Rural Mental Health and Psychological Treatment a Review for Practitioners
Review
Abstract
Background: People living in rural and remote communities have greater difficulty accessing mental health services and evidence-based therapies, such as cognitive behavior therapy (CBT), than their urban counterparts. Computerized CBT (CCBT) can exist used to finer care for depression and feet and may exist specially useful in rural settings where there are a lack of suitably trained practitioners.
Objective: To systematically review the global prove regarding the clinical effectiveness and acceptability of CCBT interventions for anxiety and/or depression for people living in rural and remote locations.
Methods: We searched seven online databases: Medline, Embase Classic and Embase, PsycINFO, CINAHL, Web of Science, Scopus, and the Cochrane Library. We also hand searched reference lists, Internet search engines, and trial protocols. Two stages of selection were undertaken. In the first, the 3 authors screened citations. Studies were retained if they reported the efficacy, effectiveness or acceptability of CCBT for depression and/or anxiety disorders, were peer reviewed, and written in English. The qualitative data analysis software, NVivo 10, was and so used to run automated text searches for the give-and-take "rural," its synonyms, and stemmed words. All studies identified were read in full and were included in the study if they measured or meaningfully discussed the efficacy or acceptability of CCBT amidst rural participants.
Results: A full of 2594 studies were identified, of which 11 met the selection criteria and were included in the review. The studies that disaggregated efficacy information by location of participant reported that CCBT was equally constructive for rural and urban participants. Rural location was found to both positively and negatively predict adherence beyond studies. CCBT may be more adequate among rural than urban participants—studies to appointment showed that rural participants were less likely to desire more contiguous contact with a practitioner and constitute that computerized commitment addressed confidentiality concerns.
Conclusions: CCBT can be effective for addressing depression and anxiety and is acceptable among rural participants. Farther piece of work is required to confirm these results across a wider range of countries, and to determine the well-nigh feasible model of CCBT commitment, in partnership with people who live and piece of work in rural and remote communities.
doi:10.2196/jmir.4145
Keywords
Introduction
Groundwork
In whatever one twelvemonth, 10% and xiv% of Australian adults feel melancholia problems and feet disorders, respectively [,]. These rates of mental illness are in line with global trends—the average 12-month depression prevalence charge per unit of 18 high- and low-income countries is 5.4% []. For anxiety disorders, 12-month prevalence rates range from 7% to 15.5% in Euro/Anglo cultures [].
In Commonwealth of australia, over thirty% of the population lives outside major cities, with xi% living in outer regional, remote, and very remote areas []. The reported prevalence of mental health disorders is similar across rural and urban areas [,]. However, at that place are certain population groups in rural and remote areas that experience college levels of mental disorders—men in outer regional and remote areas are significantly more likely to experience college levels of psychological distress than men in major cities [], and women in nonmetropolitan areas anile 30 to 44 years also face slightly higher rates of mental health disorders than their urban counterparts [].
Globally, the prevalence of anxiety disorders is significantly higher among rural versus urban populations []. Furthermore, suicide rates are markedly higher in rural areas compared with major cities, as has been documented in Australia, the United states, the United kingdom, and New Zealand []. In Australia, suicide rates increment with level of remoteness and are largely driven by increased suicides amidst young men [,,].
Treatment, Services, and Access
There is a potent bear witness base of operations and subsequently established guidelines for the effective drug and nondrug handling of depression and feet. For instance, supportive clinical care, cognitive behavior therapy (CBT), antidepressants, and interpersonal therapy (IPT) are all recommended treatment options for different forms of depression []. For anxiety, prove-based interventions include self-assist strategies, group and individual psychoeducational interventions including CBT, and pharmacological treatments for circuitous conditions [].
Still, despite an agreement of what works in treating low and anxiety, many people exercise non receive acceptable care. Less than one-quarter of Australians access psychosocial services, even when they are available []. Of the people with depression or anxiety who do seek treatment, nether half are offered an appropriate handling option [].
Accessing health services can be particularly difficult for people living outside metropolitan areas and away from service hubs. Smaller proportions of rural versus urban populations seek or receive professional help for a mental wellness trouble [,].
In that location are numerous factors that foreclose people from accessing mental wellness services. Availability of services and trained mental health professionals are major barriers to access in rural and remote Australia [,]. In comparison with the 115 psychologists for every 100,000 persons in major cities, the rate in rural areas declines from 66.5 in inner regional to 29 in very remote areas []. Other barriers may include cultural norms effectually stoicism and not wanting to show vulnerability, denial, poor mental health literacy, stigma effectually mental affliction and mental health service use, and the fiscal and personal demands required of treatment [,,]. Studies from a number of English-speaking countries have shown that mental health stigma is peculiarly prevalent in rural areas, is greater amongst men, and impacts willingness to seek assist [].
The consequences of untreated low and anxiety are broad ranging and often debilitating. These weather can atomic number 82 to reduced quality of life and productivity, increased likelihood of developing substance abuse disorders [], nonadherence to care and handling [,], increased run a risk of concrete health bug such as cardiovascular disease [], and increased suicide risk []. Stack [] reported that 87% of suicides involve at least i mental disorder, and that people experiencing major low are as much equally twenty times more probable to commit suicide than people without depression. Accessing appropriate treatment for depression tin can reduce suicide risk by up to fifty%, peculiarly amongst young men [].
Computerized Cerebral Behavior Therapy
Computerized cerebral behavior therapy (CCBT) is an effective treatment option for people with anxiety and/or depression, both as a standalone treatment and as a component of a stepped-intendance treatment plan. Numerous reviews and meta-analyses have plant that CCBT achieves moderate to large upshot sizes for depression and anxiety [-], similar to those found for therapist-delivered CBT [,]. That said, the comparative effectiveness of CCBT and therapist-delivered CBT is somewhat contested. For example, a Cochrane review by Mayo-Wilson and Montgomery [] establish therapist-delivered CBT to be more than effective than computerized commitment.
The delivery of testify-based psychotherapy via personal computers, mobile phones, and tablets provides an opportunity to increase its uptake in rural and remote communities. Information technology may assistance minimize the impact of inadequate numbers and unequal distribution of accordingly trained therapists, and subsequent long wait times, besides as the financial demands of treatment, travel times [,], and stigma associated with accessing mental wellness services. Computerized CBT every bit a mechanism to improve testify-based service provision in rural and remote areas may increase the uptake of evidence-based interventions. However, few studies have explicitly explored the effectiveness and acceptability of CCBT in rural communities.
This review synthesizes the global evidence regarding the clinical effectiveness and acceptability of CCBT interventions for preventing or treating anxiety and low in people who alive in rural and remote areas. It provides recommendations for future research and practise with relevance to rural communities in English-speaking countries around the world.
Methods
Overview
Literature was systematically reviewed in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines [].
Search Strategy
The search strategy was developed by authors KV and CO with input from an bookish enquiry librarian. The concluding strategy included variations of the post-obit terms: anxiety, depression, eHealth, computerized, online, awarding, health, cognitive behavior therapy, and computerized cognitive behavior therapy. Other terms such as "e-therapy," "Internet-delivered," and "telephone-based" did not identify additional citations and were excluded from the strategy. A full re-create of the search strategy is provided in .
The search was conducted in a number of health and science databases: Medline (1946-2014), Embase Classic and Embase (1947-2014), PsycINFO (1806-2014), CINAHL (1981-2014), Web of Scientific discipline (1950-2014), Scopus (1960-2014), and the Cochrane Library (all reviews and trials, May 2014). Additional articles were identified through pearling (ie, hand searching) selected reference lists and trial protocols.
Selection Criteria
Ii screening phases were conducted. In the initial phase, studies were included if they (1) reported the clinical efficacy, effectiveness, acceptability and/or feasibility of CBT delivered via the Internet, through the employ of a computer or other mobile electronic device; (ii) had a focus on the prevention or treatment of generalized or social anxiety disorders, multiple forms of anxiety, and/or depression; (3) included participants from any population group in any location; (four) were conducted in any year upwardly until the search date of May 22, 2014; and (five) were written in English. Primary and secondary studies with quantitative and qualitative designs, too as systematic reviews and meta-analyses, were included.
Studies that focused solely on individual phobias, posttraumatic stress disorder, or postnatal depression were not included in this review, although studies that addressed whatever combination of anxiety disorders were included. Generalized anxiety disorder (GAD) and social anxiety disorder are two of the most prevalent anxiety disorders, with 12-calendar month prevalence rates in Australia of 2.7% and four.7%, respectively []. In the U.k., approximately 4.four% of the population are experiencing generalized anxiety at any one time, in comparison to panic disorder and obsessive compulsive disorder (OCD) at 1.1% []. Furthermore, these forms of anxiety are more likely to be treatable with more generalizable forms of CBT. For these reasons, findings regarding the efficacy of CCBT for these disorders are likely to be more broadly applicable and were, therefore, included every bit the focus of this review.
In the second phase of screening, studies that measured efficacy or acceptability among rural participants or meaningfully discussed the application of CCBT in rural settings were retained for inclusion.
Study Selection
All iii authors were involved in the initial phase of the written report selection process. KV conducted an initial review of all citations by title and discarded any that were clearly irrelevant. KV and CO then reviewed the abstracts of all remaining citations (half each), discarding any that did non meet the inclusion criteria. In response to any uncertainty, the other reviewing author was consulted. If both authors were unsure or disagreed, the third author (MJ) was consulted to attain a last decision. Full texts were located for all citations that potentially matched the inclusion criteria. Each text was reviewed past KV and CO independently to decide on the terminal list of included manufactures, again with input from MJ when required.
NVivo 10 (QSR International, Cambridge, MA), a software package that supports qualitative data analysis, was used to support the second stage of screening. All studies that met the inclusion criteria at stage one were imported into NVivo. Automated text (word) searches were run to identify studies that included the discussion "rural," its stemmed variations, and synonyms. The full texts of studies identified through this process were then assessed by KV to determine the final list of included studies. Where KV was undecided, MJ was consulted.
Data Extraction and Bias Assessment
A structured, only flexible, data extraction table was developed. Data were extracted for a range of outcomes measuring patient experience every bit well equally clinical effect. These included written report design, population and intervention characteristics, clinical efficacy, rates of uptake and adherence, qualitative measures of satisfaction, and perceived benefits and disadvantages.
The Cochrane Collaboration's tool for assessing run a risk of bias [] was used to appraise bias amongst randomized controlled trials (RCTs), assessed at written report level. Relevant criteria from the Grades of Recommendation, Assessment, Development, and Evaluation (Class) handbook were used to assess bias in all other study designs []. Several authors were contacted with requests for further data regarding study methods to support the accurate completion of these assessments.
Results
Overview
The initial database search identified 2587 citations. Of these, 195 were selected for full-text review at the kickoff phase of screening, along with six studies identified through pearling. A total of 142 studies met the inclusion criteria and were retained for the second stage of screening. The automated text search revealed that 45 of these studies included the word "rural," a synonym, or stemmed word at least once. Of these, 10 met the inclusion criteria and were included in the review. One actress study was identified past mitt searching at this stage, resulting in 11 studies beingness finally included in this review [-]. outlines this process and provides the reasons for exclusion at each stage.
Study Characteristics
Among the xi included studies were four papers reporting the findings of three RCTs, one systematic review, one qualitative study, and v studies which used quasi-experimental designs. Nine of the studies were conducted in Australia and ii—regarding i trial—in Scotland. Characteristics and key findings of the xi studies are reported in .
Eight papers regarding six different trials measured rural location as a predictor of outcomes, adherence, or acceptability [-]. The qualitative study explored the acceptability of a CCBT package amongst rural youth []. The final 2 studies discussed the potential application of their results to rural populations [,].
Across the nine studies reporting at to the lowest degree some rural participants were a full of eleven,260 participants. Between 16% and 100% of study participants lived in rural areas. Four of the xi studies explored the value of CCBT among children and/or young people, while five studies tested CCBT for adults. The systematic review included five studies with adult participants and four with children and/or young people.
| Citation; program | Study design | Location | Participants: north, % rural; gender, %; age grouping, age in years, mean or range | Chief findings |
| Calear et al 2013 []; MoodGYM, anxiety & depression | RCTa | Australia | 1477, ~16; female, 56; adolescents, 12-17 | Living in a rural location predicted greater adherence. |
| Neil et al 2009 []; MoodGYM, anxiety & depression | Quasi-experimental | Australia | 8207, nineteen; female, 71; adolescents, xiii-19 | Living in a rural area predicted greater adherence. |
| Sethi 2013 []; MoodGYM, feet & low | RCT | Australia | 89, 0; female, 58; youth, 18-25 | CCBTbmay be a feasible option for youth, but unsuitable for people with low literacy. |
| Griffiths & Christensen 2007 []; MoodGYM + Blue Pages | Systematic review | International | Due north/Ac,d | CCBT may be inconsistent with rural residents' preferred mode of learning—should consider tailoring programs to rural users. |
| Cheek et al 2014 []; SPARX, depression | Qualitative study | Commonwealth of australia | 16, 100; male, 75; adolescents, 13-18 | New Zealand programme adequate for Australian participants. |
| Hayward et al 2007 []; FearFighter, anxiety & depression | Uncontrolled trial | Scotland | 35, 100; female, 66; 16 years and over, 40.2 | Participants had pregnant improvements on measures of low and anxiety. Patients and GPsewere satisfied. |
| MacGregor et al 2009 []; FearFighter, anxiety & depression | Survey & qualitative | Scotland | 35, 100; female, 66; 16 years and over, 40.2 | Content was generally appropriate for rural dwellers (except for references to city centers, buses, and lifts). |
| Kay-Lambkin et al 2011; [] CCBT for comorbid depression & substance use | RCT | Australia | 274, 41; male, 57; 16 years and over, 40 | Rurality did not affect treatment response (low). Computerized therapy led to 2.5 times greater reduction in alcohol employ than therapist delivered (P=.006). |
| Kay-Lambkin et al 2012 []f | RCT | Australia | 163, 33; N/A; sixteen years and overone thousand | No significant differences between rural and urban regarding preferred treatment method. No effect of rurality on retention or treatment response. |
| Mewton et al 2012 []; CRUfAD clinic, feet | Quasi-experimental | Australia | 588, 43; female, 71; 16 years and over, 39.v | Those in a nonrural location were i.viii times more probable to consummate the vi class components. Need to tailor courses for rural users. |
| Sunderland et al 2012 []; CRUfAD clinic, depression & anxiety | Quasi-experimental | Australia | 663, ~45; female person, 66; N/A, 43 | Rurality did not influence effectiveness of CCBT for anxiety and low. |
aRandomized controlled trial (RCT).
bComputerized cerebral behavior therapy (CCBT).
cNon applicable (North/A).
dThe review included 12 papers regarding nine studies. Of these nine studies, five were regarding adults, i regarding tertiary students, and three regarding children/secondary schoolhouse students. Gender breakdown varied across studies.
eGeneral practioners (GPs).
fParticipants from this study were a subset of Kay-Lambkin et al 2011 [].
chiliadMean age for this subsample was unavailable.
Efficacy
Three papers, regarding two trials, reported clinical efficacy data disaggregated by location [,,]. All found no difference in the treatment response to CCBT for low and feet betwixt rural and urban participants. Another written report, conducted entirely with rural participants, found that CCBT led to meaning improvements in anxiety and low [].
1 schoolhouse-based study found that rurality predicted loftier adherence to CCBT among adolescents, and that higher adherence led to greater reductions in depression and anxiety []. However, of the iv trials with children/young people, none disaggregated efficacy information by rural/urban location. Furthermore, while the review past Griffiths and Christensen included studies reporting the efficacy of CCBT for both children/young people and adults, none of their included studies disaggregated the data by location []. Information technology is, therefore, not possible to identify patterns regarding the interaction of rural location, age, and efficacy from the studies included in this review.
Uptake and Referral
The included studies did not consistently report rates of uptake, in several cases due to retrospective report designs. The study in rural Scotland institute that 24% of people referred to CCBT declined to undertake the handling []. In Kay-Lambkin and colleagues' trial [], less than ix% (54) of 617 participants assessed for eligibility refused to participate. Notwithstanding, the rate of uptake in this trial was still only 44% of the original participants assessed—twoscore% were excluded as they did non meet inclusion criteria and a further 7% did not nourish their first assessment.
The included systematic review [] constitute that, of spontaneous users of the CCBT program MoodGYM worldwide, 20.5% were from rural and remote areas. In further support of its acceptability among rural mental wellness patients, Kay-Lambkin and colleagues reported that nigh half of their sample self-referred to CCBT [].
General practitioners (GPs) have an important role in connecting patients to CCBT in rural communities. Rural participants are more likely to have been referred to CCBT by their GPs than urban participants—23% versus 2% referred by a GP, respectively (P<.001) []. Hayward and colleagues' trial in rural Scotland also relied on GPs to connect patients to CCBT []. The written report reported that CCBT was highly adequate amid GPs in regard to suitability for provision to rural and remote patients.
Adherence/Compunction
The included studies reported mixed findings in regard to adherence and attrition rates among rural versus urban participants, though they near normally reported rural participants to be equally probable, if not more likely, to adhere to CCBT treatment.
Two studies with developed participants compared rates of adherence by location. Kay-Lambkin and colleagues found that rurality did not affect retentiveness []. In contrast, Mewton and colleagues found that rural participants were significantly less probable to complete CCBT, with urban participants almost twice as probable to complete the full course []. The two studies with adolescents that compared adherence outcomes by location both found that rural residence predicted significantly greater adherence to the MoodGYM program [,]. Lack of availability of alternative services, greater motivation of supervising staff members, or a preference for health self-management in rural participants are potential explanations for this [,,]. shows the efficacy and acceptability outcomes of the studies.
| Report | Uptake | Adherence | Other acceptability | Clinical upshot |
| Calear et al 2013 [] | Due north/Aa(school based) | Rural had greater adherence (P=.01). | N/A | Non disaggregated by location. |
| Cheek et al 2014 [] | N/A | N/A | New Zealand program adequate to rural Australian youth; design important. | Due north/A |
| Griffiths & Christensen 2007 [] | 20.five% spontaneous users worldwide rural/remote | N/A | Should consider tailoring content. May not be suitable for learning styles of rural participants. | Both programs examined led to improvements in mental health, knowledge, and attitudes to mental health. |
| Hayward et al 2007 [] | 89 referred; 13 unsuitable; 21 refused; 55 passwords issued (62%) | 26 completed (47% of participants who received passwords) | 97% satisfied with help received. GPs feel demos of program could increment referrals by GPs. | Meaning improvement in depression and anxiety (P<.001). |
| Kay-Lambkin et al 2011 [] | 617 assessed; 244 unsuitable; 54 refused; 274 randomized (44%); 260 began | 86 (33% of starters) received all sessions; 163 (63% of starters) completed iii-calendar month follow-upwardly. | N/A | No significant effect of rurality on effectiveness: depression (P=.seventy) or substance utilise. Therapist and CCBT equally effective for low (P=.02). |
| Kay-Lambkin et al 2012 [] | Northward/A: 3-month follow-upward information | Rurality did not affect attendance or therapeutic alliance. | Rurality did not bear upon preference for therapist/ computerized delivery. Rural less likely to want more therapist contact—18% vs 48% urban. | Rurality did not influence treatment response. |
| MacGregor et al 2009 [] | 89 referred; 13 unsuitable; 21 refused; 55 passwords issued (62%) | N/A | Content acceptable to rural/remote participants. Modest changes may be beneficial. | N/A |
| Mewton et al 2012 [] | N/A | 55.1% completion; rural had poorer adherence (P<.05). Urban ane.8 times more probable to consummate. | N/A | Significant reduction in anxiety and psychological distress; improved quality of life (WHODASb) (all P<.001). |
| Neil et al 2009 [] | Due north/A | Rural had greater adherence: whole sample (P=.01), school sample (P<.001). | N/A | N/A |
| Sethi 2013 [] | 103 assessed; 89 eligible and randomized (86%) | 100% completed (assume none rural as not reported) | Unsuitable for people with low literacy. | N/A, equally location of participants not reported. |
| Sunderland et al 2012 [] | N/A: data from completers simply | Northward/A | N/A | Rurality did not influence treatment response: depression (P=.83), anxiety (P=.77). |
aNon applicable (N/A).
bWorld Health Organization Inability Assessment Schedule (WHODAS).
Other Measures of Acceptability
There is some testify to suggest that, on completion, CCBT was considered to be more acceptable to rural than to urban adult participants. In one study, rural participants were more likely to report that CCBT had helped them with their depression and substance utilize—92% versus 75% of urban participants []. Furthermore, fewer rural CCBT participants reported wanting more than face-to-face contact equally compared with urban participants—xviii% versus 48%, respectively. Hayward and colleagues found that 97% of their rural (whole) sample was satisfied with the back up provided through CCBT [].
Studies with both young people and adults institute that privacy when accessing mental health services was of great importance to rural participants. For example, Cheek et al [] found that visibility and confidentiality when accessing services, likewise as attitudes of health professionals, were barriers to immature people accessing mental wellness services in a small rural town in Australia. They also found that the opportunity to complete CCBT in individual was an highly-seasoned feature of the treatment. In another study, two-thirds of the rural adult participants missed therapist contact, and yet ii-thirds also felt that the benefits of CCBT included increased autonomy and confidentiality [].
Risk of Bias
A gamble of bias cess was conducted for all studies, with the exception of the systematic review. Overall, the hazard of bias was moderate. This is consistent with a large review of the broader CCBT show by Grist and Cavanagh [], which establish an overall moderate risk of bias across 49 studies. Information technology also established that risk of bias was unlikely to influence upshot sizes in the included studies.
Across the RCTs included in this review, the risk of bias was rated as low for ii studies [,], and moderate for 2 studies [,]. Baseline differences across treatment groups, and between completers and noncompleters of outcome measures, were the primary sources of potential bias. Of the quasi-experimental studies, the take a chance in 1 study was unclear due to insufficient information on several variables [] and moderate in another [], due to low numbers of participants completing the consequence measurements. The three other studies were rated as likely to exist at low risk of bias [,,].
The qualitative study by Cheek and colleagues [] was rated as at moderate adventure of bias. Due to its size and scope, replication of the study in varying locations would be valuable to farther sympathize the generalizability of the findings.
Across the included studies, strict participant option criteria in several may limit the generalizability of their findings. Withal, a number of the studies included groups of participants who are otherwise oft excluded, such as youth and people with severe symptoms or comorbidities. We believe this goes some way toward balancing this limitation.
A number of studies in the broader CCBT literature have found evidence of a publication bias. Studies reporting negative findings are less likely to exist published [,,]. In this review, publication bias is also a existent possibility, given that nosotros identified and included only published data.
Word
Overview
Computerized CBT can exist clinically constructive for the prevention and treatment of anxiety and depression, and offers a valuable alternative to traditional face-to-face delivery. This may be particularly pertinent to the delivery of services in underresourced and otherwise underserved communities.
Efficacy and Acceptability
We located eleven studies that begin to identify the feasibility of CCBT in rural and remote communities. Nonetheless diversity in study designs, participants, software packages, styles, and locations of delivery, the studies indicate that CCBT has equal effects for urban and rural participants. Furthermore, they support the effectiveness of CCBT in real-earth rural clinical do and community settings, with all included trials conducted in school, university, community, or clinical (ie, online mental wellness or GP clinic) sites.
The included studies betoken that rurality is unlikely to accept a negative affect on uptake or adherence. Among the wider CCBT evidence base, depression uptake has been identified as a key barrier to implementation, with an average of 12% of participants offered CCBT commencing handling [,,]. The rates of uptake amidst several studies included in this review were much higher—44% and 56% in studies by Kay-Lambkin et al [] and Hayward et al [], respectively. Importantly, these studies included patients with comorbidities and had minimal inclusion criteria, respectively.
Satisfaction and acceptability are generally high amid people who undertake CCBT. Acceptability increases significantly one time patients take received a demonstration or take undertaken the handling [,,,]. Kay-Lambkin et al showed that treatment preference fulfilment—computerized versus therapist delivered—had a greater impact on adherence for rural versus urban participants []. Furthermore, changes in depression were significantly associated with treatment preference fulfilment across their whole sample. Fostering understanding and promoting the credibility of CCBT prior to implementation in rural areas may profoundly improve its acceptability, uptake, and reach.
This review provides show to support a number of the causeless benefits of CCBT for rural populations, including its ability to overcome barriers that take traditionally limited access to mental health services. For example, studies in both Commonwealth of australia and Scotland found that the ability to complete CCBT privately helped minimize confidentiality concerns and stigma regarding accessing mental health services [,]. Furthermore, the delivery of CCBT does non rely on a preponderance of trained therapists, and even guided versions crave considerably less therapist time than contiguous CBT [,,]. Staff who are non trained mental health practitioners are able to provide the guidance required by some CCBT programs without significantly reduced clinical result [,,,].
Opportunities and Challenges for Rural Implementation
Computerized CBT has the potential to complement the inadequate numbers of qualified mental health professionals in rural communities. Implementing CCBT inside the existing service mural equally a "offset response" handling may be advisable. Within such a model, all patients would kickoff exist offered CCBT, with therapist fourth dimension reserved for those who do not respond well, or require further or more intensive therapies [,]. This could alleviate pressure on trained therapists and ensure their services are available to those most in need. A study in the United kingdom [] found that 19% of participants required referral to a therapist on completion of CCBT. These patients then required, on boilerplate, but iii.5—compared with the usual fifteen—sessions of CBT with a therapist. Combining therapist and calculator-delivered CBT has also been shown to be a particularly constructive method for treating feet and depression among adolescents and similarly reduces the therapist time required to treat each patient [,].
More than inquiry is needed into the feasibility of delivering CCBT across varying geographical and demographic sites and groups. Understanding local barriers to uptake and adherence, and solutions to these, volition be crucial, as they are probable to vary between towns, regions, and countries.
The extent to which content needs to exist tailored to rural users' location and age also requires further study. Computerized CBT packages may benefit from being tailored to more accurately reflect the concrete nature of the rural context [], or in line with different learning styles or education levels [,]. Notwithstanding, Cheek and colleagues institute that a program adult in New Zealand was acceptable to youth in a rural Australian town [], suggesting the possibility of translation of CCBT programs across locations without pregnant alterations.
Limitations
Despite the apply of a systematic methodology, it is possible that some studies take been missed. While some mitt searching and pearling was conducted, not every reference list of identified reviews and studies was searched. Furthermore, no unpublished findings were included in the review and it is, therefore, at run a risk of publication bias.
Inclusion criteria were limited to studies that addressed generalized and social anxiety disorders, depression, or several types of anxiety disorders concurrently. CCBT for private phobias, posttraumatic stress disorder, and postnatal low were excluded, although such studies could hold valuable insights to inform the wider awarding of CCBT. Furthermore, CCBT has been used for 25 different clinical disorders [], not only mental health conditions [-]. To ensure that its full potential is realized, a similar review into the efficacy and acceptability of CCBT for other conditions in rural and remote areas would exist valuable.
The studies identified were predominantly Australian, with 2 from Scotland. The conclusions and recommendations drawn are, therefore, particularly relevant to the Australian context. The authors believe, however, that given the like challenges faced across the earth in providing evidence-based mental health to rural communities, these findings can be expected to be relevant to English-speaking countries more broadly.
Conclusions
At that place is a strong focus on workforce development in rural health inquiry and provision. Withal rural and remote communities, globally, continue to face up pregnant challenges in attracting specialist health professionals, highlighting the need for alternative models of delivering evidence-based intendance. The studies that we reviewed provide initial show that CCBT could be a valuable tool for increasing the accessibility of psychological therapies in rural and remote communities. It is likely to be effective and acceptable amid rural participants and practitioners.
In the hereafter, practitioners need to be supported to understand and refer clients with detail needs to appropriate evidence-based CCBT programs. Workforce development programs at university level and beyond demand to prepare the workforce to appreciate the potential of CCBT. Demonstration of CCBT packages aimed at both users and practitioners may be an important action to build acceptability and trust in rural communities and to ensure that the therapy is accessed by those who need it.
Future inquiry is required to analyze the findings of this review, given the relatively small number of studies identified and the small number of countries represented. Models of CCBT delivery that piece of work within existing health systems and fill service gaps need to be developed and tested in varied rural and remote environments and countries.
Authors' Contributions
MJ conceptualized the study. KV developed the search strategy with aid from MJ and Academic Research Librarian, Carole Gibbs. KV conducted the database searches. MJ, KV, and CO conducted the starting time round of citation screening and extracted data from included studies. KV conducted the second phase of screening with input from MJ. KV wrote the majority of the paper with significant input and revisions by MJ and CO.
Conflicts of Interest
None declared.
Abbreviations
| CBT: cognitive behavior therapy |
| CCBT: computerized cognitive beliefs therapy |
| GAD: generalized anxiety disorder |
| GP: general practitioner |
| Grade: Grades of Recommendation, Assessment, Development, and Evaluation |
| IPT: interpersonal therapy |
| OCD: obsessive compulsive disorder |
| PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analysis |
| RCT: randomized controlled trial |
| WHODAS: World Wellness Arrangement Disability Assessment |
Edited past Thou Eysenbach; submitted 14.12.xiv; peer-reviewed by I Mindlis, L Mclellan; comments to writer 19.03.15; revised version received 15.04.15; accepted 27.04.15; published 05.06.15
Copyright©Kari Dee Vallury, Martin Jones, Chloe Oosterbroek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 05.06.2015.
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