The Clinical Effectiveness of Web-Based Cognitive Behavioral Therapy With Face-to-Face Therapist Support for Depressed Primary Care Patients: Randomized Controlled Trial

Background

Most patients with mild to moderate depression receive treatment in primary care, but despite guideline recommendations, structured psychological interventions are infrequently delivered. Research supports the effectiveness of Internet-based treatment for depression; however, few trials have studied the effect of the MoodGYM program plus therapist support. The use of such interventions could improve the delivery of treatment in primary care.

Objective

To evaluate the effectiveness and acceptability of a guided Web-based intervention for mild to moderate depression, which could be suitable for implementation in general practice.

Methods

Participants (N=106) aged between 18 and 65 years were recruited from primary care and randomly allocated to a treatment condition comprising 6 weeks of therapist-assisted Web-based cognitive behavioral therapy (CBT), or to a 6-week delayed treatment condition. The intervention included the Norwegian version of the MoodGYM program, brief face-to-face support from a psychologist, and reminder emails. The primary outcome measure, depression symptoms, was measured by the Beck Depression Inventory-II (BDI-II). Secondary outcome measures included the Beck Anxiety Inventory (BAI), the Hospital Anxiety and Depression Scale (HADS), the Satisfaction with Life Scale (SWLS), and the EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D). All outcomes were based on self-report and were assessed at baseline, postintervention, and at 6-month follow-up.

Results

Postintervention measures were completed by 37 (71%) and 47 (87%) of the 52 participants in the intervention and 54 participants in the delayed treatment group, respectively. Linear mixed-models analyses revealed a significant difference in time trends between the groups for the BDI-II, (P=.002), for HADS depression and anxiety subscales (P<.001 and P=.001, respectively), and for the SWLS (P<.001). No differential group effects were found for the BAI and the EQ-5D. In comparison to the control group, significantly more participants in the intervention group experienced recovery from depression as measured by the BDI-II. Of the 52 participants in the treatment program, 31 (60%) adhered to the program, and overall treatment satisfaction was high. The reduction of depression and anxiety symptoms was largely maintained at 6-month follow-up, and positive gains in life satisfaction were partly maintained.

Conclusions

The intervention combining MoodGYM and brief therapist support can be an effective treatment of depression in a sample of primary care patients. The intervention alleviates depressive symptoms and has a significant positive effect on anxiety symptoms and satisfaction with life. Moderate rates of nonadherence and predominately positive evaluations of the treatment also indicate the acceptability of the intervention. The intervention could potentially be used in a stepped-care approach, but remains to be tested in regular primary health care.

Trial Registration

Australian New Zealand Clinical Trials Registry: ACTRN12610000257066; http://apps.who.int/trialsearch/trial.aspx?trialid=ACTRN12610000257066 (Archived by WebCite at http://www.webcitation.org/6Ie3YhIZa).     

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.     

Changes in depressive symptoms, social support, and loneliness over 1 year after a minimum 3-month videoconference program for older nursing home residents

Background

A 3-month videoconference interaction program with family members has been shown to decrease depression and loneliness in nursing home residents. However, little is known about the long-term effects on residents’ depressive symptoms, social support, and loneliness.

Objective

The purpose of this longitudinal quasi-experimental study was to evaluate the long-term effectiveness of a videoconference intervention in improving nursing home residents’ social support, loneliness, and depressive status over 1 year.

Methods

We purposively sampled 16 nursing homes in various areas of Taiwan. Elderly residents (N = 90) of these nursing homes meeting our inclusion criteria were divided into an experimental (n = 40) and a comparison (n = 50) group. The experimental group received at least 5 minutes/week for 3 months of videoconference interaction with their family members in addition to usual family visits, and the comparison group received regular family visits only. Data were collected in face-to face interviews on social support, loneliness, and depressive status using the Social Support Behaviors Scale, University of California Los Angeles Loneliness Scale, and Geriatric Depression Scale, respectively, at four times (baseline, 3 months, 6 months, and 12 months after baseline). Data were analyzed using the generalized estimating equation approach.

Results

After the videoconferencing program, participants in the experimental group had significantly lower mean change in instrumental social support scores at 6 months (–0.42, P = .03) and 12 months (–0.41, P = .03), and higher mean change in emotional social support at 3 (0.74, P < .001) and 12 months (0.61, P = .02), and in appraisal support at 3 months (0.74, P = .001) after adjusting for confounding variables. Participants in the experimental group also had significantly lower mean loneliness and depressive status scores at 3 months (–5.40, P < .001; –2.64, P < .001, respectively), 6 months (–6.47, P < .001; –4.33, P < .001), and 12 months (–6.27, P = .001; –4.40, P < .001) compared with baseline than those in the comparison group.

Conclusion

Our videoconference program had a long-term effect in alleviating depressive symptoms and loneliness for elderly residents in nursing homes. This intervention also improved long-term emotional social support and short-term appraisal support, and decreased residents’ instrumental social support. However, this intervention had no effect on informational social support.     

Chinese My Trauma Recovery,A Web-Based Intervention for Traumatized Persons in Two Parallel Samples: Randomized Controlled Trial

Background

Guided self-help interventions for PTSD (post-traumatic stress disorder) are a promising tool for the dissemination of contemporary psychological treatment.

Objective

This study investigated the efficacy of the Chinese version of the My Trauma Recovery (CMTR) website.

Methods

In an urban context, 90 survivors of different trauma types were recruited via Internet advertisements and allocated to a randomized controlled trial (RCT) with a waiting list control condition. In addition, in a rural context, 93 survivors mainly of the 2008 Sichuan earthquake were recruited in-person for a parallel RCT in which the website intervention was conducted in a counseling center and guided by volunteers. Assessment was completed online on a professional Chinese survey website. The primary outcome measure was the Post-traumatic Diagnostic Scale (PDS); secondary outcome measures were Symptom Checklist 90-Depression (SCL-D), Trauma Coping Self-Efficacy Scale (CSE), Post-traumatic Cognitive Changes (PCC), and Social Functioning Impairment (SFI) questionnaires adopted from the My Trauma Recovery website.

Results

For the urban sample, findings indicated a significant group×time interaction in post-traumatic symptom severity (F _1,88=7.65, P=.007). CMTR reduced post-traumatic symptoms significantly with high effect size after one month of treatment (F _1,45=15.13, Cohen’s d=0.81, P<.001) and the reduction was sustained over a 3-month follow-up (F _1,45=17.29, Cohen’s d=0.87, P<.001). In the rural sample, the group×time interaction was also significant in post-traumatic symptom severity (F _1,91=5.35, P=.02). Post-traumatic symptoms decreased significantly after treatment (F _1,48=43.97, Cohen’s d=1.34, P<.001) and during the follow-up period (F _1,48=24.22, Cohen’s d=0.99, P<.001). Additional outcome measures (post-traumatic cognitive changes, depression) indicated a range of positive effects, in particular in the urban sample (group×time interactions: F _1,88=5.32-8.37, all Ps<.03), contributing to the positive evidence for self-help interventions. Differences in the effects in the two RCTs are exploratorily explained by sociodemographic, motivational, and setting feature differences between the two samples.

Conclusions

These findings give support for the short-term efficacy of CMTR in the two Chinese populations and contribute to the literature that self-help Web-based programs can be used to provide mental health help for traumatized persons.

Trial Registration

Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611000951954; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12611000951954 (Archived by WebCite at http://www.webcitation.org/6G7WyNODk).     

Assessment of the Cost-Effectiveness and Clinical Outcomes of a Fourth-Generation Synchronous Telehealth Program for the Management of Chronic Cardiovascular Disease

Background

Telehealth programs are a growing field in the care of patients. The evolution of information technology has resulted in telehealth becoming a fourth-generation synchronous program. However, long-term outcomes and cost-effectiveness analysis of fourth-generation telehealth programs have not been reported in patients with chronic cardiovascular diseases.

Objective

We conducted this study to assess the clinical outcomes and cost-effectiveness of a fourth-generation synchronous telehealth program for patients with chronic cardiovascular diseases.

Methods

We retrospectively analyzed 575 patients who had joined a telehealth program and compared them with 1178 patients matched for sex, age, and Charlson comorbidity index. The program included: (1) instant transmission of biometric data, (2) daily telephone interview, and (3) continuous decision-making support. Data on hospitalization, emergency department (ED) visits, and medical costs were collected from the hospital’s database and were adjusted to the follow-up months.

Results

The mean age was 64.5 years (SD 16.0). The mean number of monthly ED visits (mean 0.06 SD 0.13 vs mean 0.09 SD 0.23, P<.001), hospitalizations (mean 0.05 SD 0.12 vs mean 0.11 SD 0.21, P<.001), length of hospitalization (mean 0.77 days SD 2.78 vs mean 1.4 SD 3.6, P<.001), and intensive care unit admissions (mean 0.01 SD 0.07 vs mean 0.036 SD 0.14, P<.001) were lower in the telehealth group. The monthly mean costs of ED visits (mean US$20.90 SD 66.60 vs mean US$37.30 SD 126.20, P<.001), hospitalizations (mean US$386.30 SD 1424.30 vs mean US$878.20 SD 2697.20, P<.001), and all medical costs (mean US$587.60 SD 1497.80 vs mean US$1163.60 SD 3036.60, P<.001) were lower in the telehealth group. The intervention costs per patient were US$224.80 per month. Multivariate analyses revealed that age, telehealth care, and Charlson index were the independent factors for ED visits, hospitalizations, and length of hospitalization. A bootstrap method revealed the dominant cost-effectiveness of telehealth care over usual care.

Conclusions

Better cost-effectiveness and clinical outcomes were noted with the use of a fourth-generation synchronous telehealth program in patients with chronic cardiovascular diseases. The intervention costs of this new generation of telehealth program do not increase the total costs for patient care.     

Determinants of Successful Weight Loss After Using a Commercial Web-Based Weight Reduction Program for Six Months: Cohort Study

Background

The Internet is widely available and commonly used for health information; therefore, Web-based weight loss programs could provide support to large parts of the population in self-guided weight loss. Previous studies showed that Web-based weight loss interventions can be effective, depending on the quality of the program. The most effective program tools are visual progress charts or tools for the self-monitoring of weight, diet, and exercises. KiloCoach, a commercial program currently available in German-speaking countries, incorporates these features. A previous investigation showed that the program effectively supports users in losing weight.

Objective

We investigated weight loss dynamics stratified by weight loss success after 6-month use of KiloCoach. Furthermore, we analyzed possible associations between intensity of program use and weight loss. The results are intended for tailoring user recommendations for weight-loss Internet platforms.

Methods

Datasets of KiloCoach users (January 1, 2008 to December 31, 2011) who actively used the platform for 6 months or more were assigned to this retrospective analysis. Users (N=479) were 42.2% men, mean age of 44.0 years (SD 11.7), with a mean body mass index (BMI) of 31.7 kg/m² (SD 3.2). Based on the weight loss achieved after 6 months, 3 success groups were generated. The unsuccessful group lost <5%, the moderate success group lost 5%-9.9%, and the high success group lost ≥10% of their baseline body weight. At baseline, the unsuccessful (n=261, 54.5%), moderate success (n=133, 27.8%), and high success (n=85, 17.8%) groups were similar in age, weight, BMI, and gender distribution.

Results

After 6 months, the unsuccessful group lost 1.2% (SD 2.4), the moderate success group lost 7.4% (SD 1.5), and the high success group lost 14.2% (SD 3.8) of their initial weight (P<.001). Multivariate regression showed that early weight loss (weeks 3-4), the total number of dietary protocols, and the total number of weight entries were independent predictors for 6-month weight reduction (all P<.001) explaining 52% of the variance in weight reduction. Sensitivity analysis by baseline carried forward method confirmed all independent predictors of 6-month weight loss and reduced the model fit by only 11%. The high success group lost weight faster and maintained weight loss more efficiently than the other groups (P<.001). Early weight loss was associated with weight maintenance after 1 year and 2 years (both P<.001). Weight dynamics did not differ between men and women over 6 months when adjusted for baseline and usage parameters (P=.91). The percentage of male long-term users was unusually high (42.2%).

Conclusions

Our results suggest that early weight loss and close program adherence (ie, 5 dietary protocols per week and weekly entering of current weight), especially in the early phase of program usage, can improve weight loss outcome.     

A Web-Based Sexual Violence Bystander Intervention for Male College Students: Randomized Controlled Trial

Background

Bystander intervention approaches offer promise for reducing rates of sexual violence on college campuses. Most interventions are in-person small-group formats, which limit their reach and reduce their overall public health impact.

Objective

This study evaluated the efficacy of RealConsent, a Web-based bystander approach to sexual violence prevention, in enhancing prosocial intervening behaviors and preventing sexual violence perpetration.

Methods

A random probability sample of 743 male undergraduate students (aged 18 to 24 years) attending a large, urban university located in the southeastern United States was recruited online and randomized to either RealConsent (n=376) or a Web-based general health promotion program (n=367). Participants were surveyed online at baseline, postintervention, and 6-months postintervention. RealConsent was delivered via a password-protected Web portal that contained six 30-minute media-based and interactive modules covering knowledge of informed consent, communication skills regarding sex, the role of alcohol and male socialization in sexual violence, empathy for rape victims, and bystander education. Primary outcomes were self-reported prosocial intervening behaviors and sexual violence perpetration. Secondary outcomes were theoretical mediators (eg, knowledge, attitudes).

Results

At 6-month follow-up RealConsent participants intervened more often (P=.04) and engaged in less sexual violence perpetration (P=.04) compared to controls. In addition, RealConsent participants reported greater legal knowledge of sexual assault (P<.001), greater knowledge of effective consent (P<.001), less rape myths (P<.001), greater empathy for rape victims (P<.001), less negative date rape attitudes (P<.001), less hostility toward women (P=.01), greater intentions to intervene (P=.04), less hyper-gender ideology (P<.001), less positive outcome expectancies for nonconsensual sex (P=.03), more positive outcome expectancies for intervening (P<.001), and less comfort with other men’s inappropriate behaviors (P<.001).

Conclusions

Our results support the efficacy of RealConsent. Due to its Web-based format, RealConsent has potential for broad-based dissemination thereby increasing its overall public health impact on sexual violence.

Trial Registration

Clinicaltrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT01903876","term_id":"NCT01903876"}}NCT01903876; http://clinicaltrials.gov/show/{"type":"clinical-trial","attrs":{"text":"NCT01903876","term_id":"NCT01903876"}}NCT01903876 (Archived by WebCite at http://www.webcitation.org/6S1PXxWKt).     

Predictors of In-Hospital Mortality Among Older Patients

OBJECTIVE:

The objective of this study was to determine predictors of in-hospital mortality among older patients admitted to a geriatric care unit.

INTRODUCTION:

The growing number of older individuals among hospitalized patients demands a thorough investigation of the factors that contribute to their mortality.

METHODS:

This was a prospective observational study implemented from February 2004 to October 2007 in a tertiary university hospital. A consecutive sample of 922 patients was evaluated for possible inclusion in this study. Patients hospitalized for palliative care, those who declined to participate, and those with incomplete data were excluded, resulting in a group of 856 patients aged 60 to 104 years. Bivariate and multivariate analyses were performed to determine associations between in-patient mortality and gender, age, length of stay, number of prescribed medications and diagnoses at admission, history of heart failure, neoplastic disease, immobility syndrome, delirium, infectious disease, and laboratory tests at admission (serum albumin and creatinine).

RESULTS:

The overall mortality rate was 16.4%. The following factors were associated with higher in-hospital mortality: delirium (OR=4.13, CI=2.65–6.44, P<.001), neoplastic disease (OR=3.38, CI=2.11–5.42, P<.001), serum albumin levels at admission <3.3mg/dL (OR=3.23, CI=2.03–5.13, P<.001), serum creatinine levels at admission ≥ 1.3mg/dL (OR=2.39, CI=1.53–3.72, P<.001), history of heart failure (OR=1.97, CI=1.20–3.22, P=.007), immobility (OR=1.84, CI=1.16–2.92, P =.009), and advanced age (OR=1.03, CI=1.01–1.06, P=.019).

CONCLUSIONS:

This study strengthens the perception of delirium as a mortality predictor among older inpatients. Cancer, immobility, low albumin levels, elevated creatinine levels, history of heart failure and advanced age were also related to higher mortality rates in this population.     

Effects of a multilingual information website intervention on the levels of depression literacy and depression-related stigma in Greek-born and Italian-born immigrants living in Australia: a randomized controlled trial

Background

Little is known about the efficacy of Internet-based information interventions in increasing depression literacy or reducing depression stigma and depressive symptoms in people from non–English-speaking backgrounds.

Objective

Our objective was to investigate the effects of Multicultural Information on Depression Online (MIDonline), an Internet-based multilingual depression-specific information resource, on depression literacy, depression stigma, and depressive symptoms in Greek-born and Italian-born immigrants to Australia.

Method

In all, 202 Greek- and Italian-born immigrants aged 48 to 88 years were randomly allocated to an online depression information intervention (n =110) or a depression interview control group (n = 92). Participants allocated to the information intervention only had access to the website during the 1- to 1.5-hour intervention session. The primary outcome measures were depression literacy (depression knowledge), personal stigma (personal stigma toward people with a mental illness), perceived stigma (participants’ views about the probable attitude of the general community toward people with mental illness), and depressive symptoms. Depression literacy, personal and perceived stigma, and depressive symptoms were assessed at preassessment, postassessment, and at a 1-week follow-up assessment. The trial was undertaken at Monash University, Melbourne, Australia. Randomization and allocation to trial group were carried out using a computer-generated table.

Results

For depression literacy, there was a significant difference between the MIDonline and the control group with those in the MIDonline intervention displaying higher depression literacy scores postassessment (F_1,178 = 144.99, P < .001) and at the follow-up assessment (F_1,178 = 129.13, P < .001) than those in the control group. In addition, those in the MIDonline intervention showed a significantly greater decrease in mean personal stigma scores postassessment (F_1,178 = 38.75, P < .001) and at the follow-up assessment (F_1,176 = 11.08, P = .001) than those in the control group. For perceived stigma, there was no significant difference between the MIDonline intervention and the control group at postassessment (F_1,178 = 0.60, P = .44) and at the follow-up assessment (F_1,176 = 1.06, P = .30). For level of depression, there was no significant difference between the MIDonline intervention and the control group at preassessment (F_1,201 = 0.56, P = .45), postassessment (F_1,178 = 0.03, P = .86), or at the follow-up assessment, (F _1,175 = 1.71, P = .19). Within group effect sizes for depression literacy were −1.78 (MIDonline) and −0.07 (control); for personal stigma, they were 0.83 (MIDonline) and 0.06 (control); for perceived stigma, they were 0.14 (MIDonline) and 0.16 (control); and for depressive symptoms, they were 0.10 (MIDonline) and 0.10 (control).

Conclusions

Current results suggested that the Internet may be a feasible and effective means for increasing depression knowledge and decreasing personal stigma in non–English-speaking immigrant populations residing in English-speaking countries. The lack of change in perceived stigma in this trial is consistent with results in other trials examining online depression stigma interventions in English-speaking groups.

Trial Registration

ISRCTN76460837; http://www.controlled-trials.com/ISRCTN76460837 (Archived by WebCite at http://www.webcitation.org/5xjxva4Uq)     

Health e-Cards as a Means of Encouraging Help Seeking for Depression Among Young Adults: Randomized Controlled Trial

Background

There is a need to identify interventions that increase help seeking for depression among young adults.

Objective

The aim was to evaluate a brief depression information intervention employing health e-cards (personalized emails containing links to health information presented on a Web page).

Methods

A randomized controlled trial was carried out with 348 19- to 24-year-olds drawn from the community. Participants were randomized to receive one of three conditions, all of which delivered a short series of health e-cards. Two active conditions involved the delivery of depression information designed to increase help-seeking behavior and intentions and to improve beliefs and knowledge associated with help seeking. A control arm delivered information about general health issues unrelated to depression. The primary outcome was help-seeking behavior. Secondary outcomes were help-seeking intentions; beliefs about the efficacy of depression treatments and help sources; ability to recognize depression; knowledge of the help-seeking process; and depressive symptoms. The study’s primary focus was outcomes relating to formal help seeking (consultation with a general practitioner or mental health professional) but also targeted behaviors, intentions, and beliefs relating to informal help seeking.

Results

Relative to the control condition, depression health e-cards were not associated with an increase in formal help-seeking behavior, nor were they associated with improved beliefs about depression treatments; ability to recognize depression; knowledge of the help-seeking process; or depressive symptoms. Depression e-cards were associated with improved beliefs about the overall efficacy of formal help sources (z = 2.4, P = .02). At post-intervention, participants in all conditions, relative to pre-intervention, were more likely to have higher intentions of seeking help for depression from a formal help source (t ₆₄₁ = 5.8, P < .001) and were more likely to rate interpersonal psychotherapy as being helpful (z = 2.0, P = .047). Depression e-cards were not associated with any significant changes in informal help-seeking behavior, intentions, or beliefs.

Conclusions

The study found no evidence that providing depression information in the form of brief e-cards encourages help seeking for depression among young adults. Involvement in the study may have been associated with increased help-seeking intentions among participants in all conditions, suggesting that mechanisms other than depression information may increase help seeking.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): ISRCTN98406912; http://www.controlled-trials.com/ISRCTN98406912/ISRCTN98406912 (Archived by WebCite at http://www.webcitation.org/5k221KiMi)     

Social influence as a driver of engagement in a web-based health intervention

Background

Web-based health interventions can drive behavior change, but their effectiveness depends on participants’ usage. A well-recognized challenge with these interventions is nonusage attrition or weak engagement that results in participants receiving low doses of the intervention, negatively affecting outcomes. We present an approach based on the theoretical concepts of social influence and complex contagion in an effort to address the engagement problem in a specific, commercial, online behavior change intervention.

Objective

To examine the relation between social ties and engagement within a specific online intervention. The aims were (1) to determine whether experiencing the intervention socially influences engagement, such that individuals with social ties show higher engagement than those without ties, and (2) to evaluate whether complex contagion increases engagement—that is, whether engagement increases as the number of ties an individual has in the intervention increases.

Methods

We analyzed observational data from 84,828 subscribed members of a specific Web-based intervention, Daily Challenge. We compiled three measures of engagement for every member: email opens, site visits, and challenge completions (response to action prompts). We compared members with and without social ties within the intervention on each measure separately using 2-tailed independent-sample t tests. Finally, we performed linear regressions with each simple engagement measure as the dependent variable and number of social ties as the independent variable.

Results

Compared with those without social ties, participants with social ties opened more emails (33.0% vs 27.2%, P < .001), visited the website more often (12.6 vs 6.7 visits, P < .001), and reported completing more of the actions they were prompted to perform (11.0 vs 6.1 actions, P < .001). Social ties were significant predictors of email opens (beta = 0.68, P < .001), site visits (beta = 1.52, P < .001), and reported action completions (beta = 1.32, P < .001).

Conclusions

Our initial findings are higher engagement in participants with social ties in the program and are consistent with the view that social influence can drive engagement in a Web-based health intervention.     

A Service-Based Evaluation of a Therapist-Supported Online Cognitive Behavioral Therapy Program for Depression

Background

Evidence suggests that Internet-delivered cognitive behavioral therapy (CBT) may be as effective as face-to-face delivery for depression, but attrition and engagement rates remain a challenge.

Objective

This service-based study aimed to evaluate an online, therapist-supported, CBT-based program for depression. The program was specifically designed to address engagement issues, most notably by integrating online therapist support and communication within the platform.

Methods

Participants were 80 adults who were registered university students. Participants used the modular online program over 8 weeks, supported by a therapist. Engagement information was gathered automatically by the online system, and analyzed for all participants. Severity of participants’ self-reported symptoms of depression were assessed preintervention and postintervention using the Beck Depression Inventory-II (BDI-II). Postintervention measures were completed by 53 participants.

Results

A high level of engagement was observed compared to a previous study within the same service, along with extensive use of a range of program features. A statistically significant (P<.001) decrease in self-reported depressive symptomatology from preintervention (mean BDI-II 25.47) to postintervention (mean BDI-II 15.53) with a large effect size (d=1.17) was also observed.

Conclusions

The results indicate the potential of unintrusive and easily provided online support to enhance engagement with online interventions. The system described in the paper also illustrates how such online support can be tightly integrated with interactive online programs by using a range of design strategies intended to improve the user experience.     

Perceived frequency of peer-assisted learning in the laboratory and collegiate clinical settings

Context:

Peer-assisted learning (PAL) has been recommended as an educational strategy to improve students'' skill acquisition and supplement the role of the clinical instructor (CI). How frequently students actually engage in PAL in different settings is unknown.

Objective:

To determine the perceived frequency of planned and unplanned PAL (peer modeling, peer feedback and assessment, peer mentoring) in different settings.

Design:

Cross-sectional study.

Setting:

Laboratory and collegiate clinical settings.

Patients or Other Participants:

A total of 933 students, 84 administrators, and 208 CIs representing 52 (15%) accredited athletic training education programs.

Intervention(s):

Three versions (student, CI, administrator) of the Athletic Training Peer Assisted Learning Survey (AT-PALS) were administered. Cronbach α values ranged from .80 to .90.

Main Outcome Measure(s):

Administrators'' and CIs'' perceived frequency of 3 PAL categories under 2 conditions (planned, unplanned) and in 2 settings (instructional laboratory, collegiate clinical). Self-reported frequency of students'' engagement in 3 categories of PAL in 2 settings.

Results:

Administrators and CIs perceived that unplanned PAL (0.39 ± 0.22) occurred more frequently than planned PAL (0.29 ± 0.19) regardless of category or setting (F_1,282 = 83.48, P < .001). They perceived that PAL occurred more frequently in the collegiate clinical (0.46 ± 0.22) than laboratory (0.21 ± 0.24) setting regardless of condition or category (F_1,282 = 217.17, P < .001). Students reported engaging in PAL more frequently in the collegiate clinical (3.31 ± 0.56) than laboratory (3.26 ± 0.62) setting regardless of category (F_1,860 = 13.40, P < .001). We found a main effect for category (F_2,859 = 1318.02, P < .001), with students reporting they engaged in peer modeling (4.01 ± 0.60) more frequently than peer mentoring (2.99 ± 0.88) (P < .001) and peer assessment and feedback (2.86 ± 0.64) (P < .001).

Conclusions:

Participants perceived that students engage in unplanned PAL in the collegiate clinical setting with a stronger inclination toward engagement in peer modeling. Educators should develop planned PAL activities to capitalize on the inherent desire of the students to collaborate with their peers.     

Heat stress and cardiovascular, hormonal, and heat shock proteins in humans

Context:

Conditions such as osteoarthritis, obesity, and spinal cord injury limit the ability of patients to exercise, preventing them from experiencing many well-documented physiologic stressors. Recent evidence indicates that some of these stressors might derive from exercise-induced body temperature increases.

Objective:

To determine whether whole-body heat stress without exercise triggers cardiovascular, hormonal, and extra-cellular protein responses of exercise.

Design:

Randomized controlled trial.

Setting:

University research laboratory.

Patients or Other Participants:

Twenty-five young, healthy adults (13 men, 12 women; age = 22.1 ± 2.4 years, height = 175.2 ± 11.6 cm, mass = 69.4 ± 14.8 kg, body mass index = 22.6 ± 4.0) volunteered.

Intervention(s):

Participants sat in a heat stress chamber with heat (73°C) and without heat (26°C) stress for 30 minutes on separate days. We obtained blood samples from a subset of 13 participants (7 men, 6 women) before and after exposure to heat stress.

Main Outcome Measure(s):

Extracellular heat shock protein (HSP72) and catecholamine plasma concentration, heart rate, blood pressure, and heat perception.

Results:

After 30 minutes of heat stress, body temperature measured via rectal sensor increased by 0.8°C. Heart rate increased linearly to 131.4 ± 22.4 beats per minute (F_6,24 = 186, P < .001) and systolic and diastolic blood pressure decreased by 16 mm Hg (F_6,24 = 10.1, P < .001) and 5 mm Hg (F_6,24 = 5.4, P < .001), respectively. Norepinephrine (F_1,12 = 12.1, P = .004) and prolactin (F_1,12 = 30.2, P < .001) increased in the plasma (58% and 285%, respectively) (P < .05). The HSP72 (F_1,12 = 44.7, P < .001) level increased with heat stress by 48.7% ± 53.9%. No cardiovascular or blood variables showed changes during the control trials (quiet sitting in the heat chamber with no heat stress), resulting in differences between heat and control trials.

Conclusions:

We found that whole-body heat stress triggers some of the physiologic responses observed with exercise. Future studies are necessary to investigate whether carefully prescribed heat stress constitutes a method to augment or supplement exercise.     

Patients’ Experiences of Helpfulness in Guided Internet-Based Treatment for Depression: Qualitative Study of Integrated Therapeutic Dimensions

Background

Quantitative research on Internet-based cognitive behavioral therapy (ICBT) has collected substantial evidence for the effectiveness of this treatment approach on health outcomes. Less is known about how patients find ICBT to be generally meaningful and helpful for treating depression.

Objective

To explore patients’ experiences of being in ICBT treatment with a focus on the treatment dimensions that they considered helpful.

Methods

Choosing a phenomenological-hermeneutical approach, 14 patients were interviewed with semistructured qualitative interviews to elicit their understanding of using ICBT. The patients took part in a clinical trial using ICBT with MoodGYM, which also featured brief consultations with a clinical psychologist. The interviews were transcribed and analyzed according to the chosen methodology and organized into significant themes.

Results

The phenomenological-hermeneutical analysis identified 5 themes relating overall to the meaning of this mode of treatment in terms of helpfulness. Two related to treatment in general: (1) taking action to address one’s problems and (2) the value of talking to a professional. The next two themes specifically addressed guided self-help using the MoodGYM program: (3) acquiring relevant knowledge, and (4) restructuring the new knowledge acquired through ICBT. A fifth theme concerned (5) actual changes in patients’ perceptions and interactions, related to either the self-help material or the face-to-face consultations with the therapist.

Conclusions

Three important dimensions were made explicit: the active engagement of the patient, the guidance of the therapist, and the content of the treatment program. The findings pointed to (1) the role of MoodGYM as a source of new knowledge providing patients with a structured approach to work with their depression, (2) the patient’s role as the primary agent of change through adapting relevant knowledge from MoodGYM to their situation, and (3) the dialogue with the therapist as a trusting relationship in which to share thoughts and feelings, receive feedback and advice, and to assist the patient in making use of the MoodGYM content.     

Comparison of recovery strategies on maximal force-generating capacity and electromyographic activity level of the knee extensor muscles

Context:

With regard to intermittent training exercise, the effects of the mode of recovery on subsequent performance are equivocal.

Objective:

To compare the effects of 3 types of recovery intervention on peak torque (PT) and electromyographic (EMG) activity of the knee extensor muscles after fatiguing isokinetic intermittent concentric exercise.

Design:

Crossover study.

Setting:

Research laboratory.

Patients or Other Participants:

Eight elite judo players (age = 18.4 ± 1.4 years, height = 180 ± 3 cm, mass = 77.0 ± 4.2 kg).

Interventions :

Participants completed 3 randomized sessions within 7 days. Each session consisted of 5 sets of 10 concentric knee extensions at 80% PT at 120°/s, with 3 minutes of recovery between sets. Recovery interventions were passive, active, and electromyostimulation. The PT and maximal EMG activity were recorded simultaneously while participants performed isokinetic dynamometer trials before and 3 minutes after the resistance exercise.

Main Outcome Measure(s):

The PT and maximal EMG activity from the knee extensors were quantified at isokinetic velocities of 60°/s, 120°/s, and 180°/s, with 5 repetitions at each velocity.

Results:

The reduction in PT observed after electromyo-stimulation was less than that seen after passive (P < .001) or active recovery (P < .001). The reduction in PT was less after passive recovery than after active recovery (P < .001). The maximal EMG activity level observed after electromyostimulation was higher than that seen after active recovery (P < .05).

Conclusions:

Electromyostimulation was an effective recovery tool in decreasing neuromuscular fatigue after high-intensity, intermittent isokinetic concentric exercise for the knee extensor muscles. Also, active recovery induced the greatest amount of neuromuscular fatigue.     

Two Fully Automated Web-Based Interventions for Risky Alcohol Use: Randomized Controlled Trial

Background

Excessive alcohol use is a widespread problem in many countries, especially among young people. To reach more people engaging in high-risk drinking behaviors, a number of online programs have been developed in recent years. Change Your Drinking is a German, diary-based, fully automated alcohol intervention. In 2010, a revised version of the program was developed. It is more strongly oriented to concepts of relapse prevention than the previous version, includes more feedback, and offers more possibilities to interact with the program. Moreover, the program duration was extended from 10 to 14 days.

Objective

This paper examines whether the revised version of Change Your Drinking is more effective in reducing alcohol consumption than the original version.

Methods

The effectiveness of both program versions was compared in a Web-based, open, randomized controlled trial with follow-up surveys 6 weeks and 3 months after registration. Participants were recruited online and were randomly assigned to either the original or the revised version of Change Your Drinking. The following self-assessed outcomes were used: alcohol use days, alcohol intake in grams, the occurrence of binge drinking and risky drinking (all referring to the past 7 days prior to each survey), and the number of alcohol-related problems.

Results

A total of 595 participants were included in the trial. Follow-up rates were 58.0% after 6 weeks and 49.6% after 3 months. No significant group differences were found in any of the outcomes. However, the revised version was used by more participants (80.7%) than the original version (55.7%). A significant time effect was detected in all outcomes (alcohol use days: P=.002; alcohol intake in grams: P<.001; binge drinking: P<.001; alcohol-related problems: P=.004; risky drinking: P<.001).

Conclusions

The duration and complexity of the program played a minor role in reducing alcohol consumption. However, differences in program usage between the versions suggest the revised version was more attractive to participants.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 31586428; http://www.controlled-trials.com/ISRCTN31586428/ (Archived by WebCite at http://www.webcitation.org/6BFxApCUT)     

Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders

Background

For youth living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), nonadherence to antiretroviral therapy (ART) can lead to poor health outcomes and significantly decreased life expectancy.

Objective

To evaluate the feasability, acceptability, and preliminary efficacy of short message service (SMS) or text message reminders to improve adherence to ART for youth living with HIV/AIDS.

Methods

We conducted this prospective pilot study using a pre–post design from 2009 to 2010 at a community-based health center providing clinical services to youth living with HIV/AIDS. Eligibility criteria included HIV-positive serostatus, age 14–29 years, use of a personal cell phone, English-speaking, and being on ART with documented poor adherence. During the 24-week study period, participants received personalized daily SMS reminders and a follow-up message 1 hour later assessing whether they took the medication, and asking participants to respond via text message with the number 1 if they took the medication and 2 if they did not. Outcome measures were feasibility, acceptability, and adherence. Self-reported adherence was determined using the visual analog scale (VAS) and AIDS Clinical Trial Group (ACTG) questionnaire 4-day recall. Viral load and CD4 cell count were followed as biomarkers of adherence and disease progression at 0, 12, and 24 weeks.

Results

Participants (N = 25) were mean age 23 (range 14–29) years, 92% (n = 23) male, 60% (n = 15) black, and 84% (n = 21) infected through unprotected sex. Mean VAS scores significantly increased at 12 and 24 weeks in comparison with baseline (week 0: 74.7, week 12: 93.3, P < .001; week 24: 93.1, P < .001). ACTG questionnaire 4-day recall also improved (week 0: 2.33, week 12: 3.24, P = .002; week 24: 3.19, P = .005). There was no significant difference in CD4 cell count or viral load between baseline and 12- or 24-week follow-up, although there was a trend toward improvement of these biomarkers and a small to moderate standardized effect size (range of Cohen d: –0.51 to 0.22). Of 25 participants, 21 (84%) were retained, and 20 of the 21 (95%) participants who completed the study found the intervention helpful to avoid missing doses.

Conclusions

In this pilot study, personalized, interactive, daily SMS reminders were feasible and acceptable, and they significantly improved self-reported adherence. Larger controlled studies are needed to determine the impact of this intervention on ART adherence and other related health outcomes for youth living with HIV/AIDS.