Efficacy and cost-effectiveness of a therapist-assisted web-based intervention for depression and anxiety in patients with ischemic heart disease attending cardiac rehabilitation [eMindYourHeart trial]: a randomised controlled trial protocol.

BACKGROUND: One in five patients with ischaemic heart disease (IHD) develop comorbid depression or anxiety. Depression is associated with risk of non-adherence to cardiac rehabilitation (CR) and dropout, inadequate risk factor management, poor quality of life (QoL), increased healthcare costs and premature death. In 2020, IHD and depression are expected to be among the top contributors to the disease-burden worldwide. Hence, it is paramount to treat both the underlying somatic disease as well as depression and anxiety. eMindYourHeart will evaluate the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention targeting depression and anxiety in patients with IHD, which may help fill this gap in clinical care. METHODS: eMindYourHeart is a multi-center, two-armed, unblinded randomised controlled trial that will compare a therapist-assisted eHealth intervention to treatment as usual in 188 CR patients with IHD and comorbid depression or anxiety. The primary outcome of the trial is symptoms of depression, measured with the Hospital Anxiety and Depression Scale (HADS) at 3 months. Secondary outcomes evaluated at 3, 6, and 12 months include symptoms of depression and anxiety (HADS), perceived stress, health complaints, QoL (HeartQoL), trial dropout (number of patients dropped out in either arm at 3 months) and cost-effectiveness. DISCUSSION: To our knowledge, this is the first trial to evaluate both the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention in patients with IHD and comorbid psychological distress as part of CR. Integrating screening for and treatment of depression and anxiety into standard CR may decrease dropout and facilitate better risk factor management, as it is presented as "one package" to patients, and they can access the eMindYourHeart program in their own time and at their own convenience. The trial holds a strong potential for improving the quality of care for an increasing population of patients with IHD and comorbid depression, anxiety or both, with likely benefits to patients, families, and society at large due to potential reductions in direct and indirect costs, if proven successful. Trial registration The trial was prospectively registered on https://clinicaltrials.gov/ct2/show/NCT04172974 on November 21, 2019 with registration number [NCT04172974].

Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis.

BACKGROUND: Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects. OBJECTIVE: This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome. METHODS: We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials. RESULTS: We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls. CONCLUSIONS: iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients' greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings.

Body image concerns in patients with an implantable cardioverter defibrillator: A scoping review.

BACKGROUND: Patients with an implantable cardioverter defibrillator (ICD) retain a scar and a bump at the site of implant. This may lead to body image concerns (BICs) that influence patients' quality of life. Few studies have examined the prevalence and impact of BICs postimplant, prompting us to conduct a scoping review of the field. METHODS: We searched the Medline, Embase, PsycINFO, and Cinahl databases in August 2016 and repeated in May 2017. Included were studies reporting on patients ≥ 18 years, an ICD implant (transvenous, subcutaneous, or ICD with cardiac resynchronization therapy [CRT-D]), reporting on BICs, and published in peer-reviewed English-language journals. We excluded nonsystematic reviews, opinion pieces/letters, case studies, conference abstracts, PhD dissertations, protocol papers, studies of ICD shock treatment of atrial fibrillation, and of abdominally or submammary implanted ICDs. RESULTS: A total of 40 articles were included: 16 qualitative and 24 quantitative. None of the included studies had BICs as their primary endpoint. Results showed that BICs are present in various degrees in the ICD population and can be attributed to the visibility of the ICD (the scar and bump). Women and younger patients had greater problems with BICs, although men also had concerns. Two items of the "Florida Patient Acceptance Survey" were the most frequently used to assess BICs. CONCLUSION: BICs were present among ICD patients, but the degree of impact on their lives varied. There is a need for developing a BICs questionnaire to examine the prevalence of BICs and the potential impact on patients' lives in longitudinal studies.

Invited commentary on Confusing procedures with process in cognitive bias modification research†.

The notion that cognitive bias modification should be appraised exclusively on the basis of trials where its postulated mechanisms were successfully changed starkly contradicts the standards of evidence-based psychotherapy. In the laboratory or as a treatment, cognitive bias modification cannot continue to eschew the rigorous scrutiny applied to other interventions.

Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis.

BACKGROUND: Cognitive bias modification (CBM) interventions are strongly advocated in research and clinical practice. AIMS: To examine the efficiency of CBM for clinically relevant outcomes, along with study quality, publication bias and potential moderators. METHOD: We included randomised controlled trials (RCTs) of CBM interventions that reported clinically relevant outcomes assessed with standardised instruments. RESULTS: We identified 49 trials and grouped outcomes into anxiety and depression. Effect sizes were small considering all the samples, and mostly non-significant for patient samples. Effect sizes became non-significant when outliers were excluded and after adjustment for publication bias. The quality of the RCTs was suboptimal. CONCLUSIONS: CBM may have small effects on mental health problems, but it is also very well possible that there are no significant clinically relevant effects. Research in this field is hampered by small and low-quality trials, and by risk of publication bias. Many positive outcomes are driven by extreme outliers.

Cost-effectiveness of blended vs. face-to-face cognitive behavioural therapy for severe anxiety disorders: study protocol of a randomized controlled trial.

BACKGROUND: Anxiety disorders are among the most prevalent psychiatric conditions, and are associated with poor quality of life and substantial economic burden. Cognitive behavioural therapy is an effective treatment to reduce anxiety symptoms, but is also costly and labour intensive. Cost-effectiveness could possibly be improved by delivering cognitive behavioural therapy in a blended format, where face-to-face sessions are partially replaced by online sessions. The aim of this trial is to determine the cost-effectiveness of blended cognitive behavioural therapy for adults with anxiety disorders, i.e. panic disorder, social phobia or generalized anxiety disorder, in specialized mental health care settings compared to face-to-face cognitive behavioural therapy. In this paper, we present the study protocol. It is hypothesized that blended cognitive behavioural therapy for anxiety disorders is clinically as effective as face-to-face cognitive behavioural therapy, but that intervention costs may be reduced. We thus hypothesize that blended cognitive behavioural therapy is more cost-effective than face-to-face cognitive behavioural therapy. METHODS/DESIGN: In a randomised controlled equivalence trial 156 patients will be included (n = 78 in blended cognitive behavioural therapy, n = 78 in face-to-face cognitive behavioural therapy) based on a power of 0.80, calculated by using a formula to estimate the power of a cost-effectiveness analysis: [Formula: see text]. Measurements will take place at baseline, midway treatment (7 weeks), immediately after treatment (15 weeks) and 12-month follow-up. At baseline a diagnostic interview will be administered. Primary clinical outcomes are changes in anxiety symptom severity as measured with the Beck Anxiety Inventory. An incremental cost-effectiveness ratio will be calculated to obtain the costs per quality-adjusted life years (QALYs) measured by the EQ-5D (5-level version). Health-economic outcomes will be explored from a societal and health care perspective. DISCUSSION: This trial will be one of the first to provide information on the cost-effectiveness of blended cognitive behavioural therapy for anxiety disorders in routine specialized mental health care settings, both from a societal and a health care perspective. TRIAL REGISTRATION: Netherlands Trial Register NTR4912. Registered 13 November 2014.

Short-term effectiveness of web-based guided self-help for phobic outpatients: randomized controlled trial.

BACKGROUND: Internet-based guided self-help has been successfully used in the general population, but it is unknown whether this method can be effectively used in outpatient clinics for patients waiting for face-to-face psychotherapy for phobias. OBJECTIVE: The aim was to assess the clinical effectiveness of Phobias Under Control, an Internet-based intervention based on exposure therapy with weekly guidance. METHODS: We conducted a randomized controlled trial, recruiting 212 outpatients scheduled to receive face-to-face psychotherapy for any type of phobia at an outpatient clinic. Participants suffering from at least 1 DSM-IV or ICD-10 classified phobia (social phobia, agoraphobia with or without panic disorder, and/or specific phobia as ascertained by a telephone interview at baseline) were randomly allocated to either a 5-week Internet-based guided self-help program based on exposure therapy with weekly student support followed by face-to-face psychotherapy (n=105) or a wait-list control group followed by face-to-face psychotherapy (n=107). Primary outcome was the Fear Questionnaire (FQ). Secondary outcomes were the Beck Anxiety Inventory (BAI) and Center of Epidemiological Studies-Depression scale (CES-D). Assessments took place by telephone at baseline (T0) and on the Internet at posttest (T1, self-assessment at 5 weeks after baseline). Missing data at T1 were imputed. RESULTS: At posttest, analysis of covariance on the intention-to-treat sample showed significant but small effect sizes between intervention and control groups on the FQ (d=0.35, P=.02), CES-D (d=0.34, P=.03), and a nonsignificant effect size on the BAI (d=0.28. P=.05). Although initial acceptance was good, high nonresponse was observed, with 86 of 212 participants (40.5%) lost to follow-up at T1 and only 14 of 105 (13.3%) intervention participants finishing all 5 weeks. CONCLUSIONS: Phobias Under Control is modestly effective in lowering phobic and depressive symptoms in a relatively short period and may be clinically beneficial when implemented in routine outpatient practice. TRIAL REGISTRATION: Netherlands Trial Register NTR2233; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2233 (Archived by WebCite at http://www.webcitation.org/6O2ioOQSs).

Return-to-work rates and predictors of absence duration after COVID-19 over the course of the pandemic.

OBJECTIVES: The aim of this study was to evaluate employee return-to-work (RTW) rates and examine predictors of absence duration after COVID-19. RTW rates were referenced against RTW rates after absence due to flu-like symptoms and assessed over the course of the pandemic. METHODS: Routinely collected data from a nationally operating Dutch occupational health service was used. The data were retrieved from employees who reported sick due to COVID-19 (N=30 396) or flu-like symptoms (N=15 862). Data consisted of responses to a triage survey combined with longitudinal register-based information on sickness absence. RTW rates after COVID-19 were evaluated through Kaplan-Meier estimates and compared to RTW rates for flu-like symptoms, and between three periods with different dominant virus variants. Predictors for absence duration were examined through Cox proportional hazards models. RESULTS: RTW after COVID-19 was found to be notably later than after flu-like symptoms (median RTW=10 versus 6 days, respectively). On average, 5.5% of employees who contracted COVID-19 were absent for over 12 weeks. Time-to-RTW shortened as different virus variants became dominant over time. The main predictors contributing to later RTW were older age, female sex, belonging to a risk group, and the symptoms shortness of breath and fatigue. CONCLUSIONS: Estimates of the RTW rate after COVID-19 and identification of predictors may aid healthcare professionals in gaining insight into variations in the disease course and rehabilitation process. The present findings can help employers and policy-makers grasp the impact of COVID-19 on the workplace.

How to assess severe burnout? Cutoff points for the Burnout Assessment Tool (BAT) based on three European samples.

OBJECTIVE: Despite decades of burnout research, clinical validated cut-off scores that discriminate between those who suffer from burnout and those who don't are still lacking. To establish such cut-off scores, the current study uses a newly developed questionnaire, the Burnout Assessment Tool (BAT) that consists of four subscales (exhaustion, mental distancing, and emotional and cognitive impairment). Separate cut-offs were computed for those at risk for burnout and those suffering from severe burnout for the original BAT-23 as well as for the shortened BAT-12. METHODS: Relative operating characteristic (ROC) analyses were carried out using representative samples of healthy employees from The Netherlands (N=1370), Belgium (Flanders; N=1403) and Finland (N=1350). In addition, samples of employees who received a burnout diagnosis were used (N=335, 158 and 50, respectively). RESULTS: The diagnostic accuracy of the BAT (area under the curve) ranges from good to excellent with the exception of mental distancing, which is fair. The country-specific cut-off values as well as their specificity and sensitivity are comparable to those of the pooled sample. CONCLUSIONS: In addition to country-specific cut-offs, general cut-offs can be used tentatively in other similar countries, pending future replication studies. Caution is warranted for using cut-offs for mental distance as the sensitivity and specificity of this subscale is relatively poor. It is concluded that the BAT can be used in organizational surveys for identifying employees at risk for burnout and, in clinical treatment settings, for identifying those with severe burnout, keeping in mind the tentativeness of the present cut-offs.

Effectiveness and cost-effectiveness of web-based treatment for phobic outpatients on a waiting list for psychotherapy: protocol of a randomised controlled trial.

BACKGROUND: Phobic disorders are highly prevalent and constitute a considerable burden for patients and society. As patients wait for face-to-face psychotherapy for phobic disorders in outpatient clinics, this time can be used for guided self-help interventions. The aim of this study is to investigate a five week internet-based guided self-help programme of exposure therapy in terms of clinical effectiveness and impact on speed of recovery in psychiatric outpatients, as well as the cost-effectiveness of this pre-treatment waiting list intervention. METHODS/DESIGN: A randomised controlled trial will be conducted among 244 Dutch adult patients recruited from waiting lists of outpatient clinics for face-to-face psychotherapy for phobic disorders. Patients suffering from at least one DSM-IV classified phobic disorder (social phobia, agoraphobia or specific phobia) are randomly allocated (at a 1:1 ratio) to either a five-week internet-based guided self-help program followed by face-to-face psychotherapy, or a control group followed by face-to-face psychotherapy. Waiting list status and duration are unchanged and actual need for further treatment is evaluated prior to face-to-face psychotherapy. Clinical and economic self-assessment measurements take place at baseline, post-test (five weeks after baseline) and at 3, 6, 9 and 12 months after baseline. DISCUSSION: Offering pre-treatment internet-based guided self-help efficiently uses time otherwise lost on a waiting list and may increase patient satisfaction. Patients are expected to need fewer face-to-face sessions, reducing total treatment cost and increasing speed of recovery. Internet-delivered treatment for phobias may be a valuable addition to psychotherapy as demand for outpatient treatment increases while budgets decrease. TRIAL REGISTRATION: Netherlands Trial Register NTR2233.

Persuasive system design does matter: a systematic review of adherence to web-based interventions.

BACKGROUND: Although web-based interventions for promoting health and health-related behavior can be effective, poor adherence is a common issue that needs to be addressed. Technology as a means to communicate the content in web-based interventions has been neglected in research. Indeed, technology is often seen as a black-box, a mere tool that has no effect or value and serves only as a vehicle to deliver intervention content. In this paper we examine technology from a holistic perspective. We see it as a vital and inseparable aspect of web-based interventions to help explain and understand adherence. OBJECTIVE: This study aims to review the literature on web-based health interventions to investigate whether intervention characteristics and persuasive design affect adherence to a web-based intervention. METHODS: We conducted a systematic review of studies into web-based health interventions. Per intervention, intervention characteristics, persuasive technology elements and adherence were coded. We performed a multiple regression analysis to investigate whether these variables could predict adherence. RESULTS: We included 101 articles on 83 interventions. The typical web-based intervention is meant to be used once a week, is modular in set-up, is updated once a week, lasts for 10 weeks, includes interaction with the system and a counselor and peers on the web, includes some persuasive technology elements, and about 50% of the participants adhere to the intervention. Regarding persuasive technology, we see that primary task support elements are most commonly employed (mean 2.9 out of a possible 7.0). Dialogue support and social support are less commonly employed (mean 1.5 and 1.2 out of a possible 7.0, respectively). When comparing the interventions of the different health care areas, we find significant differences in intended usage (p=.004), setup (p<.001), updates (p<.001), frequency of interaction with a counselor (p<.001), the system (p=.003) and peers (p=.017), duration (F=6.068, p=.004), adherence (F=4.833, p=.010) and the number of primary task support elements (F=5.631, p=.005). Our final regression model explained 55% of the variance in adherence. In this model, a RCT study as opposed to an observational study, increased interaction with a counselor, more frequent intended usage, more frequent updates and more extensive employment of dialogue support significantly predicted better adherence. CONCLUSIONS: Using intervention characteristics and persuasive technology elements, a substantial amount of variance in adherence can be explained. Although there are differences between health care areas on intervention characteristics, health care area per se does not predict adherence. Rather, the differences in technology and interaction predict adherence. The results of this study can be used to make an informed decision about how to design a web-based intervention to which patients are more likely to adhere.

Development of an internet-delivered program and platform for the treatment of depression and anxiety in patients with ischemic heart disease in eMindYourHeart.

To design and evaluate a mental health treatment program and internet-based delivery platform for patients with ischemic heart disease (IHD) attending cardiac rehabilitation with the aim of reducing the risks associated with anxiety and/or depression. Patients diagnosed with IHD and comorbid anxiety and/or depression. Participatory design of treatment program and internet platform through staged inclusion of participants in two groups. Group 1 was enrolled as co-researchers with prolonged engagement in the project. Group 2 participated only in the pilot evaluation workshop. Three patients were included in Group 1, two patients in Group 2. Inclusion of patients proved challenging, but the extended collaboration with co-researchers yielded valuable circumstantial insight and resulted in the design of a novel nine-module treatment program. Additionally, the inclusion of two participant groups helped shape the development of an internet platform based on an open-source content management system. Our grouped participation method contributes with several recommendations and reflections of advantages of this approach. Collaboration with co-researchers helped us gain a deeper understanding of the impact of language on self-perception and potential stigma. Prolonged participation led to a higher level of trust and familiarity, which enabled uncovering of issues otherwise hidden.

Internet-based treatment of anxiety and depression in patients with ischaemic heart disease attending cardiac rehabilitation: a feasibility study (eMindYourHeart).

Aims: Anxiety and depression are prevalent in 20% of patients with ischaemic heart disease (IHD); however, treatment of psychological conditions is not commonly integrated in cardiac rehabilitation (CR). Internet-based psychological treatment holds the potential to bridge this gap. To examine the feasibility of an eHealth intervention targeting anxiety and depression in patients with IHD attending CR. Methods and results: We used a mixed-methods design, including quantitative methods to examine drop-out and change in anxiety and depression scores, and qualitative methods (thematic analysis) to evaluate patients' and nurses' experiences with the intervention. The therapist-guided intervention consisted of 12 modules provided via a web-based platform. The primary outcome was drop-out, with a drop-out rate <25% considered acceptable. Patients were considered as non-drop-out if they completed ≥5 modules. Out of 60 patients screened positive for anxiety and/or depression, 29 patients were included. The drop-out rate was 24% (7/29). Patients had a mean improvement in anxiety and depression scores of 5.5 and 4.6, respectively. On average, patients had 8.0 phone calls with their therapist and 19.7 written messages. The qualitative analysis of patients' experiences identified four themes: treatment platform, intervention, communication with therapist, and personal experience. Patients were positive towards the intervention, although some found the assignments burdensome. From the nurses, we identified three themes: intervention, inclusion procedure, and collaboration with study team. The nurses were positive, however, due to limited time some struggled with the inclusion procedure. Conclusion: Integrating an eHealth intervention in CR is feasible and the drop-out rate acceptable.

Analysis of Usage Data from a Self-Guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Controlled Trial.

This study examined user engagement with ZeroPhobia, a self-guided app-based virtual reality (VR) Cognitive Behavior Therapy for acrophobia symptoms using cardboard VR viewers. Dutch acrophobic adults (n = 96) completed assessments at baseline and immediately following treatment. Primary outcome measures were the Acrophobia Questionnaire (AQ) and the Igroup Presence Questionnaire (IPQ). Usage data consisted of number of VR sessions practiced, practice time, and fear ratings directly after practicing. Results show that of the 66 participants who played at least one level, the majority continued to finish all levels, spending on average 24.4 min in VR. Self-reported fear consistently decreased between the start and finish of levels. Post-test AQ scores depended quadratically on time spent in VR. Higher pre-test AQ scores were significantly associated with subjective anxiety after the first level and a reduction of post-test AQ scores, but not with number of sessions, suggesting it might be more beneficial to play one level for a longer time period instead of practicing many VR levels. Results also show an optimum exposure level at which increasing practice time does not result in increased benefit. Self-guided VR acrophobia treatment is effective and leads to consistent reductions in self-reported anxiety both between levels and after treatment. Most participants progressed effectively to the highest self-exposure level, despite the absence of a therapist.

Laughter-inducing therapies: Systematic review and meta-analysis.

RATIONALE: Laughter-inducing therapies are being applied more regularly in the last decade, and the number of scientific reports of their beneficial effects is growing. Laughter-inducing therapies could be cost-effective treatments for different populations as a complementary or main therapy. A systematic review and meta-analysis has not yet been performed on these therapies for different populations and outcomes, but is needed to examine their potential benefits. This research aims to broadly describe the field of laughter-inducing therapies, and to estimate their effect on mental and physical health for a broad range of populations and conditions. METHOD: A systematic review of the field was undertaken, followed by a meta-analysis of RCTs and quasi-experimental studies. The systematic review included intervention studies, one-session therapies, lab studies and narrative reviews to provide a broad overview of the field. The meta-analysis included RCTs or quasi-experimental studies that assessed multi-session laughter or humor therapies compared to a control group, performed on people of any age, healthy or with a mental or physical condition. English and non-English articles were searched using PubMed, Web of Science, EBSCO and EMBASE. Search terms included laugh(ing), laughter, humo(u)r, program, therapy, yoga, exercise, intervention, method, unconditional, spontaneous, simulated, forced. Studies were classified as using humor ('spontaneous' laughter) or not using humor ('simulated' laughter). RESULTS: This systematic review and meta-analysis suggests that (1) 'simulated' (non-humorous) laughter is more effective than 'spontaneous' (humorous) laughter, and (2) laughter-inducing therapies can improve depression. However, overall study quality was low, with substantial risk of bias in all studies. With rising health care costs and the increasing elderly population, there is a potential for low-cost, simple interventions that can be administered by staff with minimal training. Laughter-inducing therapies show a promise as an addition to main therapies, but more methodologically rigorous research is needed to provide evidence for this promise.

The psychological subtype of intimate partner violence and its effect on mental health: protocol for a systematic review and meta-analysis.

BACKGROUND/AIM: Psychological violence is estimated to be the most common form of intimate partner violence (IPV). Despite this, research on the independent effect of psychological violence on mental health is scarce. Moreover, the lack of a clear and consistent definition of psychological violence has made results difficult to compare. The present study therefore aims to consolidate knowledge on psychological violence by conducting a systematic review and random-effects meta-analysis on the association between psychological violence and mental health problems, when controlling for other types of violence (e.g. physical and sexual) and taking into account severity, frequency, and duration of psychological violence. METHOD: The present study is registered in the International Prospective Register for Systematic Reviews (PROSPERO; #CRD42018116026) and the study design follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Additional file 1). A dual search will be conducted in the electronic databases PsycINFO, PubMed, EMBASE, and Web of Science. Data will be extracted using Endnote and Covidence and a meta-analysis will be conducted using Metafor-package in the programming language R. The Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project will be used to assess the quality of the included studies (i.e. weak, moderate and strong). RESULTS AND DISCUSSION: The present review will help consolidate knowledge on psychological violence by evaluating whether frequency, severity or actual "type" of psychological violence produces the most harm. A thorough quality assessment will help overcome potential limitations regarding expected variations in terminology and assessment of psychological violence. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018116026 .

Adherence to a web-based pre-treatment for phobias in outpatient clinics.

BACKGROUND: Non-adherence in Internet interventions is a persistent and multifaceted issue and potentially limits the applicability and effectiveness of these interventions. Factors that influence non-adherence are poorly understood, especially in outpatient samples with more complex symptoms. OBJECTIVE: The current study is a secondary analysis of data from a randomised controlled trial that examined the cost-effectiveness of offering an Internet-based exposure treatment to phobic outpatients on a wait-list to receive face-to-face psychotherapy. METHODS: We collected baseline demographic and clinical information, and adherence data of the Internet-based intervention and conducted regression analyses to predict non-adherence to the intervention. RESULTS: The adherence to the intervention was low, with only 13.3% of 105 patients completing all five lessons of the intervention. The median number of exercises completed (out of a possible 8) was 3. In a multi-predictor model, a higher baseline score of anxiety (OR = 0.94, 95% CI 0.90-0.99) was a risk factor for low adherence. Higher age (OR = 1.05, 95% CI 1.00-1.09) was a protective factor against non-adherence. Participants who adhered to the intervention were more likely to complete post-test assessments, further biasing results. However, overall participant attrition was high. The results are based on a small subset of participants and should be interpreted with caution. CONCLUSIONS: Poor baseline clinical status and age are factors to consider when deciding whether to offer an Internet-based intervention to outpatients. Low adherence among those patients might be related to intrinsic motivation and might even be lower in outpatient settings where participants expect to receive face-to-face treatment. It might be worthwhile to develop a concise instrument to assess intrinsic motivation and treatment expectations for using Internet-based interventions, and for the therapist to review the range of possible (Internet-based) intervention options to suit personal preferences and expectations. TRIAL REGISTRATION: Netherlands Trial Register, NTR2233.

The Effectiveness of Cognitive Bias Modification Interventions for Substance Addictions: A Meta-Analysis.

BACKGROUND AND AIMS: Cognitive bias modification (CBM) interventions, presumably targeting automatic processes, are considered particularly promising for addictions. We conducted a meta-analysis examining randomized controlled trials (RCTs) of CBM for substance addiction outcomes. METHODS: Studies were identified through systematic searches in bibliographical databases. We included RCTs of CBM interventions, alone or in combination with other treatments, for any type of addiction. We examined trial risk of bias, publication bias and possible moderators. Effects sizes were computed for post-test and follow-up, using a random-effects model. We grouped outcome measures and reported results for addiction (all related measures), craving and cognitive bias. RESULTS: We identified 25 trials, 18 for alcohol problems, and 7 for smoking. At post-test, there was no significant effect of CBM for addiction, g = 0.08 (95% CI -0.02 to 0.18) or craving, g = 0.05 (95% CI -0.06 to 0.16), but there was a significant, moderate effect on cognitive bias, g = 0.60 (95% CI 0.39 to 0.79). Results were similar for alcohol and smoking outcomes taken separately. Follow-up addiction outcomes were reported in 7 trials, resulting in a small but significant effect of CBM, g = 0.18 (95% CI 0.03 to 0.32). Results for addiction and craving did not differ by substance type, sample type, delivery setting, bias targeted or number of sessions. Risk of bias was high or uncertain in most trials, for most criteria considered. Meta-regression analyses revealed significant inverse relationships between risk of bias and effect sizes for addiction outcomes and craving. The relationship between cognitive bias and respectively addiction ESs was not significant. There was consistent evidence of publication bias in the form of funnel plot asymmetry. CONCLUSIONS: Our results cast serious doubts on the clinical utility of CBM interventions for addiction problems, but sounder methodological trials are necessary before this issue can be settled. We found no indication that positive effects on biases translate into effects on addiction outcomes.

Economic evaluation of Internet-based problem-solving guided self-help treatment in comparison with enhanced usual care for depressed outpatients waiting for face-to-face treatment: A randomized controlled trial.

BACKGROUND: Previous studies have demonstrated the effectiveness of Internet-based interventions for depression in comparison with usual care. However, evidence on the cost-effectiveness of these interventions when delivered in outpatient clinics is lacking. The aim of this study was to estimate the cost-effectiveness of an Internet-based problem-solving guided self-help intervention in comparison with enhanced usual care for outpatients on a waiting list for face-to-face treatment for major depression. After the waiting list period, participants from both groups received the same treatment at outpatient clinics. METHODS: An economic evaluation was performed alongside a randomized controlled trial with 12 months follow-up. Outcomes were improvement in depressive symptom severity (measured by CES-D), response to treatment and Quality-Adjusted Life-Years (QALYs). Statistical uncertainty around cost differences and incremental cost-effectiveness ratios were estimated using bootstrapping. RESULTS: Mean societal costs for the intervention group were €1579 higher than in usual care, but this was not statistically significant (95% CI - 1395 to 4382). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective in comparison with usual care was 0.57 at a ceiling ratio of €15,000/additional point of improvement in CES-D, and 0.25 and 0.30 for an additional response to treatment and an extra QALY respectively, at a ceiling ratio of €30,000. Sensitivity analysis showed that from a mental healthcare provider perspective the probability of the intervention being cost-effective was 0.68 for a ceiling ratio of 0 €/additional unit of effect for the CES-D score, response to treatment and QALYs. As the ceiling ratio increased this probability decreased, because the mean costs in the intervention group were lower than the mean costs in the usual care group. LIMITATIONS: The patients in the intervention group showed low adherence to the Internet-based treatment. It is possible that greater adherence would have led to larger clinical effects. CONCLUSIONS: Offering an Internet-based intervention to depressed outpatients on waiting list for face-to-face treatment was not considered cost-effective in comparison with enhanced usual care from a societal perspective. There was a high probability of the intervention being cost-effective in comparison with enhanced usual care from the perspective of the mental healthcare provider.