Randomized Controlled Trial of Web-Based Treatment of Social Phobia Without Clinician Guidance

Posttreatment attrition and its predictors, attrition bias, and treatment efficacy of the anxiety online programs

Background

Although relatively new, the field of e-mental health is becoming more popular with more attention given to researching its various aspects. However, there are many areas that still need further research, especially identifying attrition predictors at various phases of assessment and treatment delivery.

Objective

The present study identified the predictors of posttreatment assessment completers based on 24 pre- and posttreatment demographic and personal variables and 1 treatment variable, their impact on attrition bias, and the efficacy of the 5 fully automated self-help anxiety treatment programs for generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder with or without agoraphobia (PD/A), obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD).

Methods

A complex algorithm was used to diagnose participants’ mental disorders based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision; DSM-IV-TR). Those who received a primary or secondary diagnosis of 1 of 5 anxiety disorders were offered an online 12-week disorder-specific treatment program. A total of 3199 individuals did not formally drop out of the 12-week treatment cycle, whereas 142 individuals formally dropped out. However, only 347 participants who completed their treatment cycle also completed the posttreatment assessment measures. Based on these measures, predictors of attrition were identified and attrition bias was examined. The efficacy of the 5 treatment programs was assessed based on anxiety-specific severity scores and 5 additional treatment outcome measures.

Results

On average, completers of posttreatment assessment measures were more likely to be seeking self-help online programs; have heard about the program from traditional media or from family and friends; were receiving mental health assistance; were more likely to learn best by reading, hearing and doing; had a lower pretreatment Kessler-6 total score; and were older in age. Predicted probabilities resulting from these attrition variables displayed no significant attrition bias using Heckman’s method and thus allowing for the use of completer analysis. Six treatment outcome measures (Kessler-6 total score, number of diagnosed disorders, self-confidence in managing mental health issues, quality of life, and the corresponding pre- and posttreatment severity for each program-specific anxiety disorder and for major depressive episode) were used to assess the efficacy of the 5 anxiety treatment programs. Repeated measures MANOVA revealed a significant multivariate time effect for all treatment outcome measures for each treatment program. Follow-up repeated measures ANOVAs revealed significant improvements on all 6 treatment outcome measures for GAD and PTSD, 5 treatment outcome measures were significant for SAD and PD/A, and 4 treatment outcome measures were significant for OCD.

Conclusions

Results identified predictors of posttreatment assessment completers and provided further support for the efficacy of self-help online treatment programs for the 5 anxiety disorders.

Trial Registration

Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG).

Online interventions for depression and anxiety - a systematic review

Background: Access to mental health care is limited. Internet-based interventions (IBIs) may help bridge that gap by improving access especially for those who are unable to receive expert care. Aim: This review explores current research on the effectiveness of IBIs for depression and anxiety. Results: For depression, therapist-guided cognitive behavioral therapy (CBT) had larger effect sizes consistently across studies, ranging from 0.6 to 1.9; while stand-alone CBT (without therapist guidance) had a more modest effect size of 0.3–0.7. Even other interventions for depression (non-CBT/non-randomized controlled trial (RCT)) showed modestly high effect sizes (0.2–1.7). For anxiety disorders, studies showed robust effect sizes for therapist-assisted interventions with effect sizes of 0.7–1.7 (efficacy similar to face-to-face CBT) and stand-alone CBT studies also showed large effect sizes (0.6–1.7). Non-CBT/Non-RCT studies (only 3) also showed significant reduction in anxiety scores at the end of the interventions. Conclusion: IBIs for anxiety and depression appear to be effective in reducing symptomatology for both depression and anxiety, which were enhanced by the guidance of a therapist. Further research is needed to identify various predictive factors and the extent to which stand-alone Internet therapies may be effective in the future as well as effects for different patient populations.

Pretreatment attrition and formal withdrawal during treatment and their predictors: an exploratory study of the anxiety online data

BACKGROUND

Although in its infancy, the field of e-mental health interventions has been gaining popularity and afforded considerable research attention. However, there are many gaps in the research. One such gap is in the area of attrition predictors at various stages of assessment and treatment delivery.

OBJECTIVE

This exploratory study applied univariate and multivariate analysis to a large dataset provided by the Anxiety Online (now called Mental Health Online) system to identify predictors of attrition in treatment commencers and in those who formally withdrew during treatment based on 24 pretreatment demographic and personal variables and one clinical measure.

METHODS

Participants were assessed using a complex online algorithm that resulted in primary and secondary diagnoses in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Those who received a primary or secondary diagnosis of 1 of 5 anxiety disorders (generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and panic disorder) were offered an online 12-week disorder-specific treatment program.

RESULTS

Of 9394 potential participants, a total of 3880 clients enrolled and 5514 did not enroll in one of the treatment programs following the completion of pretreatment assessment measures (pretreatment attrition rate: 58.70%). A total of 3199 individuals did not formally withdraw from the 12-week treatment cycle, whereas 142 individuals formally dropped out (formal withdrawal during treatment dropout rate of 4.25%). The treatment commencers differed significantly (P<.001-.03) from the noncommencers on several variables (reason for registering, mental health concerns, postsecondary education, where first heard about Anxiety Online, Kessler-6 score, stage of change, quality of life, relationship status, preferred method of learning, and smoking status). Those who formally withdrew during treatment differed significantly (P=.002-.03) from those who did not formally withdraw in that they were less likely to express concerns about anxiety, stress, and depression; to rate their quality of life as very poor, poor, or good; to report adequate level of social support; and to report readiness to make or were in the process of making changes.

CONCLUSIONS

This exploratory study identified predictors of pretreatment attrition and formal withdrawal during treatment dropouts for the Anxiety Online program.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG).

Internet-based individually versus group guided self-help treatment for social anxiety disorder: protocol of a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) is one of the most common mental disorders and causes subjective suffering and economic burden worldwide. Although effective treatments are available, a lot of cases go untreated. Internet-based self-help is a low-threshold and flexible treatment alternative for SAD. Various studies have already shown that internet-based self-help can be effective to reduce social phobic symptoms significantly. Most of the interventions tested include therapist support, whereas the role of peer support within internet-based self-help has not yet been fully understood. There is evidence suggesting that patients' mutual exchange via integrated discussion forums can increase the efficacy of internet-based treatments. This study aims at investigating the added value of therapist-guided group support on the treatment outcome of internet-based self-help for SAD.

METHODS/DESIGN

The study is conducted as a randomized controlled trial. A total of 150 adults with a diagnosis of SAD are randomly assigned to either a waiting-list control group or one of the active conditions. The participants in the two active conditions use the same internet-based self-help program, either with individual support by a psychologist or therapist-guided group support. In the group guided condition, participants can communicate with each other via an integrated, protected discussion forum. Subjects are recruited via topic related websites and links; diagnostic status will be assessed with a telephone interview. The primary outcome variables are symptoms of SAD and diagnostic status after the intervention. Secondary endpoints are general symptomology, depression, quality of life, as well as the primary outcome variables 6 months later. Furthermore, process variables such as group processes, the change in symptoms and working alliance will be studied.

DISCUSSION

The results of this study should indicate whether group-guided support could enhance the efficacy of an internet-based self-help treatment for SAD. This novel treatment format, if shown effective, could represent a cost-effective option and could further be modified to treat other conditions, as well.

TRIAL REGISTRATION

ISRCTN75894275.

Uptake and adherence of a self-directed internet-based mental health intervention with tailored e-mail reminders in senior high schools in Norway

BACKGROUND

Internet-based cognitive behavioural therapy (ICBT) is a promising approach to the prevention and reduction of depressive symptoms among adolescents. This study aimed to evaluate the feasibility and efficacy of disseminating a self-directed internet-based mental health intervention (MoodGYM) in senior high schools. It also sought to investigate possible effects of tailored and weekly e-mail reminders on initial uptake and adherence to the intervention.

METHOD

A baseline survey was conducted in four senior high schools in two Norwegian municipalities (n = 1337). 52.8% (707/1337) of the students consented to further participation in the trial and were randomly allocated to one of three MoodGYM intervention groups (tailored weekly e-mail reminder (n = 175), standardized weekly e-mail reminder (n = 176 ) or no e-mail reminder (n = 175)) or a waitlist control group (n = 180). We tested for effects of the intervention on depression and self-esteem using multivariate analysis of variance, effects of tailored e-mail and self-reported current need of help on initial uptake of the intervention using logistic regression and the effect of weekly e-mails on adherence using ordinal regression.

RESULTS

There was substantial non-participation from the intervention, with only 8.5% (45/527) participants logging on to MoodGYM, and few proceeding beyond the first part of the programme. No significant effect on depression or self-esteem was found among the sample as a whole or among participants with elevated depression scores at baseline. Having a higher average grade in senior high school predicted initial uptake of the intervention, but tailored e-mail and self-reported current need of help did not. Weekly e-mail prompts did not predict adherence. The main reasons for non-use reported were lack of time/forgetting about it and doubt about the usefulness of the program.

CONCLUSION

Overall, disseminating a self-directed internet-based intervention to a school population proved difficult despite steps taken to reduce barriers in terms of tailoring feedback and dispatching weekly e-mail reminders. Providing mental health interventions within the school environment is likely to ensure better uptake among senior high school students, but there is a need to effectively communicate that such programmes can be helpful.

TRIAL REGISTRATION

The trial was registered retrospectively as ACTRN12612001106820.

A feasibility open trial of internet-delivered cognitive-behavioural therapy (iCBT) among consumers of a non-governmental mental health organisation with anxiety

Background. To date the efficacy and acceptability of internet-delivered cognitive behavioural treatments (iCBT) has been examined in clinical trials and specialist facilities. The present study reports the acceptability, feasibility and preliminary efficacy of an established iCBT treatment course (the Wellbeing Course) administered by a not-for-profit non-governmental organisation, the Mental Health Association (MHA) of New South Wales, to consumers with symptoms of anxiety.

Methods. Ten individuals who contacted the MHA’s telephone support line or visited the MHA’s website and reported at least mild symptoms of anxiety (GAD-7 total scores ≥5) were admitted to the study. Participants were provided access to the Wellbeing Course, which comprises five online lessons and homework assignments, and brief weekly support from an MHA staff member via telephone and email. The MHA staff member was an experienced mental health professional and received minimal training in administering the intervention.

Results. All 10 participants completed the course within the 8 weeks. Post-treatment and two month follow-up questionnaires were completed by all participants. Mean within-group effect sizes (Cohen’s d) for the Generalized Anxiety Disorder 7 Item (GAD-7) and Patient Health Questionnaire 9 Item (PHQ-9) were large (i.e., > .80) and consistent with previous controlled research. The Course was also rated as highly acceptable with all 10 participants reporting it was worth their time and they would recommend it to a friend.

Conclusions. These results provide support for the potential clinical utility of iCBT interventions and the acceptability and feasibility of employing non-governmental mental health organisations to deliver these treatments. However, further research is needed to examine the clinical efficacy and cost-effectiveness of delivering iCBT via such organisations.

Media-delivered cognitive behavioural therapy and behavioural therapy (self-help) for anxiety disorders in adults

BACKGROUND

Anxiety disorders are the most common mental health problems. They are chronic and unremitting. Effective treatments are available, but access to services is limited. Media-delivered behavioural and cognitive behavioural interventions (self-help) aim to deliver treatment with less input from professionals compared with traditional therapies.

OBJECTIVES

To assess the effects of media-delivered behavioural and cognitive behavioural therapies for anxiety disorders in adults.

SEARCH METHODS

Published and unpublished studies were considered without restriction by language or date. The Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR) was searched all years to 1 January 2013. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Complementary searches were carried out on Ovid MEDLINE (1950 to 23 February 2013) and PsycINFO (1987 to February, Week 2, 2013), together with International trial registries (the trials portal of the World Health Organization (ICTRP) and ClinicalTrials.gov). Reference lists from previous meta-analyses and reports of randomised controlled trials were checked, and authors were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials of media-delivered behavioural or cognitive behavioural therapy in adults with anxiety disorders (other than post-traumatic stress disorder) compared with no intervention (including attention/relaxation controls) or compared with face-to-face therapy.

DATA COLLECTION AND ANALYSIS

Both review authors independently screened titles and abstracts. Study characteristics and outcomes were extracted in duplicate. Outcomes were combined using random-effects models, and tests for heterogeneity and for small study bias were conducted. We examined subgroup differences by type of disorder, type of intervention provided, type of media, and recruitment methods used.

MAIN RESULTS

One hundred and one studies with 8403 participants were included; 92 studies were included in the quantitative synthesis. These trials compared several types of media-delivered interventions (with varying levels of support) with no treatment and with face-to-face interventions. Inconsistency and risk of bias reduced our confidence in the overall results. For the primary outcome of symptoms of anxiety, moderate-quality evidence showed medium effects compared with no intervention (standardised mean difference (SMD) 0.67, 95% confidence interval (CI) 0.55 to 0.80; 72 studies, 4537 participants), and low-quality evidence of small effects favoured face-to-face therapy (SMD -0.23, 95% CI -0.36 to -0.09; 24 studies, 1360 participants). The intervention was associated with greater response than was seen with no treatment (risk ratio (RR) 2.34, 95% CI 1.81 to 3.03; 21 studies, 1547 participants) and was not significantly inferior to face-to-face therapy in these studies (RR 0.78, 95 % CI 0.56 to 1.09; 10 studies, 575 participants), but the latter comparison included versions of therapies that were not as comprehensive as those provided in routine clinical practice. Evidence suggested benefit for secondary outcome measures (depression, mental-health related disability, quality of life and dropout), but this evidence was of low to moderate quality. Evidence regarding harm was lacking.

AUTHORS' CONCLUSIONS

Self-help may be useful for people who are not able or are not willing to use other services for people with anxiety disorders; for people who can access it, face-to-face cognitive behavioural therapy is probably clinically superior. Economic analyses were beyond the scope of this review.Important heterogeneity was noted across trials. Recent interventions for specific problems that incorporate clinician support may be more effective than transdiagnostic interventions (i.e. interventions for multiple disorders) provided with no guidance, but these issues are confounded in the available trials.Although many small trials have been conducted, the generalisability of their findings is limited. Most interventions tested are not available to consumers. Self-help has been recommended as the first step in the treatment of some anxiety disorders, but the short-term and long-term effectiveness of media-delivered interventions has not been established. Large, pragmatic trials are needed to evaluate and to maximise the benefits of self-help interventions.

A naturalistic study of the acceptability and effectiveness of internet-delivered cognitive behavioural therapy for psychiatric disorders in older australians

Objectives

The current study investigates the acceptability, effectiveness and uptake of internet-delivered cognitive behavioural therapy (iCBT) amongst older individuals (>60 years) seeking psychiatric treatment in general practice.

Methods

The sample consisted of 2413 (mean age 39.5; range 18–83 years) patients prescribed iCBT through This Way Up clinic by their primary care clinician. The intervention consisted of six fully automated, unassisted online lessons specific to four disorders major depression, generalised anxiety disorder, panic disorder or social phobia. Patients were categorised into five age groups (18–29 years, 30–39 years, 40–49 years, 50–59 years, 60 years and above). 225 (9.3%) patients were aged over 60 years. Analyses were conducted across the four disorders to ensure sufficient sample sizes in the 60 years and older age group. Age differences in adherence to the six lesson courses were assessed to demonstrate acceptability. Age-based reductions in psychological distress (Kessler Psychological Distress Scale; K10) and disability (the World Health Organisation Disability Assessment Schedule; WHODAS-II) were compared to demonstrate effectiveness. To evaluate the uptake of iCBT, the age distribution of those commencing iCBT was compared with the prevalence of these disorders in the 2007 Australian National Survey of Mental Health and Well-Being.

Results

Older adults were more likely to complete all six lessons when compared with their younger counterparts. Marginal model analyses indicated that there were significant reductions in the K10 and WHODAS-II from baseline to post-intervention, regardless of age (p<0.001). The measurement occasion by age interactions were not significant, indicating that individuals showed similar reductions in the K10 and WHODAS-II regardless of age. In general, the age distribution of individuals commencing the iCBT courses matched the age distribution of the four diagnoses in the Australian general population, indicating that iCBT successfully captures older individuals who need treatment.

Conclusion

iCBT is effective and acceptable for use in older populations.

Persuasive system design does matter: a systematic review of adherence to web-based interventions

Background

Although web-based interventions for promoting health and health-related behavior can be effective, poor adherence is a common issue that needs to be addressed. Technology as a means to communicate the content in web-based interventions has been neglected in research. Indeed, technology is often seen as a black-box, a mere tool that has no effect or value and serves only as a vehicle to deliver intervention content. In this paper we examine technology from a holistic perspective. We see it as a vital and inseparable aspect of web-based interventions to help explain and understand adherence.

Objective

This study aims to review the literature on web-based health interventions to investigate whether intervention characteristics and persuasive design affect adherence to a web-based intervention.

Methods

We conducted a systematic review of studies into web-based health interventions. Per intervention, intervention characteristics, persuasive technology elements and adherence were coded. We performed a multiple regression analysis to investigate whether these variables could predict adherence.

Results

We included 101 articles on 83 interventions. The typical web-based intervention is meant to be used once a week, is modular in set-up, is updated once a week, lasts for 10 weeks, includes interaction with the system and a counselor and peers on the web, includes some persuasive technology elements, and about 50% of the participants adhere to the intervention. Regarding persuasive technology, we see that primary task support elements are most commonly employed (mean 2.9 out of a possible 7.0). Dialogue support and social support are less commonly employed (mean 1.5 and 1.2 out of a possible 7.0, respectively). When comparing the interventions of the different health care areas, we find significant differences in intended usage (p = .004), setup (p < .001), updates (p < .001), frequency of interaction with a counselor (p < .001), the system (p = .003) and peers (p = .017), duration (F = 6.068, p = .004), adherence (F = 4.833, p = .010) and the number of primary task support elements (F = 5.631, p = .005). Our final regression model explained 55% of the variance in adherence. In this model, a RCT study as opposed to an observational study, increased interaction with a counselor, more frequent intended usage, more frequent updates and more extensive employment of dialogue support significantly predicted better adherence.

Conclusions

Using intervention characteristics and persuasive technology elements, a substantial amount of variance in adherence can be explained. Although there are differences between health care areas on intervention characteristics, health care area per se does not predict adherence. Rather, the differences in technology and interaction predict adherence. The results of this study can be used to make an informed decision about how to design a web-based intervention to which patients are more likely to adhere.

Does a pre-treatment diagnostic interview affect the outcome of internet-based self-help for social anxiety disorder? a randomized controlled trial

BACKGROUND

Numerous studies suggest that Internet-based self-help treatments are effective in treating anxiety disorders. Trials evaluating such interventions differ in their screening procedures and in the amount of clinician contact in the diagnostic assessment phase. The present study evaluates the impact of a pre-treatment diagnostic interview on the outcome of an Internet-based treatment for Social Anxiety Disorder (SAD).

METHOD

One hundred and nine participants seeking treatment for SAD were randomized to either an interview-group (IG, N = 53) or to a non-interview group (NIG, N = 56). All participants took part in the same 10-week cognitive-behavioural unguided self-help programme. Before receiving access to the programme, participants of the IG underwent a structured diagnostic interview. Participants of the NIG started directly with the programme.

RESULTS

Participants in both groups showed significant and substantial improvement on social anxiety measures from pre- to post-assessment (d IG = 1.30-1.63; d NIG = 1.00-1.28) and from pre- to 4-month follow-up assessment (d IG = 1.38-1.87; d NIG = 1.10-1.21). Significant between-groups effects in favour of the IG were found on secondary outcome measures of depression and general distress (d = 0.18-0.42).

CONCLUSIONS

These findings suggest that Internet-based self-help is effective in treating SAD, whether or not a diagnostic interview is involved. However, the pre-treatment interview seems to facilitate change on secondary outcomes such as depression and general distress.

Client Contact in Self-Help Therapy for Anxiety and Depression: Necessary But Can Take a Variety of Forms Beside Therapist Contact

Self-administered therapies (SATs) have been promoted as a way to increase access to evidence-based mental health services. Recent meta-analyses and literature reviews suggest that SATs with clinical guidance are more effective than SATs with no contact for the treatment of anxiety and depression. However, little attention has been paid to the role of nonguidance contact, contact that does not involve the provision of assistance in the application of specific therapy techniques such as emails to encourage treatment adherence. The present article examines the impact of nonguidance contact on the outcomes of SATs for anxiety and depression. Electronic databases were searched to identify studies conducted over the past two decades by independent research teams that have tested cognitive-behavioural SATs over multiple trials. Findings suggest that the involvement or guidance of a therapist is not essential for SATs to produce significant benefits as long as nonguidance contact is provided. It is suggested that even very minimal levels of nonguidance contact increase SAT's outcomes by motivating treatment engagement and improving adherence. The benefit of SATs that can be accessed directly by large numbers of individuals and that do not require therapist involvement to ensure efficacy can potentially significantly increase the cost effectiveness and quality of mental health service delivery.

Therapist experience and knowledge acquisition in internet-delivered CBT for social anxiety disorder: a randomized controlled trial

Background

Guided internet-delivered cognitive behavior therapy (ICBT) has been tested in several trials on social anxiety disorder (SAD) with moderate to large effects. The aims of this study were threefold. First, to compare the effects of ICBT including online discussion forum with a moderated online discussion forum only. Second, to investigate if knowledge about SAD increased following treatment and third to compare the effects of inexperienced versus experienced therapists on patient outcomes.

Methods

A total of 204 participants with a primary diagnosis of SAD were included and randomized to either guided ICBT or the control condition. ICBT consisted of a 9-week treatment program which was guided by either psychology students at MSc level (n = 6) or by licensed psychologists with previous experience of ICBT (n = 7). A knowledge test dealing with social anxiety was administered before and after treatment. Measures of social anxiety and secondary outcomes dealing with general anxiety, depression, and quality of life were administered before and after treatment. In addition, a 1-year follow-up was conducted on the treated individuals.

Results

Immediately following treatment, the ICBT group showed superior outcome on the Liebowitz Social Anxiety Scale self-report version with a between group posttreatment Hedges g effect size of g = 0.75. In addition, significant differences on all the secondary outcomes were observed. Gains were well maintained one year later. Knowledge, as assessed by the knowledge test, increased following treatment with little gain in the control group. Therapist experience did not result in different outcomes, but experienced therapists logged in less frequently compared to the inexperienced therapists, suggesting that they needed less time to support patients.

Discussion

We conclude that guided ICBT reduce symptoms of SAD, increase knowledge about SAD and that therapist experience does not make a difference apart from the finding that experienced therapist may require less time to guide patients.

Trial Registration

UMIN.ac.jp UMIN000001383

Adherence as a determinant of effectiveness of internet cognitive behavioural therapy for anxiety and depressive disorders

Since 2009, the Clinical Research Unit for Anxiety and Depression (CRUfAD) has been providing primary care clinicians with internet cognitive behaviour therapy (iCBT) courses to prescribe to patients. Although these courses have demonstrated efficacy in research trials, adherence in primary care is less than half that of the research trials. The present studies pose three questions: first, do course non-completers drop out because of lack of efficacy? Second, can changes in delivery (e.g. adding choice, reminders and financial cost) improve adherence? Last, does clinician contact improve adherence? The results showed that non-completers derive benefit before dropping out; that adding reminders, choice of course and timing, and financial cost can significantly improve adherence; and that clinician contact during the course is associated with increased adherence. It is concluded that improved adherence is an important determinant of effectiveness.

Internet-based treatment of depression: a randomized controlled trial comparing guided with unguided self-help

Internet-delivered self-help for depression with therapist guidance has shown efficacy in several trials. Results from meta-analyses suggest that guidance is important and that self-help programs without support are less effective. However, there are no direct experimental comparisons between guided and unguided internet-based treatments for depression. The present study compared the benefits of a 10-week web-based unguided self-help treatment with the same intervention complemented with weekly therapist support via e-mail. A waiting-list control group was also included. Seventy-six individuals meeting the diagnostic criteria of major depression or dysthymia were randomly assigned to one of the three conditions. The Beck Depression Inventory (BDI-II) was used as the primary outcome measure. Secondary outcomes included general psychopathology, interpersonal problems, and quality of life. Sixty-nine participants (91%) completed the assessment at posttreatment and 59 (78%) at 6-month follow-up. Results showed significant symptom reductions in both treatment groups compared to the waiting-list control group. At posttreatment, between-group effect sizes on the BDI-II were d = .66 for unguided self-help versus waiting-list and d = 1.14 for guided self-help versus waiting-list controls. In the comparison of the two active treatments, small-to-moderate, but not statistically significant effects in favor of the guided condition were found on all measured dimensions. In both groups, treatment gains were maintained at 6-month follow-up. The findings provide evidence that internet-delivered treatments for depression can be effective whether support is added or not. However, all participants were interviewed in a structured diagnostic telephone interview before inclusion, which prohibits conclusions regarding unguided treatments that are without any human contact.

Effectiveness randomized controlled trial of face to face versus Internet cognitive behaviour therapy for social phobia

OBJECTIVE

To compare the effectiveness of Internet cognitive behaviour therapy (CBT) with face-to-face CBT in social phobia.

METHODS

Randomized controlled trial of 75 patients with social phobia referred to an anxiety disorders clinic. A total of 37 patients participated, and post-treatment data was obtained from 25 Subjects (Ss). An intention to treat analysis was used. The same therapist (M.D.) treated both groups.

RESULTS

Both groups made significant progress on symptoms and disability measures. There were no significant differences in outcome between the Internet and face-to-face groups. The total amount of therapist time required was 18 min per patient for the Internet group and 240 min per patient for the face-to-face group.

CONCLUSIONS

Both forms of treatment were equally effective and this is consistent with previous findings in depression and panic disorder. The difference in clinician time required was substantial. If Internet CBT was offered as 'standard of care' the staff time saved would permit a stepped care model in which in-depth therapy for the difficult to recover patients could be provided without an increase in staff.

Internet-delivered psychotherapy for depression in adults

PURPOSE OF REVIEW

The rapidly growing number of published research papers attests to the increasing interest in Internet-delivered psychotherapy (iPT). The present article reviews the current status of iPT for the treatment of adults with symptoms of depression.

RECENT FINDINGS

Randomized controlled trials have confirmed the efficacy of guided iPT in treating people with diagnosed or elevated symptoms of depression with equivalent results obtained by programs based on cognitive behavioural or problem solving models. With guidance, effect sizes are comparable to those obtained in face-to-face psychotherapy and low-intensity interventions are as effective as those with higher levels of therapist contact. On current evidence, entirely self-guided programs appear to have fewer benefits, but deliver tangible benefits to completers.

SUMMARY

Recent studies indicate the utility of iPT. Large-scale trials are needed to evaluate optimal strategies for disseminating iPT. Future studies should independently replicate findings and efforts are required to educate patients and health professionals about iPT.

Internet-based treatment of social phobia: a randomized controlled trial comparing unguided with two types of guided self-help

Internet-based self-help for social phobia with minimal therapist support via email have shown efficacy in several controlled trials by independent research teams. The role and necessity of therapist guidance is, however, still largely unclear. The present study compared the benefits of a 10-week web-based unguided self-help treatment for social phobia with the same intervention complemented with minimal, although weekly, therapist support via email. Further, a third treatment arm was included, in which the level of support was flexibly stepped up, from no support to email or telephone contact, on demand of the participants. Eighty-one individuals meeting diagnostic criteria for social phobia were randomly assigned to one of the three conditions. Primary outcome measures were self-report measures of symptoms of social phobia. Secondary outcome measures included symptoms of depression, interpersonal problems, and general symptomatology. Measures were taken at baseline, post-treatment, and at 6-month follow-up. Data from a telephone-administered diagnostic interview conducted at post-treatment were also included. Results showed significant symptom reductions in all three treatment groups with large effect sizes for primary social phobia measures (Cohen's d=1.47) and for secondary outcome measures (d=1.16). No substantial and significant between-groups effects were found on any of the measures (Cohen's d=00-.36). Moreover, no difference between the three conditions was found regarding diagnosis-free status, clinically significant change, dropout rates, or adherence measures such as lessons or exercises completed. These findings indicate that Internet-delivered treatment for social phobia is a promising treatment option, whether no support is provided or with two different types of therapist guidance.

Randomized controlled trial of Internet cognitive behavioural treatment for social phobia with and without motivational enhancement strategies

OBJECTIVE

The present study (Shyness 7) has two aims: Firstly, to replicate an earlier trial showing that a self-guided Internet treatment for social phobia is efficacious, and secondly, to examine whether the addition of self-guided motivational enhancement strategies improves completion rates and clinical outcomes.

METHOD

Randomized controlled trial (RCT) of self-guided Internet-based cognitive behavioural treatment (iCBT), or iCBT plus self-guided motivational enhancement strategies (iCBT+MS), was conducted. An intention-to-treat and last observation carried forward model was used for data analyses. The participants consisted of 108 volunteers with social phobia. The iCBT intervention consisted of two online lessons about symptoms and treatment of anxiety disorders and six lessons about management of social phobia (the Shyness programme) with complex automated reminders. The motivational intervention was based on traditional techniques including understanding and exploring ambivalence about change using a cost–benefit analysis, developing and resolving discrepancy between values and symptoms, and enhancing self-efficacy for change. The main outcome measures were the Social Interaction Anxiety Scale and Social Phobia Scale.

RESULTS

More iCBT+MS group participants completed the eight lessons than iCBT group participants (75% versus 56%, respectively), but there were no between-group differences in outcome measures at post-treatment or at 3 month follow up. Large mean within-groups effect sizes (Cohen's d) for the two social phobia measures were found for both the iCBT and iCBT+ MS groups (1.1 and 0.95, respectively), which were sustained at 3 month follow up (1.06 and 1.07, respectively). Both iCBT and iCBT+MS group participants reported that the procedures were highly acceptable.

CONCLUSIONS

Both self-guided versions of the Shyness programme were reliably efficacious, confirming that people with social phobia may significantly benefit from a highly structured self-guided intervention. The addition of motivational techniques increased completion rates but did not improve clinical outcomes or acceptability.

Is internet treatment for depressive and anxiety disorders ready for prime time?

Internet treatment programs for anxiety and depressive disorders are becoming available and offer cost-effective alternatives to face-to-face treatment with medication or cognitive behaviour therapy. The Clinical Research Unit for Anxiety and Depression at St Vincent's Hospital, Sydney, offers internet treatment courses at the VirtualClinic (http://www.virtualclinic.org.au) for people who meet diagnostic criteria for major depression, social phobia, panic disorder and generalised anxiety disorder. These courses are free to people recruited for research. The results of VirtualClinic trials show a high level of patient adherence and strong reductions in symptoms, and that very little clinician time is required. The four treatment programs that have been successfully evaluated in the VirtualClinic have been made available on a not-for-profit basis ($5 service fee) at the CRUfADclinic (http://www.crufadclinic.org) for general practitioners and other clinicians to use with their patients. These programs could be the first level of treatment in a stepped-care environment, where patients who do not benefit sufficiently could then receive face-to-face treatment from their clinician or be referred for specialist treatment.

Clinician-assisted Internet-based treatment is effective for panic: A randomized controlled trial

OBJECTIVE

To determine the efficacy of an Internet-based clinician-assisted cognitive behavioural treatment program (the Panic program) for panic disorder (with or without agoraphobia).

METHOD

Fifty-nine individuals meeting diagnostic criteria for panic disorder with agoraphobia were randomly assigned to a treatment group or to a waitlist control group. Treatment group participants completed the Panic program, comprising six on-line lessons, weekly homework assignments, received weekly email contact from a psychiatry registrar, and contributed to a moderated online discussion forum with other participants. An intention-to-treat model was used for data analyses.

RESULTS

Twenty-three (79%) of treatment group participants completed all lessons within the 8-week program, and post-treatment data were collected from 22/29 treatment group and 22/25 waitlist group participants. Compared to the control group, treatment group participants reported significantly reduced symptoms of panic as measured by the Panic Disorder Severity Scale, Body Sensation Questionnaire, and Agoraphobic Cognitions Questionnaires. Significant reductions were also reported on measures of disability and depression. The mean within- and between-group effect size (Cohen's d) on the Panic Disorder Severity Scale was 0.93 and 0.59, respectively, and effects were sustained at 1-month follow-up. Mean therapist time per participant was 75 minutes for the program.

CONCLUSIONS

These results replicate those from the open trial of the Panic Program indicating the efficacy of the Internet-based clinician-assisted cognitive behavioural treatment program for panic disorder with agoraphobia.

Characteristics of adults with anxiety or depression treated at an internet clinic: comparison with a national survey and an outpatient clinic

Background

There is concern that people seeking treatment over the Internet for anxiety or depressive disorders may not resemble the general population or have less severe disorders than patients attending outpatient clinics or cases identified in community surveys. Thus the response to treatment in Internet based trials might not generalize.

Methodology

We reviewed the characteristics of applicants to an Australian Internet-based treatment clinic for anxiety and depression, and compared this sample with people from a national epidemiological survey and a sample of patients at a specialist outpatient anxiety and depression clinic. Participants included 774 volunteers to an Internet clinic, 454 patients at a specialist anxiety disorders outpatient clinic, and 627 cases identified in a national epidemiological survey. Main measures included demographic characteristics, and severity of symptoms as measured by the Kessler 10-Item scale (K-10), the 12-item World Health Organisation Disability Assessment Schedule second edition (WHODAS-II), the Penn State Worry Questionnaire (PSWQ), the Body Sensations Questionnaire (BSQ), the Automatic Cognitions Questionnaire (ACQ), the Social Interaction Anxiety Scale (SIAS) and the Social Phobia Scale (SPS).

Principal Findings

The severity of symptoms of participants attending the two clinics was similar, and both clinic samples were more severe than cases in the epidemiological survey. The Internet clinic and national samples were older and comprised more females than those attending the outpatient clinic. The Internet clinic sample were more likely to be married than the other samples. The Internet clinic and outpatient clinic samples had higher levels of educational qualifications than the national sample, but employment status was similar across groups.

Conclusions

The Internet clinic sample have disorders as severe as those attending an outpatient clinic, but with demographic characteristics more consistent with the national sample. These data indicate that the benefits of Internet treatment could apply to the wider population.

Clinician-Assisted Internet-Based Treatment is Effective for Generalized Anxiety Disorder: Randomized Controlled Trial

Objective: The aim of the present study was to determine the efficacy of an Internet-based clinician-assisted computerized cognitive behavioural treatment (CaCCBT) programme for generalized anxiety disorder (the Worry programme).

Methods: Forty-eight individuals meeting diagnostic criteria for generalized anxiety disorder (GAD) were randomly assigned to the Worry programme or to a waitlist control group. In the clinician-assisted Worry programme, participants complete six online lessons, weekly homework assignments, receive weekly email contact from a clinical psychologist, and contribute to a moderated online discussion forum with other participants. An intention-to-treat model was used for data analyses. The main outcome measures were Generalized Anxiety Disorder–7 Item Scale (GAD-7) and the Penn State Worry Questionnaire (PSWQ).

Results: A total of 75% of treatment group participants completed all six lessons within the 9 week programme and post-treatment data were collected from 21/24 treatment group and 19/21 control group participants. Treatment group participants reported significantly reduced symptoms of worry as measured on the GAD-7 and PSWQ and reduced symptoms of depression as measured on the Patient Health Questionnaire–9 Item Scale (PHQ-9). Mean within- and between-groups effect sizes (Cohen's d) across the two measures of GAD were 1.3 and 1.1, respectively. Participants found the treatment programme acceptable and satisfactory. The clinician spent a total mean of 130 min per person over the programme.

Conclusions: The Worry programme, the first randomized controlled trial of CaCCBT for GAD, resulted in clinically significant improvements. These results are consistent with literature indicating that Internet-based programmes, when combined with clinical guidance, can significantly reduce the symptoms of common mental disorders.

An RCT Comparing Effect of Two Types of Support on Severity of Symptoms for People Completing Internet-Based Cognitive Behaviour Therapy for Social Phobia

Objective: The present study (Shyness 6) compares the benefits and acceptability of two types of guidance on severity of symptoms during Internet treatment for social phobia.

Methods: Non-inferiority randomized controlled trial of Internet treatment, supplemented with weekly telephone calls from a technician (computerized cognitive-behavioural treatment (CCBT + Tel), or regular access to a clinician-moderated online discussion forum (CCBT + Forum), was carried out. An intention-to-treat model was used for data analyses. The participants consisted of 82 volunteers with social phobia. The intervention consisted of six lessons of CCBT for social phobia (the Shyness programme) with complex automated reminders. The main outcome measures were the Social Interaction Anxiety Scale and Social Phobia Scale.

Results: A total of 79% of CCBT + Tel and 79% of CCBT + Forum group participants completed all six lessons. Large mean within-groups effect sizes (Cohen's d) for the two social phobia measures were found for the CCBT + Tel and CCBT + Forum groups (1.31 and 1.54, respectively). Each participant in the CCBT + Tel group received a mean total of 38 min of technician time over the 8 week programme, while participants in the CCBT + Forum group received a mean total of 37 min of clinician time. Quantitative and qualitative data indicate that both the CCBT + Tel and CCBT + Forum procedures were equally and highly acceptable to participants.

Conclusions: The Shyness programme with either telephone support or access to a clinician-moderated online forum resulted in good clinical outcomes with equivalent patient acceptability. These results confirm that people with social phobia may significantly benefit from a highly structured education programme administered by clinical or non-clinical staff.