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The need for clinical services in U.S. colleges exceeds the supply. Digital Mental health Interventions (DMHIs) are a potential solution, but successful implementation depends on stakeholder acceptance. This study investigated the relevance of DMHIs from students' perspectives. In 2020-2021, an online cross-sectional survey using mixed methods was conducted with 479 students at 23 colleges and universities. Respondents reported views and use of standard mental health services and DMHIs and rated the priority of various DMHIs to be offered through campus services. Qualitative data included open-ended responses. Among respondents, 91% reported having experienced mental health problems, of which 91% reported barriers to receiving mental health services. Students highlighted therapy and counseling as desired and saw flexible access to services as important. With respect to DMHIs, respondents had the most experience with physical health apps (46%), mental health questionnaires (41%), and mental well-being apps (39%). Most were unaware of or had not used apps or self-help programs for mental health problems. Students were most likely to report the following DMHIs as high priorities: a crisis text line (76%), telehealth (66%), websites for connecting to services (62%), and text/messaging with counselors (62%). They considered a self-help program with coach support to be convenient but some also perceived such services to be possibly less effective than in-person therapy. Students welcome DMHIs on campus and indicate preference for mental health services that include human support. The findings, with particular focus on characteristics of the DMHIs prioritized, and students' awareness and perceptions of scalable DMHIs emphasized by policymakers, should inform schools looking to implement DMHIs.
Topooco N, Fowler LA, Fitzsimmons-Craft EE, DePietro B, Vázquez MM, Firebaugh ML, Ceglarek P, Monterubio G, Newman MG, Eisenberg D, Wilfley DE, Taylor CB. Digital interventions to address mental health needs in colleges: Perspectives of student stakeholders.
Internet Interv. 2022 Mar 23;28:100528. doi: 10.1016/j.invent.2022.100528. eCollection 2022 Apr. PMID: 35378846 Free PMC article.
The COVID-19 pandemic has heightened the need for mental healthcare that can be delivered remotely and at scale to college students. This study evaluated the efficacy of online self-help for stress among students during the pandemic. College students with moderate or higher stress (N = 585) were recruited between November 2020 and February 2021, when COVID-19 had a major impact on colleges. Participants were randomly assigned to receive either online self-help using cognitive-behavioral therapy and positive psychology principles to support resilience and coping with pandemic-related stressors (n = 301) or referral to usual care (n = 284). Stress (primary outcome), depression, and anxiety (secondary outcomes) were assessed at pretreatment, one-month post-treatment, and three-month follow-up. Participants in the online self-help condition experienced significantly larger reductions in stress (d = –0.18, p = .035) and depression (d = –0.20, p = .018) from pretreatment to post-treatment than participants in the referral group. Reductions in stress from pretreatment to follow-up were also larger in the treatment versus referral group (d = –0.23, p = .005). Groups did not differ in change in anxiety. More time using the self-help program predicted greater improvement in depression at post-treatment (d = –0.41, p = .001) and follow-up (d = –0.32, p = .007), although usage was unrelated to change in stress or anxiety. Online self-help targeting resilience and coping during the pandemic appears efficacious for long-term alleviation of stress and short-term alleviation of depression symptoms among the college students.
Rackoff GN, Fitzsimmons-Craft EE, Taylor CB, Eisenberg D, Wilfley DE, Newman MG. A Randomized Controlled Trial of Internet-Based Self-Help for Stress During the COVID-19 Pandemic. J Adolesc Health. 2022 Aug;71(2):157-163. doi: 10.1016/j.jadohealth.2022.01.227. Epub 2022 Feb 4. PMID: 35351353 Free PMC article. Clinical Trial.
Prevention of eating disorders (EDs) is of high importance. However, digital programs with human moderation are unlikely to be disseminated widely. The aim of this study was to test whether a chatbot (i.e., computer program simulating human conversation) would significantly reduce ED risk factors (i.e., weight/shape concerns, thin-ideal internalization) in women at high risk for an ED, compared to waitlist control, as well as whether it would significantly reduce overall ED psychopathology, depression, and anxiety and prevent ED onset. Women who screened as high risk for an ED were randomized (N = 700) to (1) chatbot based on the StudentBodies© program; or (2) waitlist control. Participants were followed for 6 months. For weight/shape concerns, there was a significantly greater reduction in intervention versus control at 3- (d = -0.20; p = .03) and 6-m-follow-up (d = -0.19; p = .04). There were no differences in change in thin-ideal internalization. The intervention was associated with significantly greater reductions than control in overall ED psychopathology at 3- (d = -0.29; p = .003) but not 6-month follow-up. There were no differences in change in depression or anxiety. The odds of remaining nonclinical for EDs were significantly higher in intervention versus control at both 3- (OR = 2.37, 95% CI [1.37, 4.11]) and 6-month follow-ups (OR = 2.13, 95% CI [1.26, 3.59]). Findings provide support for the use of a chatbot-based EDs prevention program in reducing weight/shape concerns through 6-month follow-up, as well as in reducing overall ED psychopathology, at least in the shorter-term. Results also suggest the intervention may reduce ED onset.
Fitzsimmons-Craft EE, Chan WW, Smith AC, Firebaugh ML, Fowler LA, Topooco N, DePietro B, Wilfley DE, Taylor CB, Jacobson NC. Effectiveness of a chatbot for eating disorders prevention: A randomized clinical trial.
Int J Eat Disord. 2022 Mar;55(3):343-353. doi: 10.1002/eat.23662. Epub 2021 Dec 28. PMID: 35274362 Clinical Trial
Online guided self-help may be an effective and scalable intervention for symptoms of generalized anxiety disorder (GAD) among university students in India. Based on an online screen for GAD administered at 4 Indian universities, 222 students classified as having clinical (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria) or subthreshold (Generalized Anxiety Disorder Questionnaire, Fourth Edition, score ≥ 5.7) GAD were randomly assigned to receive either 3 months of guided self-help cognitive-behavioral therapy (n = 117) or a waitlist control condition (n = 105). Guided self-help participants recorded high program usage on average across all participants enrolled (M = 9.99 hr on the platform; SD = 20.87). Intent-to-treat analyses indicated that participants in the guided self-help condition experienced significantly greater reductions than participants in the waitlist condition on GAD symptom severity (d = -.40), worry (d = -.43), and depressive symptoms (d = -.53). No usage variables predicted symptom change in the guided self-help condition. Participants on average reported that the program was moderately helpful, and a majority (82.1%) said they would recommend the program to a friend. Guided self-help appears to be a feasible and efficacious intervention for university students in India who meet clinical or subthreshold GAD criteria. The trial is registered with ClinicalTrials.gov (NCT02410265). (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Newman MG, Kanuri N, Rackoff GN, Jacobson NC, Bell MJ, Taylor CB. A randomized controlled feasibility trial of internet-delivered guided self-help for generalized anxiety disorder (GAD) among university students in India. Psychotherapy (Chic). 2021 Dec;58(4):591-601. doi: 10.1037/pst0000383. PMID: 34881930 Free PMC article. Clinical Trial.
Virtual reality exposure therapy (VRE) has shown promising efficacy for the treatment of social anxiety disorder (SAD) and related comorbidities. However, most trials conducted to date were therapist-led, and little is known about the efficacy of self-guided VRE. Therefore, this randomized controlled trial (RCT) aimed to determine the efficacy of a self-directed VRE for SAD. Forty-four community-dwelling or undergraduate adults diagnosed with SAD based on the Mini International Neuropsychiatric Interview were randomly assigned to VRE designed to last four sessions or more (n = 26) or waitlist (WL; n = 18). Self-reported SAD severity (Social Phobia Diagnostic Questionnaire and Social Interaction Anxiety Scale), job interview anxiety (Measure of Anxiety in Selection Interviews), trait worry (Penn State Worry Questionnaire), and depression symptoms (Patient Health Questionnaire-9) were administered at baseline, post-treatment, 3-month-follow-up (3MFU), and 6-month-follow-up (6MFU). Piecewise multilevel modeling analyses were conducted to manage clustering in the data. VRE vs. WL resulted in greater reductions in SAD symptom severity, job interview fear, and trait worry, with moderate-to-large effect sizes (Hedge's g = -0.54 to -1.11) from pre-to-post treatment. Although significant between-group differences did not emerge for change in depression, VRE led to change in depression, whereas waitlist did not. These gains were also maintained at 3MFU and 6MFU. Further, facets of presence increased during the course of VRE (g = 0.36-0.45), whereas cybersickness decreased (g = -0.43). Brief, self-guided VRE might ameliorate SAD and comorbid worry, for young-to-middle-aged adults with SAD. Other theoretical and practical implications were also discussed.
Zainal NH, Chan WW, Saxena AP, Taylor CB, Newman MG. Pilot randomized trial of self-guided virtual reality exposure therapy for social anxiety disorder.Behav Res Ther. 2021 Dec;147:103984. doi: 10.1016/j.brat.2021.103984. Epub 2021 Oct 6. PMID: 34740099 Free PMC article. Clinical Trial.
The current study leveraged social media to connect with teens with EDs to identify population specific characteristics and to gather feedback on an mHealth intervention. We recruited teens with EDs from social media in two phases: (1) Discovery Group, (2) Testing Group. The Discovery Group (n = 14) participants were recruited from Facebook/Instagram and were asked to review the app for up to one week and provide qualitative feedback. After incorporating feedback from the Discovery Group, we refined our social media outreach methods to connect with 30 teens with EDs to pilot this mobile app. Recruitment from a variety of platforms on social media was successful, with the majority of enrolled participants in the Testing Group coming from Snapchat (60%) and a large percentage of participants belonging to gender and sexual minority groups (63%). Participants from both groups experienced extremely high rates of depression (100% Discovery, 90% Testing) and/or anxiety symptoms (100% Discovery, 93% Testing) in addition to ED symptoms, and noted this as a possible barrier to app engagement. Use of social media for recruitment of teens with EDs is feasible and may connect with groups who may be more difficult to reach using traditional recruitment methods. Among the Discovery Group there was high acceptability of and interest in an app to support ED recovery, and characteristics of both groups demonstrated need for support in other mental health domains. Future studies should evaluate the preliminary efficacy of such tools among teens to determine the effects of such interventions on ED symptoms and other mental health outcomes.
Kasson E, Vázquez MM, Doroshenko C, Fitzsimmons-Craft EE, Wilfley DE, Taylor CB, Cavazos-Rehg PA. Exploring Social Media Recruitment Strategies and Preliminary Acceptability of an mHealth Tool for Teens with Eating Disorders.
Int J Environ Res Public Health. 2021 Jul 28;18(15):7979. doi: 10.3390/ijerph18157979. PMID: 34360270
About a third of college students struggle with anxiety, depression, or an eating disorder, and only 20-40% of college students with mental disorders receive treatment. Inadequacies in mental health care delivery result in prolonged illness, disease progression, poorer prognosis, and greater likelihood of relapse, highlighting the need for a new approach to detect mental health problems and engage college students in services. We have developed a transdiagnostic, low-cost mobile mental health targeted prevention and intervention platform that uses population-level screening to engage college students in tailored services that address common mental health problems. We will test the impact of this mobile mental health platform for service delivery in a large-scale trial across 20+ colleges. Students who screen positive or at high-risk for clinical anxiety, depression, or an eating disorder and who are not currently engaged in mental health services (N = 7884) will be randomly assigned to: 1) intervention via the mobile mental health platform; or 2) referral to usual care (i.e., campus health or counseling center). We will test whether the mobile mental health platform, compared to referral, is associated with improved uptake, reduced clinical cases, disorder-specific symptoms, and improved quality of life and functioning. We will also test mediators, predictors, and moderators of improved mental health outcomes, as well as stakeholder-relevant outcomes, including cost-effectiveness and academic performance. This population-level approach to service engagement has the potential to improve mental health outcomes for the millions of students enrolled in U.S. colleges and universities.
Fitzsimmons-Craft EE, Taylor CB, Newman MG, Zainal NH, Rojas-Ashe EE, Lipson SK, Firebaugh ML, Ceglarek P, Topooco N, Jacobson NC, Graham AK, Kim HM, Eisenberg D, Wilfley DE. Harnessing mobile technology to reduce mental health disorders in college populations: A randomized controlled trial study protocol.
Contemp Clin Trials. 2021 Apr;103:106320. doi: 10.1016/j.cct.2021.106320. Epub 2021 Feb 11. PMID: 33582295
Digital guided self-help for eating disorders (GSH-ED) can reduce treatment disparities. Understanding program participants' interests throughout the program can help adapt programs to the service users' needs. Participants were 383 college students receiving a digital GSH-ED, who were each assigned a coach to help them better utilize the intervention through text correspondence. A thematic and affective analysis of the texts participants had sent found they primarily focused on: strategies for changing their ED-related cognitions, behaviors, and relationships; describing symptoms without expressing an active endeavor to change; and participants' relationship with their coach. Most texts also expressed affect, demonstrating emotional engagement with the intervention. Findings suggest that participants in GSH-ED demonstrate high involvement with the intervention, and discuss topics that are similar to those reported in clinician-facilitated interventions. The themes discussed by digital program participants can inform future iterations of GSH-ED, thereby increasing scalability and accessibility of digital evidence-based ED interventions.
Sadeh-Sharvit S, Idan O, Fowler LA, Fitzsimmons-Craft EE, Firebaugh ML, Smith A, Graham AK, Goel NJ, Flatt RE, Balantekin KN, Monterubio GE, Karam AM, Funk B, Trockel MT, Wilfley DE, Taylor CB. Digital guided self-help for eating disorders: thematic analysis of participant text messages to coaches. Eat Disord. 2022 Sep 30:1-9. doi: 10.1080/10640266.2022.2110698. Online ahead of print. PMID: 36178245
Eating disorders (EDs) are common, serious psychiatric disorders on college campuses, yet most affected individuals do not receive treatment. Digital interventions have the potential to bridge this gap. To determine whether a coached, digital, cognitive behavior therapy (CBT) intervention improves outcomes for college women with EDs compared with referral to usual care. This cluster randomized trial was conducted from 2014 to 2018 at 27 US universities. Women with binge-purge EDs (with both threshold and subthreshold presentations) were recruited from enrolled universities. The 690 participants were followed up for up to 2 years after the intervention. Data analysis was performed from February to September 2019. Universities were randomized to the intervention, Student Bodies-Eating Disorders, a digital CBT-guided self-help program, or to referral to usual care. The main outcome was change in overall ED psychopathology. Secondary outcomes were abstinence from binge eating and compensatory behaviors, as well as ED behavior frequencies, depression, anxiety, clinical impairment, academic impairment, and realized treatment access. A total of 690 women with EDs (mean [SD] age, 22.12 [4.85] years; 414 [60.0%] White; 120 [17.4%] Hispanic; 512 [74.2%] undergraduates) were included in the analyses. For ED psychopathology, there was a significantly greater reduction in the intervention group compared with the control group at the postintervention assessment (β [SE], -0.44 [0.10]; d = -0.40; t1387 = -4.23; P < .001), as well as over the follow-up period (β [SE], -0.39 [0.12]; d = -0.35; t1387 = -3.30; P < .001). There was not a significant difference in abstinence from any ED behaviors at the postintervention assessment (odds ratio, 1.48; 95% CI, 0.48-4.62; P = .50) or at follow-up (odds ratio, 1.51; 95% CI, 0.63-3.58; P = .36). Compared with the control group, the intervention group had significantly greater reductions in binge eating (rate ratio, 0.82; 95% CI, 0.70-0.96; P = .02), compensatory behaviors (rate ratio, 0.68; 95% CI, 0.54-0.86; P < .001), depression (β [SE], -1.34 [0.53]; d = -0.22; t1387 = -2.52; P = .01), and clinical impairment (β [SE], -2.33 [0.94]; d = -0.21; t1387 = -2.49; P = .01) at the postintervention assessment, with these gains sustained through follow-up for all outcomes except binge eating. Groups did not differ in terms of academic impairment. The majority of intervention participants (318 of 385 participants [83%]) began the intervention, whereas only 28% of control participants (76 of 271 participants with follow-up data available) sought treatment for their ED (odds ratio, 12.36; 95% CI, 8.73-17.51; P < .001). In this cluster randomized clinical trial comparing a coached, digital CBT intervention with referral to usual care, the intervention was effective in reducing ED psychopathology, compensatory behaviors, depression, and clinical impairment through long-term follow-up, as well as realizing treatment access. No difference was found between the intervention and control groups for abstinence for all ED behaviors or academic impairment. Given its scalability, a coached, digital, CBT intervention for college women with EDs has the potential to address the wide treatment gap for these disorders.
Fitzsimmons-Craft EE, Taylor CB, Graham AK, Sadeh-Sharvit S, Balantekin KN, Eichen DM, Monterubio GE, Goel NJ, Flatt RE, Karam AM, Firebaugh ML, Jacobi C, Jo B, Trockel MT, Wilfley DE. Effectiveness of a Digital Cognitive Behavior Therapy-Guided Self-Help Intervention for Eating Disorders in College Women: A Cluster Randomized Clinical Trial.
JAMA Netw Open. 2020 Aug 3;3(8):e2015633. doi: 10.1001/jamanetworkopen.2020.15633. PMID: 32865576
The integration of artificial intelligence (AI) technologies into mental health holds the promise of increasing patient access, engagement, and quality of care, and of improving clinician quality of work life. However, to date, studies of AI technologies in mental health have focused primarily on challenges that policymakers, clinical leaders, and data and computer scientists face, rather than on challenges that frontline mental health clinicians are likely to face as they attempt to integrate AI-based technologies into their everyday clinical practice. In this Perspective, we describe a framework for "pragmatic AI-augmentation" that addresses these issues by describing three categories of emerging AI-based mental health technologies which frontline clinicians can leverage in their clinical practice-automation, engagement, and clinical decision support technologies. We elaborate the potential benefits offered by these technologies, the likely day-to-day challenges they may raise for mental health clinicians, and some solutions that clinical leaders and technology developers can use to address these challenges, based on emerging experience with the integration of AI technologies into clinician daily practice in other healthcare disciplines.
Kellogg KC, Sadeh-Sharvit S. Pragmatic AI-augmentation in mental healthcare: Key technologies, potential benefits, and real-world challenges and solutions for frontline clinicians.
Front Psychiatry. 2022 Sep 6;13:990370. doi: 10.3389/fpsyt.2022.990370. eCollection 2022. PMID: 36147984 Free PMC article.
Eating disorders (EDs) contribute considerably to the global burden of disease. However, most affected individuals do not receive treatment. Mobile apps present an enormous opportunity to increase access to mental healthcare services. This study examined whether the degree of usage of a self-help app for EDs mediated the app's effects on the clinical response by individuals with EDs. App usage measures included the total number of cognitive-behavioral meal logs, total number of days spent using the app, and the last day the app was used during the study period. Mediation analysis was performed using the MacArthur framework. All usage variables met the analytic requirements for testing mediation (group means (sd) for app and standard app, respectively: logs = 74 (108) vs. 51.4 (88.1), days spent = 14.3 (17.5) vs. 10.6 (15.0), p-values from Wilcox rank sum tests p < .01). Regression coefficients indicated mediation effects. The mediation effects demonstrated support that increased engagement (as measured by logs and time spent on the app) was related to an increased likelihood of achieving a significant clinical change by the end of the trial. Greater and longer engagement in an ED app mediates its efficacy in terms of ED remission.
Kim JP, Sadeh-Sharvit S, Welch HA, Neri E, Tregarthen J, Lock J. Eating disorders early app use mediates treatment effect on clinical improvement.
Int J Eat Disord. 2022 Mar;55(3):382-387. doi: 10.1002/eat.23652. Epub 2021 Dec 14. PMID: 34904745
Sexual assault is a common form of trauma that is associated with elevated risk for negative psychosocial outcomes. Although survivors' social relationships could serve as a major protective factor against negative outcomes, survivors' supporters often lack knowledge regarding effective responses and may inadvertently respond in ways that are detrimental to healing. Communication and Recovery Enhancement (CARE) is a 2-session early intervention for survivors of a past-10-week sexual assault and their supporters that aims to improve supporters' ability to respond effectively. In this paper, we present a study protocol for a pilot randomized clinical trial of CARE (NCT05345405). The goal of this pilot trial is to understand the feasibility, acceptability, and preliminary efficacy of two versions of CARE: a version in which survivors and supporters attend sessions together (dyadic version) and a version in which supporters attend sessions alone (supporter-only version). Survivors aged 14+ with elevated posttraumatic stress will enroll with a supporter of their choosing. Dyads will be randomized to dyadic CARE, supporter-only CARE, or waitlist control, and will complete self-report assessments at baseline, post-session-1, and follow-ups (1, 2, and 3 months post-baseline). We will use descriptive statistics, effect sizes, and exploratory statistical tests to characterize the acceptability of both CARE versions, impact on knowledge change from baseline to 1 month, impact on disclosure experiences at 1 month, and impact on functional outcomes at 3 months. Results will be used to inform future changes to CARE and determine whether a fully-powered randomized controlled trial is warranted.
Dworkin ER, Ruzek JI, Cordova MJ, Fitzpatrick S, Merchant L, Stewart T, Santos JP, Mohr J, Bedard-Gilligan M. Supporter-focused early intervention for recent sexual assault survivors: Study protocol for a pilot randomized clinical trial.
Contemp Clin Trials. 2022 Aug;119:106848. doi: 10.1016/j.cct.2022.106848. Epub 2022 Jul 9. PMID: 35817294
Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid-term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.
Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Friedman M, Gersons BPR, de Jong J, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev AY, Solomon Z, Steinberg AM, Ursano RJ. Psychiatry. Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence.
2021 Winter;84(4):311-346. doi: 10.1080/00332747.2021.2005387. PMID: 35061969
Layne CM, Ruzek JI, Dixon K. From Resilience and Restoration to Resistance and Resource Caravans: A Developmental Framework for Advancing the Disaster Field.
Psychiatry. 2021 Winter;84(4):393-409. doi: 10.1080/00332747.2021.2005444. PMID: 35061961 No abstract available.
Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment.
Schnurr PP, Chard KM, Ruzek JI, Chow BK, Resick PA, Foa EB, Marx BP, Friedman MJ, Bovin MJ, Caudle KL, Castillo D, Curry KT, Hollifield M, Huang GD, Chee CL, Astin MC, Dickstein B, Renner K, Clancy CP, Collie C, Maieritsch K, Bailey S, Thompson K, Messina M, Franklin L, Lindley S, Kattar K, Luedtke B, Romesser J, McQuaid J, Sylvers P, Varkovitzky R, Davis L, MacVicar D, Shih MC. JAMA Netw Open. 2022 Jan 4;5(1):e2136921. doi: 10.1001/jamanetworkopen.2021. Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial. 36921. PMID: 35044471 Free PMC article.
A process for reviewing mental health apps: Using the One Mind PsyberGuide Credibility Rating System
Given the increasing number of publicly available mental health apps, we need independent advice to guide adoption. This paper discusses the challenges and opportunities of current mental health app rating systems and describes the refinement process of one prominent system, the One Mind PsyberGuide Credibility Rating Scale (PGCRS). PGCRS Version 1 was developed in 2013 and deployed for 7 years, during which time a number of limitations were identified. Version 2 was created through multiple stages, including a review of evaluation guidelines and consumer research, input from scientific experts, testing, and evaluation of face validity. We then re-reviewed 161 mental health apps using the updated rating scale, investigated the reliability and discrepancy of initial scores, and updated ratings on the One Mind PsyberGuide public app guide. Reliabilities across the scale's 9 items ranged from -0.10 to 1.00, demonstrating that some characteristics of apps are more difficult to rate consistently. The average overall score of the 161 reviewed mental health apps was 2.51/5.00 (range 0.33-5.00). Ratings were not strongly correlated with app store star ratings, suggesting that credibility scores provide different information to what is contained in star ratings. PGCRS summarizes and weights available information in 4 domains: intervention specificity, consumer ratings, research, and development. Final scores are created through an iterative process of initial rating and consensus review. The process of updating this rating scale and integrating it into a procedure for evaluating apps demonstrates one method for determining app quality.
Neary M, Bunyi J, Palomares K, Mohr DC, Powell A, Ruzek J, Williams LM, Wykes T, Schueller SM. A process for reviewing mental health apps: Using the One Mind PsyberGuide Credibility Rating System. Digit Health. 2021 Oct 29;7:20552076211053690. doi: 10.1177/20552076211053690. eCollection 2021 Jan-Dec. PMID: 34733541 Free PMC article.
The COVID-19 pandemic has and will continue to result in negative mental health outcomes such as depression, anxiety and traumatic stress in people and populations throughout the world. A population mental health perspective informed by clinical psychology, psychiatry and dissemination and implementation science is ideally suited to address the broad, multi-faceted and long-lasting mental health impact of the pandemic. Informed by a systematic review of the burgeoning empirical research on the COVID-19 pandemic and research on prior coronavirus pandemics, we link pandemic risk factors, negative mental health outcomes and appropriate intervention strategies. We describe how social risk factors and pandemic stressors will contribute to negative mental health outcomes, especially among vulnerable populations. We evaluate the scalability of primary, secondary and tertiary interventions according to mental health target, population, modality, intensity and provider type to provide a unified strategy for meeting population mental health needs. Traditional models, in which evidence-based therapies delivered are delivered in-person, by a trained expert, at a specialty care location have proved difficult to scale. The use of non-traditional models, tailoring preventive interventions to populations based on their needs, and ongoing coordinated evaluation of intervention implementation and effectiveness will be critical to refining our efforts to increase reach.
Boden M, Zimmerman L, Azevedo KJ, Ruzek JI, Gala S, Abdel Magid HS, Cohen N, Walser R, Mahtani ND, Hoggatt KJ, McLean CP. Addressing the mental health impact of COVID-19 through population health.
Clin Psychol Rev. 2021 Apr;85:102006. doi: 10.1016/j.cpr.2021.102006. Epub 2021 Mar 5. PMID: 33714167 Free PMC article. Review.
Burnout is widespread among behavioral health clinicians treating posttraumatic stress disorder (PTSD) among military populations. Intervention-based strategies have shown some benefit in addressing clinician burnout. One Web-based tool, the PTSD Clinicians Exchange, was designed to disseminate clinical best practices for the treatment of PTSD and facilitate self-care to mitigate burnout. This study sought to determine whether this tool could reduce burnout among clinicians treating military populations. A total of 605 behavioral health clinicians from the U.S. Department of Veterans Affairs, the Department of Defense, and the community were enrolled in a randomized controlled trial to test the effectiveness of the PTSD Clinicians Exchange. Clinicians were assessed on demographic characteristics, practice patterns, and organizational support with an online survey at baseline and at 6 and 12 months. Burnout, secondary traumatic stress (STS), and compassion satisfaction were measured with the Professional Quality of Life Scale. At baseline, no differences were observed in mean±SD burnout scores for the intervention (19.9±5.1) and control groups (20.2±5.4). Participation in the Exchange had no effect on burnout score at 12 months; burnout scores remained stable across the study period. In a multivariable stepwise regression model, older age, lower burnout at baseline, and lower STS scores and higher compassion satisfaction scores at 12 months were significantly associated with lower burnout scores. The PTSD Clinicians Exchange did not mitigate burnout among clinicians, possibly because of the content provided, the dissemination mechanism, or participants' limited use of the Web site. These results can be used to inform and enhance future interventions.
Clarke-Walper K, Penix EA, Trachtenberg F, Simon E, Coleman J, Magnavita A, Ortigo K, Regala S, Marceau L, Ruzek JI, Rosen RC, Wilk JE. Efficacy of a Web-Based Tool in Reducing Burnout Among Behavioral Health Clinicians: Results From the PTSD Clinicians Exchange.
Psychiatr Res Clin Pract. 2020 Sep 9;2(1):3-9. doi: 10.1176/appi.prcp.20190004. eCollection 2020 Summer. PMID: 36101889 Free PMC article.
Regular assessment of the effectiveness of behavioral interventions is a potent tool for improving their relevance to patients. However, poor provider and patient adherence characterize most measurement-based care tools. Therefore, a new approach for measuring intervention effects and communicating them to providers in a seamless manner is warranted. This paper provides a brief overview of the available research evidence on novel ways to measure the effects of behavioral treatments, integrating both objective and subjective data. We highlight the importance of analyzing therapeutic conversations through natural language processing. We then suggest a conceptual framework for capitalizing on data captured through directly collected and nondisruptive methodologies to describe the client's characteristics and needs and inform clinical decision-making. We then apply this context in exploring a new tool to integrate the content of therapeutic conversations and patients' self-reports. We present a case study of how both subjective and objective measures of treatment effects were implemented in cognitive-behavioral treatment for depression and anxiety and then utilized in treatment planning, delivery, and termination. In this tool, called Eleos, the patient completes standardized measures of depression and anxiety. The content of the treatment sessions was evaluated using nondisruptive, independent measures of conversation content, fidelity to the treatment model, and the back-and-forth of client-therapist dialogue. Innovative applications of advances in digital health are needed to disseminate empirically supported interventions and measure them in a noncumbersome way. Eleos appears to be a feasible, sustainable, and effective way to assess behavioral health care.
Sadeh-Sharvit S, Hollon SD. Leveraging the Power of Nondisruptive Technologies to Optimize Mental Health Treatment: Case Study. JMIR Ment Health. 2020 Nov 26;7(11):e20646. doi: 10.2196/20646. PMID: 33242025
Digital technology, which includes the collection, analysis, and use of data from a variety of digital devices, has the potential to reduce the prevalence of disorders and improve mental health in populations. Among the many advantages of digital technology is that it allows preventive and clinical interventions, both of which are needed to reduce the prevalence of mental health disorders, to be feasibly integrated into health care and community delivery systems and delivered at scale. However, the use of digital technology also presents several challenges, including how systems can manage and implement interventions in a rapidly changing digital environment and handle critical issues that affect population-wide outcomes, including reaching the targeted population, obtaining meaningful levels of uptake and use of interventions, and achieving significant outcomes. We describe a possible solution, which is to have an outcome optimization team that focuses on the dynamic use of data to adapt interventions for populations, while at the same time, addressing the complex relationships among reach, uptake, use, and outcome. We use the example of eating disorders in young people to illustrate how this solution could be implemented at scale. We also discuss system, practitioner-related, and other issues related to the adaptation of such an approach. Digital technology has great potential for facilitating the reduction of mental illness rates in populations. However, achieving this goal will require the implementation of new approaches. As a solution, we argue for the need to create outcome optimization teams, tasked with integrating data from various sources and using advanced data analytics and new designs to develop interventions/strategies to increase reach, uptake, use/engagement, and outcomes for both preventive and treatment interventions.
Taylor, C. B., Ruzek, J. I., Fitzsimmons-Craft, E. E., Sadeh-Sharvit, S., Topooco, N., Weissman, R. S., ... & Oldenburg, B. (2020). Using digital technology to reduce the prevalence of mental health disorders in populations: Time for a new approach. Journal of Medical Internet Research, 22(7), e17493.
The unprecedented COVID‐19 crisis presents an imperative for mental health care systems to make digital mental health interventions a routine part of care. Already because of COVID‐19, many therapists have rapidly moved to using telehealth in place of in‐person contact. In response to this shift, Waller and colleagues compiled a series of expert recommendations to help clinicians pivot to delivering teletherapy to address eating disorders during COVID‐19. However, numerous barriers still impede widespread adoption and implementation of digital interventions. In this commentary, we aim to extend the recommendations for clinicians offered by Waller and colleagues by presenting a roadmap of the systems‐ and policy‐level requirements that are needed. We advocate for addressing barriers associated with training, licensing, safety, privacy, payment, and evaluation, as these factors have greatly limited use of these promising interventions. We also indicate that longer‐term goals should include introducing truly innovative digital mental health practices, such as stepped‐care models and simultaneously providing preventive and self‐management services in addition to clinical services, into the health care system. Now is the time to catalyze change and comprehensively address the barriers that have prevented widespread delivery of these efficacious digital services to the millions of people who would benefit.
Taylor, C. B., Fitzsimmons‐Craft, E. E., & Graham, A. K. (2020). Digital technology can revolutionize mental health services delivery: The COVID‐19 crisis as a catalyst for change. International Journal of Eating Disorders.
Objective: The treatment gap between those who need and those who receive care for eating disorders is wide. Scaling a validated, online screener that makes individuals aware of the significance of their symptoms/behaviors is a crucial first step for increasing access to care. The objective of the current study was to determine the reach of disseminating an online eating disorder screener in partnership with the National Eating Disorders Association (NEDA), as well to examine the probable eating disorder diagnostic and risk breakdown of adult respondents. We also assessed receipt of any treatment. Method: Participants completed a validated eating disorder screen on the NEDA website over 6 months in 2017. Results: Of 71,362 respondents, 91.0% were female, 57.7% 18-24 years, 89.6% non-Hispanic, and 84.7% White. Most (86.3%) screened positive for an eating disorder. In addition, 10.2% screened as high risk for the development of an eating disorder, and only 3.4% as not at risk. Of those screening positive for an eating disorder, 85.9% had never received treatment and only 3.0% were currently in treatment. Discussion: The NEDA online screen may represent an important eating disorder detection tool, as it was completed by >71,000 adult respondents over just 6 months, the majority of whom screened positive for a clinical/subclinical eating disorder. The extremely high percentage of individuals screening positive for an eating disorder who reported not being in treatment suggests a wide treatment gap and the need to offer accessible, affordable, evidence-based intervention options, directly linked with screening.
Fitzsimmons-Craft EE, Balantekin KN, Graham AK, Smolar L, Park D, Mysko C, Funk B, Taylor CB, Wilfley DE. Results of disseminating an online screen for eating disorders across the U.S.: Reach, respondent characteristics, and unmet treatment need. Int J Eat Disord. 2019 Jun;52(6):721-729. doi: 10.1002/eat.23043. Epub 2019 Feb 13.
The purpose of this study was to conduct a longer-term (i.e., 9-month) follow-up of students identified with possible anorexia nervosa (AN) as part of the Healthy Body Image Program, an online platform for screening and delivering tailored feedback and interventions, offered at 36 US universities. Participants were 61 individuals who screened positive for AN and who completed the follow-up. Regarding results, some indices of ED pathology and psychiatric comorbidity decreased over time, while others did not. Participants most commonly endorsed feeling ashamed, nervous, validated, and sad in response to receiving the referral. One-third (33%) reported already being in treatment at the time they received the referral, 26% initiated treatment since that time, and 41% did not initiate treatment. The most common reasons for seeking treatment were emotional distress, concern with eating, and health concerns. The strongest treatment barriers were believing one should be able to help themselves, believing the problem was not serious enough to warrant treatment, and not having time. Findings highlight the high level of pathology in students identified with possible AN, even nine months after they were first identified and provided resources, and the relatively low rates of treatment utilization given the seriousness of these illnesses.
Fitzsimmons-Craft EE, Eichen DM, Monterubio GE, Firebaugh ML, Goel NJ, Taylor CB, Wilfley DE. Longer-term follow-up of college students screening positive for anorexia nervosa: psychopathology, help seeking, and barriers to treatment. Eat Disord. 2019 May 20:1-17. doi: 10.1080/10640266.2019.1610628.
The United States Department of Veterans Affairs (VA) provides Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) for PTSD at all of its facilities, but little is known about systematic differences between patients who do and do not initiate these treatments. VA administrative data were analyzed for 6,251 veterans receiving psychotherapy over one year in posttraumatic stress disorder (PTSD) specialty clinics at nine VA medical centers. CPT and PE were initiated by 2,173 (35%) patients. Veterans' probability of initiating either CPT or PE (considered together) was 29% lower (adjusted odds ratio = .61) if they had a psychiatric hospitalization within the same year, and 15% lower (AOR = .78) if they had service-connected disability for PTSD. Veterans' probability of starting CPT or PE was 19% lower (AOR = .74) if they were Hispanic or Latino, 10% lower (AOR = .84), if they were male rather than female, and 9% lower (AOR = .87) if they were divorced, separated or widowed rather than currently married. Probability of receiving CPT or PE was also lower if verans had more co-occurring psychiatric diagnoses (AOR per diagnosis = .88), were older (AOR per every five years = .95), or lived further away from the VA clinic (AOR per every ten miles = .98). Nonetheless, most patients initiating CPT or PE had two or more comorbidities and were service-connected for PTSD. Observed gender, age and ethnic differences in initiation of CPT and PE appear unrelated to clinical suitability and warrant further study.
Rosen CS, Bernardy NC, Chard KM, Clothier B, Cook JM, Crowley J, Eftekhari A, Kehle-Forbes SM, Mohr DC, Noorbaloochi S, Orazem RJ, Ruzek JI, Schnurr PP, Smith BN, Sayer NA. Which patients initiate cognitive processing therapy and prolonged exposure in department of veterans affairs PTSD clinics? J Anxiety Disord. 2019 Mar;62:53-60. doi: 10.1016/j.janxdis.2018.11.003.
Background: We describe an approach to implementation and dissemination that focuses on changing outcomes variables within a large, defined population and attempts to provide cost-effective opportunities and resources-which might include the provision of both digital and traditional interventions-to address individual needs and interests. We present a case example of how aspects of this model are being applied to increase reach, engagement and outcomes for individuals who complete a national eating disorders screen, and are likely to have an eating disorder but who are not in treatment. We then describe how this model can apply to post-traumatic stress (PTS) and conclude with a discussion of limitations and issues with the model. Methods: The National Eating Disorders Association (NEDA) provides online screening for eating disorders. Results: From February 2017 through March 2018, over 200,000 individuals completed the NEDA screen. Of these, 96% screened positive or at risk for an eating disorder, and most of those who screened positive for a clinical/subclinical eating disorder were not currently in treatment. Less than 10% engaged in self-help or guided self-help online digital program, or expressed interest in calling a helpline for referral to treatment. Conclusions: A systematic digital approach to implementation and dissemination has the potential to increase the number of individuals who benefit from interventions in defined populations. Uptake rates need to be improved.
Taylor CB, Ruzek JI, Fitzsimmons-Craft EE, Graham AK, Balantekin KN. A systematic digital approach to implementation and dissemination of eating disorders interventions to large populations identified through online screening: implications for post-traumatic stress. Mhealth. 2018 Jul 10;4:25. doi: 10.21037/mhealth.2018.05.06. eCollection 2018.
Introduction: Research indicates that individuals with generalized anxiety disorder (GAD) may experience deficits in positive affect (PA), and tend to dampen or intentionally suppress PA. Despite the presence of PA-related pathology in GAD, little is known about change in PA during GAD treatment. Objective: This study examines changes in PA, negative affect (NA) and worry in seven participants during cognitive behavioral therapy (CBT) for GAD.METHOD: Intensive repeated measures (i.e., time series) data were subjected to person-specific regression analysis to delineate individual change trajectories. Results: Significant improvement in worry was observed in all but one participant. Fear and irritability - indices of NA - each improved in 5/7 participants while sadness improved in 4/7 participants (worsening in one). Of all symptom domains, PA had the poorest treatment response: PA improved in only 2/7 participants and actually significantly worsened in 5/7 individuals even as NA and worry improved during therapy. Conclusion: These findings indicate that treatment gains from traditional CBT for GAD may not generalize to improvements in PA regulation, or even emotional functioning more broadly. This evidence is a call to increase the focus on PA regulation in treatment for GAD; perhaps PA could be a missing piece in our understanding of ways to bolster GAD treatment outcomes.
Bosley HG, Fisher AJ, Taylor CB. Differential responses of positive affect, negative affect, and worry in CBT for generalized anxiety disorder: A person-specific analysis of symptom course during therapy. Psychother Res. 2018 Jul;28(4):630-642. doi: 10.1080/10503307.2016.1233366.
Background: Depression is a major contributor to the burden of disease in the adolescent population. Internet-based interventions can increase access to treatment. Aims: To evaluate the efficacy of internet-based cognitive–behavioural therapy (iCBT), including therapist chat communication, in treatment of adolescent depression. Method: Seventy adolescents, 15–19 years of age and presenting with depressive symptoms, were randomised to iCBT or attention control. The primary outcome was the Beck Depression Inventory II (BDI-II). Results: Significant reductions in depressive symptoms were found, favouring iCBT over the control condition (F(1,67) = 6.18, P < 0.05). The between-group effect size was Cohen's d = 0.71 (95% CI 0.22–1.19). A significantly higher proportion of iCBT participants (42.4%) than controls (13.5%) showed a 50% decrease in BDI-II score post-treatment (P < 0.01). The improvement for the iCBT group was maintained at 6 months. Conclusions: The intervention appears to effectively reduce symptoms of depression in adolescents and may be helpful in overcoming barriers to care among young people.
Topooco, N., Berg, M., Johansson, S., Liljethörn, L., Radvogin, E., Vlaescu, G., Nordgren
L. B., Zetterqvist M. & Andersson, G. (2018). Chat-and internet-based cognitive–behavioural therapy in treatment of adolescent depression: randomised controlled trial. BJPsych open, 4(4), 199-207. doi: 10.1192/bjo.2018.18.
Objective: Family-based treatment (FBT) is an evidence-based treatment for adolescent anorexia nervosa (AN), but many families cannot access it. This study evaluated feasibility, acceptability, and preliminary treatment effects of a parental guided self-help (GSH) version of FBT for adolescent AN. Method: This was a case-series design. Parents of medically stable adolescents (11-18 years) with DSM-5 AN were recruited over 12 months. Parents received online training in parental GSH FBT and 12 20-30 min GSH sessions by phone or online over 6 months. Recruitment, dropout, changes in weight, and eating-related psychopathology were assessed. Analyses used mixed modeling that included all data for all participants. Results: Of the 19 families that participated, most were white (94%) and from intact families (88%). Baseline median BMI (mBMI) percent was 85.01% (SD = 4.31). Participants' mBMI percent increased to 97.31% (SD ± 7.48) at the end of treatment (EOT) (ES = 2.06; CI= 0.13-3.99). Eating-related psychopathology improved by EOT (ES = 0.58; CI=.04-1.21). Dropout rate was 21% during treatment and 33% during follow-up. Discussion: Parental GSH-FBT is feasible and acceptable to families willing to undertake online treatment. Follow-up data was only available for nine families (47%); thus further systematic evaluation is required before reaching conclusions about the efficacy of this approach.
Lock J, Darcy A, Fitzpatrick KK, Vierhile M, Sadeh-Sharvit S. Parental guided self-help family based treatment for adolescents with anorexia nervosa: A feasibility study. Int J Eat Disord. 2017 Sep;50(9):1104-1108. doi: 10.1002
Internet and mobile technologies offer potentially critical ways of delivering mental health support in low-resource settings. Much evidence indicates an enormous negative impact of mental health problems in low- and middle-income countries (LMICs), and many of these problems are caused, or worsened, by exposure to wars, conflicts, natural and human-caused disasters, and other traumatic events. Though specific mental health treatments have been found to be efficacious and cost-effective for low-resource settings, most individuals living in these areas do not have access to them. Low-intensity task-sharing interventions will help, but there is a limit to the scalability and sustainability of human resources in these settings. To address the needs of trauma survivors, it will be important to develop and implement Internet and mobile technology resources to help reduce the scarcity, inequity, and inefficiency of current mental health services in LMICs. Mobile and Internet resources are experiencing a rapid growth in LMICs and can help address time, stigma, and cost barriers and connect those who have been socially isolated by traumatic events. This review discusses current research in technological interventions in low-resource settings and outlines key issues and future challenges and opportunities. Though formidable challenges exist for large-scale deployment of mobile and Internet mental health technologies, work to date indicates that these technologies are indeed feasible to develop, evaluate, and deliver to those in need of mental health services, and that they can be effective.
Ruzek JI, Yeager CM. Internet and mobile technologies: addressing the mental health of trauma survivors in less resourced communities. Glob Ment Health (Camb). 2017 Aug 30;4:e16. doi: 10.1017/gmh.2017.11.
Objective: Posttraumatic stress disorder (PTSD) is highly prevalent in the population, but relatively few affected individuals receive treatment for it. Smartphone applications (apps) could help address this unmet need by offering sound psychoeducational information and evidence-based cognitive behavioral coping tools. We conducted a randomized controlled trial to assess the efficacy of a free, publicly available smartphone app (PTSD Coach) for self-management of PTSD symptoms. Method: One hundred 20 participants who were an average of 39 years old, mostly women (69.2%) and White (66.7%), recruited primarily through online advertisements, were randomized to either a PTSD Coach (n = 62) or a waitlist condition (n = 58) for 3 months. Web-administered self-report measures of PTSD, PTSD symptom coping self-efficacy, depression, and psychosocial functioning were conducted at baseline, posttreatment, and 3 months following treatment. Results: Following the intent-to-treat principle, repeated-measures analyses of variance (ANOVAs) revealed that at posttreatment, PTSD Coach participants had significantly greater improvements in PTSD symptoms (p = .035), depression symptoms (p = .005), and psychosocial functioning (p = .007) than did waitlist participants; however, at posttreatment, there were no significant mean differences in outcomes between conditions. A greater proportion of PTSD Coach participants achieved clinically significant PTSD symptom improvement (p = .018) than waitlist participants. Conclusion: PTSD Coach use resulted in significantly greater improvements in PTSD symptoms and other outcomes relative to a waitlist condition. Given the ubiquity of smartphones, PTSD Coach may provide a wide-reaching, convenient public health intervention for individuals with PTSD symptoms who are not receiving care.
Kuhn E, Kanuri N, Hoffman JE, Garvert DW, Ruzek JI, Taylor CB. A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. J Consult Clin Psychol. 2017 Mar;85(3):267-273. doi: 10.1037/ccp0000163.
Older adults living in congregate housing have been uniquely impacted by the COVID-19 pandemic. The sudden interruption of routine activities, social isolation, and support adversely affected the wellbeing of residents in retirement facilities around the country and world. The stress of social isolation was fueled by the interruption of routine activities and support that in turn, adversely affected the wellbeing, mood, and cognition of many residents. Therefore, university clinical programs in psychology and counseling can address the needs of community older residents by preparing student clinicians to work with the aging population and to engage in telehealth models of outreach and interventions. This manuscript outlines a model of partnership between long-term care assisted living organizations and clinical training programs at a west coast university to meet community and educational needs of older residents.
Sheperis, D.S., Gomez, R., Wathen, C., Frank, M., & Brown, L. (2022). Addressing Isolation, Loneliness and Mental Health of Older Adults Living during COVID-19: A University Training Partnership with Senior Living Communities. Gerontology and Geriatrics Education. https://doi.org/10.1080/02701960.2022.2096602
Teletherapy is an approach to working with clients that mental health providers have used in some form for years. However, the onset of COVID forced the provision of therapy into teletherapy almost exclusively for a period of time. Currently, mental health providers conducting therapy virtually are not required to be trained in telehealth and are operating without consistent uniform standards of practice. This manuscript pulls from the current literature and guidelines across counseling, psychology, psychiatry, family therapy, and social work to provide a Proposed Standards of Practice for Telehealth. Such standards benefit mental health counselor by grounding practice in common aims and benefits out clients by creating a unified framework for providers engaging in telehealth with their clients. This manuscript provides a review of current literature around the provision of teletherapy and proposes a set of standards of care based on existing literature. In addition, gaps in current literature are addressed.
Sheperis, D. S. & *Smith, A. (2021) Telehealth Best Practice: A Call for Standards of Care, Journal of Technology in Counselor Education and Supervision: Vol. 1 : Iss. 1 , Article 4. d0i: https://doi.org/10.22371/tces/0004
Background:Barriers to accessing in-person care can prevent veterans with posttraumatic stress disorder (PTSD) from receiving trauma-focused treatments such as exposure therapy. Mobile apps may help to address unmet need for services by offering tools for users to self-manage PTSD symptoms. Renew is a mobile mental health app that focuses on exposure therapy and incorporates a social support function designed to promote user engagement.
Objective:We examined the preliminary efficacy of Renew with and without support from a research staff member compared with waitlist among 93 veterans with clinically significant PTSD symptoms. We also examined the impact of study staff support on participant engagement with the app.
Methods:In a pilot randomized controlled trial, we compared Renew with and without support from a research staff member (active use condition) with waitlist (delayed use condition) over 6 weeks. Participants were recruited through online advertisements. The Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) was used to measure PTSD symptoms at pre, post, and 6-week follow-up. Usage data were collected to assess engagement with Renew.
Results:Results indicated a small effect size (d=–0.39) favoring those in the active use conditions relative to the delayed use condition, but the between-group difference was not significant (P=.29). There were no differences on indices of app engagement between the 2 active use conditions. Exploratory analyses found that the number of support persons users added to the app, but not the number of support messages received, was positively correlated with app engagement.
Conclusions:Findings suggest Renew may hold promise as a self-management tool to reduce PTSD symptoms in veterans. Involving friends and family in mobile mental health apps may help bolster engagement with no additional cost to public health systems.
Publications
These are just a few highlights of the many projects that team members from the Center for m²Health have been involved in the past few years.
For a full list of publications since 2019, click here.
Articles with open access are marked with an asterix (*)
A significant gap exists between those who need and those who receive care for eating disorders (EDs). Novel solutions are needed to encourage service use and address treatment barriers. This study developed and evaluated the usability of a chatbot designed for pairing with online ED screening. The tool aimed to promote mental health service utilization by improving motivation for treatment and self-efficacy among individuals with EDs. A chatbot prototype, Alex, was designed using decision trees and theoretically-informed components: psychoeducation, motivational interviewing, personalized recommendations, and repeated administration. Usability testing was conducted over four iterative cycles, with user feedback informing refinements to the next iteration. Post-testing, participants (N= 21) completed the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and a semi-structured interview. Interview feedback detailed chatbot aspects participants enjoyed and aspects necessitating improvement. Feedback converged on four themes: user experience, chatbot qualities, chatbot content, and ease of use. Following refinements, users described Alex as humanlike, supportive, and encouraging. Content was perceived as novel and personally relevant. USE scores across domains were generally above average (~5 out of 7), and SUS scores indicated “good” to “excellent” usability across cycles, with the final iteration receiving the highest average score. Overall, participants generally reflected positively on interactions with Alex, including the initial version. Refinements between cycles further improved user experiences. This study provides preliminary evidence of the feasibility and acceptance of a chatbot designed to promote motivation for and use of services among individuals with EDs. Low rates of service utilization and treatment have been observed among individuals following online eating disorder screening. Tools are needed, including scalable, digital options, that can be easily paired with screening, to improve motivation for addressing eating disorders and promote service utilization.
Shah J, DePietro B, D'Adamo L, Firebaugh ML, Laing O, Fowler LA, Smolar L, Sadeh-Sharvit S, Taylor CB, Wilfley DE, Fitzsimmons-Craft EE. Development and usability testing of a chatbot to promote mental health services use among individuals with eating disorders following screening. Int J Eat Disord. 2022 Sep;55(9):1229-1244. doi: 10.1002/eat.23798. Epub 2022 Aug 18. PMID: 36056648
The need for clinical services in U.S. colleges exceeds the supply. Digital Mental health Interventions (DMHIs) are a potential solution, but successful implementation depends on stakeholder acceptance. This study investigated the relevance of DMHIs from students' perspectives. In 2020-2021, an online cross-sectional survey using mixed methods was conducted with 479 students at 23 colleges and universities. Respondents reported views and use of standard mental health services and DMHIs and rated the priority of various DMHIs to be offered through campus services. Qualitative data included open-ended responses. Among respondents, 91% reported having experienced mental health problems, of which 91% reported barriers to receiving mental health services. Students highlighted therapy and counseling as desired and saw flexible access to services as important. With respect to DMHIs, respondents had the most experience with physical health apps (46%), mental health questionnaires (41%), and mental well-being apps (39%). Most were unaware of or had not used apps or self-help programs for mental health problems. Students were most likely to report the following DMHIs as high priorities: a crisis text line (76%), telehealth (66%), websites for connecting to services (62%), and text/messaging with counselors (62%). They considered a self-help program with coach support to be convenient but some also perceived such services to be possibly less effective than in-person therapy. Students welcome DMHIs on campus and indicate preference for mental health services that include human support. The findings, with particular focus on characteristics of the DMHIs prioritized, and students' awareness and perceptions of scalable DMHIs emphasized by policymakers, should inform schools looking to implement DMHIs.
Topooco N, Fowler LA, Fitzsimmons-Craft EE, DePietro B, Vázquez MM, Firebaugh ML, Ceglarek P, Monterubio G, Newman MG, Eisenberg D, Wilfley DE, Taylor CB. Digital interventions to address mental health needs in colleges: Perspectives of student stakeholders.
Internet Interv. 2022 Mar 23;28:100528. doi: 10.1016/j.invent.2022.100528. eCollection 2022 Apr. PMID: 35378846 Free PMC article.
The COVID-19 pandemic has heightened the need for mental healthcare that can be delivered remotely and at scale to college students. This study evaluated the efficacy of online self-help for stress among students during the pandemic. College students with moderate or higher stress (N = 585) were recruited between November 2020 and February 2021, when COVID-19 had a major impact on colleges. Participants were randomly assigned to receive either online self-help using cognitive-behavioral therapy and positive psychology principles to support resilience and coping with pandemic-related stressors (n = 301) or referral to usual care (n = 284). Stress (primary outcome), depression, and anxiety (secondary outcomes) were assessed at pretreatment, one-month post-treatment, and three-month follow-up. Participants in the online self-help condition experienced significantly larger reductions in stress (d = –0.18, p = .035) and depression (d = –0.20, p = .018) from pretreatment to post-treatment than participants in the referral group. Reductions in stress from pretreatment to follow-up were also larger in the treatment versus referral group (d = –0.23, p = .005). Groups did not differ in change in anxiety. More time using the self-help program predicted greater improvement in depression at post-treatment (d = –0.41, p = .001) and follow-up (d = –0.32, p = .007), although usage was unrelated to change in stress or anxiety. Online self-help targeting resilience and coping during the pandemic appears efficacious for long-term alleviation of stress and short-term alleviation of depression symptoms among the college students.
Rackoff GN, Fitzsimmons-Craft EE, Taylor CB, Eisenberg D, Wilfley DE, Newman MG. A Randomized Controlled Trial of Internet-Based Self-Help for Stress During the COVID-19 Pandemic. J Adolesc Health. 2022 Aug;71(2):157-163. doi: 10.1016/j.jadohealth.2022.01.227. Epub 2022 Feb 4. PMID: 35351353 Free PMC article. Clinical Trial.
Prevention of eating disorders (EDs) is of high importance. However, digital programs with human moderation are unlikely to be disseminated widely. The aim of this study was to test whether a chatbot (i.e., computer program simulating human conversation) would significantly reduce ED risk factors (i.e., weight/shape concerns, thin-ideal internalization) in women at high risk for an ED, compared to waitlist control, as well as whether it would significantly reduce overall ED psychopathology, depression, and anxiety and prevent ED onset. Women who screened as high risk for an ED were randomized (N = 700) to (1) chatbot based on the StudentBodies© program; or (2) waitlist control. Participants were followed for 6 months. For weight/shape concerns, there was a significantly greater reduction in intervention versus control at 3- (d = -0.20; p = .03) and 6-m-follow-up (d = -0.19; p = .04). There were no differences in change in thin-ideal internalization. The intervention was associated with significantly greater reductions than control in overall ED psychopathology at 3- (d = -0.29; p = .003) but not 6-month follow-up. There were no differences in change in depression or anxiety. The odds of remaining nonclinical for EDs were significantly higher in intervention versus control at both 3- (OR = 2.37, 95% CI [1.37, 4.11]) and 6-month follow-ups (OR = 2.13, 95% CI [1.26, 3.59]). Findings provide support for the use of a chatbot-based EDs prevention program in reducing weight/shape concerns through 6-month follow-up, as well as in reducing overall ED psychopathology, at least in the shorter-term. Results also suggest the intervention may reduce ED onset.
Fitzsimmons-Craft EE, Chan WW, Smith AC, Firebaugh ML, Fowler LA, Topooco N, DePietro B, Wilfley DE, Taylor CB, Jacobson NC. Effectiveness of a chatbot for eating disorders prevention: A randomized clinical trial.
Int J Eat Disord. 2022 Mar;55(3):343-353. doi: 10.1002/eat.23662. Epub 2021 Dec 28. PMID: 35274362 Clinical Trial
Online guided self-help may be an effective and scalable intervention for symptoms of generalized anxiety disorder (GAD) among university students in India. Based on an online screen for GAD administered at 4 Indian universities, 222 students classified as having clinical (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria) or subthreshold (Generalized Anxiety Disorder Questionnaire, Fourth Edition, score ≥ 5.7) GAD were randomly assigned to receive either 3 months of guided self-help cognitive-behavioral therapy (n = 117) or a waitlist control condition (n = 105). Guided self-help participants recorded high program usage on average across all participants enrolled (M = 9.99 hr on the platform; SD = 20.87). Intent-to-treat analyses indicated that participants in the guided self-help condition experienced significantly greater reductions than participants in the waitlist condition on GAD symptom severity (d = -.40), worry (d = -.43), and depressive symptoms (d = -.53). No usage variables predicted symptom change in the guided self-help condition. Participants on average reported that the program was moderately helpful, and a majority (82.1%) said they would recommend the program to a friend. Guided self-help appears to be a feasible and efficacious intervention for university students in India who meet clinical or subthreshold GAD criteria. The trial is registered with ClinicalTrials.gov (NCT02410265). (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Newman MG, Kanuri N, Rackoff GN, Jacobson NC, Bell MJ, Taylor CB. A randomized controlled feasibility trial of internet-delivered guided self-help for generalized anxiety disorder (GAD) among university students in India. Psychotherapy (Chic). 2021 Dec;58(4):591-601. doi: 10.1037/pst0000383. PMID: 34881930 Free PMC article. Clinical Trial.
Virtual reality exposure therapy (VRE) has shown promising efficacy for the treatment of social anxiety disorder (SAD) and related comorbidities. However, most trials conducted to date were therapist-led, and little is known about the efficacy of self-guided VRE. Therefore, this randomized controlled trial (RCT) aimed to determine the efficacy of a self-directed VRE for SAD. Forty-four community-dwelling or undergraduate adults diagnosed with SAD based on the Mini International Neuropsychiatric Interview were randomly assigned to VRE designed to last four sessions or more (n = 26) or waitlist (WL; n = 18). Self-reported SAD severity (Social Phobia Diagnostic Questionnaire and Social Interaction Anxiety Scale), job interview anxiety (Measure of Anxiety in Selection Interviews), trait worry (Penn State Worry Questionnaire), and depression symptoms (Patient Health Questionnaire-9) were administered at baseline, post-treatment, 3-month-follow-up (3MFU), and 6-month-follow-up (6MFU). Piecewise multilevel modeling analyses were conducted to manage clustering in the data. VRE vs. WL resulted in greater reductions in SAD symptom severity, job interview fear, and trait worry, with moderate-to-large effect sizes (Hedge's g = -0.54 to -1.11) from pre-to-post treatment. Although significant between-group differences did not emerge for change in depression, VRE led to change in depression, whereas waitlist did not. These gains were also maintained at 3MFU and 6MFU. Further, facets of presence increased during the course of VRE (g = 0.36-0.45), whereas cybersickness decreased (g = -0.43). Brief, self-guided VRE might ameliorate SAD and comorbid worry, for young-to-middle-aged adults with SAD. Other theoretical and practical implications were also discussed.
Zainal NH, Chan WW, Saxena AP, Taylor CB, Newman MG. Pilot randomized trial of self-guided virtual reality exposure therapy for social anxiety disorder.Behav Res Ther. 2021 Dec;147:103984. doi: 10.1016/j.brat.2021.103984. Epub 2021 Oct 6. PMID: 34740099 Free PMC article. Clinical Trial.
The current study leveraged social media to connect with teens with EDs to identify population specific characteristics and to gather feedback on an mHealth intervention. We recruited teens with EDs from social media in two phases: (1) Discovery Group, (2) Testing Group. The Discovery Group (n = 14) participants were recruited from Facebook/Instagram and were asked to review the app for up to one week and provide qualitative feedback. After incorporating feedback from the Discovery Group, we refined our social media outreach methods to connect with 30 teens with EDs to pilot this mobile app. Recruitment from a variety of platforms on social media was successful, with the majority of enrolled participants in the Testing Group coming from Snapchat (60%) and a large percentage of participants belonging to gender and sexual minority groups (63%). Participants from both groups experienced extremely high rates of depression (100% Discovery, 90% Testing) and/or anxiety symptoms (100% Discovery, 93% Testing) in addition to ED symptoms, and noted this as a possible barrier to app engagement. Use of social media for recruitment of teens with EDs is feasible and may connect with groups who may be more difficult to reach using traditional recruitment methods. Among the Discovery Group there was high acceptability of and interest in an app to support ED recovery, and characteristics of both groups demonstrated need for support in other mental health domains. Future studies should evaluate the preliminary efficacy of such tools among teens to determine the effects of such interventions on ED symptoms and other mental health outcomes.
Kasson E, Vázquez MM, Doroshenko C, Fitzsimmons-Craft EE, Wilfley DE, Taylor CB, Cavazos-Rehg PA. Exploring Social Media Recruitment Strategies and Preliminary Acceptability of an mHealth Tool for Teens with Eating Disorders.
Int J Environ Res Public Health. 2021 Jul 28;18(15):7979. doi: 10.3390/ijerph18157979. PMID: 34360270
About a third of college students struggle with anxiety, depression, or an eating disorder, and only 20-40% of college students with mental disorders receive treatment. Inadequacies in mental health care delivery result in prolonged illness, disease progression, poorer prognosis, and greater likelihood of relapse, highlighting the need for a new approach to detect mental health problems and engage college students in services. We have developed a transdiagnostic, low-cost mobile mental health targeted prevention and intervention platform that uses population-level screening to engage college students in tailored services that address common mental health problems. We will test the impact of this mobile mental health platform for service delivery in a large-scale trial across 20+ colleges. Students who screen positive or at high-risk for clinical anxiety, depression, or an eating disorder and who are not currently engaged in mental health services (N = 7884) will be randomly assigned to: 1) intervention via the mobile mental health platform; or 2) referral to usual care (i.e., campus health or counseling center). We will test whether the mobile mental health platform, compared to referral, is associated with improved uptake, reduced clinical cases, disorder-specific symptoms, and improved quality of life and functioning. We will also test mediators, predictors, and moderators of improved mental health outcomes, as well as stakeholder-relevant outcomes, including cost-effectiveness and academic performance. This population-level approach to service engagement has the potential to improve mental health outcomes for the millions of students enrolled in U.S. colleges and universities.
Fitzsimmons-Craft EE, Taylor CB, Newman MG, Zainal NH, Rojas-Ashe EE, Lipson SK, Firebaugh ML, Ceglarek P, Topooco N, Jacobson NC, Graham AK, Kim HM, Eisenberg D, Wilfley DE. Harnessing mobile technology to reduce mental health disorders in college populations: A randomized controlled trial study protocol.
Contemp Clin Trials. 2021 Apr;103:106320. doi: 10.1016/j.cct.2021.106320. Epub 2021 Feb 11. PMID: 33582295
Digital guided self-help for eating disorders (GSH-ED) can reduce treatment disparities. Understanding program participants' interests throughout the program can help adapt programs to the service users' needs. Participants were 383 college students receiving a digital GSH-ED, who were each assigned a coach to help them better utilize the intervention through text correspondence. A thematic and affective analysis of the texts participants had sent found they primarily focused on: strategies for changing their ED-related cognitions, behaviors, and relationships; describing symptoms without expressing an active endeavor to change; and participants' relationship with their coach. Most texts also expressed affect, demonstrating emotional engagement with the intervention. Findings suggest that participants in GSH-ED demonstrate high involvement with the intervention, and discuss topics that are similar to those reported in clinician-facilitated interventions. The themes discussed by digital program participants can inform future iterations of GSH-ED, thereby increasing scalability and accessibility of digital evidence-based ED interventions.
Sadeh-Sharvit S, Idan O, Fowler LA, Fitzsimmons-Craft EE, Firebaugh ML, Smith A, Graham AK, Goel NJ, Flatt RE, Balantekin KN, Monterubio GE, Karam AM, Funk B, Trockel MT, Wilfley DE, Taylor CB. Digital guided self-help for eating disorders: thematic analysis of participant text messages to coaches. Eat Disord. 2022 Sep 30:1-9. doi: 10.1080/10640266.2022.2110698. Online ahead of print. PMID: 36178245
Eating disorders (EDs) are common, serious psychiatric disorders on college campuses, yet most affected individuals do not receive treatment. Digital interventions have the potential to bridge this gap. To determine whether a coached, digital, cognitive behavior therapy (CBT) intervention improves outcomes for college women with EDs compared with referral to usual care. This cluster randomized trial was conducted from 2014 to 2018 at 27 US universities. Women with binge-purge EDs (with both threshold and subthreshold presentations) were recruited from enrolled universities. The 690 participants were followed up for up to 2 years after the intervention. Data analysis was performed from February to September 2019. Universities were randomized to the intervention, Student Bodies-Eating Disorders, a digital CBT-guided self-help program, or to referral to usual care. The main outcome was change in overall ED psychopathology. Secondary outcomes were abstinence from binge eating and compensatory behaviors, as well as ED behavior frequencies, depression, anxiety, clinical impairment, academic impairment, and realized treatment access. A total of 690 women with EDs (mean [SD] age, 22.12 [4.85] years; 414 [60.0%] White; 120 [17.4%] Hispanic; 512 [74.2%] undergraduates) were included in the analyses. For ED psychopathology, there was a significantly greater reduction in the intervention group compared with the control group at the postintervention assessment (β [SE], -0.44 [0.10]; d = -0.40; t1387 = -4.23; P < .001), as well as over the follow-up period (β [SE], -0.39 [0.12]; d = -0.35; t1387 = -3.30; P < .001). There was not a significant difference in abstinence from any ED behaviors at the postintervention assessment (odds ratio, 1.48; 95% CI, 0.48-4.62; P = .50) or at follow-up (odds ratio, 1.51; 95% CI, 0.63-3.58; P = .36). Compared with the control group, the intervention group had significantly greater reductions in binge eating (rate ratio, 0.82; 95% CI, 0.70-0.96; P = .02), compensatory behaviors (rate ratio, 0.68; 95% CI, 0.54-0.86; P < .001), depression (β [SE], -1.34 [0.53]; d = -0.22; t1387 = -2.52; P = .01), and clinical impairment (β [SE], -2.33 [0.94]; d = -0.21; t1387 = -2.49; P = .01) at the postintervention assessment, with these gains sustained through follow-up for all outcomes except binge eating. Groups did not differ in terms of academic impairment. The majority of intervention participants (318 of 385 participants [83%]) began the intervention, whereas only 28% of control participants (76 of 271 participants with follow-up data available) sought treatment for their ED (odds ratio, 12.36; 95% CI, 8.73-17.51; P < .001). In this cluster randomized clinical trial comparing a coached, digital CBT intervention with referral to usual care, the intervention was effective in reducing ED psychopathology, compensatory behaviors, depression, and clinical impairment through long-term follow-up, as well as realizing treatment access. No difference was found between the intervention and control groups for abstinence for all ED behaviors or academic impairment. Given its scalability, a coached, digital, CBT intervention for college women with EDs has the potential to address the wide treatment gap for these disorders.
Fitzsimmons-Craft EE, Taylor CB, Graham AK, Sadeh-Sharvit S, Balantekin KN, Eichen DM, Monterubio GE, Goel NJ, Flatt RE, Karam AM, Firebaugh ML, Jacobi C, Jo B, Trockel MT, Wilfley DE. Effectiveness of a Digital Cognitive Behavior Therapy-Guided Self-Help Intervention for Eating Disorders in College Women: A Cluster Randomized Clinical Trial.
JAMA Netw Open. 2020 Aug 3;3(8):e2015633. doi: 10.1001/jamanetworkopen.2020.15633. PMID: 32865576
The integration of artificial intelligence (AI) technologies into mental health holds the promise of increasing patient access, engagement, and quality of care, and of improving clinician quality of work life. However, to date, studies of AI technologies in mental health have focused primarily on challenges that policymakers, clinical leaders, and data and computer scientists face, rather than on challenges that frontline mental health clinicians are likely to face as they attempt to integrate AI-based technologies into their everyday clinical practice. In this Perspective, we describe a framework for "pragmatic AI-augmentation" that addresses these issues by describing three categories of emerging AI-based mental health technologies which frontline clinicians can leverage in their clinical practice-automation, engagement, and clinical decision support technologies. We elaborate the potential benefits offered by these technologies, the likely day-to-day challenges they may raise for mental health clinicians, and some solutions that clinical leaders and technology developers can use to address these challenges, based on emerging experience with the integration of AI technologies into clinician daily practice in other healthcare disciplines.
Kellogg KC, Sadeh-Sharvit S. Pragmatic AI-augmentation in mental healthcare: Key technologies, potential benefits, and real-world challenges and solutions for frontline clinicians.
Front Psychiatry. 2022 Sep 6;13:990370. doi: 10.3389/fpsyt.2022.990370. eCollection 2022. PMID: 36147984 Free PMC article.
Eating disorders (EDs) contribute considerably to the global burden of disease. However, most affected individuals do not receive treatment. Mobile apps present an enormous opportunity to increase access to mental healthcare services. This study examined whether the degree of usage of a self-help app for EDs mediated the app's effects on the clinical response by individuals with EDs. App usage measures included the total number of cognitive-behavioral meal logs, total number of days spent using the app, and the last day the app was used during the study period. Mediation analysis was performed using the MacArthur framework. All usage variables met the analytic requirements for testing mediation (group means (sd) for app and standard app, respectively: logs = 74 (108) vs. 51.4 (88.1), days spent = 14.3 (17.5) vs. 10.6 (15.0), p-values from Wilcox rank sum tests p < .01). Regression coefficients indicated mediation effects. The mediation effects demonstrated support that increased engagement (as measured by logs and time spent on the app) was related to an increased likelihood of achieving a significant clinical change by the end of the trial. Greater and longer engagement in an ED app mediates its efficacy in terms of ED remission.
Kim JP, Sadeh-Sharvit S, Welch HA, Neri E, Tregarthen J, Lock J. Eating disorders early app use mediates treatment effect on clinical improvement.
Int J Eat Disord. 2022 Mar;55(3):382-387. doi: 10.1002/eat.23652. Epub 2021 Dec 14. PMID: 34904745
Sexual assault is a common form of trauma that is associated with elevated risk for negative psychosocial outcomes. Although survivors' social relationships could serve as a major protective factor against negative outcomes, survivors' supporters often lack knowledge regarding effective responses and may inadvertently respond in ways that are detrimental to healing. Communication and Recovery Enhancement (CARE) is a 2-session early intervention for survivors of a past-10-week sexual assault and their supporters that aims to improve supporters' ability to respond effectively. In this paper, we present a study protocol for a pilot randomized clinical trial of CARE (NCT05345405). The goal of this pilot trial is to understand the feasibility, acceptability, and preliminary efficacy of two versions of CARE: a version in which survivors and supporters attend sessions together (dyadic version) and a version in which supporters attend sessions alone (supporter-only version). Survivors aged 14+ with elevated posttraumatic stress will enroll with a supporter of their choosing. Dyads will be randomized to dyadic CARE, supporter-only CARE, or waitlist control, and will complete self-report assessments at baseline, post-session-1, and follow-ups (1, 2, and 3 months post-baseline). We will use descriptive statistics, effect sizes, and exploratory statistical tests to characterize the acceptability of both CARE versions, impact on knowledge change from baseline to 1 month, impact on disclosure experiences at 1 month, and impact on functional outcomes at 3 months. Results will be used to inform future changes to CARE and determine whether a fully-powered randomized controlled trial is warranted.
Dworkin ER, Ruzek JI, Cordova MJ, Fitzpatrick S, Merchant L, Stewart T, Santos JP, Mohr J, Bedard-Gilligan M. Supporter-focused early intervention for recent sexual assault survivors: Study protocol for a pilot randomized clinical trial.
Contemp Clin Trials. 2022 Aug;119:106848. doi: 10.1016/j.cct.2022.106848. Epub 2022 Jul 9. PMID: 35817294
Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid-term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.
Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Friedman M, Gersons BPR, de Jong J, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev AY, Solomon Z, Steinberg AM, Ursano RJ. Psychiatry. Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence.
2021 Winter;84(4):311-346. doi: 10.1080/00332747.2021.2005387. PMID: 35061969
Layne CM, Ruzek JI, Dixon K. From Resilience and Restoration to Resistance and Resource Caravans: A Developmental Framework for Advancing the Disaster Field.
Psychiatry. 2021 Winter;84(4):393-409. doi: 10.1080/00332747.2021.2005444. PMID: 35061961 No abstract available.
Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment.
Schnurr PP, Chard KM, Ruzek JI, Chow BK, Resick PA, Foa EB, Marx BP, Friedman MJ, Bovin MJ, Caudle KL, Castillo D, Curry KT, Hollifield M, Huang GD, Chee CL, Astin MC, Dickstein B, Renner K, Clancy CP, Collie C, Maieritsch K, Bailey S, Thompson K, Messina M, Franklin L, Lindley S, Kattar K, Luedtke B, Romesser J, McQuaid J, Sylvers P, Varkovitzky R, Davis L, MacVicar D, Shih MC. JAMA Netw Open. 2022 Jan 4;5(1):e2136921. doi: 10.1001/jamanetworkopen.2021. Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial. 36921. PMID: 35044471 Free PMC article.
A process for reviewing mental health apps: Using the One Mind PsyberGuide Credibility Rating System
Given the increasing number of publicly available mental health apps, we need independent advice to guide adoption. This paper discusses the challenges and opportunities of current mental health app rating systems and describes the refinement process of one prominent system, the One Mind PsyberGuide Credibility Rating Scale (PGCRS). PGCRS Version 1 was developed in 2013 and deployed for 7 years, during which time a number of limitations were identified. Version 2 was created through multiple stages, including a review of evaluation guidelines and consumer research, input from scientific experts, testing, and evaluation of face validity. We then re-reviewed 161 mental health apps using the updated rating scale, investigated the reliability and discrepancy of initial scores, and updated ratings on the One Mind PsyberGuide public app guide. Reliabilities across the scale's 9 items ranged from -0.10 to 1.00, demonstrating that some characteristics of apps are more difficult to rate consistently. The average overall score of the 161 reviewed mental health apps was 2.51/5.00 (range 0.33-5.00). Ratings were not strongly correlated with app store star ratings, suggesting that credibility scores provide different information to what is contained in star ratings. PGCRS summarizes and weights available information in 4 domains: intervention specificity, consumer ratings, research, and development. Final scores are created through an iterative process of initial rating and consensus review. The process of updating this rating scale and integrating it into a procedure for evaluating apps demonstrates one method for determining app quality.
Neary M, Bunyi J, Palomares K, Mohr DC, Powell A, Ruzek J, Williams LM, Wykes T, Schueller SM. A process for reviewing mental health apps: Using the One Mind PsyberGuide Credibility Rating System. Digit Health. 2021 Oct 29;7:20552076211053690. doi: 10.1177/20552076211053690. eCollection 2021 Jan-Dec. PMID: 34733541 Free PMC article.
The COVID-19 pandemic has and will continue to result in negative mental health outcomes such as depression, anxiety and traumatic stress in people and populations throughout the world. A population mental health perspective informed by clinical psychology, psychiatry and dissemination and implementation science is ideally suited to address the broad, multi-faceted and long-lasting mental health impact of the pandemic. Informed by a systematic review of the burgeoning empirical research on the COVID-19 pandemic and research on prior coronavirus pandemics, we link pandemic risk factors, negative mental health outcomes and appropriate intervention strategies. We describe how social risk factors and pandemic stressors will contribute to negative mental health outcomes, especially among vulnerable populations. We evaluate the scalability of primary, secondary and tertiary interventions according to mental health target, population, modality, intensity and provider type to provide a unified strategy for meeting population mental health needs. Traditional models, in which evidence-based therapies delivered are delivered in-person, by a trained expert, at a specialty care location have proved difficult to scale. The use of non-traditional models, tailoring preventive interventions to populations based on their needs, and ongoing coordinated evaluation of intervention implementation and effectiveness will be critical to refining our efforts to increase reach.
Boden M, Zimmerman L, Azevedo KJ, Ruzek JI, Gala S, Abdel Magid HS, Cohen N, Walser R, Mahtani ND, Hoggatt KJ, McLean CP. Addressing the mental health impact of COVID-19 through population health.
Clin Psychol Rev. 2021 Apr;85:102006. doi: 10.1016/j.cpr.2021.102006. Epub 2021 Mar 5. PMID: 33714167 Free PMC article. Review.
Burnout is widespread among behavioral health clinicians treating posttraumatic stress disorder (PTSD) among military populations. Intervention-based strategies have shown some benefit in addressing clinician burnout. One Web-based tool, the PTSD Clinicians Exchange, was designed to disseminate clinical best practices for the treatment of PTSD and facilitate self-care to mitigate burnout. This study sought to determine whether this tool could reduce burnout among clinicians treating military populations. A total of 605 behavioral health clinicians from the U.S. Department of Veterans Affairs, the Department of Defense, and the community were enrolled in a randomized controlled trial to test the effectiveness of the PTSD Clinicians Exchange. Clinicians were assessed on demographic characteristics, practice patterns, and organizational support with an online survey at baseline and at 6 and 12 months. Burnout, secondary traumatic stress (STS), and compassion satisfaction were measured with the Professional Quality of Life Scale. At baseline, no differences were observed in mean±SD burnout scores for the intervention (19.9±5.1) and control groups (20.2±5.4). Participation in the Exchange had no effect on burnout score at 12 months; burnout scores remained stable across the study period. In a multivariable stepwise regression model, older age, lower burnout at baseline, and lower STS scores and higher compassion satisfaction scores at 12 months were significantly associated with lower burnout scores. The PTSD Clinicians Exchange did not mitigate burnout among clinicians, possibly because of the content provided, the dissemination mechanism, or participants' limited use of the Web site. These results can be used to inform and enhance future interventions.
Clarke-Walper K, Penix EA, Trachtenberg F, Simon E, Coleman J, Magnavita A, Ortigo K, Regala S, Marceau L, Ruzek JI, Rosen RC, Wilk JE. Efficacy of a Web-Based Tool in Reducing Burnout Among Behavioral Health Clinicians: Results From the PTSD Clinicians Exchange.
Psychiatr Res Clin Pract. 2020 Sep 9;2(1):3-9. doi: 10.1176/appi.prcp.20190004. eCollection 2020 Summer. PMID: 36101889 Free PMC article.
Regular assessment of the effectiveness of behavioral interventions is a potent tool for improving their relevance to patients. However, poor provider and patient adherence characterize most measurement-based care tools. Therefore, a new approach for measuring intervention effects and communicating them to providers in a seamless manner is warranted. This paper provides a brief overview of the available research evidence on novel ways to measure the effects of behavioral treatments, integrating both objective and subjective data. We highlight the importance of analyzing therapeutic conversations through natural language processing. We then suggest a conceptual framework for capitalizing on data captured through directly collected and nondisruptive methodologies to describe the client's characteristics and needs and inform clinical decision-making. We then apply this context in exploring a new tool to integrate the content of therapeutic conversations and patients' self-reports. We present a case study of how both subjective and objective measures of treatment effects were implemented in cognitive-behavioral treatment for depression and anxiety and then utilized in treatment planning, delivery, and termination. In this tool, called Eleos, the patient completes standardized measures of depression and anxiety. The content of the treatment sessions was evaluated using nondisruptive, independent measures of conversation content, fidelity to the treatment model, and the back-and-forth of client-therapist dialogue. Innovative applications of advances in digital health are needed to disseminate empirically supported interventions and measure them in a noncumbersome way. Eleos appears to be a feasible, sustainable, and effective way to assess behavioral health care.
Sadeh-Sharvit S, Hollon SD. Leveraging the Power of Nondisruptive Technologies to Optimize Mental Health Treatment: Case Study. JMIR Ment Health. 2020 Nov 26;7(11):e20646. doi: 10.2196/20646. PMID: 33242025
Digital technology, which includes the collection, analysis, and use of data from a variety of digital devices, has the potential to reduce the prevalence of disorders and improve mental health in populations. Among the many advantages of digital technology is that it allows preventive and clinical interventions, both of which are needed to reduce the prevalence of mental health disorders, to be feasibly integrated into health care and community delivery systems and delivered at scale. However, the use of digital technology also presents several challenges, including how systems can manage and implement interventions in a rapidly changing digital environment and handle critical issues that affect population-wide outcomes, including reaching the targeted population, obtaining meaningful levels of uptake and use of interventions, and achieving significant outcomes. We describe a possible solution, which is to have an outcome optimization team that focuses on the dynamic use of data to adapt interventions for populations, while at the same time, addressing the complex relationships among reach, uptake, use, and outcome. We use the example of eating disorders in young people to illustrate how this solution could be implemented at scale. We also discuss system, practitioner-related, and other issues related to the adaptation of such an approach. Digital technology has great potential for facilitating the reduction of mental illness rates in populations. However, achieving this goal will require the implementation of new approaches. As a solution, we argue for the need to create outcome optimization teams, tasked with integrating data from various sources and using advanced data analytics and new designs to develop interventions/strategies to increase reach, uptake, use/engagement, and outcomes for both preventive and treatment interventions.
Taylor, C. B., Ruzek, J. I., Fitzsimmons-Craft, E. E., Sadeh-Sharvit, S., Topooco, N., Weissman, R. S., ... & Oldenburg, B. (2020). Using digital technology to reduce the prevalence of mental health disorders in populations: Time for a new approach. Journal of Medical Internet Research, 22(7), e17493.
The unprecedented COVID‐19 crisis presents an imperative for mental health care systems to make digital mental health interventions a routine part of care. Already because of COVID‐19, many therapists have rapidly moved to using telehealth in place of in‐person contact. In response to this shift, Waller and colleagues compiled a series of expert recommendations to help clinicians pivot to delivering teletherapy to address eating disorders during COVID‐19. However, numerous barriers still impede widespread adoption and implementation of digital interventions. In this commentary, we aim to extend the recommendations for clinicians offered by Waller and colleagues by presenting a roadmap of the systems‐ and policy‐level requirements that are needed. We advocate for addressing barriers associated with training, licensing, safety, privacy, payment, and evaluation, as these factors have greatly limited use of these promising interventions. We also indicate that longer‐term goals should include introducing truly innovative digital mental health practices, such as stepped‐care models and simultaneously providing preventive and self‐management services in addition to clinical services, into the health care system. Now is the time to catalyze change and comprehensively address the barriers that have prevented widespread delivery of these efficacious digital services to the millions of people who would benefit.
Taylor, C. B., Fitzsimmons‐Craft, E. E., & Graham, A. K. (2020). Digital technology can revolutionize mental health services delivery: The COVID‐19 crisis as a catalyst for change. International Journal of Eating Disorders.
Objective: The treatment gap between those who need and those who receive care for eating disorders is wide. Scaling a validated, online screener that makes individuals aware of the significance of their symptoms/behaviors is a crucial first step for increasing access to care. The objective of the current study was to determine the reach of disseminating an online eating disorder screener in partnership with the National Eating Disorders Association (NEDA), as well to examine the probable eating disorder diagnostic and risk breakdown of adult respondents. We also assessed receipt of any treatment. Method: Participants completed a validated eating disorder screen on the NEDA website over 6 months in 2017. Results: Of 71,362 respondents, 91.0% were female, 57.7% 18-24 years, 89.6% non-Hispanic, and 84.7% White. Most (86.3%) screened positive for an eating disorder. In addition, 10.2% screened as high risk for the development of an eating disorder, and only 3.4% as not at risk. Of those screening positive for an eating disorder, 85.9% had never received treatment and only 3.0% were currently in treatment. Discussion: The NEDA online screen may represent an important eating disorder detection tool, as it was completed by >71,000 adult respondents over just 6 months, the majority of whom screened positive for a clinical/subclinical eating disorder. The extremely high percentage of individuals screening positive for an eating disorder who reported not being in treatment suggests a wide treatment gap and the need to offer accessible, affordable, evidence-based intervention options, directly linked with screening.
Fitzsimmons-Craft EE, Balantekin KN, Graham AK, Smolar L, Park D, Mysko C, Funk B, Taylor CB, Wilfley DE. Results of disseminating an online screen for eating disorders across the U.S.: Reach, respondent characteristics, and unmet treatment need. Int J Eat Disord. 2019 Jun;52(6):721-729. doi: 10.1002/eat.23043. Epub 2019 Feb 13.
The purpose of this study was to conduct a longer-term (i.e., 9-month) follow-up of students identified with possible anorexia nervosa (AN) as part of the Healthy Body Image Program, an online platform for screening and delivering tailored feedback and interventions, offered at 36 US universities. Participants were 61 individuals who screened positive for AN and who completed the follow-up. Regarding results, some indices of ED pathology and psychiatric comorbidity decreased over time, while others did not. Participants most commonly endorsed feeling ashamed, nervous, validated, and sad in response to receiving the referral. One-third (33%) reported already being in treatment at the time they received the referral, 26% initiated treatment since that time, and 41% did not initiate treatment. The most common reasons for seeking treatment were emotional distress, concern with eating, and health concerns. The strongest treatment barriers were believing one should be able to help themselves, believing the problem was not serious enough to warrant treatment, and not having time. Findings highlight the high level of pathology in students identified with possible AN, even nine months after they were first identified and provided resources, and the relatively low rates of treatment utilization given the seriousness of these illnesses.
Fitzsimmons-Craft EE, Eichen DM, Monterubio GE, Firebaugh ML, Goel NJ, Taylor CB, Wilfley DE. Longer-term follow-up of college students screening positive for anorexia nervosa: psychopathology, help seeking, and barriers to treatment. Eat Disord. 2019 May 20:1-17. doi: 10.1080/10640266.2019.1610628.
The United States Department of Veterans Affairs (VA) provides Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) for PTSD at all of its facilities, but little is known about systematic differences between patients who do and do not initiate these treatments. VA administrative data were analyzed for 6,251 veterans receiving psychotherapy over one year in posttraumatic stress disorder (PTSD) specialty clinics at nine VA medical centers. CPT and PE were initiated by 2,173 (35%) patients. Veterans' probability of initiating either CPT or PE (considered together) was 29% lower (adjusted odds ratio = .61) if they had a psychiatric hospitalization within the same year, and 15% lower (AOR = .78) if they had service-connected disability for PTSD. Veterans' probability of starting CPT or PE was 19% lower (AOR = .74) if they were Hispanic or Latino, 10% lower (AOR = .84), if they were male rather than female, and 9% lower (AOR = .87) if they were divorced, separated or widowed rather than currently married. Probability of receiving CPT or PE was also lower if verans had more co-occurring psychiatric diagnoses (AOR per diagnosis = .88), were older (AOR per every five years = .95), or lived further away from the VA clinic (AOR per every ten miles = .98). Nonetheless, most patients initiating CPT or PE had two or more comorbidities and were service-connected for PTSD. Observed gender, age and ethnic differences in initiation of CPT and PE appear unrelated to clinical suitability and warrant further study.
Rosen CS, Bernardy NC, Chard KM, Clothier B, Cook JM, Crowley J, Eftekhari A, Kehle-Forbes SM, Mohr DC, Noorbaloochi S, Orazem RJ, Ruzek JI, Schnurr PP, Smith BN, Sayer NA. Which patients initiate cognitive processing therapy and prolonged exposure in department of veterans affairs PTSD clinics? J Anxiety Disord. 2019 Mar;62:53-60. doi: 10.1016/j.janxdis.2018.11.003.
Background: We describe an approach to implementation and dissemination that focuses on changing outcomes variables within a large, defined population and attempts to provide cost-effective opportunities and resources-which might include the provision of both digital and traditional interventions-to address individual needs and interests. We present a case example of how aspects of this model are being applied to increase reach, engagement and outcomes for individuals who complete a national eating disorders screen, and are likely to have an eating disorder but who are not in treatment. We then describe how this model can apply to post-traumatic stress (PTS) and conclude with a discussion of limitations and issues with the model. Methods: The National Eating Disorders Association (NEDA) provides online screening for eating disorders. Results: From February 2017 through March 2018, over 200,000 individuals completed the NEDA screen. Of these, 96% screened positive or at risk for an eating disorder, and most of those who screened positive for a clinical/subclinical eating disorder were not currently in treatment. Less than 10% engaged in self-help or guided self-help online digital program, or expressed interest in calling a helpline for referral to treatment. Conclusions: A systematic digital approach to implementation and dissemination has the potential to increase the number of individuals who benefit from interventions in defined populations. Uptake rates need to be improved.
Taylor CB, Ruzek JI, Fitzsimmons-Craft EE, Graham AK, Balantekin KN. A systematic digital approach to implementation and dissemination of eating disorders interventions to large populations identified through online screening: implications for post-traumatic stress. Mhealth. 2018 Jul 10;4:25. doi: 10.21037/mhealth.2018.05.06. eCollection 2018.
Introduction: Research indicates that individuals with generalized anxiety disorder (GAD) may experience deficits in positive affect (PA), and tend to dampen or intentionally suppress PA. Despite the presence of PA-related pathology in GAD, little is known about change in PA during GAD treatment. Objective: This study examines changes in PA, negative affect (NA) and worry in seven participants during cognitive behavioral therapy (CBT) for GAD.METHOD: Intensive repeated measures (i.e., time series) data were subjected to person-specific regression analysis to delineate individual change trajectories. Results: Significant improvement in worry was observed in all but one participant. Fear and irritability - indices of NA - each improved in 5/7 participants while sadness improved in 4/7 participants (worsening in one). Of all symptom domains, PA had the poorest treatment response: PA improved in only 2/7 participants and actually significantly worsened in 5/7 individuals even as NA and worry improved during therapy. Conclusion: These findings indicate that treatment gains from traditional CBT for GAD may not generalize to improvements in PA regulation, or even emotional functioning more broadly. This evidence is a call to increase the focus on PA regulation in treatment for GAD; perhaps PA could be a missing piece in our understanding of ways to bolster GAD treatment outcomes.
Bosley HG, Fisher AJ, Taylor CB. Differential responses of positive affect, negative affect, and worry in CBT for generalized anxiety disorder: A person-specific analysis of symptom course during therapy. Psychother Res. 2018 Jul;28(4):630-642. doi: 10.1080/10503307.2016.1233366.
Background: Depression is a major contributor to the burden of disease in the adolescent population. Internet-based interventions can increase access to treatment. Aims: To evaluate the efficacy of internet-based cognitive–behavioural therapy (iCBT), including therapist chat communication, in treatment of adolescent depression. Method: Seventy adolescents, 15–19 years of age and presenting with depressive symptoms, were randomised to iCBT or attention control. The primary outcome was the Beck Depression Inventory II (BDI-II). Results: Significant reductions in depressive symptoms were found, favouring iCBT over the control condition (F(1,67) = 6.18, P < 0.05). The between-group effect size was Cohen's d = 0.71 (95% CI 0.22–1.19). A significantly higher proportion of iCBT participants (42.4%) than controls (13.5%) showed a 50% decrease in BDI-II score post-treatment (P < 0.01). The improvement for the iCBT group was maintained at 6 months. Conclusions: The intervention appears to effectively reduce symptoms of depression in adolescents and may be helpful in overcoming barriers to care among young people.
Topooco, N., Berg, M., Johansson, S., Liljethörn, L., Radvogin, E., Vlaescu, G., Nordgren
L. B., Zetterqvist M. & Andersson, G. (2018). Chat-and internet-based cognitive–behavioural therapy in treatment of adolescent depression: randomised controlled trial. BJPsych open, 4(4), 199-207. doi: 10.1192/bjo.2018.18.
Objective: Family-based treatment (FBT) is an evidence-based treatment for adolescent anorexia nervosa (AN), but many families cannot access it. This study evaluated feasibility, acceptability, and preliminary treatment effects of a parental guided self-help (GSH) version of FBT for adolescent AN. Method: This was a case-series design. Parents of medically stable adolescents (11-18 years) with DSM-5 AN were recruited over 12 months. Parents received online training in parental GSH FBT and 12 20-30 min GSH sessions by phone or online over 6 months. Recruitment, dropout, changes in weight, and eating-related psychopathology were assessed. Analyses used mixed modeling that included all data for all participants. Results: Of the 19 families that participated, most were white (94%) and from intact families (88%). Baseline median BMI (mBMI) percent was 85.01% (SD = 4.31). Participants' mBMI percent increased to 97.31% (SD ± 7.48) at the end of treatment (EOT) (ES = 2.06; CI= 0.13-3.99). Eating-related psychopathology improved by EOT (ES = 0.58; CI=.04-1.21). Dropout rate was 21% during treatment and 33% during follow-up. Discussion: Parental GSH-FBT is feasible and acceptable to families willing to undertake online treatment. Follow-up data was only available for nine families (47%); thus further systematic evaluation is required before reaching conclusions about the efficacy of this approach.
Lock J, Darcy A, Fitzpatrick KK, Vierhile M, Sadeh-Sharvit S. Parental guided self-help family based treatment for adolescents with anorexia nervosa: A feasibility study. Int J Eat Disord. 2017 Sep;50(9):1104-1108. doi: 10.1002
Internet and mobile technologies offer potentially critical ways of delivering mental health support in low-resource settings. Much evidence indicates an enormous negative impact of mental health problems in low- and middle-income countries (LMICs), and many of these problems are caused, or worsened, by exposure to wars, conflicts, natural and human-caused disasters, and other traumatic events. Though specific mental health treatments have been found to be efficacious and cost-effective for low-resource settings, most individuals living in these areas do not have access to them. Low-intensity task-sharing interventions will help, but there is a limit to the scalability and sustainability of human resources in these settings. To address the needs of trauma survivors, it will be important to develop and implement Internet and mobile technology resources to help reduce the scarcity, inequity, and inefficiency of current mental health services in LMICs. Mobile and Internet resources are experiencing a rapid growth in LMICs and can help address time, stigma, and cost barriers and connect those who have been socially isolated by traumatic events. This review discusses current research in technological interventions in low-resource settings and outlines key issues and future challenges and opportunities. Though formidable challenges exist for large-scale deployment of mobile and Internet mental health technologies, work to date indicates that these technologies are indeed feasible to develop, evaluate, and deliver to those in need of mental health services, and that they can be effective.
Ruzek JI, Yeager CM. Internet and mobile technologies: addressing the mental health of trauma survivors in less resourced communities. Glob Ment Health (Camb). 2017 Aug 30;4:e16. doi: 10.1017/gmh.2017.11.
Objective: Posttraumatic stress disorder (PTSD) is highly prevalent in the population, but relatively few affected individuals receive treatment for it. Smartphone applications (apps) could help address this unmet need by offering sound psychoeducational information and evidence-based cognitive behavioral coping tools. We conducted a randomized controlled trial to assess the efficacy of a free, publicly available smartphone app (PTSD Coach) for self-management of PTSD symptoms. Method: One hundred 20 participants who were an average of 39 years old, mostly women (69.2%) and White (66.7%), recruited primarily through online advertisements, were randomized to either a PTSD Coach (n = 62) or a waitlist condition (n = 58) for 3 months. Web-administered self-report measures of PTSD, PTSD symptom coping self-efficacy, depression, and psychosocial functioning were conducted at baseline, posttreatment, and 3 months following treatment. Results: Following the intent-to-treat principle, repeated-measures analyses of variance (ANOVAs) revealed that at posttreatment, PTSD Coach participants had significantly greater improvements in PTSD symptoms (p = .035), depression symptoms (p = .005), and psychosocial functioning (p = .007) than did waitlist participants; however, at posttreatment, there were no significant mean differences in outcomes between conditions. A greater proportion of PTSD Coach participants achieved clinically significant PTSD symptom improvement (p = .018) than waitlist participants. Conclusion: PTSD Coach use resulted in significantly greater improvements in PTSD symptoms and other outcomes relative to a waitlist condition. Given the ubiquity of smartphones, PTSD Coach may provide a wide-reaching, convenient public health intervention for individuals with PTSD symptoms who are not receiving care.
Kuhn E, Kanuri N, Hoffman JE, Garvert DW, Ruzek JI, Taylor CB. A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. J Consult Clin Psychol. 2017 Mar;85(3):267-273. doi: 10.1037/ccp0000163.
Older adults living in congregate housing have been uniquely impacted by the COVID-19 pandemic. The sudden interruption of routine activities, social isolation, and support adversely affected the wellbeing of residents in retirement facilities around the country and world. The stress of social isolation was fueled by the interruption of routine activities and support that in turn, adversely affected the wellbeing, mood, and cognition of many residents. Therefore, university clinical programs in psychology and counseling can address the needs of community older residents by preparing student clinicians to work with the aging population and to engage in telehealth models of outreach and interventions. This manuscript outlines a model of partnership between long-term care assisted living organizations and clinical training programs at a west coast university to meet community and educational needs of older residents.
Sheperis, D.S., Gomez, R., Wathen, C., Frank, M., & Brown, L. (2022). Addressing Isolation, Loneliness and Mental Health of Older Adults Living during COVID-19: A University Training Partnership with Senior Living Communities. Gerontology and Geriatrics Education. https://doi.org/10.1080/02701960.2022.2096602
Teletherapy is an approach to working with clients that mental health providers have used in some form for years. However, the onset of COVID forced the provision of therapy into teletherapy almost exclusively for a period of time. Currently, mental health providers conducting therapy virtually are not required to be trained in telehealth and are operating without consistent uniform standards of practice. This manuscript pulls from the current literature and guidelines across counseling, psychology, psychiatry, family therapy, and social work to provide a Proposed Standards of Practice for Telehealth. Such standards benefit mental health counselor by grounding practice in common aims and benefits out clients by creating a unified framework for providers engaging in telehealth with their clients. This manuscript provides a review of current literature around the provision of teletherapy and proposes a set of standards of care based on existing literature. In addition, gaps in current literature are addressed.
Sheperis, D. S. & *Smith, A. (2021) Telehealth Best Practice: A Call for Standards of Care, Journal of Technology in Counselor Education and Supervision: Vol. 1 : Iss. 1 , Article 4. d0i: https://doi.org/10.22371/tces/0004
Background:Barriers to accessing in-person care can prevent veterans with posttraumatic stress disorder (PTSD) from receiving trauma-focused treatments such as exposure therapy. Mobile apps may help to address unmet need for services by offering tools for users to self-manage PTSD symptoms. Renew is a mobile mental health app that focuses on exposure therapy and incorporates a social support function designed to promote user engagement.
Objective:We examined the preliminary efficacy of Renew with and without support from a research staff member compared with waitlist among 93 veterans with clinically significant PTSD symptoms. We also examined the impact of study staff support on participant engagement with the app.
Methods:In a pilot randomized controlled trial, we compared Renew with and without support from a research staff member (active use condition) with waitlist (delayed use condition) over 6 weeks. Participants were recruited through online advertisements. The Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) was used to measure PTSD symptoms at pre, post, and 6-week follow-up. Usage data were collected to assess engagement with Renew.
Results:Results indicated a small effect size (d=–0.39) favoring those in the active use conditions relative to the delayed use condition, but the between-group difference was not significant (P=.29). There were no differences on indices of app engagement between the 2 active use conditions. Exploratory analyses found that the number of support persons users added to the app, but not the number of support messages received, was positively correlated with app engagement.
Conclusions:Findings suggest Renew may hold promise as a self-management tool to reduce PTSD symptoms in veterans. Involving friends and family in mobile mental health apps may help bolster engagement with no additional cost to public health systems.
McLean, C. P., Davis, C. A., & Miller, M. Ruzek, J., & Neri, E. (2022). The effects of an exposure-based mobile app on symptoms of PTSD in veterans: A pilot randomized controlled trial. Journal of Medical Internet Research mHealth, 10(11), E38951.
Objective: Given the increasing number of publicly available mental health apps, we need independent advice to guide adoption. This paper discusses the challenges and opportunities of current mental health app rating systems and describes the refinement process of one prominent system, the One Mind PsyberGuide Credibility Rating Scale (PGCRS). Methods: PGCRS Version 1 was developed in 2013 and deployed for 7 years, during which time a number of limitations were identified. Version 2 was created through multiple stages, including a review of evaluation guidelines and consumer research, input from scientific experts, testing, and evaluation of face validity. We then re-reviewed 161 mental health apps using the updated rating scale, investigated the reliability and discrepancy of initial scores, and updated ratings on the One Mind PsyberGuide public app guide. Results: Reliabilities across the scale’s 9 items ranged from −0.10 to 1.00, demonstrating that some characteristics of apps are more difficult to rate consistently. The average overall score of the 161 reviewed mental health apps was 2.51/5.00 (range 0.33–5.00). Ratings were not strongly correlated with app store star ratings, suggesting that credibility scores provide different information to what is contained in star ratings. Conclusion: PGCRS summarizes and weights available information in 4 domains: intervention specificity, consumer ratings, research, and development. Final scores are created through an iterative process of initial rating and consensus review. The process of updating this rating scale and integrating it into a procedure for evaluating apps demonstrates one method for determining app quality.
Neary, M., Bunyi, J., Palomares, K., Mohr, D. C., Powell, A., Ruzek, J., Williams, L. M., Wykes, T., Schueller, S. M. (in press). A process for reviewing mental health apps: Using the One Mind PsyberGuide Credibility Rating System. Digital Health.
Dworkin, E. R., Ruzek, J. I., Cordova, M. C., Mohr, J., Fitzpatrick, S., & Bedard-Gilligan, M. (In press). Early intervention for recent sexual assault survivors and their supporters: Study protocol for a randomized controlled pilot trial. Contemporary Clinical Trials.
Ruzek, J. I. (2022). Community-based early intervention with trauma survivors. In J. G. Beck & D. M. Sloan (Eds.), Oxford handbook of traumatic stress (2nd Edition). Oxford: Oxford University Press.
Ruzek, J. I., Burkman, K. M., & Yalch, M. M. (Manuscript submitted for publication). Comparing group therapies for trauma survivors. In J. I. Ruzek, M. M. Yalch, & K. M. Burkman (Eds.), Group approaches to treating traumatic stress in adults. New York: Guilford Press.
Ruzek, J. I. (Manuscript submitted for publication). Group psychotherapy and beyond: Expanding concepts of group intervention. In J. I. Ruzek, M. M. Yalch, & K. M. Burkman (Eds.), Group approaches to treating traumatic stress in adults. New York: Guilford Press.
Ruzek, J. I. (Manuscript submitted for publication). Group psychotherapy and beyond: Expanding concepts of group intervention. In J. I. Ruzek, M. M. Yalch, & K. M. Burkman (Eds.), Group approaches to treating traumatic stress in adults. New York: Guilford Press.