Effectiveness of an Internet-based preparation for psychosomatic treatment: Results of a controlled observational study

Highlights

• We examine the effectiveness of an Internet-based preparation program for depression in routine psychosomatic care.

• Web-based interventions open new avenues to support patients waiting to commence inpatient therapy.

• Participants showed higher rates of reliable improvements during inpatient treatment.

• Preparation for psychotherapy is an effective approach to bolster response rates.

Abstract

Objective

Patients often have to sustain long waiting periods between the time they first apply for psychotherapy and the actual uptake of the treatment. To support patients who are on a wait-list for inpatient psychosomatic treatment an Internet-based preparatory treatment (VORSTAT) was developed. In a randomized controlled trial, VORSTAT proved to increase treatment motivation prior to intake and to accelerate the accommodation phase at the beginning of inpatient treatment. No impact of VORSTAT on inpatient treatment outcome was found. The aim of the present study was to investigate the effectiveness of VORSTAT after implementing the service into routine care.

Methods

A large naturalistic observational study comparing VORSTAT participants (N = 911) against non-participants (N = 1721) was conducted. Propensity scores were used to control for potential confounding variables due to the non-randomized group allocation. Reliable improvement of self-reported impairment achieved during inpatient treatment was used as outcome measure.

Results

VORSTAT participants showed higher rates of reliable improvement in physical impairment (50.8% vs. 44.9%), psychological impairment (41.2% vs. 29.9%), and social problems (22.3% vs. 15.2%).

Conclusion

An Internet-based preparation for psychotherapy is an effective approach to improve outcome of inpatient psychosomatic treatment.

Introduction

The German mental healthcare system is organized in a sectorial way and includes inpatient and outpatient services. Inpatient treatment for mental illness is widely available and much more common than in most other countries in the world [1]. It is characterized by high intensity care up to 30 h therapy per week, a multimodal and multiprofessional approach, and an average length of stay of 13 to 41 days [1], [2]. Despite the fact that provision and utilization of psychotherapy in Germany are high, the fragmented system of mental health care services causes long waiting times for individuals who are applying for treatment. As the average waiting time amounts up to three months for outpatient and 2.3 months for inpatient psychotherapy, many patients remain without professional support during the time when they urgently need it [3], [4].

A number of studies have examined strategies for preparing patients for treatment during this waiting period for psychotherapy. Research indicates that preparatory interventions based on educational and motivational techniques can reduce early treatment attrition, improve motivation for treatment, and enhance treatment outcome [5]. The majority of the studies have been carried out in outpatient settings, have tested very brief interventions, and have examined premature termination as outcome. Studies investigating strategies for preparing clients for inpatient treatment suggest, that educational group sessions with prior contact to the therapist who will be in charge during inpatient treatment, preparatory sessions based on the motivational interviewing approach, and targeted self-help manuals might be beneficial [6].

In the last years the potential of Internet-based interventions to complement conventional care for mental illness have been increasingly discussed [7]. In line with this development, the use of Internet-based interventions for the pre-treatment support of patients waiting for psychotherapy is currently explored [8], [9]. First pilot work on Internet-based self-help treatments indicates that patients on a wait-list prefer to engage in an online pre-treatment program to mere waiting. Moreover, guided problem solving therapy prior to face-to-face therapy seems to increase the speed of recovery [10], however, drop-out from Internet-based self-help interventions is high [10], [11], [12]. Despite this pilot work, data on successfully implemented e-health interventions are rare [13]. One important step e-health interventions have to undergo prior to dissemination is to prove their feasibility and effectiveness under routine care conditions in order to maximize external validity [14].

The use of an Internet-delivered program for treatment preparation has several advantages (see [15]). It can be used from anywhere at any time, and thus, increases the availability of the service for patients. This is a major benefit for specialized hospitals in which patients from all over the country receive treatment. The information provided can be continuously updated and tailored to the patients' needs. Anonymous communication facilitates disclosure of personal or shameful issues. Last but not least, the participants can exchange information with experts and peers and can share emotional support.

In order to provide guidance to patients during the waiting period until the uptake of their inpatient treatment, an Internet-based pre-treatment intervention (VORSTAT) was developed ([16]). VORSTAT is an online portal to facilitate communication among prospective patients, and between prospective patients and hospital staff. Parts of the intervention have been proven feasible and well-accepted in earlier research on online aftercare following inpatient treatment [17]. The efficacy of the VORSTAT program was tested in a comprehensive cohort study (CCS [18])¹ between 2009 and 2011 in a sample of 589 patients waiting for the admission to inpatient treatment in a hospital for psychosomatics. In this study, VORSTAT proved technically feasible and well accepted by the patients. Forty-three percent of the invited patients participated in the program, of these 58% accepted randomization. A total of 335 patients were randomly assigned to a control group (CG) that received standard care plus access to the following VORSTAT modules: psychoeducational materials, moderated forums, patient progress reports and a monitoring system that tracks participants' symptom course; or to an intervention group (INT) that received additional access to the VORSTAT modules: expert guided Internet group chats, therapeutic writing exercises, and a supportive monitoring system which provide tailored feedback on the current status, as well as on positive and negative changes. Participants who declined randomization did not differ from those randomized with respect to sociodemographic factors, the degree of therapy motivation, and the levels of impairment. The overall objective of the initial efficacy trial was to determine whether participation in VORSTAT yields to an increased speed of symptom change during the early phase of inpatient treatment. Key findings were [19]: patients of the CG and the INT showed statistically significant improvements in physical impairment, psychological impairment, and social problems after two weeks of inpatient treatment, without a significant between-group difference. Moreover, no differences between the groups in the amount of symptom change were found at discharge. It is assumed that the two conditions of the randomized control trial might have been too similar (due to the CCS design) — especially as the unique tools for the INT were not used frequently. However VORSTAT shortened the accommodation phase: Participants of the INT showed higher rates of reliable improvements of their psychological well-being after two weeks of inpatient treatment (INT: 58.8% vs. CG: 40.2%). Finally, there was a significant positive impact of the intervention on the level of therapy motivation at hospital admission.

Based on these findings, it was decided to implement VORSTAT as part of the routine services of the hospital. The present study sought to extend prior work by examining the effectiveness of VORSTAT following the implementation into routine care. We hypothesized that VORSTAT participants would show better outcome at the end of inpatient treatment compared to non-participants.