ArticlePDF Available

The COVID-19 pandemic: The ‘black swan’ for mental health care and a turning point for e-health

Journal Pre-proof
The COVID-19 pandemic: The ‘black swan’ for mental health
care and a turning point for e-health
Tim R. Wind, Marleen Rijkeboer, Gerhard Andersson, Heleen
PII: S2214-7829(20)30046-4
Reference: INVENT 100317
To appear in: Internet Interventions
Received date: 17 March 2020
Revised date: 18 March 2020
Accepted date: 18 March 2020
Please cite this article as: T.R. Wind, M. Rijkeboer, G. Andersson, et al., The COVID-19
pandemic: The ‘black swan’ for mental health care and a turning point for e-health,
Internet Interventions (2020),
This is a PDF file of an article that has undergone enhancements after acceptance, such
as the addition of a cover page and metadata, and formatting for readability, but it is
not yet the definitive version of record. This version will undergo additional copyediting,
typesetting and review before it is published in its final form, but we are providing this
version to give early visibility of the article. Please note that, during the production
process, errors may be discovered which could affect the content, and all legal disclaimers
that apply to the journal pertain.
© 2020 Published by Elsevier.
Journal Pre-proof
The COVID-19 pandemic: The black swan for mental health care and a turning point for e-
Tim R. Wind, PhD1, Marleen Rijkeboer, PhD2 Gerhard Andersson, PhD3, & Heleen Riper,
PhD 4 5
1Foundation Centrum '45, Oegstgeest, The Netherlands | partner in Arq Psychotrauma Expert
Group, Nienoord 5, 1112 XE Diemen, The Netherlands
2Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience,
Maastricht University, The Netherlands
3Department of Behavioural Science and Learning, Linköping University, Linköping, Sweden
and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
4Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit,
Amsterdam, The Netherlands
5 Department of Research and Innovation, GGZ in Geest/Amsterdam University Medical
Center, VU University Medical Center, Amsterdam, Netherlands
In February 2020, Duan and Zhu (2020) stressed the need for a solid Chinese evidence-based
mental health care system in times of public health emergencies such as the outbreak of the
Coronavirus disease-2019 (COVID-19). That would enable treatment of people who suffer
from mental health problems in relation to the epidemic. The WHO has meanwhile labelled
the Coronavirus a pandemic, and it is now hitting Europe, the USA, and Australia hard as
well. In an attempt to reduce the risk of infections, many mental health care providers in
Journal Pre-proof
Journal Pre-proof
afflicted countries are currently closing their doors for patients who need ambulatory face-to-
face therapy. They are simultaneously trying to replace some of these contacts with digital
therapies. Most probably, European mental health care institutions have yet to experience the
full impact of the coronavirus crisis. At the same time, the demand for mental health care
among infected patients and their relatives is expected to rise (Blumenstyk, 2020). Levels of
anxiety will increase, both through direct causes including fears of contamination, stress,
grief, and depression triggered by exposure to the virus, and through influences from the
consequences of the social and economic mayhem that is occurring on individual and societal
levels. We expect that this "black swan" moment (Blumenstyk, 2020) - an unforeseen event
that changes everything - will lead to a partly, though robust, shift in mental health care
provision towards online prevention, treatment, and care in the near future. We also need to
consider the role of psychological processes and fear that may cause further harm on top of
the pandemic (Asmundson, & Taylor, 2020).
The obvious solution to continue mental health care within a pandemic is to provide mental
health care at a „warm‟ distance by video-conferencing psychotherapy and internet
interventions. A systematic review showed that videoconferencing psychotherapy show
promising results for anxiety and mood disorders (Berryhill et al., 2019), and the evidence-
base for therapist-guided internet interventions is even stronger (Andersson, 2016; ). Yet,
despite two decades of evidence-based e-mental health services, numerous barriers have
stalled the overall implementation in routine care thus far (Vis et al., 2018; Tuerk et al.,
2019). One of the most important barriers highlighted, however, has been that e-mental health
has not been integrated as a normal part of routine care practice due to the lack of acceptance
by health professionals themselves (Topocoo et al., 2017). Myths on telehealth such as “the
therapeutic alliance can only be established face-to-face” have dominated the field, in spite of
Journal Pre-proof
Journal Pre-proof
research showing the opposite (Berger, 2017). In that sense, learning curves in the adoption of
new e-mental health technologies by both patients and psychologists have progressed far
more slowly than initially expected, thus tallying with the estimate that it takes on average16
years for a health care innovation to be implemented (Rogers et al., 2017). There are however
exceptions in the world but progress is still slow.
In the Netherlands and elsewhere, we are now witnessing a phenomenon whereby the
outbreak of COVID-19 is hastening managers, ICT-staff, and clinicians to overcome all such
barriers overnight, from a pragmatic standpoint seldom seen before. The virus seems a
greater catalyst for the implementation of online therapy and e-health tools in routine practice
than two decades of many brilliant, but failed, attempts in this domain (Mohr et al., 2018).
After all, since predictions about COVID-19 are largely unclear as of yet, it is now time to
create a longer-term solution to the problem of heterogeneous patient populations, such as
those still active in the community and those that are house-bound or isolated in hospitals.
Videoconferencing and internet interventions could therefore be very helpful in mental health
care, as well as in physical care and can be easily upscaled to serve isolated regions and reach
across borders.
Thus, the “black swan virus” has already enabled wide-scale acceptance of videoconferencing
by health professionals and patients alike creating a win-win situation for both. We should
stress that e-mental health applications hold value far beyond the provision of
videoconferencing psychotherapy in the current situation of crisis. Countries hit by the
Corona virus may also consider adopting a wider public e-mental health approach, which
would focus additionally on prevention and on reaching people at risk for mental health
disorders. In this respect, not only guided but also fully self-guided interventions, such as self-
Journal Pre-proof
Journal Pre-proof
help apps or online therapeutic modules, could also be applied in settings and countries with
scarce mental health resources (Christiani & Setiawan, 2018). We should also consider the
need for treatment development (for the psychological problems caused by corona virus
isolation), which is by far more rapid in the field of internet interventions than in traditional
psychotherapy (Andersson et al., 2019).
It is likely that the response to this emergency will be more than a temporary increase in
online work (Blumenstyk, 2020). Once mental health care institutions have developed the
capabilities of serving their patients via videoconferencing and other digital technologies,
there is little reason for them to give these up, in view of the many advantages (Blumenstyk,
2020; Tuerk et al., 2019).This black swan should be a call for action by encouraging providers
to move more rapidly towards blended care models (van der Vaart et al., 2014; Kooistra et al
2019). Agility, flexibility, and resilience are essential skills for 21-st-century institutions,
particularly when unforeseen disruptive viruses and devastating events driven by climate
change are likely to be increasingly common (Blumenstyk, 2020). We urge practitioners to
promptly start adopting e-mental health care applications, both as methods to continue their
care to current patients in need and as interventions to cope with the imminent upsurge in
mental health symptoms due to the coronavirus.
Andersson, G. (2016). Internet-delivered psychological treatments. Annu. Rev. Clin.
Psychol, 12, 157-179.
Andersson, G., Titov, N., Dear, B. F., Rozental, A., & Carlbring, P. (2018). Internet-
delivered psychological treatments: from innovation to implementation. World
Psychiatry, 18, 20-28.
Journal Pre-proof
Journal Pre-proof
Asmundson, G. J. G., & Taylor, S. (2020). How health anxiety influences responses to
viral outbreaks like COVID-19: What all decision-makers, health authorities, and
health care professionals need to know. J Anxiety Disord, 71, 102211.
Berger, T. (2017). The therapeutic alliance in internet interventions: A narrative
review and suggestions for future research. Psychother Res, 27, 511-524.
Berryhill, M.B., Culmer, N., Williams, N., Halli-Tierney, A., Betancourt, A., Roberts,
H. & King, M. (2019). Videoconferencing psychotherapy and depression: A
systematic review. Telemedicine and e-Health, 25, 435-446.
Blumenstyk, G. (2020). Why coronavirus looks like a „black swan‟ moment for higher
ed. The Chronicle. Published March 11, 2020:
Christiani, Y. & Setiawan, A. (2018). Internet-based treatment of depression in
Indonesia. Lancet Psychiatry, 5, 688-689.
Duan, L. & Zhu, G. (2020). Psychological interventions for people affected by the
COVID-19 epidemic. Lancet Psychiatry, S2215-0366(20)30073-0.
Karyotaki, E., Ebert, D. D., Donkin, L., Riper, H., Twisk, J., Burger, S., … &
Cuijpers, P. (2018). Do guided internet-based interventions result in clinically relevant
changes for patients with depression? An individual participant data meta-
analysis. Clinical Psychology Review, 63, 80-92.
Kooistra, L. C., Wiersma J. E., Ruwaard J., Neijenhuijs K., Lokkerbol J., van Oppen
P., Smit F., & Riper, H. (2019). Cost and Effectiveness of Blended Versus Standard
Cognitive Behavioral Therapy for Outpatients With Depression in Routine Specialized
Mental Health Care: Pilot Randomized Controlled Trial. Journal of Medical Internet
Research, 10, e14261
Journal Pre-proof
Journal Pre-proof
Mohr, D. C., Riper, H., & Schueller, S. M. (2018). A solution-focused research
approach to achieve an implementable revolution in digital mental health. JAMA
Psychiatry, 75, 113-114.
Rogers, H., Madathil, K.C., Agnisarman, S., Narashima, S., Ashok, A., Nair, A.,
Welch, B.M. & McElligott, J.T. (2017). A systematic review of the implementation
challenges of telemedicine systems in ambulances. Telemedicine and e-Health, 23(9),
Topooco, N., Riper, H., Araya, R., Berking, M., Brunn, M., Chevreul, K., Cieslak, R.,
Ebert, D. D., Etchmendy, E., Herrero, R., Kleiboer, A., Krieger, T., García-Palacios,
A., Cerga-Pashoja, A., Smoktunowicz, E., Urech, A., Vis, C., Andersson, G., & On
behalf of the E-COMPARED consortium. (2017). Attitudes towards digital treatment
for depression: A European stakeholder survey. Internet Interv, 8, 1-9.
Tuerk, P.W., Keller, S.M. & Acierno, R. (2019). Treatment for anxiety and depression
via clinical videoconferencing: Evidence base and barriers to expanded access in
practice. Focus, 16, 363-369.
Vis, C., Mol, M., Kleiboer, A., Bührmann, L., Finch, T., Smit, J., & Riper, H. (2018).
Improving implementation of eMental health for mood disorders in routine practice:
Systematic review of barriers and facilitating factors. JMIR Mental Health, 5, e20
van der Vaart, R., Witting, M., Riper, H., Kooistra, L., Bohlmeijer, E. T., & van
Gemert-Pijnen, L. J. (2014). Blending online therapy into regular face-to-face therapy
for depression: content, ratio and preconditions according to patients and therapists
using a Delphi study. BMC Psychiatry, 14, 355.
Journal Pre-proof
... 12 Despite the obvious promise of telehealth, uptake and integration into routine care prior to the onset of COVID-19 had been slow. 13 In Australia, as in other parts of the world, COVID-19 triggered an escalation in the use of telehealth by mental health service providers. 3,14 Increased rates of mental health distress associated with COVID-19 were experienced 15 and a range of strategies to improve access to needed psychological support were implemented. ...
... 26 Current indications suggest that the widespread use and uptake of telehealth related to COVID-19 has brought changes which are likely to be sustained beyond the end of COVID-19 public health restrictions. 3,13 Despite some ongoing reservations, mental health practitioners express an intention to continue using telehealth for mental health service delivery beyond the end of COVID-19. 12,21 Our findings suggest that this development is likely to be wellreceived by many people accessing mental health help as it offers enhanced choice and access exceeding that achievable via in-person services alone. ...
Full-text available
Objectives To examine preferences for telehealth versus in-person services for people who sought mental health support from an unfamiliar service during the COVID-19 pandemic and to identify the factors that influenced these preferences. Methods Data are drawn from semi-structured interviews with 45 participants (32 people who accessed mental health services, 7 informal support people, and 6 people who accessed services themselves as well as identifying as informal supports). Data relating to experiences of telehealth, comparisons with in-person services and preferences were coded inductively and analysed using qualitative content analysis. Results Just over half of the participants in our sample preferred telehealth or at least regarded it as a suitable option. Those who preferred telehealth were more likely to have had direct experience, particularly via videoconferencing, as part of their access to this new mental health service. Reasons for preferring in-person services included belief in the superiority of interpersonal communication in these settings, compatibility with personal communication style and discomfort with technology. Those preferring telehealth cited its convenience, elimination of the need to travel for services, the comfort and safety afforded by accessing services at home and the ability to communicate more openly. Conclusions Hybrid models of care which harness the unique benefits of both in-person and remote service modalities appear to have a legitimate place in models of mental health care outside of pandemic situations. These results illuminate the potential of telehealth services when engaging with people seeking mental health help for the first time and in situations where existing relationships with service providers have not yet been established.
... Undoubtedly, the COVID-19 pandemic had an unprecedented impact on mental healthcare provision (52,53). Strikingly, nearly a quarter of respondents felt the pandemic caused no impact at all on their access to mental health services. ...
Full-text available
Introduction Digital mental health is a promising solution to support people with severe mental health problems (SMI) in China. However, little is known about the ownership rate of digital technologies and attitudes towards utilising digital health technologies (DHTs) among people with SMI in the Chinese context. The aims of this study were to understand: (i) digital technology ownership and usage rate of people with SMI in China; (ii) attitudes toward DHTs in mental health services; and (iii) how the COVID-19 pandemic has influenced views on digital mental health. Methods A cross-sectional survey was given to outpatients with SMI using the REDCap platform. To capture a diverse sample of people with SMI, the survey was distributed across psychiatric hospitals, general hospitals with a psychiatric unit, secondary hospitals, and community healthcare centres. Results In total, 447 survey respondents completed the survey. Relative high ownership rates of digital technologies were found, with smartphone ownership (95.5%) and access to the internet (82.1%) being the highest technologies reported. However, less than half of respondents reported frequent health-related usage of digital technologies, which may be related to the lack of knowledge in using DHTs. Most respondents found DHTs being useful for access to mental health services during the pandemic and were willing to use DHTs after the pandemic. Discussion Our data suggest that, despite the high ownership rate of digital technologies, training programmes to improve digital health literacy for people with SMI in China are necessary to realise the full potential of digital mental health.
... In our surveys among professionals and among clients, a majority indicated a preference for a return to in-person treatment or in-person blended with video conferencing when COVID-19 lockdown restrictions would be lifted (de Beurs et al., 2021a(de Beurs et al., , 2021b, The majority of the respondents indicated that interpersonal contact and information transfer is leaner in video conferencing mode as nonverbal and implicit communication is limited. However, as communication through video conferencing is becoming increasingly common, in everyday life as well as between professionals and patients, from primary care delivery by general practitioners (Meurs et al., 2022) to sexual health care (Zimbile et al., 2022), hesitation to use video conferencing in mental health care may also subside, in which the COVID-19 crisis may play a pivotal role (Wind et al., 2020). ...
Full-text available
Background Social distancing measures during the COVID‐19 pandemic forced an abrupt transformation of treatment delivery for mental health care. In mid‐March 2020, nearly all in‐person contact was replaced with video conferencing. The pandemic thus offered a natural experiment and a unique opportunity to conduct an observational study of whether alcohol use disorder treatment through video conferencing is non‐inferior to in‐person treatment. Methods In a large urban substance use disorder treatment center in the Netherlands, treatment evaluation is routine practice. Outcome data are regularly collected to support shared decision making and monitor patient progress. For this study, pre‐test and post‐test data on alcohol use (Measurements in the Addictions for Triage and Evaluation), psychopathology (Depression Anxiety Stress Scales), and quality of life (Manchester Short Assessment of Quality of Life) were used to compare outcomes of cognitive behavioral therapy treatment for three cohorts: patients who received treatment for a primary alcohol use disorder performed prior to ( n = 628), partially during ( n = 557), and entirely during ( n = 653) the COVID‐19 lockdown. Results Outcome was similar across the three cohorts: No inferior outcomes were found for treatments that were conducted predominantly through video conferencing during lockdown or treatments that started in‐person, but were continued through video conferencing, compared to in‐person treatments that were conducted prior to COVID‐19. The number of drop‐outs were also similar between cohorts. However, there was a difference in average treatment intensity between cohorts, with treatment partially or fully conducted during the COVID‐19 pandemic lasting longer. Conclusions Treatment for a primary alcohol use disorder, provided partially or predominantly through video conferencing during the COVID‐19 pandemic resulted in abstinence rates and secondary outcomes similar to traditional in‐person care, in spite of the potentially negative effects of the COVID‐related lockdown measures themselves. These results from everyday clinical practice corroborate findings of randomized controlled studies and meta‐analyses in which video conferencing appeared non‐inferior to in‐person care in clinical effectiveness.
... To face these challenges and continue providing mental health care at the height of COVID-19, an urgent need of new treatment options preferable from the field of e-mental health arose (6). One of these options might be the use of virtual reality (VR), a computergenerated simulation of a real environment which can be explored and interacted with by a person using a special VR headset (7). ...
Full-text available
Background: The COVID-19 pandemic was particularly difficult for individuals with mental disorders. Due to governmental restrictions, face-to-face offers for psychiatric outpatients like therapies, psychoeducational groups or relaxation courses were limited. Virtual reality (VR) might be a new possibility to support these patients by providing them with a home-based relaxation tool. Objective: The aim of this study was to evaluate the acceptability, feasibility, and user satisfaction of a supportive therapy-accompanying, relaxation VR intervention in psychiatric outpatients during the COVID-19 pandemic in Germany. Methods: The four-weeks VR intervention consisted of regular watching of relaxing videos in the participants’ home environment. Sociodemographics, feasibility (frequency of use, user-friendliness), satisfaction (Client Satisfaction Questionnaire-8), depressive symptoms (Patient Health Questionnaire-9), quality of life (abbreviated World Health Organization Quality of Life assessment), and credibility and expectancy (Credibility Expectancy Questionnaire-8) were measured in an intention-to-treat (ITT) analysis and a per-protocol (PP) analysis of completers. Results: In total, N = 40 patients participated in the study. Most of the participants in the ITT analysis (n = 30, 75.0%) used the VR device three or 4 weeks. A majority of the N = 29 completers (PP: n = 18, 62.1%) used it all 4 weeks. Most participants used the device two or more times a week (ITT: n = 30, 83.3%; PP: n = 26, 89.7%) and described the user-friendliness as rather or very easy (ITT: n = 33, 91.7%; PP: n = 26, 89.7%). User satisfaction was high (ITT: 19.42, SD = 4.08; PP: M = 20.00, SD = 4.19) and did not correlate with participants’ sex or age (all p < 0.05). Depressive symptoms and psychological quality of life improved significantly from pre-to post-intervention (ITT and PP, all p < 0.05). Higher pre-intervention credibility significantly correlated with a better outcome of satisfaction (ITT and PP), depressive symptoms, physical, psychological, and social quality of life (PP; all p < 0.05). Conclusion: A supportive therapy-accompanying VR relaxation intervention is feasible and acceptable in a psychiatric outpatient setting. Due to the high satisfaction and user-friendliness, VR can be an easy to implement relaxation tool to support psychiatric outpatients. Clinical trial registration:, DRKS00027911.
... The propagation of remote mental health services during COVID-19 might expand access to mental health care during and beyond the pandemic (Wind et al., 2020;Zhou et al., 2020), which is unfortunately low among healthcare students and professionals, even among those with substantial risk factors for suicide (Givens and Tjia, 2002). Barriers to using face-to-face mental health services, which are often offered in institutions where healthcare students and professionals work, include lack of time and fear of documentation in academic or professional records. ...
Full-text available
Introduction Despite the propagation of virtual mental health services for vulnerable groups during COVID-19 pandemic, the implementation and evaluation of remote evidence-based practices (EBP) to manage them in low- and middle-income countries remains scarce. In the current study, we describe and evaluate the implementation process and clinical impact of brief, remote, manualized EBP for crisis intervention and suicide risk management among healthcare workers attending patients with COVID-19 (COVID-19-HCWs) in Mexico. Methods The implementation process comprised community engagement of volunteer mental health specialists, creation of new clinical teams with different disciplines and skills, intervention systematization through manuals and education through 4-h remote training as main strategies. Mexican COVID-19-HCWs who had used a free 24-h helpline rated their pre- and post-intervention emotional distress. Therapists recorded patients’ pre-intervention diagnosis, severity, and suicide risk, the techniques used in each case, and their post-treatment perception of COVID-19-HCWs’ improvement at the end of the intervention. Results All techniques included in the intervention manual were employed at least in one case ( n = 51). At the beginning of the intervention, 65.9% of the COVID-19-HCWs were considered moderately ill or worse according to Clinical Global Impression-Severity (CGI-S) scores, whereas at the end, 79.4% of them were perceived as much or very much improved according to CGI-Improvement scores (CGI-I), and their emotional distress had been significantly reduced ( p < 0.001). Discussion This prospective study provides evidence that implementation of remote EBP is feasible and useful to reduce emotional distress and suicide risk among COVID-19-HCWs from a middle-income country. However, this study was limited by lack of a control group, improvement ratings provided by therapists and non-anonymous satisfaction ratings.
... It forced child psychotherapists to experiment with this modality of therapy without prior intention and prior experience in most cases (Udwin, Kufferath-Lin, Prout, Hoffman, & Rice, 2021). Online therapy is a therapeutic module whose use has become increasingly common in recent decades, with the increasing accessibility and efficiency of the Internet (Aviram & Nadan, 2022;Wind, Rijkeboer, Andersson, & Riper, 2020). There is evidence indicating that adult psychotherapy by videoconferencing (telehealth) has good clinical effectiveness for various conditions (Backhaus et al., 2012). ...
Full-text available
This qualitative study explored the experiences of child psychotherapists who were inexperienced in online therapy and transitioned in response to the COVID-19 pandemic. Providing online therapy to children poses distinct challenges due to different factors, including the focus on play and developmental differences. The study aimed to shed light on the therapists' perceptions of the therapeutic space in online therapy, and the impact of the transition on the practice of child psychotherapy. Twenty experienced child psychotherapists were interviewed in depth to explore their experiences of transitioning to online therapy during the COVID-19 pandemic in Israel. Participants were recruited voluntarily using convenience and snowball sampling. The study was designed and analyzed by two experienced clinical psychologists using qualitative content analysis. The findings revealed that the online space is an integral part of the transformative processes in psychotherapy for children and youth, and psychotherapists can make necessary adjustments to the new setting through adaptability.The study underscored the challenge of finding flexible personal resources to promote adaptation processes to change.
Full-text available
Background Guided self-help has been shown to be effective for other mental conditions and, if effective for post-traumatic stress disorder, would offer a time-efficient and accessible treatment option, with the potential to reduce waiting times and costs. Objective To determine if trauma-focused guided self-help is non-inferior to individual, face-to-face cognitive-behavioural therapy with a trauma focus for mild to moderate post-traumatic stress disorder to a single traumatic event. Design Multicentre pragmatic randomised controlled non-inferiority trial with economic evaluation to determine cost-effectiveness and nested process evaluation to assess fidelity and adherence, dose and factors that influence outcome (including context, acceptability, facilitators and barriers, measured qualitatively). Participants were randomised in a 1 : 1 ratio. The primary analysis was intention to treat using multilevel analysis of covariance. Setting Primary and secondary mental health settings across the United Kingdom’s National Health Service. Participants One hundred and ninety-six adults with a primary diagnosis of mild to moderate post-traumatic stress disorder were randomised with 82% retention at 16 weeks and 71% at 52 weeks. Nineteen participants and ten therapists were interviewed for the process evaluation. Interventions Up to 12 face-to-face, manualised, individual cognitive-behavioural therapy with a trauma focus sessions, each lasting 60–90 minutes, or to guided self-help using Spring , an eight-step online guided self-help programme based on cognitive-behavioural therapy with a trauma focus, with up to five face-to-face meetings of up to 3 hours in total and four brief telephone calls or e-mail contacts between sessions. Main outcome measures Primary outcome: the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, at 16 weeks post-randomisation. Secondary outcomes: included severity of post-traumatic stress disorder symptoms at 52 weeks, and functioning, symptoms of depression, symptoms of anxiety, alcohol use and perceived social support at both 16 and 52 weeks post-randomisation. Those assessing outcomes were blinded to group assignment. Results Non-inferiority was demonstrated at the primary end point of 16 weeks on the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition [mean difference 1.01 (one-sided 95% CI −∞ to 3.90, non-inferiority p = 0.012)]. Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, score improvements of over 60% in both groups were maintained at 52 weeks but the non-inferiority results were inconclusive in favour of cognitive-behavioural therapy with a trauma focus at this timepoint [mean difference 3.20 (one-sided 95% confidence interval −∞ to 6.00, non-inferiority p = 0.15)]. Guided self-help using Spring was not shown to be more cost-effective than face-to-face cognitive-behavioural therapy with a trauma focus although there was no significant difference in accruing quality-adjusted life-years, incremental quality-adjusted life-years −0.04 (95% confidence interval −0.10 to 0.01) and guided self-help using Spring was significantly cheaper to deliver [£277 (95% confidence interval £253 to £301) vs. £729 (95% CI £671 to £788)]. Guided self-help using Spring appeared to be acceptable and well tolerated by participants. No important adverse events or side effects were identified. Limitations The results are not generalisable to people with post-traumatic stress disorder to more than one traumatic event. Conclusions Guided self-help using Spring for mild to moderate post-traumatic stress disorder to a single traumatic event appears to be non-inferior to individual face-to-face cognitive-behavioural therapy with a trauma focus and the results suggest it should be considered a first-line treatment for people with this condition. Future work Work is now needed to determine how best to effectively disseminate and implement guided self-help using Spring at scale. Trial registration This trial is registered as ISRCTN13697710. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/97) and is published in full in Health Technology Assessment ; Vol. 27, No. 26. See the NIHR Funding and Awards website for further award information.
The COVID-19 health crisis has once again highlighted the importance of psychological interventions in emergency and crisis situations, even if the modality of intervention must be remote. The present chapter intends to be a contribution from the experience of on-line clinical care during the period of confinement in March and April. An on-line primary psychological care service was made available for people with clinical care needs due to the pandemic situation. Between March and April, about 20 individual and group consultations were received for anxiety and distress crises, among others. The interventions carried out allowed to register improvements in the emotional state of the first communication. The results show the possible adaptation of evidence-based psychological interventions to the on-line modality. Some considerations about the on-line modality and the need for further training in this dynamic are presented.
Background: High dropout rates are a common problem reported in online studies. Understanding which risk factors interrelate with dropping out from the studies provides the option to prevent dropout by tailoring effective strategies. Objective: This study aims to add understanding to the predictors of online study dropout among psychosomatic rehabilitation patients. We investigated whether sociodemographics, voluntary interventions, physical and mental health, digital use for health and rehabilitation, and COVID-pandemic-related variables determine study dropout. Methods: Patients (N=2155) were recruited from four psychosomatic rehabilitation clinics in Germany and filled in the online questionnaire at T1, which was prior to their rehabilitation stay. Around half of them (1082/2155, 50.2%) dropped out at T2, which was after the rehabilitation stay, during which three voluntary digital trainings were provided to patients. According to the number of trainings that patients participated in, they were defined into a comparison group or intervention groups. Chi-squared tests were performed to examine the differences between the dropout patients and the retained patients in terms of sociodemographic variables; and to compare the dropout rate differences between comparison and intervention groups. Logistic regression analyses were used to assess what factors were related to retained in the survey. Results: The comparison group had the highest dropout rate of 68.4% (173/253), compared to the intervention groups with 48.0% (749/1561), 50.0% (96/192), and 43.0% (64/149) dropout rate. Patients with a diagnosed combined anxiety and depressive disorder had the highest dropout rates of up to 63.5% (47/74). Younger patients (<50 years old) and less educated patients were more likely to drop out of the study. Patients who had fewer health-related app and/or internet use behaviours were more likely to drop out of the study. Patients who remained in their job, and patients who were infected by the coronavirus were more likely to drop out of the study. Conclusions: This study investigated the predictors of dropout in online studies. Different factors of patients' sociodemographics, physical and mental health, digital use, COVID pandemic correlates, and study design can correlate with the dropout rate. For online studies with a focus on mental health, it is suggested to consider those possible dropout predictors and take appropriate strategies to help patients with a high risk of dropping out overcome difficulties completing the study. Clinicaltrial: Identifier: NCT04453475; NCT04453475.
Full-text available
Internet interventions, and in particular Internet‐delivered cognitive behaviour therapy (ICBT), have existed for at least 20 years. Here we review the treatment approach and the evidence base, arguing that ICBT can be viewed as a vehicle for innovation. ICBT has been developed and tested for several psychiatric and somatic conditions, and direct comparative studies suggest that therapist‐guided ICBT is more effective than a waiting list for anxiety disorders and depression, and tends to be as effective as face‐to‐face CBT. Studies on the possible harmful effects of ICBT are also reviewed: a significant minority of people do experience negative effects, although rates of deterioration appear similar to those reported for face‐to‐face treatments and lower than for control conditions. We further review studies on change mechanisms and conclude that few, if any, consistent moderators and mediators of change have been identified. A recent trend to focus on knowledge acquisition is considered, and a discussion on the possibilities and hurdles of implementing ICBT is presented. The latter includes findings suggesting that attitudes toward ICBT may not be as positive as when using modern information technology as an adjunct to face‐to‐face therapy (i.e., blended treatment). Finally, we discuss future directions, including the role played by technology and machine learning, blended treatment, adaptation of treatment for minorities and non‐Western settings, other therapeutic approaches than ICBT (including Internet‐delivered psychodynamic and interpersonal psychotherapy as well as acceptance and commitment therapy), emerging regulations, and the importance of reporting failed trials.
Full-text available
Introduction: Depression is the leading cause of disability in the world. Despite the prevalence of depression, a small proportion of individuals seek mental health services. A cost-effective method for increasing access to mental health services is the implementation of telemental-health programs. This review aims to summarize the state of the field on the efficacy and effectiveness of videoconferencing psychotherapy (VCP) for the treatment of depression. Materials and methods: Systematic literature searches were performed using PsychINFO, PubMed, and EMBASE. Specific inclusion criteria were used to identify controlled and uncontrolled studies evaluating VCP for the treatment of depression. Data extraction included study assessment quality, research design, sample size, intervention details, outcome results, intervention effect size, and statistical differences between VCP and in-person (IP) therapy. Results: Of the 1,424 abstracts screened, 92 articles were critically reviewed. Thirty-three articles were included in the review, with 14 randomized controlled studies, 4 controlled nonrandomized studies, and 15 uncontrolled studies. Sample size ranged from 1 to 243 participants. Twenty-one studies reported statistically significant reductions in depressive symptoms following VCP, and the median effect size for studies ranged from medium to the very large range. Most controlled studies reported no statistical differences between VCP and IP groups receiving the same intervention. Conclusions: VCP for the treatment of depression is a promising method for delivering mental health services. More rigorous research is needed to evaluate VCP on depression in various contexts and participants.
Full-text available
Background: Electronic mental health interventions (eMental health or eMH) can be used to increase accessibility of mental health services for mood disorders, with indications of comparable clinical outcomes as face-to-face psychotherapy. However, the actual use of eMH in routine mental health care lags behind expectations. Identifying the factors that might promote or inhibit implementation of eMH in routine care may help to overcome this gap between effectiveness studies and routine care. Objective: This paper reports the results of a systematic review of the scientific literature identifying those determinants of practices relevant to implementing eMH for mood disorders in routine practice. Methods: A broad search strategy was developed with high sensitivity to four key terms: implementation, mental health care practice, mood disorder, and eMH. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was applied to guide the review and structure the results. Thematic analysis was applied to identify the most important determinants that facilitate or hinder implementation of eMH in routine practice. Results: A total of 13,147 articles were screened, of which 48 studies were included in the review. Most studies addressed aspects of the reach (n=33) of eMH, followed by intervention adoption (n=19), implementation of eMH (n=6), and maintenance (n=4) of eMH in routine care. More than half of the studies investigated the provision of mental health services through videoconferencing technologies (n=26), followed by Internet-based interventions (n=20). The majority (n=44) of the studies were of a descriptive nature. Across all RE-AIM domains, we identified 37 determinants clustered in six main themes: acceptance, appropriateness, engagement, resources, work processes, and leadership. The determinants of practices are expressed at different levels, including patients, mental health staff, organizations, and health care system level. Depending on the context, these determinants hinder or facilitate successful implementation of eMH. Conclusions: Of the 37 determinants, three were reported most frequently: (1) the acceptance of eMH concerning expectations and preferences of patients and professionals about receiving and providing eMH in routine care, (2) the appropriateness of eMH in addressing patients' mental health disorders, and (3) the availability, reliability, and interoperability with other existing technologies such as the electronic health records are important factors for mental health care professionals to remain engaged in providing eMH to their patients in routine care. On the basis of the taxonomy of determinants of practices developed in this review, implementation-enhancing interventions can be designed and applied to achieve better implementation outcomes. Suggestions for future research and implementation practice are provided.
Full-text available
Digital mental health (DMH) interventions have promised to revolutionize mental health care by increasing its accessibility, availability, attractiveness, and cost-effectiveness. The first generation of web-based DMH interventions have consistently been found to be clinically effective for common mental disorders, such as depression and anxiety, in more than 100 randomized clinical trials (RCTs) and meta-analyses, particularly when accompanied by low-intensity coaching.¹ Inspired by this research, numerous health care systems have attempted to implement DMH interventions to address the large burden of mental health. However, these real-world implementation efforts have failed, often because they are not used by patients or therapists. This large research to practice gap suggests failures at many points, including DMH intervention design, research methods, and implementation approaches. The promised revolution in mental health will require a paradigm shift that addresses all 3 components to overcome the design, research, and routine care chasms.
This review summarizes six decades of clinical outcome research relevant to evidence-based practices for depression and anxiety delivered via clinical videoconferencing. The authors conducted a literature search of previous systematic reviews and an updated search of publications specific to anxiety and depression. Overall, strong evidence supports the safety and clinical effectiveness of administering evidence-based psychotherapy for anxiety and depression via clinical videoconferencing among heterogeneous populations and age ranges, and in multiple care settings, with similar outcomes to in-person care. Despite the overall clinical effectiveness of the modality, the authors discuss common logistical and institutional barriers to long-term effective implementation. Future systems-level research is required to investigate replicable and sustainable models for implementing and expanding access to evidence-based psychotherapies via clinical videoconferencing.
Background: Cognitive behavioral therapy (CBT) is an effective treatment, but access is often restricted due to costs and limited availability of trained therapists. Blending online and face-to-face CBT for depression might improve cost-effectiveness and treatment availability. Objective: This pilot study aimed to examine the costs and effectiveness of blended CBT compared with standard CBT for depressed patients in specialized mental health care to guide further research and development of blended CBT. Methods: Patients were randomly allocated to blended CBT (n=53) or standard CBT (n=49). Blended CBT consisted of 10 weekly face-to-face sessions and 9 Web-based sessions. Standard CBT consisted of 15 to 20 weekly face-to-face sessions. At baseline and 10, 20, and 30 weeks after start of treatment, self-assessed depression severity, quality-adjusted life-years (QALYs), and costs were measured. Clinicians, blinded to treatment allocation, assessed psychopathology at all time points. Data were analyzed using linear mixed models. Uncertainty intervals around cost and effect estimates were estimated with 5000 Monte Carlo simulations. Results: Blended CBT treatment duration was mean 19.0 (SD 12.6) weeks versus mean 33.2 (SD 23.0) weeks in standard CBT (P<.001). No significant differences were found between groups for depressive episodes (risk difference [RD] 0.06, 95% CI -0.05 to 0.19), response to treatment (RD 0.03, 95% CI -0.10 to 0.15), and QALYs (mean difference 0.01, 95% CI -0.03 to 0.04). Mean societal costs for blended CBT were €1183 higher than standard CBT. This difference was not significant (95% CI -399 to 2765). Blended CBT had a probability of being cost-effective compared with standard CBT of 0.02 per extra QALY and 0.37 for an additional treatment response, at a ceiling ratio of €25,000. For health care providers, mean costs for blended CBT were €176 lower than standard CBT. This difference was not significant (95% CI -659 to 343). At €0 per additional unit of effect, the probability of blended CBT being cost-effective compared with standard CBT was 0.75. The probability increased to 0.88 at a ceiling ratio of €5000 for an added treatment response, and to 0.85 at €10,000 per QALY gained. For avoiding new depressive episodes, blended CBT was deemed not cost-effective compared with standard CBT because the increase in costs was associated with negative effects. Conclusions: This pilot study shows that blended CBT might be a promising way to engage depressed patients in specialized mental health care. Compared with standard CBT, blended CBT was not considered cost-effective from a societal perspective but had an acceptable probability of being cost-effective from the health care provider perspective. Results should be carefully interpreted due to the small sample size. Further research in larger replication studies focused on optimizing the clinical effects of blended CBT and its budget impact is warranted. Trial registration: Netherlands Trial Register NTR4650; International registered report identifier (irrid): RR2-10.1186/s12888-014-0290-z.