Cognitive Behavioral Therapy, Mindfulness-Based Cognitive Therapy and Acceptance Commitment Therapy for Anxiety Disorders: Integrating Traditional with Digital Treatment Approaches.

Anxiety disorders are an enormous societal burden given their high lifetime prevalence among adult populations worldwide. A variety of anxiety disorders can be successfully treated with psychological treatments such as cognitive behavioral therapy (CBT), mindfulness-based cognitive therapy (MBCT), and acceptance and commitment therapy (ACT), either as stand-alone individual or group treatment or as adjunctive treatment to pharmacotherapy. Furthermore, a growing body of evidence suggests that therapist-guided Internet-delivered CBT (iCBT) and, to some degree, digitalized mindfulness- and acceptance-based interventions may be an efficacious complement to traditional face-to-face therapy. In view of the current advances regarding the integration of traditional and innovative treatment approaches, this chapter provides an overview on the theory and evidence base for different delivery modes of CBT-related interventions for specific phobia, panic disorder, agoraphobia, social anxiety disorder, and generalized anxiety disorder in adults. Finally, implications for clinical practice and research will be derived, and future directions for the psychological treatment of anxiety disorders will be outlined.

Comparing stress, areas of stress and coping-strategies between distance-learning and on-campus students - A mixed-methods approach.

In recent years, the increase in stress experienced by students, and the related health problems have become a key challenge for health psychologists. The aim of this cross-sectional survey study was to compare stress, areas of stress and coping-strategies of 246 distance-learning (81.7% female; 33.62 years, SD = 9.30) and 254 on-campus students (82.3% female; 24.23 years, SD = 3.99). One-way analyses of variance showed no significant differences in perceived stress and stress symptoms between the student groups. Stress-inducing areas were revealed by qualitative content analysis. Chi-square tests showed that on-campus students significantly more often reported study- and performance-related areas, whereas conflicts between work and private life were more present among distance-learning students. Results also indicated that on-campus students significantly more often cope with stress by means of social support. These findings may help tailoring stress-management interventions for different student groups.

Investigating the Persuasive Effects of Testimonials on the Acceptance of Digital Stress Management Trainings Among University Students and Underlying Mechanisms: A Randomized Controlled Trial.

Objective: This experiment aims to investigate the influence of narrative information varying in the degree of perceived similarity and source credibility in supplemented testimonials on the acceptance of digital mental health services (digi-MHSs). Methods: In fall 2020, n=231 university students were randomly assigned to an active control group (aCG, n=55, "information only") or one of three intervention groups (IGs) receiving information plus different testimonials being presented either by nonacademic staff (IG1, n=60), university students (IG2, n=58) or experts (IG3, n=58). We assessed mediation effects of similarity and credibility on acceptance in terms of attitudes and usage intentions. Results: Exposure to testimonials was associated with higher usage intentions (d=0.50) and more positive attitudes toward digi-MHSs (d=0.32) compared to mere information (aCG). Regarding source-related effects, one-way ANOVA showed group differences in intentions ( η p 2 =0.13) that were significantly higher after exposure to testimonials targeted at students than in the other groups after adjusting for baseline intentions ( η p 2 =0.24). Concerning underlying mechanisms, there were full mediation effects of similarity (IG1 versus IG2) on attitudes [95%CI (0.030, 0.441)] and intentions to use digi-MHSs [95%CI (0.100, 0.528)] and of credibility on attitudes [IG2 versus IG3; 95%CI (-0.217, -0.004)], all favoring students' testimonials. Conclusion: Overall, this study indicates that the acceptance of digi-MHSs can be substantially increased by providing a simple, context-sensitive information intervention, including testimonials by university students. Since we identified mediating effects of credibility on cognitive attitudes and similarity on affect-driven intentions, a future trial could vary these features using narrative versus statistic information on digi-MHSs.

Effect of an internet- and app-based stress intervention compared to online psychoeducation in university students with depressive symptoms: Results of a randomized controlled trial.

Depression is highly prevalent among university students. Internet-based interventions have been found to be effective in addressing depressive symptoms, but it is open if this also applies to interventions directed at academic stress. It is also largely unclear if the techniques employed in such programs provide significant additional benefits when controlling for non-specific intervention effects. A sample of N = 200 students with elevated levels of depression (CES-D ≥ 16) of a large distance-learning university were randomly assigned to either an Internet- and App-based stress intervention group (IG; n = 100) or an active control group (CG; n = 100) receiving an Internet-based psychoeducational program of equal length. Self-report data was assessed at baseline, post-treatment (7 weeks) and three-month follow-up. The primary outcome was depression (CES-D) post-treatment. Secondary outcomes included mental health outcomes, modifiable risk factors, and academic outcomes. We found significant between-group effects on depressive symptom severity (d = 0.36; 95% CI: 0.08-0.64), as well as behavioral activation (d = 0.61; 95% CI: 0.30-0.91), perceived stress (d = 0.45; 95% CI: 0.18-0.73), anxiety (d = 0.35; 95% CI: 0.03-0.67) and other secondary outcomes post-treatment. Effects on depression were sustained at three-month follow-up. Response rates for depressive symptoms were significantly higher in the IG (26%) than the CG (14%) at post-test (χ 2=4.5, p = 0.04), but not at three-month follow-up (p = 0.454). We also found significant effects on relevant academic outcomes, including work impairment (follow-up; d = 0.36), work output (post-treatment; d = 0.27) and work cutback (follow-up; d = 0.36). The intervention was more effective for depressive symptoms compared to the CG, and so controlling for unspecific intervention effects. This suggests that specific techniques of the intervention may provide significant additional benefits on depressive symptoms. Trial registration: German Clinical Trial Registration (DRKS): DRKS00011800 (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011800).

Exploring the influence of testimonial source on attitudes towards e-mental health interventions among university students: Four-group randomized controlled trial.

Electronic mental health services (eMHSs) offer additional options for the dissemination of psychological interventions for university students. Still, many university students are reluctant to use eMHSs. Narrative messages may help increase the awareness and acceptance of quality-approved programs. However, little is known about the usefulness of narrative messages to improve attitudes towards eMHSs. In this experiment, we thus aimed to explore in how far different ways of targeting information to students affect their attitudes towards eMHSs for stress prevention and therapy, and to identify potential determinants of attitude change. N = 451 students (Mean = 32.6 years, SD = 10.2, 75% female, 7% with eMHS experience) were randomly assigned to one of four study arms involving information designed to induce different levels of perceived similarity. While the active control condition only received general information (arm 1, "information only", n = 116), the other experimental arms were additionally exposed to testimonials on specific eMHSs either addressing an unspecified audience (arm 2, n = 112), employees (arm 3, n = 115) or working university students (arm 4, n = 108). Two-way ANOVA revealed no impact of information on the alteration of attitudes towards eMHSs for stress coping (d = 0.20). Only a small effect of target-group specific testimonials on attitudes towards online therapies was identified at post-intervention (d = 0.29). Regression analyses demonstrated significant influences of source credibility and perceived similarity on attitudes for preventative eMHSs (ps<0.01), as well as a partial mediation effect of perceived similarity in favor of testimonials targeted to students (95% CI [0.22, 0.50]). Overall, this study indicated no meaningful impact of information on attitudes and limited evidence for benefits of tailored narrative messages. Since attitudes were already positive at baseline, further research with a representative student sample mimicking real-world decision scenarios is needed to gain an in-depth understanding of acceptance-facilitating message features that may contribute to promote the adoption of evidence-based eMHSs.

Determinant Factors of Public Acceptance of Stress Management Apps: Survey Study.

BACKGROUND: Chronic stress is a major public health concern. Mobile health (mHealth) apps can help promote coping skills in daily life and prevent stress-related issues. However, little is known about the determinant factors of public acceptance of stress management in relation to preferences for psychological services. OBJECTIVE: The aim of this survey study was to (1) assess determinant factors of public acceptance (behavioral use intention) of stress management apps based on an adapted and extended version of the Unified Theory of Acceptance and Use of Technology (UTAUT) model and (2) explore preferences for mHealth apps compared with other mental health services. METHODS: Using convenience sampling, participants completed a multiscale 54-item Web-based survey. Based on significant correlations with acceptance, hierarchical stepwise regression analysis was performed within three blocks: (1) background and stress-related control variables, (2) beliefs and attitudes toward using mHealth, and (3) the core UTAUT determinants. The preference for mHealth apps in comparison with nine other mental health services (operationalized as readiness to use) was analyzed using paired t tests. RESULTS: Of 141 participants, nearly half (69/141, 48.9%) indicated prior mHealth use. Acceptance of stress coping apps was moderate (mean 3.10, SD 1.03, range 1-5). Hierarchical stepwise regression including four of 11 variables (R2=.62; P=.01, f2=1.63) identified positive attitudes toward using mHealth for stress coping (beta=0.69, P<.001, 46% R2 increase above block 1, f2=0.85), skepticism/perceived risks (beta=-0.14, P=.01, f2=0.16), and stress symptoms (beta=0.12, P=.03, f2=0.14) as significant predictors of acceptance. UTAUT determinants added no predictive contribution beyond attitudes (all P>.05, R2 increase of 1%), whereas post hoc analysis showed significant R2 increases of attitudes and skepticism/perceived risks beyond UTAUT determinants (all P<.001, R2 increase of 13%). The readiness to use apps was equivalent to or significantly higher than most service types, but lower than information websites. CONCLUSIONS: Attitudes may be at least as predictive for the acceptance of stress management apps as for more elaborated outcome beliefs. Efforts aimed at improving the public adoption of mHealth could put more emphasis on the pleasant aspects of app use, address misconceptions, offer stress screening tools on health websites, and increase options to try high-quality apps.

Internet- and App-Based Stress Intervention for Distance-Learning Students With Depressive Symptoms: Protocol of a Randomized Controlled Trial.

Background: Mental disorders are highly prevalent among university students. Distance-learning students are particularly burdened and have limited access to conventional university health services. Interventions for stress are sought after in distance learners and may help increase treatment coverage. Internet-based interventions have been shown to be effective in preventing and treating depression, but it remains unclear if interventions directed at academic stress also have this potential. Aim: The trial presented here investigates the effectiveness of an Internet- and App-based stress intervention in distance-learning students with elevated levels of depression. Methods: A sample of N = 200 students of a large German distance university with elevated levels of depression [Center for Epidemiological Studies' Depression Scale (CES-D) ≥ 16] will be randomly assigned to either an Internet- and App-based stress management intervention group (IG) or a control group (CG) receiving an Internet-based psychoeducational program for academic stress. The IG consists of eight Internet-based sessions promoting stress management skills using cognitive-behavioral and problem-solving techniques. A mobile App will be employed to facilitate training transfer. Self-report data will be assessed at baseline (T0), post-treatment (T1; 7 weeks), and 3-month follow-up (T2). Potential moderators will be assessed at baseline. The primary outcome is depression (CES-D) post-treatment. Secondary outcomes include mental health outcomes, modifiable risk and protective factors, and academic outcomes. Data will be analyzed on an intention-to-treat principle along with sensitivity analyses to assess the robustness of findings. Additional health economic analyses will be conducted. Discussion: Results will provide the basis to assess the acceptance and effectiveness of Internet-delivered stress interventions in distance-learning students with symptoms of depression. Ethics and dissemination: The study has been reviewed and approved by the University of Erlangen-Nuremberg ethics committee (Erlangen, Germany; 33_17 Bc). Results of the study will be disseminated through peer-reviewed publications. Trial Registration: German Clinical Trial Registration (DRKS), identifier DRKS00011800.

Improving attitudes toward e-mental health services in the general population via psychoeducational information material: A randomized controlled trial.

INTRODUCTION: In recent years, effective Internet-delivered electronic (e-) mental health services have been developed to overcome the limited resources in face-to-face health care. For the successful dissemination of e-mental health services, individual predictors for their uptake and utilization need to be explored. For instance, little is known about the role of different information sources in attitudes toward Internet therapies. On the basis of technology acceptance framework, this pilot study aimed to identify differences in both attitudes and intentions to use e-mental health treatment services after providing psychoeducational information. METHODS: 439 participants (mean age 33 years, SD = 10.6 years; 72% female) were randomly assigned to one of three text-based information groups (neutral text: n = 111; expert evaluation: n = 108; user evaluation: n = 112) or a control condition (no information: n = 108). We assessed attitudes toward e-mental health treatments using a 15-item German e-therapy attitudes measure. RESULTS: Descriptive analyses revealed overall neutral attitudes toward Internet therapies. Ambivalent perceptions were found in terms of Perceived Usefulness (positive attitude) and Relative Advantage (negative attitude). The awareness of Internet therapies was rather low. Most participants evaluated self-help books, health websites and face-to-face counselling as more useful than web-based counselling and therapies and reported higher intentions to use conventional services in case of emotional problems. As hypothesized, variance analyses demonstrated that text-based information, especially expert evaluations, were associated with significantly more positive attitudes toward e-mental health treatment services compared to the control condition. CONCLUSIONS: Taken together, this pilot study suggested a positive connection between the provision of general facts about e-mental health treatment services and attitudes as well as behavioral intentions to future use such services. However, a limitation was the omission of baseline attitudes assessment. Thus, further research is needed to gain deeper insights into the impact of information on attitudes.

Public Attitudes Toward Guided Internet-Based Therapies: Web-Based Survey Study.

BACKGROUND: Internet interventions have been proposed to improve the accessibility and use of evidence-based psychological treatments. However, little is known about attitudes toward such treatments, which can be an important barrier to their use. OBJECTIVE: This study aimed to (1) determine attitudes toward guided internet interventions, (2) assess its acceptability compared with other internet-based formats, and (3) explore predictors of acceptance. METHODS: A convenience-sample Web-based survey (N=646) assessed attitudes toward guided internet therapies (ie, perceived usefulness and helpfulness, and advantage relative to face-to-face therapy), preferences for delivery modes (ie, e-preference: guided internet interventions, unguided internet interventions, or videoconferencing psychotherapy), and potential predictors of attitudes and preferences: sociodemographics, help-seeking-related variables, attachment style, and perceived stress. RESULTS: Although most participants perceived internet interventions as useful or helpful (426/646, 65.9%), a few indicated their advantage relative to face-to-face therapy (56/646, 8.7%). Most participants preferred guided internet interventions (252/646, 39.0%) over videoconferencing psychotherapy (147/646, 22.8%), unguided internet interventions (124/646, 19.2%), and not using internet interventions (121/646, 18.8%; missing data: 1/646, 0.2%). Attachment avoidance and stress were related to e-preference (all P<.05). Moreover, preference for therapist-guided internet interventions was higher for individuals who were aware of internet-based treatment (χ26=12.8; P=.046). CONCLUSIONS: Participants assessed therapist-guided internet interventions as helpful, but not equivalent to face-to-face therapies. The vast majority (523/646, 81.0%) of the participants were potentially willing to use internet-based approaches. In lieu of providing patients with only one specific low-intensity treatment, implementation concepts should offer several options, including guided internet interventions, but not limited to them. Conversely, our results also indicate that efforts should focus on increasing public knowledge about internet interventions, including information about their effectiveness, to promote acceptance and uptake.