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Background: Depression and anxiety are prevalent and under treated conditions that create enormous burden for the patient and the health system. Internet-delivered cognitive behavior therapy (ICBT) improves patient access to treatment by providing therapeutic information via the Internet, presented in sequential lessons, accompanied by brief weekly therapist support. While there is growing research supporting ICBT, use of ICBT within community mental health clinics is limited. In a recent trial, an external unit specializing in ICBT facilitated use of ICBT in community mental health clinics in one Canadian province (ISRCTN42729166; registered November 5, 2013). Patient outcomes were very promising and uptake was encouraging. This paper reports on a parallel process evaluation designed to understand facilitators and barriers impacting the uptake and implementation of ICBT. Methods: Therapists (n = 22) and managers (n = 11) from seven community mental health clinics dispersed across one Canadian province who were involved in implementing ICBT over ~2 years completed an online survey (including open and closed-ended questions) about ICBT experiences. The questions were based on the Consolidated Framework for Implementation Research (CFIR), which outlines diverse constructs that have the potential to impact program implementation. Results: Analyses suggested ICBT implementation was perceived to be most prominently facilitated by intervention characteristics (namely the relative advantages of ICBT compared to face-to-face therapy, the quality of the ICBT program that was delivered, and evidence supporting ICBT) and implementation processes (namely the use of an external facilitation unit that aided with engaging patients, therapists, and managers and ICBT implementation). The inner setting was identified as the most significant barrier to implementation as a result of limited resources for ICBT combined with greater priority given to face-to-face care. Conclusions: The results contribute to understanding facilitators and barriers to using ICBT within community mental health clinics and serve to identify recommendations for improving uptake and implementation of ICBT in clinic settings. [ABSTRACT FROM AUTHOR]

Background: Review of the literature reveals a need to develop a questionnaire that measures patient perceptions of factors impacting continuity of care following discharge from hospital. Such a measure has the potential to guide quality improvement initiatives related to continuity of care.Objective: Our objective was to develop and examine the psychometric properties of a measure that would meet this need, the Patient Continuity of Care Questionnaire (PCCQ).Method: The PCCQ was administered to 204 inpatients 4 weeks after discharge. The questionnaire was assessed by item and principal components analysis. Factors derived from principal components analysis were assessed for internal consistency and construct validity.Results: A principal components analysis resulted in six subscales including perceptions of: (1) relationships with providers in hospital, (2) information transfer to patients, (3) relationships with providers in community, (4) management of written forms, (5) management of follow-up and (6) management of communication among providers. These subscales were internally consistent in our sample and demonstrated construct validity through correlations with other related constructs.Conclusion: This initial study supports the reliability and validity of the PCCQ for measuring patient perceptions of factors central to continuity of care. The questionnaire subscales correspond to the theoretical components of continuity of care that have been proposed in the literature, namely informational, relational and management continuity. The subscales may be of value for identifying problems in continuity of care and for evaluating interventions aimed at improving continuity of care for patients after hospital discharge. [ABSTRACT FROM AUTHOR]

This study describes the development of a tool used to track the who, what, when, and how much of case coordination for elderly, community-based clients. The Case Coordination Activity Tracking Form measures phase of coordination (assessment, plan development, plan implementation, monitoring reassessment, and discharge), type of activity (in person, telephone, documentation, research, travel, case conference), with whom contact took place (client, family, client/family together, supervisor/colleague, service provider, physician, program access committee), and special circumstances (e.g., infection control). Over a 6-month span, we used the tool to study case coordination of services for elderly, community-based clients. The average amount of coordination time was 5.15 hours (n = 234), with 71% of the clients requiring between 2 and 6 hours of coordination, and 26% of the clients accounting for 49% of the total coordination time. Frequency and average amount of coordination declined greatly after the first month. Not all clients required coordination each month, and monitoring was the most common activity in later months. The tool was found to be reliable and easy to use, and of benefit to decision makers, managers, and case coordinators in measuring analyzing and describing case coordination. This tool could be readily used with other client groups. [ABSTRACT FROM AUTHOR]

Background: In internet-delivered cognitive behavioural therapy (ICBT) programs, beyond standardized core ICBT lessons, brief additional resources are sometimes available to clients to address comorbid concerns or offer additional information/strategies. These resources remain understudied in terms of how they are selected and perceived by clients, as well as their relationship to satisfaction and outcomes., Methods: Among clients ( N  = 793) enrolled in a 5-lesson transdiagnostic ICBT course, we examined client use and perceptions of 18 additional resources at 8 weeks in terms of whether clients found resources informative (yes/no) and or helpful (yes/no). Resources elaborated on cognitive strategies (managing beliefs, risk calculation) or on managing specific problems (agricultural stress, alcohol misuse, anger, assertiveness, chronic conditions, communication, grief, health anxiety, motivation, pain, panic, postpartum depression/anxiety, PTSD, sleep, workplace accomodations, worry). Clients also completed symptom measures and ICBT satisfaction questions at 8 weeks., Results: Approximately 50 % ( n  = 398) of clients rated the resources and, on average, clients reported that 3.35 (SD = 3.34) resources were informative and 2.35 (SD = 2.52) resources were helpful as measured by direct questions developed for this study. Higher pre-treatment PTSD and GAD scores were related to a greater number of resources perceived as informative and or helpful. Rating more resources as informative and or helpful had a weak but positive association with ICBT satisfaction and depression, anxiety, PTSD and insomnia change scores. Limitations of the study include that 31 % ( n  = 245) did not respond to questions about use of resources and 18.9 % ( n  = 150) said they did not review resources., Conclusions: There is considerable use of diverse additional resources in ICBT in routine care. Associations suggest that clients are using resources to personalize treatment to their needs and these resources are associated with treatment satisfaction and outcomes. The correlational associations between symptoms and perceived helpfulness of resources can help inform personalization algorithms to optimize ICBT delivery for clients. Further research on how to match clients with, encourage use of, and maximize benefits of resources would be beneficial., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) for patients experiencing anxiety and depression can produce large improvements in symptoms. Comorbid insomnia is common among individuals seeking treatment for anxiety and depression, yet transdiagnostic ICBT rarely targets insomnia and many ICBT patients report that symptoms of insomnia remain after treatment. This trial explored the impact of including a brief intervention for insomnia alongside an existing transdiagnostic ICBT course that included brief weekly therapist assistance. Patients were randomly assigned to receive either the Standard transdiagnostic ( n =  75) or a Sleep-Enhanced course ( n =  142), which included information on sleep restriction and stimulus control. Intent-to-treat analyses using generalized estimating equation (GEE) showed significant, large reductions in all primary outcomes (insomnia: d  = 0.96, 95 % CI [0.68, 1.24]; depression: d  = 1.04, 95 % CI [0.76, 1.33]; and anxiety: d  = 1.23, 95 % CI [0.94, 1.52]) from pre-treatment to post-treatment, with changes maintained at 3-months. Patients assigned to the Sleep-Enhanced course reported larger reductions in insomnia than patients in the Standard transdiagnostic course (Cohen's d  = 0.31, 95 % CI [0.034, 0.60]) at post-treatment but no significant between-group differences in any of the primary outcomes were found at follow-up. Patient-reported adherence to sleep restriction guidelines ( p  = .03), but not stimulus control instructions ( p  = .84) was associated with greater reductions in insomnia symptoms during the course. Overall, patients who received the Sleep-Enhanced course were satisfied with the materials and most patients reported making sleep behaviour changes. The trial results demonstrate that including a brief intervention targeting insomnia can be beneficial for many patients who enroll in ICBT primarily for symptoms related to anxiety and depression., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Agriculture producers are less likely to seek or to receive mental health services compared to the general population. Additional research is needed to identify effective and accessible mental health interventions for this underserved population. This study used a mixed-methods approach and open trial design to examine the acceptability and effectiveness of therapist-assisted internet-delivered cognitive behaviour therapy (ICBT) supplemented with an additional agricultural resource for clients from agricultural backgrounds receiving ICBT in routine care. Clients ( n  = 34) participated in an online, five-lesson course that provided psychoeducation and strategies for dealing with symptoms of anxiety and depression, with weekly therapist assistance. Clients also received a tailored resource (developed with input from those with an agricultural background) providing culturally specific information and case stories pertinent to agricultural communities. Intent-to-treat analyses showed that the ICBT program was effective in reducing anxiety and depression symptoms among the agricultural population. Large within-group pre-to-post-treatment Cohen's effect sizes of d  = 1.14, 95 % CI [0.41, 1.86] and d  = 1.15, 95 % CI [0.42, 1.87] were found for depression and anxiety, respectively and comparable to the same program offered to the general population. Clients also experienced reductions in perceived stress and significant improvements in resiliency from pre- to post-treatment. Semi-structured interviews conducted at post-treatment with the agricultural clients ( n  = 31) on their experiences with ICBT identified four main themes: perceived strengths of ICBT and the tailored resource, suggestions to improve service delivery for agriculture producers, clients experienced internal and external challenges to participating in ICBT, and the positive impact of the course reached beyond the client. Very high satisfaction rates were found. These results provide support for the acceptability and effectiveness of ICBT with a tailored resource offered in routine care among agriculture producers., Competing Interests: None., (© 2024 The Authors.)

Background: Delivery of psychosocial interventions via the Internet has the potential to overcome barriers and increase access; however, effectiveness is yet to be established among those with spinal cord injury (SCI)., Methods: The objective of this meta-analysis is to evaluate the efficacy of Internet-based psychosocial interventions on the symptoms of anxiety, depression, and pain amongst those with SCI. The databases Medline, PsycInfo, and EMBASE were used to locate studies published between 1990 and December 2020. A study was included if (1) the study involved the application of an online psychosocial intervention; (2) adults with SCI; and (3) reported outcomes on depression and/or anxiety. From each study, participant characteristics and study details were extracted. A standardized mean difference (SMD) ± standard error and 95% confidence interval (CI) was calculated for each outcome of interest and the results were pooled using a fixed-effects model., Results: The search yielded 920 studies, of which five were included in the final meta-analysis; It was revealed that Internet-based psychosocial interventions had a small effect on reducing overall anxiety (SMD: 0.42 ± 0.09, p   < 0.001) and depression (SMD: 0.41 ± 0.09, p   < 0.001) symptoms at the end of the study period. Online psychosocial interventions also had a moderate effect in maintaining reduction of anxiety (SMD: 0.50 ± 0.1, p   < 0.001) and depressive (SMD: 0.64 ± 0.10, p   < 0.001) symptoms at 3-month follow-up., Conclusion: The results of this meta-analysis provide evidence for the use of internet-based psychosocial interventions to manage anxiety and depression symptoms among those with spinal cord injuries.

Background: Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown., Objective: This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety., Methods: All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients' use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients' alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into low-risk and hazardous drinking categories based on pretreatment Alcohol Use Disorders Identification Test (AUDIT) scores., Results: During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (P=.004) and separated, divorced, or widowed (P<.001). Reviewers also consumed more weekly drinks (P<.001), scored higher on the AUDIT (P<.001), and were more likely to exhibit hazardous drinking (P<.001). Regardless of their drinking level (ie, low risk vs hazardous), all clients showed a reduction in AUDIT-Consumption scores (P=.004), depression (P<.001), and anxiety (P<.001) over time; in contrast, there was no change in clients' drinks per week over time (P=.81). Reviewing alcohol resources did not predict changes in AUDIT-Consumption scores or drinks per week., Conclusions: Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource., (©Vanessa Peynenburg, Ram P Sapkota, Tristen Lozinski, Christopher Sundström, Andrew Wilhelms, Nickolai Titov, Blake Dear, Heather Hadjistavropoulos. Originally published in JMIR Mental Health (https://mental.jmir.org), 18.04.2023.)

Background: Despite growing evidence for the effectiveness of internet-delivered cognitive behaviour therapy (ICBT), engagement and treatment outcomes are lower for some clients. Online motivational interviewing (MI) has been investigated prior to offering ICBT to facilitate engagement and outcomes, but only appears to improve engagement., Purpose: This feasibility study investigated the potential use of a brief MI resource offered during ICBT rather than before, by examining: (1) use of the resource; (2) client and treatment variables associated with use; (3) whether use of the resource was associated with improved engagement and outcomes; and (4) how those who used the resource evaluated it., Method: This study used data collected from 763 clients enrolled in an ICBT course. Symptoms related to depression, anxiety and disability were assessed at pre- and post-treatment. The website tracked treatment engagement. Clients completed an MI resource evaluation measure at post-treatment., Results: Approximately 15% of clients used the resource. Clients who were older, had higher education, scored in the clinical range on depression, and scored lower on anxiety at pre-treatment were more likely to use the resource. Those who reported using the resource had higher engagement (i.e., more lessons and messages) in ICBT, but lower improvement in disability post-treatment. Positive feedback on the MI resource outweighed negative feedback, with 94 % of clients identifying a positive aspect of the resource and 66 % of clients reporting making changes in response to the resource. Overall, the MI resource appears to be used by and perceived as beneficial by a small portion of clients who complete ICBT. The study provides insight into use of the resource and directions for future research related to MI and ICBT., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Background: Internet-delivered cognitive behavioral therapy (ICBT) can improve access to mental health care for students, although high attrition rates are concerning and little is known about long-term outcomes. Motivational interviewing (MI) exercises and booster lessons can improve engagement and outcomes in face-to-face cognitive behavioral therapy., Objective: This study aimed to examine the use of pretreatment MI exercises and booster lessons in ICBT for postsecondary students., Methods: In this factorial trial (factor 1: web-based MI before treatment; factor 2: self-guided booster lesson 1 month after treatment), 308 clients were randomized to 1 of 4 treatment conditions, with 277 (89.9%) clients starting treatment. All clients received a 5-week transdiagnostic ICBT course (the UniWellbeing course). Primary outcomes included changes in depression, anxiety, and perceived academic functioning from before treatment to after treatment and at the 1-month and 3-month follow-ups., Results: Overall, 54% (150/277) of students completed treatment and reported large improvements in symptoms of depression and anxiety and small improvements in academic functioning after treatment, which were maintained at the 1-month and 3-month follow-ups. Pretreatment MI did not contribute to better treatment completion or engagement, although small between-group effects favored MI for reductions in depression (Cohen d=0.23) and anxiety (Cohen d=0.25) after treatment. Only 30.9% (43/139) of students randomized to one of the booster conditions accessed the booster. Overall, no main effects were found for the booster. Subanalyses revealed that clients who accessed the booster had larger decreases in depressive symptoms (Cohen d=0.31) at the 3-month follow-up. No interactions were found between MI and the booster., Conclusions: Rather than offering MI before treatment, clients may experience more benefits from MI exercises later in ICBT when motivation wanes. The low uptake of the self-guided booster limited our conclusions regarding its effectiveness. Future research should examine offering a booster for a longer duration after treatment, with therapist support and a longer follow-up period., Trial Registration: ClinicalTrials.gov NCT04264585; https://clinicaltrials.gov/ct2/show/NCT04264585., (©Vanessa Peynenburg, Heather Hadjistavropoulos, David Thiessen, Nickolai Titov, Blake Dear. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 07.09.2022.)

Background: Postpartum depression (PPD) and postpartum anxiety (PPA) are often comorbid and are associated with significant personal and economic costs. Fewer than half of the mothers experiencing PPD or PPA symptoms receive face-to-face treatment, suggesting a need for alternative delivery formats such as internet-delivered cognitive behavioral therapy (ICBT)., Objective: This pilot study aimed to examine the impact of a therapist-assisted, transdiagnostic ICBT program on symptoms of PPD and PPA, as there is only one previous study on transdiagnostic ICBT with this population, which did not include therapist assistance., Methods: Clients endorsing the symptoms of PPD or PPA (N=63) were randomized to an 8-week transdiagnostic ICBT course (Wellbeing Course for New Moms) or to treatment as usual (TAU). Clients completed measures of depression, anxiety, stress, postnatal bonding, and relationship satisfaction, as well as measures of treatment satisfaction and therapeutic alliance, before treatment, after treatment, and at the 1-month follow-up. Outcome measures were also completed at the 6-month follow-up for clients who completed the ICBT course., Results: Both the ICBT and TAU groups experienced statistically significant improvements over time. The ICBT group experienced larger improvements after treatment and at the 1-month follow-up on more measures than the TAU group, with medium between-group Cohen d effects on primary outcome measures for anxiety (Cohen d=0.65, 95% CI 0.13-1.17), PPD (Cohen d=0.52, 95% CI 0.01-1.04), and depression (Cohen d=0.56, 95% CI 0.05-1.08), and on secondary outcome measures of overall distress (Cohen d=0.69, 95% CI 0.17-1.21), anxiety (Cohen d=0.59, 95% CI 0.07-1.11), and stress (Cohen d=0.76, 95% CI 0.23-1.28). Time-by-group interactions for proportional reductions between groups over time were only significant after treatment and at the 1-month follow-up for the primary anxiety measure (P=.006). This study was underpowered for detecting small or medium effects. Overall, clients perceived the treatment as credible, and 95% (21/22) of the clients were satisfied with the treatment content and therapist support., Conclusions: Findings from this pilot study provide preliminary support for transdiagnostic ICBT in treating PPD and PPA symptoms to improve access to psychological treatments., Trial Registration: ClinicalTrials.gov NCT04012580; https://clinicaltrials.gov/ct2/show/NCT04012580., (©Victoria Suchan, Vanessa Peynenburg, David Thiessen, Marcie Nugent, Blake Dear, Nickolai Titov, Heather Hadjistavropoulos. Originally published in JMIR Formative Research (https://formative.jmir.org), 06.09.2022.)

In routine care, Internet-delivered Cognitive Behaviour Therapy (ICBT) is often delivered with therapist support via emails/phone calls, but the cost-effectiveness of varying amounts of therapist support or having therapists specialized in ICBT is not known. This study compared the cost-effectiveness of specialized therapists providing ICBT support once-weekly (1WS) versus providing support once-weekly supplemented with a one-business-day response to patient emails (1W/1BD-S). We further compared the cost-effectiveness of 1W support offered by therapists employed in a specialized clinic (1WS) versus community clinics where therapists primarily deliver face-to-face therapy (1WC). Patients were randomly allocated to groups: 1WS group ( n  = 216), 1W/1BD-S group ( n  = 233), and 1WC group ( n  = 226). At baseline, 12, 24 and 52-week follow-up, patients completed the Treatment Inventory of Costs in Patients with Psychiatric Disorders questionnaire (TiC-P) adapted for use in Canada to assess healthcare use and productivity losses. Additionally, to assess Quality Adjusted Life Years (QALYs) gained, patients completed the EQ-5D-5L at the same time periods. We quantified uncertainties by one-way and probabilistic sensitivity analysis and reported Incremental cost-effectiveness ratios (ICER), cost-effectiveness planes and acceptability curves. Cost-effectiveness over 52 weeks was CAD 3072/QALY for 1WC, CAD 3244/QALY for 1W/1BD-S, and CAD 3528/QALY for 1WS. Our model suggests that 1WS is the best strategy since the incremental cost per QALY is below the $50,000 threshold (ICER is CAD 42,328/QALY compared to the next most effective, 1WC). 1W/1BD-S is dominated by the other strategies. The cost-effectiveness acceptability curves suggest that the 1WS group has a higher probability for cost-effectiveness (38 %) than 1W/1BD-S (30 %) and 1WC (32 %) when the willingness to pay is $50,000 per QALY. These results have important implications for health policymakers deciding on delivery of ICBT for the treatment of anxiety and/depressive disorders., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that appear to have influenced the work reported in this paper., (© 2022 The Authors.)

While internet-delivered cognitive behavioural therapy (ICBT) is effective, some patients suggest extended support post-treatment could improve care. In this randomized factorial trial, we examined the benefits of an 8-week therapist-assisted ICBT program offered with or without an optional 4-week extension of support (Factor 1) and with or without an optional booster lesson (Factor 2). Patients screened for ICBT for depression and/or anxiety were randomly assigned to the conditions ( N  = 434) and we examined the use of the extension and booster, differences between those who did or did not use extension or booster, and the impact of the extension or booster on outcomes, engagement, and satisfaction at 26-weeks post-enrollment. Therapists recorded time and observations with offering support during the extension and booster. In the extension group, 54.4% ( n  = 56) requested the extension, while in the booster group 50.9% ( n  = 56) accessed the booster, and in the combined group, 41.6% ( n  = 47) requested the extension and 51.3% ( n  = 58) accessed the booster. Those who requested the extension were older, and more likely to report medication and mental health service use and severe mental health-related disability at pre-treatment; they also reported putting less effort into ICBT and finding skills more difficult. The booster was more often used among those with lower symptom severity, and those who put more effort into and had more positive experiences with ICBT. As expected, those assigned to extension sent more messages to their therapist, and those assigned to booster logged in more often. Therapists also took more time to deliver ICBT with an extension (>18 min) or booster (>13 min) compared to the 8-week program, and perceived extension and booster as beneficial for some, but not all patients. Treatment satisfaction was high across conditions, and effect sizes were large from pre-treatment to 26-week follow-up on most measures. No significant group differences were found in this study. Lack of group differences, however, could reflect low use of the extension and booster. Results provide helpful information about the demand for extensions and boosters, and provide directions for future research., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Importance: Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them., Objective: To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information., Data Sources: We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019., Study Selection: Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization., Data Extraction and Synthesis: We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression., Main Outcomes and Measures: Patient Health Questionnaire-9 (PHQ-9) scores., Results: Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9., Conclusions and Relevance: In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.

Public safety personnel (PSP) experience unique occupational stressors and suffer from high rates of mental health problems. The COVID-19 pandemic has impacted virtually all aspects of human life around the world and has introduced additional occupational stressors for PSP. The objective of this study was to explore how PSP, especially those seeking digital mental health services, have been affected by the pandemic. Our research unit, PSPNET, provides internet-delivered cognitive behavioral therapy to PSP in the Canadian province of Saskatchewan. When the pandemic spread to Saskatchewan, PSPNET began inquiring about the impact of the pandemic on prospective clients during the eligibility screening process. We used content analysis to analyze data from telephone screening interviews ( n = 56) and descriptive statistics to analyze data from a questionnaire concerning the impacts of COVID-19 ( n = 41). The results showed that most PSP reported facing several novel emotional challenges (e.g., social isolation, boredom, anger, and fear) and logistical challenges (e.g., related to childcare, finances, work, and access to mental healthcare). Most participants indicated they felt at least somewhat afraid of contracting COVID-19 but felt more afraid of their families contracting the virus than themselves. However, few participants reported severe challenges of any kind, and many (40%) indicated that they had not been significantly negatively impacted by the pandemic. Overall, the results suggest that PSP are not expressing significant concern at this time in meeting the novel challenges posed by COVID-19. Continued research will be required to monitor how diverse PSP populations and treatment outcomes are affected by the pandemic as the situation evolves.

With the growing demand for internet-delivered cognitive behavioural therapy (iCBT), this pragmatic factorial (2 × 2 × 2) randomized controlled trial evaluated strategies for facilitating iCBT engagement and outcomes in routine care. Specifically, the benefits to patients and therapists of using homework reflection questionnaires and offering patients twice-weekly therapist support were examined. Patients ( n  = 632) accepted into iCBT for depression and/or anxiety were randomly assigned to complete homework reflection questionnaires or not (factor 1), receive once- or twice-weekly support (factor 2), and to receive care from therapists employed in one of two settings (iCBT clinic or a community mental health clinic; factor 3). Outcomes were measured at pre-treatment, and 8, 12, and 24-weeks post-enrollment. Therapist time was tracked and a focus group was conducted to examine therapist experiences. No differences in patient outcomes were found between therapists employed in the two settings; as such, these two groups were combined for further analyses. In terms of engagement, homework reflection questionnaires were associated with fewer website log-ins and days accessing iCBT; twice-weekly support was associated with more patient emails sent to therapists. Despite engagement differences, homework reflection questionnaires and twice-weekly support did not significantly impact primary outcomes; all groups showed large improvements in depression and anxiety that were maintained at 24-week follow-up. Therapists perceived a number of benefits and challenges associated with responding to homework reflection questionnaires and offering twice-weekly support; most notably the strategies did not benefit all patients. Twice-weekly support was associated with increased therapist time and organizational challenges. It is concluded that neither completion of homework questionnaires nor offering twice-weekly support significantly improve iCBT in routine care., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that appear to have influenced the work reported in this paper., (© 2020 The Author(s).)

Background: Gambling and tobacco smoking are highly comorbid among North American adults. However, there is a paucity of treatment options that are integrated (i.e. targeting both gambling and tobacco smoking simultaneously), accessible, and evidence based., Methods: The aim of this two-arm open-label randomized controlled trial is to examine the effectiveness of an online, self-guided integrated treatment for problem gambling and tobacco smoking. A target sample of 214 participants will be recruited and be randomized into either an 8-week integrated or gambling only control condition. Both conditions will consist of seven online modules following cognitive behavioural therapy and motivational interviewing principles. Our three primary outcomes are (1) the number of days gambled, (2) money spent on gambling activities, and (3) time spent in gambling activities. Secondary outcomes include gambling disorder symptoms, cigarette use, and nicotine dependence symptoms. Assessments will be completed at baseline, at completion (i.e. 8 weeks from baseline), and at follow-up (i.e. 24 weeks from baseline). Generalized linear mixed modelling will be used to evaluate our primary and secondary outcomes. We expect that participants receiving online integrated treatment will show larger reductions in gambling relative to those receiving a control gambling only intervention. We further hypothesize that reductions in smoking will mediate these group differences., Discussion: The rates of problem gambling and tobacco smoking are high in North America; yet, the treatment options for both are limited, with no integrated treatments available. If supported, our pilot study will be a cost-effective and accessible way to improve treatments for co-occurring problem gambling and tobacco use., Trial Registration: ClinicalTrials.gov NCT03614884 . Registered on August 3, 2019.

In routine care, internet-delivered cognitive behaviour therapy (iCBT) regularly includes therapist support delivered via secure email, but the optimal response time to emails is unknown. In this study, we compared the benefits of therapists providing support once-weekly versus therapists providing support once-weekly supplemented with a one-business-day response to all patient emails. This pragmatic randomized controlled trial included therapists employed by a specialized iCBT clinic or community mental health clinics, where providing iCBT is a secondary service. Patients with depression and/or anxiety who enrolled in transdiagnostic iCBT (5 core lessons over 8 weeks) were randomized to: 1) once-weekly support supplemented with a one-business-day response to patient emails by specialized therapists ( n  = 233); 2) once-weekly support also offered by specialized therapists ( n  = 216); or 3) once-weekly support offered by community clinic therapists ( n  = 226). Outcomes were measured at 8, 12, 24, and 52-weeks post-enrollment. Patient engagement and treatment experiences (e.g., treatment satisfaction, therapist alliance) were also assessed and a focus group was conducted with therapists. Supplementing once-weekly therapist support with a one-business-day response to patient emails resulted in therapists sending more emails to patients ( M : 13 versus 9) and required more therapist time over treatment ( M : 155 versus 109 min), but was not associated with improved outcomes, patient engagement or treatment experiences. All groups showed large improvements in symptoms of depression and anxiety maintained at 52-week follow-up, strong engagement and positive treatment experiences. Therapists viewed challenges of responding to patient emails within one-business-day to outweigh benefits. Contrary to expectations, supplementing once-weekly therapist support with a one-business-day response to all patient emails did not benefit patients and increased therapist time as well as therapist challenges when delivering iCBT in routine care., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that appear to have influenced the work reported in this paper., (© 2020 The Author(s).)

Since the emergence of psychological interventions delivered via the Internet they have differed in numerous ways. The wealth of formats, methods, and technological solutions has led to increased availability and cost-effectiveness of clinical care, however, it has simultaneously generated a multitude of terms. With this paper, we first aim to establish whether a terminology issue exists in the field of Internet-delivered psychological interventions. If so, we aim to determine its implications for research, education, and practice. Furthermore, we intend to discuss solutions to mitigate the problem; in particular, we propose the concept of a common glossary. We invited 23 experts in the field of Internet-delivered interventions to respond to four questions, and employed the Delphi method to facilitate a discussion. We found that experts overwhelmingly agreed that there were terminological challenges, and that it had significant consequences for conducting research, treating patients, educating students, and informing the general public about Internet-delivered interventions. A cautious agreement has been reached that formulating a common glossary would be beneficial for the field to address the terminology issue. We end with recommendations for the possible formats of the glossary and means to disseminate it in a way that maximizes the probability of broad acceptance for a variety of stakeholders., (© 2020 The Authors.)

Depression and anxiety are common among people who have experienced an acute coronary event (e.g., heart attack). Multidisciplinary cardiac rehabilitation programs often focus on reducing risk factors associated with future cardiac events, however, mental health interventions are not routinely available. Given known difficulties with access to mental health treatment, the present study sought to explore the efficacy and acceptability of an Internet-delivered cognitive behavioural therapy program ( Cardiac Wellbeing Course ) among participants who experienced an acute coronary event. The five-lesson course was delivered over eight weeks and was provided with brief weekly contact, via telephone and secure email with a guide. Participants were randomized to the Cardiac Wellbeing Course ( n  = 25) or waiting-list control group ( n  = 28). Symptoms were assessed at pre-treatment, post-treatment, and four-week follow-up. Completion rates (84%) and satisfaction ratings (95%) were high. Statistically significant between-group improvements were observed for the treatment group on primary measures of general anxiety (Cohen's d  = 1.62; 67% reduction), depression (Cohen's d  = 1.09; 61% reduction), and physical activity levels (Cohen's d  = 0.27; 70% increase). Statistically significant improvements were also observed on secondary measures of distress (Cohen's d  = 0.98; 51% reduction), cardiac anxiety (Cohen's d  = 0.92; 34% reduction), and mental-health quality of life (Cohen's d  = 0.23; 24% improvement). The changes were maintained at four-week follow-up. The current findings add to the existing literature and highlight the potential of Internet-delivered cognitive behavioural therapy programs among participants who have experienced an acute coronary event., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 The Authors.)

Study Design: Observational pre-post study., Objective: Guided internet-delivered CBT (ICBT) offers an alternative approach for mental health service delivery in the community for those with spinal cord injury (SCI). The feasibility and acceptability of guided ICBT programme is available for various chronic health conditions; however, the evidence related to SCI is limited. The primary aim of the current study was to examine feasibility and acceptability of a guided transdiagnostic ICBT programme for persons with SCI., Setting: Community., Methods: In this single-group pre-post study, persons with SCI (n = 20) living in the community were provided with a guided 8-week transdiagnostic ICBT programme for overall well-being. Study feasibility was examined by the following outcomes: patient recruitment, engagement, and attrition. Acceptability of the programme was evaluated post-treatment. Reductions in symptoms of depression and anxiety were assessed at baseline, post-intervention, and at 3-month follow-up., Results: Approximately 60% of eligible participants were recruited. The study found high rates of programme completion (90%) and outcome data were obtained from 90% of participants. Improvement in symptoms of depression (and anxiety) were seen after treatment. Gains were maintained at 3-month follow-up., Conclusions: Guided transdiagnostic ICBT programme is a feasible and acceptable treatment option for those with psychological needs following SCI.

Purpose: To compare the effectiveness and acceptability of two low-intensity methods of offering a transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) intervention for treating symptoms of anxiety and depression among cancer survivors., Methods: Cancer survivors with symptoms of anxiety or depression (n = 86) were randomly assigned to receive a transdiagnostic ICBT programme (Wellbeing After Cancer) that was either guided by a technician (n = 42) or self-guided (n = 44). Measures of anxiety, depression, fear of cancer recurrence, and quality of life were completed at pre-treatment, post-treatment, and 4 weeks following treatment completion., Results: Large within-group effect sizes were observed on measures of depression, anxiety, and mental health-related quality of life (d range, 0.98-1.86) at post-treatment. Medium effects were found for reductions in fear of cancer recurrence (d range, 0.65-0.78). Non-inferiority was established for the primary outcome measures of anxiety and depression. All participants reported high satisfaction ratings of the programme; however, technician-guided participants were slightly more satisfied with their level of support (d = 0.57, p = .014)., Conclusions: The Wellbeing After Cancer Course was associated with improved levels of anxiety, depression, fear of cancer recurrence, and quality of life, regardless of how ICBT was offered., Implications for Cancer Survivors: ICBT is emerging as an accessible and effective treatment for depression, anxiety, and fear of cancer recurrence in cancer survivors. The success of non-therapist-guided options increases the potential scalability of ICBT, which is particularly valuable for cancer survivors from rural areas who have less access to mental health services.

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.

Introduction: Percutaneous coronary intervention (PCI) aims to provide instant relief of symptoms, and improve functional capacity and prognosis in patients with coronary artery disease. Although patients may experience a quick recovery, continuity of care from hospital to home can be challenging. Within a short time span, patients must adjust their lifestyle, incorporate medications and acquire new support. Thus, CONCARD PCI will identify bottlenecks in the patient journey from a patient perspective to lay the groundwork for integrated, coherent pathways with innovative modes of healthcare delivery. The main objective of the CONCARD PCI is to investigate (1) continuity of care, (2) health literacy and self-management, (3) adherence to treatment, and (4) healthcare utilisation and costs, and to determine associations with future short and long-term health outcomes in patients after PCI., Methods and Analysis: This prospective multicentre cohort study organised in four thematic projects plans to include 3000 patients. All patients undergoing PCI at seven large PCI centres based in two Nordic countries are prospectively screened for eligibility and included in a cohort with a 1-year follow-up period including data collection of patient-reported outcomes (PRO) and a further 10-year follow-up for adverse events. In addition to PROs, data are collected from patient medical records and national compulsory registries., Ethics and Dissemination: Approval has been granted by the Norwegian Regional Committee for Ethics in Medical Research in Western Norway (REK 2015/57), and the Data Protection Agency in the Zealand region (REG-145-2017). Findings will be disseminated widely through peer-reviewed publications and to patients through patient organisations., Trial Registration Number: NCT03810612., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Emerging evidence from research trials suggests that Internet-delivered cognitive behaviour therapy (ICBT) produces similar symptom improvements whether patients receive weekly therapist support (standard support) or therapist support only when requested (optional support). It remains unknown, however, how many patients receiving ICBT as part of routine clinical care would prefer optional support compared to standard support and how outcomes compare when patients select their preferred treatment option. In this uncontrolled trial, we investigated patient preference and outcomes for standard versus optional support among patients with depression and or anxiety who were offered an 8-week transdiagnostic ICBT intervention in routine care. Of 401 patients accepted for ICBT, 22% selected optional support and 78% selected standard support. At assessment, patients who selected optional support had lower symptoms of anxiety and panic than patients who selected standard support. At post-treatment, both groups achieved similar large improvements in symptoms of anxiety and depression, with improvements sustained at 3-month follow-up. Patients receiving optional support sent and received fewer messages compared to patients receiving standard support. This study demonstrates the potential of optional therapist support to meet the needs and preferences of patients and to also reduce therapist costs in routine care., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)