The effectiveness of internet cognitive behavioural therapy for generalized anxiety disorder in clinical practice

Comparing the efficacy of electronic cognitive behavioral therapy to medication and combination therapy for generalized anxiety disorder: a quasi-experimental clinical trial

Background

Generalized anxiety disorder (GAD) is a debilitating mental health disorder with first-line treatments include cognitive behavioral therapy (CBT) and pharmacotherapy. CBT is costly, time-consuming, and inaccessible. Electronic delivery (e-CBT) is a promising solution to address these barriers. However, due to the novelty of this intervention, more research testing the e-CBT efficacy independently and in conjunction with other treatments is needed.

Objective

This study investigated the efficacy of e-CBT compared to and in conjunction with pharmacotherapy for GAD.

Methods

This study employed a quasi-experimental design where patients selected their preferred treatment modality. Patients with GAD were enrolled in either e-CBT, medication, or combination arms. The 12-week e-CBT program was delivered through a digital platform. The medications followed clinical guidelines. The efficacy of each arm was evaluated using questionnaires measuring depression, anxiety, and stress severity, as well as quality of life.

Results

There were no significant differences between arms (N e-CBT = 41; N Medication = 41; N Combination = 33) in the number of weeks completed or baseline scores. All arms showed improvements in anxiety scores after treatment. The medication and combination arms improved depression scores. The e-CBT and Combination arms improved quality of life, and the combination arm improved stress scores. There were no differences between the groups in depression, anxiety, or stress scores post-treatment. However, the combination arm had a significantly larger improvement in quality of life. Gender and treatment arm were not predictors of dropout, whereas younger age was.

Conclusion

Incorporating e-CBT on its own or in combination with pharmaceutical interventions is a viable option for treating GAD. Treating GAD with e-CBT or medication appears to offer significant improvements in symptoms, with no meaningful difference between the two. Combining the treatments also offer significant improvements, while not necessarily superior to either independently. The findings suggest that all options are viable. Taking the patient's preferred treatment route based on their lifestyle, personality, and beliefs into account when deciding on treatment should be a priority for care providers.

A randomized clinical trial of behavioral activation and exposure-based therapy for adults with generalized anxiety disorder

Objective

Exposure-based therapy (EXP) and behavioral activation (BA) are empirically-supported behavioral intervention techniques that target avoidance and approach behavior to alleviate symptoms. Although EXP is an established treatment for generalized anxiety disorder (GAD), the effectiveness of BA for GAD has not been directly tested or compared with that of EXP. This study examined the efficacy of EXP and BA for adults with GAD.

Method

In a randomized clinical trial (clinicaltrials.gov: NCT02807480) with partial blinding in Tulsa, OK, 102 adults with GAD were allocated to manualized, 10-session EXP or BA between April 2016-April 2021. Primary analyses were intention-to-treat and included the 94 (46 EXP, 48 BA) participants who started treatment. The GAD-7 self-report scale was the primary outcome measure.

Results

Similar GAD-7 declines were observed at post-treatment for EXP (d=-0.97 [95% CI -1.40 to -0.53]) and BA (d=-1.14 [95% CI -1.57 to -0.70]), and were maintained through 6-month follow-up (EXP: d=-2.13, BA: d=-1.98). Compared to EXP, BA yielded more rapid declines in anxiety and depression scores during therapy (d=0.75-0.77), as well as lower anxiety and depression scores (d=0.13-0.14) and greater participant-rated improvement (d=0.64) at post-treatment. Bayesian analyses indicated 74-99% probability of greater change in BA than EXP at post-treatment.

Conclusions

BA and EXP are both effective in treating GAD, and BA may confer greater benefit during treatment. Future research is warranted to inform personalized treatment approaches.

Co-occurring insomnia and anxiety: a randomized controlled trial of internet cognitive behavioral therapy for insomnia versus internet cognitive behavioral therapy for anxiety

STUDY OBJECTIVES

Insomnia and anxiety are highly prevalent and frequently co-occur. Given limited therapeutic resources and time constraints, the aim of this study was to compare which treatment-internet cognitive behavioral therapy (CBT) for insomnia or internet CBT for anxiety-leads to the best outcomes in individuals with comorbid insomnia and anxiety.

METHODS

120 participants with comorbid insomnia and clinical anxiety (as defined by scores above the clinical cutoff on the insomnia severity index (ISI) and the generalized anxiety disorder 7-item scale (GAD-7)) were randomized to receive internet-based cognitive behavioral therapy (iCBT) for insomnia or iCBT for anxiety. The primary outcome measures were the ISI and the generalized anxiety disorder 7-item scale. Primary outcome measures were assessed before treatment, at mid-treatment, at post-treatment, and 3 months after treatment. Secondary outcome measures assessed depression symptoms, distress, and sleep diary parameters.

RESULTS

Participants in both groups experienced large reductions in symptoms of insomnia, anxiety, depression, and distress, as well as improvements in sleep efficiency and total sleep time. Improvements were maintained at follow-up. Crucially, at the end of treatment, the insomnia treatment was more effective in reducing symptoms of insomnia than the anxiety treatment, and equally effective in reducing symptoms of anxiety. Treatment gains were maintained at 3-month follow-up, however, there were no differences between groups at that time point.

CONCLUSIONS

These results suggest that in the common case of a patient presenting with comorbid insomnia and anxiety, treatment for insomnia may be the most efficient treatment strategy.

TRIAL REGISTRATION

The trial was registered with the Australian and New Zealand Clinical Trials Registry, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001141235. Trial ID: ACTRN12618001141235. Trial name: a comparison of internet-based CBT for insomnia versus internet-based CBT for anxiety in a comorbid sample.

Comparing the effectiveness of existing anxiety treatment options among patients evaluated for chest pain and anxiety in the emergency department setting: Study protocol for the PACER pragmatic randomized comparative effectiveness trial

BACKGROUND

Anxiety disorders are a common underlying cause of symptoms among low-risk chest pain patients evaluated in the emergency department setting. However, anxiety is often undiagnosed and undertreated in any setting, and causes considerable functional impairment to work, family, and social life.

OBJECTIVES

The Patient-Centered Treatment of Anxiety after Low-Risk Chest Pain in the Emergency Room (PACER) study is a pragmatic randomized trial to test the comparative effectiveness of existing anxiety treatments of graduated intensities and determine what options work best for patient subgroups based on anxiety severity and other comorbidities.

METHODS

The PACER trial will enroll 375 emergency department patients with low-risk chest pain and anxiety (GAD-7 score ≥ 8) and randomize them to either: 1) referral to primary care with enhanced care coordination, 2) online self-administered cognitive behavioral therapy with guided peer support, or 3) therapist-administered cognitive behavior therapy. Outcomes include anxiety symptoms (primary) as well as physical symptom burden, depression symptoms, functional impairment, ED recidivism, and occurrence of major adverse cardiac events. Statistical analyses will be conducted primarily using linear mixed models to perform a repeated measures analysis of patient-reported outcomes, assessed at 3, 6, 9, and 12-month follow-ups.

DISCUSSION

PACER is an innovative and pragmatic clinical trial that will compare the effectiveness of several evidence-based telecare-delivered treatments for anxiety. Results have the potential to inform clinical guidelines for evaluation and management of low-risk chest pain patients and promote adoption of findings in ED departments across the country.

Comparative efficacy of face-to-face and internet-based cognitive behavior therapy for generalized anxiety disorder: A meta-analysis of randomized controlled trial

Objective

The study aimed to ascertain the comparative efficacy of these two forms on reducing anxiety scores of scales in patients with a generalized anxiety disorder (GAD) by examining the available evidence for face-to-face cognitive behavior therapy (CBT) and internet-based cognitive behavior therapy (ICBT). Moreover, this study attempted to determine whether ICBT can obtain similar benefits as CBT for GAD patients during coronavirus disease 2019 (COVID-19) due to the quarantine policy and the requirement of social distance.

Methods

This meta-analysis was registered with the International Prospective Register of Systematic Reviews (PROSPERO) according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (registration number CRD42021241938). Therefore, a meta-analysis of randomized controlled trials (RCTs) examining CBT or ICBT was conducted in this study to treat GAD patients diagnosed with DMS-IV. The researchers searched PubMed, MEDLINE, Embase, PsycINFO, and the Cochrane Database of Systematic Reviews for relevant studies published from 2000 to July 5, 2022. Evidence from RCTs was synthesized by Review Manager 5.4 as mean difference (MD) for change in scores of scales through a random-effects meta-analysis.

Results

A total of 26 trials representing 1,687 participants were pooled. The results demonstrated that ICBT and CBT were very close in the effect size of treating GAD (MD = -2.35 vs. MD = -2.79). Moreover, they still exhibited a similar response (MD = -3.45 vs. MD = -2.91) after studies with active control were removed.

Conclusion

Regarding the treatment of GAD, ICBT can achieve a similar therapeutic effect as CBT and could be CBT's candidate substitute, especially in the COVID-19 pandemic era, since the internet plays a crucial role in handling social space constraints.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=241938, identifier CRD42021241938.

Internet-Delivered Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Nationwide Routine Care: Effectiveness Study

Background

Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficacious for generalized anxiety disorder (GAD), but few studies are yet to report its effectiveness in routine care.

Objective

In this study, we aim to examine whether a new 12-session iCBT program for GAD is effective in nationwide routine care.

Methods

We administered a specialized, clinic-delivered, therapist-supported iCBT for GAD in 1099 physician-referred patients. The program was free of charge for patients, and the completion time was not predetermined. We measured symptoms with web-based questionnaires. The primary measure of anxiety was the GAD 7-item scale (GAD-7); secondary measures were, for pathological worry, the Penn State Worry Questionnaire and, for anxiety and impairment, the Overall Anxiety Severity and Impairment Scale.

Results

Patients completed a mean 7.8 (SD 4.2; 65.1%) of 12 sessions, and 44.1% (485/1099) of patients completed all sessions. The effect size in the whole sample for GAD-7 was large (Cohen d=0.97, 95% CI 0.88-1.06). For completers, effect sizes were very large (Cohen d=1.34, 95% CI 1.25-1.53 for GAD-7; Cohen d=1.14, 95% CI 1.00-1.27 for Penn State Worry Questionnaire; and Cohen d=1.23, 95% CI 1.09-1.37 for Overall Anxiety Severity and Impairment Scale). Noncompleters also benefited from the treatment. Greater symptomatic GAD-7–measured relief was associated with more completed sessions, older age, and being referred from private or occupational care. Of the 894 patients with a baseline GAD-7 score ≥10, approximately 421 (47.1%) achieved reliable recovery.

Conclusions

This nationwide, free-of-charge, therapist-supported HUS Helsinki University Hospital–iCBT for GAD was effective in routine care, but further research must establish effectiveness against other treatments and optimize the design of iCBT for GAD for different patient groups and individual patients.

Web-Based Interventions to Help Australian Adults Address Depression, Anxiety, Suicidal Ideation, and General Mental Well-being: Scoping Review

BACKGROUND

A large number of Australians experience mental health challenges at some point in their lives. However, in many parts of Australia, the wait times to see general practitioners and mental health professionals can be lengthy. With increasing internet use across Australia, web-based interventions may help increase access to timely mental health care. As a result, this is an area of increasing research interest, and the number of publicly available web-based interventions is growing. However, it can be confusing for clinicians and consumers to know the resources that are evidence-based and best meet their needs.

OBJECTIVE

This study aims to scope out the range of web-based mental health interventions that address depression, anxiety, suicidal ideation, or general mental well-being and are freely available to Australian adults, along with their impact, acceptability, therapeutic approach, and key features.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews (PRISMA-ScR [PRISMA extension for Scoping Reviews]) guided the review process. Keywords for the search were depression, anxiety, suicide, and well-being. The search was conducted using Google as well as the key intervention databases Beacon, Head to Health, and e-Mental Health in Practice. Interventions were deemed eligible if they targeted depression, anxiety, suicidal ideation, or general mental well-being (eg, resilience) in adults; and were web-based, written in English, interactive, free, and publicly available. They also had to be guided by an evidence-based therapeutic approach.

RESULTS

Overall, 52 eligible programs were identified, of which 9 (17%) addressed depression, 15 (29%) addressed anxiety, 13 (25%) addressed general mental well-being, and 13 (25%) addressed multiple issues. Only 4% (2/52) addressed distress in the form of suicidal ideation. The most common therapeutic approach was cognitive behavioral therapy. Half of the programs guided users through exercises in a set sequence, and most programs enabled users to log in and complete the activities on their own without professional support. Just over half of the programs had been evaluated for their effectiveness in reducing symptoms, and 11% (6/52) were being evaluated at the time of writing. Program evaluation scores ranged from 44% to 100%, with a total average score of 85%.

CONCLUSIONS

There are numerous web-based programs for depression, anxiety, suicidal ideation, and general well-being, which are freely and publicly available in Australia. However, identified gaps include a lack of available web-based interventions for culturally and linguistically diverse populations and programs that use newer therapeutic approaches such as acceptance and commitment therapy and dialectical behavior therapy. Despite most programs included in this review being of good quality, clinicians and consumers should pay careful attention when selecting which program to recommend and use, as variations in the levels of acceptability and impact of publicly available programs do exist.

Comorbid personality difficulties are not associated with poorer outcomes for online cognitive behaviour therapy for symptoms of anxiety and depression

Little is known about the prevalence and impact on treatment of comorbid personality disorders for adults undertaking online cognitive behaviour therapy (internet-delivered or internet-based cognitive behaviour therapy (iCBT)) for anxiety and depressive disorders. This study explored how common comorbid personality difficulties were in a large sample of consecutive patients (N = 1 132) seeking iCBT for their symptoms of anxiety and depression in routine care settings. Patients completed the Standardized Assessment of Personality-abbreviated Scale Self-Report prior to commencing an iCBT programme, as well as completing assessments of anxiety and depression symptom severity and psychological distress pre-iCBT and post-iCBT. Consistent with previous studies, a high proportion of the sample (62.6%) reported experiencing comorbid personality difficulties. However, comorbid personality difficulties were not significantly associated with poorer treatment adherence or higher post-treatment symptom severity or psychological distress (controlling for baseline symptom severity, demographic characteristics and treatment variables). Current findings support an inclusive approach to iCBT provision where comorbid personality difficulties do not appear to be a contraindication for treatment. © 2021 John Wiley & Sons, Ltd.

The effects of the type of delivery of cognitive-behavioral therapy for healthcare workers: A systematic review

OBJECTIVE

The aim of this literature review is to assess the extent of knowledge of the effectiveness of cognitive-behavioral therapy (CBT) for healthcare workers by type of delivery.

METHODS

The study examined relevant literature published between 2009 and 2020 using searches of four scientific databases: PubMed, CINAHL, Embase, and PsycINFO.

RESULTS

For work stress, work-related outcomes, and mental and musculoskeletal problems, the effectiveness of face-to-face (FTF) interventions were confirmed, whereas, for stress and insomnia, the effectiveness of non-face-to-face (NFTF) interventions was confirmed. FTF interventions were proven to make a significant difference to the outcome of the goal; however, their effects were not clearly distinguished from those of NFTF interventions.

CONCLUSION

Results of this review highlight the lack of research aimed at establishing the effectiveness of NFTF interventions. In addition, further research is needed on the long-term effectiveness of the intervention process and perception of participants and clinicians on group delivery interventions.

Determining the Efficacy of Electronic Cognitive Behavioral Therapy for Generalized Anxiety Disorder Compared to Pharmaceutical Interventions: Protocol for a Quasi-Experimental Study

BACKGROUND

Generalized anxiety disorder (GAD) is an extremely prevalent and debilitating mental health disorder. Currently, the gold standard treatment for GAD is cognitive behavioral therapy (CBT) and/or pharmacotherapy. The most common medications used to treat GAD are selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors. While CBT is the gold standard treatment for GAD, it is costly, time-consuming, and often inaccessible. Fortunately, the electronic delivery of CBT (e-CBT) has emerged as a promising solution to address these barriers. e-CBT has shown to offer comparable results to in-person CBT while improving accessibility for patients and time efficiency for clinicians.

OBJECTIVE

This study aims to investigate the treatment efficacy of e-CBT compared to and in conjunction with pharmacotherapy for GAD.

METHODS

This study will use a quasi-experimental design to allow patients the freedom to choose which treatment modality they would like to receive. Participants with a diagnosis of GAD will be enrolled in 1 of 3 possible treatment arms: (1) e-CBT, (2) medication, or (3) a combination of e-CBT and medication. The e-CBT program will include a 12-week psychotherapy program delivered through the Online Psychotherapy Tool-a secure, cloud-based, digital mental health platform. The treatment efficacy of e-CBT will be compared with that of medication alone and medication in combination with e-CBT.

RESULTS

The study received ethics approval in April 2019 and participant recruitment began in June 2019. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, 146 participants (e-CBT: n=53; medication: n=49; combination: n=44) have been recruited. Data collection is expected to conclude by June 2021, and data analysis is expected to be completed by October 2021. Linear regression (for continuous outcomes) and binomial regression (for categorical outcomes) analysis will be conducted using interpretive qualitative methods.

CONCLUSIONS

If either the efficacy of e-CBT is shown to be comparable to that of medication or the effects of both treatments are augmented when used in tandem, these findings could have major implications on the mental health care system. e-CBT is a more accessible and affordable treatment that could increase mental health care capacity 4-fold if proven viable.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04478526; https://clinicaltrials.gov/ct2/show/NCT04478526.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27772.

Self-guided online cognitive behavioural therapy for insomnia: A naturalistic evaluation in patients with potential psychiatric comorbidities

BACKGROUND

Insomnia is the most prevalent sleep disorder worldwide, and regularly co-occurs with anxiety and depression. Cognitive behavioural therapy is the gold standard treatment for insomnia (CBT-I), however demand for treatment providers drastically exceeds supply. Internet-delivered programs for insomnia (iCBT-I) improve treatment access. However the effects of unguided iCBT-I for individuals with comorbidities within a naturalistic setting remains unexplored. We developed a novel unguided iCBT-I program and evaluated its impact on insomnia, psychological distress, and wellbeing when accessed by the public.

METHODS

317 participants experiencing insomnia for over 3 months enrolled in the program. The program consisted of 4 lessons delivered online with automated web support. Insomnia symptoms, psychological distress, and general wellbeing were assessed at lesson 1 and 4. Intention-to-treat linear mixed models were used to examine effects on insomnia, distress, and wellbeing.

RESULTS

Participants experienced large (g = 1.11) and significant reductions in insomnia, moderate (g = 0.55) and significant reductions in distress, and small (g = 0.37) but significant improvements in wellbeing. 65% of participants who reported pre-treatment insomnia severity at clinical levels remitted following treatment.

LIMITATIONS

To examine the program in a naturalistic setting, we did not employ a control group or follow participants beyond the completion of treatment.

CONCLUSIONS

Unguided iCBT-I is effective for individuals in the community who experience insomnia and are likely experiencing comorbid mental health problems. These effects in the absence of guided contact strengthen the utility of unguided iCBT-I as a scalable and cost-effective method of disseminating treatments for this disorder.

The effectiveness of internet-delivered cognitive behavioural therapy for health anxiety in routine care

INTRODUCTION

Randomised controlled trials have shown that internet-delivered cognitive behavioural treatment (iCBT) is an effective treatment for health anxiety, but the effectiveness of these programs in routine care has not been investigated. This study examined the effectiveness of iCBT for health anxiety symptoms in routine care settings in the community.

METHODS

Using an open-trial design, we investigated adherence to, and effectiveness of a 6-lesson iCBT program for health anxiety symptoms amongst individuals (n = 391, mean age 41 years, 64% female) who enrolled in the program either self-guided (n = 312) or under the supervision of community clinicians (general practitioners, psychologists and other allied health professionals) (n = 79). Primary outcome was health anxiety severity on the Short Health Anxiety Inventory (SHAI), and secondary outcomes were depression severity on the Patient Health Questionnaire 9-item (PHQ-9) (depression) and distress (Kessler-10: K-10).

RESULTS

Adherence to the iCBT program was modest (45.6% in the clinician-supervised group, 33.0% in the unguided group), but within-subjects effect sizes were large (SHAI: g = 1.66, 95%CI: 1.45-1.88; PHQ-9: g = 1.12, 95%CI: 0.92-1.32; K-10: g = 1.35, 95%CI: 1.15-1.56).

LIMITATIONS

No control group, lack of follow-up data.

CONCLUSIONS

iCBT is an effective treatment for health anxiety symptoms in routine care, but methods to increase adherence are needed to optimise benefits to participants. Randomised controlled effectiveness trials with long-term follow-up are needed.

Effectiveness of internet-delivered cognitive behavioural therapy in reducing sickness absence among young employees with depressive symptoms: study protocol for a large-scale pragmatic randomised controlled trial

INTRODUCTION

Depression is a highly prevalent condition with typical onset in early adulthood. Internet-delivered cognitive behavioural therapy (iCBT) is a promising cost-effective and more widely available alternative to face-to-face CBT. However, it is not known whether it can reduce sickness absence in employees showing depressive symptoms. The randomised controlled trial component of the DAQI (Depression and sickness absence in young adults: a quasi-experimental trial and web-based treatment intervention) project aims to investigate if iCBT is effective in reducing sickness absence compared with care as usual (CAU) among young employees with depressive symptoms in primary care provided in an occupational health setting.

METHODS AND ANALYSIS

This study will use a randomised controlled single-centre service-based trial of an existing iCBT programme (Mental Hub iCBT for Depression) to evaluate whether or not this treatment can reduce the number of sickness absence days in public sector employees aged 18-34 years who present at the occupational health service with mild depressive symptoms (score ≥9 on the Beck Depression Inventory-IA). Control participants will be offered CAU, with no constraints regarding the range of treatments. The active condition will consist of seven weekly modules of iCBT, with support from a web therapist. Primary outcome will be participants' all-cause sickness absence as indicated in employer's and national administrative records up to 6 months from study entry. Secondary outcomes relating to long-term sickness absence (over 11 calendar days) for mental and musculoskeletal disorders and psychotropic medication use will be obtained from the Finnish Social Insurance Institution's administrative records; and short sickness absence spells (up to 11 calendar days) will be extracted from employer's records. Analyses will be conducted on an intention-to-treat basis.

ETHICS AND DISSEMINATION

The Coordinating Ethics Committee of the Hospital District of Helsinki and Uusimaa has approved the study (HUS/974/2019). The results will be published in peer-reviewed scientific journals and in publications for lay audience.

TRIAL REGISTRATION NUMBER

ISRCTN10877837.

Facilitating access to iCBT: a randomized controlled trial assessing a translated version of an empirically validated program using a minimally monitored delivery model

BACKGROUND

Despite its established efficacy, access to internet-delivered CBT (iCBT) remains limited in a number of countries. Translating existing programs and using a minimally monitored model of delivery may facilitate its dissemination across countries.

AIMS

This randomized control trial aims to evaluate the efficacy of an iCBT transdiagnostic program translated from English to French and offered in Canada using a minimally monitored delivery model for the treatment of anxiety and depression.

METHOD

Sixty-three French speakers recruited in Canada were randomized to iCBT or a waiting-list. A French translation of an established program, the Wellbeing Course, was offered over 8 weeks using a minimally monitored delivery model. Primary outcome measures were the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9), which were obtained pre-treatment, post-treatment and at 3-month follow-up.

RESULTS

Mixed-effects models revealed that participants in the treatment group had significantly lower PHQ-9 and GAD-7 scores post-treatment than controls with small between-groups effect sizes (d = 0.34 and 0.37, respectively). Within-group effect sizes on primary outcome measures were larger in the treatment than control group. Clinical recovery rates on the PHQ-9 and GAD-7 were significantly higher among the treatment group (40 and 56%, respectively) than the controls (13 and 16%, respectively).

CONCLUSIONS

The provision of a translated iCBT program using a minimally monitored delivery model may improve patients' access to treatment of anxiety and depression across countries. This may be an optimal first step in improving access to iCBT before sufficient resources can be secured to implement a wider range of iCBT services.

Computer-Assisted Cognitive-Behavior Therapy and Mobile Apps for Depression and Anxiety

PURPOSE OF REVIEW

We reviewed research on computer-assisted cognitive-behavior therapy (CCBT) and mobile applications with the goals of assessing the effectiveness of these newer methods of delivering or augmenting treatment and making recommendations on the clinical use of computer tools in psychotherapy of depression and anxiety.

RECENT FINDINGS

Research on CCBT has found solid evidence for efficacy when the use of a therapeutic computer program is supported by a clinician or other helping professionals. Lower levels of efficacy or ineffectiveness typically have been found when computer programs are used as stand-alone treatments. A large number of mobile apps have been created that claim to be useful for depression and/or anxiety. However, considerable caution is warranted in evaluating mobile apps and recommending them to patients. Research on mobile apps is still in an early stage of development. A number of well-established CCBT programs have been studied in multiple randomized, controlled trials and have been found to be effective. Such programs appear to have adequate quality, security, and efficacy to be used in clinical practice. Mobile apps offer easy portability and immediate access to coping strategies and may be useful for augmenting treatment. But clinicians need to select apps with integrity and reliable content for clinical use.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

Treating anxiety and depression in young adults: A randomised controlled trial comparing clinician-guided versus self-guided Internet-delivered cognitive behavioural therapy

BACKGROUND

Internet-delivered cognitive behaviour therapy may increase access by young adults to evidence-based treatments for anxiety and depression.

OBJECTIVE

The aim of this study was to compare the efficacy of an Internet-delivered cognitive behaviour therapy intervention designed for adults aged 18-24 years, when delivered in clinician-guided versus self-guided formats.

DESIGN

The intervention, the Mood Mechanic Course, is a transdiagnostic treatment that simultaneously targets symptoms of anxiety and depression using cognitive and behavioural skills. The brief intervention comprised four lessons, delivered over 5 weeks. Following a brief telephone interview, young adults ( n = 191) with symptoms of anxiety and depression were randomly allocated to either (1) clinician-guided treatment ( n = 96) or (2) self-guided treatment ( n = 95).

RESULTS

At post treatment, large reductions (average improvement; clinician guided vs self-guided) were observed in symptoms of anxiety (44% vs 35%) and depression (40% vs 31%) in both groups. Significant improvements were also observed in general psychological distress (33% vs 29%), satisfaction with life (18% vs 15%) and disability (36% vs 29%). No marked or consistent differences in clinical outcomes emerged between conditions at post-treatment, at 3-month or 12-month follow-up. Satisfaction was high with both treatment formats, but slightly higher for clinician-guided treatment.

CONCLUSION

These results indicate the potential of carefully developed Internet-delivered cognitive behaviour therapy interventions for young adults with anxiety and depression provided in either self or therapist-guided format. Further large-scale research is required to determine the short- and long-term advantages and disadvantages of different models of support.

Facilitating the Dissemination of iCBT for the Treatment of Anxiety and Depression: A Feasibility Study

Translating existing internet-based cognitive-behavioural therapy (iCBT), along with the use of transdiagnostic and self-guided formats, may prove to be a cost-effective option of disseminating iCBT. Only recently have encouraging findings been reported for a self-guided delivery. This study assessed the feasibility of a French and self-guided version of an existing English iCBT course, called the Wellbeing Course, for the treatment of anxiety and depression. Existing ICBT programs have not yet been delivered in French, although this language is spoken worldwide. Thirty-one participants were included in a single group pre-post open trial with a 3-month follow-up. Feasibility outcomes were attrition, treatment adherence, acceptability, and preliminary efficacy. Primary outcome measures were the Patient Health Questionnaire 9-item (PHQ-9) and the Generalised Anxiety Disorder 7-item (GAD-7). Nearly 75% of the participants completed the program. Over 80% of the participants provided posttreatment and follow-up data. All study completers reported that they would recommend the Wellbeing Course to a friend having similar problems. Significant reductions in symptoms of anxiety and depression were found following treatment, consistent with earlier studies. These preliminary findings support the use of the assessed strategies to facilitate the cross-cultural dissemination of iCBT for a more universal access to quality psychological care.

Digital Technologies in the Treatment of Anxiety: Recent Innovations and Future Directions

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of the efficacy, limitations, and future of e-health treatments for anxiety. Within this, we provide detail on "first-generation" e-health approaches, such as computerized therapies. Additionally, we assess the emergence and early efficacy of newer methods of treatment delivery, including smartphone apps and virtual reality interventions, discussing the potential and pitfalls for each.

RECENT FINDINGS

There is now substantial clinical research demonstrating the efficacy of internet-delivered cognitive behavioral therapy in the treatment of anxiety. However, the ability of these interventions for engaging patients in "real-world" settings is unclear. Recently, smartphone apps for anxiety have presented a more popular and ubiquitous method of intervention delivery, although the evidence base supporting these newer approaches drastically falls behind the extensive marketing and commercialization efforts currently driving their development. Meanwhile, the increasing availability of novel technologies, such as "virtual reality" (VR), introduces further potential of e-health treatments for generalized anxiety and anxiety-related disorders such as phobias and obsessive compulsive disorder, while also creating additional challenges for research. Although still in its infancy, e-health research is already presenting several promising avenues for delivering effective and scalable treatments for anxiety. Nonetheless, several important steps must be taken in order for academic research to keep pace with continued technological advances.

Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis

BACKGROUND

A 2010 meta-analysis of internet-delivered CBT (iCBT) RCTs argued 'computer therapy for the anxiety and depressive disorders was effective, acceptable and practical health care' without data on effectiveness or practicality in routine practice.

METHODS

Databases, reviews and meta-analyses were searched for randomised controlled trials of cCBT or iCBT versus a control group (care as usual, waitlist, information control, psychological placebo, pill placebo, etc.) in people who met diagnostic criteria for major depression, panic disorder, social anxiety disorder or generalised anxiety disorder. Number randomised, superiority of treatment versus control (Hedges'g) on primary outcome measure, length of follow-up, follow up outcome, patient adherence and satisfaction/harm were extracted; risk of bias was assessed. A search for studies on effectiveness of iCBT in clinical practice was conducted.

RESULTS

64 trials were identified. The mean effect size (efficacy) was g = 0.80 (NNT 2.34), and benefit was evident across all four disorders. Improvement was maintained at follow-with good acceptability. Research probity was good, and bias risk low. In addition, nine studies comparing iCBT with traditional face-to-face CBT and three comparing iCBT with bibliotherapy were identified. All three modes of treatment delivery appeared equally beneficial. The results of effectiveness studies were congruent with the results of the efficacy trials.

LIMITATIONS

Studies variably measured changes in quality of life and disability, and the lack of comparisons with medications weakens the field.

CONCLUSIONS

The conclusions drawn in the original meta-analysis are now supported: iCBT for the anxiety and depressive disorders is effective, acceptable and practical health care.

Maladaptive Behaviours Associated with Generalized Anxiety Disorder: An Item Response Theory Analysis

Background: Cognitive models of generalized anxiety disorder (GAD) suggest that maladaptive behaviours may contribute to the maintenance of the disorder; however, little research has concentrated on identifying and measuring these behaviours. To address this gap, the Worry Behaviors Inventory (WBI) was developed and has been evaluated within a classical test theory (CTT) approach. Aims: As CTT is limited in several important respects, this study examined the psychometric properties of the WBI using an Item Response Theory approach. Method: A large sample of adults commencing treatment for their symptoms of GAD (n = 537) completed the WBI in addition to measures of GAD and depression symptom severity. Results: Patients with a probable diagnosis of GAD typically engaged in four or five maladaptive behaviours most or all of the time in an attempt to prevent, control or avoid worrying about everyday concerns. The two-factor structure of the WBI was confirmed, and the WBI scales demonstrated good reliability across a broad range of the respective scales. Together with previous findings, our results suggested that hypervigilance and checking behaviours, as well as avoidance of saying or doing things that are worrisome, were the most relevant maladaptive behaviours associated with GAD, and discriminated well between adults with low, moderate and high degrees of the respective WBI scales. Conclusions: Our results support the importance of maladaptive behaviours to GAD and the utility of the WBI to index these behaviours. Ramifications for the classification, theoretical conceptualization and treatment of GAD are discussed.

The 12-item Self-Report World Health Organization Disability Assessment Schedule (WHODAS) 2.0 Administered Via the Internet to Individuals With Anxiety and Stress Disorders: A Psychometric Investigation Based on Data From Two Clinical Trials

BACKGROUND

The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a widespread measure of disability and functional impairment, which is bundled with the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) for use in psychiatry. Administering psychometric scales via the Internet is an effective way to reach respondents and allow for convenient handling of data.

OBJECTIVE

The aim was to study the psychometric properties of the 12-item self-report WHODAS 2.0 when administered online to individuals with anxiety and stress disorders. The WHODAS 2.0 was hypothesized to exhibit high internal consistency and be unidimensional. We also expected the WHODAS 2.0 to show high 2-week test-retest reliability, convergent validity (correlations approximately .50 to .90 with other self-report measures of functional impairment), that it would differentiate between patients with and without exhaustion disorder, and that it would respond to change in primary symptom domain.

METHODS

We administered the 12-item self-report WHODAS 2.0 online to patients with anxiety and stress disorders (N=160) enrolled in clinical trials of cognitive behavior therapy, and analyzed psychometric properties within a classical test theory framework. Scores were compared with well-established symptom and disability measures, and sensitivity to change was studied from pretreatment to posttreatment assessment.

RESULTS

The 12-item self-report WHODAS 2.0 showed high internal consistency (Cronbach alpha=.83-.92), high 2-week test-retest reliability (intraclass correlation coefficient=.83), adequate construct validity, and was sensitive to change. We found preliminary evidence for a three-factorial structure, but one strong factor accounted for a clear majority of the variance.

CONCLUSIONS

We conclude that the 12-item self-report WHODAS 2.0 is a psychometrically sound instrument when administered online to individuals with anxiety and stress disorders, but that it is probably fruitful to also report the three subfactors to facilitate comparisons between studies.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02540317; https://clinicaltrials.gov/ct2/show/NCT02540317 (Archived by WebCite at http://www.webcitation.org/6vQEdYAem); Clinicaltrials.gov NCT02314065; https://clinicaltrials.gov/ct2/show/NCT02314065 (Archived by WebCite at http://www.webcitation.org/6vQEjlUU8).

The first 30 months of the MindSpot Clinic: Evaluation of a national e-mental health service against project objectives

OBJECTIVE

The MindSpot Clinic provides online mental health services to Australian adults with anxiety and depression. This paper describes users of MindSpot between January 2013 and June 2015. Outcomes are considered against three key objectives: improving access to mental health services, improving public awareness of how to access services and providing evidence-based treatments.

METHOD

Website traffic data were examined to determine patterns of use. Demographic characteristics, past service utilisation and reasons for contacting MindSpot were analysed. Outcomes for patients enrolled in a MindSpot treatment course were also analysed. Primary outcomes were scores on the 9-Item Patient Health Questionnaire, Generalised Anxiety Disorder 7-Item, Yale-Brown Obsessive Compulsive Scale and Post-Traumatic Stress Disorder Checklist-Civilian Version, administered at assessment, post-treatment and 3-month follow-up.

RESULTS

The website was visited by almost 500,000 Australians, of which 33,990 adults started assessments, and 25,469 people completed assessment and were eligible for analysis. Mean age was 36.4 years (standard deviation = 13.3 years; range = 18-94 years), and 72% were female. The proportion living in rural or remote regions and who identified as Aboriginal and Torres Strait Islander closely matched national statistics. The majority (82%) reported that they were not currently in contact with mental health services. Most patients sought an assessment, information about treatment options, or referral to another service, and only 24% of those completing an assessment commenced a MindSpot treatment course. Of these, large clinical effects ( d: 0.7-2.4; average symptom reductions: 25.5% to 61.6%) were found from assessment to follow-up on all outcome measures. Deterioration ranged from 1.0% to 4.3%.

CONCLUSION

Based on the number of website visits, completed assessments and treatment outcomes, MindSpot achieved its three programme objectives. This model of service provision has considerable value as a complement to existing services, and is proving particularly important for improving access for people not using existing services.

Reducing behavioral avoidance with internet-delivered cognitive behavior therapy for generalized anxiety disorder

Recent research has sought to identify maladaptive behaviors that are associated with generalized anxiety disorder (GAD). Although maladaptive behaviors may contribute to the maintenance of the disorder, little is known about how these behaviors change during the course of cognitive behavior therapy and whether such changes relate to treatment outcomes. This study examined changes in maladaptive behaviors, symptoms of GAD and depression, and disability across internet-based cognitive behavior therapy (iCBT) for GAD in two large clinical samples (N = 206 and 298). Assessments were completed at pre and post-treatment. Significant reductions in patients' maladaptive behaviors (WBI), GAD and depression severity (GAD-7 and PHQ-9), and disability (WHODAS-II) were observed following iCBT. Reductions in maladaptive behaviors predicted post-treatment GAD symptom severity after controlling for pre-treatment GAD symptom severity and reductions in depression and disability. Findings provide further support for the importance of maladaptive behaviors in contemporary conceptualizations of GAD and highlight the need for experimental investigations to examine the possible causal relationships between maladaptive behaviors and GAD.

The effectiveness of unguided internet cognitive behavioural therapy for mixed anxiety and depression

Clinician-guided internet-delivered cognitive behavioral therapy (iCBT) is an effective treatment for depression and anxiety disorders. However, few studies have examined the effectiveness of completely unguided iCBT. The current research investigated adherence to, and the effects of two brief unguided iCBT programs on depression and anxiety symptom severity, and psychological distress. Study 1 evaluated a four-lesson transdiagnostic iCBT program for anxiety and depression (N = 927). Study 2 then evaluated a three-lesson version of the same program (N = 5107) in order to determine whether reducing the duration of treatment would influence adherence and treatment effects. Cross-tabulations and independent t-tests were used to examine the extent to which users adhered and remitted with treatment. Linear mixed models were used to evaluate the effects of treatment in the entire sample, and stratified by gender and completer-type (e.g., users who completed some but not all lessons vs. those who completed all lessons of treatment). Among those who began treatment, 13.83% completed all four lessons in Study 1. Shortening the course to three lessons did not improve adherence (e.g., 13.11% in Study 2). In both studies, users, on average, experienced moderate to large effect size reductions in anxiety and depressive symptom severity, as well as psychological distress. This pattern of results was robust across gender and for those who did and did not complete treatment. Approximately two-thirds of those who completed treatment experienced remission. These data show that unguided iCBT programs, which have the capacity to attract large numbers of individuals with clinically significant symptoms of depression and anxiety, and psychological distress, can produce significant improvements in wellbeing.

Integrating iCBT for generalized anxiety disorder into routine clinical care: Treatment effects across the adult lifespan

The burden attributable to late-life Generalized Anxiety Disorder (GAD) is set to increase alongside the ageing population. Yet, the psychogeriatric workforce is limited in size and few studies have focused on the treatment of GAD among older patients. Internet-delivered cognitive behavioral therapy (iCBT) could be integrated into existing infrastructure and scale the psychogeriatric workforce, if shown to be effective across the adult lifespan. This study examined age-related differences in presentation, adherence and effects of iCBT for GAD among patients in routine clinical care (N=942; 18-29years (n=267); 30-39years (n=260); 40-49years (n=180); 50-59years (n=124); and 60+ years (n=111)). Compared to younger patients, older patients were less likely to present with probable GAD and MDD diagnoses (<60years vs. 60+ years) and more likely to complete treatment (<50years vs. 50+ years). iCBT produced moderate to large effect size reductions in symptom severity, distress and impairment independent of age. iCBT is therefore an effective treatment for GAD across the adult lifespan, which can be delivered in routine clinical care. Continuing to integrate iCBT into existing services has the potential to improve the capacity of the existing workforce to manage those seeking help for GAD particularly as the population ages.

Psychometric Properties of the Worry Behaviors Inventory: Replication and Extension in a Large Clinical and Community Sample

BACKGROUND

The use of maladaptive behaviors by individuals with generalized anxiety disorder (GAD) is theoretically important and clinically meaningful. However, little is known about the specificity of avoidant behaviors to GAD and how these behaviors can be reliably assessed.

AIMS

This study replicated and extended the psychometric evaluation of the Worry Behaviors Inventory (WBI), a brief self-report measure of avoidant behaviors associated with GAD.

METHOD

The WBI was administered to a hospital-based sample of adults seeking treatment for symptoms of anxiety and/or depression (n = 639) and to a community sample (n = 55). Participants completed measures of symptom severity (GAD, depression, panic disorder, health anxiety, and personality disorder), and measures of checking, reassurance-seeking and behavioral inhibition. Analyses evaluated the factor structure, convergent, divergent, incremental, and discriminant validity, as well the temporal stability and treatment sensitivity of the WBI.

RESULTS

The two-factor structure found in the preliminary psychometric evaluation of the WBI was replicated. The WBI was sensitive to changes across treatment and correlated well with measures of GAD symptom severity and maladaptive behaviors. The WBI was more strongly related to GAD symptom severity than other disorders. The WBI discriminated between clinical and community samples.

CONCLUSIONS

The WBI provides clinicians and researchers with a brief, clinically meaningful index of problematic behaviors that may guide treatment decisions and contribute to our understanding of maintaining factors in GAD.

Transdiagnostic versus diagnosis specific cognitive behavioural therapies for anxiety: A meta-analysis

Research evaluating transdiagnostic CBT (tCBT) demonstrates its efficacy. Some evidence suggests equivalence between tCBT and diagnosis-specific CBT (dxCBT), however more investigations are necessary to clarify any difference in efficacy. This meta-analysis was conducted to compare tCBT and dxCBT, and to investigate the differential impact of comorbidity on effect sizes. Pre and post scores from primary anxiety measures in 83 treatment conditions, taken from studies primarily targeting anxiety disorders, were summarised and compared. Meta-regression analyses were then used to test the effects of comorbidity. DxCBT and tCBT meta-effects were found to be large, where g=0.951, 95% CI: 0.874-1.027, and g=1.059, 95% CI: 0.876-1.242, respectively. While statistically different (p=0.008), overlap of confidence intervals indicated a lack of clinical significance. Furthermore, no relationship between comorbidity rate and tCBT outcome was observed. These results were discussed in the context of previous findings in the transdiagnostic CBT literature.

Transdiagnostic versus disorder-specific internet-delivered cognitive behaviour therapy for anxiety and depression in primary care

BACKGROUND

Disorder-specific and transdiagnostic internet cognitive behaviour therapy (iCBT) programs are effective for anxiety and depression, but no studies have compared their effectiveness in primary care.

METHODS

Patient characteristics, adherence and effectiveness of Transdiagnostic iCBT (n=1005) were compared to disorder-specific programs for generalized anxiety disorder (GAD) (n=738) and depression (n=366) in a naturalistic non-randomised comparison study. Patients completed their iCBT program in primary care. The PHQ-9 (depression), GAD-7 (generalized anxiety), K-10 (distress), and the WHODAS-II (disability) were measured at pre- and post-treatment.

RESULTS

Patients in the Transdiagnostic program had higher comorbidity rates and baseline distress. All programs were associated with medium to large within-group effect sizes for improving anxiety, depression and distress between pre- and post-treatment (d's=0.64-1.39). Controlling for baseline group differences in severity, we found small effect sizes favoring the Transdiagnostic program over the GAD program in reducing PHQ-9 (d=0.44, 95%CI: 0.34-0.53), K-10 (d=0.21, 95%CI: 0.16-0.35) and WHODAS scores (d=0.20, 95%CI: 0.10-0.29), and small effect sizes favoring the Transdiagnostic program over the Depression program in reducing GAD-7 scores (d=0.48, 95%CI: 0.36-0.60). A smaller proportion of patients completed the Transdiagnostic program (44.9%) compared to the depression (51.6%) and GAD (49.2%) programs, which was attributable to baseline differences in age and symptom severity.

CONCLUSIONS

Both Transdiagnostic iCBT and disorder-specific iCBT programs are effective in primary care, but there appears to be small effects favoring Transdiagnostic iCBT. Methods to increase adherence are needed to optimize the benefits to patients, and these findings await replication in a RCT.

Factors Mediating Dysphoric Moods and Help Seeking Behaviour Among Australian Parents of Children with Autism

This study compared levels of state affect, dysphoric mood, and parenting sense of competence in Australian parents of children with or without autism. The effects of personality and location on the parents' experience were also examined, while controlling for current affect. Possible relationships among personality, location factors and help-seeking behavior were also explored in parents of children with autism. Prior findings of higher dysphoric mood levels in parents of children with autism were supported, as was the positive correlation between dysphoric moods and Neuroticism levels. Parenting Sense of Competence did not differ across locations, and there were no parent type by location interactions. Access to services among parents of a child with autism did not moderate dysphoria levels.

World Health Organization disability assessment schedule 2.0: An international systematic review

PURPOSE

This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument.

METHOD

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on "whodas" using the ProQuest, PubMed, and Google Scholar electronic databases.

RESULTS

We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry).

CONCLUSIONS

The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single "minimal clinically important .difference" score for the WHODAS 2.0 has not yet been established.

Internet-delivered treatment for older adults with anxiety and depression: implementation of the Wellbeing Plus Course in routine clinical care and comparison with research trial outcomes

BACKGROUND

The Wellbeing Plus Course is an internet-delivered psychological intervention for older adults with anxiety or depression.

AIMS

To compare the effectiveness of the Wellbeing Plus Course in a public health setting (clinic group) with its efficacy in a randomised controlled trial (research group).

METHOD

Participants (n=949) were Australian adults aged 60 and above. Primary outcome measures were the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder scale (GAD-7).

RESULTS

Initial symptom severity was higher in the clinic group and course completion was lower. Both groups showed significant symptom reductions at post-treatment and were satisfied with the treatment. Results were maintained at 3-month follow-up. Within-group symptom changes were comparable between settings; there were no between-group differences on primary outcomes or satisfaction.

CONCLUSIONS

The Wellbeing Plus Course is as effective and acceptable in routine clinical care, as it is in controlled research trials.

DECLARATION OF INTEREST

N.T. and B.F.D developed the Wellbeing Plus Course but derived no financial benefit from it.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Finding Web-Based Anxiety Interventions on the World Wide Web: A Scoping Review

BACKGROUND

One relatively new and increasingly popular approach of increasing access to treatment is Web-based intervention programs. The advantage of Web-based approaches is the accessibility, affordability, and anonymity of potentially evidence-based treatment. Despite much research evidence on the effectiveness of Web-based interventions for anxiety found in the literature, little is known about what is publically available for potential consumers on the Web.

OBJECTIVE

Our aim was to explore what a consumer searching the Web for Web-based intervention options for anxiety-related issues might find. The objectives were to identify currently publically available Web-based intervention programs for anxiety and to synthesize and review these in terms of (1) website characteristics such as credibility and accessibility; (2) intervention program characteristics such as intervention focus, design, and presentation modes; (3) therapeutic elements employed; and (4) published evidence of efficacy.

METHODS

Web keyword searches were carried out on three major search engines (Google, Bing, and Yahoo-UK platforms). For each search, the first 25 hyperlinks were screened for eligible programs. Included were programs that were designed for anxiety symptoms, currently publically accessible on the Web, had an online component, a structured treatment plan, and were available in English. Data were extracted for website characteristics, program characteristics, therapeutic characteristics, as well as empirical evidence. Programs were also evaluated using a 16-point rating tool.

RESULTS

The search resulted in 34 programs that were eligible for review. A wide variety of programs for anxiety, including specific anxiety disorders, and anxiety in combination with stress, depression, or anger were identified and based predominantly on cognitive behavioral therapy techniques. The majority of websites were rated as credible, secure, and free of advertisement. The majority required users to register and/or to pay a program access fee. Half of the programs offered some form of paid therapist or professional support. Programs varied in treatment length and number of modules and employed a variety of presentation modes. Relatively few programs had published research evidence of the intervention's efficacy.

CONCLUSIONS

This review represents a snapshot of available Web-based intervention programs for anxiety that could be found by consumers in March 2015. The consumer is confronted with a diversity of programs, which makes it difficult to identify an appropriate program. Limited reports and existence of empirical evidence for efficacy make it even more challenging to identify credible and reliable programs. This highlights the need for consistent guidelines and standards on developing, providing, and evaluating Web-based interventions and platforms with reliable up-to-date information for professionals and consumers about the characteristics, quality, and accessibility of Web-based interventions.

Disorder-specific versus transdiagnostic and clinician-guided versus self-guided internet-delivered treatment for panic disorder and comorbid disorders: A randomized controlled trial

Transdiagnostic cognitive behaviour therapy (TD-CBT) aims to target the symptoms of multiple disorders whereas disorder-specific CBT (DS-CBT) targets the symptoms of principal disorders. This study compared the relative benefits of internet-delivered TD-CBT and DS-CBT when provided in clinician-guided (CG-CBT) and self-guided (SG-CBT) formats for people with a principal diagnosis of Panic Disorder (PD). Participants (n=145) were randomly allocated to receive TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of PD (Cohen's d ≥ 0.71; avg. reduction ≥ 36%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen's d ≥ 0.71; avg. reduction ≥ 33%), generalised anxiety disorder (Cohen's d ≥ 0.91; avg. reduction ≥ 34%) and social anxiety disorder (Cohen's d ≥ 0.50; avg. reduction ≥ 15%) were found over the 24-month follow-up period. Highlighting their efficacy and acceptability, no marked and consistent differences were observed between TD-CBT and DS-CBT or CG-CBT and DS-CBT.

Internet-delivered acceptance-based behaviour therapy for generalized anxiety disorder: A randomized controlled trial

Generalized anxiety disorder (GAD) is a disabling condition which can be treated with cognitive behaviour therapy (CBT). The present study tested the effects of therapist-guided internet-delivered acceptance-based behaviour therapy on symptoms of GAD and quality of life. An audio CD with acceptance and mindfulness exercises and a separate workbook were also included in the treatment. Participants diagnosed with GAD (N = 103) were randomly allocated to immediate therapist-guided internet-delivered acceptance-based behaviour therapy or to a waiting-list control condition. A six month follow-up was also included. Results using hierarchical linear modelling showed moderate to large effects on symptoms of GAD (Cohen's d = 0.70 to 0.98), moderate effects on depressive symptoms (Cohen's d = 0.51 to 0.56), and no effect on quality of life. Follow-up data showed maintained effects. While there was a 20% dropout rate, sensitivity analyses showed that dropouts did not differ in their degree of change during treatment. To conclude, our study suggests that internet-delivered acceptance-based behaviour therapy can be effective in reducing the symptoms of GAD.

Computerized Cognitive Behavior Therapy for Anxiety and Depression in Rural Areas: A Systematic Review

Background

People living in rural and remote communities have greater difficulty accessing mental health services and evidence-based therapies, such as cognitive behavior therapy (CBT), than their urban counterparts. Computerized CBT (CCBT) can be used to effectively treat depression and anxiety and may be particularly useful in rural settings where there are a lack of suitably trained practitioners.

Objective

To systematically review the global evidence regarding the clinical effectiveness and acceptability of CCBT interventions for anxiety and/or depression for people living in rural and remote locations.

Methods

We searched seven online databases: Medline, Embase Classic and Embase, PsycINFO, CINAHL, Web of Science, Scopus, and the Cochrane Library. We also hand searched reference lists, Internet search engines, and trial protocols. Two stages of selection were undertaken. In the first, the three authors screened citations. Studies were retained if they reported the efficacy, effectiveness or acceptability of CCBT for depression and/or anxiety disorders, were peer reviewed, and written in English. The qualitative data analysis software, NVivo 10, was then used to run automated text searches for the word “rural,” its synonyms, and stemmed words. All studies identified were read in full and were included in the study if they measured or meaningfully discussed the efficacy or acceptability of CCBT among rural participants.

Results

A total of 2594 studies were identified, of which 11 met the selection criteria and were included in the review. The studies that disaggregated efficacy data by location of participant reported that CCBT was equally effective for rural and urban participants. Rural location was found to both positively and negatively predict adherence across studies. CCBT may be more acceptable among rural than urban participants—studies to date showed that rural participants were less likely to want more face-to-face contact with a practitioner and found that computerized delivery addressed confidentiality concerns.

Conclusions

CCBT can be effective for addressing depression and anxiety and is acceptable among rural participants. Further work is required to confirm these results across a wider range of countries, and to determine the most feasible model of CCBT delivery, in partnership with people who live and work in rural and remote communities.

Cognitive behaviour therapy via the internet for depression: a useful strategy to reduce suicidal ideation

BACKGROUND

Depression is a major risk factor for suicide. Given the strong association between depression and suicide, treatment for depression should be a fundamental component of suicide prevention. Currently it is not. This study aims to demonstrate the usefulness of internet-delivered cognitive behavioural therapy (iCBT) for depression as a means of reducing suicide ideation.

METHODS

The sample comprised 484 patients who were prescribed iCBT for depression by their primary care physician. The outcomes of interest were major depression, as indexed by the PHQ-8, and suicidal ideation as measured by question 9 of the PHQ-9. Marginal models were used to appropriately analyse available data without biasing parameter estimates.

RESULTS

Following iCBT for depression, suicidal ideation and depression decreased in parallel over time. The prevalence of suicidal ideation reduced from 50% at baseline to 27% after treatment, whilst the prevalence of major depression reduced from 70% to 30%. Depression scores and suicidal ideation decreased after treatment regardless of demographic or clinical variables of interest.

LIMITATIONS

This is a naturalistic study; randomisation and scientific control were not possible.

CONCLUSIONS

The current study demonstrates the usefulness of iCBT for depression as a means of reducing suicidal ideation which can be implemented on a large scale without enacting major structural change at the societal level. These findings need to be replicated in randomised controlled trials.

Internet-delivered cognitive behavior therapy for anxiety disorders is here to stay

Anxiety disorders are common and disabling. Cognitive behavior therapy is the treatment of choice but is often difficult to obtain. Automated, internet-delivered, cognitive behavior therapy (iCBT) courses may be an answer. There are three recent systematic reviews of randomized controlled trials that show that the benefits are substantial (d = 1.0) and similar to face to face CBT. There are two large effectiveness trials that demonstrate strong effects when iCBT is used in primary care; 60 % of patients who complete the courses no longer meet diagnostic criteria. The courses are suitable for most people with a primary anxiety disorder. Research studies usually exclude people whose anxiety is secondary to schizophrenia, bipolar disorder, or substance abuse or who are actively suicidal. Little additional input from clinicians is required. Patients find the courses very convenient. Clinically, the principal advantage is the fidelity of the treatment. What you prescribe is what the patient sees.

Mental health related Internet use among psychiatric patients: a cross-sectional analysis

BACKGROUND

The Internet is of great importance in today's health sector, as most Internet users utilize online functions for health related purposes. Concerning the mental health care sector, little data exist about the Internet use of psychiatric patients. It is the scope of this current study to analyze the quantity and pattern of Internet usage among mental health patients.

METHODS

Patients from all services of the Department of Psychiatry at a university hospital were surveyed by completing a 29-item questionnaire. The data analysis included evaluation of frequencies, as well as group comparisons.

RESULTS

337 patients participated in the survey, of whom 79.5% were Internet users. Social media was utilized by less than half of the users: social networks (47.8%), forums (19.4%), chats (18.7%), blogs (12.3%). 70.9% used the Internet for mental health related reasons. The contents accessed by the patients included: information on mental disorders (57.8%), information on medication (43.7%), search for mental health services (38.8%), platforms with other patients (19.8%) and platforms with mental health professionals (17.2%). Differences in the pattern of use between users with low, medium and high frequency of Internet use were statistically significant for all entities of social media (p < 0.01), search for mental health services (p = 0.017) and usage of platforms with mental health professionals (p = 0. 048). The analysis of differences in Internet use depending on the participants' type of mental disorder revealed no statistically significant differences, with one exception. Regarding the Internet's role in mental health care, the participants showed differing opinions: 36.2% believe that the Internet has or may have helped them in coping with their mental disorder, while 38.4% stated the contrary.

CONCLUSIONS

Most psychiatric patients are Internet users. Mental health related Internet use is common among patients, mainly for information seeking. The use of social media is generally less frequent. It varies significantly between different user types and was shown to be associated with high frequency of Internet use. The results illustrate the importance of the Internet in mental health related contexts and may contribute to the further development of mental health related online offers.

Therapist-assisted Internet-delivered cognitive behavior therapy for depression and anxiety: translating evidence into clinical practice

This dissemination study examined the effectiveness of therapist-assisted Internet-delivered Cognitive Behavior Therapy (ICBT) when offered in clinical practice. A centralized unit screened and coordinated ICBT delivered by newly trained therapists working in six geographically dispersed clinical settings. Using an open trial design, 221 patients were offered 12 modules of ICBT for symptoms of generalized anxiety (n=112), depression (n=83), or panic (n=26). At baseline, midpoint and post-treatment, patients completed self-report measures. On average, patients completed 8 of 12 modules. Latent growth curve modeling identified significant reductions in depression, anxiety, stress and impairment (d=.65-.78), and improvements in quality of life (d=.48-.66). Improvements in primary symptoms were large (d=.91-1.25). Overall, therapist-assisted ICBT was effective when coordinated across settings in clinical practice, but further attention should be given to strategies to improve completion of treatment modules.

Internet psychotherapy and the future of personalized treatment

Internet-delivered cognitive behavioral therapy (iCBT) was developed to overcome some of the barriers in accessing best practice face-to-face CBT. iCBT affords many benefits, such as high fidelity, greater accessibility, convenience, and reduced cost to patients and health-care systems. Recent meta-analyses of iCBT for depressive and anxiety disorders demonstrate large effect size for superiority of iCBT over control conditions (ES>.95; number needed to treat (NNT) = 2) and data collected in routine practice supports the effectiveness of these programs. Tailoring treatment to match patient variables may be one means to increase adherence and optimize clinical outcomes. However, we propose that a "personalized medicine" approach will require looking beyond patient characteristics and comorbidities to consideration of the cognitive processes that subserve depression and anxiety symptomatology.