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Testing the Differential Impact of an Internet-Based Mental Health Intervention on Outcomes of Well-being and Psychological Distress During COVID-19: Uncontrolled Intervention Study

Sep 15, 2021

February 20, 2021 . Testing the Differential Impact of an Internet-Based Mental Health Intervention on Outcomes of Well-being and Psychological Distress During COVID-19: Uncontrolled Intervention Study Testing the Differential Impact of an Internet-Based Mental Health Intervention on Outcomes of Well-being and Psychological Distress During COVID-19: Uncontrolled Intervention Study Authors of this article: 2Órama Institute for Mental Health and Wellbeing, Flinders University, Adelaide, Australia 3College of Education, Psychology and Social Work, Flinders University, Adelaide, Australia 4College of Nursing and Health Sciences, Flinders University, Adelaide, Australia 5Health Counselling & Disability Services, Flinders University, Adelaide, Australia 6Adelaide Nursing School, Adelaide University, Adelaide, Australia Corresponding Author: North Terrace Abstract Background: During COVID-19, the psychological distress and well-being of the general population has been precarious, increasing the need to determine the impact of complementary internet-based psychological interventions on both positive mental health as well as distress states. Psychological distress and mental well-being represent distinct dimensions of our mental health, and congruent changes in outcomes of distress and well-being do not necessarily co-occur within individuals. When testing intervention impact, it is therefore important to assess change in both outcomes at the individual level, rather than solely testing group differences in average scores at the group level. Objective: This study set out to investigate the differential impact of an internet-based group mental health intervention on outcomes of positive mental health (ie, well-being, life satisfaction, resilience) and indicators of psychological distress (ie, depression, anxiety, stress). Methods: A 5-week mental health intervention was delivered to 89 participants using the Zoom platform during 2020. Impact on outcomes of distress, well-being, and resilience was assessed at the start and end of the program with multiple analysis of variance (MANOVA) and reliable change indices (RCIs) being used to determine program impact at the group and individual levels, respectively. Results: The intervention significantly improved all mental health outcomes measured, (F6,83=5.60, P<.001; Wilks Λ=.71; partial η2=.29) showing small to moderate effect sizes on individual outcomes. The largest effect sizes were observed for life satisfaction and overall well-being (η2=.22 and η2=.2, respectively). Larger effect sizes were noted for those with problematic mental health scores at baseline. A total of 92% (82/89) of participants demonstrated reliable change in at least one mental health outcome. Differential response patterns using RCI revealed that more than one-half of the participants showed improvement in both mental well-being and psychological distress, over one-quarter in outcomes of well-being only, and almost one-fifth in distress only. Conclusions: The results provide evidence for the significant impact of an internet-based mental health intervention during COVID-19 and indicate the importance of assessing dimensions of both well-being and distress when determining mental health intervention effectiveness. JMIR Ment Health 2021;8(9):e28044 0.68 aProblematic scores refer to scores where participants did not meet the cut-off for high well-being, normal resilience, or no presence of distress. Discussion This study demonstrated that an internet-based mental health program could elicit differential change in outcomes of mental well-being and psychological distress in a nonclinical population during COVID-19. Results demonstrated that mental health outcomes in the sample improved from the beginning to the end of the intervention and that participants with poorer baseline scores had a significantly better response compared to those with greater average baseline scores. Furthermore, the results highlighted that reliable change in outcomes of mental well-being and psychological distress could occur independently, with type of distress (depression, anxiety, stress) resulting in differential response patterns. The results here bolster the evidence that internet-based interventions can play a significant role in dealing with the mental health consequences of the pandemic [ 60 , 61 , 85 , 86 ]. This intervention was delivered over internet-based teleconferencing software using trained professionals outside of a clinical setting. The training, which focuses on promoting mental health, not the specific treatment of mental illness, was designed to be able to be delivered without the reliance on clinical staff. This approach of upskilling nonclinical staff to deliver mental health training has successfully been utilized by our team before and facilitates scalability and reach of the solution [ 87 , 88 ]. Mental health systems are typically under-resourced, which has further deteriorated during COVID-19, fueling calls for innovative solutions as the one presented in this article, particularly those that safeguard ethical principles [ 85 , 89 ]. Finding positive results for interventions that aim to promote mental health in both outcomes of well-being and distress in a general population under duress makes for promising standalone first-line interventions or as solutions to deal with existing system issues (eg, waitlists) [ 18 ]. While the significant impact of the intervention in a general nonclinical population was promising, the use of the term “nonclinical” warrants attention. This term mainly reflects the inclusion criteria rather than an actual lack of clinical symptoms among participants. As may be expected, the majority of participants did in fact show mild symptoms of distress (53/89, 60%). This proportion, at first glance, may appear higher than typically reported in the general population, such as the frequently cited “one in five who are struggling with symptoms of a common mental disorder” [ 90 ]. This increased rate may partly be attributed to the result of the pandemic but may also be explained by the fact that our sample stemmed from 2 different population pools: the general adult population and tertiary university students. Previous studies have demonstrated that mental health outcomes in students are worse across many domains than in the general population [ 51 , 91 , 92 ], which was supported in our study. These findings first elicit the need to thoroughly investigate and improve the mental health of, demands on, and lifestyle of our tertiary students [ 93 ], but second, highlights an area that requires the attention of researchers who may use student cohorts for their mental health research and wish to compare their findings to a sample of the general population. The findings support previous research indicating that improvements in distress do not automatically result in improvements in well-being and vice versa. Similar to the findings by Trompetter et al [ 68 ], this study showed that, while participation in the intervention led to overall improved mental well-being and reduced psychological distress, not every individual improved in both domains. These results provide an additional piece of evidence that supports the independence of outcomes for mental well-being and mental disorder [ 27 ]. As research by dual-factor model scholars such as Keyes [ 24 ] and Greenspoon and Saklofske [ 53 ] proposes, the ultimate end goal of our mental health care system ought to strive for “complete” states of mental health, that is states of high well-being and no distress or symptoms of mental disorder in as many people as possible. This indeed would be the expectation if we were to deliver mental health care that lived up to and met the contemporary definitions of mental health such as the one posited by the World Health Organization [ 1 ]. Results here show though, that in order to meet this aspirational international standard, it is critical to systematically measure both outcomes of well-being as well as psychological distress when assessing the impact of psychological interventions in research and practice [ 27 ]. The difference in intra-individual responses between psychological distress types furthermore points to the complex relationship between states of well-being and distress and their outcome measures [ 25 ]. Most participants who showed changes in depression had simultaneous improvements in well-being outcomes, which was not the case for anxiety or stress. A possible explanation for these patterns of change points to the inherent similarity between the construct of depression and happiness [ 29 ]. For instance, evidence for dual-factor models is less convincing for people with severe depression [ 94 ], and these models do not work as well when outcome measures specifically take advantage of the emotion of “happiness” or other affective states of hedonic well-being. In the data presented here, even the moderate correlation (r=.5) between the measure of life satisfaction (SWLS) and general well-being (MHC-SF), which captures the factors of hedonic, eudemonic, and social well-being, shows that these 2 well-being measures vary substantially. Therefore, it is essential to carefully consider the most appropriate measure when assessing the impact of interventions or treatment modalities, as this decision has consequences for the perceived impact of the intervention in both types of outcomes [ 95 ]. Our finding that effect sizes were higher for people meeting the threshold of psychological distress or low well-being is encouraging. In addition to providing insight into the impact of interventions for individuals with different states of mental health, promoting the importance of baseline mental health on interventions has practical implications for treatment models. There is an ever-increasing burden of mental health problems, with mental health systems around the globe feeling the strain [ 96 , 97 ]. Advocates of change have long been calling for new solutions to help support the provision of complementary services and group-based mental health interventions that can be delivered online and in person. The Be Well Plan program offers a solution that can be implemented to ameliorate current system pressures, complementing other accessible solutions such as low-intensity cognitive behavioral therapy [ 98 , 99 ]. Consequently, it is important to determine an effective model of universal programs that have the greatest impact on mental health outcomes, while reducing the burden of disease. While more research is needed to understand the particular effectiveness of each program component on different mental health outcomes [ 73 ], our findings support the need to improve and innovate lower tiers in evidence-based, stepped-care models or stimulate a stronger focus on well-being within integrated care models [ 100 , 101 ]. This research has limitations requiring comment. First, the results stem from an uncontrolled study, which means that the evidence is not conclusive in supporting the efficacy of the intervention. The intervention was delivered in response to the immediate mental health demands in the community during the pandemic; therefore, the team made a conscious call to deliver the intervention to anyone who signed on immediately, rather than randomize them into waitlists. This design limitation, however, does not impact the validity of the findings, as a core aim of the study was to explore a within-subject change design. That said, it is important to compare and verify reliable change between an active intervention and a comparable control condition in future studies. Uncontrolled studies, for example, do not account for various confounding factors (eg, the impact of extraneous events and lifestyle factors). In this case, the study was conducted while the COVID-19 pandemic was ongoing, which could have had a significant impact on mental health outcomes during this extraordinary period [ 45 ] and therefore would have impacted the results one way or the other. Second, the results presented only refer to short-term outcomes, clearly warranting the need to examine long-term changes. For instance, improvement in well-being has been shown to be associated with long-term recovery of mental disorder in observational studies [ 31 ]. It is hypothesized that well-being may therefore be a therapeutic focus for long-term (symptom) recovery [ 18 ], but a rigorous body of research intervention studies is yet to be established [ 27 ]. Third, the current results apply to a general population cohort; extrapolation to clinical populations should be used with caution. Although the sample did include participants that showed higher distress levels, the presence of psychological symptoms does not equal the presence of disorder, which requires assessment using different outcome measures [ 5 ]. The results presented by Trompetter and colleagues [ 68 ], however, did apply to clinical populations and therefore pose a reference point for those working in the clinical area. A fourth and similar limitation lies in the specificity of our outcome measures. This study used a general measure of distress implying that the results should not be generalized to determining the impact on explicit symptoms of mental disorder [ 102 ]. The current results only refer to the differential changes in well-being and distress, demonstrating that changes in outcomes of mental well-being and psychological distress do not automatically go hand in hand after participation in a mental health intervention. Both outcomes should be considered and assessed when investigating the impact of psychological interventions and changes in mental health outcomes. Finally, the study did not collect in-depth data on intervention usage, which means the study is limited in being able to talk to the fidelity of the training or its short- or long-term use by the participants. This will be an important focus area for future studies on the Be Well Plan. To conclude, this study provides evidence for the impact of an internet-based mental health intervention during a period of significant community need. The intervention resulted in improvements in both participant mental well-being and psychological distress. After analyzing within-individual effects of the program, a differential response pattern was observed, indicating that improvement in mental well-being and reduction in psychological distress were not necessarily congruent. This indicates the importance of assessing dimensions of both well-being and distress when determining intervention effectiveness, which in the case of the Be Well Plan, added evidence to the impact that internet-based mental health promotion interventions can have generally and during times of societal distress such as pandemics. Acknowledgments The author team would like to acknowledge the contributions of South Australian Health and Medical Research Institute staff members including Monique Newberry, Marissa Carey, Kim Seow, Stuart Freebairn, and Laura Lo. Conflicts of Interest The South Australian Health and Medical Research Institute, which employs JvA and MI, receives financial compensation from providing the Be Well Plan to organizations and the community. 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