Publications by authors named "David D Ebert"

72 Publications

Stakeholders' views on online interventions to prevent common mental health disorders in adults implemented into existing healthcare systems in Europe.

Eur J Public Health 2021 Jul;31(Supplement_1):i55-i63

Ferdinand Porsche FernFH-Distance Learning University of Applied Sciences, Wiener Neustadt 2700, Austria.

Background: Online preventive interventions can help to reduce the incidence of mental disorders. Whereas knowledge on stakeholders' attitudes and factors relevant for successfully integrating online treatment into existing healthcare systems is available, knowledge is scarce for online prevention.

Methods: Stakeholders from Germany, Switzerland, Austria and Spain were surveyed. Potential facilitators/delivery staff (e.g. psychologists, psychotherapists) completed an online questionnaire (n = 183), policy makers (i.e. from the governing sector or health insurance providers) participated in semi-structured interviews (n = 16) and target groups/potential users of mental illness prevention (n = 49) participated in ten focus groups. Thematic analysis was used to identify their experiences with and attitudes and needs regarding online programmes to prevent mental disorders. Additionally, it was examined which groups they consider underserved and which factors they consider as fostering and hindering for reach, adoption, implementation and maintenance (cf. RE-AIM model) when integrating online prevention into existing healthcare systems.

Results: Main advantages of online mental illness prevention are perceived in low structural and psychological barriers. Lack of personal contact, security, privacy and trust concerns were discussed as disadvantages. Relevant needs are high usability and target group appropriateness, evidence for effectiveness and the use of motivational tools.

Conclusions: Positive attitudes among stakeholders are the key for successful integration of online mental illness prevention into existing healthcare systems. Potential facilitators/delivery staff must receive training and support to implement these programmes; the programmes must be attractive and continuously evaluated, updated and promoted to ensure ongoing reach; and existing infrastructure and contextual factors must be considered.
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http://dx.doi.org/10.1093/eurpub/ckab043DOI Listing
July 2021

Online prevention programmes for university students: stakeholder perspectives from six European countries.

Eur J Public Health 2021 Jul;31(Supplement_1):i64-i70

King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK.

Background: Students beginning university are at a heightened risk for developing mental health disorders. Online prevention and early intervention programmes targeting mental health have the potential to reduce this risk, however, previous research has shown uptake to be rather poor. Understanding university stakeholders' (e.g. governing level and delivery staff [DS] and students) views and attitudes towards such online prevention programmes could help with their development, implementation and dissemination within university settings.

Methods: Semi-structured interviews, focus groups and online surveys were completed with staff at a governing level, university students and DS (i.e. student health or teaching staff) from six European countries. They were asked about their experiences with, and needs and attitudes towards, online prevention programmes, as well as the factors that influence the translation of these programmes into real-world settings. Results were analyzed using thematic analysis.

Results: Participating stakeholders knew little about online prevention programmes for university settings; however, they viewed them as acceptable. The main themes to emerge were the basic conditions and content of the programmes, the awareness and engagement, the resources needed, the usability and the responsibility and ongoing efforts to increase reach.

Conclusions: Overall, although these stakeholders had little knowledge about online prevention programmes, they were open to the idea of introducing them. They could see the potential benefits that these programmes might bring to a university setting as a whole and the individual students and staff members.
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http://dx.doi.org/10.1093/eurpub/ckab040DOI Listing
July 2021

Effects of a minimal-guided on-line intervention for alcohol misuse in Estonia: a randomized controlled trial.

Addiction 2021 Jun 29. Epub 2021 Jun 29.

National Institute for Health Development; Centre for Health Marketing, Tallinn, Estonia.

Background And Aims: Estonia has one of the highest alcohol-attributable mortality rates within the European Union. The aim of this study was to estimate the efficacy of an on-line self-help intervention to reduce problem drinking at the population level.

Design: On-line open randomized controlled trial with an 8-week intervention and an active control group (intervention n = 303, control n = 286). Assessments took place at baseline and at 6 months follow-up.

Setting: On- and offline channels were used for population-based recruitment within a nation-wide prevention campaign in Estonia.

Participants: Inclusion criteria were age ≥ 18 years, heavy drinking [Alcohol Use Disorders Identification (AUDIT) test score ≥ 8], literacy in Estonian and at least weekly access to the internet; n = 589 participants were randomized (50% male, 1% other; mean age 37.86 years; 45% with higher level of education).

Intervention And Comparator: The intervention consisted of 10 modules based on principles of cognitive-behavioral therapy and motivational interviewing. The active control group received access to a website with a self-test including personalized normative feedback and information for standard alcohol treatment.

Measurements: The primary outcome was AUDIT scores at 6 months follow-up adjusted for baseline scores.

Findings: Intention-to-treat analyses were applied. Missing data were addressed by using baseline observation carried forward (BOCF) and multiple imputation by chained equations (MI); 175 completed follow-up in the intervention group and 209 in the control group. AUDIT score at follow-up was significantly smaller in the intervention [BOCF mean = 13.91, standard deviation (SD) = 7.61, MI mean = 11.03, SD = 6.55] than control group (BOCF mean = 15.30, SD = 7.31; MI mean = 14.30, SD = 7.21), with a group difference of -1.38 [95% confidence interval (CI) = -2.58, -0.18], P = 0.02 for BOCF and -3.26 (95% CI = -2.01, -4.51), P < 0.001 for MI.

Conclusions: A randomized controlled trial has found that an on-line self-help intervention with minimal guidance was effective at reducing problem drinking in Estonia.
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http://dx.doi.org/10.1111/add.15633DOI Listing
June 2021

"Take Care of You" - Efficacy of integrated, minimal-guidance, internet-based self-help for reducing co-occurring alcohol misuse and depression symptoms in adults: Results of a three-arm randomized controlled trial.

Drug Alcohol Depend 2021 Aug 18;225:108806. Epub 2021 Jun 18.

Swiss Research Institute for Public Health and Addiction, University of Zurich, Zurich, Switzerland.

Background: Depression and harmful alcohol use are two of the top five leading causes of years of life lost to disability in high-income countries. Integrated treatment targeting both at the same time is often considered more complicated and difficult and, therefore, more expensive. Consequently, integrated internet-based interventions could be a valuable addition to traditional care.

Methods: A three-arm randomized controlled trial was conducted comparing the effectiveness of (1) an integrated, minimal-guidance, adherence-focused self-help intervention designed to reduce both alcohol use and depression symptoms (AFGE-AD); (2) a similar intervention designed to reduce alcohol use only (AFGE-AO), and (3) internet access as usual (IAU) as a control condition, in at least moderately depressed alcohol misusers from February 2016-March 2020. We recruited 689 alcohol misusers (51.6 % males, mean age = 42.8 years) with at least moderate depression symptoms not otherwise in treatment from the general population. Six months after baseline, 288 subjects (41.8 %) were reachable for the final assessment.

Results: All interventions yielded reduced alcohol-use after six months (AFGE-AD: -16.6; AFGE-AO: -19.8; IAU: -13.2). Those who undertook active-interventions reported significantly fewer standard drinks than controls (AFGE-AD: p = .048, d=0.10; AFGE-AO: p = .004, d=0.20). The two active-intervention groups also reported significantly less severe depression symptoms than controls (AFGE-AD: p = .006, d=0.41; AFGE-AO: p = .008, d=0.43). Testing revealed noninferiority between the two interventions.

Conclusions: This study documented sustained effectiveness of the first integrated, fully internet-based self-help intervention developed for the reduction of both alcohol use and depression symptoms in at least moderately depressed adult alcohol misusers recruited from the general population.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108806DOI Listing
August 2021

"Take Care of You" - Efficacy of integrated, minimal-guidance, internet-based self-help for reducing co-occurring alcohol misuse and depression symptoms in adults: Results of a three-arm randomized controlled trial.

Drug Alcohol Depend 2021 Aug 18;225:108806. Epub 2021 Jun 18.

Swiss Research Institute for Public Health and Addiction, University of Zurich, Zurich, Switzerland.

Background: Depression and harmful alcohol use are two of the top five leading causes of years of life lost to disability in high-income countries. Integrated treatment targeting both at the same time is often considered more complicated and difficult and, therefore, more expensive. Consequently, integrated internet-based interventions could be a valuable addition to traditional care.

Methods: A three-arm randomized controlled trial was conducted comparing the effectiveness of (1) an integrated, minimal-guidance, adherence-focused self-help intervention designed to reduce both alcohol use and depression symptoms (AFGE-AD); (2) a similar intervention designed to reduce alcohol use only (AFGE-AO), and (3) internet access as usual (IAU) as a control condition, in at least moderately depressed alcohol misusers from February 2016-March 2020. We recruited 689 alcohol misusers (51.6 % males, mean age = 42.8 years) with at least moderate depression symptoms not otherwise in treatment from the general population. Six months after baseline, 288 subjects (41.8 %) were reachable for the final assessment.

Results: All interventions yielded reduced alcohol-use after six months (AFGE-AD: -16.6; AFGE-AO: -19.8; IAU: -13.2). Those who undertook active-interventions reported significantly fewer standard drinks than controls (AFGE-AD: p = .048, d=0.10; AFGE-AO: p = .004, d=0.20). The two active-intervention groups also reported significantly less severe depression symptoms than controls (AFGE-AD: p = .006, d=0.41; AFGE-AO: p = .008, d=0.43). Testing revealed noninferiority between the two interventions.

Conclusions: This study documented sustained effectiveness of the first integrated, fully internet-based self-help intervention developed for the reduction of both alcohol use and depression symptoms in at least moderately depressed adult alcohol misusers recruited from the general population.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108806DOI Listing
August 2021

"Take Care of You" - Efficacy of integrated, minimal-guidance, internet-based self-help for reducing co-occurring alcohol misuse and depression symptoms in adults: Results of a three-arm randomized controlled trial.

Drug Alcohol Depend 2021 Aug 18;225:108806. Epub 2021 Jun 18.

Swiss Research Institute for Public Health and Addiction, University of Zurich, Zurich, Switzerland.

Background: Depression and harmful alcohol use are two of the top five leading causes of years of life lost to disability in high-income countries. Integrated treatment targeting both at the same time is often considered more complicated and difficult and, therefore, more expensive. Consequently, integrated internet-based interventions could be a valuable addition to traditional care.

Methods: A three-arm randomized controlled trial was conducted comparing the effectiveness of (1) an integrated, minimal-guidance, adherence-focused self-help intervention designed to reduce both alcohol use and depression symptoms (AFGE-AD); (2) a similar intervention designed to reduce alcohol use only (AFGE-AO), and (3) internet access as usual (IAU) as a control condition, in at least moderately depressed alcohol misusers from February 2016-March 2020. We recruited 689 alcohol misusers (51.6 % males, mean age = 42.8 years) with at least moderate depression symptoms not otherwise in treatment from the general population. Six months after baseline, 288 subjects (41.8 %) were reachable for the final assessment.

Results: All interventions yielded reduced alcohol-use after six months (AFGE-AD: -16.6; AFGE-AO: -19.8; IAU: -13.2). Those who undertook active-interventions reported significantly fewer standard drinks than controls (AFGE-AD: p = .048, d=0.10; AFGE-AO: p = .004, d=0.20). The two active-intervention groups also reported significantly less severe depression symptoms than controls (AFGE-AD: p = .006, d=0.41; AFGE-AO: p = .008, d=0.43). Testing revealed noninferiority between the two interventions.

Conclusions: This study documented sustained effectiveness of the first integrated, fully internet-based self-help intervention developed for the reduction of both alcohol use and depression symptoms in at least moderately depressed adult alcohol misusers recruited from the general population.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108806DOI Listing
August 2021

Effectiveness of a digital alcohol moderation intervention as an add-on to depression treatment for young adults: study protocol of a multicentre pragmatic randomized controlled trial.

BMC Psychiatry 2021 05 22;21(1):265. Epub 2021 May 22.

Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands.

Background: Depressive disorders and problematic drinking often co-occur, also among young adults. These co-occurring conditions are associated with various negative health outcomes compared to both conditions alone. Early intervention by addressing alcohol use and depressive symptoms simultaneously in the same treatment might improve both conditions. However, evidence on the (cost-) effectiveness of digital combined depression and alcohol interventions for young adults is currently insufficient. We therefore developed an add-on digital alcohol moderation adherence-focussed guided intervention to complement treatment as usual (TAU) for depressive disorders. The digital intervention is a web-app, including 6 modules based on motivational interviewing and cognitive behavioural therapy. This study aims to evaluate the (cost-)effectiveness of a digital alcohol moderation intervention + TAU compared to TAU on alcohol and depression outcomes among young adults with co-occurring depressive disorders and problematic alcohol use.

Methods: One hundred fifty-six participants, aged 18-35 years, with problematic alcohol use and a diagnosed depressive disorder will participate in a pragmatic multicentre two-arm randomized controlled trial. Problematic alcohol use is operationalised as scoring ≥5 for women and ≥ 8 for men on the Alcohol Use Disorder Identification Test (AUDIT). Participants will be randomized to either the experimental group (digital alcohol intervention + TAU) or control group (TAU only). Participants will be recruited at three Dutch mental health care centres and through social media. Assessments take place at baseline and after 3, 6 and 12 months post-randomization. The primary outcome is treatment response at 6-month follow-up, operationalized as a composite score that combines alcohol use and depression measures and indicates whether treatment has been successful or not. Secondary outcomes are depressive symptoms and alcohol use (i.e. number of weekly standard drinks and AUDIT score). An economic evaluation will be conducted alongside the trial.

Discussion: This study evaluates the (cost-) effectiveness of an add-on digital alcohol moderation intervention for young adults who are in treatment for depressive disorders. If proven effective, the digital intervention could be implemented in mental health care and improve treatment for people with co-occurring depressive disorders and problematic alcohol use.

Trial Registration: Pre-registered on October 29, 2019 in The Netherlands Trial Register ( NL8122 ).
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http://dx.doi.org/10.1186/s12888-021-03222-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140318PMC
May 2021

Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data.

Lancet Psychiatry 2021 06 3;8(6):500-511. Epub 2021 May 3.

Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway.

Background: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom.

Methods: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683.

Findings: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components.

Interpretation: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package.

Funding: Japan Society for the Promotion of Science.
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http://dx.doi.org/10.1016/S2215-0366(21)00077-8DOI Listing
June 2021

Psychological treatment of depression in institutional settings: A meta-analytic review.

J Affect Disord 2021 05 12;286:340-350. Epub 2021 Mar 12.

Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam; WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam.

Background: Many depressed patients are treated in institutional settings. The number of studies focusing on psychotherapies for depressed patients in institutional settingsis limited, and only a few up-to-date meta-analyses have integrated the results of these studies.

Methods: We conducted a meta-analysis of 32 randomized trials with 37 comparisons between psychotherapy and control conditions, examining the effects of psychotherapy for adult patients in institutional settings with depressive disorders.

Results: We found that psychotherapy had a significant, small to moderate effect on depressive symptoms (g=0.42; 95% CI: 0.29~0.56), with low to moderate heterogeneity (I=33; 95% CI: 0~55). The effects remained small but significant after adjustment for publication bias (g=0.27; 95% CI: 0.12~0.42) and in the studies with low risk of bias (g=0.32; 95% CI: 0.11~0.52). The effects were largely retained at 9 to 15 months follow-up and still significant, again after adjustment for publication bias and in studies with low risk of bias. We found no significant difference across types of institutional settings, including psychiatric inpatient settings and nursing homes, although no studies with a low risk of bias were available in nursing homes.

Limitations: We included different types of institutional settings, although we did not find a significant difference between settings. The number of studies was small and risk of bias was high in a considerable number of trials.

Conclusions: This meta-analysis provides evidence for a small to moderate and sustained effect of psychotherapy in patients in institutional settings with depression.
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http://dx.doi.org/10.1016/j.jad.2021.03.017DOI Listing
May 2021

How can we estimate QALYs based on PHQ-9 scores? Equipercentile linking analysis of PHQ-9 and EQ-5D.

Evid Based Ment Health 2021 Mar 2. Epub 2021 Mar 2.

Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.

Background: Quality-adjusted life years (QALYs) are widely used to measure the impact of various diseases on both the quality and quantity of life and in their economic valuations. It will be clinically important and informative if we can estimate QALYs based on measurements of depression severity.

Objective: To construct a conversion table from the Patient Health Questionnaire-9 (PHQ-9), the most frequently used depression scale in recent years, to the Euro-Qol Five Dimensions Three Levels (EQ-5D-3L), one of the most commonly used instruments to assess QALYs.

Methods: We obtained individual participant data of randomised controlled trials of internet cognitive-behavioural therapy which had administered depression severity scales and the EQ-5D-3L at baseline and at end of treatment. Scores from depression scales were all converted into the PHQ-9 according to the validated algorithms. We used equipercentile linking to establish correspondences between the PHQ-9 and the EQ-5D-3L.

Findings: Individual-level data from five trials (total N=2457) were available. Subthreshold depression (PHQ-9 scores between 5 and 10) corresponded with EQ-5D-3L index values of 0.9-0.8, mild major depression (10-15) with 0.8-0.7, moderate depression (15-20) with 0.7-0.5 and severe depression (20 or higher) with 0.6-0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L score by 0.03 and a ten-point improvement by approximately 0.25.

Conclusions And Clinical Implications: The conversion table between the PHQ-9 and the EQ-5D-3L scores will enable fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments.
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http://dx.doi.org/10.1136/ebmental-2020-300240DOI Listing
March 2021

Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis.

JAMA Psychiatry 2021 Apr;78(4):361-371

Benson Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts.

Importance: Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them.

Objective: To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information.

Data Sources: We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019.

Study Selection: Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization.

Data Extraction And Synthesis: We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression.

Main Outcomes And Measures: Patient Health Questionnaire-9 (PHQ-9) scores.

Results: Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9.

Conclusions And Relevance: In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.
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http://dx.doi.org/10.1001/jamapsychiatry.2020.4364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8027916PMC
April 2021

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

Clin Psychol Rev 2021 02 1;83:101953. Epub 2020 Dec 1.

Department of Clinical Psychology and Psychotherapy, Ulm University, Germany.

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.
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http://dx.doi.org/10.1016/j.cpr.2020.101953DOI Listing
February 2021

StudiCare mindfulness-study protocol of a randomized controlled trial evaluating an internet- and mobile-based intervention for college students with no and "on demand" guidance.

Trials 2020 Nov 26;21(1):975. Epub 2020 Nov 26.

Department of Clinical Psychology and Psychotherapy, Institute for Psychology and Education, Ulm University, Albert-Einstein-Allee 47, 89081, Ulm, Germany.

Background: College is an exciting but also challenging time with an increased risk for mental health issues. Only a minority of the college students concerned get professional help, a problem that might be improvable by internet- and mobile-based interventions (IMIs). However, adherence of IMIs is a concern. While guidance might be a solution, it is resource-intensive, derailing potential implementation on population level. The first aim of this trial is to evaluate the efficacy of the IMI StudiCare Mindfulness (StudiCare-M) for college students with "on demand" and no guidance. The second aim is to examine potential moderators and mediators, contributing to the questions of "how" and "for whom" such interventions work.

Methods: In this three-armed randomized controlled trial, both an unguided and "guidance on demand" (GoD) condition of StudiCare-M are compared to a waitlist control group. StudiCare-M is based on principles of acceptance and commitment therapy and stress management and consists of 7 modules plus two booster sessions. Participants in the GoD condition may ask their e-coach for support whenever needed. A total of 387 college students with moderate to low mindfulness are recruited at 15+ cooperating universities in Germany, Austria, and Switzerland via circular emails. Assessments take place before as well as 1, 2, and 6 months after randomization. The primary outcome is mindfulness. Secondary outcomes include stress, depression, anxiety, interoception, presenteeism, wellbeing, intervention satisfaction, adherence, and potential side effects. Among examined moderators and mediators are sociodemographic variables, pre-treatment symptomatology, treatment expectancy, self-efficacy, cognitive fusion, emotion regulation, and alexithymia. All data will be analyzed according to intention-to-treat (ITT) principles.

Discussion: Providing effective interventions to help college students become more resilient can make a valuable contribution to the health and functionality of future society. If effective under the condition of minimal or no guidance, StudiCare-M offers a low-threshold potentially resource-efficient possibility to enhance college student mental health on a population level. Moderation- and mediation analyses will deliver further insights for optimization of target groups and intervention content.

Trial Registration: WHO International Clinical Trials Registry Platform via the German Clinical Studies Trial Register DRKS00014774 . Registered on 18 May 2018.
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http://dx.doi.org/10.1186/s13063-020-04868-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691111PMC
November 2020

The effects of patients' expectations on surgery outcome in total hip and knee arthroplasty: a prognostic factor meta-analysis.

Health Psychol Rev 2020 Dec 21:1-17. Epub 2020 Dec 21.

Department of Psychology, University of Zurich, Zurich, Switzerland.

Patients' expectations are among the most frequently studied psychological prognostic factors in total knee and hip arthroplasty (TKA/THA). So far, however, evidence on the effect of patients' preoperative expectations on surgery outcome is inconclusive. Heterogeneity of expectation constructs and the use of psychometrically not evaluated measurement instruments have constituted major obstacles for the integration of the current literature. Using a theory-based model of expectation constructs , this meta-analysis set out to disentangle the conflicting results in the current literature. Systematic literature searches yielded  = 46 studies (= 10,465) that reported associations of preoperative expectations with postoperative pain, functioning and disability, and satisfaction. Random effects meta-analysis revealed a robust small association ( = .16; 95% CI .13, .19) between patients' positive preoperative expectations and better postoperative outcomes. This effect did not differ between THA and TKA, different outcome categories and different follow-up periods. Studies using psychometrically evaluated expectation measures reported significantly higher effects (= .19 95% CI .16, .22). Whether this effect varies among different expectation constructs remains unclear. High-quality studies using validated, multidimensional expectation measures are needed to further understand the role of different expectation constructs in THA and TKA surgery.
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http://dx.doi.org/10.1080/17437199.2020.1854051DOI Listing
December 2020

Moderators of psychological and psychoeducational interventions for the prevention of anxiety: A systematic review.

J Anxiety Disord 2020 12 28;76:102317. Epub 2020 Sep 28.

Biomedical Research Institute of Malaga (IBIMA), C/ Sevilla 23, 29009, Málaga, Spain; Prevention and Health Promotion Research Network (redIAPP), ISCIII, Gran Via de les Corts Catalanes, 587, 08007, Barcelona, Spain.

The aim of this study was to assess the available evidence on potential moderators of psychological and psychoeducational interventions for the prevention of anxiety. A systematic review using PubMed, PsycINFO, Web of Science, Embase, OpenGrey, and CENTRAL was performed up to October 2019. Two independent researchers assessed the fulfillment of eligibility criteria, extracted the data and performed a quality assessment of the included studies. Outcomes were moderators of the reduction of anxious symptoms or the incidence of anxiety disorders. Fourteen studies reporting results on moderator analyses performed in 13 randomized controlled trials were included. Twenty-seven potential moderators were organized into six categories: sociodemographic, clinical characteristics, cognitive variables, life events, interpersonal functioning and intervention characteristics. The most frequently examined variables were gender, age and baseline anxiety. We found insufficient evidence for all moderator categories studied. In children and adolescents, we found some studies with significant results for the low family support variable and higher levels of anxiety symptoms at baseline, which were both associated with higher effectiveness. Limited conclusions can be drawn about for whom and under what conditions interventions work in the prevention of anxiety. A strong need to improve the methodological quality and the number of moderator studies was identified.
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http://dx.doi.org/10.1016/j.janxdis.2020.102317DOI Listing
December 2020

User Experience and Effects of an Individually Tailored Transdiagnostic Internet-Based and Mobile-Supported Intervention for Anxiety Disorders: Mixed-Methods Study.

J Med Internet Res 2020 09 16;22(9):e16450. Epub 2020 Sep 16.

Clinical, Neuro- & Development Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.

Background: Internet interventions have been shown to be effective in treating anxiety disorders. Most interventions to date focus on single disorders and disregard potential comorbidities.

Objective: The aim of this mixed-methods study was to investigate feasibility, user experience, and effects of a newly developed individually tailored transdiagnostic guided internet intervention for anxiety disorders.

Methods: This study is an uncontrolled, within-group, baseline, postintervention pilot trial with an embedded qualitative and quantitative process and effect evaluation. In total, 49 adults with anxiety disorders (generalized anxiety disorder n=20, social phobia n=19, agoraphobia without panic n=12, panic with agoraphobia n=6, panic without agoraphobia n=4, subclinical depression n=41) received access to the 7-session intervention. We examined motivation and expectations, intervention use, user experience, impact, and modification requests. Qualitative data were assessed using semistructured interviews and analyzed by qualitative content analysis. Quantitative outcomes included symptom severity of anxiety and depression (Hamilton Anxiety Rating Scale [HAM-A], Quick Item Inventory of Depressive Symptomatology clinician rating [QIDS-C]), diagnostic status in clinical interviews (Mini International Neuropsychiatric Interview [MINI]), and web-based self-reports (Generalized Anxiety Disorder-7 [GAD-7], Center for Epidemiological Studies Depression Scale [CES-D], Beck Anxiety Inventory [BAI], Panic and Agoraphobia Scale [PAS], Social Phobia Scale [SPS], Patient Health Questionnaire-9 [PHQ-9]) at baseline and postassessment. Quantitative data was analyzed by comparing within-group means expressed as Cohen d.

Results: Anxiety symptom severity (HAM-A d=1.19) and depressive symptoms (QIDS-C d=0.42) improved significantly, and 54% (21/39) no longer were diagnosed as having any anxiety disorder. The main positive effects were the general improvement of disease burden and attentiveness to feelings and risk situations while the main negative effects experienced were lack of change in disease burden and symptom deterioration. The most prevalent reasons for participation were the advantages of online treatment, symptom burden, and openness toward online treatment. Helpful factors included support, psychoeducation and practicing strategies in daily life; the main hindering factors were too little individualization and being overwhelmed by the content and pace.

Conclusions: The intervention was found to be feasible and results show preliminary data indicating potential efficacy for improving anxiety and depression. The next step should be the evaluation within a randomized controlled trial. Concerning intervention development, it was found that future interventions should emphasize individualization even more in order to further improve the fit to individual characteristics, preferences, and needs.
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http://dx.doi.org/10.2196/16450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527916PMC
September 2020

Sources of Stress and Their Associations With Mental Disorders Among College Students: Results of the World Health Organization World Mental Health Surveys International College Student Initiative.

Front Psychol 2020 30;11:1759. Epub 2020 Jul 30.

Department of Health Care Policy, Harvard Medical School, Boston, MA, United States.

The college years are stressful for many students. Identifying the sources of stress and their relative importance in leading to clinically significant emotional problems may assist in the development of targeted stress management interventions. The current report examines the distribution and associations of perceived stress across major life areas with 12-month prevalence of common mental disorders in a cross-national sample of first-year college students. The 20,842 respondents were from 24 universities in 9 countries that participated in the World Health Organization World Mental Health International College Student Initiative. Logistic regression analysis examined associations of current perceived stress in six life areas (financial situation, health, love life, relationships with family, relationships at work/school, problems experienced by loved ones) with six types of 12-month mental disorders (major depressive disorder, bipolar disorder, generalized anxiety disorder, panic disorder, alcohol use disorder, drug use disorder). Population attributable risk proportions (PARPs) were calculated to estimate the upper-bound potential effects of interventions focused on perceived stress in reducing prevalence of mental disorders. The majority of students (93.7%) reported at least some stress in at least one of the six areas. A significant dose-response association was found between extent of stress in each life area and increased odds of at least one of the six disorders. The multivariable models that included all stress measures were significant for all disorders ( = 20.6-70.6, < 0.001). Interpretation of PARPs as representing causal effects of stresses on disorders suggests that up to 46.9-80.0% of 12-month disorder prevalence might be eliminated if stress prevention interventions were developed to block the associations of stress with these disorders.
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http://dx.doi.org/10.3389/fpsyg.2020.01759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406671PMC
July 2020

Consensus statement on the problem of terminology in psychological interventions using the internet or digital components.

Internet Interv 2020 Sep 2;21:100331. Epub 2020 Jun 2.

Department of Psychology, Stockholm University, Frescati Hagvag 8, 114 19 Stockholm, Sweden.

Since the emergence of psychological interventions delivered via the Internet they have differed in numerous ways. The wealth of formats, methods, and technological solutions has led to increased availability and cost-effectiveness of clinical care, however, it has simultaneously generated a multitude of terms. With this paper, we first aim to establish whether a terminology issue exists in the field of Internet-delivered psychological interventions. If so, we aim to determine its implications for research, education, and practice. Furthermore, we intend to discuss solutions to mitigate the problem; in particular, we propose the concept of a common glossary. We invited 23 experts in the field of Internet-delivered interventions to respond to four questions, and employed the Delphi method to facilitate a discussion. We found that experts overwhelmingly agreed that there were terminological challenges, and that it had significant consequences for conducting research, treating patients, educating students, and informing the general public about Internet-delivered interventions. A cautious agreement has been reached that formulating a common glossary would be beneficial for the field to address the terminology issue. We end with recommendations for the possible formats of the glossary and means to disseminate it in a way that maximizes the probability of broad acceptance for a variety of stakeholders.
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http://dx.doi.org/10.1016/j.invent.2020.100331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305336PMC
September 2020

Moderators of psychological and psychoeducational interventions for the prevention of depression: A systematic review.

Clin Psychol Rev 2020 07 11;79:101859. Epub 2020 May 11.

Biomedical Research Institute of Malaga (IBIMA), C/ Sevilla 23, 29009 Málaga, Spain; Prevention and Health Promotion Research Network (redIAPP), ISCIII, Gran Via de les Corts Catalanes, 587, 08007 Barcelona, Spain.

Psychological and psychoeducational interventions have proven to be effective in preventing depression. However, the identification of the patients that benefit the most from each type of intervention has not yet been established. A systematic review was performed of the literature on moderators of preventive psychological and psychoeducational interventions for depression in all types of population. A search was performed on PubMed, PsycINFO, Web of Science, Embase, Cochrane Central Register of Controlled Trials and OpenGrey up to July 2019. Fulfillment of eligibility criteria, data collection, and study quality assessment were assessed by two independent researchers. Outcomes were moderators of the reduction of depressive symptoms or the incidence of depression. Twenty-seven moderator effect studies performed in 19 randomized controlled trials were included. Thirty-four potential sociodemographic, clinical, interpersonal, personality and life-event moderators were evaluated. Baseline depressive symptoms, gender, age, baseline parental depression and social support were the most frequently studied potential moderators. In interventions for children and adolescents, the moderator for which evidence was strongest was having parents free of depression at baseline. Psychological and psychoeducational interventions seem to be more effective in children and adolescents who exhibit a lower use of substances and whose parents do not have symptoms of depression at baseline. In adults, a lower age was associated with greater effects of preventive interventions. ETHICS: As this systematic review is based on published data, approval from the local ethics committee was not required.
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http://dx.doi.org/10.1016/j.cpr.2020.101859DOI Listing
July 2020

Testing the efficacy of a minimal-guidance online self-help intervention for alcohol misuse in Estonia: study protocol of a randomized controlled trial.

BMC Public Health 2020 May 27;20(1):790. Epub 2020 May 27.

Estonian National Institute for Health Development, Tallinn, Estonia.

Background: Despite an initial steep decrease in alcohol misuse among Estonians through structural intervention means and the scaling up of alcohol counselling in the mid-2000's, most of the country's alcohol misuse indicators remain clearly higher than European averages. Consequently, an online self-help program was launched as part of an initial behavioral intervention initiative to foster progress in alcohol prevention on a population level.

Methods: A two-arm randomized controlled trial (RCT) has been designed to compare the efficacy of a culturally-adapted minimal-guidance online self-help program, the 8-week "Selge" online program against a control condition that consists of a self-administered test of alcohol use and advice regarding usual treatment in Estonia. A target sample of 600 individuals will be recruited and randomly assigned to either condition. The program will contain 10 modules based on principles of cognitive behavioural therapy (CBT) and motivational interviewing (MI). Participants in the control group will have access to the full treatment after they complete their final follow-up assessment. The primary outcome will be change in the Alcohol Use Disorders Identification Test (AUDIT) score between the 6-month follow-up and baseline assessments. Secondary outcomes will include the number of standard drinks consumed and alcohol-free days, drinking motives and motivation for change, as well as changes in mental health. Assessments will be completed at baseline, at the end of treatment, and at 6 months follow-up. Data analysis will follow the intention-to-treat principle and employ (generalised) linear mixed models.

Discussion: The "Selge" program is the first and only internet program for the intervention of alcohol misuse in Estonia. If proven effective, it will foster progress in the intervention of alcohol misuse in the Estonian population and be implemented as a standard program amidst the continuum of intervention and care.

Trial Registration: Current Controlled Trials ISRCTN48753339 registered 04/06/2019 retrospectively.
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http://dx.doi.org/10.1186/s12889-020-08791-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251728PMC
May 2020

Effectiveness of a Guided Web-Based Self-help Intervention to Prevent Depression in Patients With Persistent Back Pain: The PROD-BP Randomized Clinical Trial.

JAMA Psychiatry 2020 10;77(10):1001-1011

Institute of Psychology and Education, Department of Clinical Psychology and Psychotherapy, University of Ulm, Ulm, Germany.

Importance: Depression is a frequent comorbid condition in patients with persistent back pain and is associated with substantial adverse consequences, including the risk of developing opioid use disorders. Shifting the focus from depression treatment to preventing depression might be a viable way to reduce the disease burden.

Objective: To evaluate the effectiveness of a web-based self-help intervention to reduce the incidence of major depressive episode (MDE) in patients with persistent back pain.

Design, Setting, And Participants: Prevention of Depression in Back Pain Patients (PROD-BP) was a pragmatic, observer-blinded randomized clinical trial with a parallel design conducted in Germany. Eligible adults with a diagnosis of persistent back pain and subclinical depressive symptoms, but who were depression free, were recruited either on-site or after discharge from 82 orthopedic clinics between October 1, 2015, and July 31, 2017. All analyses were conducted according to the intention-to-treat principle from October 31, 2018, to April 30, 2019.

Interventions: The intervention group received an e-coach-guided, web-based self-help intervention that was based on cognitive behavioral therapy and tailored to the needs of patients with persistent back pain. The intervention included 6 obligatory modules and 3 optional modules to be completed by participants as well as feedback from e-coaches. Both the intervention and control groups had unrestricted access to treatment as usual.

Main Outcomes And Measures: Primary outcome was time to onset of an MDE over a 12-month period as assessed by blinded diagnostic raters using the Structured Clinical Interview for DSM-5. Secondary outcomes included depression severity, quality of life, pain intensity, pain-related disability, pain self-efficacy, work capacity, and user satisfaction assessed with a variety of instruments.

Results: A total of 295 participants (mean [SD] age, 52.8 [7.7] years; 184 women [62.4%]) were recruited and randomized to either the intervention group (n = 149) or control group (n = 146). The intervention reduced the risk of MDE onset by 52% (hazard ratio, 0.48; 95% CI, 0.28-0.81; P < .001). Twenty-one participants (14.1%) in the intervention group and 41 participants (28.1%) in the control group experienced an MDE over the 12-month period. The number needed to treat to prevent 1 new case of MDE was 2.84 (95% CI, 1.79-9.44).

Conclusions And Relevance: Results of this trial showed that among patients with persistent back pain, depression can be prevented by a guided web-based self-help intervention in addition to treatment as usual. This finding suggests that using a scalable digital approach to integrate psychological treatment into routine pain management is feasible.

Trial Registration: German Clinical Trials Register Identifier: DRKS00007960.
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http://dx.doi.org/10.1001/jamapsychiatry.2020.1021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7254449PMC
October 2020

Dimensionality of the system usability scale among professionals using internet-based interventions for depression: a confirmatory factor analysis.

BMC Psychiatry 2020 05 12;20(1):218. Epub 2020 May 12.

Department of Research and Innovation, GGZ inGeest, Specialized Mental Health Care, Oldenaller 1, 1081, Amsterdam, HJ, Netherlands.

Background: The System Usability Scale (SUS) is used to measure usability of internet-based Cognitive Behavioural Therapy (iCBT). However, whether the SUS is a valid instrument to measure usability in this context is unclear. The aim of this study is to assess the factor structure of the SUS, measuring usability of iCBT for depression in a sample of professionals. In addition, the psychometric properties (reliability, convergent validity) of the SUS were tested.

Methods: A sample of 242 professionals using iCBT for depression from 6 European countries completed the SUS. Confirmatory Factor Analysis (CFA) was conducted to test whether a one-factor, two-factor, tone-model or bi-direct model would fit the data best. Reliability was assessed using complementary statistical indices (e.g. omega). To assess convergent validity, the SUS total score was correlated with an adapted Client Satisfaction Questionnaire (CSQ-3).

Results: CFA supported the one-factor, two-factor and tone-model, but the bi-factor model fitted the data best (Comparative Fit Index = 0.992, Tucker Lewis Index = 0.985, Root Mean Square Error of Approximation = 0.055, Standardized Root Mean Square Residual = 0.042 (respectively χ (9) = 69.82, p < 0.001; χ (8) 33.04, p < 0.001). Reliability of the SUS was good (ω = 0.91). The total SUS score correlated moderately with the CSQ-3 (CSQ1 r = .49, p < 0.001; CSQ2 r = .46, p < 0.001; CSQ3 r = .38, p < 0.001), indicating convergent validity.

Conclusions: Although the SUS seems to have a multidimensional structure, the best model showed that the total sumscore of the SUS appears to be a valid and interpretable measure to assess the usability of internet-based interventions when used by professionals in mental healthcare.
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http://dx.doi.org/10.1186/s12888-020-02627-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216472PMC
May 2020

Effectiveness of a guided online mindfulness-focused intervention in a student population: Study protocol for a randomised control trial.

BMJ Open 2020 03 24;10(3):e032775. Epub 2020 Mar 24.

Department of Clinical & Health Psychology, Ulm University, Ulm, Baden-Württemberg, Germany.

Background: Previous studies show that university students experience higher psychological stress than the general population, resulting in increased vulnerability for mental disorders for the student population. Online mindfulness interventions will be delivered to students as a potentially promising and more flexible approach compared to face-to-face interventions with the aim of improving their mental health. This study purposes to investigate the effectiveness of a guided online mindfulness-focused intervention for university students by using both self-reported and psychobiological measures.

Methods And Analyses: In this multicentre, two-armed randomised controlled trial with a parallel design, a guided version of the online mindfulness-focused intervention 'StudiCare Mindfulness' will be compared with a waitlist control group. In total, 120 participants will be recruited at different universities (of Applied Sciences) in (Neu-) Ulm. Data will be assessed prior to randomisation, after eight weeks (post-intervention) and six months after randomisation (follow-up). The primary outcome measure is mindfulness. The secondary outcome measures include depression, anxiety and stress levels, well-being, interoceptive sensibility, emotion regulation and alexithymia. Psychobiological parameters comprise interoceptive accuracy, hair cortisol and FKBP5 genotype. Sociodemographic variables, treatment expectations, side and adverse side effects, as well as intervention satisfaction and adherence will be assessed. All data analyses will be conducted according to the intention-to-treat principle.

Ethics And Dissemination: All study procedures have been approved by the Ethics Committee of Ulm University (application No. 48/18). The findings will be disseminated widely through peer-reviewed publications and conference presentations.

Trial Registration Number: DRKS00014701.
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http://dx.doi.org/10.1136/bmjopen-2019-032775DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202707PMC
March 2020

Clinical and Cost-Effectiveness of Personalized Tele-Based Coaching for Farmers, Foresters and Gardeners to Prevent Depression: Study Protocol of an 18-Month Follow-Up Pragmatic Randomized Controlled Trial (TEC-A).

Front Psychiatry 2020 4;11:125. Epub 2020 Mar 4.

Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.

Farmers show high levels of depressive symptoms and mental health problems in various studies. This study is part of a nationwide prevention project carried out by a German social insurance company for farmers, foresters, and gardeners (SVLFG) to implement internet- and tele-based services among others to improve mental health in this population. The aim of the present study is to evaluate the (cost-)effectiveness of personalized tele-based coaching for reducing depressive symptom severity and preventing the onset of clinical depression, compared to enhanced treatment as usual. In a two-armed, pragmatic randomized controlled trial ( = 312) with follow-ups at post-treatment (6 months), 12 and 18 months, insured farmers, foresters, and gardeners, collaborating family members and pensioners with elevated depressive symptoms (PHQ-9 ≥ 5) will be randomly allocated to personalized tele-based coaching or enhanced treatment as usual. The coaching is provided by psychologists and consists of up to 34 tele-based sessions for 25-50 min delivered over 6 months. Primary outcome is depressive symptom severity at post-treatment. Secondary outcomes include depression onset, anxiety, stress, and quality of life. A health-economic evaluation will be conducted from a societal perspective. This study is the first pragmatic randomized controlled trial evaluating the (cost-)effectiveness of a nationwide tele-based preventive service for farmers. If proven effective, the implementation of personalized tele-based coaching has the potential to reduce disease burden and health care costs both at an individual and societal level. German Clinical Trial Registration: DRKS00015655.
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http://dx.doi.org/10.3389/fpsyt.2020.00125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064472PMC
March 2020

The importance of physical and mental health in explaining health-related academic role impairment among college students.

J Psychiatr Res 2020 04 29;123:54-61. Epub 2020 Jan 29.

Department of Health Care Policy, Harvard Medical School, Boston, USA. Electronic address:

Research consistently documents high rates of mental health problems among college students and strong associations of these problems with academic role impairment. Less is known, though, about prevalence and effects of physical health problems in relation to mental health problems. The current report investigates this by examining associations of summary physical and mental health scores from the widely-used Short-Form 12 (SF-12) Health Survey with self-reported academic role functioning in a self-report survey of 3,855 first-year students from five universities in the northeastern United States (US; mean age 18.5; 53.0% female). The mean SF-12 physical component summary (PCS) score (55.1) was half a standard deviation above the benchmark US adult population mean. The mean SF-12 mental component summary (MCS) score (38.2) was more than a full standard deviation below the US adult population mean. Two-thirds of students (67.1%) reported at least mild and 10.5% severe health-related academic role impairment on a modified version of the Sheehan Disability Scale. Both PCS and MCS scores were significantly and inversely related to these impairment scores, but with nonlinearities and interactions and much stronger associations involving MCS than PCS. Simulation suggests that an intervention that improved the mental health of all students with scores below the MCS median to be at the median would result in a 61.3% reduction in the proportion of students who experienced severe health-related academic role impairment. Although low-cost scalable interventions exist to address student mental health problems, pragmatic trials are needed to evaluate the effectiveness of these interventions in reducing academic role impairment.
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http://dx.doi.org/10.1016/j.jpsychires.2020.01.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047531PMC
April 2020

Prevention of eating disorders at universities: A systematic review and meta-analysis.

Int J Eat Disord 2020 06 14;53(6):813-833. Epub 2020 Jan 14.

Department of Clinical, Neuro, and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.

Background: Eating problems are highly prevalent among young adults. Universities could be an optimal setting to prevent the onset of eating disorders through psychological intervention. As part of the World Mental Health-International College Student initiative, this systematic review and meta-analysis synthesizes data on the efficacy of eating disorder prevention programs targeting university students.

Method: A systematic literature search of bibliographical databases (CENTRAL, MEDLINE, PsycINFO) for randomized trials comparing psychological preventive interventions for eating disorders targeting university students with psychoeducation or inactive controls was performed on October 22, 2019.

Results: Twenty-seven studies were included. Thirteen (48.1%) were rated to have a low risk of bias. The relative risk of developing a subthreshold or full-blown eating disorder was incidence rate ratio = 0.62 (95% CI [0.44, 0.87], n = 8, numbers-needed-to-treat [NNT] = 26.08; standardized clinical interviews only), indicating a 38% decrease in incidence in the intervention groups compared to controls. Small to moderate between-group effects at posttest were found on eating disorder symptoms (g = 0.35, 95% CI [0.24, 0.46], NNT = 5.10, n = 26), dieting (g = 0.43, 95% CI [0.29, 0.57], NNT = 4.17, n = 21), body dissatisfaction (g = 0.40, 95% CI [0.27, 0.53], NNT = 4.48, n = 25), drive for thinness (g = 0.43, 95% CI [0.27, 0.59], NNT = 4.23, n = 12), weight concerns (g = 0.33, 95% CI [0.10, 0.57], NNT = 5.35, n = 13), and affective symptoms (g = 0.27, 95% CI [0.15, 0.38], NNT = 6.70, n = 18). The effects on bulimia nervosa symptoms were not significant. Heterogeneity was moderate across comparisons.

Discussion: Eating disorder prevention on campus can have significant, small-to-moderate effects on eating disorder symptoms and risk factors. Results also suggest that the prevention of subthreshold and full-syndrome eating disorders is feasible using such interventions. More research is needed to identify ways to motivate students to use preventive eating disorder interventions.

Antecedentes: Los trastornos de la conducta alimentaria son altamente prevalentes entre los adultos jóvenes. Las universidades podrían ser un entorno óptimo para prevenir la aparición de trastornos alimentarios a través de la intervención psicológica. Como parte de la iniciativa World Mental Health-International College Student, esta revisión sistemática y meta-análisis sintetiza datos sobre la eficacia de los programas de prevención de trastornos alimentarios dirigidos a estudiantes universitarios. MÉTODO: Una búsqueda bibliográfica sistemática de datos bibliográficas (CENTRAL, MEDLINE, PsycINFO) para ensayos aleatorios que comparaban intervenciones preventivas psicológicas para trastornos alimentarios dirigidos a estudiantes universitarios con psicoeducación o controles inactivos fue realizada hasta el 22 de octubre de 2019.

Resultados: Se incluyeron 27 estudios. Trece (48,1%) fueron calificados como de bajo riesgo de sesgo. El riesgo relativo de desarrollar un trastorno de la conducta alimentaria subclínico (parcial) o completo fue IRR = 0.62 (95% CI [0.44, 0.87], n = 8, NNT = 26.08; sólo entrevistas clínicas estandarizadas), lo que indica una disminución del 38% en la incidencia en los grupos de intervención en comparación con los controles. Se encontraron efectos pequeños a moderados entre los grupos en la post-prueba en los síntomas del trastorno alimentario (g = 0.35, 95% CI [0.24, 0.46], NNT = 5.10, n = 26), dieta (g = 0.43, 95% CI [0.29, 0.57], NNT = 4.17, n = 21), insatisfacción corporal (g = 0.40, 95% CI [0.27, 0.53], NNT = 4.48, n = 25), impulso por delgadez (g = 0.43, 95% CI [0.27, 0.59], NNT = 4.23, n = 12), problemas de peso (g = 0.33, 95% CI [0.10, 0.57], NNT = 5.35, n = 13) y síntomas afectivos (g = 0.27, 95% CI [0.15, 0.38], NNT = 6.70, n = 18). Los efectos sobre los síntomas de la bulimia nervosa no fueron significativos. La heterogeneidad fue moderada en las comparaciones. DISCUSIÓN: La prevención de los trastornos de la conducta alimentaria en el campus universitario puede tener efectos significativos, de pequeños a moderados, sobre los síntomas del trastorno alimentario y los factores de riesgo. Los resultados también sugieren que la prevención de los trastornos alimentarios subclínicos o parciales y síndromes completos es factible utilizando tales intervenciones. Se necesita más investigación para identificar formas de motivar a los estudiantes a usar intervenciones preventivas para los trastornos de la conducta alimentaria.
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http://dx.doi.org/10.1002/eat.23224DOI Listing
June 2020

Binge eating and purging in first-year college students: Prevalence, psychiatric comorbidity, and academic performance.

Int J Eat Disord 2020 03 23;53(3):339-348. Epub 2019 Dec 23.

Department of Neurosciences, Center for Public Health Psychiatry, KU Leuven, Leuven, Belgium.

Background: Binge eating and purging behaviors (BPB) are common among college students, but evidence is scant on prevalence and associations of BPB with mental health problems and objective academic performance. This study aims to investigate: (a) 12-month prevalence of BPB among college first-year students, (b) comorbidity patterns of BPB with various mental health problems, and (c) the association of BPB with objective academic functioning.

Methods: Using data from the Leuven College Surveys (Belgium), as part of the World Mental Health Surveys International College Student initiative, we cross-sectionally assessed 12-month BPB and mental health problems among college first-year students (n = 4,889; response rate = 73.2%) at the beginning of the academic year. Objective measures of academic functioning (final grades, expressed in academic year percentage "AYP" [0-100%] and academic failure) were obtained from administrative records at the end of the academic year.

Results: Twelve-month prevalence of BPB was 7.6% (7.3%binge eating and 1.0%purging), with higher rates among females than males. Bivariate models showed an association between BPB and numerous mental health problems (ORs = 3.4-18.4). Multivariate models showed associations with non-suicidal self-injury, post-traumatic stress, internalizing/externalizing problems and suicidal ideation. After controlling for sociodemographic characteristics and comorbid mental health problems, BPB were still associated with lower AYP (-4.1 to -11.2% range) and elevated odds of academic year failure (ORs = 1.4-4.2).

Conclusions: BPB (especially binge eating) are relatively common and associated with mental health problems, comparatively low academic performance, and higher risk of academic failure among college first-year students. Further study is needed to examine the causal dynamics underlying these associations.
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http://dx.doi.org/10.1002/eat.23211DOI Listing
March 2020

Standalone smartphone apps for mental health-a systematic review and meta-analysis.

NPJ Digit Med 2019 2;2:118. Epub 2019 Dec 2.

1Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.

While smartphone usage is ubiquitous, and the app market for smartphone apps targeted at mental health is growing rapidly, the evidence of standalone apps for treating mental health symptoms is still unclear. This meta-analysis investigated the efficacy of standalone smartphone apps for mental health. A comprehensive literature search was conducted in February 2018 on randomized controlled trials investigating the effects of standalone apps for mental health in adults with heightened symptom severity, compared to a control group. A random-effects model was employed. When insufficient comparisons were available, data was presented in a narrative synthesis. Outcomes included assessments of mental health disorder symptom severity specifically targeted at by the app. In total, 5945 records were identified and 165 full-text articles were screened for inclusion by two independent researchers. Nineteen trials with 3681 participants were included in the analysis: depression ( = 6), anxiety ( = 4), substance use ( = 5), self-injurious thoughts and behaviors ( = 4), PTSD ( = 2), and sleep problems ( = 2). Effects on depression (Hedges'  = 0.33, 95%CI 0.10-0.57,  = 0.005, NNT = 5.43,  = 59%) and on smoking behavior ( = 0.39, 95%CI 0.21-0.57, NNT = 4.59,  ≤ 0.001,  = 0%) were significant. No significant pooled effects were found for anxiety, suicidal ideation, self-injury, or alcohol use ( = -0.14 to 0.18). Effect sizes for single trials ranged from  = -0.05 to 0.14 for PTSD and  = 0.72 to 0.84 for insomnia. Although some trials showed potential of apps targeting mental health symptoms, using smartphone apps as standalone psychological interventions cannot be recommended based on the current level of evidence.
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http://dx.doi.org/10.1038/s41746-019-0188-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889400PMC
December 2019

The Effects of Stress Beliefs on Daily Affective Stress Responses.

Ann Behav Med 2020 03;54(4):258-267

Department of Psychology, University of Kassel, Kassel, Germany.

Background: Negative beliefs about the effects of stress have been associated with poorer health and increased mortality. However, evidence on the psychological mechanisms linking stress beliefs to health is scarce, especially regarding real-life stress.

Purpose: The aim of the current study was to investigate the effects of stress beliefs on affect in the daily stress process in a population prone to health-impairing effects of stress: university students.

Methods: Using daily diaries, 98 university students reported on daily perceived social and work-related stressors as well as positive and negative affect for 10 consecutive days. Stress beliefs, depressive and anxiety symptoms, neuroticism, and demographic variables were assessed prior to the daily diary phase.

Results: Hierarchical linear models revealed a significant cross-level interaction between negative stress beliefs and the association of daily social stressors with negative affect (B = 0.24; 99% confidence interval [CI] = 0.08-0.41, p < .001). When experiencing social stress, participants who held high negative stress beliefs had higher daily negative affect (simple slope = 4.09; p < .001); however, for participants who held low negative stress beliefs the association between daily social stress and daily negative affect was considerably smaller (simple slope = 2.12; p < .001). Moreover, individuals believing stress to be controllable showed higher positive affect throughout the 10-day daily diary phase.

Conclusions: Negative stress beliefs were found to moderate the affective response to daily real-life stressors. Given the established relationship between affect and health, this study provides initial evidence of psychological mechanisms linking stress beliefs to health.
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http://dx.doi.org/10.1093/abm/kaz046DOI Listing
March 2020

The effects of fifteen evidence-supported therapies for adult depression: A meta-analytic review.

Psychother Res 2020 03 8;30(3):279-293. Epub 2019 Aug 8.

Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.

In the past decades, many different types of psychotherapy for adult depression have been developed. In this meta-analysis we examined the effects of 15 different types of psychotherapy using 385 comparisons between a therapy and a control condition: Acceptance and commitment therapy, mindfulness-based cognitive behavior therapy (CBT), guided self-help using a self-help book from David Burns, Beck's CBT, the "Coping with Depression" course, two subtypes of behavioral activation, extended and brief problem-solving therapy, self-examination therapy, brief psychodynamic therapy, non-directive counseling, full and brief interpersonal psychotherapy, and life review therapy. The effect sizes ranged from = 0.38 for the "Coping with Depression" course to = 1.10 for life review therapy. There was significant publication bias for most therapies. In 70% of the trials there was at least some risk of bias. After adjusting studies with low risk of bias for publication bias, only two types of therapy remained significant (the "Coping with Depression" course, and self-examination therapy). We conclude that the 15 types of psychotherapy may be effective in the treatment of depression. However, the evidence is not conclusive because of high levels of heterogeneity, publication bias, and the risk of bias in the majority of studies.
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http://dx.doi.org/10.1080/10503307.2019.1649732DOI Listing
March 2020