Mechanisms of change in digital cognitive behavioral therapy for depression in patients with chronic back pain: A mediation analysis of a multicenter randomized clinical trial.

BACKGROUND: While there is evolving knowledge on change processes of digital cognitive behavioral therapy (CBT) in the treatment of depression, little is known about how these interventions produce therapeutic change in the comorbid constellation of chronic back pain (CBP). Here, we examined whether the effects of a digital intervention to treat depression in patients with CBP are mediated by three pain-related variables (i.e., pain self-efficacy, pain-related disability, pain intensity). METHODS: This study is a secondary analysis of a randomized clinical trial conducted in routine care at 82 orthopedic clinics across Germany. In total, 209 adults with CBP and diagnosed depression (SCID interview) were randomly assigned to the intervention (n = 104) or treatment-as-usual (n = 105). Cross-lagged mediation models were estimated to investigate longitudinal mediation effects of putative mediators with depression symptom severity (PHQ-9) as primary outcome at post-treatment. RESULTS: Longitudinal mediation effects were observed for pain self-efficacy (ß = -0.094, 95%-CI [-0.174, -0.014], p = 0.021) and pain-related disability (ß = -0.068, 95%-CI [-0.130, -0.001], p = 0.047). Furthermore, the hypothesized direction of the mediation effects was supported, reversed causation did not occur. Pain intensity did not reveal a mediation effect. CONCLUSIONS: The results suggest a relevant role of pain self-efficacy and pain-related disability as change processes in the treatment of depression for patients with CBP in routine care. However, further research is needed to disclose potential reciprocal relationships of mediators, and to extend and specify our knowledge of the mechanisms of change in digital CBT for depression.

Mediators of digital depression prevention in patients with chronic back pain: Findings from a multicenter randomized clinical trial.

OBJECTIVE: The mechanisms of change in digital interventions for the prevention of depression are largely unknown. Here, we explored whether five theoretically derived intervening variables (i.e., pain intensity, pain-related disability, pain self-efficacy, quality of life [QoL], and work capacity) were mediating the effectiveness of a digital intervention specifically designed to prevent depression in patients with chronic back pain (CBP). METHOD: This study is a secondary analysis of a pragmatic, observer-masked randomized clinical trial conducted at 82 orthopedic clinics in Germany. A total of 295 adults with a diagnosis of CBP and subclinical depressive symptoms were randomized to either the intervention group (n = 149) or treatment-as-usual (n = 146). Longitudinal mediation analyses were conducted with structural equation modeling and depression symptom severity as primary outcome (Patient Health Questionnaire-9 [PHQ-9]; 6 months after randomization) on an intention-to-treat basis. RESULTS: Beside the effectiveness of the digital intervention in preventing depression, we found a significant causal mediation effect for QoL as measured with the complete scale of Assessment of Quality of Life (AQoL-6D; axb: -0.234), as well as for the QoL subscales mental health (axb: -0.282) and coping (axb: -0.249). All other potential intervening variables were not significant. CONCLUSION: Our findings suggest a relevant role of QoL, including active coping, as change mechanism in the prevention of depression. Yet, more research is needed to extend and specify our knowledge on empirically supported processes in digital depression prevention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Mechanisms of Change in Digital Health Interventions for Mental Disorders in Youth: Systematic Review.

BACKGROUND: Digital health interventions (DHIs) are efficacious for several mental disorders in youth; however, integrated, evidence-based knowledge about the mechanisms of change in these interventions is lacking. OBJECTIVE: This systematic review aims to comprehensively evaluate studies on mediators and mechanisms of change in different DHIs for common mental disorders in children and adolescents. METHODS: A systematic literature search of the electronic databases Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PsycINFO was conducted, complemented by backward and forward searches. Two independent reviewers selected studies for inclusion, extracted the data, and rated the methodological quality of eligible studies (ie, risk of bias and 8 quality criteria for process research). RESULTS: A total of 25 studies that have evaluated 39 potential mediators were included in this review. Cognitive mediators were the largest group of examined intervening variables, followed by a broad range of emotional and affective, interpersonal, parenting behavior, and other mediators. The mediator categories with the highest percentages of significant intervening variables were the groups of affective mediators (4/4, 100%) and combined cognitive mediators (13/19, 68%). Although more than three-quarters of the eligible studies met 5 or more quality criteria, causal conclusions have been widely precluded. CONCLUSIONS: The findings of this review might guide the empirically informed advancement of DHIs, contributing to improved intervention outcomes, and the discussion of methodological recommendations for process research might facilitate mediation studies with more pertinent designs, allowing for conclusions with higher causal certainty in the future.