Motivational Variables as Moderating Effects of a Web-Based Mental Health Program for University Students: Secondary Analysis of a Randomized Controlled Trial.

BACKGROUND: Self-guided web-based interventions have the potential of addressing help-seeking barriers and symptoms common among university students, such as depression and anxiety. Unfortunately, self-guided interventions are also associated with less adherence, implicating motivation as a potential moderator for adherence and improvement for such interventions. Previous studies examining motivation as a moderator or predictor of improvement on web-based interventions have defined and measured motivation variably, producing conflicting results. OBJECTIVE: This secondary analysis of data from a randomized controlled trial aimed to examine constructs of motivation as moderators of improvement for a self-guided 8-week web-based intervention in university students (N=1607). METHODS: Tested moderators included internal motivation, external motivation, and confidence in treatment derived from the Treatment Motivation Questionnaire. The primary outcome was an improvement in depression and anxiety measured by the Depression Anxiety Stress Scale-21. RESULTS: Piecewise linear mixed effects models showed that internal motivation significantly moderated symptom change for the intervention group (t1504=-2.94; P=.003) at average and high (+1 SD) motivation levels (t1507=-2.28; P=.02 and t1507=-4.05; P<.001, respectively). Significant results remained even after controlling for baseline severity. The results showed that confidence in treatment did not significantly moderate symptom change for the intervention group (t1504=1.44; P=.15). In this sample, only internal motivation was positively correlated with service initiation, intervention adherence, and intervention satisfaction. CONCLUSIONS: The combination of a web-based intervention and high or moderate internal motivation resulted in greater improvement in the total Depression Anxiety Stress Scale-21 score. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. The results suggest that the combination of a web-based intervention and high or moderate internal motivation results in greater improvement. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. To better understand the moderating role of internal motivation, future research is encouraged to replicate these findings in diverse samples as well as to examine related constructs such as baseline severity and adherence. Understanding these characteristics informs treatment strategies to maximize adherence and improvement when developing web-based interventions as well as allows services to be targeted to individuals likely to benefit from such interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/study/NCT04361045.

Randomized controlled trial of a web-based program for preventing anxiety and depression in university students.

OBJECTIVE: Few online interventions targeting anxiety and depression in university students are designed for universal delivery, and none for group-level delivery. This randomized controlled trial (NCT No. 04361045) examined the effectiveness of such a prevention program. METHOD: StriveWeekly is a web-based intervention designed with weekly self-guided skill modules (e.g., behavioral activation) that are synchronously delivered to all users. Student participants (n = 1,607) were recruited from one large public university, and 65.4% had no prior mental health service use. Participants were randomly assigned to 8 weeks of StriveWeekly (n = 804) or a waitlist condition (n = 803). Participants completed web-based surveys at baseline, posttest, and 3-month follow-up. The primary outcome was the self-reported Depression Anxiety and Stress Scale-21. RESULTS: Piecewise linear mixed-effect models found significant group by time interactions for depression (t = -3.05, p = .002), anxiety (t = -3.01, p = .003), and total symptoms (t = -3.34, p < .001). Relative to the waitlist, students assigned to StriveWeekly improved more from baseline to posttest (between-group d = 0.18-0.21). These small effects were maintained through follow-up, and subsequently replicated by the original waitlist. The intervention was initiated by 73.0% of students in the StriveWeekly condition (modules completed: M = 3.72), and 71.6% of all posttest respondents rated the intervention highly. CONCLUSION: Findings supported StriveWeekly's effectiveness for large scale indicated prevention of anxiety and depression symptoms in university students. However, further development and research are still needed, as not all students used the intervention, reported satisfaction, or experienced improvement. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Digital Intervention Barriers Scale-7 (DIBS-7): Development, Evaluation, and Preliminary Validation.

BACKGROUND: The translation of mental health services into digital formats, deemed digital mental health interventions (DMHIs), has the potential to address long-standing obstacles to accessing care. However, DMHIs have barriers of their own that impact enrollment, adherence, and attrition in these programs. Unlike in traditional face-to-face therapy, there is a paucity of standardized and validated measures of barriers in DMHIs. OBJECTIVE: In this study, we describe the preliminary development and evaluation of such a scale, the Digital Intervention Barriers Scale-7 (DIBS-7). METHODS: Following an iterative QUAN → QUAL mixed methods approach, item generation was guided by qualitative analysis of feedback from participants (n=259) who completed a DMHI trial for anxiety and depression and identified barriers related to self-motivation, ease of use, acceptability, and comprehension of tasks. Item refinement was achieved through DMHI expert review. A final item pool was administered to 559 treatment completers (mean age 23.02 years; 438/559, 78.4% female; 374/559, 69.9% racially or ethnically minoritized). Exploratory factor analyses and confirmatory factor analyses were estimated to determine the psychometric properties of the measure. Finally, criterion-related validity was examined by estimating partial correlations between the DIBS-7 mean score and constructs related to treatment engagement in DMHIs. RESULTS: Statistical analyses estimated a 7-item unidimensional scale with high internal consistency (α=.82, ω=0.89). Preliminary criterion-related validity was supported by significant partial correlations between the DIBS-7 mean score and treatment expectations (pr=-0.25), number of modules with activity (pr=-0.55), number of weekly check-ins (pr=-0.28), and treatment satisfaction (pr=-0.71). CONCLUSIONS: Overall, these results provide preliminary support for the use of the DIBS-7 as a potentially useful short scale for clinicians and researchers interested in measuring an important variable often associated with treatment adherence and outcomes in DMHIs.

Measuring Adherence Within a Self-Guided Online Intervention for Depression and Anxiety: Secondary Analyses of a Randomized Controlled Trial.

BACKGROUND: Self-guided online interventions offer users the ability to participate in an intervention at their own pace and address some traditional service barriers (eg, attending in-person appointments, cost). However, these interventions suffer from high dropout rates, and current literature provides little guidance for defining and measuring online intervention adherence as it relates to clinical outcomes. OBJECTIVE: This study aims to develop and test multiple measures of adherence to a specific self-guided online intervention, as guided by best practices from the literature. METHODS: We conducted secondary analyses on data from a randomized controlled trial of an 8-week online cognitive behavioral program that targets depression and anxiety in college students. We defined multiple behavioral and attitudinal adherence measures at varying levels of effort (ie, low, moderate, and high). Linear regressions were run with adherence terms predicting improvement in the primary outcome measure, the 21-item Depression, Anxiety, and Stress Scale (DASS-21). RESULTS: Of the 947 participants, 747 initiated any activity and 449 provided posttest data. Results from the intent-to-treat sample indicated that high level of effort for behavioral adherence significantly predicted symptom change (F4,746=17.18, P<.001; and ß=-.26, P=.04). Moderate level of effort for attitudinal adherence also significantly predicted symptom change (F4,746=17.25, P<.001; and ß=-.36, P=.03). Results differed in the initiators-only sample, such that none of the adherence measures significantly predicted symptom change (P=.09-.27). CONCLUSIONS: Our findings highlight the differential results of dose-response models testing adherence measures in predicting clinical outcomes. We summarize recommendations that might provide helpful guidance to future researchers and intervention developers aiming to investigate online intervention adherence. TRIAL REGISTRATION: ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/ct2/show/NCT04361045.

Feasibility of a web-based program for universal prevention of anxiety and depression in university students: An open trial.

Objective: To examine the feasibility of a self-guided, Web-based program for universal prevention of anxiety and depression in university students. Participants: University students (n = 651) enrolled in the tested program (March, 2016). Methods: The program delivered eight weeks of mental health skills (e.g., behavioral activation, mindfulness). Data was collected online through an entry survey, weekly check-in surveys, and a post-program feedback survey. Results: Campus-wide recruitment emails were the most encountered recruitment strategy (82%). In terms of adherence, the program was initiated by 73% of students and fully completed by 11% of students. There was some evidence of program acceptability (e.g., 71% of students endorsed the program as "useful"). Common qualitative themes further suggested acceptability for some aspects of the program while also highlighting others for revision. Conclusion: Findings support further development of the online program and recommendations are made for improving the platform before future testing.

Identifying intervention strategies for preventing the mental health consequences of childhood adversity: A modified Delphi study.

Exposure to childhood adversity is a powerful risk factor for psychopathology. Despite extensive efforts, we have not yet identified effective or scalable interventions that prevent the emergence of mental health problems in children who have experienced adversity. In this modified Delphi study, we identified intervention strategies for effectively targeting both the neurodevelopmental mechanisms linking childhood adversity and psychopathology - including heightened emotional reactivity, difficulties with emotion regulation, blunted reward processing, and social information processing biases, as well as a range of psychopathology symptoms. We iteratively synthesized information from experts in the field and relevant meta-analyses through three surveys, first with experts in intervention development, prevention, and childhood adversity (n = 32), and then within our study team (n = 8). The results produced increasing stability and good consensus on intervention strategy recommendations for specific neurodevelopmental mechanisms and symptom presentations and on strength of evidence ratings of intervention strategies targeting youth and parents. More broadly, our findings highlight how intervention decision making can be informed by meta-analyses, enhanced by aggregate group feedback, saturated before consensus, and persistently subjective or even contradictory. Ultimately, the results converged on several promising intervention strategies for prevention programming with adversity-exposed youth, which will be tested in an upcoming clinical trial.

A systematic review of prevention programs targeting depression, anxiety, and stress in university students.

BACKGROUND: Given the prevalence of anxiety, depression, and stress among university students, it is important to assess the effectiveness of prevention programs for these problems. Beyond examining effect sizes, applying a common elements approach can enhance our understanding of which practice elements are most frequently included in symptom-reducing programs. METHOD: This review examined effective (i.e., outcome-producing) prevention programs targeting depression, anxiety, and/or stress in university students. Programs could be delivered in a group-based, online/computer-delivered, or self-administered format and at the universal, selective, or indicated prevention level. RESULTS: The resulting sample of 62 articles covered 68 prevention programs for college, graduate, or professional students across 15 countries. Average effect sizes for programs were moderate (overall g = 0.65), regardless of delivery format or prevention level. The most common practice elements (overall and for programs producing large effects) were: psychoeducation (72%), relaxation (69%), and cognitive monitoring/restructuring (47%). Many programs were limited by: (a) symptom target-outcome mismatches, (b) disproportionately female samples, and (c) inconsistently reported adherence data. LIMITATIONS: Commonness of practice elements across outcome-producing interventions does not imply their extensiveness nor unique contribution to effectiveness. Coding was based on information in articles rather than manuals, and inter-rater reliability was moderate for some practice elements. CONCLUSION: The outcome-producing prevention programs in our sample had common practice elements and produced moderate reduction in symptoms overall. Future research of depression, anxiety, and stress prevention programs for university students can investigate practice elements' unique and combined impact on outcomes, further explore under-tested practice elements, and use findings to inform intervention design.

What's in a name? Branding of online mental health programming for university students.

OBJECTIVE: University students experience many help-seeking barriers, and thus not all students who could benefit from mental health services enroll in them. This study aimed to examine student enrollment in response to strategic marketing of an online prevention program for anxiety and depression. METHOD: Data were collected from students at two universities during recruitment phases for the online program. The program was branded as either "The Happiness Challenge" or "ReBoot Camp" through parallel sets of recruitment materials using language intended to address help-seeking barrier concerns (e.g., stigma, inaccessibility). The yielded samples were examined for unaddressed psychological need rates, demographic composition, and differential enrollment by student subgroups into either program brand. RESULTS: Replicated results between Study 1 (n = 651 students; 71.2% undergraduate, 80.3% female, 27.9% White non-Hispanic) and Study 2 (n = 718 students; 60.6% undergraduate, 73.4% female, 53.2% White non-Hispanic) showed that more than a third of students qualified as having "unmet need" for services, enrollment was disproportionately self-identified as female and Asian students, Asian students were less likely to report prior service use and more likely to be categorized as having "unmet need," and ReBoot Camp was disproportionately selected by male students. CONCLUSION: Findings suggest that recruitment effectively reached students with unaddressed mental health need, including high enrollment by Asian students, who historically seek services less often. Additionally, important gender differences emerged in preferences for program name. These findings could inform how to market services in university settings to reach more students, including those from underserved subgroups. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Durability of Cognitive Behavioral Therapy Effects for Youth and Adolescents With Anxiety, Depression, or Traumatic Stress:A Meta-Analysis on Long-Term Follow-Ups.

Cognitive behavioral therapies (CBT) for youth with anxiety, traumatic stress, and depression have demonstrated strong effects in individual studies and meta-analyses. Relatively more attention has been given to posttreatment effects, though, and assessment of follow-up effects has been limited at the meta-analytic level. The current meta-analysis aimed to (a) examine the effects of youth CBT at posttreatment, 1-month, 3-month, 6-month, 1-year, and long-term (2+ years) follow-up as well as (b) identify research-related variables (e.g., measure respondent type) that relate to effects. Using a random effects model across 110 child and adolescent CBT groups, within-group effect sizes were large at posttreatment (g = 1.24) and from 1-month through long-term follow-up (g = 1.23-1.82), and effect sizes did not significantly differ by treatment target (i.e., anxiety, traumatic stress, depression). However, availability of outcome data for effect sizes diminished across later follow-up assessments. Moreover, effect sizes were significantly associated with outcome respondent type across assessment timing, with outcome measures from caregiver and youth respondents associated with smaller effect sizes (B = -0.97, p < 0.001) relative to outcome measures that were evaluator-reported. Results provide initial support for the durability of treatment effects for youth CBTs and highlight the importance of some confounding variables. Implications for improving treatment research standards and prioritizing assessment of long-term follow-up assessment are discussed.

Treatment Features Associated with Youth Cognitive Behavioral Therapy Follow-Up Effects for Internalizing Disorders: A Meta-Analysis.

Our aim was to investigate whether four treatment features (i.e., the inclusion of parental involvement, goal-setting strategies, maintenance/relapse prevention sessions, the addition of booster sessions) were associated with posttreatment and follow-up effect size of youth cognitive behavioral therapies (yCBTs) for anxiety, depression, posttraumatic stress disorder, and obsessive-compulsive disorder in age groups spanning young children to adolescents. We conducted a random-effects meta-analysis of 106 yCBTs tested in 76 randomized clinical trials from the PracticeWise Database to examine average effects of yCBTs posttreatment and at a later follow-up assessment. We coded the use of parental involvement, goal setting, booster sessions, and maintenance/relapse prevention in each yCBT and conducted random-effects meta-regression analyses to investigate whether these treatment features were associated with yCBT effects at posttreatment as well as at follow-up. Overall, yCBTs produced large pre- to posttreatment effects (d = 1.05), 95% confidence interval [0.94, 1.15], and larger pre- to follow-up effects (d = 1.29), 95% confidence interval [1.18, 1.40]. Metaregression results indicated that parental involvement was significantly associated with larger pre- to posttreatment effect sizes as well as pre- to follow-up effect sizes. Booster sessions, goal setting, and maintenance/relapse prevention were not significantly related to effect sizes at posttreatment or follow-up. Parental involvement may be helpful for maximizing long-term effectiveness of yCBT. Future studies should investigate for whom and under what conditions inclusion of yCBT treatment features is related to the durability of treatment gains.

Applying new evidence standards to youth cognitive behavioral therapies - A review.

This review included 136 published randomized controlled trials (RCTs) of youth cognitive behavioral therapy (CBT) treatments. We aimed to test the premise that evidence-based youth treatments can be better differentiated from each other by applying more nuanced standards of evidence. Accordingly, we applied three standards to this article sample to determine how many treatments produced significant results: (a) on multiple target symptom measures, (b) at follow-up, and/or (c) against an active comparison group. We identified how many trials met standards individually and in combination. Although 87 of the 136 articles produced at least one significant treatment result at post-assessment, the subsets of "passing" articles were smaller and varied for any one of our three standards, with only 11 articles (8%) meeting all three standards simultaneously. Implications are discussed regarding the definition of "evidence-based," the need for multi-parameter filtering in treatment selection and clinical decision making, and future directions for research. We ultimately argue the value in assessing youth treatments for different types of evidence, which is better achieved through dynamic sets of standards, rather than a single approach to assessing general strength of evidence.

Managing In-Session "Surprises:" Provider Responses to Emergent Life Events during Evidence-Based Treatment Implementation.

This study aimed to: (1) pilot a psychotherapy coding system for provider responses to emergent life events (ELEs; unexpected events that have a significant negative impact on the client), (2) examine the impact of ELEs on evidence-based treatment (EBT) delivery in community settings. Raters coded 30 randomly-sampled EBT session recordings with and without reported ELEs. Inter-rater reliability and validity for the system were generally high. When an ELE occurred, providers were significantly less likely to deliver the EBT, and when they did, they rarely linked the EBT to the event. Findings highlight the potential for ELEs to disrupt EBT implementation.

Evidence-Based Decision Making in Youth Mental Health Prevention.

Given the impressive amount of knowledge relevant to prevention efforts, this paper articulates strategies to capitalize on such knowledge through evidence-based decision making. Knowledge, or "evidence," is understood here as coming from multiple sources, including research, individual people, group history, and relevant theory. The presented strategies to facilitate evidence-based decision making are: (1) intervention knowledge management; (2) collaborative design; (3) knowledge resources for intervention; and (4) developmentally sensitive training and supervision. Examples and benefits are outlined for each strategy. It is ultimately argued that evidence-based decision making embodies the scientific approach, and is worth consideration within primary prevention, given its early success in secondary intervention of youth mental health.

Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety.

Anxiety disorders are the most common mental health disorder among children and adolescents. We examined 111 treatment outcome studies testing 204 treatment conditions for child and adolescent anxiety published between 1967 and mid-2013. Studies were selected for inclusion in this review using the PracticeWise Evidence-Based Services database. Using guidelines identified by this journal (Southam-Gerow & Prinstein, 2014), studies were included if they were conducted with children and/or adolescents (ages 1-19) with anxiety and/or avoidance problems. In addition to reviewing the strength of the evidence, the review also examined indicators of effectiveness, common practices across treatment families, and mediators and moderators of treatment outcome. Six treatments reached well-established status for child and adolescent anxiety, 8 were identified as probably efficacious, 2 were identified as possibly efficacious, 6 treatments were deemed experimental, and 8 treatments of questionable efficacy emerged. Findings from this review suggest substantial support for cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with anxiety disorders. Several other treatment approaches emerged as probably efficacious that are not primarily CBT based, suggesting that there are alternative evidence-based treatments that practitioners can turn to for children and adolescents who do not respond well to CBT. The review concludes with a discussion of treatments that improve functioning in addition to reducing symptoms, common practices derived from evidence-based treatments, mediators and moderators of treatment outcomes, recommendations for best practice, and suggestions for future research.

The Common Elements of treatment engagement for clinically high-risk youth and youth with first-episode psychosis.

AIM: Without treatment, clinically high-risk (CHR) youth or youth with first-episode psychosis (FEP) have increased risk for significant complications from their illness; yet, treatment engagement among these youth is critically low. The purpose of this study was to examine engagement efforts with CHR/FEP youth to stimulate new ideas that might facilitate participation in services for this population. METHODS: A literature review using distillation methods identified engagement practices reported in two bodies of literature. The first body of literature (i.e. 'CHR/FEP engagement') included 13 studies employing qualitative designs to explore consumer perspectives about treatment engagement practices in samples of CHR/FEP youth and their families. The second body of research (i.e. 'CHR/FEP RCTs') included 18 randomized controlled trials (RCTs) testing treatments for CHR/FEP youth and their families. Engagement practice frequencies were compared with the frequency of these practices within effective engagement interventions, as tested in 40 RCTs within the broader child and adolescent mental health literature (i.e. 'CAMH engagement'). RESULTS: Treatment attrition and attendance were the most frequent engagement outcomes measured in the CHR/FEP RCTs. There were notable efforts described in the CHR/FEP RCTs towards engaging youth and families, yet CHR/FEP RCTs reportedly included only a small proportion of engagement practices described in either the CHR/FEP or CAMH engagement literatures. CONCLUSION: Results suggest there might be practices available to complement current efforts at engaging CHR/FEP youth in treatment, and that increased attention to the measurement of engagement outcomes could provide important information regarding engagement in a population with low treatment engagement rates.

Low vagal tone magnifies the association between psychosocial stress exposure and internalizing psychopathology in adolescents.

Vagal tone is a measure of cardiovascular function that facilitates adaptive responses to environmental challenge. Low vagal tone is associated with poor emotional and attentional regulation in children and has been conceptualized as a marker of sensitivity to stress. We investigated whether the associations of a wide range of psychosocial stressors with internalizing and externalizing psychopathology were magnified in adolescents with low vagal tone. Resting heart period data were collected from a diverse community sample of adolescents (ages 13-17; N = 168). Adolescents completed measures assessing internalizing and externalizing psychopathology and exposure to stressors occurring in family, peer, and community contexts. Respiratory sinus arrhythmia (RSA) was calculated from the interbeat interval time series. We estimated interactions between RSA and stress exposure in predicting internalizing and externalizing symptoms and evaluated whether interactions differed by gender. Exposure to psychosocial stressors was associated strongly with psychopathology. RSA was unrelated to internalizing or externalizing problems. Significant interactions were observed between RSA and child abuse, community violence, peer victimization, and traumatic events in predicting internalizing but not externalizing symptoms. Stressors were positively associated with internalizing symptoms in adolescents with low RSA but not in those with high RSA. Similar patterns were observed for anxiety and depression. These interactions were more consistently observed for male than female individuals. Low vagal tone is associated with internalizing psychopathology in adolescents exposed to high levels of stressors. Measurement of vagal tone in clinical settings might provide useful information about sensitivity to stress in child and adolescent clients.

The biopsychosocial model of stress in adolescence: self-awareness of performance versus stress reactivity.

Extensive research among adults supports the biopsychosocial (BPS) model of challenge and threat, which describes relationships among stress appraisals, physiological stress reactivity, and performance; however, no previous studies have examined these relationships in adolescents. Perceptions of stressors as well as physiological reactivity to stress increase during adolescence, highlighting the importance of understanding the relationships among stress appraisals, physiological reactivity, and performance during this developmental period. In this study, 79 adolescent participants reported on stress appraisals before and after a Trier Social Stress Test in which they performed a speech task. Physiological stress reactivity was defined by changes in cardiac output and total peripheral resistance from a baseline rest period to the speech task, and performance on the speech was coded using an objective rating system. We observed in adolescents only two relationships found in past adult research on the BPS model variables: (1) pre-task stress appraisal predicted post-task stress appraisal and (2) performance predicted post-task stress appraisal. Physiological reactivity during the speech was unrelated to pre- and post-task stress appraisals and to performance. We conclude that the lack of association between post-task stress appraisal and physiological stress reactivity suggests that adolescents might have low self-awareness of physiological emotional arousal. Our findings further suggest that adolescent stress appraisals are based largely on their performance during stressful situations. Developmental implications of this potential lack of awareness of one's physiological and emotional state during adolescence are discussed.