Patient-Oriented Research to Improve Internet-Delivered Cognitive Behavioural Therapy for People of Diverse Ethnocultural Groups in Routine Practice.

There has been limited research on improving Internet-delivered Cognitive Behavioural Therapy (ICBT) in routine online therapy clinics that serve people from diverse ethnocultural groups (PDEGs). This article describes a patient-oriented adaptation approach used to address this gap in research. A working group consisting of people with lived experience, community representatives, ICBT clinicians, managers, and researchers was formed. The working group examined archival feedback on ICBT from past patients who self-identified as being from diverse ethnocultural backgrounds (N = 278) and the results of interviews with current patients (N = 16), community representatives (N = 6), and clinicians (N = 3). The archival data and interviews revealed the majority of the patients reported being satisfied with and benefitting from ICBT. Suggestions for improvement were not related to the cognitive-behavioural model and techniques, but rather to making treatment materials more inclusive. Consequently, the ICBT adaptation focused on adding content related to cultural influences on mental health, addressing stigma, diversifying case stories, examples, and imagery, adding audiovisual introductions, and replacing English idioms with more descriptive language. Moreover, further training was offered to clinicians, and efforts were made to improve community outreach. This study demonstrates a process for using patient-oriented research to improve ICBT within routine care serving patients of diverse backgrounds.

The Impacts of a Psychoeducational Alcohol Resource During Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety: Observational Study.

BACKGROUND: Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown. OBJECTIVE: This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety. METHODS: All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients' use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients' alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into low-risk and hazardous drinking categories based on pretreatment Alcohol Use Disorders Identification Test (AUDIT) scores. RESULTS: During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (P=.004) and separated, divorced, or widowed (P<.001). Reviewers also consumed more weekly drinks (P<.001), scored higher on the AUDIT (P<.001), and were more likely to exhibit hazardous drinking (P<.001). Regardless of their drinking level (ie, low risk vs hazardous), all clients showed a reduction in AUDIT-Consumption scores (P=.004), depression (P<.001), and anxiety (P<.001) over time; in contrast, there was no change in clients' drinks per week over time (P=.81). Reviewing alcohol resources did not predict changes in AUDIT-Consumption scores or drinks per week. CONCLUSIONS: Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource.

Examining Change in the Frequency of Adaptive Actions as a Mediator of Treatment Outcomes in Internet-Delivered Therapy for Depression and Anxiety.

Adaptive actions, including healthy thinking and meaningful activities, have been associated with emotional wellbeing. The Things You Do Questionnaire-21 item (TYDQ-21) has recently been created to measure the frequency of such actions. A study using the TYDQ-21 found that adaptive actions increased across Internet-delivered therapy for symptoms of depression and anxiety, and higher TYDQ-21 scores were associated with lower psychological distress at post-treatment. The current study examined the relationships between adaptive actions and psychological distress among adults (n = 1114) receiving Internet-delivered therapy as part of routine care in Canada, and explored whether adaptive actions mediated reductions in depression and anxiety. As hypothesised, adaptive actions increased alongside reductions in depression and anxiety symptoms from baseline to post-treatment. Treatment effects were consistent when the intervention was provided with regular weekly therapist support or with optional weekly therapist support, and some (but not all) types of adaptive actions had a mediating effect on change in depressive symptoms. The present findings support further work examining adaptive actions as a mechanism of change in psychotherapy, as well as the utility and scalability of Internet-delivered treatments to target and increase adaptive actions with the aim of improving mental health.

Examining the Utility of a Sleep Resource in Transdiagnostic Internet-Delivered Cognitive Behavior Therapy: An Observational Study.

Patients seeking transdiagnostic internet-delivered cognitive behavior therapy (T-ICBT) for anxiety or depression often have sleep difficulties. A brief resource that includes sleep psychoeducation and strategies for improving sleep (e.g., stimulus control and sleep restriction) may address comorbid insomnia without the need for an insomnia-specific ICBT course. This observational study explored patient use and feedback of a brief sleep resource available to all patients (n = 763) enrolled in an 8-week T-ICBT course. Overall, 30.1% of patients (n = 230) reviewed the resource and were older, more engaged with the ICBT course (i.e., more likely to complete the program, more logins, and greater number of days enrolled in the course) and had higher pretreatment insomnia symptoms than those who did not review the resource. Resource reviewers did not report larger improvements in symptoms of insomnia than non-reviewers, even among patients with clinical levels of insomnia, and average insomnia levels remained above the clinical cutoff at posttreatment. While patients were satisfied with the resource and it was beneficial to some patients, more research is needed to further explore how it may be integrated into T-ICBT and how therapists can encourage the use of the resource among patients who may benefit from the resource.

Understanding Client Difficulties in Transdiagnostic Internet-Delivered Cognitive Behaviour Therapy: A Qualitative Analysis of Homework Reflections.

Internet-delivered cognitive behaviour therapy (ICBT) is helpful for many clients, but less is known about the challenges clients face during ICBT, such as difficulties with skill practice, development, or maintenance. Understanding client difficulties can help therapists support clients with skill development and prevent treatment drop-out, but has not been systematically studied. This study included a conventional content analysis of clients' responses to a homework reflection question about difficulties with lessons and skills. Data was drawn from a previously published trial of 301 clients who were randomly assigned to receive homework reflection questions during ICBT. A decreasing number of clients responded to the question about skill difficulties with each lesson. Clients who answered the question about difficulties were more engaged with ICBT (i.e., more lessons completed, logins, days enrolled in ICBT, and messages sent to therapists). Clients shared skill-specific challenges (including initial challenges and more advanced challenges), generic challenges (content or skills being cognitively draining or emotionally draining, contextual challenges, forgetfulness, limited time, and lack of familiarity with the skill), or no challenges. Thought challenging (59.6%) and graded exposure (57.5%) were associated with the greatest number of skill-specific challenges. Findings can help therapists anticipate and address common client challenges during ICBT.

Five-year observational study of Internet-delivered cognitive behavioural pain management when offered as routine care by an online therapy clinic.

BACKGROUND: Internet-delivered cognitive behavioural pain management programmes (PMPs) are effective, but less is known about their use outside of research trials. Five years of data from offering the Internet-delivered cognitive behavioural PMP in an online therapy clinic was examined to assess effectiveness, acceptability and predictors of outcomes. METHODS: Patients (N = 293) were offered a previously validated 8-week Internet-delivered cognitive behavioural PMP and administered measures at pre-treatment, post-treatment and 3 months. RESULTS: There was growth in demand for an Internet-delivered cognitive behavioural PMP over time (n = 64 first year to n = 133 fifth year). Moderate-to-large improvements on depression (post-treatment 35% reduction; 3-month 41% reduction) and anxiety (post-treatment 37% reduction; 3-month 41% reduction), and small-to-moderate improvements on disability (post-treatment 19% reduction; 3-month 20% reduction) were found. Lesson completion and satisfaction were high. Lower pain acceptance, lower pain self-efficacy and higher pain intensity were associated with lower improvements on depression, anxiety and disability. CONCLUSIONS: This longitudinal observational study provides support for Internet-delivered cognitive behavioural PMPs when offered as routine care by an online therapy clinic. SIGNIFICANCE: This 5-year observational study provides support for Internet-delivered cognitive behavioural pain management programs (PMPs) offered as routine care in an online therapy clinic. Interest in the service grew over 5 years. Outcomes, engagement and satisfaction were strong. Higher pain acceptance, pain self-efficacy and lower pain severity were associated with greater post-treatment improvements on depression, anxiety and disability.

Optimizing internet-delivered cognitive behaviour therapy for alcohol misuse: a study protocol for a randomized factorial trial examining the effects of a pre-treatment assessment interview and health educator guidance.

BACKGROUND: Alcohol misuse is a common, disabling, and costly issue worldwide, but the vast majority of people with alcohol misuse never access treatment for varying reasons. Internet-delivered cognitive behaviour therapy (ICBT) may be an attractive treatment alternative for individuals with alcohol misuse who are reluctant to seek help due to stigma, or who live in rural communities with little access to face-to-face treatment. With the growing development of ICBT treatment clinics, investigating ways to optimize its delivery within routine clinic settings becomes a crucial avenue of research. Some studies in the alcohol treatment literature suggest that assessment interviews conducted pre-treatment may improve short- and long-term drinking outcomes but no experimental evaluation of this has been conducted. Further, research on internet interventions for alcohol misuse suggests that guidance from a therapist or coach improves outcomes, but more research on the benefits of guidance in ICBT is still needed. METHODS: This study is a 2X2 factorial randomized controlled trial where all of the expected 300 participants receive access to the Alcohol Change Course, an eight-week ICBT program. A comprehensive pre-treatment assessment interview represents factor 1, and guidance from a health educator represents factor 2. All participants will be asked to respond to measures at screening, pre-treatment, mid-treatment, post-treatment and 3, 6 and 12 months after treatment completion. DISCUSSION: This study will provide valuable information on optimization of ICBT for alcohol misuse within routine clinic settings. TRIAL REGISTRATION: ClinicalTrials.gov, registered June 13th 2019, NCT03984786.

Stakeholder Perceptions of Internet-Delivered Cognitive Behavior Therapy as a Treatment Option for Alcohol Misuse: Qualitative Analysis.

BACKGROUND: Internet-delivered cognitive behavior therapy (ICBT) has been found to be effective for treating alcohol misuse in research trials, but it is not available as part of routine care in Canada. Recent recommendations in the literature highlight the importance of integrating perspectives from both patient and health care stakeholders when ICBT is being implemented in routine practice settings. OBJECTIVE: This study aimed to gain an understanding of how ICBT is perceived as a treatment option for alcohol misuse by interviewing diverse stakeholders. Specifically, the objectives were to (1) learn about the perceived advantages and disadvantages of ICBT for alcohol misuse and (2) elicit recommendations to inform implementation efforts in routine practice. METHODS: A total of 30 participants representing six stakeholder groups (ie, patients, family members, academic experts, frontline managers, service providers, and health care decision makers) participated in semistructured interviews. To be included in the study, stakeholders had to reside in Saskatchewan, Canada, and have personal or professional experience with alcohol misuse. Interviews were transcribed verbatim, anonymized, and analyzed using thematic analysis. RESULTS: Stakeholders identified numerous advantages of ICBT for alcohol misuse (eg, accessibility, convenience, privacy, relevance to technology-based culture, and fit with stepped care) and several disadvantages (eg, lack of internet access and technological literacy, isolation, less accountability, and unfamiliarity with ICBT). Stakeholders also provided valuable insight into factors to consider when implementing ICBT for alcohol misuse in routine practice. In terms of intervention design, stakeholders recommended a 6- to 8-week guided program that uses Web-based advertising, point-of-sale marketing, and large-scale captive audiences to recruit participants. With regard to treatment content, stakeholders recommended that the program focus on harm reduction rather than abstinence; be evidence based; appeal to the diverse residents of Saskatchewan; and use language that is simple, encouraging, and nonjudgmental. Finally, in terms of population characteristics, stakeholders felt that several features of the alcohol misuse population, such as psychiatric comorbidity, readiness for change, and stigma, should be considered when developing an ICBT program for alcohol misuse. CONCLUSIONS: Stakeholders' insights will help maximize the acceptability, appropriateness, and adoption of ICBT for alcohol misuse and in turn contribute to implementation success. The methodology and findings from this study could be of benefit to others who are seeking to implement ICBT in routine practice.

A systematic review of internet-delivered cognitive behavior therapy for alcohol misuse: study characteristics, program content and outcomes.

Alcohol misuse is a common, disabling and costly issue worldwide. Internet-delivered cognitive behavior therapy (ICBT) has the potential to reduce the harms of alcohol misuse, particularly for individuals who are unable or unwilling to access face-to-face therapy. A systematic review was conducted using Medline, CINAHL, EMBASE and PsycINFO databases for all relevant articles published from 1980 to January 2019. Randomized controlled trials (RCTs) were included if (i) an ICBT intervention targeting alcohol misuse was delivered; (ii) participants were aged 18 years or older; and (iii) primary outcomes were quantity of drinking. A qualitative analysis was conducted on the content of the ICBT programs. Fourteen studies met inclusion criteria. Most studies included participants from the general population, while studies conducted within clinic settings with diagnosed individuals were rare. The programs were similar in terms of included modules. Small effects were seen in studies on self-guided ICBT, while therapist-guided ICBT rendered small to large effects. The current review indicates that ICBT has a significant effect in reducing alcohol consumption. Larger studies evaluating ICBT compared to active control groups especially within clinic settings are warranted.