Publications by authors named "Tobias Krieger"

53 Publications

Optimizing cognitive-behavioral therapy for social anxiety disorder and understanding the mechanisms of change: Study protocol for a randomized factorial trial.

Internet Interv 2021 Dec 10;26:100480. Epub 2021 Nov 10.

Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse, 8, 3012 Bern, Switzerland.

Background: Social anxiety disorder (SAD) is characterized by a marked fear of negative evaluation in social situations and significant impairments. Even with the most effective treatments, remission rates are around 50%. An important reason for the limited effectiveness of treatments is the lack of evidence-based explanation of how treatments work and what their active ingredients might be. An approach to unpack the active ingredients and mechanisms of treatment is the factorial design.

Objectives: The study is a factorial trial aiming (1) to examine the main effects and interactions for the four main treatment components of internet-based cognitive-behavioral therapy (ICBT) for SAD (i.e., psychoeducation, cognitive restructuring, attentional training, and exposure) and (2) to examine whether and which change mechanisms mediate the relationship between treatment components and symptom reduction.

Methods: A total of 464 adults diagnosed with SAD will be randomized to one of 16 conditions containing combinations of the treatment components. The primary endpoint is SAD symptomatology at eight weeks. Secondary endpoints include symptoms of depression and anxiety, quality of life, and negative effects. Hypothesized change mechanisms are the increase of knowledge about SAD, the decrease of dysfunctional cognitions, the decrease of self-focused attention, and the decrease of avoidance and safety behaviors.

Discussion: A better understanding of the differential efficacy of treatment components and mechanisms of treatment underlying ICBT for SAD might inform clinicians and researchers to plan more potent and scalable treatments.

Trial Registration: clinicaltrials.gov (NCT04879641) on June, 11th 2021. https://clinicaltrials.gov/ct2/show/NCT04879641.
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http://dx.doi.org/10.1016/j.invent.2021.100480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8605076PMC
December 2021

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 07;31(31 Suppl 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
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8495679PMC
July 2021

Differential Effects of Psychological Interventions in Online and Face-to-Face Settings on DSM-5 and ICD-11 Maladaptive Trait Domains: An Exploratory Pilot Study.

Front Psychiatry 2021 14;12:648367. Epub 2021 Jun 14.

Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany.

While mental health treatments have proven to be effective for a range of mental health problems, there is comparably little research on its effects on personality disorders or difficulty (PD). New dimensional conceptualizations of PD such as the ICD-11 PD model enable the cost- and time-effective dimensional assessment of severity and style of PD. Furthermore, they constitute a promising tool to investigate PD, not only as a treatment endpoint but also as a predictive or influencing factor for mental health treatments. In this study, we investigated the effects in two different mental health treatment settings [online ( = 38); face-to-face and blended [FTF/blended] ( = 35)] on the reduction of maladaptive personality traits as well as the interaction between maladaptive personality patterns and the response on primary endpoints (i.e., mental distress). Results indicate that both treatment settings have comparable within-group effects on the reduction of distress symptoms, while the treatment in the FTF/blended setting seems to have a stronger impact on the reduction of maladaptive traits. Further, reduction of maladaptive trait expressions was a reliable predictor of treatment response in the FTF/blended setting while explaining less variance in the online setting. Beyond the promising findings on the utility of maladaptive trait change as an outcome measure, we discuss possible applications as an information source for treatment decisions.
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http://dx.doi.org/10.3389/fpsyt.2021.648367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236509PMC
June 2021

Optimizing the Context of Support to Improve Outcomes of Internet-Based Self-help in Individuals With Depressive Symptoms: Protocol for a Randomized Factorial Trial.

JMIR Res Protoc 2021 Feb 2;10(2):e21207. Epub 2021 Feb 2.

Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland.

Background: Internet-based self-help interventions for individuals with depressive symptoms, in which the main component is often a web-based self-help program, have been shown to be efficacious in many controlled trials. However, there are also trials on self-help programs showing no significant effect when delivered in routine care, and some studies report high dropout and low adherence rates. Research suggests that these findings do not emerge primarily due to the specific content of a self-help program. It seems more important how a program is embedded in the context of human and automated support before and during the use of a self-help program.

Objective: This study aims to better understand the effects of 4 supportive contextual factors on outcomes of and adherence to a web-based self-help program for depressive symptoms. In a factorial experiment, 2 of 4 supportive factors, for which there is evidence for their role on outcomes and adherence, are realized during the intervention-personal guidance and automated email reminders. The other 2 factors are realized before the intervention-a diagnostic interview and a preintervention module aimed at increasing the motivation to use the program with motivational interviewing techniques.

Methods: The study is a full factorial randomized trial. Adults with mild to moderate depressive symptoms (Patient Health Questionnaire-9 score: 5-14) are recruited from the community through the internet and conventional media. All participants receive access to a web-based self-help program based on problem-solving therapy. They are randomized across 4 experimental factors, each reflecting the presence versus absence of a supportive factor (guidance, automated reminders, diagnostic interview, preintervention module) resulting in a 16-condition balanced factorial design. The primary outcome is depressive symptoms at 10 weeks post assessment. Secondary outcomes include adherence to the program, anxiety, stress, health-related quality of life, possible negative effects, and treatment satisfaction. Potential moderators and mediators (eg, treatment expectancy, problem-solving skills, working alliance with the study team) will also be investigated.

Results: Ethical approval was received on January 20, 2020. The study was initiated in February 2020, and 240 participants have been enrolled in the study as of November 1, 2020. Recruitment for a total of 255 participants is ongoing. Data collection is expected to be completed by May 2021.

Conclusions: A better understanding of relevant supportive factors in the dissemination of web-based interventions is necessary to improve outcomes of and adherence to web-based self-help programs. This study may inform health care systems and guide decisions to optimize the implementation context of web-based self-help programs for depressive symptoms.

Trial Registration: ClinicalTrials.gov NCT04318236; https://clinicaltrials.gov/ct2/show/NCT04318236.

International Registered Report Identifier (irrid): DERR1-10.2196/21207.
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http://dx.doi.org/10.2196/21207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886615PMC
February 2021

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

JMIR Res Protoc 2020 Nov 12;9(11):e20936. Epub 2020 Nov 12.

Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland.

Background: Emotion regulation has been identified as an important transdiagnostic factor relevant to the treatment of mental health disorders. Many empirically validated psychotherapeutic treatments incorporate elements targeting emotion regulation. Most of these treatment approaches are conceptualized as standard face-to-face treatments not as blended treatments, which include an internet-based intervention.

Objective: The aim of this study is to examine, for the first time, a new internet-based intervention-REMOTION-that will be provided transdiagnostically, as an add-on to psychotherapy, to provide a blended treatment format.

Methods: A total of 70 participants will be assigned (1:1 allocation ratio) to either the intervention group (REMOTION + psychotherapy) or the treatment-as-usual group that receives psychotherapy alone. To maximize external validity, a typical outpatient treatment sample of patients diagnosed with a range of disorders such as depression, anxiety disorders, and adjustment disorder will be recruited from a university outpatient clinic. Patients with bipolar disorder, psychotic disorders, or acute suicidality will be excluded from the study. The feasibility and potential effectiveness of the intervention will be examined by assessing data at baseline, 6 weeks (post), and 12 weeks (follow-up). The primary outcome is general symptom severity, assessed with the Brief Symptom Inventory. Secondary outcomes are emotion regulation, depressive symptoms, anxiety symptoms, health related quality of life, well-being, and a variety of feasibility parameters. Quantitative data will be analyzed on an intention-to-treat basis.

Results: Participant recruitment and data collection started in February 2020, and as of November 2020, are ongoing. Results for the study are expected in 2022.

Conclusions: This pilot randomized controlled trial will inform future studies using transdiagnostic blended treatment.

Trial Registration: ClinicalTrials.gov NCT04262726; http://clinicaltrials.gov/ct2/show/NCT04262726.

International Registered Report Identifier (irrid): DERR1-10.2196/20936.
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http://dx.doi.org/10.2196/20936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691093PMC
November 2020

[Internet-based psychotherapeutic interventions].

Fortschr Neurol Psychiatr 2020 Oct 13;88(10):677-689. Epub 2020 Oct 13.

Over the past few years, research and application of internet-based psychotherapeutic interventions has grown rapidly. This kind of new therapeutic format offers a variety of chances for treating patients with psychotherapeutic disorders, but also arouses skepticism and concerns. This overview focuses on different forms of internet-based psychotherapeutic interventions, reflects the current state of research, and points out new areas of development as well as its implementation in daily practice.
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http://dx.doi.org/10.1055/a-1165-7496DOI Listing
October 2020

Effectiveness and Cost-Effectiveness of Internet-Based Cognitive Behavioral Therapy for Insomnia in Clinical Settings.

Front Psychiatry 2020 20;11:838. Epub 2020 Aug 20.

Sleep-Wake-Epilepsy-Center, Department of Neurology, Inselspital, Bern University Hospital, University Bern, Bern, Switzerland.

Background: Internet-delivered cognitive-behavior treatment for insomnia (iCBT-I) has the potential to fill the gap created by the discrepancy between insomnia cases and number of trained professionals. Although the effectiveness of this method was proven in multiple studies conducted in research settings, its feasibility in routine care is still unclear. Predictors, mediators, and moderators of treatment effect remain uncertain since previous studies often give contradictory results. The present study aims to investigate clinical effectiveness and cost-effectiveness of an internet-based CBT-I program Sleepsy in comparison with care as usual (CAU) among patients with CI recruited from clinical settings. Baseline data will be further analyzed to find predictors of treatment outcome.

Methods/design: The proposed study is a parallel-group randomized controlled trial comparing CAU plus iCBT-I with CAU in a clinical setting. One hundred ten participants will be referred from the medical doctors in Moscow. Both groups will have access to CAU, which corresponds to the treatment prescribed by the referring doctor. Patients of the first group will additionally get access to the iCBT-I program with the opportunity to contact a specialist (guidance on request) in a secured environment. The primary outcome is insomnia severity change from pre- to post-treatment. Secondary outcomes include change of subjective sleep characteristics, life quality, fatigue, daytime sleepiness, comorbid affective disorders, dysfunctional beliefs about sleep, sleep hygiene, healthcare consumption, productivity losses, and longer term outcomes at 3 months follow-up. Predictor analysis will include baseline scores of the aforementioned outcomes along with treatment expectancies and personality traits.

Discussion: The proposed study is one of the first studies evaluating whether iCBT-I also works in routine care. We expect that recruitment of the participants let us determine the target group more precisely and exclude health problems interfering with treatment. Using CAU as control condition may result in a loss of power to detect a meaningful difference. Nevertheless, this approach is reasonable since it reconstructs the clinical situation faced by practicing doctors.
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http://dx.doi.org/10.3389/fpsyt.2020.00838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7469927PMC
August 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

Effects of patient-therapist interpersonal complementarity on alliance and outcome in cognitive-behavioral therapies for depression: Moving toward interpersonal responsiveness.

J Couns Psychol 2021 Oct 27;68(5):582-592. Epub 2020 Aug 27.

Clinical Psychology and Psychotherapy Department.

This study analyzed patient-therapist in-session interpersonal complementarity effects on the therapeutic alliance and depression severity during the initial and working phase of cognitive-behavioral therapy for depression. It also explored whether patients' interpersonal problems moderate those complementarity effects. We drew on a sample of 90 dyads derived from a randomized controlled trial of two cognitive-behavioral therapies for depression. Using an observer-based measure, we assessed patients' and therapists' interpersonal behavior in Sessions 1, 5, 9, and 13 and computed their complementarity regarding interpersonal affiliation (i.e., correspondence) and dominance (i.e., reciprocity). Patients completed measures of interpersonal problems at baseline and session-by-session measures of depression severity and quality of the therapeutic alliance. Response surface analyses based on polynomial regressions showed that patient-therapist complementarity in higher affiliative behaviors was associated with a stronger alliance. Interpersonal problems regarding agency moderated the complementarity effects of the dominance dimensions on depression severity. Overly dominant patients benefited more from a nonreciprocal relationship in the dominance dimension, whereas submissive patients benefited more from complementarity in that dimension. Furthermore, interpersonal problems of communion significantly moderated the effects of complementarity in affiliative behaviors on both the alliance and outcome. These results suggest the relevance of both interpersonal correspondence and reciprocity for the psychotherapy process, informing clinical practice in terms of interpersonal responsiveness. The moderation effects of interpersonal problems provide preliminary evidence, which should be replicated in future research, to determine relevant markers indicating for whom a complementary approach would be beneficial in cognitive therapy for depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000528DOI Listing
October 2021

An Integrative Neuro-Psychotherapy Treatment to Foster the Adjustment in Acquired Brain Injury Patients-A Randomized Controlled Study.

J Clin Med 2020 Jun 2;9(6). Epub 2020 Jun 2.

Department of Neurology, Inselspital Bern, Bern University Hospital, 3010 Bern, Switzerland.

Adjustment disorders (AjD) with depressive symptoms following an acquired brain injury (ABI) is a common phenomenon. Although brain injuries are increasing more and more, research on psychological therapies is comparably scarce. The present study compared, by means of a randomized controlled trial (RCT), a newly developed integrative treatment (Standard PLUS) to a standard neuropsychological treatment (Standard). Primary outcomes were depressive symptoms assessed with the Beck Depression Inventory (BDI-II) at post-treatment and 6-month follow-up assessment. In total, 25 patients (80% after a stroke) were randomized to one of the two conditions. Intention-to-treat analyses showed that the two groups did not significantly differ either at post-treatment nor at follow-up assessment regarding depressive symptoms. Both treatments showed large within-group effect sizes on depressive symptoms. Regarding secondary outcomes, patients in the Standard PLUS condition reported more emotion regulation skills at post-assessment than in the control condition. However, this difference was not present anymore at follow-up assessment. Both treatments showed medium to large within-group effects sizes on most measures for patients suffering from an AjD after ABI. More research with larger samples is needed to investigate who profits from which intervention.
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http://dx.doi.org/10.3390/jcm9061684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355481PMC
June 2020

Discrepant negative self-associations as a risk factor for depressive deterioration after outpatient psychotherapy.

J Behav Ther Exp Psychiatry 2020 12 4;69:101576. Epub 2020 May 4.

Department of Clinical Psychology and Psychotherapy, University of Bern & Psychosomatic Competence Center, Department of Neurology, University Hospital, Inselspital, Fabrikstrasse 8, 3012, Bern, Switzerland.

Background And Objectives: This paper examines the discrepancy between implicit and explicit negative self-associations (NSA) after cognitive psychotherapy for depression as a predictor of long-term outcome.

Methods: One hundred and twenty patients completed an Implicit-Association Test relating the self with depressive attributes and a self-report questionnaire with identical item content, at the end of time-limited outpatient depression psychotherapy. At post-treatment and at 3-, 6-, and 12-month follow-up, patients completed the BDI-II. We used different strategies to operationalized implicit and explicit NSA discrepancies and three-level Hierarchical linear models to analyze the effects.

Results: We found significant interactive effects of discrepancy between implicit and explicit NSA and the direction of the discrepancy on long-term outcome. In patients with a greater explicit than implicit NSA (a damaged self-esteem pattern) a greater absolute discrepancy was associated with worse long-term outcome in terms of BDI scores at the end of follow-up and rate of change during follow-up. Consistently, with an alternative method, we found that damaged self-esteem discrepancies were associated with worse estimated BDI-II scores at the end of follow-up.

Limitations: The inclusion in the sample of only treatment completers limits the generalizability of the results. Furthermore, the follow-up period captured only the first 12 months after treatment.

Conclusions: Our results support the notion that a discrepancy between implicit and explicit negative self-associations may pose a risk factor for deterioration after psychotherapy for depression.
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http://dx.doi.org/10.1016/j.jbtep.2020.101576DOI Listing
December 2020

Effect of airway management strategies during resuscitation from out-of-hospital cardiac arrest on clinical outcome: A registry-based analysis.

Resuscitation 2020 07 5;152:157-164. Epub 2020 May 5.

Emergency Department, University Hospital of Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany.

Aim: An effective airway management is pivotal for treating hypoxia and to ensure reoxygenation during cardiopulmonary resuscitation (CPR). This matched-pair analysis from the German Resuscitation Registry (GRR) investigates the outcomes of various methods of airway management used on out-of-hospital cardiac arrest (OHCA) patients.

Methods: 89,220 OHCA patients were reported between 01/01/2007 and 12/31/2017. After applying exclusion and inclusion criteria, the resulting 19,196 patient's data were analyzed. Endpoints were return of spontaneous circulation (ROSC), hospital admission, 24-h survival, hospital discharge, and discharge with cerebral performance categories 1,2 (CPC1,2). Three categories of airway management were defined: endotracheal tube ("ETT"), laryngeal tube ("LT_only"), and laryngeal to endotracheal tube exchange ("LTEX"). The groups were matched with respect to age, gender, aetiology or location of OHCA, witnessing or CPR by lay people, initial rhythm, and use of epinephrine and amiodarone.

Results: "ETT" versus "LT_only" was associated with higher short- and long-term outcome rates and better neurological recovery (CPC_1.2: 7.7 vs. 5.8%, OR = 1.35, 95%-CI = 1.09-1.67, n = 5552). "LTEX" versus "LT_only" showed significantly higher ROSC- and 24-h survival rate (33.7 vs. 21.8%, OR = 1.82, 95%-CI = 1.51-2.2, n = 2302). "LTEX" versus "ETT" revealed significantly higher ROSC- and 24-h survival rate (34.6 vs. 30.4%, OR = 1.21, 95%-CI = 1.03-1.42, n = 2608).

Conclusion: "ETT" was associated with higher survival rates and better neurological outcomes in comparison to "LT_only". The strategy of "LTEX" versus "LT_only" or "ETT" was only associated with better short-term outcomes. Our observational registry data suggests that endotracheal intubation by physician staffed EMS is the optimal airway strategy for OHCA in our system.
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http://dx.doi.org/10.1016/j.resuscitation.2020.04.015DOI Listing
July 2020

Theory-specific patient change processes and mechanisms in different cognitive therapies for depression.

J Consult Clin Psychol 2020 Aug 27;88(8):774-785. Epub 2020 Apr 27.

Department of Clinical Psychology and Psychotherapy, University of Bern.

Objective: This study aimed to identify differential patient change processes and mechanisms associated with long-term outcome in exposure-based cognitive therapy (EBCT) and cognitive-behavioral therapy (CBT) for depression.

Method: We drew on a randomized controlled trial in which 149 patients were randomly assigned to either EBCT or CBT, with the treatments showing comparable efficacy at 12-month follow-up (grosse Holtforth et al., 2019). Based on Doss's (2004) 4-step model of psychotherapy change and using sequential multilevel structural equation models, we tested putative theory-based change processes and mechanisms for both treatments. Specifically, we examined emotional processing and cognitive restructuring during treatment as hypothesized change processes of EBCT and CBT, respectively. Furthermore, as potential change mechanisms during follow-up, we examined theory-relevant mechanisms for each treatment, preselected via multilevel models.

Results: Although the full serial mediational pathways were not supported, EBCT fostered greater during-treatment increases in emotional processing and higher self-efficacy during follow-up than CBT, both of which associated with better long-term depression outcome. Unexpectedly, cognitive restructuring change did not differ between EBCT and CBT. Across both CBT and EBCT, greater during-treatment increases in cognitive restructuring related to lower cognitive-behavioral avoidance and greater self-efficacy across follow-up, which associated with lower long-term depression.

Conclusions: Results suggest that therapists might improve long-term depression outcome by fostering both emotional processing (via emotion-focused techniques as included in EBCT) and cognitive restructuring (by using general CBT techniques included in both treatments), which operate either directly or through varied treatment-common mechanisms (e.g., greater self-efficacy and reduced cognitive-behavioral avoidance). (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000502DOI Listing
August 2020

The Association of Therapeutic Alliance With Long-Term Outcome in a Guided Internet Intervention for Depression: Secondary Analysis From a Randomized Control Trial.

J Med Internet Res 2020 03 24;22(3):e15824. Epub 2020 Mar 24.

Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland.

Background: Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes.

Objective: The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties.

Methods: A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment.

Results: We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ=-1.74, standard error [SE]=0.40, 95% CI -2.52 to -0.96, t=-4.37, P<.001) and patient well-being (γ=3.10, SE=1.14, 95% CI 0.87-5.33, t=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68).

Conclusions: The results of this study point out the importance of attuning internet interventions to patients' expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient's individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats.
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http://dx.doi.org/10.2196/15824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139432PMC
March 2020

Using the Personalized Advantage Index for Individual Treatment Allocation to Blended Treatment or Treatment as Usual for Depression in Secondary Care.

J Clin Med 2020 Feb 11;9(2). Epub 2020 Feb 11.

Department of Clinical Psychology, University of Bern, 3012 Bern, Switzerland.

A variety of effective psychotherapies for depression are available, but patients who suffer from depression vary in their treatment response. Combining face-to-face therapies with internet-based elements in the sense of blended treatment is a new approach to treatment for depression. The goal of this study was to answer the following research questions: (1) What are the most important predictors determining optimal treatment allocation to treatment as usual or blended treatment? and (2) Would model-determined treatment allocation using this predictive information and the personalized advantage index (PAI)-approach result in better treatment outcomes? Bayesian model averaging (BMA) was applied to the data of a randomized controlled trial (RCT) comparing the efficacy of treatment as usual and blended treatment in depressive outpatients. Pre-treatment symptomatology and treatment expectancy predicted outcomes irrespective of treatment condition, whereas different prescriptive predictors were found. A PAI of 2.33 PHQ-9 points was found, meaning that patients who would have received the treatment that is optimal for them would have had a post-treatment PHQ-9 score that is two points lower than if they had received the treatment that is suboptimal for them. For 29% of the sample, the PAI was five or greater, which means that a substantial difference between the two treatments was predicted. The use of the PAI approach for clinical practice must be further confirmed in prospective research; the current study supports the identification of specific interventions favorable for specific patients.
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http://dx.doi.org/10.3390/jcm9020490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073663PMC
February 2020

Interpersonal agency as predictor of the within-patient alliance effects on depression severity.

J Consult Clin Psychol 2020 Apr 19;88(4):338-349. Epub 2019 Dec 19.

Department of Clinical Psychology and Psychotherapy.

Objective: Several studies have reported significant within-patient effects of the therapeutic alliance on outcome. However, it remains uncertain whether there are specific patient groups for whom an improved alliance might be particularly beneficial. The relational nature of the alliance makes patients' interpersonal problems a promising candidate for examining such differential effects. This study aims to analyze (i) between- and within-patient effects of the alliance on depression severity, (ii) the effects of patients' baseline interpersonal problems on the within-patient alliance-outcome association, and (iii) whether within-patient effects of the alliance remain significant when adjusting for patients' initial interpersonal problems.

Method: A sample of 141 patients with depression and undergoing outpatient psychotherapy completed the Inventory of Interpersonal Problems at baseline as well as a brief version of the Working Alliance Inventory and the Well-Being Index (as a proxy of depression severity) session by session.

Results: Multilevel models revealed both significant between- and within-patient effects of the alliance on improvements in depression severity. Patients' problems relating to agency had a significant effect on the within-patient effect of alliance, with more submissive patients benefiting more from an improved therapeutic alliance. Finally, the between- and within-patient effects of the alliance remained significant when adjusting for the patients' agentic interpersonal problems and treatment condition.

Conclusions: The results provide evidence on which types of patients would particularly benefit from an improved therapeutic alliance. For patients suffering from low interpersonal agency and reporting problems with submissiveness, an enhanced alliance during the therapy process might improve treatment outcome. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000475DOI Listing
April 2020

[Internet-Based Psychotherapeutic Interventions].

Psychother Psychosom Med Psychol 2019 Oct 10;69(9-10):413-426. Epub 2019 Oct 10.

Over the past few years, research and application of internet-based psychotherapeutic interventions has grown rapidly. This kind of new therapeutic format offers a variety of chances for treating patients with psychotherapeutic disorders, but also arouses skepticism and concerns. This overview focuses on different forms of internet-based psychotherapeutic interventions, reflects the current state of research, and points out new areas of development as well as its implementation in daily practice.
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http://dx.doi.org/10.1055/a-0963-9055DOI Listing
October 2019

The latent structure of interpersonal problems: Validity of dimensional, categorical, and hybrid models.

J Abnorm Psychol 2019 Nov 26;128(8):823-839. Epub 2019 Sep 26.

Psychologische Hochschule Berlin.

Interpersonal problems are key transdiagnostic constructs in psychopathology. In the past, investigators have neglected the importance of operationalizing interpersonal problems according to their latent structure by using divergent representations of the construct: (a) computing scores for severity, agency, and communion ("dimensional approach"), (b) classifying persons into subgroups with respect to their interpersonal profile ("categorical approach"). This hinders cumulative research on interpersonal problems, because findings cannot be integrated both from a conceptual and a statistical point of view. We provide a comprehensive evaluation of interpersonal problems by enlisting several large samples (Ns = 5,400, 491, 656, and 712) to estimate a set of latent variable candidate models, covering the spectrum of purely dimensional (i.e., confirmatory factor analysis using Gaussian and nonnormal latent t-distributions), hybrid (i.e., semiparametric factor analysis), and purely categorical approaches (latent class analysis). Statistical models were compared with regard to their structural validity, as evaluated by model fit (corrected Akaike's information criterion and the Bayesian information criterion), and their concurrent validity, as defined by the models' ability to predict relevant external variables. Across samples, the fully dimensional model performed best in terms of model fit, prediction, robustness, and parsimony. We found scant evidence that categorical and hybrid models provide incremental value for understanding interpersonal problems. Our results indicate that the latent structure of interpersonal problems is best represented by continuous dimensions, especially when one allows for nonnormal latent distributions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/abn0000460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816327PMC
November 2019

A randomized controlled trial comparing guided internet-based multi-component treatment and internet-based guided sleep restriction treatment to care as usual in insomnia.

Sleep Med 2019 10 22;62:43-52. Epub 2019 Feb 22.

Institute for Psychology, University of Bern, Bern, Switzerland.

Background: Internet-based cognitive behavioral treatment (iCBT-I) for insomnia comprising different sleep-related cognitive and behavioral interventional components has shown some promise. However, it is not known which components are necessary for a good treatment outcome.

Method: People suffering from insomnia (N = 104) without any other comorbid psychiatric disorders were randomized (2:2:1) to two guided internet-based self-help interventions for insomnia [multi-component cognitive behavioral self-help intervention (MCT); sleep restriction intervention for insomnia (SRT)], and care as usual [CAU]. In all three conditions, additional care or treatment was allowed. The primary outcome was insomnia severity measured with the insomnia severity index (ISI) at eight weeks. Furthermore, the two active conditions were compared regarding sleep efficacy from daily diary data over the eight weeks, and other measures from the daily protocols. Secondary outcomes included sleep quality, depressive symptoms, dysfunctional beliefs, and quality of life at post-treatment (eight weeks) and follow-up (six months after randomization).

Results: Both conditions were more effective than CAU at post-treatment, with medium to large between-group effect sizes on the primary outcome (ISI; MCT: Cohen's d = -1.15; SRT: d = -0.68) and small to medium between-group effect sizes for secondary outcomes. Treatment gains were maintained at six-month follow-up. Active conditions did not differ from each other on all measures from pre to post, except for dysfunctional beliefs about sleep, and sleep protocol data throughout the intervention. Participants in MCT were significantly more satisfied with the intervention than participants in SRT.

Conclusions: Results of the present study indicate that CAU + MCT and CAU + SRT are both effective compared to CAU. There were no statistical differences regarding efficacy between the two active conditions, but participants in MCT reported to be more satisfied with the intervention.
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http://dx.doi.org/10.1016/j.sleep.2019.01.045DOI Listing
October 2019

Using the Personalized Advantage Index for individual treatment allocation to cognitive behavioral therapy (CBT) or a CBT with integrated exposure and emotion-focused elements (CBT-EE).

Psychother Res 2020 07 11;30(6):763-775. Epub 2019 Sep 11.

Department of Clinical Psychology and Psychotherapy, University of Bern, Switzerland.

Even though different psychotherapeutic interventions for depression have shown to be effective, patients suffering from depression vary substantially in their treatment response. The goal of this study was to answer the following research questions: (1) What are the most important predictors determining optimal treatment allocation to cognitive behavioral therapy (CBT) or CBT with integrated exposure and emotion-focused elements (CBT-EE)?, and (2) Would model-determined treatment allocation using this predictive information result in better treatment outcomes? Bayesian Model Averaging (BMA) was applied to the data of a randomized controlled trial comparing the efficacy of CBT and CBT-EE in depressive outpatients. Predictions were made for every patient for both treatment conditions and an optimal versus a suboptimal treatment was identified in each case. An index comparing the two estimates, the Personalized Advantage Index (PAI), was calculated. Different predictors were found for both conditions. A PAI of 1.35 BDI-II points for the two conditions was found and 46% of the sample was predicted to have a clinically meaningful advantage in one of the therapies. Although the utility of the PAI approach must be further confirmed in prospective research, the present study study promotes the identification of specific interventions favorable for specific patients.
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http://dx.doi.org/10.1080/10503307.2019.1664782DOI Listing
July 2020

The Working Alliance Inventory for guided Internet interventions (WAI-I).

J Clin Psychol 2020 06 25;76(6):973-986. Epub 2019 Jun 25.

Department of Psychiatry and Psychotherapy, Lübeck University, Lübeck, Germany.

Objective: This study analyses the psychometric properties of the Working Alliance Inventory adapted for guided Internet interventions (WAI-I).

Methods: We drew on the data set from a multicenter trial that examined a guided Internet intervention (deprexis) for patients with mild to moderate depression. Two hundred twenty-three patients completed the WAI-I and the Patient Satisfaction Questionnaire (ZUF-8) at posttreatment, and the Attitudes toward Psychological Online-Interventions Questionnaire (APOI) at baseline. We ran confirmatory factor analyses (CFA) testing two- and three-factor solutions and calculated Cronbach's α, item-total correlations, and correlations of the WAI-I with APOI and ZUF-8.

Results: The results suggested a two-factor solution, with a very good model fit and evidence of factor independency, adequate internal consistency, and external validity for the complete scale and the sub-scales.

Conclusions: The WAI-I showed as a reliable and valid instrument to capture alliance in guided Internet interventions, which might facilitate process-outcome research and treatment development efforts.
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http://dx.doi.org/10.1002/jclp.22823DOI Listing
June 2020

An Internet-Based Compassion-Focused Intervention for Increased Self-Criticism: A Randomized Controlled Trial.

Behav Ther 2019 03 17;50(2):430-445. Epub 2018 Aug 17.

University of Bern.

Increased levels of self-criticism and a lack of self-compassion have been associated with the development and maintenance of a range of psychological disorders. In the current study, we tested the efficacy of an online version of a compassion-focused intervention, mindfulness-based compassionate living (MBCL), with guidance on request. A total of 122 self-referred participants with increased levels of self-criticism were randomly assigned to care as usual (CAU) or the intervention group (CAU + online intervention). Primary endpoints were self-reported depressive, anxiety and distress symptoms (DASS-21) and self-compassion (SCS) at 8 weeks. Secondary endpoints were self-criticism, mindfulness, satisfaction with life, fear of self-compassion, self-esteem, and existential shame. At posttreatment, the intervention group showed significant changes with medium to large effect sizes compared to the control group regarding primary outcomes (Cohen's d: 0.79 [DASS] and -1.21 [SCS]) and secondary outcomes (Cohen's ds: between 0.40 and 0.94 in favor of the intervention group). The effects in the intervention group were maintained at 6-months postrandomization. Adherence measures (number of completed modules, self-reported number of completed exercises per week) predicted postintervention scores for self-compassion but not for depressive, anxiety, and distress symptoms in the intervention group. The current study shows the efficacy of an online intervention with a transdiagnostic intervention target on a broad range of measures, including depressive and anxiety symptoms and self-compassion.
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http://dx.doi.org/10.1016/j.beth.2018.08.003DOI Listing
March 2019

Efficacy and cost-effectiveness of guided and unguided internet- and mobile-based indicated transdiagnostic prevention of depression and anxiety (ICare Prevent): A three-armed randomized controlled trial in four European countries.

Internet Interv 2019 Apr 15;16:52-64. Epub 2018 Apr 15.

Department of Clinical Psychology and Psychotherapy, Nägelsbachstraße 25a, Germany.

Background: Depression and anxiety are highly prevalent and often co-occur. Several studies indicate the potential of disorder-specific psychological interventions for the prevention of each of these disorders. To treat comorbidity, transdiagnostic treatment concepts seem to be a promising approach, however, evidence for transdiagnostic concepts of prevention remains inconclusive. Internet- and mobile-based interventions (IMIs) may be an effective means to deliver psychological interventions on a large scale for the prevention of common mental disorders (CMDs) such as depression and anxiety. IMIs have been shown to be effective in treating CMDs, e.g. in reducing symptoms of depression and anxiety. However, there is a lack of studies examining the efficacy of interventions reducing the incidence of CMDs. Moreover, the comparative cost-effectiveness of guided versus unguided IMIs for the prevention of depression and anxiety has not been studied yet. Hence, this study aims at investigating the (cost-) effectiveness of guided and unguided internet- and mobile-based transdiagnostic individually tailored indicated prevention of depression and anxiety.

Methods: A multi-country three-armed randomized controlled trial will be conducted to compare a guided and unguided intervention to treatment as usual (TAU). Both active conditions are based on the same intervention, , and differ only with regard to guidance format. Altogether, 954 individuals with subclinical symptoms of depression (CES-D ≥ 16) and anxiety (GAD-7 ≥ 5) who do not have a full-blown disorder will be recruited in Germany, Switzerland, Spain and the Netherlands, and randomized to one of three conditions (guided intervention, unguided intervention, or TAU). The TAU arm will receive access to the training after a 12-month waiting period. The primary outcome will be time to CMD onset (any depression/anxiety disorder) within a follow-up period of 12 months after baseline. Secondary outcomes will include disorder-specific symptom severity (depression/anxiety) assessed by diagnostic raters blinded to intervention condition at post-intervention, self-reports, acceptability, health related quality of life, and psychosocial variables associated with developing a CMD. Assessments will take place at baseline, mid-intervention (5 weeks into the intervention), post-intervention (8 weeks after randomization) and follow-up (6 and 12 months after randomization). Data will be analyzed on an intention-to-treat basis and per protocol. Cost-effectiveness will be evaluated from a public health and a societal perspective, including both direct and indirect costs.

Discussion: The present study will further enhance the evidence-base for transdiagnostic preventive interventions and provide valuable information about optimal trade-off between treatment outcome and costs.

Trial Registration: German Clinical Trial Registration (DRKS - http://www.drks.de/drks_web/): DRKS00011099.
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http://dx.doi.org/10.1016/j.invent.2018.04.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6364519PMC
April 2019

The Factor Structure of the Forms of Self-Criticising/Attacking & Self-Reassuring Scale in Thirteen Distinct Populations.

J Psychopathol Behav Assess 2018 13;40(4):736-751. Epub 2018 Jun 13.

15Marie Curie Palliative Care Research Department, University College London, TottenhamCourt Road 149, London, W1T 7NF UK.

There is considerable evidence that self-criticism plays a major role in the vulnerability to and recovery from psychopathology. Methods to measure this process, and its change over time, are therefore important for research in psychopathology and well-being. This study examined the factor structure of a widely used measure, the Forms of Self-Criticising/Attacking & Self-Reassuring Scale in thirteen nonclinical samples ( = 7510) from twelve different countries: Australia ( = 319), Canada ( = 383), Switzerland ( = 230), Israel ( = 476), Italy ( = 389), Japan ( = 264), the Netherlands ( = 360), Portugal ( = 764), Slovakia ( = 1326), Taiwan ( = 417), the United Kingdom 1 ( = 1570), the United Kingdom 2 ( = 883), and USA ( = 331). This study used more advanced analyses than prior reports: a bifactor item-response theory model, a two-tier item-response theory model, and a non-parametric item-response theory (Mokken) scale analysis. Although the original three-factor solution for the FSCRS (distinguishing between Inadequate-Self, Hated-Self, and Reassured-Self) had an acceptable fit, two-tier models, with two general factors (Self-criticism and Self-reassurance) demonstrated the best fit across all samples. This study provides preliminary evidence suggesting that this two-factor structure can be used in a range of nonclinical contexts across countries and cultures. Inadequate-Self and Hated-Self might not by distinct factors in nonclinical samples. Future work may benefit from distinguishing between self-correction versus shame-based self-criticism.
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http://dx.doi.org/10.1007/s10862-018-9686-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6223807PMC
June 2018

Transdiagnostic Tailored Internet- and Mobile-Based Guided Treatment for Major Depressive Disorder and Comorbid Anxiety: Study Protocol of a Randomized Controlled Trial.

Front Psychiatry 2018 4;9:274. Epub 2018 Jul 4.

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

Depression is highly prevalent and often accompanied by comorbid anxiety disorder. Internet-based interventions have shown to be one effective treatment modality; however, comorbidities are often not targeted. Transdiagnostic tailored internet-and mobile-based interventions (IMIs) might be promising to overcome such issues. This study aims to evaluate the efficacy, moderators, and cost-effectiveness of a transdiagnostic tailored internet- and mobile-based guided intervention for depression and comorbid anxiety in individuals with major depressive disorder (MDD). Two-hundred participants with MDD will be randomly assigned to an 8-week guided self-help internet intervention (IC) or a 6-month wait-list control group (WLC). Participants of the IC will receive weekly content-focused feedback on module completion as well as monitored adherence reminders from an eCoach. The primary outcome is clinician-rated depression severity (QIDS-C) at post-assessment assessed by diagnostic raters blind to study condition. Secondary outcomes include, e.g., change in diagnostic status (MDD and anxiety disorders), remission and response rates, disorder symptom severity, health related quality of life, incongruence related to needs and values, and behavioral activation. Assessments will take place at baseline (T1), post-assessment (T2), 6-month follow-up (T3), and 12-month follow-up in the IC. Data will be analyzed on an intention-to-treat basis and per protocol. A large number of a priori defined moderators of treatment outcome will be assessed at baseline and tested in predicting treatment outcome. Cost-effectiveness will be evaluated from a societal perspective. The present study will provide evidence on the efficacy, potential cost-effectiveness, and moderators of a transdiagnostic tailored guided internet- and mobile-based treatment protocol.

Trial Registration: German Register of Clinical Studies DRKS00011690 (https://www.drks.de/drks_web/).
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http://dx.doi.org/10.3389/fpsyt.2018.00274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039558PMC
July 2018

A mobile app for social anxiety disorder: A three-arm randomized controlled trial comparing mobile and PC-based guided self-help interventions.

J Consult Clin Psychol 2018 06;86(6):493-504

Department of Clinical Psychology and Psychotherapy.

Objective: Internet-based cognitive-behavioral treatments (ICBT) have shown promise for various mental disorders, including social anxiety disorder (SAD). Most of these treatments have been delivered on desktop computers. However, the use of smartphones is becoming ubiquitous and could extend the reach of ICBT into users' everyday life. Only a few studies have empirically examined the efficacy of ICBT delivered through a smartphone app and there is no published study on mobile app delivered ICBT for SAD. This three-arm randomized-controlled trial (RCT) is the first to compare the efficacy of guided ICBT for smartphones (app) and conventional computers (PC) with a wait list control group (WL).

Method: A total of 150 individuals meeting the diagnostic criteria for SAD were randomly assigned to one of the three conditions. Primary endpoints were self-report measures and diagnostic status of SAD.

Results: After 12 weeks of treatment, both active conditions showed superior outcome on the composite of all SAD measures (PC vs. WL: d = 0.74; App vs. WL: d = 0.89) and promising diagnostic response rates (NNTPC = 3.33; NNTApp = 6.00) compared to the WL. No significant between-groups effects were found between the two active conditions on the composite score (Cohen's d = 0.07). Treatment gains were maintained at 3-month follow-up. Program use was more evenly spread throughout the day in the mobile condition, indicating an integration of the program into daily routines.

Conclusions: ICBT can be delivered effectively using smartphones. (PsycINFO Database Record
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http://dx.doi.org/10.1037/ccp0000301DOI Listing
June 2018

A patient perspective on advantages and disadvantages of blended cognitive behaviour therapy for depression: A qualitative content analysis.

Psychother Res 2019 11 31;29(8):986-998. Epub 2018 Jan 31.

Department of Psychology, University of Bern , Bern , Switzerland.

Blended cognitive behavioural therapy (bCBT), which combines face-to-face (FtF), and internet-based cognitive behavioural therapy (iCBT), may be a particularly promising approach, but little is known about the effectiveness and patients' subjective evaluations of the bCBT format. The aim of this qualitative study is to explore perceived advantages and disadvantages of bCBT from the patients' perspective in specialized mental health care. Semi-structured interviews were conducted with 15 patients suffering from major depression who underwent treatment in a bCBT format. The interview data were processed by means of a qualitative content analysis. The content analysis generated 18 advantages and 15 disadvantages which were grouped into 6 main topics. In general, bCBT was perceived as purposive and effective for treating depression. The patients perceived the combined treatment as complementary and emphasized the advantage of the constant availability of the online programme. Furthermore, a segment analysis revealed that patients reported different advantages and disadvantages of bCBT as a function of the severity of their depressive episode. The findings of the present study reveal advantages and disadvantages of bCBT, which should be taken into account in the further implementation of this new treatment format. Blended treatment seems to balance missing aspects of stand-alone internet-based and face-to-face treatment for depression. Patients suffering from major depression perceived the blended format as purposive and effective after 18 weeks. Patients with different levels of depression severity may perceive different advantages and disadvantages of blended treatment for depression.
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http://dx.doi.org/10.1080/10503307.2018.1430910DOI Listing
November 2019

Patient characteristics and the therapist as predictors of depressed patients' outcome expectation over time: A multilevel analysis.

Psychother Res 2019 08 25;29(6):709-722. Epub 2018 Jan 25.

d Department of Clinical Psychology and Psychotherapy , Institute of Psychology, University of Bern , Bern , Switzerland.

Although there is an established link between patients' early positive outcome expectation for and their actual improvement from therapy, there is little research on patients' change in outcome expectation across therapy and both patient and therapist correlates of early outcome expectation level and change. The present study examined: (i) the overall trajectory of change in patients' outcome expectation through cognitive-behavioral therapy (CBT) for depression; (ii) patient characteristics as predictors of both initial outcome expectation and change in outcome expectation; and (iii) between-therapist effects in outcome expectation change. Depressed patients (= 143) received a brief course of CBT. Outcome expectation was measured at screening, pretreatment, session 7, and session 14. Outcome expectation linearly increased from screening to session 14. When controlling for other patient characteristics at intake, having previous depressive episodes was negatively associated with initial outcome expectation and higher well-being was positively associated with initial outcome expectation. When controlling for early alliance and early symptom change, outcome expectation change was predicted by previous depressive episodes. Finally, therapist effects emerged in outcome expectation over time. Various depressed patients' characteristics predict initial outcome expectation level and change, with significant between-therapists' differences related to outcome expectation change.
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http://dx.doi.org/10.1080/10503307.2018.1428379DOI Listing
August 2019

Evaluating an e-mental health program ("deprexis") as adjunctive treatment tool in psychotherapy for depression: Results of a pragmatic randomized controlled trial.

J Affect Disord 2018 02 10;227:455-462. Epub 2017 Nov 10.

Division of Psychopathology and Clinical Intervention, University of Zurich, Switzerland.

Background: Depressive disorders place a significant disease burden on individuals as well as on societies. Several web-based interventions for depression have shown to be effective in reducing depressive symptoms. However, it is not known whether web-based interventions, when used as adjunctive treatment tools to regular psychotherapy, have an additional effect compared to regular psychotherapy for depression.

Methods: Adults (N = 98) with a unipolar affective disorder were recruited in routine outpatient psychotherapy practices in Germany from therapists over the course of their initial sessions and randomized within therapists to one of two active treatment conditions: regular psychotherapy or psychotherapy plus a web-based depression program ("deprexis"). Primary outcome was depressive symptoms measured with the Beck Depression Inventory (BDI-II) at 12 weeks. Secondary outcomes were anxiety symptoms, somatic symptoms and quality of life at 12 weeks and six months follow-up. The study also included an assessment of the working alliance after six and 12 weeks.

Results: The combination of psychotherapy with the web-based program was more effective than psychotherapy alone at 12 weeks, with medium between-group effect sizes on primary depressive symptoms (Cohen's d = .51) and small to medium between-group effect sizes on secondary outcomes (Cohen's d = .07-.55). Furthermore, we did not observe negative side effects in the blended format, e.g., a lower working alliance than in psychotherapy alone.

Limitations: The study had a smaller than planned sample size and the dropout rate at follow-up was high.

Conclusions: This study provides first evidence that the use of a web-based program as an adjunctive tool in regular psychotherapy could be a promising option to consider in future treatment for depression.
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http://dx.doi.org/10.1016/j.jad.2017.11.021DOI Listing
February 2018

Identifying relapse prevention elements during psychological treatment of depression: Development of an observer-based rating instrument.

J Affect Disord 2018 02 6;227:358-365. Epub 2017 Nov 6.

University of Zurich, Department of Clinical Psychology and Psychotherapy Research, Switzerland. Electronic address:

Background: Although observer-rated instruments assessing therapist's adherence to relapse-preventive treatments are available, they do not adequately cover specific relapse-preventive elements that focus on implementation of strategies after terminating treatment. This study describes the development of the KERI-D (Kodierbogen zur Erfassung Rückfallprophylaktischer Interventionen bei Depression/Coding System to Assess Interventions of Relapse Prevention in Depression). The KERI-D is a new observer-based rating tool for acute or continuation/maintenance-phase sessions and assesses relapse-prevention elements including implementation into patient's daily routines.

Methods: The development of the KERI-D included iterative steps referring to theoretical, clinical and empirical sources. It consists of 19 content items within four categories (self-care, early warning signs, triggering events/situations, termination of therapy) and one global item. For empirical analyses, videotaped psychotherapy sessions of 36 psychotherapies were rated by three independent observers and analyzed for their psychometric properties.

Results: Most items showed moderate to good inter-rater reliability (median ICC = .80) and retest reliability (median ICC = .93). Principal-axis factor analysis revealed three subscales, and first evidence of content validity was demonstrated. No associations with clinical follow-up data were found.

Limitations: Analysis was limited to a relatively small sample of selected psychotherapy sessions. Evaluation of predictive validity is a desirable next step to further examine applicability and scope of the instrument.

Conclusions: The KERI-D is the first observer-based rating instrument measuring specific relapse-prevention strategies in psychotherapy for depression. It may help to identify elements that prove effective in reducing relapse/recurrence in the long-term and thereby help to optimize effect duration of depression treatment.
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http://dx.doi.org/10.1016/j.jad.2017.11.009DOI Listing
February 2018
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