Preferences and perceived barriers for internet-based treatment among adolescents with anxiety or depressive disorders: A qualitative study

Background Over the past two decades, the development of internet-based treatments for adolescents with anxiety and depressive disorders has advanced rapidly. To date, adolescents' preferences and perceived barriers for internet-based treatment remain largely unknown, especially in clinical samples. Therefore, this study explored the preferences and perceived barriers of adolescents with anxiety or depression regarding internet-based treatment. Methods This qualitative study included 21 adolescent patients with anxiety or depressive disorder, and varied levels of experience with internet-based treatment. Two focus groups (N1 = 5, N2 = 6) and semi-structured interviews (N = 10) were conducted, recorded, transcribed, and analyzed using a reflexive thematic analysis approach. Results The thematic analysis yielded five main themes, and 12 subthemes. The main themes were: independence, accessibility, content, therapist contact, and appearance. Adolescents highlighted self-direction as a benefit of internet-based treatment, and motivational challenges as a drawback. They found internet-based interventions convenient and particularly fitting for implementation during waiting periods before formal treatment. Guided interventions were preferred over mere self-help. Furthermore, adolescents stressed the importance of a clear, organized design, and recommended accessibility on both mobile phones and computers. Conclusion Findings provide a clear overview of the needs and preferences of adolescents with anxiety or depressive disorder regarding internet-based treatment. To address their diverse needs, internet-based interventions should be tailorable, should incorporate therapist guidance, and should already be available during the treatment waiting period. Results of this study can guide the development and implementation of new internet-based interventions, and may thereby help to further optimize their uptake among adolescent patients.


Introduction
Anxiety and depressive disorders are common in adolescence (Polanczyk et al., 2015).Both disorders cause severe distress and have a negative impact on adolescents' social functioning, educational achievements, physical health, and quality of life (de Lijster et al., 2018;Jaycox et al., 2009).Moreover, anxiety and depressive disorders can persist into adulthood and predict a variety of other adult mental health disorders (Essau et al., 2014).Even though the disease burden of both disorders is high, many youths do not receive treatment (Mojtabai et al., 2016).Adolescents often face barriers in seeking help for mental health problems, such as stigma and embarrassment, inaccessibility, and long waitlists (Gulliver et al., 2010;MacDonald et al., 2021).
Internet-based treatment (i.e., treatment delivered via the internet on smartphone apps or websites) has emerged as an alternative to faceto-face therapy that may help overcome these barriers (e.g., Andrews et al., 2018;Batterham et al., 2015).Several meta-analyses have shown that internet-based treatments are effective for adolescents with anxiety and depressive disorders (e.g., Christ et al., 2020;Grist et al., 2018).Further, internet-based treatment appears to be cost-effective for adults with anxiety or depressive disorder (Mitchell et al., 2021).Moreover, these treatments are found to be a feasible substitute for traditional faceto-face therapies for adolescents due to their compatibility with their digital lifestyle, time efficiency, and convenience (Andersson and Titov, 2014;Domhardt et al., 2018).
Despite increased interest in internet-based treatment for adolescent mental health issues, several challenges persist.Internet-based treatments generally have lower uptake and higher dropout rates than faceto-face treatments, particularly for self-help interventions without therapist support (Fleming et al., 2018;Richardson et al., 2010).These factors form important barriers for the broad implementation of internet-based treatment into clinical practice, which has proven difficult thus far (Batterham et al., 2015).Understanding adolescents' preferences and perceived barriers regarding internet-based treatment is needed to improve its uptake.A qualitative study conducted by Mar et al. (2014) on a non-clinical sample of adolescents experiencing suicidal ideation found that internet-based interventions should be userfriendly, interactive, and include guidance.Further, some studies have investigated youths' perspectives on specific interventions through codesign to increase engagement (e.g., Ludlow et al., 2023).However, adolescents' perspectives on internet-based treatment in general remain largely unknown, particularly in clinical samples with anxiety or depressive disorder.

Current study
The objective of this qualitative study is to increase insight into preferences and perceived barriers for internet-based treatment among clinically referred adolescents with anxiety or depressive disorder.More specifically, we will examine their views and experiences regarding advantages and disadvantages, important functions, guidance, and appearance of internet-based treatment.

Participants
All 39 participants from a larger pilot study (Wisman et al., 2023) were invited to this qualitative study.21 (53.8 %) adolescents with anxiety or depressive disorders, referred to mental health care, participated in focus groups and semi-structured interviews.Participants did not differ on any demographic variable at baseline from other participants in our pilot study, which aimed to examine the acceptability and feasibility of an add-on internet-based emotion regulation training (ERT) for adolescents with depressive and/or anxiety disorder.Inclusion criteria were: aged 13-18 years at baseline; diagnosed with depressive or anxiety disorder; enrolled for treatment at Arkin in Amsterdam.A more detailed description is given elsewhere (Wisman et al., 2023).
Table 1 shows the characteristics of the participants of the current qualitative study.In total 21 participants, aged 15-20 (M = 17.1, SD = 1.4), were included.Around half of the adolescents had experience with any form of internet-based treatment for psychological problems.

Ethics
All participants provided written informed consent as well as the parents of the participants under 16.The Medical Research Ethics Committees United (MEC-U) has approved the study.

Data collection
Qualitative data were collected between December 2020 and November 2021 through focus groups and semi-structured interviews, which took place through videoconference due to COVID-19 restrictions.When contacted, the topics and approximate duration of the focus groups and the interviews were explained.Participants received a gift card of 25 euros for their time and effort.
Two focus groups were conducted with N = 5 and N = 6 participants, followed by semi-structured interviews with N = 10 others (see Fig. 1).Initially, we aimed to form two focus groups of six participants each by inviting 23 randomly selected individuals, resulting in 11 attending and one no-show.As data saturation was not reached, we sought deeper insights into the themes by contacting the remaining 16 participants from the pilot study.Ten agreed to participate in additional semistructured interviews.Reasons for declining included being too busy (N = 4) or not interested (N = 4).Others provided no reason or were unreachable (N = 9).One participant agreed at first, but was unreachable afterward.

Focus groups
The duration of both focus groups was 90 min.The topic list of the focus groups was based on previous research (e.g., Liverpool et al., 2020;Mar et al., 2014) and the current research question, and was used to roughly structure the focus groups (See Appendix A).Open-ended questions were used to initiate discussions and offer room for deviation into other topics, and follow-up questions were used to gain a more profound comprehension of the participants' perspectives (Rubin and Rubin, 2005).The discussions were moderated by a clinical  psychologist/researcher (MW) and a child psychologist/researcher (JE).

Semi-structured interviews
To add more depth to the topics discussed in the focus groups, complementary individual semi-structured interviews were held, which lasted 24 to 57 min.The topic list was similar to the one used in the focus groups, but some additional questions were added based on outcomes of the focus groups.Each interview was conducted by a child psychologist/ researcher (JE), and a research assistant was present during most interviews.

Data analyses
All audio-files were transcribed anonymously and texts were analyzed using reflexive thematic analysis (TA; Braun and Clarke, 2006).TA is described as "a method for identifying, analyzing and reporting patterns (themes) within data" (Braun and Clarke, 2006;page 79).In reflexive TA, meaningful themes are identified and analyzed by the use of structured steps (Braun and Clarke, 2006).It was chosen for its flexibility, systematic approach, and ability to identify and analyze patterns within qualitative data, making it well-suited to explore the perspectives and experiences shared by the adolescents.First, one researcher (JE) became familiar with the data and generated initial codes using MAXQDA 2022 (VERBI software, 2021).Subsequently, two researchers (JE, MW) developed the coding framework and coded the data.Third, two researchers (JE, MW) identified themes, which they reviewed in relation to the codes and the data set.Finally, they differentiated the themes into subthemes.The analyses were reviewed, revised, and discussed with CC and MN.Disagreement between authors was resolved through comments, feedback, and in-depth discussions of the themes until consensus was reached.Descriptive analyses of quantitative data were performed with IBM SPSS Statistis, version 28.0.

Results
The reflexive TA resulted in five main themes, with a total of 12 subthemes (see Table 2), which are discussed below.

Theme (1) Independence
The first theme 'independence' included the subthemes: 'advantages of independence' and 'disadvantages of independence'.See Table 3 for illustrative quotes per subtheme.

Advantages of independence
Several advantages of the independent nature of internet-based treatment were brought up: adolescents liked being able to work on their mental health issues on their own 1 .The independent nature of internet-based treatment would provide them more self-direction over their therapy compared to regular face-to-face treatment.Moreover, having the option to choose specific aspects of an intervention was mentioned as a benefit 2 .

Disadvantages of independence
On the other hand, adolescents also expressed challenges related to independence in internet-based treatment.The experience of completing treatment independently was linked to the feeling of having to complete homework 3 .Adolescents noted they may struggle to stay engaged and motivated when completing internet-based treatment, without the same level of encouragement often provided in face-to-face settings 4,5 .Another concern raised was the risk of forgetting or postponing to log in.Some preferred the structure of face-to-face therapy, with set appointments and follow-up from a therapist.

Convenience
Adolescents emphasized the convenience and practicality of internet-based treatment.This form of treatment would be less time consuming and suits their busy schedules, due to the absence of physical   appointments and travel time 6 .Additionally, some adolescents stressed the convenience of staying at home, where they feel secure 7 .Others mentioned that avoiding the additional effort of leaving the house enables more focus on the therapy itself.

Availability
Adolescents mentioned the benefits of availability of treatment: receiving help whenever needed.Internet-based treatments can provide immediate support, which traditional face-to-face therapy cannot always provide 8 .Some adolescents experience long waiting lists before receiving face-to-face treatments, causing additional stress and anxiety.Internet-based treatment may be beneficial during this waiting time 9 .

Psychoeducation
Having easily accessible information was stressed as one of the benefits of internet-based treatment 10 .The online psychoeducation could have the added advantage of reducing feelings of isolation for adolescents.Recognition in the description of mental health problems, experience stories, and videos could provide a sense of community for them 11 .Furthermore, one adolescent noted that it would be beneficial to provide parents online psychoeducational resources regarding their child's mental disorder 12 .

Acquiring new skills
Adolescents expressed that one of the main functions of this type of treatment was to acquire new skills: provide practical tools and strategies to help them cope with their mental health problems 13,14 .This could contribute to an overall sense of well-being.

Exercises
Adolescents frequently acknowledged exercises as an important aspect of internet-based treatment, but preferred them to be optional.They valued flexibility and indicated that they would feel constrained if completion of all exercises was required for program advancement.While some adolescents preferred exercises within the platform, others suggested practicing in real-life could be more effective 15,16 .Regarding homework exercises, some found these beneficial for addressing issues outside sessions, while others disliked them due to associations with school-related stress 17,18 .

Personalization
Some of the adolescents with prior experience with internet-based treatment mentioned that standard modules were not tailored to their needs 19 .Rather than offering restrictive, obligatory exercises, they suggested that a broad range of exercises should be available, leaving room for tailoring to the individual's needs and pace 20 .

Therapeutic relationship
Most adolescents felt that internet-based treatment lacks the personal connection that comes with face-to-face therapy.By some, internet-based therapy was perceived as being too mechanical and unnatural to replace face-to-face therapy 21 .Interpreting tone and emotion was perceived as more challenging in an online environment.
Most adolescents mentioned that internet-based therapy could provide a sense of safety and security that face-to-face therapy may lack.Anonymity and physical distance provided by the screen may make it  easier for people to express themselves 22 .The online nature would allow for a more thoughtful and edited expression of thoughts and emotions.This was perceived as particularly beneficial for those with difficulties expressing themselves verbally, such as adolescents with anxiety.Some stated that building a therapeutic relationship in an internetbased treatment was not possible for them, or that the bond would not be as strong as in face-to-face therapy 23 .Others mentioned that it would be possible, similar to forming close relationships with online friends 24 .

Guidance
Almost all adolescents preferred guided internet-based treatment over self-help 25 .Feedback provides a sense of human contact, can provide a framework, helps them track their progress in the treatment, and informs them whether they are on the right track or not.Some preferred to receive online feedback through a chat function within the online platform or email, while others preferred face-to-face feedback 26,27 .

Design
Adolescents brought up the importance of having a clear, organized design for the internet-based platform, which should be easy to follow and navigate through 28 .The majority of adolescents preferred softer, more calming colors, such as pastels or muted natural colors.Specifically red and black were mentioned to be avoided, being associated with failure or negativism, and a depressed mood, respectively 29 .Some adolescents desired the ability to personalize and customize the look of the internet-based platform 30 .

Device
Some adolescents found it more convenient to use an app on their mobile phone, which allows for setting reminders and engaging wherever and whenever they have a spare moment 31,32 .Others preferred following internet-based treatment from a laptop or computer, which would be more organized, easier to read and write on, and may be less distracting than a mobile phone 33 .

General findings
This study aimed to explore preferences and perceived barriers for internet-based treatment among adolescents with anxiety or depressive disorder.Focus groups and semi-structured interviews revealed five main themes, which are discussed below.
The first theme that came forward was 'independence', with the subthemes 'advantages of independence' and 'disadvantages of independence'.One of the perceived advantages of independence was selfdirection over one's therapy, in line with earlier research among youths (Hollis et al., 2017).Perceived disadvantages included the lack of structured appointments, and motivational challenges, especially for depressed adolescents.A review concluded that many children and adolescents with mental health problems do not participate in internetbased treatment due to time constraints (Liverpool et al., 2020).Our study indicates that adolescents with anxiety or depressive disorder may not experience difficulties in "having time", but rather in "making time" (e.g., self-motivation).
The second theme was 'accessibility'.The first subtheme 'convenience' highlights the time-saving nature and compatibility of internetbased treatment with busy schedules, which is also a commonly cited advantage among adults (e.g., Andersson and Titov, 2014).The second subtheme that came forward was 'availability' of internet-based treatment.Adolescents greatly appreciated the idea of starting with internetbased treatment while waiting for face-to-face treatment, which corresponds with professional Dutch guidelines that consider e-health highly suitable for waitlist support among youths (Akwa, 2022).However, the current provision of internet-based interventions for adolescents during the waiting period remains limited.A survey among U.S. therapists indicated that only a minority currently uses internet-based treatment as a waiting list intervention, despite a widespread willingness to do so (Peipert et al., 2022).
The third theme that arose was 'content', with subthemes 'psychoeducation', 'acquiring new skills', 'exercises', and 'personalization'.In line with a recent study (Leigh et al., 2023), adolescents mentioned that psychoeducation could potentially reduce feelings of isolation, for example by experience stories.Additionally, offering practical tools to acquire new skills and thereby increase coping and well-being was considered important.Views on exercises and homework in internetbased treatment varied.Homework engagement is associated with positive clinical outcomes (e.g., Mausbach et al., 2010), and online homework has been suggested as a possible solution to improve engagement (e.g., Bunnell et al., 2021).However, although some of our participants emphasized the importance of exercises or homework, others found them restricting and stressful.In the final subtheme, 'personalization', adolescents emphasized the need for tailored modules, aligning with previous research (Garrido et al., 2019;Liverpool et al., 2020).
The fourth theme was 'therapist contact', with the subthemes 'therapeutic relationship' and 'guidance'.Adolescents discussed the potential benefits of the online environment in terms of safety and anonymity.This aligns with a meta-analysis into digital health interventions among children and adolescents, in which reduced stigma arose as a benefit (Hollis et al., 2017).However, most adolescents found it difficult to build a therapeutic relationship online, which corresponds to studies showing that adolescents have a strong desire to connect with 'real people' and can feel alone in internet-based treatment (Mar et al., 2014;Liverpool et al., 2020).In the present study, a majority preferred guided internet-based treatment over self-help, with some favoring online guidance and a majority leaning toward face-to-face guidance (i.e., blended care).These preferences align with better outcomes of guided internet-based treatment compared to self-help internet-based treatment among adolescents (Grist et al., 2018) and research demonstrating clinician support to enhance adherence to internet-based treatment among adults with anxiety and depression (Richards and Richardson, 2012).The final theme that arose was 'appearance', with the subthemes 'design' and 'device'.Adolescents emphasized the importance of a clear, organized design, in line with a study among a community sample of adolescents and young adults (Garrido et al., 2019).Some mentioned they would prefer to personalize their own internet-based environment, which was also highlighted during the co-design process of a new digital mental health platform for youth (Ludlow et al., 2023).Preferences for devices were diverse, with some favoring mobile phones for convenience, while others preferred laptops or computers for a more formal, organized, and less distracting experience.

Strengths and limitations
Strengths of this study include the combination of focus groups and semi-structured interviews, offering insights into both group dynamics and in-depth individual perspectives.Second, unlike many qualitative studies that focus on the feasibility of specific internet-based interventions, this study takes a broader approach by exploring general views, preferences and barriers to internet-based treatment.Further, the inclusion of participants of a clinical population with common mental disorders and with varied levels of experience with internet-based treatment provides a more comprehensive understanding of the target population.This study also has a number of limitations.The findings may have limited transferability due to the specific context and sample characteristics, which should be considered when applying the results to other settings.Furthermore, a potential selection bias may exist as only adolescents willing to participate were included.Additionally, preconceptions may have influenced the coding process, potentially impacting the confirmability of the results.Further, focus groups and interviews were conducted via videoconference, and while videoconferencing can yield data quality comparable to face-to-face methods, it presents challenges such as technical issues and difficulties in observing non-verbal cues (Almujlli et al., 2022).Finally, while the inclusion of adolescents with diverse levels of experience in internet-based treatment is considered a strength, it may also have introduced unexamined differences in perspectives based on group characteristics.

Recommendations
First of all, preferences differ substantially between adolescents and further research is needed to explore preferences among different subgroups of adolescents, taking into account various patient characteristics.Results of our study show that personalization of interventions is important to align with their different needs and desires.Self-motivation came forward as one of the most important barriers for internet-based treatment.Sustaining participant motivation through strategies, such as additional reminders (e.g., Achilles et al., 2020), is thus of great importance.Further, to alleviate stress, keeping homework exercises optional and encouraging in-session practice is recommended.Another important recommendation is to develop guided forms of internet-based treatment, preferably with at least one face-to-face or videoconference session with a therapist next to online feedback.Considering the divided preferences regarding type of device, internet-based interventions should be compatible on both mobile phones and computers.Furthermore, adolescents suggested already starting with internet-based treatment during the often alarmingly long waiting lists.Currently, internetbased interventions as waiting list care for adolescents is not yet widely disseminated, while these interventions are well-suited for utilization during the waiting period.

Conclusions
In conclusion, developing internet-based interventions for adolescents with anxiety and depressive disorders is a complex task.The findings from this study highlight the need for thoughtful consideration of the unique needs and preferences of this specific target population.The study highlights the importance of personalized, guided internetbased interventions to address adolescents' diverse needs and motivational barriers.Furthermore, it is advisable to create interventions compatible on both mobile phones and computers, and implement them during the waiting period for treatment.The preferences indicated in the current study may enhance the development and implementation of novel internet-based interventions for the treatment of anxiety and/or depressive disorders.
E: "Before I could talk to someone, I was on a kind of waiting list, so then you could do it, for example[internetbased treatment].At that time, I didn't know what was wrong with me, so I was already stressing out about what was happening to me.(…) I think that would be very good."Note: E: Previous experience with internet-based treatment; NE: No experience with internet-based treatment; SI: Semi-structured interview participant; FG: Focus group participant.
NE: "If you're struggling with something or something is going on, you can open the module and look it up."11 Participant 12 SI, E: "Well, I have seen videos of people who have a little bit the same thing as I have, well that helps a bit because then you know you're not alone."12 Participant 12 SI, E: "And, for example, explaining to my parents what's going on.They don't need to know exactly how I feel or whether I'm super depressed this week.I don't want to discuss that with them.But they do need to know what's going on, you know."E: "It's much less helpful for me to have a platform that is very specific.I would rather have a very large platform.So people don't feel like they're being put into boxes or that it's forced upon them, so that you have all the freedom to choose."Note: E: Previous experience with internet-based treatment; NE: No experience with internet-based treatment; SI: Semi-structured interview participant; FG: Focus group participant.
E: "If you fill something out online, you should also receive online feedback."27 Participant 9 FG, NE: "I think if you get feedback in person, it's more valuable and sticks better with people, and it doesn't feel very formal, which has less of an effect."Note: E: Previous experience with internet-based treatment; NE: No experience with internet-based treatment; SI: Semi-structured interview participant; FG: Focus group participant.

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If you were to follow an internet-based treatment for depressive or anxiety complaints, what components would you like to see in it?• What kind of content or information should be included?➔ What do you consider most important?➔ What would you rather NOT see in an internet-based treatment?• What are your thoughts on exercises in an internet-based treatment?➔ Can you further explain your view?• What are your thoughts on homework in an internet-based treatment?➔ Can you further explain your view?c.Guidance • What is your view on guidance in internet-based treatment?• Would you like to receive feedback from a therapist during internetbased treatment?➔ Why would you like this/would you not like this? ➔ What do you think of complete self-help without the possibility of contact with a therapist?➔ Why? • Do you consider it possible to build a relationship with your therapist if you follow a treatment that is entirely internet-based, in which your therapist provides feedback on your exercises via chat or email?➔ Why or why not? d.Other • What device would you prefer to use for following an internet-based treatment?➔ Why do you prefer this? ➔ What are the advantages and disadvantages of the different options for you?• What should an internet-based treatment platform look like?