Cost effectiveness of guided Internet-based interventions for depression in comparison with control conditions: An individual-participant data meta-analysis.

BACKGROUND: There is limited evidence on the cost effectiveness of Internet-based treatments for depression. The aim was to evaluate the cost effectiveness of guided Internet-based interventions for depression compared to controls. METHODS: Individual-participant data from five randomized controlled trials (RCT), including 1,426 participants, were combined. Cost-effectiveness analyses were conducted at 8 weeks, 6 months, and 12 months follow-up. RESULTS: The guided Internet-based interventions were more costly than the controls, but not statistically significant (12 months mean difference = €406, 95% CI: - 611 to 1,444). The mean differences in clinical effects were not statistically significant (12 months mean difference = 1.75, 95% CI: - .09 to 3.60 in Center for Epidemiologic Studies Depression Scale [CES-D] score, .06, 95% CI: - .02 to .13 in response rate, and .00, 95% CI: - .03 to .03 in quality-adjusted life-years [QALYs]). Cost-effectiveness acceptability curves indicated that high investments are needed to reach an acceptable probability that the intervention is cost effective compared to control for CES-D and response to treatment (e.g., at 12-month follow-up the probability of being cost effective was .95 at a ceiling ratio of 2,000 €/point of improvement in CES-D score). For QALYs, the intervention's probability of being cost effective compared to control was low at the commonly accepted willingness-to-pay threshold (e.g., at 12-month follow-up the probability was .29 and. 31 at a ceiling ratio of 24,000 and 35,000 €/QALY, respectively). CONCLUSIONS: Based on the present findings, guided Internet-based interventions for depression are not considered cost effective compared to controls. However, only a minority of RCTs investigating the clinical effectiveness of guided Internet-based interventions also assessed cost effectiveness and were included in this individual-participant data meta-analysis.

Effectiveness of a Web-Based Guided Self-help Intervention for Outpatients With a Depressive Disorder: Short-term Results From a Randomized Controlled Trial.

BACKGROUND: Research has convincingly demonstrated that symptoms of depression can be reduced through guided Internet-based interventions. However, most of those studies recruited people form the general population. There is insufficient evidence for the effectiveness when delivered in routine clinical practice in outpatient clinics. OBJECTIVE: The objective of this randomized controlled trial was to study patients with a depressive disorder (as defined by the Diagnostic and Statistical Manual of Disorders, fourth edition), as assessed by trained interviewers with the Composite International Diagnostic Interview, who registered for treatment at an outpatient mental health clinic. We aimed to examine the effectiveness of guided Internet-based self-help before starting face-to-face treatment. METHODS: We recruited 269 outpatients, aged between 18 and 79 years, from outpatient clinics and randomly allocated them to Internet-based problem solving therapy (n=136), with weekly student support, or to a control condition, who remained on the waitlist with a self-help booklet (control group; n=133). Participants in both conditions were allowed to take up face-to-face treatment at the outpatient clinics afterward. We measured the primary outcome, depressive symptoms, by Center for Epidemiological Studies Depression scale (CES-D). Secondary outcome measures were the Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), Insomnia Severity Index questionnaire (ISI), and EuroQol visual analog scale (EQ-5D VAS). All outcomes were assessed by telephone at posttest (8 weeks after baseline). RESULTS: Posttest measures were completed by 184 (68.4%) participants. We found a moderate to large within-group effect size for both the intervention (d=0.75) and the control (d=0.69) group. However, the between-group effect size was very small (d=0.07), and regression analysis on posttreatment CES-D scores revealed no significant differences between the groups (b=1.134, 95% CI -2.495 to 4.763). The per-protocol analysis (≥4 sessions completed) results were also not significant (b=1.154, 95% CI -1.978 to 7.637). Between-group differences were small and not significant for all secondary outcomes. Adherence to the intervention was low. Only 36% (49/136) received an adequate dosage of the intervention (≥4 of 5 sessions). The overall treatment satisfaction was moderate. CONCLUSIONS: Internet-based problem solving therapy is not more effective in reducing symptoms of depression than receiving an unguided self-help book during the waitlist period at outpatient mental health clinics. The effect sizes are much smaller than those found in earlier research in the general population, and the low rates of adherence indicate that the acceptability of the intervention at this stage of treatment for depressed outpatients is low. However, taking into account that there is much evidence for the efficacy of Internet-based treatments, it is too early to draw firm conclusions about the effectiveness of these treatments in outpatient clinics as a whole. TRIAL REGISTRATION: Netherlands Trial Register NTR2824; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2824 (Archived by WebCite at http://www.webcitation/ 6g3WEuiqH).

Guided online treatment in routine mental health care: an observational study on uptake, drop-out and effects.

BACKGROUND: Due to limited resources patients in the Netherlands often have to wait for a minimum of six weeks after registration for mental health care to receive their first treatment session. Offering guided online treatment might be an effective solution to reduce waiting time and to increase patient outcomes at relatively low cost. In this study we report on uptake, drop-out and effects of online problem solving treatment that was implemented in a mental health center. METHODS: We studied all 104 consecutive patients aged 18-65 years with elevated symptoms of depression, anxiety and/or burnout who registered at the center during the first six months after implementation. They were offered a five week guided online treatment. At baseline, five weeks and twelve weeks we measured depressive (BDI-II), anxiety (HADS-A) and burnout symptoms (MBI). RESULTS: A total of 55 patients (53%) agreed to start with the online treatment. Patients who accepted the online treatment were more often female, younger and lower educated than those who refused. There were no baseline differences in clinical symptoms between the groups. There were large between group effect sizes after five weeks for online treatment for depression (d = 0.94) and anxiety (d = 1.07), but not for burnout (d = -.07). At twelve weeks, when both groups had started regular face-to-face treatments, we no longer found significant differences between the groups, except for anxiety (d = 0.69). CONCLUSION: The results of this study show that the majority of patients prefer online guided online treatment instead of waiting for face-to-face treatment. Furthermore, online PST increases speed of recovery and can therefore be offered as a first step of treatment in mental healthcare.

A self-guided internet-delivered intervention for adults with ADHD: Results from a randomized controlled trial.

Background: Attention-deficit/hyperactivity disorder (ADHD) in adulthood, with an estimated prevalence of 2-3 %, is associated with several challenges in daily life functioning. Still, the availability of evidence-based psychological interventions for adults with ADHD is limited. Interventions delivered over the Internet on smartphones or personal computers may help to increase the availability of and access to effective psychological interventions. Objective: This study reports on the efficacy of a self-guided psychological Internet-delivered intervention on severity levels of ADHD symptomatology and quality of life in adults with ADHD. Methods: Adults with a self-reported ADHD diagnosis (N = 120) were included in a randomized controlled trial with two arms: 1) self-guided Internet-delivered intervention for managing symptoms and impairments related to ADHD (n = 61); 2) online psychoeducation module (control group, n = 59). The primary clinical outcome was severity levels of ADHD as measured with the Adult ADHD Self-Report Scale. Secondary outcomes were quality of life as measured with the Adult ADHD Quality of Life scale and stress as measured with the Perceived Stress Scale. Measures were obtained at three time points: before (baseline), immediately after (8 weeks) and 3 months after the intervention. The secondary objective of the study was to explore user satisfaction with and adherence to the intervention. Results: Linear Mixed Model analysis revealed moderate to large between group effect-size improvements on self-report measures of ADHD symptomatology (d = 0.70) and quality of life (d = 0.53). Importantly, effects were maintained at 3-month follow-up (d = 0.76 and d = 0.52). In terms of adherence, 29 % completed all modules, while 59 % completed at least five modules (out of 7). Treatment satisfaction was adequate, with n = 34 (79 %) indicating that they were very satisfied or satisfied with the intervention, and n = 37 (88 %) indicating that they would recommend the intervention to a friend. Discussion: The study demonstrated the efficacy of a self-guided Internet-delivered intervention by showing reliable and statistically significant improvements in self-reported ADHD symptomatology and quality of life. The intervention may be suitable for better managing ADHD symptoms in primary care and as a low intensity intervention population wide. Trial registration: ClinicalTrials.gov, Identifier NCT04726813, January 27, 2021.

Internet-Delivered Self-help for Adults With ADHD (MyADHD): Usability Study.

BACKGROUND: Although effective pharmacological treatment exists, many adults with attention-deficit/hyperactivity disorder (ADHD) prefer a nonpharmacological option for managing their symptoms. Internet-delivered self-help interventions have the potential to address this unmet supportive care need reported by adults with ADHD, at relatively low costs. However, if the intervention does not offer optimal functions, content, and layout, it could decrease adherence and engagement and potentially compromise the effectiveness of such interventions. Thus, there is a need for examining the usability and factors that enhance and impair the usability of internet-delivered self-help interventions. OBJECTIVE: This study evaluates the usability of an internet-delivered self-help intervention for adults with ADHD (MyADHD). The main goals were to (1) collect qualitative and quantitative data on usability and (2) identify usability problems. METHODS: Individual think-aloud interviews and staged usability testing (N=5) were conducted to evaluate the usability of the MyADHD intervention in terms of function, content, and design. MyADHD end users provided iterative feedback to maximize engagement and usability. They performed tasks involved in operating the intervention and provided "think-aloud" commentary and postsession usability ratings. The interviews were recorded, transcribed verbatim, and analyzed. RESULTS: Participants were satisfied with the overall usability of the program. The average perceived usability score out of 100 was 70 for the first round of testing and improved to 77.5 after applying modifications, with a mean score of 75.5 (SD 5.9) for all rounds of usability testing. The analysis of the interviews revealed 3 central themes: functionality, content, and layout. CONCLUSIONS: Optimizing the usability of internet-delivered self-guided interventions is a critical step in the design and development process. The usability testing in this study provided valuable information from users' perspectives on the content and platform of the intervention. Analysis revealed the need for intervention enhancement with regard to design, functionality, and content from the perspective of potential end users. Overall, participants saw value in the MyADHD intervention and were confident that they could use it for the self-management of symptoms and expressed the desire to use the entire intervention when it becomes available. Through this development process, we produced an intervention that is likely to be used successfully and is ready for deployment in a randomized controlled trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04511169; https://clinicaltrials.gov/ct2/show/NCT04511169.

The Effect of SMS Reminders on Adherence in a Self-Guided Internet-Delivered Intervention for Adults With ADHD.

Background: Self-guided Internet-delivered interventions may serve as an accessible and flexible non-pharmacological treatment supplement for adults with ADHD. However, these interventions are challenged by low adherence. Objective: To examine whether weekly SMS reminders improve adherence to a self-guided Internet-delivered intervention for adults with ADHD. Method: The study used a multiple randomized trial design where the participants who had not completed their weekly module within 2 days were randomized to either receive or not receive an SMS reminder. The primary outcome was adherence, defined as module completion, logins, time spent on intervention, and self-reported practice of coping strategies. Results: A total of 109 adults with a self-reported ADHD diagnosis were included in the study. The results showed that SMS reminders were associated with an increased likelihood of login within 48 h during the second module of the intervention, but not for the remaining modules. Moreover, receiving an SMS reminder was associated spending more time on the modules and faster login time in module three and five, specifically. However, the overall results did not show an effect of SMS reminders on module completion, number of logins or practice of coping strategies. Conclusion: The results showed that SMS reminders do not improve number of logins, module completion rates or practice of coping strategies, but they may lead to faster login time and more time spent on the modules. To utilize the potential of self-guided Internet-delivered intervention in making non-pharmacological accessible for adults with ADHD, new methods to facilitate meaningful engagement should be developed and tested. Trial Registration: ClinicalTrials.gov NCT04511169.

Towards adaptive technology in routine mental health care.

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.

A self-guided Internet-delivered intervention for adults with ADHD: a protocol for a randomized controlled trial.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) in adulthood, with an estimated prevalence of 2-3%, is associated with several challenges in daily life functioning. The availability of evidence-based psychological interventions for adults with ADHD is still poor. Interventions delivered over the Internet on smartphones or personal computers may help to increase the availability of effective psychological interventions. The primary aim of this randomized controlled trial is to examine the efficacy of a self-guided Internet-delivered intervention on severity levels of ADHD symptomatology and quality of life. METHODS: We aim to include 118 participants with a self-reported ADHD diagnosis in a randomized controlled trial with two arms: 1) self-guided Internet-delivered intervention for coping with ADHD (N = 59); 2) self-guided online psychoeducation (control group, N = 59). After 3 months, the control group will be given access to the intervention. The primary clinical outcomes are inattention and quality of life. Secondary clinical outcomes are hyperactivity, stress and depression. Measures will be obtained at three time points: before (baseline), immediately after (8 weeks) and 3 months after the intervention. Uptake, usage, adherence and satisfaction will be explored. DISCUSSION: This RCT will provide valuable information on the clinical effectiveness of an Internet-delivered intervention for adults with ADHD. This study is, to our knowledge, one of the first randomized control trials that investigates the effects of a self-guided Internet-delivered psychological intervention in a fairly large group of adults with ADHD. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier NCT04726813, January 27, 2021.

A self-guided Internet-delivered intervention for adults with ADHD: A feasibility study.

BACKGROUND: Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent neurodevelopmental disorder that tends to persist into adulthood. Many adults with ADHD seek non-pharmacological treatment in addition to pharmacological treatment. Still, there are few non-pharmacological treatment options available. The aim of the current study was to explore the feasibility of a self-guided Internet-delivered intervention for adults with ADHD. METHODS: The study has an uncontrolled, within-group, pre-post design. Thirteen participants with an ADHD diagnosis were included and given access to the first three modules of a seven-module intervention. To explore the feasibility of the intervention, the adherence, credibility, and treatment satisfaction were examined. Preliminary efficacy of the intervention was examined through self-report measures of inattention, hyperactivity, depression, anxiety, stress, and quality of life. RESULTS: In terms of adherence, seven participants (54%) completed all three intervention modules (M = 1.85, SD = 1.3). The participants reported both good credibility and treatment satisfaction with the intervention. The participants also reported challenges related to usability and technical issues. Although the clinical outcomes must be interpreted with caution due to the study design and the small sample size, a statistically significant reduction in severity of inattention was reported by the participants following the intervention (p = .006, d = 1.57). The reduction was non-significant for hyperactivity (p = .326, d = 0.33). The participants who completed all three modules in the intervention (n = 7) also reported a significant decrease in stress (p = .042, d = 0.67) and a significant increase in quality of life (p = .016, d = 0.99). No significant changes were found on measures of anxiety and depression. CONCLUSION: The adherence to the intervention was relatively low, but the participants who completed the study reported good credibility and satisfaction with the intervention. These results indicate that there is a need to improve the intervention to make it more engaging before conducting a randomized-controlled trial investigating the clinical effects of the full seven-module intervention.

Designing Videos With and for Adults With ADHD for an Online Intervention: Participatory Design Study and Thematic Analysis of Evaluation.

BACKGROUND: Adults with attention deficit hyperactivity disorder (ADHD) represent a heterogeneous group with both strengths and difficulties associated with the diagnosis. An online intervention attuned to their needs may improve their everyday functioning. When designing online interventions, it is important to adapt the therapeutic content to the values and needs of the target group. OBJECTIVE: This paper describes and evaluates a participatory process used to produce content for an online intervention for adults with ADHD by producing video vignettes clarifying core training principles grounded in the participants' everyday experiences. METHODS: We report on the qualitative data from 2 research phases: the design and evaluation of video vignettes for an online intervention. In the first phase, 12 adults with ADHD, 2 clinicians, and 2 research assistants participated in the production of video vignettes for the online intervention. In the second phase, participants (n=109) gave feedback on the videos as part of a clinical trial of the intervention. A subgroup (n=7) was interviewed in-depth regarding their experiences with the videos. The qualitative data were analyzed using thematic analysis. RESULTS: In the first phase, the participants with ADHD contributed with experiences from challenging everyday situations. In the process, we navigated between therapeutic principles and the participants' experiential perspectives to create content relevant and consistent with the target group's values and experiences. In the second phase, we identified 3 themes related to the participants' experiences and interpretation of the video vignettes: (1) recognition of ADHD-related challenges, (2) connection with the characters and the situations, and (3) video protagonists as companions and role models for change. CONCLUSIONS: A participatory design process for designing online mental health interventions can be used to probe and balance between the therapeutic principles defined by clinicians and the participants' experiences with mental health issues in the production of therapeutic content. In our study, the inclusion of video vignettes in an online intervention enabled a contextualized and relevant presentation of everyday experiences and psychosocial factors in the life of an adult with ADHD. TRIAL REGISTRATION: ClinicalTrials.gov NCT04511169; https://clinicaltrials.gov/ct2/show/NCT04511169.

Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data.

BACKGROUND: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom. METHODS: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683. FINDINGS: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. INTERPRETATION: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package. FUNDING: Japan Society for the Promotion of Science.

Internet-delivered mental health treatment systems in Scandinavia - A usability evaluation.

Mental health problems are a major public health concern worldwide. Approximately 50% of the population will experience mental problems during their life. Traditional treatment is based on psychopharmacotherapy or psychotherapy, with face-to-face interaction between the patient and the therapist. New technologies such as Internet-delivered treatments are seen as an opportunity to offer more scalable and cost-efficient treatments in the field of mental health. Despite the growing interest and new evidence supporting the effect of Internet-delivered treatments is it remarkably little research on how the technology and the usability of Internet-delivered treatment programs affects the treatment. In this paper, we propose a set of evaluation criteria for evaluating the usability and the responsive design of Internet-delivered treatment systems. By our knowledge we are the first to include usability and universal design principles in the evaluation of Internet-delivered treatment systems. Our findings indicate that despite the good treatment results and proven clinical effects, the systems in general have several issues regarding usability, universal design and outdated technology. Based on our findings we propose that there should be established guidelines for testing the usability and technology of Internet-delivered treatment systems.

E-Learning to Improve Suicide Prevention Practice Skills Among Undergraduate Psychology Students: Randomized Controlled Trial.

BACKGROUND: Despite increasing evidence of the effectiveness of digital learning solutions in higher vocational education, including the training of allied health professionals, the impact of Web-based training on the development of practical skills in psychiatry and psychology, in general, and in suicide prevention, specifically, remains largely understudied. OBJECTIVE: This study aimed to determine the effectiveness of an electronic learning (e-learning) module on the adherence to suicide prevention guidelines, knowledge of practical skills, and provider's confidence to have a conversation about suicidal behavior with undergraduate psychology students. METHODS: The e-learning module, comprising video recordings of therapist-patient interactions, was designed with the aim of transferring knowledge about suicide prevention guideline recommendations. The program's effects on guideline adherence, self-evaluated knowledge, and provider's confidence were assessed using online questionnaires before the program (baseline and at 1 month [T1] and 3 months after baseline). The eligible third- and fourth-year undergraduate psychology students were randomly allocated to the e-learning (n=211) or to a waitlist control condition (n=187), with access to the intervention after T1. RESULTS: Overall, the students evaluated e-learning in a fairly positive manner. The intention-to-treat analysis showed that the students in the intervention condition (n=211) reported higher levels of self-evaluated knowledge, provider's confidence, and guideline adherence than those in the waitlist control condition (n=187) after receiving the e-learning module (all P values<.001). When comparing the scores at the 1- and 3-month follow-up, after both groups had received access to the e-learning module, the completers-only analysis showed that the levels of knowledge, guideline adherence, and confidence remained constant (all P values>.05) within the intervention group, whereas a significant improvement was observed in the waitlist control group (all P values<.05). CONCLUSIONS: An e-learning intervention on suicide prevention could be an effective first step toward improved knowledge of clinical skills. The learning outcomes of a stand-alone module were found to be similar to those of a training that combined e-learning with a face-to-face training, with the advantages of flexibility and low costs.

Psychological Interventions for the Fear of Public Speaking: A Meta-Analysis.

Background: Fear of Public Speaking (FoPS) or public speaking anxiety is a type of social anxiety and the single most commonly feared situation in the population. FoPS is disabling with negative occupational, academic, and social consequences, reported by up to one third of the population. FoPS in adolescence and adulthood is associated with an increased risk of developing generalized social anxiety disorder with further impairments. Since the last review on FoPS, a significant number of randomized controlled trials (RCTs) have been conducted assessing the effects of novel interventions with innovative modes of delivery. Objectives: The objectives of the present meta-analysis are to (1) examine the short and long-term effects of psychological interventions aimed at FoPS on FoPS and generalized social anxiety; (2) assess whether differences exist between technology-assisted modes of delivery (e.g., Internet-delivered therapies) and more traditional modes of delivering treatment (e.g., face-to-face therapies); (3) investigate whether differences in effect exist between theoretical frameworks; (4) inspect the differences in effect size between self-report measures and other measures (i.e., physiological and behavioral); (5) examine the effects of psychological interventions aimed at FoPS on secondary outcome measures (e.g., depression); and (6) investigate whether a "sleeper effect" is present for psychological interventions for FoPS and generalized social anxiety. Methods: The study investigates the effects of psychological interventions for FoPS through a quantitative meta-analysis of RCTs, using a random-effects model. Results: A total of 30 RCTs with 1,355 participants were included through systematic searches of PsycINFO, MEDLINE, Web of Science, and Cochrane Library. The majority of the studies investigated the effects of cognitive or behavioral interventions. Nearly half of the studies used active control groups (e.g., attention placebo), whereas the other half used passive (e.g., waitlist) controls. The overall effect of psychological interventions for FoPS across 62 interventions was 0.74 (Hedges g; 95% CI: 0.61-0.87) with low to moderate heterogeneity. No difference in effect was found across theoretical frameworks. The effects based on self-report measures were larger compared to physiological and behavioral outcomes. Effects were robust against both active and passive control groups. Furthermore, psychological interventions for FoPS had a small to moderate effect on generalized social anxiety disorder (g = 0.35; 95% CI: 0.22-0.48). The effect of psychological interventions aimed at FoPS at follow-up was large (g = 1.11, 95% CI: 0.90-1.31) and moderate to large for generalized social anxiety (g = 0.70, 95% CI: 0.59-0.80). A sleeper effect was found for cognitive and behavioral interventions, indicating that patients continued to improve after treatment termination. There were some indications of publication bias. Conclusions: Psychological interventions are effective in reducing FoPS. Interventions using technology-assisted modes of delivery are equally effective as traditional face-to-face interventions in reducing FoPS. This finding highlights an opportunity to increase access to evidence-based treatments through technology-delivered interventions, which can be implemented at schools, in primary care and specialist mental health care. Moreover, psychological interventions aimed at FoPS have an effect on generalized social anxiety. Further implications are discussed.

Do guided internet-based interventions result in clinically relevant changes for patients with depression? An individual participant data meta-analysis.

Little is known about clinically relevant changes in guided Internet-based interventions for depression. Moreover, methodological and power limitations preclude the identification of patients' groups that may benefit more from these interventions. This study aimed to investigate response rates, remission rates, and their moderators in randomized controlled trials (RCTs) comparing the effect of guided Internet-based interventions for adult depression to control groups using an individual patient data meta-analysis approach. Literature searches in PubMed, Embase, PsycINFO and Cochrane Library resulted in 13,384 abstracts from database inception to January 1, 2016. Twenty-four RCTs (4889 participants) comparing a guided Internet-based intervention with a control group contributed data to the analysis. Missing data were multiply imputed. To examine treatment outcome on response and remission, mixed-effects models with participants nested within studies were used. Response and remission rates were calculated using the Reliable Change Index. The intervention group obtained significantly higher response rates (OR = 2.49, 95% CI 2.17-2.85) and remission rates compared to controls (OR = 2.41, 95% CI 2.07-2.79). The moderator analysis indicated that older participants (OR = 1.01) and native-born participants (1.66) were more likely to respond to treatment compared to younger participants and ethnic minorities respectively. Age (OR = 1.01) and ethnicity (1.73) also moderated the effects of treatment on remission.Moreover, adults with more severe depressive symptoms at baseline were more likely to remit after receiving internet-based treatment (OR = 1.19). Guided Internet-based interventions lead to substantial positive treatment effects on treatment response and remission at post-treatment. Thus, such interventions may complement existing services for depression and potentially reduce the gap between the need and provision of evidence-based treatments.

Economic evaluation of Internet-based problem-solving guided self-help treatment in comparison with enhanced usual care for depressed outpatients waiting for face-to-face treatment: A randomized controlled trial.

BACKGROUND: Previous studies have demonstrated the effectiveness of Internet-based interventions for depression in comparison with usual care. However, evidence on the cost-effectiveness of these interventions when delivered in outpatient clinics is lacking. The aim of this study was to estimate the cost-effectiveness of an Internet-based problem-solving guided self-help intervention in comparison with enhanced usual care for outpatients on a waiting list for face-to-face treatment for major depression. After the waiting list period, participants from both groups received the same treatment at outpatient clinics. METHODS: An economic evaluation was performed alongside a randomized controlled trial with 12 months follow-up. Outcomes were improvement in depressive symptom severity (measured by CES-D), response to treatment and Quality-Adjusted Life-Years (QALYs). Statistical uncertainty around cost differences and incremental cost-effectiveness ratios were estimated using bootstrapping. RESULTS: Mean societal costs for the intervention group were €1579 higher than in usual care, but this was not statistically significant (95% CI - 1395 to 4382). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective in comparison with usual care was 0.57 at a ceiling ratio of €15,000/additional point of improvement in CES-D, and 0.25 and 0.30 for an additional response to treatment and an extra QALY respectively, at a ceiling ratio of €30,000. Sensitivity analysis showed that from a mental healthcare provider perspective the probability of the intervention being cost-effective was 0.68 for a ceiling ratio of 0 €/additional unit of effect for the CES-D score, response to treatment and QALYs. As the ceiling ratio increased this probability decreased, because the mean costs in the intervention group were lower than the mean costs in the usual care group. LIMITATIONS: The patients in the intervention group showed low adherence to the Internet-based treatment. It is possible that greater adherence would have led to larger clinical effects. CONCLUSIONS: Offering an Internet-based intervention to depressed outpatients on waiting list for face-to-face treatment was not considered cost-effective in comparison with enhanced usual care from a societal perspective. There was a high probability of the intervention being cost-effective in comparison with enhanced usual care from the perspective of the mental healthcare provider.

Effectiveness and cost effectiveness of guided online treatment for patients with major depressive disorder on a waiting list for psychotherapy: study protocol of a randomized controlled trial.

BACKGROUND: Depressive disorders are highly prevalent and result in negative consequences for both patients and society. It is therefore important that these disorders are treated adequately. However, due to increased demand for mental healthcare and subsequent increased costs, it would be desirable to reduce costs associated with major depressive disorder while maintaining or improving the quality of care within the healthcare system. Introducing evidence-based online self-help interventions in mental healthcare might be the way to maintain clinical effects while minimizing costs by reducing the number of face-to-face sessions. This study aims to evaluate the clinical and economical effects of a guided online self-help intervention when offered to patients with major depressive disorder on a waiting list for psychotherapy in specialized mental health centers (MHCs). METHODS: Patients at mental health centers identified with a Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) diagnosis of major depression who are awaiting face-to-face treatment are studied in a randomized controlled trial. During this waiting list period, patients are randomized and either (1) receive an internet-based guided self-help treatment or (2) receive a self-help book. The 5-week internet-based guided self-help intervention and the self-help booklet are based on problem solving treatment. After the intervention, patients are allowed to start regular face-to-face treatment at MHCs. Costs and effects are measured at baseline, after the intervention at 6 to 8 weeks, 6 months and 12 months. The primary outcome measure is symptoms of depression. Secondary outcome measures are diagnosis of depression, number of face-to-face sessions, absence of work and healthcare uptake in general. Additional outcome measures are anxiety, insomnia, quality of life and mastery. DISCUSSION: This study evaluates the effectiveness and cost effectiveness of internet-based guided self-help in patients at specialized mental health centers. The aim is to demonstrate whether the introduction of internet-based self-help interventions in regular mental healthcare for depressive disorders can maintain clinical effects and reduce costs. Strengths and limitations of this study are discussed. TRIAL REGISTRATION: Netherlands Trial Register NTR2824.