Heleen Riper

Background: Cognitive behavioral therapy (CBT) is an effective and widely used treatment for major depressive disorder (MDD). However, access is limited by long waiting lists and a shortage of trained therapists. Evidence-based guided and self-guided digital interventions can address these challenges, but their large-scale adoption in routine primary and specialized mental health care has been slow. Blended CBT (bCBT), combining face-to-face therapy with structured, guided digital treatment modules, may increase treatment capacity while maintaining the benefits of therapist support. Objective: The European Comparative Effectiveness Research on Internet-based Depression Treatment study, conducted across 9 European countries, is the first large-scale comparative bCBT study for MDD. The hypothesis was that bCBT is clinically noninferior and cost-effective when compared with treatment as usual (TAU), which mainly consisted of face-to-face CBT. Methods: A multisite randomized controlled trial was conducted with a noninferiority margin of d =0.20. Main inclusion criteria were age ≥18 years, a diagnosis of MDD based on the Mini International Neuropsychiatric Interview, and a baseline Patient Health Questionnaire-9 (PHQ-9) score of ≥5. The primary outcome was the PHQ-9, with secondary outcomes including MDD remission at 12 months, therapeutic alliance, and costs. Intention-to-treat analyses were performed, and linear mixed modeling was used to assess intervention effects. Cost-effectiveness analyses were conducted from a health care perspective. Results: A total of 835 patients were included in the study. bCBT was shown to be noninferior to TAU on the primary PHQ-9 outcome during treatment (3 months after the baseline assessment, d =−0.26, 95% CI −0.43 to −0.09), at 6 months (posttreatment, d =−0.21, 95% CI −0.39 to−0.04), and at 12-month follow-up ( d =−0.01, 95% CI −0.19 to 0.17). Furthermore, the bCBT group had a significantly lower likelihood of experiencing an MDD episode at 12 months (odds ratio 0.67, 95% CI 0.45‐0.99). Subgroup analyses indicated that participants with and with no antidepressant use at baseline in both groups benefited equally from their treatment. Deterioration rates (Reliable Change Index) were below 5% in both groups. bCBT appeared acceptable for patients and therapists, with a strong working alliance in both groups. From a health care perspective, bCBT was not cost-effective at 12 months' assessment, as its total costs were not significantly lower than TAU. However, the probability that bCBT is cost-effective is high (0.95) at a willingness to pay (WTP) of €3800 per improvement in the PHQ-9 score, and 0.76 at a WTP of €10,000 per MDD case prevented (average 2017 exchange rate was €1=US $1.13). Conclusions: bCBT offers an effective and safe digitally supported alternative to face-to-face TAU for patients with MDD and their therapists in routine clinical care. From a health care perspective, its cost-effectiveness depends on policymakers’ WTP for the additional clinical benefits achieved.

An estimated 60% of autistic adults suffer from insomnia symptoms, which significantly impairs daily functioning and wellbeing. This study evaluated the effectiveness of i-Sleep Autism, a 5-week, guided self-help internet-delivered cognitive behavioral therapy-based intervention (ICBT-I) for insomnia in autistic adults. In co-creation with seven autistic adults with sleeping problems, i-Sleep Autism was adapted from i-Sleep, a pre-existing non-autism specific intervention. A total of 163 adults with autism and insomnia (ISI ≥ 10) was randomly allocated to i-Sleep Autism (n = 82) or waitlist control (n = 81; receiving psychoeducation and sleep hygiene). Participants were assessed at baseline (T0), mid-intervention (T1; 3-weeks), post-test (T2; 6-weeks), and follow-up (T3; 6 months) on insomnia severity (primary outcome), pre-sleep arousal, anxiety, depression, daily functioning, and quality of life. In the intervention group, 56.1% completed four, and 50% all five modules. Intent-To-Treat analyses revealed a significant reduction in insomnia severity at T1 and T2 (d = 1.02, 95%CI = [0.65, 1.40]), and cognitive- and somatic pre-sleep arousal at post-test, when comparing intervention to control. The intervention group showed significantly higher quality of life at post-test. At T2, 37.8% of the intervention group versus 11.1% of the control group showed clinically meaningful improvement of insomnia. Effects on insomnia severity were maintained at 6-month follow up. No significant effects were found for anxiety, depression, or daily functioning. This is the first RCT to investigate autism-adapted ICBT-I for autistic adults suffering from insomnia. i-Sleep Autism effectively and sustainably improves insomnia. Additional strategies are needed to support dropouts and those who did not benefit. Statement of Significance Insomnia is very common among autistic adults and has substantial consequences for daily functioning and well-being, yet evidence-based sleep interventions for this group are lacking. This study provides the first randomized controlled evaluation of an internet-delivered cognitive behavioral intervention for insomnia that was adapted in collaboration with autistic adults. The findings demonstrate that autism-adapted, guided, digital sleep interventions can meaningfully improve sleep and related outcomes in autistic adults, with effects that are sustained over time. At the same time, considerable variation in engagement and response highlights the need for further refinement and personalization. Future research should focus on identifying who benefits most, optimizing support for non-responders, and improving accessibility and adherence.

Background: Depressive symptoms are common among older adults and can significantly impact their quality of life. However, many older adults face barriers to accessing psychological treatment. Internet-based cognitive behavioral therapy (iCBT) is a promising alternative to face-to-face treatments, but its feasibility among older adults has been less extensively studied than in adult populations. Objective: This study evaluated the feasibility of guided iCBT for adults aged 55 years and older with mild to moderate depressive symptoms recruited from the general population. Methods: This study is a feasibility study with a single-group, pretest-posttest design (n=21), in which all participants received guided iCBT for 8 weeks. Assessments were conducted at baseline (T0) and after the intervention (T1). The primary outcome was feasibility, conceptualized as satisfaction, usability, engagement, and uptake of iCBT. Secondary outcome measures included depression severity, working alliance, and technical alliance. Results: Participants were mostly highly educated (13/21, 61.9%), female (18/21, 85.7%), had an average age of 59.85 (SD 4.19; range 55-68) years, and reported moderate digital literacy. Feasibility outcomes indicated high satisfaction and engagement and moderate usability. Working alliance was rated as good by both participants and coaches, and technical alliance was rated as moderate by the participants. There was a nonsignificant modest decrease in depressive symptoms (Cohen d=0.47). Of the 20 participants who started the intervention, all completed the first 2 modules, but completion declined across the remaining 6 modules, with only 1 (5%) participant completing all modules. Conclusions: This study found that guided iCBT has the potential to be a feasible option for older adults experiencing depressive symptoms, with participants reporting generally positive satisfaction, moderate engagement, and a moderate therapeutic bond with their coaches. However, below-average usability ratings and a moderate technical alliance suggest that some aspects of the platform require improvement. Future research should focus on improving usability and adherence, as well as testing the intervention in a larger and more diverse population.

Background: Greater homework adherence in cognitive behavioral therapy (CBT) is associated with positive treatment outcomes. However, the problems emerging from CBT homework use are common and affect adherence. In recent years, gamification has been explored to increase intervention adherence, but not yet in relation specifically to homework assignments. Objective: In this study, the aim was to gain a better understanding of obstacles to CBT homework and the use of gamification to overcome these. Methods: Concept mapping, a method to organize related information visually, was used in this study. For the 1-day face-to-face concept mapping session, 7 therapists (32 to 55 y, 6 females) participated and generated items based on 2 focal questions of interest. The generated items were grouped on perceived similarity, and each individual item was rated on (1) severity and difficulty (focal question 1) and (2) importance, acceptance by therapist, and acceptance by patient (focal question 2). The item groups on perceived similarity were inserted into computer software. Based on multidimensional scaling and hierarchical cluster analyses, item clusters were generated by the computer software and were presented to the therapists. The therapists were asked for their preference for the number of items a cluster should contain. Results: Through brainstorming, the therapists collectively generated a list of 29 possible reasons for not doing homework by patients. In the same manner, a list of 38 game design elements that could help patients make CBT homework was generated. External factors (eg, no time due to crisis situations) and lack of motivation (eg, not aspiring to a therapy goal) were perceived as the most important reasons for patients not to do homework. External and symptoms-unrelated internal factors were considered by therapists as the most difficult for patients to change for improved homework adherence. The game design elements, facilitation, and rewards were rated as most important to help patients do homework. These elements were also seen as most accepted by therapists. Conclusions: Facilitation of doing homework and rewards seem to have the potential to tackle some of the external factors and lack of motivation to make CBT homework that patients could have. Conclusions were limited by the small number of participating therapists. Future research is needed on the effects of specific game design elements, the number of these elements, their combinations, and patients’ preferences.

BACKGROUND The COVID-19 lockdown accelerated the adoption of telepsychiatry, including synchronous videoconferencing in adult mental health care. It is still unclear whether videoconferencing works equally well for all user groups. This study examines clinicians’ and clients’ experiences with videoconferencing during the first Dutch lockdown (April 2020) and one year later (April 2021), focusing on the appraisal of online individual (OIT) and online group treatment (OGT) in outpatient adult mental health care, covering first-line (primary) and second-line (specialized) services. OBJECTIVE To examine the appraisal of OIT and OGT among clients and clinicians in 2020 and 2021, and to explore subgroup differences by gender, age and diagnosis/profession. METHODS Two independent cross-sectional surveys were conducted in 2020 (clients: n = 350; clinicians: n = 146) and 2021 (clients: n = 357; clinicians: n = 122) at a Dutch mental health service. Participants evaluated their OIT and OGT experiences using newly developed service-evaluation questionnaires. For the appraisal score, we only used items that explicitly compared videoconferencing with face-to-face (FTF) care; principal axis factoring was used to derive appraisal scores. Hierarchical regression tested the added predictive value of survey year for appraisal of videoconferencing: step 1 included participant variables (gender, age, diagnosis/profession), and step 2 added survey year. Exploratory subgroup analyses examined within-year variation in appraisal by gender, age, and diagnosis/profession. RESULTS Despite a prevailing preference for FTF treatment, clients reported significantly higher appraisal with OIT in 2021 compared to 2020 (B = 0.22, P = .001), while appraisal of OGT did not differ significantly between years. Clinicians reported higher appraisal in 2021 than in 2020 for both OIT (B = 0.69, P < .001) and OGT (B = 1.40, P = .003). Exploratory subgroup analyses based on gender, age, or diagnosis found no meaningful differences in appraisal for either clients or clinicians. CONCLUSIONS Appraisal of videoconferencing was higher in 2021 than in 2020, most clearly among clinicians, yet both clients and clinicians still preferred FTF care on average. At present, videoconferencing appears best suited as a complementary option, with relevance for expanding access to mental health care globally in a rapidly changing landscape.

Introduction: Internet‐based cognitive behavioral therapy (iCBT) could help bridge the gap in treatment provision for mental disorders. iCBT is efficacious for the treatment of anxiety and depression in RCTs. However, more research is needed to translate findings from controlled trials to natural clinical settings. Additionally, more research is needed on predictors for treatment outcome in iCBT to guide allocation of treatment resources. Method: Data originated from a routine care guided iCBT clinic and covered 1475 adults treated for either mild‐moderate depression ( n = 719), panic disorder ( n = 376), social phobia ( n = 276), or specific phobia ( n = 104). Joint models were used to examine treatment effects and predictors. Effect estimates were supported by effect sizes (Cohen's d ) and calculations of the reliable change index (RCI). Results: All four treatments showed significant reductions on their primary outcome measure at each assessment point, according to the joint models (depression, PHQ‐9: −1.35, 95% CI: −1.44; −1.27; panic disorder, PDSS‐SR: −0.96, 95% CI: −1.04; −0.88; social phobia, SIAS: −0.96, 95% CI: −1.25; −0.67; specific phobia, FQ Main Phobia: −0.25, 95% CI: −0.33; −0.16), and effect sizes were moderate to large from baseline to the last observation (depression, d = 0.87; panic disorder, d = 0.62; social phobia, d = 0.80; specific phobia, d = 0.47). In total, 26.7% of patients improved according to RCI, and 27.0% recovered at last observation. Higher baseline symptom severity was significantly associated with the extent of improvement for all programs. Similarly, baseline comorbid severity was associated with faster improvements on primary symptoms for depression and panic disorder. Lower age, being in a relationship, and studying increased the rate of improvement for panic disorder. Conclusion: iCBT treatments for depression, panic disorder and social phobia were effective. For specific phobia, effects were smaller but still significant. Future studies should investigate process variables, theoretically relevant predictors or full prediction models to enable impactful predictions.

[This corrects the article DOI: 10.2196/18100.].

BACKGROUND Depressive symptoms are common among older adults and can significantly impact their quality of life. However, many older adults face barriers to accessing psychological treatment. Internet-based cognitive behavioral therapy (iCBT) is a promising alternative to face-to-face treatments, but its feasibility among older adults has been less extensively studied than in adult populations. OBJECTIVE This study evaluated the feasibility of guided iCBT for adults aged 55 years and older with mild to moderate depressive symptoms recruited from the general population. METHODS This study is a feasibility study with a single-group, pretest-posttest design (n=21), in which all participants received guided iCBT for 8 weeks. Assessments were conducted at baseline (T0) and after the intervention (T1). The primary outcome was feasibility, conceptualized as satisfaction, usability, engagement, and uptake of iCBT. Secondary outcome measures included depression severity, working alliance, and technical alliance. RESULTS Participants were mostly highly educated (13/21, 61.9%), female (18/21, 85.7%), had an average age of 59.85 (SD 4.19; range 55-68) years, and reported moderate digital literacy. Feasibility outcomes indicated high satisfaction and engagement and moderate usability. Working alliance was rated as good by both participants and coaches, and technical alliance was rated as moderate by the participants. There was a nonsignificant modest decrease in depressive symptoms (Cohen d=0.47). Of the 20 participants who started the intervention, all completed the first 2 modules, but completion declined across the remaining 6 modules, with only 1 (5%) participant completing all modules. CONCLUSIONS This study found that guided iCBT has the potential to be a feasible option for older adults experiencing depressive symptoms, with participants reporting generally positive satisfaction, moderate engagement, and a moderate therapeutic bond with their coaches. However, below-average usability ratings and a moderate technical alliance suggest that some aspects of the platform require improvement. Future research should focus on improving usability and adherence, as well as testing the intervention in a larger and more diverse population.