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Web-Based Psychosocial Interventions for Disaster-Related Distress: What Has Been Trialed in the Past, and What Can We Learn From This?

Published online by Cambridge University Press:  14 February 2023

Melissa B. Korman Open the ORCID record for Melissa B. Korman [Opens in a new window] ,
Jordana DeSouza  and
Janet Ellis Open the ORCID record for Janet Ellis [Opens in a new window]
Melissa B. Korman
Affiliation:
Department of Evaluative Clinical Sciences and Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
Jordana DeSouza
Affiliation:
Department of Evaluative Clinical Sciences and Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
Janet Ellis*
Affiliation:
Department of Evaluative Clinical Sciences and Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
*
Corresponding author: Janet Ellis, Department of Evaluative Clinical Sciences and Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada, Email: janet.ellis@sunnybrook.ca.
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Abstract

Objectives:

To summarize reports describing implementation and evaluation of Web-based psychosocial interventions for disaster-related distress with suggestions for future intervention and research, and to determine whether a systematic literature review on the topic is warranted.

Methods:

Systematic searches of Embase, PsycINFO, and MEDLINE were conducted. Duplicate entries were removed. Two rounds of inclusion/exclusion were conducted (abstract and full-text review). Relevant data were systematically charted by 2 reviewers.

Results:

The initial search identified 112 reports. Six reports, describing and evaluating 5 interventions, were included in a data analysis. Four of the 5 interventions were asynchronous and self-guided modular programs, with interactive components. The fifth was a short-term, online supportive group intervention. Studies utilized a variety of evaluation methods, and only 1 of 14 outcome measures used across the studies was utilized in more than 1 project.

Conclusions:

Several Web-based psychosocial interventions have been developed to target disaster-related distress, but few programs have been formally evaluated. A systematic review of the topic would not be recommended at this time due to heterogeneity in reported studies. Further research on factors impacting participation, generalizability, and methods of program delivery with consistent outcome measures is needed.

Keywords

community mental healthdelivery of health caredisastersresiliencepsychologicalstress psychological
Type
Systematic Review
Information
Disaster Medicine and Public Health Preparedness , Volume 17 , 2023 , e299
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2023. Published by Cambridge University Press on behalf of Society for Disaster Medicine and Public Health, Inc.

Disasters often result in psychosocial distress for those involved or exposed (eg, victims, first responders, and witnesses). Reference Panzer, Butler, Goldfrank, Butler, Panzer and Goldfrank1,Reference Tol, Barbui and Galappatti2 Failure to address psychosocial distress can result in the development of mental health disorders, which often last years and require specialized treatment. Reference Panzer, Butler, Goldfrank, Butler, Panzer and Goldfrank1,Reference Tol, Barbui and Galappatti2 Competing demands in the immediate aftermath of disasters (eg, managing influx of patients, family reunification, maintaining security, and supporting staff needs) can impede the identification, assessment, and treatment of psychological casualties. Reference Dick3,Reference Golabek-Goldman4 Longer term barriers to mental health assessment and treatment include socioeconomic factors and lack of effective communication about, or physical access to, resources. Reference Dick3,Reference Golabek-Goldman4 Though the importance of addressing psychosocial needs in a post-disaster environment has been widely reported and many organizations worldwide now include psychosocial responses in their disaster response plans, Reference Math, Nirmala, Moirangthem and Kumar5,Reference Steinmetz, Benight, Bishop and James6 there is limited systematic research on the effectiveness of psychosocial disaster interventions. Reference Korman, Goldberg and Khanjani7

The COVID-19 pandemic has negatively impacted the mental health of individuals worldwide, with increased rates of depression, anxiety, suicide attempts, and drug use. Reference Mertens, Gerritsen and Duijndam8–Reference Elbay, Kurtulmuş, Arpacıoğlu and Depression10 One common emotional reaction to the COVID-19 pandemic is fear of becoming ill or infecting one’s family, causing individuals to avoid social spaces, including doctors’ offices and hospitals. Reference Mertens, Gerritsen and Duijndam8 In addition to mental health disorders, unhelpful social behaviors have been identified with disaster-related distress. Through the COVID-19 pandemic, social disruption has produced group behaviors such as panic buying. Reference Kar, Menon and Arafat11 Researchers have noted that online cognitive behavioral therapy may be a potential option to address cognitive restructuring and behavioral modification. Reference Kar, Menon and Arafat11 Web-based mental health resources, including cognitive behavioral therapy and other evidence-informed psychosocial interventions, could be highly advantageous at this time, due to government recommendations to stay home whenever possible, fear of social spaces, the large number of individuals suffering from psychosocial distress, and the fact that COVID-19 has forced many to rely on web-based software for personal and professional communication.

Mental health care is complex, as differing populations and symptoms require various forms of intervention. This is further complicated when translating to a web-based approach, as this format has its own set of factors to consider (eg, whether a program is synchronous or asynchronous, interactive). Reference Andersson12–Reference Andersson and Titoy15 Nonetheless, research has highlighted guided web-based interventions as a promising treatment method, revealing that they can be as, or more, effective as traditional face-to-face mental health interventions. Reference Baumeister, Reichler, Munzinger and Lin16–Reference Fu, Burger, Arjadi and Bockting18 Multiple systematic and scoping reviews have been conducted to amalgamate literature on web-based psychosocial interventions (though not necessarily disaster-specific). There is wide heterogeneity in the types of interventions available, Reference Berryhill, Halli-Tierney and Culmer17 method of delivery, Reference Morrison, Geraghty and Lloyd19 target populations (including the potential inclusion of caregivers or partners), Reference Shaffer, Tigershtrom and Badr20 and target symptoms; Reference Renton, Tang and Ennis21 existing reviews generally focus on a specific subset. For instance, some reviews focus on interventions with specific features of interest (eg, interactive components or cognitive behavioral strategies), whereas others report on interventions targeting a specific population. Reference Shaffer, Tigershtrom and Badr20,Reference McCall, Beahm and Landry22 For example, Berryhill et al. (2019) published a review of 33 articles about videoconferencing psychotherapy for the treatment of depression. Reference Berryhill, Halli-Tierney and Culmer17 Other reviews focus on program outcomes, for example, evaluations methods, Reference Feather, Howson and Ritchie23 specific patient outcomes, or comparisons with traditional face-to-face care. Reference McCall, Beahm and Landry22,Reference Price, Yuen and Davidson24 One example is a systematic review of randomized controlled trials of digital psychological interventions in low- or middle-income countries. Reference Fu, Burger, Arjadi and Bockting18 Those authors concluded that further research in the field is needed, with systematic approaches to evaluate the interventions, in order to improve their efficacy and reproducibility. Reference Fu, Burger, Arjadi and Bockting18 Promising data on the positive impact of web-based psychosocial interventions, and the potential relative advantages of this approach (eg, increasing accessibility of mental health care), highlight the importance of additional work in this field. Reference Baumeister, Reichler, Munzinger and Lin16,Reference Fu, Burger, Arjadi and Bockting18,Reference McCall, Beahm and Landry22,Reference Berthoud, Efinger and Kheyar25–Reference Kostovich, Bormann and Gonzalez27

As the use of web-based mental health supports has been expedited due to the COVID-19 pandemic, Reference Berthoud, Efinger and Kheyar25–Reference Reay, Looi and Keightley30 it is important to synthesize knowledge gained in the past and apply these lessons in a timely and effective manner in order to mitigate negative mental health outcomes worldwide. Reference Wind, Rijkeboer, Andersson and Riper31 Web-based psychosocial interventions have been developed for and utilized in previous disaster response, Reference Yuen, Gros and Welsh32 with reports on the development and implementation processes. Reference Yuen, Gros and Welsh32 It is difficult to evaluate such interventions in the immediate aftermath of disasters; Reference Steinmetz, Benight, Bishop and James6,Reference Price, Davidson, Andrews and Access33,Reference Ruggiero, Davidson and McCauley34 it is unclear whether there is enough published data to warrant a systematic literature review of the effectiveness of these interventions.

This paper reports on a scoping review conducted to synthesize 14 years of research data on the evaluations of web-based psychosocial interventions/resources used to address disaster-related distress, and to summarize lessons learned. Reference Munn, Peters and Stern35 The paper concerns interventions for distress related to a disaster, as well as possible underlying mental health conditions. For the purposes of the paper, we defined disaster as any natural or man-made catastrophe, such as tornados or outbreaks, that impacted a large population. The primary aim in conducting this review was to create evidence-informed suggestions for the use of web-based psychosocial interventions/resources in response to the COVID-19 pandemic. To accomplish this aim, we sought to answer the following research questions:

  1. 1. What web-based psychosocial disaster-response interventions have been evaluated?

  2. 2. What types of evidence are available for such interventions?

  3. 3. What lessons have been learned through program implementation and evaluation?

  4. 4. Would a systematic literature review of the topic be warranted/beneficial at this time?

Literature Search and Methods

The Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) guided protocol development and manuscript preparation. Reference Tricco, Lillie and Zarin36

Search

Comprehensive database searches of MEDLINE (PubMED), Embase, and PsycINFO were conducted on April 7, 2021, using the search strategies outlined in Appendix A to identify all relevant documents. The search strategy was adapted by the primary reviewer (MBK) from a strategy drafted by an experienced librarian for a larger study regarding psychosocial response in disaster situations. Reference Korman, Goldberg and Khanjani7 Search results were exported to Microsoft Excel and all duplicates (n = 8) were removed by the primary reviewer.

Study Selection

Two reviewers (MBK, JD) separately screened each abstract for the following inclusion/exclusion criteria (where abstracts were not available, the full report was reviewed):

Inclusion criteria

  1. 1. Use of a specific web-based psychosocial intervention/resource in response to disaster-related distress.

  2. 2. Paper discusses intervention outcomes (eg, evaluation of feasibility or effectiveness) or experience in implementation (eg, lessons learned).

Exclusion criteria

  1. 1. Countries not included in the Organization for Economic Cooperation and Development (as healthcare systems, disaster responses, types of disasters, and Internet availability differ greatly worldwide, this criterion was used with hopes of creating actionable and relevant conclusions by targeting specific countries).

  2. 2. War/refugee situations (in an effort to increase homogeneity of data).

  3. 3. Conference abstracts (not enough information for data extraction).

The full report was read and reviewed separately by each reviewer in a second round; reports were included if they met both inclusion criteria and none of the exclusion criteria. Disagreements in study selection were discussed and resolved between the two reviewers.

Data Charting

Included reports were read and relevant data were extracted using a systematic approach to reduce risk of bias. A data-charting spreadsheet was developed by the primary reviewer in consultation with the secondary reviewer and supervising author (JE). Information regarding type of disaster was identified, in addition to broader data extraction regarding three categories of interest, to answer the first three research questions: (1) type of intervention/resource, (2) type of evaluation conducted, and (3) conclusions, lessons learned, and suggestions for future work. The two reviewers separately charted data from each included report, discussed and compared results until reaching consensus on most relevant information to include. The data-charting spreadsheet was iteratively updated throughout the process of data charting.

Data Synthesis

Reports were not grouped for synthesis and reporting, due to the small number of included reports. Data are reported according to the three categories of interest: (1) type of intervention/resource, (2) type of evaluation conducted, and (3) conclusions, lessons learned, and suggestions for future work. Categorical data are primarily reported in tables and charts, and descriptive data are primarily reported in a narrative format.

Results

Selection of Sources of Evidence

The results of the scoping review are summarized in a PRISMA diagram (Figure 1). Reference Munn, Peters and Stern35 The initial search yielded 112 entries, which was reduced to 104 after duplicates were removed. Based on the abstract review and the inclusion/exclusion criteria, 16 entries were included and 88 were excluded. The full texts of these 16 reports were retrieved and reviewed using the same inclusion/exclusion criteria as the previous round. Six reports were included in this review. Many protocol papers for ongoing studies were screened; however, they did not meet inclusion criteria to be included within this study.

Figure 1. PRISMA flow diagram.

Results and Characteristics of Sources of Evidence are presented according to our 3 main categories of interest.

The interventions

The six included reports discussed the implementation of five interventions in response to three types of disasters (Figure 2): Bounce Back Now, Reference Price, Yuen and Davidson24 My Disaster Recovery, Reference Steinmetz, Benight, Bishop and James6 Disaster Recovery Web, Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 COndiVIDi, Reference Berthoud, Efinger and Kheyar25 and an online cognitive behavioral intervention for dysfunctional worry Reference Wahlund, Mataix-Cols and Lauri28 (see Table 1 for details).

  1. Bounce Back Now (BBN) is an interactive, self-guided modular program created for disaster-affected adolescents. The four modules were developed considering best evidence for the topics of interest (listed in Table 1), and utilize psychoeducation, behavioral activation, motivational enhancement, and cognitive behavioral strategies. Participants complete a short screen upon accessing each module; participants are encouraged to complete the associated module if they screen positive; otherwise, they are given the option of completing or leaving the module. Reference Price, Yuen and Davidson24

  2. Disaster Recovery Web (DRW ) is a brief, self-guided modular intervention intended for one-time use by victims of disasters. DRW consists of seven modules (topics listed in Table 1) developed based on literature regarding mental health and health risk correlates of disaster, behavioral therapy and brief interventions, and motivational interviewing and enhancement. Participants first complete a screen and are directed to a dashboard with relevant modules. Participants are told which modules they did not “screen into” that they can access if they wish. Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37

  3. My Disaster Recovery (MDR ) is an interactive, self-guided modular program that tailors the experience to individual users, targeting coping self-efficacy pathways based on social cognitive theory. Reference Steinmetz, Benight, Bishop and James6 It includes six modules (topics listed in Table 1). Reference Steinmetz, Benight, Bishop and James6

  4. COndiVIDi (the Italian word for “sharing”) is an online supportive group intervention that was offered over three weeks of the first lockdown associated with the COVID-19 pandemic in Milan, Italy. Multiple, structured weekly groups facilitated by two expert psychotherapists were run with 8 to 12 participants of a specific population for homogeneity. Reference Brusadelli, Ferrari and Benetti26

  5. A brief, online, self-guided psychological intervention targeting COVID-19-related worry (no name provided) was developed to address unhelpful worry and behavioral manifestations. This three-week intervention includes five interactive modules (topics listed in Table 1). Reference Wahlund, Mataix-Cols and Lauri28

Figure 2. Disaster Type Reported On.

Table 1. Intervention details

* Screening refers to screening that is integrated into the intervention, not screening for research study eligibility.

Time

Time to program implementation from disaster occurrence ranged from immediately to one-year post-disaster. Timeline of intervention use intended by development teams ranged from one visit to 12 weeks. Three out of the five interventions offered participants four months of access. Reference Price, Yuen and Davidson24,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37

Population

Some interventions targeted sub-populations of the demographic of interest (ie, disaster-affected individuals). Four out of the five interventions were tailored to disaster-affected adults (n = 4), Reference Steinmetz, Benight, Bishop and James6,Reference Brusadelli, Ferrari and Benetti26,Reference Price, Davidson, Andrews and Access33 whereas BBN targeted adolescents. Reference Price, Yuen and Davidson24 COndiVIDi included supportive groups for specific adult populations (ie, psychotherapists and psychology students/trainees). Reference Brusadelli, Ferrari and Benetti26

Intervention Components

Most interventions were modular treatments (n = 4). Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Davidson, Andrews and Access33 The process of accessing modules varied between programs. For instance, DRW screened all users prior to module access, encouraging users to access and complete relevant modules, Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 whereas participants were to complete all modules in sequential order for some programs. Reference Steinmetz, Benight, Bishop and James6,Reference Yuen, Gros and Welsh32 Module content differed between interventions. Most included the use of cognitive behavioral therapy strategies and behavioral interventions (n = 3). Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Wahlund, Mataix-Cols and Lauri28 Some incorporated the use of self-efficacy pathways while encouraging self-help (n = 2), Reference Steinmetz, Benight, Bishop and James6,Reference Price, Gros and McCauley37 motivational enhancement (n = 2), Reference Price, Yuen and Davidson24,Reference Price, Gros and McCauley37 and psychoeducation (n = 2). Reference Price, Yuen and Davidson24,Reference Brusadelli, Ferrari and Benetti26 All five interventions included interactive components. The majority of interventions were asynchronous and self-guided (n = 4); Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Davidson, Andrews and Access33 COndiVIDi was the only synchronous, therapist-guided intervention. Reference Brusadelli, Ferrari and Benetti26

Type of Distress Targeted

Interventions targeted differing forms of mental health disorders or distress. Three interventions targeted posttraumatic stress disorder (PTSD), Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Price, Davidson, Andrews and Access33 depression, Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Price, Gros and McCauley37 and substance abuse. Reference Price, Yuen and Davidson24,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 Worry and other anxiety symptoms were targeted by two interventions. Reference Steinmetz, Benight, Bishop and James6,Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37

Evaluations/studies

The six included reports described five studies evaluating the interventions; two reports described different outcomes of one study evaluating the implementation of DRW. Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 Details regarding study design and outcomes measured are summarized in Table 2. All reports describe aspects of acceptability; Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Brusadelli, Ferrari and Benetti26,Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 efficacy or effectiveness were evaluated in four of the included reports. Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Brusadelli, Ferrari and Benetti26,Reference Price, Gros and McCauley37 All studies used quantitative outcome measures, Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Brusadelli, Ferrari and Benetti26,Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 with two of six reports evaluating both qualitative and quantitative outcomes. Reference Brusadelli, Ferrari and Benetti26,Reference Price, Gros and McCauley37

Table 2. Study details
Population and sample size

Studies were conducted in three countries (Figure 3). Sample sizes ranged from 52–2000 participants. Most studies targeted an adult population (n = 4); Reference Steinmetz, Benight, Bishop and James6,Reference Brusadelli, Ferrari and Benetti26,Reference Price, Davidson, Andrews and Access33 one targeted adolescents. Reference Price, Yuen and Davidson24 Participants were mainly female in three studies, Reference Steinmetz, Benight, Bishop and James6,Reference Brusadelli, Ferrari and Benetti26,Reference Wahlund, Mataix-Cols and Lauri28 with equal distribution between males and females in two (one of which used a targeted sampling approach to achieve equal distribution). Reference Price, Yuen and Davidson24,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 Most studies (n = 4) included a control group. Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Gros and McCauley37

Figure 3. Country of study.

Measures used

Fourteen validated questionnaires were used across the studies (some were modified for the purposes of the project) (Table 2). The Center for Epidemiologic Studies Depression Scale (CES-D) was used in two studies Reference Steinmetz, Benight, Bishop and James6,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 ; all others were used in only one described study.

Conclusions, lessons learned, and suggestions for future work (Appendix B)

Evaluations of BBN revealed factors impacting access and use of Web-based interventions. There were varying access rates and predictors of access for different modules, with higher rates of access in the PTSD module among adolescents who met criteria for PTSD, reported recent alcohol use, or had parents who were more educated or had accessed health-related information via the Internet. Reference Price, Yuen and Davidson24 However, those who met diagnostic criteria for depression were not necessarily more likely to access the related module. Reference Price, Yuen and Davidson24 Overall, being male was a significant predictor for decreased access for all modules, whereas parental use of the Internet was strongly associated with increased access in three of four modules. Reference Price, Yuen and Davidson24 Overall, the evaluation of BBN in tornado-affected adolescents by Price et al. (2015) provided empirical support that web-based interventions can have high rates of penetration in a population over a relatively brief period of time. Reference Price, Yuen and Davidson24 They also revealed less of a gender discrepancy in accessing mental health interventions than previously reported in studies of face-to-face interventions, Reference Price, Yuen and Davidson24,Reference Wang and Lane38 possibly indicating that the increased privacy afforded by Web-based treatments may facilitate access. Reference Price, Yuen and Davidson24

Price et al. (2013) revealed no difference in rates of non-use or dropout attrition from DRW between white, African American, and Hispanic hurricane-affected adults, Reference Price, Davidson, Andrews and Access33 despite previously reported disparities in the access of traditional mental health services between these racial groups. Reference Perilla, Norris and EA39

The 2012 study conducted by Price et al. revealed other factors (related to demographics, impact of disaster, and prior Internet use) that may be important to consider regarding use and attrition in web-based interventions. Age was found to be a predictor of non-use of the website and completion attrition. Reference Price, Gros and McCauley37 Though older participants were less likely to access the website, education buffered against this effect, and older participants were more likely to complete the intervention upon access. Reference Price, Gros and McCauley37 Property damage was associated with increased dropout attrition. Reference Price, Gros and McCauley37 Loss of basic services was a predictor of access and completion of more treatment modules. Reference Price, Gros and McCauley37 Prior health-seeking behaviors for mental health or having parents who had used the Internet to obtain health-related information were associated with increased rates of accessing web-based interventions. Reference Price, Gros and McCauley37 Previous personal use of the Internet to seek health-related information reduced non-use attrition, Reference Vicary and Fraley40 and those who had previously accessed mental health supports were more likely to access web-based interventions. Reference Price, Gros and McCauley37 Authors concluded that this supported the potential for web-based interventions to act as a post-disaster “booster” or reminder of prior learnings for those who had previously accessed therapy. Reference Price, Gros and McCauley37 The most frequent reason for lack of access reported by participants was lack of relevance to their needs. Reference Price, Gros and McCauley37

Steinmetz et al. (2012) found that MDR was effective in reducing worry and depressive symptoms, compared to information-only and care-as-usual groups, but not in helping with posttraumatic stress or coping self-efficacy. Reference Steinmetz, Benight, Bishop and James6 The authors concluded that this may indicate that symptoms of worry and depression may be more prevalent in the post-acute phase of disasters. Reference Steinmetz, Benight, Bishop and James6

COndiVIDi was the only intervention that connected multiple users. Reference Brusadelli, Ferrari and Benetti26 Participants appreciated connecting with others who had similar experiences (ie, psychotherapists being grouped with other psychotherapists). Participants also reported that having online interactions and being part of a group were extremely important to their emotional well-being during times of social distancing. Reference Brusadelli, Ferrari and Benetti26 The most important factor for facing emotions was the opportunity to share emotions and learn from others’ experience and perspectives. Reference Brusadelli, Ferrari and Benetti26 The online group helped individuals become aware of their emotions, psychological struggles, and avoidant strategies. Reference Brusadelli, Ferrari and Benetti26

The online cognitive behavioral intervention for dysfunctional worry was associated with improved daily functioning, depressive symptoms, tolerance of uncertainty, and COVID-19-related worry (40% vs 17% in the intervention and control groups, respectively). Reference Wahlund, Mataix-Cols and Lauri28

Identified Strengths of the Web-Based Approach

Multiple potential strengths of web-based mental health programming, compared to face-to-face interventions, were highlighted. Most often described were benefits related to reaching a wide audience, through mechanisms of increased inclusivity, acceptability, and reduced discrepancies in care. Specifically, studies of DRW by Price et al. (2012, 2013) confirmed the potential for high rates of penetration in a population over a brief period, Reference Price, Yuen and Davidson24 especially in self-guided, asynchronous programs, as well as the potential of Web-based interventions to reduce discrepancies in mental health care. Reference Price, Yuen and Davidson24,Reference Price, Davidson, Andrews and Access33 The authors reported that this format of intervention may increase acceptability or willingness to participate in certain populations (eg, adolescent boys) Reference Price, Yuen and Davidson24 and accessibility of programming. Reference Dick3,Reference Price, Davidson, Andrews and Access33 Similarly, in evaluating BBN, Price et al. (2015) reported the potential benefit of increased inclusivity (ie, fewer exclusion criteria for participation). Reference Price, Gros and McCauley37 Finally, it was reported that self-guided programs can reduce the potential of therapist drift and improve the consistency of treatment delivery. Reference Wahlund, Mataix-Cols and Lauri28

Suggestions for Future Research

  1. 1. Aim to increase generalizability; generalizability of reported findings may be limited by small sample size, Reference Steinmetz, Benight, Bishop and James6,Reference Brusadelli, Ferrari and Benetti26 unequal gender distribution, Reference Brusadelli, Ferrari and Benetti26 higher than average reported participant income (compared to other disaster research), Reference Price, Davidson, Andrews and Access33 and generally high Internet access and usage rates in the country of study. Reference Wahlund, Mataix-Cols and Lauri28 Compensating individuals for participation may have also inflated adherence rates. Reference Price, Yuen and Davidson24,Reference Price, Davidson, Andrews and Access33

  2. 2. Identify predictors of program access, completion, and benefit; demographic variables, relevance of intervention to cultural groups, and individual history of accessing Web-based health information should be considered so that future implementation efforts can focus on those most likely to engage in and/or benefit from interventions. Reference Steinmetz, Benight, Bishop and James6,Reference Brusadelli, Ferrari and Benetti26,Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 Similarly, motivational factors for access and completion of Web-based interventions should be investigated. Reference Price, Gros and McCauley37

  3. 3. Evaluate the impact of the timeline of intervention/evaluation in relation to different outcomes of interest; existing data may not reflect effectiveness of the intervention if individuals recovered from disaster-related distress prior to accessing supports. Three reports described relevance of content as a factor influencing participation, Reference Steinmetz, Benight, Bishop and James6,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37 with authors noting that specific content may be more (or less) relevant to users at certain timepoints in recovery. Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24

  4. 4. Gather general measures of Internet use and familiarity, as well as health behaviors/help-seeking, and detailed website usage data to help explore correlations between time spent online and outcomes of interest, and identify most acceptable and/or effective modules, pages, or topics. Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Price, Gros and McCauley37

  5. 5. Assess longer-term effects of interventions. Reference Price, Gros and McCauley37

  6. 6. Utilize controls with approximately the same time commitment as the intervention; Reference Price, Yuen and Davidson24 most included randomized controlled trials had non-interactive, information-based controls (which were less time-intensive than interventions) and showed higher completion or access in the control groups (not statistically significant), compared to the interactive intervention, and no difference in satisfaction. Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Gros and McCauley37

  7. 7. Evaluate web-based interventions as part of a stepped care approach, Reference Price, Yuen and Davidson24,Reference Price, Gros and McCauley37 or as a “booster” for those who have had prior mental health treatment. Reference Price, Gros and McCauley37

Recommendations for Future Programming

  1. 1. Develop strategies to access households without computers to increase accessibility; this might include the use of tablet and smartphone interventions, Reference Price, Yuen and Davidson24,Reference Price, Davidson, Andrews and Access33 possibly as part of a multi-method strategy, alongside paper-based approaches. Reference Price, Yuen and Davidson24

  2. 2. Include social networks or interactive content (eg, games). Reference Price, Yuen and Davidson24

  3. 3. Partner with experts in graphic design, marketing, and other relevant fields to create highly engaging content. Reference Price, Gros and McCauley37

Limitations

Few reports met the inclusion criteria of this work, and there was a large heterogeneity in these studies; this limited the authors’ ability to draw conclusions regarding effectiveness of these interventions, or to make suggestions for response to distress caused by the COVID-19 pandemic. Specifically, this limited the capacity to identify all strengths or drawbacks of web-based approaches and to generalize findings. Future research might expand the criteria to capture work done in countries not included in the Organization for Economic Cooperation and Development and in chronic disasters, such as war/refugee situations.

Discussion

This review identified reports describing the implementation and evaluation of web-based mental health interventions for disaster-related distress in Organization for Economic Cooperation and Development countries over the last 14 years. Five interventions were described in the six included reports. The small sample size (n = 6) of included reports highlights the lack of research evaluating online post-disaster mental health interventions, specifically in the acute phase of disaster (most interventions were implemented months-to-a-year following the disaster). Results reveal the importance of expanding work in this field, as this method of care provision creates the capacity to reach a large and diverse audience over a relatively brief time period, while offering a level of privacy that may increase target users’ willingness to participate. Reference Dick3,Reference Price, Yuen and Davidson24,Reference Price, Davidson, Andrews and Access33,Reference Price, Gros and McCauley37

Research has shown that it can take 17 years for knowledge translation from research to practice. Reference Morris, Wooding and Grant41 Though the gap in online mental health interventions for disaster-related distress has been identified in very recent years, it is likely that the circumstances surrounding COVID-19 (ie, the need for physical distancing, heightened focus on potential adverse mental health outcomes) fast-tracked knowledge translation in this field. Two studies included in this review were responding to the current COVID-19 pandemic, and multiple protocol papers were identified in the process of this review, highlighting the quickly growing nature of the field. This work identified a variety of factors that should be considered in ongoing/future work. Suggestions included increasing generalizability by using larger sample sizes that include adequate representation from a diverse population (considering gender, economic status, and other sociodemographic variables), assessing longer-term outcomes, gathering general measures of Internet use and familiarity, gathering detailed intervention usage data, and evaluating the use of online interventions as part of a stepped-care program.

There was a wide heterogeneity observed across included reports, in project aims, sample size, timeline of intervention and data collection, type of intervention, outcome measures, and so on. The CES-D was the only outcome measure used in more than one study (n = 2), one evaluating program acceptability, the other effectiveness. This highlights the lack of consistency between the included reports due to differing methodology and outcome measures. This inconsistency is similar to the literature on (non-disaster) online psychological interventions, Reference Fu, Burger, Arjadi and Bockting18 and, in combination with the small number of studies included, leads to the conclusion that a systematic review to compare outcome data for web-based psychosocial interventions for disasters would not be warranted at this time. However, a systematic review could be beneficial in the near future, considering the ongoing work during the COVID-19 pandemic identified in this review.

The heterogeneity in identified reports may be a relative advantage in terms of identifying lessons learned and making suggestions for future work, as included studies evaluated both feasibility and effectiveness of post-disaster web-based mental health treatments. The included studies revealed high levels of intervention acceptability and promising results regarding effectiveness and potential for rapid scaling and access of web-based mental health treatments. Methods of improving program engagement and potential effectiveness were also discussed, such as incorporating engaging, interactive materials, and social networks. Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24

Previous literature highlights the importance of interactivity in online interventions, Reference Baumeister, Reichler, Munzinger and Lin16 agreeing with suggestions from included reports to focus on interactivity in future work. Interestingly, included randomized controlled trials comparing interactive interventions (eg, DRW) to non-interactive, information-based websites showed no difference in website satisfaction between groups and lower website access and completion in the interactive intervention. Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Gros and McCauley37 The authors noted that the non-interactive information-based controls required less of a time commitment from participants; authors highlighted the need for future work to include controls with a similar time commitment as the intervention. Reference Price, Yuen and Davidson24 This finding might indicate decreased time commitment as a facilitator of engagement. Future work should evaluate engagement in, and impact of, interventions with varying time commitments to identify the minimum “dosage” or amount of time needed for individuals to benefit and the length of intervention with most uptake/engagement (ie, the amount of time that individuals are willing to commit).

Commonalities in general structure were identified across interventions though specific content and evaluation methods differed; most interventions described were modular, asynchronous, and self-guided. Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Wahlund, Mataix-Cols and Lauri28,Reference Price, Davidson, Andrews and Access33 Cognitive behavioral therapy strategies and behavioral interventions were most commonly used in these interventions. Reference Steinmetz, Benight, Bishop and James6,Reference Price, Yuen and Davidson24,Reference Wahlund, Mataix-Cols and Lauri28 These strategies have been proven effective in treating emotional distress following varying types of traumatic events (including use in disaster response), for both group and individual treatments. Reference Wamser-Nanney, Scheeringa and Weems42–Reference Shooshtary, Panaghi and Moghadam46 Strategies to enhance self-efficacy and encourage self-help, Reference Steinmetz, Benight, Bishop and James6,Reference Price, Gros and McCauley37 motivational enhancement, Reference Price, Yuen and Davidson24,Reference Price, Gros and McCauley37 and psychoeducation were also described. Reference Price, Yuen and Davidson24,Reference Brusadelli, Ferrari and Benetti26 Interventions covered a variety of topics, from PTSD to worry and the evolutionary function of worrisome thoughts. Different topics may be more relevant at different timepoints post-disaster; modular programs should consider timepoint of offering each module (or topic) post-disaster. Reference Steinmetz, Benight, Bishop and James6 For example, upon evaluating the use of MDR in addressing worry and depression post-disaster, the authors concluded that feelings of worry and depression may be most relevant in the post-acute phase and perhaps should not be targeted immediately. Reference Steinmetz, Benight, Bishop and James6 Perhaps specific social and maladaptive coping behaviors (eg, panic buying and excess alcohol consumption) Reference Kar, Menon and Arafat11 would be important to target proactively in the acute phase post-disaster. Future work should also aim to identify correlations between time variables (ie, length of overall program and time spent using the interventions/resources) and patient outcomes. Qualitative exploration of the types of distress and maladaptive coping behaviors over time, in response to a disaster, could guide the planning of future programming. Increasing the relevance of content to the target end-users could increase engagement, as “lack of relevance” was reported as the primary reason for lack of engagement in DRW. Reference Price, Gros and McCauley37 Another possible way to increase program relevance in the future is to combine multiple programs. As the programs reported on here included content on a variety of topics, combining such interventions would increase the likelihood of perceived relevance for any given individual.

In addition to amalgamating the respective modules of self-guided programming, they might consider adding an asynchronous element to encourage social support by connecting individuals with similar experiences. The opportunity for social interaction and connection with peers was appreciated by participants in the COndiVIDi study, Reference Brusadelli, Ferrari and Benetti26 and the literature identifies social support as a powerful tool to mitigate adverse mental health outcomes. Reference Brusadelli, Ferrari and Benetti26,Reference Vicary and Fraley40 Individuals have reported feeling better upon connecting to others by participating in online disaster-related activities via social media, Reference Vicary and Fraley40 even when quantitative effectiveness data do not support a correlation between online behaviors and improved well-being.

Most interventions were self-guided. Positive outcomes following participation in self-guided programming indicate that the guidance of a trained professional is not necessarily critical to program success. This is important, as self-guided programs are highly cost-effective and scalable and can result in increased consistency of treatment delivery without scheduling limitations or risk of therapist drift. Reference Wahlund, Mataix-Cols and Lauri28

Conclusion

The potential negative mental health effects of disasters are widely recognized. Web-based mental health interventions have grown in popularity over recent years, a trend that has been expedited due to the COVID-19 pandemic. Many interventions have been developed or proposed to address post-disaster mental health needs for varying populations from victims to first responders, children to adults, and so on, though a systematic evaluation of such interventions is sparse. Understanding the impact of these interventions is imperative to support the mental health of individuals during the COVID-19 pandemic. The results of this study have identified potential strengths of web-based approaches, though more work is needed to confirm these findings. Future work should highlight program accessibility and generalizability, and content relevance across heterogeneous populations.

Acknowledgments

Thank you to Dr Robert Maunder for your support in study design and manuscript edits.

Funding statement

This work was supported by the Hospital Funding by the Code Orange Steering Committee at Sunnybrook Health Sciences Centre, and the Canadian Institutes of Health Research (CIHR) Institute of Community Support Planning and Dissemination Grant Program, in partnership with CIHR Institute of Neurosciences, Mental Health and Addiction (FRN168300).

Conflict(s) of interest

None

APPENDIX A. Search Strategies Utilized for Each Database Searched

Database: Embase Classic+Embase <1947 to 2021 April 07> Search Strategy:

  1. 1. exp mass disaster/

  2. 2. exp disaster/

  3. 3. exp disaster planning/

  4. 4. exp pandemic/

  5. 5. exp terrorism/

  6. 6. (mass disaster or mass emergency or mass event* or mass trauma or “mass trauma and assessment” or mass casualty incident* or MCI or CBRNE or pandemic or traumatic events or large scale traumatic event or terrorist event or crisis event).mp.

  7. 7. or/1-6

  8. 8. exp posttraumatic stress disorder/

  9. 9. exp psychosomatic disorder/

  10. 10. exp acute stress/ or exp mental stress/

  11. 11. exp psychologic test/ or exp screening/ or exp psychological aspect/

  12. 12. exp psychologic assessment/

  13. 13. exp mental disease/ or exp separation anxiety/

  14. 14. exp burnout/

  15. 15. (psychological casualty or psychological damage or psychological trauma or psychological injury or psychological wounds or emergency mental health care or emergency mental health or emergency psychiatric or psychogenic reaction or acute stress syndrome or acute stress injur* or post traumatic stress disorder or PTSD or common psychological injuries of major event* or walking wounded or walk in patient* or early arriving patient* or patient* arriv* early or psychological screening or psychological assessment or psychological response or vicarious trauma or delayed psychological response or (famil* adj3 separat*)).mp.

  16. 16. or/8-15

  17. 17. exp early intervention/

  18. 18. exp psychosocial care/

  19. 19. exp mental health care/ or mental health service/

  20. 20. exp ambulatory care/

  21. 21. exp psychotherapy/ or exp cognitive therapy/ or exp behavior therapy/

  22. 22. exp psychiatric treatment/

  23. 23. (early intervention or (management adj5 psychological casualty) or psychosocial management or psychiatric care or distress management or supportive counseling or psychological triage or prevention of PTSD or prevention of post traumatic disorder or psychological first aid or psychological intervention or emotion* support or code orange hospital care or code orange medical team or code orange healthcare professional or code orange plan or code orange policy or code orange psychological care or code orange hospital impact).mp.

  24. 24. or/17-22

  25. 25. exp internet/

  26. 26. 7 and 16 and 24 and 25

  27. 27. limit 25to (English language and yr=”2007-current”)

Database: PsycINFO <1806 to 2021 April 7> Search Strategy:

  1. 1. exp Disasters/

  2. 2. exp Terrorism/

  3. 3. exp Pandemics/

  4. 4. exp Emergency Preparedness/

  5. 5. (mass disaster or mass emergency or mass event* or mass trauma or “mass trauma and assessment” or mass casualty incident* or MCI or CBRNE or pandemic or traumatic events or large scale traumatic event or terrorist event or crisis event).mp.

  6. 6. or/1-5

  7. 7. exp Emotional Trauma/ or exp Posttraumatic Stress Disorder/

  8. 8. exp Psychological Stress/

  9. 9. exp Mental Health/ or exp Mental Disorders/

  10. 10. exp Mass Hysteria/ or exp Psychopathology/ or exp Psychiatric Symptoms/ or exp Somatoform Disorders/

  11. 11. exp Distress/ or exp Stress Reactions/

  12. 12. exp Emotional Responses/

  13. 13. exp Vicarious Experiences/

  14. 14. (psychological casualty or psychological damage or psychological trauma or psychological injury or psychological wounds or emergency mental health care or emergency mental health or emergency psychiatric or psychogenic reaction or acute stress syndrome or acute stress injur* or post traumatic stress disorder or PTSD or common psychological injuries of major event* or walking wounded or walk in patient* or early arriving patient* or patient* arriv* early or psychological screening or psychological assessment or psychological response or vicarious trauma or delayed psychological response or (famil* adj3 separat*)).mp.

  15. 15. or/7-14

  16. 16. exp Mental Health Services/

  17. 17. exp Crisis Intervention/

  18. 18. exp Stress Management/

  19. 19. exp Early Intervention/

  20. 20. exp Psychotherapy/ or exp Intervention/

  21. 21. exp Counseling/ or exp Supportive Psychotherapy/

  22. 22. exp Coping Behavior/

  23. 23. exp Emotional Security/ or exp Social Support/ or exp Emotional Adjustment/

  24. 24. (early intervention or (management adj5 psychological casualty) or psychosocial management or psychiatric care or distress management or supportive counseling or psychological triage or prevention of PTSD or prevention of post traumatic disorder or psychological first aid or psychological intervention or emotion* support or code orange hospital care or code orange medical team or code orange healthcare professional or code orange plan or code orange policy or code orange psychological care or code orange hospital impact).mp.

  25. 25. or/16-24

  26. 26. exp internet/

  27. 27. 6 and 15 and 25 and 26

  28. 28. limit 27 to (english language and yr="2007 -Current”)

Database: Ovid MEDLINE(R) ePub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid MEDLINE and Versions(R) <1946 to 2021 April 7> Search Strategy:

  1. 1. exp disasters/ or exp disaster planning/ or emergencies/ or emergency shelter/ or mass casualty incidents/ or relief work/ or rescue work/

  2. 2. exp terrorism/ or bioterrorism/ or chemical terrorism/ or mass casualty incidents/ or september 11 terrorist attacks/

  3. 3. Pandemics/

  4. 4. (mass disaster or mass emergency or mass event* or mass trauma or “mass trauma and assessment” or mass casualty incident* or MCI or CBRNE or pandemic or traumatic event or large scale traumatic events or terrorist event or crisis event).mp.

  5. 5. or/1-4

  6. 6. exp stress disorders, traumatic/ or battered child syndrome/ or combat disorders/ or stress disorders, post-traumatic/ or stress disorders, traumatic, acute/

  7. 7. emergency services, psychiatric/

  8. 8. exp Stress, Psychological/

  9. 9. exp Adaptation, Psychological/

  10. 10. exp Burnout, Professional/

  11. 11. (psychological casualty or psychological damage or psychological trauma or psychological injury or psychological wounds or emergency mental health care or emergency mental health or emergency psychiatric or psychogenic reaction or acute stress syndrome or acute stress injur* or post traumatic stress disorder or PTSD or common psychological injuries of major event* or walking wounded or walk in patient* or early arriving patient* or patient* arriv* early or psychological screening or psychological assessment or psychological response or vicarious trauma or delayed psychological response or (famil* adj3 separat*)).mp.

  12. 12. exp Mental Disorders/

  13. 13. or/6-12

  14. 14. exp Mental Health Services/

  15. 15. Crisis Intervention/

  16. 16. exp Counseling/

  17. 17. child guidance/ or community mental health services/ or emergency services, psychiatric/ or social work, psychiatric/

  18. 18. (early intervention or (management adj5 psychological casualty) or psychosocial management or psychiatric care or distress management or supportive counseling or psychological triage or prevention of PTSD or prevention of post traumatic disorder or psychological first aid or psychological intervention or emotion* support or code orange hospital care or code orange medical team or code orange healthcare professional or code orange plan or code orange policy or code orange psychological care or code orange hospital impact).mp.

  19. 19. or/14-18

  20. 20. exp internet/

  21. 21. 5 and 13 and 19 and 20

  22. 22. limit 21 to (English language and yr=”2007-Current”)

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Figure 0

Figure 1. PRISMA flow diagram.

Figure 1

Figure 2. Disaster Type Reported On.

Figure 2

Table 1. Intervention details

Figure 3

Table 2. Study details

Figure 4

Figure 3. Country of study.