Feasibility of a blended group treatment (bGT) for major depression: uncontrolled interventional study in a university setting

Introduction

Depression presents a relevant public health concern and imposes high costs on society as well as on health systems.¹ Therefore, research priorities include health policy and system research, in particular, how to deliver cost-effective interventions in a low-resource context.^{2 3} Psychological online interventions have been found effective in reducing common mental health disorders, for example, depression⁴ and anxiety,⁵ in such low-resource contexts.

Online interventions offer many advantages; they can provide access to evidence-based treatments and patients can work through the intervention whenever they want.⁶ Usually, anonymity is preserved as patients participate at distance, resulting in low-social barriers and low risk of stigmatisation.⁷ From a health suppliers perspective, online interventions guarantee standardised treatments and show good scalability, which has led to the launch of the first online clinics.^{8 9} Internet-based interventions can also help with bridging waiting times¹⁰ or enhance treatment effects during aftercare.¹¹ At the same time, online interventions do not fit all patients’ needs (eg, need for more personal contact or diverging preferences). Consequently, classical face-to-face therapy will remain an important basis of mental healthcare. That being said, tools and methods developed in online therapy can be integrated into various forms of face-to-face therapy.¹²

Due to the variety of possible combinations, it remains difficult to define blended interventions concisely. van der Vaart and colleagues¹³ describe blended therapy as ‘[…] a combination of online and face-to-face therapy, in which online sessions replace or substitute some (parts) of the sessions with a health professional […]’. According to Kooistra and colleagues,¹⁴ the combination of both intervention strategies should merge into one integrated treatment format. In our study’s context, new media was also used as a supportive in-session tool (eg, multimedia presentations and videos). Thus, we define blended therapy as an integrated combination of face-to-face sessions with computer or application support. It aims at improving the delivery of evidence-based therapy methods and results in a possible acceleration or intensification of treatment. The online part of blended interventions often entails psychoeducation, online exercises and remote therapist feedback on accomplished exercises, as well as mobile diaries or monitoring.¹⁵ Interventions are usually delivered via online platforms¹⁶ or applications for mobile phones.¹⁷

Blended therapy is at an early stage of research, even though first studies date back to the 1980s and 1990s.^18–20 At that time, computer support had been found to be useful in the treatment of depression, anxiety or obsessive compulsive disorders.²⁰ However, these early studies do not adequately account for the rapid development that modern technologies have undergone, and user behaviour has changed dramatically since then. When examining more recent literature, good acceptability and compatibility with standard treatments are found.²¹ Additionally, computer-assisted programmes may well shorten treatment duration while maintaining observed treatment effects.²² In Europe, research on blended therapy, currently is on the rise, as a multicentre study (E-COMPARED) investigates possible time savings in routine care.²³ From a therapy process perspective, Månsson and colleagues¹⁶ suggest that blended interventions could foster adherence to evidence based-treatment rationales, because the structure provided by blended therapy might prevent therapists from so called therapist drift.²⁴ Regarding the implementation of blended therapy, the Netherlands seems to be Europe’s most promotive nation.²⁵ According to Netherlands’ leading software provider (Minddistrict), more than 17 000 professionals and 120 000 patients are currently using some of their blended services.²⁶

With little exceptions, research on blended interventions has its primary focus on individual therapy and little is known about the potential for group treatments. As it is a recommended treatment in health guidelines and national health policies,^{27 28} group therapy has various applications in inpatient and outpatient clinics.²⁹ For example, the National Institute for Health and Care Excellence³⁰ recommends group cognitive-behavioural therapy (CBT) for people with mild to moderate depression who decline other low-intensity psychosocial interventions, such as computerised CBT. Therefore, the integration of computer support and face-to-face group sessions might result in an optimised treatment, in which personal contact is preserved. Existing blended group therapy (bGT) studies reveal high acceptability for the treatment of anxiety disorders and suggest possible savings of therapist time.^31–33 To achieve savings, typical standard treatments (12–14 session) are shortened by 33%–57% (6–8 sessions). Apart from potential savings, bGT allows new ways of therapist-to-client and client-to-client interaction, such as online supervision of homework tasks or gamification.³⁴

Literature on bGT for depression remains scarce, as there do not exist any published articles prior to our first proof of concept study.³⁵ Due to the demand for low-threshold treatments,³⁶ we designed a CBT-based psychoeducational intervention entailing principles of resource-oriented psychotherapy and self-management therapy. Resource-oriented psychotherapy focuses on current concerns and tries to strengthen personal skills in order to achieve set goals.³⁷ Self-management therapy has a long tradition in the treatment of depression,³⁸ and elements such as behavioural goal setting or activity monitoring are frequently applied in blended interventions.^{39 40} Finally, psychoeducational cognitive-behavioural group therapy has recently been applied in a stepped care service model⁴¹ within the Improving Access to Psychological Therapies programme. In our first study,³⁵ high treatment effects were observed in an adult sample, exhibiting a variety of unspecified depressive symptoms. Further, participants rated online and multimedia elements as equally relevant as group experience or specific CBT techniques. In an open evaluation, 25% freely described online and multimedia support as a therapeutic factor. However, the absence of a systematic diagnostic procedure and the lack of standardised measures (eg, client satisfaction and system usability) restrict the generalisability of findings.

The present study addresses these limitations by applying the developed blended group intervention to a sample of clinically depressed adults, and by evaluating its usefulness in a more structured and standardised way. Moreover, we analysed system usage and corresponding changes over the course of time. Lastly, the study provides a detailed view on participants’ appraisals of the new format.

Methods

Results

Discussion

This feasibility study presents a user-centred evaluation of a recently developed blended group intervention for the reduction of depressive symptoms in major depression. Results indicate a high fit between psychological groups and blended components in terms of client satisfaction, system usability and the perceived relevancy of supportive computer and multimedia elements. Besides the standardised assessment of system usability and client satisfaction, the study entails a detailed view on blended elements, including possible improvements.

Corresponding primary outcome measures of the study indicate substantial effects on self-reported depressive symptoms and on general health. Compared with other psychoeducational group CBT interventions,⁴¹ observed reductions of self-reported depressiveness and rates of CSI can be classified as high. According to resource-oriented psychotherapy principles,^{39 51} participants also reported strengthened personal resources and self-management abilities (see the Primary and secondary outcome measures section). Results were maintained over a 3-month follow-up period. There was no withdrawal and only one participant deteriorated reliably (4%). These findings support prior literature on blended therapy,^{16 32} and underpin the potential of technology for psychological group interventions.

Regarding client satisfaction and system usability, participants provided positive evaluations of the investigated blended group format. For example, most patients stated that they would not leave out technology and that computer and multimedia support could help to improve existing treatments. Even though more than half of the patients had received prior therapy, the appraisal was less positive for individual therapy (cf the Applicability of the blended intervention section). This finding can be explained by a possible sceptical preconception and lack of opposite experience.¹⁴ It might also reflect patients’ perception of different requirements of the two settings. However, when compared with a concept study on blended individual therapy,⁴⁰ system usability (SUS) and client satisfaction scores (CSQ-8) of the investigated group intervention were around one SD above. As blended learning originates from educational groups (eg, teaching or corporate trainings),⁶³ interventions with more training-alike character may be particularly feasible for computer and multimedia support. This assumption is reflected by more positive appraisals for the improvement of training-alike interventions, compared with the improvement of classical group therapy (cf. the Applicability of the blended intervention section). However, the positive appraisal of treatment intensification between those forms of delivery did not differ significantly.

The investigated intervention entailed a variety of different computer and online elements. The online discussion forum and remote patient-to-therapist communication have setting-specific relevancy as they open up additional pathways for client-to-client and client-to-therapist interaction in group therapy. While remote patient-to-therapist communication was easy to install and described as important, the unguided online discussion forum was of less relevance for our patients. According to positive findings in online chat group and gamification studies,^{34 64} we conclude that online group interaction in blended interventions should either be guided by a therapist,⁶⁵ or include other incentives to increase usage and perceived relevancy. During debriefing, some patients also explained, that their need for group interaction was satisfied by the weekly reunions.

Consistent with prior results, participants related in-session and intersession computer and multimedia use to the therapeutic success of the intervention (table 6). In our first study,³⁵ 25% of participants freely described computer support as a therapeutic factor. The direct ranking presented in this study yielded a notably higher proportion of agreement and can be interpreted as a conceptual replication of previous results. Additionally, treatment intensification was described as an important advantage. Results from a forthcoming qualitative article on patients’ experiences with the blended group format support present findings (personal communication by Schuster Raphael, November 2017⁶⁶). Regarding the interpretation, patients’ appraisals might best be conceptualised as the description of a catalytic effect, which possibly fosters other established therapeutic factors, such as imparting information²⁹ or motivational clarification.³⁷ Even though first results from comparative studies are promising,^{67 68} future research has to determine, if patients’ positive appraisals translate into superior effects of blended therapy in routine care. Still, from a product development perspective, patients’ connection of blended elements with treatment success can be seen as an important success criterion.

Findings regarding process aspects of the blended group format revealed important patient preferences. Many currently conducted studies on blended therapy investigate possible savings of therapist time by reducing the number of sessions (23, 31–33). From an economical point of view, potential time savings are inherently appealing for some mental healthcare stakeholders.^{25 69} On the other hand, short interventions might entail certain risks, such as a weakened patient-to-therapist bonding.¹³ eHealth experts therefore emphasise the need for participatory research and the importance of target audience’s perceptions when designing new treatments.^{70 71} As for that matter, the majority of our sample retrospectively would have preferred more group sessions (12–15 sessions) and half of our sample required more time for group interaction during each session (cf. the Applicability of the blended intervention section). Development and future uptake of blended interventions may therefore benefit from assuring that highly structured or time-efficient treatment strategies actually meet the expectations of addressed patients in a particular care setting.

Assessed objective usage data revealed a constant decrease of web page logins and downloads (cf. the Appraisal of new media elements and usage data section). Whether this tendency indicates a relevant reduction of motivation to persist with the intervention is unclear, as satisfaction with the intervention was high and usage patterns in the first weeks can be described in terms of exaggerated activity. For example, we provided one work sheet per week for download, but the actual number of downloads was reasonably higher. In this context, Yardley and collegues⁷¹ critically reflect on current approaches to validly conceptualise engagement by analysing log files of system usage data. Further investigation on the significance of (dis)continuous usage data can be carried out by small studies of iterative participatory research.

Besides the promising results of the investigated intervention, several limitations need to be considered when interpreting its findings. First, sample size was low and the one-arm study design lacks a control condition. Thus, findings of our study have to be interpreted with limited generalisation and the true magnitude of observed effects remains unclear. Also, the study design does not allow inferring the actual extent to which specific intervention elements (eg, computer and multimedia elements) effectively contributed to the observed effects. Second, participating therapists (IF and VS) lacked prior experience with the blended format, but underwent preparatory training. Careful preparation and implementation as well as regular supervision seem to be critical success factors for blended interventions,⁷² and as some studies on online interventions show, more experience with a given treatment can result in better outcomes.⁷³ Third, even though clinical interviews were conducted to assess participants’ psychopathological status, other properties of our sample restrict generalisability. The majority of our sample was woman and relatively well educated. While comparable sample properties can be found in many online studies and our recruitment was based on a multimodal recruitment strategy,⁷⁴ future research has to determine, if the investigated intervention proves feasible for less educated or older patients. Fourth, compared with University of Salzburg (where the intervention was developed), the institute for applied psychology lacks a fully equipped routine outpatient clinic. As a consequence, further research in routine care is needed. Fifth, half of our participants lacked alternative experience with other forms of (group) therapy. Those patients’ appraisals should be interpreted as positive experience with the undergone treatment, in the absence of experience with possible alternatives. Additionally, the group format and the use of new media might have discouraged certain patients from participating in our study.

Conclusions

The present study indicates that the blended group format is feasible for the reduction of depressive symptoms in major depression. Due to their properties, psychoeducational groups with elements of self-management or behavioural activation might be particularly suitable for blending. New media can be used for in- session and intersession support and from patients’ perspective, treatment intensification is described as an important advantage. Future research should investigate the feasibility and benefits of blended group interventions in routine care.

Supplementary Material