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Introduction: Internet interventions for alcohol problems are effective, but not all participants are helped. Further, the importance of adherence has often been neglected in research on internet interventions for alcohol problems. Prediction analysis can help in prospectively assessing participants’ probability of success, and ideally, this information could be used to tailor internet interventions to individual needs. Methods: Data were obtained from a randomized controlled trial on internet interventions for alcohol use disorders. Twenty-nine candidate predictors were run in univariate logistic regressions with two dichotomous dependent outcomes: adherence (defined as completing at least 60% of the treatment modules) and low-risk drinking (defined as drinking within national public health guidelines) at two time points – immediately post-treatment and at the 6-month follow-up. Significant predictors were entered hierarchically into domain-specific logistic regressions. In the final models, predictors still showing significant effects were run in multiple logistic regressions. Results: One predictor significantly predicted adherence: treatment credibility (as in how logical the treatment is and how successful one perceives the treatment to be) assessed during the third week of the intervention. Four predictors significantly predicted low-risk drinking at the post-treatment follow-up: pre-treatment abstinence (i.e., not drinking during the 7 days before treatment started), being of the male gender, and two personality factors – a low degree of antagonism and a high degree of alexithymia. At the 6-month follow-up, pre-treatment abstinence was the only significant predictor. Conclusion: Adherence was not predictive of low-risk drinking. Personality variables may have predictive value and should be studied further. Those who abstain from alcohol during the week before treatment starts have a higher likelihood of achieving low-risk drinking than people who initially continue drinking.

Interventions intended to reduce the consumption of dietary sugars among those population groups demonstrating disproportionately greater and more frequent consumption of sugar-sweetened beverages and foods (SSBF) would benefit from intervention strategies that are tailored to population-specific barriers and facilitators. The objective of this study was to develop and evaluate the acceptability of photo-enhanced and theory-based health promotion messages that target the reduction in SSBF among adult residents of public housing developments, a population known for their high rates of chronic disease. Using the message development tool as a framework, we developed a series of 15 SSBF reduction messages, using an iterative process with community member input. We then evaluated the acceptability of the messages and compared three delivery mechanisms: print, text, and social media. We recruited participants who were residents of urban public housing developments, and who spoke either English or Spanish. A majority of participants identified as being of Hispanic ethnicity (73%). The message acceptability scoring did not appear to differ according to the assigned delivery mechanism, despite some imbalances in participants’ characteristics across delivery mechanisms. The messages that targeted motivation were least likely to be accepted. In conclusion, our findings suggest that engaging members of the community at all phases of the development process was a feasible method to develop SSBF reduction messages with a high perceived acceptability.

Objectives Difficulties with sexual desire impact up to a third of women and most do not seek or receive appropriate care for these complaints, in part due to stigma, embarrassment, and limited availability of treatment. In-person mindfulness-based interventions have lasting benefits to sexual desire and sex-related distress in controlled clinical trials but are difficult to access. Online cognitive-behavioral interventions for sexual concerns have shown promising findings, but online mindfulness interventions have received little testing. The current study assessed the feasibility of an online program (called eSense-Mindfulness) adapted from an effective face-to-face intervention for women with Sexual Interest/Arousal Disorder. Methods Thirty cisgender women (M age = 35.3) with Sexual Interest/Arousal Disorder consented and completed at least one of the eight modules of eSense-Mindfulness while providing weekly feedback regarding their experience. Feasibility was assessed via attrition rates and participant self-report regarding challenges of using the program. Limited efficacy testing was based on effect sizes for changes in sexual response and sex-related distress. Results Participants (n = 25 who completed all testing) reported high levels of usability and ease of understanding content and reported the mindfulness exercises as well as the information on partner communication to be the most relevant. Limited efficacy testing showed large effect sizes for reductions in sex-related distress, and improvements in sexual desire, arousal, and satisfaction whereas there were smaller effect sizes for improvements in lubrication, orgasm, and vaginal pain. Conclusions The findings suggest that efficacious face-to-face mindfulness interventions for sexual dysfunction in women show excellent evidence of feasibility when delivered online without personalized guidance.

Background: Digital mental health (DMH) provides effective methods of overcoming issues of time constraints, accessibility, and availability of mental health care. They can provide a valuable means...

Studies that look to disseminate psychological therapies in different countries often discuss whether and how much cultural adaptation may be required. However, most do not provide sufficient descriptions of how language translation and cultural adaptations were performed, and rarely give examples of specific changes. This makes it hard to understand how much the adapted treatment differs from the original, causing difficulty when comparing studies. This study aimed to describe the translation and cultural adaptation process used to generate a Japanese version of a UK-developed online psychological therapy for social anxiety. It aimed to evaluate the translated and adapted content with a case series of Japanese patients. Following translation and back-translation, incorporating cultural adaptations where appropriate, the new Japanese content was reviewed and a list of adaptations collated and categorised. The Japanese treatment material was then evaluated using a guided self-study approach with six Japanese patients with social anxiety. Four categories of adaptation were identified: Linguistics and Metaphors, Social Systems, Social Behaviours, and Familiarity. Assigning instances of adaptation into these categories showed good interrater reliability (0.78). The Japanese materials showed excellent treatment efficacy (pre-post Hedges’ g = 2.31). Patient feedback highlighted areas of strength, and further suggestions to improve suitability for Japanese settings. The clinical outcomes observed suggest that the translation and adaptation procedures were effective. Ways of further improving the adaptation based on patient feedback were identified. It is hoped that the translation procedure and adaptation categories described in this study may help other clinicians/researchers working to disseminate both online or in-person psychological therapies cross-culturally.

La depresión es un trastorno mental que puede limitar gravemente el funcionamiento cotidiano de las personas y también reducir la calidad de vida (Malhi y Mann, 2018). Su prevalencia es alta a nivel mundial y es una de las principales causas de discapacidad (WHO, 2017). Millones de personas padecen trastornos depresivos, afectando principalmente a adultos jóvenes en edad económicamente activa (PAHO, 2018). Los países de la región americana como Ecuador superan el 4% de prevalencia, lo que puede representar hasta el 10% de los años vividos con discapacidad (Kohn et al., 2018). Los efectos adversos de la depresión son complejos y pueden incluso llevar a desenlaces fatales como el suicidio, condición que ha sido catalogada como un problema de salud pública en América Latina y en todo el mundo. La identificación y diagnóstico de la depresión suponen un reto importante en salud pública, debido principalmente a barreras como el estigma asociado a padecer un trastorno mental (Stuart, 2016) o la a falta de recursos de diversa índole, como sistemas de salud deficientes, carencia de personal entrenado, falta de tiempo por parte de los profesionales de salud, etc. (Kroenke y Unützer, 2017; Gilbody et al., 2005). Sin embargo, durante los últimos años, diversas investigaciones han conducido al desarrollo de instrumentos psicológicos que han facilitado el tamizaje y diagnóstico de la depresión (El-Den et al., 2018), aunque se ha discutido ampliamente sobre la validez para la aplicación de estos instrumentos en contextos distintos a donde fueron creados (Haroz et al., 2017; Figueira et al., 2009). El uso de instrumentos de cribado para depresión, que sean debidamente validados y/o adaptados al entorno cultural de cada región, es crucial a la hora de tomar decisiones terapéuticas, especialmente en los países de bajos y medianos recursos (PBMI) ya que estas herramientas pueden aplicarse en los lugares donde los servicios de salud mental son limitados.Actualmente, diversas alternativas para el tratamiento de la depresión incluyen psicofármacos y/o intervenciones psicológicas basadas en evidencia (IPBE) como la terapia cognitivo conductual o la terapia interpersonal (Ramanuj et al., 2019; NICE, 2021), aunque en el presente, muchas personas todavía no pueden acceder a tratamientos adecuados, sobre todo en los PBMI (Kohn 2018). Sin embargo, cada vez se incrementan los esfuerzos para su diseminación (Cuijpers et al., 2018). De este modo, se ha evidenciado un creciente desarrollo de estudios que pretenden comprobar la efectividad de las IPBE en grupos culturalmente diversos (Hall et al., 2016). Estas investigaciones han demostrado que un proceso adecuado de adaptaciones culturales en las IPBE genera mejores resultados en términos de efectividad y adherencia a los tratamientos en estas poblaciones (Hall et al., 2019). Por otra parte, el rápido desarrollo tecnológico de los últimos años y la amplia cobertura de Internet en todo el mundo ha permitido incrementar la capacidad de diseminación de intervenciones psicológicas digitales, incluso en regiones con limitados servicios de salud mental (Fairburn y Patel, 2017). Un gran número de estudios demuestran que la aplicación de estas intervenciones digitales para tratar la depresión y otros trastornos psicológicos han demostrado ser eficaces para reducir sus síntomas, destacando el fácil acceso y sugiriendo que puede mejorar la aceptación del tratamiento al reducir el miedo a la estigmatización (Andersson y Titov, 2014). Dentro de las múltiples intervenciones digitales, unas de las más estudiadas en los últimos años son las intervenciones basadas en Internet (IBI) (Toköz et al., 2021). Las IBI son intervenciones generalmente autoadministradas a través de Internet que se basan en protocolos de terapia presencial tradicionales de diferentes enfoques terapéuticos (Richards et al., 2018; Webb et al., 2017). La terapia cognitiva basada en Internet (TCBI) para el tratamiento de la depresión es particularmente la más estudiada (Andersson, Carlbring et al., 2019; Fairburn y Patel, 2017). Las IBI han acumulado amplia evidencia empírica que sugiere niveles de eficacia comparables a los tratamientos psicológicos tradicionales cara a cara (Carlbring et al., 2018). Sin embargo, a pesar de los datos prometedores de las IBI para el manejo de la depresión, los datos sobre las tasas de abandono son elevados, por lo que existe gran interés en comprender los diversos factores que influyen en la adherencia a los nuevos formatos de tratamiento (Carlbring., 2018; Van Ballegooijen et al., 2014), así, analizar el soporte que se proporciona junto a las IBI (Baumeister et al. 2014) y las opiniones de usuarios y desarrolladores de IBI (Breedvelt et al., 2019) aportaría valiosa información. Finalmente, a pesar de los beneficios de las IBI como la rentabilidad, la accesibilidad o la escalabilidad que han sido reportados en múltiples estudios en países de altos ingresos (Andersson y Titov, 2014; Andersson et al., 2014), en la actualidad se han conducido muy pocos estudios en PBMI. En Latinoamérica, por ejemplo, se han identificado 4 estudios de eficacia a través de ensayos controlados aleatorizados para el tratamiento de la depresión a través de 2 revisiones sistemáticas recientes (Carter et al., 2021; Jiménez-Molina et al., 2019). Por tanto, parece que las IBI pueden tener un gran potencial como recurso terapéutico. Sin embargo, se necesitan más estudios para identificar las alternativas más rentables para el tratamiento de la depresión, especialmente en entornos con una mayor carencia de atención a la salud mental como en los PBMI (Fairburn y Patel, 2017). Objetivos Como ya se mencionó anteriormente, las dificultades en cuanto a la identificación y diagnóstico de la depresión, así como la brecha de acceso a tratamientos adecuados suponen un gran reto para los servicios de salud en general, por esta razón, el empleo de instrumentos de cribado correctamente validados y el uso de intervenciones basadas en Internet suponen una importante alternativa para aquellos que requieren atención. Sin embargo, en los PBMI y con población culturalmente diversa la investigación al respecto es todavía muy limitada. Por tanto, el objetivo principal de esta disertación es explorar la viabilidad y eficacia preliminar de una intervención basada en Internet cognitivo-conductual culturalmente adaptada para el tratamiento de la depresión en el entorno ecuatoriano. Los objetivos específicos de esta disertación son los siguientes: 1. Examinar las propiedades psicométricas de la versión en español del Patient Health Questionnaire-9 (PHQ-9) en el ámbito de la Sanidad Pública en Ecuador. 2. Analizar las preferencias de tratamiento y las actitudes de los usuarios hacia las intervenciones en línea para los trastornos emocionales en el entorno comunitario de Ecuador. 3. Realizar una adaptación cultural del programa español Sonreír es Divertido al entorno ecuatoriano previo a ser probado en población clínica. 3. Metodología y resultados Esta disertación doctoral está compuesta por 4 estudios aprobados previamente por el Comité de Ética de la Universidad de Valencia (números de referencia: 00016-UV-E-2019; UV-INV_ETICA-1650273) y el Comité de Investigación en Humanos del Ministerio de Salud Pública de Ecuador (número de referencia: MSP-CZ4-HGDGDZ-DI-2019-0022-M). El primer estudio (capítulo 2) examina la estructura factorial, invarianza, fiabilidad y validez convergente y divergente de la versión española del Patient Health Questionnaire-9 (PHQ-9, Diez-Quevedo et al., 2001) en el ámbito de la salud pública ecuatoriana. Para ello, 366 usuarios del Hospital Dr. Gustavo Dominguez Zambrano en Santo Domingo - Ecuador, respondieron un protocolo de evaluación que incluía las versiones en español del PHQ-9, el Beck Depression Inventory-II (BDI-II; Beck et al., 1996), la Generalized Anxiety Disorder Scale (GAD-7; Spitzer et al., 2006), la Positive and Negative Affect Scale (PANAS; Watson et al., 1988) y el Quality Life Index (QLI, Spanish version, Mezzich et al., 2000). Los resultados del análisis factorial confirmatorio mostraron un excelente ajuste para el modelo factorial unidimensional (χ227 = 66.716, p < .001; CFI = .981; RMSEA = .063; SRMR = .039) así como para el modelo factorial bidimensional (χ222 = 62.186, p < .001; CFI = .983; RMSEA = .062; SRMR = .037), pero la alta correlación entre factores latentes (somático y cognitivo/afectivo) (r = .933) sugería que no existía discriminación entre ellos. Por lo tanto, el modelo factorial unidimensional, el más parsimonioso, se mantuvo como el modelo de mejor ajuste. Además, los resultados del análisis factorial multigrupo mostraron que no existían diferencias significativas entre los modelos configural, métrico y escalar entre ambos sexos (índice de Chi cuadrado, p > .05) y (ΔCFI < .01), sugiriendo que existe equivalencia en la estructura del PHQ-9 tanto para hombres como para mujeres. Los coeficientes de consistencia interna fueron adecuados (Cronbach's α > 0.82; McDonald's ω > .85), mientras que las correlaciones moderadas a fuertes entre el PHQ-9 con otras medidas de depresión (BDI-II) (r = .76), ansiedad (GAD-7) (r = .63), afecto positivo (PANAS positivo) (r = .61) y negativo (PANAS negativo) (r = -.40), así como calidad de vida (QLI) (r = -.57) aportan evidencia de la validez convergente y divergente de este instrumento. El capítulo 3 tiene como objetivo identificar las preferencias de tratamiento para los trastornos emocionales y las opiniones hacia las intervenciones online (IO) a nivel comunitario en Ecuador. Para ello, 302 participantes fueron reclutados a través de diversos medios de comunicación y redes sociales y respondieron a una encuesta a través de Internet que inicialmente recogía datos sociodemográficos, clínicos y también de perfil tecnológico. A continuación, accedían a un vídeo informativo sobre las IO (Qué son, cuáles son sus componentes, quiénes las desarrollan, aspectos de seguridad), para finalmente completar la última parte de la encuesta que contenía preguntas relacionadas con sus preferencias, expectativas y opiniones hacia las IO, así como su uso antes, durante y después de la pandemia de COVID-19. Los resultados de este estudio mostraron que los participantes están muy predispuestos a recibir tratamientos tradicionales de manera presencial (M = 8,07) y online (M = 7,28). El formato de tratamiento mixto (presencial + OI) fue la primera elección terapéutica por parte de los participantes (42%), después el tratamiento presencial (37,1%), y en tercer lugar (14,9%) la opción online. La elección de los formatos tradicionales frente a los online ya ha sido descrita previamente (March et al., 2018; Hanson et al., 2016) incluso en una población culturalmente diversa (Choi et al., 2015). Las razones para optar por una IO fueron principalmente logísticas (por ejemplo, dificultades de movilización o de ajuste en horarios para recibir un tratamiento presencial). Además, si los participantes tuvieran que someterse a un tratamiento a través de una IO, la gran mayoría de los participantes (> 75%) elegiría las sesiones presenciales como apoyo terapéutico frente otras alternativas como correos electrónicos o mensajes de texto. Los puntajes sobre credibilidad y expectativas (CEQ, Devilly y Borkovec, 2000) fueron buenos. Especialmente, las mujeres y quienes habían recibido tratamientos en línea tenían puntuaciones más altas que los hombres y los que en algún momento recibieron tratamiento presencial o quienes no habían recibido ningún tratamiento. También las puntuaciones de las actitudes generales hacia las intervenciones en línea (APOI, Schröder et al., 2015) fueron buenas. Las subescalas "confianza en la eficacia" y "beneficio del anonimato" fueron altas (M > 12). Sin embargo, las subescalas de "escepticismo y percepción del riesgo" y "amenaza de la tecnologización" también lo fueron (M > 11). Además, el escepticismo sobre la eficacia y la percepción del riesgo fue significativamente menor para los que habían recibido una OI (M = 9,67). Las altas puntuaciones en percepción de riesgo y amenaza de tecnificación podrían estar asociadas al escaso conocimiento sobre este tipo de formatos de intervenciones psicológicas en países como Ecuador. Por último, los resultados indicaron que antes de la pandemia de COVID, un porcentaje significativo de participantes (63%) habría elegido regularmente una OI, además, que la elección habría sido mayor en épocas de pandemia (81%) e incluso después del fin de la pandemia (77%). Sin embargo, los participantes que habían utilizado servicios psicológicos a través de recursos tecnológicos (por ejemplo, IO autoguiada, formato mixto, aplicaciones móviles, etc.) durante el COVID consideraron que harían más uso de una OI en ese contexto, pero no antes ni después. El capítulo 4 describe el proceso de adaptación cultural del programa Sonreír es Divertido (Botella y otros., 2012, 2015) basado en un modelo con de tres enfoques clave: el “marco de sensibilidad cultural” propuesta por (Resnicow et al., 2000); los “principios transculturales” propuestos por Helms (2015); y el trabajo de Bernal y Sáez-Santiago (2006) referente al “marco de validez ecológica”. Para ello, en la primera fase se realizó una adaptación cultural preliminar del programa (sensibilidad cultural) que incluyó modificaciones de lenguaje, edición e inclusión de recursos audiovisuales al programa. Posteriormente, varios miembros del ministerio de Salud Pública de Ecuador (4 psicólogos, 2 médicos de familia y 3 usuarios) y 1 experto internacional en IBI evaluaron la versión preliminar del programa (validez ecológica) a través del Cuestionario de Relevancia Cultural (CRC) (Salamanca-Sanabria et al., 2019). Finalmente, tras el análisis respectivo, se integraron las recomendaciones emitidas por los evaluadores para la versión final. Los resultados de los evaluadores mostraron puntajes adecuados (M > 4) hacia el contenido del programa (lenguaje, personajes, metáforas, contenido, conceptos, objetivos, métodos y contexto) y los componentes de cada módulo (contenido, ejemplos, historias personales y ejercicios), sugiriendo que estos estaban bien reflejados en términos de equivalencia funcional, equivalencia conceptual y equivalencia lingüística. Además, se realizaron sugerencias respecto a cambios, incluir elementos y corregir palabras. Recomendaciones que fueron incluidas en la versión final del programa adaptado. El capítulo 5 pretende explorar la eficacia y viabilidad preliminares del programa Sonreír es Divertido (Botella et al.., 2012, 2015) culturalmente adaptado (E-SF) para población ecuatoriana para el tratamiento de depresión. Para ello, 89 participantes fueron incluidos en un ensayo controlado aleatorizado piloto de tres condiciones: la IBI (E-SF) con apoyo automatizado (a-IBI); la IBI más apoyo humano (p-IBI); y un grupo de control en lista de espera (WL). Se realizaron medidas en la línea de base, a los 3 y 6 meses de seguimiento. Los resultados mostraron una reducción significativa en los síntomas depresivos en los participantes que completaron la evaluación de 3 meses (a-IBI, d = 0,89; p-IBI, d = 1,65), estos cambios se mantuvieron hasta la evaluación de 6 meses (a-IBI, d = 1,40; p-IBI, d = 2,00). El grupo WL no mostró cambios en cuanto a sus síntomas. Por otra parte, se evidenciaron tamaños del efecto pequeños entre las condiciones de intervención (d < .03). Se encontraron también diferencias significativas (p < 0,05) para medidas clínicas secundarias como ansiedad, afecto y calidad de vida, tanto en a-IBI como en p-IBI, tamaños de efecto entre moderados y grandes confirmaron los cambios (d > 0,50). El 42 % de los participantes completó la evaluación de 3 meses (30% en las condiciones de intervención), lo que representa una tasa de abandono elevada en comparación con otros estudios que han empleado la intervención original Smiling is Fun (Mira et al., 2017; Montero-Marín et al., 2016). Las creencias y expectativas (CEQ) (Devilly y Borkovec, 2000) (M > 36), así como las actitudes (APOI) (Schröder et al., 2015) hacia E-SF fueron altas para todas las condiciones (M > 46). Las puntuaciones globales en APOI y en la subescala de "confianza en la eficacia" fueron significativamente más altas para el grupo WL (M = 14,74) que para a-IBI (M = 13,36) y p-IBI (M = 12,62), mientras que, las puntuaciones de la subescala de "escepticismo y percepción del riesgo" fueron más bajas para el grupo WL (M = 10,52) en comparación con las condiciones activas. Además, los participantes que realizaron la intervención, evaluaron la satisfacción con el programa mediante el Cuestionario de Satisfacción del Cliente (CSQ) (Attkisson y Greenfield, 1996) (M > 3), la alianza terapéutica (WAI-TECH-SF) (Hatcher y Gillaspy, 2006) (M > 56), y usabilidad del programa (SUS) (Brooke, 1996) (M > 65) calificada como "aceptable" según Bangor (2008). No se evidenciaron diferencias significativas entre las condiciones de intervención en estas medidas. Las opiniones generales del programa fueron buenas y reflejaron la percepción de ayuda que los participantes sintieron para resolver los problemas (por ejemplo, “Es un programa excelente me ayudó a sobrellevar los miedos y darme cuenta que puedo sobrellevar los momentos de angustia y mejora mí comportamiento”). Finalmente, 20 participantes que abandonaron el tratamiento reportaron que las principales razones para no continuar con el tratamiento fueron: la falta de tiempo, problemas logísticos (por ejemplo, acceso limitado a Internet). Además, los participantes señalaron áreas en las que el programa podría mejorar, la interacción humana/inclusión de un terapeuta, la reducción del texto en el contenido y hacer la plataforma más atractiva visualmente. Por tanto, los resultados de eficacia obtenidos en este estudio preliminar, así como las evaluaciones positivas hacia la versión adaptada culturalmente de Sonreír es Divertido apuntan a que la implementación de este tipo de programas podría ser un recurso útil para el tratamiento de la depresión, aunque hay que seguir mejorando aspectos importantes, como el abandono del tratamiento Conclusiones Las dificultades en el reconocimiento y diagnóstico de la depresión suponen retos importantes a nivel global, por lo que contar con instrumentos de evaluación fiables, breves y fáciles de usar ayuda a identificar a los pacientes en riesgo (Nabbe et al., 2017). Los resultados del estudio 1 (capítulo 2) sugieren que el PHQ-9 cuenta con propiedades psicométricas adecuadas para el tamizaje de depresión en Ecuador. Por otra parte, como se ha subrayado en esta tesis doctoral, las IBI han demostrado ser formatos terapéuticos eficaces para el manejo de la depresión (Sztein et al., 2017), así como potenciales alternativas para reducir la brecha de acceso a los tratamientos psicológicos (Barceló-Soler et al., 2020; Fairburn y Patel, 2017; Tiburcio et al., 2016). En este sentido, los resultados preliminares de eficacia del capítulo 5, las creencias, expectativas y actitudes en general hacia las Intervenciones online identificadas en el capítulo 3, así como las identificadas específicamente hacia la versión adaptada culturalmente de Sonreír es Divertido reportadas por los participantes en los capítulos 4 y 5 sugieren que la implementación de IBI validadas en contextos culturalmente diversos podría ser un recurso potencial para abordar los trastornos emocionales y reducir la brecha de tratamiento para la depresión (Andersson, Titov et al., 2019; Williams y Andrews, 2013). Consideramos que esta disertación doctoral contribuye a la creciente investigación en la región Latinoamericana, sin embargo, la información aún es muy limitada y se requiere de más estudios. Esperamos que este trabajo inspire a los investigadores a continuar con el estudio en este campo.

OBJECTIVE Suh et al (2019) found that treatments for perfectionism, even online, reduce perfectionism and concomitant psychopathology. This meta-analysis investigated the efficacy of Internet interventions and psychotherapeutic interventions for perfectionism as potential tools for overburdened college counseling centers where perfectionism is particularly prevalent. Method: PubMed, MEDLINE, and PsycINFO were searched for relevant treatment studies. Comprehensive Meta-analysis V3 was used to compute and pool effect sizes for perfectionism and concomitant psychopathology. Results: Psychological interventions (N = 18) for perfectionism yielded significant reductions in perfectionistic strivings (g = .394; n = 16), concerns (g = .603; n = 17), and clinical perfectionism (g = .960; n = 8). Effect sizes were small-to-medium for depression (g = .601; n = 12), anxiety (g = .399; n = 13), and eating disorder symptoms (g = .477; n = 7). Effect sizes were similar for Internet-mediated and non-Internet-mediated interventions. Most interventions used 8-10-session cognitive-behavioral therapy of perfectionism. Conclusion: Internet interventions for perfectionism reduce perfectionism and concomitant psychopathology. College counseling centers could eventually use them to reduce demand for in-person services.

Background: Depression is a highly prevalent mental disorder, but only a fraction of those affected receive evidence-based treatments. Recently, Internet-based interventions were introduced as an efficacious and cost-effective approach. However, even though depression is a heterogenous construct, effects of treatments have mostly been determined using aggregated symptom scores. This carries the risk of concealing important effects and working mechanisms of those treatments. Methods: In this study, we analyze outcome and long-term follow-up data from the EVIDENT study, a large (N = 1,013) randomized-controlled trial comparing an Internet intervention for depression (Deprexis) with care as usual. We use Network Intervention Analysis to examine the symptom-specific effects of the intervention. Using data from intermediary and long-term assessments that have been conducted over 36 months, we intend to reveal how the treatment effects unfold sequentially and are maintained. Results: Item-level analysis showed that scale-level effects can be explained by small item-level effects on most depressive symptoms at all points of assessment. Higher scores on these items at baseline predicted overall symptom reduction throughout the whole assessment period. Network intervention analysis offered insights into potential working mechanisms: while deprexis directly affected certain symptoms of depression (e.g., worthlessness and fatigue) and certain aspects of the quality of life (e.g., overall impairment through emotional problems), other domains were affected indirectly (e.g., depressed mood and concentration as well as activity level). The configuration of direct and indirect effects replicates previous findings from another study examining the same intervention. Conclusions: Internet interventions for depression are not only effective in the short term, but also exert long-term effects. Their effects are likely to affect only a small subset of problems. Patients reporting these problems are likely to benefit more from the intervention. Future studies on online interventions should examine symptom-specific effects as they potentially reveal the potential of treatment tailoring. Clinical Trial Registration: ClinicalTrials.gov, Identifier: NCT02178631.

BackgroundSample size planning (SSP) is vital for efficient studies that yield reliable outcomes. Hence, guidelines, emphasize the importance of SSP. The present study investigates the practice of SSP in current trials for depression.MethodsSeventy-eight randomized controlled trials published between 2013 and 2017 were examined. Impact of study design (e.g. number of randomized conditions) and study context (e.g. funding) on sample size was analyzed using multiple regression.ResultsOverall, sample size during pre-registration, during SSP, and in published articles was highly correlated (r's ≥ 0.887). Simultaneously, only 7–18% of explained variance related to study design (p = 0.055–0.155). This proportion increased to 30–42% by adding study context (p = 0.002–0.005). The median sample size was N = 106, with higher numbers for internet interventions (N = 181; p = 0.021) compared to face-to-face therapy. In total, 59% of studies included SSP, with 28% providing basic determinants and 8–10% providing information for comprehensible SSP. Expected effect sizes exhibited a sharp peak at d = 0.5. Depending on the definition, 10.2–20.4% implemented intense assessment to improve statistical power.ConclusionsFindings suggest that investigators achieve their determined sample size and pre-registration rates are increasing. During study planning, however, study context appears more important than study design. Study context, therefore, needs to be emphasized in the present discussion, as it can help understand the relatively stable trial numbers of the past decades. Acknowledging this situation, indications exist that digital psychiatry (e.g. Internet interventions or intense assessment) can help to mitigate the challenge of underpowered studies. The article includes a short guide for efficient study planning.

espanolExisten evidencias importantes que demuestran que los episodios depresivos mayores pueden prevenirse y tratarse eficazmente con intervenciones psicologicas administradas tanto por profesionales como por no profesionales debidamente capacitados. Tambien hay evidencia de que la depresion se puede prevenir y tratar mediante intervenciones digitales de autoayuda tales como paginas web y aplicaciones y que su eficacia aumenta si estas intervenciones son apoyadas por guias o coaches. En este comentario describimos enfoques digitales para la depresion desarrollados y probados en todo el mundo por el Instituto de Intervenciones Internacionales en Salud por Internet de la Universidad de Palo Alto. Recomendamos la creacion de apotecarias digitales para aumentar el acceso a las intervenciones: 1) capacitando a mas proveedores de ayuda y 2) desarrollando herramientas que estos puedan utilizar para mejorar la eficacia de estas intervenciones y para proporcionar acceso a intervenciones de autoayuda que puedan ser utilizadas directamente por cualquier persona con 3) guias o coaches con el objetivo de reducir el abandono o 4) como intervenciones totalmente automatizadas. EnglishThere is now substantial evidence that major depressive episodes can be prevented and treated effectively with psychological interventions administered by trained lay and professional providers. There is also evidence that depression can be prevented and treated using self-help digital interventions such as websites and apps, and that their effectiveness increases if these interventions are supported by guides or coaches. In this commentary we describe digital approaches for depression developed and tested across the world by Palo Alto University’s Institute for International Internet Interventions for Health. We recommend the creation of digital apothecaries to increase access to in-person interventions by 1) training more providers, and 2) developing tools providers can use to enhance the effectiveness of these interventions, and to provide access to self-help interventions that can be used directly by anyone with 3) either guides or coaches to reduce dropout, or 4) as fully automated interventions.

It is necessary for suicide prevention interventions to demonstrate safety. One important aspect of safety is evidence that deterioration rates are low. No studies have examined deterioration of suicidal ideation in the context of an internet-based cognitive behavioral therapy (CBT) intervention to reduce suicidal ideation. A secondary analysis of the outcomes of an online trial was conducted to determine rates of deterioration in a CBT intervention called Living with Deadly Thoughts, relative to an attention control condition, and to identify factors associated with deterioration.The randomized controlled trial included 418 adults with suicidal ideation at baseline (77% females, mean age 40.6 years). Deterioration was defined in two ways: a reliable increase in Suicidal Ideation Attributes Scale (SIDAS score) of ≥6.0 units; or triggering the safety protocol during the trial as determined by high levels of suicidality. Analyses were repeated with multiply imputed data. Predictors of deterioration were identified using logistic regression analysis.30 (14%) participants in the control group and 15 (7%) in the intervention group met criteria for reliable deterioration (Fisher's exactParticipation in an online suicide prevention intervention was associated with lower prevalence of reliable deterioration than participation in an attention-control intervention, providing further evidence that internet-based CBT interventions do not cause harm.HighlightsFirst study to assess deterioration in an internet suicide prevention interventionRates of reliable deterioration were higher in control (14%) than intervention (7%)No psychological or demographic factors were robustly associated with deteriorationFindings provide further evidence that internet based CBT programs are not harmful.

Background Low sexual desire and arousal are the most common sexual concerns in women, but most women lack access to effective treatment such as cognitive behavioral therapy. Web-based psychological interventions, which are economical, private, easily accessible, and potentially effective, may increase the reach of evidence-based treatment. Aim To determine the feasibility of translating cognitive behavioral therapy for the most common female sexual dysfunction, Female Sexual Interest/Arousal Disorder, into an online format. The present study examined the feasibility of an introductory psychoeducational module of eSense, an online program currently being developed that is based on existing empirically supported in-person treatments, which delivers content to the user in a visually appealing and interactive manner. Methods Sixteen cisgender women (M age = 31.9) with female sexual arousal/interest disorder worked through a pilot module of eSense inperson at a sexual health laboratory. Outcomes Qualitative semistructured interviews and online questionnaires were used to assess participants’ experiences of usability of the platform, clarity/relevance of the content, satisfaction with the experience, and any changes in clinical outcomes of sexual function and distress. Results Participants reported a high level of satisfaction with the website’s functionality and presentation. They reported greater knowledge, felt validated and more hopeful, and were eager to continue the remaining modules. Participants also reported notable prepost improvements in sexual desire, arousal, and satisfaction. Clinical Implications Initial user-experience assessment may represent a method of simultaneously improving online interventions and providing therapeutic education to participants. Strengths & Limitations This is one of the first studies, to our knowledge, to test a graphics-rich, interactive online intervention for sexual difficulties that does not require direct contact with expert providers or support groups. Limitations include the high level of education, motivation, and technical fluency of the sample and the potentially confounding effect of the researcher’s presence during interviews. Because this was a feasibility study, the sample size was small, and no control group was included, limiting conclusions about efficacy and generalizability. Conclusion The format of eSense appears to be feasible and usable, lending support to the growing evidence that it is possible to take in-person therapeutic interventions online.

This article gives an overview of current research on internet interventions in the field of mental health. As a result of COVID-19, the implementation of internet interventions has been given a boost in the mental health sectors of several countries all over the world. With regard to these developments, a definition of internet interventions is provided and the current state of research on different formats, treatment contents, and settings of internet interventions is discussed. Current research on the therapeutic alliance in internet interventions and possible negative effects is also described. The review closes with lessons learned from the past decades of research on internet interventions along with possible implications and future directions.

Some research suggests that internet interventions aimed at people with problematic alcohol use are more effective when provided with guidance from a therapist or coach. Purpose/Objectives: This tr...

Sexual dysfunction affects over 60% of cancer survivors. Internet interventions have improved sexual function, but with considerable clinician guidance, restricting scalability. This pragmatic tria...

Objectives Insomnia is highly prevalent among adolescents, with severe consequences for daily life, including mental disorders. Cognitive behavioral therapy for insomnia (CBTI) can be effective in internet-delivered and face-to-face modalities. However, it is yet unclear what the contribution is of mindfulness-based techniques to the effectiveness of traditional CBTI. The present study investigated whether use of a body scan mindfulness meditation influenced the effectiveness of CBTI for adolescents. Methods Adolescents who had received 6 weeks of internet CBTI were divided into a group who had practiced a body scan meditation (N = 26, age M = 15.33 years, SD = 1.42, 77% girls) and a group who had not (N = 28, age M = 15.64 years, SD = 1.80, 82% girls). Differences between the groups were analyzed for subjective and objective sleep outcomes from baseline to post-treatment and to 2-month follow-up. Results Moderate to large effect size improvements appeared for sleep parameters from 7-day actigraphy and sleep logs, and large effect size decreases of self-reported symptoms of insomnia and chronic sleep reduction, at post-treatment for both groups. Improvements were maintained at follow-up. However, where the non-body scan group showed no significant change of wake after sleep onset from actigraphy, and self-reported shortness of sleep and irritation, there were medium effect size improvements of these outcomes in the body scan group. Conclusions These results indicate that the use of a body scan mindfulness meditation in CBTI may have an additional positive effect on sleep, above and beyond traditional CBTI techniques.

Background Alcohol misuse is a common, disabling, and costly issue worldwide, but the vast majority of people with alcohol misuse never access treatment for varying reasons. Internet-delivered cognitive behaviour therapy (ICBT) may be an attractive treatment alternative for individuals with alcohol misuse who are reluctant to seek help due to stigma, or who live in rural communities with little access to face-to-face treatment. With the growing development of ICBT treatment clinics, investigating ways to optimize its delivery within routine clinic settings becomes a crucial avenue of research. Some studies in the alcohol treatment literature suggest that assessment interviews conducted pre-treatment may improve short- and long-term drinking outcomes but no experimental evaluation of this has been conducted. Further, research on internet interventions for alcohol misuse suggests that guidance from a therapist or coach improves outcomes, but more research on the benefits of guidance in ICBT is still needed. Methods This study is a 2X2 factorial randomized controlled trial where all of the expected 300 participants receive access to the Alcohol Change Course, an eight-week ICBT program. A comprehensive pre-treatment assessment interview represents factor 1, and guidance from a health educator represents factor 2. All participants will be asked to respond to measures at screening, pre-treatment, mid-treatment, post-treatment and 3, 6 and 12 months after treatment completion. Discussion This study will provide valuable information on optimization of ICBT for alcohol misuse within routine clinic settings. Trial registration ClinicalTrials.gov, registered June 13th 2019, NCT03984786

Funding Information: The authors wish to acknowledge the Erasmus+ Program of the European Union—Phoenix Joint doctoral program on Dynamics of Health and Welfare, Fraunhofer AICOS, and the Foundation for Science and Technology (individual research grant 2020.09045.BD)—for supporting CMS. The authors thank all participants and Elsa Oliveira and Ana Alves for their assistance with data collection and early analysis. Publisher Copyright: © 2022 JMIR Publications Inc.. All right reserved. Background: Despite the potential of digital mental health to provide cost-effective mental health care, its adoption in clinical settings is limited, and little is known about the perspectives and practices of mental health professionals regarding its implementation or the factors influencing these perspectives and practices. Objective: This study aims to characterize in depth the perspectives and practices of mental health professionals regarding the implementation of digital mental health and explore the factors affecting such perspectives and practices. Methods: A qualitative study using in-depth semistructured interviews with Portuguese mental health professionals (N=13)-psychologists and psychiatrists-was conducted. The transcribed interviews were thematically analyzed. Results: Mental health professionals deemed important or engaged in the following practices during the implementation of digital mental health: indication evaluation, therapeutic contract negotiation, digital psychological assessment, technology setup and management, and intervention delivery and follow-up. Low-threshold accessibility and professionals' perceived duty to provide support to their clients facilitated the implementation of digital mental health. Conversely, the lack of structured intervention frameworks; the unavailability of usable, validated, and affordable technology; and the absence of structured training programs inhibited digital mental health implementation by mental health professionals. Conclusions: The publication of practice frameworks, development of evidence-based technology, and delivery of structured training seem key to expediting implementation and encouraging the sustained adoption of digital mental health by mental health professionals. publishersversion published

Guidance is commonly used in Internet interventions. However, there is little work on how guidance can be optimally implemented in guided self-help approaches. Despite some general models on guidance, there is no theoretical framework as how to optimally individualize the guidance to the participants needs. The Motive-Oriented Therapeutic Relationship (MOTR) approach is based on the Plan Analyses (Caspar, 1995, 2022) and allows the therapist to provide answers that fulfil the participant’s needs in a way that is acceptable for the participants and is useful for the therapeutic goals. We argue that MOTR can be applied to guidance in Internet interventions and that it can improve adherence and outcome through different processes that help the participant navigate through different difficulties encounter during the completion of an internet intervention.

Background: Despite the efficacy of psychosocial interventions in minimizing psychosocial morbidity in breast cancer survivors (BCSs), intervention delivery across survivorship is limited by physical, organizational, and attitudinal barriers, which contribute to a mental health care treatment gap in cancer settings. Objective: The aim of this study is to develop iNNOV Breast Cancer (iNNOVBC), a guided, internet-delivered, individually tailored, acceptance and commitment therapy-influenced cognitive behavioral intervention program aiming to treat mild to moderate anxiety and depression in BCSs as well as to improve fatigue, insomnia, sexual dysfunction, and health-related quality of life in this group. This study also aims to evaluate the usefulness, usability, and preliminary feasibility of iNNOVBC. Methods: iNNOVBC was developed using a user-centered design approach involving its primary and secondary end users, that is, BCSs (11/24, 46%) and mental health professionals (13/24, 54%). We used mixed methods, namely in-depth semistructured interviews, laboratory-based usability tests, short-term field trials, and surveys, to assess iNNOVBCs usefulness, usability, and preliminary feasibility among these target users. Descriptive statistics were used to characterize the study sample, evaluate performance data, and assess survey responses. Qualitative data were recorded, transcribed verbatim, and thematically analyzed. Results: Overall, participants considered iNNOVBC highly useful, with most participants reporting on the pertinence of its scope, the digital format, the relevant content, and the appropriate features. However, various usability issues were identified, and participants suggested that the program should be refined by simplifying navigation paths, using a more dynamic color scheme, including more icons and images, displaying information in different formats and versions, and developing smartphone and tablet versions. In addition, participants suggested that tables should be converted into plain textboxes and data visualization dashboards should be included to facilitate the tracking of progress. The possibility of using iNNOVBC in a flexible manner, tailoring it according to BCSs changing needs and along the cancer care continuum, was another suggestion that was identified. Conclusions: The study results suggest that iNNOVBC is considered useful by both BCSs and mental health professionals, configuring a promising point-of-need solution to bridge the psychological supportive care gap experienced by BCSs across the survivorship trajectory. We believe that our results may be applicable to other similar programs. However, to fulfill their full supportive role, such programs should be comprehensive, highly usable, and tailorable and must adopt a flexible yet integrated structure capable of evolving in accordance with survivors changing needs and the cancer continuum. Funding Agencies|Erasmus+ program of the European Union: Phoenix Joint Doctoral Program on Dynamics of Health and Welfare; Fraunhofer Portugal Assistive Information and Communication Solutions; Foundation for Science and Technology [2020.09045]

Background: Despite the potential of digital mental health to provide cost-effective mental health care, its adoption in clinical settings is limited, and little is known about the perspectives and practices of mental health professionals regarding its implementation or the factors influencing these perspectives and practices. Objective: This study aims to characterize in depth the perspectives and practices of mental health professionals regarding the implementation of digital mental health and explore the factors affecting such perspectives and practices. Methods: A qualitative study using in-depth semistructured interviews with Portuguese mental health professionals (N=13)-psychologists and psychiatrists-was conducted. The transcribed interviews were thematically analyzed. Results: Mental health professionals deemed important or engaged in the following practices during the implementation of digital mental health: indication evaluation, therapeutic contract negotiation, digital psychological assessment, technology setup and management, and intervention delivery and follow-up. Low-threshold accessibility and professionals perceived duty to provide support to their clients facilitated the implementation of digital mental health. Conversely, the lack of structured intervention frameworks; the unavailability of usable, validated, and affordable technology; and the absence of structured training programs inhibited digital mental health implementation by mental health professionals. Conclusions: The publication of practice frameworks, development of evidence-based technology, and delivery of structured training seem key to expediting implementation and encouraging the sustained adoption of digital mental health by mental health professionals. Funding Agencies|Erasmus+ Program of the European Union-Phoenix Joint doctoral program on Dynamics of Health and Welfare; Foundation for Science and Technology [2020.09045.BD]; Fraunhofer AICOS

Informal caregivers are individuals who provide care for significant others in need of support due to frailty or illness. Being able to support a family member can be a very rewarding but at the same time a demanding task. Consequently, informal caregivers are known to experience not only positive but also negative psychological health outcomes and should be offered appropriate support. The main goal of this thesis was to evaluate if Internet-based Cognitive Behavioural Therapy (ICBT) can be suited to provide Lithuanian informal caregivers with psychological support. In addition, a secondary aim was to collect information regarding Lithuanian informal caregiver characteristics, their experienced burden and support needs. The results showed that Lithuanian informal caregivers experience unmet support needs and a high caregiver burden. The findings also show that ICBT can be an effective and acceptable support option for Lithuanian informal caregivers in reducing their burden, depression, anxiety, stress and increasing the perceived quality of life. In conclusion, ICBT should be considered a promising psychological support option for Lithuanian informal caregivers. Further research is needed to evaluate the suitability of ICBT in regular care. Informella vårdgivare är personer som tar hand om närstående som behöver stöd på grund av funktionsnedsättningar eller sjukdom. Att kunna stödja en närstående kan vara en givande men samtidigt krävande uppgift. Följaktligen är det känt att informella vårdgivare inte bara upplever positiva utan även negativa psykologiska hälsorisker och bör erbjudas lämpligt stöd. Huvudsyftet med denna avhandling var att utvärdera om internetbaserad kognitiv beteendeterapi (IKBT) kan vara ett lämpligt alternativ för att ge litauiska informella vårdgivare psykologiskt stöd. Dessutom var ett sekundärt mål att samla in information om litauiska informella vårdgivare, inklusive deras upplevda börda och behov av stöd. Resultaten visade att litauiska informella vårdgivare har behov av stöd och en omfattande vårdgivarbörda. Resultaten visar också att ICBT kan vara ett effektivt och acceptabelt alternativ för litauiska informella vårdgivare för att minska deras börda, depression, ångest, stress samt öka den upplevda livskvaliteten. Sammanfattningsvis kan ICBT betraktas som ett lovande psykologiskt stödalternativ för litauiska informella vårdgivare. Ytterligare forskning krävs för att utvärdera om IKBT kan vara ett lämpligt alternativ i den reguljär vård.

Background There is a growing interest in offering therapist-guided internet interventions for alcohol use disorders (AUD) in regular addiction services. Elucidating the therapeutic processes during these interventions may help improve clinical delivery. The aim of this paper was to investigate written messages from client to therapist in a therapist-guided internet intervention for AUD. Methods Data was extracted from the therapist-guided arm (n = 57) of a randomized trial of internet interventions for AUD. Qualitative content analysis was used to identify distinct categories of client behaviors in written messages to therapists. Coding was deductive (applying categories from past literature) as well as inductive (identifying new categories from the data). Subsequently, exploratory correlational and regression analyses were conducted to investigate whether identified client behaviors predicted module completion and drinking outcomes. Also, client questions posed in messages to therapists were categorized separately. Results Eleven distinct behavior categories were identified, of which the two most common were alliance (26.6% of total categorizations) and identifying patterns and problem behaviors (22.8%). Confrontational alliance rupture was the least common category (0.4%). One new behavior category was identified inductively – alcohol-related setback (4.1%). In the exploratory analyses, no categories consistently predicted module completion or drinking outcomes. Client questions were most commonly posed to improve understanding or use of program content or skills. Discussion The behavior categories, although not predictive of module completion or outcomes, may be of use for therapists, treatment developers and health care providers as a tool for understanding therapeutic processes in internet interventions for AUD., Highlights • Interest in internet interventions for alcohol use disorder is growing. • Content analysis was applied to messages from clients to therapists in a therapist-guided intervention. • Eleven distinct behavior categories were identified. • The most common client behavior category was alliance. • Categorizations may be of use for digital health care providers.

Background The Social Brain Toolkit, conceived and developed in partnership with stakeholders, is a novel suite of web-based communication interventions for people with brain injury and their communication partners. To support effective implementation, the developers of the Social Brain Toolkit have collaborated with people with brain injury, communication partners, clinicians, and individuals with digital health implementation experience to coproduce new implementation knowledge. In recognition of the equal value of experiential and academic knowledge, both types of knowledge are included in this study protocol, with input from stakeholder coauthors. Objective This study aims to collaborate with stakeholders to prioritize theoretically based implementation targets for the Social Brain Toolkit, understand the nature of these priorities, and develop targeted implementation strategies to address these priorities, in order to support the Social Brain Toolkit’s implementation. Methods Theoretically underpinned by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework of digital health implementation, a maximum variation sample (N=35) of stakeholders coproduced knowledge of the implementation of the Social Brain Toolkit. People with brain injury (n=10), communication partners (n=11), and clinicians (n=5) participated in an initial web-based prioritization survey based on the NASSS framework. Survey completion was facilitated by plain English explanations and accessible captioned videos developed through 3 rounds of piloting. A speech-language pathologist also assisted stakeholders with brain injury to participate in the survey via video teleconference. Participants subsequently elaborated on their identified priorities via 7 web-based focus groups, in which researchers and stakeholders exchanged stakeholder perspectives and research evidence from a concurrent systematic review. Stakeholders were supported to engage in focus groups through the use of visual supports and plain English explanations. Additionally, individuals with experience in digital health implementation (n=9) responded to the prioritization survey questions via individual interview. The results will be deductively analyzed in relation to the NASSS framework in a coauthorship process with people with brain injury, communication partners, and clinicians. Results Ethical approval was received from the University of Technology Sydney Health and Medical Research Ethics Committee (ETH20-5466) on December 15, 2020. Data were collected from April 13 to November 18, 2021. Data analysis is currently underway, with results expected for publication in mid-2022. Conclusions In this study, researchers supported individuals with living experience of acquired brain injury, of communicating with or clinically supporting someone post injury, and of digital health implementation, to directly access and leverage the latest implementation research evidence and theory. With this support, stakeholders were able to prioritize implementation research targets, develop targeted implementation solutions, and coauthor and publish new implementation findings. The results will be used to optimize the implementation of 3 real-world, evidence-based interventions and thus improve the outcomes of people with brain injury and their communication partners. International Registered Report Identifier (IRRID) DERR1-10.2196/35080

Background: There is huge variability in the way that individuals with tinnitus respond to interventions. These experiential variations, together with a range of associated etiologies, contribute to tinnitus being a highly heterogeneous condition. Despite this heterogeneity, a “one size fits all” approach is taken when making management recommendations. Although there are various management approaches, not all are equally effective. Psychological approaches such as cognitive behavioral therapy have the most evidence base. Managing tinnitus is challenging due to the significant variations in tinnitus experiences and treatment successes. Tailored interventions based on individual tinnitus profiles may improve outcomes. Predictive models of treatment success are, however, lacking.\ud \ud Objective: This study aimed to use exploratory data mining techniques (ie, decision tree models) to identify the variables associated with the treatment success of internet-based cognitive behavioral therapy (ICBT) for tinnitus.\ud \ud Methods: Individuals (N=228) who underwent ICBT in 3 separate clinical trials were included in this analysis. The primary outcome variable was a reduction of 13 points in tinnitus severity, which was measured by using the Tinnitus Functional Index following the intervention. The predictor variables included demographic characteristics, tinnitus and hearing-related variables, and clinical factors (ie, anxiety, depression, insomnia, hyperacusis, hearing disability, cognitive function, and life satisfaction). Analyses were undertaken by using various exploratory machine learning algorithms to identify the most influencing variables. In total, 6 decision tree models were implemented, namely the classification and regression tree (CART), C5.0, GB, XGBoost, AdaBoost algorithm and random forest models. The Shapley additive explanations framework was applied to the two optimal decision tree models to determine relative predictor importance.\ud \ud Results: Among the six decision tree models, the CART (accuracy: mean 70.7%, SD 2.4%; sensitivity: mean 74%, SD 5.5%; specificity: mean 64%, SD 3.7%; area under the receiver operating characteristic curve [AUC]: mean 0.69, SD 0.001) and gradient boosting (accuracy: mean 71.8%, SD 1.5%; sensitivity: mean 78.3%, SD 2.8%; specificity: 58.7%, SD 4.2%; AUC: mean 0.68, SD 0.02) models were found to be the best predictive models. Although the other models had acceptable accuracy (range 56.3%-66.7%) and sensitivity (range 68.6%-77.9%), they all had relatively weak specificity (range 31.1%-50%) and AUCs (range 0.52-0.62). A higher education level was the most influencing factor for ICBT outcomes. The CART decision tree model identified 3 participant groups who had at least an 85% success probability following the undertaking of ICBT.\ud \ud Conclusions: Decision tree models, especially the CART and gradient boosting models, appeared to be promising in predicting ICBT outcomes. Their predictive power may be improved by using larger sample sizes and including a wider range of predictive factors in future studies.

Background Treatment dropout continues to be reported from internet-delivered cognitive behavioral therapy (iCBT) interventions, and lower completion rates are generally associated with lower treatment effect sizes. However, evidence is emerging to suggest that completion of a predefined number of modules is not always necessary for clinical benefit or consideration of the needs of each individual patient. Objective The aim of this study is to perform a qualitative analysis of patients’ experiences with an iCBT intervention in a routine care setting to achieve a deeper insight into the phenomenon of dropout. Methods A total of 15 purposively sampled participants (female: 8/15, 53%) from a larger parent randomized controlled trial were interviewed via telephone using a semistructured interview schedule that was developed based on the existing literature and research on dropout in iCBT. Data were analyzed using a descriptive-interpretive approach. Results The experience of treatment leading to dropout can be understood in terms of 10 domains: relationship to technology, motivation to start, background knowledge and attitudes toward iCBT, perceived change in motivation, usage of the program, changes due to the intervention, engagement with content, experience interacting with the supporter, experience of web-based communication, and termination of the supported period. Conclusions Patients who drop out of treatment can be distinguished in terms of their change in motivation: those who felt ready to leave treatment early and those who had negative reasons for dropping out. These 2 groups of participants have different treatment experiences, revealing the potential attributes and nonattributes of dropout. The reported between-group differences should be examined further to consider those attributes that are strongly descriptive of the experience and regarded less important than those that have become loosely affiliated.

Background Acquired brain injuries (ABIs) commonly cause cognitive-communication disorders, which can have a pervasive psychosocial impact on a person’s life. More than 135 million people worldwide currently live with ABI, and this large and growing burden is increasingly surpassing global rehabilitation service capacity. A web-based service delivery model may offer a scalable solution. The Social Brain Toolkit is an evidence-based suite of 3 web-based communication training interventions for people with ABI and their communication partners. Successful real-world delivery of web-based interventions such as the Social Brain Toolkit requires investigation of intervention implementation in addition to efficacy and effectiveness. Objective The aim of this study is to investigate the implementation and effectiveness of the Social Brain Toolkit as a web-based service delivery model. Methods This is a mixed methods, prospective, hybrid type 2 implementation-effectiveness study, theoretically underpinned by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework of digital health implementation. We will document implementation strategies preemptively deployed to support the launch of the Social Brain Toolkit interventions, as well as implementation strategies identified by end users through formative evaluation of the Social Brain Toolkit. We will prospectively observe implementation outcomes, selected on the basis of the NASSS framework, through quantitative web analytics of intervention use, qualitative and quantitative pre- and postintervention survey data from all users within a specified sample frame, and qualitative interviews with a subset of users of each intervention. Qualitative implementation data will be deductively analyzed against the NASSS framework. Quantitative implementation data will be analyzed descriptively. We will obtain effectiveness outcomes through web-based knowledge tests, custom user questionnaires, and formal clinical tools. Quantitative effectiveness outcomes will be analyzed through descriptive statistics and the Reliable Change Index, with repeated analysis of variance (pretraining, posttraining, and follow-up), to determine whether there is any significant improvement within this participant sample. Results Data collection commenced on July 2, 2021, and is expected to conclude on June 1, 2022, after a 6-month sample frame of analytics for each Social Brain Toolkit intervention. Data analysis will occur concurrently with data collection until mid-2022, with results expected for publication late 2022 and early 2023. Conclusions End-user evaluation of the Social Brain Toolkit’s implementation can guide intervention development and implementation to reach and meet community needs in a feasible, scalable, sustainable, and acceptable manner. End user feedback will be directly incorporated and addressed wherever possible in the next version of the Social Brain Toolkit. Learnings from these findings will benefit the implementation of this and future web-based psychosocial interventions for people with ABI and other populations. Trial Registration Australia and New Zealand Clinical Trials Registry ACTRN12621001170819; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621001170819, Australia and New Zealand Clinical Trials Registry ACTRN12621001177842; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621001177842, Australia and New Zealand Clinical Trials Registry ACTRN12621001180808; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621001180808 International Registered Report Identifier (IRRID) DERR1-10.2196/31995

Background As the burden of neurological conditions increases globally, online psychosocial interventions offer a potentially scalable solution to enabling healthcare access. However, their successful development and implementation require research into electronic healthcare implementation specifically. Methods Using a search strategy combining the concepts of implementation, electronic healthcare, psychosocial interventions and neurological conditions, we will conduct comprehensive electronic searches for primary implementation evidence in MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, SpeechBITE and NeuroBITE databases. Included studies will be analysed according to the Non-adoption, Abandonment, Scale-Up, Spread, and Sustainability framework, appraised using the Mixed-Methods Appraisal Tool and evaluated for theoretical underpinning in implementation science, with hybrid studies of effectiveness-implementation research classified according to the type of hybrid design. Discussion This review will be the first to use a theoretical underpinning in the Non-adoption, Abandonment, Scale-Up, Spread, and Sustainability framework to evaluate strengths and gaps in existing implementation research into online psychosocial interventions for people with neurological conditions and/or their caregivers. The results may be useful to provide direction and recommendations for future clinical implementation and research into online psychosocial interventions for people with neurological conditions and/or their caregivers. Systematic review registration PROSPERO 2020: CRD42020186387.

Background The number of studies examining internet-based interventions (IBIs) for depression is increasing. Although many individuals with depression experience suicidal ideation, there is only insufficient information available on how to manage and support individuals at risk of suicide in IBI trials. Here, we examined the current practice regarding the management of individuals experiencing suicidal thoughts or behaviors in studies of IBIs for depression. Methods Information pertaining to the management of suicidality was extracted from 24 studies. Additionally, researchers in the field completed a questionnaire (n = 13) before being interviewed (n = 11) about their procedures and considerations regarding the management of suicidality. Results In most trials (N = 17; 71%), individuals at risk of suicide were excluded based on varying criteria. N = 7 studies used structured interviews and N = 5 studies used single items of self-report questionnaires for assessing suicidality. The nature and degree of support provided to individuals at risk of suicide varied and only one intervention comprised suicide-specific content. Limitations Most experts referred to research on interventions with some level of human support (e.g. written feedback) which might limit the representativeness of the results of the interviews for unguided interventions. Conclusions Suicidality is often treated more as an exclusion criterion rather than a treatable condition in research on IBIs for depression. This paper provides an overview of the current practice and gives recommendations for the design of future trials.

Background: The number of studies examining internet-based interventions (IBIs) for depression is increasing. Although many individuals with depression experience suicidal ideation, there is only insufficient information available on how to manage and support individuals at risk of suicide in IBI trials. Here, we examined the current practice regarding the management of individuals experiencing suicidal thoughts or behaviors in studies of IBIs for depression. Methods: Information pertaining to the management of suicidality was extracted from 24 studies. Additionally, researchers in the field completed a questionnaire (n = 13) before being interviewed (n = 11) about their procedures and considerations regarding the management of suicidality. Results: In most trials (N = 17; 71%), individuals at risk of suicide were excluded based on varying criteria. N = 7 studies used structured interviews and N = 5 studies used single items of self-report questionnaires for assessing suicidality. The nature and degree of support provided to individuals at risk of suicide varied and only one intervention comprised suicide-specific content. Limitations: Most experts referred to research on interventions with some level of human support (e.g. written feedback) which might limit the representativeness of the results of the interviews for unguided interventions. Conclusions: Suicidality is often treated more as an exclusion criterion rather than a treatable condition in research on IBIs for depression. This paper provides an overview of the current practice and gives recommendations for the design of future trials.

The technological revolution has created enormous opportunities for the provision of affordable, accessible, and flexible mental healthcare. Yet it also creates complexities and ethical challenges....

Digital mental health interventions (DMHIs) have emerged as a promising means of expanding access to mental healthcare. Prospective participants reporting severe symptoms or suicidal ideation are o...

Alcohol misuse is a common, disabling and costly issue worldwide. Internet-delivered cognitive behavior therapy (ICBT) has the potential to reduce the harms of alcohol misuse, particularly for individuals who are unable or unwilling to access face-to-face therapy. A systematic review was conducted using Medline, CINAHL, EMBASE and PsycINFO databases for all relevant articles published from 1980 to January 2019. Randomized controlled trials (RCTs) were included if (i) an ICBT intervention targeting alcohol misuse was delivered; (ii) participants were aged 18 years or older; and (iii) primary outcomes were quantity of drinking. A qualitative analysis was conducted on the content of the ICBT programs. Fourteen studies met inclusion criteria. Most studies included participants from the general population, while studies conducted within clinic settings with diagnosed individuals were rare. The programs were similar in terms of included modules. Small effects were seen in studies on self-guided ICBT, while therapist-guided ICBT rendered small to large effects. The current review indicates that ICBT has a significant effect in reducing alcohol consumption. Larger studies evaluating ICBT compared to active control groups especially within clinic settings are warranted.

OBJECTIVE This study analyses the psychometric properties of the Working Alliance Inventory adapted for guided Internet interventions (WAI-I). METHODS We drew on the data set from a multicenter trial that examined a guided Internet intervention (deprexis) for patients with mild to moderate depression. Two hundred twenty-three patients completed the WAI-I and the Patient Satisfaction Questionnaire (ZUF-8) at posttreatment, and the Attitudes toward Psychological Online-Interventions Questionnaire (APOI) at baseline. We ran confirmatory factor analyses (CFA) testing two- and three-factor solutions and calculated Cronbach's α, item-total correlations, and correlations of the WAI-I with APOI and ZUF-8. RESULTS The results suggested a two-factor solution, with a very good model fit and evidence of factor independency, adequate internal consistency, and external validity for the complete scale and the sub-scales. CONCLUSIONS The WAI-I showed as a reliable and valid instrument to capture alliance in guided Internet interventions, which might facilitate process-outcome research and treatment development efforts.

Background: Numerous trials have demonstrated the efficacy of internet interventions targeting alcohol or cannabis use, yet a substantial proportion of users do not benefit from the format, warranting further research to identify moderators of treatment effects. Users' initial attitudes toward treatment is a potential moderator, yet no previous study has investigated users' attitudes in the context of internet interventions for addictive disorders.Method: In this secondary analysis on two internet-based trials targeting harmful alcohol use (n = 1,169) and regular cannabis use (n = 303), respectively, we compared user groups' attitudes at the item level; explored within-group heterogeneity by submitting attitude scores to a k-means cluster analysis; and investigated whether latent subgroups in each user group moderated the treatment effects. Outcome models were run using generalized linear models with 10,000 bias-corrected bootstraps accounting for subject-level clustering.Results: While substance groups and latent subgroups converged in enjoying the anonymity provided by the format, their interest toward treatment differed. Outcome analyses revealed a significant and negative time by subgroup effect on grams of cannabis consumed and screening test score (CAST), favoring the subgroup with positive treatment attitudes. There were not any significant effects of subgroup on alcohol consumption. Despite initial treatment reluctance, participants in the neutral subgroup decreased their cannabis use (gram) significantly when receiving the intervention vs. control.Conclusions: This first, exploratory study revealed key differences between substance groups' attitudes, but more importantly that within-group heterogeneity appear to affect cannabis outcomes. Assessing attitudes could be key in patient-treatment matching, yet more research is needed.

Background: Depression is a highly prevalent mental disorder, but only a fraction of those affected receive evidence-based treatments. Recently, Internet-based interventions were introduced as an efficacious and cost-effective approach. However, even though depression is a heterogenous construct, effects of treatments have mostly been determined using aggregated symptom scores. This carries the risk of concealing important effects and working mechanisms of those treatments. Methods: In this study, we analyze outcome and long-term follow-up data from the EVIDENT study, a large (N = 1,013) randomized-controlled trial comparing an Internet intervention for depression (Deprexis) with care as usual. We use Network Intervention Analysis to examine the symptom-specific effects of the intervention. Using data from intermediary and long-term assessments that have been conducted over 36 months, we intend to reveal how the treatment effects unfold sequentially and are maintained. Results: Item-level analysis showed that scale-level effects can be explained by small item-level effects on most depressive symptoms at all points of assessment. Higher scores on these items at baseline predicted overall symptom reduction throughout the whole assessment period. Network intervention analysis offered insights into potential working mechanisms: while deprexis directly affected certain symptoms of depression (e.g., worthlessness and fatigue) and certain aspects of the quality of life (e.g., overall impairment through emotional problems), other domains were affected indirectly (e.g., depressed mood and concentration as well as activity level). The configuration of direct and indirect effects replicates previous findings from another study examining the same intervention. Conclusions: Internet interventions for depression are not only effective in the short term, but also exert long-term effects. Their effects are likely to affect only a small subset of problems. Patients reporting these problems are likely to benefit more from the intervention. Future studies on online interventions should examine symptom-specific effects as they potentially reveal the potential of treatment tailoring. Clinical Trial Registration: ClinicalTrials.gov, Identifier: NCT02178631.

Background: Depression is a highly prevalent mental disorder, but only a fraction of those affected receive evidence-based treatments. Recently, Internet-based interventions were introduced as an efficacious and cost-effective approach. However, even though depression is a heterogenous construct, effects of treatments have mostly been determined using aggregated symptom scores. This carries the risk of concealing important effects and working mechanisms of those treatments.Methods: In this study, we analyze outcome and long-term follow-up data from the EVIDENT study, a large (N = 1,013) randomized-controlled trial comparing an Internet intervention for depression (Deprexis) with care as usual. We use Network Intervention Analysis to examine the symptom-specific effects of the intervention. Using data from intermediary and long-term assessments that have been conducted over 36 months, we intend to reveal how the treatment effects unfold sequentially and are maintained.Results: Item-level analysis showed that scale-level effects can be explained by small item-level effects on most depressive symptoms at all points of assessment. Higher scores on these items at baseline predicted overall symptom reduction throughout the whole assessment period. Network intervention analysis offered insights into potential working mechanisms: while deprexis directly affected certain symptoms of depression (e.g., worthlessness and fatigue) and certain aspects of the quality of life (e.g., overall impairment through emotional problems), other domains were affected indirectly (e.g., depressed mood and concentration as well as activity level). The configuration of direct and indirect effects replicates previous findings from another study examining the same intervention.Conclusions: Internet interventions for depression are not only effective in the short term, but also exert long-term effects. Their effects are likely to affect only a small subset of problems. Patients reporting these problems are likely to benefit more from the intervention. Future studies on online interventions should examine symptom-specific effects as they potentially reveal the potential of treatment tailoring.Clinical Trial Registration:ClinicalTrials.gov, Identifier: NCT02178631.

Background: Anxiety symptoms in older adults are prevalent and disabling but often go untreated. Most trials on psychological interventions for anxiety in later life have examined the effectiveness of face-to-face cognitive behavioral therapy (CBT). To bridge the current treatment gap, other treatment approaches and delivery formats should also be evaluated.Objective: This study is the first to examine the effectiveness of a brief blended acceptance and commitment therapy (ACT) intervention for older adults with anxiety symptoms, compared with a face-to-face CBT intervention.Methods: Adults aged between 55-75 years (n=314) with mild to moderately severe anxiety symptoms were recruited from general practices and cluster randomized to either blended ACT or face-to-face CBT. Assessments were performed at baseline (T0), posttreatment (T1), and at 6- and 12-month follow-ups (T2 and T3, respectively). The primary outcome was anxiety symptom severity (Generalized Anxiety Disorder-7). Secondary outcomes were positive mental health, depression symptom severity, functional impairment, presence of Diagnostic and Statistical Manual of Mental Disorders V anxiety disorders, and treatment satisfaction.Results: Conditions did not differ significantly regarding changes in anxiety symptom severity during the study period (T0-T1: B=.18, P=.73; T1-T2: B=-.63, P=.26; T1-T3: B=-.33, P=.59). Large reductions in anxiety symptom severity (Cohen d >= 0.96) were found in both conditions post treatment, and these were maintained at the 12-month follow-up. The rates of clinically significant changes in anxiety symptoms were also not different for the blended ACT group and CBT group (chi(2)(1)=0.2, P=.68). Regarding secondary outcomes, long-term effects on positive mental health were significantly stronger in the blended ACT group (B=.27, P=.03, Cohen d=0.29), and treatment satisfaction was significantly higher for blended ACT than CBT (B=3.19, P

Although depression is the leading cause of disability worldwide, a minority of people experiencing clinically relevant depression symptoms seek professional help. The accessibility of evidence-based online treatment programs for depression, also referred to as internet interventions, can overcome many of the traditional barriers to care seeking. Online programs are typically designed to treat symptoms of depression, and are usually aimed at individuals experiencing mild-to-moderate clinical symptoms but have also been shown to be effective in treating severe depression and preventing onset and relapse. Online programs typically adapt the principles and strategies from cognitive behavioral therapy and related evidence-based forms of therapy and can be completed in either a self-guided or clinician-supported format. Emerging research is focusing on barriers to the uptake and completion of online programs, as well as the use of new digital technologies to further understand, monitor, treat, and prevent depression.

Loneliness is an adverse emotional reaction thought to stem from an unwanted and impoverished social situation. Though it commonly makes brief appearances across the lifespan for most people, it has received increasing attention as a factor relevant to somatic and psychological well-being when assuming a more chronic form. For this reason, developing ways of alleviating loneliness is an important item on the research agenda tied to this phenomenon. Psychological interventions, and cognitive behavioural therapy (CBT) in particular, have been proposed to have potential for this. This thesis sought to evaluate the effects of two different kinds of internet-based interventions targeting loneliness: one based on CBT, and one based on interpersonal psychotherapy (IPT). In addition to this general aim, Study I also investigated the presence of different subgroups in the sample of people seeking help within the framework of projects. Using the statistical method known as Latent Profile Analysis we discovered five profiles consisting of symptoms of common psychiatric disorders and loneliness. The profiles mainly differed as a function of symptom severity, though one of the larger groups was also characterised primarily by their high ratings of social anxiety. The results suggest that the sample seeking help for their loneliness can exhibit both clinical and non-clinical levels of common mental health problems. Study II served as the pilot evaluation of an ICBT programme for loneliness. A total of 73 participants were included in a randomised controlled trial where the participants were randomised to either 8 weeks of active treatment or a wait-list control group. The results indicated significantly lower loneliness ratings after the treatment phase for the ICBT condition with a moderate-to-large effect size compared to the control group. Significant differences favouring the ICBT condition were also noted for two of the four secondary measures. Study III followed up on the participants two years after the conclusion of the initial treatment period. At this point, the control group had also received access to a version of the ICBT programme with therapist support on-demand. The results indicated that the decrease in loneliness was sustained, along with similarly lasting effects on the secondary outcomes of interest. Study IV aimed to replicate the findings from the second study with a similar ICBT programme. However, this study also employed an internet-based IPT intervention to allow for conclusions regarding the possibility of reducing loneliness by other means than CBT. A sample of 170 participants were recruited and randomised to one the treatment conditions or to a waitlist control group. The results indicated that the ICBT condition had a significantly steeper reduction in loneliness than both the waitlist and the IPT condition after the conclusion of the treatment. Both active conditions produced a significant increase in quality of life. In conclusion, internet-based psychological interventions can be efficacious for reducing loneliness, though the efficacy was only found for participants who received access to the ICBT condition in Study II and IV. The benefits from this treatment programme were sustained up to two years after the conclusion of the intervention. For these reasons, ICBT is proposed to be a good candidate for offering help to people experiencing distressing feelings of loneliness. Ensamhet är en aversiv känsloreaktion som har sitt ursprung i en oönskad social situation. I kronisk form har den påkallat uppmärksamhet som en faktor med implikationer för fysisk och psykisk hälsa. På grund av detta har tillvägagångssätt för att minska ensamhet blivit en viktig punkt på forskningsagendan kopplad till detta fenomen. Psykologiska interventioner, och mer specifikt kognitiv beteendeterapi (KBT), har hävdats ha potential för att åstadkomma detta. Denna avhandling utvärderade effekterna av två internetbaserade interventioner inriktade mot ensamhet: en baserad på KBT och en baserad på interpersonell psykoterapi (IPT). Dessutom intresserade sig en av studierna för den deltagarheterogenitet som fanns i termer av psykiatriska symptom. Personerna som sökte hjälp inom ramarna för studierna kunde delas in i fem undergrupper som främst skiljde sig åt gällande hur grav symptombörda de uppvisade, men i viss mån även sett till vilken typ av psykiatriska symptom som dominerade. Resultaten från de kliniska prövningarna pekar på att det framtagna KBT-programmet har positiva effekter i form av minskad ensamhet och psykiatrisk samsjuklighet. Effekterna kvarstod även över tid. IPT-programmet var inte lika framgångsrikt.

Background: Despite the psychosocial treatment gap in cancer settings and the significant body of evidence on the efficacy and cost-effectiveness of internet interventions, research targeting Breast Cancer Survivors (BCS) is scant, and implementation in clinical settings is limited. While the reasons for this research and implementation gaps are multifactorial, including funding, technical and organizational barriers, the attitudes of the distinct stakeholders in the internet interventions’ ecosystem have been posited to play an important role in this regard. Yet, little is known about the attitudes and practices of key stakeholders such as BCS and Mental Health Professionals (MHP) to-ward these interventions or how they should be effectively designed to be widely accepted and easily implemented. Internet interventions’ development is often viewed as a “black box”. Important behaviour change processes and technological architecture design decisions are seldom reported, and development often neglects end-users’ perspectives or the contexts in which internet interventions will be deployed. This lack of human-centeredness in the development process partly explains high attrition rates and poor engagement, as well as the failed implementation of internet interventions targeting cancer survivors. Hence, there is a need for methodologically sound internet interventions development research within psychosocial oncology, that is centred on the perspectives and practices of the several actors playing in the cancer setting. Objectives: The current thesis attempts to answer this call and bring the perspectives of key stakeholders into the centre of survivorship internet interventions’ development. Its overarching aim was to develop iNNOV Breast Cancer (iNNOVBC) – an internet intervention aiming at improving psychosocial outcomes in BCS - using a User-centred design approach, thereby anchoring development on the perspectives and practices of BCS and MHP. Its specific aims were i) to gather requirements for the development of iNNOVBC; ii) to prototype iNNOVBC; and iii) to evaluate iNNOVBC’s usefulness, usability, and feasibility. Methods: To this end quantitative (i.e., surveys and task analysis usability tests) and qualitative methods (i.e., in-depth and debriefing semi-structured interviews, think-aloud lab-based usability tests and short-term field trials) were combined and four empirical studies were conducted. First, we assessed the attitudes of Portuguese Psychologists toward internet interventions and the potential barriers impacting its implementation (n= 1077; c.f., Study I). Second, we explored in-depth the perspectives and practices of MHP regarding Digital Mental Health (DMH), with a focus on internet interventions (n=13; c.f., Study II). Third, we characterized the attitudes of Portuguese BCS toward DMH and investigated the potential factors associated with such attitudes (n=336; c.f., Study III). Fourth, we documented the development of iNNOVBC and evaluated its usefulness, usability, and preliminary feasibility (n=24; c.f., Study IV). Main findings: Despite Portuguese BCS’ and MHP’s limited knowledge, experience, and guarded stance toward internet interventions, iNNOVBC was considered highly useful by these end-users, configuring a promising point-of-need solution to bridge the psychosocial supportive care gap experienced by BCS across survivorship. However, to fulfil its full supportive role and reach high levels of usability and feasibility, iNNOVBC requires further refinement. Alterations are necessary regarding the aesthetics, information architecture, cognitive load, interaction design, and the technological media for intervention delivery (e.g., mobile app version). In addition, iNNOVBC might require further tailoring and a more flexible implementation approach, so that it better adapts to the needs and contexts of its target users. These aspects need to be assessed in future pilot and Randomized Controlled Trial studies. Implications: The development of internet interventions targeting BCS should, when-ever possible involve its target end-users so that interventions reflect their real needs and are more easily accepted and implemented. Furthermore, development teams should devise comprehensive plans for the translation of interventions to clinical practice, including appropriate training and communication plans, capable of overcoming potential knowledge, training, and attitudinal barriers to successful implementation. Funding agencies: The European Union Erasmus+ programme, Fraunhofer Portugal AICOS and the Portuguese Foundation for Science and Technology

Introduction Perinatal depression is one of the most common complications during pregnancy and one year following childbirth. A negative impact on the mental and physical health of women, their children, partners, or significant others has been associated with this disease. Web-based and Mobile-based psychological interventions can reduce the burden of the disease through prevention of new cases of depression. It is crucial to know the effectiveness of these interventions to implement them around the globe. This systematic review and meta-analysis aims to assess the effectiveness of Web-based and Mobile-based psychological interventions to prevent depression during the perinatal period. Method and analysis A systematic review and meta-analysis will adhere to the PRISMA guidelines. Studies will be identified through MEDLINE, PsycINFO, Web of Science, Scopus, CINAHL, CENTRAL, Opengrey, Australian New Zealand Clinical Trial Registry, National Institute for Mental Health Research at the Australian National University, clinicaltrial.gov, beacon.anu.edu.au, and evidencebasedpsychotherapies.org from inception until 31 March 2021. We will also search the reference lists provided in relevant studies and reviews. The selection criteria will be as follows: 1) pregnant women or women who have given birth in the last 12 months and who were non-depressive at baseline; 2) Web-based and Mobile-Based psychological interventions; 3) comparators will be usual care, attention control, waiting list or no intervention; 4) outcomes will be the incidence of new cases of perinatal depression and/or the reduction of depressive symptoms as measured by validated instruments; and 5) the design of the studies will be randomized controlled trials. No restrictions regarding the year or language of publication will be considered. Pooled standardized mean differences and 95% confidence intervals will be calculated. The risk of bias of the studies will be assessed through the Cochrane Collaboration risk of bias 2.0 tool. Heterogeneity and publication bias will be estimated. Sensitivity and sub-group analyses will also be conducted. Random effects meta-regression will be performed. Ethics and dissemination As a systematic review, ethical approval is not required. The results from this study will be presented at international conferences and disseminated through peer-reviewed publications. Patients and the public will be involved in the dissemination plans. PROSPERO registration number 230,089 (submitted)., Highlights • This will be the first study to assess the effectiveness of Web-based and Mobile-based interventions in preventing perinatal depression • This systematic review and meta-analysis will include results on depression throughout the entire perinatal period. • This study will include only randomized control trials. • Only randomized control trials that excluded at baseline depressed women at baseline will be included.

COVID-19 mitigation measures present unprecedented challenges in mental healthcare delivery, posing high risk to the mental health of at-risk populations, namely patients diagnosed with COVID-19, frontline healthcare providers, and those submitted to quarantine or isolation measures, as well as the general population. Ensuring safe and equitable access to mental healthcare by these groups entails resorting to innovative psychosocial intervention strategies, such as digital mental health. In this perspective piece, we describe the impact of COVID-19 on the Portuguese population's mental health, present an overview on initiatives developed to address the challenges currently faced by the Portuguese mental healthcare system, and discuss how the timely implementation of a comprehensive digital mental health strategy, coupling research, education, implementation, and quality assessment initiatives, might buffer COVID-19's impact on the Portuguese society. published

A coach-guided Acceptance and Commitment Therapy (ACT) intervention that uses a blended approach of two face-to-face and five online sessions (iACT; N = 33) has been found to be more effective than a waiting-list control condition (WLC; N = 35) at enhancing the wellbeing of university students while also reducing stress and depression. The present study explored possible mediators of change that may account for the outcomes of the study. Mediation analyses revealed that changes in the non-reactivity subscale of mindfulness mediated changes in wellbeing, depression, and stress in the iACT group. In addition, changes in the sense of coherence subscale of meaningfulness mediated changes in all outcomes. Psychological flexibility and cognitive defusion did not mediate changes in outcomes. The results suggest that the use of practices focusing on non-reactivity, meaning the ability to allow thoughts and feelings to come and go without getting carried away by them, is especially important for enhancing the wellbeing of university students. A focus on enhancing meaningfulness also plays a significant role in reducing psychological distress. These findings provide a first step toward understanding the potential mechanisms of change taking place in brief, Internet-supported, blended ACT programs., Highlights • Changes in nonreactivity mediate changes in wellbeing, stress, depression. • Changes also in meaningfulness mediate changes in treatment outcomes. • Results support the use of practices to foster acceptance skills for students. • Results support ACT interventions that emphasize values-based processes.

Objective To describe demographic and clinical characteristics of Spanish- and English-speaking visitors to a “Healthy Mood” website. Methods An online study intended to prevent depression by teaching users mood management skills recruited participants globally using primarily Google Ads. Those who consented responded to the Patient Health Questionnaire (PHQ-9) and the MDE Screener (Muñoz, 1998) upon entry into the study. Results 1423 participants consented, 437 English speakers and 986 Spanish speakers. Of the 1271 participants with sufficient depression symptom data, 65% screened positive for a current major depressive episode, 30% were at high risk for onset of a major depressive episode, and 5% were in the low-risk category. Conclusion Websites intended to be preventive appear to attract primarily individuals who are currently experiencing enough symptoms to screen positive for a major depressive episode. Only 30% of participants were appropriate for a depression prevention intervention. Therefore, such sites must be ready to encourage those with current depression to obtain professional help as well as ensure that the online self-help interventions are appropriate for participants who could benefit from both preventive and treatment interventions., Highlights • 1423 participants consented to a study intended for depression prevention. • Consented participants represented 86 countries. • 69% of the 1423 participants who consented were Spanish speaking. • Two thirds of participants screened positive for current depressive episode. • Future prevention studies should accommodate those with higher symptom levels.

Background Although gamification continues to be a popular approach to increase engagement, motivation, and adherence to behavioral interventions, empirical studies have rarely focused on this topic. There is a need to empirically evaluate gamification models to increase the understanding of how to integrate gamification into interventions. Objective The model of gamification principles for digital health interventions proposes a set of five independent yet interrelated gamification principles. This study aimed to examine the validity and reliability of this model to inform its use in Web- and mobile-based apps. Methods A total of 17 digital health interventions were selected from a curated website of mobile- and Web-based apps (PsyberGuide), which makes independent and unbiased ratings on various metrics. A total of 133 independent raters trained in gamification evaluation techniques were instructed to evaluate the apps and rate the degree to which gamification principles are present. Multiple ratings (n≥20) were collected for each of the five gamification principles within each app. Existing measures, including the PsyberGuide credibility score, mobile app rating scale (MARS), and the app store rating of each app were collected, and their relationship with the gamification principle scores was investigated. Results Apps varied widely in the degree of gamification implemented (ie, the mean gamification rating ranged from 0.17≤m≤4.65 out of 5). Inter-rater reliability of gamification scores for each app was acceptable (κ≥0.5). There was no significant correlation between any of the five gamification principles and the PsyberGuide credibility score (P≥.49 in all cases). Three gamification principles (supporting player archetypes, feedback, and visibility) were significantly correlated with the MARS score, whereas three principles (meaningful purpose, meaningful choice, and supporting player archetypes) were significantly correlated with the app store rating. One gamification principle was statistically significant with both the MARS and the app store rating (supporting player archetypes). Conclusions Overall, the results support the validity and potential utility of the model of gamification principles for digital health interventions. As expected, there was some overlap between several gamification principles and existing app measures (eg, MARS). However, the results indicate that the gamification principles are not redundant with existing measures and highlight the potential utility of a 5-factor gamification model structure in digital behavioral health interventions. These gamification principles may be used to improve user experience and enhance engagement with digital health programs.

© Copyright © 2019 Fleming, Stasiak, Moselen, Hermansson-Webb, Shepherd, Lucassen, Bavin and Merry. Background: The way in which computerized therapy is presented may be important for its uptake. We aimed to explore adolescents’ views on the appeal of a tested computerized cognitive behavioral therapy (CCBT) for depression (SPARX), and a revised version (SPARX-R). The versions were similar but while SPARX is presented explicitly as a treatment for depression, SPARX-R is presented as providing skills that could be useful for young people for when they were depressed, down, angry, or stressed. Methods: We held 9 focus groups with a total of 79 adolescents (13–19 years old; 47 females; 34 New Zealand European; 22 Māori or Pacific; 60 reported having experienced feeling down or low for at least several days in a row). Groups viewed the opening sequences of SPARX and SPARX-R (in random order), then took part in a semi-structured discussion and completed a brief questionnaire. Responses were analyzed using a general inductive approach. Results: Participants considered both SPARX and SPARX-R useful and considered the stated purpose of the program to be important. Four themes contrasted the two approaches. The first, “naming depression is risky”, referred to perceptions that an explicit focus on depression could be off-putting, including for adolescents with depression. The second theme of “universality” reflected preferences for a universal approach as young people might not recognize that they were depressed, and all would benefit from the program. In contrast, “validation” reflected the view of a significant minority that naming depression could be validating for some. Finally, the theme of “choice” reflected a near-unanimously expressed preference for both options to be offered, allowing user choice. In questionnaire responses, 40 (68%) of participants preferred SPARX-R, 13 (18%) preferred SPARX, while 10 (14%) “didn’t mind”. Responses were similar among participants who reported that they had experienced at least a few days of low mood and those who had not. Conclusions: The way a CCBT program is presented may have implications for its appeal. The potential population impact of CCBT programs explicitly targeting depression and those targeting more universal feelings such as being stressed or feeling depressed should be explored for varied user groups.