Abstract
BACKGROUND: Blended care therapy models are intended to increase the efficiency and effectiveness of evidence-based psychotherapy by combining synchronous and asynchronous components of care. OBJECTIVE: This retrospective cohort study evaluated the clinical effects of synchronous video therapy sessions and asynchronous guided practice session elements on anxiety and depression in a blended care therapy program, with a novel focus on asynchronous provider feedback messages. METHODS: Participants were adults (N=33,492) with clinical symptoms of anxiety (Generalized Anxiety Disorder 7-item scale [GAD-7] score of ≥8) and depression (Patient Health Questionnaire 9-item scale [PHQ-9] score of ≥10) at intake. Symptom trajectories were evaluated via individual growth curve models. Time-varying covariates evaluated effects of synchronous video session attendance and the presence or absence of each asynchronous guided practice session element occurring within 7 days and 8-14 days prior to each clinical outcome assessment. Guided practice session elements included client digital lesson completion, client digital exercise completion, and feedback messages sent by providers. RESULTS: Approximately 86.6% (29,012/33,492) of clients met criteria for clinical improvement by end of care (median 6, IQR 4-8 synchronous sessions). Synchronous video session attendance and client digital lesson completion in the past 7 days and in the past 8-14 days were each uniquely and significantly associated with lower GAD-7 scores (video session effects: b(session7)=-0.82, b(session8-14)=-0.58, P values<.001; digital lesson effects: b(lesson7)=-0.18, b(lesson8-14)=-0.26, P values <.001) and PHQ-9 scores (video session effects: b(session7)=-0.89, b(session8-14)=-0.67, P values <.001; digital lesson effects: b(lesson7)=-0.12, b(lesson8-14)=-0.30, P values <.001). Client digital exercise completion in the past 8-14 days was significantly associated with lower GAD-7 scores (b(exercise8-14)=-0.10; P<.001) but exercise completion in the 7 days prior to clinical outcome assessment was not (b(exercise7)=0.00; P=.89). Exercise completion in the past 7 days was significantly associated with lower PHQ-9 scores (b(exercise7)=-0.16; P<.001) but exercise completion in the past 8-14 days was not (b(exercise8-14)=-0.05; P=.09). Provider feedback messaging in the past 7 days and in the past 8-14 days was significantly associated with lower GAD-7 and PHQ-9 scores, respectively (GAD-7: b(feedback7)=-0.12, P<.001; b(feedback8-14)=-0.07, P=.004; PHQ-9: b(feedback7)=-0.15, P<.001; b(feedback8-14)=-0.08, P=.01). CONCLUSIONS: Provider feedback between synchronous therapy sessions provided significant benefit for symptom reduction, beyond the effects of client digital engagement and synchronous video sessions. When guided practice sessions are well integrated into care, blended care therapy provides meaningful improvements upon the traditional, synchronous session-only therapy model. Provider guidance and feedback for clients between synchronous sessions support more efficient and effective mental health care overall.