Real-World Evaluation of a Large-Scale Blended Care-Cognitive Behavioral Therapy Program for Symptoms of Anxiety and Depression.

Introduction: Prior studies have supported the effectiveness of blended interventions for anxiety and depression; however, outcomes research of large-scale blended interventions for these conditions is limited. Objective: To investigate the outcomes of scaled-up blended care (BC) cognitive behavioral therapy (CBT), a program that combined video-based psychotherapy with internet CBT, for symptoms of anxiety and depression. Materials and Methods: Participants were 6,738 U.S.-based adults with elevated symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD-7] ≥ 8) and/or depression (Patient Health Questionnaire-9 [PHQ-9] ≥ 10) at baseline who received BC-CBT as an employer-offered mental health benefit. The primary outcomes, anxiety (GAD-7) and depression (PHQ-9) symptoms, were routinely measured in the program. Recovery and reliable improvement in outcomes were calculated, and growth curve models evaluated change in outcomes during treatment and the effects of engaging in psychotherapy sessions on outcomes. Results: On average, participants received treatment for 7.6 (standard deviation = 6.2) weeks. By the end of care, 5,491 (81.5%) participants had reliable improvement in either anxiety or depression symptoms; in addition, 5,535 (82.1%) fell below the clinical threshold for either anxiety or depression symptoms (i.e., recovered). Declines in anxiety and depression symptoms were statistically significant over the course of BC-CBT (both p's < 0.01), with the rate of decline significantly decreasing for each outcome as treatment progressed (both p's < 0.01). Each psychotherapy session completed was significantly associated with lower anxiety and depression symptoms during the week of the session and the subsequent week (all p's < 0.01). Conclusions: This real-world study provides evidence that scaled-up BC-CBT can be effective in the treatment of symptoms of anxiety and depression.

Effectiveness of a Cognitive Behavioral Coaching Program Delivered via Video in Real World Settings.

Background: Many employees experience high levels of stress in the workplace, which negatively impact their productivity and well-being. Effective stress management interventions exist, but are inaccessible due to insufficient numbers of mental health providers, long waiting times to initiate care, high out-of-pocket cost of care, and stigma related to receiving psychotherapy. Introduction: The purpose of this study was to test the efficacy, in real-world circumstances, of a structured, cognitive behavioral coaching (CBC) program delivered through video or telephone. Materials and Methods: Retrospective data on 289 subjects who had sought support for emotional health through a behavioral health benefit offered through employers were examined. Changes in perceived stress and well-being over the course of the program were measured using the Perceived Stress Scale (PSS) and Warwick-Edinburgh Mental Well-being Scale (WEMWBS), respectively. Rates of reliable change and satisfaction with the coaching program were also assessed. Results: Scores on both the PSS and WEMWBS improved between baseline and follow-up. Approximately 61.9% (n = 289) of participants demonstrated reliable improvement on either measure. Discussion: CBC is a promising intervention that has the potential to significantly expand access to effective and more affordable interventions for emotional health care. Conclusions: Coaching, when delivered by accredited professionals trained in cognitive behavioral theory and interventions and working in real-world settings, can be efficacious in decreasing perceived stress and increasing well-being when delivered through video or telephone.

Treating suicidal ideation in the context of depression.

BACKGROUND: Treatment recommendations suggest that suicidal ideation will decrease following successful psychotherapy for depression. However, findings from the empirical research are equivocal in this regard. It is possible suicidal ideation does not respond to empirically supported treatment (EST) for depression or that suicidal ideation limits the efficacy of ESTs for depression. METHODS: Data from 793 patients who sought EST for depression was analyzed using t-tests and multiple linear regression. RESULTS: Both patients with (n = 233) or without suicidal ideation (n = 560) were significantly less depressed following treatment. A significant reduction in suicidal ideation was also observed. At baseline, 233 (29.4%) patients reported suicidal ideation, whereas only 90 (11.3%) patients reported suicidal ideation at follow-up. The relationship between suicidal ideation at baseline and depression scores at follow-up was not significant. CONCLUSIONS: Patients with suicidal ideation who receive short-term EST can experience significant reductions in both depressive symptoms and suicidal ideation. Findings suggest that suicidal ideation at baseline does not impact treatment efficacy, but additional research that directly tests moderation is needed.

Blended Care-Cognitive Behavioral Therapy for Depression and Anxiety in Real-World Settings: Pragmatic Retrospective Study.

BACKGROUND: The past few decades saw considerable advances in research and dissemination of evidence-based psychotherapies, yet available treatment resources are not able to meet the high need for care for individuals suffering from depression or anxiety. Blended care psychotherapy, which combines the strengths of therapist-led and internet interventions, can narrow this gap and be clinically effective and efficient, but has rarely been evaluated outside of controlled research settings. OBJECTIVE: This study evaluated the effectiveness of a blended care intervention (video-based cognitive behavior therapy and internet intervention) under real-world conditions. METHODS: This is a pragmatic retrospective cohort analysis of 385 participants with clinical range depression and/or anxiety symptoms at baseline, measured using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), who enrolled in blended care psychotherapy treatment. Participants resided in the United States and had access to the blended care intervention as a mental health benefit offered through their employers. Levels of depression and anxiety were tracked throughout treatment. Hierarchical linear modeling was used to examine the change in symptoms over time. The effects of age, gender, and providers on participants' symptom change trajectories were also evaluated. Paired sample t-tests were also conducted, and rates of positive clinical change and clinically significant improvement were calculated. RESULTS: The average depression and anxiety symptoms at 6 weeks after the start of treatment were 5.94 and 6.57, respectively. There were significant linear effects of time on both symptoms of depression and anxiety (ß=-.49, P<.001 and ß=-.64, P<.001). The quadratic effect was also significant for both symptoms of depression and anxiety (ß=.04, P<.001 for both), suggesting a decelerated decrease in symptoms over time. Approximately 73% (n=283) of all 385 participants demonstrated reliable improvement, and 83% (n=319) recovered on either the PHQ-9 or GAD-7 measures. Large effect sizes were observed on both symptoms of depression (Cohen d=1.08) and of anxiety (d=1.33). CONCLUSIONS: Video blended care cognitive behavioral therapy interventions can be effective and efficient in treating symptoms of depression and anxiety in real-world conditions. Future research should investigate the differential and interactive contribution of the therapist-led and digital components of care to patient outcomes to optimize care.

Evaluating a Multimedia Tool for Suicide Risk Assessment and Management: The Linehan Suicide Safety Net.

OBJECTIVE: The present study examined the usability and effectiveness of the Linehan Suicide Safety Net (LSSN), a web-based, multimedia tool designed to support clinicians working with individuals who are suicidal. The core feature of LSSN is the Linehan Risk Assessment and Management Protocol (LRAMP), an empirically derived protocol that provides a structured checklist for assessing, managing, and documenting suicide risk. METHOD: Mental health professionals (N = 44) completed assessments at baseline and monthly during a 3-month evaluation period. RESULTS: The LSSN was rated as acceptable and highly usable. Use of the LSSN was associated with a significant increase in confidence in conducting suicide risk assessment and management and a decrease in concerns related to treating suicidal clients. CONCLUSION: The LSSN appears to be a promising tool for clinicians working with suicidal clients.

Time for a Change: College Students' Preference for Technology-Mediated Versus Face-to-Face Help for Emotional Distress.

BACKGROUND: Even with recent advances in psychological treatments and mobile technology, online computerized therapy is not yet popular. College students, with ubiquitous access to technology, experiencing high distress, and often nontreatment seekers, could be an important area for online treatment dissemination. Finding ways to reach out to college students by offering psychological interventions through technology, devices, and applications they often use, might increase their engagement in treatment. INTRODUCTION: This study evaluates college students' reported willingness to seek help for emotional distress through novel delivery mediums, to play computer games for learning emotional coping skills, and to disclose personal information online. We also evaluated the role of ethnicity and level of emotional distress in help-seeking patterns. METHODS: A survey exploring our domains of interest and the Mental Health Inventory ([MHI] as mental health index) were completed by 572 students (mean age 18.7 years, predominantly Asian American, female, and freshmen in college). RESULTS: More participants expressed preference for online versus face-to-face professional help. We found no relationship between MHI and help-seeking preference. A third of participants were likely to disclose at least as much information online as face-to-face. Ownership of mobile technology was pervasive. Asian Americans were more likely to be nontreatment seekers than Caucasians. Most participants were interested in serious games for emotional distress. DISCUSSION: Our results suggest that college students are very open to creative ways of receiving emotional help such as playing games and seeking emotional help online, suggesting a need for online evidence-based treatments.

Designing messaging to engage patients in an online suicide prevention intervention: survey results from patients with current suicidal ideation.

BACKGROUND: Computerized, Internet-delivered interventions can be efficacious; however, uptake and maintaining sustained client engagement are still big challenges. We see the development of effective engagement strategies as the next frontier in online health interventions, an area where much creative research has begun. We also argue that for engagement strategies to accomplish their purpose with novel targeted populations, they need to be tailored to such populations (ie, content is designed with the target population in mind). User-centered design frameworks provide a theoretical foundation for increasing user engagement and uptake by including users in development. However, deciding how to implement this approach to engage users in mental health intervention development is challenging. OBJECTIVE: The aim of this study was to get user input and feedback on acceptability of messaging content intended to engage suicidal individuals. METHODS: In March 2013, clinic intake staff distributed flyers announcing the study, "Your Feedback Counts" to potential participants (individuals waiting to be seen for a mental health appointment) together with the Patient Health Questionnaire. The flyer explained that a score of two or three ("more than half the days" or "nearly every day" respectively) on the suicide ideation question made them eligible to provide feedback on components of a suicide prevention intervention under development. The patient could access an anonymous online survey by following a link. After providing consent online, participants completed the anonymous survey. RESULTS: Thirty-four individuals provided data on past demographic information. Participants reported that they would be most drawn to an intervention where they knew that they were cared about, that was personalized, that others like them had found it helpful, and that included examples with real people. Participants preferred email invitations with subject lines expressing concern and availability of extra resources. Participants also provided feedback about a media prototype including a brand design and advertisement video for introducing the intervention. CONCLUSIONS: This paper provides one model (including development of an engagement survey, audience for an engagement survey, methods for presenting results of an engagement survey) for including target users in the development of uptake strategies for online mental health interventions.

Blended Care Therapy for Depression and Anxiety: Outcomes across Diverse Racial and Ethnic Groups.

BACKGROUND: Studies have reported positive outcomes of blended care therapy (BCT), which combines face-to-face care with internet modules. However, there is insufficient evidence of its effectiveness across racial and ethnic groups. This study evaluated outcomes of a BCT program, which combined video psychotherapy with internet cognitive-behavioral modules, across race and ethnicity. METHODS: Participants were 6492 adults, with elevated anxiety (Generalized Anxiety Disorder-7 [GAD-7] ≥ 8) and/or depression (Patient Health Questionnaire-9 [PHQ-9] ≥ 10) symptoms, enrolled in employer-offered BCT. Changes in anxiety (GAD-7) and depression (PHQ-9) symptoms during treatment were evaluated using individual growth curve models. Interaction terms of time with race and ethnicity tested for between-group differences. Treatment satisfaction was assessed using a Net Promoter measure (range = 1 (lowest satisfaction) to 5 (greatest satisfaction)). RESULTS: Participants' self-reported race and ethnicity included Asian or Pacific Islander (27.5%), Black or African American (5.4%), Hispanic or Latino (9.3%), and White (47.2%). Anxiety symptoms decreased during treatment (p < 0.01), with greater reductions among Hispanic or Latino participants compared to White participants (p < 0.05). Depressive symptoms decreased across treatment (p < 0.01), with significantly greater decreases among some racial and ethnic groups compared to White participants. Declines in anxiety and depressive symptoms slowed across treatment (p's < 0.01), with statistically significant differences in slowing rates of depressive symptoms across some racial and ethnic groups. Among participants with responses (28.45%), average treatment satisfaction ranged from 4.46 (SD = 0.73) to 4.67 (SD = 0.68) across race and ethnicity (p = 0.001). Racial and ethnic differences in outcomes were small in magnitude. CONCLUSIONS: BCT for anxiety and depression can be effective across diverse racial and ethnic groups.

Outcomes of a Live Messaging, Blended Care Coaching Program Among Adults With Symptoms of Anxiety: Pragmatic Retrospective Cohort Study.

BACKGROUND: Anxiety disorders are common and can be debilitating. In addition, various barriers exist that can hinder access to adequate care. Coaching that is grounded in evidence-based interventions and delivered via synchronous (ie, live) text-based messaging could potentially increase the reach of mental health services among populations who select this modality instead of other services (eg, face-to-face coaching and psychotherapy). In addition, the delivery of live messaging coaching within a blended care model has the potential to combine the benefits of coaching with those of evidence-based digital mental health tools. OBJECTIVE: This real-world study evaluates the anxiety and satisfaction outcomes of live messaging coaching blended with digital tools (ie, digital exercises and activities). METHODS: This was a retrospective cohort study of 121 adults with moderate levels of anxiety symptoms at the beginning of coaching (Generalized Anxiety Disorder-7 [GAD-7] scores: range 8-14). Participants received an employer-offered blended messaging coaching (BMC) program, and those who opted to receive all live coaching sessions via text-based messaging were included. Anxiety symptom severity was regularly measured by using the GAD-7 scale. Using growth curve models, the change in GAD-7 scores over the course of BMC was evaluated, as were the effects of text-based coaching sessions on GAD-7 scores. The proportion of participants that had a reliable improvement in anxiety symptom severity (GAD-7 score reduction of ≥4) or subclinical symptom severity (GAD-7 score of <8) at the end of care was also estimated. Participants also self-reported their likelihood of recommending their live messaging coach to someone with similar needs. RESULTS: At baseline, the average GAD-7 score was 9.88 (SD 1.80). Anxiety symptom severity significantly decreased with each week in the BMC program (week: b=-1.04; P<.001), and the rate of decline in anxiety symptom severity decreased over time (week2: b=0.06; P<.001). Each live messaging coaching session was associated with significantly lower anxiety symptom severity during the week of the coaching session (b=-1.56; P<.001) and the week immediately following the session (b=-1.03; P<.001). Overall, 86% (104/121) of participants had subclinical symptom severity or a reliable reduction in anxiety symptom severity by the end of care. Further, 33.1% (40/121) of participants reported coaching satisfaction levels; of the 40 participants in this subset, 37 (92.5%) were likely or extremely likely to recommend their live messaging coach. CONCLUSIONS: BMC that provides coaching sessions via live messaging can be beneficial for adults with moderate symptoms of anxiety who qualify for and self-select this care modality. Large-scale studies with longer follow-ups are needed.

Component analysis of a synchronous and asynchronous blended care CBT intervention for symptoms of depression and anxiety: Pragmatic retrospective study.

Background: Depression and anxiety are leading causes of disability worldwide. Though effective treatments exist, depression and anxiety remain undertreated. Blended care psychotherapy, combining the scalability of online interventions with the personalization and engagement of a live therapist, is a promising approach for increasing access to evidence-based care. Objectives: To evaluate the effectiveness and individual contribution of two components - i) digital tools and ii) video-based therapist-led sessions - in a blended care CBT-based intervention under real world conditions. Methods: A retrospective cohort design was used to analyze N = 1372 US-based individuals who enrolled in blended care psychotherapy. Of these, at baseline, 761 participants had depression symptoms in the clinical range (based on PHQ-9), and 1254 had anxiety symptoms in the clinical range (based on GAD-7). Participants had access to the program as a mental health benefit offered by their employer. The CBT-based blended care psychotherapy program consisted of regular video sessions with therapists, complemented by digital lessons and digital exercises assigned by the clinician and completed in between sessions. Depression and anxiety levels and clients' treatment engagement were tracked throughout treatment. A 3-level individual growth curve model incorporating time-varying covariates was utilized to examine symptom trajectories of PHQ-9 scores (for those with clinical range of depression at baseline) and GAD-7 scores (for those with clinical range of anxiety at baseline). Results: On average, individuals exhibited a significant decline in depression and anxiety symptoms during the initial weeks of treatment (P < .001), and a continued decline over subsequent weeks at a slower rate (P < .001). Engaging in a therapy session in a week was associated with lower GAD-7 (b = -0.81) and PHQ-9 (b = -1.01) scores in the same week, as well as lower GAD-7 (b = -0.58) and PHQ-9 (b = -0.58) scores the following week (all P < .01). Similarly, engaging with digital lessons was independently associated with lower GAD-7 (b = -0.19) and PHQ-9 (b = -0.18) scores during the same week, and lower GAD-7 (b = -0.25) and PHQ-9 (b = -0.27) the following week (all P < .01). Conclusions: Therapist-led video sessions and digital lessons had separate contributions to improvements in symptoms of depression and anxiety over the course of treatment. Future research should investigate whether clients' characteristics are related to differential effects of therapist-led and digital components of care.

Predicting non-initiation of care and dropout in a blended care CBT intervention: Impact of early digital engagement, sociodemographic, and clinical factors.

Objective: This study examines predictors of non-initiation of care and dropout in a blended care CBT intervention, with a focus on early digital engagement and sociodemographic and clinical factors. Methods: This retrospective cohort analysis included 3566 US-based individuals who presented with clinical levels of anxiety and depression and enrolled in a blended-care CBT (BC-CBT) program. The treatment program consisted of face-to-face therapy sessions via videoconference and provider-assigned digital activities that were personalized to the client's presentation. Multinomial logistic regression and Cox proportional hazard survival analysis were used to identify predictors of an increased likelihood of non-initiation of therapy and dropout. Results: Individuals were more likely to cancel and/or no-show to their first therapy session if they were female, did not disclose their ethnicity, reported poor financial status, did not have a college degree, endorsed more presenting issues during the onboarding triage assessment, reported taking antidepressants, and had a longer wait time to their first appointment. Of those who started care, clients were significantly more likely to drop out if they did not complete the digital activities assigned by their provider early in treatment, were female, reported more severe depressive symptoms at baseline, reported taking antidepressants, and did not disclose their ethnicity. Conclusions: Various sociodemographic and clinical predictors emerged for both non-initiation of care and for dropout, suggesting that clients with these characteristics may benefit from additional attention and support (especially those with poor early digital engagement). Future research areas include targeted mitigation efforts to improve initiation rates and curb dropout.

Digital cognitive-behavioural therapy to reduce suicidal ideation and behaviours: a systematic review and meta-analysis of individual participant data.

QUESTION: Digital interventions based on cognitive-behavioural therapy (iCBT) is associated with reductions in suicidal ideation. However, fine-grained analyses of effects and potential effect-moderating variables are missing. This study aimed to investigate the effectiveness of iCBT on suicidal ideation, effect moderators, effects on suicide attempts and predictors of adherence. STUDY SELECTION AND ANALYSIS: We systematically searched CENTRAL, PsycINFO, Embase and PubMed for randomised controlled trials that investigated iCBT for suicidal ideation or behaviours. Participants reporting baseline suicidal ideation were eligible. We conducted a one-stage individual participant data (IPD) meta-analysis. Suicidal ideation was the primary outcome, analysed as three indices: severity of suicidal ideation, reliable changes and treatment response. FINDINGS: We included IPD from nine out of ten eligible trials (2037 participants). iCBT showed significant reductions of suicidal ideation compared with control conditions across all indices (severity: b=-0.247, 95% CI -0.322 to -0.173; reliable changes: b=0.633, 95% CI 0.408 to 0.859; treatment response: b=0.606, 95% CI 0.410 to 0.801). In iCBT, the rate of reliable improvement was 40.5% (controls: 27.3%); the deterioration rate was 2.8% (controls: 5.1%). No participant-level moderator effects were identified. The effects on treatment response were higher for trials with waitlist-controls compared with active controls. There were insufficient data on suicide attempts. Human support and female gender predicted treatment adherence. The main source of potential bias was missing outcome data. CONCLUSIONS: The current evidence indicates that iCBT is effective in reducing suicidal ideation irrespective of age, gender and previous suicide attempts. Future studies should rigorously assess suicidal behaviour and drop-out reasons.

Development, Acceptability, and Feasibility of a Digital Module for Coping with COVID-19 Distress: Pragmatic Retrospective Study.

Background: The coronavirus disease 2019 (COVID-19) pandemic and the measures to help contain it have taken a significant toll on mental health. Blended care psychotherapy combining provider-led care with digital tools can help alleviate this toll. This study describes the development of digital activities designed to teach cognitive-behavioral skills for coping with COVID-19 distress, and evaluates initial acceptability and feasibility data. Materials and Methods: Using a pragmatic retrospective cohort design, data from 664 U.S.-based individuals enrolled in blended care psychotherapy were analyzed. Descriptive analyses summarized acceptability for the digital activities. Ordinal logistic regression analyses were conducted on a subsample (n = 162) to explore the association between clients' attitudes toward the digital lesson and reported practice of skills in the exercise. Results: The majority of clients completed the assigned digital lesson and exercise. Clients reported finding the lesson valuable and relevant for coping with COVID-19 distress, and they intended to apply the skills to their lives. Higher agreement with these attitude questions was associated with a significantly greater number of skills practiced on the digital exercise. Discussion: Clients who were assigned a cognitive-behaviorally oriented digital lesson and/or exercise within a blended care model largely engaged with the materials and found them valuable. Clients with more positive attitudes about the digital lesson reported using more coping skills. Conclusions: Digital modules that teach specific skills for coping with COVID-19 can be integrated into treatment and minimize provider burden. Future study should investigate the clinical impact of these digital activities on psychiatric symptoms and personalizing the content.

Examining the Impact of Digital Components Across Different Phases of Treatment in a Blended Care Cognitive Behavioral Therapy Intervention for Depression and Anxiety: Pragmatic Retrospective Study.

BACKGROUND: Depression and anxiety incur significant personal and societal costs. Effective psychotherapies exist, such as cognitive behavioral therapy (CBT); however, timely access to quality care is limited by myriad barriers. Blended care therapy models incorporate traditional face-to-face therapy with scalable, digital components of care, expanding the reach of evidence-based care. OBJECTIVE: The aim of this study is to determine the effectiveness of a blended care CBT program (BC-CBT) in real-world settings and examine the unique impacts of the (1) digital components of care (video lessons and digital exercises) and (2) phase of treatment (early versus late) in decreasing symptoms of anxiety and depression. METHODS: This retrospective cohort analysis included 3401 US-based individuals enrolled in a BC-CBT program, who presented with clinical levels of depression and/or anxiety. The treatment program consisted of regular therapy sessions augmented by clinician-assigned digital video lessons and exercises. A growth curve model incorporating time-varying covariates examined the relationship between engagement with BCT components (ie, therapy sessions, digital video lessons, and digital exercises) during the early (weeks 0-7) and late (weeks 8-15) phases of treatment, and weekly symptom reports on depression and anxiety measures. RESULTS: On average, a significant decline in depression and anxiety symptoms was observed during the initial weeks of treatment (P<.001), with a continued, though slower, decline over subsequent weeks (P<.001). Each session completed was associated with significant decreases in anxiety (b=-0.72) and depression (b=-0.83) in the early phase, as well as in the late phase (anxiety, b=-0.47; depression, b=-0.27). Significant decreases in anxiety (b=-0.15) and depression (b=-0.12) were observed for time spent on video lessons (measured in 10-minute intervals) in the early phase of treatment. Engaging with exercises was associated with statistically significant increases in anxiety symptoms (b=0.03) during the early phase of treatment. However, sensitivity analyses examining the effects of exercises in isolation revealed significant decreases in anxiety (b=-0.05) in the early phase, suggesting a potential suppression effect in the larger model. CONCLUSIONS: Using a retrospective cohort design, therapy sessions and digital video lessons were uniquely predictive of improvements in depression and anxiety symptoms, and their effects were modulated based on the phase of treatment (early vs late). Future research should investigate whether other treatment variables, such as therapeutic alliance or familiarity with technology, are related to differential effects on various components of care.

Outcomes of a Blended Care Coaching Program for Clients Presenting With Moderate Levels of Anxiety and Depression: Pragmatic Retrospective Study.

BACKGROUND: Depression and anxiety are leading causes of disability worldwide, but access to quality mental health care is limited by myriad factors. Cognitive-behavioral coaching is rooted in evidence-based principles and has the potential to address some of these unmet care needs. Harnessing technology to facilitate broader dissemination within a blended care model shows additional promise for overcoming barriers to care. OBJECTIVE: The aim of this study is to evaluate the outcomes of a blended care coaching (BCC) program for clients presenting with moderate levels of anxiety and depression in real-world settings. METHODS: This study examined retrospective data from US-based individuals (N=1496) who presented with moderate levels of depression and anxiety symptoms and who received blended care coaching services. Using a short-term framework, clients met with coaches via a secure video conference platform and also received digital video lessons and exercises. To evaluate the effectiveness of the BCC program, mixed effects modeling was used to examine growth trajectories of anxiety and depression scores over the course of care. RESULTS: Out of the total sample of 1496 clients, 75.9% (n=1136) demonstrated reliable improvement, and 88.6% (n=1326) recovered based on either the Generalized Anxiety Disorder-7 scale (anxiety) or Patient Health Questionnaire-9 (depression). On average, clients exhibited a significant decline in anxiety and depression symptoms during the initial weeks of coaching, with a continued decline over subsequent weeks at a lower rate. Engaging in a coaching session was associated with lower anxiety (b=-1.04) and depression (b=-0.79) symptoms in the same week, as well as lower anxiety (b=-0.74) and depression (b=-0.91) symptoms the following week (P<.001). CONCLUSIONS: The BCC program demonstrated strong outcomes in decreasing symptomology for clients presenting with moderate levels of anxiety and depression. When clients received coaching sessions, significant decreases in symptoms were observed, reflecting the importance of session attendance. Additionally, the steepest declines in symptoms tended to occur during the initial weeks of coaching, emphasizing the importance of client buy-in and early engagement. Collectively, these findings have implications for addressing unmet mental health care needs in a more accessible, cost-effective manner.

Assessing Suicidal and NonSuicidal Self-Injury via In-Depth Interview or Self-Report: Balancing Assessment Effort and Results.

OBJECTIVE: Both suicide and nonsuicidal self-injury (NSSI) represent major public health concerns, and effective assessment, management, and treatment requires assessment tools that can simultaneously be quick and accurate. This study compared the validity of a self-report measure of suicide attempts and NSSI acts with a gold standard in depth interview. METHOD: Ninety women answered questions about their suicidal behavior history using both a self-report assessment and in-depth interview. RESULTS: The plurality of patients over estimated their suicidal acts using the self-report measure when compared to the gold standard interview. CONCLUSION: Self-report assessments may not be an accurate method of retrieving information about suicide.

Suicide Ideation and Acceptability Toward Online Help-Seeking.

Suicidal individuals are unlikely to engage in face-to-face treatment. The Internet is emerging as an innovative approach for intervention delivery, particularly for those unable or unwilling to attend traditional treatment. Participants (N = 459) were recruited to fill out online questionnaires on suicide ideation and help-seeking modality preference. The majority of participants endorsed preferring face-to-face help over web-based help. Results from multinominal logistic regression indicated that suicide ideation was significantly related to preferring online methods versus face-to-face methods. This study highlights that the Internet can provide a novel platform to treat individuals at risk of suicide.

A randomized controlled trial of an Internet delivered dialectical behavior therapy skills training for suicidal and heavy episodic drinkers.

BACKGROUND: Given that alcohol misuse elevates risk of suicide death among ideators, the paucity of treatment outcome research for individuals presenting with both suicide ideation and problem drinking is particularly troubling. Dialectical behavior therapy (DBT) skills training, which effectively targets behaviors associated with emotion dysregulation including addictive and suicidal behaviors, provides a fitting model amenable to computerization. As stigma and scarcity stand as potential barriers to treatment, online dissemination platforms provide means for efficient treatment delivery that can augment the utility of suitable interventions. This pilot RCT sought to evaluate the feasibility, acceptability, and preliminary efficacy of an Internet-delivered DBT skills training intervention (iDBT-ST) for suicidal individuals who engage in heavy episodic drinking METHODS: Participants (N = 59) were randomized to receive iDBT-ST immediately or after an 8-week waiting period. Clinical outcomes were suicide ideation, alcohol use, and emotion dysregulation. RESULTS: Participants on average saw a significant reduction in all outcomes over the four-month study period. Compared to waitlist controls, individuals who received iDBT-ST immediately showed faster reductions in alcohol consumption. CONCLUSIONS: Preliminary results suggest that iDBT-ST may be a viable resource for the high-risk and underserved group represented in this study, and pathways for future development are suggested. LIMITATIONS: There was difficulty retaining and engaging participants due to technological barriers.

Internet-Delivered Dialectical Behavioral Therapy Skills Training for Suicidal and Heavy Episodic Drinkers: Protocol and Preliminary Results of a Randomized Controlled Trial.

BACKGROUND: The need to develop effective and accessible interventions for suicidal individuals engaging in heavy episodic drinking (HED) cannot be understated. While the link between alcohol use and suicidality is a complex one that remains to be elucidated, emotion dysregulation may play a key role in alcohol-related suicide risk in these individuals. OBJECTIVE: In the current study, an 8-week Internet-delivered dialectical behavior therapy (DBT) skills training intervention was developed and preliminarily evaluated for suicidal individuals who engage in HED to regulate emotions. The aim of the study is to evaluate the feasibility and effectiveness of the therapist-assisted and Internet-delivered intervention, and to inform the design of a subsequent full-scale study. METHODS: The study was a pilot randomized controlled trial comparing participants receiving immediate-treatment (n=30) to waitlist controls (n=29) over a period of 16 weeks. Intervention effects will be assessed longitudinally using hierarchical linear modeling and generalized estimating equations, along with analyses of effect sizes and clinically significant change. The primary outcomes are suicidal ideation, alcohol problems, and emotion dysregulation. Secondary outcomes include alcohol-related consequences, reasons for living, skills use, and depression. RESULTS: The trial is ongoing. A total of 60 individuals returned their informed consent and were randomized, of whom 59 individuals were intended to treat. A total of 50 participants in the study were retained through the 16-week enrollment. CONCLUSIONS: There is a dearth of evidence-based treatment for individuals presenting with high risk and complex behaviors. Furthermore, computerized interventions may provide a beneficial alternative to traditional therapies. The particular clinical features and treatment needs of suicidal individuals who also engage in HED constitute key domains for further investigation that are needed to consolidate the design of appropriate interventions for this high-risk population. TRIAL REGISTRATION: Clinicaltrials.gov NCT02932241; https://clinicaltrials.gov/ct2/show/NCT02932241 (Archived by WebCite at http://www.webcitation.org/6uJHdQsC2).