Effectiveness and Acceptability of Internet-delivered Treatment for Depression, Anxiety and Stress

Depression, anxiety and stress are among the primary causes of disease rates worldwide and
are the most prevalent mental health problems in the U.S. Each is associated with significant
economic, personal, intrapersonal and societal losses including lower quality of life and
increased mortality.

Depression, Anxiety and Stress in Students:

Depression and anxiety are also the most prevalent mental health problems among the student
population. In the 2010 American College Health Survey, 48% of college and university
students reported feeling overwhelming anxiety at least once in the previous year. Thirty-one
percent reported feeling so depressed it was difficult to function at least once in the
previous 12 months. More recently, University counseling and mental health services have
reported an increase in the number of clients seeking services and in yearly visits.

The college years can be a highly stressful time in students' lives. This is particularly
true of the period of transition to college as students are learning to cope with increased
academic pressures. Students are at a developmental stage when newfound stressors can promote
the onset of mental health difficulties. In addition to academic stress, international
students can experience significant sociocultural adjustment demands.

Young adults between 17 and 25 years of age are reported to be at greater risk of developing
a serious mental illness than individuals in other age groups. Although early diagnosis of
mental disorders can be difficult, delayed diagnosis can often lead to treatment resistance
and poorer longer-term outcomes. In addition, underachievement or failure at this point in
life can cause long-term setbacks to individuals' self-esteem and future progress.

Treating Depression, Anxiety and Stress:

Depression, anxiety and stress disorders can each be treated effectively using medications;
however, after completing a course of this type of treatment the chances of relapse are high,
and equally successful psychological therapies are often preferred. Of these,
cognitive-behavior therapy (CBT) is the most widely researched and CBT is recognized as the
leading choice of treatment for depression and anxiety in terms of post-treatment
improvements, maintaining progress, and preventing relapse. CBT also is effective for stress
management. CBT is comprised of a variety of cognitive and behavioral approaches, each
concerned with changing distressing thoughts and beliefs. Treatment is often comprised of
self-monitoring and thought recording, behavioral activation, cognitive restructuring, and
exposure.

Access to Treatment:

On a global scale, a significant number of individuals in need of treatment receive no
medical diagnosis nor do they seek treatment. The worldwide treatment gap between those
needing treatment for depression compared to those receiving treatment has been estimated at
56%; the gap in treatment for anxiety disorders has been estimated at 46%. Several factors
prevent people from accessing treatment, such as waiting lists, lack of motivation, negative
attitudes about treatment, and costs. Of those willing to seek treatment, many encounter a
lack of trained professionals or are placed on a waiting list. Although students can often
obtain mental health services on campus, many campuses have limited services or have wait
lists for services because of the high demand. A survey of U.S. students with mental health
problems revealed that common barriers to seeking services, even if they were available, were
stigma, lack of time/accessibility, and wait lists. Internet-delivered interventions are one
way to address these issues.

Internet-Delivered CBT (iCBT):

Internet-delivered CBT programs are specially designed for the treatment of specific
disorders, and can be either clinician-guided or self-administered. When such interventions
are used in the UK, 6-8 sessions is the recommended length of treatment. Many studies provide
support for the utility and effectiveness of internet-delivered treatments for depression,
anxiety and stress . Those with the additional feature of human support tend to produce
greater results.

Several studies also have assessed the efficacy of online interventions for depression,
stress, and anxiety for college students. Recent reviews of these studies have found evidence
for the efficacy of these online interventions. However, most of these studies do not assess
the efficacy of the interventions in the context of existing service delivery systems.
Rather, many are RCTs assessing efficacy in convenience samples of students (e.g., Psychology
majors). The current trial seeks to investigate the effectiveness and acceptability of
internet-delivered interventions among university students seeking services and the
procedures needed to incorporate these interventions into mental health delivery in U.S.
universities. Additionally, it hopes to support and extend existing empirical evidence for
SilverCloud programs.

University of Minnesota:

The University of Minnesota-Twin Cities is a public research university located in
Minneapolis and St. Paul, Minnesota established in 1851. It is the oldest and largest campus
within the University of Minnesota system and has the sixth-largest main campus student body
in the United States, with 57,600 students. The university is organized into 19 colleges and
schools.

Participants will be recruited through three units at the University of Minnesota-Twin
Cities. The first is Student Counseling Services (SCS) which provides free short-term
counseling to undergraduate and graduate students. The second is Boynton Mental Health Clinic
(BMHC) which also provides short term psychological services to full-time students at the
University of Minnesota. Unlike SCS, BMHC also has psychiatrists on staff and is affiliated
with the university health service. Finally, the investigators will recruit participants
through the International Student and Scholar Services (ISSS) office which provides
counseling to foreign national students on campus.

Inclusion Criteria:

- Participants must be at least 18 years of age. Participants must have self-reported
mild to severe symptoms of depression (5-27+) according to PHQ-9, self-reported mild
to severe symptoms of anxiety (5-21+) according to GAD-7, or self-reported mild to
severe symptoms of stress (15-34+) according to the stress sub-scale of DASS-21.

Exclusion Criteria:

- Students who currently are in face-to-face therapy at UCCS or BHS will be excluded.
Students who score in the "red zone" in terms of risk of self-harm on the screening
questions routinely used at UCCS will not be referred to the study. Students who score
greater than 0 on the PHQ-9 self-harm item during the initial screening phase will be
automatically directed to be further evaluated and alerted that a counselor will try
to reach them. Based on this further evaluation, they may be recommended to seek help
from their health/counseling service and may/may not be eligible to participate in the
study. They will be telephoned within 1 working day and contacted by email if they
cannot be reached by phone.