Long Term Outcomes of Blended CBT Compared to Face-to-Face CBT and Treatment as Usual for Adolescents with Depressive Disorders: Analyses at 12 Months Post-Treatment

Depression is a major problem in youth mental health and identified as the leading cause of disability worldwide. There is ample research on the acute effects of treatment, with estimated small-to-moderate effect sizes. However, there is a lack of research on long-term outcomes. A total of 129 adolescents with clinical depression (82.2% female), aged 13–22 (M = 16.60, SD = 2.03), received blended CBT, face-to-face CBT or treatment as usual. Data were collected at 12 months after the intervention and compared between treatment conditions. Clinical diagnosis, depressive symptoms, suicide risk, internalizing symptoms and externalizing symptoms decreased significantly over time, from baseline to the 12-month follow-up, and also from post-treatment to the 12-month follow-up in all three conditions. Changes were not significantly different between conditions. At the long-term, improvements following the treatment continued. Due to the large amount of missing data and use of history control condition, our findings need to be interpreted with caution. However, we consider these findings as a clinical imperative. More evidence might contribute to convincing adolescents to start with therapy, knowing it has lasting effects. Further, especially for adolescents for whom it is not possible to receive face-to-face treatment, blended treatment might be a valuable alternative. Our findings might contribute to the implementation of blended CBT.

RADIUS – ein verhaltenstherapeutisches blended treatment in der Suchtbehandlung

Was ist zu diesem Thema bekannt? Im blended treatment wird Onlinetherapie nicht mehr als stand-alone-Technik angewandt, sondern im Face-to-Face-Setting. Ziel ist die Verbindung der Vorteile aus beiden Ansätzen. Wie wird eine neue Perspektive eingebracht? CRA und RADIUS zeigen einen Prototyp des blended treatments in der Behandlung von Abhängigkeitserkrankungen. Dabei zeigen sich neue Unterstützungsmöglichkeiten und mehr Flexibilität für die Nutzer_innen. Was sind die Auswirkungen für die Praxis? Die Möglichkeit der ambulanten therapeutischen Arbeit wird aus mulitprofessioneller Perspektive erweitert. Die psychotherapeutische Zusammenarbeit kann Pflegende einbinden und die Behandlungsmöglichkeiten erweitern.

BLEND-A: blending internet treatment into conventional face-to-face treatment for alcohol use disorder - a study protocol

Background A major challenge to psychological treatment for alcohol use disorder (AUD) is patient non-compliance. A promising new treatment approach that is hypothesized to increase patient compliance is blended treatment, consisting of face-to-face contact with a therapist combined with modules delivered over the internet within the same protocol. While this treatment concept has been developed and proven effective for a variety of mental disorders, it has not yet been examined for AUD. Aims The study described in this protocol aims to examine and evaluate patient compliance with blended AUD treatment as well as the clinical and cost effectiveness of such treatment compared to face-to-face treatment only. Methods The study design is a pragmatic, stepped-wedge cluster randomized controlled trial. The included outpatient institutions (planned number of patients: n = 1800) will be randomized in clusters to implement either blended AUD treatment or face-to-face treatment only, i.e. treatment as usual (TAU). Both treatment approaches consist of motivational interviewing and cognitive behavioral therapy. Data on sociodemographics, treatment (e.g. intensity, duration), type of treatment conclusion (compliance vs. dropout), alcohol consumption, addiction severity, consequences of drinking, and quality of life, will be collected at treatment entry, at treatment conclusion, and 6 months after treatment conclusion. The primary outcome is compliance at treatment conclusion, and the secondary outcomes include alcohol consumption and quality of life at six-months follow-up. Data will be analyzed with an Intention-to-treat approach by means of generalized linear mixed models with a random effect for cluster and fixed effect for each step. Also, analyses evaluating cost-effectiveness will be conducted. Discussion Blended treatment may increase treatment compliance and thus improve treatment outcomes due to increased flexibility of the treatment course. Since this study is conducted within an implementation framework it can easily be scaled up, and when successful, blended treatment has the potential to become an alternative offer in many outpatient clinics nationwide and internationally. Trial registration Clinicaltrials.gov.: NCT04535258, retrospectively registered 01.09.20.

REMOTION Blended Transdiagnostic Intervention for Symptom Reduction and Improvement of Emotion Regulation in an Outpatient Psychotherapeutic Setting: Protocol for a Pilot Randomized Controlled Trial

Background Emotion regulation has been identified as an important transdiagnostic factor relevant to the treatment of mental health disorders. Many empirically validated psychotherapeutic treatments incorporate elements targeting emotion regulation. Most of these treatment approaches are conceptualized as standard face-to-face treatments not as blended treatments, which include an internet-based intervention. Objective The aim of this study is to examine, for the first time, a new internet-based intervention—REMOTION—that will be provided transdiagnostically, as an add-on to psychotherapy, to provide a blended treatment format. Methods A total of 70 participants will be assigned (1:1 allocation ratio) to either the intervention group (REMOTION + psychotherapy) or the treatment-as-usual group that receives psychotherapy alone. To maximize external validity, a typical outpatient treatment sample of patients diagnosed with a range of disorders such as depression, anxiety disorders, and adjustment disorder will be recruited from a university outpatient clinic. Patients with bipolar disorder, psychotic disorders, or acute suicidality will be excluded from the study. The feasibility and potential effectiveness of the intervention will be examined by assessing data at baseline, 6 weeks (post), and 12 weeks (follow-up). The primary outcome is general symptom severity, assessed with the Brief Symptom Inventory. Secondary outcomes are emotion regulation, depressive symptoms, anxiety symptoms, health related quality of life, well-being, and a variety of feasibility parameters. Quantitative data will be analyzed on an intention-to-treat basis. Results Participant recruitment and data collection started in February 2020, and as of November 2020, are ongoing. Results for the study are expected in 2022. Conclusions This pilot randomized controlled trial will inform future studies using transdiagnostic blended treatment. Trial Registration ClinicalTrials.gov NCT04262726; http://clinicaltrials.gov/ct2/show/NCT04262726 International Registered Report Identifier (IRRID) DERR1-10.2196/20936

Blended Treatment for Depressive Disorders in Youth: a Narrative Review

Depressive disorders are the most prevalent mental health disorder in adolescents with detrimental consequences; effective and available treatment is crucial. Face-to-face and computerized treatments both have advantages but also downsides. Merging these two into one so-called blended treatment seems to be an optimal combination of elements. This current review addresses blended treatment for youth depression and aims to summarize existing knowledge on effectiveness as well as patients’ and therapists’ perspectives. Results showed promising significant decreases in symptoms, but no evidence for differences between blended and face-to-face treatment was found. Patients’ perspectives were mixed; they reported strong preferences for face-to-face treatment, but participants actually receiving blended treatment were mainly positive. Therapists’ attitudes were neutral, but they expressed their worries about the unknown risks on adverse events. Future research is needed and should, beside effectiveness and cost-effectiveness, pay close attention to the risks that are mentioned by therapists.

Blended Digital and Face-to-Face Care for First-Episode Psychosis Treatment in Young People: Qualitative Study

Background A small number of studies have found that digital mental health interventions can be feasible and acceptable for young people experiencing first-episode psychosis; however, little research has examined how they might be blended with face-to-face approaches in order to enhance care. Blended treatment refers to the integration of digital and face-to-face mental health care. It has the potential to capitalize on the evidence-based features of both individual modalities, while also exceeding the sum of its parts. This integration could bridge the online–offline treatment divide and better reflect the interconnected, and often complementary, ways young people navigate their everyday digital and physical lives. Objective This study aimed to gain young people’s perspectives on the design and implementation of a blended model of care in first-episode psychosis treatment. Methods This qualitative study was underpinned by an end-user development framework and was based on semistructured interviews with 10 participants aged 19 to 28 (mean 23.4, SD 2.62). A thematic analysis was used to analyze the data. Results Three superordinate themes emerged relating to young people’s perspectives on the design and implementation of a blended model of care in first-episode psychosis treatment: (1) blended features, (2) cautions, and (3) therapeutic alliance. Conclusions We found that young people were very enthusiastic about the prospect of blended models of mental health care, in so far as it was used to enhance their experience of traditional face-to-face treatment but not to replace it overall. Aspects of blended treatment that could enhance clinical care were readily identified by young people as increasing accessibility, continuity, and consolidation; accessing posttherapy support; strengthening the relationship between young person and clinician; and tracking personal data that could be used to better inform clinical decision making. Future research is needed to investigate the efficacy of blended models of care by evaluating its impact on the therapeutic alliance, clinical and social outcomes, cost-effectiveness, and engagement.

Adherence to Blended or Face-to-Face Smoking Cessation Treatment and Predictors of Adherence: Randomized Controlled Trial

Background Blended face-to-face and web-based treatment is a promising way to deliver smoking cessation treatment. Since adherence has been shown to be an indicator of treatment acceptability and a determinant for effectiveness, we explored and compared adherence and predictors of adherence to blended and face-to-face alone smoking cessation treatments with similar content and intensity. Objective The objectives of this study were (1) to compare adherence to a blended smoking cessation treatment with adherence to a face-to-face treatment; (2) to compare adherence within the blended treatment to its face-to-face mode and web mode; and (3) to determine baseline predictors of adherence to both treatments as well as (4) the predictors to both modes of the blended treatment. Methods We calculated the total duration of treatment exposure for patients (N=292) of a Dutch outpatient smoking cessation clinic who were randomly assigned either to the blended smoking cessation treatment (n=130) or to a face-to-face treatment with identical components (n=162). For both treatments (blended and face-to-face) and for the two modes of delivery within the blended treatment (face-to-face vs web mode), adherence levels (ie, treatment time) were compared and the predictors of adherence were identified within 33 demographic, smoking-related, and health-related patient characteristics. Results We found no significant difference in adherence between the blended and the face-to-face treatments. Participants in the blended treatment group spent an average of 246 minutes in treatment (median 106.7% of intended treatment time, IQR 150%-355%) and participants in the face-to-face group spent 238 minutes (median 103.3% of intended treatment time, IQR 150%-330%). Within the blended group, adherence to the face-to-face mode was twice as high as that to the web mode. Participants in the blended group spent an average of 198 minutes (SD 120) in face-to-face mode (152% of the intended treatment time) and 75 minutes (SD 53) in web mode (75% of the intended treatment time). Higher age was the only characteristic consistently found to uniquely predict higher adherence in both the blended and face-to-face groups. For the face-to-face group, more social support for smoking cessation was also predictive of higher adherence. The variability in adherence explained by these predictors was rather low (blended R2=0.049; face-to-face R2=0.076). Within the blended group, living without children predicted higher adherence to the face-to-face mode (R2=0.034), independent of age. Higher adherence to the web mode of the blended treatment was predicted by a combination of an extrinsic motivation to quit, a less negative attitude toward quitting, and less health complaints (R2=0.164). Conclusions This study represents one of the first attempts to thoroughly compare adherence and predictors of adherence of a blended smoking cessation treatment to an equivalent face-to-face treatment. Interestingly, although the overall adherence to both treatments appeared to be high, adherence within the blended treatment was much higher for the face-to-face mode than for the web mode. This supports the idea that in blended treatment, one mode of delivery can compensate for the weaknesses of the other. Higher age was found to be a common predictor of adherence to the treatments. The low variance in adherence predicted by the characteristics examined in this study suggests that other variables such as provider-related health system factors and time-varying patient characteristics should be explored in future research. Trial Registration Netherlands Trial Register NTR5113; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5113

Patients’ User Experience of a Blended Face-to-Face and Web-Based Smoking Cessation Treatment: Qualitative Study

Background Blended web-based and face-to-face (F2F) treatment is a promising electronic health service because the strengths of one mode of delivery should compensate for the weaknesses of the other. Objective The aim of this study was to explore this compensation by examining patients’ user experience (UX) in a blended smoking cessation treatment (BSCT) in routine care. Methods Data on patients’ UX were collected through in-depth interviews (n=10) at an outpatient smoking cessation clinic in the Netherlands. A content analysis of the semantic domains was used to analyze patients’ UX. To describe the UX, the Hassenzahl UX model was applied, examining 4 of the 5 key elements of UX from a user’s perspective: (1) patients’ standards and expectations, (2) apparent character (pragmatic and hedonic attributes), (3) usage situation, and (4) consequences (appeal, emotions, and behavior). Results BSCT appeared to be a mostly positively experienced service. Patients had a positive-pragmatic standard and neutral-open expectation toward BSCT at the treatment start. The pragmatic attributes of the F2F sessions were mostly perceived as positive, whereas the pragmatic attributes of the web sessions were perceived as both positive and negative. For the hedonic attributes, there seemed to be a difference between the F2F and web sessions. Specifically, the hedonic attributes of the web sessions were experienced as mostly negative, whereas those of the F2F sessions were experienced as mostly positive. For the usage situation, the physical and social contexts were experienced positively, whereas the task and technical contexts were experienced negatively. Nevertheless, the consequential appeal of BSCT was positive. However, the consequential emotions and behavior varied, ultimately resulting in diverse combinations of consequential appeal, emotions, and behavior (positive, negative, and mixed). Conclusions This study provided insights into the UX of a blended treatment, and the results support the expectation that in a blended treatment, the strengths of one mode of delivery may compensate for the weaknesses of the other. However, in this certain setting, this is mainly achieved in only one way: F2F sessions compensated for the weaknesses of the web sessions. As a practical conclusion, this may mean that the web sessions, supported by the strengths of the F2F sessions, offer an interesting approach for further improving the blended treatment. Our theoretical findings reflect the relevance of the aspects of hedonism, such as fun, joy, or happiness in the UX, which were not mentioned in relation to the web sessions and were only scarcely mentioned in relation to the F2F sessions. Future research should further investigate the role of hedonistic aspects in a blended treatment and whether increased enjoyment of a blended treatment could increase treatment adherence and, ultimately, effectiveness.

REMOTION Blended Transdiagnostic Intervention for Symptom Reduction and Improvement of Emotion Regulation in an Outpatient Psychotherapeutic Setting: Protocol for a Pilot Randomized Controlled Trial (Preprint)

BACKGROUND Emotion regulation has been identified as an important transdiagnostic factor relevant to the treatment of mental health disorders. Many empirically validated psychotherapeutic treatments incorporate elements targeting emotion regulation. Most of these treatment approaches are conceptualized as standard face-to-face treatments not as blended treatments, which include an internet-based intervention. OBJECTIVE The aim of this study is to examine, for the first time, a new internet-based intervention—REMOTION—that will be provided transdiagnostically, as an add-on to psychotherapy, to provide a blended treatment format. METHODS A total of 70 participants will be assigned (1:1 allocation ratio) to either the intervention group (REMOTION + psychotherapy) or the treatment-as-usual group that receives psychotherapy alone. To maximize external validity, a typical outpatient treatment sample of patients diagnosed with a range of disorders such as depression, anxiety disorders, and adjustment disorder will be recruited from a university outpatient clinic. Patients with bipolar disorder, psychotic disorders, or acute suicidality will be excluded from the study. The feasibility and potential effectiveness of the intervention will be examined by assessing data at baseline, 6 weeks (post), and 12 weeks (follow-up). The primary outcome is general symptom severity, assessed with the Brief Symptom Inventory. Secondary outcomes are emotion regulation, depressive symptoms, anxiety symptoms, health related quality of life, well-being, and a variety of feasibility parameters. Quantitative data will be analyzed on an intention-to-treat basis. RESULTS Participant recruitment and data collection started in February 2020, and as of November 2020, are ongoing. Results for the study are expected in 2022. CONCLUSIONS This pilot randomized controlled trial will inform future studies using transdiagnostic blended treatment. CLINICALTRIAL ClinicalTrials.gov NCT04262726; http://clinicaltrials.gov/ct2/show/NCT04262726 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/20936