Elsevier

Journal of Affective Disorders

Volume 256, 1 September 2019, Pages 103-109
Journal of Affective Disorders

Research paper
Internet-delivered treatment for young adults with anxiety and depression: Evaluation in routine clinical care and comparison with research trial outcomes

https://doi.org/10.1016/j.jad.2019.05.058Get rights and content

Highlights

  • Online treatment for young adults reduces symptoms of anxiety and depression.

  • Symptom reductions are large at post-treatment and three-month follow-up.

  • Deterioration rates are low and treatment satisfaction is high.

  • Results obtained in routine care are comparable to research trial results.

  • Online interventions can be translated from research to real world settings.

Abstract

Introduction

Mood and anxiety disorders typically emerge in adolescence and early adult life, but young adults are often reluctant to seek treatment. The Mood Mechanic course is a transdiagnostic internet-delivered psychological intervention for symptoms of depression and anxiety, targeted at people aged 18–24 years. The current study compared the efficacy of the course when delivered under strict research trial conditions (research trial; n = 192) with its effectiveness in a routine health-care setting (routine care; n = 222).

Methods

Symptoms of depression, anxiety and general distress at baseline, during, and after treatment were measured by the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and Kessler 10-Item Scale (K-10), respectively.

Results

Both groups showed significant symptom reductions on all measures at post-treatment and 3-month follow-up. Deterioration rates were low, within-group effect sizes were large (>1.0) and both groups reported high levels of treatment satisfaction. Patients in routine care were less likely to complete post-treatment or follow-up symptom questionnaires.

Limitations

The study is based on self-reported data from treatment-seeking individuals that were motivated enough to start the course, and the absence of a control group and a formal diagnosis in the routine care sample means that some caution is needed in generalising the results.

Conclusion

The results show that the Mood Mechanic course is effective and acceptable in routine clinical care, and that online psychological interventions designed for young adults are an effective treatment option for this hard-to-reach group.

Introduction

Mood and anxiety disorders often emerge in adolescence and early adulthood, and are associated with chronic health difficulties, decreased workforce participation, and lower living standards in later life (Kessler et al., 2005, Shankman et al., 2009, Gore et al., 2011, Kieling et al., 2011, Patel et al., 2017, Gibb et al., 2018, Gili et al., 2018). However, young adults are less likely to seek or engage in treatment compared to older age groups (Rickwood et al., 2007, Merikangas et al., 2011). Barriers to care that might be particularly relevant to young adults include concerns about stigma, the costs and availability of appropriate services, insufficient mental health literacy, and negative attitudes toward professional help-seeking in young people (Collins et al., 2004, Corrigan, 2004, Coles et al., 2016, Gronholm et al., 2018).

One strategy for overcoming barriers to care and increasing engagement is to deliver mental health information and interventions via the internet, and there is good evidence from clinical research trials that online information and services targeted towards younger age groups are effective (Rickwood et al., 2007, Calear and Christensen, 2010, Johnston et al., 2014, Reyes-Portillo et al., 2014, Das et al., 2016, Dear et al., 2018, Topooco et al., 2018). There is also increasing evidence that internet-delivered cognitive behavioural therapy (iCBT) can be safely and successfully administered as part of routine mental health services for adults in general (Hedman et al., 2014, Hadjistavropoulos et al., 2017, Hobbs et al., 2017, Ruwaard et al., 2012, Williams and Andrews, 2013, Newby et al., 2017, Titov et al., 2017). Such evidence of outcomes in routine care is an important part of the clinical trial process (Powell et al., 2012, Titov et al., 2018). Consistent with clinical trial methodology, later phase trials help to determine longer term benefits and risks for patients (Powell et al., 2012, National Institutes of Health 2017).

The current study compared outcomes from a randomized controlled trial of the Mood Mechanic Course – a transdiagnostic internet-delivered cognitive behavioural therapy (iCBT) course designed for people aged 18–24 years (Johnston et al., 2014, Dear et al., 2018), with the outcomes obtained when the same course was used in routine clinical care at the MindSpot Clinic, an Australian online and telephone mental health service funded by the Australian Government since 2012 (Titov et al., 2017, Titov et al., 2015a). Based on previous published research (Dear et al., 2018, Titov et al., 2017, Titov et al., 2015a, Staples et al., 2016), it was expected that initial symptom severity would be higher in the routine care group compared to the research trial group, given that the research trial had more restrictive inclusion criteria. It was hypothesised that the routine care group would show significant improvements in symptoms of depression, anxiety, and general distress, low rates of deterioration, and high levels of satisfaction, comparable to the results obtained in the research trial.

Section snippets

Participants and design

This study is a retrospective analysis of two groups. Participants forming the research trial group were enrolled in a previously reported randomized controlled trial (RCT) conducted by the eCentreClinic between September 2013 to April 2015 (Dear et al., 2018). Participants in the original research trial were recruited online via the eCentreClinic website (www.ecentreclinic.org). Inclusion criteria for the research trial group were: (1) resident of Australia aged 18–24 years, (2) a

Demographics and symptoms at assessment

Demographic and symptom characteristics are included in Table 1. There were no significant differences between the research trial and routine care groups in age, gender ratio, marital status or vocational status (ps > .10). There was a significant difference between groups in the proportion of participants with university degrees (p < .05), with a higher proportion of the patients in routine care reporting that they held an undergraduate or postgraduate qualification.

There was a significant

Discussion

The Mood Mechanic course is a transdiagnostic internet-delivered intervention designed for young people aged 18–24 years, with symptoms of anxiety and depression. This study evaluated the effectiveness of the course following its implementation at the MindSpot Clinic, a government-funded national online mental health service. Outcomes obtained at the MindSpot Clinic were compared with outcomes obtained under research trial conditions. Demographics and symptoms at assessment for both samples

Limitations

The Mood Mechanic Course was developed alongside similar courses that have been tested in several RCTs (Dear et al., 2016, Fogliati et al., 2016, Titov et al., 2015b, Dear et al., 2015). For the current study however, the lack of a control group, as well as the use of a modified intention-to-treat protocol that excluded non-starters, does mean that some caution is needed when interpreting the results. Symptom reductions could be due at least in part to natural remission over time, or to other

Conclusion

Online mental health interventions tailored to young adults is one way of increasing engagement in a cohort that are often reluctant to seek treatment. For young adults, internet-based interventions may reduce some barriers to care that are particularly relevant to them, including stigma, costs, and an often-negative attitude toward professional help-seeking. In addition, reporting the benefits and risks of interventions used in routine care is a key step in the clinical trial process, and the

Role of the funding source

None.

CRediT authorship contribution statement

Lauren G. Staples: Conceptualization, Writing - review & editing, Data curation, Formal analysis, Writing - original draft. Blake F. Dear: Conceptualization, Writing - review & editing, Supervision, Resources. Bareena Johnson: Conceptualization, Writing - review & editing, Investigation, Methodology. Vincent Fogliati: Conceptualization, Writing - review & editing, Investigation, Methodology. Milena Gandy: Conceptualization, Writing - review & editing, Investigation, Methodology. Rhiannon

Declaration of Competing Interest

NT and BFD developed the Mood Mechanic Course but derive no financial benefit from it. NT and BFD are funded by the Australian Government to develop and operate the MindSpot Clinic.

Acknowledgements

None.

References (46)

  • C. Kieling et al.

    Child and adolescent mental health worldwide: evidence for action

    The Lancet

    (2011)
  • K.R. Merikangas et al.

    Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A)

    J. Am. Acad. Child Adolesc. Psychiatry

    (2011)
  • J.M. Newby et al.

    Transdiagnostic versus disorder-specific internet-delivered cognitive behaviour therapy for anxiety and depression in primary care

    J. Anxiety Disord.

    (2017)
  • A. Rozental et al.

    Consensus statement on defining and measuring negative effects of Internet interventions

    Internet Interv.

    (2014)
  • B.C. Schneider et al.

    Bridging the “digital divide”: a comparison of use and effectiveness of an online intervention for depression between Baby Boomers and Millennials

    J. Affect. Disord.

    (2018)
  • N. Titov et al.

    ICBT in routine care: a descriptive analysis of successful clinics in five countries

    Internet Interv.

    (2018)
  • N. Titov et al.

    Disorder-specific versus transdiagnostic and clinician-guided versus self-guided treatment for major depressive disorder and comorbid anxiety disorders: a randomized controlled trial

    J. Anxiety Disord.

    (2015)
  • A.L. Calear et al.

    Review of internet-based prevention and treatment programs for anxiety and depression in children and adolescents

    Med. J. Aust.

    (2010)
  • J. Cohen

    Statistical Powere Anlysis For the Behavioral Sciences

    (1988)
  • P. Corrigan

    How stigma interferes with mental health care

    Am. Psychol.

    (2004)
  • J.K. Das et al.

    Interventions for adolescent mental health: an overview of systematic reviews

    J. Adolesc. Health

    (2016)
  • B.F. Dear et al.

    Treating anxiety and depression in young adults: a randomised controlled trial comparing clinician-guided versus self-guided Internet-delivered cognitive behavioural therapy

    Aust. N. Z. J. Psychiatry

    (2018)
  • S.J. Gibb et al.

    Burden of psychiatric disorder in young adulthood and life outcomes at age 30

    Br. J. Psychiatry

    (2018)
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