Self-Help and Online Treatments Flashcards
• Challenges in online treatments
- Therapy adherence
- the role of the therapist
- Implementation in practice
- Quality of applications
Low intensity treatments: some history
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
IAPT:
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)
Self-help material
- 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
Self-help books (bibliotherapy)
- 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
Self-help books (First self help book:…)
“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
Allocation Concealment
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.
Moderators for the effectiveness of LIT (Review Article) (Depression)
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.
Evidence self-help books depression: Meta Analysis ((Psychological Medicine, 2007, 1217–1228)
- 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
What is online treatment?
Interventions delivered via the internet aimed to reduce physical and/or psychological problems increase knowledge, understanding, and awareness
What is online treatment? (More concrete)
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
Mix & match (online treatment)
modules can be optional and delivered in a random or fixed order
Unguided online interventions (Effectiveness):
where people work through the program on their own with no guidance (‘self-guided’, ‘stand alone’ )
Effect sizes are small but significant
Guided online interventions (effectiveness):
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
Blended treatment:
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
Mobile Applications
Ecological Momentary Interventions:
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)
Evidence Meta-analysis (Mobile applications): *Versluis, 2016, JMIR, 18(62)3: e152
- 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
Evidence Meta-analysis (mobile pplications) *Weisel, 2019, Digital Med2i4cine
• 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
Challenges in online interventions and apps
1) Treatment adherence
2) Implementation in practice
3) Quality of the intervention
Treatment adherence
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
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)
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
Why is this a problem? (Low Treatment Adherence)
(Donkin, JMIR 2011;132(93):e52))
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!
How can we increase treatment adherence?
- Deliver treatments with guidance of a coach or therapist
- Motivational approach (for example motivational interviewing)
- Persuasive technology
- Personalising treatments
- Send reminder emails …
What does support or guidance involve?
(in online interventions)
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)
Support: who, what, when?
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’)?
How does support work?
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.
How does support work? We don’t know! But…
(motivation, optional support, contact synchronicity)
- 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)
Efficiency model of support
(*Schueller et al., Clinical Psychology Science, and Practice, 2017)
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
Implementation in routine practice
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)
Implementation barriers (of online treatments)
- Attitude of the therapist
- Expectations of the client (‘credibility’)
- Finance and reimbursement
- Training of therapists
- Technical problems
Quality of self-help material
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
Quality Criteria (Self-Help)
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
recommended stepped care system for CBT
what makes self help interventions effective in depression?
Ecological Momentary Interventions
Efficiency model of support*
Avatar or agent using Motivational Interviewing
