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BACKGROUND: Cognitive deficits such as difficulties with attention, memory, and executive functions are frequently reported during remission from depression and relates to adverse functioning in daily life and risk of relapse. There is therefore a need for interventions targeting cognitive deficits after depression. However, few randomized controlled trials have investigated the efficacy of interventions targeting subjective residual cognitive deficits in adults remitted from depression. METHODS: This randomized crossover trial aimed to investigate the efficacy of an internet-delivered cognitive enhancement intervention on subjective residual cognitive deficits. Forty-four formerly depressed adults (89 % female;mean age = 39 years) were included. Twenty-three participants received the intervention, and 21 participants were assigned to a waitlist control group. The waitlist control group received the intervention after seven weeks. Analyses of follow-up assessment after six months were conducted for the combined sample. RESULTS: Significant differences were found between the intervention and waitlist control group in subjective cognitive functioning (d = 1.83) and rumination (d = 1.65). There was a difference in symptoms of depression between the groups (d = 1.22), whereas symptoms of depression increased in the waitlist control, but not in the intervention group. Fewer participants in the waitlist control group (43 %), compared to the intervention group (78 %) showed reliable improvement in self-reported cognitive deficits after receiving the intervention. LIMITATIONS: Findings should be interpreted with caution due to the small sample, and lack of an active control group. CONCLUSIONS: Internet-delivered cognitive enhancement interventions may improve subjective cognitive deficits. Waiting time to receive cognitive enhancement interventions may worsen symptoms and treatment response.
Subject(s)
Cognitive Behavioral Therapy , Cross-Over Studies , Depressive Disorder, Major , Humans , Female , Adult , Male , Depressive Disorder, Major/therapy , Cognitive Behavioral Therapy/methods , Middle Aged , Cognitive Dysfunction/therapy , Treatment Outcome , Internet-Based Intervention , InternetABSTRACT
Background: Cognitive deficits are common and disabling residual symptoms following major depressive disorder (MDD) and are related to increased risk of relapse. Residual cognitive deficits should thus be considered an important target for treatment. However, few have reported long-term outcomes of interventions targeting residual cognitive deficits. Objective: This study aimed to (1) investigate change between pre-treatment and 2-year follow-up assessments in cognitive deficits, rumination, and symptoms of MDD after an internet-delivered intervention targeting residual cognitive deficits; (2) to investigate stability in outcomes between 6-month and 2-year follow-up assessments; (3) to report the number of participants' experiencing a new episode of MDD in the follow-up period; and (4) to investigate differences in outcomes between those who experienced a new episode of MDD and those who did not. Methods: A total of 43 partly remitted adults were included to test a guided internet-delivered intervention, which consisted of 10 modules involving psychoeducation, cognitive strategies, and attention training. Participants were assessed at pre-treatment, post-treatment, after 6-months, and after 2-years, with measures assessing self-reported residual cognitive deficits, rumination, symptoms of MDD and relapse. Overall, 32 participants completed the 2-year follow-up assessment. Results: Between the pre-treatment and 2-year follow-up assessments, there was a reduction in cognitive deficits and rumination, while there was an increase in symptoms of MDD. Cognitive deficits were stable between the 6-month and the 2-year follow-up, while there was an increase in rumination and symptoms of MDD. Thirteen of 32 participants reported a new episode of MDD during the follow-up period. The relapse group reported longer duration of MDD at pre-treatment and showed a difference in all outcomes after 2 years compared to the no-relapse group. The no-relapse group showed improvement in MDD symptoms at post-treatment, while the relapse group did not. Conclusion: Delivering cognitive enhancement interventions over the internet is potentially related to stable improvements in residual cognitive deficits. The effects on rumination and symptoms of MDD are less certain. Lack of improvement in MDD symptoms after the intervention period should be investigated as an indicator of relapse. Results should be interpreted with caution due to the lack of control group and sample size.
ABSTRACT
Self-reported subjective cognitive difficulties (subjective deficits) and rumination are central residual cognitive symptoms following major depressive disorder (MDD). These are risk factors for more a severe course of illness, and despite the considerable relapse risk of MDD, few interventions target the remitted phase, a high-risk period for developing new episodes. Online distribution of interventions could help close this gap. Computerized working memory training (CWMT) shows promising results, but findings are inconclusive regarding which symptoms improve following this intervention, and its long-term effects. This study reports results from a longitudinal open-label two-year follow-up pilot-study of self-reported cognitive residual symptoms following 25 sessions (40 min), five times a week of a digitally delivered CWMT intervention. Ten of 29 patients remitted from MDD completed two-year follow-up assessment. Significant large improvements in self-reported cognitive functioning on the behavior rating inventory of executive function-adult version appeared after two-years (d = 0.98), but no significant improvements were found in rumination (d < 0.308) measured by the ruminative responses scale. The former showed moderate non-significant associations to improvement in CWMT both post-intervention (r = 0.575) and at two-year follow-up (r = 0.308). Strengths in the study included a comprehensive intervention and long follow-up time. Limitations were small sample and no control group. No significant differences between completers and drop-outs were found, however, attrition effects cannot be ruled out and demand characteristics could influence findings. Results suggested lasting improvements in self-reported cognitive functioning following online CWMT. Controlled studies with larger samples should replicate these promising preliminary findings.
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This paper summarizes the information technology-related research findings after 5 years with the INTROducing Mental health through Adaptive Technology project. The aim was to improve mental healthcare by introducing new technologies for adaptive interventions in mental healthcare through interdisciplinary research and development. We focus on the challenges related to internet-delivered psychological treatments, emphasising artificial intelligence, human-computer interaction, and software engineering. We present the main research findings, the developed artefacts, and lessons learned from the project before outlining directions for future research. The main findings from this project are encapsulated in a reference architecture that is used for establishing an infrastructure for adaptive internet-delivered psychological treatment systems in clinical contexts. The infrastructure is developed by introducing an interdisciplinary design and development process inspired by domain-driven design, user-centred design, and the person based approach for intervention design. The process aligns the software development with the intervention design and illustrates their mutual dependencies. Finally, we present software artefacts produced within the project and discuss how they are related to the proposed reference architecture. Our results indicate that the proposed development process, the reference architecture and the produced software can be practical means of designing adaptive mental health care treatments in correspondence with the patients' needs and preferences. In summary, we have created the initial version of an information technology infrastructure to support the development and deployment of Internet-delivered mental health interventions with inherent support for data sharing, data analysis, reusability of treatment content, and adaptation of intervention based on user needs and preferences.
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Objective: Residual cognitive symptoms after depression are common and associated with reduced daily life functioning and an increased risk of depression relapse. There is a lack of knowledge on treatments targeting residual cognitive symptoms after major depressive disorder (MDD), including the factors associated with treatment response. The aim of the current study is to explore factors of treatment response to a guided internet-delivered intervention for former depressed adults experiencing residual cognitive symptoms. Method: Forty-three former depressed adults with residual cognitive symptoms were included. Linear mixed model analyses were used to investigate the impact of pre-treatment demographic-, illness, and symptom variables, and therapy process variables, such as credibility, expectancy, and user behavior, on reduction in residual cognitive symptoms from pre-treatment to 6-month follow-up. Results: Having had MDD for a year or less predicted more reductions in residual cognitive symptoms from pre- to 6-month follow-up. Higher levels of perceived treatment credibility and expectancy evaluated in the early course of treatment did also predict a positive treatment response. No demographic-, symptom-variables, previous number of episodes with MDD, and user behavior were associated with change in residual cognitive symptoms. Conclusion: This study suggests that individuals with shorter duration of previous depressions might have larger reductions in residual cognitive symptoms at 6-month follow-up compared to those with a longer duration of depression. Treatment credibility and expectancy also predicted treatment response and effort should also be made to ensure interventions credibility. Results should be interpreted with caution due to the study having a low sample size. Further investigation of predictors should be conducted in a full scale randomized controlled trial.
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BACKGROUND: Cognitive difficulties are rarely addressed after the treatment of major depressive disorder (MDD). New scalable treatments are needed. To ensure relevance and engagement of novel interventions, there is a need to understand the perspectives of the users. AIM: Explore former depressed adults needs and perspectives during the planning and development of a novel internet-delivered intervention targeting residual cognitive symptoms after MDD. METHOD: The planning phase included exploratory qualitative interviews with former depressed adults (n = 16). In the development phase, a prototype including psychoeducation, attention training and compensatory strategies was tested in think-aloud interviews with former depressed adults (n = 7) and psychologists (n = 4). Data were analysed thematically. RESULTS: Analysis of exploratory interviews identified four themes. Experiences of residual cognitive symptoms consisted of two sub-themes (Everyday life is more demanding; Concerns about cognitive difficulties). Coping with residual cognitive symptoms had two sub-themes (Compensatory strategies; Acceptance). Needs from an intervention consisted of two-subthemes (Need for information; Therapist support). Barriers for engagement consisted of three sub-themes (Being overwhelmed; Not being motivated; Frequent registration). Analysis of think-aloud interviews was organized into three themes: Positive perceptions of content; Concerns regarding content; Perceptions of Layout, Visuals and Navigation. CONCLUSION: The intervention may address concerns and consequences of cognitive difficulties by including psychoeducation, compensatory strategies and elements to increase acceptance and motivation, provided in manageable proportions.
Subject(s)
Cognitive Behavioral Therapy , Depressive Disorder, Major , Adult , Humans , Depressive Disorder, Major/therapy , Motivation , Cognition , InternetABSTRACT
Residual cognitive symptoms are associated with reduced daily life functioning, quality of life and represent a risk factor for relapse of major depressive disorder (MDD). There are few studies targeting self-perceived residual cognitive symptoms after MDD. The current open pilot study examines clinical outcomes and feasibility of a novel internet-delivered cognitive enhancement treatment for mood disorders specifically tailored to target self-perceived residual cognitive symptoms after MDD. A total of 43 adults with self-perceived residual cognitive symptoms after MDD were included. Participants were assessed pre- and post-treatment and at 6-month follow-up. The intervention consists of 10 modules that includes psychoeducation, cognitive strategies, and attention training, coupled with weekly therapist guidance. Results showed a significant reduction from pre- to post-treatment in self-perceived residual cognitive symptoms (d = 0.98) and rumination (d = 0.63). Results remained significant at the 6-month follow-up (d = 1.06; d = 0.86). Reliable change in self-perceived residual cognitive symptoms were obtained in 60% of the participants from pre- to post-treatment. Completion rates (86%) and treatment satisfaction (97%) were high. This open pilot study supports that targeting self-perceived residual cognitive symptoms after MDD through internet-delivered cognitive enhancement therapy for mood disorders may be feasible and provide stable reductions in self-perceived residual cognitive symptoms and rumination.
Subject(s)
Depressive Disorder, Major , Adult , Cognition , Depressive Disorder, Major/complications , Depressive Disorder, Major/therapy , Humans , Internet , Pilot Projects , Quality of Life , Treatment OutcomeABSTRACT
Major depressive disorder (MDD) is associated with working memory (WM) impairments. These deficits often persist following remission and are associated with rumination, a recognized risk factor for depression relapse. The efficacy of WM-targeted cognitive remediation as a potential relapse prevention tool has not been investigated. The present pilot study aimed to investigate the feasibility, acceptability, and cognitive benefits of a WM-targeted cognitive remediation program in remitted depression. Twenty-eight MDD participants in remission were recruited. The intervention consisted of twenty-five 30-40-minute training sessions, coupled with weekly coaching, administered over a 5-week period. Before and after the intervention, a battery of objective neuropsychological tests and self-report measures was administered. Key outcomes were WM, inhibition and rumination. Acceptability of the intervention was observed, with 83% showing high motivation, along with WM gains for all completers (n = 18, 64% of recruited participants). The cognitive remediation selectively improved targeted WM functions, as measured by objective tests. This did not translate into self-reported improvements in everyday WM or inhibition. However, all but one completer achieved at least one personal goal related to WM and 44% achieved two or, the maximum possible, three such goals. For remitters whose WM was significantly enhanced after the intervention, the cognitive remediation also decreased dysphoric-mood related rumination. The successful pilot testing of the WM-targeted intervention supports the conduct of a fully powered randomized controlled trial as a relapse prevention approach in remitted MDD.
Subject(s)
Cognitive Remediation , Depressive Disorder, Major , Depressive Disorder, Major/complications , Depressive Disorder, Major/therapy , Humans , Memory, Short-Term , Pilot Projects , RecurrenceABSTRACT
Background: The COVID-19 pandemic and its consequences has been found to negatively affect the general population's psychological well-being. Objective: The objectives of this paper are to report on the development and clinical effects of a self-guided Internet-delivered intervention for adults in Norway who suffer from mild to moderate psychological distress during the COVID-19 pandemic. Methods: The participants, recruited between April and December 2020, were randomized to receive a new treatment module either every third or every fifth day. The clinical outcomes were self-reported depressive and anxiety symptoms and change in positive and negative emotions. Results: A total of 1256 individuals accessed the pre-screening survey, 407 were eligible and 92 provided contact information, where 82 were included in the study, n = 44 in the 3-day group and n = 38 in the 5-day group. Overall, the statistical analyses showed a significant decrease in depressive and anxiety symptoms and an increase in positive emotions, with small and moderate within group effect sizes. No significant differences between the groups were identified in clinical outcomes or adherence. Conclusion: These findings indicate that psychological distress in the general population during the COVID-19 pandemic may be reduced through the use of a scalable self-guided Internet-delivered intervention. Furthermore, the lack of significant differences between the 5-day and 3-day group may indicate that the intervention can be delivered at a more intensive pace without negatively affecting treatment outcomes. The results need to be interpreted with caution as the sample was self-selected, as well as the lack of passive control group. Hence the results may be attributed to external factors.