Cocreated internet-based stepped care for individuals with cancer and concurrent symptoms of anxiety and depression: Results from the U-CARE AdultCan randomized controlled trial.

OBJECTIVE: The aim was to evaluate the effects of cocreated internet-based stepped care (iCAN-DO) on anxiety, depression, posttraumatic stress, and health-related quality of life (HRQoL) in individuals with cancer and self-reported anxiety and/or depression symptoms, compared with standard care. METHODS: Clinically recruited individuals with breast, colorectal, or prostate cancer underwent online screening with the Hospital Anxiety and Depression Scale (HADS). Those with anxiety and/or depression symptoms (>7 on any of the HADS subscales) were randomized to iCAN-DO or standard care. iCAN-DO comprised psychoeducation and self-care strategies (step 1) and internet-based cognitive behavioral therapy (iCBT, step 2). Data were collected before randomization and at 1, 4, 7, and 10 months and analyzed with intention-to-treat regression analysis and randomization tests. RESULTS: Online screening identified 245 (27%) of 909 individuals who reported anxiety and/or depression symptoms. They were randomized to iCAN-DO (n = 124) or standard care (n = 121). Of them 49% completed the 10-month assessment, and in the iCAN-DO group 85% accessed step 1 and 13% underwent iCBT. iCAN-DO decreased the levels of symptoms of depression (-0.54, 95% confidence interval: -1.08 to -0.01, P < .05) and the proportion of individuals with symptoms of depression (P < .01) at 10 months, compared with standard care, according to HADS. There were no significant effects on anxiety, posttraumatic stress, or HRQoL. CONCLUSION: Internet-based stepped care improves symptoms of depression in individuals with cancer. Further studies are needed to gain knowledge on how to optimize and implement internet-based support in oncology care.

Identification of Anxiety and Depression Symptoms in Patients With Cancer: Comparison Between Short and Long Web-Based Questionnaires.

BACKGROUND: Physicians and nurses in cancer care easily fail to detect symptoms of psychological distress because of barriers such as lack of time, training on screening methods, and knowledge about how to diagnose anxiety and depression. National guidelines in several countries recommend routine screening for emotional distress in patients with cancer, but in many clinics, this is not implemented. By inventing screening methods that are time-efficient, such as digitalized and automatized screenings with short instruments, we can alleviate the burden on patients and staff. OBJECTIVE: The aim of this study was to compare Web-based versions of the ultrashort electronic Visual Analogue Scale (eVAS) anxiety and eVAS depression and the short Hospital Anxiety and Depression Scale (HADS) with Web-based versions of the longer Montgomery Åsberg Depression Rating Scale-Self-report (MADRS-S) and the State Trait Anxiety Inventory- State (STAI-S) with regard to their ability to identify symptoms of anxiety and depression in patients with cancer. METHODS: Data were obtained from a consecutive sample of patients with newly diagnosed (<6 months) breast, prostate, or colorectal cancer or with recurrence of colorectal cancer (N=558). The patients were recruited at 4 hospitals in Sweden between April 2013 and September 2015, as part of an intervention study administered via the internet. All questionnaires were completed on the Web at the baseline assessment in the intervention study. RESULTS: The ultrashort and short Web-based-delivered eVAS anxiety, eVAS depression and HADS were found to have an excellent ability to discriminate between persons with and without clinical levels of symptoms of anxiety and depression compared with recommended cutoffs of the longer instruments MADRS-S and STAI-S (area under the curve: 0.88-0.94). Cutoffs of >6 on HADS anxiety and >7 hundredths (hs) on eVAS anxiety identified patients with anxiety symptoms with high accuracy. For HADS depression, at a cutoff of >5 and eVAS depression at a cutoff of >7 hs, the accuracy was very high likewise. CONCLUSIONS: The use of the short and ultrashort tools, eVAS and HADS, may be a suitable initial method of Web-based screening in busy clinical settings. However, there are still a proportion of patients who lack access to the internet or the ability to use it. There is a need to find solutions for this group to find all the patients with psychological distress.

Health-Related Internet Use in People With Cancer: Results From a Cross-Sectional Study in Two Outpatient Clinics in Sweden.

BACKGROUND: The access to various forms of support during the disease trajectory is crucial for people with cancer. The provision and use of Internet health services is increasing, and it is important to further investigate the preferences and demographical characteristics of its users. Investigating the uptake and perceived value of Internet health services is a prerequisite to be able to meet the needs in the targeted group. OBJECTIVE: The objective of this study was to investigate health-related Internet use among people with cancer. METHODS: The health online support questionnaire (HOSQ), examining the incentives for health-related Internet support use, was administered in two Swedish outpatient hospital clinics. Of the 350 copies of the questionnaire handed out, 285 (81.4%) were returned, answered by persons with cancer who had completed treatment or were under active surveillance or another medical treatment. RESULTS: A total of 215 (76.2%, 215/282) participants reported Internet use since being diagnosed with cancer. Internet-users were younger (P<.001), more likely to have a partner (P=.03), and had a higher level of education than nonusers (P<.001). The most common health-related activity on the Internet was searching for information (77.2%, 166/215), and users searched significantly more immediately after diagnosis compared with later on (P<.001). Use of My Healthcare Contacts was considered the most valuable Internet activity. Having a university degree (P ˂.001) and being younger in age (P=.01) were associated with a significantly higher frequency of health- related Internet use. CONCLUSIONS: People with cancer turn to the Internet for informational support that enables them to influence their care and to stay in touch with friends and relatives. Demographical differences regarding the uptake of Web-based support remains. This indicates a need for research on how to bridge this digital gap. By learning more about the use of health-related support on the Web among people with cancer, adequate support can be offered and potential strain reduced.

Measuring Use of Health-Related Support on the Internet: Development of the Health Online Support Questionnaire (HOSQ).

BACKGROUND: Social support plays an important role for the perceived health in people with health problems and chronic diseases. Provision of different kinds of support during the disease trajectory is crucial for many people. Online support is ubiquitous and represents a promising modality for people with chronic diseases. There are no existing instruments that measure various aspects of online support. OBJECTIVE: The objective of this study was to create a generic questionnaire regarding health-related support online that can be applied to people with various health problems and illnesses. Additionally, we wanted to test the questionnaire in a cancer population to assess its adequacy in the context of severe disease. METHODS: Initial items for the Health Online Support Questionnaire (HOSQ) were inspired by sociologist James House regarding social support. An exploratory factor analysis was conducted in healthy persons or with minor health problems (n=243) on 31 initial items. The scale was reduced to 18 items and the internal consistency and reliability of the scale was examined along with content validity. Further validation was conducted by a confirmatory analysis on the 18-item scale in a cancer population (n=215). In addition, data on demographics, health problems experienced, and Internet use were collected. RESULTS: The exploratory factor analysis on the final 18-item scale resulted in 2 factors. After scrutinizing the content, these factors were labeled "reading" and "interacting" and they demonstrated good internal consistency (Cronbach alphas .88 and .77, respectively). The factors were confirmed in the cancer population. The response pattern revealed expected differences both between the interaction and reading scales and according to age, gender, education, and health problems thereby supporting the validity of the HOSQ. CONCLUSIONS: The HOSQ may be a reliable and valid instrument for measuring the use of online support for people with health problems, but the results ought to be replicated in more studies to confirm the results for different diagnoses. If the results of this study are corroborated by future studies, the HOSQ may be used as a basis for the development of different forms of support on the Internet.

U-CARE: Internet-based stepped care with interactive support and cognitive behavioral therapy for reduction of anxiety and depressive symptoms in cancer--a clinical trial protocol.

BACKGROUND: Approximately 20-30% of patients with cancer experience a clinically relevant level of emotional distress in response to disease and treatment. This in itself is alarming but it is even more problematic because it is often difficult for physicians and nurses to identify cancer patients who experience clinically relevant levels of anxiety and depression symptoms. This can result in persistent distress and can cause human suffering as well as costs for individuals and to the community. METHODS: Applying a multi-disciplinary and design-oriented approach aimed at attaining new evidence-based knowledge in basic and applied psychosocial oncology, this protocol will evaluate an intervention to be implemented in clinical practice to reduce cancer patient anxiety and depression. A prospective randomized design will be used.The overarching goal of the intervention is to promote psychosocial health among patients suffering from cancer by means of self-help programmes delivered via an Internet platform. Another goal is to reduce costs for individuals and society, caused by emotional distress in response to cancer.Following screening to detect levels of patient distress, patients will be randomized to standard care or a stepped care intervention. For patients randomized to the intervention, step 1 will consist of self-help material, a chat forum where participants will be able to communicate with each other, and a Frequently Asked Questions (FAQ) section where they can ask questions and get answers from an expert. Patients in the intervention group who still report symptoms of anxiety or depression after access to step 1 will be offered step 2, which will consist of cognitive behavioral therapy (CBT) administered by a personal therapist. The primary end point of the study is patients' levels of anxiety and depression, evaluated longitudinally during and after the intervention. DISCUSSION: There is a lack of controlled studies of the psychological and behavioral processes involved in this type of intervention for anxiety and depressive disorders. Since anxiety and depressive symptoms are relatively common in patients with cancer and the availability of adequate support efforts is limited, there is a need to develop evidence-based stepped care for patients with cancer, to be delivered via the Internet. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01630681.

The Development of a Nurse-Led Internet-Based Learning and Self-care Program for Cancer Patients With Symptoms of Anxiety and Depression-A Part of U-CARE.

BACKGROUND: Having access to information about the disease and being encouraged to participate in self-care activities may reduce anxiety and depression symptoms in cancer patients. Internet-based interventions may be one way to support effective self-care strategies to improve emotional well-being and health-related quality of life. OBJECTIVE: The aim of this study was to describe the development and acceptance of an Internet-based program intended to support cancer patients with anxiety and depression symptoms. METHODS: A structured collaboration between patients, clinicians, and researchers was used to develop a theory- and evidence-based interactive health communication application (IHCA) based on Orem's self-care deficit nursing theory with influences from Bandura's social learning theory and psychoeducation. RESULTS: The result is an IHCA described as a Nurse-led, Internet-based Learning and Self-care program that helps patients to perform self-care using different types of material in interaction with patients and healthcare staff. The acceptance of the program is consistent with the results of similar studies. CONCLUSIONS: Collaboration between patients, clinicians, and researchers seems to be a fruitful approach in the development of an IHCA aiming to support cancer patients' self-care strategies. Well-designed intervention studies are needed to evaluate the effects of the IHCA. IMPLICATIONS FOR PRACTICE: This article suggests a theoretical foundation for an IHCA and allows researchers and healthcare providers to take part in the discussion regarding format and content of IHCAs.

The Preference for Internet-Based Psychological Interventions by Individuals Without Past or Current Use of Mental Health Treatment Delivered Online: A Survey Study With Mixed-Methods Analysis.

BACKGROUND: The use of the Internet has the potential to increase access to evidence-based mental health services for a far-reaching population at a low cost. However, low take-up rates in routine care indicate that barriers for implementing Internet-based interventions have not yet been fully identified. OBJECTIVE: The aim of this study was to evaluate the preference for Internet-based psychological interventions as compared to treatment delivered face to face among individuals without past or current use of mental health treatment delivered online. A further aim was to investigate predictors of treatment preference and to complement the quantitative analyses with qualitative data about the perceived advantages and disadvantages of Internet-based interventions. METHODS: Two convenience samples were used. Sample 1 was recruited in an occupational setting (n=231) and Sample 2 consisted of individuals previously treated for cancer (n=208). Data were collected using a paper-and-pencil survey and analyzed using mixed methods. RESULTS: The preference for Internet-based psychological interventions was low in both Sample 1 (6.5%) and Sample 2 (2.6%). Most participants preferred psychological interventions delivered face to face. Use of the Internet to search for and read health-related information was a significant predictor of treatment preference in both Sample 1 (odds ratio [OR] 2.82, 95% CI 1.18-6.75) and Sample 2 (OR 3.52, 95% CI 1.33-9.29). Being born outside of Sweden was a significant predictor of preference for Internet-based interventions, but only in Sample 2 (OR 6.24, 95% CI 1.29-30.16). Similar advantages and disadvantages were mentioned in both samples. Perceived advantages of Internet-based interventions included flexibility regarding time and location, low effort, accessibility, anonymity, credibility, user empowerment, and improved communication between therapist and client. Perceived disadvantages included anonymity, low credibility, impoverished communication between therapist and client, fear of negative side effects, requirements of computer literacy, and concerns about confidentiality. CONCLUSIONS: Internet-based interventions were reported as the preferred choice by a minority of participants. The results suggest that Internet-based interventions have specific advantages that may facilitate help-seeking among some individuals and some disadvantages that may restrict its use. Initiatives to increase treatment acceptability may benefit from addressing the advantages and disadvantages reported in this study.