Theoretical adequacy, methodological quality and efficacy of online interventions targeting resilience: a systematic review and meta-analysis.

BACKGROUND: There is a growing interest in the promotion of mental health, and concepts as resilience are re-emerging and taking relevance. In addition, Information and Communication Technologies can provide potential benefits in the field of mental health, and the treatment of mental disorders in particular. This study aims to synthesize the evidence of internet-based resilience interventions, analyzing the theoretical adequacy, methodological quality and efficacy. METHODS: A systematic search was performed. The eligibility criteria stated for this article were: randomized controlled trials targeted at adults or adolescents and including any psychological intervention focussing on resilience in its rationale or design. Studies with direct (e.g. resilience scales) and proximal resilience measures (e.g. scales on well-being) were included. Risk of bias was assessed for each trial using Cochrane's Collaboration Tool. Two reviewers worked independently in order to identify potential articles. A total of 11 articles were selected. A random-effects pooling model using the Hartung-Knapp-Sidik-Jonkman method based on direct and proximal resilience measures at post-test was used. RESULTS: The overall effects of online resilience training compared to control groups at post-test were not significant; the effect size concerning the improvement of resilience was g=0.12 (95% CI: -0.14 to 0.38). In addition, a potential association between the type of outcome and the effect size could be revealed. CONCLUSIONS: The results of the present meta-analysis showed that the overall effect of online resilience trainings was not significant. Nonetheless, a tendency for a higher benefit for resilience was found in the studies with a clear assessment theory, indicating some promising effects. REGISTRATION NUMBER: PROSPERO CRD42018083339.

Online prevention programmes for university students: stakeholder perspectives from six European countries.

BACKGROUND: Students beginning university are at a heightened risk for developing mental health disorders. Online prevention and early intervention programmes targeting mental health have the potential to reduce this risk, however, previous research has shown uptake to be rather poor. Understanding university stakeholders' (e.g. governing level and delivery staff [DS] and students) views and attitudes towards such online prevention programmes could help with their development, implementation and dissemination within university settings. METHODS: Semi-structured interviews, focus groups and online surveys were completed with staff at a governing level, university students and DS (i.e. student health or teaching staff) from six European countries. They were asked about their experiences with, and needs and attitudes towards, online prevention programmes, as well as the factors that influence the translation of these programmes into real-world settings. Results were analyzed using thematic analysis. RESULTS: Participating stakeholders knew little about online prevention programmes for university settings; however, they viewed them as acceptable. The main themes to emerge were the basic conditions and content of the programmes, the awareness and engagement, the resources needed, the usability and the responsibility and ongoing efforts to increase reach. CONCLUSIONS: Overall, although these stakeholders had little knowledge about online prevention programmes, they were open to the idea of introducing them. They could see the potential benefits that these programmes might bring to a university setting as a whole and the individual students and staff members.

Effectiveness and Moderators of an Internet-Based Mobile-Supported Stress Management Intervention as a Universal Prevention Approach: Randomized Controlled Trial.

BACKGROUND: Emerging evidence indicates the effectiveness of internet-based mobile-supported stress management interventions (iSMIs) in highly stressed employees. It is yet unclear, however, whether iSMIs are also effective without a preselection process in a universal prevention approach, which more closely resembles routine occupational health care. Moreover, evidence for whom iSMIs might be suitable and for whom not is scarce. OBJECTIVE: The aim of this study was to evaluate the iSMI GET.ON Stress in a universal prevention approach without baseline inclusion criteria and to examine the moderators of the intervention effects. METHODS: A total of 396 employees were randomly assigned to the intervention group or the 6-month waiting list control group. The iSMI consisted of 7 sessions and 1 booster session and offered no therapeutic guidance. Self-report data were assessed at baseline, 7 weeks, and at 6 months following randomization. The primary outcome was perceived stress. Several a priori defined moderators were explored as potential effect modifiers. RESULTS: Participants in the intervention group reported significantly lower perceived stress at posttreatment (d=0.71, 95% CI 0.51-0.91) and at 6-month follow-up (d=0.61, 95% CI 0.41-0.81) compared to those in the waiting list control group. Significant differences with medium-to-large effect sizes were found for all mental health and most work-related outcomes. Resilience (at 7 weeks, P=.04; at 6 months, P=.01), agreeableness (at 7 weeks, P=.01), psychological strain (at 6 months, P=.04), and self-regulation (at 6 months, P=.04) moderated the intervention effects. CONCLUSIONS: This study indicates that iSMIs can be effective in a broad range of employees with no need for preselection to achieve substantial effects. The subgroups that might not profit had extreme values on the respective measures and represented only a very small proportion of the investigated sample, thereby indicating the broad applicability of GET.ON Stress. TRIAL REGISTRATION: German Clinical Trials Register DRKS00005699; https://www.drks.de/DRKS00005699.

Comparative effectiveness of three versions of a stepped care model for insomnia differing in the amount of therapist support in internet-delivered treatment: study protocol for a pragmatic cluster randomised controlled trial (GET Sleep).

INTRODUCTION: It is unclear how internet-delivered cognitive-behavioural therapy for insomnia (CBT-I) can be integrated into healthcare systems, and little is known about the optimal level of therapist guidance. The aim of this study is to investigate three different versions of a stepped care model for insomnia (IG1, IG2, IG3) versus treatment as usual (TAU). IG1, IG2 and IG3 rely on treatment by general practitioners (GPs) in the entry level and differ in the amount of guidance by e-coaches in internet-delivered CBT-I. METHODS AND ANALYSIS: In this randomised controlled trial, 4268 patients meeting International Classification of Diseases, Tenth Revision (ICD-10) criteria for insomnia will be recruited. The study will use cluster randomisation of GPs with an allocation ratio of 3:3:3:1 (IG1, IG2, IG3, TAU). In step 1 of the stepped care model, GPs will deliver psychoeducational treatment; in step 2, an internet-delivered CBT-I programme will be used; in step 3, GPs will refer patients to specialised treatment. Outcomes will be collected at baseline, and 4 weeks, 12 weeks and 6 months after baseline assessment. The primary outcome is insomnia severity at 6 months. An economic evaluation will be conducted and qualitative interviews will be used to explore barriers and facilitators of the stepped care model. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethics Committee of the Medical Centre-University of Freiburg. The results of the study will be published irrespective of the outcome. TRIAL REGISTRATION NUMBER: DRKS00021503.

Increasing intentions to use mental health services among university students. Results of a pilot randomized controlled trial within the World Health Organization's World Mental Health International College Student Initiative.

BACKGROUND: The majority of university students with mental health problems are untreated. Only a small empirical literature exists on strategies to increase mental health service use. AIMS: To investigate the effects and moderators of a brief acceptance-facilitating intervention on intention to use mental health services among university students. METHOD: Within the German site of the World Health Organization's World Mental Health International College Student (WMH-ICS) initiative, 1,374 university students were randomized to an intervention condition (IC; n = 664) or a control condition (CC; n = 710) that was implemented in the survey itself. Both conditions received the questions assessing mental disorders and suicidality that were included in other WMH-ICS surveys. The IC group then additionally received: Internet-based personalized feedback based on subject symptom severity in the domains of depression, anxiety, substance use, suicidal thoughts and behaviors, and nonsuicidal self-injury; psychoeducation tailored to the personal symptom profile; and information about available university and community mental health services. The primary outcome was reported intention to use psychological interventions in the next semester, which was the last question in the survey. A broad range of potential moderating factors was explored. RESULTS: There was a significant main effect of the intervention with students randomized to IC, reporting significantly higher intentions to seek help in the next semester than students in the CC condition (d = 0.12, 95% CI: 0.02 to 0.23). Moderator analyses indicated that the intervention was more effective among students that fulfilled the criteria for lifetime (d = 0.34; 95% CI: -0.08 to 0.7) and 12-month panic-disorder (d = 0.32; 95% CI: -0.10 to 0.74) compared with those without lifetime (d = 0.11; 95% CI: 0.00 to 0.22) or 12-month panic disorder (d = 0.11; 95% CI: 0.00 to 0.22), students with lower (d = 0.37; 95% CI: -0.77 to 1.51) than higher (d = -0.01; 95% CI: -0.36 to 0.34) self-reported physical health, and students with nonheterosexual (d = 0.38; 95% CI: 0.08 to 0.67) compared with heterosexual (d = 0.06; 95% CI: -0.06 to 0.17) sexual orientation. The intervention had no effects among students who reported that they recognized that they had an emotional problem and "are already working actively to change it" (Stage 4 "stages of change"). CONCLUSIONS: A simple acceptance-facilitating intervention can increase intention to use mental health services, although effects, are on average, small. Future studies should investigate more personalized approaches with interventions tailored to barriers and clinical characteristics of students. In order to optimize intervention effects, the development and evaluation should be realized in designs that are powered to allow incremental value of different intervention components and tailoring strategies to be evaluated, such as in multiphase optimization designs.

An Internet based intervention for improving resilience and coping strategies in university students: Study protocol for a randomized controlled trial.

BACKGROUND: The literature shows a high prevalence of depression and anxiety in young people. The university represents a change in the lives of students, and is considered a stress factor. Therefore, it is particularly relevant to develop interventions specifically addressed to students and foster supportive environments and resilient communities. As students are "digital natives", online interventions offer several potential advantages in doing this. This study aims to develop and evaluate the efficacy of an Internet-based intervention (CORE: Cultivating our Resilience), based on the Ryff model of well-being, to promote resilience and coping skills, decrease symptoms of depression and anxiety, and increase overall wellbeing in young people confronting a crucial life event (the university). This paper summarizes the study protocol. METHOD: The design of the planned study is a randomized controlled trial. A minimum of 464 participants will be randomly assigned to two conditions: 1) an unguided Internet-based intervention to enhance resilience (N = 232); 2) a care-as-usual condition (CAU) (N = 232). The primary outcome will be the Connor-Davidson resilience scale. Secondary outcomes will - among others - include other relevant clinical measures, such as anxiety and depressive symptoms, quality of life, and social support. Outcomes will be assessed 4 and 8 weeks, and 6 and 12-months follow-ups. Intention-to-treat and per-protocol analyses will be performed. DISCUSSION: The results of this study will contribute to the growing research on Internet-delivered interventions. The expected results may have a major impact on the prevention of mental disorders and possible negative consequences in at-risk populations, such as college students.