Evaluation of a therapist-guided virtual psychological pain management program when provided as routine care: a prospective pragmatic cohort study.

INTRODUCTION: Numerous randomized controlled trials have evaluated the outcomes of internet-delivered psychological pain management programs (PMPs) as a way of increasing access to care for people with chronic pain. However, there are few reports of the effectiveness of these PMPs when provided as part of routine care. METHODS: The present study sought to report the clinical and demographic characteristics of users (n = 1367) and examine the effectiveness of an established internet-delivered psychological PMP program in improving several pain-related outcomes, when offered at a national digital mental health service over a 5-year period. It also sought to comprehensively explore predictors of treatment commencement, treatment completion, and clinical improvement. RESULTS: Evidence of clinical improvements (% improvement; Hedges g) were found for all outcomes, including pain interference (18.9%; 0.55), depression (26.1%; 0.50), anxiety (23.9%; 0.39), pain intensity (12.8%; 0.41), pain self-efficacy (-23.8%; -0.46) and pain-catastrophizing (26.3%; 0.56). A small proportion of users enrolled but did not commence treatment (13%), however high levels of treatment completion (whole treatment = 63%; majority of the treatment = 75%) and satisfaction (very satisfied = 45%; satisfied = 37%) were observed among those who commenced treatment. There were a number of demographic and clinical factors associated with commencement, completion and improvement, but no decisive or dominant predictors were observed. DISCUSSION: These findings highlight the effectiveness and acceptability of internet-delivered psychological PMPs in routine care and point to the need to consider how best to integrate these interventions into the pathways of care for people with chronic pain.

A comparison of the characteristics and treatment outcomes of migrant and Australian-born users of a national digital mental health service.

BACKGROUND: To explore the characteristics and compare clinical outcomes of non-Australian born (migrant) and Australian-born users of an Australian national digital mental health service. METHODS: The characteristics and treatment outcomes of patients who completed online treatment at the MindSpot Clinic between January 2014 and December 2016 and reported a country of birth other than Australia were compared to Australian-born users. Data about the main language spoken at home were used to create distinct groups. Changes in symptoms of depression and anxiety were measured using the Patient Health Questionnaire-9 Item (PHQ-9), and Generalized Anxiety Disorder Scale - 7 Item (GAD-7), respectively. RESULTS: Of 52,020 people who started assessment at MindSpot between 1st January 2014 and 22nd December 2016, 45,082 reported a country of birth, of whom 78.6% (n = 35,240) were Australian-born, and 21.4% (n = 9842) were born overseas. Of 6782 people who completed the online treatment and reported country of birth and main language spoken at home, 1631 (24%) were migrants, 960 (59%) were from English-speaking countries, and 671 (41%) were from non-English speaking countries. Treatment-seeking migrant users reported higher rates of tertiary education than Australian-born users. The baseline symptom severity, and rates of symptom reduction and remission following online treatment were similar across groups. CONCLUSIONS: Online treatment was associated with significant reductions in anxiety and depression in migrants of both English speaking and non-English speaking backgrounds, with outcomes similar to those obtained by Australian-born patients. DMHS have considerable potential to help reduce barriers to mental health care for migrants.

Evaluation of The Practitioner Online Referral and Treatment Service (PORTS): the first 18 months of a state-wide digital service for adults with anxiety, depression, or substance use problems.

The Practitioner Online Referral and Treatment Service (PORTS) is a new digital mental health service (DMHS) providing assessment, treatment, and consultation across Western Australia, for adults with anxiety, depression, or substance use problems, and experiencing financial hardship or geographical disadvantage. From July 2017 to December 2018, a total of 2,527 individuals were referred to PORTS. Of these, 150 (6%) did not give consent for their results to be analysed. Of the remaining 2,377 patients, 615 (26%) could not be contacted to confirm the referral, 596 (25%) received assessment or information from PORTS, 427 (18%) were referred to another service, and 739 (31%) commenced treatment at PORTS. Almost half (47%) of patients were from areas with significant socio-economic disadvantage. Those referred by another mental health service were more likely to engage in treatment than those referred by a General Practitioner (GP). Overall outcomes were excellent, with large effect sizes (Cohen's d: 1.1-1.4), from assessment to post-treatment and 3-month follow-up, reliable deterioration was low, and GP and patient satisfaction was high. These results indicate that the PORTS DMHS model is a promising method for engaging primary care patients with anxiety and depression, including those experiencing financial and geographical disadvantage.

Treating anxiety and depression in young adults: A randomised controlled trial comparing clinician-guided versus self-guided Internet-delivered cognitive behavioural therapy.

BACKGROUND: Internet-delivered cognitive behaviour therapy may increase access by young adults to evidence-based treatments for anxiety and depression. OBJECTIVE: The aim of this study was to compare the efficacy of an Internet-delivered cognitive behaviour therapy intervention designed for adults aged 18-24 years, when delivered in clinician-guided versus self-guided formats. DESIGN: The intervention, the Mood Mechanic Course, is a transdiagnostic treatment that simultaneously targets symptoms of anxiety and depression using cognitive and behavioural skills. The brief intervention comprised four lessons, delivered over 5 weeks. Following a brief telephone interview, young adults ( n = 191) with symptoms of anxiety and depression were randomly allocated to either (1) clinician-guided treatment ( n = 96) or (2) self-guided treatment ( n = 95). RESULTS: At post treatment, large reductions (average improvement; clinician guided vs self-guided) were observed in symptoms of anxiety (44% vs 35%) and depression (40% vs 31%) in both groups. Significant improvements were also observed in general psychological distress (33% vs 29%), satisfaction with life (18% vs 15%) and disability (36% vs 29%). No marked or consistent differences in clinical outcomes emerged between conditions at post-treatment, at 3-month or 12-month follow-up. Satisfaction was high with both treatment formats, but slightly higher for clinician-guided treatment. CONCLUSION: These results indicate the potential of carefully developed Internet-delivered cognitive behaviour therapy interventions for young adults with anxiety and depression provided in either self or therapist-guided format. Further large-scale research is required to determine the short- and long-term advantages and disadvantages of different models of support.

The first 30 months of the MindSpot Clinic: Evaluation of a national e-mental health service against project objectives.

OBJECTIVE: The MindSpot Clinic provides online mental health services to Australian adults with anxiety and depression. This paper describes users of MindSpot between January 2013 and June 2015. Outcomes are considered against three key objectives: improving access to mental health services, improving public awareness of how to access services and providing evidence-based treatments. METHOD: Website traffic data were examined to determine patterns of use. Demographic characteristics, past service utilisation and reasons for contacting MindSpot were analysed. Outcomes for patients enrolled in a MindSpot treatment course were also analysed. Primary outcomes were scores on the 9-Item Patient Health Questionnaire, Generalised Anxiety Disorder 7-Item, Yale-Brown Obsessive Compulsive Scale and Post-Traumatic Stress Disorder Checklist-Civilian Version, administered at assessment, post-treatment and 3-month follow-up. RESULTS: The website was visited by almost 500,000 Australians, of which 33,990 adults started assessments, and 25,469 people completed assessment and were eligible for analysis. Mean age was 36.4 years (standard deviation = 13.3 years; range = 18-94 years), and 72% were female. The proportion living in rural or remote regions and who identified as Aboriginal and Torres Strait Islander closely matched national statistics. The majority (82%) reported that they were not currently in contact with mental health services. Most patients sought an assessment, information about treatment options, or referral to another service, and only 24% of those completing an assessment commenced a MindSpot treatment course. Of these, large clinical effects ( d: 0.7-2.4; average symptom reductions: 25.5% to 61.6%) were found from assessment to follow-up on all outcome measures. Deterioration ranged from 1.0% to 4.3%. CONCLUSION: Based on the number of website visits, completed assessments and treatment outcomes, MindSpot achieved its three programme objectives. This model of service provision has considerable value as a complement to existing services, and is proving particularly important for improving access for people not using existing services.

Psychometric properties of the Mini-Social Phobia Inventory (Mini-SPIN) in a large online treatment-seeking sample.

The Mini-Social Phobia Inventory (Mini-SPIN) is a brief, three-item measure designed as a screening tool for social anxiety disorder (SAD). This study investigated the Mini-SPIN's psychometric properties in a series of trials of Internet-delivered treatment. Participants were 993 people seeking Internet-delivered cognitive behavioural therapy for a range of anxiety and mood disorders. Participants completed the Mini-SPIN, and were diagnosed using the Mini International Neuropsychiatric Interview Version 5.0.0 (MINI). They also completed measures of depression, general anxiety, panic, neuroticism and general impairment. The Mini-SPIN's ability to discriminate between people with and without SAD, within a large sample of people seeking treatment for a range of psychological disorders, was assessed at initial assessment and three-month follow-up. The Mini-SPIN's criterion group validity, internal consistency, test-retest reliability, construct validity and responsiveness to treatment were also examined. Results demonstrated that the Mini-SPIN has an excellent ability to discriminate between those with and without SAD in a highly comorbid clinical sample, and also has good criterion group validity. The Mini-SPIN also exhibited excellent internal consistency, good test-retest reliability, and was responsive to treatment. These results highlight the Mini-SPIN's potential as an efficient and reliable measure of SAD in heterogeneous populations.

The frequency of actions and thoughts scale: development and psychometric validation of a measure of adaptive behaviours and cognitions.

This paper describes the development and preliminary psychometric evaluation of an instrument that measures the frequency of adaptive behaviours and cognitions related to therapeutic change during cognitive behavioural therapy (CBT), for symptoms of anxiety and depression. Two studies were conducted. In study one, 661 participants completed an online survey with 28 items targeting adaptive behaviours and cognitions. Exploratory factor analysis performed on part of the sample (n = 451) revealed that a four-factor solution 'characterised' the data. This led to the development of a 12-item instrument, the Frequency of Actions and Thoughts Scale (FATS). Confirmatory factor analysis was used to confirm the factor structure of the FATS using the remaining sample (n = 210), which revealed an acceptable model fit. In study two, 125 participants with clinically significant symptoms of anxiety, depression, or both were recruited to an Internet-delivered CBT (iCBT) treatment course. Participants completed the FATS and other measures throughout treatment, after treatment, and at three-month follow-up. Correlations and residual change scores of the FATS and its subscales with measures of anxiety, depression, behavioural activation, and CBT-related skills usage supported the construct validity of the FATS. A significant increase in FATS scores over treatment was also observed. The findings provide preliminary support for the psychometric properties of the FATS, which appears to have utility in research investigating mechanisms of change in CBT.

Procedures for risk management and a review of crisis referrals from the MindSpot Clinic, a national service for the remote assessment and treatment of anxiety and depression.

BACKGROUND: The MindSpot Clinic (MindSpot) provides remote screening assessments and therapist-guided treatment for anxiety and depression to adult Australians. Most patients are self-referred. The purpose of this study was to report on the procedures followed to maintain the safety of patients and to examine the circumstances of urgent referrals to local services made by this remote mental health service. METHOD: A description of the procedures used to manage risk, and an audit of case summaries of patients who were urgently referred for crisis intervention. The reported measures were scores on self-report scales of psychological distress (K-10) and depression (PHQ-9), the number reporting suicidal thoughts and plans, and the number of acute referrals. RESULTS: A total of 9061 people completed assessments and consented for analysis of their data in the year from 1 July, 2013 to 30 June, 2014. Of these, 2599 enrolled in online treatment at MindSpot, and the remainder were supported to access local mental health services. Suicidal thoughts were reported by 2366 (26.1 %) and suicidal plans were reported by 213 (2.4 %). There were 51 acute referrals, of whom 19 (37.3 %) lived in regional or remote locations. The main reason for referral was the patients' self-report of imminent suicidal intent. The police were notified in three cases, and in another case an ambulance attended after the patient reported taking an overdose. For the remaining acute referrals, MindSpot therapists were able to identify a local mental health service or a general practitioner, confirm receipt of a written case summary, and confirm that the patient had been contacted, or that the local service intended to contact the patient. CONCLUSIONS: Around 0.6 % of the people seeking assessment or treatment by MindSpot were referred to local mental health services for urgent face to face care. The procedures for identifying and managing those patients were satisfactory, and in every case, either emergency services or local mental health services were able to take over the patient's care. This review suggests that the uncertainty associated with taking responsibility for the remote treatment of patients who disclose active suicidal plans is not a major impediment to providing direct access online treatment for severe forms of anxiety and depression.

The orexin-1 receptor antagonist SB-334867 attenuates anxiety in rats exposed to cat odor but not the elevated plus maze: an investigation of Trial 1 and Trial 2 effects.

The orexins are hypothalamic neuropeptides most well known for their roles in regulating feeding and sleeping behaviors. Recent findings suggest that orexin-A may also modulate anxiety, although how and when the orexin system is involved remains unclear. To address this, we investigated the dose-dependent effects of the orexin-1 receptor antagonist SB-334867 in two rodent models of anxiety: the cat odor avoidance model and the elevated plus maze. In both models we tested the effects of SB-334867 when anxiety is novel (Trial 1) and familiar (Trial 2). In the first experiment, Wistar rats were treated with vehicle or SB-334867 (5, 10 or 20mg/kg, i.p.) prior to their first or second exposure to cat odor. During Trial 1, rats treated with 10mg/kg of SB-334867 approached the cat odor stimulus more than vehicle-treated rats. During Trial 2 the effects were more marked, with 10mg/kg of SB-334867 increasing approach times, increasing the number of times rats exited the hide box to engage in exploratory behavior, and decreasing overall hide times. In addition, the 20mg/kg dose decreased general activity during Trial 2. In the second experiment, the effects of SB-334867 (10 and 20mg/kg) were tested in the elevated plus maze. There were no significant differences produced by drug treatment during either Trial 1 or Trial 2. Results suggest that SB-334867 decreases anxiety induced by some, but not all, stressors.

A pilot study examining whether restricting and resuming specific actions systematically changes symptoms of depression and anxiety. A series of N-of-1 trials.

Anxiety and depressive disorders are highly prevalent and a leading cause of disability. Understanding how symptoms develop could lead to new preventive and clinical interventions. This pilot study examined whether systematically restricting specific behaviours (target actions) associated with good psychological health would increase psychological symptoms in healthy participants, and whether resuming those actions would reduce symptoms to baseline levels. Twelve adults participated in a series of N-of-1 trials comprising baseline (A), restriction (B) and recovery (C) phases. Outcomes were assessed weekly using measures of depression (PHQ-9), anxiety (GAD-7), and a validated 15-item measure of target actions (Big 5). Symptoms of depression and anxiety increased significantly from Phase A to Phase B and returned to baseline by the end of Phase C. Increased symptoms during Phase B were only observed in participants who restricted actions by more than 25%. Symptom increases were evident within 2 weeks of restriction, but most participants appeared to take longer to recover to baseline levels. This study demonstrates that reducing the frequency of specific actions may increase symptoms of anxiety and depression, which is reversed when those actions are resumed. This contributes to our understanding of the aetiology, maintenance, and recovery from depression, anxiety, and possibly other disorders.

Things You Do: A randomized controlled trial of an unguided ultra-brief intervention to reduce symptoms of depression and anxiety.

The 'Things You Do' encompass five types of actions that are strongly associated with good mental health: Healthy Thinking, Meaningful Activities, Goals and Plans, Healthy Habits, and Social Connections. Ultra-brief interventions which increase how often people perform these actions may decrease depression and anxiety. A two-arm randomized controlled trial (N = 349) compared an unguided ultra-brief intervention based on the 'Things You Do' against a waitlist control. The intervention included one online module, two practice guides, and four weeks of daily text messages. The primary timepoint was 5-weeks post-baseline. The intervention resulted in moderate reductions in depression (d = 0.51) and anxiety (d = 0.55) alongside moderate increases in the frequency of Things You Do actions (d = 0.54), compared to controls. No significant change in number of days out of role or life satisfaction were observed. Treatment completion was high (92 %), most participants reported being satisfied with the treatment (66 %), and improvements were maintained at 3-month follow-up. This study demonstrated that an automated ultra-brief 'Things You Do' intervention resulted in clinically significant reductions in depression and anxiety. Ultra-brief interventions may provide a scalable solution to support individuals who are unlikely to engage in longer forms of psychological treatment.

An open trial of the feasibility of brief internet-delivered acceptance and aommitment therapy (iACT) for chronic anxiety and depression.

Anxiety and depressive disorders are common, often chronic and result in significant disability and distress. The delivery of psychological interventions via the internet is now recognised to be a safe and effective way to treat these disorders. The predominant therapeutic model in clinical trials and in routine care has been cognitive-behavioural therapy (CBT), which helps patients identify and modify unhelpful thoughts and behaviours. However, other models of treatment for anxiety and depression, such as acceptance and commitment therapy (ACT), which uses the examination of both positive and negative experiences in the service of living a personally meaningful and values-based life, have been developed and tested, although most of these interventions are long and require more clinician support to ensure adherence and achieve positive outcomes. The aim of the present study was to examine the feasibility of a new brief, clinician supported transdiagnostic internet-delivered (iACT) program, designed to treat symptoms of both anxiety and depression and improve social function. A single-group open trial was conducted on 24 adults with long-term symptoms of anxiety and depression. The course is comprised of five online modules delivered over 8 weeks either self-guided or with support from a clinician. There was a high course completion rate (70 %) and a high level of satisfaction with the course (94 % satisfied or very satisfied). Significant clinical improvement in our primary outcome measures (within-group Cohen's d) of anxiety (d ≥ 0.62), depression (d ≥ 0.63), disability (d ≥ 0.43) and quality of life (d ≥ -0.57) were observed at posttreatment. Relatively little clinician time was required per participant (M = 30.6 min, SD = 5.7). The findings of the current study support the feasibility and potential of a transdiagnostic iACT treatment for adults experiencing long-term symptoms of anxiety and depression, including those patients who have not derived benefit from other treatments.

Prevalence and Predictors of Long COVID in Patients Accessing a National Digital Mental Health Service.

MindSpot is a national mental health service that provides assessments and treatment to Australian adults online or via telephone. Since the start of 2020, questions related to the mental health impacts of COVID-19 have been routinely administered. The objective of the current study is to report the prevalence and predictors of self-reported "long COVID" in patients completing an assessment at the MindSpot Clinic between 5 September 2022 and 7 May 2023 (n = 17,909). Consistent with the World Health Organization definition, we defined long COVID as the occurrence of ongoing physical or mental health symptoms three months after a COVID-19 infection. We conducted a descriptive univariate analysis of patients who reported: no COVID-19 diagnosis (n = 6151); a current or recent (within 3 months) COVID-19 infection (n = 2417); no symptoms three months post-COVID-19 infection (n = 7468); or COVID-related symptoms at least three months post-infection (n = 1873). Multivariate logistic regression was then used to compare patients with and without symptoms three months post-COVID to identify potential predictors for long COVID. The prevalence of long COVID was 10% of the total sample (1873/17909). Patients reporting symptoms associated with long COVID were older, more likely to be female, and more likely to be depressed and report a reduced ability to perform their usual tasks. Sociodemographic factors, including cultural background, education, and employment, were examined. These results provide evidence of the significant prevalence of symptoms of long COVID in people using a national digital mental health service. Reporting outcomes in an Australian context and in specific sub-populations is important for public health planning and for supporting patients.

Predictors of functional impairment at assessment and functional improvement after treatment at a national digital mental health service.

Mental disorders are associated with impairment to daily functioning, which affects both the individual and society. Despite this, most research on treatment outcome only report symptom change. Self-reported days out of role (DOR) is a simple measure of functional impairment used in many population studies. The current study sought to report on the degree of functional impairment measured by DOR in a clinical sample at assessment, the factors associated with this impairment, the predictors of functional improvement after treatment and the relationship between symptomatic and functional change. Using a prospective uncontrolled observational cohort study design with a sample of 17,813 patients accessing a digital mental health service (DMHS), we examined self-reported demographic, psychosocial and clinical data. Using a series of univariate regression models and multivariate classification algorithms, we found that baseline DOR was associated with age, employment and relationship status, symptom severity, symptom chronicity and with the presence of several psychosocial difficulties. Baseline DOR was best predicted by older age, disability payments, higher symptom severity and increasing number of endorsed psychosocial difficulties (R2 = 32.7 %). Forty-one per cent of the sample experienced a >50 % or greater reduction in DOR following treatment. Those who were separated, unemployed or on disability payments, or with severe and chronic depression, experienced the greatest reductions in DOR after treatment. Changes in functioning were independent of changes in symptoms, highlighting the importance of functional impairment as a treatment outcome. This study found that many of the patients who access DMHS have significant levels of functional impairment, a large proportion obtain functional improvement after treatment, and improvement in function after treatment was independent of improvement in symptoms.

An open trial of the Things You Do Questionnaire: Changes in daily actions during internet-delivered treatment for depressive and anxiety symptoms.

Many psychological treatments aim to reduce symptoms of depression and anxiety by modifying maladaptive patterns of cognitions, behavior, and other actions. The Things You Do Questionnaire (TYDQ) was developed to measure the frequency of actions that are associated with psychological health in a reliable and valid manner. The present study examined treatment-related change in the frequency of actions measured by the TYDQ. Using an uncontrolled single-group design, 409 participants with self-reported symptoms of depression, anxiety, or both received access to an 8-week internet-delivered treatment course based on cognitive behavior therapy. Most (77 %) participants completed the treatment, completed questionnaires at post-treatment (83 %), and obtained significant reductions in symptoms of depression (d = 0.88) and anxiety at post-treatment (d = 0.97), as well as improvement in a measure of satisfaction with life (d = 0.36). Factor analyses supported the five-factor structure of the TYDQ, including Realistic Thinking, Meaningful Activities, Goals and Plans, Healthy Habits, and Social Connections. Those participants who, on average, engaged in the identified actions on the TYDQ at least half the days of the week reported lower symptoms of depression and anxiety at post-treatment. The psychometric properties of both a longer 60-item (TYDQ-60) and shorter 21-item (TYDQ-21) version were acceptable. These findings provide further evidence that there are modifiable activities that are strongly associated with psychological health. Future studies will test the replicability to these results in in a broader range of samples, including those seeking psychological treatment.

Antidepressant medication use by patients accessing a national digital mental health service.

BACKGROUND: Digital mental health services (DMHSs) provide psychological treatments via the internet or phone and are increasingly being offered as part of routine care. This study describes antidepressant (AD) medication use and treatment outcomes in a large sample of routine care patients accessing a DMHS. METHODS: Patients completing an assessment with an Australia-wide DMHS (MindSpot Clinic) from 1st January to 31st December 2020 (n = 17,409) were asked about psychotropic medication use. Demographic characteristics and treatment outcomes on the PHQ-9 (depression), GAD-7 (anxiety), and K-10+ (general distress) were compared for patients taking an AD versus no AD. Treatment outcomes were also analyzed for a subgroup of patients reporting recent commencement of AD medication. RESULTS: Almost one quarter of patients (4141/17409; 23.8%) reported taking an AD, mainly selective serotonin reuptake inhibitors (SSRIs). Patients taking ADs had more severe symptoms however effect sizes were large (Cohen's d's > 1.0). Patients recently commencing ADs had the highest baseline symptoms but showed greater symptom improvement at post-treatment and 3-month follow-up. LIMITATIONS: Treatment trajectory was measured weekly using standardized scales that are sensitive to change, however they did not allow formal clinical diagnoses of depression and were subject to the effects of missing data. The observational design did not control for spontaneous recovery or for comorbid conditions that might influence recovery. CONCLUSIONS: Despite these limitations, online treatment provided by a DMHS as part of routine care is acceptable and effective for patients reporting concurrent AD medication use.

Measures of Daily Activities Associated With Mental Health (Things You Do Questionnaire): Development of a Preliminary Psychometric Study and Replication Study.

BACKGROUND: A large body of research has identified modifiable cognitions and behaviors (actions) associated with psychological health. However, little is known regarding the actions that are most strongly associated with psychological health or the frequency with which they should be performed. OBJECTIVE: This paper described 2 studies that used survey methodology to create the Things You Do Questionnaire (TYDQ), which aims to identify and rank actions (items) and domains of actions (factors) most strongly associated with psychological health. METHODS: We used digital marketing strategies to recruit Australian adult participants, who were asked to complete 2 web-based surveys comprising versions of the TYDQ; validated measures of depression, anxiety, and satisfaction with life; and demographic questions. In study 1, a total of 3040 participants rated how often they performed each of the 96 items comprising the TYDQ. This design was replicated in study 2, in which a 59-item version of the TYDQ was completed by 3160 participants. In both studies, the factor structure and validity were examined, as were the associations between individual TYDQ items and 3 mental health outcomes: depression, anxiety, and satisfaction with life. RESULTS: In study 1, factor analyses revealed that a 5-factor model comprising 27 items achieved an optimum balance between brevity and variance and accounted for 38.1%, 31.4%, and 33.2% of the variance in scores on measures of depression, anxiety, and satisfaction with life, respectively. The factors were interpreted as realistic thinking, meaningful activities, goals and plans, healthy habits, and social connections. These 5 factors were more strongly associated with psychological health than those such as practicing kindness, exercising gratitude, and practicing spirituality. This pattern of results was replicated across gender, age groups, and depression severity. The 5-factor solution found in study 1 was replicated in study 2. Analyses revealed that a 21-item version accounted for 46.8%, 38.2%, and 38.1% of the variance in scores on measures of depression, anxiety, and satisfaction with life, respectively. CONCLUSIONS: These findings indicate that some actions are more strongly associated with psychological health than others and that these activities fall within 5 broad domains, which represent skills often taught in psychological treatments. Subsequent studies are planned to explore the reliability of these items and results in other samples and to examine patterns of change in scores during treatment for anxiety and depression. If replicated, these efforts will assist in the development of new psychological interventions and provide an evidence base for public mental health campaigns designed to promote good mental health and prevent the emergence of common mental disorders.

A Comparison of Self-Referral and Referral via Primary Care Providers, through Two Similar Digital Mental Health Services in Western Australia.

Digital mental health services (DMHSs) deliver mental health information, assessment, and treatment, via the internet, telephone, or other digital channels. The current study compares two DMHSs operating in Western Australia (WA)-The Practitioner Online Referral System (PORTS) and MindSpot. Both provide telephone and online psychological services at no cost to patients or referrers. However, PORTS is accessed by patients via referral from health practitioners, and is designed to reach those who are financially, geographically, or otherwise disadvantaged. In contrast, MindSpot services are available to all Australian residents and patients can self-refer. This observational study compares characteristics and treatment outcomes for patients of PORTS and MindSpot in WA. Eligible patients were people who resided in WA and registered with either clinic from January 2019 to December 2020. Results showed that PORTS patients were more likely to be older, male, and unemployed. They were less likely to report a tertiary education and were more likely to live in areas with higher levels of socioeconomic disadvantage. Despite these differences, treatment outcomes were excellent for patients from both clinics. Results provide further evidence for the accessibility, acceptability, and effectiveness of DMHSs regardless of referral pathway or patient characteristics.

Suicide after contact with a national digital mental health service.

BACKGROUND: The safety of mental health care provided remotely via the internet, in particular, the probability of suicide after contact, is not known. METHOD: An observational cohort study of patients registered with the MindSpot Clinic an Australian national digital mental health service (DMHS), linked to the National Death Index. Measures included demographic information, the nature of contact, duration between last contact and death, scores on measures of psychological distress (K-10), depression (PHQ-9) and anxiety (GAD-7), and responses to questions about suicidal thoughts or plans for patients who died by suicide within two years of last contact with the service. RESULTS: Sixty-four (0.11%) of 59,033 patients registered with the MindSpot Clinic between 1 January 2013 and 31 December 2016 died from suicide within two years of last contact. The mean time between last contact and death was 344 days. Fourteen patients died within 90 days of last contact, and 4 of 285 who were urgently referred for crisis service intervention at the time of contact or soon afterwards died within 2 years. Suicidal thoughts (OR: 2.59), a suicide plan (OR: 10.8), and a score of "3" to item 9 of the PHQ9 (OR: 16.4) were significantly associated with subsequent suicide. Patients who died by suicide were more likely to be male (OR: 3.2), middle-aged (35-45; OR: 2.3), separated or divorced (OR: 3.1), unemployed (OR: 3.1) or receiving disability benefits (OR: 5.1). Enrolling in an online treatment course was associated with reduced risk (OR: 0.38). CONCLUSIONS: Although DMHS provide services to patients with severe symptoms of depression, only a small proportion died by suicide, and only a small number of those referred for urgent care, which suggests that the safety protocols of the clinic are relatively effective.

Understanding the untreated course of anxiety disorders in treatment-seeking samples: A systematic review and meta-analysis.

BACKGROUND: Very little is known about the course of anxiety disorders when they go untreated, despite the significant theoretical and practical value of this information, such as for treatment planning and benchmarking purposes. This meta-analysis aimed to examine the course of anxiety disorders in treatment-seeking samples using the control groups of treatment studies for anxiety disorders. METHODS: Following pre-registration, we systematically searched the literature for RCTs of treatment for anxiety disorders. Studies were included if they randomised participants to a control arm, where treatment was not received (i.e. waitlist control or no-treatment control). Meta-analyses were conducted to determine the magnitude of symptom change over the control period (Hedges' g), and rate of response (pooled prevalence). Effects were compared between anxiety disorders, alongside other potential moderators. RESULTS: Following search and screening, 173 RCTs met criteria (n = 15,250) for data extraction. Overall, untreated participants demonstrated significant, but small improvements to anxiety symptoms (g = 0.17, 95% CI 0.14, 0.21). Significant differences were observed between anxiety disorders, and according to other methodological features of the included trials. CONCLUSIONS: Results suggest that anxiety disorders are unlikely to remit without treatment, with some disorders remitting to a lesser extent than others. While this review is limited to a treatment-seeking sample, results provide theoretical and practical value for researchers and treatment providers.