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Optimizing internet-delivered cognitive behaviour therapy for alcohol misuse: a study protocol for a randomized factorial trial examining the effects of a pre-treatment assessment interview and health educator guidance.

ABSTRACT: BACKGROUND:Alcohol misuse is a common, disabling, and costly issue worldwide, but the vast majority of people with alcohol misuse never access treatment for varying reasons. Internet-delivered cognitive behaviour therapy (ICBT) may be an attractive treatment alternative for individuals with alcohol misuse who are reluctant to seek help due to stigma, or who live in rural communities with little access to face-to-face treatment. With the growing development of ICBT treatment clinics, investigating ways to optimize its delivery within routine clinic settings becomes a crucial avenue of research. Some studies in the alcohol treatment literature suggest that assessment interviews conducted pre-treatment may improve short- and long-term drinking outcomes but no experimental evaluation of this has been conducted. Further, research on internet interventions for alcohol misuse suggests that guidance from a therapist or coach improves outcomes, but more research on the benefits of guidance in ICBT is still needed. METHODS:This study is a 2X2 factorial randomized controlled trial where all of the expected 300 participants receive access to the Alcohol Change Course, an eight-week ICBT program. A comprehensive pre-treatment assessment interview represents factor 1, and guidance from a health educator represents factor 2. All participants will be asked to respond to measures at screening, pre-treatment, mid-treatment, post-treatment and 3, 6 and 12?months after treatment completion. DISCUSSION:This study will provide valuable information on optimization of ICBT for alcohol misuse within routine clinic settings. TRIAL REGISTRATION:ClinicalTrials.gov, registered June 13th 2019, NCT03984786.

SUBMITTER: Sundstrom C

PROVIDER: S-EPMC7079400 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Although Internet-delivered cognitive behaviour therapy (ICBT) for alcohol misuse is efficacious in research trials, it is not routinely available in practice. Moreover, there is considerable variability in engagement and outcomes of ICBT for alcohol misuse across studies. The Alcohol Change Course (ACC) is an ICBT program that is offered free of charge by an online clinic in Saskatchewan, Canada, which seeks to fill this service gap, while also conducting research to direct future improvements of ICBT. As there is limited qualitative patient-oriented research designed to improve ICBT for alcohol misuse, in this study, we describe patient perceptions of the ACC post-treatment. Specifically, post-treatment feedback was obtained from 191 of 312 patients who enrolled in the ACC. Qualitative thematic analysis was used to examine post-treatment written comments related to what patients liked and disliked about the course, which skills were most helpful for them, and their suggestions for future patients. The majority of patients endorsed being very satisfied or satisfied with the course (n = 133, 69.6%) and 94.2% (n = 180) perceived the course as being worth their time. Worksheets (n = 61, 31.9%) and reflections of others (n = 40, 20.9%) received the most praise. Coping with cravings (n = 63, 33.0%), and identifying and managing risky situations (n = 46, 24.1%) were reported as the most helpful skills. Several suggestions for refining the course were provided with the most frequent recommendation being a desire for increased personal interaction (n = 24, 12.6%) followed by a desire for wanting more information (n = 22, 11.5%). Many patients offered advice for future ACC patients, including suggestions to make a commitment (n = 47, 24.6%), do all of the work (n = 29, 15.2%), and keep a consistent approach to the course (n = 24, 12.6%). The results provide valuable patient-oriented directions for improving ICBT for alcohol misuse.

Project description:BackgroundInternet-delivered cognitive behavioral therapy (ICBT) can improve access to mental health care for students, although high attrition rates are concerning and little is known about long-term outcomes. Motivational interviewing (MI) exercises and booster lessons can improve engagement and outcomes in face-to-face cognitive behavioral therapy.ObjectiveThis study aimed to examine the use of pretreatment MI exercises and booster lessons in ICBT for postsecondary students.MethodsIn this factorial trial (factor 1: web-based MI before treatment; factor 2: self-guided booster lesson 1 month after treatment), 308 clients were randomized to 1 of 4 treatment conditions, with 277 (89.9%) clients starting treatment. All clients received a 5-week transdiagnostic ICBT course (the UniWellbeing course). Primary outcomes included changes in depression, anxiety, and perceived academic functioning from before treatment to after treatment and at the 1-month and 3-month follow-ups.ResultsOverall, 54% (150/277) of students completed treatment and reported large improvements in symptoms of depression and anxiety and small improvements in academic functioning after treatment, which were maintained at the 1-month and 3-month follow-ups. Pretreatment MI did not contribute to better treatment completion or engagement, although small between-group effects favored MI for reductions in depression (Cohen d=0.23) and anxiety (Cohen d=0.25) after treatment. Only 30.9% (43/139) of students randomized to one of the booster conditions accessed the booster. Overall, no main effects were found for the booster. Subanalyses revealed that clients who accessed the booster had larger decreases in depressive symptoms (Cohen d=0.31) at the 3-month follow-up. No interactions were found between MI and the booster.ConclusionsRather than offering MI before treatment, clients may experience more benefits from MI exercises later in ICBT when motivation wanes. The low uptake of the self-guided booster limited our conclusions regarding its effectiveness. Future research should examine offering a booster for a longer duration after treatment, with therapist support and a longer follow-up period.Trial registrationClinicalTrials.gov NCT04264585; https://clinicaltrials.gov/ct2/show/NCT04264585.

Project description:BACKGROUND:Internet-delivered cognitive behavior therapy (ICBT) has been found to be effective for treating alcohol misuse in research trials, but it is not available as part of routine care in Canada. Recent recommendations in the literature highlight the importance of integrating perspectives from both patient and health care stakeholders when ICBT is being implemented in routine practice settings. OBJECTIVE:This study aimed to gain an understanding of how ICBT is perceived as a treatment option for alcohol misuse by interviewing diverse stakeholders. Specifically, the objectives were to (1) learn about the perceived advantages and disadvantages of ICBT for alcohol misuse and (2) elicit recommendations to inform implementation efforts in routine practice. METHODS:A total of 30 participants representing six stakeholder groups (ie, patients, family members, academic experts, frontline managers, service providers, and health care decision makers) participated in semistructured interviews. To be included in the study, stakeholders had to reside in Saskatchewan, Canada, and have personal or professional experience with alcohol misuse. Interviews were transcribed verbatim, anonymized, and analyzed using thematic analysis. RESULTS:Stakeholders identified numerous advantages of ICBT for alcohol misuse (eg, accessibility, convenience, privacy, relevance to technology-based culture, and fit with stepped care) and several disadvantages (eg, lack of internet access and technological literacy, isolation, less accountability, and unfamiliarity with ICBT). Stakeholders also provided valuable insight into factors to consider when implementing ICBT for alcohol misuse in routine practice. In terms of intervention design, stakeholders recommended a 6- to 8-week guided program that uses Web-based advertising, point-of-sale marketing, and large-scale captive audiences to recruit participants. With regard to treatment content, stakeholders recommended that the program focus on harm reduction rather than abstinence; be evidence based; appeal to the diverse residents of Saskatchewan; and use language that is simple, encouraging, and nonjudgmental. Finally, in terms of population characteristics, stakeholders felt that several features of the alcohol misuse population, such as psychiatric comorbidity, readiness for change, and stigma, should be considered when developing an ICBT program for alcohol misuse. CONCLUSIONS:Stakeholders' insights will help maximize the acceptability, appropriateness, and adoption of ICBT for alcohol misuse and in turn contribute to implementation success. The methodology and findings from this study could be of benefit to others who are seeking to implement ICBT in routine practice.

Project description:BACKGROUND:Smoking remains a leading cause of preventable death and illness. Internet interventions for smoking cessation have the potential to significantly impact public health, given their broad reach and proven effectiveness. Given the dose-response association between engagement and behavior change, identifying strategies to promote engagement is a priority across digital health interventions. Text messaging is a proven smoking cessation treatment modality and a powerful strategy to increase intervention engagement in other areas of health, but it has not been tested as an engagement strategy for a digital cessation intervention. OBJECTIVE:This study examined the impact of 4 experimental text message design factors on adult smokers' engagement with an internet smoking cessation program. METHODS:We conducted a 2×2×2×2 full factorial screening experiment wherein 864 participants were randomized to 1 of 16 experimental conditions after registering with a free internet smoking cessation program and enrolling in its automated text message program. Experimental factors were personalization (on/off), integration between the web and text message platforms (on/off), dynamic tailoring of intervention content based on user engagement (on/off), and message intensity (tapered vs abrupt drop-off). Primary outcomes were 3-month measures of engagement (ie, page views, time on site, and return visits to the website) as well as use of 6 interactive features of the internet program. All metrics were automatically tracked; there were no missing data. RESULTS:Main effects were detected for integration and dynamic tailoring. Integration significantly increased interactive feature use by participants, whereas dynamic tailoring increased the number of features used and page views. No main effects were found for message intensity or personalization alone, although several synergistic interactions with other experimental features were observed. Synergistic effects, when all experimental factors were active, resulted in the highest rates of interactive feature use and the greatest proportion of participants at high levels of engagement. Measured in terms of standardized mean differences (SMDs), effects on interactive feature use were highest for Build Support System (SMD 0.56; 95% CI 0.27 to 0.81), Choose Quit Smoking Aid (SMD 0.38; 95% CI 0.10 to 0.66), and Track Smoking Triggers (SMD 0.33; 95% CI 0.05 to 0.61). Among the engagement metrics, the largest effects were on overall feature utilization (SMD 0.33; 95% CI 0.06 to 0.59) and time on site (SMD 0.29; 95% CI 0.01 to 0.57). As no SMD >0.30 was observed for main effects on any outcome, results suggest that for some outcomes, the combined intervention was stronger than individual factors alone. CONCLUSIONS:This factorial experiment demonstrates the effectiveness of text messaging as a strategy to increase engagement with an internet smoking cessation intervention, resulting in greater overall intervention dose and greater exposure to the core components of tobacco dependence treatment that can promote abstinence. TRIAL REGISTRATION:ClinicalTrials.gov NCT02585206; https://clinicaltrials.gov/ct2/show/NCT02585206. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):RR2-10.1136/bmjopen-2015-010687.

Project description:While internet-delivered cognitive behavioural therapy (ICBT) is effective, some patients suggest extended support post-treatment could improve care. In this randomized factorial trial, we examined the benefits of an 8-week therapist-assisted ICBT program offered with or without an optional 4-week extension of support (Factor 1) and with or without an optional booster lesson (Factor 2). Patients screened for ICBT for depression and/or anxiety were randomly assigned to the conditions (N = 434) and we examined the use of the extension and booster, differences between those who did or did not use extension or booster, and the impact of the extension or booster on outcomes, engagement, and satisfaction at 26-weeks post-enrollment. Therapists recorded time and observations with offering support during the extension and booster. In the extension group, 54.4% (n = 56) requested the extension, while in the booster group 50.9% (n = 56) accessed the booster, and in the combined group, 41.6% (n = 47) requested the extension and 51.3% (n = 58) accessed the booster. Those who requested the extension were older, and more likely to report medication and mental health service use and severe mental health-related disability at pre-treatment; they also reported putting less effort into ICBT and finding skills more difficult. The booster was more often used among those with lower symptom severity, and those who put more effort into and had more positive experiences with ICBT. As expected, those assigned to extension sent more messages to their therapist, and those assigned to booster logged in more often. Therapists also took more time to deliver ICBT with an extension (>18 min) or booster (>13 min) compared to the 8-week program, and perceived extension and booster as beneficial for some, but not all patients. Treatment satisfaction was high across conditions, and effect sizes were large from pre-treatment to 26-week follow-up on most measures. No significant group differences were found in this study. Lack of group differences, however, could reflect low use of the extension and booster. Results provide helpful information about the demand for extensions and boosters, and provide directions for future research.

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Optimizing internet-delivered cognitive behaviour therapy for alcohol misuse: a study protocol for a randomized factorial trial examining the effects of a pre-treatment assessment interview and health educator guidance.

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