Examining the Impact of Digital Components Across Different Phases of Treatment in a Blended Care Cognitive Behavioral Therapy Intervention for Depression and Anxiety: Pragmatic Retrospective Study

Background Depression and anxiety incur significant personal and societal costs. Effective psychotherapies exist, such as cognitive behavioral therapy (CBT); however, timely access to quality care is limited by myriad barriers. Blended care therapy models incorporate traditional face-to-face therapy with scalable, digital components of care, expanding the reach of evidence-based care. Objective The aim of this study is to determine the effectiveness of a blended care CBT program (BC-CBT) in real-world settings and examine the unique impacts of the (1) digital components of care (video lessons and digital exercises) and (2) phase of treatment (early versus late) in decreasing symptoms of anxiety and depression. Methods This retrospective cohort analysis included 3401 US-based individuals enrolled in a BC-CBT program, who presented with clinical levels of depression and/or anxiety. The treatment program consisted of regular therapy sessions augmented by clinician-assigned digital video lessons and exercises. A growth curve model incorporating time-varying covariates examined the relationship between engagement with BCT components (ie, therapy sessions, digital video lessons, and digital exercises) during the early (weeks 0-7) and late (weeks 8-15) phases of treatment, and weekly symptom reports on depression and anxiety measures. Results On average, a significant decline in depression and anxiety symptoms was observed during the initial weeks of treatment (P<.001), with a continued, though slower, decline over subsequent weeks (P<.001). Each session completed was associated with significant decreases in anxiety (b=–0.72) and depression (b=–0.83) in the early phase, as well as in the late phase (anxiety, b=–0.47; depression, b=–0.27). Significant decreases in anxiety (b=–0.15) and depression (b=–0.12) were observed for time spent on video lessons (measured in 10-minute intervals) in the early phase of treatment. Engaging with exercises was associated with statistically significant increases in anxiety symptoms (b=0.03) during the early phase of treatment. However, sensitivity analyses examining the effects of exercises in isolation revealed significant decreases in anxiety (b=–0.05) in the early phase, suggesting a potential suppression effect in the larger model. Conclusions Using a retrospective cohort design, therapy sessions and digital video lessons were uniquely predictive of improvements in depression and anxiety symptoms, and their effects were modulated based on the phase of treatment (early vs late). Future research should investigate whether other treatment variables, such as therapeutic alliance or familiarity with technology, are related to differential effects on various components of care.

The Essential Network (TEN): Protocol for an implementation trial of a digital-first mental health solution for Australian healthcare workers during COVID-19 (Preprint)

BACKGROUND The COVID-19 pandemic has placed healthcare workers (HCWs) under severe stress, compounded by barriers to seeking mental health support among HCWs. The Essential Network (TEN) is a blend of digital and person-to-person (blended care) mental health support services for HCWs, funded by the Australian Federal Department of Health as part of their national COVID-19 response strategy. New blended services need to demonstrate improvements in mental health symptoms and test acceptability in their target audience, as well as review implementation strategies to improve engagement. OBJECTIVE The primary objective of this implementation trial is to design and test an implementation strategy to improve uptake of TEN. The secondary objectives are examining the acceptability of TEN among HCWs, changes in mental health outcomes associated with use of TEN, as well as reductions in mental health stigma among HCWs following use of TEN. METHODS The implementation trial contains three components: a consultation study with up to 39 stakeholders or researchers with implementation experience to design an implementation strategy; a longitudinal observational study of at least 105 healthcare workers to examine the acceptability of TEN and the effectiveness of TEN at one and six months in improving mental health (as assessed by Distress Questionnaire (DQ-5), Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder (GAD-7), Oldenburg Burnout Inventory (OBI-16), and Work and Social Adjustment Scale (WSAS)) and reducing mental health stigma (Endorsed and Anticipated Stigma Inventory (EASI)); and an implementation study where TEN service uptake analytics will be examined for three months before and after the introduction of the implementation strategy. RESULTS The implementation strategy, designed with input from the consultation and observational studies, is expected to lead to an increased number of unique visits to the TEN Website in the three months following the introduction of the implementation strategy. The observational study is expected to observe high service acceptability. Moderate improvements to general mental health (DQ-5, WSAS) and a reduction in workplace- and treatment-related mental health stigma (EASI) between the baseline and 1-month timepoints. CONCLUSIONS TEN is a first-of-kind blended mental health service available to Australian HCWs. The results of this project have the potential to inform the implementation and development of blended care mental health services, as well as how such services can be effectively implemented during crisis. CLINICALTRIAL N/A

Outcomes of a Blended Care Coaching Program for Clients Presenting With Moderate Levels of Anxiety and Depression: Pragmatic Retrospective Study

Background Depression and anxiety are leading causes of disability worldwide, but access to quality mental health care is limited by myriad factors. Cognitive-behavioral coaching is rooted in evidence-based principles and has the potential to address some of these unmet care needs. Harnessing technology to facilitate broader dissemination within a blended care model shows additional promise for overcoming barriers to care. Objective The aim of this study is to evaluate the outcomes of a blended care coaching (BCC) program for clients presenting with moderate levels of anxiety and depression in real-world settings. Methods This study examined retrospective data from US-based individuals (N=1496) who presented with moderate levels of depression and anxiety symptoms and who received blended care coaching services. Using a short-term framework, clients met with coaches via a secure video conference platform and also received digital video lessons and exercises. To evaluate the effectiveness of the BCC program, mixed effects modeling was used to examine growth trajectories of anxiety and depression scores over the course of care. Results Out of the total sample of 1496 clients, 75.9% (n=1136) demonstrated reliable improvement, and 88.6% (n=1326) recovered based on either the Generalized Anxiety Disorder-7 scale (anxiety) or Patient Health Questionnaire-9 (depression). On average, clients exhibited a significant decline in anxiety and depression symptoms during the initial weeks of coaching, with a continued decline over subsequent weeks at a lower rate. Engaging in a coaching session was associated with lower anxiety (b=–1.04) and depression (b=–0.79) symptoms in the same week, as well as lower anxiety (b=–0.74) and depression (b=–0.91) symptoms the following week (P<.001). Conclusions The BCC program demonstrated strong outcomes in decreasing symptomology for clients presenting with moderate levels of anxiety and depression. When clients received coaching sessions, significant decreases in symptoms were observed, reflecting the importance of session attendance. Additionally, the steepest declines in symptoms tended to occur during the initial weeks of coaching, emphasizing the importance of client buy-in and early engagement. Collectively, these findings have implications for addressing unmet mental health care needs in a more accessible, cost-effective manner.

Examining the Impact of Digital Components Across Different Phases of Treatment in a Blended Care Cognitive Behavioral Therapy Intervention for Depression and Anxiety: Pragmatic Retrospective Study (Preprint)

BACKGROUND Depression and anxiety incur significant personal and societal costs. Effective psychotherapies exist, such as cognitive behavioral therapy (CBT); however, timely access to quality care is limited by myriad barriers. Blended care therapy models incorporate traditional face-to-face therapy with scalable, digital components of care, expanding the reach of evidence-based care. OBJECTIVE The aim of this study is to determine the effectiveness of a blended care CBT program (BC-CBT) in real-world settings and examine the unique impacts of the (1) digital components of care (video lessons and digital exercises) and (2) phase of treatment (early versus late) in decreasing symptoms of anxiety and depression. METHODS This retrospective cohort analysis included 3401 US-based individuals enrolled in a BC-CBT program, who presented with clinical levels of depression and/or anxiety. The treatment program consisted of regular therapy sessions augmented by clinician-assigned digital video lessons and exercises. A growth curve model incorporating time-varying covariates examined the relationship between engagement with BCT components (ie, therapy sessions, digital video lessons, and digital exercises) during the early (weeks 0-7) and late (weeks 8-15) phases of treatment, and weekly symptom reports on depression and anxiety measures. RESULTS On average, a significant decline in depression and anxiety symptoms was observed during the initial weeks of treatment (<i>P</i>&lt;.001), with a continued, though slower, decline over subsequent weeks (<i>P</i>&lt;.001). Each session completed was associated with significant decreases in anxiety (b=–0.72) and depression (b=–0.83) in the early phase, as well as in the late phase (anxiety, b=–0.47; depression, b=–0.27). Significant decreases in anxiety (b=–0.15) and depression (b=–0.12) were observed for time spent on video lessons (measured in 10-minute intervals) in the early phase of treatment. Engaging with exercises was associated with statistically significant increases in anxiety symptoms (b=0.03) during the early phase of treatment. However, sensitivity analyses examining the effects of exercises in isolation revealed significant decreases in anxiety (b=–0.05) in the early phase, suggesting a potential suppression effect in the larger model. CONCLUSIONS Using a retrospective cohort design, therapy sessions and digital video lessons were uniquely predictive of improvements in depression and anxiety symptoms, and their effects were modulated based on the phase of treatment (early vs late). Future research should investigate whether other treatment variables, such as therapeutic alliance or familiarity with technology, are related to differential effects on various components of care.

A Group Intervention for Motivational Deficits: Preliminary Investigation of a Blended Care Approach Using Ambulatory Assessment

Motivational deficits are an important predictor of functional outcomes in individuals with a serious mental illness such as schizophrenia and mood spectrum disorders. The aim of the present study was to explore the feasibility, acceptability, and preliminary efficacy of a group version of “Switch,” an intervention that targets motivational deficits, enriched with an ecological momentary intervention (EMI) approach (i.e., prompts on the participants’ smartphone to encourage the use of trained strategies in their daily life). Eight participants with schizophrenia, schizoaffective, or major depressive disorder entered the study. The intervention took place twice a week for 2 months. Assessment measures included traditional evaluations of motivational negative symptoms, apathy, quality of life and daily functioning, in addition to ambulatory assessment methods strategies, including the experience sampling method (ESM) to assess motivation and related processes, and actigraphy (daily step-count) to assess participants’ activity level. Four participants were considered as non-completers (followed less than 2/3 of the program) and four were considered as completers. Only completers presented a decrease in amotivation/apathy and an improvement in functional outcomes after the intervention and at follow-up. Furthermore, mixed-effects ESM models showed significant interaction effects on multiple processes related to motivation, indicating improvements only in completers: heightened motivation, increased engagement in meaningful and effortful activities, better mood, higher levels of confidence, increased frequency of projection into the future (pleasure anticipation), and of positive reminiscence. This preliminary investigation provides evidence that Switch may be an effective intervention, with specific effects on motivation and associated processes.

Patients’ Perspectives on the Usability of a Blended Approach to an Integrated Intervention for Patients With Medically Unexplained Physical Symptoms: Mixed Methods Study

Background Medically unexplained physical symptoms are physical symptoms, such as pain, fatigue, and dizziness, that persist for more than a few weeks and cannot be explained after adequate medical examination. Treatment for preventing the chronicity of symptoms is recommended. A promising approach is identifying patients who are at risk and subsequently offering a blended care intervention that focuses on promoting self-management while using eHealth as a supportive tool. When these interventions match with a patient’s expectations, their effectiveness grows. Objective This study aimed to obtain more insights into usability from the patient perspective to improve future interventions. Methods A mixed methods design (ie, the use of qualitative and quantitative data) was used. Through semistructured interviews, in-depth insights were gained into patients’ perspectives on usability. The analysis process was continuous and iterative. Data were synthesized and categorized into different themes. The System Usability Scale, which measures the usability of a system, was used to compare participants that found usability to be low, medium, or high. This study was approved by the Medical Ethical Committee Utrecht (approval number: 17-391/C). Results Saturation was reached after interviewing 13 participants. The following four themes emerged from the interviews: motivations and expectations prior to participating in the program, the applicability of e-coaching, the role of health care professionals, and the integrated design of the blended approach. Conclusions The successful implementation of integrated blended care interventions based on patients’ perspectives requires matching treatments to patients’ individual situations and motivations. Furthermore, personalizing the relative frequency of face-to-face appointments and e-coaching can improve usability.

Blended Care in In-Patient Acute Psychiatric Care. The Example of a Group Training for Social Competences in Adults—A Pretest–Posttest Feasibility Study

Introduction: Deficits in social skills can be an important modulating factor in the development and progress of various mental disorders. However, limited resources in inpatient care often impede effective social skills training. This study investigates the feasibility of a blended group training for social skills (SST) in an inpatient psychiatric setting. Methods and Analysis: For this one-group pretest–posttest trial, inpatients with a diagnosed mental disorder were recruited. Participation in the blended SST lasted four weeks and took place within usual inpatient psychiatric care. The blended intervention comprised four face-to-face group sessions and three complementary online modules within four weeks. Assessments took place before (t1) and after (t2) the training. Feasibility outcomes (use, acceptance, satisfaction, implementability into usual psychiatric inpatient care) and effectiveness outcomes regarding social skills were assessed. Results: N = 15 participants were recruited. Most patients completed all questionnaires (93%) and all modules of the blended SST concept (60%). All participants (100%) would recommend the blended intervention to a friend. Regarding social skills, exploratory analyses revealed a non-significant medium-sized effect (Cohen’s d = 0.5 95%CI 0.3 to 1.25, p = 0.08). Discussion: This trial shows that a blended care SST is feasible for the use in acute psychiatric inpatient care setting. Although the wards were acute, with high turnover and change of inpatients, 60% of participants were treated per protocol over four weeks. Overall, the evidence on blended care concepts in psychiatric care settings is extremely poor to date. Hence, this trial should encourage intensified blended inpatient psychiatric care research.

“At least someone thinks I’m doing well”: a real-world evaluation of the quit-smoking app StopCoach for lower socio-economic status smokers

Background Smoking is more prevalent and persistent among lower socio-economic status (SES) compared with higher-SES groups, and contributes greatly to SES-based health inequities. Few interventions exist that effectively help lower-SES smokers quit. This study evaluated “De StopCoach”, a mobile phone delivered eHealth intervention targeted at lower-SES smokers based on the evidence-based StopAdvisor, in a real-world setting (five municipalities) in The Netherlands in 2019–2020. Method We conducted individual semi-structured interviews with project leaders, healthcare professionals, and participating smokers (N = 22), and examined log data from the app (N = 235). For practical reasons, SES of app users was not measured. Qualitative data were analysed using the Framework Approach, with the Consolidated Framework for Implementation Research (CFIR) and Unified Theory of Acceptance and Use of Technology (UTAUT) as theoretical models. Results Qualitative data showed that factors from the Intervention and Setting domains were most important for the implementation. StopCoach seemed suitable for lower-SES smokers in terms of performance and effort expectancy, especially when integrated with regular smoking cessation counseling (SCC). Key barriers to implementation of the app were limited integration of the app in SCC programs in practice, difficulty experienced by project leaders and healthcare professionals to engage the local community, and barriers to SCC more generally (e.g., perceived resistance to quitting in patients) that prevented healthcare professionals from offering the app to smokers. Quantitative data showed that 48% of app users continued using the app after the preparation phase and pre-quit day, and that 33% of app users had attempted to quit. Both app adherence and quit attempts were more likely if smokers also received SCC from a professional coach. Posthoc analyses suggest that adherence is related to higher likelihood of a quit attempt among participants with and without a professional coach. Conclusions Smokers, healthcare professionals and project leaders indicated in the interviews that the StopCoach app would work best when combined with SCC. It also appears from app log that app adherence and quit attempts by app users can be facilitated by combining the app with face-to-face SCC. As such, blended care appears promising for helping individual smokers quit, as it combines the best of regular SCC and eHealth. Further research on blended care for lower-SES smokers is needed.