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      Blending online therapy into regular face-to-face therapy for depression: content, ratio and preconditions according to patients and therapists using a Delphi study

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          Abstract

          Background

          Blending online modules into face-to-face therapy offers perspectives to enhance patient self-management and to increase the (cost-)effectiveness of therapy, while still providing the support patients need. The aim of this study was to outline optimal usage of blended care for depression, according to patients and therapists.

          Methods

          A Delphi method was used to find consensus on suitable blended protocols (content, sequence and ratio). Phase 1 was an explorative phase, conducted in two rounds of online questionnaires, in which patients’ and therapists’ preferences and opinions about online psychotherapy were surveyed. In phase 2, data from phase 1 was used in face-to-face interviews with therapists to investigate how blended therapy protocols could be set up and what essential preconditions would be.

          Results

          Twelve therapists and nine patients completed the surveys. Blended therapy was positively perceived among all respondents, especially to enhance the self-management of patients. According to most respondents, practical therapy components (assignments, diaries and psycho-education) may be provided via online modules, while process-related components (introduction, evaluation and discussing thoughts and feelings), should be supported face-to-face. The preferred blend of online and face-to-face sessions differs between therapists and patients; most therapists prefer 75% face-to-face sessions, most patients 50 to 60%. The interviews showed that tailoring treatment to individual patients is essential in secondary mental health care, due to the complexity of their problems. The amount and ratio of online modules needs to be adjusted according to the patient’s problems, skills and characteristics. Therapists themselves should also develop skills to integrate online and face-to-face sessions.

          Conclusions

          Blending online and face-to-face sessions in an integrated depression therapy is viewed as a positive innovation by patients and therapists. Following a standard blended protocol, however, would be difficult in secondary mental health care. A database of online modules could provide flexibility to tailor treatment to individual patients, which asks motivation and skills of both patients and therapists. Further research is necessary to determine the (cost-)effectiveness of blended care, but this study provides starting points and preconditions to blend online and face-to-face sessions and create a treatment combining the best of both worlds.

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          Most cited references28

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          Prevalence and clinical course of depression: a review.

          Depression is one of the leading causes of disease worldwide. Historically conceived as either a disease of the mind or of the brain, treatment options followed this aetiology. Current diagnostic assessment of depression is based on descriptions of symptoms, their presence and magnitude over time. Epidemiological studies demonstrate that depressive disorders are highly prevalent: displaying high rates of lifetime incidence, early age onset, high chronicity, and role impairment. These studies have deepened our understanding of the course of depression; remission, recovery, relapse and recurrence. An illustration of recovery rates has begun to demonstrate the complexity of the nature and course of depression. The majority recovers; however, recovery may not be permanent and future episodes carry the threat of chronicity. A key variable influencing rates of recovery, relapse, and recurrence is the presence of medical or psychiatric comorbid illnesses. The review considers the literature on Major Depression beginning with a brief historical overview, its classification, and a synthesis of the current knowledge regarding prevalence and course. Copyright © 2011 Elsevier Ltd. All rights reserved.
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            A review of technology-assisted self-help and minimal contact therapies for anxiety and depression: is human contact necessary for therapeutic efficacy?

            Technology-based self-help and minimal contact therapies have been proposed as effective and low-cost interventions for anxiety and mood disorders. The present article reviews the literature published before 2010 on these treatments for anxiety and depression using self-help and decreased therapist-contact interventions. Treatment studies are examined by disorder as well as amount of therapist contact, ranging from self-administered therapy and predominantly self-help interventions to minimal contact therapy where the therapist is actively involved in treatment but to a lesser degree than traditional therapy and predominantly therapist-administered treatments involving regular contact with a therapist for a typical number of sessions. In the treatment of anxiety disorders, it is concluded that self-administered and predominantly self-help interventions are most effective for motivated clients. Conversely, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses when accounting for both attrition and compliance. Additionally, predominantly self-help computer-based cognitive and behavioral interventions are efficacious in the treatment of subthreshold mood disorders. However, therapist-assisted treatments remain optimal in the treatment of clinical levels of depression. Although the most efficacious amount of therapist contact varies by disorder, computerized treatments have been shown to be a less-intensive, cost-effective way to deliver empirically validated treatments for a variety of psychological problems. Copyright © 2010 Elsevier Ltd. All rights reserved.
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              Experiences of guided Internet-based cognitive-behavioural treatment for depression: A qualitative study

              Background Internet-based self-help treatment with minimal therapist contact has been shown to have an effect in treating various conditions. The objective of this study was to explore participants' views of Internet administrated guided self-help treatment for depression. Methods In-depth interviews were conducted with 12 strategically selected participants and qualitative methods with components of both thematic analysis and grounded theory were used in the analyses. Results Three distinct change processes relating to how participants worked with the treatment material emerged which were categorized as (a) Readers, (b) Strivers, and (c) Doers. These processes dealt with attitudes towards treatment, views on motivational aspects of the treatment, and perceptions of consequences of the treatment. Conclusions We conclude that the findings correspond with existing theoretical models of face-to-face psychotherapy within qualitative process research. Persons who take responsibility for the treatment and also attribute success to themselves appear to benefit more. Motivation is a crucial aspect of guided self-help in the treatment of depression.
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                Author and article information

                Contributors
                r.vandervaart@fsw.leidenuniv.nl
                m.witting@saxion.nl
                h.riper@vu.nl
                l.c.kooistra@vu.nl
                e.t.bohlmeijer@utwente.nl
                j.e.w.c.vangemert-pijnen@utwente.nl
                Journal
                BMC Psychiatry
                BMC Psychiatry
                BMC Psychiatry
                BioMed Central (London )
                1471-244X
                14 December 2014
                14 December 2014
                2014
                : 14
                : 1
                : 355
                Affiliations
                [ ]Department of Psychology, Health & Technology, University of Twente, Enschede, the Netherlands
                [ ]Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands
                [ ]Lectorate Community Care & Youth, Saxion University of Applied Sciences, Enschede, the Netherlands
                [ ]Department of Clinical Psychology, VU University Amsterdam, Amsterdam, the Netherlands
                Article
                355
                10.1186/s12888-014-0355-z
                4271498
                25496393
                52e65cea-63d4-4a05-a814-4c4f197fbc2e
                © van der Vaart et al.; licensee BioMed Central. 2014

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 7 January 2014
                : 8 December 2014
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2014

                Clinical Psychology & Psychiatry
                Clinical Psychology & Psychiatry

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