Is it worth it? Greater risk aversion with lower life satisfaction among depressed individuals.

Decisions of individuals with depression are often risk-averse. Risk-aversion may also extend to decisions regarding treatment, which may cause individuals to forgo or delay treatment. It is also well established that depression is associated with lower satisfaction with life. However, whether life satisfaction is associated with risk aversion for individuals with depression is not yet known. Three groups of participants (Depressed: n = 61; Chronic pain: n = 61; Comorbid depression and pain: n = 58) completed a clinical interview and several self-report questionnaires, including the Satisfaction with Life Scale (SWLS). Participants also completed two utility elicitation tasks: time trade-off (TTO), which measures utilities of health states without implied risks, and standard gamble (SG), which measures utilities of health states in the presence of risk (presented in this study as a hypothetical clinical trial described as having both potential harms and benefits). Risk aversion is defined as the difference in the utility ratings generated via SG and via TTO. For both TTO and SG, individuals evaluated their own depression or pain. When perfect health was used as a hypothetical benefit in TTO and SG tasks, satisfaction with life was not associated with risk preferences, for either depressed participants or participants with chronic pain (all ps ns). However, for participants with depression, when the hypothetical benefit was a more ecologically valid 'mild' depression in TTO and SG tasks, lower satisfaction with life was associated with greater risk aversion (p < .005; p < .03). For depressed individuals, therefore, lower satisfaction with life may be associated with risk aversion regarding treatments when benefits are seen as minor, which may result in treatment avoidance and, consequently, further worsening of both symptoms and life satisfaction.

LungCARE: Encouraging Shared Decision-Making in Lung Cancer Screening-a Randomized Trial.

BACKGROUND: Lung cancer screening (LCS) is recommended for individuals at high risk due to age and smoking history after a shared decision-making conversation. However, little is known about best strategies for incorporating shared decision-making, especially in a busy primary care setting. OBJECTIVE: To develop a novel tool, Lung Cancer Assessment of Risk and Education (LungCARE) to guide LCS decisions among eligible primary care patients. DESIGN: Pilot cluster randomized controlled trial of LungCARE versus usual care. PARTICIPANTS: Patients of providers in a university primary care clinic, who met criteria for LCS. INTERVENTION: Providers were randomized to LungCARE intervention or control. LungCARE participants completed a computer tablet-based video assessment of lung cancer educational needs in the waiting room prior to a primary care visit. Patient and provider both received a summary handout of patient concerns and responses. MAIN MEASURES: All eligible patients completed baseline interviews by telephone. One week after the index visit, participants completed a follow-up telephone survey that assessed patient-physician discussion of LCS, referral to and scheduling of LCS, as well as LCS knowledge and acceptability of LungCARE. Two months after index visit, we reviewed patients' electronic health records (EHRs) for evidence of a shared decision-making conversation and referral to and receipt of LCS. KEY RESULTS: A total of 66 participants completed baseline and follow-up visits (34: LungCARE; 32: usual care). Mean age was 65.9 (± 6.0). Based on EHR review, compared to usual care, LungCARE participants were more likely to have discussed LCS with their physicians (56% vs 25%; p = 0.04) and to be referred to LCS (44% vs 13%; p < 0.02). Intervention participants were also more likely to complete LCS (32% vs 13%; p < 0.01) and had higher knowledge scores (mean score 6.5 (± 1.7) vs 5.5 (± 1.4; p < 0.01). CONCLUSIONS: LungCARE increased discussion, referral, and completion of LCS and improved LCS knowledge. CLINICAL TRIAL REGISTRATION: NCT03862001.

I'm judging you! Influence of depression on moral judgments of COVID-19 infection control behaviors and policies.

Health officials recommended a number of COVID-19 infection control measures, such as social distancing and face covering. This study explores whether depression influences individuals' moral judgments regarding COVID-19 infection control behaviors and policies. In this study, participants (N = 340) were US residents, recruited via Amazon Mechanical Turk in March of 2020. Participants completed several questionnaires, such as demographics, including political affiliation, a depression screener, and a series of questions designed to capture individuals' moral judgments of infection control behaviors and policies. ANCOVA analyses indicated that, controlling for demographics, political affiliation, and the degree of news following, depression symptom level was consistently inversely related to the likelihood of judging infection control in moral terms. Depression symptom level was also inversely related to sensitivity to manipulation of moral judgments for personal behaviors, but not for policies. Individuals with higher levels of depression symptoms may be less willing to advocate for higher personal safety measures, which could lead to a higher likelihood of disease transmission. Outside of the pandemic, the lower propensity for moral judgment could translate into greater acceptance of morally questionable acts and behaviors from others.

Suicidality in the Arab World: Results from an Online Screener.

Suicide in the Arab World is grossly understudied. This study sought to understand suicidality among Arabic-speaking individuals visiting an online depression screener. A large sample (N = 23,201) from the Arab World was recruited online. 78.9% (n = 17,042) reported suicidality (thoughts of death or suicide, or a suicide attempt) and 12.4% reported a suicide attempt in the past 2 weeks. Binary logistic regressions indicated that women tended to report more suicidality, and that suicidality tended to decline with age (all ps < 0.001), across all levels of suicidality. Comparing countries with n ≥ 1000 (Algeria, Egypt, Jordan, Morocco, and Saudi Arabia), several 3-way (gender * age * country) and 2-way interactions indicated that some countries departed from the usual pattern of responses. For instance, in Algeria, neither gender nor age differences were observed in reported attempts. Women and younger adults in the Arab World may be at higher risk of suicidality. Differences between and within countries warrant further exploration.

Self-harm behaviors and their intentions: a cross-cultural analysis.

BACKGROUND: Self-harm behaviors (performed with either lethal and non-lethal intentions) are common, especially among individuals suffering from mood disorders, and the reasons individuals self-harm vary both by person and by the type of behavior. Understanding these variations may help clinicians determine levels of risk more accurately. AIMS: To understand whether culture and gender are associated with the likelihood of engaging in specific self-harm behaviors and whether the intention (lethal, ambivalent, non-lethal) of these behaviors vary with culture and gender. METHODS: 2826 individuals took part in an international multilingual online depression/suicidality screening study and reported at least one instance of self-harm in the past year. Participants were grouped into six broad cultural categories (Latin America, South Asia, Russian, Western English, Chinese, Arab). RESULTS: 3-way (culture x gender x intent) interactions were observed for several self-harm behaviors (overdosing, self-burning, asphyxiating, poisoning, and jumping from heights), suggesting that individuals engage in each of these behaviors with different intentions depending on gender and culture. Cultures and genders likewise differed in the likelihood of engaging in several self-harm behaviors. CONCLUSIONS: Clinicians should consider culture and gender when assessing for suicide risk, as similar self-harming behaviors may reflect different intentions depending on an individual's culture and gender.

Intolerance of Uncertainty and Health-Related Anxiety in Youth amid the COVID-19 Pandemic: Understanding and Weathering the Continuing Storm.

The COVID-19 pandemic is a public health crisis that continues to impact individuals worldwide. While children may be less susceptible to severe medical complications, they are nonetheless vulnerable to stress and anxiety associated with the pandemic. However, current understanding of psychological functioning and potential strategies to mitigate distress amid a pandemic is naturally limited. Consequently, this article is an attempt to fill that gap. Existing literature on pandemics, health-related anxieties, intolerance of uncertainty, and psychopathological sequelae is summarized within the context of the COVID-19 outbreak. Conclusions from the empirical data and emerging theoretical models are reviewed and synthesized. Finally, several potentially engaging and effective examples of developmentally appropriate interventions targeting intolerance of uncertainty and health-related anxieties in pediatric patients during the peri- and post-pandemic periods are described.

Facilitator Contact, Discussion Boards, and Virtual Badges as Adherence Enhancements to a Web-Based, Self-guided, Positive Psychological Intervention for Depression: Randomized Controlled Trial.

BACKGROUND: Adherence to self-guided interventions tends to be very low, especially in people with depression. Prior studies have demonstrated that enhancements may increase adherence, but little is known about the efficacy of various enhancements in comparison to, or in combination with, one another. OBJECTIVE: The aim of our study is to test whether 3 enhancements-facilitator contact (FC), an online discussion board, and virtual badges (VB)-alone, or in combination, improve adherence to a self-guided, web-based intervention for depression. We also examined whether age, gender, race, ethnicity, comfort with technology, or baseline depression predicted adherence or moderated the effects that each enhancement had on adherence. METHODS: Participants were recruited through web-based sources and, after completing at least 4 out of 7 daily emotion reports, were sequentially assigned to 1 of 9 conditions-the intervention alone; the intervention plus 1, 2, or all 3 enhancements; or an emotion reporting control condition. The intervention was a positive psychological program consisting of 8 skills that specifically targeted positive emotions, and it was delivered over 5 weeks in a self-guided, web-based format. We operationalized adherence as the number of skills accessed. RESULTS: A total of 602 participants were enrolled in this study. Participants accessed, on average, 5.61 (SD 2.76) of 8 skills. The total number of enhancements participants received (0-3) did not predict the number of skills accessed. Participants who were assigned to the VB+FC condition accessed significantly more skills than those in the intervention only conditions. Furthermore, participants in arms that received the combination of both the VB and FC enhancements (VB+FC and VB+FC+online discussion board) accessed a greater number of skills relative to the number of skills accessed by participants who received either VB or FC without the other. Moderation analyses revealed that the receipt of VB (vs no VB) predicted higher adherence among participants with moderately severe depression at baseline. CONCLUSIONS: The results suggested that the VB+FC combination significantly increased the number of skills accessed in a self-guided, web-based intervention for elevated depression. We have provided suggestions for refinements to these enhancements, which may further improve adherence. TRIAL REGISTRATION: ClinicalTrials.gov NCT02861755; http://clinicaltrials.gov/ct2/show/NCT02861755.

Blended Care-Cognitive Behavioral Therapy for Depression and Anxiety in Real-World Settings: Pragmatic Retrospective Study.

BACKGROUND: The past few decades saw considerable advances in research and dissemination of evidence-based psychotherapies, yet available treatment resources are not able to meet the high need for care for individuals suffering from depression or anxiety. Blended care psychotherapy, which combines the strengths of therapist-led and internet interventions, can narrow this gap and be clinically effective and efficient, but has rarely been evaluated outside of controlled research settings. OBJECTIVE: This study evaluated the effectiveness of a blended care intervention (video-based cognitive behavior therapy and internet intervention) under real-world conditions. METHODS: This is a pragmatic retrospective cohort analysis of 385 participants with clinical range depression and/or anxiety symptoms at baseline, measured using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), who enrolled in blended care psychotherapy treatment. Participants resided in the United States and had access to the blended care intervention as a mental health benefit offered through their employers. Levels of depression and anxiety were tracked throughout treatment. Hierarchical linear modeling was used to examine the change in symptoms over time. The effects of age, gender, and providers on participants' symptom change trajectories were also evaluated. Paired sample t-tests were also conducted, and rates of positive clinical change and clinically significant improvement were calculated. RESULTS: The average depression and anxiety symptoms at 6 weeks after the start of treatment were 5.94 and 6.57, respectively. There were significant linear effects of time on both symptoms of depression and anxiety (ß=-.49, P<.001 and ß=-.64, P<.001). The quadratic effect was also significant for both symptoms of depression and anxiety (ß=.04, P<.001 for both), suggesting a decelerated decrease in symptoms over time. Approximately 73% (n=283) of all 385 participants demonstrated reliable improvement, and 83% (n=319) recovered on either the PHQ-9 or GAD-7 measures. Large effect sizes were observed on both symptoms of depression (Cohen d=1.08) and of anxiety (d=1.33). CONCLUSIONS: Video blended care cognitive behavioral therapy interventions can be effective and efficient in treating symptoms of depression and anxiety in real-world conditions. Future research should investigate the differential and interactive contribution of the therapist-led and digital components of care to patient outcomes to optimize care.

Association between subjective social status and facets of depression self-stigma.

Individuals with depressive symptoms frequently experience stigma, which may lower self-esteem and increase social withdrawal, further exacerbating symptoms. The association between depressive symptoms and subjective social status (SSS; perceived standing within one's community) have previously been identified. However, no work has connected the constructs of SSS and self-stigma among people with depression. Participants (N = 230) who screened positive for current major depressive episode via a self-report completed an online survey. A significant negative association between SSS and overall stigma (p = .024) was observed, which was largely explained by general self-stigma (p = .016) and stigmatizing experiences (p = .015) subscales. The results offer preliminary evidence that SSS may be associated with negative social consequences of stigmatizing health conditions.

Using Google AdWords for international multilingual recruitment to health research websites.

BACKGROUND: Google AdWords, the placement of sponsored links in Google search results, is a potent method of recruitment to Internet-based health studies and interventions. However, the performance of Google AdWords varies considerably depending on the language and the location of the target audience. OBJECTIVE: Our goal was to describe differences in AdWords performance when recruiting participants to the same study conducted in four languages and to determine whether AdWords campaigns can be optimized in order to increase recruitment while decreasing costs. METHODS: Google AdWords were used to recruit participants to the Mood Screener, a multilingual online depression screening tool available in English, Russian, Spanish, and Chinese. Two distinct recruitment periods are described: (1) "Unmanaged", a 6-month period in which ads were allowed to run using only the AdWords tool itself, with no human intervention, and (2) "Managed", a separate 7-week period during which we systematically sought to optimize our recruitment campaigns. RESULTS: During 6 months of unmanaged recruitment, our ads were shown over 1.3 million times, resulting in over 60,000 site visits. The average click-through rate (ratio of ads clicked to ads displayed) varied from 1.86% for Chinese ads to 8.48% for Russian ads, as did the average cost-per-click (from US $0.20 for Chinese ads to US $0.50 for English ads). Although Chinese speakers' click-through rate was lowest, their rate of consenting to participate was the highest, at 3.62%, with English speakers exhibiting the lowest consent rate (0.97%). The conversion cost (cost to recruit a consenting participant) varied from US $10.80 for Russian speakers to US $51.88 for English speakers. During the 7 weeks of "managed" recruitment, we attempted to improve AdWords' performance in regards to the consent rate and cost by systematically deleting underperforming ads and adjusting keywords. We were able to increase the number of people who consent after coming to the site by 91.8% while also decreasing per-consent cost by 23.3%. CONCLUSIONS: Our results illustrate the need to linguistically and culturally adapt Google AdWords campaigns and to manage them carefully to ensure the most cost-effective results.

Suicide attempts in the absence of depression: Differences between broad cultural groups.

Suicide is one of the leading causes of death worldwide (WHO, 2021). Depression is a common precursor to suicide and suicidality; however, individuals' experience of depression and the meaning of suicide differs depending on one's cultural background (Colucci, 2013; Goodmann et al., 2021; Kleinman, 2004). The current study explores the relationship between suicide and depression among six broad cultural groups in a large sample (N = 17,015) of adults representing six broad cultural groups (Latin America, South Asia, former Soviet Bloc, Western English-speakers, Chinese, and Arab World). Participants were recruited to a multilingual depression and suicide screening study via Google Ads (Leykin et al., 2012; Gross et al., 2014). As expected, the presence of depression was associated with suicide attempts. However, cultural group moderated this association, with Chinese participants being most likely to report suicide attempts while screening negative for depression. Although depression remains an important predictor of suicidality, it appears that certain cultural groups may be at higher risk even when depression is not present. Clinicians should consider using culturally adapted assessments for depression and suicidality.

Understanding attrition from international Internet health interventions: a step towards global eHealth.

Worldwide automated Internet health interventions have the potential to greatly reduce health disparities. High attrition from automated Internet interventions is ubiquitous, and presents a challenge in the evaluation of their effectiveness. Our objective was to evaluate variables hypothesized to be related to attrition, by modeling predictors of attrition in a secondary data analysis of two cohorts of an international, dual language (English and Spanish) Internet smoking cessation intervention. The two cohorts were identical except for the approach to follow-up (FU): one cohort employed only fully automated FU (n = 16 430), while the other cohort also used 'live' contact conditional upon initial non-response (n = 1000). Attrition rates were 48.1 and 10.8% for the automated FU and live FU cohorts, respectively. Significant attrition predictors in the automated FU cohort included higher levels of nicotine dependency, lower education, lower quitting confidence and receiving more contact emails. Participants' younger age was the sole predictor of attrition in the live FU cohort. While research on large-scale deployment of Internet interventions is at an early stage, this study demonstrates that differences in attrition from trials on this scale are (i) systematic and predictable and (ii) can largely be eliminated by live FU efforts. In fully automated trials, targeting the predictors we identify may reduce attrition, a necessary precursor to effective behavioral Internet interventions that can be accessed globally.

Discrepancies in suicide screenings: Results from an international study.

BACKGROUND: When screening for suicidality, clinicians usually ask questions in ascending order of severity. Clinicians often discontinue questioning after negative responses to the first question or questions, presuming that these individuals are unlikely to endorse any further suicidality. In this study, the accuracy of this presumption is evaluated in a large international sample. METHODS: Participants were 21,385 individuals reporting a suicide attempt in the past two weeks. Participants were recruited, primarily via Google Ads, to a quintilingual (English, Spanish, Chinese, Arabic, and Russian) multinational depression and suicide screening study. RESULTS: Examining three initial screening questions (i.e., thoughts of death, wanting to die, and thinking about committing suicide), 14.8 % (n = 3179) of participants denied one or more question, 3.96 % (n = 847) denied two, and 1.95 % (n = 416) denied all three questions. The proportions of individuals with discrepant responses differed between linguistic-geographical groups, with Chinese and South Asian groups being more likely to be discrepant across all questions (all ps < .001). LIMITATIONS: Suicidality was assessed using an internet-based self-report measure, and linguistic-geographical groups explored in this study are very broad, which may limit generalizability. CONCLUSIONS: Results suggest that prematurely discontinuing suicide screening may fail to capture some individuals who made a recent attempt, and that in some groups, this discrepancy may be more pronounced. Clinicians should assess all individuals as thoroughly as possible regardless of initial responses, inquire about other significant risk factors, and be culturally sensitive.

Internet interventions for improving psychological well-being in psycho-oncology: review and recommendations.

OBJECTIVE: Too few cancer patients and survivors receive evidence-based interventions for mental health symptoms. This review examines the potential for Internet interventions to help fill treatment gaps in psychosocial oncology and presents evidence regarding the likely utility of Internet interventions for cancer patients. METHODS: The authors examined available literature regarding Internet interventions tailored to cancer patients' mental health needs and reviewed elements of Internet interventions for mental health relevant to advancing psycho-oncology Internet intervention research. RESULTS: Few rigorous studies focusing on mental health of cancer patients have been conducted online. A growing body of evidence supports the efficacy, accessibility, and acceptability of mental health Internet interventions for a variety of general and medical patient populations. The authors present recommendations and guidelines to assist researchers in developing, testing, and disseminating Internet interventions for cancer patients and survivors, to manage and improve their mental health. Issues unique to Internet interventions-including intervention structure, customization, provider interaction, and privacy and confidentiality issues-are discussed. These guidelines are offered as a step toward establishing a set of "best practices" for Internet interventions in psycho-oncology and to generate further discussion regarding the goals of such interventions and their place in cancer care. CONCLUSIONS: Internet interventions have the potential to fill an important gap in quality cancer care by augmenting limited available mental health services. These interventions should be developed in a manner consistent with best practices and must be empirically tested and validated. Copyright © 2011 John Wiley & Sons, Ltd.

Are consumers of Internet health information "cyberchondriacs"? Characteristics of 24,965 users of a depression screening site.

BACKGROUND: The number of individuals looking for health information on the Internet continues to expand. The purpose of this study was to understand the prevalence of major depression among English-speaking individuals worldwide looking for information on depression online. METHODS: An automated online Mood Screener website was created and advertised via Google AdWords, for 1 year. Participants (N = 24,965) completed a depression screening measure and received feedback based on their results. Participants were then invited to participate in a longitudinal mood screening study. RESULTS: Of the 24,965 who completed the screening, 66.6% screened positive for current major depression, 44.4% indicated current suicidality, and 7.8% reported a recent (past 2 weeks) suicide attempt. Of those consenting to participate in the longitudinal study (n = 1,327 from 86 countries), 77.4% screened positive for past depression, 64.6% reported past suicidality, and 17.5% past suicide attempt. Yet, only 25% of those screening positive for current depression, and only 37.2% of those reporting a recent suicide attempt are in treatment. CONCLUSION: Many of the consumers of Internet health information may genuinely need treatment and are not "cyberchondriacs." Online screening, treatment, and prevention efforts may have the potential to serve many currently untreated clinically depressed and suicidal individuals.

Enrolling in deep brain stimulation research for depression: influences on potential subjects' decision making.

BACKGROUND: Ethical concerns regarding early-phase clinical trials of DBS for treatment-resistant depression (TRD) include the possibility that participants' decisions to enroll might be motivated by unrealistic expectations of personal benefit or minimization of risks. METHODS: Thematic analyses were conducted on a sample of 26 adults considering participation in two DBS trials. Influences on the decision making of these potential DBS trial participants were derived from responses to questions posed in the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), a semi-structured interview designed to evaluate decisional capacity to consent to research. RESULTS: Participants cited numerous factors as influential in their enrollment decisions, including perceived lack of other treatment options, desire to take initiative, beliefs about DBS as a novel treatment, possibility of DBS efficacy, hoped-for improvements, potential risks and disadvantages of DBS or clinical trial participation, and altruism. No individual expressed a set of motivations or influencing factors that suggested compromised decision-making capacity or diminished voluntariness of decision making. CONCLUSIONS: These results suggest that individuals make the decision to enroll in early-phase trials of DBS for TRD based on a number of complex and sometimes idiosyncratic considerations, and that the trials that were studied utilized sufficiently robust informed consent processes. These findings offer evidence that the emerging research area of DBS can be advanced in an ethically sound manner, provided that safeguards and processes for discussing trials with participants are carefully and proactively enacted.

Interpreting the outcomes of automated internet-based randomized trials: example of an International Smoking Cessation Study.

BACKGROUND: Smoking is one of the largest contributors to the global burden of disease. Internet interventions have been shown to reduce smoking rates successfully. However, improved methods of evaluating effectiveness need to be developed for large-scale Internet intervention trials. OBJECTIVE: To illustrate a method to interpret outcomes of large-scale, fully automated, worldwide Internet intervention trials. METHODS: A fully automated, international, Internet-based smoking cessation randomized controlled trial was conducted in Spanish and English, with 16,430 smokers from 165 countries. The randomized controlled trial replicated a published efficacy trial in which, to reduce follow-up attrition, 1000 smokers were followed up by phone if they did not provide online follow-up data. RESULTS: The 7-day self-reported abstinence rates ranged from 36.18% (2239/6189) at 1 month to 41.34% (1361/3292) at 12 months based on observed data. Given high rates of attrition in this fully automated trial, when participants unreachable at follow-up were presumed to be smoking, the abstinence rates ranged from 13.63% (2239/16.430) at 1 month to 8.28% (1361/16,430) at 12 months. We address the problem of interpreting results with high follow-up attrition rates and propose a solution based on a smaller study with intensive phone follow-up. CONCLUSIONS: Internet-based smoking cessation interventions can help large numbers of smokers quit. Large-scale international outcome studies can be successfully implemented using automated Internet sites. Interpretation of the studies' results can be aided by extrapolating from results obtained from subsamples that are followed up by phone or similar cohort maintenance methods. TRIAL REGISTRATION: ClinicalTrials.gov NCT00721786; http://clinicaltrials.gov/ct2/show/NCT00721786 (Archived by WebCite at http://www.webcitation.org/63mhoXYPw).

From online randomized controlled trials to participant preference studies: morphing the San Francisco Stop Smoking site into a worldwide smoking cessation resource.

BACKGROUND: Internet interventions have the potential to address many of the health problems that produce the greatest global burden of disease. We present a study illustrating this potential. The Spanish/English San Francisco Stop Smoking Internet site, which yielded quit rates of 20% or more at 12 months in published randomized controlled trials (RCTs), was modified to make it accessible to Spanish- and English-speaking smokers 18 years of age or older anywhere in the world. OBJECTIVE: To illustrate that Internet interventions designed to conduct RCTs can be adapted to serve as universal health care resources. We also examine quit rates obtained in the current participant preference study (in which users could choose from all elements tested in previous RCTs) to determine whether they differ from the quit rates found in the RCTs. METHODS: We modified the San Francisco Stop Smoking Internet site so that, instead of being randomly assigned to a specific intervention, participants could personalize the site by choosing among nine site elements (eg, stop smoking guide, reminder emails, journal, mood management intervention, or virtual group). Participants completed a baseline assessment, and reported smoking and mood data at 1-, 3-, 6-, and 12-month follow-ups. We assessed the modified website's reach and outcomes (quit rates), and compared the quit rates of the current participant preference study with those of the previous RCTs. RESULTS: In the first year of recruitment, 94,158 individuals from 152 countries and territories visited the site; 13,488 participants left some data; 9173 signed consent; 7763 completed the baseline survey; and 1955, 1362, 1106, and 1096 left 1-, 3-, 6-, and 12-month data, respectively. Observed quit rates were 38.1% (n = 668), 44.9% (n = 546), 43.6% (n = 431), and 45.4% (n = 449), respectively. The current participant preference study yielded higher observed quit rates (odds ratio 1.30) than the previous RCT when controlling for individuals' demographic and smoking characteristics. CONCLUSIONS: After strict RCTs are completed, Internet intervention sites can be made into worldwide health intervention resources without reducing their effectiveness. TRIAL REGISTRATION: Clinicaltrials.gov NCT00721786; http://clinicaltrials.gov/ct2/show/NCT00721786 (Archived by WebCite at http://www.webcitation.org/66npiZF4y).

Assessing the impact of relative social position and absolute community resources on depression and obesity among smokers.

We tested two competing hypotheses-relative social position and community resources-in regards to their effect on two co-occurring health problems (depression, and obesity) in a sample of smokers participating in an online smoking cessation intervention. Income and education data at the zip code level from the 2000 Census was linked with individual level data. Logistic regression models were used for each co-occurring problem to determine how each SES variable (individually and interactively) was associated with the presence of co-occurring health problems. We found that lower individual education was related to poorer health for all outcomes (Depression: OR = 1.25; Obesity: OR = 1.24; Both: OR = 1.46), lower community education was only related to obesity (OR = 1.20). Lower individual income was related to higher rates of depressive symptoms (OR = 1.64) and both health problems (OR = 1.55); a significant interaction of individual and community income (Wald = 6.13, p < .05) revealed that high income individuals were less likely to be depressed if they lived in lower-income communities and became more likely to be so as community income increased. Relative social position was confirmed for depression, whereas community resources were prominent only for obesity. Higher individual education most consistently predicted positive health outcomes, making it a potentially powerful target to reduce health disparities.

Component analysis of a synchronous and asynchronous blended care CBT intervention for symptoms of depression and anxiety: Pragmatic retrospective study.

Background: Depression and anxiety are leading causes of disability worldwide. Though effective treatments exist, depression and anxiety remain undertreated. Blended care psychotherapy, combining the scalability of online interventions with the personalization and engagement of a live therapist, is a promising approach for increasing access to evidence-based care. Objectives: To evaluate the effectiveness and individual contribution of two components - i) digital tools and ii) video-based therapist-led sessions - in a blended care CBT-based intervention under real world conditions. Methods: A retrospective cohort design was used to analyze N = 1372 US-based individuals who enrolled in blended care psychotherapy. Of these, at baseline, 761 participants had depression symptoms in the clinical range (based on PHQ-9), and 1254 had anxiety symptoms in the clinical range (based on GAD-7). Participants had access to the program as a mental health benefit offered by their employer. The CBT-based blended care psychotherapy program consisted of regular video sessions with therapists, complemented by digital lessons and digital exercises assigned by the clinician and completed in between sessions. Depression and anxiety levels and clients' treatment engagement were tracked throughout treatment. A 3-level individual growth curve model incorporating time-varying covariates was utilized to examine symptom trajectories of PHQ-9 scores (for those with clinical range of depression at baseline) and GAD-7 scores (for those with clinical range of anxiety at baseline). Results: On average, individuals exhibited a significant decline in depression and anxiety symptoms during the initial weeks of treatment (P < .001), and a continued decline over subsequent weeks at a slower rate (P < .001). Engaging in a therapy session in a week was associated with lower GAD-7 (b = -0.81) and PHQ-9 (b = -1.01) scores in the same week, as well as lower GAD-7 (b = -0.58) and PHQ-9 (b = -0.58) scores the following week (all P < .01). Similarly, engaging with digital lessons was independently associated with lower GAD-7 (b = -0.19) and PHQ-9 (b = -0.18) scores during the same week, and lower GAD-7 (b = -0.25) and PHQ-9 (b = -0.27) the following week (all P < .01). Conclusions: Therapist-led video sessions and digital lessons had separate contributions to improvements in symptoms of depression and anxiety over the course of treatment. Future research should investigate whether clients' characteristics are related to differential effects of therapist-led and digital components of care.