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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 (PPPPP=.004), depression (PPP=.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.

Assigning homework to patients to facilitate skill development is an essential part of internet-delivered cognitive behavior therapy (ICBT). This study examined if patients' self-ratings of homework engagement, including conceptual (e.g., understandability, difficulty, perceived usefulness) and practical (e.g., effort put into reviewing the lessons, practicing skills, continuity in use of the learned skills) engagement predicts ICBT outcomes for anxiety and depression using a subsample of data from a previously published randomized controlled trial.Three hundred and one adult patients (74.56% female; 91.29% Caucasians;Patient-rated homework engagement significantly predicted rate of change in depression and anxiety symptom severity but was not significantly associated with initial levels of either outcome. Patients who reported higher engagement with assigned homework activities achieved more symptom reduction over treatment and follow-up at 12 weeks.The findings provide evidence of the importance of patients' self-rated engagement with homework in ICBT as well psychometric evidence supporting use of homework ratings to assess engagement. Further studies are needed to replicate the association between homework engagement and reduction in anxiety and depression symptoms. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

BACKGROUND Internet-delivered cognitive behaviour therapy (ICBT) can improve access to mental healthcare 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 CBT. OBJECTIVE The current study was designed to examine the use of pre-treatment MI exercises and booster lessons in ICBT for post-secondary students. METHODS In this factorial trial (factor 1: online MI pre-treatment; factor 2: self-guided booster lesson 1-month post-treatment), 308 clients were randomized to one of four 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 pre-treatment to post-treatment and 1- and 3-month follow-up. RESULTS Overall, 54.0% (n=150) of students completed treatment and reported large improvements in symptoms of depression and anxiety, and small improvements in academic functioning at post-treatment, which were maintained at 1- and 3-month follow-up. Pre-treatment MI did not contribute to better treatment completion or engagement, but small between-group effects favoured MI for reductions in depression (Cohen’s d: 0.23) and anxiety (Cohen’s d: 0.25) at post-treatment. Only 30.9% (n=43) of students randomized to one of the booster conditions accessed the booster. No main effects were found for booster overall. Sub-analyses revealed that clients who accessed the booster had larger decreases in depressive symptoms (Cohen’s d: 0.31) at 3-month follow-up. No interactions were found between MI and booster. CONCLUSIONS Rather than offering MI at pre-treatment, clients may experience more benefit from MI exercises later in ICBT when motivation wanes. Low uptake of the self-guided booster limits our conclusions about its effectiveness. Future research should examine offering a booster at a longer duration after treatment, with therapist support, and with a longer follow-up period. CLINICALTRIAL ClinicalTrials.gov: (NCT04264585)

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

BACKGROUND Postpartum depression (PPD) and postpartum anxiety (PPA) are often comorbid and associated with significant personal and economic costs. Fewer than half of mothers experiencing PPD or PPA receive face-to-face treatment, suggesting a need for alternative delivery formats such as internet-delivered cognitive behaviour therapy (ICBT). OBJECTIVE The goal of the pilot study was to examine the impact of a therapist-assisted, transdiagnostic ICBT program on PPD and PPA, as there is only one previous study on transdiagnostic ICBT with this population and the study did notinclude therapist assistance. METHODS Clients endorsing symptoms of PPD/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 at pre-treatment, post-treatment, and 1-month follow-up, as well as measures of treatment satisfaction and therapeutic alliance. Outcome measures were also completed at 6-month follow-up for clients who completed ICBT. RESULTS Both the ICBT and TAU groups experienced statistically significant improvements over time. The ICBT group experienced larger improvements at post-treatment and 1-month follow-up on more measures than TAU, with medium between-group Cohen’s d effects on primary outcome measures for anxiety (Cohen’s d = 0.65, 95% CI: 0.13, 1.17), postpartum depression (Cohen’s d = 0.52, 95% CI: 0.01, 1.04), and depression (Cohen’s d = 0.56, 95% CI: 0.05, 1.08), and on secondary outcome measures of overall distress (Cohen’s d = 0.69, 95% CI: 0.17, 1.21), anxiety (Cohen’s d = 0.59, 95% CI: 0.07, 1.11), and stress (Cohen’s d = 0.76, 95% CI: 0.23, 1.28). Time-by-group interactions for proportional reductions between groups over time were only significant at post-treatment and 1-month follow-up for the primary anxiety measure (p = .006). The study was underpowered for detecting small or medium effects. Overall, clients perceived the treatment as credible and 95% of clients (21/22) were satisfied with treatment content and therapist support. CONCLUSIONS Findings from this pilot study provide preliminary support for transdiagnostic ICBT in treating PPD/PPA to improve access to psychological treatments. CLINICALTRIAL ClinicalTrials.gov NCT04012580

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

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 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 eight-week integrated or gambling-only control condition. Both conditions will consist of seven online modules following cognitive behavioral therapy and motivational interviewing principles. Our three primary outcomes are (1) 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., eight-weeks from baseline), and 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 intervention will be a cost-effective and accessible way to improve treatments for co-occurring problem gambling and tobacco use.Trial registration: Clinicaltrials.gov; ID NCT03614884. Registered August 3, 2019

BACKGROUND Alcohol misuse and emotional problems (ie, depression and anxiety) are highly comorbid among Canadian young adults. However, there is a lack of integrated, accessible, and evidence-based treatment options for these young adults. OBJECTIVE The main goal of this study is to develop and test the efficacy of an integrated, online self-help program designed to target both alcohol misuse and emotional problems. METHODS A two-arm randomized controlled trial design will be used to compare the efficacy of the online integrated treatment to a psychoeducational control group. A target sample of 214 participants will be recruited and randomly assigned to either condition. The integrated treatment will last 8 weeks, and participants will work through 12 modules. Modules will incorporate content based on principles of cognitive behavioral therapy and motivational interviewing. Participants in the control group will receive links to psychoeducational resources and will have access to the full treatment after follow-up. The primary outcome will be the number of Canadian standard drinks consumed in the week leading up the assessment. Secondary outcomes of interest include symptoms of depression, anxiety, alcohol-related problems, quality of life, and use of other drugs. Assessments will be completed at 3 time-points: at baseline, at the end of treatment (ie, 8 weeks), and at follow-up (ie, 24 weeks). Upon completion, data will be analyzed using generalized linear mixed models. RESULTS Data collection began in June 2018 and will continue until January 2020. Final study results will be submitted for publication by July 2020. CONCLUSIONS Currently, there are no integrated treatments designed to target alcohol misuse and the range of emotional problems experienced by young adults. This research stands to provide an effective, accessible (ie, Web-based), and feasible option to treat the many struggling young adults in this country. CLINICALTRIAL ClinicalTrials.gov ID NCT03406039; https://clinicaltrials.gov/ct2/show/NCT03406039 (Archived by WebCite at http://www.webcitation.org/72fDefnrh) REGISTERED REPORT IDENTIFIER PRR1-10.2196/11298

Many effective social marketing campaigns seek to change health-related behavior by utilizing various health-protective behavioral theories. In this article, we review and integrate three such theories: protection motivation theory (PMT), the extended parallel process model (EPPM), and the transtheoretical model (TTM). We highlight how EPPM and TTM can be used to refine PMT by adding insight into the decision-making process involved when consumers consider whether or not to follow a particular recommended health behavior. Specifically, the development of an integrated PMT model can provide insight into the characteristics of people more or less likely to change, what happens when persuasion fails, and what can be done to increase persuasion. Developing an integrated PMT model opens new avenues of research that have the potential to increase our understanding of behavior and assist in creating more persuasive social marketing campaigns.

Initial perceptions of programmatic shifts are important to gauge if organizational change is to be successful. We used qualitative methods to understand the perceptions of multidisciplinary team members who were responsible for developing integrated care pathways for chronic heart disease in an attempt to improve continuity of care. Members viewed continuity of care as problematic and perceived ICPs as a template for increasing knowledge and enhancing communication. Numerous barriers to ICP use were noted. Information collected in this study may assist others who are developing integrated care pathways.

The purpose of this study was to assess the needs of older case coordinated clients receiving community health services, by examining changes in cognitive status, physical and mental health status, social support, risk for institutionalization, and service use over a 6-month period from initial intake into home care. Significant predictors of professional and supportive home care, as well as emergency room use and hospital days, were also examined. Standardized interviews were conducted with 234 clients at the time of referral; follow-up interviews were conducted with 179 of these clients after 6 months of case coordination. Results reveal that physical and mental health improved, while cognitive status remained stable. Although social interaction and instrumental support decreased, subjective support remained stable. Risk of institutionalization decreased. Occupational therapy, nursing, and homemaking were the most frequently used services. The best predictor of professional and supportive home care was a risk of institutionalization score. The needs of this older adult population changed even within the relatively short span of 6 months. Frequent review of needs in some form may be warranted in order to maintain effective service plans.

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.

Continuity of care, defined as the patient experiencing coherent care over time and place, is challenged when a rural senior with multiple medical problems is transferred to a regional hospital for acute care. From an illustrative case of an older patient with pneumonia and atrial fibrillation, we catalogue potential breaks in continuity of care. Optimal continuity of care is characterised not only by regular contact with the providers who establish collaboration with patients and their caregivers, but also by communication, co-ordination, contingency, convenience, and consistency. Because it is not possible to have the same providers continuously available (relational continuity), for continuity of care, there is a need for integrative system approaches, such as: (1) policy and standards, disease management programs, integrated clinical pathways (management continuity), (2) electronic health information systems and telecommunications technology (communication continuity). The evaluation of these approaches requires measures that account for the multi-faceted nature of continuity of care.