Efficacy of computer- and/or internet-based cognitive-behavioral guided self-management for depression in adults: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Depression is a worldwide disease. CBT-based self-help treatment allows patients with mild to moderate depression symptoms to improve their depression or to bridge the waiting- or pandemic period until they receive further clinical treatment. OBJECTIVE: This systematic review and meta-analysis aims to explore the efficacy, acceptability and improvement in quality of life of computer-delivered and/or internet-based CBT self-help interventions with minimal guidance (up to 10 min) for depression. The second aim was to compare the effectiveness of reducing depression symptoms at post-treatment of treatment by the type of minimal guidance: (1) e-mail, (2) telephone calls, (3) e-mail and telephone together, or (4) face-to-face. METHODS: The Cochrane depression, anxiety, and neurosis review group's specialized register electronic searches, grey literature, reference lists and correspondence were used to search for published and unpublished RCTs that reported efficacy of computer- and/or internet-based CBT self-help treatments for depression with minimal guidance up to 10 min per week. Methodological quality of included studies was evaluated with Cochrane Collaboration tools for assessing risk of bias. The meta-analysis was accomplished using the RevMen software. RESULTS: In total, 2809 study abstracts were checked for eligibility. Out of these, 19 studies (21 samples) with a total of 3226 participants were included. The results showed that concerning efficacy, the treatment group is superior to the control group with a medium to large effect size of 0.65. Also, treatment groups with combined guidance by e-mail and telephone calls together had greater effects (SMD -0.76) than groups with other types of minimal guidance (guided by e-mail SMD -0.63; guided face to-face SMD - 0.66; guided by telephone calls SMD -0.49). Findings showed also, that iCBT with minimal guidance had small but statistically significant effect size of 0.28 in improving quality of life. Moreover, there were higher drop-out rates in the treatment condition (RR 1.36) than in the control groups. CONCLUSIONS: The results of this meta-analysis support the efficacy of computer- and/or internet-based CBT self-help programs with minimal weekly guidance up to only 10 min for improving depression symptoms at post-treatment for adults. In addition, the results are pointing towards two practical implications. Firstly, depressed persons can use self-help treatment with minimal guidance at home to improve their symptoms or to bridge the waiting time - or pandemic period - before they receive professional face-to-face treatment. Secondly, it can help clinicians to make the decision about using CBT-based self-help treatments for patients that do not need urgent professional treatment, or to combine it with face-to-face therapy.

Understanding Patient Experience Using Internet-based Email Surveys: A Feasibility Study at Mount Sinai Hospital.

Email is becoming a widely accepted communication tool in healthcare settings. This study sought to test the feasibility of Internet-based email surveys of patient experience in the ambulatory setting. We conducted a study of email Internet-based surveys sent to patients in selected ambulatory clinics at Mount Sinai Hospital in Toronto, Canada. Our findings suggest that email links to Internet surveys are a feasible, timely and efficient method to solicit patient feedback about their experience. Further research is required to optimally leverage Internet-based email surveys as a tool to better understand the patient experience.

Mount Sinai Hospital's approach to Ontario's Health System Funding Reform.

In April 2012, the Ontario government introduced Health System Funding Reform (HSFR), a transformational shift in how hospitals are funded. Mount Sinai Hospital recognized that moving from global funding to a "patient-based" model would have substantial operational and clinical implications. Adjusting to the new funding environment was set as a top corporate priority, serving as the strategic basis for re-examining and redesigning operations to further improve both quality and efficiency. Two years into HSFR, this article outlines Mount Sinai Hospital's approach and highlights key lessons learned.

Mental health treatment seeking among patients with OCD: impact of age of onset.

BACKGROUND: Several studies have described the deficits in the health care provided to persons with obsessive-compulsive disorder (OCD), however, without making any distinction between psychiatric-psychotherapeutic professionals and general practitioners or other professionals. Also, the relation between subjectively defined early signs of the disorder, diagnosis and utilization of professional help has not yet been investigated systematically. The present study addresses these questions, using a self-rating questionnaire for patients with OCD (questionnaire on the utilization of professional help by patients with OCD). METHODS: Eighty-eight patients with OCD, who came to our University Hospital Outpatient Clinic for obsessive-compulsive disorders in Leipzig, participated in the study. The questionnaire, which had been developed specially for this survey, asked study participants to remember when they had first perceived signs of their disorder and their first-time utilization of professional help. RESULTS: Patients with OCD and early onset of disorder sought professional help later than did patients with later onset of disorder. When professional help was utilized, it took 2 years on average before the diagnosis was made. Patients with OCD first consulted a psychiatrist or psychotherapist and not the general practitioner as their first professional contact person. CONCLUSION: First signs in the early stages of OCD, particularly with an onset in childhood and adolescence have to be diagnosed at an earlier stage for appropriate treatment. Psychiatrists and psychotherapists, not primarily general practitioners, have a particularly high demand for further education about early diagnosis and treatment of OCD.

Long-Term Efficacy of Internet-Based Cognitive Behavioral Therapy Self-Help Programs for Adults With Depression: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Depression is a worldwide mental disorder and a leading cause of disability. Many people with depression do not want to take medication or have the motivation to seek psychotherapy treatment for many reasons. Guided internet-based self-help programs may be a promising solution for addressing these issues. This kind of intervention has proven to be effective in reducing depression symptoms on a short-term scale. However, as treatment often is a long-term rehabilitation process, it is important to examine not only the short-term effects of internet-based cognitive behavioral therapy (iCBT) self-help treatment but also the follow-up or long-term efficacy of this kind of intervention. OBJECTIVE: This systematic review and meta-analysis aimed to identify studies that examined follow-up data ≥8 weeks after posttreatment measurements and thereby examined the long-term efficacy of iCBT self-help programs with minimal weekly guidance for people with depression. It aimed to analyze the long-term efficacy of iCBT treatments compared to control conditions as well as long-term efficacy within the iCBT treatment conditions. Additionally, it aimed to conduct subgroup analyses according to the follow-up time points for each outcome. Finally, it examined long-term improvements in quality of life. METHODS: The Cochrane Collaboration Depression, Anxiety, and Neurosis Controlled Trials Register (CCDANCTR), grey literature, reference lists, and correspondence were used to search for published and unpublished randomized controlled trials (RCTs) that reported the long-term or follow-up efficacy of computer-based or iCBT self-help treatments for depression with minimal guidance of up to 10 min/wk. The search took place between 2015 and 2022 (October). RESULTS: The search resulted in a total of 2809 study abstracts, of which 15 studies (with 17 samples) met all inclusion criteria and were included in the long-term analysis. The results showed that the depression outcomes of all follow-up time points together in the treatment conditions were favored over the control conditions with a medium effect size of 0.43 (n=1689 participants; 9 RCTs; standardized mean difference [SMD] -0.43, 95% CI -0.67 to -0.20; P<.001). The analysis of long-term efficacy within the iCBT treatment conditions showed that the follow-up outcomes of the treatment groups were favored over the posttreatment outcomes with a small effect size of 0.20 (n=2196 participants; 17 RCTs; SMD 0.20, 95% CI 0.07-0.49; P=.003). Findings for improving quality of life also showed that the iCBT conditions were favored over the control conditions with a small effect size of 0.19 (n=1345 participants; 3 RCTs; SMD 0.19, 95% CI 0.08-0.30; P<.001). CONCLUSIONS: This systematic review and meta-analysis found that iCBT self-help interventions had a superior long-term efficacy for individuals with depressive symptoms compared to control groups. The within-group analysis of iCBT treatment conditions also showed statistically significant improvements in reducing depressive symptoms at follow-up compared to posttreatment measurements.

Vision-to-event and movement-to-event coordination in an unimanual circling task.

Coordination of actions with events in extracorporeal space is essential for many everyday tasks. In the present study, we investigated how transformations, like in tool use, and varying the spatial context affect action coordination. For this aim, we used a circling task that required participants to coordinate the visual feedback of hand movements with a clockwise circling stimulus (event). The trajectories of stimulus and visual feedback were presented horizontally aligned (group horizontal), within each other (group interleaved) or vertically aligned (group vertical). Within groups, we varied the instructed rotation direction of stimulus and visual feedback (same and different), and y-direction of visual feedback relative to the stimulus (same and different). To dissociate movements and the associated proprioceptive/kinesthetic feedback from visual movement feedback, participants performed the tasks under regular and transformed visual feedback (180° angular shift). Results indicated that action coordination follows the principle of vision-to-event coordination (similar data patterns with regular and transformed feedback), but subtle effects of movement-to-event coordination were also observed (larger difference in performance between same y-direction and different y-direction conditions with regular than with transformed feedback). The presence of a transformation affected performance negatively. The different visual layouts affected the different conditions differentially, pointing to the importance of the visual context. In conclusion, vision-to-event coordination dominates unimanual action coordination. The quality of performance is influenced by perceptual processes based on differential processing of the horizontal and vertical axis, and based on Gestalt principles.

Depression in the workplace: a systematic review of evidence-based prevention strategies.

BACKGROUND: Depression is one of the most common mental disorders, causing enormous personal and economic burden. In its early stages, however, it is the most manageable of mental disorders. The workplace, where a large proportion of the adult population can be reached, might be a good setting for prevention interventions that target depression directly. AIMS: Identify evidence-based indicated/secondary prevention strategies for depression in the workplace. METHODS: Systematic review of articles published until February 2010 using PubMed, EbscoHost and the Cochrane Library. Studies were selected based on different inclusion criteria, such as diagnosis of depression with validated screening instruments and presence of a control group. RESULTS: A total of 9,173 articles were found. One evaluated intervention study in the workplace met all inclusion criteria (French APRAND programme). The intervention, which combined the provision of diagnosis and psychoeducation, had a positive effect on people with depression, with a significant trend towards chances of recovery or remission after 1 year. The remaining studies did not meet the predefined inclusion criteria of this systematic review. CONCLUSION: The findings are quite sobering given the high prevalence of depression and the individual and societal burden caused by it. More tailor-made interventions in the workplace targeting depression directly are needed.

Impact of a campaign on the public's attitudes towards depression.

A public campaign was launched in 2000 as part of the four-level community-based intervention 'Nuremberg Alliance Against Depression' (NAD) in Nuremberg, Germany. Evaluation results will be presented. A baseline survey was done before the campaign in Nuremberg and Wuerzburg (control region), two surveys followed 10 and 22 months after the implementation. Multiple regression analyses were performed, with time, place and the interaction of time and location as independent and the corresponding items as dependent variables. For the general population, the campaign was successful in creating awareness for the NAD. For persons who reported experience with depression and persons aware of the NAD, analyses showed positive desirable effects: more awareness of depression and the NAD. In addition, among those aware, more positive attitudes towards medication treatment and antidepressants developed and also 'lack of self-discipline' declined as causal explanation as did the notion 'pull yourself together' as treatment option. The campaign induced relevant changes mainly in persons aware of the NAD and persons who reported to have had experience with depression. The fact that many of the changes in the general population declined in the second year of the campaign, when activities were done with lower intensity, illustrates the need for permanent depression awareness action.

Collaboration to partnerships.

Partnerships are at the center of the Hospital of the University of Pennsylvania Nursing Excellence Professional Practice (HUP-NEPP) model. Through the use of collaboration, skilled communication, and respectful workplace, partnerships can be formed, leading ultimately to world-class patient care. At HUP, interdisciplinary partnerships are evidenced by the clinical nurses through shared governance. This article describes the components necessary to form successful partnerships.

[Screening Instruments for the Detection of Male-Specific Symptoms of Unipolar Depression - A Critical Overview]. / Screeninginstrumente zur Erfassung von männerspezifischen Symptomen der unipolaren Depression ­ Ein kritischer Überblick.

BACKGROUND: Epidemiological studies have repeatedly pointed out gender differences in unipolar depression, whereas women have a 1.5 to 3 times higher risk of receiving a diagnosis. This however stands in sharp contrast with the 10 times higher suicide-rate of men, although depression is among the main risk-factors for suicide. Current literature therefore suspects an under-diagnosis of depression in men which is yet to be explained. While there is a vast body of literature covering the influence of gender norms, different symptomatology and use of health care services of men and women, systematic examinations of the role of diagnostic inventories or screening-instruments are currently not available. METHOD: A systematic literature search was conducted in order to provide an overview of current male-specific instruments for the detection of depression and to point out research gaps in the field of depression in men. RESULTS: Gender-specific inventories were used in 8 out of 122 relevant titles. Differences in the prevalence of unipolar depression tend to diminish or even disappear when gender-specific inventories are being used. DISCUSSION: Existing male-specific screening-instruments have only partly been validated and gender-specific instruments specifically designed for the detection of depression in primary care are currently lacking.

[From the First Symptoms of Depression to Treatment. When and Where are People Seeking Help? Does Stigma Play a Role? - Results from a Survey at a German Convention for People with Depression]. / Von den ersten Symptomen bis zur Behandlung einer Depression. Wann und bei wem suchen Menschen mit Depression Hilfe? Welche Rolle spielt Stigmatisierung?

Objective Only a few of the people affected by depression receive early treatment. The aim of this study is to determine the time interval between first onset of symptoms and treatment utilization and the role of stigma in this process. Methods Survey with participants from the 2nd German Patient Convention in Leipzig, Germany for patients, relatives and the general public. Results About one fourth of the respondents stated that the time interval between first symptoms of depression and treatment utilization was longer than three years. One third said that they received treatment immediately or until up to three months after the first symptoms of depression, and one third after three months up to three years. The majority (64 %) said that they first received a depression diagnosis from a specialist. The most common treatments used were psychotherapy, pharmacotherapy and a combination of both. Self-help, physical activity and occupational therapy were named as the most popular non-medical treatments. Conclusion A possible explanation for delayed treatment utilization could be the perceived public stigma, which was higher in people with depression in comparison to other convention attendees (relatives and general public).

Influence of newspaper reporting on adolescents' attitudes toward people with mental illness.

BACKGROUND: Numerous studies have established proof of selective media reporting about the mentally ill, with the majority of the reports focusing almost exclusively on violence and dangerousness. A handful of studies found that there is an association between negative media portrayals and negative attitudes toward people with mental illness. However, empirical evidence of the impact of newspaper reports about mentally ill people on readers' attitudes is very scarce. AIMS: To examine the impact of a newspaper article linking mentally ill persons with violent crime and the impact of an article providing factual information about schizophrenia on students' attitudes toward people with mental illness. METHOD: A total of 167 students aged 13-18 years were randomly assigned one of two articles. A period of 1 week before and 3 weeks after reading the newspaper article, they were asked to complete a self-administered questionnaire for the assessment of their attitudes toward mentally ill people. RESULTS: Respondents who read the article linking mentally ill persons with violent crime displayed an increased likelihood to describe a mentally ill person as dangerous and violent. Conversely, respondents who read the informative article used terms like 'violent' or 'dangerous' less frequently. The desire for social distance remained virtually unchanged at follow-up in both groups. CONCLUSION: Two potential approaches to break the unwanted link between negative media reporting and negative attitudes are suggested. First, an appeal to media professionals to report accurate representations of mental illness. And second, an appeal to the adults living and working with adolescents to provide opportunities to discuss and reflect on media contents.

The relationship between biogenetic causal explanations and social distance toward people with mental disorders: results from a population survey in Germany.

AIMS: Several studies have found an inverse relationship between people's readiness to endorse biogenetic causal explanations of mental disorder and their desire for social distance from people with mental disorders. The aim of this study is to examine why this may be the case. METHOD: In the spring of 2001, a population survey was carried out among German citizens aged 18 years and older, living in private households. A total of 5025 interviews were conducted, reflecting a response rate of 65.1%. At the beginning of the personal, fully structured interview, respondents were presented with a vignette containing a diagnostically unlabelled psychiatric case history, either depicting a case of schizophrenia or major depressive disorder. Using five-point Likert scales, causal attributions as well as perceived dangerousness, fear and the desire for social distance were assessed. RESULTS: The more respondents endorse a brain disease as a cause, the more dangerous they believe the person with schizophrenia or major depression to be. Respondents who perceive the individual in the vignette as being dangerous express a higher degree of fear and a greater preference for social distance from these individuals. As compared with brain disease, the relationships between heredity and perceived dangerousness are less pronounced for both disorders. CONCLUSIONS: Our analysis showed that endorsing biogenetic explanations decreases the likelihood of social acceptance of people with schizophrenia and major depression. Rejecting behavioural responses in the form of social distance desired from people with schizophrenia and major depression result from cognitive emotional processes in which biogenetic causal attributions are linked to lack of self-control, unpredictability and dangerousness, which, in turn, are associated with fear of these people.

Heavy use of psychiatric inpatient care from the perspective of the patients affected.

BACKGROUND: Patients who spend an above-average amount of time in inpatient care are termed heavy users. Up to this point, very little has been known about what drives these patients to their heavy use of inpatient treatment. AIM: For this reason, the present study investigates the causes for frequent inpatient admissions of heavy users from the perspective of the patients affected. METHODS: Twenty heavy users who were identified in a quantitative preliminary study were interviewed using a qualitative analysis of the contents. RESULTS: Heavy users housed in sheltered accommodation either experienced frequent inpatient stays because of their symptomatic burden, or because of poor integration in their residences. Among the heavy users living in private residences was a subgroup that compensated for the lack of support from the private sphere with frequent hospital visits. A second subgroup turned to hospital care only during acute relapse episodes. In a third subgroup, secondary substance abuse accounted for the high demand for inpatient treatment. CONCLUSION: Findings suggest that, using community-based psychiatric support offers tailored to the needs of the heavy user subgroups, inpatient treatment could be avoided.

Empirical evidence for an invariant three-factor structure of the Parental Bonding Instrument in six European countries.

The objective of the present study was to test the Parental Bonding Instrument's (PBI) three-factor structure (care, overprotection, and authoritarianism) found by [Cox, B.J., Enns, M.W., Clara, I.P. 2000, The Parental Bonding Instrument: confirmatory evidence for a three-factor model in a psychiatric clinical sample and in the National Comorbidity Survey, Social Psychiatry and Psychiatric Epidemiology 35 (2000) 353-357.] on an eight-item short form of the scale. A total of 8813 respondents from the six European countries participating in the ESEMeD project (Belgium, France, Germany, Italy, The Netherlands, and Spain) completed either the PBI-paternal or the PBI-maternal scale. Maximum likelihood confirmatory factor analysis was used to compare the original factor model of Cox et al. with a three-factor solution that emerged from an exploration of the structure with principal component factor analysis. When gender and age subgroups, as well as different countries, were taken into account, the accuracy of the model was confirmed. The fit indices for the new model indicated a generally better model fit than the ones for the model originally developed by Cox et al. Further efforts should be directed to the modeling of the dimension authoritarianism. The results provide the opportunity to estimate the influence of the extracted factors on mental disorders in different countries. The application of the short form of the PBI seems suitable primarily for large epidemiological studies.

The disregarded caregivers: subjective burden in spouses of schizophrenia patients.

Although the burdens of relatives of schizophrenia patients have been the subject of numerous studies, there are hardly any publications on the living situation of the patients' spouses. The findings of this qualitative interview study of 52 spouses of schizophrenia patients are, therefore, especially noteworthy. Spouses not only face illness-specific burdens but also burdens resulting from their partnership and family roles. From a biographical point of view, schizophrenia is often evaluated by the spouse as a decisive point in life that seriously affects the couple's relationship, the family, and the spouse's own life. The chronic burdens of everyday living can profoundly reduce the quality of life and the subject's satisfaction with the partnership. Though partnerships with schizophrenia patients are at risk of breakdown and separation in many respects, they are often maintained for years. Despite the illness-related burdens, many spouses take positive stock of living together. Stable partnerships seem to be achievable when the partner's impairment is perceived as moderate or moderately severe, and when the frequency at which psychotic episodes occur is assessed as still being tolerable. Spouses who suffer from mental illness or impairment themselves often experience the partnership as an appropriate and satisfactory way of life. In these cases, the mutual understanding rooted in the subject's own experiences with the illness is important.

The stigma of mental illness: patients' anticipations and experiences.

BACKGROUND: There are studies that either deal with the stigmatization patients anticipate or with patients' concrete stigmatization experiences. Up until now, however, research is short of studies that investigate both aspects of subjective stigmatization simultaneously. AIMS: This study aims at investigating to what extent patients with schizophrenia or depression anticipate and experience stigmatization and how this is influenced by the type of mental disorder and the social environment. METHOD: A total of 210 patients with schizophrenia or a depressive episode were interviewed, one half living in a city and the other in a small town. RESULTS: Most of the patients expect negative reactions from the environment, particularly as concerns the access to work. Concrete stigmatization experiences were most frequently reported in the domain of interpersonal interaction. Even though schizophrenia patients and patients with depression anticipated stigmatization similarly frequently, the former reported concrete stigmatization experiences more frequently than the latter. Conversely, patients living in a small town anticipated stigmatization more frequently than patients from the city, even though both had actually experienced stigmatization at a similar rate. CONCLUSION: The results underline the necessity to differentiate between anticipated and experienced stigmatization. This is highly relevant for planning interventions aimed at reducing the stigma of mental disorder.

Effects of angular gain transformations between movement and visual feedback on coordination performance in unimanual circling.

Tool actions are characterized by a transformation (of spatio-temporal and/or force-related characteristics) between movements and their resulting consequences in the environment. This transformation has to be taken into account, when planning and executing movements and its existence may affect performance. In the present study we investigated how angular gain transformations between movement and visual feedback during circling movements affect coordination performance. Participants coordinated the visual feedback (feedback dot) with a continuously circling stimulus (stimulus dot) on a computer screen in order to produce mirror symmetric trajectories of them. The movement angle was multiplied by a gain factor (0.5-2; nine levels) before it was presented on the screen. Thus, the angular gain transformations changed the spatio-temporal relationship between the movement and its feedback in visual space, and resulted in a non-constant mapping of movement to feedback positions. Coordination performance was best with gain = 1. With high gains the feedback dot was in lead of the stimulus dot, with small gains it lagged behind. Anchoring (reduced movement variability) occurred when the two trajectories were close to each other. Awareness of the transformation depended on the deviation of the gain from 1. In conclusion, the size of an angular gain transformation as well as its mere presence influence performance in a situation in which the mapping of movement positions to visual feedback positions is not constant. When designing machines or tools that involve transformations between movements and their external consequences, one should be aware that the mere presence of angular gains may result in performance decrements and that there can be flaws in the representation of the transformation.

Effects of angular shift transformations between movements and their visual feedback on coordination in unimanual circling.

Tool actions are characterized by a transformation between movements and their resulting consequences in the environment. This transformation has to be taken into account when tool actions are planned and executed. We investigated how angular shift transformations between circling movements and their visual feedback affect the coordination of this feedback with visual events in the environment. We used a task that required participants to coordinate the visual feedback of a circular hand movement (presented on the right side of a screen) with a circling stimulus (presented on the left side of a screen). Four stimulus-visual feedback relations were instructed: same or different rotations of stimulus and visual feedback, either in same or different y-directions. Visual speed was varied in three levels (0.8, 1, and 1.2 Hz). The movement-visual feedback relation was manipulated using eight angular shifts: (-180, -135, -90, -45, 0, 45, 90, and 135°). Participants were not able to perform the different rotation/different y-direction pattern, but instead fell into the different rotation/same y-direction pattern. The different rotation/same y-direction pattern and the same rotation/same y-direction pattern were performed equally well, performance was worse in the same rotation/different y-direction pattern. Best performance was observed with angular shifts 0 and -45° and performance declined with larger angular shifts. Further, performance was better with negative angular shifts than with positive angular shifts. Participants did not fully take the angular shift transformation into account: when the angular shifts were negative the visual feedback was more in advance, and when angular shifts were positive the visual feedback was less in advance of the stimulus than in 0° angular shift. In conclusion, the presence and the magnitude of angular shift transformations affect performance. Internal models do not fully take the shift transformation into account.

Personal and perceived stigmatization of depression: a comparison of data from the general population, participants of a depression congress and job placement officers in Germany.

Personal and perceived depression stigma was assessed with Griffiths and colleagues׳ Depression Stigma Scale in 1509 German adults. The sample comprised three groups of participants: attendees of a depression congress, job placement officers and a representative general population sample. In all groups, personal stigma was lower than perceived stigma. Personal stigma was significantly higher in the general population than in the placement officers, and lowest in congress attendees. Perceived stigma was lower in congress attendees than in the general population. Personal stigma was lower in women decreased with age. The finding of lower personal stigma compared to perceived stigma might reflect effects of social desirability. Those with less contact with persons with depression, i.e. job placement officers and the general population, may be less tolerant and lack understanding of depression, resulting in higher levels of personal stigma. These findings support the notion that depression campaigns should be tailor-made to address gender and age-specific differences in personal and perceived stigma.