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Low Intensity Treatments > Self-Help and Online Treatments > Flashcards

Self-Help and Online Treatments Flashcards

1
Q

• Challenges in online treatments

A
  • Therapy adherence
  • the role of the therapist
  • Implementation in practice
  • Quality of applications
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2
Q

Low intensity treatments: some history

A

UK: political and economical arguments for low intensity treatments and the need for efficient use of resources to lift the burden of common mental disorders

  • Efficiency: lower dose of the treatment, less and shorter sessions, groups
  • Vehicles: use of self-help material for more efficiency
  • Early access to services:
    • in the community,
    • self-referral,
    • prevention
    • and early intervention

Low intensity treatments vs high intensity treatments (=traditional face to face treatments) comes from stepped care approach

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3
Q

IAPT:

A

Improving Access to Psychological Therapies:

UK wide service to deliver Low Intensity Treatments for common mental health disorders in about 5 sessions.

  • new profession: Psychological Wellbeing Practitioners (PWP)
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4
Q

Self-help material

A
  • Low intensity treatments often make use of ‘vehicles’ such as self-help material i.e. books, audio, the internet, or mobile apps
  • The therapeutic techniques and working mechanism are similar to face to face interventions.
  • Guided self-help can be considered a low intensity treatment, self-help material on its own probably not
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5
Q

Self-help books (bibliotherapy)

A
  • Standardised psychological treatments that people can follow on their own using a self-help book
  • The treatment is described in detail and schematically

NB Books with general information on disorders without a clear treatment programme aimed at change, are NOT suitable for bibliotherapy

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6
Q

Self-help books (First self help book:…)

A

“Dale Carnegie - How to Win Friends and Influence People”

First self-help book, 1936 Still for sale, more than 16 million copies sold

More psychological approach and a focus on psychological health came later

End of the ‘70 first book based on empirical evidence

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7
Q

Allocation Concealment

A

Allocation Concealment is a technique used to prevent selection bias in Randomised Controlled Trials (RCT’s) by concealing the allocation sequence from those assigning participants to the intervention groups, until the moment of assignment.

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8
Q

Moderators for the effectiveness of LIT (Review Article) (Depression)

A

greater effectiveness:

  • unclear allocation concealment,
  • observer-rated outcome measures
  • and waiting lits control groups.

As well:

  • Recruitment in non-cinical settings,
  • patients with depression (Rather than those only at risk)
  • and contact with therapist (guided self-help)
  • use of CBT techniques were predictors of effectveness.
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9
Q

Evidence self-help books depression: Meta Analysis ((Psychological Medicine, 2007, 1217–1228)

A
  • Special attention for )moderators predicting heterogenous outcomes
  • A lot of heterogeneity, average effect 0.43
  • Guidance or support by a coach was the most important predictor of the outcome
  • A non-clinical setting,
  • depression (vs mild symptoms),
  • cognitive behavioural therapy were related to better outcomes (univariate analyses)
  • not related to outcome were:
    • Session duration,
    • content,
    • mode of delivery,
    • theoretical approach
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10
Q

What is online treatment?

A

Interventions delivered via the internet aimed to reduce physical and/or psychological problems increase knowledge, understanding, and awareness

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11
Q

What is online treatment? (More concrete)

A

These interventions are often modular, online (digitalised) versions of face-to-face treatments

Participants work through the problems on their own

Mix & match : modules can be optional and delivered in a random or fixed order

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12
Q

Mix & match (online treatment)

A

modules can be optional and delivered in a random or fixed order

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13
Q

Unguided online interventions (Effectiveness):

A

where people work through the program on their own with no guidance (‘self-guided’, ‘stand alone’ )

Effect sizes are small but significant

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14
Q

Guided online interventions (effectiveness):

A

where people work through the program on their own with minimal guidance from a coach or therapist

Effect sizes comparable to face-to-face treatment

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15
Q

Blended treatment:

A

face-to-face and online treatment integrated in one treatment protocol

ot much known but first results from a large European trial on blended depression treatment compared to treatment as usual are promising

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16
Q

Mobile Applications

Ecological Momentary Interventions:

A

intervention content is sent to participants at just the right time to reduce negative health behaviors and support the development of new behavior’

  • Monitor (Gather Mobile sensing Data, Collect online social network relationships and interactions)
  • Learn (Develop behavior models, infer when to trigger interventions, adapt sensing)
  • Deliver (Tailored behavior change intervention, user feedback via smartphone)
17
Q

Evidence Meta-analysis (Mobile applications): *Versluis, 2016, JMIR, 18(62)3: e152

A
  • Meta-analysis Versluis* shows a small to moderate effect in 13 studies (anxiety, depression, stress), mostly clinical samples
  • (Again) the effects was larger when a therapist was involved (50% of the studies involved a therapist)
  • Quality of the studies was relatively low, details of the interventions not always provided
18
Q

Evidence Meta-analysis (mobile pplications) *Weisel, 2019, Digital Med2i4cine

A

• Meta-analysis Weisel*

  • shows a small to moderate effect of stand alone app in 19 studies (anxiety, depression, substance use, harm, sleep) in people with symptoms
  • Significant effect of apps targeting depression and smoking
  • Conclusion: apps as stand alone intervention cannot be recommended as the evidence is not sufficient
19
Q

Challenges in online interventions and apps

A

1) Treatment adherence
2) Implementation in practice
3) Quality of the intervention

20
Q

Treatment adherence

A

Treatment adherence is the extent to which participants receive the content of the intervention (the ‘dose’, or ‘intended usage’)

Operationalization:

  • Number of sessions completed
  • Number of logins on the website
  • Total login time
  • Number of assignments completed
21
Q

Treatment adherence findings for online interventions

(Kelders, JMIR 2012;14(6):e152, Chistensen, JMIR 2009;11(2):e13), Richards, Clinical Psychology Review, 2012 329-342 VanBallegooijen PlosOne, 2014; 9(L7E)C TeU1R0E0 26 K7P4I 2 020 28)

A

Treatment adherence in online interventions is generally low (‘easy opt in, opt out’)

On average, 50% of participants complete the intervention Research report variations between 1-99%!

However, a recent meta-analyses by Van Ballegooijen showed that completion rates are lower than face-to-face treatments, but average sessions completed did not differ

22
Q

Why is this a problem? (Low Treatment Adherence)

(Donkin, JMIR 2011;132(93):e52))

A

Clients who receive a larger dose of the intervention have better outcomes

Psychological interventions: The average number of lessons completed is important

Lifestyle interventions: The number of logins is most important

NB We don’t know what happens to people who drop-out if they remain in the treatment, they may not benefit, they may feel better already!

23
Q

How can we increase treatment adherence?

A
  • Deliver treatments with guidance of a coach or therapist
  • Motivational approach (for example motivational interviewing)
  • Persuasive technology
  • Personalising treatments
  • Send reminder emails …
24
Q

What does support or guidance involve?

(in online interventions)

A

Support the client to gain optimal benefit of the treatment:

  • Technical support (how to use the program)
  • User support (empathy, understanding, motivation)
  • Clinical support (education, therapeutic feedback, application)
25
Q

Support: who, what, when?

A

Lots of options:

  • Content : usage, motivation, feedback
  • Mode : telephone, email, chat, SMS etc….
  • Expertise : therapist, administrator, lay person
  • Dose : frequency and timing of the support
  • Who initiates the contact (‘pull’ or ‘push’)?
26
Q

How does support work?

A

We don’t know!

It is unclear who should provide the support, what the most relevant type of support is, and how frequent, how much support should be provided.

27
Q

How does support work? We don’t know! But…

(motivation, optional support, contact synchronicity)

A
  • Motivation is important but not sufficient to maximize treatment effect
  • Optional (self-initiated) support is hardly ever used
  • A-synchrone contact is supposed to lead to better effects (compared to synchrone contact)
28
Q

Efficiency model of support

(*Schueller et al., Clinical Psychology Science, and Practice, 2017)

A

Support should focus on ‘failures’:

  • Usability
  • Engagement: Motivation
  • Fit: does the application fit with client needs?
  • Knowledge: Incorrect use of the application e.g. exercises
  • Implementation: application in daily life (generalizability)

Support is focused on reinforcing these aspects

29
Q

Implementation in routine practice

A

eMental Health applications have not been implemented at a large scale in routine practice

We don’t know how to offer them in routine practice and this depends on current health care procedures

This is probably dependent on the setting (general population, primary care, specialized mental health care) and the patient population (disorder, symptom severity)

30
Q

Implementation barriers (of online treatments)

A
  • Attitude of the therapist
  • Expectations of the client (‘credibility’)
  • Finance and reimbursement
  • Training of therapists
  • Technical problems
31
Q

Quality of self-help material

A

There are many books, online interventions, apps, and other self-help material, but it is hard to differentiate the good ones from the bad once

32
Q

Quality Criteria (Self-Help)

A

1) Credibility : content, theory-based, expert developer, clear target group and goal
2) Technical features : system works well
3) Functionality : easy to use, appealing
4) Safety : side effects, harm, risks
5) Privacy and security

33
Q

recommended stepped care system for CBT

A
34
Q

what makes self help interventions effective in depression?

A
35
Q

Ecological Momentary Interventions

A
36
Q

Efficiency model of support*

A
37
Q

Avatar or agent using Motivational Interviewing

A

Low Intensity Treatments (9 decks)

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