Comparison of the working alliance in blended cognitive behavioral therapy and treatment as usual for depression in Europe: secondary data analysis of the E-COMPARED randomized controlled trial

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cris.lastimport.scopus2025-07-03T03:11:05Z
dc.abstract.enBackground: 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.
dc.affiliationWydział Psychologii w Warszawie
dc.affiliationInstytut Psychologii
dc.contributor.authorDoukani, Asmae
dc.contributor.authorQuartagno, Matteo
dc.contributor.authorSera, Franscesco
dc.contributor.authorFree, Caroline
dc.contributor.authorKukuma, Ritsuko
dc.contributor.authorRiper, Heleen
dc.contributor.authorKleiboer, Annet
dc.contributor.authorCerga-Pashoja, Arlinda
dc.contributor.authorvan Schaik, Anneke
dc.contributor.authorBotella, Cristina
dc.contributor.authorBerger, Thomas
dc.contributor.authorChevreul, Karine
dc.contributor.authorMatynia, Maria
dc.contributor.authorKrieger, Tobias
dc.contributor.authorHazo, Jean-Baptiste
dc.contributor.authorDraisma, Stasja
dc.contributor.authorTitzler, Ingrid
dc.contributor.authorTopooco, Naira
dc.contributor.authorMathiasen, Kim
dc.contributor.authorVernmark, Kristofer
dc.contributor.authorUrech, Antoine
dc.contributor.authorMaj, Anna
dc.contributor.authorAndersson, Gerhard
dc.contributor.authorBerking, Matthias
dc.contributor.authorBanos, Rosa Maria
dc.contributor.authorAraya, Ricardo
dc.date.access2024-05-31
dc.date.accessioned2024-06-07T11:42:33Z
dc.date.available2024-06-07T11:42:33Z
dc.date.created2024
dc.date.issued2024-05-31
dc.description.abstract<jats:sec> <jats:title>Background</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Objective</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>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).</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Trial Registration</jats:title> <jats:p>ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&amp;filters=&amp;sort=&amp;offset=1&amp;totalResults=1&amp;page=1&amp;pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573</jats:p> </jats:sec> <jats:sec> <jats:title>International Registered Report Identifier (IRRID)</jats:title> <jats:p>RR2-10.1186/s13063-016-1511-1</jats:p> </jats:sec>
dc.description.accesstimeat_publication
dc.description.grantnumber603098
dc.description.granttitleE-COMPARED European Comparative Effectiveness Research on Internet-based Depression Treatment
dc.description.physical1-18
dc.description.versionfinal_published
dc.description.volume26
dc.identifier.doi10.2196/47515
dc.identifier.issn1438-8871
dc.identifier.urihttps://share.swps.edu.pl/handle/swps/707
dc.identifier.weblinkhttps://pubmed.ncbi.nlm.nih.gov/38819882/
dc.languageen
dc.pbn.affiliationpsychologia
dc.rightsCC-BY
dc.rights.questionYes_rights
dc.rights.urihttps://creativecommons.org/licenses/by/3.0
dc.share.articleOPEN_JOURNAL
dc.subject.enblended psychotherapy
dc.subject.encognitive behavioral therapy
dc.subject.endepression
dc.subject.endigital mental health interventions
dc.subject.enmental health
dc.subject.enprogram usability
dc.subject.enpsychotherapy
dc.subject.entherapeutic alliance
dc.subject.enusability heuristics
dc.subject.enworking alliance
dc.swps.sciencecloudsend
dc.titleComparison of the working alliance in blended cognitive behavioral therapy and treatment as usual for depression in Europe: secondary data analysis of the E-COMPARED randomized controlled trial
dc.title.journalJournal of Medical Internet Research
dc.typeJournalArticle
dspace.entity.typeArticle