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Protocol Depression Awareness and Self-Management Through the Internet: Protocol for an Internationally Standardized Approach

Authors:
  • National Suicide Research Foundation

Abstract and Figures

Background: Depression incurs significant morbidity and confers increased risk of suicide. Many individuals experiencing depression remain untreated due to systemic and personal barriers to care. Guided Internet-based psychotherapeutic programs represent a promising means of overcoming such barriers and increasing the capacity for self-management of depression. However, existing programs tend to be available only in English and can be expensive to access. Furthermore, despite evidence of the effectiveness of a number of Internet-based programs, there is limited evidence regarding both the acceptability of such programs and feasibility of their use, for users and health care professionals. Objective: This paper will present the protocol for the development, implementation, and evaluation of the iFightDepression tool, an Internet-based self-management tool. This is a cost-free, multilingual, guided, self-management program for mild to moderate depression cases. Methods: The Preventing Depression and Improving Awareness through Networking in the European Union consortium undertook a comprehensive systematic review of the available evidence regarding computerized cognitive behavior therapy in addition to a consensus process involving mental health experts and service users to inform the development of the iFightDepression tool. The tool was implemented and evaluated for acceptability and feasibility of its use in a pilot phase in 5 European regions, with recruitment of users occurring through general practitioners and health care professionals who participated in a standardized training program. Results: Targeting mild to moderate depression, the iFightDepression tool is based on cognitive behavioral therapy and addresses behavioral activation (monitoring and planning daily activities), cognitive restructuring (identifying and challenging unhelpful thoughts), sleep regulation, mood monitoring, and healthy lifestyle habits. There is also a tailored version of the tool for young people, incorporating less formal language and additional age-appropriate modules on relationships and social anxiety. The tool is accompanied by a 3-hour training intervention for health care professionals. Conclusions: It is intended that the iFightDepression tool and associated training for health care professionals will represent a valuable resource for the management of depression that will complement existing resources for health care professionals. It is also intended that the iFightDepression tool and training will represent an additional resource within a multifaceted approach to improving the care of depression and preventing suicidal behavior in Europe.
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Protocol
Depression Awareness and Self-Management Through the
Internet: Protocol for an Internationally Standardized Approach
Ella Arensman1,2, MSc,PhD; Nicole Koburger3,4, Dipl-Psych; Celine Larkin1, BA,PhD; Gillian Karwig1; Claire Coffey1;
Margaret Maxwell5, PhD; Fiona Harris5, PhD; Christine Rummel-Kluge3,4, MD; Chantal van Audenhove6, MSc,PhD;
Merike Sisask7,8, PhD; Anna Alexandrova-Karamanova9,10, MSc,PhD; Victor Perez11,12,13, MD,PhD; György Purebl14,
MD,PhD; Annabel Cebria12,13,15, Mphil,CP; Diego Palao12,15, MD,PhD; Susana Costa16; Lauraliisa Mark7,8; Mónika
Ditta Tóth14; Marieta Gecheva9,17; Angela Ibelshäuser18, Mag; Ricardo Gusmão16,19, MD,MSc,PhD; Ulrich Hegerl3,4,
MD
1National Suicide Research Foundation, Cork, Ireland
2Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
3University Hospital, Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
4German Depression Foundation, Depression Research Centre, Leipzig, Germany
5Nursing, Midwifery & Allied Health Professions Research Unit, School of Health Sciences, University of Stirling, Stirling, United Kingdom
6LUCAS, Centre for Care Research and Consultancy, University of Leuven, Leuven, Belgium
7Estonian-Swedish Mental Health and Suicidology Institute, Tallinn, Estonia
8Institute of Social Work, Tallinn University, Tallinn, Estonia
9Health Psychology Research Center, Sofia, Bulgaria
10Institute for Population and Human Studies, Bulgarian Academy of Sciences, Sofia, Bulgaria
11Institut de Neuropsiquiatria i Addicions, Hospital del Mar, CIBERSAM, Universitat Autònoma de Barcelona, Barcelona, Spain
12Universitat Autònoma de Barcelona, Department of Psychiatry and Forensic Medicine, Barcelona, Spain
13Centro de Investigación Biomédica, Red de Salud Mental, CIBERSAM, Barcelona, Spain
14Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary
15Corporació Sanitària Parc Taulí de Sabadell, Department of Mental Health, Sabadell, Spain
16NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
17Family National Association, Sofia, Bulgaria
18pro mente Tirol, Innsbruck, Austria
19Instituto de Saude Publica, Universidade do Porto, Porto, Portugal
Corresponding Author:
Ella Arensman, MSc,PhD
National Suicide Research Foundation
University College Cork
4.28 Western Gateway Building
Cork,
Ireland
Phone: 353 (0)21 4205541
Fax: 353 (0)21 4205
Email: EArensman@ucc.ie
Abstract
Background: Depression incurs significant morbidity and confers increased risk of suicide. Many individuals experiencing
depression remain untreated due to systemic and personal barriers to care. Guided Internet-based psychotherapeutic programs
represent a promising means of overcoming such barriers and increasing the capacity for self-management of depression. However,
existing programs tend to be available only in English and can be expensive to access. Furthermore, despite evidence of the
effectiveness of a number of Internet-based programs, there is limited evidence regarding both the acceptability of such programs
and feasibility of their use, for users and health care professionals.
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Objective: This paper will present the protocol for the development, implementation, and evaluation of the iFightDepression
tool, an Internet-based self-management tool. This is a cost-free, multilingual, guided, self-management program for mild to
moderate depression cases.
Methods: The Preventing Depression and Improving Awareness through Networking in the European Union consortium
undertook a comprehensive systematic review of the available evidence regarding computerized cognitive behavior therapy in
addition to a consensus process involving mental health experts and service users to inform the development of the iFightDepression
tool. The tool was implemented and evaluated for acceptability and feasibility of its use in a pilot phase in 5 European regions,
with recruitment of users occurring through general practitioners and health care professionals who participated in a standardized
training program.
Results: Targeting mild to moderate depression, the iFightDepression tool is based on cognitive behavioral therapy and addresses
behavioral activation (monitoring and planning daily activities), cognitive restructuring (identifying and challenging unhelpful
thoughts), sleep regulation, mood monitoring, and healthy lifestyle habits. There is also a tailored version of the tool for young
people, incorporating less formal language and additional age-appropriate modules on relationships and social anxiety. The tool
is accompanied by a 3-hour training intervention for health care professionals.
Conclusions: It is intended that the iFightDepression tool and associated training for health care professionals will represent a
valuable resource for the management of depression that will complement existing resources for health care professionals. It is
also intended that the iFightDepression tool and training will represent an additional resource within a multifaceted approach to
improving the care of depression and preventing suicidal behavior in Europe.
(JMIR Res Protoc 2015;4(3):e99) doi:10.2196/resprot.4358
KEYWORDS
cognitive behavioral therapy; computerized; depression; Internet-based; primary care; self-management
Introduction
Overview
Depression and suicidal behavior, including both suicide and
nonfatal self-harm, are 2 important and largely overlapping
public health problems in Europe [1]. European countries are
overrepresented among the highest national rates of suicide in
the world [2,3], and unipolar depressive disorders are the third
cause of disability-adjusted life years in Europe [2]. People
suffering from major depression are 21 times more likely to die
by suicide than nondepressed individuals [4]. Depressive
disorders are present in approximately half of completed suicides
[1,5], and this proportion is even higher if the presence of
subclinical depressive symptoms is considered [6,7].
Research Context of iFightDepression: Depression and
the Current Situation of Care
Given the connection between depression and suicide, it is not
surprising that improving the care of people with depression is
considered an effective suicide prevention approach [8]. Several
successful European studies provide support for this approach.
The pioneering Gotland study [9,10], the Nuremberg Alliance
against Depression [11,12], and further studies evaluating
multilevel community-based interventions, such as the
implementation of a local Alliance against Depression in
Hungary [13], have demonstrated that interventions to improve
the recognition and treatment of depression can effectively
reduce the incidence of suicidal acts. The European Alliance
Against Depression (EAAD) [14] and the European
Commission-funded “Optimising Suicide Prevention Programs
and their Implementation in Europe (OSPI-Europe)” project
[15] have explored the potential of such community-based
interventions to improve awareness of depression and to prevent
suicidal behavior across several European countries. These
interventions operate on multiple levels within the community,
including the following: (1) cooperation with primary care
services, focusing on trainings for general practitioners (GPs)
to improve professional recognition of depression, including
education about lethal medication and information regarding
the detection, assessment, and diagnosis of depression; (2) public
relation activities involving education of the broad public with
a multifaceted depression awareness campaign; (3) cooperation
with community facilitators and stakeholders, including training
workshops focusing on recognition of depression, facilitation
of access to appropriate care, and cooperation to restrict access
to lethal means; and (4) facilitation of care and support for
patients, high-risk groups, and their relatives, with the provision
of information regarding helplines and emergency contacts and
the initiation of, and support for, self-help groups [16].
Such multilevel interventions have demonstrated effectiveness
with regard to the reduction of stigma toward depression,
improvement of both lay and professional knowledge and
awareness of depression, and increased motivation of individuals
to seek help for depression as a result of broad general public
health campaigns and increased professional recognition of
depression. However, despite this promising evidence, the need
to improve the care for individuals who are motivated to seek
help for their depression has become evident [17,18].
Specifically, as the number of depressed individuals motivated
to seek help increases, the demand on available resources and
support services increases as well. As a result, individuals may
encounter structural barriers such as limited availability of
specialized care in rural areas, or lengthy waiting times for
psychotherapeutic treatment [19]. Thus, once a person decides
to access help for depression, or professional education increases
awareness and detection of depression in clinical practice, there
may be limited effective assistance available.
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The importance of improving the care for individuals with
depression is also demonstrated in light of diagnostic and
therapeutic deficits at the primary care level. Patients with
depression who seek help often present to general practice with
mainly somatic complaints [20,21]. If depression occurs in
individuals living in difficult life circumstances (eg, those
experiencing somatic comorbidities and unemployment), it is
often seen as a secondary phenomenon, a reaction to life
circumstances, and not as an independent severe disorder that
should be treated according to appropriate guidelines. In
addition, recent studies have demonstrated that depression is
underdetected and inadequately screened within primary care
[22,23]. These are a number of reasons why only approximately
50% of depressed patients are correctly diagnosed at the primary
care level [24,25].
Even if a diagnosis is made, very often specific psychotherapy
is not available, nor is pharmacotherapy prescribed. When
pharmacotherapy is initiated, there are sometimes challenges
with drug dosage and time span [26,27]. Finally, even if
pharmacological or psychological treatment is offered, there
may be considerable compliance problems [28,29]. Moreover,
many national health services in Europe are increasingly ill
placed to provide specialized interventions for depression in
light of the current economic recession: governmental
cost-saving measures adopted in several countries have included
the reduction of budgets for mental health services with
subsequent effects on service availability [30]. Given the
decreasing availability of effective treatment services for
depression, it is apparent that additional resources are urgently
needed to offer support to both patients and health care
professionals for the management of depression.
Depression and Self-Management Using the Internet
Because of the current constraints within national health services
and the resultant limitations on delivering best practices of
mental health care delivery within primary care [31], much of
the responsibility for the initial care of mild to moderate
depression lies with primary care providers. In such settings,
there is a need for treatment complementarity: primary care
providers and patients should be provided with a range of
evidence-based and effective options for the management of
depression. Antidepressants are effective and are widely used
to treat depression, but patients may be reluctant to use
antidepressant medication. Clinical guidelines regarding the
management of depression now recommend a “stepped-care”
approach to depression, whereby lower intensity psychosocial
interventions may be used to treat lower levels of depression
[32]. This is important, given that even mild or minor forms of
depression negatively affect quality of life [33], and are
associated with functional impairments [34], increased mortality,
and risk of transition to severe depression and suicidal behavior
[35]. Lower intensity psychosocial interventions often
incorporate the concept of self-management, an approach that
can complement treatment combinations for mild and moderate
depression by empowering patients while reducing demands
on health care services [36].
Self-management is an important aspect in the management of
long-term illnesses. It refers to “interventions, trainings, and
skills by which patients with a chronic condition, disability, or
disease can effectively learn how to take care of themselves and
effectively deal with difficult situations” [37]. Originally applied
to chronic somatic diseases with success [38-40], it is
increasingly being applied to mental health [41]. The Internet
has provided new avenues for self-management as it enables
cost-effective access to self-management resources at the
patient’s own convenience and in a location of their choice.
Computerized cognitive behavioral therapy (cCBT) is one type
of a lower intensity intervention recommended for the treatment
of mild to moderate depression in several clinical guidelines
[32,42], which incorporates the principles of self-management.
The Preventing Depression and Improving Awareness
Through Networking in the European Union Project
The Preventing Depression and Improving Awareness through
Networking in the European Union (PREDI-NU) is an
international European Union-funded project that involves
expert clinicians and researchers in the fields of depression and
suicide prevention from 11 European countries, in addition to
an international expert advisory panel. The project was funded
from September 2011 to September 2014 and builds upon the
aforementioned research by the EAAD and OSPI-Europe.
Specifically, the PREDI-NU project intends to fill gaps in the
availability of evidence-based self-management resources for
mild to moderate depression through information and
communications technology. In light of this, it encompasses the
following 3 main aims:
1. The development of a multilingual European depression
awareness and information website [43], to raise awareness of
depression and suicidal behavior, to improve knowledge and
attitudes regarding depression and suicidal behavior, and to
promote help seeking and mental health.
2. The development of an evidence-based, multilingual
self-management program for mild to moderate depression to
be implemented and “guided” by primary care practitioners or
mental health professionals who attend standardized professional
training.
3. Implementation of the self-management program in 5
European regions, in addition to evaluation of the acceptability
of the program and feasibility of its use, to inform future
implementation of the program after project running time.
The purpose of this paper is to describe the study protocol
regarding the development, implementation, and evaluation of
the self-management program.
Methods
Development of the Self-Management Program
A systematic review informed by the realist approach [44]
explored the evidence for cCBT. This was conducted during
the 1st year of the PREDI-NU project to inform development
of the self-management program. The systematic review aimed
to specifically examine (1) what interventions work, for whom,
and in what circumstances, and (2) to identify best practice
recommendations for implementation of self-help ehealth
technologies. This review consisted of a rigorous systematic
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literature search resulting in 52 papers, of which 22 were
meta-reviews or systematic reviews, 5 were guidelines, and the
rest were feasibility studies or studies informing the
development, implementation, or use of cCBT. For the purposes
of this protocol paper, results from the review will be referred
to generally, and extensive results will be published in a separate
future study.
The review indicated that numerous cCBT programs for
depression have been developed, and that positive randomized
controlled trial evidence exists for several packages, namely,
Beating the Blues [45], MoodGYM [46,47], and Colour Your
Life [48]. However, there is no clear evidence of any one
program being more effective than another; additionally, there
is little knowledge to guide the development or implementation
of such interventions. Furthermore, despite evidence of their
effectiveness, there is limited evidence on the acceptability (to
both patients and professionals) and feasibility of the use of
Internet-based self-management interventions for the
management of depression, which may limit their uptake in
primary care practice [49] and is likely to be a contributing
factor to the high rates of attrition and noncompletion of such
programs. Moreover, many established programs are available
only in English and only with payment of a fee to the user or
for the general practice. Although the review indicated that
guided Web-based interventions are more effective in reducing
depression than unguided programs [32,50-52], there is no clear
evidence regarding the optimal level or format of delivery of
guidance, and little consistent evidence to support
implementation of cCBT overall.
This systematic review was supplemented by scoping existing
cCBT websites internationally and identifying key features for
inclusion within the self-management program to be developed.
To ensure that procedures and materials meet international
standards of evidence-based practice, a rigorous consensus
process informed development of the program, involving a panel
of international experts on cCBT and a scientific advisory board
of international experts with extensive experience of Web-based
interventions for depression and related mental health issues.
Representatives from patient and family organizations also
provided input into this consensus process.
Design and Contents of the Self-Management Program
Using the aforementioned, evidence-based, and best-practice
approach, the PREDI-NU consortium developed the
iFightDepression tool, a guided Internet-based self-management
program for individuals experiencing mild to moderate
depression, with versions for both adults aged 25 years and
older and young people between 15 and 24 years of age. The
iFightDepression tool is derived from a cognitive behavioral
therapy approach and primarily focuses on the associations
between thoughts, feelings, and behavior. A screenshot of the
home page of the iFightDepression tool is shown in Figure 1.
In addition to introductory and emergency contact material, the
iFightDepression tool comprises 6 core modules relating to
behavioral activation, sleep and mood monitoring, and cognitive
restructuring: “Thinking, Feeling, and Doing”; “Sleep and
Depression”; “Planning and Doing Things That You Enjoy”;
“Getting Things Done”; “Identifying Negative Thoughts”; and
“Changing Negative Thoughts”. Individuals are encouraged to
complete the modules in the structured order in which they
appear in the tool; this is to encourage individuals to initiate
behavior activation, to examine the relationship between their
sleep, moods, and activities, and to integrate positive activities
into their daily schedules before the modules relating to
cognitive restructuring are undertaken, as these may be more
challenging. It has also been suggested that individuals complete
the modules at a rate of no more than 1 module/week, with an
estimation of 30-40 minutes for the completion of each module.
However, while these instructions are recommended, users can
determine their personal pace and order of modules if they wish,
as suggested by patient representatives involved in the
development of the tool. Each module incorporates associated
tasks and corresponding worksheets to consolidate learning and
promote self-monitoring. In addition to encouraging users to
plan and reflect on activities, moods, and thoughts, the tasks
and worksheets help users to observe the associations between
what they think, what they do, and how they feel.
The “Sleep and Depression” module is innovative and is based
on the recently published vigilance regulation model of affective
disorders [53]. It supports patients to examine the relationship
between the duration of their sleep/time in bed and mood, and
to identify personal optimal sleep times. Research suggests that
there is a subgroup of patients who feel more tired, exhausted,
and depressed after longer-than-usual sleep/time in bed, and
that they show improvement after shortening of sleep/time in
bed [53]. The effects of partial or total therapeutic sleep
deprivation on depression are striking and well established [53].
However, in contrast to chronic sleep restriction, therapeutic
sleep deprivation cannot easily be implemented in routine care
or self-management approaches. The iFightDepression tool
encourages patients to explore the association between their
sleep patterns and their mood and to adjust their personal
sleeping habits accordingly.
In addition to the 6 core modules, there are optional modules
(2 tailored specifically for young people and 1 for both young
people and adults) that address related psychosocial issues,
namely, relationships, social anxiety, and healthy lifestyle habits.
The iFightDepression tool also encourages individuals to
monitor their mood using an embedded, electronic version of
the Patient Health Questionnaire-9 (PHQ-9) [54], a short
questionnaire that measures the presence/absence of depressive
symptoms in the 2 weeks prior to completing the questionnaire,
in addition to the frequency of these symptoms. Individuals’
scores on the PHQ-9 are automatically plotted on a graph, which
allows individuals to visually and clearly track their mood over
time. The PHQ-9 was also included within the tool as a safety
measure—should an individual’s depressive symptoms worsen
(as evidenced by 3 consecutive scores reflecting a specific result
of “severe depression,” and/or a positive response to the 9th
item within the questionnaire—“thoughts that you would be
better off dead or of hurting yourself in some way”), a feedback
window automatically appears that encourages the user to
contact their GP, health care professional, or emergency
services.
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Figure 1. Home page of the iFightDepression tool.
Implementation of the iFightDepression Tool
Specific Protocol Regarding Implementation of the Tool
The iFightDepression tool was implemented through GPs and
health care professionals who completed a standardized 3-hour
training workshop regarding implementation and guidance of
the tool. Specifically, the tool was targeted toward professionals
working in the area of mental health who are experienced in the
assessment and diagnosis of depression; for example, GPs,
family physicians, psychologists, psychiatrists, community
mental health nurses, mental health social workers, and clinical
nurse specialists. Trained health care professionals were
instructed to initially assess patients presenting with depression
for eligibility to use the tool (ie, a diagnosis of mild to moderate
depression); it was recommended to professionals to use the
PHQ-9 or the WHO-Five Well-Being Index in addition to their
clinical judgment to ensure that the iFightDepression tool
represented an appropriate resource for a patient, given his/her
current level of depression. Professionals subsequently provide
guidance as the individual commences use of and progresses
through the tool.
The iFightDepression tool is intended to complement the
available approaches for clinicians regarding the management
and treatment of depression, as an adjunct to a patient’s usual
care. However, the iFightDepression tool is also intended to be
used as a single resource for an individual when deemed
appropriate; for example, to bridge waiting times for patient
access to face-to-face psychotherapy.
Implementation Phases of PREDI-NU
Two phases of implementation occurred during PREDI-NU,
with a pilot phase undertaken at the beginning of the 2nd year
of PREDI-NU in 5 European regions, followed by a first-phase
evaluation to inform enhancement of the iFightDepression tool
for continued implementation in these regions. Specifically,
following the pilot phase, feedback about the acceptability of
the tool and feasibility of its use from patients, health care
professionals, and a group of healthy Internet users, in addition
to recommendations and input from the scientific advisory board
of international experts, was used to enhance all materials
relevant to the intervention, including the tool itself and
materials for the professional training workshop. The 3rd and
final year of the project involved the implementation of the
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optimized tool, aiming at sustainable implementation through
the development of materials for Train-the-Trainer workshops
to qualify senior health professionals to deliver the standardized
3-hour professional training workshops to peers, colleagues,
and additional interested professionals.
Before the pilot phase of implementation, local advisory panels
were formed in each of the intervention regions, allowing the
regions to explore and balance adaptation to local resources and
constraints and facilitate access to health care professionals.
Shared decision making was undertaken across regions regarding
adaptation to procedures of implementation to ensure what could
be described as an “empowerment implementation” approach
[55].
Professional Guidance
“Guidance” was incorporated into the protocol for
implementation of the iFightDepression tool as a key element,
whereby individuals both maintain contact with and receive
support from a trained GP or health care professional throughout
their use of the tool. Guidance was included for the following
reasons:
1. The systematic review of previous cCBT interventions
demonstrated that guided Internet-based interventions are more
effective than nonguided interventions.
2. It is expected that the incorporation of guidance may minimize
potential attrition of individuals using the iFightDepression tool,
as the review indicated that some level of human contact may
improve completion rates of online self-help interventions by
increasing motivation.
3. Furthermore, the inclusion of guidance represents an
additional safety net as individuals whose depressive symptoms
worsen throughout their use of the tool will be encouraged to
contact and inform their GP or mental health professional: both
during interaction with their health care professional and by
way of the informative “feedback” window that is displayed
within the tool if patients demonstrate more severe depressive
symptoms or suicidal and self-harm ideation after completing
the PHQ-9.
The systematic review also indicated that no clear evidence
exists regarding the optimal level or format of delivery of
guidance. A standardized set of guidelines was thus established
regarding guidance of the iFightDepression tool. It comprised
the following:
1. Guidance would amount to at least 45 minutes over the course
of an individual’s use of the iFightDepression tool, and that
guidance would be mainly motivational in nature.
2. The nature of the guidance can be flexible and may differ
between professional groups (GPs, psychotherapists, other
mental health professionals) as they are working within different
settings and time constraints. The exact means of
implementation may also depend on the personal preference
and working style of the professional.
3. There should be at least two face-to-face sessions in addition
to the initial personal appointment where the tool is
recommended to patients: halfway through a patient’s use of
the tool and upon completion of the tool. These face-to-face
sessions may be incorporated within standard follow-up
appointments provided by the health care professional as part
of treatment as usual. This level of guidance is in line with
previous studies and national guidelines for the primary care of
depression [32].
4. Additional guidance can be provided by telephone; however,
it may also be provided in other ways, such as by email or text.
Professional Training
To ensure a standardized approach to implementation of the
self-management program, both regionally and internationally,
a specific mandatory training workshop was developed for all
health care professionals interested in implementing the
iFightDepression tool and in guiding patients. The training
workshop is 3 hours in length and focuses on the
symptomatology and treatment of depression, the concepts of
self-management and cCBT, the contents of the
iFightDepression tool, and the specific protocols for
implementing and guiding the tool in routine practice in addition
to assessing individuals for eligibility to use the tool. The
development and inclusion of such standardized professional
training sessions is innovative as the systematic review
informing PREDI-NU indicated that the majority of existing
guided cCBT studies do not specify whether the professionals
providing guidance and support were specifically trained to use
the interventions with clients in a standardized manner.
Furthermore, it facilitates the potential for the increased
detection and recognition of depression, particularly within
primary care services.
Evaluation Aims
PREDI-NU primarily focused on assessing the acceptability of
the iFightDepression tool and the feasibility of its use for
patients, primary care practitioners, and health care
professionals. A comprehensive evaluation strategy including
quantitative and qualitative analyses of process and outcome
measures was integrated throughout all phases of the project.
In line with the aim of describing the protocol of the
development, implementation, and evaluation of the
iFightDepression tool, procedures and instruments of evaluation
will be listed briefly below, while a separate future report on
the results of the evaluation process will be published after
further data have been obtained and analyzed.
Process evaluation comprised focus groups to explore the views,
experiences, and recommendations of the professionals guiding
the tool, patients using the tool, and healthy Internet users, to
obtain more detailed information regarding the acceptability of
the tool and the feasibility of its use. Data from the focus groups
were transcribed and categorized according to a specific
template developed by the PREDI-NU Consortium regarding
the iFightDepression tool itself, procedures of implementation
and guidance of the tool, recruitment and assessment of patients,
and experiences of the professional training.
Outcome evaluation measures included a range of questionnaires
developed to assess the specific characteristics of each patient.
Baseline measurement of patient characteristics comprised
checklists to be completed by both patients and professionals.
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The professional’s checklist recorded the patient’s mental health
history, current treatment, and clinical evaluation. The latter
partly drew on the Clinical Global Impression-Severity of Illness
measure, which allows for a clinical impression about the current
mental health status of the patient to be obtained [56]. The
patient’s checklist recorded the patient’s mental health history,
their current situation, and attitudes toward and expectations of
Web-based self-management. It was also mandatory for patients
to complete the PHQ-9 at baseline, 6 weeks, and 3 months after
first log-in. The postintervention assessment at 3 months
comprised additional items addressing their experience of the
iFightDepression tool. The PHQ-9 was available at all times to
patients to regularly assess and monitor their mood at a
self-chosen frequency (eg, daily or weekly).
Evaluation measures also included a questionnaire for
professionals after training. This questionnaire assessed the
adequacy, feasibility, and acceptability of the training program
and expectations about working with the iFightDepression tool,
including procedures of recruitment and guidance. It is intended
that the implementation and evaluation of the tool via
professionals will allow for linkage of patients’ data to the
clinical appraisal of their GP or health care professional. It is
expected that the incorporation of quantitative and qualitative
data will ensure a more complete picture of the acceptability
and feasibility of the tool.
Finally, the intensity of the intervention was derived from
recording the number of users of the tool, number of information
materials distributed, number of trainings provided, number of
professionals attending training, and number of patients invited
to participate in the study.
Results
Targeting mild to moderate depression, the iFightDepression
tool is based on cognitive behavioral therapy and addresses
behavioral activation (monitoring and planning daily activities),
sleep regulation, problem solving, cognitive restructuring
(identifying and challenging unhelpful thoughts), mood
monitoring, and healthy lifestyle habits. There is also a tailored
version of the tool for young people, incorporating less formal
language and additional age-appropriate modules on
relationships and social anxiety. The tool is accompanied by a
3-hour training intervention for health care professionals, who
are guiding the patients while using the tool.
Discussion
Effectiveness of Online Interventions
Evidence exists demonstrating the effectiveness of a number of
online interventions for depression that are based on the
principles of cognitive behavioral therapy. However, only a
small number are supported by robust research evidence. Little
evidence exists regarding the acceptability of these interventions
or the feasibility of their use, for either individuals experiencing
depression or health care professionals managing depression in
clinical practice. While a comprehensive review of the literature
has demonstrated that “guided” online interventions are more
effective than nonguided interventions, there is little evidence
regarding the optimal length, content, and type of the guidance.
In this paper, we have described the protocol for the
development, implementation, and evaluation of a new
Internet-based guided self-management program—the
iFightDepression tool.
Implementation of the Ifightdepression Tool
The iFightDepression tool can be considered innovative for a
number of reasons. It is free of charge for both professionals
and patients to use and implemented through health care
professionals with defined standards of referral and guidance.
It is multilingual, and is currently available in 9
languages—English, German, Spanish, Catalonian, Dutch,
Hungarian, Estonian, Italian, and Bulgarian. In addition, it
includes youth-focused modules and a specific module
addressing the relationship between sleep patterns and mood.
Implementation of the tool was undertaken in a standardized
manner, with the development of a specific training workshop
for professionals. Finally, the iFightDepression tool was
enhanced based on results from an evaluation process that
focused on assessing the acceptability of the tool and feasibility
of its use, both with patients and health care professionals. The
iFightDepression tool therefore represents an evidence-informed
and standardized online intervention for individuals with mild
to moderate depression that can be implemented throughout
Europe in a uniform manner. It is intended that the
iFightDepression tool will empower patients by virtue of its
focus on increasing the capacity of individuals to self-manage
their symptoms of depression with guidance from their health
care professional. It is also intended to afford health care
professionals a free evidence-based resource for effectively
managing depression within their practice in a feasible manner
[27], either as an adjunct to treatment as usual or as a single
resource where appropriate. As a feasible and evidence-based
addition to existing treatment options, the iFightDepression tool
and associated professional training represent a promising
resource in addressing the growing divide between the number
of individuals in Europe who are in need of care as a result of
their depression [57], current structural constraints of health
systems [58], and the decreasing availability of resources for
improving the care of depression. There is the potential for the
iFightDepression tool to be used within a stepped-care approach
and included in the range of treatment interventions in primary
care and mental health services for mild to moderate depression
[59]. It is intended that iFightDepression, as a resource that
specifically addresses mild to moderate depression, will assist
in preventing individuals from developing a more severe form
of depression and subsequent suicidal behavior. An additional
potential use of the tool could involve that of relapse prevention,
as a resource for patients who have recovered from severe
depression but who still fall within the mild to moderate range
of depression. Furthermore, the iFightDepression tool may be
of particular interest and benefit for depressed individuals who
may not be able to access face-to-face interventions, such as
those with hearing deficits or those who may not be able to
travel due to severe chronic physical illnesses.
As the approach was adopted throughout the PREDI-NU project
across a number of European regions, it is evident that the
iFightDepression materials can easily be transferred to different
national and international contexts. Throughout PREDI-NU,
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several institutions from the project consortium that had not
originally planned to implement the iFightDepression tool within
their regions have either commenced or planned to commence
implementation of the tool, including those in Bulgaria and
Belgium. Consequently, there is a clear potential for wider
implementation of the tool in other countries and regions.
The funding for the PREDI-NU project ended in August 2014,
and the iFightDepression resources are administered via the
EAAD, allowing for sustainable use of the iFightDepression
tool and the project outcomes. These will be integrated within
the materials and procedures of implementation of the 4-level
community-based intervention of the EAAD [60] as an addition
to the multifaceted approach for improving the care of people
with depression and preventing suicidal behavior. In addition,
an online version of the standardized training program will be
developed and further research will be conducted to evaluate
the effectiveness and efficacy of the iFightDepression tool.
Thus, there is a clear indication of iFightDepression to
complement the range of available resources for mild to
moderate depression within primary care and mental health
services in Europe.
Acknowledgments
This protocol arises from the project PREDI-NU, which has received funding from the European Union in the framework of the
Health Program under grant agreement no 2010 12 14. The PREDI-NU Consortium is sincerely grateful to the members of the
International Advisory Board for their continued support and guidance throughout the project: Professor Pim Cuijpers (Department
of Clinical Psychology and EMGO Institute, VU University Amsterdam, Netherlands), Professor Ken Kirkby (University of
Tasmania School of Medicine; Department of Health and Human Services, Australia), Professor Stan Kutcher (Dalhousie
University, Department of Psychiatry; Sun Life Financial Chair in Adolescent Mental Health, Canada), and Dr Cathy Richards
(NHS Lothian, United Kingdom). We would like to thank the members of all regional Advisory Boards in the participating
countries for their commitment and input to the PREDI-NU project. We are grateful to Dr Sibylle Freitag and Patrizia Torremante
(GABO) for their input in the coordination of the study. We are also grateful to Innovagency (Portugal) for their input into the
development of the iFightDepression tool. We thank Robert Radler (GABO) and Daniel Boettger (Department of Medicine,
University of Leipzig, Germany) for their assistance with the technical development and maintenance of the iFightDepression
tool. We thank Grace O’Regan for her help in editing this manuscript.
Conflicts of Interest
None declared.
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Abbreviations
cCBT: Computerized Cognitive Behavioral Therapy
EAAD: European Alliance Against Depression
GPs: general practitioners
OSPI-Europe: Optimising Suicide Prevention Programs and their Implementation in Europe
PHQ-9: Patient Health Questionnaire-9
PREDI-NU: Preventing Depression and Improving Awareness through Networking in the EU
Edited by G Eysenbach; submitted 19.02.15; peer-reviewed by W van Ballegooijen; comments to author 08.04.15; revised version
received 28.04.15; accepted 28.04.15; published 06.08.15
Please cite as:
Arensman E, Koburger N, Larkin C, Karwig G, Coffey C, Maxwell M, Harris F, Rummel-Kluge C, van Audenhove C, Sisask M,
Alexandrova-Karamanova A, Perez V, Purebl G, Cebria A, Palao D, Costa S, Mark L, Tóth MD, Gecheva M, Ibelshäuser A, Gusmão
R, Hegerl U
Depression Awareness and Self-Management Through the Internet: Protocol for an Internationally Standardized Approach
JMIR Res Protoc 2015;4(3):e99
URL: http://www.researchprotocols.org/2015/3/e99/
doi:10.2196/resprot.4358
PMID:
©Ella Arensman, Nicole Koburger, Celine Larkin, Gillian Karwig, Claire Coffey, Margaret Maxwell, Fiona Harris, Christine
Rummel-Kluge, Chantal van Audenhove, Merike Sisask, Anna Alexandrova-Karamanova, Victor Perez, György Purebl, Annabel
Cebria, Diego Palao, Susana Costa, Lauraliisa Mark, Mónika Ditta Tóth, Marieta Gecheva, Angela Ibelshäuser, Ricardo Gusmão,
Ulrich Hegerl. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 06.08.2015. This is an
open-access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information,
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... 18 El riesgo suicida se relaciona prevalentemente con patología mental de base, la depresión y los trastornos afectivos son patologías que aparecen en la literatura relacionadas con un riesgo superior a la población general. [18][19][20][21] Como refiere Arensman 19 en un estudio realizado en el año 2015 y en línea a lo descrito en los resultados, la intervención de los profesionales en el manejo de estas patologías, alteraciones del humor, alucinaciones, delirios, trastorno personalidad, incide en la prevención de la conducta suicida; los profesionales de enfermería del estudio refieren intervenir con frecuencia en las descompensaciones y crisis conductuales derivadas de la patología de base, y se consideran agentes activos principales en el manejo ambiental. La antigüedad en el puesto se evidencia como una variable que favorece tanto la intervención en el manejo de estas patologías de base como en el manejo ambiental. ...
... Existe evidencia descrita por diferentes autores [16][17][18][19][20][21][22] que relaciona la conducta suicida tanto con factores de riesgo como con factores de protección de esta. En nuestro estudio los profesionales refieren carencias en la detección, tanto de los factores de riesgo como de los factores de protección vinculados a estas conductas. ...
... En diferentes estudios de investigación se denota la importancia de la formación y actualización de los profesionales, la protocolización de programas de intervención y la capacitación en intervenciones basadas en la evidencia que resultan efectivas en la prevención e intervención sobre estas conductas de riesgo. [18][19][20][21][22][23][24] En los resultados obtenidos se señala una falta de actualización, escasa participación en grupos de trabajo, foros profesionales y sesiones clínicas, especialmente los profesionales de menor edad; así como carencias formativas para el desarrollo de intervenciones basadas en la evidencia presente, los profesionales con mayor antigüedad suplen en parte, esta falta formativa, con la experiencia. ...
... ifigh tdepr ession. com/ en/) is an evidence-based tool rooted in the principles of CBT (Arensman et al., 2015;Oehler et al., 2020). The tool includes six weekly online workshops on specific topics regarding depressive symptoms (1. ...
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Understanding implementation-related factors and processes is key to ensuring that Internet-based interventions are embedded in practice and provide added value to the delivery of evidence-based care. The aim of this study was to evaluate the attitudes towards an Internet-based cognitive behavioural therapy (iCBT) intervention for the treatment of depression as well as its level of normalization and early implementation success (operationalized as intention to use the intervention) among German health care professionals (HCP). Data were collected following onetime information sessions on an iCBT tool using the Evidence-Based Practice Attitude Scale (EBPAS) and the Normalization Process Theory Measure (NoMAD). Influences of attitudes on normalization as well as influences of attitude and normalization on intention to use were analysed. Most participants ( n = 78; 86.3% clinical psychologists, 9.6% general practitioners) intended to use the intervention in the future (82.1%) and had a moderately positive attitude towards iCBT interventions. The perceived level of normalization (i.e., the level of how well iCBT is integrated in practice) was moderate in the overall sample. High appeal, openness towards iCBT, low requirement to use it, and low perceived divergence (perceived difference between current and new practices) had a significant positive effect on normalization. This study indicates that iCBT can be implemented in German routine mental healthcare. However, implementation processes might benefit from tailored information campaigns that clearly highlight the effectiveness and benefits of iCBT interventions to foster openness towards iCBT interventions among HCPs.
... iFightDepression 3 is a free, web-based, multilingual, self-management tool meant for young people and adults who are suffering from mild depression [8]. The platform offers its services in 9 different languages including English, German, Spanish, Catalonian, Dutch, Hungarian, Estonian, Italian, and Bulgarian [2]. iFightDepression is intended to promote self-monitoring, cognitive restructuring and sleep regulation for individuals who are suffering from moderate depression. ...
Conference Paper
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Building on the rising interest in online crowdsourcing platforms, and the ever-rising concerns over mental health issues worldwide; in this paper, we propose a novel citizen-oriented web-based Collective Intelligence (CI) platform called 'CommunityCare'. The platform is meant to be focused on end-users' communities and aims to empower its users by allowing them to work collectively when helping those suffering from mental health issues such as depression, anxiety, and stress. Through our work, we attempt to make two distinct contributions: first, we elucidate an abstract yet novel CI platform for mental health, that could enable citizen volunteers and medical practitioners to work together to help those suffering from psychological/behavioural issues; and second, we evaluate our previously proposed 'generic' CI framework by utilizing the said platform as a use case for the same. We describe the 'CommunityCare' platform through the four primary components of CI systems, namely: staffing, processes, goals and motivation.
... Each week's workshop covered a different topic (eg, an activity diary, monitoring and adapting one's sleep, or challenging automated negative thoughts). The content and development are described in more detail elsewhere [22,33]. iFD offers the opportunity to complete worksheets on the web or to use a printed version. ...
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Background An increasing number of studies suggest that web-based interventions for patients with depression can reduce their symptoms and are expected to fill currently existing treatment gaps. However, evidence for their efficacy has mainly been derived from comparisons with wait-list or treatment as usual controls. In particular, designs using wait-list controls are unlikely to induce hope and may even have nocebo effects, making it difficult to draw conclusions about the intervention’s efficacy. Studies using active controls are rare and have not yielded conclusive results. Objective The main objective of this study is to assess the acute and long-term antidepressant efficacy of a 6-week, guided, web-based self-management intervention building on the principles of cognitive behavioral therapy (iFightDepression tool) for patients with depression compared with web-based progressive muscle relaxation as an active control condition. MethodsA total of 348 patients with mild-to-moderate depressive symptoms or dysthymia (according to the Mini International Neuropsychiatric Interview) were recruited online and randomly assigned to 1 of the 2 intervention arms. Acute antidepressant effects after 6 weeks and long-term effects at 3-, 6-, and 12-month follow-up were studied using the Inventory of Depressive Symptomatology–self-rating as a primary outcome parameter and change in quality of life (Short Form 12) and user satisfaction (client satisfaction questionnaire) as secondary outcome parameters. Treatment effects were assessed using mixed model analyses. ResultsOver the entire observation period, a greater reduction in symptoms of depression (P=.01) and a greater improvement of life quality (P
... The use of a blended approach, i.e. combining in-person and Internet-based activities, allows employees to choose their own balance between disclosure and anonymity (Lehr, et al. 2016). By doing that, it is possible to develop an occupational e-mental health website including training materials based on previous work such as iFightDepression (Arensman, et al., 2015), ReConnect (Gammon, et al., 2017) and SMART (Williams, et al., 2018), but specifically created to support workplace mental health. ...
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Pg. 13 In this era of change, higher education vessels, commissioned with the task of advancing knowledge, face the emergence of a global knowledge economy that call into question, the purpose, function, and delivery of education. By incorporating internationalization aspects into the core of strategy, universities hope to strengthen their enterprise in an era where self-sustainment and continued renewal help ensure their future. Although supportive literature focuses on structural aspects of implementing internationalization strategy (such as: the recruitment of foreign students and faculty, curriculum's that consider employ-ability globally and the nurturing of partnerships internationally), there seems to be a gap in literature that outlines issues relating to substance that could be beneficial for higher education institutions wishing to enact change through an internationalization strategy. Creating university specific strategies that are communicated through entrepreneurial thinking, have the potential to provide fertile ground for innovation where higher education institutions can thrive in a continual state of becoming. The purpose of this conceptual contribution is to bring forward theory that can be used to support innovation, collaboration, and communication among faculty (academics, organization staff). This is accomplished by bringing to the forefront, alternative views on the ideologies and rationales hidden within the concept of internationalization, along with how change and disruption can contribute to development and knowledge creation by transforming how people experience university life.. This contribution contains rationales and ideologies that support both academic and organizational faculty and is part of a publication series that explores concepts of internationalization as a strategic choice at Arcada University of Applied Sciences, located in Helsinki, Finland. Keywords: Entrepreneurial thinking, Higher education, Internationalization strategy, University experience
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Empowered by advancements in social media technologies, Collective Intelligence (CI) systems in recent decades have enabled effective and efficient mobilization and utilization of the skills and knowledge of crowds over the web. Unfortunately, even with the plethora of CI solutions available on the web, the development of CI systems remains an exhaustive and costly venture. Literature suggests that this is because there is a fundamental gap in our understanding of CI systems in general. This work addresses this gap, through a first-of-its-kind ‘generic’ CI framework and model, designed to empower researchers, developers, and stakeholders by enabling them to better understand existing and develop new CI platforms.
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Background: Depression is one of the leading causes of human misery and disability worldwide. For those fortunate enough to have access to the rapidly expanding World Wide Web, online self-help tools can guide those suffering from depression, with or without professional intervention, to better manage their symptoms and maintain some measure of self-actualization. This study assesses the efficacy of the widely used, online self-help tool, iFightDepression®. Methods: A six-week, observational study was conducted with 143 participants (29.4% men, mean age: 37.8; standard deviation [SD] = 12.05, range = 18-70, years) in three intervention groups, as follows: 1) Treatment As Usual (TAU), 2) TAU combined with access to the iFightDepression® tool (TAU + iFD®), 3) TAU combined with iFightDepression® and weekly phone support (TAU + iFD® + phone). Depression symptoms were measured pre- and post- by Patient Health Questionnaire-9. Results: There was a significantly greater decrease of depressive symptoms in both iFD® groups compared to the TAU group (time × group interaction: F(2) = 34.657, p < 0.001, partial η2 = 0.331). The reliable change index calculation identified one participant (0.7%) as having experienced a statistically reliable deterioration in depression. A total of 102 participants (71.3%) showed no reliable change, while 40 participants (28.0%) showed a statistically reliable improvement. Multiple binary logistic regression analysis found odds of reliable improvement to be significantly higher in both iFD® groups compared to the TAU group (TAU + iFD®: OR = 18.52, p = 0.015, TAU + iFD® + Phone: OR = 126.72, p < 0.001). Participants living in Budapest were found to have significantly higher odds for a reliable improvement compared to those living in the countryside (odds ratio [OR] = 4.04, p = 0.023). Finally, higher levels of depressive symptoms at baseline (pretest) were also associated with increased odds for post-intervention improvement (OR = 1.58, p < 0.001). The variance explained by the model is 62.0%. With regards to the iFD® self-help program, the mean of completed modules was 4.8 (SD = 1.73, range = 1-6). Participants in the group supported by weekly phone calls completed significantly more modules (n = 50, M = 5.7, SD = 0.76) than participants without weekly telephone support (n = 52, M = 3.9, SD = 1.94, Z = 5.253, p < 0.001). However, there was no significant difference in the number of completed modules between respondents with a reliable improvement in depression (n = 39, M = 4.9, SD = 1.57) and those without a reliable change (n = 63, M = 4.7, SD = 1.83, Z = 0.343, p = 0.731). Conclusion: Our results confirm previous findings regarding the efficacy of web-based interventions with the low-intensity guidance of mental health professional. Findings suggest that a relatively short additional weekly call may result in a significant decrease in depressive symptoms and higher number of completed iFD® modules. The study confirms that the IFD® tool, both alone and with additional phone support, is a possible and effective way to help patients with mild to moderate and, in some cases, even severe depression. Providing mental and primary health care systems with the availability of online self-help tools may contribute to the efficacious treatment of depression and prevention of the increase in depressive symptoms.
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Background and Objectives: The Internet is widely used and disseminated amongst youngsters and many web-based applications may serve to improve mental health care access, particularly in remote and distant sites or in settings where there is a shortage of mental health practitioners. However, in recent years, specific digital psychiatry interventions have been developed and implemented for special populations such as children and adolescents. Materials and Methods: Hereby, we describe the current state-of-the-art in the field of TMH application for young mental health, focusing on recent studies concerning anxiety, obsessive-compulsive disorder and affective disorders. Results: After screening and selection process, a total of 56 studies focusing on TMH applied to youth depression (n = 29), to only youth anxiety (n = 12) or mixed youth anxiety/depression (n = 7) and youth OCD (n = 8) were selected and retrieved. Conclusions: Telemental Health (TMH; i.e., the use of telecommunications and information technology to provide access to mental health assessment, diagnosis, intervention, consultation, supervision across distance) may offer an effective and efficacious tool to overcome many of the barriers encountering in the delivery of young mental health care.
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In this era of change, higher education vessels, commissioned with the task of advancing knowledge, face the emergence of a global knowledge economy that call into question, the purpose, function, and delivery of education. By incorporating internationalization aspects into the core of strategy, universities hope to strengthen their enterprise in an era where self-sustainment and continued renewal help ensure their future. Although supportive literature focuses on structural aspects of implementing internationalization strategy (such as: the recruitment of foreign students and faculty, curriculum's that consider employ-ability globally and the nurturing of partnerships internationally), there seems to be a gap in literature that outlines issues relating to substance that could be beneficial for higher education institutions wishing to enact change through an internationalization strategy. Creating university specific strategies that are communicated through entrepreneurial thinking, have the potential to provide fertile ground for innovation where higher education institutions can thrive in a continual state of becoming. The purpose of this conceptual contribution is to bring forward theory that can be used to support innovation, collaboration, and communication among faculty (academics, organization staff). This is accomplished by bringing to the forefront, alternative views on the ideologies and rationales hidden within the concept of internationalization, along with how change and disruption can contribute to development and knowledge creation by transforming how people experience university life.. This contribution contains rationales and ideologies that support both academic and organizational faculty and is part of a publication series that explores concepts of internationalization as a strategic choice at Arcada University of Applied Sciences, located in Helsinki, Finland. Keywords: Entrepreneurial thinking, Higher education, Internationalization strategy, University experience
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This article summarises the results of a study on how European countries have responded to budgetary pressures in the context of the global economic crisis. The study highlights the wide range of health policy responses and notes some of the trade-offs involved. To date, national governments in the European Union (EU) have been largely responsible for making these trade-offs but where countries are receiving bailout packages, international organisations are now directly intervening in national health policies. Regardless of who the decision maker is, these trade-offs should be understood and made explicit. Ideally, policy decisions should be guided by a focus on enhancing value in the health system rather than on identifying areas in which cuts might most easily be made.
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Objective To examine the process of case finding for depression in people with diabetes and coronary heart disease within the context of a pay-for-performance scheme. Design Ethnographic study drawing on observations of practice routines and consultations, debriefing interviews with staff and patients and review of patient records. Setting General practices in Leeds, UK. Participants 12 purposively sampled practices with a total of 119 staff; 63 consultation observations and 57 patient interviews. Main outcome measure Audio recorded consultations and interviews with patients and healthcare professionals along with observation field notes were thematically analysed. We assessed outcomes of case finding from patient records. Results Case finding exacerbated the discordance between patient and professional agendas, the latter already dominated by the tightly structured and time-limited nature of chronic illness reviews. Professional beliefs and abilities affected how case finding was undertaken; there was uncertainty about how to ask the questions, particularly among nursing staff. Professionals were often wary of opening an emotional ‘can of worms’. Subsequently, patient responses potentially suggesting emotional problems could be prematurely shut down by professionals. Patients did not understand why they were asked questions about depression. This sometimes led to defensive or even defiant answers to case finding. Follow-up of patients highlighted inconsistent systems and lines of communication for dealing with positive results on case finding. Conclusions Case finding does not fit naturally within consultations; both professional and patient reactions somewhat subverted the process recommended by national guidance. Quality improvement strategies will need to take account of our results in two ways. First, despite their apparent simplicity, the case finding questions are not consultation-friendly and acceptable alternative ways to raise the issue of depression need to be supported. Second, case finding needs to operate within structured pathways which can be accommodated within available systems and resources.
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The suicide rate in Hungary is high in international comparison. The two-year community-based four-level intervention programme of the European Alliance Against Depression (EAAD) is designed to improve the care of depression and to prevent suicidal behaviour. Our aim was to evaluate the effectiveness of a regional community-based four-level suicide prevention programme on suicide rates. The EAAD programme was implemented in Szolnok (population 76,311), a town in a region of Hungary with an exceptionally high suicide rate. Effectiveness was assessed by comparing changes in suicide rates in the intervention region after the intervention started with changes in national suicide rates and those in a control region (Szeged) in the corresponding period. For the duration of the programme and the follow-up year, suicide rates in Szolnok were significantly lower than the average of the previous three years (p = .0076). The suicide rate thus went down from 30.1 per 100,000 in 2004 to 13.2 in 2005 (-56.1 %), 14.6 in 2006 (-51.4 %) and 12.0 in 2007 (-60.1 %). This decrease of annual suicide rates in Szolnok after the onset of the intervention was significantly stronger than that observed in the whole country (p = .017) and in the control region (p = .0015). Men had the same decrease in suicide rates as women. As secondary outcome, an increase of emergency calls to the hotline service (200%) and outpatient visits at the local psychiatry clinic (76%) was found. These results seem to provide further support for the effectiveness of the EAAD concept. Whilst the majority of suicide prevention programs mainly affect female suicidal behaviour, this programme seems to be beneficial for both sexes. The sustainability and the role of the mediating factors (social service and health care utilization, community attitudes about suicide) should be key points in future research.
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Background Most patients with mild to moderate depression receive treatment in primary care, but despite guideline recommendations, structured psychological interventions are infrequently delivered. Research supports the effectiveness of Internet-based treatment for depression; however, few trials have studied the effect of the MoodGYM program plus therapist support. The use of such interventions could improve the delivery of treatment in primary care. Objective To evaluate the effectiveness and acceptability of a guided Web-based intervention for mild to moderate depression, which could be suitable for implementation in general practice. Methods Participants (N=106) aged between 18 and 65 years were recruited from primary care and randomly allocated to a treatment condition comprising 6 weeks of therapist-assisted Web-based cognitive behavioral therapy (CBT), or to a 6-week delayed treatment condition. The intervention included the Norwegian version of the MoodGYM program, brief face-to-face support from a psychologist, and reminder emails. The primary outcome measure, depression symptoms, was measured by the Beck Depression Inventory-II (BDI-II). Secondary outcome measures included the Beck Anxiety Inventory (BAI), the Hospital Anxiety and Depression Scale (HADS), the Satisfaction with Life Scale (SWLS), and the EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D). All outcomes were based on self-report and were assessed at baseline, postintervention, and at 6-month follow-up. ResultsPostintervention measures were completed by 37 (71%) and 47 (87%) of the 52 participants in the intervention and 54 participants in the delayed treatment group, respectively. Linear mixed-models analyses revealed a significant difference in time trends between the groups for the BDI-II, (P=.002), for HADS depression and anxiety subscales (P
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Background Routinely conducting case finding (also commonly referred to as screening) in patients with chronic illness for depression in primary care appears to have little impact. We explored the views and experiences of primary care nurses, doctors and managers to understand how the implementation of case finding/screening might impact on its effectiveness. Methods Two complementary qualitative focus group studies of primary care professionals including nurses, doctors and managers, in five primary care practices and five Community Health Partnerships, were conducted in Scotland. Results We identified several features of the way case finding/screening was implemented that may lead to systematic under-detection of depression. These included obstacles to incorporating case finding/screening into a clinical review consultation; a perception of replacing individualised care with mechanistic assessment, and a disconnection for nurses between management of physical and mental health. Far from being a standardised process that encouraged detection of depression, participants described case finding/screening as being conducted in a way which biased it towards negative responses, and for nurses, it was an uncomfortable task for which they lacked the necessary skills to provide immediate support to patients at the time of diagnosis. Conclusion The introduction of case finding/screening for depression into routine chronic illness management is not straightforward. Routinized case finding/screening for depression can be implemented in ways that may be counterproductive to engagement (particularly by nurses), with the mental health needs of patients living with long term conditions. If case finding/screening or engagement with mental health problems is to be promoted, primary care nurses require more training to increase their confidence in raising and dealing with mental health issues and GPs and nurses need to work collectively to develop the relational work required to promote cognitive participation in case finding/screening.
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Depressive disorders as well as fatal and non-fatal suicidal behaviour continue to be important mental health issues. Because of the close relation between depression and suicidal behaviour, it is likely that preventive actions improving care and optimising treatment for depressed patients result in a reduction of suicidal acts. This was shown in the Nuremberg Alliance against Depression, a two-year four-level community based intervention program associated with a 24% reduction of suicidal acts (completed and attempted suicides combined) compared to a baseline year and a control region. Serving as a model project, this approach has up to now been adopted in more than 100 regions in Germany and Europe. Within the suicide prevention project OSPI-Europe, the four-level-approach was optimized and further implemented and evaluated in different European regions.
Article
OBJECTIVE—To systematically review the effectiveness of self-management training in type 2 diabetes.RESEARCH DESIGN AND METHODS—MEDLINE, Educational Resources Information Center (ERIC), and Nursing and Allied Health databases were searched for English-language articles published between 1980 and 1999. Studies were original articles reporting the results of randomized controlled trials of the effectiveness of self-management training in people with type 2 diabetes. Relevant data on study design, population demographics, interventions, outcomes, methodological quality, and external validity were tabulated. Interventions were categorized based on educational focus (information, lifestyle behaviors, mechanical skills, and coping skills), and outcomes were classified as knowledge, attitudes, and self-care skills; lifestyle behaviors, psychological outcomes, and quality of life; glycemic control; cardiovascular disease risk factors; and economic measures and health service utilization.RESULTS—A total of 72 studies described in 84 articles were identified for this review. Positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demonstrated in studies with short follow-up (<6 months). Effects of interventions on lipids, physical activity, weight, and blood pressure were variable. With longer follow-up, interventions that used regular reinforcement throughout follow-up were sometimes effective in improving glycemic control. Educational interventions that involved patient collaboration may be more effective than didactic interventions in improving glycemic control, weight, and lipid profiles. No studies demonstrated the effectiveness of self-management training on cardiovascular disease–related events or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studies reviewed, and external generalizability was often limited.CONCLUSIONS—Evidence supports the effectiveness of self-management training in type 2 diabetes, particularly in the short term. Further research is needed to assess the effectiveness of self-management interventions on sustained glycemic control, cardiovascular disease risk factors, and ultimately, microvascular and cardiovascular disease and quality of life.
Article
Objective: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity. Measurements: The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. Results: As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. Conclusion: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
Article
Background: Self management approaches with mental health problems have been developing recently through condition-specific courses, e.g., the Manic Depression Fellowship Course, Rethink Self Management Course and generic courses, e.g., the Wellness Recovery Action Plan (WRAP) and the Expert Patient Programme. These approaches have been service user led and developed and are now beginning to be taken seriously by mental health professionals. Aims: To trace the development of recovery and self management approaches in the UK and abroad and to explore whether self management models transferred from physical health are helpful for mental health. Results: Programmes for recovery derived from physical illnesses cannot be implemented in mental health without some changes and disorder specific self management programmes are complementary rather than alternatives. Both have their advantages and disadvantages. In particular, models which are professionally led are not only less attractive to service users but also seem to “lend responsibility” rather than sharing it. Conclusion: Self management models derived from a recovery model and service users' experiences may have more value than models derived from physical health. Declaration of interest: None.