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Migrants face many barriers to mental health care, such as different cultural concepts of distress, unfamiliar pathways to care, and language. Digital mental health interventions are effective and scalable in multi-language versions. However, their implementation into routine care is in its infancy. Here, we report on the Arabic- and German-language implementation of two digital interventions in Germany: The iFightDepression® website, providing information about depression to the public, and the iFightDepression® tool, offering guided self-management for depression. Their acceptability (time on page, usage behavior) was comparable between the two user groups. The website penetration of the target populations was nine times lower among Arab migrants in Germany than Germans (89 vs. 834 unique page views/ 100,000). The adoption of the tool was lower among Arabic than German users (conversion rate from invitation to completed registration: 30.8% vs. 59.0%, p

Zusammenfassung Hintergrund E‑Mental-Health (EMH) spielt im ambulanten Versorgungssetting depressiver Störungen zunehmend eine Rolle. Ziel dieser Studie war die Implementierung und Evaluierung der Anwendbarkeit und des Nutzens des onlinebasierten Selbstmanagementprogramms „iFightDepression“ (iFD) als Zusatzangebot im Rahmen einer leitliniengerechten Behandlung auf einer Spezialstation für affektive Störungen. Methodik Es wurden insgesamt 78 stationäre PatientInnen mit einer unipolaren Depression unterschiedlichen Schweregrades (ICD-10 F32.0‑3, F33.0-3) oder einer Dysthymie (F34) rekrutiert. Die Interventionsdauer mit dem iFD-Tool belief sich vom Zeitpunkt der stationären Aufnahme bis zur Entlassung und wurde vom Stationspersonal begleitet. Die Erhebung der Symptomschwere sowie von Parametern zur Behandlungserwartung und Therapievorerfahrung erfolgte online vor der Intervention (T0), die Interventionszufriedenheit wurde unmittelbar vor der stationären Entlassung (T1) mittels eines Paper-pencil-Fragebogens erfasst. Ergebnisse Von den 78 Teilnehmenden loggten sich 42 mindestens einmal in das iFD-Tool ein. Es zeigten sich moderat hohe Erwartungswerte sowie leicht überdurchschnittliche Zufriedenheitswerte bezüglich der Behandlung. 67 % der aktiven NutzerInnen gaben an, das iFD-Tool poststationär weiter nutzen zu wollen. Wesentliche Gründe gegen die Nutzung waren eine kurze Aufenthaltsdauer, eine schwere depressive Symptomatik und fehlende Medienkompetenz. Diskussion Eine Implementierung des iFD-Tools im stationären Setting ist prinzipiell machbar und führte zu positiven Rückmeldungen seitens der NutzerInnen. Auch konnten sich die meisten aktiv an der Studie Teilnehmenden eine weitere Nutzung des iFD-Tools nach der Entlassung gut vorstellen. Allerdings weisen die insgesamt geringen Nutzungs- (42/78, 54 %) und Komplettierungsraten auf Nutzungsbarrieren hin, deren Überwindung entsprechende Anpassungen der Intervention speziell für den stationären Einsatz erforderlich machen.

BACKGROUND Internet-based Cognitive Behaviour Therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for effective strategies to improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective and tailored implementation is considered as a promising approach. The self-guided ‘Integrated Theory-based Framework for Implementation Tailoring Strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves (1) identifying local barriers, (2) matching selected barriers to implementation strategies, (3) developing an actionable work plan, and (4) applying, monitoring, and adapting where necessary. OBJECTIVE We compared the effectiveness of the ItFits-toolkit with Implementation-As-Usual (IAU) in implementing iCBT in twelve routine mental health care organisations in nine countries. METHODS A stepped-wedge cluster randomised trial design with repeated measures was applied. The total trial period was 30 months. The primary outcome was normalisation of iCBT delivery by service providers (therapists, referrers, IT developers, administrators) measured with the NoMAD as a proxy for implementation success. Three-level linear mixed-effects modelling was applied to estimate the effects. iCBT uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. Perceived satisfaction (CSQ-3), usability (SUS), and impact of the ItFits-toolkit by implementers was assessed to assesses the acceptability of the ItFits-toolkit. RESULTS In total, 456 mental health service providers were included in the study. Compared to IAU, the ItFits-toolkit had a small significant positive effect on normalisation levels in service providers (M=0.09, SD=0.04, p=0.02, Cohen’s d=0.12). Uptake of iCBT by patients was on par with IAU. Compared to IAU, implementers did not spent more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it. CONCLUSIONS The ItFits-toolkit performed better than usual implementation activities in implementing iCBT services in routine practice. However, the effect on normalization levels in mental health service providers was very small. There lies practical utility in the ItFits-toolkit for supporting implementers to develop and apply effective tailored implementation strategies. However, these findings warrant modesty about the effectiveness of self-guided tailored implementation in implementing iCBT services in routine practice. CLINICALTRIAL ClinicalTrials.gov (No. NCT03652883) INTERNATIONAL REGISTERED REPORT RR2-10.1186/s13063-020-04686-4

Major depression (MD) is a highly prevalent and severe disorder with many patients having no access to efficient treatments such as pharmaco- and psychotherapy. Web-based interventions promise to be a method to provide resource-efficient and widespread access to psychotherapeutic support. Meta-analyses summarizing studies that use face-to-face psychotherapy as a comparator provide evidence for equivalent antidepressant efficacy. Web-based interventions seem to be particularly efficacious when they are accompanied by some form of professional guidance. However, they are also associated with a variety of possible risks (eg, suicidal crises can be overlooked) and unwanted effects (eg, increase in rumination and somatization due to self-monitoring) that are so far under-studied. Although some naturalistic studies yield smaller effect sizes than randomized controlled trials (RCTs), well-designed interventions with adequate guidance have been shown to be successfully integrable into routine care. .La depresión mayor (DM) es un trastorno altamente prevalente y grave, con muchos pacientes que no pueden acceder a tratamientos farmacológicos ni psicoterapéuticos eficientes. Las intervenciones basadas en la web prometen constituir un método que facilite un acceso amplio y eficiente para el apoyo psicoterapéutico. Los metanálisis de estudios que emplean la psicoterapia presencial como comparador, entregan evidencia de una eficacia antidepresiva equivalente. Las intervenciones basadas en la web parecen ser especialmente eficaces cuando van acompañadas de alguna forma de orientación profesional. Sin embargo, también están asociadas con una variedad de posibles riesgos (como pasar por alto situaciones con riesgo suicida) y efectos no deseados (como aumento de la rumiación y somatización debido al autocontrol) que hasta la fecha han sido poco estudiados. Aunque algunos estudios naturalísticos producen efectos de menor tamaño que los ensayos controlados randomizados (ECR), se ha demostrado que las intervenciones bien diseñadas con la orientación adecuada se integran exitosamente a la atención de rutina.De nombreux patients atteints de dépression majeure, maladie sévère à la prévalence élevée, ne bénéficient pas de traitements efficaces, qu’ils soient pharmacologiques ou psychothérapeutiques. Les thérapies à distance ou en ligne se présentent comme des alternatives à l’aide psychothérapeutique, efficaces et accessibles au plus grand nombre. Leur efficacité antidépressive serait équivalente à celle d’une psychothérapie en présentiel selon des métaanalyses regroupant des études comparatives. Les thérapies à distance semblent être encore plus efficaces si elles bénéficient de l’intervention d’un professionnel, quelle qu’en soit la forme. . Cependant, des risques leur sont également associés (comme la négligence d’un risque suicidaire) et les effets indésirables (l’augmentation des ruminations et la somatisation liée à l’auto-surveillance, par exemple), sont encore peu étudiés. La taille d’effet des études observationnelles peut être inférieure à celle des études contrôlées randomisées (ECR) mais, bien conçues et menées par un professionnel compétent, ces thérapies à distance ont trouvé une place efficace en pratique courante.

E‑mental health mainly plays a role in the outpatient treatment of patients with depressive disorders. The goal of this study was to implement and evaluate the web-based, therapist-guided self-management tool "iFightDepression" (iFD) to clarify if there is a benefit for inpatient use.In this study 78 inpatients with affective disorders (ICD-10 F32.0‑3, F33.0-3) or dysthymia (F34) were recruited. The intervention duration with the iFD tool went from admission until discharge, therapeutic support was granted by the ward staff. Symptom severity, intervention expectations and experience with therapy were processed in an online questionnaire before the intervention (T0) while intervention satisfaction was captured after the intervention shortly before discharge (T1) in a paper-pencil questionnaire.Out of 78 participating inpatients 42 used the iFD tool at least once. Moderate to high levels of expectation regarding the iFD tool and mildly above-average level of satisfaction after the intervention were observed. Of the active users 67% indicated they would continue to use the iFD tool after discharge. The main reasons for not using the iFD tool were short duration of stay, severity of disease and lack of digital literacy.An implementation of the iFD tool is feasible on principle. Active users gave positive feedback concerning the intervention and most participants claimed to continue using the iFD tool after discharge; however, low usage rates among study participants (42/78, 54%) showed barriers of implementation that have to be addressed and underline the importance of adaptations regarding the use of the intervention in a clinical setting.HINTERGRUND: E‑Mental-Health (EMH) spielt im ambulanten Versorgungssetting depressiver Störungen zunehmend eine Rolle. Ziel dieser Studie war die Implementierung und Evaluierung der Anwendbarkeit und des Nutzens des onlinebasierten Selbstmanagementprogramms „iFightDepression“ (iFD) als Zusatzangebot im Rahmen einer leitliniengerechten Behandlung auf einer Spezialstation für affektive Störungen.Es wurden insgesamt 78 stationäre PatientInnen mit einer unipolaren Depression unterschiedlichen Schweregrades (ICD-10 F32.0‑3, F33.0-3) oder einer Dysthymie (F34) rekrutiert. Die Interventionsdauer mit dem iFD-Tool belief sich vom Zeitpunkt der stationären Aufnahme bis zur Entlassung und wurde vom Stationspersonal begleitet. Die Erhebung der Symptomschwere sowie von Parametern zur Behandlungserwartung und Therapievorerfahrung erfolgte online vor der Intervention (T0), die Interventionszufriedenheit wurde unmittelbar vor der stationären Entlassung (T1) mittels eines Paper-pencil-Fragebogens erfasst.Von den 78 Teilnehmenden loggten sich 42 mindestens einmal in das iFD-Tool ein. Es zeigten sich moderat hohe Erwartungswerte sowie leicht überdurchschnittliche Zufriedenheitswerte bezüglich der Behandlung. 67 % der aktiven NutzerInnen gaben an, das iFD-Tool poststationär weiter nutzen zu wollen. Wesentliche Gründe gegen die Nutzung waren eine kurze Aufenthaltsdauer, eine schwere depressive Symptomatik und fehlende Medienkompetenz.Eine Implementierung des iFD-Tools im stationären Setting ist prinzipiell machbar und führte zu positiven Rückmeldungen seitens der NutzerInnen. Auch konnten sich die meisten aktiv an der Studie Teilnehmenden eine weitere Nutzung des iFD-Tools nach der Entlassung gut vorstellen. Allerdings weisen die insgesamt geringen Nutzungs- (42/78, 54 %) und Komplettierungsraten auf Nutzungsbarrieren hin, deren Überwindung entsprechende Anpassungen der Intervention speziell für den stationären Einsatz erforderlich machen.

Background Internet- and mobile-based interventions are most efficacious in the treatment of depression when they involve some form of guidance, but providing guidance requires resources such as trained personnel, who might not always be available (eg, during lockdowns to contain the COVID-19 pandemic). Objective The current analysis focuses on changes in symptoms of depression in a guided sample of patients with depression who registered for an internet-based intervention, the iFightDepression tool, as well as the extent of intervention use, compared to an unguided sample. The objective is to further understand the effects of guidance and adherence on the intervention’s potential to induce symptom change. Methods Log data from two convenience samples in German routine care were used to assess symptom change after 6-9 weeks of intervention as well as minimal dose (finishing at least two workshops). A linear regression model with changes in Patient Health Questionnaire (PHQ-9) score as a dependent variable and guidance and minimal dose as well as their interaction as independent variables was specified. Results Data from 1423 people with symptoms of depression (n=940 unguided, 66.1%) were included in the current analysis. In the linear regression model predicting symptom change, a significant interaction of guidance and minimal dose revealed a specifically greater improvement for patients who received guidance and also worked with the intervention content (β=–1.75, t=–2.37, P=.02), while there was little difference in symptom change due to guidance in the group that did not use the intervention. In this model, the main effect of guidance was only marginally significant (β=–.53, t=–1.78, P=.08). Conclusions Guidance in internet-based interventions for depression is not only an important factor to facilitate adherence, but also seems to further improve results for patients adhering to the intervention compared to those who do the same but without guidance.

BACKGROUND Internet- and mobile-based interventions are most efficacious in the treatment of depression when they involve some form of guidance, but providing guidance requires resources such as trained personnel, who might not always be available (eg, during lockdowns to contain the COVID-19 pandemic). OBJECTIVE The current analysis focuses on changes in symptoms of depression in a guided sample of patients with depression who registered for an internet-based intervention, the iFightDepression tool, as well as the extent of intervention use, compared to an unguided sample. The objective is to further understand the effects of guidance and adherence on the intervention’s potential to induce symptom change. METHODS Log data from two convenience samples in German routine care were used to assess symptom change after 6-9 weeks of intervention as well as minimal dose (finishing at least two workshops). A linear regression model with changes in Patient Health Questionnaire (PHQ-9) score as a dependent variable and guidance and minimal dose as well as their interaction as independent variables was specified. RESULTS Data from 1423 people with symptoms of depression (n=940 unguided, 66.1%) were included in the current analysis. In the linear regression model predicting symptom change, a significant interaction of guidance and minimal dose revealed a specifically greater improvement for patients who received guidance and also worked with the intervention content (β=–1.75, t=–2.37, P=.02), while there was little difference in symptom change due to guidance in the group that did not use the intervention. In this model, the main effect of guidance was only marginally significant (β=–.53, t=–1.78, P=.08). CONCLUSIONS Guidance in internet-based interventions for depression is not only an important factor to facilitate adherence, but also seems to further improve results for patients adhering to the intervention compared to those who do the same but without guidance.

Background An increasing number of studies suggest that web-based interventions for patients with depression can reduce their symptoms and are expected to fill currently existing treatment gaps. However, evidence for their efficacy has mainly been derived from comparisons with wait-list or treatment as usual controls. In particular, designs using wait-list controls are unlikely to induce hope and may even have nocebo effects, making it difficult to draw conclusions about the intervention’s efficacy. Studies using active controls are rare and have not yielded conclusive results. Objective The main objective of this study is to assess the acute and long-term antidepressant efficacy of a 6-week, guided, web-based self-management intervention building on the principles of cognitive behavioral therapy (iFightDepression tool) for patients with depression compared with web-based progressive muscle relaxation as an active control condition. Methods A total of 348 patients with mild-to-moderate depressive symptoms or dysthymia (according to the Mini International Neuropsychiatric Interview) were recruited online and randomly assigned to 1 of the 2 intervention arms. Acute antidepressant effects after 6 weeks and long-term effects at 3-, 6-, and 12-month follow-up were studied using the Inventory of Depressive Symptomatology–self-rating as a primary outcome parameter and change in quality of life (Short Form 12) and user satisfaction (client satisfaction questionnaire) as secondary outcome parameters. Treatment effects were assessed using mixed model analyses. Results Over the entire observation period, a greater reduction in symptoms of depression (P=.01) and a greater improvement of life quality (P Conclusions The fact that antidepressant effects have been found for a guided self-management tool in comparison with an active control strengthens the evidence base for the efficacy of web-based interventions. The antidepressant effect became most prominent at the 3-month follow-up. After 6 weeks of intervention, significant positive effects were observed on life quality but not on depressive symptoms. Although the effect size of such web-based interventions on symptoms of depression might be smaller than that suggested by earlier studies using wait-list control conditions, they can be a cost-effective addition to antidepressants and face-to-face psychotherapy. Trial Registration International Clinical Trials Registry Platform ICTRP080-15-09032015; https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00009323

Background Internet-based Cognitive Behavioural Therapy (iCBT) is found effective in treating common mental disorders. However, the use of these interventions in routine care is limited. The international ImpleMentAll study is funded by the European Union’s Horizon 2020 programme. It is concerned with studying and improving methods for implementing evidence-based iCBT services for common mental disorders in routine mental health care. A digitally accessible implementation toolkit (ItFits-toolkit) will be introduced to mental health care organizations with the aim to facilitate the ongoing implementation of iCBT services within local contexts. This study investigates the effectiveness of the ItFits-toolkit by comparing it to implementation-as-usual activities. Methods A stepped wedge cluster randomized controlled trial (SWT) design will be applied. Over a trial period of 30 months, the ItFits-toolkit will be introduced sequentially in twelve routine mental health care organizations in primary and specialist care across nine countries in Europe and Australia. Repeated measures are applied to assess change over time in the outcome variables. The effectiveness of the ItFits-toolkit will be assessed in terms of the degree of normalization of the use of the iCBT services. Several exploratory outcomes including uptake of the iCBT services will be measured to feed the interpretation of the primary outcome. Data will be collected via a centralized data collection system and analysed using generalized linear mixed modelling. A qualitative process evaluation of routine implementation activities and the use of the ItFits-toolkit will be conducted within this study. Discussion The ImpleMentAll study is a large-scale international research project designed to study the effectiveness of tailored implementation. Using a SWT design that allows to examine change over time, this study will investigate the effect of tailored implementation on the normalization of the use of iCBT services and their uptake. It will provide a better understanding of the process and methods of tailoring implementation strategies. If found effective, the ItFits-toolkit will be made accessible for mental health care service providers, to help them overcome their context-specific implementation challenges. Trial registration ClinicalTrials.gov NCT03652883. Retrospectively registered on 29 August 2018

Introduction A growing number of internet interventions have been shown to help in alleviating symptoms of depression. So far, only little research has focused on other methods than CBT. The present study aimed to investigate the level of satisfaction with a positive psychology online training among patients with mild and moderate depression or dysthymia. Secondary outcome measures included changes in symptom severity, health related quality of life, and negative effects. Methods A total of 81 participants were allocated to the intervention. They were asked to complete online questionnaires and were called by one of the study psychologists at baseline, at post-treatment, and at follow-up (3 months after completion of the intervention). Shorter questionnaires were administered after each module. Results Overall satisfaction was promising. While participants seemed to be very satisfied with many aspects of the program itself, they were slightly less satisfied with its impact on the problems they sought to solve. Overall, negative effects attributed to the program were small with one exception. At post-treatment, 22.6% of the participants felt that they or their problems were not taken seriously by the program. Symptom severity decreased over time with mild to moderate effect sizes. There was a moderate increase in satisfaction with mental health at both post-treatment and follow-up. Conclusions The online program investigated here may be a useful resource-oriented addition to the standard treatment of depression., Highlights • An internet-based positive psychology intervention was investigated among persons with depression • Satisfaction was promising, symptom severity decreased, and health-related quality of life increased • Negative effects were assessed and found to be small • We conclude that the program may be a useful resource-oriented addition to the standard treatment of depression

Objective Previous research suggests that online positive psychology interventions (PPI) are frequently used by individuals with symptoms of depression. We aimed to investigate differences in the way depressed and nondepressed users react to the content of an existing online PPI, originally designed for the general public. Method In a retrospective online survey, we assessed discontinuation parameters, aspects of satisfaction with the program, and negative reactions among users of an online PPI. Results Bivariate and multivariate analyses showed that, overall, reactions between depressed and nondepressed individuals were similar. Differences were observed concerning reasons for using and for discontinuing the program, the perception of exercises, and negative reactions. Conclusions Although satisfaction with the program was high, it did not seem to fully meet users' expectations and might be more difficult to complete during episodes of depression. Implications of this study for the adaptation of online PPIs addressing depressed individuals are discussed.

BACKGROUND An increasing number of studies suggest that web-based interventions for patients with depression can reduce their symptoms and are expected to fill currently existing treatment gaps. However, evidence for their efficacy has mainly been derived from comparisons with wait-list or treatment as usual controls. In particular, designs using wait-list controls are unlikely to induce hope and may even have nocebo effects, making it difficult to draw conclusions about the intervention’s efficacy. Studies using active controls are rare and have not yielded conclusive results. OBJECTIVE The main objective of this study is to assess the acute and long-term antidepressant efficacy of a 6-week, guided, web-based self-management intervention building on the principles of cognitive behavioral therapy (iFightDepression tool) for patients with depression compared with web-based progressive muscle relaxation as an active control condition. METHODS A total of 348 patients with mild-to-moderate depressive symptoms or dysthymia (according to the Mini International Neuropsychiatric Interview) were recruited online and randomly assigned to 1 of the 2 intervention arms. Acute antidepressant effects after 6 weeks and long-term effects at 3-, 6-, and 12-month follow-up were studied using the Inventory of Depressive Symptomatology–self-rating as a primary outcome parameter and change in quality of life (Short Form 12) and user satisfaction (client satisfaction questionnaire) as secondary outcome parameters. Treatment effects were assessed using mixed model analyses. RESULTS Over the entire observation period, a greater reduction in symptoms of depression (P=.01) and a greater improvement of life quality (Pd=0.281; 95% CI 0.069 to 0.493), but not after 6 weeks (main outcome: d=0.192; 95% CI −0.020 to 0.404) and 6 and 12 months. The intervention was significantly superior to the control condition with respect to user satisfaction (25.31 vs 21.97; t259=5.804; P CONCLUSIONS The fact that antidepressant effects have been found for a guided self-management tool in comparison with an active control strengthens the evidence base for the efficacy of web-based interventions. The antidepressant effect became most prominent at the 3-month follow-up. After 6 weeks of intervention, significant positive effects were observed on life quality but not on depressive symptoms. Although the effect size of such web-based interventions on symptoms of depression might be smaller than that suggested by earlier studies using wait-list control conditions, they can be a cost-effective addition to antidepressants and face-to-face psychotherapy. CLINICALTRIAL International Clinical Trials Registry Platform ICTRP080-15-09032015; https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00009323

Langst hat die Digitalisierung auch Eingang in die Gesundheitsversorgung psychisch Kranker gefunden, wo entsprechende Ansatze unter dem Begriff E-Mental Health zusammengefasst werden. In diesem Kapitel sollen exemplarisch E-Mental-Health-Angebote fur Menschen mit depressiven Storungen vorgestellt werden, da Depressionen aufgrund ihrer Haufigkeit und Schwere sowie auch wegen bestehender Versorgungsdefizite zu den Erkrankungen mit dem grosten Optimierungsspielraum zahlen und hier digitale Angebote wichtige Erganzungen zur Leitlinienbehandlung bieten konnen. Am Beispiel von drei konkreten Anwendungsbereichen (Online-Diskussionsforen, Digitale Psychotherapie- und Selbstmanagement-Programme sowie Smartphone-basiertes Selbstmonitoring) sollen Chancen, aber auch mogliche Risiken und Nebenwirkungen dieser E-Mental-Health-Angebote diskutiert werden.