Objectives The primary purpose of this randomized controlled trial (RCT) was to evaluate the efficacy of a guided internet-based recovery training for employees who suffer from both work-related ...strain and sleep problems (GET.ON Recovery). The recovery training consisted of six lessons, employing well-established methods from cognitive behavioral therapy for insomnia (CBT-I) such as sleep restriction, stimulus control, and hygiene interventions as well as techniques targeted at reducing rumination and promoting recreational activities. Methods In a two-arm RCT (N=128), the effects of GET.ON Recovery were compared to a waitlist-control condition (WLC) on the basis of intention-to-treat analyses. German teachers with clinical insomnia complaints (Insomnia Severity Index ≥15) and work-related rumination (Irritation Scale, cognitive irritation subscale ≥15) were included. The primary outcome measure was insomnia severity. Results Analyses of covariance (ANCOVA) revealed that, compared to the WLC, insomnia severity of the intervention group decreased significantly stronger (F=74.11, P<0.001) with a d=1.45 95% confidence interval (95% CI) 1.06–1.84 The number needed to treat (NNT) was <2 for reliable change and NNT <4 for reduction in expert-rated diagnosis of primary insomnia. Conclusion The training significantly reduces sleep problems and fosters mental detachment from work and recreational behavior among adult stressed employees at post-test and 6-months follow up. Given the low threshold access this training could reach out to a large group of stressed employees when results are replicated in other studies.
Internet-based interventions can be effective treatments for anxiety and depression. Meta-analytic evidence suggests that they should be delivered with human support to reach optimal effects. These ...findings have not consistently been replicated in direct comparisons of supported and unsupported interventions, however. This study examined the role of support in Internet-based problem solving treatment (PST) for symptoms of anxiety and/or depression. Adults with mild to moderate symptoms of anxiety and/or depression were recruited from the general population and randomized to: (1) PST without support (n = 107), (2) PST with support on request (n = 108), (3) PST with weekly support (n = 106), (4) no Internet-based intervention but non-specific chat or email (n = 110), or (5) waitlist control (WLC; n = 106). Primary outcomes were symptoms of anxiety (HADS) and depression (CES-D) measured at baseline and 6 weeks later. Analyses were first based on the intention-to-treat principle (ITT) and repeated with intervention completers. Only participants who received PST with weekly support improved significantly more than WLC for depressive symptoms. Results for anxiety were less robust but in favor of the weekly support condition. The results underscore the importance of structural support in Internet-based interventions for depression and anxiety.
•Internet-based interventions for anxiety and depression can be effective treatments.•Research suggests they should be delivered with human support for optimal effects.•We examined different levels of support of support in an RCT with 5 conditions.•Structural support improved outcomes of the Internet-based problem solving therapy.
Blended therapies (BT) combine face-to-face (f2f) sessions with internet- and mobile-based interventions (IMIs). However, the use of blended interventions in routine care is still rare and depends on ...the acceptance of key health care professionals such as the therapists. Little is yet known about the therapists' perspective on and experiences with blended approaches. The aim of this pilot study was to identify barriers and facilitators, as perceived by psychotherapists, for implementing a blended therapy for depression.
Semi-structured expert interviews were conducted with five therapists, who were part of the German study arm of the FP7-project E-Compared (www.e-compared.eu). All patients (N = 173) were treated in the context of a registered RCT (DRKS00006866) in which the clinical and cost-effectiveness of BT for depression, consisting of ten internet- and mobile-based cognitive behavioral therapy modules and six f2f sessions, was compared to the treatment usually provided by general practitioners. To identify barriers and facilitators an interview guide based on the theoretical domains framework (TDF) was developed. The interviews were audio-recorded, transcribed verbatim and analyzed using a qualitative content analysis by two independent coders.
The results revealed 29 barriers and 33 facilitators, which are hindering or enabling factors on the levels of ‘implementation in the health care system’, ‘therapy’, ‘therapists’ and ‘patients’. Key barriers stated by all therapists were ‘Limited customizability and autonomy of decisions concerning blending the therapy’ (number of statements, k = 44); ‘Disease-related contraindications for BT’ (k = 25); ‘Negative affect was caused by burden through technical problems’ (k = 18); ‘Limited number of f2f sessions hindered the therapy process’; and ‘Establishment of therapeutic alliance was burdened by technical issues’ (each k = 15). Key facilitators stated by all therapists were: ‘Patients’ interest, willingness and motivation to participate’ (k = 22); ‘Patients' access to online content between f2f sessions and after therapy end’ (k = 20); ‘Preset structure of IMI-part guided the treatment course of BT’ (k = 18); and ‘Effective help with BT in a short time frame’ (k = 15), as well as ‘Reduction of the treatment gap’ (k = 13).
Therapists supported the implementation of BT for depression. Results indicated the consideration of a wide range of determinants: among others, the possibility of individualizing the treatment; the autonomy of decision making in respect to the ratio and number of online and f2f sessions; the necessity of providing training; the need to develop a concept of embedding BT in the health care system and funding the additional effort; and the use of sophisticated technical solutions.
•Blended therapies (BT) combine face to face sessions with internet- and mobile-based interventions as new treatment format•Therapists advocated the implementation of BT for depression in routine care•Therapists saw the possibility of combining the best of both in their daily work•Results indicated the consideration of a wide range of hindering and facilitating determinants regarding the implementation•BT as a 13-weeks blended approach may help to reduce the treatment gap
•Digital prevention and treatment interventions reduce Cannabis use at post-treatment•Treatment interventions seem to produce clinically negligible effects•Prevention interventions produce effects ...that are maintained for up to 12 months•Necessity to establish a core outcome set for the reporting of Cannabis use outcomes
Frequent Cannabis use has been linked to a variety of negative mental, physical, and social consequences. We assessed the effects of digital prevention and treatment interventions on Cannabis use reduction in comparison with control conditions.
Systematic review with two separate meta-analyses. Thirty randomized controlled trials met the inclusion criteria for the review, and 21 were included in the meta-analyses. Primary outcome was self-reported Cannabis use at post-treatment and follow-up. Hedges’s g was calculated for all comparisons with non-active control. Risk of bias was examined with the Cochrane risk-of-bias tool.
The systematic review included 10 prevention interventions targeting 8138 participants (aged 12 to 20) and 20 treatment interventions targeting 5195 Cannabis users (aged 16 to 40). The meta-analyses showed significantly reduced Cannabis use at post-treatment in the prevention interventions (6 studies, N = 2564, g = 0.33; 95% CI 0.13 to 0.54, p = 0.001) and in the treatment interventions (17 comparisons, N = 3813, g = 0.12; 95% CI 0.02 to 0.22, p = 0.02) as compared with controls. The effects of prevention interventions were maintained at follow-ups of up to 12 months (5 comparisons, N = 2445, g = 0.22; 95% CI 0.12 to 0.33, p < 0.001) but were no longer statistically significant for treatment interventions.
Digital prevention and treatment interventions showed small, significant reduction effects on Cannabis use in diverse target populations at post-treatment compared to controls. For prevention interventions, the post-treatment effects were maintained at follow-up up to 12 months later.
Objective: This randomized controlled trial evaluated the efficacy of an Internet-based intervention, which aimed to improve recovery from work-related strain in teachers with sleeping problems and ...work-related rumination. In addition, mechanisms of change were also investigated. Methods: A sample of 128 teachers with elevated symptoms of insomnia (Insomnia Severity Index ISI ≥ 15) and work-related rumination (Cognitive Irritation Scale ≥ 15) was assigned to either an Internet-based recovery training (intervention condition IC) or to a waitlist control condition (CC). The IC consisted of 6 Internet-based sessions that aimed to promote healthy restorative behavior. Self-report data were assessed at baseline and again after 8 weeks. Additionally, a sleep diary was used starting 1 week before baseline and ending 1 week after postassessment. The primary outcome was insomnia severity. Secondary outcomes included perseverative cognitions (i.e., work-related rumination and worrying), a range of recovery measures and depression. An extended 6-month follow-up was assessed in the IC only. A serial multiple mediator analysis was carried out to investigate mechanisms of change. Results: IC participants displayed a significantly greater reduction in insomnia severity (d = 1.37, 95% confidence interval: 0.99-1.77) than did participants of the CC. The IC was also superior with regard to changes in all investigated secondary outcomes. Effects were maintained until a naturalistic 6-month follow-up. Effects on insomnia severity were mediated by both a reduction in perseverative cognitions and sleep effort. Additionally, a greater increase in number of recovery activities per week was found to be associated with lower perseverative cognitions that in turn led to a greater reduction in insomnia severity. Conclusions: This study provides evidence for the efficacy of an unguided, Internet-based occupational recovery training and provided first evidence for a number of assumed mechanisms of change.
ABSTRACT
Aims Self‐help interventions for adult problem drinkers in the general population have proved effective. The question is whether this also holds for self‐help interventions delivered over ...the internet.
Design We conducted a pragmatic randomized trial with two parallel groups, using block randomization stratified for gender and with follow‐up at 6 months.
Setting The intervention and trial were conducted online in the Netherlands in 2003–2004.
Participants We selected 261 adult problem drinkers from the general population with a weekly alcohol consumption above 210 g of ethanol for men or 140 g for women, or consuming at least 60 g (men) or 40 g (women) at least 1 day a week over the past 3 months. Participants were randomized to either the experimental drinking less (DL) condition or to the control condition (PBA).
Intervention DL is a web‐based, multi‐component, interactive self‐help intervention for problem drinkers without therapist guidance. The recommended treatment period is 6 weeks. The intervention is based on cognitive–behavioural and self‐control principles. The control group received access to an online psychoeducational brochure on alcohol use (PBA).
Outcome measures We assessed the following outcome measures at 6‐month follow‐up: (i) the percentage of participants who had reduced their drinking levels to within the normative limits of the Dutch guideline for low‐risk drinking; and (ii) the reduction in mean weekly alcohol consumption.
Findings At follow‐up, 17.2% of the intervention group participants had reduced their drinking successfully to within the guideline norms; in the control group this was 5.4% odds ratio (OR) = 3.66; 95% confidence interval (CI) 1.3–10.8; P = 0.006; number needed to treat (NNT) = 8.5. The intervention subjects decreased their mean weekly alcohol consumption significantly more than control subjects, with a difference of 12.0 standardized units (95% CI 5.9–18.1; P < 0.001; standardized mean difference 0.40).
Conclusions To our knowledge this is one of the first randomized controlled trials on a web‐based self‐help intervention without therapist guidance for self‐referred problem drinkers among the adult general population. The intervention showed itself to be effective in reducing problem drinking in the community.
Emerging evidence indicates the effectiveness of internet-based mobile-supported stress management interventions (iSMIs) in highly stressed employees. It is yet unclear, however, whether iSMIs are ...also effective without a preselection process in a universal prevention approach, which more closely resembles routine occupational health care. Moreover, evidence for whom iSMIs might be suitable and for whom not is scarce.
The aim of this study was to evaluate the iSMI GET.ON Stress in a universal prevention approach without baseline inclusion criteria and to examine the moderators of the intervention effects.
A total of 396 employees were randomly assigned to the intervention group or the 6-month waiting list control group. The iSMI consisted of 7 sessions and 1 booster session and offered no therapeutic guidance. Self-report data were assessed at baseline, 7 weeks, and at 6 months following randomization. The primary outcome was perceived stress. Several a priori defined moderators were explored as potential effect modifiers.
Participants in the intervention group reported significantly lower perceived stress at posttreatment (d=0.71, 95% CI 0.51-0.91) and at 6-month follow-up (d=0.61, 95% CI 0.41-0.81) compared to those in the waiting list control group. Significant differences with medium-to-large effect sizes were found for all mental health and most work-related outcomes. Resilience (at 7 weeks, P=.04; at 6 months, P=.01), agreeableness (at 7 weeks, P=.01), psychological strain (at 6 months, P=.04), and self-regulation (at 6 months, P=.04) moderated the intervention effects.
This study indicates that iSMIs can be effective in a broad range of employees with no need for preselection to achieve substantial effects. The subgroups that might not profit had extreme values on the respective measures and represented only a very small proportion of the investigated sample, thereby indicating the broad applicability of GET.ON Stress.
German Clinical Trials Register DRKS00005699; https://www.drks.de/DRKS00005699.
Depression is a worldwide problem warranting global solutions to tackle it. Enhancing well-being has benefits in its own right and could be a good strategy for preventing depression. Providing ...well-being interventions via the Internet may have synergetic effects.
Psyfit ("mental fitness online") is a fully automated self-help intervention to improve well-being based on positive psychology. This study examines the clinical effects of this intervention.
We conducted a 2-armed randomized controlled trial that compared the effects of access to Psyfit for 2 months (n=143) to a waiting-list control condition (n=141). Mild to moderately depressed adults in the general population seeking self-help were recruited. Primary outcome was well-being measured by Mental Health Continuum-Short Form (MHC-SF) and WHO Well-being Index (WHO-5); secondary outcomes were depressive symptoms, anxiety, vitality, and general health measured by Center for Epidemiological Studies Depression Scale (CES-D), Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), and Medical Outcomes Study-Short Form (MOS-SF) vitality and general health subscales, respectively. Online measurements were taken at baseline, 2 months, and 6 months after baseline.
The dropout rate was 37.8% in the Psyfit group and 22.7% in the control group. At 2-month follow-up, Psyfit tended to be more effective in enhancing well-being (nonsignificantly for MHC-SF: Cohen's d=0.27, P=.06; significantly for WHO-5: Cohen's d=0.31, P=.01), compared to the waiting-list control group. For the secondary outcomes, small but significant effects were found for general health (Cohen's d=0.14, P=.01), vitality (d=0.22, P=.02), anxiety symptoms (Cohen's d=0.32, P=.001), and depressive symptoms (Cohen's d=0.36, P=.02). At 6-month follow-up, there were no significant effects on well-being (MHC-SF: Cohen's d=0.01, P=.90; WHO-5: Cohen's d=0.26, P=.11), whereas depressive symptoms (Cohen's d=0.35, P=.02) and anxiety symptoms (Cohen's d=0.35, P=.001) were still significantly reduced compared to the control group. There was no clear dose-response relationship between adherence and effectiveness, although some significant differences appeared across most outcomes in favor of those completing at least 1 lesson in the intervention.
This study shows that an online well-being intervention can effectively enhance well-being (at least in the short-term and for 1 well-being measure) and can help to reduce anxiety and depression symptoms. Further research should focus on increasing adherence and motivation, reaching and serving lower-educated people, and widening the target group to include people with different levels of depressive symptoms.
Netherlands Trial Register (NTR) number: NTR2126; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2126 (archived by WebCite at http://www.webcitation.org/6IIiVrLcO).
Internet-delivered interventions can be effective in treating mental disorders. However, their rate of use in German psychiatric inpatient routine care is low. The current study aimed to investigate ...the attitude of mental health care professionals working in inpatient care regarding internet-delivered interventions, including presumed benefits, barriers and facilitators. In total, 176 health professionals from ten inpatient psychiatric hospitals throughout Germany were surveyed on site. The professionals’ attitude towards internet-delivered interventions in inpatient care was assessed by an adapted version of the ‘Attitude toward Telemedicine in Psychiatry and Psychotherapy’ (ATTiP) questionnaire. To identify benefits, barriers and facilitators, we developed open-response questions that were based on the ‘Unified Theory of Acceptance and Use of Technology’ (UTAUT) and analyzed by a qualitative content analysis. Professionals reported little experience or knowledge about internet-delivered interventions. Their attitude towards internet-delivered interventions in psychiatric inpatient care was rather indifferent. The most frequently mentioned potential benefits were an optimised treatment structure and patient empowerment; the most frequently anticipated barriers were too severe symptoms of patients, the feared neglect of face-to-face contacts and insufficient technical equipment; and the most frequently mentioned facilitators were high usability of the internet-based intervention, a sufficient functional level of the patient and further education of staff. For successful implementation in the inpatient sector, internet-delivered interventions must be adapted to the special needs of severely mentally ill patients and to the hospital management systems and workflow. In addition, technical preconditions (internet access, devices) must be met. Last, further education of mental health care professionals is needed.
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