Predictors of treatment outcomes and adherence in internet-based cognitive behavioral therapy for social anxiety in China

Feasibility of Guided Internet-Based Cognitive Behavioral Therapy for Panic Disorder and Social Anxiety Disorder in Japan: Pilot Single-Arm Trial

BACKGROUND

Cognitive behavioral therapy (CBT) is effective in treating anxiety disorders. Accessibility to CBT has been limited in Japan due to the shortage of therapists. While an open-source e-learning system can be used to create a simple internet-based cognitive behavioral therapy (ICBT) program, the safety and outpatient acceptance of this treatment approach have not been explored in Japan.

OBJECTIVE

The aim of this study was to investigate whether outpatients with anxiety disorders could accept and successfully complete the ICBT program with guidance by CBT therapists when implementing therapeutic modules and CBT tasks. Due to being in the initial phase of a novel treatment in Japan, this study was intended for verification with a small sample size.

METHODS

In total, 6 adults, including 4 male participants and 2 female participants, were enrolled in a single-arm trial. The intervention involved guided ICBT comprising 12 sessions, including CBT text, comprehension confirmation tests, and explanatory videos about cognitive behavioral models, accessible through a website. The therapist guided the participants in accessing the ICBT program and answering their questions using a chat tool. The primary outcome was anxiety severity assessed using the State-Trait Anxiety Inventory-Trait. Secondary outcomes included the Panic Disorder Severity Scale, Liebowitz Social Anxiety Scale (LSAS), Beck Anxiety Inventory (BAI), Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Working Alliance Inventory-Short Form (WAI-SF). Statistical analyses were performed using paired 2-tailed t tests to assess the changes in clinical symptoms. The total WAI-SF score at the final session was used to evaluate the therapeutic alliance. For statistical analyses, mean changes for total State-Trait Anxiety Inventory-Trait, BAI, Panic Disorder Severity Scale, LSAS, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 scores were analyzed using the paired 2-tailed t test. The 2-sided significance level for hypothesis testing was set at 5%, and 2-sided 95% CIs were calculated.

RESULTS

Most participants diligently engaged with the ICBT program. No adverse events were reported. The mean total scores for the primary outcome decreased by 11.0 (SD 9.6) points (95% CI -22.2 to 0.20; Hedges g=0.95), but it was not statistically significant. The mean total scores for the secondary outcomes that assess clinical symptoms decreased, with a significant reduction observed in the BAI of 15.7 (SD 12.1) points (95% CI -28.4 to -3.0; P=.03; Hedges g=1.24). The mean total scores for PDSS and LSAS decreased significantly, by 12.0 (SD 4.24) points (95% CI -50.1 to 26.1; P=.16; Hedges g=1.79) and 32.4 (SD 11.1) points (95% CI -59.7 to -4.3; P=.04; Hedges g=1.38), respectively. Of the participants, 67% (n=4) showed treatment response, and 50% (n=3) achieved remission after the intervention. The therapeutic alliance, measured using the WAI-SF, was moderate.

CONCLUSIONS

Guided ICBT may be feasible for the treatment of outpatients with panic disorder and social anxiety disorder in Japan.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry UMIN0000038118; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000043439.

Pathological network changes in patients with social anxiety disorder before and after an Internet-based CBT

A network perspective may shed light on the understanding of Internet-based CBT efficacy for social anxiety disorder. Previous cross-sectional evidence revealed a densely interconnected network for individuals with social anxiety. Yet, longitudinal network changes before and after ICBT are lacking. This study aimed to investigate pathological network changes with Graphical Gaussian Model among patients with social anxiety disorder (n = 249). Social phobia scale (SPS) and Social interaction anxiety scale (SIAS) were measured before and after 8 weeks Internet-based CBT. Results revealed the connection between symptom tension when speaking and symptom awkward when being watched was the most robust edges during ICBT interventions. The pathological network benefited from ICBT and exhibited modification in several prominent interconnections. The overall network connectivity continues to exhibit comparable strength after ICBT. This study represents the first examination of social anxiety network changes after patients with SAD completed a systematic ICBT. Changes in critical edges and nodes provide valuable insights for the design and efficacy assessment of ICBT interventions.

Development of social anxiety cognition scale for college students: Basing on Hofmann's model of social anxiety disorder

Introduction

To develop the Chinese version of the Social Anxiety Cognition Scale for College Students (SACS-CS) based on Hofmann's model of social anxiety disorder and examine its reliability and validity.

Methods

Based on literature analysis and structured interviews, a theoretical model was constructed and behavioral examples were collected. According to the results of participants' and experts' evaluations, the initial SACS-CS was developed. The study data were collected from a total of 500 valid participants, randomly divided into two samples. Sample 1 (n = 200) and sample 2 (n = 300) were considered for exploratory factor analysis and confirmatory factor analysis (CFA), respectively. Internal reliability and validity were examined using all 500 participants, and temporal reliability was established using sample 3 (n = 70), who completed the scale again after 4 weeks.

Results

The SACS-CS consists of 21 items, grouped under four factors: self-perception, social skills, emotional control, and cost estimation. The four-factor model fits well. The internal consistency coefficient of the scale and the four factors ranged from 0.87 to 0.96, and the test-retest reliability ranged from 0.76 to 0.84. The scores of the scale and the four factors were significantly correlated with the score of the Interaction Anxiousness Scale (r = 0.54-0.64).

Discussion

The SACS-CS possesses good reliability and validity and can be applied in the cognitive assessment of college students' social anxiety. The scale could help people with different social anxiety disorder conditions receive more personalized interventions.

Factors Associated With Treatment Response in an Internet-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement

Internet-based psychological interventions have proven effective in the treatment of prolonged grief disorder (PGD). Yet, some patients do not benefit from treatment in a clinically significant way. We aimed to examine predictors of symptom reduction in an Internet-based intervention for PGD after cancer bereavement, in order to identify possible treatment mechanisms and discern directions for future intervention design. A secondary analysis of data from a randomized wait-list controlled trial on an Internet-based intervention for PGD after cancer bereavement was conducted. Multiple regression models were used (1) to test for the influence of pretreatment PGD, working alliance, avoidance and gender on PGD symptom reduction; and (2) to explore further predictors of treatment success with a best subset selection protocol. The regression models explained 18% (Model 1) and 34% (Model 2) of variance in symptom reduction. Participants with more favorable symptom change had more severe pretreatment PGD scores and better working alliance. Those with lower social support and less posttraumatic growth experienced more PGD symptom change. In conclusion, therapeutic alliance is an important factor that should be monitored and fostered. Findings regarding social support and posttraumatic growth need further replication and clarification.

Gender Differences in Usage and Subjective Appreciation of an Online Cognitive Behavioral Therapy for Wildfire Evacuees: Descriptive Study

BACKGROUND

Based on the most common psychological difficulties of the evacuees from the 2016 Fort McMurray wildfires in Alberta, Canada, a therapist-guided cognitive behavioral self-treatment was developed. This study aimed to explore how gender influences the usage and subjective appreciation of the RESILIENT online treatment.

METHODS

Our study included 81 English-speaking evacuees with significant posttraumatic symptoms, or with some posttraumatic symptoms accompanied by at least mild depression symptoms or subclinical insomnia, and who logged into the platform at least once. Various usage and subjective appreciation variables were analyzed, including number of completed sessions, number of logins, number of words per session, perceived efforts, perception of usefulness and intention to continue using the different strategies.

RESULTS

No difference was detected in most objective usage indicators. The number of words written in sessions 7 and 10 was significantly greater for women than for men. Regarding subjective appreciation, men had a greater perception of having put strong efforts in the cognitive restructuring strategy, while women reported in a greater proportion that they wanted to continue using physical exercise as a behavioral activation strategy.

CONCLUSIONS

Our study offers a first look into how women and men use online treatments, and what their preferences are.

Impact of guidance on intervention adherence in computerised interventions for mental health problems: a meta-analysis

Web-based interventions are increasingly used for the prevention, treatment and aftercare of mental disorders. A crucial factor to the efficacy of such online programmes is adherence to the intervention content and procedure. It has been frequently suggested that adherence in web-based interventions is low and little is known about which factors influence adherence. To increase intervention uptake and completion, studies increasingly include interventions with some form of guidance. Guided interventions have been shown to have higher efficacy, however, evidence for the impact on adherence is limited and mixed. This meta-analysis explored the impact of human guidance on intervention completion in web-based mental health interventions. A total of 22 studies were included with interventions primarily targeting symptoms of depression and anxiety disorders. Results showed that guidance significantly increases the average amount of intervention completion [g = 0.29, 95% confidence interval (CI) 0.18-0.40] and the proportion of intervention completers [log odds ratio (OR) = 0.50, 95% CI 0.34-0.66] with small effects. On average, full completion rates were 12% higher in guided intervention groups. This meta-analysis demonstrated that guidance in web-based mental health interventions does increase adherence, but more research is required to better understand the specific mechanisms between guidance, adherence and outcomes.

Optimizing cognitive-behavioral therapy for social anxiety disorder and understanding the mechanisms of change: Study protocol for a randomized factorial trial

BACKGROUND

Social anxiety disorder (SAD) is characterized by a marked fear of negative evaluation in social situations and significant impairments. Even with the most effective treatments, remission rates are around 50%. An important reason for the limited effectiveness of treatments is the lack of evidence-based explanation of how treatments work and what their active ingredients might be. An approach to unpack the active ingredients and mechanisms of treatment is the factorial design.

OBJECTIVES

The study is a factorial trial aiming (1) to examine the main effects and interactions for the four main treatment components of internet-based cognitive-behavioral therapy (ICBT) for SAD (i.e., psychoeducation, cognitive restructuring, attentional training, and exposure) and (2) to examine whether and which change mechanisms mediate the relationship between treatment components and symptom reduction.

METHODS

A total of 464 adults diagnosed with SAD will be randomized to one of 16 conditions containing combinations of the treatment components. The primary endpoint is SAD symptomatology at eight weeks. Secondary endpoints include symptoms of depression and anxiety, quality of life, and negative effects. Hypothesized change mechanisms are the increase of knowledge about SAD, the decrease of dysfunctional cognitions, the decrease of self-focused attention, and the decrease of avoidance and safety behaviors.

DISCUSSION

A better understanding of the differential efficacy of treatment components and mechanisms of treatment underlying ICBT for SAD might inform clinicians and researchers to plan more potent and scalable treatments.

TRIAL REGISTRATION

clinicaltrials.gov (NCT04879641) on June, 11th 2021. https://clinicaltrials.gov/ct2/show/NCT04879641.

Digital mental health in China: a systematic review

Mental health problems are highly prevalent in China; however, China's mental health services lack resources to deliver high-quality care to people in need. Digital mental health is a promising solution to this short-fall in view of the population's digital literacy. In this review, we aim to: (i) investigate the effectiveness, acceptability, usability, and safety of digital health technologies (DHTs) for people with mental health problems in China; (ii) critically appraise the literature; and (iii) make recommendations for future research directions. The databases MEDLINE, PsycINFO, EMBASE, Web of Science, CNKI, WANFANG, and VIP were systemically searched for English and Chinese language articles evaluating DHTs for people with mental health problems in mainland China. Eligible studies were systematically reviewed. The heterogeneity of studies included precluded a meta-analysis. In total, 39 articles were retrieved, reporting on 32 DHTs for various mental health problems. Compared with the digital mental health field in the West, the Chinese studies targeted schizophrenia and substance use disorder more often and investigated social anxiety mediated by shame and culturally specific variants, DHTs were rarely developed in a co-production approach, and methodology quality was less rigorous. To our knowledge, this is the first systematic review focused on digital mental health in the Chinese context including studies published in both English and the Chinese language. DHTs were acceptable and usable among Chinese people with mental health problems in general, similar to findings from the West. Due to heterogeneity across studies and a paucity of robust control trial research, conclusions about the efficacy of DHTs are lacking.

Predicting Treatment Outcomes in Guided Internet-Delivered Therapy for Anxiety Disorders-The Role of Treatment Self-Efficacy

Aim: Guided Internet-delivered therapy has shown to be an effective treatment format for anxiety disorders. However, not all patients experience improvement, and although predictors of treatment outcome have been identified, few are consistent over time and across studies. The current study aimed to examine whether treatment self-efficacy (self-efficacy regarding the mastery of obstacles during treatment) in guided Internet-delivered therapy for anxiety disorders in adults could be a predictor of lower dropout rates and greater symptom reduction. Method: The analyzed data comes from an open effectiveness study including 575 patients receiving guided Internet-delivered therapy for panic disorder or social anxiety disorder. Treatment self-efficacy was measured at pre-treatment. Symptom reduction was measured at 10 measurement points, including a 6-month follow-up. A mixed linear model was applied in the analysis. Results: The results showed that high treatment self-efficacy was a predictor of both lower dropout rates and greater symptom reduction. Significant interaction effects between time and treatment self-efficacy were found for several of the nine modules that constitutes the treatment program, suggesting that treatment self-efficacy could be a moderator of symptom reduction. Three of nine modules in the panic disorder treatment and six of nine in the social anxiety disorder treatment showed significant interaction effects. Conclusion: The results suggest that measuring treatment self-efficacy may be a valuable tool to identify patients at risk of dropping out, and that treatment self-efficacy could be a predictor and moderator of symptom reduction in guided Internet-delivered therapy. The implications of the results are discussed.

Données d’utilisation d’un autotraitement guidé en ligne pour promouvoir la résilience après une catastrophe naturelle

Objectifs Malgré l’existence de plusieurs traitements en ligne pour les personnes avec un trouble de stress posttraumatique (TSPT), peu d’études se sont penchées sur les données d’utilisation d’une telle intervention. Étant donné le potentiel de la modalité en ligne à pallier les obstacles limitant l’accès à l’aide psychologique, il importe de documenter les interactions des usagers avec ces outils en lien avec l’amélioration des symptômes ciblés. L’objectif de cette étude est de documenter les données d’utilisation de la plateforme de traitement en ligne RESILIENT par les personnes évacuées des feux de Fort McMurray, Alberta (Canada), et d’examiner leur association avec l’efficacité du traitement sur les symptômes de trouble de stress posttraumatique (TSPT), d’insomnie et de dépression, et l’adhésion au traitement, mesurée par le nombre de modules consultés par les participants.

Méthode Quatre-vingt-dix-sept personnes évacuées des feux de Fort McMurray présentant des symptômes de TSPT, d’insomnie et de dépression sont incluses dans la présente étude. Les participants étaient invités à utiliser la plateforme RESILIENT, un autotraitement en ligne guidé par un thérapeute qui cible les symptômes de TSPT, le sommeil et l’humeur, et comprend 12 modules offrant des stratégies de thérapies cognitives et comportementales (TCC) basées sur les données probantes. Des données d’utilisation objectives (p. ex. nombre de modules consultés) et subjectives (p. ex. niveau d’efforts investis) ont été recueillies.

Résultats Afin de prédire la réduction des symptômes de TSPT, de dépression et d’insomnie, ainsi que le nombre de modules consultés par les participants, des modèles de régressions séquentielles ont été effectués, avec un contrôle statistique pour les symptômes prétraitement, l’âge et le genre. Les modèles finaux ont révélé qu’une réduction des symptômes de TSPT, de dépression et d’insomnie était prédite significativement par le nombre de modules consultés (β = - 0,41 ; - 0,53 ; - 0,49 respectivement, tous p < 0,001) ainsi que par le niveau d’efforts moyen autorapporté au module 7 (mi-parcours) (β = - 0,43 ; p < 0,001 ; β = - 0,38 ; p = 0,005 et β = - 0,36 ; p = 0,007 respectivement). Le nombre de modules consultés, par ailleurs, était prédit significativement par le nombre de mots dans le 4e module (β = 0,34 ; p < 0,001) et dans le 7e module (β = 0,44 ; p < 0,001), ainsi que par le nombre d’entrées dans le journal du sommeil (β = 0,28 ; p < 0,001).

Conclusion Les résultats ont confirmé qu’une plus grande interaction avec la plateforme influence positivement l’efficacité du traitement et qu’une utilisation accrue en début de traitement semble être un bon prédicteur de l’achèvement de celui-ci. Cette étude confirme l’importance de soutenir l’engagement des participants envers le traitement en ligne afin d’optimiser son efficacité.

Cultural adaptation of internet- and mobile-based interventions for mental disorders: a systematic review

Providing accessible and effective healthcare solutions for people living in low- and middle-income countries, migrants, and indigenous people is central to reduce the global mental health treatment gap. Internet- and mobile-based interventions (IMI) are considered scalable psychological interventions to reduce the burden of mental disorders and are culturally adapted for implementation in these target groups. In October 2020, the databases PsycInfo, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for studies that culturally adapted IMI for mental disorders. Among 9438 screened records, we identified 55 eligible articles. We extracted 17 content, methodological, and procedural components of culturally adapting IMI, aiming to consider specific situations and perspectives of the target populations. Adherence and effectiveness of the adapted IMI seemed similar to the original IMI; yet, no included study conducted a direct comparison. The presented taxonomy of cultural adaptation of IMI for mental disorders provides a basis for future studies investigating the relevance and necessity of their cultural adaptation.PROSPERO registration number: CRD42019142320.

Internet-based cognitive-behavioural therapy for tinnitus: secondary analysis to examine predictors of outcomes

OBJECTIVES

The current study examined predictors of outcomes of internet-based cognitive-behavioural therapy (ICBT) for individuals with tinnitus.

DESIGN

Secondary analysis of intervention studies.

SETTING

Internet-based guided tinnitus intervention provided in the UK.

PARTICIPANTS

228 individuals who underwent ICBT.

INTERVENTIONS

ICBT.

PRIMARY AND SECONDARY OUTCOME MEASURES

The key predictor variables included demographic, tinnitus, hearing-related and treatment-related variables as well as clinical factors (eg, anxiety, depression, insomnia), which can have an impact on the treatment outcome. A 13-point reduction in Tinnitus Functional Index (TFI) scores has been defined as a successful outcome.

RESULTS

Of the 228 subjects who were included in the study, 65% had a successful ICBT outcome. As per the univariate analysis, participants with a master's degree or above had the highest odds of having a larger reduction in tinnitus severity (OR 3.47; 95% CI 1.32 to 12.51), compared with the participants who had education only up to high school or less. Additionally, the baseline tinnitus severity was found to be a significant variable (OR 2.65; 95% CI 1.50 to 4.67) contributing to a successful outcome with the intervention. Both linear and logistic regression models have identified education level and baseline tinnitus severity to be significant predictor variables contributing to a reduction in tinnitus severity post-ICBT. As per the linear regression model, participants who had received disability allowance had shown a 25.3-point lower TFI reduction compared with those who did not experience a decrease in their workload due to tinnitus after adjusting for baseline tinnitus severity and their education level.

CONCLUSIONS

Predictors of intervention outcome can be used as a means of triaging patients to the most suited form of treatment to achieve optimal outcomes and to make healthcare savings. Future studies should consider including a heterogeneous group of participants as well as other predictor variables not included in the current study.ClinicalTrial.gov Registration: NCT02370810 (completed); NCT02665975 (completed).

Examining correlates of cannabis users' engagement with a digital intervention for substance use disorder: An observational study of clients in UK services delivering Breaking Free Online

BACKGROUND

Cannabis is among the most widely used drugs, with the literature demonstrating that cannabis use disorder (CUD) may be more prevalent than previously thought. Research should explore novel approaches to behavioral support to meet treatment need, including computer-assisted therapies such as Breaking Free Online (BFO). This study aimed to understand how participants' baseline sociodemographic and clinical characteristics are associated with engagement with BFO, and how both participants' characteristics and their engagement may be associated with cannabis use and biopsychosocial functioning at follow-up.

METHODS

An observational study with 1830 individuals presenting to UK-based publicly funded treatment services who reported cannabis as their primary problem substance and engaged with BFO as a self-directed intervention.

RESULTS

Moderate-severe depression/anxiety (51%) and elevated severity of cannabis dependence scores (39%) characterized the baseline sample. Women demonstrated greater clinical complexity at baseline than men. Baseline mental health and biopsychosocial functioning were associated with whether participants completed a follow-up assessment. Among 460 participants who completed a follow-up assessment, intervention engagement was positively associated with self-reported quality of life and biopsychosocial functioning at follow-up.

CONCLUSIONS

Cannabis users demonstrated substantial clinical complexity at baseline, with depression/anxiety and biopsychosocial functioning being associated with BFO engagement. Greater BFO engagement was also associated with better quality of life and biopsychosocial functioning at follow-up. Some groups, including those with greater mental health and biopsychosocial impairment at baseline and women, may require support to engage with BFO to maximize clinical benefits.