Publications by authors named "Nickolai Titov"

129 Publications

Brief online motivational interviewing pre-treatment intervention for enhancing internet-delivered cognitive behaviour therapy: A randomized controlled trial.

Internet Interv 2021 Sep 20;25:100394. Epub 2021 Apr 20.

MindSpot Clinic, Department of Psychology, Macquarie University, Sydney, Australia.

While the efficacy of therapist-guided internet-delivered cognitive behaviour therapy (iCBT) for anxiety and depression is well-established, a significant proportion of clients show little to no improvement with this approach. Given that motivational interviewing (MI) is found to enhance face-to-face treatment of anxiety, the current trial examined potential benefits of a brief online MI intervention prior to therapist-guided iCBT. Clients applying to transdiagnostic therapist-guided iCBT in routine care were randomly assigned to receive iCBT with ( = 231) or without ( = 249) the online MI pre-treatment. Clients rated motivation at screening and pre-iCBT and anxiety and depression at pre- and post-treatment and at 13- and 25-week follow-up after enrollment. Clients in the MI plus iCBT group made more motivational statements in their emails and were enrolled in the course for a greater number of days compared to clients who received iCBT only, but did not demonstrate higher motivation after completing the MI intervention or have higher course completion. Clients in both groups, at screening and pre-iCBT, reported high levels of motivation. No statistically significant group differences were found in the rate of primary symptom change over time, with both groups reporting large reductions in anxiety and depression pre- to post-treatment (Hedges' range = 0.96-1.11). During follow-up, clients in the iCBT only group reported additional small reductions in anxiety, whereas clients in the MI plus iCBT group did not. The MI plus iCBT group also showed small increases in depression during follow-up, whereas improvement was sustained for the iCBT only group. It is concluded that online MI does not appear to enhance client outcomes when motivation at pre-treatment is high.
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http://dx.doi.org/10.1016/j.invent.2021.100394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099490PMC
September 2021

Initial Outcomes of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy Tailored to Public Safety Personnel: Longitudinal Observational Study.

J Med Internet Res 2021 May 5;23(5):e27610. Epub 2021 May 5.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia.

Background: Canadian public safety personnel (PSP) experience high rates of mental health disorders and face many barriers to treatment. Internet-delivered cognitive behavioral therapy (ICBT) overcomes many such barriers, and is effective for treating depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms.

Objective: This study was designed to fill a gap in the literature regarding the use of ICBT tailored specifically for PSP. We examined the effectiveness of a tailored ICBT program for treating depression, anxiety, and PTSD symptoms among PSP in the province of Saskatchewan.

Methods: We employed a longitudinal single-group open-trial design (N=83) with outcome measures administered at screening and at 8 weeks posttreatment. Data were collected between December 5, 2019 and September 11, 2020. Primary outcomes included changes in depression, anxiety, and PTSD symptoms. Secondary outcomes included changes in functional impairment; symptoms of panic, social anxiety, and anger; as well as treatment satisfaction, working alliance, and program usage patterns.

Results: Clients reported large symptom reductions on measures of depression and anxiety, as well as moderate reductions on measures of PTSD and secondary symptoms, except for social anxiety. Most clients who reported symptoms above clinical cut-offs on measures of depression, anxiety, and PTSD during screening experienced clinically significant symptom reductions. Results suggested good engagement, treatment satisfaction, and working alliance.

Conclusions: Tailored, transdiagnostic ICBT demonstrated promising outcomes as a treatment for depression, anxiety, and PTSD among Saskatchewan PSP and warrants further investigation.

Trial Registration: Clinicaltrials.gov NCT04127032; https://www.clinicaltrials.gov/ct2/show/NCT04127032.
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http://dx.doi.org/10.2196/27610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8135031PMC
May 2021

Utilization, Patient Characteristics, and Longitudinal Improvements among Patients from a Provincially Funded Transdiagnostic Internet-delivered Cognitive Behavioural Therapy Program: Observational Study of Trends over 6 Years: Utilisation, caractéristiques des patients et améliorations longitudinales chez les patients d'un programme de thérapie cognitivo-comportementale financé par la province, transdiagnostique et dispensé par internet: Une étude observationnelle des tendances sur six ans.

Can J Psychiatry 2021 Apr 12:7067437211006873. Epub 2021 Apr 12.

eCentre Clinic, Department of Psychology, 7788Macquarie University, Sydney, Australia.

Objective: There is strong evidence supporting internet-delivered cognitive behaviour therapy (iCBT) and consequently growing demand for iCBT in Canada. Transdiagnostic iCBT that addresses both depression and anxiety is particularly promising as it represents an efficient method of delivering iCBT in routine care. The Online Therapy Unit, funded by the Saskatchewan government, has been offering transdiagnostic iCBT for depression and anxiety since 2013. In this article, to broadly inform implementation efforts, we examined trends in utilization, patient characteristics, and longitudinal improvements for patients receiving transdiagnostic iCBT over 6 years.

Methods: Patients who completed telephone screening between November 2013 and December 2019 were included in this observational study. Patients provided demographics and mental health history at screening and completed measures at pre-treatment, post-treatment and at 3- to 4-month follow-up. Treatment engagement and satisfaction were assessed.

Results: A total of 5,321 telephone screenings were completed and 4,283 of patients were accepted for treatment over the 6-year period (80.5% acceptance). The most common reason for referral to another service was high suicide risk/severe symptoms (47.1%). Examination of trends showed growing use of transdiagnostic iCBT over time (37% increase per year). There was remarkable stability in patient characteristics across years. Most patients were concurrently using medication (57.3%) with 11.9% reporting using iCBT while on a waiting list for face-to-face treatment highlighting the importance of integrating iCBT with other services. Consistent across years, large improvements in depression and anxiety symptoms were found and maintained at 3- to 4-month follow-up. There was strong patient engagement with iCBT and positive ratings of treatment experiences.

Conclusions: As there is growing interest in iCBT in Canada, this large observational study provides valuable information for those implementing iCBT in terms of likely user characteristics, patterns of use, and improvements. This information has potential to assist with resource allocation and planning in Canada and elsewhere.
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http://dx.doi.org/10.1177/07067437211006873DOI Listing
April 2021

Rapid Report 3: Mental health symptoms, characteristics, and regional variation, for users of an Australian digital mental health service during the first 8 months of COVID-19.

Internet Interv 2021 Apr 27;24:100378. Epub 2021 Feb 27.

MindSpot Clinic, Macquarie University, Australia.

Background: The MindSpot Clinic provides services to Australians with anxiety and depression. Routine data collection means that MindSpot has been able to monitor trends in mental health symptoms and service use prior to and during the COVID-19 pandemic, and these have been reported in two earlier studies. This third study describes user characteristics and volumes in the first 8 months of COVID-19, including a comparison between users from states and territories with significantly different COVID-19 infection rates.

Methods: We examined trends in demographics and symptoms for participants starting an online assessment during the COVID-19 pandemic, from March to October 2020. Participants from the state of Victoria (n = 4203), which experienced a significantly larger rate of COVID-19 infections relative to the rest of Australia, were compared to participants from the rest of Australia (n = 10,500). Results were also compared to a baseline "comparison period" prior to the COVID-19 pandemic.

Results: A total of 14,703 people started a mental health assessment with MindSpot between 19th March and 28th October 2020. We observed two peaks in service demand, one in the early weeks of the pandemic, and the second in August-September when COVID-19 transmission was high in Victoria. Mean symptom scores on standardised measures of distress (K-10), depression (PHQ-9) and anxiety (GAD-7) were lower during this second peak in service demand, but there were significantly higher levels of concern about COVID-19 in participants from Victoria, and a higher proportion of Victorian respondents reported that they had made significant changes in response to the pandemic. Many respondents reported changes to their mental health, such as increased feelings of worry. Most respondents reported implementing strategies to help manage the psychological impact of COVID-19, such as maintaining social connections and limiting exposure to news or social media.

Conclusions: We did not observe increased levels of clinical anxiety or depression on standardised symptom measures. However, there were increases in service demand, and increased levels of concern and difficulties related to COVID-19, particularly in Victoria. Encouragingly, a significant proportion of participants have implemented coping strategies. These results continue to suggest that the mental health impacts of COVID-19 represent a normal response to an abnormal situation rather than an emerging mental health crisis. This distinction is important as we develop individually appropriate and proportional mental health system responses.
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http://dx.doi.org/10.1016/j.invent.2021.100378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7937977PMC
April 2021

Predictors, Outcomes, and Statistical Solutions of Missing Cases in Web-Based Psychotherapy: Methodological Replication and Elaboration Study.

JMIR Ment Health 2021 Feb 5;8(2):e22700. Epub 2021 Feb 5.

Department of Psychology, Macquarie University, MindSpot Clinic, Macquarie Park, Australia.

Background: Missing cases present a challenge to our ability to evaluate the effects of web-based psychotherapy trials. As missing cases are often lost to follow-up, less is known about their characteristics, their likely clinical outcomes, or the likely effect of the treatment being trialed.

Objective: The aim of this study is to explore the characteristics of missing cases, their likely treatment outcomes, and the ability of different statistical models to approximate missing posttreatment data.

Methods: A sample of internet-delivered cognitive behavioral therapy participants in routine care (n=6701, with 36.26% missing cases at posttreatment) was used to identify predictors of dropping out of treatment and predictors that moderated clinical outcomes, such as symptoms of psychological distress, anxiety, and depression. These variables were then incorporated into a range of statistical models that approximated replacement outcomes for missing cases, and the results were compared using sensitivity and cross-validation analyses.

Results: Treatment adherence, as measured by the rate of progress of an individual through the treatment modules, and higher pretreatment symptom scores were identified as the dominant predictors of missing cases probability (Nagelkerke R=60.8%) and the rate of symptom change. Low treatment adherence, in particular, was associated with increased odds of presenting as missing cases during posttreatment assessment (eg, odds ratio 161.1:1) and, at the same time, attenuated the rate of symptom change across anxiety (up to 28% of the total symptom with 48% reduction effect), depression (up to 41% of the total with 48% symptom reduction effect), and psychological distress symptom outcomes (up to 52% of the total with 37% symptom reduction effect) at the end of the 8-week window. Reflecting this pattern of results, statistical replacement methods that overlooked the features of treatment adherence and baseline severity underestimated missing case symptom outcomes by as much as 39% at posttreatment.

Conclusions: The treatment outcomes of the cases that were missing at posttreatment were distinct from those of the remaining observed sample. Thus, overlooking the features of missing cases is likely to result in an inaccurate estimate of the effect of treatment.
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http://dx.doi.org/10.2196/22700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7895640PMC
February 2021

Banbury Forum Consensus Statement on the Path Forward for Digital Mental Health Treatment.

Psychiatr Serv 2021 Jun 20;72(6):677-683. Epub 2021 Jan 20.

Department of Preventive Medicine, Center for Behavioral Intervention Technologies, Northwestern University, Chicago (Mohr); Optum, Eden Prairie, Minnesota (Azocar); One Medical and Alliant International University, San Francisco (Bertagnolli); Information Science, Cornell Tech, New York City (Choudhury); National Institute for Health and Care Excellence, Manchester, England (Chrisp); Department of Health Care Policy (Frank) and Department of Psychiatry (Torous), Harvard Medical School, Boston; health care consultant, Baltimore (Harbin); Care Management Institute, Kaiser Permanente, Oakland, California (Histon); Department of Psychiatry and Behavioral Sciences, Stanford University, and National Center for PTSD, Veterans Affairs Palo Alto Health Care System, Palo Alto, California (Kaysen); Department of Family Medicine and Public Health, University of California, San Diego (Nebeker); E-Mental Health Research Group, School of Psychology, Trinity College, University of Dublin, Dublin, and Department of Clinical Research and Innovation, SilverCloud Health, Boston (Richards); Department of Psychological Science, University of California, Irvine (Schueller); MindSpot Clinic, Department of Psychology, Macquarie University, Sydney, New South Wales, Australia (Titov); Department of Psychiatry, University of Washington, Seattle (Areán).

A major obstacle to mental health treatment for many Americans is accessibility: the United States faces a shortage of mental health providers, resulting in federally designated shortage areas. Although digital mental health treatments (DMHTs) are effective interventions for common mental disorders, they have not been widely adopted by the U.S. health care system. National and international expert stakeholders representing health care organizations, insurance companies and payers, employers, patients, researchers, policy makers, health economists, and DMHT companies and the investment community attended two Banbury Forum meetings. The Banbury Forum reviewed the evidence for DMHTs, identified the challenges to successful and sustainable implementation, investigated the factors that contributed to more successful implementation internationally, and developed the following recommendations: guided DMHTs should be offered to all patients experiencing common mental disorders, DMHT products and services should be reimbursable to support integration into the U.S. health care landscape, and an evidence standards framework should be developed to support decision makers in evaluating DMHTs.
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http://dx.doi.org/10.1176/appi.ps.202000561DOI Listing
June 2021

A Cost-effectiveness Analysis of an Internet-delivered Pain Management Program Delivered With Different Levels of Clinician Support: Results From a Randomised Controlled Trial.

J Pain 2021 03 20;22(3):344-358. Epub 2020 Nov 20.

Centre for Health Economy, Macquarie University, Sydney, Australia.

There is growing interest in the potential of internet-delivered pain management programs (PMPs) to increase access to care for people with chronic pain. However, very few economic evaluations of these interventions have been reported. Using existing data, the current study examined the cost-effectiveness of an internet-delivered PMP for a mixed group chronic pain patients (n = 490) provided with different levels of clinician support. The findings indicated that each additional clinical outcome (defined as a ≥ 30% reduction in disability, depression, anxiety, and pain) was associated with cost-savings when the intervention was provided in a self-guided format (ICER range: -$404--$808 AUD) or an optional-guided format (ICER range: -$314--$541 AUD), and a relatively small fixed cost when provided in the clinician-guided format (ICER range: $88-$225 AUD). The results were driven by a reduction in service use costs among the treatment groups, which offset the costs of providing the internet-delivered PMP in the self-guided and optional-guided formats. The same general pattern of results was found when more stringent clinical outcomes (defined as a ≥ 50% reduction) were employed. These findings suggest that carefully developed and administered internet-delivered PMPs, provided with different levels of clinician support, can be highly cost effective for patients with a broad range of pain conditions. PERSPECTIVE: This study examines the cost-effectiveness of an internet-delivered PMP provided to adults with a broad range of chronic pain conditions. Evidence of cost-effectiveness was found across a broad range of clinical outcomes and with different levels of clinician support.
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http://dx.doi.org/10.1016/j.jpain.2020.11.003DOI Listing
March 2021

Rapid report 2: Symptoms of anxiety and depression during the first 12 weeks of the Coronavirus (COVID-19) pandemic in Australia.

Internet Interv 2020 Dec 22;22:100351. Epub 2020 Oct 22.

MindSpot Clinic, Macquarie University, Australia.

Background: The MindSpot Clinic, funded by the Australian Government, is a national digital mental health service (DMHS) providing services to people experiencing anxiety and depression. We recently reported increased service use in the early weeks of the COVID-19 pandemic (19 March to 15 April 2020), and a small increase in anxiety symptoms. This follow-up paper examines trends in service use and symptoms, over 12 weeks from 19 March to 10 June 2020.

Methods: Demographics, symptoms, and psychosocial stressors were compared for participants starting an online assessment over four time-periods: A baseline "Comparison period" prior to the COVID-19 pandemic (1 to 28 September 2019), "Weeks 1-4" of the COVID-19 pandemic in Australia (19 March-15 April 2020), "Weeks 5-8" (16 April-13 May 2020) and "Weeks 9-12" (14 May-10 June). Responses to questions about the impact of COVID-19 and strategies used by participants to improve their mental wellbeing are also reported.

Results: A total of 5455 people started a mental health assessment with MindSpot from 19 March to 10 June 2020. The number of assessments per week rose steadily from 303 in week 1 to a peak of 578 in week 5. Symptoms of anxiety were highest in Weeks 1-4, declining steadily over subsequent weeks. Psychological distress and depression, as measured by the K-10 and PHQ-9 respectively, remained stable. Concern about COVID-19 was highest in the first week then steadily declined during the following weeks. The proportions of participants reporting changes to routine were consistent across the 12 weeks, and most participants reported adopting helpful strategies to improve their mental wellbeing.

Conclusions: We observed an initial increase in service use, which reduced over the 12 weeks. The initial rise in anxiety symptoms returned to baseline. Reported concern about the effect of COVID-19 declined steadily over 12 weeks. Symptoms of psychological distress and depression measured by the K-10 and PHQ-9, and the proportion reporting suicidal thoughts and plans did not change, and to date we have not identified indications of a mental health crisis. However, the long-term effects of COVID-19 on the economy and large sections of society are yet to be fully realised, indicating the importance of ongoing monitoring and reporting of trends as indicators of the mental health of the nation.
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http://dx.doi.org/10.1016/j.invent.2020.100351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580521PMC
December 2020

User characteristics and outcomes from a national digital mental health service: an observational study of registrants of the Australian MindSpot Clinic.

Lancet Digit Health 2020 11 19;2(11):e582-e593. Epub 2020 Oct 19.

MindSpot Clinic, Macquarie University, Sydney, NSW, Australia.

Background: Interest is growing in digital and telehealth delivery of mental health services, but data are scarce on outcomes in routine care. The federally funded Australian MindSpot Clinic provides online and telephone psychological assessment and treatment services to Australian adults. We aimed to summarise demographic characteristics and treatment outcomes of patients registered with MindSpot over the first 7 years of clinic operation.

Methods: We used an observational design to review all patients who registered for assessment with the MindSpot Clinic between Jan 1, 2013, and Dec 31, 2019. We descriptively analysed the demographics, service preferences, and baseline symptoms of patients. Among patients enrolled in a digital treatment course, we evaluated scales of depression (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder 7-Item Scale [GAD-7]), as primary measures of treatment outcome, from the screening assessment to post-treatment and a 3 month follow-up. The Kessler Psychological Distress 10-Item Plus Scale was also used to assess changes in general distress and disability, and course satisfaction was measured post-treatment.

Outcomes: A total of 121 652 screening assessments were started, of which 96 018 (78·9%) were completed. The mean age of patients was 35·7 years (SD 13·8) and 88 702 (72·9%) were women. Based on available assessment data, 36 866 (34·5%) of 106 811 participants had never previously spoken to a health professional about their symptoms, and most people self-reported symptoms of anxiety (88 879 [81·9%] of 108 494) or depression (78 803 [72·6%] of 108 494), either alone or in combination, at baseline. 21 745 patients started treatment in a therapist-guided online course, of whom 14 503 (66·7%) completed treatment (≥four of five lessons). Key trends in service use included an increase in the proportion of people using MindSpot primarily for assessment and information, from 52·6% in 2013 to 66·7% in 2019, while the proportion primarily seeking online treatment decreased, from 42·6% in 2013 to 26·7% in 2019. Effect sizes and percentage changes were large for estimated mean scores on the PHQ-9 and GAD-7 from assessment to post-treatment (PHQ-9, Cohen's d effect size 1·40 [95% CI 1·37-1·43]; and GAD-7, 1·45 [1·42-1·47]) and the 3 month follow-up (PHQ-9, 1·36 [1·34-1·38]; and GAD-7, 1·42 [1·40-1·44]); proportions of patients with reliable symptom deterioration (score increase of ≥6 points [PHQ-9] or ≥5 points [GAD-7]) were low post-treatment (of 13 058 respondents, 184 [1·4%] had symptom deterioration on the PHQ-9 and 282 [2·2%] on the GAD-7); and patient satisfaction rates were high (12 452 [96·6%] of 12 895 respondents would recommend the course and 12 433 [96·7%] of 12 860 reported the course worthwhile). We also observed small improvements in disability following treatment as measured by days out of role.

Interpretation: Our findings indicate improvement in psychological symptoms and positive reception among patients receiving online mental health treatment. These results support the addition of digital services such as MindSpot as a component in contemporary national mental health systems.

Funding: None.
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http://dx.doi.org/10.1016/S2589-7500(20)30224-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571905PMC
November 2020

Understanding Problems With Sleep, Sexual Functioning, Energy, and Appetite Among Patients Who Access Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Anxiety and Depression: Qualitative Exploratory Study.

JMIR Form Res 2020 Oct 13;4(10):e15037. Epub 2020 Oct 13.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia.

Background: Transdiagnostic internet-delivered cognitive behavioral therapy (T-ICBT) is an effective treatment for anxiety and depression, and nowadays, there is interest in exploring ways to optimize T-ICBT in routine care. T-ICBT programs are designed to address the primary cognitive-affective and behavioral symptoms of anxiety and depression (eg, low mood, worry, anhedonia, and avoidance). Treatment also has the potential to resolve other symptom concerns (eg, sleep disruption, sexual dysfunction, lack of energy, and appetite or weight changes). Having additional information regarding the extent of these concerns and how concerns change over time could prove beneficial for further development of T-ICBT in routine care.

Objective: This exploratory formative study aims to better understand sleep, sexual functioning, energy, and appetite concerns among T-ICBT clients seeking treatment for depression and anxiety. A qualitative analytic approach was used to identify themes in the symptom concerns reported by patients in the areas of sleep, sexual functioning, energy, and appetite at the time of enrollment. Patient responses to related items from screening measures for anxiety and depression were also examined pre- and posttreatment.

Methods: Patients in routine care who applied for a T-ICBT program for depression and anxiety over a 1-year period were included in this study. As part of the application and screening process, participants completed depression and anxiety symptom measures (ie, 9-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder scale). These same measures were administered posttreatment. Subsequently, they were asked if they were experiencing any problems with sleep, sexual activity, energy, or appetite (yes or no). If their response was yes, they were presented with an open-ended comment box that asked them to describe the problems they had experienced in those areas.

Results: A total of 462 patients were admitted to T-ICBT during the study period, of which 438 endorsed having some problems with sleep, sexual activity, energy, or appetite. The analysis of open-ended responses indicated that 73.4% (339/462) of patients reported sleep problems (eg, difficulty initiating or maintaining sleep), 69.3% (320/462) of patients reported problems with energy or motivation (eg, tiredness and low motivation), 57.4% (265/462) of patients reported appetite or body weight concerns (eg, changes in appetite and weight loss or gain), and 30.1% (139/462) of patients described concerns with sexual functioning (eg, loss of interest in sex and difficulty with arousal). Item analysis of symptom measures demonstrated that T-ICBT produced improvements in sleep, energy, and appetite in 8 weeks. Sexual dysfunction and weight changes were not represented in the screening measures, so it remains unclear what effect T-ICBT has on these symptoms.

Conclusions: Sleep disruption, lack of energy, appetite or weight changes, and sexual dysfunction are common concerns reported by clients enrolled in T-ICBT in routine practice and may deserve greater attention in T-ICBT program development and administration.
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http://dx.doi.org/10.2196/15037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592064PMC
October 2020

Effects of Internet-Based Cognitive Behavioral Therapy in Routine Care for Adults in Treatment for Depression and Anxiety: Systematic Review and Meta-Analysis.

J Med Internet Res 2020 08 31;22(8):e18100. Epub 2020 Aug 31.

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

Background: Although there is evidence for the efficacy of internet-based cognitive behavioral therapy (iCBT), the generalizability of results to routine care is limited.

Objective: This study systematically reviews effectiveness studies of guided iCBT interventions for the treatment of depression or anxiety.

Methods: The acceptability (uptake, participants' characteristics, adherence, and satisfaction), effectiveness, and negative effects (deterioration) of nonrandomized pre-post designs conducted under routine care conditions were synthesized using systematic review and meta-analytic approaches.

Results: A total of 19 studies including 30 groups were included in the analysis. Despite high heterogeneity, individual effect sizes of investigated studies indicate clinically relevant changes, with effect sizes ranging from Hedges' g=0.42-1.88, with a pooled effect of 1.78 for depression and 0.94 for anxiety studies. Uptake, participants' characteristics, adherence, and satisfaction indicate a moderate to high acceptability of the interventions. The average deterioration across studies was 2.9%.

Conclusions: This study provides evidence supporting the acceptability and effectiveness of guided iCBT for the treatment of depression and anxiety in routine care. Given the high heterogeneity between interventions and contexts, health care providers should select interventions that have been proven in randomized controlled clinical trials. The successful application of iCBT may be an effective way of increasing health care in multiple contexts.
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http://dx.doi.org/10.2196/18100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490682PMC
August 2020

A feasibility trial of an internet-delivered psychological intervention to manage mental health and functional outcomes in neurological disorders.

J Psychosom Res 2020 09 29;136:110173. Epub 2020 Jun 29.

eCentreClinic, Department of Psychology, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.

Objective: Mental health and cognitive difficulties are highly prevalent across neurological disorders and significantly contribute to poorer patient outcomes. Unfortunately, access to effective psychological services for these comorbidities are limited. To determine whether a novel transdiagnostic internet-delivered psychological intervention, the Wellbeing Neuro Course, was feasible, acceptable and efficacious a single-group feasibility open trial was employed.

Methods: The Wellbeing Neuro Course, targets mental health and cognitive difficulties, across a variety of neurological disorders. It is comprised of six online lessons, based on Cognitive Behavioural Therapy and Compensatory Cognitive Rehabilitation, delivered over 10 weeks and provided with weekly support from a mental health professional via email and telephone. 105 adults with diagnoses of either epilepsy, multiple sclerosis, Parkinson's disease and/or acquired brain injury, underwent the intervention.

Results: The intervention was found to be highly acceptable with high intervention completion and levels of satisfaction (>95%). There was evidence of clinically significant improvements in primary outcomes (within-group Cohen's d; average reductions) of depression (d = 0.93; avg. reduction ≥36%), anxiety (ds = 0.66, avg. reduction ≥36%), and disability (ds ≥ 0.49; avg. reduction ≥23%) at post-intervention, maintained at 3-month follow-up. For secondary outcomes there were significant improvements in fatigue severity and perceived cognitive difficulties of attention, planning and prospective memory. Findings were achieved with minimal clinician time, highlighting its public health potential.

Conclusion: This open trial provides preliminary evidence the Wellbeing Neuro Course is acceptable and reduces symptoms of depression, anxiety and disability in neurological disorders. Future controlled trials of the intervention are now needed.

Trial Registration: ACTRN12617000581369.
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http://dx.doi.org/10.1016/j.jpsychores.2020.110173DOI Listing
September 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

Rapid report: Early demand, profiles and concerns of mental health users during the coronavirus (COVID-19) pandemic.

Internet Interv 2020 Sep 1;21:100327. Epub 2020 Jun 1.

MindSpot Clinic, Macquarie University, Australia.

Background: Trends in contact with a high volume national digital mental health service (DMHS), the MindSpot Clinic, provide a unique opportunity to assess the mental health effects of the COVID-19 pandemic.

Methods: Three methods were used to assess changes in responses to COVID-19. First, website visits and call centre traffic were compared across two time periods: the "comparison period" (1 to 28 September 2019), and during the early weeks of the "COVID-19 pandemic" (19 March to 15 April 2020). Second, demographic and symptom data were compared across all patients who started an assessment during the comparison (n = 1650) and the COVID-19 period (n = 1668). Third, responses to questions about the impact of COVID-19 introduced to the assessment from 19 March 2020, and reports from treating therapists were examined.

Results: There was an 89% increase in website visits and a 90% increase in telephone calls to the clinic in the early COVID-19 period compared to the comparison period. There was a higher proportion of females in the COVID-19 sample (76.9% vs. 72.9%), and a lower proportion reported being in employment (52.8% vs. 60.8%). There was a small but significant increase in the severity of anxiety symptoms, and an increase in the number of people reporting recent onset of anxiety and depression. However, there were no differences between groups in severity of symptoms of distress or depression. Most people (94%) reported concern about the impact of COVID-19, and 88% reported making changes in lifestyle. Older adults had higher levels of concern about COVID-19. Therapists reported that patients were concerned about how to access testing, manage quarantine, financial security and the effect of social isolation.

Conclusions: COVID-19 has resulted in a significant increase in contact with an established DMHS, but we have not yet detected increases in baseline symptom severity. With the prospect of prolonged restriction of movement, DMHS such as MindSpot could play an important role in both providing clinical services and monitoring the mental health of the population.
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http://dx.doi.org/10.1016/j.invent.2020.100327DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262525PMC
September 2020

Preparing mental health systems for climate crisis.

Lancet Planet Health 2020 03;4(3):e89-e90

School of Psychology, Curtin University, Perth, WA 6845, Australia; Centre for Clinical Interventions, Northbridge, WA, Australia.

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http://dx.doi.org/10.1016/S2542-5196(20)30036-XDOI Listing
March 2020

A comparison of the characteristics and treatment outcomes of migrant and Australian-born users of a national digital mental health service.

BMC Psychiatry 2020 03 11;20(1):111. Epub 2020 Mar 11.

MindSpot Clinic, Macquarie University, Sydney, Australia.

Background: To explore the characteristics and compare clinical outcomes of non-Australian born (migrant) and Australian-born users of an Australian national digital mental health service.

Methods: The characteristics and treatment outcomes of patients who completed online treatment at the MindSpot Clinic between January 2014 and December 2016 and reported a country of birth other than Australia were compared to Australian-born users. Data about the main language spoken at home were used to create distinct groups. Changes in symptoms of depression and anxiety were measured using the Patient Health Questionnaire-9 Item (PHQ-9), and Generalized Anxiety Disorder Scale - 7 Item (GAD-7), respectively.

Results: Of 52,020 people who started assessment at MindSpot between 1st January 2014 and 22nd December 2016, 45,082 reported a country of birth, of whom 78.6% (n = 35,240) were Australian-born, and 21.4% (n = 9842) were born overseas. Of 6782 people who completed the online treatment and reported country of birth and main language spoken at home, 1631 (24%) were migrants, 960 (59%) were from English-speaking countries, and 671 (41%) were from non-English speaking countries. Treatment-seeking migrant users reported higher rates of tertiary education than Australian-born users. The baseline symptom severity, and rates of symptom reduction and remission following online treatment were similar across groups.

Conclusions: Online treatment was associated with significant reductions in anxiety and depression in migrants of both English speaking and non-English speaking backgrounds, with outcomes similar to those obtained by Australian-born patients. DMHS have considerable potential to help reduce barriers to mental health care for migrants.
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http://dx.doi.org/10.1186/s12888-020-02486-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065305PMC
March 2020

Audit and feedback of therapist-assisted internet-delivered cognitive behaviour therapy within routine care: A quality improvement case study.

Internet Interv 2020 Apr 6;20:100309. Epub 2020 Feb 6.

MindSpot Clinic and eCentreClinic, Department of Psychology, Macquarie University, Balaclava Road, North Ryde, NSW, Australia.

With the growing use of ICBT in routine care clinics there is a need for literature on how to monitor and improve the quality of therapist behaviours in clinical practice. In this paper, we first provide background literature on Audit and Feedback (A&F), a common quality improvement technique, and then present a case study regarding the use of A&F to improve quality of therapist behaviours in emails sent to patients provided with ICBT in routine care. The A&F measure used was derived from previous research on therapist's email behaviours in ICBT. Fifteen undesirable therapist behaviours (e.g., ) were audited in 1840 emails sent from eight therapists to 198 randomly selected patients, representing 18% of 1114 patients who started between one and five lessons of ICBT in the previous year and did not formally withdraw from treatment ( = 31 patients). The therapists who were audited were provided feedback four times over a one-year period from October 2018 to September 2019. Overall, in all audit periods, we found a low percentage of undesirable therapist behaviours (i.e., therapists displayed the behaviour in 12% or less of the total emails sent). For most therapist behaviours, we saw a trend towards improvement across the four audit cycles. Three therapist behaviours (i.e., , , ) did not follow this pattern and were flagged for clinical discussion to determine why behaviours were elevated and whether these behaviours represented unrealistic expectations. The process was valuable for monitoring and improving therapist behaviours and highlights the need for future research on standards for therapist behaviours (e.g., which behaviours to focus on, setting acceptable levels of undesirable behaviour).
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http://dx.doi.org/10.1016/j.invent.2020.100309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011000PMC
April 2020

Does concurrent medication usage affect patient response to internet-delivered cognitive behaviour therapy for depression and anxiety?

Internet Interv 2020 Mar 29;19:100302. Epub 2019 Dec 29.

Online Therapy Unit, Department of Psychology, University of Regina, Regina, SK, Canada.

Background: There is growing interest in Internet-delivered cognitive behavioural therapy (ICBT) as an alternative to face-to-face therapy for anxiety and depression because it reduces barriers to accessing traditional treatment (e.g., travel distance, cost, stigma). Extensive research has demonstrated that ICBT is an effective treatment for anxiety and depression and that it produces effect sizes comparable to medication and face-to-face therapy. In routine practice, however, ICBT patients commonly receive simultaneous pharmacological treatment, and few studies have examined how medication affects patient outcomes.

Objective: The objective of this study was to explore whether use of psychotropic medications predicts outcomes or adherence among patients receiving ICBT for depression and anxiety in a large community sample.

Methods: This study used data from 1201 patients who received an 8-week course of ICBT for anxiety and depression that included weekly therapist support as part of routine care. Patients reported medication usage and completed measures of depression and anxiety before treatment, after treatment, and at three-month follow-up.

Results: 60% of patients at pre-treatment reported regularly taking psychotropic medication. Common classes of medication reported included: (i) selective serotonin reuptake inhibitors (34%); (ii) anxiolytics (15%); (iii) serotonin and norepinephrine reuptake inhibitors (14%); (iv) antipsychotics (8%); and (v) norepinephrine-dopamine reuptake inhibitors (7%). At post-treatment and three-month follow-up, overall medication usage reduced slightly to 55%, with the greatest reduction seen in anxiolytics. Logistic regression revealed that none of the classes of medication commonly reported at pre-treatment were associated with study completion rates. A recursive partitioning algorithm found that usage of tetracyclic medication was related to smaller pre-to-post reductions in anxiety symptoms and did not identify any medication types that were related to differences in depressive symptom change. Patients on medication tended to report higher levels of anxiety symptoms at intake and experienced somewhat more modest symptom reductions than patients not taking medications; nevertheless, they still experienced large reductions in depression and anxiety over the course of treatment.

Conclusions: These results show that medication usage is very common in a diverse community sample of patients seeking ICBT for anxiety and depression. Patients reporting medication usage at intake are likely to benefit from treatment approximately as much as patients not taking medication. These results support the continued referral of patients receiving psychotropic medication to ICBT programs for anxiety and depression. Program designers might also consider providing information about the common medications (SSRIs, SNRIs, anxiolytics) used by this population alongside CBT materials.
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http://dx.doi.org/10.1016/j.invent.2019.100302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7016234PMC
March 2020

An Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Clients Referred and Funded by Insurance Companies Compared With Those Who Are Publicly Funded: Longitudinal Observational Study.

JMIR Ment Health 2020 Feb 4;7(2):e16005. Epub 2020 Feb 4.

MindSpot, Department of Psychology, Macquarie University, Sydney, Australia.

Background: Anxiety and depression are leading causes of disability but are often undertreated. Internet-delivered cognitive behavioral therapy (ICBT) improves access to treatment by overcoming barriers to obtaining care. ICBT has been found to be efficacious in research trials and routine care, but there is limited research of ICBT when it is recommended and funded by insurance companies for clients on or recently in receipt of disability benefits or accommodations.

Objective: The aim of this study was to examine ICBT engagement, treatment satisfaction, and effectiveness among individuals involved with 2 insurance companies. The 2 samples were benchmarked against published outcomes from a publicly funded (PF) ICBT clinic.

Methods: Individuals who were on or recently in receipt of disability benefits and were either insurance company (IC) employees (n=21) or IC plan members (n=19) were referred to ICBT funded by the respective insurance companies. Outcomes were benchmarked against outcomes of ICBT obtained in a PF ICBT clinic, with clients in the clinic divided into those who reported no involvement with insurance companies (n=414) and those who were on short-term disability (n=44). All clients received the same 8-week, therapist-assisted, transdiagnostic ICBT course targeting anxiety and depression. Engagement was assessed using completion rates, log-ins, and emails exchanged. Treatment satisfaction was assessed posttreatment. Depression, anxiety, and disability measures were administered pretreatment, posttreatment, and at 3 months.

Results: All samples showed high levels of ICBT engagement and treatment satisfaction. IC employees experienced significant improvement at posttreatment (depression d=0.77; anxiety d=1.13; and disability d=0.91) with outcomes maintained at 3 months. IC plan members, who notably had greater pretreatment disability than the other samples, experienced significant moderate effects at posttreatment (depression d=0.58; anxiety d=0.54; and disability d=0.60), but gains were not maintained at 3 months. Effect sizes at posttreatment in both IC samples were significantly smaller than in the PF sample who reported no insurance benefits (depression d=1.14 and anxiety d=1.30) and the PF sample who reported having short-term disability benefits (depression d=0.95 and anxiety d=1.07). No difference was seen in effect sizes among IC employees and the PF samples on disability. However, IC plan members experienced significantly smaller effects on disability d=0.60) compared with the PF sample with no disability benefits d=0.90) and those on short-term disability benefits d=0.94).

Conclusions: Many clients referred and funded by insurance companies were engaged with ICBT and found it acceptable and effective. Results, however, were not maintained among those with very high levels of pretreatment disability. Small sample sizes in the IC groups are a limitation. Directions for research related to ICBT funded by insurance companies have been described.
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http://dx.doi.org/10.2196/16005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058169PMC
February 2020

Guidance on defining the scope and development of text-based coaching protocols for digital mental health interventions.

Digit Health 2019 Jan-Dec;5:2055207619896145. Epub 2019 Dec 16.

Center for Behavioral Intervention Technologies, Northwestern University, Chicago, IL, USA.

A body of literature suggests that the provision of human support improves both adherence to and clinical outcomes for digital mental health interventions. While multiple models of providing human support, or coaching, to support digital mental health interventions have been introduced, specific guidance on how to develop coaching protocols has been lacking. In this Education Piece, we provide guidance on developing coaching protocols for text-based communication in digital mental health interventions. Researchers and practitioners who are tasked with developing coaching protocols are prompted to consider the scope of coaching for the intervention, the selection and training of coaches, specific coaching techniques, how to structure communication with clients and how to monitor adherence to guidelines, and quality of coaching. Our goal is to advance thinking about the provision of human support in digital mental health interventions to inform stronger, more engaging, and effective intervention designs.
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http://dx.doi.org/10.1177/2055207619896145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6920342PMC
December 2019

Negative effects associated with internet-delivered cognitive behaviour therapy: An analysis of client emails.

Internet Interv 2019 Dec 4;18:100278. Epub 2019 Sep 4.

MindSpot Clinic and eCentreClinic, Department of Psychology, Macquarie University, Balaclava Road, North Ryde, NSW, Australia.

Internet-delivered cognitive behaviour therapy (ICBT) is an efficacious form of treatment for anxiety and depression, yet it is still possible for clients to experience negative effects associated with treatment. In the ICBT literature, the term negative effects is broadly used to refer to all potentially adverse or unwanted events or experiences that are perceived as undesirable by the client and may or may not be associated with long-term symptoms or distress. Previous ICBT studies have asked clients to retrospectively describe negative effects at post-treatment; however, no research has examined the content of clients' emails to their therapist to see whether clients are reporting negative effects as they arise. In the current study, 96 clients (80 completers; 16 non-completers) were randomly selected from a published ICBT trial and directed content analysis was used to examine client emails for mention of negative effects. In addition, correlational analyses were used to examine the relationship between negative effects and: 1) demographic characteristics; 2) treatment engagement; 3) treatment satisfaction; 4) working alliance; and 5) symptom outcomes among completers. The results indicated that 61.5% of clients experienced at least one negative effect during treatment, although total number of negative effects was not significantly correlated with client demographic characteristics, lessons completed, working alliance, treatment satisfaction, or symptom outcomes. Among completers, , , and were the most commonly reported negative effects, whereas was the most commonly reported negative effect by non-completers. Negative effects that have been identified in previous research, such as symptom deterioration, novel symptoms, and severe adverse events, were not identified in client emails. The high incidence of negative effects in the current study suggests there may be value in systematically monitoring client emails for negative effects throughout treatment as a supplement to retrospective post-treatment reports. This will give therapists the opportunity to intervene as negative effects occur and potentially mitigate any impact they have on treatment outcomes. Future research, both qualitative and quantitative, is needed to gain a more nuanced understanding of negative effects associated with ICBT.
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http://dx.doi.org/10.1016/j.invent.2019.100278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926340PMC
December 2019

Development of the Internet-Delivered Cognitive Behaviour Therapy Undesirable Therapist Behaviours Scale (ICBT-UTBS).

Internet Interv 2019 Dec 18;18:100255. Epub 2019 Jun 18.

MindSpot Clinic and eCentreClinic, Department of Psychology, Macquarie University, Balaclava Road, North Ryde, NSW, Australia.

Internet-delivered cognitive behaviour therapy (ICBT) is often provided with therapist assistance via asynchronous secure emails, but there is limited research on undesirable behaviours exhibited by therapists in their correspondence with patients. In this study, an ICBT-Undesirable Therapist Behaviour Scale (ICBT-UTBS) was developed and used to assess the nature, frequency, and correlates of undesirable therapist behaviours in routine practice. Thematic analysis was used to identify undesirable therapist behaviours in 720 emails sent to 91 randomly selected patients in the context of a previous clinical trial of transdiagnostic ICBT for depression and anxiety. The following undesirable behaviours were identified, albeit infrequently, in therapist emails: (6.4%), (4.0%), (0.6%), (0.6%), (0.6%), and (0.3%). At least one undesirable behaviour was found in 10.7% of all emails coded. Moreover, 37.4% of patients received at least one email containing an undesirable therapist behaviour. Number of undesirable therapist behaviours was not correlated with patient engagement, working alliance, treatment satisfaction, or patient outcome variables. However, undesirable therapist behaviours were negatively correlated with patient gender and therapist characteristics (e.g., clinical setting, therapist profession). The results of the present study provide preliminary psychometric support for the ICBT-UTBS, a measure of ICBT treatment integrity. In the future, the ICBT-UTBS should be used in combination with the ICBT-Therapist Rating Scale (ICBT-TRS), a measure of desirable or recommended therapist behaviours, for training purposes and to monitor ICBT therapists in routine practice.
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http://dx.doi.org/10.1016/j.invent.2019.100255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926341PMC
December 2019

A randomized controlled trial of internet-delivered cognitive behaviour therapy to prevent the development of depressive disorders in older adults with multimorbidity.

J Affect Disord 2020 03 13;264:464-473. Epub 2019 Nov 13.

Macquarie University, Australia.

Background: Multimorbidity, which commonly impacts older adults is associated with higher rates of depression. We aimed to investigate whether internet delivered cognitive-behaviour therapy (iCBT) could prevent depressive disorders in older adults with multimorbidity who were not currently depressed.

Method: 302 primary care and community participants aged 65 years and over, who had multimorbidity but did not meet criteria for a depressive disorder were randomised to an intervention group who received an eight-week, five session iCBT (n = 150) or to a control group (n = 152) who received treatment as usual. Diagnostic interviews were conducted at baseline, and three and six months after the intervention period, where indicated, and the presence of depressive disorder was the primary outcome.

Results: The intention to treat, chi-square analyses indicated there were significantly fewer cases of depressive disorder in the treatment group compared to the control group by six-month follow-up (χ²(1,302) = 5.21, p = .02).

Limitations: The main limitations of this RCT are a short follow up period and low proportion of participants who developed depressive disorders. Participants were relatively well educated, with a majority having English as their first language.

Conclusions: These results indicate that depressive disorder was prevented in the first six months following iCBT with three times the number of cases of depressive disorder in the control group compared to the treatment group. Further research is required to determine whether iCBT can be effective for preventing depressive disorder in this population over a longer time period.
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http://dx.doi.org/10.1016/j.jad.2019.11.077DOI Listing
March 2020

Identifying Key Risk Factors for Dizziness Handicap in Middle-Aged and Older People.

J Am Med Dir Assoc 2020 03 17;21(3):344-350.e2. Epub 2019 Oct 17.

Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia. Electronic address:

Objectives: More than 10% of people aged 50 years and older report dizziness. Despite available treatments, dizziness remains unresolved for many people due in part to suboptimal assessment. We aimed to identify factors associated with dizziness handicap in middle-aged and older people to identify targets for intervention to address this debilitating problem. A secondary aim was to determine whether factors associated with dizziness differed between middle-aged (<70 years) and older people (≥ 70 years).

Design: Secondary analysis of baseline and prospective data from a randomized controlled trial.

Setting And Participants: In total, 305 individuals aged 50 to 92 years reporting significant dizziness in the past year were recruited from the community.

Methods: Participants were classified as having either mild or no dizziness handicap (score <31) or moderate/severe dizziness handicap (score: 31‒100) based on the Dizziness Handicap Inventory. Participants completed health questionnaires and underwent assessments of psychological well-being, lying and standing blood pressure, vestibular function, strength, vision, proprioception, processing speed, balance, stepping, and gait. Participants reported dizziness episodes in monthly diaries for 6 months following baseline assessment.

Results: Dizziness Handicap Inventory scores ranged from 0 to 86 with 95 participants (31%) reporting moderate/severe dizziness handicap. Many vestibular, cardiovascular, psychological, balance-related, and medical/medications measures were significantly associated with dizziness handicap severity and dizziness episode frequency. Binary logistic regression identified a positive Dix Hallpike/head-roll test for benign paroxysmal positional vertigo [odds ratio (OR) 2.09, 95% confidence interval (CI) (1.11‒3.97)], cardiovascular medication use [OR 1.90, 95% CI (1.09‒3.32)], high postural sway when standing on the floor with eyes closed (sway path ≥160 mm) [OR 2.97, 95% CI (1.73‒5.10)], and anxiety (Generalized Anxiety Disorder Scale 7-item Scale score ≥8) [OR 3.08, 95% CI (1.36‒6.94)], as significant and independent predictors of moderate/severe dizziness handicap. Participants aged 70 years and over were significantly more likely to report cardiovascular conditions than those aged less than 70 years old.

Conclusions And Implications: Assessments of cardiovascular conditions and cardiovascular medication use, benign paroxysmal positional vertigo, anxiety, and postural sway identify middle-aged and older people with significant dizziness handicap. A multifactorial assessment including these factors may assist in tailoring evidence-based therapies to alleviate dizziness handicap in this group.
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http://dx.doi.org/10.1016/j.jamda.2019.08.016DOI Listing
March 2020

Stakeholder perspectives on evidence for digital mental health interventions: Implications for accreditation systems.

Digit Health 2019 Jan-Dec;5:2055207619878069. Epub 2019 Sep 19.

Centre for Mental Health Research, Research School of Population Health, The Australian National University, Canberra, Australia.

Background: Digital mental health interventions can be effective for treating mental health problems, but uptake by consumers and clinicians is not optimal. The lack of an accreditation pathway for digital mental health interventions is a barrier to their uptake among clinicians and consumers. However, there are a number of factors that may contribute to whether a digital intervention is suitable for recommendation to the public. The aim of this study was to identify the types of evidence that would support the accreditation of digital interventions.

Method: An expert workshop was convened, including researcher, clinician, consumer (people with lived experience of a mental health condition) and policymaker representatives.

Results: Existing methods for assessing the evidence for digital mental health interventions were discussed by the stakeholders present at the workshop. Empirical evidence from randomised controlled trials was identified as a key component for evaluating digital interventions. However, information on the safety of users, data security, user ratings, and fidelity to clinical guidelines, along with data from routine care including adherence, engagement and clinical outcomes, were also identified as important considerations when evaluating an intervention. There are considerable challenges in weighing the evidence for a digital mental health intervention.

Conclusions: Empirical evidence should be the cornerstone of any accreditation system to identify appropriate digital mental health interventions. However, robust accreditation systems should also account for program and user safety, user engagement and experience, and fidelity to clinical treatment guidelines.
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http://dx.doi.org/10.1177/2055207619878069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6755623PMC
September 2019

Opioid use before and after completion of an online pain management program.

J Consult Clin Psychol 2019 Oct;87(10):904-917

MindSpot Clinic, Macquarie University.

Objective: The purpose of this study was to examine the effect of a pain management course that has demonstrated efficacy in pain reduction on the use of opioid medication.

Method: Self-reported medication use was recorded at baseline assessment for all patients enrolled in a validated pain management program provided free by a university research clinic (N = 471). Participants were randomized either to receive immediate treatment or to be a wait-list control. Opioid use at baseline assessment, with the daily doses converted to morphine equivalents, was compared with the self-reported opioid medication use at posttreatment and 3-month follow-up. The relationship between opioid use and measures of psychological symptoms, pain, and disability was examined.

Results: At assessment, 85% (n = 399) reported taking some form of pain modifying or psychotropic medication, 43.1% (n = 203) reported regular opioid use and 22.9% (n = 108) reported taking additional as required (pro re nata, or PRN) opioid-containing medication. On completion, there were significant reductions in the number who reported taking regular opioids and a large reduction in the use of PRN opioids and in the reported doses of opioids. Those reductions were more strongly associated with reductions in symptoms of anxiety and depression than in measures of disability and pain.

Conclusions: The reduction in the self-reported use of regular and PRN opioid pain-relieving medication following completion of an online pain management program with demonstrated efficacy in pain reduction appeared to be related to effective treatment of symptoms of anxiety and depression. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000407DOI Listing
October 2019

Evaluation of The Practitioner Online Referral and Treatment Service (PORTS): the first 18 months of a state-wide digital service for adults with anxiety, depression, or substance use problems.

Cogn Behav Ther 2020 07 25;49(4):307-326. Epub 2019 Sep 25.

MindSpot Clinic, Macquarie University , Sydney, Australia.

The Practitioner Online Referral and Treatment Service (PORTS) is a new digital mental health service (DMHS) providing assessment, treatment, and consultation across Western Australia, for adults with anxiety, depression, or substance use problems, and experiencing financial hardship or geographical disadvantage. From July 2017 to December 2018, a total of 2,527 individuals were referred to PORTS. Of these, 150 (6%) did not give consent for their results to be analysed. Of the remaining 2,377 patients, 615 (26%) could not be contacted to confirm the referral, 596 (25%) received assessment or information from PORTS, 427 (18%) were referred to another service, and 739 (31%) commenced treatment at PORTS. Almost half (47%) of patients were from areas with significant socio-economic disadvantage. Those referred by another mental health service were more likely to engage in treatment than those referred by a General Practitioner (GP). Overall outcomes were excellent, with large effect sizes (Cohen's : 1.1-1.4), from assessment to post-treatment and 3-month follow-up, reliable deterioration was low, and GP and patient satisfaction was high. These results indicate that the PORTS DMHS model is a promising method for engaging primary care patients with anxiety and depression, including those experiencing financial and geographical disadvantage.
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http://dx.doi.org/10.1080/16506073.2019.1666162DOI Listing
July 2020

From Research to Practice: Ten Lessons in Delivering Digital Mental Health Services.

J Clin Med 2019 Aug 17;8(8). Epub 2019 Aug 17.

MindSpot Clinic and Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia.

There is a large body of research showing that psychological treatment can be effectively delivered via the internet, and Digital Mental Health Services (DMHS) are now delivering those interventions in routine care. However, not all attempts to translate these research outcomes into routine care have been successful. This paper draws on the experience of successful DMHS in Australia and Canada to describe ten lessons learned while establishing and delivering internet-delivered cognitive behavioural therapy (ICBT) and other mental health services as part of routine care. These lessons include learnings at four levels of analysis, including lessons learned working with (1) consumers, (2) therapists, (3) when operating DMHS, and (4) working within healthcare systems. Key themes include recognising that DMHS should provide not only treatment but also information and assessment services, that DMHS require robust systems for training and supervising therapists, that specialist skills are required to operate DMHS, and that the outcome data from DMHS can inform future mental health policy. We also confirm that operating such clinics is particularly challenging in the evolving funding, policy, and regulatory context, as well as increasing expectations from consumers about DMHS. Notwithstanding the difficulties of delivering DMHS, we conclude that the benefits of such services for the broader community significantly outweigh the challenges.
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http://dx.doi.org/10.3390/jcm8081239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6722769PMC
August 2019

Facilitating access to iCBT: a randomized controlled trial assessing a translated version of an empirically validated program using a minimally monitored delivery model.

Behav Cogn Psychother 2020 Mar 16;48(2):185-202. Epub 2019 Aug 16.

École de Psychologie, Université de Moncton, Canada.

Background: Despite its established efficacy, access to internet-delivered CBT (iCBT) remains limited in a number of countries. Translating existing programs and using a minimally monitored model of delivery may facilitate its dissemination across countries.

Aims: This randomized control trial aims to evaluate the efficacy of an iCBT transdiagnostic program translated from English to French and offered in Canada using a minimally monitored delivery model for the treatment of anxiety and depression.

Method: Sixty-three French speakers recruited in Canada were randomized to iCBT or a waiting-list. A French translation of an established program, the Wellbeing Course, was offered over 8 weeks using a minimally monitored delivery model. Primary outcome measures were the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9), which were obtained pre-treatment, post-treatment and at 3-month follow-up.

Results: Mixed-effects models revealed that participants in the treatment group had significantly lower PHQ-9 and GAD-7 scores post-treatment than controls with small between-groups effect sizes (d = 0.34 and 0.37, respectively). Within-group effect sizes on primary outcome measures were larger in the treatment than control group. Clinical recovery rates on the PHQ-9 and GAD-7 were significantly higher among the treatment group (40 and 56%, respectively) than the controls (13 and 16%, respectively).

Conclusions: The provision of a translated iCBT program using a minimally monitored delivery model may improve patients' access to treatment of anxiety and depression across countries. This may be an optimal first step in improving access to iCBT before sufficient resources can be secured to implement a wider range of iCBT services.
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http://dx.doi.org/10.1017/S135246581900047XDOI Listing
March 2020

Examining an internet-delivered intervention for anxiety and depression when delivered as a part of routine care for university students: A phase IV trial.

J Affect Disord 2019 09 2;256:567-577. Epub 2019 Jul 2.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia; MindSpot Clinic, MQ Health, Macquarie University, Sydney, Australia.

Background: There has been growing interest in the potential of emerging internet-delivered psychological treatments for supporting the mental health needs of university students. However, no large-scale prospective effectiveness trials examining their real-world potential have been reported.

Objective: The aim of the current study was to evaluate the acceptability and effectiveness of a brief, 5-week, internet-delivered and therapist-guided intervention for anxiety and depression, when delivered as part of routine care by a university counselling service.

Design: A large, prospective, single-group Phase-IV clinical trial. Students (n = 1326) engaging with the university counselling service were provided the opportunity to receive the intervention based on their preferences and identified needs. Students completed standardised measures of anxiety and depression at pre-treatment, each week of the intervention, post-treatment and 3-month follow-up.

Results: Over a 4 year period, 1081 students (10% of those presenting to the counselling service) participated in the intervention. Large clinical reductions in symptoms of both anxiety (% reduction = 41%; Cohen's d = 0.94) and depression (% reduction = 36%; Cohen's d = 0.81) were observed alongside high levels of acceptability. The intervention required relatively little counsellor time (M = 36.28 mins; SD = 20.56) per student, and symptom deterioration was observed in less than 5% of students.

Conclusion: The findings of the current study are supportive of internet-delivered interventions provided as routine care to university students. Further research is needed to carefully explore whether these interventions could be used with a larger proportion of students presenting to counselling services, paying close attention to acceptability, engagement and clinical outcomes.
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http://dx.doi.org/10.1016/j.jad.2019.06.044DOI Listing
September 2019