Trends Influencing Future Delivery of Mental Health Services in Large Healthcare Systems

The delivery of mental health services, particularly psychotherapy and other psychosocial care, is being increasingly limited by financial constraints. We briefly review three trends that will play an increasingly important role in the delivery of mental health services in large organizations such as health maintenance organizations. These are (a) an increasing role for self-help and bibliotherapy interventions, both in traditional and electronic formats; (b) mental health services being offered in settings other than mental health specialty clinics; and (c) an increased emphasis on mechanisms for improving the quality and type of services offered, including quality improvement methods and pay-for-performance.     

Treatment feasibility of a digital tool for brief self-help behavioural therapy for insomnia (FastAsleep)

Cognitive behavioural therapy for insomnia is efficacious and recommended for insomnia, but availability is scarce. Cognitive behavioural therapy for insomnia self-help interventions could increase availability, especially if unguided. Optimizing cognitive behavioural therapy for insomnia methods and system user-friendliness, we developed a short, digital, self-help programme—FastAsleep—based on the behavioural components of sleep restriction and stimulus control. This study investigated its feasibility and preliminary effects. Thirty media-recruited participants with moderate to severe insomnia were assessed via telephone before using FastAsleep for 4 weeks, and were interviewed afterwards. Self-ratings with web questionnaires were conducted at screening, pre-, mid- and post-treatment, and at 3-month follow-up. Primary outcomes were feasibility (credibility, adherence, system user-friendliness and adverse effects), and secondary outcomes were changes in symptom severity (insomnia, depression and anxiety). Adherence was generally high, participants' feasibility ratings were favourable, and adverse effects matched previously reported levels for cognitive behavioural therapy for insomnia. Symptoms of insomnia decreased after the treatment period (Hedge's g = 1.79, 95% confidence interval = 1.20–2.39), as did symptoms of depression and anxiety. FastAsleep can be considered feasible and promising for alleviating insomnia symptoms among patients fit for self-care. Future controlled trials are needed to establish the efficacy of FastAsleep and its suitability in a stepped care model.     

Participation in 12-Step-Based Fellowships Among Dually-Diagnosed Persons

Abstract

Twelve-step groups (12SG), a useful recovery resource, are underutilized by dually-diagnosed persons. There has been little empirical research in this area. This study followed members of a dual-focus 12-step-based fellowship (N = 277) over one year to gain a greater understanding of participation in both specialized dual focus and traditional 12SG among dually-diagnosed persons, including reasons for attending, perceived benefits of and obstacles to affiliation, and predictors of affiliation. Findings indicate that dually-diagnosed persons do engage in both types of fellowships; patterns of engagement differed across fellowships, suggesting different comfort levels. Both types of fellowships were used to deal with addiction. Greater difficulty with substance use at baseline was associated with greater likelihood of attending 12SG at follow-up; the reverse was true for self-reported substance use at baseline. Findings are discussed in light of existing literature and clinical implications are suggested.     

Changes in Locus-of-Control Attitudes about Drug Misuse in a Self-Help Group in a Methadone Maintenance Clinic

Clients of a methadone-maintenance clinic in Brooklyn, New York participating in a clinically-guided self-help (CGSH) program plus standard treatment (methadone maintenance plus individual counseling) demonstrated statistically significant changes in locus-of-control beliefs, from external to internal causation, about personal responsibility for drug misuse. Members of two control groups—one participating in a didactic lecture program plus standard treatment and the other receiving only standard treatment—failed to demonstrate similar changes. This increase in internal locus of control in the CGSH group suggests the potential efficacy of CGSH as a relapse-prevention therapeutic technique.     

Intensive Referral of Veterans to Mutual-Help Groups: A Mixed-Methods Implementation Evaluation

Community-based support group participation protects against substance use disorder (SUD) relapse, but referrals during treatment are inconsistently delivered and may not acknowledge barriers facing rural patients. This formative evaluation of a rural intensive referral intervention (RAIR) to community-based support groups for Veterans seeking SUD treatment surveyed patients (n = 145) and surveyed and interviewed treatment staff (n = 28). Patients and staff did not differ significantly on quantitative ratings of the helpfulness of, or satisfaction with, seven RAIR components, but staff did not deliver the intervention consistently or as designed, citing two themes: lack of commitment and lack of resources.     

Differences in outcomes between the JoyBar control and standard wheelchair joystick control on two maneuverability tasks: a pilot study

Purpose: To determine if older adult, novice wheelchair users who drive a power wheelchair with a JoyBar control complete maneuverability tasks in less time and with less error than those who drive a power wheelchair with a standard joystick control.

Materials and methods: A parallel randomized controlled trial design conducted at a medical rehabilitation and research centre with ambulatory older adults aged 60 and above (n?=?27). The intervention was the JoyBar alternative wheelchair control. The primary outcome measure was total time to complete each of the two maneuverability tasks. The secondary outcome measure was total number of errors during each of the maneuverability tasks.

Results: An independent, two sampled t-test was conducted and revealed that the JoyBar group took a greater amount of time to complete both maneuverability tasks than the control group (p?p?Conclusions: Maneuverability of a powered wheelchair by novice wheelchair users was not improved through the use of the JoyBar when compared to a standard wheelchair joystick, as measured by rates of error and time to complete maneuverability tasks.

• Implications for rehabilitation

• Clients who are new to powered wheelchair use may perform maneuverability tasks faster, with equivalent accuracy, using a standard joystick versus the JoyBar.

• Clients who use a JoyBar may require adjustments to the programming of their wheelchair to ensure optimal performance.

• Additional training may be required to achieve proficiency in maneuverability tasks with a JoyBar versus a standard joystick.

     

Randomised controlled non-inferiority trial with 3-year follow-up of internet-delivered versus face-to-face group cognitive behavioural therapy for depression

Background

Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in the treatment of mild to moderate depression, but there have been no direct comparisons with the more established group-based CBT with a long-term follow-up.

Method

Participants with mild to moderate depression were recruited from the general population and randomized to either guided ICBT (n=33) or to live group treatment (n=36). Measures were completed before and after the intervention to assess depression, anxiety, and quality of life. Follow-ups were conducted at one-year and three-year after the treatment had ended.

Results

Data were analysed on an intention-to-treat basis using linear mixed-effects regression analysis. Results on the self-rated version of the Montgomery–Åsberg Depression Scale showed significant improvements in both groups across time indicating non-inferiority of guided ICBT, and there was even a tendency for the guided ICBT group to be superior to group-based CBT at three year follow-up. Within-group effect sizes for the ICBT condition at post-treatment showed a Cohen′s d=1.46, with a similar large effect at 3-year follow-up, d=1.78. For the group CBT the corresponding within-group effects were d=0.99 and d=1.34, respectively.

Limitations

The study was small with two active treatments and there was no placebo or credible control condition.

Conclusions

Guided ICBT is at least as effective as group-based CBT and long-term effects can be sustained up to 3 years after treatment.     

Smartphones for Smarter Delivery of Mental Health Programs: A Systematic Review

Background

The rapid growth in the use of mobile phone applications (apps) provides the opportunity to increase access to evidence-based mental health care.

Objective

Our goal was to systematically review the research evidence supporting the efficacy of mental health apps for mobile devices (such as smartphones and tablets) for all ages.

Methods

A comprehensive literature search (2008-2013) in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, PsycINFO, PsycTESTS, Compendex, and Inspec was conducted. We included trials that examined the effects of mental health apps (for depression, anxiety, substance use, sleep disturbances, suicidal behavior, self-harm, psychotic disorders, eating disorders, stress, and gambling) delivered on mobile devices with a pre- to posttest design or compared with a control group. The control group could consist of wait list, treatment-as-usual, or another recognized treatment.

Results

In total, 5464 abstracts were identified. Of those, 8 papers describing 5 apps targeting depression, anxiety, and substance abuse met the inclusion criteria. Four apps provided support from a mental health professional. Results showed significant reductions in depression, stress, and substance use. Within-group and between-group intention-to-treat effect sizes ranged from 0.29-2.28 and 0.01-0.48 at posttest and follow-up, respectively.

Conclusions

Mental health apps have the potential to be effective and may significantly improve treatment accessibility. However, the majority of apps that are currently available lack scientific evidence about their efficacy. The public needs to be educated on how to identify the few evidence-based mental health apps available in the public domain to date. Further rigorous research is required to develop and test evidence-based programs. Given the small number of studies and participants included in this review, the high risk of bias, and unknown efficacy of long-term follow-up, current findings should be interpreted with caution, pending replication. Two of the 5 evidence-based mental health apps are currently commercially available in app stores.