BackgroundDepression and anxiety are prevalent and under treated conditions that create enormous burden for the patient and the health system. Internet-delivered cognitive behavior therapy (ICBT) improves patient access to treatment by providing therapeutic information via the Internet, presented in sequential lessons, accompanied by brief weekly therapist support. While there is growing research supporting ICBT, use of ICBT within community mental health clinics is limited. In a recent trial, an external unit specializing in ICBT facilitated use of ICBT in community mental health clinics in one Canadian province (ISRCTN42729166; registered November 5, 2013). Patient outcomes were very promising and uptake was encouraging. This paper reports on a parallel process evaluation designed to understand facilitators and barriers impacting the uptake and implementation of ICBT.MethodsTherapists (n = 22) and managers (n = 11) from seven community mental health clinics dispersed across one Canadian province who were involved in implementing ICBT over ~2 years completed an online survey (including open and closed-ended questions) about ICBT experiences. The questions were based on the Consolidated Framework for Implementation Research (CFIR), which outlines diverse constructs that have the potential to impact program implementation.ResultsAnalyses suggested ICBT implementation was perceived to be most prominently facilitated by intervention characteristics (namely the relative advantages of ICBT compared to face-to-face therapy, the quality of the ICBT program that was delivered, and evidence supporting ICBT) and implementation processes (namely the use of an external facilitation unit that aided with engaging patients, therapists, and managers and ICBT implementation). The inner setting was identified as the most significant barrier to implementation as a result of limited resources for ICBT combined with greater priority given to face-to-face care.ConclusionsThe results contribute to understanding facilitators and barriers to using ICBT within community mental health clinics and serve to identify recommendations for improving uptake and implementation of ICBT in clinic settings.Electronic supplementary materialThe online version of this article (10.1186/s12888-017-1496-7) contains supplementary material, which is available to authorized users.

Postpartum depression impacts up to 15% of Canadian women following childbirth. Remarkably, many women suffering from this disorder do not receive appropriate treatment. The aim of this study was to conduct a parallel-group randomized controlled trial to determine the efficacy of Therapist-Assisted Internet-delivered Cognitive Behavior Therapy (TA-ICBT) for the treatment of postpartum depression. This study was registered with the International Standard Randomized Controlled Trials (ISRCTN: 85456371) and received funding from Canadian Institutes of Health Research (#101526) and the Saskatchewan Health Research Foundation. Fifty women who gave birth to an infant in the past year, who scored above 10 on the Edinburgh Postnatal Depression Scale (EPDS), and who resided in Saskatchewan, Canada were eligible to participate. Participants were randomly assigned to receive either TA-ICBT (n = 25) or waitlist control (n = 25). The efficacy of the treatment was investigated at baseline and at seven- to 10-week follow-up. TA-ICBT participants were also contacted four-weeks following treatment completion. Symptoms of postpartum depression decreased more for participants in the TA-ICBT group (average reduction of 6.24 points on the EPDS; n = 21 included in analyses) compared to those participants in the waitlist control group (average reduction of 2.42 points on the EPDS; n = 20 included in analyses), and these results were clinically significant and maintained at four-week follow-up. TA-ICBT participants demonstrated a reduction in postnatal anxiety, general stress, and parental distress, and an increase in psychological and environmental quality of life when compared to the waitlist control participants. Study implications, limitations, and future research directions are discussed.Trial RegistrationControlled-Trials.com ISRCTN85456371

Internet-delivered cognitive behaviour therapy (ICBT) is effective for treating anxiety and depression. The relative benefits of offering standard weekly compared to optional weekly therapist support in conjunction with ICBT within routine care has not been examined. Patients seeking ICBT for depression and or anxiety in routine care were randomized to standard (n=92) or optional (n=88) weekly support. The optional approach resulted in therapists receiving half as many messages from (1.70 vs. 3.96) and sending half as many messages to patients (3.62 vs. 7.29). Optional Support was associated with lower completion rates (56.6% versus 82.4%), but, similar to Standard Support, resulted in large reductions on the GAD-7 (within Cohen's d≥1.08; avg. reduction ≥47%) and PHQ-9 (within Cohen's d≥0.82; avg. reduction ≥43%) at post-treatment and 3-month follow-up. Optional weekly support appears clinically effective and acceptable for many patients and may reduce costs, but safety requires monitoring given lower completion rates.

Patients' program preference and baseline psychological functioning, rather than personality, were predictive of program benefits. These results suggest incorporating program preference can maximize the efficacy of integrative oncology interventions, and emphasize the methodological importance of assessing and accommodating for preferences when conducting mind-body clinical trials.

Internet-delivered cognitive behaviour therapy (ICBT) is an efficacious, yet novel approach to the treatment of depression and anxiety. It has the potential to improve access to evidenced-based care, but only if potential patients are aware of, understand, and have positive expectations about this treatment. In order to establish whether the use of an educational video could improve favourable expectations of ICBT, two studies were conducted. The goal of the first study was to determine whether an educational video would improve perceptions of ICBT among individuals seeking ICBT treatment and to determine what type of information (client testimonials versus statistical information related to outcomes) facilitates the greatest increase in positive expectations of ICBT. Participants who visited an ICBT service (N = 71) website were invited to first complete brief questionnaires assessing initial perceptions of ICBT. They were then randomly assigned to watch one of two videos containing either client testimonials (n = 32) or statistical information related to outcomes (n = 39). Patient perceptions of ICBT were then reassessed. Perceptions of ICBT were significantly higher post-video than pre-video and the type of information did not impact perceptions of ICBT. In the second study, the research was extended by examining perceptions of ICBT before and after watching an educational video (including both statistical and narrative information as this had no impact on perceptions) in a sample of individuals (N = 94) who were experiencing anxiety and depression but were not specifically seeking ICBT. As with treatment seekers, perceptions of ICBT were significantly higher post-video than pre-video. Comparison of the treatment and non-treatment seekers revealed no differences in perceptions of ICBT between the samples. The findings suggest that educational videos are an effective way to increase expectations of ICBT. Future directions for research are described.