TY - JOUR
T1 - Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe
T2 - Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial
AU - Doukani, Asmae
AU - Quartagno, Matteo
AU - Sera, Francesco
AU - Free, Caroline
AU - Kakuma, Ritsuko
AU - Riper, Heleen
AU - Kleiboer, Annet
AU - Cerga-Pashoja, Arlinda
AU - van Schaik, Anneke
AU - Botella, Cristina
AU - Berger, Thomas
AU - Chevreul, Karine
AU - Matynia, Maria
AU - Krieger, Tobias
AU - Hazo, Jean Baptiste
AU - Draisma, Stasja
AU - Titzler, Ingrid
AU - Topooco, Naira
AU - Mathiasen, Kim
AU - Vernmark, Kristofer
AU - Urech, Antoine
AU - Maj, Anna
AU - Andersson, Gerhard
AU - Berking, Matthias
AU - Baños, Rosa María
AU - Araya, Ricardo
N1 - Publisher Copyright:
©Asmae Doukani, Matteo Quartagno, Francesco Sera, Caroline Free, Ritsuko Kakuma, Heleen Riper, Annet Kleiboer, Arlinda Cerga-Pashoja, Anneke van Schaik, Cristina Botella, Thomas Berger, Karine Chevreul, Maria Matynia, Tobias Krieger, Jean-Baptiste Hazo, Stasja Draisma, Ingrid Titzler, Naira Topooco, Kim Mathiasen, Kristofer Vernmark, Antoine Urech, Anna Maj, Gerhard Andersson, Matthias Berking, Rosa María Baños, Ricardo Araya.
PY - 2024
Y1 - 2024
N2 - Background: Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression. Objective: This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments. Methods: We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised–Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables. Results: Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=−0.12, 95% CI −0.17 to −0.06) and TAU (B=−0.06, 95% CI −0.11 to −0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=−0.030, 95% CI −0.05 to −0.01; P=.005). Conclusions: To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance.
AB - Background: Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression. Objective: This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments. Methods: We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised–Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables. Results: Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=−0.12, 95% CI −0.17 to −0.06) and TAU (B=−0.06, 95% CI −0.11 to −0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=−0.030, 95% CI −0.05 to −0.01; P=.005). Conclusions: To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance.
KW - blended psychotherapy
KW - cognitive behavioral therapy
KW - depression
KW - digital mental health interventions
KW - mental health
KW - program usability
KW - psychotherapy
KW - therapeutic alliance
KW - usability heuristics
KW - working alliance
UR - http://www.scopus.com/inward/record.url?scp=85195013009&partnerID=8YFLogxK
U2 - 10.2196/47515
DO - 10.2196/47515
M3 - Journal article
C2 - 38819882
AN - SCOPUS:85195013009
SN - 1439-4456
VL - 26
JO - Journal of Medical Internet Research
JF - Journal of Medical Internet Research
M1 - e47515
ER -