IntroductionBlended therapies (BT) combine face-to-face (f2f) sessions with internet- and mobile-based interventions (IMIs). However, the use of blended interventions in routine care is still rare and depends on the acceptance of key health care professionals such as the therapists. Little is yet known about the therapists' perspective on and experiences with blended approaches. The aim of this pilot study was to identify barriers and facilitators, as perceived by psychotherapists, for implementing a blended therapy for depression.MethodsSemi-structured expert interviews were conducted with five therapists, who were part of the German study arm of the FP7-project E-Compared (www.e-compared.eu). All patients (N = 173) were treated in the context of a registered RCT (DRKS00006866) in which the clinical and cost-effectiveness of BT for depression, consisting of ten internet- and mobile-based cognitive behavioral therapy modules and six f2f sessions, was compared to the treatment usually provided by general practitioners. To identify barriers and facilitators an interview guide based on the theoretical domains framework (TDF) was developed. The interviews were audio-recorded, transcribed verbatim and analyzed using a qualitative content analysis by two independent coders.ResultsThe results revealed 29 barriers and 33 facilitators, which are hindering or enabling factors on the levels of ‘implementation in the health care system’, ‘therapy’, ‘therapists’ and ‘patients’. Key barriers stated by all therapists were ‘Limited customizability and autonomy of decisions concerning blending the therapy’ (number of statements, k = 44); ‘Disease-related contraindications for BT’ (k = 25); ‘Negative affect was caused by burden through technical problems’ (k = 18); ‘Limited number of f2f sessions hindered the therapy process’; and ‘Establishment of therapeutic alliance was burdened by technical issues’ (each k = 15). Key facilitators stated by all therapists were: ‘Patients’ interest, willingness and motivation to participate’ (k = 22); ‘Patients' access to online content between f2f sessions and after therapy end’ (k = 20); ‘Preset structure of IMI-part guided the treatment course of BT’ (k = 18); and ‘Effective help with BT in a short time frame’ (k = 15), as well as ‘Reduction of the treatment gap’ (k = 13).DiscussionTherapists supported the implementation of BT for depression. Results indicated the consideration of a wide range of determinants: among others, the possibility of individualizing the treatment; the autonomy of decision making in respect to the ratio and number of online and f2f sessions; the necessity of providing training; the need to develop a concept of embedding BT in the health care system and funding the additional effort; and the use of sophisticated technical solutions.

Background Internet-based Cognitive Behavioural Therapy (iCBT) is found effective in treating common mental disorders. However, the use of these interventions in routine care is limited. The international ImpleMentAll study is funded by the European Union’s Horizon 2020 programme. It is concerned with studying and improving methods for implementing evidence-based iCBT services for common mental disorders in routine mental health care. A digitally accessible implementation toolkit (ItFits-toolkit) will be introduced to mental health care organizations with the aim to facilitate the ongoing implementation of iCBT services within local contexts. This study investigates the effectiveness of the ItFits-toolkit by comparing it to implementation-as-usual activities. Methods A stepped wedge cluster randomized controlled trial (SWT) design will be applied. Over a trial period of 30 months, the ItFits-toolkit will be introduced sequentially in twelve routine mental health care organizations in primary and specialist care across nine countries in Europe and Australia. Repeated measures are applied to assess change over time in the outcome variables. The effectiveness of the ItFits-toolkit will be assessed in terms of the degree of normalization of the use of the iCBT services. Several exploratory outcomes including uptake of the iCBT services will be measured to feed the interpretation of the primary outcome. Data will be collected via a centralized data collection system and analysed using generalized linear mixed modelling. A qualitative process evaluation of routine implementation activities and the use of the ItFits-toolkit will be conducted within this study. Discussion The ImpleMentAll study is a large-scale international research project designed to study the effectiveness of tailored implementation. Using a SWT design that allows to examine change over time, this study will investigate the effect of tailored implementation on the normalization of the use of iCBT services and their uptake. It will provide a better understanding of the process and methods of tailoring implementation strategies. If found effective, the ItFits-toolkit will be made accessible for mental health care service providers, to help them overcome their context-specific implementation challenges. Trial registration ClinicalTrials.gov NCT03652883. Retrospectively registered on 29 August 2018

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Background Blended treatments, combining digital components with face-to-face (FTF) therapy, are starting to find their way into mental health care. Knowledge on how blended treatments should be set up is, however, still limited. To further explore and optimize blended treatment protocols, it is important to obtain a full picture of what actually happens during treatments when applied in routine mental health care. Objective The aims of this study were to gain insight into the usage of the different components of a blended cognitive behavioral therapy (bCBT) for depression and reflect on actual engagement as compared with intended application, compare bCBT usage between primary and specialized care, and explore different usage patterns. Methods Data used were collected from participants of the European Comparative Effectiveness Research on Internet-Based Depression Treatment project, a European multisite randomized controlled trial comparing bCBT with regular care for depression. Patients were recruited in primary and specialized routine mental health care settings between February 2015 and December 2017. Analyses were performed on the group of participants allocated to the bCBT condition who made use of the Moodbuster platform and for whom data from all blended components were available (n=200). Included patients were from Germany, Poland, the Netherlands, and France; 64.5% (129/200) were female and the average age was 42 years (range 18-74 years). Results Overall, there was a large variability in the usage of the blended treatment. A clear distinction between care settings was observed, with longer treatment duration and more FTF sessions in specialized care and a more active and intensive usage of the Web-based component by the patients in primary care. Of the patients who started the bCBT, 89.5% (179/200) also continued with this treatment format. Treatment preference, educational level, and the number of comorbid disorders were associated with bCBT engagement. Conclusions Blended treatments can be applied to a group of patients being treated for depression in routine mental health care. Rather than striving for an optimal blend, a more personalized blended care approach seems to be the most suitable. The next step is to gain more insight into the clinical and cost-effectiveness of blended treatments and to further facilitate uptake in routine mental health care.