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Background There is no meta-analysis that specifically evaluates the effectiveness of Internet- and mobile-based interventions (IMIs) in adults with diagnosed panic disorder and/or agoraphobia (PD/A) so far. The current meta-analysis aims to fill this gap (PROSPERO CRD 42016034016). Methods Systematic literature searches in six databases for randomised and controlled clinical trials investigating IMIs in adults, who met diagnostic criteria for PD/A. Study selection and data extraction were conducted independently by two reviewers. Random-effects meta-analyses, pre-planned subgroup and sensitivity analyses were conducted when appropriate. Primary outcomes were PD and A symptom severity. In addition, adherence, response, remission, quality of life, anxiety and depression symptom severity were examined. Results A total of 16 trials (1015 patients), with 21 comparisons (9 IMI vs. waitlist; 7 IMI vs. IMI; 5 IMI vs. active treatment condition), were included. IMIs revealed beneficial effects on panic (Hedges’ g range −2.61 to −0.25) and agoraphobia symptom severity when compared to waitlist (pooled g = −1.15, [95%-CI = −1.56; −0.74]). Studies comparing IMIs to active controls (i.e., face-to-face CBT and applied relaxation) did not find significant differences for reductions in panic (g = −0.02, [95%-CI = −0.25; 0.21]) and agoraphobia symptom severity (g = −0.10, [95%-CI = −0.39; 0.19]). Furthermore, IMIs were superior to waitlist controls regarding anxiety and depression symptom severity and quality of life. Limitations Tests for publication bias were not feasible due to the limited number of trials per comparison, and the risk of bias assessment indicated some methodological shortcomings. Conclusions Findings from this meta-analytic review provide support for the effectiveness of IMIs in patients with verified PD/A. However, before IMIs can be included in treatment guidelines for PD/A, future high quality research is needed that substantiates and extends the evidence base, especially in regard to intervention safety.

Abstract. This meta-review integrates the current meta-analysis literature on the efficacy of internet- and mobile-based interventions (IMIs) for mental disorders and somatic diseases in children and adolescents. Further, it summarizes the moderators of treatment effects in this age group. Using a systematic literature search of PsycINFO and MEDLINE/PubMed, we identified eight meta-analyses (N = 8,417) that met all inclusion criteria. Current meta-analytical evidence of IMIs exists for depression (range of standardized mean differences, SMDs = .16 to .76; 95 % CI: –.12 to 1.12; k = 3 meta-analyses), anxiety (SMDs = .30 to 1.4; 95 % CI: –.53 to 2.44; k = 5) and chronic pain (SMD = .41; 95 % CI: .07 to .74; k = 1) with predominantly nonactive control conditions (waiting-list; placebo). The effect size for IMIs across mental disorders reported in one meta-analysis is SMD = 1.27 (95 % CI: .96 to 1.59; k = 1), the effect size of IMIs for different somatic conditions is SMD = .49 (95 % CI: .33 to .64; k = 1). Moderators of treatment effects are age (k = 3), symptom severity (k = 1), and source of outcome assessment (k = 1). Quality ratings with the AMSTAR-2-checklist indicate acceptable methodological rigor of meta-analyses included. Taken together, this meta-review suggests that IMIs are efficacious in some health conditions in youths, with evidence existing primarily for depression and anxiety so far. The findings point to the potential of IMIs to augment evidence based mental healthcare for children and adolescents.

While the efficacy of Internet- and mobile-based interventions (IMIs) for treating anxiety disorders is well established, there is no comprehensive overview about the underlying therapeutic processes so far. Thus, this systematic review and meta-analysis evaluated research on mediators and mechanisms of change in IMIs for adult anxiety disorders (PROSPERO: CRD42020185545). A systematic literature search was performed in five databases (i.e., CENTRAL, Embase, MEDLINE, PsycINFO and ClinicalTrials.gov). Two reviewers independently screened studies for inclusion, assessed the risk of bias and adherence to quality criteria for process research. Overall, 26 studies (N=6042) investigating 64 mediators were included. Samples consisted predominantly of participants with clinically relevant symptoms of generalized anxiety disorder and severe health anxiety, as well as of participants with non-clinically relevant anxiety symptoms. The largest group of examined mediators (45%) were cognitive variables, evincing also the second highest proportion of significance (19/29); followed in numbers by skills (examined: 22%; significant: 10/14) and a wide range of other (19%; 7/12), emotional/affective (11%; 2/7) and behavioral mediators (3%; 1/2). Meta-analytical synthesis of mediators, limited by a small number of eligible studies, was conducted by deploying a two-stage structural equation modeling approach, resulting in a significant indirect effect for negative thinking (k=3 studies) and non-significant indirect effects for combined cognitive variables, both in clinical (k=5) and non-clinical samples (k=3). The findings of this review might further the understanding on presumed change mechanisms in IMIs for anxiety, informing intervention development and the concurrent optimization of outcomes. Furthermore, by reviewing eligible mediation studies, we discuss methodological implications and recommendations for future process research, striving for causally robust findings. Future studies should investigate a broader range of variables as potential mediators, as well as to develop and apply original (digital) process and engagement measures to gather qualitative and high-resolution data on therapeutic processes. Copyright © 2021 Elsevier Ltd. All rights reserved.

Key Points Question Does pediatrician training in motivational interviewing (MI) facilitate the use of mental health care services for youths with chronic medical conditions? Findings In this cluster randomized trial with 164 youths with chronic medical conditions and comorbid anxiety or depression, training physicians in MI did not significantly improve uptake rates of psychological counseling among youths compared with usual care. MI training was associated with longer patient-physician conversations and lower anxiety scores at 1-year rescreening. Meaning More research is needed to determine whether training pediatricians in MI and allotting more consultation time to discuss mental health could facilitate use of counseling services by youths with chronic medical conditions., This cluster randomized clinical trial examined the efficacy of pediatricians using motivational interviewing (MI) vs treatment as usual in increasing youths’ utilization of mental health care., Importance Despite the high prevalence of anxiety and depression in youths with chronic medical conditions (CMCs), physicians encounter substantial barriers in motivating these patients to access mental health care services. Objective To determine the efficacy of motivational interviewing (MI) training for pediatricians in increasing youths’ use of mental health care. Design, Setting, and Participants The COACH-MI (Chronic Conditions in Adolescents: Implementation and Evaluation of Patient-Centered Collaborative Healthcare—Motivational Interviewing) study was a single-center cluster randomized clinical trial at the University Children’s Hospital specialized outpatient clinics in Düsseldorf, Germany. Treating pediatricians were cluster randomized to a 2-day MI workshop or treatment as usual (TAU). Patient recruitment and MI conversations occurred between April 2018 and May 2020 with 6-month follow-up and 1-year rescreening. Participants were youths aged 12 to 20 years with CMCs and comorbid symptoms of anxiety and depression; they were advised by their MI-trained or untrained physicians to access psychological counseling services. Statistical analysis was performed from October 2020 to April 2021. Interventions MI physicians were trained through a 2-day, certified MI training course; they recommended use of mental health care services during routine clinical appointments. Main Outcomes and Measures The primary outcome of uptake of mental health care services within the 6-month follow-up was analyzed using a logistic mixed model, adjusted for the data’s cluster structure. Uptake of mental health services was defined as making at least 1 appointment by the 6-month follow-up. Results Among 164 youths with CMCs and conspicuous anxiety or depression screening, 97 (59%) were female, 94 (57%) had MI, and 70 (43%) had TAU; the mean (SD) age was 15.2 (1.9) years. Compared with patients receiving TAU, the difference in mental health care use at 6 months among patients whose physicians had undergone MI training was not statistically significant (odds ratio [OR], 1.96; 95% CI, 0.98-3.92; P = .06). The effect was moderated by the subjective burden of disease (F2,158 = 3.42; P = .04). Counseling with an MI-trained physician also led to lower anxiety symptom scores at 1-year rescreening (F1,130 = 4.11; P = .045). MI training was associated with longer conversations between patients and physicians (30.3 [16.7] minutes vs 16.8 [12.5] minutes; P

Background Although the efficacy of Internet- and mobile-based interventions (IMIs) for anxiety is established, little is known about the intervention components responsible for therapeutic change. We conducted the first comprehensive meta-analytic review of intervention components of IMIs for adult anxiety disorders. Methods Randomized controlled trials (RCTs) comparing IMIs for anxiety disorders to active online control groups, or IMIs to dismantled variations of the same intervention (± specific components) were identified by a systematic literature search in six databases. Outcomes were validated observer-rated or self-report measures for anxiety symptom severity and treatment adherence (number of completed modules and completer rate). This meta-analytic review is registered with PROSPERO (CRD42017068268). Results We extracted the data of 34 RCTs (with 3,724 participants) and rated the risk of bias independently by two reviewers. Random-effects meta-analyses were performed on 19 comparisons of intervention components (i.a., different psychotherapeutic orientations, disorder-specific vs. transdiagnostic approaches, guidance factors). IMIs had a large effect when compared to active online controls on symptom severity (standardized mean difference [SMD] of -1.67 [95% CI: -2.93, -0.42]; P = 0.009). Thereby, guided IMIs were superior to unguided interventions on symptom severity (SMD of -0.39 [95% CI: -0.59, -0.18]; P = 0.0002) and adherence (SMD of 0.38 [95% CI: 0.10, 0.66]; P = 0.007). Conclusions Overall, the results of this meta-analysis lend further support to the efficacy of IMIs for anxiety, pointing to their potential to augment service supplies. Still, future research is needed to determine which ingredients are essential, as this meta-analytic review found no evidence for incremental effects of several single intervention components apart from guidance.