Usage of unguided, guided, and blended care for depression offered in routine clinical care: Lessons learned.

Introduction: Internet-delivered psychotherapy is often considered to be a promising way to extend mental healthcare services around the world. Research findings that have emerged over the past two decades have strengthened this claim. However, very little is known about the usage of internet-delivered psychotherapy in real-life circumstances. Methods: The current study explored the real-life usage of depressiehulp.be, a publicly available online platform for depression that offers pure self-help, online guided self-help, and blended treatment for depression in Flanders, Belgium, using data collected from 2656 participants between May 2018 and May 2022. Results: Both duration of engagement with the online platform and number of exercises completed increased with increasing levels of therapist guidance. Findings also showed a particular pattern of engagement for each of the online treatments. Overall, participants completed most exercises during the first days of treatment. However, participants using pure online self-help showed the fastest decrease of engagement over time, with most dropping out after completing a few exercises, and more than half of all participants who enrolled in the self-help programme did not even begin the programme. In both guided and blended treatment, participants tended to show higher levels of engagement with the online platform. In each treatment modality, a relatively small but notable group of participants showed high levels of engagement. There was no relationship between severity of depression and duration of engagement. Conclusions: The current study demonstrates the importance of therapist support in online interventions and offers additional insights into how, and to what extent, online platforms are used. Future research should explore clinical impact and policy implications.

Digital mental health: challenges and next steps.

Digital innovations in mental health offer great potential, but present unique challenges. Using a consensus development panel approach, an expert, international, cross-disciplinary panel met to provide a framework to conceptualise digital mental health innovations, research into mechanisms and effectiveness and approaches for clinical implementation. Key questions and outputs from the group were agreed by consensus, and are presented and discussed in the text and supported by case examples in an accompanying appendix. A number of key themes emerged. (1) Digital approaches may work best across traditional diagnostic systems: we do not have effective ontologies of mental illness and transdiagnostic/symptom-based approaches may be more fruitful. (2) Approaches in clinical implementation of digital tools/interventions need to be creative and require organisational change: not only do clinicians and patients need training and education to be more confident and skilled in using digital technologies to support shared care decision-making, but traditional roles need to be extended, with clinicians working alongside digital navigators and non-clinicians who are delivering protocolised treatments. (3) Designing appropriate studies to measure the effectiveness of implementation is also key: including digital data raises unique ethical issues, and measurement of potential harms is only just beginning. (4) Accessibility and codesign are needed to ensure innovations are long lasting. (5) Standardised guidelines for reporting would ensure effective synthesis of the evidence to inform clinical implementation. COVID-19 and the transition to virtual consultations have shown us the potential for digital innovations to improve access and quality of care in mental health: now is the ideal time to act.

Telepsychology in Europe since COVID-19: How to Foster Social Telepresence?

All over the world, measures were taken to prevent the spread of COVID-19. Social distancing not only had a strong influence on mental health, but also on the organization of care systems. It changed existing practices, as we had to rapidly move from face-to-face contact to remote contact with patients. These changes have prompted research into the attitudes of mental healthcare professionals towards telepsychology. Several factors affect these attitudes: at the institutional and organizational level, but also the collective and personal experience of practitioners. This paper is based on an original European survey conducted by the EFPA (European Federation of Psychologists' Associations) Project Group on eHealth in 2020, which allowed to observe the variability in perceptions of telepsychology between countries and mental healthcare professionals. This study highlights different variables that contributed to the development of attitudes, such as motivations, acquired experience, or training. We found the "feeling of telepresence"-which consists of forgetting to some extent that we are at a distance, in feeling together-and social telepresence in particular as main determinants of the perception and the practice of telepsychology.

The first steps in facing your fears: The acceptability of virtual reality and in vivo exposure treatment for specific fears.

Phobic individuals are often reluctant to engage in exposure in vivo (IVE). We examined whether providing exposure in virtual reality (VRE) can increase the acceptability. In Study 1, we provided 186 fearful participants with (hypothetical) VRE and IVE treatment offers and examined their willingness to engage in treatment, estimated success, negative beliefs, acceptance/refusal and their preference. Almost 70 % preferred VRE over IVE and acceptance rates were higher for the VRE offer (58 %) than for IVE (35 %). Although participants held fewer negative beliefs about VRE, they did rate IVE as slightly more successful. In Study 2, we examined whether VRE can serve as a stepping stone to IVE in a sample of 102 spider fearful individuals. Willingness to engage, estimated success and negative beliefs about IVE were assessed before and after VRE. After VRE, participants rated IVE as more successful, but were not more willing to engage in IVE, nor were they more inclined to accept an IVE offer. No decreases in negative beliefs were observed. In conclusion, VRE is deemed more acceptable than IVE and could lower refusal rates, hereby resulting in more phobic individuals receiving treatment. Future research should shed light on underlying motivations and associations.

Remote Consultations for Mental Health: Patient Experiences.

OBJECTIVE: An exponential implementation of remote mental health care has been observed, but little data is available on experiences and barriers of remote health from a patient's perspective. This study investigated experiences associated with several forms of remote consultations (both telephone and online video) for mental health care during the COVID-19 coronavirus pandemic with a particular focus on patients' experiences. METHODS: This study includes results of an online web-based survey filled in by 512 patients on the use and experiences of remote mental health consultations and circulating between March and October 2021. RESULTS: Psychiatric consultations were initiated by the health care provider in 47.0% of cases, while psychological consultations were most often initiated in shared decision with the patient (54.9%). Only 28.8% of participants mentioned advantages regarding teleconsultations over face-to-face, compared to 39.3% for online video consultations. Moreover, 49.3% saw clear disadvantages for teleconsultations and 32.7% for video consultations. Positive factors associated with remote mental health care included when faced with transportation problems, followed by consultations primarily focusing on medication (for telephone consultations) or on more practical aspects (for video consultations). 25.0% of patients deemed conversations when being angry or sad to be feasible by telephone, and 33.0% considered these feasibly using video consultations. CONCLUSION: Remote consultations were deemed feasible, but the positive factors did not seem to outweigh the face-to-face contacts from a patient's perspective. Remote consultations will probably remain present in the following decades, although care must be taken when providing the possibility of remote mental health care.

The feasibility of using Apple's ResearchKit for recruitment and data collection: Considerations for mental health research.

In 2015, Apple launched an open-source software framework called ResearchKit. ResearchKit provides an infrastructure for conducting remote, smartphone-based research trials through the means of Apple's App Store. Such trials may have several advantages over conventional trial methods including the removal of geographic barriers, frequent assessments of participants in real-life settings, and increased inclusion of seldom-heard communities. The aim of the current study was to explore the feasibility of participant recruitment and the potential for data collection in the non-clinical population in a smartphone-based trial using ResearchKit. As a case example, an app called eMovit, a behavioural activation (BA) app with the aim of helping users to build healthy habits was used. The study was conducted over a 9-month period. Any iPhone user with access to the App Stores of The Netherlands, Belgium, and Germany could download the app and participate in the study. During the study period, the eMovit app was disseminated amongst potential users via social media posts (Twitter, Facebook, LinkedIn), paid social media advertisements (Facebook), digital newsletters and newspaper articles, blogposts and other websites. In total, 1,788 individuals visited the eMovit landing page. A total of 144 visitors subsequently entered Apple's App Store through that landing page. The eMovit product page was viewed 10,327 times on the App Store. With 79 installs, eMovit showed a conversion rate of 0.76% from product view to install of the app. Of those 79 installs, 53 users indicated that they were interested to participate in the research study and 36 subsequently consented and completed the demographics and the participants quiz. Fifteen participants completed the first PHQ-8 assessment and one participant completed the second PHQ-8 assessment. We conclude that from a technological point of view, the means provided by ResearchKit are well suited to be integrated into the app process and thus facilitate conducting smartphone-based studies. However, this study shows that although participant recruitment is technically straightforward, only low recruitment rates were achieved with the dissemination strategies applied. We argue that smartphone-based trials (using ResearchKit) require a well-designed app dissemination process to attain a sufficient sample size. Guidelines for smartphone-based trial designs and recommendations on how to work with challenges of mHealth research will ensure the quality of these trials, facilitate researchers to do more testing of mental health apps and with that enlarge the evidence-base for mHealth.

Online consultations in mental healthcare: Modelling determinants of use and experience based on an international survey study at the onset of the pandemic.

Introduction: While online consultations have shown promise to be a means for the effective delivery of high-quality mental healthcare and the first implementations of these digital therapeutic contacts go back nearly two decades, uptake has remained limited over the years. The onset of the COVID-19 pandemic dramatically altered this relative standstill and created a unique turning point, with a massive amount of both professionals and clients having first hands-on experiences with technology in mental healthcare. Objective: The current study aimed to document the uptake of online consultations and explore if specific characteristics of mental health professionals across and beyond Europe could predict this. Methods: An international survey was designed to assess mental health professionals' (initial) experiences with online consultations at the onset of the pandemic: their willingness to make use of them and their prior and current experiences, alongside several personal characteristics. Logistic mixed-effects models were used to identify predictors of the use of online consultations, personal experience with this modality, and the sense of telepresence. Results: A total of 9115 healthcare professionals from 73 countries participated of which about two-thirds used online consultations during the initial COVID-19 outbreak. The current study identifies multiple determinants relating to the use and experience of online consultations, including the professionals' age, experience with the technology before the outbreak, the professional context, and training. Conclusions: Despite strong evidence supporting the relevance of training in digital mental health, this is clearly still lacking. Nevertheless, the COVID-19 pandemic presented a first, and potentially transformative, experience with online consultations for many healthcare professionals. The insights from this study can help support professionals and, importantly, (mental) healthcare organisations to create optimal circumstances for selective and high-quality continued use of online consultations.

An adaptation algorithm for personalised virtual reality exposure therapy.

BACKGROUND: Anxiety disorders are highly prevalent in mental health problems. The lives of people suffering from an anxiety disorder can be severely impaired. Virtual Reality Exposure Therapy (VRET) is an effective treatment, which immerses patients in a controlled Virtual Environment (VE). This creates the opportunity to confront feared stimuli and learn how to deal with them, which may result in the reduction of anxiety. The configuration of these VEs requires extensive effort to maximise the potential of Virtual Reality (VR) and the effectiveness of the therapy. Manual configuration becomes infeasible when the number of possible virtual stimuli combinations is infinite. Due to the growing complexity, acquiring the skills to truly master a VR system is difficult and it increases the threshold for psychotherapists to use such useful systems. We therefore developed a prototype of a supportive algorithm to facilitate the use of VRET in a clinical setting. This automatised system assists psychotherapists to use the wide range of functionalities without burdening them with technical challenges. Thus, psychotherapists can focus their attention on the patient. METHODS: In this paper both the prototype of the algorithm and a first proof of concept are described. The algorithm suggests environment configurations for VRET, tailored to the individual therapeutic needs of each patient. The system aims to maximise learning during exposure therapy for different combinations of stimuli by using the Rescorla-Wagner model as a predictor for learning. In a first proof of concept, the VE configurations suggested by the algorithm for three anonymised clinical vignettes were compared with prior manual configurations by two psychotherapists. RESULTS: The prototype of the algorithm and a first proof of concept are described. The first proof of concept demonstrated the relevance and potential of the proposed system, as it managed to propose similar configurations for the clinical vignettes compared to those made by therapists. Nonetheless, because of the exploratory nature of the study, no claims can yet be made about its efficacy. CONCLUSIONS: With the increasing ubiquity of immersive technologies, this technology for assisted configuration of VEs could make VRET a valuable tool for psychotherapists.

E-mental health implementation in inpatient care: Exploring its potential and future challenges.

Background: There is a great evidence base today for the effectiveness of e-mental health, or the use of technology in mental healthcare. However, large-scale implementation in mental healthcare organisations is lacking, especially in inpatient specialized mental healthcare settings. Aim: The current study aimed to gain insights into the factors that promote or hinder the implementation of e-mental health applications on organisational, professional and patient levels in Belgium. Methods: Four Belgian psychiatric hospitals and psychiatric departments of general hospitals invited their professionals and patients to use Moodbuster, which is a modular web-based platform with a connected smartphone application for monitoring. The platform was used in addition to treatment as usual for three to four months. The professionals and patients completed pre- and post-implementation questionnaires on their reasons to participate or to decline participation and experiences with the Moodbuster platform. Results: Main reasons for the organisations to participate in the implementation study were a general interest in e-mental health and seeing it is a helpful add-on to regular treatment. The actual use of Moodbuster by professionals and patients proved to be challenging with only 10 professionals and 24 patients participating. Implementation was hindered by technical difficulties and inpatient care specific factors such as lack of structural facilities to use e-mental health and patient-specific factors. Professionals saw value in using e-mental health applications for bridging the transition from inpatient to outpatient care. Twenty-two professionals and 31 patients completed the questionnaire on reasons not to participate. For the patients, lack of motivation because of too severe depressive symptoms was the most important reason not to participate. For professionals, it was lack of time and high workload. Conclusions: The current implementation study reveals several important barriers to overcome in order to successfully implement e-mental health in inpatient psychiatric care.

Freely Available Virtual Reality Experiences as Tools to Support Mental Health Therapy: a Systematic Scoping Review and Consensus Based Interdisciplinary Analysis.

The primary purpose of this article is to review the potential therapeutic value of freely available VR content as an addition to the practitioners 'toolkit'. Research has shown that virtual reality (VR) may be useful to extend existing guided imagery-based practices found in traditional mental health therapy. However, the use of VR technology within routine mental health practice remains low, despite recent reductions in equipment costs. A systematic scoping review and interdisciplinary analysis of freely available VR experiences was performed across two popular online databases (SteamVR and Oculus.com). A total of 1785 experiences were retrieved and screened for relevance with 46 meeting the inclusion criteria. VR content was then reviewed for potential therapeutic value by an interdisciplinary panel with experience across a number of therapeutic interventions including cognitive behavioural therapy, Rogerian counselling, mindfulness-based therapies. and family therapy. Eleven (22%) of the 50 freely available VR experiences were reported to have therapeutic potential as tools to support routine mental health therapy. These included support with the following mental health issues-low mood, social anxiety, stress reduction and fear of heights. Guidance of a qualified mental health practitioner was recommended in all cases to maximise the benefit of the VR experiences retrieved. While the quality is variable, freely available VR experiences may contain valuable content that could support mental health therapy. This includes as a homework activity or as an initial setting for case formulation and behavioural experiments.

Reviewing the availability, efficacy and clinical utility of Telepsychology in dialectical behavior therapy (Tele-DBT).

BACKGROUND: Telepsychology is increasingly being implemented in mental health care. We conducted a scoping review on the best available research evidence regarding availability, efficacy and clinical utility of telepsychology in DBT. The review was performed using PRISMA-ScR guidelines. Our aim was to help DBT-therapists make empirically supported decisions about the use of telepsychology during and after the current pandemic and to anticipate the changing digital needs of patients and clinicians. METHODS: A search was conducted in PubMed, Embase, PsycARTICLES and Web of Science. Search terms for telepsychology were included and combined with search terms that relate to DBT. RESULTS: Our search and selection procedures resulted in 41 articles containing information on phone consultation, smartphone applications, internet delivered skills training, videoconferencing, virtual reality and computer- or video-assisted interventions in DBT. CONCLUSIONS: The majority of research about telepsychology in DBT has focused on the treatment mode of between-session contact. However, more trials using sophisticated empirical methodologies are needed. Quantitative data on the efficacy and utility of online and blended alternatives to standard (i.e. face-to-face) individual therapy, skills training and therapist consultation team were scarce. The studies that we found were designed to evaluate feasibility and usability. A permanent shift to videoconferencing or online training is therefore not warranted as long as face-to-face is an option. In all, there is an urgent need to compare standard DBT to online or blended DBT. Smartphone apps and virtual reality (VR) are experienced as an acceptable facilitator in access and implantation of DBT skills. In addition, we have to move forward on telepsychology applications by consulting our patients, younger peers and experts in adjacent fields if we want DBT to remain effective and relevant in the digital age.

Online consultations in mental healthcare during the COVID-19 outbreak: An international survey study on professionals' motivations and perceived barriers.

INTRODUCTION: While the general uptake of e-mental health interventions remained low over the past years, physical distancing and lockdown measures relating to the COVID-19 pandemic created a need and demand for online consultations in only a matter of weeks. OBJECTIVE: This study investigates the uptake of online consultations provided by mental health professionals during lockdown measures in the first wave of the COVID-19 pandemic in the participating countries, with a specific focus on professionals' motivations and perceived barriers regarding online consultations. METHODS: An online survey on the use of online consultations was set up in March 2020. The Unified Theory of Acceptance and Use of Technology (UTAUT) guided the deductive qualitative analysis of the results. RESULTS: In total, 2082 mental health professionals from Austria, Belgium, Cyprus, France, Germany, Italy, Lebanon, Lithuania, the Netherlands, Norway, Portugal, Spain, and Sweden were included. The results showed a high uptake of online consultations during the COVID-19 pandemic but limited previous training on this topic undergone by mental health professionals. Most professionals reported positive experiences with online consultations, but concerns about the performance of online consultations in a mental health context (e.g., in terms of relational aspects) and practical considerations (e.g., relating to privacy and security of software) appear to be major barriers that hinder implementation. CONCLUSIONS: This study provides an overview of the mental health professionals' actual needs and concerns regarding the use of online consultations in order to highlight areas of possible intervention and allow the implementation of necessary governmental, educational, and instrumental support so that online consultations can become a feasible and stable option in mental healthcare.

Cross-cultural differences in user-centred research: An international living lab survey.

Digital health applications and interactive technologies increasingly allow organisations to transcend national boundaries and expand the provision of tools and services to communities across the world. Making the transfer beyond the context in which applications were originally conceptualized is challenging, as these have to be tailored towards local end-user needs and regulations. Such information is not always readily available, which risks successful uptake in novel settings. Living labs help to bridge this gap, by performing user experience research and supporting user-centred design for cross-border projects. Dissimilarities in recruitment and participation of end users could however influence study outcomes. Therefore, this study explores to what extent living labs are aware of potential cross-cultural differences. The sample consists of 36 living labs from 20 countries, most focusing on health and care, the silver economy and information technology. Regional differences are reported on participants' motivation and on the impact of gender, age, professional status and socio-economic status on participants' contribution. Awareness of potential differences during recruitment and grouping and supporting equal contribution in sessions could improve the quality of user-centred research in international contexts, while still maintaining sufficient standardisation. Further research with larger international samples is needed to replicate and extend these findings.

Telepsychotherapy During the COVID-19 Pandemic: The Experience of Lebanese Mental Health Professionals.

The COVID-19 pandemic has taken the mental health system by surprise, with the state of lockdown forcing businesses to close their doors, including many mental health services. This has driven many psychotherapists and other mental health professionals towards telepsychotherapy, relying on online consultations to provide continuity of care. However, the adoption of telepsychotherapy required major adaptations from both mental health professionals and patients. This study set out to explore the predictors of the use of online consultations and the perceived level of comfort using telepsychotherapy in a sample of 73 Lebanese mental health professionals. Data was collected via online dissemination of a survey. Results show that 82% of participants made use of online consultations in the past few days, reflecting the adaptation of Lebanese mental health professionals to the atypical newly imposed situation triggered by the COVID-19 pandemic and its consequent lockdown. Having previous experience in the use of online consultations and perceived level of telepresence were significant predictors of the level of comfort of mental health professionals in the execution online consultations. We suggest that more awareness and trainings are required around the practice of telepsychotherapy outside the context of the COVID-19 pandemic.

Dropping the E: The potential for integrating e-mental health in psychotherapy.

E-mental health, or the use of technology in mental healthcare, has been the focus of research for over two decades. Over that period, the evidence base for the potential of technology to improve psychotherapeutic practice has grown steadily. This sharply contrasts with the actual use of e-mental health by psychotherapists, which has remained limited. In this article, we aim to illustrate how and when different technological tools and applications can play a role in psychotherapy. At the same time, we also highlight current limitations and discuss challenges for future research. A specific, yet hypothetical case, is used to guide this narrative review and make proposed applications tangible and concrete.

Technological and Digital Interventions for Mental Health and Wellbeing: An Overview of Systematic Reviews.

Background: Research increasingly shows how selective and targeted use of technology within care and welfare can have several advantages including improved quality of care and active user involvement. Purpose: The current overview of reviews aims to summarize the research on the effectiveness of technology for mental health and wellbeing. The goal is to highlight and structure the diverse combinations of technologies and interventions used so far, rather than to summarize the effectiveness of singular approaches. Methods: The current overview includes reviews published in the past five years with a focus on effectiveness of digital and technological interventions targeting mental health and wellbeing. Results: A total of 246 reviews could be included. All reviews examined the effectiveness of digital and technological interventions in the context of care and welfare. A combination of two taxonomies was created through qualitative analysis, based on the retrieved interventions and technologies in the reviews. Review classification shows a predominance of reviews on psychotherapeutic interventions using computers and smartphones. It is furthermore shown that when smartphone applications as stand-alone technology are researched, the primary focus is on self-help, and that extended reality is the most researched emerging technology to date. Conclusion: This overview of reviews shows that a wide range of interventions and technologies, with varying focus and target populations, have been studied in the field of care and wellbeing. The current overview of reviews is a first step to add structure to this rapidly changing field and may guide both researchers and clinicians in further exploring the evidence-base of particular approaches.

Combining Biofeedback with Stress Management Interventions: A Systematic Review of Physiological and Psychological Effects.

Current mental healthcare systems experience difficulties meeting the challenges of a growing population with elevated stress symptoms. Outpatient stress management interventions have already proven to be effective in routine care and recent technological advances now allow to expand such interventions, for example by adding a physiological component like biofeedback. Adding biofeedback to stress management interventions appears promising, but there is a lack of insight into the general conceptualization and evaluation of the resulting interventions, both in relation to psychological and physiological stress indicators. A comprehensive literature search was performed to investigate stress management interventions with a biofeedback component. This systematic review provides an overview of these interventions and explores to what extent they can improve both physiological and psychological indicators of stress. Fourteen RCTs were included. A large diversity was observed in intervention design and effectiveness. Nevertheless, there is preliminary evidence that the use of biofeedback can improve both physiological and psychological indicators of stress. Biofeedback could provide an accessible and low-cost addition to stress interventions. Further research into the effectiveness of different components of biofeedback interventions is needed.

Virtually Unexpected: No Role for Expectancy Violation in Virtual Reality Exposure for Public Speaking Anxiety.

In the current study, we examined the role of expectancy violation and retrospective reasoning about the absence of feared outcomes in virtual reality exposure therapy (VRET). Participants fearful of public speaking were asked to give speeches in virtual reality. We asked each participant individually to report their expectancies about feared outcomes in public speaking situations and which of these could be tested in VRET. Each of the expectancies was categorized as being related to: (1) participants' own reactions, (2) (overt) reactions of the audience, or (3) (covert) negative evaluation. We examined whether the proportion of testable expectancies could predict treatment outcome and which type of expectancies were evaluated as being more testable in VRET. Additionally, we experimentally manipulated retrospective reasoning about whether or not expectancies related to the overt reactions of the audience could be violated by providing verbal information after VRET about whether or not the virtual audience was interactive. A reduction in public speaking anxiety was observed from pre- to post-VRET. Treatment effects were, however, not predicted by the individually reported proportions of testable expectancies. Participants evaluated expectancies about their own reactions as being more testable in VRET compared to expectancies about reactions of the audience or about being negatively evaluated. In addition, we did not find evidence that the experimental manipulation regarding whether or not the audience was interactive influenced treatment effects. In conclusion, the results of the current study suggest that the effects of VRET are not univocally explained by the mechanism of expectancy violation.

Fear of Hypoglycemia, Parenting Stress, and Metabolic Control for Children with Type 1 Diabetes and Their Parents.

This study sets out to extend current knowledge of parenting stress and fear of hypoglycemia (FoH) in parents of children with type 1 diabetes mellitus (T1DM). We examined if the relationship between parental and children's FoH and metabolic control, as reflected by HbA1c, is mediated by parenting stress. A total of 63 parents and children with T1DM were recruited during their routine physician's appointment. Parents completed questionnaires on parenting stress and FoH. Children eight years and older also completed a questionnaire on FoH. HbA1c values were obtained from all children. Mediation analysis revealed an indirect association between parental FoH and HbA1c values through parenting stress (Sobel's z = 2.42, p = .02), but no indirect association between children's FoH and HbA1c. We concluded that parental FOH has an indirect association with the child's metabolic control that is mediated by parenting stress. More simply, fear of hypoglycemia predicts parent stress, which in turn, predicts metabolic control.