Online Intervention Targeting Postnatal Depression and Anxiety in Chilean First-Time Mothers: Feasibility Trial.

OBJECTIVE: Internet-based interventions may positively impact maternal symptoms of postnatal depression and anxiety. This study assessed the feasibility, acceptability, perceived usefulness, and preliminary effectiveness of an m-Health version of "What Were We Thinking?" (m-WWWT). METHODS: A mixed-methods with a 2-arm randomized parallel design was used. From a total of 477 women, 157 met the inclusion criteria. 128 first-time mothers of full-term infants, aged 4-10 weeks, who received health care at primary public health centers in Chile, were randomly assigned to the experimental (EG, n = 65) or control (CG, n = 63) groups; data of 104 of them (53 and 51, respectively) was analyzed. We used percentages and rates to measure feasibility outcomes and mixed analysis of variance (ANOVA) and latent class analyses (LCA) to assess preliminary effectiveness. Participants completed questionnaires on mental health, social support, and maternal self-efficacy upon recruitment and 3 months after completing the intervention. For the qualitative component, 12 women from the EG were interviewed. RESULTS: Quantitative results show good feasibility outcomes, such as high recruitment (82%), low attrition (EG = 12% and CG = 17%), and high follow-up (EG = 97% and CG = 91%) rates. Qualitative results indicate high acceptability and perceived usefulness of m-WWWT. Mixed ANOVA did not show significant differences between the groups (all p >.05). However, multinomial regression analysis in LCA showed that women with low baseline symptoms of depression and anxiety benefit from the intervention (B = 0.43, 95% confidence interval 1.09-2.16). CONCLUSION: m-WWWT is feasible to be implemented in Chile; future studies are needed to assess the intervention's effectiveness.

A complex intervention to support breastfeeding: A feasibility and acceptability study.

AIMS: The aims of this study are to assess the acceptability and feasibility of a multicomponent intervention to support breastfeeding women and their families and explore its effectiveness. METHODS: A pilot study with control and intervention groups was conducted using the complex intervention framework in two primary healthcare centres. Overall, 44 childbearing women, their partners/relatives and 20 healthcare professionals participated in the study. The intervention's feasibility and acceptability were measured. The percentage of exclusive breastfeeding rates and women's self-efficacy were measured at pre-intervention, at 10 days postpartum, and again at 2, 4 and 6 months postpartum. Postpartum depression risk was measured at 2 and 6 months postpartum. Professional self-efficacy was measured at pre-intervention and 3 months later. RESULTS: The intervention was feasible and acceptable. No difference in self-efficacy existed between the intervention and control groups. Preliminary effects of the intervention were found in exclusive breastfeeding percentage and postpartum depression risk in the intervention group. CONCLUSION: The intervention is feasible and acceptable. The results are promising not only for breastfeeding maintenance but also for preventing postpartum depression and recovering exclusive breastfeeding during pandemics. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03944642.

An explanatory model of parental sensitivity in the mother-father-infant triad.

Quality of early family interactions has been associated with child development, bonding, and mental health. Childhood adversity, stress, and depression impact parenting, affecting the quality of the interaction within the mother-father-child triad. The aim of the present study was to analyze the influence of parents' adverse childhood experiences, depressive symptoms, and parental stress, on their sensitive response toward their tooddler and quality of traidic interactions. A correlational cross-sectional method was used. The sample included 80 mother-father-child triads, of toddlers with social-emotional difficulties. Parents early adverse experiences, parental stress, and depressive symptoms were assessed through self-report measures. Observational measures on parental sensitivity and triadic interaction were used. For mothers and fathers, adverse childhood experiences were associated with depressive symptoms in adulthood. Sensitivity toward their child and stress were positively associated among both parents. Symptoms of depression in mothers were associated with lower sensitivity toward their child, but in fathers, their sensitive response was influenced by the level of parental stress in the mother. In both parents, greater sensitivity in the dyadic interaction with the child was associated with a higher quality of the triadic interactions, in the triad as a whole, and in the regulation and involvement of the child.

Se ha asociado la calidad de las tempranas interacciones de familia con el desarrollo, la unión afectiva y la salud mental del niño. La adversidad en la niñez, el estrés y la depresión tienen un impacto en la crianza, lo cual afecta la calidad de la interacción dentro de la tríada madre-padre-niño. El propósito del presente estudio fue analizar la influencia que las adversas experiencias de niñez de los padres, los síntomas depresivos y el estrés de crianza ejercen sobre sus sensibles respuestas hacia su niño pequeñito y la calidad de las interacciones tríadicas. Se utilizó un método correlacional entre las secciones. El grupo muestra estuvo compuesto de 80 tríadas madre-padre-niño, de niños pequeñitos con dificultades socio-emocionales. A través de medidas de auto-reportes, se evaluaron las tempranas experiencias adversas de los padres, el estrés de crianza, así como los síntomas depresivos. Se usaron medidas de observación de la sensibilidad de los padres y la interacción tríadica. Para mamás y papás, las adversas experiencias de niñez estuvieron asociadas con síntomas depresivos en la edad adulta. La sensibilidad hacia su niño y el estrés se asociaron positivamente entre ambos padres. Se asociaron los síntomas de depresión en las madres con una más baja sensibilidad hacia su niño, pero en los papás la respuesta sensible estuvo influida por el nivel de estrés de crianza de la madre. En ambos padres, una mayor sensibilidad en la interacción diádica con el niño se asoció con una más alta calidad de las interacciones tríadicas, en la tríada en general, así como en la regulación y participación del niño.

La qualité des interactions précoces de la famille a été liée au développement de l'enfant, à la connexion et à la santé mentale. L'adversité durant l'enfant, le stress et la dépression impactent le parentage, affectant la qualité de l'interaction au sein de la triade mère-père-enfant. Le but de cette étude était d'analyser l'influence d'expériences négatives de l'enfance, de symptômes dépressifs et de stress parental sur leur réaction sensible envers leur petit enfant et la qualité des interactions triadiques. Une méthode transversale corrélative a été utilisée. L'échantillon a inclus 80 triades mère-père-enfant, de jeunes enfants avec des difficultés socio-émotionnelles. Les expériences négatives précoces des parents, le stress parental, et les symptômes dépressifs ont été évalués au travers de mesures d'auto-évaluation. Des mesures d'observation de la sensibilité parentale et de l'interaction triadique ont été utilisées. Pour les mères et les pères les expériences négatives de l'enfance étaient liées à des symptômes dépressifs à l'âge adulte. La sensibilité envers leur enfant et le stress étaient liés de manière positive chez les deux parents. Les symptômes de dépression chez les mères étaient liés à une sensibilité moindre envers leur enfant mais chez les pères leur réaction sensible était influencée par le niveau de stress parental chez la mère. Chez les deux parents une plus grande sensibilité dans l'interaction dyadique avec l'enfant était liée à une qualité plus élevée des interactions triadiques, dans la triade dans son ensemble, et dans la régulation et l'engagement de l'enfant.

Home Language and Literacy Environments and Early Literacy Trajectories of Low-Socioeconomic Status Chilean Children.

This study used Latent Class Analysis to identify groups of children exposed to similar Home Language and Literacy Environments (HLLE) and explored whether belonging to a given HLLE group was related to children's language and early literacy growth from prekindergarten to kindergarten. Participants were 1,425 Chilean mothers and their children (Mage  = 52.52 months at baseline) from low-socioeconomic status households. Four HLLE groups were identified, which were associated with different trajectories of language and early literacy development. Children from groups whose mothers either read and talk about past events with them or teach them letters in addition to reading and talking about past events, showed higher relative vocabulary and letter knowledge. Implications for research and interventions are discussed.

The CRIAA Program complex intervention in primary care to support women and their families in breastfeeding: Study protocol for a pilot trial.

AIM: To report a pilot study protocol to assess the feasibility of a complex intervention, in the primary healthcare context, to support women and their families in breastfeeding. DESIGN: A pilot/feasibility trial with control and intervention groups. METHODS: The study will be conducted in two primary healthcare centres with 40 childbearing women (20 control group; 20 intervention group), with their partner/meaningful person and their respective healthcare professionals. Intervention group participants will receive the intervention: (a) in a breastfeeding workshop during their third trimester of pregnancy; and (b) via virtual breastfeeding support for six months postpartum. Health professionals will be trained to deliver the intervention. The control group will receive standard care in the outpatient clinic. The pilot will help determine the intervention's feasibility. Data collected pre-intervention, 10-days postpartum and two-, four-, and six-months postpartum will provide estimates of the intervention's preliminary effects on self-efficacy and main outcomes. Research Ethics Committee approval was obtained in April 2019. DISCUSSION: Breastfeeding support is a complex reality influenced by multiple factors. Therefore, approaches to breastfeeding are also, requiring interventions that address its multidimensional nature, including all actors involved. The proposed intervention will be applied by an interdisciplinary professional health team, allowing for its incorporation into standard practice and its perpetual maintenance. IMPACT: The study will produce an original, comprehensive, complex intervention addressing contextual, and organizational factors to promote breastfeeding support using an interdisciplinary and family-based approach; breastfeeding self-efficacy is the core concept. The program evaluation and feasibility study will permit exploration of the integration of the intervention's novel aspects into the daily work of professionals and reveal how to better use existing resources in a full-scale clinical trial. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03944642.

[Effect of a multidimensional intervention for prevention of falls in the eldery]. / Efecto de una intervención multidimensional en personas mayores autovalentes para el manejo del riesgo de caídas.

OBJECTIVE: To evaluate the effect of a multidimensional intervention on the perception and management of risk factors and frequency of falls in independent elderly people living in the community. DESIGN: Randomised clinical trial. SETTING: Family health centre, primary care. PARTICIPANTS: Independent elderly people living in the community. INTERVENTION: For intervention group (IG) a multidimensional intervention, consisting of home visits and telephone follow-up was carried out for 5 months (n=77), and those assigned to the control group (CG, n=77) received usual care in the family health centre. MAIN MEASUREMENTS: Perception of risk of falls, number of risk factors and number of falls in the study period. RESULTS: In both groups there were increases in the perception of risk factors for falling associated with walking (IG: P<.001 and CG: P<.001). Belonging to the IG was significantly associated with a decrease in the risk factors associated with surfaces (r=0.25) and shoes (r=0.24), as well as an increase in the perception of risk of falls associated with walking (r=0.21) and the presence of objects or furniture (r=0.36). In the IG, 5 participants (7.9%) suffered at least one fall in the 5-month period and 18 (27.7%) patients in the CG (P=.004). CONCLUSIONS: The multidimensional intervention was effective in reducing the frequency of falls and in the management of extrinsic risk factors associated with surfaces, lighting, and support devices.

Is maternal depression related to mother and adolescent reports of family functioning?

While adolescent-parent disagreements about family functioning are common, they may also be indicative of family members' health problems and may compromise adolescent adjustment. This study examines the association between maternal depressive symptoms and family functioning perceptions, considering both the adolescents' and their mothers' points of view. A sample of 943 Chilean dyads of adolescents (69% female, Mage = 14.43 years old) and their mothers (Mage = 43.20 years) reported their perceptions of family cohesion and adaptability. Mothers also reported their depressive symptoms. Results indicated that mothers perceived their family as more cohesive and more adaptable than their children. There was a negative association between maternal and adolescent reports of family cohesion and maternal depressive symptoms. In the mother' reports, this association depended on adolescent's age. In the case of adolescents' reports, this association depended on adolescent's gender. Finally, maternal depressive symptoms were a significant predictor of mother-adolescent agreement about family cohesion.

[Psychometric properties of a spanish version of the Beck depression inventory IA]. / Propiedades psicométricas del inventario de depresión de Beck IA para la población chilena.

BACKGROUND: According to the Chilean National Health Survey (2009-2010), 17% of people aged 15 years or more have depressive symptoms. Thus, freely-available, easily-administered, and highly sensitive screening tests for depression are needed in clinical and research settings. AIM: To evaluate the psychometric properties of a Spanish version of the Beck Depression Inventory (BDI-IA) in adult Chilean population. MATERIAL AND METHODS: The inventory was applied to a sample of 1.105 adults aged between 18 to 73 years (94% women). Ninety nine participants were outpatients receiving treatment for affective disorders, 932 were parents and/or guardians of students enrolled in schools and 73 were university students (sample with no known depressive disorder). To perform data analysis, two groups from the random combination of both samples were generated. RESULTS: The inventory showed an appropriate degree of internal consistency (Cronbach alpha = .92). An exploratory factor analysis suggested a one-factor solution. This solution was reinforced with a confirmatory factor analysis, which displayed an adequate goodness of fit. The cutoff score, based on the Youden Index, was 13/14 points. It was able to discriminate between depressed and non-depressed participants. CONCLUSIONS: These results indicate that the BDI-IA is an appropriate instrument to assess depressive symptoms in Chilean adults.

Brief report: Agreement between parent and adolescent autonomy expectations and its relationship to adolescent adjustment.

While disagreement in autonomy expectations between parents and their adolescent children is normative, it may also compromise adolescent adjustment. This study examines the association between parents' and adolescents' agreement on autonomy expectations by cognitive social domains and adolescent adjustment. A sample of 211 Chilean dyads of adolescents (57% female, Mage = 15.29 years) and one of their parents (82% mothers, Mage = 44.36 years) reported their expectations for the age at which adolescents should decide on their own regarding different issues in their life. Indexes of parent-adolescent agreement on autonomy expectations were estimated for issues of personal and prudential domains. Greater agreement in the prudential than in the personal domain was observed. For boys and girls, higher agreement in adolescent-parent autonomy expectations in the personal domain was associated with lower substance use. A negative association between level of agreement in adolescent-parent autonomy expectations in the prudential domain and externalizing behaviors and substance use was found.

Acceptability Study of "Ascenso": An Online Program for Monitoring and Supporting Patients with Depression in Chile.

BACKGROUND: Major depression is a highly prevalent and severe mental disease. Despite the effective treatment options available, the risk of relapse is high. Interventions based on information and communication technologies generate innovative opportunities to provide support to patients after they completed treatment for depression. MATERIALS AND METHODS: This acceptability study evaluated the Internet-based program Apoyo, Seguimiento y Cuidado de Enfermedades a partir de Sistemas Operativos (ASCENSO) in terms of its feasibility and acceptability in a sample of 35 patients in Chile. RESULTS: The study reveals high rates of acceptance and satisfaction among patients who actively used the program. As obstacles, patients mentioned technical problems, a lack of contact with other participants, and an insufficient connection between the program and the health service professionals. CONCLUSIONS: ASCENSO appears to be a promising complement to regular care for depression. Following improvements of the program based on participants' feedback, future research should evaluate its efficacy and cost-effectiveness.

Reducing Stigma Toward People with Serious Mental Illness Through a Virtual Reality Intervention: A Randomized Controlled Trial.

Background: Stigma toward people with serious mental illnesses (SMI), like schizophrenia, is a serious global public health challenge that limits the quality of life of those affected and poses a major barrier that keeps people from seeking professional help. There is an urgent need for novel, effective, and scalable interventions to decrease stigmatized perceptions of chronic psychotic disorders and to reduce the health burden imposed by them. Method: We conducted a randomized controlled trial to assess the impact of a new immersive virtual reality game (Inclúyete-VR) on the level of stigma toward people with SMI, measured by the Attribution questionnaire (AQ-27). Participants in the experimental group were exposed in an immersive way to hallucinations common in schizophrenia, then shown different psychosocial resources available for their recovery and social inclusion; those in the control group used VR software unrelated to mental health. VR sessions were delivered through Oculus headgear and lasted 25 minutes. Results: We randomly assigned 124 university students (55% female) to experimental or control conditions (n = 62 each). We used mixed ANOVA to compare outcomes before and after the intervention between the two groups. We found a significant intervention-by-time interaction (P < 0.001), with a reduction in the experimental group of overall stigma levels on the AQ-27 scale and its three subscales: dangerousness-fear, avoidance, and lack of solidarity (P < 0.001 for all). Conclusions: The Inclúyete-VR software proved effective in the short term in reducing stigma toward people with severe mental illness. The program's longer-term efficacy, scalability, and dissemination remain to be studied. ClinicalTrials.gov Identifier: NCT05393596.

[Medium-term effect of an intervention program for adolescent mothers]. / Efectos de mediano plazo de un programa de intervención para madres adolescentes.

OBJECTIVE: To analyze the medium-term results of an experimental study which evaluates the effects of home visits by para-professionals to a sample of adolescent mothers, which was successful in the short-term. DESIGN: Quantitative, follow up of two cohorts. FIELD OF STUDY: Two health centers in low socioeconomic areas, Santiago, Chile. PARTICIPANTS: From a sample of 104 adolescent mothers and their children, 69 were contacted when their sons or daughters were 48 month old. Lost data was about 33.6%. INTERVENTIONS: Outcomes variables were: mental health of the mothers; their social, work, and family integration; their interaction with the child; and language and socio-emotional development of the child. The independent variable was the intervention: home visiting. PRINCIPAL MEASUREMENT: The short-term evaluation in the experimental and control groups was carried out using standardized questionnaires when the children were between 12 and 15 months old, and the medium-term evaluation at the age of 48 months. RESULTS: The short term positive effects on the mental health of the mother and on language development of the child were not sustained in the medium-term. The only positive effect was the stability in the relationship with their partners. CONCLUSIONS: On the basis of these results, the importance of maintaining regular visits, in order to prevent the fading of the initial effects, is discussed.

Understanding the use/non-use of an internet-based intervention complementing standard depression treatment: A qualitative study of user's experiences.

Introduction: There is sufficient evidence about the effectiveness of internet-based interventions; however, the users' level of adoption and utilization remains low, with this phenomenon requiring adequate explanation. Objective: The aim of this qualitative study was to explore the users' perceptions and experience of a web-based program (ASCENSO), designed to complement (usual) in-person depression treatment. Method: Twelve participants of the ASCENSO program, comprised of adult individuals (M = 44.3, SD = 13.4) of both genders (67% women) undergoing treatment for depression, were interviewed through semi-structured interviews. The data obtained from these interviews were analyzed utilizing a constructivist grounded theory approach. The interviews were transcribed and analyzed by trained coders. A constant comparative analysis of emergent themes was conducted. Results: These show that users employ and appreciate the program when their interaction with it emulates a "humanized relationship," that is, when the program is proactive in assisting users with their requests and when it responds in a pertinent and individualized manner to their emotional states and needs. Conclusions: Our findings highlight the challenges associated with the development of algorithms capable of attracting different potential users. These should be designed to generate a virtual relationship that emulates human interaction and targets the characteristics of each user, for example, considering the specific phenomenology of their health condition, their present emotional states, and perceived needs. Elements that will vary as mental symptomatology evolve.

Adolescent temperament and parental control in the development of the adolescent decision making in a Chilean sample.

The study analyzes the way in which adolescents' temperamental characteristics interact with parental control to shape adolescent decision making development. A sample of high-school Chilean adolescents (N = 391) answered a self-report questionnaire that included measures of behavioral autonomy (the extent to which adolescents make decisions in personal and prudential domains), parental behavioral and psychological control, and temperamental characteristics. A path analysis model indicated that adolescents' anger-frustration had a direct association with decision-making in the personal and prudential domains; fearfulness had an inverse association with adolescent decision-making, but only in the prudential domain. Perceived psychological control was associated with adolescents' reduced decision-making autonomy in the personal domain, while perceived behavioral control was associated with less adolescent autonomy in both personal and prudential domains. Additionally, a moderation effect was found such that the association of parental behavioral control on decision-making in the prudential domain was dependent on the adolescent fearfulness level.

Corrigendum: Parental psychological control: Maternal, adolescent, and contextual predictors.

[This corrects the article DOI: 10.3389/fpsyg.2021.712087.].

Adapting to Adversity: Effects of COVID-19 on Parenting in Chile.

The pandemic outbreak in March 2020 and its associated sanitary regulations and restrictions triggered an abrupt and significant change for society in general and for families' organization in particular. In Chile, the Santiago Metropolitan District was under a strict lockdown that involved the closure of the entire educational system. From a systemic-family stress perspective, the impact of these changes might have consequences not only for each individual family member, but for the parental dynamic and, consequently, for children's well-being. This paper presents the results of a follow-up study showing changes in self-reported parental depression and the perceived home organization of mothers and fathers assessed at three different moments: before the pandemic, at the initial outbreak, and after 1 month of strict lockdown. Relevant moderators were explored using linear mixed models to understand the within-subject changes in mothers' and fathers' self-reports across the different assessment times. Financial strain, personality traits of self-criticism and dependency, previous parent-child quality interaction, recent major stressful events, and number of children are highlighted as relevant factors that moderate changes in home chaos and parental mental health perception. Significant risks and protective factors are described for fathers and mothers. The use of pre-pandemic measures as baseline levels enabled the identification of personal and family characteristics that were related to better outcomes. The results help increase our understanding of the sanitary regulations' impacts on the family system and identify vulnerability indicators that should be considered.

Online intervention to prevent postnatal depression and anxiety in Chilean new mothers: Protocol for a feasibility trial.

Symptoms of postpartum depression and anxiety in new mothers are prevalent and negatively impact maternal emotional wellbeing and infant development. Barriers to accessing treatment prevent women from receiving mental health care, a situation that has worsened due to the COVID-19 pandemic. mHealth interventions hold the potential to support women during the transition to parenthood despite these barriers and to promote the use of preventive interventions. This study uses a mixed methods design to assess the feasibility and preliminary effectiveness of a psychoeducational, guided mHealth intervention to prevent postpartum mental health difficulties in women who receive care in primary health centers in Chile. The study will contribute to evidence-based research on the effectiveness of mHealth interventions for new mothers from an understudied cultural background. The findings will also enable the development of a larger randomized controlled trial to assess the effectiveness of the intervention, which, if effective, could significantly contribute to the emotional wellbeing of women and their families.

Parental Psychological Control: Maternal, Adolescent, and Contextual Predictors.

Parental psychological control (PC) hinders the development of autonomy, identity formation, and the attainment of self-determination and individuation of adolescents. The aim of this study was to deepen the understanding of which conditions increase the risk of the use of maternal PC by simultaneously considering the contribution of adolescent temperament, maternal separation anxiety, and adolescents' perception of interparental conflict. A correlational study involving a sample of 106 Chilean adolescent-mother dyads was done. Adolescents were, on average, 15.42 years old (SD = 1.09) and 77% male. Mothers were, on average, 45.46 years old (SD = 6.39). We administered self-report questionnaires to the adolescent measuring effortful control and frustration as temperamental dimensions, along with the perception of interparental conflict. Mothers reported on their separation anxiety. Both the adolescents and their mothers reported on the use of maternal PC. Adolescents reported higher levels of maternal PC than their mothers did. All predictors were associated with PC reports. Higher levels of maternal anxiety about adolescent distancing, inter-parental conflict, and adolescent frustration were associated with higher reported levels of PC. In contrast, higher levels of adolescent effortful control were associated with lower levels of maternal PC. Finally, when maternal separation anxiety and inter-parental conflict were high there was a higher use of maternal PC. The present findings inform on how adolescent's self-regulatory skills could reduce the risk of being exposed to maternal PC. And highlight the importance of using a systemic and interactional conceptualization when trying to understand their use.

An Adjunctive Internet-Based Intervention to Enhance Treatment for Depression in Adults: Randomized Controlled Trial.

BACKGROUND: Internet-based interventions promise to enhance the accessibility of mental health care for a greater number of people and in more remote places. Their effectiveness has been shown for the prevention and treatment of various mental disorders. However, their potential when delivered as add-on to conventional treatment (ie, blended care) is less clear. OBJECTIVE: The aim of this study is to study the effectiveness of an internet intervention (ASCENSO) implemented in addition to face-to-face treatment as usual (TAU) for depression. METHODS: A 2-arm, parallel-group, randomized controlled trial was conducted in an outpatient private mental health care center in Chile. In all, 167 adults, diagnosed with major depressive disorder, without severe comorbidities, and with internet access, were included. Eighty-four participants were assigned to the intervention group and received medical and psychological TAU from the mental health center plus access to the ASCENSO online platform. The control group (n=83) received only TAU. The ASCENSO platform includes psycho-educational information, depressive symptom monitoring and feedback, and managing emergencies based on the principles of cognitive behavioral therapy. Emergency management was mental health provider-assisted. TAU includes access to primary care physicians and psychiatrists, to a brief individual psychotherapy, and to medication when needed. The baseline questionnaires were administered in person, and 6- and 9-months assessments were conducted online. Depression symptoms and quality of life were measured by self-administered questionnaires, and treatment adherence was determined via the Mental Health Center's internal records. The usage of ASCENSO was assessed by server logs. Reduction on depressive symptomatology was considered as the primary outcome of the intervention and quality of life as a secondary outcome. RESULTS: Of the 84 participants in the intervention group, 5 participants (6%) never accessed the online platform. Of the remaining 79 participants who accessed ASCENSO, 1 (1%, 1/79) did not answer any of the symptom questionnaire, and most participants (72/79, 91%) answered the monitoring questionnaires irregularly. The ASCENSO intervention implemented in addition to face-to-face care did not improve the outcome of the usual care delivered at the mental health center, either in terms of reduction of depressive symptoms (F2,6087= 0.48; P=.62) or in the improvement of quality of life (EQ-5D-3L: F2,7678=0.24; P=.79 and EQ-VAS: F2,6670= 0.13; P=.88). In contrast, for the primary (F2,850=78.25; P<.001) and secondary outcomes (EQ-5D-3L: F2,1067=37.87; EQ-VAS: F2,4390= 51.69; P<.001) in both groups, there was an improvement from baseline to 6 months (P<.001), but there was no change at 9 months. In addition, no effects on adherence to or use of TAU were found. Finally, the dropout rate for the face-to-face treatment component was 54% (45/84) for the intervention group versus 39% (32/83) for the control group (P=.07). CONCLUSIONS: The fact that the adjunctive access to ASCENSO did not improve outcome could be due to both the rather high effectiveness of TAU and to patients' limited use of the online platform. TRIAL REGISTRATION: ClinicalTrials.gov NCT03093467; https://clinicaltrials.gov/ct2/show/NCT03093467.

Clients', therapists', and observers' agreement on the amount, temporal location, and content of psychotherapeutic change and its relation to outcome.

Clients', therapists', and observers' identification of change was studied in 27 therapeutic processes, and agreement on the amount, temporal location, and content of change was related to outcome. Results show that clients reported more changes in successful therapies. Client-therapist temporal match of change moments was low irrespective of outcome. Results from all three perspectives were consistent in that manifestation of new behaviors and emotions was the most representative content of change among all therapies. Meanwhile, client-therapist agreement on the frequency of grouped change indicators reported was associated with positive outcome, whereas client-observer agreement was related to negative outcome. Therapists and observers agreed in both successful and nonsuccessful therapies. The relationship between agreement and therapeutic outcome is discussed in relation to each dimension of analysis.