta-analyses. Discussion: This collaborative meta-analysis of individual participant data from randomized controlled trials of ACT for chronic pain versus control conditions will demonstrate how the known benefits of ACT for chronic pain vary across different subtypes of the chronic pain population. The results of the meta-analyses will be based on a comprehensive search of multiple databases and will help to inform future clinical trials and decision-making on the use of ACT in chronic pain and improve the quality, design, and reporting of future trials in this field

Effectiveness of Internet- and Mobile-Based Cognitive Behavioral Therapy to Reduce Suicidal Ideation and Behaviours: A Systematic Review and Meta-Analysis of Individual Participant Data

This individual participant data analysis (IPD-MA) aimed to provide a fine-grained overview of the effects of digital interventions to reduce suicidal ideation. In particular, the project focused on clinically relevant changes in suicidal ideation, participant-level moderators of suicidal ideation, as well as predictors of treatment adherence

Mediators and mechanisms of change in internet- and mobile-based interventions for depression:A systematic review

The efficacy of Internet- and mobile-based interventions (IMIs) for depression in adults is well established. Yet, comprehensive knowledge on the mediators responsible for therapeutic change in these interventions is pending. Therefore, we conducted the first systematic review on mediators in IMIs for depression, investigating mechanisms of change in interventions with different theoretical backgrounds and delivery modes (PROSPERO CRD42019130301). Two independent reviewers screened references from five databases (i.e., Cochrane Library, Embase, MEDLINE/PubMed, PsycINFO and ICTRP), selected studies for inclusion and extracted data from eligible studies. We included 26 RCTs on mediators in IMIs for depression (6820 participants), rated their risk of bias and adherence to methodological quality criteria for psychotherapy process research. Primary studies examined 64 mediators, with cognitive variables (e.g., perceived control, rumination or interpretation bias) being the largest group of both examined (m = 28) and significant mediators (m = 22); followed by a range of other mediators, including mindfulness, acceptance and behavioral activation. Our findings might contribute to the empirically-informed advancement of interventions and mental health care practices, enabling optimized treatment outcomes for patients with depression. Furthermore, we discuss implications for future research and provide methodological recommendations for forthcoming mediation studies with more pertinent designs, allowing for inferences with higher causal specificity