Implementing digital mental health interventions at scale: one-year evaluation of a national digital CBT service in Ireland.

BACKGROUND: In recent years, exponential growth in digital innovations and internet access has provided opportunities to deliver health services at a much greater scale than previously possible. Evidence-based technology-enabled interventions can provide cost-effective, accessible, and resource-efficient solutions for addressing mental health issues. This study evaluated the first year of a supported digital cognitive behavioral therapy (CBT) service provided by the national health service in Ireland, which has been accessible to individuals who receive a referral from one of five referring groups: General Practitioners, Primary Care Psychology, Counselling Primary Care, Community Mental Health, and Jigsaw (a nationwide youth mental health service). METHODS: A retrospective, observational study examining data from the service between April 2021 to April 2022 was conducted. Descriptive statistics on referrals, account activations, user demographics, program usage, and user satisfaction were extracted, and pre-to-post clinical outcomes for depression measured by the Patient Health Questionnaire-9 and for anxiety measured by the Generalised Anxiety Disorder-7 were analysed using linear mixed effect models. RESULTS: There were 5,298 referrals and 3,236 (61%) account activations within the year. Most users were female (72.9%) and aged between 18 and 44 years (75.4%). The CBT programs were associated with significant reductions in both depression (ß = 3.34, 95% CI [3.03, 3.65], p < 0.001) and anxiety (ß = 3.64, 95% CI [3.36, 3.93], p < 0.001), with large effect sizes (Cohen's d > 0.8). Time spent using the programs was also found to be a predictor of the variability in these clinical outcomes (p < 0.001), and accounting for this resulted in significantly better model fits (p < 0.001). User satisfaction ratings were also very high, exceeding 94%. CONCLUSIONS: Efforts to improve the representation of male and older adult users are warranted. However, overall, the results demonstrate how digital CBT can be provided at scale and lead to symptom reductions with large effect sizes for patients seeking help for depression and anxiety. The findings substantiate the continued use and expansion of this service in Ireland and the more widespread implementation of similar services in other international public healthcare settings.

The Effectiveness of Low-Intensity Psychological Interventions for Comorbid Depression and Anxiety in Patients with Long-Term Conditions: A Real-World Naturalistic Observational Study in IAPT Integrated Care.

BACKGROUND: Low-intensity psychological interventions may be a cost-effective, accessible solution for treating depression and anxiety in patients with long-term conditions, but evidence from real-world service settings is lacking. This study examined the effectiveness of low-intensity psychological interventions provided in the Improving Access to Psychological Therapies programme in England for patients with and without long-term conditions. METHODS: A retrospective analysis was conducted on patients (total N = 21,051, long-term conditions n = 4024) enrolled in three low-intensity psychological interventions, i.e. Internet-delivered cognitive behavioural therapy (iCBT), guided self-help (GSH), and psychoeducational group therapy (PGT) within a Talking Therapies service from 2016 to 2020. Primary outcomes included pre-post-treatment changes in depression (Patient Health Questionnaire-9) and anxiety (Generalised Anxiety Disorder-7). RESULTS: Overall, both cohorts significantly improved on all outcomes post-treatment, with large effect sizes. Patients with long-term conditions experienced a greater reduction in depression while those without experienced a greater reduction in anxiety, but these differences were marginal (< 1 score difference on both measures). No difference between the cohorts was shown when comparing the differential effectiveness across interventions, but those engaging in iCBT showed greater reduction in depression and anxiety than those in GSH and PGT, while those in GSH improved more than PGT. CONCLUSIONS: Low-intensity psychological interventions, particularly iCBT, were effective in treating depression and anxiety in patients with long-term conditions in a real-world service setting. Our large-scale study supports the continued and increased implementation of low-intensity psychological interventions for this subpopulation via integrated care.

Comparison of outcomes across low-intensity psychological interventions for depression and anxiety within a stepped-care setting: A naturalistic cohort study using propensity score modelling.

Low-intensity interventions for common mental disorders (CMD) address issues such as clinician shortages and barriers to accessing care. However, there is a lack of research into their comparative effectiveness in routine care. We aimed to compare treatment effects of three such interventions, utilizing four years' worth of routine clinical data. Users completing a course of guided self-help bibliotherapy (GSH), internet-delivered cognitive behavioural therapy (iCBT) or psychoeducational group therapy (PGT) from a stepped-care service within the NHS in England were included. Propensity score models (stratification and weighting) were used to control for allocation bias and determine average treatment effect (ATE) between the interventions. 21,215 users comprised the study sample (GSH = 12,896, iCBT = 6862, PGT = 1457). Adherence-to-treatment rates were higher in iCBT. All interventions showed significant improvements in depression (PHQ-9), anxiety (GAD-7) and functioning (WSAS) scores, with largest effect sizes for iCBT. Both propensity score models showed a significant ATE in favour of iCBT versus GSH and PGT, and in favour of GSH versus PGT. Discernible differences in effectiveness were seen for iCBT in comparison with GSH and PGT. Given variance in delivery mode and human resources between different low-intensity interventions, building on these findings would be valuable for future service provision and policy decision making.

The relationship between posttherapeutic Cognitive Behavior Therapy skills usage and follow-up outcomes of internet-delivered Cognitive Behavior Therapy.

BACKGROUND: Clients independently applying Cognitive Behavior Therapy (CBT) skills is an important outcome of CBT-based treatments. The relationship between posttherapeutic CBT skills usage and clinical outcomes remains under-researched-especially after internet-delivered CBT (iCBT). OBJECTIVE: Explore contemporaneous and lagged effects of posttherapeutic CBT skills usage frequency on iCBT follow-up outcomes. METHOD: Nested within a randomized controlled trial, 241 participants received 8-week supported iCBT for anxiety and/or depression, completing measures of anxiety, depression, functional impairment, and CBT skills usage frequency at 3-, 6-, 9-, and 12-month follow-up. Cross-lagged panel models evaluated primary aims. RESULTS: While analyses support a contemporaneous relationship between anxiety, depression, functional impairment, and CBT skills usage frequency, no consistent lagged effects were observed. CONCLUSION: Findings align with qualitative research but the role of CBT skills usage in the maintenance of iCBT effects remains unclear. Innovative research modeling temporal and possibly circular relationships between CBT skill usage and clinical outcomes is needed to inform iCBT optimization.

The Acceptability and Initial Effectiveness of "Space From Money Worries": An Online Cognitive Behavioral Therapy Intervention to Tackle the Link Between Financial Difficulties and Poor Mental Health.

Background: Previous research has shown a strong relationship between financial difficulties and mental health problems. Psychological factors such as hope and worry about finances appear to be an important factor in this relationship. Objective: To develop an online based psychological intervention (Space from Money Worries) to tackle the psychological mechanisms underlying the relationship between poor mental health and financial difficulties, and to conduct an initial evaluation of the acceptability and preliminary efficacy of the intervention. Materials and Methods: 30 participants accessing Increasing Access to Psychological Therapies (IAPT) services completed GAD-7 to measure anxiety and PHQ-9 to measure depression upon signing up to the online intervention and again 4 to 8 weeks after this. Participants also completed a measure of perceived financial distress/wellbeing and a "Money and Mental Health Scale" constructed for the evaluation. Results: Overall, 77% (n = 23) completed the intervention and follow-up assessments. Intent to Treat Analysis showed that there were statistically significant improvements in symptoms of depression, anxiety, improved perceived financial wellbeing and reduced scores on the money and mental health scale. The vast majority of participants rated each module positively. Conclusions: Space from Money Worries appears to be acceptable and may lead to improvements in mental health, perceived financial wellbeing and a reduced relationship between financial difficulties and poor mental health. However, future research with a larger sample and a control group are needed to confirm that these changes are due to the intervention.

Internet-delivered CBT intervention (Space for Sleep) for insomnia in a routine care setting: Results from an open pilot study.

Insomnia is a highly prevalent, often comorbid disorder associated with difficulties sleeping, remaining awake, and impaired quality of life. Internet-delivered Cognitive Behavioral Therapy for insomnia (ICBT-I) has the potential to help large numbers of people with sleep disorders. This study investigated the preliminary effects of an 8-week guided ICBT-I intervention within a routine stepped-care service. Fifty-six (N = 56) patients consented to participate. The primary outcome was assessed using the Insomnia Severity Index (ISI) and secondary outcome measures included the Patient Health Questionnaire 9-item (PHQ-9), Generalized Anxiety Disorder 7-item (GAD-7), and the Work and Social Adjustment Scale (WSAS), each administered at baseline and weekly thereafter. Intention-to-treat analyses indicated that ICBT-I produced statistically significant pre- to post- reductions in symptoms of insomnia, yielding within-group effects of d = 0.82 suggesting a potential for improved outcomes. Similar improvements were seen across secondary outcomes, with small-to-medium post-treatment within-group effects observed: depression (d = 0.63), anxiety (d = 0.39), and functional impairment (d = 0.31). These findings are supportive of the intervention's potential effectiveness and speak to the importance of several implementation factors that could enhance the effects of the intervention. The results contribute to the growing evidence base for digital interventions designed to help those with sleep difficulties and will inform the design of a future controlled evaluation of ICBT-I under routine clinical settings.