Claudia Maria Van der Heijde

Background: Mental health problems account worldwide for over an eighth of the global burden of disease and waiting lists nowadays are commonplace. E-Health has potential to reduce mental illness, whilst waiting for therapy or as a stand alone. A big problem with implementation of E-health in clinical practice is non adherence. Non-clinical guidance could make a difference as compared to the non guidance modus. Our research question is: what factors contribute to the potential of non-clinical guidance in overcoming non adherence for e-mental Health for patients with depressive, anxiety and stress symptoms? Methods: We did a qualitative study in a Dutch general practice. The treatment consisted of several modules accompanied by non-clinical guidance by a healthcare assistant. Out of 190 invited patients, 31 patients participated. Eight weeks after being invited, 11 semi-structured interviews were conducted until data saturation. Thematic analysis was used with open, axial and selective coding. Results: Three major themes emerged: 1) The patients were satisfied with the non-clinical guidance in almost all aspects: Negative comments arose from an urge for more contact or tailoring. 2) The form of the guidance (e.g. non-clinical; used interface) was subordinate to the amount and tailoring of it. 3) Adherence could further be improved through a more personal introduction, explaining the benefits of certain exercises and more time management. Conclusions: The potential of non-clinical guidance in overcoming non adherence for e-mental Health can be improved by further tailoring and increasing the interactivity when needed. Further research is also needed, after the suggested improvements, whether the intervention is effective, compared to a therapist guided and a non guided version. This study needs to be repeated in other clinical settings. Key messages: • Non-clinical guidance, alongside e-mental health has potential to help with non adherence, thereby decreasing the burden of waiting lists. • Non-clinical guidance was positively received by patients who received e-mental health, although further tailoring could make online treatment even a larger success.

Background: Worldwide percentages of people with mental health problems are substantial and increased during the COVID pandemic (to about 25 % in the general population). E-mental health has potential to help with waiting lists, rising health care costs and work pressure. To reach the desired effects, participants need to use the technology as intended. Non-usage though is a common problem. Research question is: what elements obstruct the intention to use e-mental Health interventions, plus what are barriers to bridging the intention-behaviour gap? Methods: In a qualitative study, semi-structured interviews were conducted (interview guide). We recruited patients who were invited for an e-mental health intervention in a Dutch general practice but did not start the intervention. Data saturation occurred with 11 patients. Open, axial and selective coding was done on the transcribed interviews using the software ATLAS.ti. Results: Five main themes were associated with non-use: 1) ‘Expectations about the eHealth in general’ were neutral to positive. 2) ‘thresholds to start e-mental health’ were: negative expectations about the content, lacking mental capacity due to mental problems, missing personal contact, the therapy with the mental health professional in general did not fit their needs or aversion towards more screen time. 3) ‘lack of planning’. 4) lacking encouragement from mental health professional 5) ‘Expectations from therapy in general’. (a.o. face-to-face contact and tailoring) Conclusions: Embedding the e-mental health more into regular therapy has potential to overcome non-usage. The mental health care professional has social influence to increase usage, by a clear and convincing introduction plus joint review of the exercises during consultations. This study needs to be repeated in other clinical settings. Future research should also include age (computer use) and disease prognosis to define when e-mental health is a suitable solution for patients. Key messages: • E-mental health interventions have potential to help with waiting lists, rising health care costs and workload, but non usage is a problem. • Embedding the e-mental health more into regular therapy has potential to overcome non-usage.

Background: Migraines attacks cause great suffering in individual patients. There is great unfulfilled potential to increase patients’ knowledge about various personal triggers and subsequent treatments. The objective of this study is to pilot test an e-Health tool that aims to increase migraine patients’ knowledge. It takes into account personal preferences and contributes to informed decision-making in choosing the appropriate method. Considering the shortage of primary care physicians and other health care providers, such an e-Health tool could be of great value. Methods: lessmigraine.nl consists of a website with information plus an electronic decision aid. It was evaluated on its content, development process and effectiveness, and its contribution to the patients’ empowerment process. A first round of usability testing was done using semi-structured interviews and thematic analysis with 12 patients from a Dutch General Practice until data saturation. After minor improvements to the e-tool, in a first implementation step subsequently 85 patients used the e-tool. Results: Patients’ expectations were exceeded in terms of the content of the e-Health tool, as all patients discovered new potential migraine triggers. Most patients found the tool effective in the sense that it provided enough information to decide on an appropriate treatment. The implementation was successful in the sense that all 85 participants completed the e-tool. Most important triggers were stress, sleeping problems, changes in weather and flickering or bright light. Conclusions: The majority of the migraine patients were satisfied with the e-Health tool. It enlarged their knowledge of prevention and treatment options and therefore empowered them in their decision-making process and communication with their GP. Other aspects of implementation need to be studied. This study needs to be repeated in other clinical settings. Key messages: • Migraines cause great suffering in individual patients: Considering the shortage of primary care physicians and other health care providers, an e-Health tool could be of great value. • The e-Health tool increases patients’ knowledge about migraine, including personal triggers and subsequent treatments.

Emerging adulthood is an important developmental phase often accompanied by peaks in loneliness, social anxiety, and depression. However, knowledge is lacking on how the relationships between emotional loneliness, social loneliness, social isolation, social anxiety and depression evolve over time. Gaining insight in these temporal relations is crucial for our understanding of how these problems arise and maintain each other across time. Young adults from a university sample (N = 1,357; M = 23.60 years, SD = 6.30) filled out questionnaires on emotional and social loneliness, social isolation, depressive and social anxiety symptoms at three time points within a 3‐year period. Random intercept cross‐lagged panel models were used to disentangle reciprocal and prospective associations of loneliness subtypes, social isolation, depressive and social anxiety symptoms across time. Results showed that on the within‐person level, increases in emotional and social loneliness as well as social isolation predicted higher depression levels on later timepoints. Increases in depressive symptoms also predicted increases in subsequent social loneliness, but not in emotional loneliness. Finally, increases in depressive symptoms predicted increases in social isolation. There were no significant temporal relations between loneliness and social isolation on the one hand and social anxiety symptoms on the other hand. Social distancing imposed by COVID‐19 related government restrictions may have impacted the current results. The findings suggest that emotional and social loneliness precede development of depressive symptoms, which in turn precedes development of social loneliness and social isolation, indicating a potential vicious cycle of social loneliness, social isolation and depressive symptoms in emerging adulthood. Social anxiety did not precede nor follow loneliness, depressive symptoms, or social isolation. The current study sheds more light on the temporal order of loneliness and psychopathological symptoms and hereby assists in identifying times where prevention and intervention efforts may be especially helpful to counter development of depression and loneliness.

Background: Internet-based cognitive behavioral interventions (iCBTs) are efficacious treatments for depression and anxiety. However, it is unknown whether adding human guidance is feasible and beneficial within a large educational setting. Objective: This study aims to potentially demonstrate the superiority of 2 variants of a transdiagnostic iCBT program (human-guided and computer-guided iCBT) over care as usual (CAU) in a large sample of university students and the superiority of human-guided iCBT over computer-guided iCBT. Methods: A total of 801 students with elevated levels of anxiety, depression, or both from a large university in the Netherlands were recruited as participants and randomized to 1 of 3 conditions: human-guided iCBT, computer-guided iCBT, and CAU. The primary outcome measures were depression (Patient Health Questionnaire) and anxiety (Generalized Anxiety Disorder scale). Secondary outcomes included substance use–related problems (Alcohol Use Disorder Identification Test and Drug Abuse Screening Test—10 items). Linear mixed models were used to estimate the effects of time, treatment group, and their interactions (slopes). The primary research question was whether the 3 conditions differed in improvement over 3 time points (baseline, midtreatment, and after treatment) in terms of depression and anxiety symptoms. Results were analyzed according to the intention-to-treat principle using multiple imputation. Patients were followed exploratively from baseline to 6 and 12 months. Results: In both short-term and long-term analyses, the slopes for the 3 conditions did not differ significantly in terms of depression and anxiety, although both web-based interventions were marginally more efficacious than CAU over 6 months (P values between .02 and .03). All groups showed significant improvement over time (P<.001). For the secondary outcomes, only significant improvements over time (across and not between groups) were found for drug use (P<.001). Significant differences were found in terms of adherence, indicating that participants in the human-guided condition did more sessions than those in the computer-guided condition (P=.002). Conclusions: The transdiagnostic iCBT program offers a practical, feasible, and efficacious alternative to usual care to tackle mental health problems in a large university setting. There is no indication that human guidance should be preferred over technological guidance. The potential preference of human support also depends on the scale of implementation and cost-effectiveness, which need to be addressed in future trials. Trial Registration: International Clinical Trials Registry Platform NL7328/NTR7544; https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON26795

According to cognitive theories, loneliness is associated with biased cognitive processes. However, studies investigating interpretation bias (IB) related to feelings of loneliness are scarce. The current study aimed to investigate (a) whether emotional loneliness (perceived absence of intimacy) and social loneliness (perceived absence of satisfying connections) are associated with a negative IB while controlling for related psychosocial symptoms, and (b) whether these two types of loneliness show content-specific IB. Sample 1 included an unselected university sample (N= 138, 81.9% female,M= 20.8 years,SD= 4.4), and Sample 2 utilized a preselected university sample with elevated anxiety/depression levels (N= 315, 69.5% female,M= 23.8 years,SD= 4.3). Participants completed questionnaires on emotional and social loneliness, social isolation, social anxiety, depression, hostility, and an ambiguous scenarios task measuring IB. The results showed that emotional and social loneliness were uniquely associated with a negative IB related to the unavailability of social network. Social loneliness was additionally positively related to an IB for rejection and negatively to an IB for hostility in Sample 2. These results provide evidence for a content-specific negative IB in both types of loneliness. Future studies are needed to replicate these findings as it could aid in developing an effective treatment program for loneliness targeting underlying cognitions in young adults.

Rationale, Aims and objectives The management of vaginal health care in general practice settings is performing suboptimal. Vaginal complaints are of frequent and recurrent nature and often stay untreated or are maltreated. eHealth and increased empowerment of patients offer opportunities to improve vaginal health care offered by GPs. The aim is to develop and evaluate an e-tool for women with vaginal complaints, for improving vaginal health care. With this e-tool women can estimate the necessity to schedule a GP consult, wait, or self-diagnose and self-treat. Methods For this qualitative study, the setting is a large general practitioners’ office in the Netherlands. After developing the electronic decision aid, we used a purposive sample of 10 women of different ages, to evaluate the e-tool. The data was collected through semi-structured and cognitive interviews, encouraging the thinking aloud method. The interviews were processed with thematic content analysis. Information about (dis)satisfaction was obtained with comparing expectations and perceptions of the subsets content, development process and effectiveness of the e-tool. Results Besides providing information, the e-tool enables women to self-structure their symptoms and prepare them for consultation with their GP (if necessary) or self-diagnose and self-treat (if appropriate). Although in general the women were satisfied, we also got various tips for improvement and further refinement of this electronic decision aid. Conclusions To the best of our knowlegde, this is the first, scientifically developed, (prototype) of an e-tool for self-diagnosis and treatment of vaginal complaints. In the near future, implementing an e-tool for vaginal complaints in general practice, seems promising in making vaginal health care more effective and efficient.

Background: Smoking while using contraception containing ethinylestradiol increases the risk of cardiovascular diseases. Therefore, it is especially important to stimulate women who use these contraceptives to quit smoking. Objectives: This study aimed to examine the role of risk perception and coping in relation to the intention of these women to quit smoking, using the Protection Motivation Theory as the theoretical foundation. Design: This was an explanatory sequential mixed-methods design. Methods: An online survey ( n = 68) was used to examine the relationship among risk perception, coping assessment, and intention to quit smoking. After that 15 in-depth semi-structured interviews were conducted to understand how women appraised risk and coping strategies during their quit attempt(s). Results: Results from the survey showed that risk perception induces the intention to quit smoking. More specifically, perceived vulnerability appeared to be a significant predictor. The interviews showed that women were largely unfamiliar with the combined risks surrounding smoking and contraception use but acknowledged the risks of smoking. In the survey, women seemed to perceive themselves as self-efficacious. However, interview participants mentioned that they encountered many difficulties. Conclusion: Based on these findings, we conclude women are largely unaware of the synergetic risk of contraception use and smoking. Stimulating risk perception and knowledge might help women to create the intention to quit smoking. However, to turn this intention into behavior, providing women with concrete tools to assist them might successfully sustain their quit attempt.