These are just a few highlights of the many projects that team members from the Center for m²Health have been involved in.
For a full list of publications since 2014, click here.
Articles with open access are marked with an asterix (*)
Position Paper: Digital Technology Can Help Transform Mental Health in the U.S.
CO-chairs: Taylor, C. B. & Ruzek, J. I.
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.
Promoting positive body image and intuitive eating in women with overweight and obesity via an online intervention: Results from a pilot feasibility study.
Background: Body dissatisfaction and dietary restraint are established risk factors for eating disorders and are also prevalent in individuals who are overweight and obese. Studies have shown that online prevention programs can lower these risk factors. The aim of this feasibility pilot study was to estimate effects of a 12-week online health promotion and eating disorder prevention program in a sample of women with overweight or obesity, but without binge eating. Methods: The program was evaluated in an uncontrolled pre-post-follow-up study over 12 months. Outcome measures were eating disorder related cognitions and attitudes. Participants were recruited via flyers, online posts, press releases, and mailings through cooperating health insurances. Results: 371 women who completed the screening met the inclusion criteria. 323 women took part in the baseline assessment and were granted access to the intervention. 50 women completed all sessions. An intention-to-treat analysis showed significant and long-term reductions in weight and shape concerns, restrictive eating and increases in life satisfaction and self-esteem (d = 0.31-0.86), and a short-term increase in fruit and vegetable consumption (d = 0.70). Conclusion: everyBody fit seems a feasible program for improving body image and reducing disordered eating in overweight and obese women, with medium to large effects on various outcomes. The efficacy of the intervention needs to be established in a randomized controlled trial.
Beintner I, Emmerich OLM, Vollert B, Taylor CB, Jacobi C. Promoting positive body image and intuitive eating in women with overweight and obesity via an online intervention: Results from a pilot feasibility study. Eat Behav. 2019 Jun 11;34:101307. doi: 10.1016/j.eatbeh.2019.101307.
Longer-term follow-up of college students screening positive for anorexia nervosa: psychopathology, help seeking, and barriers to treatment.
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.
Which patients initiate cognitive processing therapy and prolonged exposure in department of veterans affairs PTSD clinics?
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.
*A systematic digital approach to implementation and dissemination of eating disorders interventions to large populations identified through online screening: implications for post-traumatic stress.
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.
Differential responses of positive affect, negative affect, and worry in CBT for generalized anxiety disorder: A person-specific analysis of symptom course during therapy.
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.
*Chat-and internet-based cognitive–behavioural therapy in treatment of adolescent depression: randomised controlled trial.
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.
Parental guided self-help family based treatment for adolescents with anorexia nervosa: A feasibility study.
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: addressing the mental health of trauma survivors in less resourced communities.
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.
A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms.
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.
The economic case for digital interventions for eating disorders among United States college students.
Objective: Eating disorders (EDs) are serious health problems affecting college students. This article aimed to estimate the costs, in United States (US) dollars, of a stepped care model for online prevention and treatment among US college students to inform meaningful decisions regarding resource allocation and adoption of efficient care delivery models for EDs on college campuses. Method: Using a payer perspective, we estimated the costs of (1) delivering an online guided self-help (GSH) intervention to individuals with EDs, including the costs of "stepping up" the proportion expected to "fail"; (2) delivering an online preventive intervention compared to a "wait and treat" approach to individuals at ED risk; and (3) applying the stepped care model across a population of 1,000 students, compared to standard care. Results: Combining results for online GSH and preventive interventions, we estimated a stepped care model would cost less and result in fewer individuals needing in-person psychotherapy (after receiving less-intensive intervention) compared to standard care, assuming everyone in need received intervention. Conclusions: A stepped care model was estimated to achieve modest cost savings compared to standard care, but these estimates need to be tested with sensitivity analyses. Model assumptions highlight the complexities of cost calculations to inform resource allocation, and considerations for a disseminable delivery model are presented. Efforts are needed to systematically measure the costs and benefits of a stepped care model for EDs on college campuses, improve the precision and efficacy of ED interventions, and apply these calculations to non-US care systems with different cost structures.
Kass AE, Balantekin KN, Fitzsimmons-Craft EE, Jacobi C, Wilfley DE, Taylor CB. The economic case for digital interventions for eating disorders among United States college students. Int J Eat Disord. 2017 Mar;50(3):250-258. doi: 10.1002/eat.22680.
Effectiveness of Cognitive Behavioral Therapy for Veterans with Depression and Suicidal Ideation.
The current study examined suicidal ideation (SI) and depression outcomes among Veterans receiving Cognitive Behavioral Therapy for depression (CBT-D) throughout the Department of Veterans Affairs health care system. Patient outcomes included Beck Depression Inventory-II total score and SI item. Of 902 patients, 427 (47%) had no SI, 405 (45%) had SI but no suicidal intent, 26 (3%) indicated suicidal desire, 8 (1%) indicated suicide intent if they had the chance, and 36 (4%) did not answer this question at session one. The odds of SI decreased by 64% from 1.03 at session one to 0.37 at final assessment (OR = 0.36; 95% CI: 0.31, 0.43). Findings reveal that CBT-D was associated with significant decreases in SI and depression among Veterans.
Brown GK, Karlin BE, Trockel M, Gordienko M, Yesavage J, Taylor CB. Effectiveness of Cognitive Behavioral Therapy for Veterans with Depression and Suicidal Ideation. Arch Suicide Res. 2016 Oct-Dec;20(4):677-82. doi: 10.1080/13811118.2016.1162238.
Reducing eating disorder onset in a very high risk sample with significant comorbid depression: A randomized controlled trial.
Objective: Eating disorders (EDs) are serious problems among college-age women and may be preventable. An indicated online eating disorder (ED) intervention, designed to reduce ED and comorbid pathology, was evaluated. Method: 206 women (M age = 20 ± 1.8 years; 51% White/Caucasian, 11% African American, 10% Hispanic, 21% Asian/Asian American, 7% other) at very high risk for ED onset (i.e., with high weight/shape concerns plus a history of being teased, current or lifetime depression, and/or nonclinical levels of compensatory behaviors) were randomized to a 10-week, Internet-based, cognitive-behavioral intervention or waitlist control. Assessments included the Eating Disorder Examination (EDE, to assess ED onset), EDE-Questionnaire, Structured Clinical Interview for DSM Disorders, and Beck Depression Inventory-II. Results: ED attitudes and behaviors improved more in the intervention than control group (p = .02, d = 0.31); although ED onset rate was 27% lower, this difference was not significant (p = .28, NNT = 15). In the subgroup with highest shape concerns, ED onset rate was significantly lower in the intervention than control group (20% vs. 42%, p = .025, NNT = 5). For the 27 individuals with depression at baseline, depressive symptomatology improved more in the intervention than control group (p = .016, d = 0.96); although ED onset rate was lower in the intervention than control group, this difference was not significant (25% vs. 57%, NNT = 4). Conclusions: An inexpensive, easily disseminated intervention might reduce ED onset among those at highest risk. Low adoption rates need to be addressed in future research.
Taylor CB, Kass AE, Trockel M, Cunning D, Weisman H, Bailey J, Sinton M, Aspen V, Schecthman K, Jacobi C, Wilfley DE. Reducing eating disorder onset in a very high risk sample with significant comorbid depression: A randomized controlled trial. J Consult Clin Psychol. 2016 May;84(5):402-14. doi: 10.1037/ccp0000077.