Digital Interventions for Dual Diagnosis

Dual diagnosis is a leading contributor of disease burden worldwide. Whilst integrated treatment is recommended, there are considerable barriers that may inhibit access to integrated care, including a lack of training and resources. Digital interventions may enable access to support, providing a space for people to engage in treatment when they need it most. This chapter reviews the current literature on the efficacy of digital interventions for dual diagnosis. Computer-based interventions were effective at improving dual diagnosis outcomes; however, the combined effect of computer-based interventions and therapist support was found to be more effective than the effects of computer-based interventions alone. The evidence-base around smartphone applications is lacking, and there are perceived difficulties with this technology in addressing the complexity of issues faced by people with dual diagnosis. Future research should include standardised terminology to describe techniques used within interventions and consider a variety of research methods to understand implementation.

The acceptability of a therapist-assisted internet-delivered cognitive behaviour therapy program for the treatment of anxiety disorders in adolescents: a qualitative study

Computerized treatments have been shown to be effective in young people with anxiety disorders. However, there has been limited investigation into the experiences of adolescents in undertaking this treatment. This qualitative study explored adolescents’ experiences of being treated for an anxiety disorder, using an online intervention with therapist support, as part of a randomised controlled trial. Individual semi-structured interviews were conducted with thirteen adolescents aged between 13 and 17 years, who had received the online intervention. Data were analysed using reflexive thematic analysis. Two cross-cutting themes were identified: (i) Usability of the program, and (ii) Putting techniques into practice. Although the convenience of online sessions was recognised as positive, many of the adolescents expressed a preference for face-to-face sessions. The length of sessions and the large amount of reading involved was highlighted by most participants. The transdiagnostic nature of the content meant some elements of the programme were seen as less relevant. While many participants appreciated the ‘fun’ aspect of the program, others felt that certain aspects of the program were not suitable for their age group. Exposure, psychoeducation and cognitive restructuring were generally received positively, whereas responses to the use of relaxation and rewards were much more mixed. Our findings highlight the potential utility for online treatments delivered with therapist support. However, they also highlight how issues with both the format and treatment components can impact the acceptability of a program. As such, further work is warranted to improve the acceptability of online treatments for adolescents with anxiety disorders.

Internet-based treatment of gambling problems: A systematic review and meta-analysis of randomized controlled trials

Background and aimsThe effect of internet-based psychological treatment for gambling problems has not been previously investigated by meta-analysis. The present study is therefore a quantitative synthesis of studies on the effects of internet-based treatment for gambling problems. Given that effects may vary according to the presence of therapist support and control conditions, it was presumed that subgroup analyses would elucidate such effects.MethodsA systematic search with no time constraints was conducted in PsycINFO, MEDLINE, Web of Science, and the Cochrane Library. Two authors independently extracted data using a predefined form, including study quality assessment based on the Cochrane risk of bias tool. Effect sizes were calculated using random-effects models. Heterogeneity was indexed by Cochran’s Q and the I2 statistics. Publication bias was investigated using trim and fill.ResultsThirteen studies were included in the analysis. Random effects models at post-treatment showed significant effects for general gambling symptoms (g = 0.73; 95% CI = 0.43–1.03), gambling frequency (g = 0.29; 95% CI = 0.14–0.45), and amount of money lost gambling (g = 0.19; 95% CI = 0.11–0.27). The corresponding findings at follow-up were g = 1.20 (95% CI = 0.79–1.61), g = 0.36 (95% CI = 0.12–0.60), and g = 0.20 (95% CI = 0.12–0.29) respectively. Subgroup analyses showed that for general gambling symptoms, studies with therapist support yield larger effects than studies without, both post-treatment and at follow-up. Additionally, on general gambling symptoms and gambling frequency, there were lower effect sizes for studies with a control group compared to studies without a control group at follow-up. Studies with higher baseline severity of gambling problems were associated with larger effect sizes at both posttreatment and follow-up than studies with more lenient inclusion criteria concerning gambling problems.Discussion and conclusionsInternet-based treatment has the potential to reach a large proportion of persons with gambling problems. Results of the meta-analysis suggest that such treatments hold promise as an effective approach. Future studies are encouraged to examine moderators of treatment outcomes, validate treatment effects cross-culturally, and investigate the effects of novel developments such as ecological momentary interventions.

Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans (Preprint)

BACKGROUND Blended models which incorporate elements of both internet and face-to-face therapies have been shown to be effective. Therapist and patients have expressed concerns that less rather more therapy sessions relative to self-guided internet sessions may be associated with lower therapeutic alliance, lower program completion rates and poorer outcomes. OBJECTIVE A multi-site quasi-experimental comparison study with a noninferiority design conducted in routine clinical care was used to assess webSTAIR, a 10-module blended therapy for trauma-exposed individuals delivered with 10 weekly therapist sessions (Coach10) compared to 5 biweekly sessions (Coach5). It was hypothesized that Coach5 would be “as good as” Coach10 regarding a range of outcomes. METHODS : A total of 202 Veterans were enrolled in the study (Coach5 n = 101, Coach10 n = 101). PTSD symptoms, depression, emotion regulation, interpersonal problems and social functioning measures were collected at pretreatment, mid, posttreatment and 3-month follow-up. Noninferiority analyses were conducted on symptom outcome measures. Comparisons of continuous and categorical measures regarding participant and therapist activities were conducted. RESULTS : Participants reported moderate to severe levels of baseline PTSD and/or depression. Significant reductions were obtained on all symptom measures at post and 3-month follow-up. Coach5 was not inferior to Coach10 on any outcome. Therapeutic alliance was high and equivalent across the two treatment conditions and completion rates and web usage were similar. Coach5 therapists’ total session time was substantially less than Coach10. Both programs were associated with a low and equal number of therapist activities related to scheduling and crisis/motivational sessions. CONCLUSIONS A blended model delivered with 5 sessions of therapist support was noninferior to 10 sessions among individuals with moderate to severe symptoms. Future studies identifying patient characteristics as moderators of outcomes in high versus low dose of therapist support will help create flexible technology-based intervention programming.