This document summarizes research on internet and therapist-supported substance use treatment programs. Studies found that internet-based programs alone can significantly reduce substance use, though some participants prefer face-to-face support. An alcohol and depression trial found that adding a therapist to an internet program significantly increased the number of logins and percentage of the program completed. Further research is still needed to fully understand how therapist support impacts engagement and retention in internet-based treatment programs.

1. OnTrack substance use programs David Kavanagh Jennifer Connolly Dawn Proctor Leanne Hides Steven Edge Jeremy Gibson Institute of Health & Biomedical Innovation Queensland University of Technology Britt Klein Swinburne University of Technology Frances Kay-Lambkin, Judy Proudfoot University of NSW Angela White University of Queensland August, 2011

2. Our programs based on Successful studies using mailed treatments Pre-Post SD units Full Info/Monitoring .85,.85,.88 .65,.50,.49 (Diff .20-.39) Internet trials by others (vs. controls) College samples (mainly normative feedback, preventive) .13 -.17 (Diff .30 Riper et al. (2007) community sample .69 .13 (Diff .56) Our research with potential users

3. Internet survey (n = 3008) Important web features Easy navigation/search Open access Right amount of information Easy to understand language Does not require extra software Interesting pages Trustworthy

4. Likely use Portal giving advice on websites Online tests/self-assessments with feedback Downloadable fact sheets Systems tailoring information to user Observation of free search—max 6.5 min on a site Less if young not 1st site (2 min)

5. Implications Rapid access to key elements and within program, a strong initial module Screening, feedback, information without login Self-tailoring, self-pacing within the program but with advice on order, pace Attractive, easy to use Minimised text entry; pictorial icons Brief videos to explain concepts Summary pages to refer to Diary, progress summaries

11. Current OnTrack programs Alcohol Alcohol & Depression Depression (recurrences) Get Real—psychosis-like experiences Family & Friends

12. app to track drinking

13. Coming soon... Drug diversion (practitioner-assisted) Substance use program for clients “Say when” (binge drinking) for Better Health Channel Indigenous version of alcohol/drug program Likely Substance use tools for CRC Youth Health & Wellbeing

14. Usage >35,000 Australian visits over 1st 20 months 5.2 pages/visit; 5.0 min 2299 users; 1314 in alcohol programs They do come back to the programs Alcohol: Brief Full # logins: 10.4 16.4 ns Duration of use (days) 42.6 69.6 <.10 Alcohol + Depression Brief Full # logins: 7.8 10.6 ns

15. What do they use?Alcohol & Depression studyMost frequent “Signpost” /6 and Tool 1 Making Plans Introduction 0 Welcome To OnTrack 1 Deciding What to Do 1 Monitoring 1 Feeling Confident 1 Building My Support Team 1 Making a Plan 1 Planning tool 2 First Steps Introduction 1 Making Plans Feedback 2 Mindfulness Intro 1 Making Plans Summary 2 Activities I Enjoy 2 Mindfulness Practice 2 Mindfulness Sensations 2 Fun Activity Planning 2 What I've Got Already 3 Closing a Risky Track Introduction

16. So…don’t choose to do allAre they correct?

17. Alcohol pilot trial (n = 56)Abstinent Days/Wk Time Time x Gender

18. Drinks per week Time Time x Gender

19. Days/week over 6 drinks Time Time x Gender Time x Gender x Condition

20. For greatest reach: Internet only

21. Internet survey (3008) If a problem with alcohol, would want Internet only 19% Therapist support + internet 18% telephone 22% face-to-face 35% email

22. Similar responses from 9 focus groups Cautious, somewhat negative re internet treatment Impersonal Skeptical re validity of assessment, effects of treatment Need for ongoing support Positive comments re Initial step—e.g. screening Anonymity Likely to require more motivation

23. …and in interviews with participants of an internet-based alcohol trial I found it hard to get motivated to follow the program being web-based I found it hard doing it on my own I wasn’t challenged if I didn’t do the steps Some sort of external accountability might help Maybe you need to have a face-to-face [element]… I think I’m more of a person that needs more of a one-on-one person…

24. ...and might expect therapists to be important Alliance argued to account for substantial variance in face-to-face treatment outcomes

25. Brands & Kavanagh (in submission) RCTs directly comparing no/less vs. more contact Psychological treatment for a health problem Not solely preventive Contact not solely involving support groups Paper in English Computer not just an adjunct to face to face Not confound between contact/other elements Presented sufficient data for analysis Prior to December 2010

26. Low vs. high contact

27. Alcohol and Depression trial Brief intervention based on Motivational interview—pros & cons, self-efficacy Building social support Concrete goal, plan Full intervention Wide range of CBT, mindfulness elements Full intervention + therapist/coach Regular emails, modified according to progress/issues

28. Current data suggest-no effect of therapist-brief initially not as effective, but catches up

29. Since a therapist is preferred by usersdoes it aid retention in program?

30. Alcohol & Depression (n = 203) Full program: No therapist Therapist Number of logins 10.6 15.4* % program completed 27% 41%

31. Need to examine further, whether impacts on initial engagement impacts on retention when going badly more important if depression is higher there are better ways to boost coaches’ impact preference, expectancies are modified by marketing

32. Some strategies flow from epidemiology Co-occurrence is common Often complex problems Similar risk factors to rest of population Substantial impact on mortality, symptoms, functioning In severe disorder, may have symptomatic impact from small amount Substances compound any cognitive effects of disorder