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The high incidence and relapse rates of major depressive disorder demand novel treatment options. Standard treatments (psychotherapy, medication) usually do not target cognitive control impairments, although these seem to play a crucial role in achieving stable remission. The urgent need for treatment combined with poor availability of adequate psychological interventions has instigated a shift toward internet interventions. Numerous computerized programs have been developed that can be presented online and offline. However, their uptake and adherence are oftentimes low.
The aim of this study was to perform a user requirements analysis for an internet-based training targeting cognitive control. This training focuses on ameliorating cognitive control impairments, as these are still present during remission and can be a risk factor for relapse. To facilitate uptake of and adherence to this intervention, a qualitative user requirements analysis was conducted to map mandatory and desirable requirements.
We conducted a user requirements analysis through a focus group with 5 remitted depressed individuals and individual interviews with 6 mental health care professionals. All qualitative data were transcribed and examined using a thematic analytic approach.
Results showed mandatory requirements for the remitted sample in terms of training configuration, technological and personal factors, and desirable requirements regarding knowledge and enjoyment. Furthermore, knowledge and therapeutic benefits were key requirements for therapists.
The identified requirements provide useful information to be integrated in interventions targeting cognitive control in depression.
In 2010, 7.4% of the total worldwide disease burden was attributed to mental and substance use disorders, of which depressive disorders accounted for the most disability-adjusted life years [
In this context, research suggests that impairments in cognitive control (eg, [
The idea behind CCT is that performing it activates the prefrontal cortex repetitively, which improves attention and cognitive control (for reviews, see [
Provided the encouraging findings of well-controlled studies using CCT and the potential to reach a wider population of at-risk individuals through Web-based administration, the CCT program needs to be suitable for Web-based administration. The CCT studies presented above used the Paced Auditory Serial Addition Task (PASAT; [
One of the ways to achieve this is by means of
A
This study is a first step in developing a new intervention targeted at RMD individuals as a relapse prevention program, through CCT. To increase uptake and adherence, a user requirements analysis was considered crucial.
The aim of this study was to explore and map the needs and preferences of an RMD sample and an MHP sample. More specifically, we have 4 research questions. Questions 1 and 2 were queries for the RMD population. Questions 3 and 4 were key questions examined in the group of MHPs.
What are the mandatory basic requirements to start CCT?
How can user engagement and adherence to CCT be optimized?
What are mandatory basic requirements to implement CCT in treatment?
How can implementation of CCT in treatment be facilitated?
To receive feedback regarding the aPASAT and the broader platform, a user requirements analysis was conducted. To this end, we organized a focus group for RMD individuals, seeing that this is a cost-effective method for analyzing user requirements [
Five participants were included in this focus group. The sample consisted of 3 men and 2 women, and their ages ranged from 32 to 62 years (mean 48.4, SD 9.9). All had suffered from at least 2 depressive episodes in the past and were in remission at the time of the focus group. Three participants (1 woman) also participated in an RCT study regarding CCT in the previous year [
Six MHPs agreed to be interviewed. All received a psychology degree from a Belgian university. Mean age was 36.7 years (SD 13.1) and ranged between 26 and 65 years. Of the 6 experts, 2 were females. Three participants worked as psychologists, one had recently retired but used to work as a psychologist, one was a researcher who also works as a psychologist with patients, and one was a researcher specialized in electronic and mobile apps for mental health care. The last 2 held a doctoral degree. All participants indicated to have a moderate to high affinity for technology as measured by the short version of the ATS. Participants were recruited via email. We focused on contacting therapists using a cognitive (behavioral) approach, as well as recruiting professionals from different working environments (eg, hospital, private practice, and mental health centers). Participants received an incentive of 15 euros.
Both the focus group and the interviews were recorded on 2 audio recorders, placed at 2 different locations on the table around which everyone was seated. For the aPASAT demo, a standard Dell laptop (Dell Technologies Inc, Round Rock, Texas, USA) running Windows 7 (Microsoft Corporation, Redmond, Washington, USA) was used. The focus group and the interviews had a distinct topic list because these were conducted with different target groups. These lists were created in advance by the first author (JV), based on the research questions, and sent out to 2 coauthors (JVL and EHWK) for adaptation and approval. These lists were not changed during the focus group or interviews, but the order was flexibly adapted. However, all topics were covered.
Participants completed informed consent, a demographic questionnaire, and the ATS. The seating arrangement is illustrated in
Participants completed informed consent, a demographic questionnaire, and the ATS. The interview started with broad, easy-to-answer questions as an icebreaker. After this, the aPASAT demo was presented, and the interview core questions were asked, each followed by probing questions or requests to elaborate. The interviews ended with the incentive. Duration of the interviews ranged from 45 to 90 minutes. Given the busy schedule of interested therapists, the interviews took place at a location of their choice. This resulted in 3 interviews in the work setting, 2 at the faculty, and 1 at home. The interviewer did not have previous interview experience. However, literature regarding interviews was consulted, and 2 test interviews were conducted with researchers, experienced with interviews.
Seating arrangement of the focus group. Karl (K), Jeff (J), Chris (C), Will (W), and Rachel (R) were participants. M, N, X1, and X2 were moderator, note taker, researcher from the randomized controlled trial (RCT) study, and an employee of a game developer company, respectively.
All conversations were recorded, transcribed, and analyzed using NVivo (QSR International, Melbourne, Australia), a software package for qualitative data analysis, using an inductive thematic analytic approach (as described in [
The results are organized in relation to each of the 4 research questions proposed earlier. Furthermore, each section includes a table that reflects the main findings. Finally, some pitfalls and opportunities are added at the end.
When I did the sessions at home, the only time I could complete them was when my children were sleeping and when I asked my girlfriend not to talk for 20 minutes.
Features that might help RMD individuals to adhere to CCT are written down in
I believe you need to be clear, in order to motivate people to keep doing it, to be really clear what it will yield.
Participants further agreed that response-related feedback during training is important. This should ideally be clear, instant, and easy to process (in other words, it should not interfere with the ongoing task). Patients reported that in many contexts, feedback is important to improve task performance, whereby improvement itself can be a motivating element in the words of Karl (male, 32 years old, RMD individual):
The first session, I was searching. The second one, I was cursing. The third one I was cursing some more, but from the fourth session on, I found it agreeable. Why? Because I noticed I was getting better. So, it is fun, to notice your own progression.
Overview of the mandatory requirements for the remitted depressed (RMD) individuals. CCT: cognitive control training. PC: personal computer. FAQ: frequently asked questions.
Category and subcategory | Requirement | Implementation | |
Functionality | Software works, no bugs, no crashes | Develop bug-free CCT | |
Usability | Software should be user-friendly | Easy to use; simple text; visually appealing; available on PC and tablet | |
Skills | Some internet and technical knowledge | State clear expectations; devise good manual; write clear FAQ section | |
Access | Internet connection, device in possession | CCT is compatible with most browsers; both on PC and tablet | |
Time | Not too long and flexible planning of sessions | 15 minutes per session; calendar tool to plan next session | |
Location | Flexible | CCT on an internet website | |
Setting | Calm and private, but not isolated | Including tablets enables users to complete sessions at preferred location | |
Pricing | For free | Available for free |
Overview of the desirable requirements for the remitted depressed (RMD) individuals. CCT: cognitive control training. FAQ: frequently asked questions.
Category and subcategory | Requirement | Implementation | |
Psychoeducation | Knowledge about CCT mechanism and expected outcomes, preferably in an interactive manner | Provide psychoeducation that is clear, simple, and interactive | |
Practical or technical assistance | Practical and technical guidelines regarding CCT and protocol in case of problems | Devise FAQ section; communicate contact options | |
Gamification | Training should be enjoyable, engaging, and challenging, by including feedback and reinforcing messages | Include performance-dependent feedback; include performance-independent stimulating messages; individualize CCT | |
Incentivization | Monetary reward after completing all sessions or monetary penalty when dropout | Will not be implemented; available for free | |
Motivation by therapist | Rationale, follow-up, and encouragement by the therapist when asked for or needed | Therapist will play a role in dissemination and administration, but options not clear at this point |
Another gamification element that patients agreed on was simulated social reinforcement, which can be seen as a kind of reward. Social reinforcement is a form of positive reinforcement and an umbrella term for getting approval from others, by means of attention, praise, and encouragement, among others, as shown in the example of Chris (female, 50 years old, RMD individual):
[When playing Candy Crush Saga]…there is a little figure jumping up and down and telling me “Well done!,” which I enjoy hearing once in a while. Or you can hear “Sweet!,” which I also enjoy hearing.
The therapist could also play a role in adhering to the training and, more interestingly, this was also offered in the interviews with MHPs; thus, it certainly is considered possible to fulfill this role. Moreover, some MHPs even regarded motivating patients their responsibility, seeing how a therapist’s opinion and presentation of a treatment can impact a patient’s reception and motivation.
Features that facilitate implementation of CCT are listed in
When I imagine my colleagues, I think there are certainly some, because they regard it as hocus-pocus, that are not willing to offer it [the training].
Overview of the mandatory requirements for the mental health care professionals (MHPs).
Category and subcategory | Requirement | Implementation | |
Permission | Need permission from supervisor or MHP | Get approval by showing scientific evidence; giving psychoeducation | |
Time | Offering training should not be time-consuming | Devise training to be minimally time-consuming for MHP | |
Usage | Be informed about practical information of the training | Provide clear guidelines; practical or technical assistance (eg, contact person) | |
Format | Available and shareable training | Freely available website (not CD-ROM or other physical carriers) |
Overview of the desirable requirements for mental health care professionals. CCT: cognitive control training.
Category and subcategory | Requirement | Implementation | |
Psychoeducation | Knowledge about CCT mechanism and expected outcomes | Provide clear psychoeducation; tailor it to the working environment | |
Therapeutic benefits | CCT is beneficial in preventing or postponing a relapse; without major side effects | Test effectiveness of the CCT extensively; check for side effects | |
Resource access | Having access to scientific papers or clinical tools through the university | Unfortunately not possible to implement | |
Training feedback | Information about execution, performance, and outcome of the patients they proposed CCT to | Unclear at this point; if possible, grant therapist restricted access to database |
It might be encouraging to receive training feedback as well as outcomes with regard to depressive complaints, which would allow seeing whether training is effective for specific patients. Therapists indicated that such information could increase motivation to implement training, as Hailey (female, 26 years old, and psychologist) stated:
If we, as caregivers, are able to check whether or not they completed a session, or that you [the researchers] would be able to send us a message, for instance “We noticed that this person is not really strict with completing the sessions,” we might be able to call that person and really motivate [him/her], like, “Really try to do it anyway” and explain again why exactly it is a good idea.
In the example above, it is also clear that MHPs are willing to take on a motivational role, as discussed in the previous section.
RMD individuals and MHPs raised a number of additional concerns and comments that could be taken into account to prevent problems with the training. We will briefly present seven such concerns. First, the PASAT itself is based on math operations, which can be frustrating for some people, especially when time pressure is added. Second, privacy and data protection is considered important.
Third, technological skills will vary where it is important to strike a balance for being easy to operate for novice as well as skilled users. Fourth, the amount of additional work in addition to the training (such as questionnaires) needs to be limited. Fifth, having the training publically available means that nobody gets excluded this way, but this comes with the risk of offering the training to relapsed individuals that will not be helped by the training on its own, resulting in a fail experience, further decreasing this person’s mood. Sixth, the effect of the training is the strengthening of cognitive control, which is hard to measure and notice and comes only after multiple training sessions, but users might be focused on their performance which is easily measured and visible. Finally, gamification might lead to extra frustration. Having too many gamification elements within the training, so that it distracts from the task, should be avoided.
Facilitating factors are already existing opportunities which might support the uptake of and adherence to this training. First, depression and relapse rates are high, ensuring our training has a large potential user base. Second, in clinical practice, RMD individuals are requesting preventative programs. There are some relapse prevention programs (eg, mindfulness-based interventions), but the need for targeted interventions for cognitive vulnerability remains. However, RMD individuals sometimes take initiative themselves. Some of them will play brain training or attention games on their own. Here, it is safe to say that the step to our training would not be huge, and these individuals are motivated to prevent a relapse. Finally, some therapists still have follow-up sessions with RMD individuals, so offering the training through the therapist might be a useful strategy.
The aim of this study was to conduct a user requirements analysis with RMD individuals and MHPs to take into account their preferences in the next steps of development of Web-based CCT, aimed at relapse prevention in depression. For this purpose, we conducted a focus group with RMD individuals and interviewed MHPs. We performed qualitative analyses on the input provided by these participants. Finally, we identified some hindering and facilitating factors that can influence uptake of and adherence to the training.
For the RMD group, there were several mandatory requirements: the training should be functional and user-friendly and match this group’s technological skill and access. Performing the training sessions should also fit within their daily routine. Furthermore, this group desired the training to be engaging. Finally, they can be motivated by knowledge of how training works (ie, psychoeducation), training progress, gamification elements in the training, external factors, and their therapist.
The MHP group postulated some key requirements as well. Offering the training should be approved by their supervisor or director when they are working in a mental health care center. When they are self-employed or need supervisor approval, scientific arguments and research showing the effectiveness of the training and explaining how the training works are needed. Psychoeducation and feedback about patients’ progress can increase the chance that therapists will offer this training.
This study has 2 main strengths. First, as the endpoint of this project is creating an intervention for RMD individuals, we actually involved these end users, as well as MHPs who are in frequent contact with this population. This is in accordance with a recent call by an international collaboration, called “COMETS” (Collaboration On Maximizing the impact of E-Therapy and Serious gaming). COMETS was created to increase the uptake and adherence to internet interventions for mental health [
A second strength is that our findings are in agreement with literature regarding internet-based cognitive behavior therapy, which adds to the reliability of the findings of this study. For instance, previous research has shown beneficial effects of an intuitive and interactive product [
Nevertheless, this study also has some limitations. First, both target populations were represented by a small sample. Findings can therefore not be easily generalized, but it does give us some specific insights. During the focus group with only 5 RMD individuals, opinions already diverged greatly. Although relatively few people were included, enrolling too many people in a focus group might work counterproductive [
As a second limitation, because some of the questioned variables are a matter of personal preference, we did not go into detail about those in this study. For instance, Bartle [
Future steps of this project will be to develop the software of the training and platform, based on the input from the RMD individuals and the MHPs, after which it will be tested in several experiments to ensure that the training is efficacious and can be disseminated. The present requirements analysis is a crucial step in ensuring that the target population will be motivated and engaged to perform the cognitive control program.
adaptive PASAT
affinity for technology scale
cognitive control training
Collaboration On Maximizing the impact of E-Therapy and Serious gaming
interstimulus interval
mental health care professionals
paced auditory serial addition task
remitted depressed
This research was supported by an Applied Biomedical (TBM) grant of the Agency for Innovation through Science and Technology (IWT), part of the Research Foundation–Flanders (FWO), awarded to the PrevenD project (B/14730/01). KH was supported by a Special Research Fund (BOF) of Ghent University (B/13808/01).
None declared.