Bridging the gap from medical to psychological safety assessment: consensus study in a digital mental health context.

BACKGROUND: Digital Mental Health Interventions (DMHIs) that meet the definition of a medical device are regulated by the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK. The MHRA uses procedures that were originally developed for pharmaceuticals to assess the safety of DMHIs. There is recognition that this may not be ideal, as is evident by an ongoing consultation for reform led by the MHRA and the National Institute for Health and Care Excellence. AIMS: The aim of this study was to generate an experts' consensus on how the medical regulatory method used for assessing safety could best be adapted for DMHIs. METHOD: An online Delphi study containing three rounds was conducted with an international panel of 20 experts with experience/knowledge in the field of UK digital mental health. RESULTS: Sixty-four items were generated, of which 41 achieved consensus (64%). Consensus emerged around ten recommendations, falling into five main themes: Enhancing the quality of adverse events data in DMHIs; Re-defining serious adverse events for DMHIs; Reassessing short-term symptom deterioration in psychological interventions as a therapeutic risk; Maximising the benefit of the Yellow Card Scheme; and Developing a harmonised approach for assessing the safety of psychological interventions in general. CONCLUSION: The implementation of the recommendations provided by this consensus could improve the assessment of safety of DMHIs, making them more effective in detecting and mitigating risk.

Outcomes of transdiagnostic internet-delivered cognitive behavioural therapy tailored to public safety personnel: A longitudinal observational study.

First responders and other public safety personnel (PSP) experience high rates of mental health problems and face barriers to accessing mental healthcare. Internet-delivered cognitive behavioural therapy (ICBT) is an effective and accessible treatment for various mental health concerns. Canadian PSP report favorable attitudes toward ICBT, and preliminary outcomes demonstrate that they benefit from it. Expanding on this research, the current study consisted of a longitudinal observational study of 560 Canadian PSP who participated in ICBT. It was designed to assess the longer term effectiveness of ICBT and moderators of outcomes by gender, linguistic and occupational group, and years of occupational experience. We evaluated symptom change at 8, 26, and 52 weeks post-enrollment, and results among PSP who had elevated clinical scores, showed large reductions (Hedges' g) in symptoms of depression (g = 1.3), anxiety (g =1.48), posttraumatic stress (g =1.24), panic (g =1.19), and anger (g =1.07) and moderate reductions in symptoms of social anxiety (g =.48-.56). Moderator analyses revealed modest differences in pre-treatment symptoms among certain groups but no group differences in symptom change over time. Clients showed good completion of treatment materials and reported high treatment satisfaction. The results suggest further study of ICBT tailored to PSP is warranted, including evaluating ICBT tailored for PSP in other countries.

Internet-delivered therapy for alcohol misuse: engagement, satisfaction, and outcomes when patients select their preference for therapist- or self-guided treatment.

BACKGROUND: Alcohol misuse is common and causes substantial harm. Internet-delivered cognitive behaviour therapy (ICBT) is effective in reducing alcohol misuse; however, the literature investigating how treatment outcomes are impacted by patients' preferences for therapist- versus self-guided ICBT for alcohol misuse is sparse. METHODS: In this preference trial, 74 eligible patients (who reported ≥ 14 drinks in the previous week and obtained scores suggesting hazardous or harmful drinking) chose between enrolling in either therapist- or self-guided ICBT for alcohol misuse. We investigated whether those who chose therapist- versus self-guided ICBT differed in their (a) drinking outcomes-as measured by Timeline Follow-Back (TLFB) and heavy drinking days (HDD) at post-treatment and 3-month follow-up-and (b) post-treatment ICBT engagement and satisfaction. RESULTS: The majority (81.1%) of eligible patients chose therapist-guided ICBT. These patients reported higher psychotropic medication use, drinking difficulties, and anxiety symptoms. For both the therapist- and self-guided patients, a modified intention-to-treat analysis revealed large within-group treatment effects for TLFB (ß = - 2.64, SE 0.66; p < 0.001) and HDD (ß = - 0.34, SE 0.07; p < 0.001), with large pre-to-post-treatment Cohen's effect sizes of d = 0.97 (95% CI [0.49, 1.45]) for TLFB and d = 1.19 (95% CI [0.69, 1.68]) for HDD. The interaction comparing the effects of therapist- to self-guided ICBT over time was not significant for TLFB (p = 0.34) or HDD (p = 0.06). With treatment, for both therapist- and self-guided patients, there was a significant improvement in drinking difficulties, cravings, and confidence with controlling cravings, as well as in anxiety, depression, and functional impairment. Further, the majority (75.7%) of patients completed five or more lessons, as well as reported overall satisfaction with the treatment (88.9%) and increased confidence in managing their symptoms (86.7%); these outcomes also did not differ between therapist- and self-guided patients. CONCLUSIONS: The current study shows that ICBT for alcohol misuse is associated with reduced drinking and comorbid mental health difficulties over time, irrespective of whether patients chose to complete the course on their own or with therapist guidance. TRIAL REGISTRATION NUMBER: NCT04611854 ( https://clinicaltrials.gov/ct2/show/NCT04611854 ).

Satisfaction, engagement, and outcomes in internet-delivered cognitive behaviour therapy adapted for people of diverse ethnocultural groups: an observational trial with benchmarking.

Introduction: Depression and anxiety are the most common mental health disorders worldwide. Internet-Delivered Cognitive Behaviour Therapy (ICBT) can reduce barriers to care to broad cross sections of the population. However, People of Diverse Ethnocultural Backgrounds (PDEGs) other than White/Caucasian underutilize mental health services and are under represented in clinical trials of psychological interventions. Methods: To address this research gap we adapted an evidence-based ICBT program for PDEGs. The current pilot study explores the engagement, satisfaction, and effectiveness in the adapted ICBT program by PDEGs (N=41) when benchmarked against a sample of PDEGs (N=134) who previously completed a non-adapted version of the ICBT program. Results: An intent-to-treat analyses showed that the adapted ICBT program is effective in reducing anxiety and depression symptoms among PDEGs. Large within-group pre-to post-treatment Cohen's effect sizes of d = 1.23, 95% CI [0.68, 1.77] and d = 1.24, 95% CI [0.69, 1.79] were found for depression and anxiety, respectively. Further, 81.8% of the PDEGs who received the adapted ICBT reported overall satisfaction, 90.9% reported increased confidence in managing symptoms, and 70.7% completed majority of the psychoeducational lessons in the ICBT program. Conclusion: No statistically significant differences in the clinical outcomes, engagement, and satisfaction were found between the pilot study and benchmark sample. Future directions for ICBT research with PDEGs are described. Clinical trial registration: https://beta.clinicaltrials.gov/study/NCT05523492, identifier NCT05523492.

Examining how organizational leaders perceive internet-delivered cognitive behavioural therapy for public safety personnel using the RE-AIM implementation framework.

Background: Within Canada, internet-delivered cognitive behavioural therapy (ICBT) has recently been tailored by PSPNET to meet the needs of public safety personnel (PSP) to help address high rates of mental health problems within this population. Perceptions and outcomes of ICBT among PSP are promising, but it remains unknown how PSPNET is perceived by PSP organizational leaders. It is important to assess this gap because these leaders have significant potential to influence the uptake of ICBT. Methods: In the current study, PSP leaders (n = 10) were interviewed to examine their perceptions of PSPNET and opportunities to improve ICBT implementation. The RE-AIM evaluation framework was used to assess PSP leaders' perceptions of PSPNET in terms of reach, effectiveness, adoption, implementation, and maintenance. Results: The results evidenced that leaders perceived PSPNET as effective in reaching and serving PSP and PSP organizations. PSP leaders reported perceiving ICBT as effectively implemented, especially for being freely offered to individual PSP and for improving PSP's access to experienced therapists specifically trained to work with PSP. Participants indicated organizations have promoted and will continue promoting PSPNET longer-term, facilitating adoption and maintenance. Factors perceived as facilitating successful service delivery included building relationships and trust with PSP organizations and general support for PSP leadership mental health initiatives. PSP leaders identified perceived areas for improving ICBT implementation (e.g., ensuring leaders have access to data on PSPNET uptake and outcomes, creating promotional videos, expanding availability of PSPNET to other provinces, offering additional options for receiving therapist support). Implications: Overall, the study provides insights into PSP leaders' perceptions of the implementation of ICBT among PSP and ideas for optimizing implementation efforts.

Discharge Information About Adverse Drug Reactions Indicates Lower Self-Reported Adverse Drug Reactions and Fewer Concerns in Patients After Percutaneous Coronary Intervention.

AIM: There are discrepancies between the information patients desire about adverse drug reactions (ADRs) and the information they receive from healthcare providers; this is an impediment to shared decision-making. This study aimed to establish whether patients received information about ADRs resulting from prescribed pharmacotherapy, before hospital discharge, after percutaneous coronary intervention (PCI) and to determine whether receiving information about ADRs was associated with incidence of self-reported ADRs or concerns related to prescribed pharmacotherapy. METHODS: CONCARDPCI, a prospective multicentre cohort study including 3,417 consecutive patients after PCI, was conducted at seven high-volume referral PCI centres in two Nordic countries. Clinical data were collected from patients' medical records and national quality registries. Patient-reported outcome measures were registered 2 months (T1), 6 months (T2), and 12 months (T3) after discharge. Covariate-adjusted logistic regression yielded adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS: At discharge, 38% of participants had been informed about potential ADRs. For these patients, the incidence of self-reported ADRs was significantly lower at T1 (aOR 0.61, 95% CI 0.50-0.74; p<0.001), T2 (aOR 0.60, 95% CI 0.49-0.74; p<0.001), and T3 (aOR 0.57, 95% CI 0.46-0.71; p<0.001). Those who were not informed reported higher levels of concern about prescribed pharmacotherapy at all measuring points (p<0.001 for all comparisons). Those living alone (aOR 0.73, 95% CI 0.57-0.92; p=0.008), who were female (aOR 0.57, 95% CI 0.44-0.72; p<0.001), and with three or more versus no comorbidities (aOR 0.61, 95% CI 0.44-0.84; p=0.002) were less likely to receive information. CONCLUSION: A substantial proportion of patients were not informed about potential ADRs from prescribed pharmacotherapy after PCI. Patients informed about ADRs had lower incidences of self-reported ADRs and fewer concerns about prescribed pharmacotherapy.

Web-Based Mindfulness Meditation as an Adjunct to Internet-Delivered Cognitive Behavioral Therapy for Public Safety Personnel: Mixed Methods Feasibility Evaluation Study.

BACKGROUND: Public safety personnel (PSP) are individuals who work to ensure the safety and security of communities (eg, correctional workers, firefighters, paramedics, and police officers). PSP have a high risk of developing mental disorders and face unique barriers to traditional mental health treatments. The PSP Wellbeing Course is a transdiagnostic, internet-delivered cognitive behavioral therapy (iCBT) course tailored to assist PSP with symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). The initial course outcomes are promising, but some clients report some challenges with learning skills and recommend adding additional resources. Mindfulness meditations, which help people to experience the world and their reactions to the world in open and nonjudgmental ways, may complement the existing PSP Wellbeing Course. OBJECTIVE: This study aims to examine the feasibility of mindfulness meditations in iCBT tailored for PSP. Information was gathered to evaluate engagement and client experiences with mindfulness meditations, symptom change, and the relationship between mindfulness meditation use and symptom change. METHODS: A mixed methods study was conducted on PSP enrolled in the PSP Wellbeing Course who were offered 5 mindfulness meditations during the program (ie, 1/lesson). Clients completed questionnaires on depression, anxiety, PTSD, anger, insomnia, resilience, and mindfulness at pretreatment and at 8 weeks; an 8-week treatment satisfaction questionnaire; and brief weekly measures of mindfulness meditation engagement. We used paired sample t tests (2-tailed) to assess changes in outcomes over time and partial correlations to assess whether mindfulness meditation use predicted outcomes at posttreatment. A total of 12 clients were interviewed about their perceptions of the mindfulness meditations, and interviews were analyzed using directed content analysis. RESULTS: Among the 40 clients enrolled, 27 (68%) reported using the mindfulness meditations, practicing for an average of 4.8 (SD 8.1) minutes each week. Most interviewees described the mindfulness meditations as beneficial but also reported challenges, such as discomfort while sitting with their feelings. Clients provided suggestions for better integration of mindfulness into iCBT. Overall, clients who completed the PSP Wellbeing Course with mindfulness meditations experienced statistically significant improvements in symptoms of anxiety (P=.001), depression (P=.001), PTSD (P=.001), and anger (P=.001) but not insomnia (P=.02). Clients also experienced improvements in resilience (P=.01) and mindfulness (P=.001). Self-reported time spent meditating was not associated with changes in symptoms over time. CONCLUSIONS: This study provides new insight into the integration of mindfulness meditations with iCBT for PSP. It demonstrates the partial feasibility of adding mindfulness meditations to iCBT, revealing that some, but not all, PSP engaged with the meditations and reported benefits. PSP reported using the mindfulness meditations inconsistently and described challenges with the meditations. Improvements can be made to better integrate mindfulness meditation into iCBT, including offering mindfulness meditation as an optional resource, providing more psychoeducation on managing challenges, and offering shorter meditations.

Perceptions of client stories in internet-delivered cognitive behaviour therapy: A mixed-methods evaluation.

Internet-delivered Cognitive-Behavioural Therapy (ICBT) aims to support people with mental health concerns using online treatment materials. Client stories (either real or a composite based on many clients) are often used in ICBT to facilitate learning. However, these stories remain understudied in terms of how they are perceived by clients, as well as their relationship to ICBT engagement, satisfaction, and outcomes. Among a sample of 324 clients enrolled in transdiagnostic ICBT targeting symptoms of depression and anxiety, we examined client perceptions of stories through mixed-method qualitative (open-ended) and quantitative (closed-ended) data collection. Specifically, 234 (72.22 %) clients responded to questions about stories at 4 weeks and 221 (68.21 %) responded to questions at 8 weeks. Most clients who responded to questions endorsed reviewing at least some stories (79.06 % at 4 weeks, 71.95 % at 8 weeks). Moreover, they rated stories positively in terms of being relatable, making clients feel less alone, increasing knowledge, providing ideas for how to use skills, and motivating clients to use skills. These perceptions of stories remained stable over the course of treatment. Stories were perceived more positively among those with lower symptom severity at 8 weeks as well as those who were more satisfied with ICBT at 8 weeks. Story perceptions at 4 weeks were predictive of decreased post-treatment anxiety symptom severity but not depression while controlling for baseline scores, age, and education. 26.49 % of clients at 4 weeks who reviewed stories and 33.33 % at 8 weeks provided suggestions about how to improve stories. In a qualitative analysis, we found 5 categories of suggestions including increasing the variety of issues and relatability of stories, ensuring the stories are realistic, refining the formatting, and making the stories shorter. Overall, this study provides insights into how client stories could be improved to play a more significant role in future ICBT programs.

Internet-Delivered Cognitive Behavioral Therapy Tailored to Spouses and Significant Others of Public Safety Personnel: Formative Evaluation Study.

BACKGROUND: Spouses and significant others (SSOs) of public safety personnel (PSP) are affected by the risks and requirements of these occupations. Internet-delivered cognitive behavioral therapy (ICBT) provides a convenient and accessible treatment format that can be tailored to the needs of SSOs of PSP. OBJECTIVE: This study aimed to assess the initial use and client perceptions (eg, likes, helpfulness, and areas for improvement) of a self-guided, transdiagnostic ICBT course designed for Canadian SSOs of PSP and identify opportunities to further tailor ICBT for this group. METHODS: SSOs were invited to complete a 5-lesson, self-guided, transdiagnostic ICBT course. Descriptive statistics were used to analyze the demographic and clinical characteristics of participants. Content analysis was used to analyze the data from open-ended survey responses and interviews to understand their experiences with ICBT. RESULTS: Clients (N=118) endorsed various mental health concerns (eg, depression, anxiety, posttraumatic stress symptoms, and relationship concerns) with a range of severity levels. Most clients identified as White (110/116, 94.8%) and women (108/116, 91.5%), with a mean age of 42.03 (SD 9.36) years. Of the 26 clients who were interviewed, 89% (23/26) reported believing that ICBT is helpful and 92% (24/26) reported finding at least 1 skill helpful. Clients provided suggestions for course improvements. On the basis of this feedback and quantitative data, changes were made to areas such as the delivery of materials, content, case stories, and timelines. Overall, the results indicated that many SSOs of PSP had positive perceptions of ICBT tailored to their needs and found several aspects of the course helpful, supporting the continued delivery of tailored ICBT to this population. However, there remains a need for continued promotion of the course and outreach to diverse groups of SSOs of PSP. CONCLUSIONS: Findings from this formative evaluation provide insight into the unique experiences and needs of SSOs of PSP and provide preliminary evidence for the use of tailored ICBT to support the mental health of this group in Canada.

Internet-delivered cognitive behavioural therapy for symptoms of PTSD among public safety personnel: Initial outcomes of an open cohort preference trial of transdiagnostic and disorder-specific therapy.

Public safety personnel (PSP) face high rates of mental health problems and many barriers to care. Initial outcomes of transdiagnostic internet-delivered cognitive behavioural therapy (ICBT) tailored for PSP are promising, but prior research has not evaluated outcomes of PTSD-specific ICBT among PSP or PSP's preferences for transdiagnostic or PTSD-specific ICBT. The current paper presents the initial outcomes (N = 150) of a mixed-methods observational study designed to (a) investigate preferences for transdiagnostic or PTSD-specific ICBT among PSP with elevated symptoms of PTSD and/or a primary concern with PTSD symptoms and (b) explore potential differences in client engagement, satisfaction, and symptom changes between the two forms of ICBT. PSP completed questionnaires before and after their preferred ICBT program. Mixed-methods analyses included generalized estimating equations, descriptive statistics, and inductive conventional qualitative content analysis. More clients (n = 85; 57 %) selected transdiagnostic ICBT than PTSD-specific ICBT (n = 65; 43 %), but the difference in the number of clients who selected each course was not statistically significant. Clients in both ICBT programs reported similar and favorable treatment satisfaction (e.g., 98 % would recommend the course to a friend), treatment engagement (i.e., 69 % accessed at least four of the five lessons), and pre-post improvement in symptoms (e.g., Hedges' g = 0.81 for reduction in PTSD symptom). Transdiagnostic ICBT resulted in greater reductions in symptoms of panic disorder than PTSD-specific ICBT. Qualitative analyses showed similarities across the ICBT programs in client feedback. The current study provides further evidence supporting the use and outcomes of ICBT for PSP in both transdiagnostic and disorder-specific formats. Implications for the literatures on PSP mental health and ICBT, as well as practical recommendations, are discussed.

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.

Evaluation of a therapist-guided virtual psychological pain management program when provided as routine care: a prospective pragmatic cohort study.

INTRODUCTION: Numerous randomized controlled trials have evaluated the outcomes of internet-delivered psychological pain management programs (PMPs) as a way of increasing access to care for people with chronic pain. However, there are few reports of the effectiveness of these PMPs when provided as part of routine care. METHODS: The present study sought to report the clinical and demographic characteristics of users (n = 1367) and examine the effectiveness of an established internet-delivered psychological PMP program in improving several pain-related outcomes, when offered at a national digital mental health service over a 5-year period. It also sought to comprehensively explore predictors of treatment commencement, treatment completion, and clinical improvement. RESULTS: Evidence of clinical improvements (% improvement; Hedges g) were found for all outcomes, including pain interference (18.9%; 0.55), depression (26.1%; 0.50), anxiety (23.9%; 0.39), pain intensity (12.8%; 0.41), pain self-efficacy (-23.8%; -0.46) and pain-catastrophizing (26.3%; 0.56). A small proportion of users enrolled but did not commence treatment (13%), however high levels of treatment completion (whole treatment = 63%; majority of the treatment = 75%) and satisfaction (very satisfied = 45%; satisfied = 37%) were observed among those who commenced treatment. There were a number of demographic and clinical factors associated with commencement, completion and improvement, but no decisive or dominant predictors were observed. DISCUSSION: These findings highlight the effectiveness and acceptability of internet-delivered psychological PMPs in routine care and point to the need to consider how best to integrate these interventions into the pathways of care for people with chronic pain.

Efficacy of an Online Workplace Mental Health Accommodations Psychoeducational Course: A Randomized Controlled Trial.

Workplace accommodations can improve work functioning for employees with mental health concerns, yet few employees receive accommodations. The current study examined the benefits of providing education on workplace accommodations. In total, 89 participants with symptoms of depression and/or anxiety were randomized to an online psychoeducation course or wait-list control (WLC). The course provided education on symptoms, accommodations, tips for requesting accommodations and making disclosures, and coping strategies. Primary outcomes included the impact of the course on requesting and receiving accommodations, accommodation knowledge, self-stigma, and workplace relationships at 8 weeks post-randomization. Additional analyses examined the impact of the course on symptoms, absenteeism, presenteeism, and self-efficacy and whether supervisory leadership and organizational inclusivity impact disclosure and accommodation use. Participants in the course reported improvements in accommodation knowledge, self-efficacy, and presenteeism compared to the WLC. Both groups reported reduced self-stigma and increased disclosures over time. Specifically, partial disclosures were associated with supportive organizations and supervisors. No group differences were found on accommodation use, symptoms, workplace relationships, or comfort with disclosure. Few participants made accommodation requests, therefore a statistical analysis on requesting or receiving accommodations was not performed. Overall, providing psychoeducation has the potential to assist individuals with depression and anxiety who may require workplace accommodations, but further research is required.

Sustaining and Expanding Internet-Delivered Cognitive Behavioral Therapy (ICBT) for Public Safety Personnel across Canada: A Survey of Stakeholder Perspectives.

Public safety personnel (PSP) experience an elevated risk of mental health problems and face barriers to treatment. Internet-delivered cognitive behavioral therapy (ICBT) has been tailored to PSP to improve access to mental health care. In this study, we sought to investigate perceptions of ICBT, particularly among those with and without prior knowledge of ICBT and between PSP leaders and non-leaders. A survey was administered to 524 PSP from across Canada to identify (a) how PSP perceive ICBT, (b) the extent of organizational support for tailored ICBT in PSP organizations, particularly leadership's support, and (c) perceived facilitators and barriers to funding tailored ICBT. The results indicated that PSP perceive ICBT to have more advantages than disadvantages. PSP who had previously heard of tailored ICBT had more positive perceptions. PSP indicated that there is a need for ICBT, and PSP leaders indicated their support for the implementation of tailored ICBT. The study identified that there is a need for increasing awareness of the effectiveness of and need for ICBT in order to facilitate funding of services. Overall, the current study indicates that PSP support ICBT as a valued form of therapy and that policy makers and service providers seeking to provide ICBT to PSP may increase support for ICBT services through more education and awareness.

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.

Efficacy of a novel online integrated treatment for problem gambling and tobacco smoking: Results of a randomized controlled trial.

Background and aims: Problem gambling and tobacco use are highly comorbid among adults. However, there are few treatment frameworks that target both gambling and tobacco use simultaneously (i.e., an integrated approach), while also being accessible and evidence-based. The aim of this two-arm open label RCT was to examine the efficacy of an integrated online treatment for problem gambling and tobacco use. Methods: A sample of 209 participants (Mage = 37.66, SD = 13.81; 62.2% female) from North America were randomized into one of two treatment conditions (integrated [n = 91] or gambling only [n = 118]) that lasted for eight weeks and consisted of seven online modules. Participants completed assessments at baseline, after treatment completion, and at 24-week follow-up. Results: While a priori planned generalized linear mixed models showed no condition differences on primary (gambling days, money spent, time spent) and secondary outcomes, both conditions did appear to significantly reduce problem gambling and smoking behaviours over time. Post hoc analyses showed that reductions in smoking and gambling craving were correlated with reductions in days spent gambling, as well as with gambling disorder symptoms. Relatively high (versus low) nicotine replacement therapy use was associated with greater reductions in gambling behaviours in the integrated treatment condition. Discussion and conclusions: While our open label RCT does not support a clear benefit of integrated treatment, findings suggest that changes in smoking and gambling were correlated over time, regardless of treatment condition, suggesting that more research on mechanisms of smoking outcomes in the context of gambling treatment may be relevant.

Development and psychometric properties of a short version of the Patient Continuity of Care Questionnaire.

INTRODUCTION: Hospitalization due to cardiac conditions is increasing worldwide, and follow-up after hospitalization usually occurs in a different healthcare setting than the one providing treatment during hospitalization. This leads to a risk of fragmented care and increases the need for coordination and continuity of care after hospitalization. Furthermore, international reports highlight the importance of improving continuity of care and state that it is an essential indicator of the quality of care. Patients' perceptions of continuity of care can be evaluated using the Patient Continuity of Care Questionnaire (PCCQ). However, the original version is extensive and may prove burdensome to complete; therefore, we aimed to develop and evaluate a short version of the PCCQ. METHODS: This was a psychometric validation study. Content validity was evaluated among user groups, including patients (n = 7), healthcare personnel (n = 15), and researchers (n = 7). Based on the results of the content validity and conceptual discussions among the authors, 12 items were included in the short version. Data from patients were collected using a consecutive sampling procedure involving patients 6 weeks after hospitalization due to cardiac conditions. Rasch analysis was used to evaluate the psychometric properties of the short version of the PCCQ. RESULTS: A total of 1000 patients were included [mean age 72 (SD = 10), 66% males]. The PCCQ-12 presented a satisfactory overall model fit and a person separation index of 0.79 (Cronbach's α: .91, ordinal α: .94). However, three items presented individual item misfits. No evidence of multidimensionality was found, meaning that a total score can be calculated. A total of four items presented evidence of response dependence but, according to the analysis, this did not seem to affect the measurement properties or reliability of the PCCQ-12. We found that the first two response options were disordered in all items. However, the reliability remained the same when these response options were amended. In future research, the benefits of the four response options could be evaluated. CONCLUSION: The PCCQ-12 has sound psychometric properties and is ready to be used in clinical and research settings to measure patients' perceptions of continuity of care after hospitalization. PATIENT OR PUBLIC CONTRIBUTION: Patients, healthcare personnel and researchers were involved in the study because they were invited to select items relevant to the short version of the questionnaire.

Online psychosocial intervention for persons with spinal cord injury: A meta-analysis.

BACKGROUND: Delivery of psychosocial interventions via the Internet has the potential to overcome barriers and increase access; however, effectiveness is yet to be established among those with spinal cord injury (SCI). METHODS: The objective of this meta-analysis is to evaluate the efficacy of Internet-based psychosocial interventions on the symptoms of anxiety, depression, and pain amongst those with SCI. The databases Medline, PsycInfo, and EMBASE were used to locate studies published between 1990 and December 2020. A study was included if (1) the study involved the application of an online psychosocial intervention; (2) adults with SCI; and (3) reported outcomes on depression and/or anxiety. From each study, participant characteristics and study details were extracted. A standardized mean difference (SMD) ± standard error and 95% confidence interval (CI) was calculated for each outcome of interest and the results were pooled using a fixed-effects model. RESULTS: The search yielded 920 studies, of which five were included in the final meta-analysis; It was revealed that Internet-based psychosocial interventions had a small effect on reducing overall anxiety (SMD: 0.42 ± 0.09, p < 0.001) and depression (SMD: 0.41 ± 0.09, p < 0.001) symptoms at the end of the study period. Online psychosocial interventions also had a moderate effect in maintaining reduction of anxiety (SMD: 0.50 ± 0.1, p < 0.001) and depressive (SMD: 0.64 ± 0.10, p < 0.001) symptoms at 3-month follow-up. CONCLUSION: The results of this meta-analysis provide evidence for the use of internet-based psychosocial interventions to manage anxiety and depression symptoms among those with spinal cord injuries.

Engagement with homework in an Internet-delivered therapy predicts reduced anxiety and depression symptoms: A latent growth curve analysis.

OBJECTIVE: Assigning homework to patients to facilitate skill development is an essential part of internet-delivered cognitive behavior therapy (ICBT). This study examined if patients' self-ratings of homework engagement, including conceptual (e.g., understandability, difficulty, perceived usefulness) and practical (e.g., effort put into reviewing the lessons, practicing skills, continuity in use of the learned skills) engagement predicts ICBT outcomes for anxiety and depression using a subsample of data from a previously published randomized controlled trial. METHOD: Three hundred and one adult patients (74.56% female; 91.29% Caucasians; Mage = 36.33) randomly assigned to complete Homework Reflection Questionnaires (HWRQ) were included in this study. Patients completed the Patient Health Questionnaire (PHQ-9) and generalized anxiety disorder (GAD-7) at pretreatment, midtreatment (4 weeks), posttreatment (8 weeks), and at follow-up (12 weeks). HWRQ related to each of five lessons were completed at the beginning of the subsequent lessons or at posttreatment (e.g., Lesson 1 HWRQ completed at start of Lesson 2). Latent growth curve modeling was used to test the effect of engagement with homework activities in reduction of anxiety and depression symptoms over time. RESULTS: Patient-rated homework engagement significantly predicted rate of change in depression and anxiety symptom severity but was not significantly associated with initial levels of either outcome. Patients who reported higher engagement with assigned homework activities achieved more symptom reduction over treatment and follow-up at 12 weeks. CONCLUSION: The findings provide evidence of the importance of patients' self-rated engagement with homework in ICBT as well psychometric evidence supporting use of homework ratings to assess engagement. Further studies are needed to replicate the association between homework engagement and reduction in anxiety and depression symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).