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Background: Telephone-administered psychotherapy (tCBT) and internet-based treatments (iCBT) may overcome barriers to mental health treatment. TCBT has demonstrated efficacy similar to traditional psychotherapy, however, few studies have compared iCBT to efficacious interventions. This exploratory study examined the noninferiority of iCBT relative to tCBT. We also explored pretreatment moderators of outcome and assessed treatment dropout., Methods: As a secondary exploratory analysis of a 304-participant randomized noninferiority trial, we compared iCBT, the first level of a stepped-care intervention, with tCBT on depression outcome after 5 weeks of treatment (prior to stepping). Multiple linear regression models were fit to examine moderators of 5-week depression. Differences in dropout were examined using Kaplan-Meier survival analysis., Results: After 5 weeks of treatment, both interventions significantly reduced depression severity. The effect size difference between the two interventions was d=0.004 [90% CI=-0 . 19 to 0 . 19]; the CI did not cross the non-inferiority margin. Pretreatment depression was significantly associated with depression at week 5. The relationship between cognitive strategy usefulness and depression at week 5 differed between interventions, controlling for pretreatment depression. There was no significant difference in dropout between interventions., Limitations: Given the stepped-care trial design, iCBT and tCBT could not be compared at the end of treatment or follow-up. Analyses were exploratory and should be interpreted with caution., Conclusions: A large sample, powered for noninferiority, found iCBT no less efficacious than tCBT at reducing depression symptoms after five weeks of treatment., (Copyright © 2020. Published by Elsevier B.V.)

This trial examined whether a stepped care program for depression, which initiated treatment with internet cognitive behavioral therapy, including telephone and messaging support, and stepped up non-responders to telephone-administered cognitive behavioral therapy (tCBT), was noninferior, less costly to deliver, and as acceptable to patients compared to tCBT alone. Adults with a diagnosis of major depressive episode (MDE) were randomized to receive up to 20 weeks of stepped care or tCBT. Stepped care (n = 134) was noninferior to tCBT (n = 136) with an end-of-treatment effect size of d = 0.03 and a 6-month post-treatment effect size of d = -0.07 [90% CI 0.29 to 0.14]. Therapist time in stepped care was 5.26 (SD = 3.08) hours versus 10.16 (SD 4.01) for tCBT (p < 0.0001), with a delivery cost difference of $-364.32 [95% CI $-423.68 to $-304.96]. There was no significant difference in pre-treatment preferences (p = 0.10) or treatment dropout (39 in stepped care; 27 in tCBT; p = 0.14). tCBT patients were significantly more satisfied than stepped care patients with the treatment they received (p < 0.0001). These findings indicate that stepped care was less costly to deliver, but no less effective than tCBT. There was no significant difference in treatment preference or completion, however satisfaction with treatment was higher in tCBT than stepped care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01906476., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Internet-based cognitive behavioral therapy (iCBT) may overcome barriers to mental health care and has proven efficacious. However, this approach currently exists outside the existing mental health care delivery system. Stepped care is a proposed framework for integrating digital mental health (DMH) into health systems by initiating iCBT and "stepping up" care to a more intensive intervention should iCBT prove ineffective. This study explores pre-treatment factors associated with reaching stepping criteria among patients receiving iCBT. This exploratory analysis of a stepped care arm of a larger randomized trial examined participants who were stepped to a more intensive intervention if they did not respond to iCBT. The association of pre-treatment factors on stepping were examined using Kruskal-Wallis and Chi-square tests. One-fifth of the 151 participants met criteria for stepping within the 20-week treatment period. Only pre-treatment depression severity and treatment preference were associated with increased likelihood of stepping ( p = 0.049 and 0.048, respectively). The low number of individuals who stepped provides support for iCBT as an effective, low intensity treatment for depression. The modest association of pre-treatment depression and preference to not receive iCBT may be useful in identifying patients who are less likely to respond.

Objective: Medical school presents a time of psychological distress for many students, who are less likely than the general population to seek mental health treatment due to multiple treatment barriers. Internet-based cognitive behavioral therapy (iCBT) programs may be an acceptable option for medical students. This study aims to assess acceptability and usability of ThinkFeelDo, an iCBT program, and to examine the impact of the program on perceived stress, quality of life, and the development of cognitive and behavioral coping skills., Method: Fourteen medical students (M age = 25.4 years, 50% female) participated in the 6-week ThinkFeelDo program and completed baseline and end of treatment assessments., Results: ThinkFeelDo was used (login M = 11.9, SD = 9.8) and was rated as somewhat useful. Participants requested further refinement of lessons to better fit the typical narrative of a medical student and endorsed interest in the program being offered at the beginning of medical school. At end of program, participants increased the frequency with which they used cognitive and behavioral coping skills, t(10) = -3.400, p = .007., Conclusions: Results of this study indicate that medical students are willing to utilize online mental health programs and may receive benefit. However, the sample was small, self-selected, and without a comparison group. Feedback collected through this study provides insight on how to effectively integrate iCBT programs into the medical school experience.

Objective: This pilot study evaluated the feasibility and efficacy of two methods of delivering a cognitive behaviorally informed Internet intervention for depression for adults 65 years and older., Methods: Forty-seven participants were enrolled and assigned to receive one of two versions of the Internet intervention, either delivered individually (III) or with peer support (II+PS), or to a wait list control group (WLC). Primary outcomes included change in depressive symptoms from baseline to post-intervention (week 8), site use, self-reported usability, and coach time. Secondary outcomes included measures of social support and isolation and anxiety., Results: Follow-up data were provided by 85.1% (40 of 47) of enrolled participants. There were significant differences in depression change across groups (F (2,37)  = 3.81, p = 0.03). Greater reductions in depressive symptoms were found for the III (p = 0.02) and II+PS (p = 0.03) compared with WLC, and significantly less coach time was required in the II+PS (p = 0.003)., Conclusions: These results highlight the potential of cognitive-behaviorally informed Internet interventions for older adults with depression, and indicate that peer-supported programs are both acceptable and equivalent to individually delivered Internet interventions. Including peer support may be a viable and potentially more cost-effective option for disseminating online treatments for depression for older adults., (Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: Chronic fatigue syndrome (CFS) symptoms have been shown to be exacerbated by stress and ameliorated by group-based psychosocial interventions such as cognitive behavioral stress management (CBSM). Still, patients may have difficulty attending face-to-face groups. This study compared the effects of a telephone-delivered (T-CBSM) vs a live (L-CBSM) group on perceived stress and symptomology in adults with CFS., Methods: Intervention data from 100 patients with CFS (mean age 50years; 90% female) participating in T-CBSM (N=56) or L-CBSM (N=44) in previously conducted randomized clinical trials were obtained. Perceived Stress Scale (PSS) and the Centers for Disease Control and Prevention symptom checklist scores were compared with repeated measures analyses of variance in adjusted and unadjusted analyses., Results: Participants across groups showed no differences in most demographic and illness variables at study entry and had similar session attendance. Both conditions showed significant reductions in PSS scores, with L-CBSM showing a large effect (partial ε 2 =0.16) and T-CBSM a medium effect (partial ε 2 =0.095). For CFS symptom frequency and severity scores, L-CBSM reported large effect size improvements (partial ε 2 =0.19-0.23), while T-CBSM showed no significant changes over time., Conclusions: Two different formats for delivering group-based CBSM-live and telephone-showed reductions in perceived stress among patients with CFS. However, only the live format was associated with physical symptom improvements, with specific effects on post-exertional malaise, chills, fever, and restful sleep. The added value of the live group format is discussed, along with implications for future technology-facilitated group interventions in this population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2016 Elsevier Inc. All rights reserved.)