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    Nationwide Implementation of Unguided Cognitive Behavioral Therapy for Adolescent Depression: Observational Study of SPARX
    (JMIR Publications, 2024-09-03) Fleming T; Lucassen M; Frampton C; Parag V; Bullen C; Merry S; Shepherd M; Stasiak K
    Background: Internet-based cognitive behavioral therapy (iCBT) interventions are effective in clinical trials; however, iCBT implementation data are seldom reported. Objective: The objective of this study is to evaluate uptake, adherence, and changes in symptoms of depression for 12-to 19-year-olds using an unguided pure self-help iCBT intervention (SPARX; Smart, Positive, Active, Realistic, X-factor thoughts) during the first 7 years of it being publicly available without referral in Aotearoa New Zealand. Methods: SPARX is a 7-module, self-help intervention designed for adolescents with mild to moderate depression. It is freely accessible to anyone with a New Zealand Internet Protocol address, without the need for a referral, and is delivered in an unguided “serious game” format. The New Zealand implementation of SPARX includes 1 symptom measure—the Patient Health Questionnaire adapted for Adolescents (PHQ-A)—which is embedded at the start of modules 1, 4, and 7. We report on uptake, the number of modules completed, and changes in depressive symptoms as measured by the PHQ-A. Results: In total, 21,320 adolescents aged 12 to 19 years (approximately 2% of New Zealand 12‐ to 19-year-olds) registered to use SPARX. Of these, 63.6% (n=13,564; comprising n=8499, 62.7% female, n=4265, 31.4% male, and n=800, 5.9% another gender identity or gender not specified; n=8741, 64.4% New Zealand European, n=1941, 14.3% Māori, n=1202, 8.9% Asian, n=538, 4.0% Pacific, and n=1142, 8.4% another ethnic identity; mean age 14.9, SD 1.9 years) started SPARX. The mean PHQ-A at baseline was 13.6 (SD 7.7) with 16.1% (n=1980) reporting no or minimal symptoms, 37.4% (n=4609) reporting mild to moderate symptoms (ie, the target group) and 46.7% (n=5742) reporting moderately severe or severe symptoms. Among those who started, 51.1% (n=6927) completed module 1, 7.4% (n=997) completed at least 4 modules, and 3.1% (n=416) completed all 7 modules. The severity of symptoms reduced from baseline to modules 4 and 7. Mean PHQ-A scores for baseline, module 4, and module 7 for those who completed 2 or more assessments were 14.0 (SD 7.0), 11.8 (SD 7.9), and 10.5 (SD 8.5), respectively; mean difference for modules 1-4 was 2.2 (SD 5.7; P<.001) and for modules 1-7 was 3.6 (SD 7.0; P<.001). Corresponding effect sizes were 0.38 (modules 1-4) and 0.51 (modules 1-7). Conclusions: SPARX reached a meaningful proportion of the adolescent population. The effect size for those who engaged with it was comparable to trial results. However, completion was low. Key challenges included logistical barriers such as slow download speeds and compatibility with some devices. Ongoing attention to rapidly evolving technologies and engagement with them are required. Real-world implementation analyses offer important insights for understanding and improving the impact of evidence-based digital tools and should be routinely reported.
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    "Help yourself to CBT" : mechanisms of change within a group guided self-help programme targeting low mood in New Zealand : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology, Massey University, Albany, New Zealand
    (Massey University, 2015) Forman, Inga
    This thesis explores the processes of change within a Low Intensity Cognitive Behaviour Therapy (LICBT) intervention targeting low mood in a community sample of adults in New Zealand. Low intensity interventions (e.g. self-help programmes) are a relatively new area of interest in the area of psychological treatment. They aim to increase people’s access to evidence based methods of therapy whilst removing many of the major issues associated with traditional treatment methods, such as long waiting lists, financial limitations, and inaccessibility to many in the wider community (Lovell & Richards, 2000). LICBT interventions have been shown to significantly improve outcomes for mild to moderate depressive symptoms across different samples (McKendree-Smith, Floyd & Scogin, 2003). The current study assessed change processes within the guided self-help programme ‘Living life to the Full’ (LLTTF, Williams, 2008). Due to methodological issues, the study was not able to soundly address hypotheses regarding the effectiveness of the programme. However, the statistical significance of changes across outcome measures were examined along with their clinical significance at an individual level. Participants showed statistically significant reductions in psychological distress from baseline to post-programme. Results for depression and quality of life were not significant. When results were examined at a single case level for clinical significance, a number of participants showed clinically significant change across the three main outcome measures. An analysis of individual change processes was also completed, with the examination of early rapid response patterns for individual participants. Early rapid response patterns occurred for a number of participants, supporting preliminary evidence that certain change patterns apparent in CBT research may also occur in LICBT interventions. A link was also found between early rapid responding and more positive post programme outcomes. Group process results showed that as predicted, the low intensity nature of the programme is likely to have affected the perceived group environment and relationship to the group facilitator. The LLTTF programme was positively evaluated by the majority of programme completers and though the sample size was small, results suggest this type of intervention is an effective platform from which to further develop low intensity therapeutic paradigms in New Zealand.
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    Will the needle make me bleed to death? : The development and evaluation of a cognitive-behavioural therapy for chronically ill children with needle-related distress : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University, Wellington, New Zealand
    (Massey University, 2011) McIvor, Jessica Anne
    For some chronically ill children, having an injection is a regular occurrence and can result in distress and avoidance behaviour for the child and their family. There can also be negative health implications of these children not having their injections. Research supports the effectiveness of cognitive-behavioural therapy for childhood needle-related distress (NRD), although there are significant gaps in the literature that need to be addressed. The aim of the present study was to develop and evaluate a six-session cognitive-behavioural therapy to alleviate NRD among chronically ill children. The research was designed to pilot this manualised approach, which was based on an existing therapy utilised at the Massey Health Conditions Psychology Service, relevant theory and empirical research. The therapy programme known as the “Coping Kids Treatment Manual” differed from previous research by incorporating cognitive components, carer involvement and multiple exposure sessions. A single-subject multiple-baseline across participants design was used to assess the effectiveness of the treatment manual. Four chronically ill children (aged 6-14 years) of New Zealand European descent diagnosed with NRD and their carers participated in this study. Child and carer self-report measures were collected during baseline, treatment and once at one month follow-up. Results showed that, compared to pre-treatment levels, the majority of children and their carers demonstrated a reduction in distress and increase in coping behaviours related to needle injection situations. Follow-up data showed treatment gains were maintained and/or improved at one month. Most importantly, these gains were accompanied by three of the four children successfully receiving an in-vivo needle injection during session five of the intervention. Findings are interpreted in terms of previous literature, and implications are discussed according to theory, research and clinical practice. Limitations of the present study are highlighted and recommendations for future research directions are outlined. Suggestions for future research include evaluating the effectiveness of the treatment manual with a larger and more diverse group of children, extending follow-up periods and utilising more rigorous measures. Additional research is also required to investigate what components are most critical in producing meaningful change and to what extent carer involvement enhances treatment outcomes. Overall, preliminary findings offered support for the effectiveness of the Coping Kids Treatment Manual in treating four chronically ill children with NRD.
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    An investigation into the presence of seasonal symptoms in a sample treated for depression : a thesis presented in partial fulfillment of the requirements for a degree of Doctorate of Clinical Psychology at Massey University, Albany, New Zealand
    (Massey University, 2011) Page, Susan; Page, Susan
    The “winter blues” would appear to be a global concept. This thesis examined features of depression, seasonal change and meteorological data in relation to theories on the development of seasonal depression and Seasonal Affective Disorder (SAD). It reviewed the neurotransmitter based theories of causation where increased exposure to light is thought to stimulate normal neurotransmitter production. It also examined the dual vulnerability hypothesis (DVH) which postulated that vegetative symptoms arose from a different vulnerability than depressive symptoms. Levels of vegetative symptoms and depression were analysed in relation to the different climate experienced in Auckland, New Zealand. Three studies were undertaken. In the first study, the sample consisted of 195 individuals in New Zealand who self-referred to participate in a separate research project examining the effects of “homework” and cognitive behavioural therapy for first time depression. Meteorological data were investigated in order to explore any potential vulnerability to seasonal depression in this sample. Additionally, age and gender were explored in relation to season of presentation. The second study involved the subsample (n = 81) who were assessed for therapy and examined season and symptom profile in relation to when the person presented. The third study traced the progress through therapy of 28 adults who were selected from the second study for CBT. The Beck Depression Inventory (BDI-II) provided additional data to test the related hypotheses Rate of change in depression scores and symptom expression in relation to seasonality were analysed using multilevel modelling (MLM). Daily hours of bright sunlight was found to have an unusual relationship to temperature in New Zealand when compared with previous research. In this setting increased sunshine was associated with lower temperatures. Therefore, the variables were separated in order to ascertain whether one affected results more than others. Bright sunshine hours affected the expression of vegetative symptoms with a decrease observed over time in relation to increased photoperiod. Subtle relationships between temperature and vegetative symptoms were observed. However, there was an overall lack of correlation between vegetative and depressive symptoms observed in the CBT sample, and sunlight was not observed to have any effect on typical depressive symptoms. The investigation provided partial support for the neurotransmitter basis of vegetative symptoms and for the dual vulnerability hypothesis. Gender and age were correlated with vegetative symptom endorsement, although over time only gender was found to have any ongoing significance in the presentation of seasonal symptoms with women more likely to exhibit vegetative responses over time.
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    Is the black dog really a dalmatian? : an investigation into whether stress impact and attributional style lead to different outcomes for individuals receiving 20 sessions of cognitive behavioural therapy for depression : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Auckland, New Zealand
    (Massey University, 2010) Good, Kimberly Suzanne
    There is a need for greater clarity in the relationship between psychosocial stress and depression and its application to outcomes in cognitive behavioural therapy (CBT). A preponderance of research focuses primarily on the causal relationship between stress and depression and is limited by the traditional assumption of homogeneity amongst first-episode sufferers of mild to moderate depression. In actual fact, the perceived intensity and type of stress as well as an individual‘s attributional style may create significant differences in how they respond to therapy and overcome depression. This research had four aims: to develop an understanding about why individuals differ in their CBT recovery trajectories; to examine how the stress-diathesis framework relates to treatment outcomes; to develop a way of effectively assessing and measuring the quantitative impact of stress; and to develop an effective approach towards assessing contextual aspects of stress. The research inquiry was guided by stress-diathesis theory and a reformulated stress-diathesis framework was proposed that specified a quantitative – qualitative stress distinction. This accorded with the study‘s development of two stress measures. A measure for objectively quantifying stress was introduced, along with a therapist questionnaire that identifies precipitating stressors in depression and the qualitative aspects of the stress experience. A final sample of 26 clients experiencing their first episode of Major Depressive Disorder (MDD) was achieved. Clients were recruited for 20 sessions of CBT with 2- and 6-month follow-ups. Depression severity was measured each session with the Beck Depression Inventory (BDI-II) and attributional style was measured at six time points with the Attributional Style Questionnaire (ASQ). Stress impact was measured using the Impact of Event Scale – Video Format (IES-VF) and the Identification of Precipitating Stressors Questionnaire (IPSQ) was developed to assess precipitating stressors of depression. Multilevel analysis suggested that attributional style moderates the relationship between change in stress and change in depression. Clients with predominantly depressogenic attributional styles showed a delay in depression improvement compared to clients with non-depressogenic styles, even when significant stress reductions were achieved. Gender, therapy completion and marital status were also significant predictors of recovery. Preliminary support was achieved for the classification of clients into three recovery subgroups, according to whether they achieved rapid, expected or minimal stress improvements. Post-hoc analyses also indicated that chronicity and impact on autonomy appear to be the most influential stressor characteristics. Implications for future research and clinical considerations are discussed.
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    Efficacy of cognitive behavioural therapy for clients who have sustained a traumatic brain injury (TBI) : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy (PhD) in Psychology at Massey University, Wellington, New Zealand
    (Massey University, 2009) Christianson, Muriel Katherine
    While the focus of rehabilitation following traumatic brain injury (TBI) is often on management of physical and cognitive impairments, emotional and behavioural changes in the person with the injury may represent major hurdles in adjustment following injury. Mood, anxiety and adjustment disorders are common following TBI. A manualised cognitive behavioural therapy (CBT) treatment programme was developed that incorporated provision of education on consequences of TBI, used cognitive and behavioural strategies to recognise and manage emotional reactions to injury, and promoted achievement of personal goals. Participants were nine people with TBI referred to Massey University Psychology Clinic Wellington, for psychotherapy to assist in managing symptoms of psychological distress or adjustment difficulties following injury. Measures used included the Hospital Anxiety and Depression Scale (HADS) to monitor progress in reduction of symptoms of Anxiety and Depression; the Patient Competency Rating Scale (PCRS) to assess competency across areas of day-to-day living; and the Homework Rating Scale Second Edition (HRS-II) to assess the value of homework assignments for participants. Results were presented graphically in group format and in the form of individual case studies outlining progress in achieving individual goals. There was considerable variation in the responses of participants to treatment. When anxiety and depression were secondary to other referral issues such as fatigue and pain that remained high over treatment sessions, there was limited movement on HADS Anxiety and Depression scores. The small number of participants impacted on the ability to detect differences between Patient and Informant ratings on the PCRS or to demonstrate increased levels of awareness over treatment sessions. Consistent completion of Homework assignments proved difficult for participants. Factors that impacted on achievement of personal goals included ongoing levels of fatigue and pain, levels of personal expectation, interpersonal and organisational skills, insight into emotional reactions, and good family and social support. There is a part for a CBT approach in adjusting to changes following TBI, particularly in assisting with reassessing expectations following injury.
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