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Development and initial evaluation of blended cognitive behavioural treatment for Major Depression in Routine Specialized Mental Health Care

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Development and initial evaluation of blended cognitive behavioural treatment for Major Depression in Routine Specialized Mental Health Care

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Background: Blended care combines face-to-face treatment with web-based components in mental health care settings. Blended treatment could potentially improve active patient participation, by letting patients work though part of the protocol autonomously. Further, blended treatment might lower the costs of mental health care, by reducing treatment duration and/or therapist contact. However, knowledge on blended care for depression is still limited. Objectives: To develop a blended cognitive behavioural treatment (bCBT) for depressed patients in an outpatient specialized mental health care centre and to conduct a preliminary evaluation of this bCBT protocol. Method: A bCBT protocol was developed, taking recommendations into account from depressed patients (n = 3) and therapists and experts in the field of e-health (n = 18). Next, an initial evaluation of integrated high-intensive bCBT was conducted with depressed patients (n = 9) in specialized mental health care. Patients' clinical profiles were established based on pre-treatment diagnostic information and patient self-reports on clinical measures. Patient treatment adherence rates were explored, together with patient ratings of credibility and expectancy (CEQ) before treatment, and system usability (SUS) and treatment satisfaction after treatment (CSQ-8). During and after treatment, the blended treatment protocol was evaluated in supervision sessions with the participating therapists (n = 7). Results: Seven out of nine patients started bCBT, of whom five completed ≥90% of treatment. System usability was evaluated as being above average (range 63 to 85), and patients were mostly to very satisfied with bCBT (range 16 to 32). Patients reported improvements in depression, health-related quality of life and anxiety. We observed that therapists evaluated the highly structured blended treatment as a helpful tool in providing evidence-based treatment to this complex patient group. Discussion: Although no conclusions can be drawn based on the current study, our observations suggest that a blended CBT approach might shorten treatment duration and has the potential to be a valuable treatment option for patients with severe depression in specialized mental health care settings. Further exploration of the effectiveness of our bCBT protocol by means of a randomized controlled trial is warranted.
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Development and initial evaluation of blended cognitive behavioural
treatment for major depression in routine specialized mental health care
Lisa C. Kooistra
a,b,
, Jeroen Ruwaard
a,b
, Jenneke E. Wiersma
b,c
, Patricia van Oppen
b,c
, Rosalie van der Vaart
d
,
Julia E.W.C. van Gemert-Pijnen
e
,HeleenRiper
a,b,c,f
a
Faculty of Behavioural and Movement Sciences, Department of Clinical-, Neuro- and Developmental Psychology, VU University Amsterdam, Van der Boechorststraat 1, BT 1081 Amsterdam, The
Netherlands
b
EMGO Institute for Health Care and Research, VU University Medical Centre, Van der Boechorststraat 1, BT 1081 Amsterdam, The Netherlands
c
Department of Psychiatry, GGZ inGeest and VU University Medical Centre, P.O. Box 7057, Amsterdam MB 1007, the Netherlands
d
Health, Medical and Neuropsychology Unit, Leiden University, Wassenaarseweg 52, AK 2333, Leiden, The Netherlands
e
Department of Psychology, Health & Technology, University of Twente, Drienerlolaan 5, NB 7522, Enschede, The Netherlands
f
Faculty of Health Sciences, the Institute of Clinical Research /Telepsychiatric Centre, Mental Health Services in the Region of Southern Denmark, University of Southern Denmark, Winsløwparken
19, DK-5000 Odense, Denmark
abstractarticle info
Article history:
Received 4 August 2015
Received in revised form 24 December 2015
Accepted 25 January 2016
Available online 27 January 2016
Background: Blended care combines face-to-face treatment with web-based components in mental health care set-
tings. Blended treatment could potentially improve active patient participation, by letting patients work though part
of the protocol autonomously. Further, blended treatment might lower the costs of mental health care, by reducing
treatment duration and/or therapist contact. However, knowledge on blended care for depression is still limited.
Objectives: To develop a blended cognitive behavioural treatment (bCBT) for depressed patients in an outpatient
specialized mental health care centre and to conduct a preliminary evaluation of this bCBT protocol.
Method: A bCBT protocol was developed, taking recommendations into account from depressed patients (n = 3)
and therapists and experts in the eld of e-health (n = 18). Next, an initial evaluation of integrated high-
intensive bCBT was conducted with depressed patients (n = 9) in specialized mental health care. Patients' clinical
proles were established based on pre-treatment diagnostic information and patient self-reports on clinical mea-
sures. Patient treatment adherence rates were explored, together with patient ratings of credibility and expectancy
(CEQ) before treatment, and system usability (SUS) and treatment satisfaction after treatment (CSQ-8). During and
after treatment, the blended treatment protocol was evaluated in supervision sessions with the participating ther-
apists (n = 7).
Results: Seven out of nine patients started bCBT, of whom ve completed 90% of treatment. System usability was
evaluated as being above average (range 63 to 85), and patients were mostly to very satised with bCBT (range 16 to
32). Patients reported improvements in depression, health-related quality of life and anxiety. We observed that
therapists evaluated the highly structured blended treatment as a helpful tool in providing evidence-based treat-
ment to this complex patient group.
Discussion: Although no conclusions can be drawn based on the current study, our observations suggest that a blend-
ed CBT approach might shorten treatment duration and has the potential to be a valuable treatment option for pa-
tients with severe depression in specialized mental health care settings. Further exploration of the effectiveness of
our bCBT protocol by means of a randomized controlled trial is warranted.
© 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords:
Blended cognitive behavioural therapy
Online treatment
Face-to-face treatment
Depression
Routine practise
Outpatient specialized mental health care
1. Introduction
Cognitive behavioural treatment (CBT) for depression has been
studied extensively and has proved to be a clinically effective
psychotherapy (Butler et al., 2006; Cuijpers et al., 2013a, b). More re-
cently, studies have shown that CBT for depression can be effectively ad-
ministered in web-base d settings (Andersson and Cuijpers, 2009;
Andrews et al., 2010; Kelders et a l., 2015; Richards and Richardson,
2012). Furthermore, web-based treatment appears to be acceptable to
both patients and therapists (Andrews and Williams, 2014; Becker
and Jensen-Doss, 2013).
Although most studies focussed on patients with mild to moderate
symptoms (Richards and Richardson, 2012), recent studies also show
Internet Interventions 4 (2016) 6171
Corresponding author at: Faculty of Behavioural and Movement Sciences, Department
of Clinical-, Neuro- and Developmental Psychology, VU University Amsterdam, Van der
Boechorststraat 1, BT 1081 Amsterdam, The Netherlands.
E-mail address: l.c.kooistra@vu.nl (L.C. Kooistra).
http://dx.doi.org/10.1016/j.invent.2016.01.003
2214-7829 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Contents lists available at ScienceDirect
Internet Interventions
journal homepage: www.elsevier.com/locate/invent
promising treatment effects and acceptability for patients with more
severe symptoms (Andrews and Williams, 2014; Hedman et al., 2014;
Ruwaard et al., 2012; Williams and Andrews, 2013). Furthermore,
internet interventions guided by a professional have been shown
to have similar treatment effects to face -to-face treatment
(Andersson et al., 2014), although the number of studies that exam-
ined the relative efcacy of face-to-fa ce versus online psychotherapy
is limited.
An important potential benet of web-based treatment is that it can
facilitate the delivery of evidence-based treatment protocols, such as
CBT (Andrews and Williams, 2014). Research sugge sts that only a
limited amount of patients in routine practise actually receives
evidence-ba sed treatment (Gyani et al., 2014; Harvey and Gumport,
2015). This is caused both by under-treatment of mental disorders
such as depression (Demyttenaere et al., 2004; Harvey and Gumport,
2015) and therapist drift from evidence-based treatment protoc ols
(Waller, 2009). By providing CBT in a web-based f ormat, therapist
adherence to evidence-based treatment protocols can potentially be
improved (Andersson, 2010; Månsso n et al., 2013), because the
online treatment environment provides all core treatment constructs
(Andr ews and Willia ms, 2014). In addition, online treatment is
believed to improve the accessibility and affordability of evidence-
based mental health care. Studies suggest that online treatments
may reduce therapist time per patient, because patients are encouraged
to work through the treatment protocol more autonomously, and ther-
apists can provide feedback online instead of during face-to-face ses-
sions at the clinic (Hedman et al., 2014; Kenter et al., 2015). This, in
turn, may lower treatment costs and allow therapists to take on more
patients.
Within the Dutch h ealth care syste m these potential benets are
highly relevant to specialized mental health care, because mental health
services in this setting focus on more complex, chronic and severe pa-
tients. Therefore, treatment costs tend to be higher compared to prima-
ry care (Spijker et al., 2013) in combination with long waiting lists due
to treatment duration and limited nancial resources (Bower and
Gilbody, 2005; Lovell and Richards, 2000).
Despite the potential benets of online treatment, only a small
number of patients are reached with online therapies in routine practise,
particularly in specialized mental health care (Bremmer and van Es,
2013; Kenter et al., 2015). A possible reason for the relatively low
uptake in routine practise could be that end-users, such as patients
and therapists, lack knowledge about the potential costs and benets
of online treatment (Bremmer and van Es, 2013). Further, therapists
are sceptical about whether online treatment could benet treatment
outcomes compared to face-to-face treatment (Becker and Jensen-
Doss, 2013).
The integration of on line treatment into routine mental health
care could potentially be stimulated by offering treatment in a blended
format (Cuijpers and Riper, 2014). This form of treatment integrates
face-to-face treatment sessions and online sessions into one treatment
protocol (Riper et al., 2013). Blended treatment aims to preserve
personal contact and the therapeutic relationship that is associated
with stand-alone face-to-face psychotherapy, while utilizing web-
based treatment to stimulate active patient participation and im-
prove the accessibility and affordability of treatmen t (
Kenter et al. ,
2015).
A
nother possible benet of blended treatment is that it can facilitate
increased treatment intensity, for example by adding one online session
per week alongsid e a face-to-face session. A recent met aregression
analysis (Cuijpers et al., 2013b) indicated that intensifying treatment
augments the effectiveness of face-to-face psychotherapy, with a treat-
ment intensity of two sessions per week increasing the effect size with
g = 0.45 compared to one session per week.
Although high intensity blended treatment has not yet been studied,
preliminary evidence that a blended treatment format can offer CBT
effectively was provid ed by the uncontrolled study of Månsson and
colleagues (nsson et al., 2013), focussin g on a community-based
sample of patients with moderate anxiety or depression (n = 15).
Further, a recent Delphi study suggested that blended treatment is pos-
itively perceived by patients and therapists (Van der Vaart et al., 2014).
Other available studies focussed on combined cognit ive behav-
ioural face- to-face and online treatment for depression. The results
suggest that this combination treatment can achieve promising clin-
ical results (Hickie et al., 2010; Høifødt et al., 2013; Kenter et al.,
2013; Robertson et al., 2006). However, combining the two treat-
ment formats rather than blending them int o one treatment protocol
can also lead to increased treatm ent dosage and higher costs (Kenter
et al., 2015).
The current study expands on the aforementioned studies by devel-
oping a highly structured and integrated blended CBT (bCBT) protocol
for depressed patients in specialized mental health care. This paper de-
scribes the development of the protocol and initial experiences with
blended treatment.
2. Methods
2.1. Development of blended cognitive behavioural treatment (bCBT)
Our primary objective was to develop a bCBT protocol for depression
in specialized mental health care, because, to the best of our knowledge,
such a protocol was not yet available.
2.1.1. Therapist and expert recommendations
In order to acquire input on how online and face-to-face treatment
sessions could be integrated, we consulted CBT therapists working at a
specialized mental health care centre in Amsterdam, the Netherlands,
and Dutch experts in the eld of web-based treatment (n = 18) in
four two-hour group discussions. During these meetings, we discussed
possible benets and limitations of online a nd face-to-face sessions,
and participants could express specic recommendations for the blend-
ed CBT protocol. Sessions were recorded and transcribed,
1
and minutes
were taken during the sessions by the rst author (LK).
Next, authors one (LK), two (JR), three (JW), four (PvO) and seven
(HR) discussed the ndings. Based on group consensus, the following
therapist recommendations were incorporated into the treatment
protocol:
Tre atment starts with a face-to-face session, in order to establish
a therapeutic relati onship, motivate patients for tr eatment and
explain working with the online treatment environment to
patients.
Face-t o-face sessions and online sessions are provided in equal
measure (50%/50% ratio). Therapists expected that the proposed
ratio would enable them to provide adequate therapist support
to p atients, thus promoting treatment motivation a nd preventing
patients from dropping out of treatment.
Face-to-face sessions focus on adapting the treatment content to
individual patient needs, for example by p ractis ing skills in rol e
plays and helping patients t o identify their core problems. Online
sessions are used to offer background information, record mood
ratings and provide homework excercises.
The treatment is structured as a xed sequence of treatment
modules, instead of tailoring online content to individual pa tients
by al lowing therapists and p atients to choose from tr eatment
modules and/or adjust th e order of module s. This was done pri-
marily to ensure delivery of the full CBT protocol. Therapists
also noted that a exible rather than xed approach would
1
Due to technical problems, the audio recordings of one therapist group-session and
one expert group session were not usable.
62 L.C. Kooistra et al. / Internet Interventions 4 (2016) 6171
require them to have extensive knowledge on the content of
the protocol and experience with working with the web-based
treatment environment. This led th em to prefer working
with a xed treatment protocol duri ng the initial eval uation
phase.
Online sessions in clude an optional, open-ended sessi on evalua -
tion question, to allow patients 1) to comment on the online ses-
sions, and 2) to promote reective thinking on the meaning and
impact of the homework excersise s.
Email remi nders are sent in ord er to encourage patients to access
the online platform and engag e in treatment.
Online therapist feedback is provided after each online session , in
order to monitor and motiv ate patients between the face-to-face
and online sessions.
2.1.2. Patient recommendations
In order to incorporate the patient perspective, we showed the pro-
totypes of the bCBT protocol (MS Word document) and web-based
treatment delivery system (Minddistrict; www.minddistrict.com), to a
convenience sample of patients (n = 3) during a 90-min group meeting.
The patients (two males, one female) were in the nal phase of face-to-
face CBT treatment for depression at an outpatient clinic of a specialized
mental health care centre in Amsterdam, the Netherlands. The meeting
took place at the mental health care centre and was led by the third au-
thor (JW). Minutes were taken during the meeting by the rst author
(LK). Next, authors one (LK), two (JR), three (JW), four (PvO) and
seven (HR) discussed the patient recommendations. Based on group
consensus, the following elements were incorporated into the treat-
ment protocol:
The patients raised concerns about the amount of homework. Based
on this, online exercises are split into mandatory and optional
exercises, to ensure that completion of exercises is feasible on bad
days, preventing unnecessary negative effects of treatment work-
load.
No changes were made to the web-based treatment delivery system.
The patients have access to one new session at a time in the web-
based treatment system, instead of all sessions at once.
At the beginning of each face-to-face session, 15 min are reserved for
patients to discuss personal issues that arose over the past week.
This can be related to the online homework, but can also incorporate
discussions of other challenges that patients faced.
Face-to-face sessions are provided on a weekly basis, because the pa-
tients thought it was important to see their therapist regularly at the
specialized mental health care clinic. This matched the therapist
recommendations.
2.2. Initial evaluation of blended cognitive behavioural treatment (bCBT)
The prototype of the bCBT protocol was offered to a small group of
patients, in order to explore the reach and acceptability of the bCBT pro-
tocol. Measurements were taken at baseline (pre-treatment) and post-
treatment (10 weeks). The Medical Ethics Review Committee of the VU
University Medical Centre in Amsterdam, the Netherlands approved the
study (REF 2013/381). The study was carried out between January 2014
and May 2014.
2.2.1. Participants
Patients (n = 9) were recruited at an outpatient clinic of a spe-
cialized mental health care centre in Amste rdam, the Netherlands.
To participate, patients had to be 18 years or older and be diagnosed
with a current depressive episode, based on the criteria from t he
Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR, APA, 2000). Additionally,
patients needed to have adequate prociency in the Dutch language,
and access to the Internet at home via a (tablet) computer. Patients
were exclude d from the study if individual and/or outpatient
CBT for d epression was not indicated, or if they were already receiv-
ing psychotherapy. Concurrent pharmacotherapy was not an
exclusion criterion. Inclusion and exclusion criteria were assessed
at the outpatient clinic during the routine face-t o-face intake
assessment.
2.2.2. Procedures
The third author (JW) approached patients after their intake assess-
ment at the outpatient clinic and informed them about the study and
bCBT. Potential participants received an information broch ure via
email. After providing written informed consent, patients lled in the
online baseline self-report questionnaires. Before the start of blended
t
reatment, the use of the online treatment platform was demonstrated
to the included patients during an individual 30-min face-to-face ses-
sion at the outpatient clinic. Face-to-face treatment sessions (45 min)
took place at the clinic and patients completed the online sessions at
home. After blended treatment, patients were asked to ll in the online
post-treatment assessments.
Once every two weeks a supervision meeting was held with
the participating therapists. At the end of the study, when all patients
had completed the blended protocol, a nal evaluation meeting
was held in order to prov ide therapists with the opportunity to
evaluate the bCBT protocol. Minutes were taken during all supervision
sessions. The nal evaluation meeting was audio-rec orded and
transcribed.
2.2.3. Measures
In order to gain insight into the feasibility (Leon et al., 2011) of bCBT,
we rst examined the reach of the intervention in terms of the
proportion of patients enrolled at the mental health care cent re that
was eligible for bCBT. Next, the clinical proles and treatment outcomes
of patients that were enrolled in bCBT were explored based on patients'
electronic patient records and clinical self-report measures. Finally,
patients' treatment adherence to bCBT, and patient self-reports
on treatment acceptability, usage and satisfaction were a ssessed.
All self-report measures used in our study are considered to
have good psychometric properties and were administe red via the
Internet.
2.2.3.1. Clinical proles. Information on baseline functioning was extract-
ed from the electronic patient les. This information included current
DSM-IV-TR diagnosis (APA, 2000), use of anti-depressant medication
and cur rent Global Assessment of Functioning (GAF) index sc ore
(APA, 2000). Socio-demographic information such as gender, age, na-
tionality, level of education and employment status were collected
with a self-report ques tionnaire at baseline as part of the c urrent
study. In addition, clinical self-report measures were used to gain in-
sight into the clinical patient proles before and im mediately after
treatment. We used questionnaires that were proposed by the mental
health care centre for routine outcome measurement (ROM) before
and immediately after treatment.
The 30-item self-report version of the Inventory of Depressive
Symptoms (IDS-SR
30
) was used to assess the severity of depressive symp-
toms in the past week (Rush et al., 2000). Total scores range from 0 to 84,
with higher scores indicating greater severity of depressive symptoms
(Trivedi et al., 2004). The severity index ranges from 0 to 4 and is built
up as follows; IDS-SR
30
scores 0 to 13 = 0 (None), scores 14 to 25 =
1 (Mild), scores 26 to 38 = 2 (Moderate), scores 39 to 48 = 3 (Severe),
and scores 49 to 84 = 4 (Very severe).
The Beck Anxiety Inventory (BAI) (Beck and Steer, 1993) was used
to measure anxiety. Total scores range from 0 to 63, with higher scores
indicating a higher level of anxiety (Trivedi et al., 2004). The severity
index ranges from 0 to 3 and is built up as follows; BAI scores 0 to
63L.C. Kooistra et al. / Internet Interventions 4 (2016) 6171
9 = 0 (Normal or no anxiety), scores 10 to 18 = 1 (Mild to moderate),
scores 19 to 29 = 2 (Moderate to sever e), and scores 30 to 63 = 3
(Severe anxiety) (Aaron T Beck et al., 1988).
Furthermore, health-related quality of life was measured with the
EuroQol qu estionnaire (EQ-5D-3 L) (EuroQol Group, 1990; Lamers
et al., 2006). The questionnaire is composed of a visual analogue scale
(VAS) ranging from 0 to 100, and ve items with 3 response categories
each. The combination of responses on the ve items is converted into
health states based on utility weights (Lamers et al., 2006). Health
state scores range from 0 to 1, with 1 representing the best possible
state of health (Brooks, 1996).
2.2.3.2. Patient evaluation of bCBT. Treatment expectancy and credibility
were measured before the start of bCBT with the 6-item credibility/ex-
pectancy questionnaire (CEQ)(Devilly and Borkovec, 2000). Total scores
on the credibility and expectancy scales range between 3 and 27. Total
scores for the overall scale range between 6 and 54. Higher scores indi-
cate higher credibility and more positive treatment expectations
(Devilly and Borkovec, 2000).
After bCBT, pati ents rated system usability of the online treat-
ment platf orm on the 10-item System Usability Scale (SUS)
(Bangor et al., 2008; Brooke, 1996). Total SUS scores are convert-
ed to a 0 to 100 scale, wit h higher scores b eing indicati ve of
greater system usabilit y. A S US scor e above 68 is considere d
above average (Sauro, 2011), indicati ng acceptable experienced
system usability.
Post-treatment satisfaction with bCBT was measured with the
Client Satisfaction Questionnaire-8 (CSQ-8) (Larsen et al., 1979). The
CSQ-8 consists of 8 items. The tota l sc ores range between 8 and 32,
with higher scores indicating better treatment satisfaction (De Brey,
1983).
Information on treatment adherence (number of completed face-
to-face sessions) was extracted from the electronic patient les. Infor-
mation on the use of the number of completed online sessions was ex-
tracted from the web-based treatment platform (Minddistrict; www.
minddistrict.com).
2.2.4. Analyses
Data on treatment adherence, credibility, usage and satisfaction and
clinical measures are presented on an individual patient level. Simple
summary statistics (M, SD) are presented to provide a clinical descrip-
tion of the included group of participants.
3. Results
3.1. Blended cognitive behavioural treatment (bCBT)
Based on the information gathered in the development phase, an in-
tegrated bCBT protocol was developed by authors one (LK), two (JR),
three (JW), four (PvO) and seven (HR). Fig. 1 provides an overview of
the treatment content and sequence.
The content of the blended protocol is based on a Dutch protocol for
face-to-face CBT in specialized mental health care (Bockting and
Huibers, 2011) which recommends providing 16 to 20 weekly sessions.
This face-to-face CBT protocol is based on the protocol by Beck (Beck
et al., 1979). The blended treatment is intensied compared to standard
CBT, delivering one face-to-face session and one online session per
week for te n weeks, instead of one face-to-face per week for
20 weeks. Both face-to-face and online sessions are highly structured,
and are comprised of psycho-education, behavioural activation, cogni-
tive th erapy and relapse prevention (Spijker et al., 2013)withthe
same order and dosage for all patients.
Fig. 1. Overview of the blended treatment protocol Note: F-to-F sessions: face-to-face sessions; Online FB: online feedback.
64 L.C. Kooistra et al. / Internet Interventions 4 (2016) 6171
3.1.1. Face-to-face sessions
Treatment starts with a face-to-face session in which 1) the therapist
and patient become acquainted with each other, 2) the general aspects
of bCBT are explained, and 3) the online treatment platform is intro-
duced. Each further face-to-face session begins with a short open reec-
tion on the patient's mood, experiences and homework in the past
week, before addressing that week's topic dictated by the protocol. If pa-
tients do not complete a scheduled online session prior to their visit to
the clinic, therapists guide patients through the online session during
the face-to-face session.
3.1.2. Online sessions
The online element of bCBT consists of two parts: 1) a session
that patients work through by themselves, and 2) p ersonalized
therapist f eedback on the completed homework assignments.
Nine online sessions elaborate on the them es of the face-to-f ace
sessions, and consist of psycho-educatio n ( written information,
and a short video in whi ch the information is explained in lay
terms), and homework e xercises, which are illustrated by vi-
gnettes of two ctional patients. In order to facilitate the use of
the online platform, an additional online session that provides sp e-
cic information o n how to work with the plat form is available at
the start of treatment.
Patients are encouraged to access the online platform on a daily
basis, in order to keep a mood diary and complete homework exer-
cises, such as daily activity monitoring. The online sessions are
delivered through a web-based treatment platform (Minddistrict;
www.minddistrict.com), which patients and therapists access se-
curely with a personal login account. The back of ce of the plat-
form enables professional users such as therapists and supervisors
to monitor patients and/or therapists. A messaging system enables
therapists to communicate with each other and with their patients
on the platform. When patients do not complete a scheduled online
session on time, therapis ts use the messaging system to motivate pa-
tients to complete the online session before the upcoming face-to-
face session.
3.2. Initial evaluation of bCBT
3.2.1. Recruitment and allocation of patients
Fig. 2 describes the ow of patients in the study. During the two-
month recruitment period, fty-two patients with depressive symp-
toms were referred to the mental health care centre. The intake staff
at the mental health care centre indicated treatments other than indi-
vidual CBT for twenty-seven patients (52%). Most often this concerned
an indication for 1) other types of psychotherapy (n = 12) such as inter-
personal therapy (IPT), psychoanalytic treatment or cognitive behav-
ioural analysis system of psychotherapy (CBASP) or 2) inpatient or
day-treatment (n = 11).
Twenty-ve patients (48%) were indicated for cognitive behav-
ioural treatment (CBT). Out of these patients, ten were excluded be-
cause the pr imary diagnosis was n ot depre ssion, and one patient had
Fig. 2. Patient Flow Diagram.
65L.C. Kooistra et al. / Internet Interventions 4 (2016) 6171
insufcie nt command o f the Dutch language. F ourteen patients
(27%) t hus met inclusion criteria, of whom t hree decided not to re-
ceive treatment at the specialized mental heal t h care c ent re. There-
fore, eleven patients could be approached for study participation,
of wh om nine agreed to participate in the study and lled in the
baseline quest ionnaires.
3.2.2. Study and treatment adherence
Complete follow-up data is available from seven out of nine
patients (see Table 1). The two patient s who did not complete the
follow-up measures also did not start bCBT (patients 4 and 7).
Patient 4 chose to receive face-to-face CBT instead of bCBT, because
of a malfunctioning computer at home. Patient 7 coul d no longer
travel to the outpatient clinic for the face-to-face sessions, due to -
nan cial problems.
Out of the seven patients who started bCBT, ve completed 90%
or mor e of the blended treatment protocol, receivi ng the full face-
to-face protocol and completing seven (n = 1) or all nine ( n = 4)
online sessions. In this group the bCBT protocol was delivered
in 10 to 13 w eeks (mean = 12, SD = 1.3). Reasons for the two
other pat ients to discontinue bCBT after the start o f treatment
were a full remission of the depressive disorder due to the use of
anti-depressant medication (patient 1) and a shift in the main
focus of treatment from depr ession to attention de cit disorder
(patient 9).
3.2.3. Patient characteristics and clinical proles
Characteristics of the nine participants (ve females, four males)
are d isplayed in Table 1. Six patients reported severe to very severe
depressive symptoms on the IDS-SR
30
and seven w ere diagnose d
with a co-morbid disorder such as anxiety, post-traumatic stress
disorder or an au tism spectrum dis order. Four patient s re ported
that t he current depressive e pisode was their rst episode. For two
patients the current episode was their second e pisode, and the
remaining three patients reported having two or more prior
episodes.
At follow-up a decrease in depression severity was reported by
seven out of eight patients. Severity of depressive s ymptoms in
this group ranged from no severity (n = 3), to mild severity (n = 2)
to mod erate severity (n = 3). Patient 7 reported an increase of two
points on de IDS-SR
30
compared to baseline, indicating very severe
depressive symptoms. Anxiety scores at follow-up decreased in six
out of seven patients. Severity of anxiety symptoms in this group
ranged from normal or no anxiety at follow-up (n = 2), to mild to mod-
erate symptoms (n = 2), to moderate to severe anxiety symptoms
(n = 2). Patient 3 reported having the same mild to moderate anxiety
level before and after treatment.
Health-related quality of life increa sed in four patients. Patient 5
reported the same level of health-relate d quality of life at follow-up
and patient 6 reported a decrease in health-related quality of life after
treatment, due to an increase in physical pain.
3.2.4. Patient evaluation of bCBT
3.2.4.1. Treatment credibility and expectancy. Table 1 displays pre-
treatment credibility and expectancy (CEQ) scores for all nine patients.
Total scores ranged from 31 to 42 (mean = 33.9, SD = 3.6), with six out
of nine patients reporting a neutral attitude concerning overall treat-
ment credibility and expectancy and three patients having a somewhat
to moderately positive attitude.
Table 1
Patient characteristics pre-intervention and post-treatment at individual patient level and group level.
Time Pt 1 Pt 2 Pt 3 Pt 4 Pt 5 Pt 6 Pt 7 Pt 8 Pt 9 Mean (SD)
Demographic characteristics
Sex T0MMF MF F F MF
Age T0 45 43 27 30 39 29 50 45 33 37.98 (8.36)
Education T0 High Mod. High Low High High Low Mod. High
Employed T0 Y Y Y Y Y Y Y N N
Current GAF T0 50 45 50 55 45 50 65 50 51.25 (6.41)
Anti-depressant use T0 Y N Y N Y Y N N N
Co-morbid disorder T0 N Y Y Y Y Y N Y Y
Treatment characteristics
# Face-to-face sessions T1 3 10 11 6 9 10 1 10 4 7.11 (3.69)
# Online sessions T1 3 9 9 0 9 9 0 7 2 5.33 (4.03)
Treatment duration (weeks) T1 3 10 13 7 13 10 1 12 3 7.92 (4.57)
Evaluation of bCBT
CEQ total T0 31 37 42 32 33 34 33 33 31 33.88 (3.61)
CEQ credibility T0 19 18 21 17 17 22 18 17 18 18.56 (1.81)
CEQ expectancy T0 12 19 21 15 16 12 15 16 13 15.33 (3.23)
SUS T1 78 68 70 85 75 63 77 73.21 (7.32)
CSQ-8 T1 22 21 23 32 21 16 24 22.71 (4.82)
Clinical measures
IDS-SR (index)
T0 21 (1) 48 (3) 28 (2) 58 (4) 53 (4) 42 (3) 48 (3) 40 (3) 26 (2) 40.44 (12.87)
T1 5 (0) 24 (1) 11 (0) 26 (2) 23 (1) 50 (4) 36 (2) 11 (0) 23.25 (14.73)
BAI (index)
T0 10 (1) 29 (3) 10 (1) 38 (3) 43 (3) 21 (2) 22 (2) 10 (1) 15 (1) 22 (12.39)
T1 2 (0) 22 (2) 10 (1) 19 (2) 18 (1) 9 (0) 10 (1) 12.86 (7.03)
EQ-VAS
T0 44 50 50 19 46 40 50 33 70 44.67 (13.9)
T1 90 75 75 76 59 66 82 74.71 (10.09)
EQ-5D
T0 0.810 0.377 0.604 0.190 0.686 0.427 0.251 0.337 0.686 0.481 (0.221)
T1 1 0.686 0.774 0.686 0.209 0.772 0.896 0.718 (0.251)
#: Number of; BAI: Beck Anxiety Inventory; CEQ: Credibility/Expectancy Questionnaire; CSQ-8: Client Satisfaction Questionnaire-8; IDS-SR: Inventory of Depressive Symptomatology, Self-
Report. Index: IDS-SR Severity index; Education level: Lower: primary school education; Mod. (Moderate): High school or vocational education; Higher: college degree or upwards; EQ-
VAS: EuroQol-5D-3 L VAS scale; EQ-5D: EuroQol-5D-3 L; GAF index: Global Assessment of Functioning. Mastery: Mastery Scale; Mod.: Moderate; Pt: Patient number;
SD: standard deviation; SUS: system usability scale. Note: given sample limitations, means and standard deviations in the last column should be interpreted as a descriptive summary of
the clinical prole of the group of participants only.
66 L.C. Kooistra et al. / Internet Interventions 4 (2016) 6171
When treatment credibility and expectancy are explored separately,
the range of patients' treatment credibility scores was 17 to 22
(mean = 18.6, SD = 1.8,), with all patients rating bCBT as somewhat
(n = 7) t o moderately credible (n = 2). Treatment expectancy
ranged from 12 to 21 (mean = 15.3, SD = 3.2), ranging from
slightly nega tive (n = 3), to neutral (n = 4), to m oderately positive
(n = 2). Patients' rational e xpect ations appeared to be higher than
their emotional expectations (range 40 to 84, mean = 57.7, SD =
17.3 for thinking versus range 10 to 70, mean 46.4, SD = 19.8, for
feeling).
3.2.5. System usability
At follow-up, seven patients completed the system usability scale
(SUS), evaluating syst em usability of the web-bas ed treatment plat-
form. Table 1 displays individual patient scores. Six out of seven patients
scored 68 or hig her, which is indicative of an above ave rage score
(Sauro, 2011). Total scores ranged from 63 to 85 (mean = 73.2, SD =
7.3), which can be translated into system evaluation adjectives ranging
from OK to good (n = 2) to good to excellent (n = 5) (Bangor et al.,
2009).
3.2.6. Treatment satisfaction
At follow-up, seven patients completed the Client Satisfaction
Questionnaire-8 (CSQ-8), evaluating blended treatment satisfaction.
Table 1 displays individual patient scores. The range in treatment
satisfaction scores was 16 to 32 (mean = 22.7, SD = 4.8). One
participant (patient 8) was somewhat di ssatised with the
content of CBT treatment, suggesting that ano ther type of psycho-
therapy (such as CBASP) might have been a better t. The other
six participants were mostly (n = 5) to very satised (n = 1) with
bCBT.
3.2.7. Exploration of written patient evaluations
As discusse d in the Methods secti on, patie nts could provi de a
written evaluation a t the end of each online sessio n. The open-
ended question, phrased what was your experience with this
lesson, was added to enable patients to 1) to comment on
(evaluate) the o nline sessions, and/or 2) t o promote r eective
thinking on the meaning and impact of the homework excersises.
Relative to the number of completed online sessions per patient, pa-
tients provided 33% to 100% of possible responses (mean = 68.14,
SD = 21.43).
An explorative evaluation was performed, comparing the con-
tent of responses to the intended categories 1) session evaluation
and 2 ) r eection. A su mmary of al l responses ( n = 35) can be
found in Appendix A. The majority of responses appeared to be
of a reective nature (n = 25), with patients elaborating on the
emotional reaction t hey had to the session and/or evaluating
their progress. Examples of such re sponses are: I fou nd it hard
to write everything down. I recognize a lot of myself in the text.
I want to get started in order to rega in control and Because I ru-
min ate a lot, things have not been going well for me. I want to do
th
ings r ight, but I at the same time I do realize that just doing
things is more import ant. I became aware of the fact that I need
structure.
Patients provided information on how they evaluated the ses-
sion on six occasions. For example, two patients commented on
the way cognitive dysfunctions were illustrate d. This was done
by presenting reactions of two ctional patient s to vario us scenar-
ios, such as losing your job, with one patient providing negative
interpretations and thoughts and the other patient pro viding
more positive alternative views. An example of an evaluative re-
sponse was: I did not like the wa y the dysfunctions were present-
ed. It reminde d me of high sch ool. Nevertheless I answered all
que stions.
We also noticed that patients used the open-ended question to pro-
vide information on context (n = 11), such as circum stances under
which the online session was completed: I feel stressed because the
weekend has started and I forgot to work on this session. Yoga was
not as relaxing as I hoped and at the moment I am having two of my
friends over, or past-week experi ences: I went to see colleagues. It
felt good, but now it is hard to unwind again. That still is an important
theme for me.
In addition to the responses on the open-ended question, two pa-
tients provided their therapist with an evaluation of bCBT in general.
Patient 5 stated that: the online part of treatment really helped me a
lot because you can always access it and by d oing so you can put
everything into practise more easily. Patient 6 had a different expe-
rience, and stated that she felt like after e-health the real treatment
could start, explaining further that the treatment protocol felt
restricting because it did not address the full spectrum of he r
problems.
4. Discussion
The aim of this study was to develop an integrated high-intensive
bCBT for depression in outpatient specialized mental health care and
to conduct an initial evaluation of the treatment protocol. Our results in-
dicate that bCBT has the potential to be a suitable intervention for de-
pression in specialized mental health care.
4.1. Reach of bCBT
There was a high willingness to receive blended treatment. Out
of the eleven patients that could be approached for study partici-
pation during the two-month recruitment period, nine agreed to
receive bCB T. The difference bet ween the total number of referre d
patients and the number of patients scre ened for bCBT is largely
explained by the fac t that only a limited proportion of patients
was indicated for CBT for depression (15 out of 52; 29%). This
was mainl y due to the fact that patients were often indicate d
for other treat ments than CBT b y the intake st aff, such as IPT,
CBASP or intensive group treatment (day treatment). In order to
accommodate more pati ents within sp ecialized mental he alth
car e, it could therefore be valuable to explore the option of blend-
ing on line and face-to-face sessions for these kind s of treatment as
well.
Despite making up a relatively small proportion of referred patients,
our patient group did appear to be representative for the patient popu-
lation that is expected in outpatient specialized mental health care,
which includes patients presenting with co-morbid disorders, moderate
to (very) severe depressive symptoms and serious impairments in gen-
eral functioning (Piek et al., 2011).
4.2. Adherence
In the current study, four out of nine patients received the full
bCBT protocol and one patient completed 90% the protocol (i.e. all
10 face-to-face sessions and 7 out of 9 online sessions). We observed
slight d ifferences in the number of face-to-face sessions needed to
ensure delivery of the full content of the bCBT protocol, with one pa-
tient receiving nine face-to-face sessions, three patients receiving all
ten sessions and one patient receiving eleven sessions. Treatment
duration among com pleters ranged from 10 to 13 weeks, in dic ating
that bCBT i ndeed has the pote ntial to s horten treatment duration
compared to the minimu m of 16 to 20 weeks ne eded in face-to-
face CBT.
Reasons for discontinuing bCBT once treatment had started ap-
peared to be unrelated to the blended nature of treatment. Perhaps
unsurprisingly, we found that having Internet access and a function-
al computer at home are key elements for patients in order to be able
67L.C. Kooistra et al. / Internet Interventions 4 (2016) 6171
to receive bCBT. Therapists also not ed this during supervision ses-
sions, adding that ha ving access to up-to-da te hard- and sof tware
atthementalhealthcarecentreisneededinordertomakesure
the online treatment environment can be accessed during the face-
to-face session.
Althoughthesamplesizeistoosmalltodrawconclusions,we
consider the adherence rates to be promising. Future research
needs to establish to what extent these rates are representative for
the patient group in general and how they compare to standard
face-to-face CBT. For example, a recent meta-analysis found
that overall, patient s completed 84% of sessions in face-to-face CBT
and 80% of sessions in guided online CBT (VanBallegooijenetal.,
2014).
4.3. Patient evaluation of bCBT
A notable nding is that while patients' pre-treatment expectations
were mainly neutral, most patients appeared to have positive attitudes
towards bCBT after they received treatment. Patients' responses to
the open-ended question at the end the rst online session appear
to mirror this somewhat sceptical baseline attitud e, with three
patients mentioning that it was hard to start with this online session
(see Appendix A).
In future research it would be interesting to further investigate
patients' attitudes towards bCBT and to study the consequences
for treat ment adhe rence. For example, the study by Wilh elmsen
and colleagues (Wilhelmsen et al., 2013)foundthatasenseof
relatedness in terms of feeling connected to the therapis t and being
able to identify with the online CBT modules a ppears to be an impor-
tant element for patients (n = 14) to persist with bCBT in primary
care.
4.4. Study observations
During the supervision sessions, we observed that therapists
evaluated the highly structured protocol as easy to use and to im-
plement in their daily practise. When compared to standard fac e-
to-face t herapy, therapists expressed it was con venient and
timesaving to have all homework forms and diaries available on-
line, instead of using paper-and-pencil versions. In addition, we
observed that the bCBT protocol appeared to help therapists to ad-
here to an evidence-based treatment manual, since patients have
insight in the content of treatment. Based on t his, we believe
that bCBT can potentially reduce therapis t drift from the treatment
protocol.
However, due to the complex and co-morbid nature of this particu-
lar patient group, a highly structured protocol that predominantly fo-
cuses on depression will not always provide en ough trea tment for
some patients to reach remission, and continuation of CBT or a referral
to another treatment will be necessary. This can also be seen in the cur-
rent study. Nevertheless, looking at their clinical proles after treat-
ment, most patients did appear to benet from b CBT. By treating
depression rst with an evidence-based treatment such as CBT, we be-
lieve better decisions can be made concerning the next steps in
treatment.
4.5. Study limitations
This study should be seen as a rst step in the development and eval-
uation of intensive bCBT for depressed patients in specialized mental
health care and our observations provide some insight in the potential
use of bCBT. However no conclusions can be drawn based on the current
sample and our ndings cannot be generalized beyond the included
group of patients.
Further, although the system usability measure (SUS) gives a
general indication of how patients e valuated the web-based
treatment platform, we advise future studies to examine treat-
ment satisfaction and system usability more closely, for example
by assessing actual use of all web-based treatment elements
via logles (Van Gemert-Pijne n et al., 2014), or by observing
patients as they work through one or more of the online
sessions.
Finally, extensive collection and evaluation of qualitative data
was beyond the scope of the current paper. Therefore, no formal
methods were used to quantify the needs and recommendations
of end-users. We would advise future studies to examine qualita-
tive evaluations more t horoughly by using fo rmal methods.
Examples of such evaluations c an be found in the studies by
Wilhelmsen et al. (2013)), Van der Vaart et al. (2014)
)andLy
e
t al. (2015).
5. Conclusion
Our observations suggest that blending face-to-face and online CBT
sessions has the potential to be a valuable treatment option for patients
with severe depression at specialized mental health care settings. This
nding needs to be interpreted with caut ion, as more extensive re-
search is required to establish whether our initial observations can be
generalized beyond the current study.
By combining a personalized approach with the stan dardized
structure of evidence-based treatment protocols, it seems possible to re-
tain and combine the benets associated with stand-alone online and
face-to-face treatments. Further, bCBT can potentially reduce the num-
ber of face- to-fac e sessions and overall length of therapy. This could
benet accessibility of care and might lower the costs of mental health
care.
Exploration of the effectiveness of blended depression treatment by
means of a randomized controlled trial is warranted to conrm this.
Therefore, such a study is currently conducted by our group (Kooistra
et al., 2014). In addition to CBT, it might be valuable to explore blended
formats for other psychotherapies, such as IPT and CBASP, in order to
extent the reach of blended treatment.
Authors' information
The authors declare that they do not have competing interests.
Authors' contributions
HR (PI) and JvGP obtained funding for this study. All authors
contributed to the design of the study and LK, JE, JW, HR and PvO
contributed to development of the intervention. LK and JW coordinated
the recruitment of patients and the data collection. JW was responsible
for the supervis ion of therapists during the study. LK wrote the
manuscript. All authors read, contributed and approved the nal
manuscript.
Conict of interest
The authors declare that the y do not have any actual or potential
conict of interest including any nancial, personal or other relation-
ships with other people or organizations within three years of begin-
ning the submitted work that could inapprop riately inuence, or be
perceived to inuence, their work.
Acknowledgements
This study was funded by Innovatiefonds Zorgverzekeraars
(Healthcare Insurers' Innovation Fund), project number B-12-059, dos-
sier number 2444 and ZonMw (the Netherlands Organization for Health
Research and Development), project number 837001007.
68 L.C. Kooistra et al. / Internet Interventions 4 (2016) 6171
Appendix A. Patients' written responses to the online sessions.
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Patient Session Label
Online session 1: psycho-education
Patient 1 It was good to look back at what happened in the fall. How can it be that you are down one moment and you feel so much better in the next? I now
recognize negativity in others and see how that blocks you. As soon as I start thinking too much about myself, I try to meditate. This really works for me.
R
Patient 2 I found it hard to write everything down. I recognize a lot of myself in the text. I want to get started in order to regain control. R
Patient 3 This lesson did not provide me with a lot of new information. I am not quite sure how I feel about our example patients. I get that the content of their
depression is not really important within this context, but my experience is very different from theirs.
E
Patient 5 Difcult. I would rather not think about it. R
Patient 8 It was difcult to start with this session. I either postponed it, or let myself be distracted by other things. To be honest I would rather not think about it. R
Patient 9 It was really good to think about everything. The story of the female example patient made me really emotional. I recognize feeling overwhelmed by
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Online session 2: motivation and goal-setting
Patient 1 Reading everything I wrote, I know who I am but I also see that I play several characters in my life. I would like to make this less confusing and more
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Patient 3 I feel stressed because the weekend has started and I forgot to work on this session. Yoga was not as relaxing as I hoped and at the moment I am
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Patient 5 I think this was a difcult session. It took me a few days to complete it. I know how I want things to be, but even now I am not sure whether this will
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Patient 8 I had great difculty with completing this session and I postponed working on it for a long time. At rst glance I could not think of any goal or
possible change. Then I understood that setting (positive and feasible) goals is the rst step towards improvement, and that it is therefore important.
R
Online session 3: activity monitoring
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this week in a more positive way.
C/R
Online session 4: positive activities
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Patient 5 It was a helpful session. I should pay more attention to the things I like doing and just schedule them. If I start planning things, this will provide structure.
Knowing what my day will look like in the morning might prevent me from panicking when I think about all the things that I need to do during the day.
R
Patient 6 I went to see colleagues. It felt good, but now it is hard to unwind again. That still is an important theme for me. C/R
Patient 8 I copied the list with things that can make you feel better. Maybe it is a good idea to print this and hang it on the wall. I think I will do the same with
my list of goals, so that I will continue to remember them.
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things is more important. I became aware of the fact that I need structure.
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Patient 3 The to-do lists are going well. I do nd it difcult to t them in a specic time schedule. R
Patient 5 I have noticed that it is very helpful for me to plan ahead. This Wednesday I planned to take a walk. When the moment to go out came, I really did not
feel like going. I went anyway, because that was how I planned it. Afterwards I felt a lot better and regretted not doing this sooner. If I would not have
planned the walk, I would have stayed in and aid on the couch.
C/R
Patient 8 I nd it difcult to write down all the things that I do during the day, let alone grade how these activities made me feel. This is why I stopped doing it. E
Online session 6: cognitive dysfunctions
Patient 2 I recognized a lot of myself in the text. Negative thinking just creeps up on you and it is hard to keep ghting this. R
Patient 3 The way the different dysfunctions are presented with the two ctional women was too simplied
for my taste. I thought this was insulting. E
Patient 5 I started writing down several thoughts. While doing this, I realized that these thoughts all stem from the same cognitive dysfunction. It was difcult
to think about this, because normally I would just avoid thinking about it.
R
Patient 6 I did not like the way the dysfunctions were presented. It reminded me of high school. Nevertheless I answered all questions. E
Patient 8 I am a bit at a loss. It is 8 o'clock at night and I do not feel like doing anything. I might just go to bed. C
Online session 7: recognizing dysfunctional thoughts
Patient 2 I think this is hard to do. E/R
Patient 3 I did not have a good week. C
Patient 6 I believe I try to suppress certain fears and thoughts, but then certain events still remind me of them. So for me I think events remind me of my
thoughts, rather than causing them to occur. [Provides an example of a past week experience during which this process occurred].
C/R
Online session 8: changing dysfunctional thoughts
Patient 2 It all seems easy to do, but in practise it is harder to accomplish. E/R
Patient 5 This was a good session for me, because I quickly became aware of what I was doing wrong. R
Patient 6 [Provides personal information on past week experiences with negative thinking] C
Online session 9: relapse prevention
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Patient 5 This was not easy for me, but it felt good to think about it. I do not feel quite stable yet. Two weeks ago I felt on top of the world and then last week I
felt less happy again. Nevertheless, I could come out of this again! This gives me hope for the future.
R
E: Evaluation of online session; C: Context; R: Reection.
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... [31][32][33] In addition to the traditional face-to-face REBT, bREBT provides the employees with increased access to the complementary support program across time and place. 34 It reduces the cost of clinical visits and increases support-seeking skills in an unspecified environment. 35 Blended therapy is more effective than face-to-face sessions. ...
... 35 Blended therapy is more effective than face-to-face sessions. 34 In this study, bREBT was in the form of face-to-face therapy with inter-session internet-based therapy for stress reduction among teachers of children with NDDs. We, therefore, hypothesize that bREBT will lead to reduced stress among teachers of children with NDDs. ...
... 20,25,26 The researcher adopted the ABCDE model in explaining the relationships existing between activating (A) events associated with teaching children with ASD, dysfunctional thoughts, beliefs, or cognitions arising from those events (B); and the emotional and behavioral consequences of the beliefs (C). 34,35 Activating event (A) in teaching children with NDDs could be a challenging situation associated with learning difficulties of the children, behavioral problems, extra work-load, and teachers' personal experiences; the belief (B) is the interpretation and cognitive imagery formed due to "A". Such cognition about the event (B) elicits a consequence/effect (C) for the teacher, which may be adaptive or maladaptive. ...
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Background/Objectives Neuro-developmental disorders impose a wide range of learning barriers on learners, increasing stress among their teachers. Evidence attests to the heightened stress among teachers teaching children with such conditions. This study tested the efficacy of blended Rational Emotive Behavior Therapy in reducing job stress among teachers of children with neuro-developmental disorders in Abia State, Nigeria. Method The current study adopted a group-randomized waitlist control trial design with pretest, post-test, and follow-up assessments. Participants ( N = 83) included teachers of children with neuro-developmental disorders in inclusive and specialized schools. The blended Rational Emotive Behavior Therapy group participated in a 2 h intersession face-to-face and online Rational Emotive Behavior Therapy (REBT) program weekly for 12 weeks. Data were collected using the Single Item Stress Questionnaire, Teachers’ Stress Inventory, and Participants’ Satisfaction questionnaire. The waitlisted group also received a blended Rational Emotive Behavior Therapy intervention after all data collection. Data collected at baseline; post-test as well as follow-up 1 and 2 evaluations were analyzed using mean, standard deviation, t-test statistics, repeated measures analysis of variance, and charts. Results Results revealed that the mean perceived stress, stress symptoms, and the total teachers’ stress score of the blended Rational Emotive Behavior Therapy group at post-test and follow-up assessments reduced significantly, compared to the waitlisted group. Participants also reported a high level of satisfaction with the therapy and procedures. Conclusion From the findings of this study, we conclude that blended Rational Emotive Behaviour Therapy is efficacious in occupational stress management among teachers of children with neuro-developmental disorders.
... Compared to traditional face-to-face REOHC, bREOHC could provide the employers with increased access to the complementary support program across time and place (Kooistra et al., 2016). It reduces cost of clinical visits and increases support seeking skills in an unspecified environment (Kooistra et al., 2019). ...
... Hence, the present findings serve as base for further studies and researchers are encouraged to replicate and confirm in other studies using blended treatment format. Results of the present study also strengthen other studies on blended approaches using other psychotherapeutic modalities such as CBT/REBT (Mackie et al., 2017;Ugwuanyi et al., 2020a;van de Wal et al., 2017;Kooistra et al., 2016;Romijn et al., 2015;Rasing et al., 2019;Kenter et al., 2015;Berto, 2014;Zwerenz et al., 2017;Titzler et al., 2018) which have yielded positive results. ...
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Background/objectives Heightened stress tends to undermine both teachers' efficacy and students' outcomes. Managing job stress in teachers of children with special education needs is continually recommended due to the increased demands for the teachers to adapt curriculum content, learning materials and learning environments for learning. This study investigated the efficacy of blended Rational Emotive Occupational Health Coaching in reducing occupational stress among teachers of children with special needs in Abia State, Nigeria. Method The current study adopted a group-randomized waitlist control trial design with pretest, post-test and follow-up assessments. Participants (N = 83) included teachers of children with special education needs in inclusive and specialized schools. The bREOHC group was exposed to intersession face-to-face and online REOC program weekly for twelve (12) weeks. Data were collected using Single Item Stress Questionnaire (SISQ), Teachers' Stress Inventory and Participants' Satisfaction questionnaire (PSQ). Data collected at baseline; post-test as well as follow-up 1 and 2 evaluations were analyzed using mean, standard deviation, t-test statistics, repeated measures ANOVA and bar charts. Results Results revealed that the mean perceived stress, stress symptoms and the total teachers' stress score of the bREOHC group at post-test and follow up assessments reduced significantly, compared to the waitlisted group. Participants also reported high level of satisfaction with the therapy and procedures. Conclusion From the findings of this study, we conclude that blended REOHC is efficacious in occupational stress management among teachers of children with special education needs.
... In bCBT, patients receive a combination of online and face-to-face therapy. This may help therapists and patients adhere to treatment protocols while allowing for a different kind of flexibility during the physical consultations compared with the structured, guided self-help programs [29]. Face-to-face consultations in bCBT can alleviate the feelings of isolation that patients may experience in guided self-help, and it can help make the structured treatment content of CBT relatable and adaptable to the patient's symptom profile [30]. ...
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Background: Sleep disturbance symptoms are common in major depressive disorder (MDD) and have been found to hamper the treatment effect of conventional face-to-face psychological treatments such as cognitive behavioral therapy. To increase the dissemination of evidence-based treatment, blended cognitive behavioral therapy (bCBT) consisting of web-based and face-to-face treatment is on the rise for patients with MDD. To date, no study has examined whether sleep disturbance symptoms have an impact on bCBT treatment outcomes and whether it affects bCBT and treatment-as-usual (TAU) equally. Objective: The objectives of this study are to investigate whether baseline sleep disturbance symptoms have an impact on treatment outcomes independent of treatment modality and whether sleep disturbance symptoms impact bCBT and TAU in routine care equally. Methods: The study was based on data from the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment Versus Treatment-as-Usual) study, a 2-arm, multisite, parallel randomized controlled, noninferiority trial. A total of 943 outpatients with MDD were randomized to either bCBT (476/943, 50.5%) or TAU consisting of routine clinical MDD treatment (467/943, 49.5%). The primary outcome of this study was the change in depression symptom severity at the 12-month follow-up. The secondary outcomes were the change in depression symptom severity at the 3- and 6-month follow-up and MDD diagnoses at the 12-month follow-up, assessed using the Patient Health Questionnaire-9 and Mini-International Neuropsychiatric Interview, respectively. Mixed effects models were used to examine the association of sleep disturbance symptoms with treatment outcome and treatment modality over time. Results: Of the 943 patients recruited for the study, 558 (59.2%) completed the 12-month follow-up assessment. In the total sample, baseline sleep disturbance symptoms did not significantly affect change in depressive symptom severity at the 12-month follow-up (β=.16, 95% CI -0.04 to 0.36). However, baseline sleep disturbance symptoms were negatively associated with treatment outcome for bCBT (β=.49, 95% CI 0.22-0.76) but not for TAU (β=-.23, 95% CI -0.50 to 0.05) at the 12-month follow-up, even when adjusting for baseline depression symptom severity. The same result was seen for the effect of sleep disturbance symptoms on the presence of depression measured with Mini-International Neuropsychiatric Interview at the 12-month follow-up. However, for both treatment formats, baseline sleep disturbance symptoms were not associated with depression symptom severity at either the 3- (β=.06, 95% CI -0.11 to 0.23) or 6-month (β=.09, 95% CI -0.10 to 0.28) follow-up. Conclusions: Baseline sleep disturbance symptoms may have a negative impact on long-term treatment outcomes in bCBT for MDD. This effect was not observed for TAU. These findings suggest that special attention to sleep disturbance symptoms might be warranted when MDD is treated with bCBT. Future studies should investigate the effect of implementing modules specifically targeting sleep disturbance symptoms in bCBT for MDD to improve long-term prognosis.
... Blended care interventions have been implemented across a diverse range of the clinical settings, including primary care (Høifødt et al., 2013), inpatient, general outpatient clinics (Schuster et al., 2020), specialized outpatient mental health clinics (Kooistra et al., 2016), and online clinics . However, large-scale effectiveness research for blended care interventions has been limited, and primarily focused on cost-effectiveness (Kleiboer et al., 2016) rather than clinical effectiveness. ...
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Background: Depression and anxiety are leading causes of disability worldwide. Though effective treatments exist, depression and anxiety remain undertreated. Blended care psychotherapy, combining the scalability of online interventions with the personalization and engagement of a live therapist, is a promising approach for increasing access to evidence-based care. Objectives: To evaluate the effectiveness and individual contribution of two components - i) digital tools and ii) video-based therapist-led sessions - in a blended care CBT-based intervention under real world conditions. Methods: A retrospective cohort design was used to analyze N = 1372 US-based individuals who enrolled in blended care psychotherapy. Of these, at baseline, 761 participants had depression symptoms in the clinical range (based on PHQ-9), and 1254 had anxiety symptoms in the clinical range (based on GAD-7). Participants had access to the program as a mental health benefit offered by their employer. The CBT-based blended care psychotherapy program consisted of regular video sessions with therapists, complemented by digital lessons and digital exercises assigned by the clinician and completed in between sessions. Depression and anxiety levels and clients' treatment engagement were tracked throughout treatment. A 3-level individual growth curve model incorporating time-varying covariates was utilized to examine symptom trajectories of PHQ-9 scores (for those with clinical range of depression at baseline) and GAD-7 scores (for those with clinical range of anxiety at baseline). Results: On average, individuals exhibited a significant decline in depression and anxiety symptoms during the initial weeks of treatment (P < .001), and a continued decline over subsequent weeks at a slower rate (P < .001). Engaging in a therapy session in a week was associated with lower GAD-7 (b = -0.81) and PHQ-9 (b = -1.01) scores in the same week, as well as lower GAD-7 (b = -0.58) and PHQ-9 (b = -0.58) scores the following week (all P < .01). Similarly, engaging with digital lessons was independently associated with lower GAD-7 (b = -0.19) and PHQ-9 (b = -0.18) scores during the same week, and lower GAD-7 (b = -0.25) and PHQ-9 (b = -0.27) the following week (all P < .01). Conclusions: Therapist-led video sessions and digital lessons had separate contributions to improvements in symptoms of depression and anxiety over the course of treatment. Future research should investigate whether clients' characteristics are related to differential effects of therapist-led and digital components of care.
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Background Internet-based cognitive behavioral therapy (iCBT) has been demonstrated to be cost- and clinically effective. There is a need, however, for increased therapist contact for some patient groups. Combining iCBT with traditional face-to-face (FtF) consultations in a blended format may produce a new treatment format (B-CBT) with multiple benefits from both traditional CBT and iCBT, such as individual adaptation, lower costs than traditional therapy, wide geographical and temporal availability, and possibly lower threshold to implementation. Objective The primary aim of this study is to compare directly the clinical effectiveness of B-CBT with FtF-CBT for adult major depressive disorder. Methods A 2-arm randomized controlled noninferiority trial compared B-CBT for adult depression with treatment as usual (TAU). The trial was researcher blinded (unblinded for participants and clinicians). B-CBT comprised 6 sessions of FtF-CBT alternated with 6-8 web-based CBT self-help modules. TAU comprised 12 sessions of FtF-CBT. All participants were aged 18 or older and met the diagnostic criteria for major depressive disorder and were recruited via a national iCBT clinic. The primary outcome was change in depression severity on the 9-item Patient Health Questionnaire (PHQ-9). Secondary analyses included client satisfaction (8-item Client Satisfaction Questionnaire [CSQ-8]), patient expectancy (Credibility and Expectancy Questionnaire [CEQ]), and working (Working Alliance Inventory [WAI] and Technical Alliance Inventory [TAI]). The primary outcome was analyzed by a mixed effects model including all available data from baseline, weekly measures, 3-, 6, and 12-month follow-up. Results A total of 76 individuals were randomized, with 38 allocated to each treatment group. Age ranged from 18 to 71 years (SD 13.96) with 56 (74%) females. Attrition rate was 20% (n=15), which was less in the FtF-CBT group (n=6, 16%) than in the B-CBT group (n=9, 24%). As many as 53 (70%) completed 9 or more sessions almost equally distributed between the groups (nFtF-CBT=27, 71%; nB-CBT=26, 68%). PHQ-9 reduced 11.38 points in the FtF-CBT group and 8.10 in the B-CBT group. At 6 months, the mean difference was a mere 0.17 points. The primary analyses confirmed large and significant within-group reductions in both groups (FtF-CBT: β=–.03; standard error [SE] 0.00; P<.001 and B-CBT: β=–.02; SE 0.00; P<.001). A small but significant interaction effect was observed between groups (β=.01; SE 0.00; P=.03). Employment status influenced the outcome differently between groups, where the B-CBT group was seen to profit more from not being full-time employed than the FtF group. Conclusions With large within-group effects in both treatment arms, the study demonstrated feasibility of B-CBT in Denmark. At 6 months’ follow-up, there appeared to be no difference between the 2 treatment formats, with a small but nonsignificant difference at 12 months. The study seems to demonstrate that B-CBT is capable of producing treatment effects that are close to FtF-CBT and that completion rates and satisfaction rates were comparable between groups. However, the study was limited by small sample size and should be interpreted with caution. Trial Registration ClinicalTrials.gov NCT02796573; https://clinicaltrials.gov/ct2/show/NCT02796573 International Registered Report Identifier (IRRID) RR2-10.1186/s12888-016-1140-y
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Guided internet-based treatment is more efficacious than completely unguided or self-guided internet-based treatment, yet within the spectrum of guidance, little is known about the added value of human support compared to more basic forms of guidance. The primary aims of this meta-analysis were: (1) to examine whether human guidance was more efficacious than technological guidance in text-based internet treatments (“e-therapy”) for mental disorders, and (2) whether more intensive human guidance outperformed basic forms of human guidance. PsycINFO, PubMed and Web of Science were systematically searched for randomized controlled trials that directly compared various types and degrees of online guidance. Thirty-one studies, totaling 6215 individuals, met inclusion criteria. Results showed that human guidance was slightly more efficacious than technological guidance, both in terms of symptom reduction (g = 0.11; p < .01) and adherence (0.26 < g < 0.29; p's < 0.01). On the spectrum of human support, results were slightly more favorable for regular guidance compared to optional guidance, but only in terms of adherence (OR = 1.89, g = 0.35; p < .05). Higher qualification of online counselors was not associated with efficacy. These findings extend and refine previous reports on guided and unguided online treatments.
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Objectives: SlowMo is the first blended digital therapy for paranoia, showing significant small-moderate reductions in paranoia in a recent large-scale randomized controlled trial (RCT). This study explored the subjective service-user experience of the SlowMo therapy content and design; the experience of the blended therapy approach, including the triangle of the therapeutic alliance; and the experience of the digital aspects of the intervention. Design: Qualitative co-produced sub-study of an RCT. Methods: Participants were 22 adult service users with schizophrenia-spectrum psychosis and persistent distressing paranoia, who completed at least one SlowMo therapy session and a 24-week follow-up, at one of 3 sites in Oxford, London, and Sussex, UK. They were interviewed by peer researchers, using a topic guide co-produced by the Patient and Public Involvement (PPI) team. The transcribed data were analysed thematically. Multiple coding and triangulation, and lay peer researcher validation were used to reach a consensus on the final theme structure. Results: Six core themes were identified: (i) starting the SlowMo journey; (ii) the central role of the supportive therapist; (iii) slowing things down; (iv) value and learning from social connections; (v) approaches and challenges of technology; and (vi) improvements in paranoia and well-being. Conclusions: For these service users, slowing down for a moment was helpful, and integrated into thinking over time. Learning from social connections reflected reduced isolation, and enhanced learning through videos, vignettes, and peers. The central role of the supportive therapist and the triangle of alliance between service user, therapist, and digital platform were effective in promoting positive therapeutic outcomes.
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TrustTable (www.trusttable.at) was created as a pilot project to provide a web-based solution for integrative and multiprofessional patient care. This is presented in the context of psychiatric and psychotherapeutic practice. Blended care, a combination of online and face-to-face therapy, is of particular importance. In order to optimally use the advantages of both treatment modalities for personalized treatment according to the current needs and abilities of the patient, the autonomy of the therapist was taken into particular consideration. For ethical reasons, the project was opened as telemedical crisis support at the beginning of the COVID-19 crisis for experts and patients and has been continuously developed since then.
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Background: Thorough holistic development of eHealth can contribute to a good fit among the technology, its users, and the context. However, despite the availability of frameworks, not much is known about specific research activities for different aims, phases, and settings. This results in researchers having to reinvent the wheel. Consequently, there is a need to synthesize existing knowledge on research activities for participatory eHealth development processes. Objective: The 3 main goals of this review are to create an overview of the development strategies used in studies based on the CeHRes (Center for eHealth Research) Roadmap, create an overview of the goals for which these methods can be used, and provide insight into the lessons learned about these methods. Methods: We included eHealth development studies that were based on the phases and/or principles of the CeHRes Roadmap. This framework was selected because of its focus on participatory, iterative eHealth design in context and to limit the scope of this review. Data were extracted about the type of strategy used, rationale for using the strategy, research questions, and reported information on lessons learned. The most frequently mentioned lessons learned were summarized using a narrative, inductive approach. Results: In the included 160 papers, a distinction was made between overarching development methods (n=10) and products (n=7). Methods are used to gather new data, whereas products can be used to synthesize previously collected data and support the collection of new data. The identified methods were focus groups, interviews, questionnaires, usability tests, literature studies, desk research, log data analyses, card sorting, Delphi studies, and experience sampling. The identified products were prototypes, requirements, stakeholder maps, values, behavior change strategies, personas, and business models. Examples of how these methods and products were applied in the development process and information about lessons learned were provided. Conclusions: This study shows that there is a plethora of methods and products that can be used at different points in the development process and in different settings. To do justice to the complexity of eHealth development, it seems that multiple strategies should be combined. In addition, we found no evidence for an optimal single step-by-step approach to develop eHealth. Rather, researchers need to select the most suitable research methods for their research objectives, the context in which data are collected, and the characteristics of the participants. This study serves as a first step toward creating a toolkit to support researchers in applying the CeHRes Roadmap to practice. In this way, they can shape the most suitable and efficient eHealth development process.