Examining Beating the Blues, comprising of: 'The effectiveness and acceptability of Beating the Blues computerised cognitive behaviour therapy programme: a systematic review'; and, 'Beating the Blues: engagement, attrition and clinical outcomes of a computerised cognitive behaviour therapy programme and the impact of COVID-19.'
INTRODUCTION: There is a high prevalence of common mental health disorders globally. Although effective treatments exist, there are several barriers to accessing these interventions. Digital mental health interventions (DMHI) have been developed over the last few decades as a way of addressing these barriers and increasing accessibility to evidence-based therapeutic interventions. Beating the Blues (BtB) is a longstanding computerised Cognitive Behaviour Therapy (cCBT) programme that has been used extensively in the United Kingdom (UK). Although cCBT programmes have been shown to be effective, there are high attrition rates and evidence around acceptability of these programmes is inconclusive. Further research is needed to understand engagement and attrition of DMHI. The COVID-19 pandemic has been a unique context to explore this. In addition to the impacts on mental health, the subsequent restrictions resulted in rapid changes to mental health service delivery and an increased reliance on digital interventions. Given the unprecedented nature of the pandemic, it is unclear how the COVID-19 pandemic impacted mental health as well as engagement and attrition from DMHI. This thesis aimed to explore the existing evidence around BtB in terms of effectiveness and acceptability. It further aimed to evaluate attrition, engagement and clinical effectiveness of BtB and the impacts of COVID-19 on these factors. METHODS: The first chapter of the thesis portfolio involved conducting a systematic review of the evidence for the effectiveness and acceptability of BtB. Publication databases and grey literature were searched, and 23 studies were included. A narrative synthesis was conducted. The second chapter of the thesis portfolio involved conducting an empirical study using routine data from n=4517 referrals to a cCBT service using BtB. The data was statistically analysed to explore associations of uptake, registration, attrition, and clinical effectiveness. The impact of COVID-19 on these variables was examined through grouping the sample pre and during COVID-19. MAIN FINDINGS: The results of the systematic review indicated that BtB is effective at reducing symptoms of depression and overall psychological distress across contexts, populations and settings. The findings were inconclusive for the treatment of anxiety. There was some limited evidence for the effectiveness of BtB in relation to secondary outcomes measures. The evidence for acceptability of BtB was mixed and the methodologies tended to be less rigorous than effectiveness studies. Variable attrition rates were noted but tended to be higher in naturalistic settings than experimental settings. Programme and participant characteristics associated with acceptability were discussed. The results of the empirical research found that BtB was effective at reducing symptoms of anxiety and depression pre and during COVID-19. In line with review findings, the attrition rates were high. Participants had significantly higher baseline levels of depression during COVID-19 and engaged more with the programme during this time than pre COVID-19. Younger age and higher baseline levels of depression significantly predicted attrition. These models, however, had limited predictive power and there are likely to be other unknown factors contributing to engagement and attrition. CONCLUSIONS: The systematic review and empirical research found that BtB is an effective intervention, particularly in relation to treatment of depression. Engagement and attrition, however, pose a barrier to the implementation of these programmes. Strengths and limitations of the review and study were discussed. As a longstanding DMHI, the evidence from BtB has significant implications for informing DMHI research and ongoing clinical practice. There continues to be a lack of consensus around predictors of attrition and how acceptability of DMHI influences engagement and attrition. Further research is needed with use of more nuanced forms of data, to fully understand these factors.