Human contact in internet-based interventions for depression: A pre-registered replication and meta-analysis of randomized trials.

Introduction: Internet-based self-help interventions have shown to be effective in the treatment of depression. Several meta-analyses indicated that human contact has a crucial impact on adherence and outcome. While most research focused on the role of guidance during interventions, a review by Andersson and Johansson (2012) suggested that contact before the intervention too may play an important role. Objective: We investigated the impact of the degree of contact in internet-based interventions (IBIs) for depression on outcome in adults suffering from elevated symptoms of depression. Methods: We conducted a preregistered meta-analysis (www.osf.io/4mzyd) and included trials comparing IBIs for depression against control conditions (treatment as usual [TAU] or waiting list [WL]) in patients with symptoms of unipolar depression searching the databases PsycINFO and Cochrane's Central Register of Controlled Trials (CENTRAL) limited to entries from EMBASE and PubMed. Following Andersson and Johansson (2012), contact before an intervention was defined as having had a diagnostic interview before the IBI, and contact during intervention was defined as having received guidance during the IBI. IBIs were grouped as providing (0) no contact, (1) contact before the IBI, (2) contact during the IBI, or (3) contact both before and during the IBI. The primary outcome was standardized mean difference (SMD) of the IBI and control in depressive symptoms at treatment termination. Secondary outcomes were study dropout and adherence to the IBI. Results: We included 56 eligible trials that randomized 13,335 patients to 75 internet-based intervention conditions and control groups (TAU in 23 trials, WL in 33 trials). In total, 44 trials (78.57 %) were judged to show some concerns or a high risk of bias. Overall heterogeneity was high regarding the primary outcome (I2s < 66 %) and even higher for secondary outcomes (I2s < 91 %). Degree of contact was a robust predictor of outcome and adherence in all pre-registered and exploratory analyses. We found the effect of the IBI to increase with higher degree of contact. However, in pair-wise contrasts, only IBIs offering both contact before and during the intervention (SMD = 0.573, 95 % CI: 0.437, 0.709) significantly outperformed interventions offering no contact (SMD = 0.224, 95 % CI: 0.090, 0.340). Conclusions: The results suggest that contact before and during an intervention increases the effects of IBIs. The combination of contact before and during the intervention seems to a pivotal role regarding adherence as well as treatment outcome for patients suffering from depression.

Working alliance and adherence mediate the effect of guidance in a web-based program for participants with mild to moderate depressive symptoms: A secondary mediation analysis.

Guided web-based self-help programs for individuals with depressive symptoms have shown to be more efficacious than unguided programs. However, research has paid little attention to why guided interventions are superior. The present study investigated whether working alliance and adherence to the program mediated the effect of guidance on depressive symptom outcome. The study is a secondary analysis of a randomized factorial trial. In the trial, 302 adults with mild to moderate depressive symptoms (Patient Health Questionnaire-9 score: 5-14) were randomized to either a guided or an unguided group. All participants received access to a web-based self-help program based on problem-solving therapy. Working alliance with the treatment providers was assessed using an adapted version of the Working Alliance Inventory for Guided Internet Interventions two weeks (early-treatment) and eight weeks (post-treatment) after pre-treatment. The primary outcome was depressive symptoms at post-treatment. The total working alliance score was significantly higher for guided participants compared to unguided participants (at early-treatment: t 248.6 = -3.36, p < .001, d = 0.42, at post-treatment: t 194.9 = -4.77, p < .001, d = 0.66). The total working alliance score correlated significantly with the change in depressive symptoms for guided (rs = 0.16, 0.34) and unguided participants (rs = 0.26, 0.23). The WAI-I total score statistically mediated the relationship between guidance and outcome (at early-treatment: B = -0.028, at post-treatment: B = -0.053). Furthermore, the subscale tasks (at post-treatment: B = -0.051), the subscale goals (at early-treatment: B = -0.031 and at post-treatment: B = -0.052), and adherence to the program (B = -0.034) mediated the relationship between guidance and outcome. Finally, in a multiple mediation model both early-treatment working alliance and adherence to the program (B = -0.050) mediated the relationship between guidance and outcome. These findings indicate that guidance increases working alliance to treatment providers as early as two weeks after treatment beginning. The alliance predicts outcome and mediates the relationship between guidance and outcome. Participants' agreement with tasks and goals of a program seems to be more important than the bond with treatment providers. Treatment providers might therefore attune web-based programs to the preferences and expectations of participants. In addition to the working alliance, adherence to the program co-mediates the relationship between guidance and outcome.

Two sides of the same coin? Patient and therapist experiences with a transdiagnostic blended intervention focusing on emotion regulation.

Introduction: The combination of internet-based intervention and psychotherapy, commonly termed blended therapy (BT), has gained popularity in recent years. While advantages and disadvantages of BT have been identified from the patient and therapist perspective, the two perspectives have rarely been examined within the same treatment. Moreover, almost all available research on patient and therapist experiences with BT is disorder-specific. This study aimed to investigate patient and therapist experiences within the same transdiagnostic BT. Methods: A qualitative analysis of semi-structured interviews with eight patients and eight therapists taking part in a transdiagnostic blended intervention focusing on the topic of emotion regulation was conducted. A qualitative content analysis approach was used. Category frequencies were calculated and similarities and differences between the patient and therapist experience were explored. Results: Ten main themes and 59 subthemes were identified in the category system for patient interviews and ten main themes and 50 subthemes were identified in the category system for therapist interviews. Similarities and differences between the two perspectives were reported with regard to 1) expectations toward the intervention, 2) the internet-based intervention, 3) symptomatology and emotion regulation, 4) the therapeutic relationship and 5) the blended format. Conclusion: This study provides first insights on the experiences with transdiagnostic BT focusing on emotion regulation. Based on the results, different recommendations for the improvement of transdiagnostic BT are made. Future research on patient and therapist experiences with transdiagnostic BT is necessary, in order to further improve the experience of those involved.

Optimizing the context of support of web-based self-help in individuals with mild to moderate depressive symptoms: A randomized full factorial trial.

Web-based self-help programs for individuals with depressive symptoms are efficacious. Differences in effect sizes and adherence rates might be due to contextual factors. This randomized factorial trial investigated the effects of four potentially supportive contextual factors on outcome and adherence. Two factors were provided through human contact (guidance and a diagnostic interview), and two factors were provided without human contact (a motivational interviewing module and automated emails). We recruited 316 adults with mild to moderate depressive symptoms (Patient Health Questionnaire-9 score: 5-14). All participants received access to a problem-solving therapy program. Participants were randomized across the four experimental factors (present or absent), resulting in a 16-condition design. The primary outcome was depressive symptoms 10 weeks after baseline. The secondary outcome was program adherence. Overall, results showed significant symptom reduction for the primary depression measure (Cohen's d = 0.38-0.91). Guided participants showed significantly less severe symptoms of depression at post-treatment (d = 0.15) and higher treatment adherence (d = 0.53). At follow-up, these differences were no longer present. The remaining three factors did not influence primary outcome and adherence. These findings indicate that guidance leads to a faster reduction of depressive symptoms and higher treatment adherence.

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

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.