Suicide disproportionately burdens low- and middle-income countries. In Uganda, attempt survivors encounter intense stigma, minimal mental-health services and social exclusion, elevating their risk of future attempts. Rural African data on post-attempt experiences are scarce. From June to August 2023, we conducted semi-structured, in-depth interviews in Buyende District with 18 attempt survivors, 17 relatives, 10 healthcare workers and 9 community health workers. Transcripts were translated into English and thematically analyzed using the framework method within a phenomenologically informed qualitative design. Three interlinked themes emerged. (1) Stigma-shaped immediate responses: cultural, religious and legal norms fostered moral judgment, social distancing, bureaucratic delays and occasionally police involvement. (2) Informal, uneven support: survivors relied on family aid, religious counseling and ad-hoc community advocacy; effectiveness varied widely. (3) Conditional reintegration: sustained practical help, employment and communal acceptance promoted recovery, whereas their absence perpetuated economic hardship and marginalization. Post-attempt trajectories in rural Uganda are governed by multilevel stigma and fragile support systems. Priority actions include provider training, family-community psychoeducation, stigma-reduction initiatives, structured follow-up care and decriminalization of suicide to foster compassionate responses and reduce repeat attempts.

OBJECTIVES:The Collaborative Care Model (CoCM) is an evidence-based model designed for primary care and has shown improved late-life depression outcomes. This study explored the perspectives of a non-specialist workforce, community health workers (CHWs), on adapting CoCM to community organizations by expanding CHW roles to include that of behavioral health care manager (BHCM). METHOD:Guided by the Theoretical Framework of Acceptability, we conducted semi-structured interviews with CHWs from community-based and clinical settings across five states.Participants discussed their attitudes, perceived self-efficacy, and recommendations regarding four BHCM tasks: administering behavioral health measures, using a patient registry, collaborating with mental health specialists and primary care providers, and delivering psychosocial interventions. Thematic analysis was used to analyze the data. RESULTS:CHWs expressed interest, support, and perceived self-efficiacy, with traiing and supervision, for the proposed role expansion, and cited alignment with their mission and community needs. Their strengths included community trust, linkage, and knowledge of resources as a workforce. Collaborating with mental health specialists was viewed as a model strength, but collaboration with primary care providers was a potential barrier. CONCLUSION:Findings support the acceptability of developing a BHCM workforce among CHWs, but understanding the perspectives of other stakeholders would be warranted for CHW role redesign.

Introduction Around one-third of community-dwelling older adults experience clinically significant depressive symptoms but nearly half receive no care. Various barriers hinder access to care, including workforce shortage, transportation, cost, and stigma. Do More, Feel Better (DMFB) is a behavioral activation intervention delivered by older adult lay volunteer coaches through senior centers aimed at improving depressive symptoms. This study aimed to obtain input from aging service organization representatives across the U.S. regarding interest and implementation of DMFB. Methods Participants were recruited through national and local contacts of the research team in the aging services network (e.g., National Council on Aging, USAging, National Institute of Senior Centers). An electronically administered cross-sectional survey was distributed, and data were collected between December 2024 and March 2025, resulting in 243 respondents. Descriptive statistics were conducted to summarize characteristics of respondent organizations and perceptions of DMFB. Qualitative data was coded using thematic analysis. Two researchers independently coded open-ended responses explaining their interest in DMFB as well as additional resources required for implementation. Results Nearly all (98.4%) of respondent organizations served older adults as their primary population. When asked how significant the need for depression care for older adults was in their community on a scale of 1-10 (1=not at all to 10=highly), respondents rated it a mean of 8.66 (SD = 1.54). Almost all indicated they would either strongly consider (41.6%) or consider (51.9%) participating in an implementation study of DMFB. Most respondents indicated that their organizations had existing resources relevant to the delivery of DMFB, such as having a staff member who could serve as Champion (65%), experience with other evidence-based programs (70%), and space (70%); 31% had an existing pool of volunteers. As expected, however, many organizations did not have existing resources specific to depression or DMFB (e.g., 32% conducted regular depression screening) and thus would welcome the study’s technical assistance if they chose to partner on the study.When asked why participants would be interested in participating in an implementation study of DMFB, qualitative themes included an identified need and anticipated benefits of a community-based intervention addressing depression in older adults. Main themes regarding resources required to implement DMFB included additional funding, staff or volunteers to carry out the program, and training for staff and volunteers. Conclusions This study demonstrated the need and interest in implementing a program like DMFB for aging service organizations. Respondents rated the demand for depression care for older adults high, and a majority indicated interest in participating in DMFB. Considering the rate of depression in older adults, it is imperative to gauge interest in implementing a program at a community level and what additional resources are needed to do so.

Introduction:Suicide is a critical public health issue worldwide. Risk factors are exacerbated by cultural stigma, socioeconomic hardship, and limited mental healthcare access. However, few studies have examined the lived experiences of suicide attempt survivors in Africa to probe the underlying drivers. Objectives:To explore the lived experiences and perceived drivers of suicide attempts in rural Uganda among individuals with lived experience, their families, healthcare providers, and community health workers. Methods:We conducted in-depth qualitative interviews in Buyende District, Uganda from June to August 2023 with a purposive sample of 54 participants aged 23 to 70: people who had survived a suicide attempt (n = 18) and their family members (n = 17), healthcare providers (n = 10), and community health workers (n = 9). Interviews were recorded, transcribed, translated, and analyzed using a thematic framework method. Results:Four main themes emerged as critical factors leading to suicide attempts: (1) familial and spousal conflict, involving relationship breakdown, resource denial, and social isolation; (2) financial stress, including chronic poverty, acute debts, and perceived socioeconomic failure; (3) mental illness and substance use, notably depression, psychotic symptoms, and alcohol use complicating existing psychological distress; and (4) religious and spiritual influences on the attribution of suicidal thoughts. Conclusion:In this qualitative study from rural Uganda, suicide attempts across were perceived to result from intertwined interpersonal, economic, mental health, and spiritual factors. Participants rarely framed suicide as the result of a single cause, but rather as a response to cumulative and unresolved distress. Moments of missed support suggest opportunities for targeted intervention.

OBJECTIVE:Older adults are underrepresented in digital mental health research. As Medicare expands reimbursement for such services, understanding benefit is paramount. This study examined longitudinal engagement and clinical outcomes among older adults receiving virtual psychotherapy. DESIGN:Retrospective cohort study of patients who received usual psychotherapy care delivered as asynchronous message-based care and/or live tele-sessions. SETTING:Talkspace, a U.S. telemedicine platform. PARTICIPANTS:Talkspace users aged 65+ (n = 510) with elevated depression and/or anxiety symptoms and a randomly selected comparison sample of 510 adults 25-35 with similar depression/anxiety scores. MEASUREMENTS:Cohorts were compared across engagement with the platform and clinical outcomes (change in PHQ-9 [depressive symptoms] or GAD-7 [anxiety symptoms]) over 15 weeks. RESULTS:Older adults engaged with the digital platform for a shorter duration than younger adults (mean [SD], 16.4 [26.6] versus 24.6 [31.6] weeks; t(989.45) = -4.45, p < 0.001) but did not differ in weekly message frequency, message word count, or video session attendance. Both groups showed significant reductions in depression and anxiety symptoms over 15 weeks. Among participants retained in treatment at week 15, 78.8% of older adults achieved at least the minimally important clinical difference for depression and 64.3% for anxiety, with corresponding rates of 50.0% and 53.7% among younger adults. CONCLUSION:Adults aged 65 years and older engaged in digital psychotherapy at levels not significantly different from younger adults. Both older and younger groups experienced substantial reductions in depressive and anxiety symptoms and did not significantly differ in these improvements. Findings support feasibility and clinical utility for older adults.

Estimates indicate that over 300 million people worldwide have depression, with prevalence increasing around 50% over the last 30 years. Despite the availability of evidence-based psychological therapies, barriers to access remain in areas such as treatment availability, the burden associated with accessing services, and treatment sessions often only available at times suitable to the service rather than the patient. Harnessing the potential of a mobile phone app to deliver a low-intensity behavioral activation intervention to support low mood presents a scalable solution to address these barriers. Located in the development phase of the MRC Complex Interventions Framework, this study describes the Iona Mind Wellbeing for Mood (IMWM) smartphone app and reports log data recognizing patterns of engagement with specific factor techniques associated with behavioral activation. Consistent with other research on other digital health interventions, there was a large difference between people downloading IMWM (1725), engaging with it to be considered an Engaged User (281; 16%), and completing more than one PHQ-8 and GAD-7 (65; 23%) following assessment. Paired samples t tests were undertaken to explore the potential to reduce PHQ-8 and GAD-7 scores and the relationship with engagement. For those completing the PHQ-8 and GAD-7 outcome measures, there was a significant reduction in PHQ-8 (t(48) = 5.2; p < 0.01) and GAD-7 (t(48) = 3.5; p < 0.01) scores, respectively, with reductions greater with higher baseline severity. Users were able to successfully engage with the majority of techniques associated with behavioral activation, as well as with most of the wider features associated with a cognitive behavioral therapy (CBT) approach, excluding reflection. The algorithmically driven conversational agent was successfully employed to assist the user in breaking down activities to reduce difficulty and retain engagement. Despite these levels of engagement, however, engagement did not predict changes in scores for either the PHQ-8 [F(2,62) = 2.71; p > 0.05] or GAD-7 [F(2,62) = 0.59; p > 0.05]. These results encourage the ongoing use of log data to further enhance usability and engagement prior to undertaking a pilot randomized controlled trial to explore potential effectiveness.

Objectives:Executive dysfunction is common in later-life depression (LLD). This study examined whether: 1) executive function predicts change in depressive symptoms during brief psychotherapy and 2) performance on cognitive tests changes during psychotherapy. Design:Post hoc analysis of a noninferiority randomized clinical trial comparing 9 weekly sessions of problem-solving therapy (PST) and Engage, a streamlined psychotherapy for depression. Setting:Two-site trial at academic medical centers in Seattle, WA and New York, NY. Participants:Participants were 150 older adults (68% women) with major depressive disorder, Mini-Mental State Examination (MMSE) ≥24, and cognitive test data available for primary analysis. Participants ranged in age from 60 to 89 years (M = 70.4, SD = 7.4). Measurements:Cognitive measures included the Iowa Gambling Task (IGT), Wisconsin Card Sorting Test (WCST), Stroop test, Digit Span, and Hopkins Verbal Learning Test (HVLT-R). Treatment outcomes consisted of longitudinal assessment using the Hamilton Depression Rating Scale (HAM-D) and World Health Organization Disability Assessment Schedule 2.0 (WHODAS). Results:Linear mixed effects models showed that baseline executive functioning did not predict improvement in HAM-D scores. Better Stroop performance was associated with improved WHODAS scores. Paired t-tests revealed pre- and post-treatment improvement in executive functioning test performance as measured by the IGT (Total Money subscale; p = 0.002) and Stroop test (p = 0.002) across 9 weeks of both treatments. Conclusions:Baseline cognitive functions, including executive function, did not influence reduction in depressive symptoms during brief psychotherapies. Brief psychotherapies may improve aspects of executive function such as decision-making related to reward. ClinicalTrialsgov Identifier:NCT0208G201.

Introduction Depressive symptoms are common in the growing geriatric surgical population and are associated with important patient-centred surgical outcomes, including postoperative delirium, discharge to postacute care facility and decline in functional status. Few interventions have been developed to address depressive symptoms in the perioperative setting.Methods and analysis We designed a feasibility and acceptability study of a nine-session problem-solving therapy (PST) telehealth perioperative intervention aimed at reducing postoperative functional decline and depressive symptoms among at-risk older adults undergoing major surgical procedures. Acceptability will be evaluated using a patient-centred five-question survey, assessing participant satisfaction and perceived usefulness of the perioperative intervention. A feasibility assessment will rely on objective measures including ease of participant recruitment, frequency and timing of delivery of intervention sessions and retention of participants throughout the duration of the intervention. With respect to the efficacy of the proposed PST intervention, the primary outcome of interest is postoperative functional status, as measured by the WHO Disability Assessment Schedule 2.0 at the 6-month postoperative time point. The secondary outcome of interest is the degree of depressive symptoms as assessed by the Patient Health Questionnaire-9 at both 3 months and 6 months postoperatively. The broader goals of this study include: (1) assessing the feasibility of implementing a PST perioperative intervention for older surgical patients at risk of postoperative functional decline, (2) demonstrating the acceptability of the PST intervention and (3) assessing the preliminary impact of the PST intervention on postoperative functional status and depressive symptoms.Ethics and dissemination The study received ethical approval from the University of California San Francisco Institutional Review Board. Results of this study will be published in peer-reviewed scientific journals with further dissemination at local institutional meetings and professional conferences.Trial registration number NCT06174701.

BackgroundAlthough substantial progress has been made in establishing evidence-based psychosocial clinical interventions and implementation strategies for mental health, translating research into practice—particularly in more accessible, community settings—has been slow. ObjectiveThis protocol outlines the renewal of the National Institute of Mental Health–funded University of Washington Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness Center, which draws from human-centered design (HCD) and implementation science to improve clinical interventions and implementation strategies. The Center’s second round of funding (2023-2028) focuses on using the Discover, Design and Build, and Test (DDBT) framework to address 3 priority clinical intervention and implementation strategy mechanisms (ie, usability, engagement, and appropriateness), which we identified as challenges to implementation and scalability during the first iteration of the center. Local redesign teams work collaboratively and share decision-making to carry out DDBT. MethodsAll 4 core studies received institutional review board approval by June 2024, and each pilot project will pursue institutional review board approval when awarded. We will provide research infrastructure to 1 large effectiveness study and 3 exploratory pilot studies as part of the center grant. At least 4 additional small pilot studies will be solicited and funded by the center. All studies will explore the use of DDBT for clinical interventions and implementation strategies to identify modification targets to improve usability, engagement, and appropriateness in accessible nonspecialty settings (Discover phase); develop redesign solutions with local teams to address modification targets (Design and Build phase); and determine if redesign improves usability, engagement, and appropriateness (Test phase), as well as implementation outcomes. Center staff will collaborate with local redesign teams to develop and test clinical interventions and implementation strategies for community settings. We will collaborate with teams to use methods and centerwide measures that facilitate cross-project analysis of the effects of DDBT-driven redesign on outcomes of interest. ResultsAs of January 2025, three of the 4 core studies are underway. We will generate additional evidence on the robustness of DDBT and whether combining HCD and implementation science is an asset for improving clinical interventions and implementation strategies. ConclusionsDuring the first round of the center, we established that DDBT is a useful approach to systematically identify and address chronic challenges of implementing clinical interventions and implementation strategies. In this subsequent grant, we expect to increase evidence of DDBT’s impact on clinical interventions and implementation strategies by expanding a list of common challenges that could benefit from modification, a list of exemplary solutions to address these challenges, and guidance on using the DDBT framework. These resources will contribute to broader discourse on how to enhance implementation of clinical interventions and implementation strategies that integrate HCD and implementation science. International Registered Report Identifier (IRRID)PRR1-10.2196/65446

Objective:This qualitative study aimed to explore the psychosocial experience of older adults undergoing major elective surgery from the perspective of both the patient and family caregiver.Summary Background Data:Older adults face unique psychological and social vulnerabilities that can increase susceptibility to poor health outcomes. How these vulnerabilities influence surgical treatment and recovery is understudied in the geriatric surgical population.Methods:Adults aged 65 and older undergoing a high-risk major elective surgery at the University of California, San Francisco and their caregivers were recruited. Semi-structured interviews were conducted at three time points: 1 to 2 weeks before surgery, and at 1- and 3-months following surgery. An inductive qualitative approach was used to identify underlying themes.Results:Twenty-five older adult patients (age range 65-82 years, 60% male) and 11 caregivers (age range 53-78 years, 82% female) participated. Three themes were identified. First, older surgical patients experienced significant challenges to emotional well-being both before and after surgery, which had a negative impact on recovery. Second, older adults relied on a combination of personal and social resources to navigate these challenges. Lastly, both patients and caregivers desired more resources from the healthcare system to address "the emotional piece" of surgical treatment and recovery.Conclusions:Older adults and their caregivers described multiple overlapping challenges to emotional well-being that spanned the course of the perioperative period. Our findings highlight a critical component of perioperative care with significant implications for the recovery of older surgical patients.

Importance:There is a need to determine the relative effect of message-based psychotherapy (MBP), an asynchronous approach that uses emails, texts, or voice or video messages to permit therapeutic exchanges, compared with video-based psychotherapy (VBP) and whether a combination of modalities would result in better outcomes for those who do not respond to either treatment alone. Objectives:To compare MBP with VBP on a commercial digital mental health platform and test combinations of modalities for participants who did not respond to single-modality treatment. Design, Setting, and Participants:In this sequential multiple assignment randomized clinical trial, psychotherapy was delivered by therapists on a commercial digital mental health platform from January 10, 2022, to January 14, 2024, among 850 participants who were 18 years of age or older, English or Spanish speaking, living in the US in a state where the digital mental health platform had available therapists, scored 10 or more on the 9-item Patient Health Questionnaire (PHQ-9), and received a diagnosis of depression during intake assessment. Interventions:At baseline, participants were randomized to MBP or weekly VBP. At week 6, nonresponders were rerandomized to MBP with weekly or monthly VBP. Participants received treatment for 12 weeks. Main Outcomes and Measures:Primary outcomes included depression severity (measured by the PHQ-9), social functioning, response to treatment, and remission. Secondary outcomes included treatment engagement, therapeutic alliance, and indicators of treatment quality and satisfaction. Analysis was performed on an intention-to-treat basis. Results:The analytic sample included 850 participants (mean [SD] age, 33.8 [10.5] years; 562 women [66.1%]; mean [SD] PHQ-9 score, 15.0 [4.8]), with 423 randomized to MBP and 427 to VBP. Treatment disengagement by week 5 was more likely for VBP than MBP (VBP, 91 [21.3%]; MBP, 56 [13.2%]; Cramér V = 0.10; 95% CI, 0.03-0.13; P = .003). There were no significant differences on depression or social functioning score changes between MBP and VBP or on depression score changes for nonresponders randomized to MBP with weekly vs monthly VBP. At week 12, MBP and VBP did not differ in the proportion of participants who responded to treatment (MBP, 144 of 303 [47.5%]; VBP, 134 of 284 [47.2%]; Cramér V < .001; 95% CI, -0.08 to 0.09; P = .99) or who experienced remission (MBP, 95 of 303 [31.4%]; VBP, 86 of 284 [30.3%]; Cramér V = 0.01; 95% CI, -0.07 to 0.09; P = .85). Among nonresponders, VBP had a stronger initial therapeutic alliance than MBP at week 4 (P < .001; d = 0.48-0.57). Among participants assessed for rerandomization, there were no statistically significant differences among those who responded to treatment by week 5 (MBP, 105 of 363 [28.9%]; VBP, 93 of 336 [27.7%]; Cramér V = 0.01; 95% CI, -0.06 to 0.08; P = .78). Therapeutic alliance ratings increased across all conditions by week 10; however, these changes were not statistically significant. Video-based psychotherapy was more frequently recommended than MBP (VBP, 69 of 71 [97.2%]; MBP, 70 of 80 [87.5%]; odds ratio, 0.18; 95% CI, 0.04-0.88; P = .03). There were no significant differences in clinical outcomes between nonresponders randomized to weekly vs monthly VBP. Conclusions and Relevance:In this sequential multiple assignment randomized clinical trial comparing MBP with VBP, there were no differences between groups on improvement in depression or social functioning. More participants in the VBP group disengaged from treatment, while VBP also had greater therapeutic alliance early in treatment among nonresponders. There were no differential effects from rerandomizing nonresponders. Findings reinforced MBP as a viable alternative to VBP. Broader insurance reimbursement for MBP could improve access to evidence-based care. Future research should explore optimizing early alliance-building in MBP. Trial Registration:ClinicalTrials.gov Identifier: NCT04513080.

Importance:Most older adults with depression lack access to efficacious psychotherapies due to a critical clinician shortage. Even when treated, response rates are limited to approximately 50%. A treatment decision rule (TDR) may maximize treatment efficacy and resources by assigning patients to their optimal intervention. This is the first study to propose a TDR for late-life depression designed for community settings. Objective:To develop a scalable TDR for assignment to a psychotherapy or usual care intervention for late-life depression that can be delivered easily in community settings. Design, Setting, and Participants:In this prognostic study, adults 60 years or older with major depression participated in randomized controlled trials comparing psychotherapy with usual care. Participants were recruited from outpatient and community settings of Weill Cornell Medicine and the University of California San Francisco between 2002 and 2011. Data were analyzed from May 2023 to May 2025. Interventions:Participants received either psychotherapy (problem-solving therapy, psychotherapy for late-life depression and medical burden) or usual care (supportive therapy, treatment as usual, or case management). Main Outcomes and Measures:The primary outcome was mean reduction in depression severity (measured by the Hamilton Depression Rating Scale [HAM-D]). A generated effect modifier TDR was applied to identify the optimal intervention for each patient based on baseline characteristics (demographics, depression severity, social support, cognition, and disability). The TDR maximized depression severity reduction and the proportion of patients treated with the usual care intervention. Results:In 427 older adults with late-life depression (mean [SD] age, 72.7 [8.7] years; 70% female), the predicted HAM-D score reduction with TDR-based intervention was a mean of 49.1% (95% CI, 47.4%-51.0%). The TDR improved expected depression severity reduction by 34% compared with usual care (HAM-D reduction, 36.6% [95% CI, 34.5%-38.7%]) and the TDR was somewhat superior to assigning all patients to receive psychotherapy (HAM-D reduction, 46.7% [95% CI, 44.2%-48.8%]). Older adults with higher depression severity, stronger social support, and lower cognitive functioning should receive psychotherapy; those with lower depression severity, higher cognitive functioning, and low social support would benefit from usual care. Conclusions and Relevance:In this study of older adults with depression, pending prospective testing, the automatic TDR may be used in community settings to inform treatment assignment. The TDR has the potential to increase precision, cost-effectiveness, and response rates among older adults with depression. Trial Registration:ClinicalTrials.gov Identifiers: NCT00601055, NCT00151372, NCT00052091, NCT00540865.

Background: Digital mental health interventions (DMHI) may offer scalable treatment for common mental health conditions. However, many commercially available apps have not been subjected to rigorous evaluation of effectiveness, particularly among users experiencing clinically significant symptomatology. We examined depression and anxiety symptom outcomes associated with a top-rated, commercially available self-guided DMHI based on cognitive behavioral therapy ("Sanvello") relative to waitlist control. Methods: This preregistered web-based, 2-arm, parallel-group randomized trial enrolled U.S. adults with self-reported elevated symptoms of depression and/or anxiety. Those assigned to the treatment condition were provided 8 weeks of access to Sanvello. Co-primary outcomes of depression (Patient Health Questionnaire [PHQ-9]) and anxiety (Generalized Anxiety Disorder 7-item scale [GAD-7]) severity were assessed at baseline and 2, 4, 6, and 8 weeks. Results: Intention-to-treat analyses included 280 participants (mean age 32.47 +/- 9.32 years; 86.1 % women). Generalized linear mixed models showed a significant improvement in depression (F(4,779) = 6.51, p < .001) and anxiety (F(4,907) = 3.28, p = .01) associated with the DMHI over time. The intervention was also associated with a greater proportion of participants exhibiting depression response (25 [45.5 %] vs 26 [16.9 %]) and remission (10 [18.2 %] vs 7 [4.5 %]) on the PHQ-9, and anxiety response (31 [44.9 %] vs 39 [22.8 %]) and remission (20 [29.0 %] vs 27 [15.8 %]) on the GAD-7, relative to waitlist. Limitations: Findings may not represent people with serious mental illness, suicidality, or the broader population of DMHI users. Conclusions: A commercially available, self-guided DMHI was effective at improving symptoms in individuals experiencing depression or anxiety. Trial registration: ClinicalTrials.gov [NCT05373329]

BackgroundLow-intensity cognitive behavioral therapy (LICBT) has been implemented by the Improving Access to Psychological Therapies services across England to manage excessive worry associated with generalized anxiety disorder and support emotional well-being. However, barriers to access limit scalability. A solution has been to incorporate LICBT techniques derived from an evidence-based protocol within the Iona Mind Well-being app for Worry management (IMWW) with support provided through an algorithmically driven conversational agent. ObjectiveThis study aims to examine engagement with a mobile phone app to support worry management with specific attention directed toward interaction with specific LICBT techniques and examine the potential to reduce symptoms of anxiety. MethodsLog data were examined with respect to a sample of “engaged” users who had completed at least 1 lesson related to the Worry Time and Problem Solving in-app modules that represented the “minimum dose.” Paired sample 2-tailed t tests were undertaken to examine the potential for IMWW to reduce worry and anxiety, with multivariate linear regressions examining the extent to which completion of each of the techniques led to reductions in worry and anxiety. ResultsThere was good engagement with the range of specific LICBT techniques included within IMWW. The vast majority of engaged users were able to interact with the cognitive behavioral therapy model and successfully record types of worry. When working through Problem Solving, the conversational agent was successfully used to support the user with lower levels of engagement. Several users engaged with Worry Time outside of the app. Forgetting to use the app was the most common reason for lack of engagement, with features of the app such as completion of routine outcome measures and weekly reflections having lower levels of engagement. Despite difficulties in the collection of end point data, there was a significant reduction in severity for both anxiety (t53=5.5; P<.001; 95% CI 2.4-5.2) and low mood (t53=2.3; P=.03; 95% CI 0.2-3.3). A statistically significant linear model was also fitted to the Generalized Anxiety Disorder–7 (F2,51=6.73; P<.001), while the model predicting changes in the Patient Health Questionnaire–8 did not reach significance (F2,51=2.33; P=.11). This indicates that the reduction in these measures was affected by in-app engagement with Worry Time and Problem Solving. ConclusionsEngaged users were able to successfully interact with the LICBT-specific techniques informed by an evidence-based protocol although there were lower completion rates of routine outcome measures and weekly reflections. Successful interaction with the specific techniques potentially contributes to promising data, indicating that IMWW may be effective in the management of excessive worry. A relationship between dose and improvement justifies the use of log data to inform future developments. However, attention needs to be directed toward enhancing interaction with wider features of the app given that larger improvements were associated with greater engagement.

Objectives:To evaluate coaches' experiences delivering a lay-led depression intervention (Do More, Feel Better; DMFB) during a Type I hybrid effectiveness-implementation RCT. Methods:We conducted a process evaluation to assess DMFB feasibility, appropriateness, fidelity, and acceptability in 12 senior centers in Florida, New York, and Washington (USA). DMFB is streamlined Behavioral Activation delivered by older adult volunteers from senior center communities. Data sources included eligibility and exit interviews with surveys and external fidelity ratings of session recordings. Results:The study sample included 45 older adults (Mage = 69.8, SDage = 6.3), 85.3% women, 45.4% people of color, 24.1% low-income, 53.1% live alone. Feasibility: Of 66 individuals interested in serving as DMFB lay coaches, 45 (68.2%) were eligible, 34 (51.2%) were trained, 27 (40.1%) were certified, and 24 (36.4%) engaged 1 or more clients. Appropriateness: Eligible older adult volunteers had high capacity to serve as coaches (M = 5.3, SD = 0.8, 6-pt scale), bringing lived experience helping others, managing their mental health, good communication and organizational skills, and valuing volunteering. Fidelity: External global ratings were "very good" (M = 4.6, SD = 0.7, 5-pt scale); areas for improvement were managing time for PHQ-) administration and activity scheduling, and need for more person-centered communication. Acceptability: Coaches rated high confidence delivering DMFB (M = 4.7, SD = 0.6, 5-pt scale) and that they received adequate training (M = 4.5, SD = 0.6, 5-pt scale) and supervision (M = 4.6, SD = 0.6, 5-pt scale). Coaches found satisfaction helping others, connecting with clients, and applying DMFB to their mental health. Conclusions:This study adds to limited literature on implementation outcomes for lay-led community-based interventions for older adults. Preliminary findings document successful implementation.

There is a need to determine the relative effect of message-based psychotherapy (MBP), an asynchronous approach that uses emails, texts, or voice or video messages to permit therapeutic exchanges, compared with video-based psychotherapy (VBP) and whether a combination of modalities would result in better outcomes for those who do not respond to either treatment alone. To compare MBP with VBP on a commercial digital mental health platform and test combinations of modalities for participants who did not respond to single-modality treatment. In this sequential multiple assignment randomized clinical trial, psychotherapy was delivered by therapists on a commercial digital mental health platform from January 10, 2022, to January 14, 2024, among 850 participants who were 18 years of age or older, English or Spanish speaking, living in the US in a state where the digital mental health platform had available therapists, scored 10 or more on the 9-item Patient Health Questionnaire (PHQ-9), and received a diagnosis of depression during intake assessment. At baseline, participants were randomized to MBP or weekly VBP. At week 6, nonresponders were rerandomized to MBP with weekly or monthly VBP. Participants received treatment for 12 weeks. Primary outcomes included depression severity (measured by the PHQ-9), social functioning, response to treatment, and remission. Secondary outcomes included treatment engagement, therapeutic alliance, and indicators of treatment quality and satisfaction. Analysis was performed on an intention-to-treat basis. The analytic sample included 850 participants (mean [SD] age, 33.8 [10.5] years; 562 women [66.1%]; mean [SD] PHQ-9 score, 15.0 [4.8]), with 423 randomized to MBP and 427 to VBP. Treatment disengagement by week 5 was more likely for VBP than MBP (VBP, 91 [21.3%]; MBP, 56 [13.2%]; Cramér V = 0.10; 95% CI, 0.03-0.13; P = .003). There were no significant differences on depression or social functioning score changes between MBP and VBP or on depression score changes for nonresponders randomized to MBP with weekly vs monthly VBP. At week 12, MBP and VBP did not differ in the proportion of participants who responded to treatment (MBP, 144 of 303 [47.5%]; VBP, 134 of 284 [47.2%]; Cramér V < .001; 95% CI, −0.08 to 0.09; P = .99) or who experienced remission (MBP, 95 of 303 [31.4%]; VBP, 86 of 284 [30.3%]; Cramér V = 0.01; 95% CI, −0.07 to 0.09; P = .85). Among nonresponders, VBP had a stronger initial therapeutic alliance than MBP at week 4 ( P < .001; d = 0.48-0.57). Among participants assessed for rerandomization, there were no statistically significant differences among those who responded to treatment by week 5 (MBP, 105 of 363 [28.9%]; VBP, 93 of 336 [27.7%]; Cramér V = 0.01; 95% CI, −0.06 to 0.08; P = .78). Therapeutic alliance ratings increased across all conditions by week 10; however, these changes were not statistically significant. Video-based psychotherapy was more frequently recommended than MBP (VBP, 69 of 71 [97.2%]; MBP, 70 of 80 [87.5%]; odds ratio, 0.18; 95% CI, 0.04-0.88; P = .03). There were no significant differences in clinical outcomes between nonresponders randomized to weekly vs monthly VBP. In this sequential multiple assignment randomized clinical trial comparing MBP with VBP, there were no differences between groups on improvement in depression or social functioning. More participants in the VBP group disengaged from treatment, while VBP also had greater therapeutic alliance early in treatment among nonresponders. There were no differential effects from rerandomizing nonresponders. Findings reinforced MBP as a viable alternative to VBP. Broader insurance reimbursement for MBP could improve access to evidence-based care. Future research should explore optimizing early alliance-building in MBP. ClinicalTrials.gov Identifier: NCT04513080

Background “Do More, Feel Better” (DMFB) is a Behavioral Activation intervention designed for lay providers to address depression in older adults attending senior centers. This study explored senior center partners’ perspectives on implementing DMFB outside research settings, focusing on adaptations to proposed implementation strategies, implementation determinants, and preimplementation outcomes, including feasibility, acceptability, and appropriateness. Methods Using a convergent mixed-methods design, we conducted semi-structured interviews and surveyed 12 senior centers partners from Washington, Florida, and New York as part of a collaborative randomized controlled trial. Stratified, purposive sampling was used to select for administrators and frontline staff. We used the implementation science frameworks FRAME-IS, CFIR, and IOF, respectively, to identify recommended adaptations to strategies, determinants, and preimplementation outcomes. Rapid qualitative analysis, descriptive analyses, and joint display cross-comparing qualitative themes with quantitative data were used. Results Partners supported train-the-trainer strategy and educational materials but recommended adding content on supervision and confidentiality; offering expert consultation and support for the lead trainer beyond technical assistance; and broadening client inclusion criteria. New strategies that emerged from the data included interactive training, volunteer incentives, and local DMFB networks. Barriers included limited funding for a lead trainer, finding the right candidate, a volunteer workforce, and mental health stigma. Facilitators included program credibility, alignment with center missions, meeting community and organizational needs, and contextual fit. Quantitative ratings confirmed high feasibility, acceptability, and appropriateness. Conclusions DMFB is promising for real-world implementation using a train-the-trainer model if supported by adequate training, access to expert consultation and support, and funding.

BackgroundPatients with chronic pain on opioids frequently experience loneliness, which is associated with poorer health outcomes and higher risk for opioid misuse and opioid use disorder. Given that almost half of opioids are prescribed in primary care, a critical need exists for the development and testing of interventions to reduce loneliness in primary care patients at risk for opioid misuse. Cognitive behavioral therapy and social prescribing have been shown to be efficacious in reducing loneliness and improving outcomes in other populations but have not been tested in patients at risk for substance use disorder. The overall objective of our study is to reduce opioid misuse and opioid use disorder by addressing loneliness in patients on long-term opioid therapy in real-world primary care settings.MethodsWe will conduct a 3-arm pragmatic, randomized controlled trial to compare the effectiveness of two group-based, telehealth-delivered interventions with treatment as usual: (1) cognitive behavioral therapy to address maladaptive thought patterns and behaviors around social connection and (2) a social prescribing intervention to connect participants with social opportunities and develop supportive social networks. Our primary outcome is loneliness as measured by the UCLA Loneliness Scale and our dependent secondary outcome is opioid misuse as measured by the Common Opioid Misuse Measure. We will recruit 102 patients on long-term opioid therapy who screen positive for loneliness from 2 health care systems in Washington State. Implementation outcomes will be assessed using the RE-AIM framework.DiscussionOur study is innovative because we are targeting loneliness, an under-addressed but critical social risk factor that may prevent opioid misuse and use disorder in the setting where most patients are receiving their opioid prescriptions for chronic pain. If successful, the project will have a positive impact in reducing loneliness, reducing opioid misuse, improving function and preventing substance use disorder.Trial RegistrationNCT06285032, issue date: February 28, 2024, original.

This cohort study examines the trajectories of postoperative depressive symptoms in older patients undergoing major surgery and the differences in patient characteristics between the trajectory groups.