Multimodal e-mental health treatment for depression: a feasibility trial

Background

Internet interventions for depression have shown less than optimal adherence. This study describes the feasibility trial of a multimodal e-mental health intervention designed to enhance adherence and outcomes for depression. The intervention required frequent brief log-ins for self-monitoring and feedback as well as email and brief telephone support guided by a theory-driven manualized protocol.

Objective

The objective of this feasibility trial was to examine if our Internet intervention plus manualized telephone support program would result in increased adherence rates and improvement in depression outcomes.

Methods

This was a single arm feasibility trial of a 7-week intervention.

Results

Of the 21 patients enrolled, 2 (9.5%) dropped out of treatment. Patients logged in 23.2 ± 12.2 times over the 7 weeks. Significant reductions in depression were found on all measures, including the Patient Health Questionnaire depression scale (PHQ-8) (Cohen’s d = 1.96, P < .001), the Hamilton Rating Scale for Depression (d = 1.34, P < .001), and diagnosis of major depressive episode (P < .001).

Conclusions

The attrition rate was far lower than seen either in Internet studies or trials of face-to-face interventions, and depression outcomes were substantial. These findings support the feasibility of providing a multimodal e-mental health treatment to patients with depression. Although it is premature to make any firm conclusions based on these data, they do support the initiation of a randomized controlled trial examining the independent and joint effects of Internet and telephone administered treatments for depression.     

The potential of Web-based interventions for heart disease self-management: a mixed methods investigation

Background

Existing initiatives to support patient self-management of heart disease do not appear to be reaching patients most in need. Providing self-management programs over the Internet (web-based interventions) might help reduce health disparities by reaching a greater number of patients. However, it is unclear whether they can achieve this goal and whether their effectiveness might be limited by the digital divide.

Objective

To explore the effectiveness of a web-based intervention in decreasing inequalities in access to self-management support in patients with coronary heart disease (CHD).

Methods

Quantitative and qualitative methods were used to explore use made of a web-based intervention over a period of 9 months. Patients with CHD, with or without home Internet access or previous experience using the Internet, were recruited from primary care centers in diverse socioeconomic and ethnic areas of North London, UK. Patients without home Internet were supported in using the intervention at public Internet services.

Results

Only 10.6% of eligible patients chose to participate (N=168). Participants were predominantly Caucasian well-educated men, with greater proportions of male and younger CHD patients among participants than were registered at participating primary care practices. Most had been diagnosed with CHD a number of years prior to the study. Relatively few had been newly diagnosed or had experienced a cardiac event in the previous 5 years. Most had home Internet access and prior experience using the Internet. A greater use of the intervention was observed in older participants (for each 5-year age increase, OR 1.25 for no, low or high intervention use, 95% CI, 1.06-1.47) and in those that had home Internet access and prior Internet experience (OR 3.74, 95% CI, 1.52-9.22). Less use was observed in participants that had not recently experienced a cardiac event or diagnosis (≥ 5 years since cardiac event or diagnosis; OR 0.69, 95% CI, 0.50-0.95). Gender and level of education were not statistically related to level of use of the intervention. Data suggest that a recent cardiac event or diagnosis increased the need for information and advice in participants. However, participants that had been diagnosed several years ago showed little need for information and support. The inconvenience of public Internet access was a barrier for participants without home Internet access. The use of the intervention by participants with little or no Internet experience was limited by a lack of confidence with computers and discomfort with asking for assistance. It was also influenced by the level of participant need for information and by their perception of the intervention.

Conclusions

The availability of a web-based intervention, with support for use at home or through public Internet services, did not result in a large number or all types of patients with CHD using the intervention for self-management support. The effectiveness of web-based interventions for patients with chronic diseases remains a significant challenge.     

Enhancing group cognitive‐behavioral therapy for hoarding disorder with between‐session Internet‐based clinician support: A feasibility study

Objective

Hoarding disorder (HD) is difficult to treat. In an effort to increase efficacy and engagement in cognitive‐behavioral therapy (CBT), we developed and evaluated a novel intervention comprising group CBT combined with between‐session Internet‐based clinician support for people with HD.

Method

Twenty participants with HD received group CBT combined with an Internet‐support system enabling therapist–participant communication between group sessions.

Results

The treatment was associated with a significant reduction on the Saving Inventory—Revised (SI‐R) and a large effect size (Cohen's d = 1.57) was found at posttreatment. Treatment gains were maintained at the 3‐month follow‐up. Group attendance was high and no participants dropped out from treatment prematurely. Between‐session motivational support from the therapist was most frequently mentioned as the main strength of the system.

Conclusion

The results of this study support adding Internet‐based clinician support to group CBT for HD to increase treatment adherence and, potentially, improve the overall efficacy of CBT.

     

Seeking Health Information Online: Association With Young Australian Women’s Physical,Mental, and Reproductive Health

Background

Relatively little is known about the extent to which young adults use the Internet as a health information resource and whether there are factors that distinguish between those who do and do not go online for health information.

Objective

The aim was to identify the sociodemographic, physical, mental, and reproductive health factors associated with young women’s use of the Internet for health information.

Methods

We used data from 17,069 young women aged 18-23 years who participated in the Australian Longitudinal Study on Women’s Health. Multivariable logistic regression was used to estimate the association between sociodemographic, physical, mental, and reproductive health factors associated with searching the Internet for health information.

Results

Overall, 43.54% (7433/17,069) of women used the Internet for health information. Women who used the Internet had higher odds of regular urinary or bowel symptoms (OR 1.44, 95% CI 1.36-1.54), psychological distress (very high distress: OR 1.24, 95% CI 1.13-1.37), self-reported mental health diagnoses (OR 1.16, 95% CI 1.09-1.23), and menstrual symptoms (OR 1.25, 95% CI 1.15-1.36) than women who did not use the Internet for health information. Internet users were less likely to have had blood pressure checks (OR 0.85, 95% CI 0.78-0.93) and skin cancer checks (OR 0.90, 95% CI 0.84-0.97) and to have had a live birth (OR 0.74, 95% CI 0.64-0.86) or pregnancy loss (OR 0.88, 95% CI 0.79-0.98) than non-Internet users.

Conclusions

Women experiencing “stigmatized” conditions or symptoms were more likely to search the Internet for health information. The Internet may be an acceptable resource that offers “anonymized” information or support to young women and this has important implications for health service providers and public health policy.     

Improving access to information and support for patients with less common cancers: hematologic cancer patients' views about Web-based approaches

Background

Meeting the psychosocial needs of vulnerable groups such as cancer survivors remains an ongoing challenge. This is particularly so for those who have less access to the usual forms of medical specialist and in-person support networks. Internet-based approaches offer an opportunity to better meet patients’ information and support needs by overcoming the barrier of geographic isolation.

Objective

The aim of the study was to assess the reported level of access to the Internet, preferred sources of information, and preferred sources of support among survivors of hematologic cancers.

Method

A population-based, Australian state cancer registry invited eligible survivors to complete a survey about psychosocial needs, including items measuring Internet access and patterns of use. Of the 732 eligible survivors invited to participate, 268 (36.6%) completed and returned the pen-and-paper-based survey.

Results

The majority of participants (186/254, 73.2%) reported a high level of access to the Internet, with higher Internet access associated with a higher level of education, larger household, younger age, and being married or employed. A total of 62.2% (156/251) of survivors indicated they were likely to use the Internet for accessing information, with the percentage much lower (69/251, 28%) for accessing support via the Internet. Likelihood of using the Internet for support was associated with feeling anxious and being employed.

Conclusions

While the Internet appears to offer promise in increasing equitable access to information and support for cancer survivors for both metropolitan and regional areas, it is viewed less favorably for support and by particular subgroups (eg, older people and those without a university degree) within the survivor population. Promoting greater understanding of this mode of support may be required to achieve its potential. Information and support options other than Web-based approaches may continue to be needed by vulnerable groups of cancer survivors.     

Seal of transparency heritage in the CISMeF quality-controlled health gateway

Background  

It is an absolute necessity to continually assess the quality of health information on the Internet. Quality-controlled subject gateways are Internet services which apply a selected set of targeted measures to support systematic resource discovery.     

Munchausen by internet: current research and future directions

Background

The Internet has revolutionized the health world, enabling self-diagnosis and online support to take place irrespective of time or location. Alongside the positive aspects for an individual’s health from making use of the Internet, debate has intensified on how the increasing use of Web technology might have a negative impact on patients, caregivers, and practitioners. One such negative health-related behavior is Munchausen by Internet.

Objective

Munchausen by Internet occurs when medically well individuals fake recognized illnesses in virtual environments, such as online support groups. This paper focuses on the aspect of Munchausen by Internet in which individuals actively seek to disrupt groups for their own satisfaction, which has not yet been associated with the wider phenomena of Internet trolls (users who post with the intention of annoying someone or disrupting an online environment).

Methods

A wide-ranging review was conducted to investigate the causes and impacts of online identity deception and Munchausen by Internet drawing on academic research and case studies reported online and in the media.

Results

The limited research relating to motivation, opportunity, detection, effects, and consequences of Munchausen by Internet is highlighted and it is formally linked to aspects of trolling. Case studies are used to illustrate the phenomenon. What is particularly worrying is the ease with which the deception can be carried out online, the difficulty in detection, and the damaging impact and potential danger to isolated victims.

Conclusions

We suggest ways to deal with Munchausen by Internet and provide advice for health group facilitators. We also propose that Munchausen by Internet and Munchausen by Internet trolling should be formally acknowledged in a revised version of the Diagnostic and Statistical Manual DSM-5. This will assist in effectively identifying and minimizing the growth of this behavior as more people seek reassurance and support about their health in the online environment. We also suggest directions for future research.     

Medical informatics in an undergraduate curriculum: a qualitative study

Background  

There is strong support for educating physicians in medical informatics, and the benefits of such education have been clearly identified. Despite this, North American medical schools do not routinely provide education in medical informatics.     

Using the Internet for information about breast cancer: A questionnaire-based study

Objectives

To identify the proportion of breast cancer patients that used the Internet for breast cancer information; to classify patterns of use based on patient demographics; and to evaluate whether using the Internet for this purpose was beneficial or problematic. Also to recognize whether a specific demographic group was more likely to experience problems when using the Internet for breast cancer information.

Methods

A 10-item questionnaire was given to patients who attended the breast unit at the University Hospital of South Manchester between May and June 2011 following breast cancer treatment within the last 5 years.

Results

200 questionnaires were completed. 50.5% of patients had used the Internet for breast cancer information, with younger (p < 0.001) patients with a higher household income (p < 0.001) being most likely to do so. The majority (73%) found it beneficial; however 31% had experienced problems. Ethnicity affected the likelihood of experiencing problems with white patients encountering fewer problems (25%) than non-white patients (64%) (p = 0.008).

Conclusion

A significant proportion of breast cancer patients will encounter difficulties when using the Internet for breast cancer information, particularly those from ethnic minorities.

Practice implications

Health professionals need to include a discussion about Internet use in consultations with breast cancer patients.     

A systematic review of tests of empathy in medicine

Background  

Empathy is frequently cited as an important attribute in physicians and some groups have expressed a desire to measure empathy either at selection for medical school or during medical (or postgraduate) training. In order to do this, a reliable and valid test of empathy is required. The purpose of this systematic review is to determine the reliability and validity of existing tests for the assessment of medical empathy.     

Adult vaccination coverage levels among users of complementary/alternative medicine – results from the 2002 National Health Interview Survey (NHIS)

Background  

While many Complementary/Alternative Medicine (CAM) practitioners do not object to immunization, some discourage or even actively oppose vaccination among their patients. However, previous studies in this area have focused on childhood immunizations, and it is unknown whether and to what extent CAM practitioners may influence the vaccination behavior of their adult patients. The purpose of this study was to describe vaccination coverage levels of adults aged ≥ 18 years according to their CAM use status and determine if there is an association between CAM use and adult vaccination coverage.     

Using the Internet for Health-Related Activities: Findings From a National Probability Sample

Background

eHealth tools on the Internet have the potential to help people manage their health and health care. However, little is known about the distribution and use of different kinds of eHealth tools across the population or within population subgroups.

Objective

The purpose of this study was to examine the prevalence and predictors of participation in specific online health-related activities.

Methods

A secondary data analysis of the National Cancer Institute’s Health Information National Trends Survey (HINTS) 2005 was conducted to study three online behaviors among Internet users (n = 3244): searching for health information for oneself, participating in a support group for those with similar health or medical conditions, and purchasing medicine or vitamins.

Results

A total of 58% of Internet users reported searching for health information for themselves, 3.8% used online support groups, and 12.8% bought medicine or vitamins online in the past year. Multivariate analysis found that those seeking health information were more likely to be women (OR = 2.23, 95% CI = 1.60, 3.09), have cable or satellite Internet connections (OR = 1.73, 95% CI = 1.22, 2.45) or DSL connections (OR = 1.94, 95% CI = 1.36, 2.76), have Internet access from work (OR = 2.43, 95% CI = 1.27, 4.67) or from home and work (OR = 1.73, 95% CI = 1.31, 2.30), and report more hours of weekday Internet use (OR = 4.12, 95% CI = 2.41, 7.07). Those with a high school education or less (OR = 0.44, 95% CI = 0.31, 0.63) and those with some college (OR = 0.66, 95% CI = 0.49, 0.89) were less likely to search for health information. Online support groups were more likely to be used by those with “fair” health (OR = 3.28, 95% CI = 1.21, 8.92) and “poor” health (OR = 5.98, 95% CI = 1.49, 24.07) and those with lower incomes (OR = 2.64, 95% CI = 1.09, 6.41) and less likely to be used by those with Internet access both at home and work (OR = 0.56, 95% CI = 0.35, 0.90). Those who were age 35-49 (OR = 2.16, 95% CI = 1.43, 3.26), age 50-64 (OR = 2.44, 95% CI = 1.53, 3.89), and age 65-74 (OR = 2.18, 95% CI = 1.30, 3.67) and those who were married (OR = 1.93, 95% CI = 1.13, 3.30) were more likely to purchase medicine or vitamins online.

Conclusions

The Internet was most widely used as a health information resource, with less participation in the purchase of medicine and vitamins and in online support groups. Results suggest that modifying survey questions to better capture forms of online support and medications purchased could provide greater understanding of the nature of participation in these activities.     

Assessment of the quality and variability of health information on chronic pain websites using the DISCERN instrument

Background  

The Internet is used increasingly by providers as a tool for disseminating pain-related health information and by patients as a resource about health conditions and treatment options. However, health information on the Internet remains unregulated and varies in quality, accuracy and readability. The objective of this study was to determine the quality of pain websites, and explain variability in quality and readability between pain websites.     

Disappearance of myocardial perfusion defects on prone SPECT imaging: Comparison with cardiac magnetic resonance imaging in patients without established coronary artery disease

Background  

It is of great clinical importance to exclude myocardial infarction in patients with suspected coronary artery disease who do not have stress-induced ischemia. The diagnostic use of myocardial perfusion single-photon emission computed tomography (SPECT) in this situation is sometimes complicated by attenuation artifacts that mimic myocardial infarction. Imaging in the prone position has been suggested as a method to overcome this problem.     

Determinants of engagement in face-to-face and online patient support groups

Background

Although peer-to-peer contact might empower patients in various ways, studies show that only a few patients actually engage in support groups.

Objective

The objective of our study was to explore factors that facilitate or impede engagement in face-to-face and online peer support, using the Theory of Planned Behavior.

Methods

A questionnaire was completed by 679 patients being treated for arthritis, breast cancer, or fibromyalgia at two Dutch regional hospitals.

Results

Our results showed that only a minority of the patients engaged in organized forms of peer support. In total 10% (65/679) of the respondents had engaged in face-to-face meetings for patients in the past year. Only 4% (30/679) of the respondents had contact with peers via the Internet in the past year. Patients were more positive about face-to-face peer support than about online peer support (P < .001). In accordance with the Theory of Planned Behavior, having a more positive attitude (P < .01) and feeling more supported by people in the social environment (P < .001) increased the intention to participate in both kinds of peer support. In addition, perceived behavioral control (P = .01) influenced the intention to participate in online peer support. Nevertheless, the intention to engage in face-to-face and online peer support was only modestly predicted by the Theory of Planned Behavior variables (R ² = .33 for face-to-face contact and R ² = .26 for online contact).

Conclusion

Although Health 2.0 Internet technology has significantly increased opportunities for having contact with fellow patients, only a minority seem to be interested in organized forms of peer contact (either online or face-to-face). Patients seem somewhat more positive about face-to-face contact than about online contact.     

Impact of Patient Access to Internet Health Records on Glaucoma Medication: Randomized Controlled Trial

Background

Glaucoma is one of the leading causes of blindness. Reduction of intraocular pressure is the only proven way to prevent progression of glaucomatous optic neuropathy. The majority of glaucoma patients need to use antiglaucoma ophthalmic solutions over the course of their life. Thus, good adherence and persistency of glaucoma treatment are important factors for better glaucoma care.

Objective

The purpose of this study was to investigate the impact of an Internet-based glaucoma care support system on glaucoma medication use.

Methods

Patients were randomly divided into two groups. The non–Internet access (NIA) group consisted of patients who had access to the Internet-based glaucoma care support system during the 4-year period only when they were examined by ophthalmologists. The Internet access (IA) group consisted of patients who had the same Internet-based glaucoma care support system access as the NIA group for the first 2 years following enrollment but who were also given free access to the glaucoma care support system for the remaining 2 years. Changes in glaucoma medication use were investigated.

Results

In total, 81 patients in the IA group and 90 patients in the NIA group satisfied the study protocol. The number of antiglaucoma ophthalmic solutions used during the study period significantly increased in the NIA group (P<.03) but not in the IA group. The percentages of patients with unchanged, increased, and decreased antiglaucoma ophthalmic solution use during the study period were 61.1% (55/90), 17.8% (16/90), and 3.3% (3/90), respectively, in the NIA group, and 56.8% (46/81), 8.6% (7/81), and 13.6% (11/81), respectively, in the IA group (P<.001). Internet access significantly shifted from an increasing intraocular pressure trend to a decreasing trend in the IA group (P=.002) among the patients who did not have any medication changes.

Conclusions

Allowing patients to browse their medical data may reduce the use and improve the effectiveness of glaucoma medication.

Trial Registration

UMIN-CTR Clinical Trial Number: UMIN000006982; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000008238&language=E (Archived by WebCite at http://www.webcitation.org/6MRPQeEAv).     

eHealth,Participatory Medicine,and Ethical Care: A Focus Group Study of Patients’ and Health Care Providers’ Use of Health-Related Internet Information

Background

The rapid explosion in online digital health resources is seen as transformational, accelerating the shift from traditionally passive patients to patients as partners and altering the patient–health care professional (HCP) relationship. Patients with chronic conditions are increasingly engaged, enabled, and empowered to be partners in their care and encouraged to take responsibility for managing their conditions with HCP support.

Objective

In this paper, we focus on patients’ and HCPs’ use of health-related Internet information and how it influences the patient-HCP relationship. In particular, we examine the challenges emerging in medical encounters as roles and relationships shift and apply a conceptual framework of relational ethics to examine explicit and nuanced ethical dimensions emerging in patient-HCP interactions as both parties make increased use of health-related Internet information.

Methods

We purposively sampled patients and HCPs in British Columbia, Canada, to participate in focus groups. To be eligible, patients self-reported a diagnosis of arthritis and at least one other chronic health condition; HCPs reported a caseload with >25% of patients with arthritis and multimorbidity. We used a semistructured, but flexible, discussion guide. All discussions were audiotaped and transcribed verbatim. Elements of grounded theory guided our constant comparison thematic analytic approach. Analysis was iterative. A relational ethics conceptual lens was applied to the data.

Results

We recruited 32 participants (18 patients, 14 HCPs). They attended seven focus groups: four with patients and three with rehabilitation professionals and physicians. Predominant themes to emerge were how use of health-related Internet information fostered (1) changing roles, (2) patient-HCP partnerships, and (3) tensions and burdens for patients and HCPs.

Conclusions

Relational aspects such as mutual trust, uncertainty, and vulnerability are illuminated in patient-HCP interactions around health-related Internet information and the negotiated space of clinical encounters. New roles and associated responsibilities have key ethical dimensions that make clear the changes are fundamental and important to understand in ethical care. When faced with tensions and burdens around incorporating health-related Internet information as a resource in clinical encounters, participants described a particular ambivalence illustrating the fundamental changes being negotiated by both patients and HCPs.     

Changes Over Time in the Utilization of Disease-Related Internet Information in Newly Diagnosed Breast Cancer Patients 2007 to 2013

Background

As the number of people with Internet access rises, so does the use of the Internet as a potentially valuable source for health information. Insight into patient use of this information and its correlates over time may reveal changes in the digital divide based on patient age and education. Existing research has focused on patient characteristics that predict Internet information use and research on treatment context is rare.

Objective

This study aims to (1) present data on the proportion of newly diagnosed breast cancer patients treated in German breast centers from 2007 to 2013 who used the Internet for information on their disease, (2) look into correlations between Internet utilization and sociodemographic characteristics and if these change over time, and (3) determine if use of Internet information varies with the hospitals in which the patients were initially treated.

Methods

Data about utilization of the Internet for breast cancer–specific health information was obtained in a postal survey of breast cancer patients that is conducted annually in Germany with a steady response rate of 87% of consenting patients. Data from the survey were combined with data obtained by hospital personnel (eg, cancer stage and type of surgery). Data from 27,491 patients from 7 consecutive annual surveys were analyzed for this paper using multilevel regression modeling to account for clustering of patients in specific hospitals.

Results

Breast cancer patients seeking disease-specific information on the Internet increased significantly from 26.96% (853/3164) in 2007 to 37.21% (1485/3991) in 2013. Similar patterns of demographic correlates were found for all 7 cohorts. Older patients (≥70 years) and patients with <10 years of formal education were less likely to use the Internet for information on topics related to their disease. Internet use was significantly higher among privately insured patients and patients living with a partner. Higher cancer stage and a foreign native language were associated with decreased use in the overall model. Type of surgery was not found to be associated with Internet use in the multivariable models. Intraclass correlation coefficients were small (0.00-0.03) suggesting only a small contribution of the hospital to the patients’ decision to use Internet information. There was no clear indication of a decreased digital divide based on age and education.

Conclusions

Use of the Internet for health information is on the rise among breast cancer patients. The strong age- and education-related differences raise the question of how relevant information can be adequately provided to all patients, especially to those with limited education, older age, and living without a partner.     

Organ procurement organizations Internet enrollment for organ donation: Abandoning informed consent

Background  

Requirements for organ donation after cardiac or imminent death have been introduced to address the transplantable organs shortage in the United States. Organ procurement organizations (OPOs) increasingly use the Internet for organ donation consent.