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

A digital iCBT intervention for social anxiety disorder in Quebec and Ontario: protocol for a multi-phase effectiveness-implementation study

BACKGROUND

Social anxiety disorder (SAD) is one of the most prevalent anxiety disorders in Canada. Viable therapy options for the treatment of SAD include CBT being delivered virtually. In Australia, an innovative internet-delivered cognitive-behavioral therapy (iCBT) program for social anxiety has been developed, implemented, and demonstrated as effective. To make available high-quality and real-time evidence in response to the crucial need to access psychological services to meet population mental health needs, we propose to conduct a Canadian adaptation of the iCBT Shyness Program and to examine the program's effectiveness, and implementation in two Canadian provinces (Quebec and Ontario).

METHODS

The overall study design is a hybrid effectiveness-implementation study of a quasi-experimental parallel group trial. Prior to implementing the iCBT Shyness Program, it will undergo an initial adaptation to the Canadian context and focus groups will be conducted with key actor groups to discuss the adaptations to the graphics, narration of the lessons, and this to better reflect varying socio-cultural context among Canadian French- and English-speaking populations. We will evaluate the effectiveness of the program in three parallel pathways reflecting real-world pathways: (1) self-refer to the intervention; (2) recommended by a health professional without guidance; and (3) recommended by a health professional, with low-intensity guidance. Data collection will be carried out at baseline, at the beginning of each lesson, 12-week and 6-month follow-up. Outcomes measured will include anxiety and depressive symptoms, psychological distress, disability, as well as health service utilization and satisfaction. Semi-structured interviews will then be conducted with study participants and health care providers to explore facilitating factors and barriers to the implementation of the iCBT adapted program.

DISCUSSION

This study will provide evidence on the effectiveness, barriers and facilitating factors to implementing a low-intensity iCBT in the Canadian context for SAD, which will bridge an important care gap for undeserved populations in Canada with SAD. Findings will inform the eventual scaling up of the program in community-based primary care across Canada. This would improve equity of the health care system by helping a large number of Canadians to timely access to mental health services.

TRIAL REGISTRATION

clinicaltrials.gov NCT06403995. Prospectively registered on 05/03/2024.

Exploring student preferences for implementing a digital mental health intervention in a university setting: Qualitative study within a randomised controlled trial

Objective

Digital interventions can be effective in preventing and treating common mental health conditions among university students. Incorporating student experiences and perspectives in the design and implementation of these programmes may improve uptake and engagement. This qualitative study explored university students' perspectives of a low-intensity video-based mental health intervention, their recommendations for implementing the programme in university settings, and their views and recommendations to address barriers to engagement.

Methods

Participants (N = 115) were students (mean = 20.63 years, SD = 2.10) with elevated distress from 31 Australian universities drawn from a randomised controlled trial of the Uni Virtual Clinic-Lite (UVC-Lite). Data from students randomised to the intervention condition were collected via semi-structured interviews (n = 12) and open-ended questions during post-intervention surveys (n = 103). Data were analysed using content analysis.

Results

Participants generally reported positive views of the intervention, and most felt it should be offered to students as a universal intervention. Multiple methods of disseminating the intervention were suggested, including through university counselling, official platforms (e.g. student support services) and informal channels (e.g. word-of-mouth promotion). Difficulty integrating the programme into everyday life, pre-existing beliefs about mental health and technology-related factors were highlighted as barriers to engagement.

Conclusion

A low-intensity video-based mental health intervention was generally considered to be acceptable and appropriate for students with mild to moderate distress. Participants provided several suggestions to encourage uptake of the intervention and possible pathways to disseminate the intervention to students. The effectiveness of these should be examined in future trials.

Remote cognitive behaviour therapy for social anxiety disorder: A meta-analysis

Remote cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) has the potential to improve access to treatment by reducing economic, geographic, and psychological barriers. The aim of this study was to use a meta-analytic approach to examine the efficacy of the different remote CBT methods for treating SAD. A systematic electronic database search was used to identify 31 studies (n = 2905; mean age range: 24.73-41.65 years; mean female representation = 60.2 %). Pooled within-group analyses indicated large effect sizes from pre-treatment to post-treatment (Hedges' g = 1.06; 95 % CI: 0.96-1.16) and pre-treatment to follow up (g = 1.18; 95 % CI: 1.03-1.33) for remote CBT. Internet-delivered CBT (g = 1.08; 95 % CI: 0.98-1.19) and application-delivered CBT (g = 1.19; 95 % CI: 0.75-1.64) produced large within-group effect sizes. Bibliotherapy-delivered CBT (g = 0.79; 95 % CI: 0.45-1.13) produced medium within-group effect sizes. Pooled between-group findings indicate that remote CBT treatments were more effective than passive control (g = 0.87; 95 % CI: 0.70-1.03) and non-CBT remote treatments (g = 0.41; 95 % CI: 0.17-0.66), and were at least as effective, or slightly more effective, than face-to-face CBT treatments (g = 0.34; 95 % CI: 0.14-0.54). These findings have important implications for the dissemination of remote and stepped-care treatments for SAD.

Guided versus self-guided internet delivered cognitive behavioural therapy for diagnosed anxiety and related disorders: a preliminary meta-analysis

Guided and self-guided internet-delivered cognitive-behavioural therapy (ICBT) has been demonstrated to be efficacious in the treatment of anxiety and related disorders (ARDs). The aim of the current study was to examine the efficacy of guided and self-guided ICBT for adults diagnosed with ARDs using a meta-analytic synthesis of randomised controlled trials directly comparing the two treatment approaches. Eleven studies (n = 1414) were included. There was a small, but significantly pooled between-group effect size at post-treatment (g = 0.16; 95% CI: 0.03-0.28) favouring guided ICBT. At follow-up, the between-group effect size was small and non-significant (g = 0.13; 95% CI: -0.04-0.30). Gender distribution moderated outcome at post-treatment (higher proportions of females resulted in a smaller between-group effect size). Type of support provided in the guided-treatment arm moderated treatment outcome at follow-up (those receiving synchronous support had a larger between-group effect size). Amount of guidance in the guided-treatment arm moderated effect sizes at post-treatment and follow-up (more guidance leading to larger between-group effect sizes). Automated reminders, disorder type, and treatment length did not moderate outcomes. The results suggest that guided and self-guided ICBT interventions result in similar outcomes, however guided interventions may be marginally more effective in the short term.

StudiCare procrastination - Randomized controlled non-inferiority trial of a persuasive design-optimized internet- and mobile-based intervention with digital coach targeting procrastination in college students

BACKGROUND

Academic procrastination is widespread among college students. Procrastination is strongly negatively correlated with psychological well-being, thus early interventions are needed. Internet- and mobile-based cognitive behavioral therapy (iCBT) could provide a low-threshold treatment option. Human guidance seems to be a decisive mechanism of change in iCBT. Persuasive design optimization of iCBT and guidance by a digital coach might represent a resource-saving alternative. The study evaluated the non-inferiority of a digital coach in comparison to human guidance with regard to the primary outcome procrastination.

METHODS

The iCBT StudiCare procrastination was optimized by principles of the Persuasive System Design (PSD). A total of 233 college students were randomly assigned to either StudiCare procrastination guided by a digital coach (intervention group, IG) or by a human eCoach (control group, CG). All participants were assessed at baseline, 4-, 8- and 12-weeks post-randomization. Symptom change and between-group differences were assessed with latent growth curve models and supported by effect size levels. The non-inferiority margin was set at Cohen's d = - 0.3.

RESULTS

The primary outcome procrastination measured by the Irrational Procrastination scale (IPS) significantly decreased across groups (γ = - 0.79, p < .001, Cohen's d = -0.43 to -0.89) from baseline to 12-weeks post-randomization. There were no significant differences between groups (γ = -0.03, p = .84, Cohen's d = -0.03 to 0.08). Regarding symptoms of depression, no significant time x group effect was found (γ = 0.26, p = .09; Cohen's d = -0.15 to 0.21). There was also no significant time x group effect on the improvement of symptoms of anxiety (γ = 0.25, p = .09). However, Cohen's ds were above the non-inferiority margin 8-weeks (Cohen's d = 0.51) and 12-weeks post-randomization (Cohen's d = 0.37), preferring the CG. Of the IG, 34% and of the CG, 36% completed 80% of the modules.

CONCLUSIONS

The PSD optimized version of StudiCare procrastination is effective in reducing procrastination. The digital coach was not inferior to human guidance. Guidance by a digital coach in iCBT against procrastination for college students could be a resource-saving alternative to human guidance.

TRIAL REGISTRATION

The trial was registered at the WHO International Clinical Trials Registry Platform via the German Clinical Trial Register (ID: DRKS00025209, 30/04/2021).

What I missed from my online therapist: A survey-based qualitative investigation of patient experiences of therapist contact in guided internet interventions

Background

The effectiveness of internet-delivered cognitive behavioral therapy (ICBT) in alleviating symptoms of psychological disorders has been demonstrated across qualitative and quantitative studies. Generally, guided ICBT is considered more effective than unguided ICBT. Yet, what therapist contact and guidance specifically add to the treatment is less clear. There is a need for more knowledge about how patients experience the relationship with their therapist in guided ICBT. The aim of the study was to explore what patients missed in the contact with their therapist in guided ICBT in routine care.

Methods

The study used a qualitative design to explore patients´ experiences of the therapist contact in guided ICBT for social anxiety disorder, panic disorder and major depressive disorder. Following treatment, 579 patients received a survey with the open-ended question "What did you miss in the contact with your therapist?" The responses were explored thematically using qualitative content analysis.

Results

A total of 608 unique responses were provided. Of these, 219 responses gave voice to some degree of perceived lack or limitation in their interaction with the therapist or the treatment in general. The analysis yielded three main categories: The first theme, Therapist-ascribed shortcomings, concerned experiences of something missing or lacking in the contact with the ICBT therapist. More specifically, the patients expressed a need for more emotionally attuned and tailored interaction. The second theme was Program obstacles, encompassing expressed wishes for increased therapist responsivity and more contact face-to-face. Self-attributed limitations, the third category, concerned patient experiences of barriers to treatment engagement as originating in themselves.

Conclusion

This study sheds light on what patients receiving guided ICBT in routine care missed in the contact with their therapist. The patients who expressed that something was missing in the contact with their therapist constituted a small part of the responses in the sample, even after being directly asked. The themes that emerged point to significant experiences of being inadequately related and responded to, both with potential adverse consequences for the treatment. These findings give new insights to the role of the guidance in ICBT and have implications for the training and supervision of guided ICBT therapists.

Two decades of digital interventions for anxiety disorders: a systematic review and meta-analysis of treatment effectiveness

BACKGROUND

Digital interventions for anxiety disorders are a promising solution to address barriers to evidence-based treatment access. Precise and powerful estimates of digital intervention effectiveness for anxiety disorders are necessary for further adoption in practice. The present systematic review and meta-analysis examined the effectiveness of digital interventions across all anxiety disorders and specific to each disorder v. wait-list and care-as-usual controls.

METHODS

A systematic search of bibliographic databases identified 15 030 abstracts from inception to 1 January 2020. Forty-seven randomized controlled trials (53 comparisons; 4958 participants) contributed to the meta-analysis. Subgroup analyses were conducted by an anxiety disorder, risk of bias, treatment support, recruitment, location and treatment adherence.

RESULTS

A large, pooled effect size of g = 0.80 [95% Confidence Interval: 0.68-0.93] was found in favor of digital interventions. Moderate to large pooled effect sizes favoring digital interventions were found for generalized anxiety disorder (g = 0.62), mixed anxiety samples (g = 0.68), panic disorder with or without agoraphobia (g = 1.08) and social anxiety disorder (g = 0.76) subgroups. No subgroups were significantly different or related to the pooled effect size. Notably, the effects of guided interventions (g = 0.84) and unguided interventions (g = 0.64) were not significantly different. Supplemental analysis comparing digital and face-to-face interventions (9 comparisons; 683 participants) found no significant difference in effect [g = 0.14 favoring digital interventions; Confidence Interval: -0.01 to 0.30].

CONCLUSION

The precise and powerful estimates found further justify the application of digital interventions for anxiety disorders in place of wait-list or usual care.

Three-arm randomised controlled trial of an m-health app and digital engagement strategy for improving treatment adherence and reducing suicidal ideation in young people: study protocol

INTRODUCTION

Youth suicidal ideation and behaviour is concerning due to its widespread prevalence, morbidity and potentially fatal consequences. Digital mental health interventions have been found to improve access to low-cost and high-quality support for a range of mental health issues, yet there are few digital interventions available for suicide prevention in young people. In addition, no studies have examined how digital engagement strategies may impact the engagement and efficacy of digital interventions in suicide prevention. The current protocol describes a three-arm parallel randomised controlled trial. A therapeutic smartphone application ('LifeBuoy'; intervention condition) will be tested against a condition that consists of the LifeBuoy application plus access to a digital engagement strategy ('LifeBuoy+engagement'; intervention condition) to determine whether the addition of the digital strategy improves app engagement metrics. To establish the efficacy of the LifeBuoy application, both of these intervention conditions will be tested against an attention-matched control condition (a placebo app).

METHODS AND ANALYSIS

669 young Australians aged 17-24 years who have experienced suicidal ideation in the past 30 days will be recruited by Facebook advertisement. The primary outcomes will be suicidal ideation severity and level of app engagement. Primary analyses will use an intention-to-treat approach and compare changes from baseline to 30-day, 60-day and 120-day follow-up time points relative to the control group using mixed-effect modelling. A subset of participants in the intervention groups will be interviewed on their experience with the app and engagement strategy. Qualitative data will be analysed using an inductive approach, independent of a theoretical confirmative method to identify the group themes.

ETHICS AND DISSEMINATION

The study has been approved by the University of New South Wales Human Research Ethics Committee (HC210400). The results of the trial will be disseminated via peer-reviewed publications in scientific journals and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12621001247864.

Technology-supported strategies for promoting user engagement with digital mental health interventions: A systematic review

Background

Although digital mental health interventions (DMHIs) offer a potential solution for increasing access to mental health treatment, their integration into real-world settings has been slow. A key reason for this is poor user engagement. A growing number of studies evaluating strategies for promoting engagement with DMHIs means that a review of the literature is now warranted. This systematic review is the first to synthesise evidence on technology-supported strategies for promoting engagement with DMHIs.

Methods

MEDLINE, EmbASE, PsycINFO and PubMed databases were searched from 1 January 1995 to 1 October 2021. Experimental or quasi-experimental studies examining the effect of technology-supported engagement strategies deployed alongside DMHIs were included, as were secondary analyses of such studies. Title and abstract screening, full-text coding and quality assessment were performed independently by two authors. Narrative synthesis was used to summarise findings from the included studies.

Results

24 studies (10,266 participants) were included. Engagement strategies ranged from reminders, coaching, personalised information and peer support. Most strategies were disseminated once a week, usually via email or telephone. There was some empirical support for the efficacy of technology-based strategies towards promoting engagement. However, findings were mixed regardless of strategy type or study aim.

Conclusions

Technology-supported strategies appear to increase engagement with DMHIs; however, their efficacy varies widely by strategy type. Future research should involve end-users in the development and evaluation of these strategies to develop a more cohesive set of strategies that are acceptable and effective for target audiences, and explore the mechanism(s) through which such strategies promote engagement.

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.

The effect of depression on treatment outcome in social anxiety disorder: an individual-level meta-analysis

Social anxiety disorder (SAD) is highly comorbid with depression. In the present meta-analysis, we conducted the first individual-level examination of the association between pre-treatment depression and improvement in social anxiety symptoms during treatment. We identified eligible studies on cognitive behavior therapy (CBT) and pharmacotherapy for SAD and contacted authors to obtain individual-level data. We obtained these data from 41 studies, including 46 treatment conditions (n = 4,381). Our results showed that individuals who had high levels of depression at pre-treatment experienced greater decreases in social anxiety symptoms from pre- to post-treatment, but not at follow-up. When analyzing treatment modalities (individual CBT, group CBT, internet-delivered CBT, and pharmacotherapy), we found that depressive symptoms were associated with better post-treatment outcomes for individual CBT and internet-delivered CBT, but not for pharmacotherapy or group CBT. Our findings suggest that depression does not negatively affect treatment outcome in SAD and may even lead to improved outcomes in some treatment formats. Clinical implications of these findings are discussed.

Strengthening positive social pathways via digital social applications in individuals with social skills deficits: A scoping review

BACKGROUND

Effective digital social capital interventions have great potential to establish trusted social pathways to access supportive services and to enable talking about issues contributing to distress.

AIM

This review explores the digital social capital interventions used in individuals with social skills deficits, and the best social health outcomes achieved.

METHOD

Four databases (PubMed, CINAHL, PsychINFO, and Web of Science) were used with no time limitation, and 33 papers were included.

RESULTS

A diverse range of digital social programs was used for social capital improvement based on individuals' characteristics (e.g. age range and illnesses). Programs ranged from digitally-enhanced self-help or self-guided treatment (to enhance the self-efficacy of individuals), to group treatments and/or web-based caregiver support services. They comprised mobile social apps, video blogging, video-communication system/video-conferencing, and online social communication, to more advanced techniques such as virtual reality. All of these modalities were shown to be beneficial for improving the social health of individuals. Interventions targeted two aspects of social capital: (1) cognitive social capital, focusing on enhancing trust and control, self-efficacy on life. Some examples were cognitive behavioural therapy, and increasing the received and more importantly perceived social support. (2) structural social capital, focusing on individuals' relationships with family/carers, friends, peers to other connections at the macro level, such as health care providers and their community as a whole. The two interconnected aspects of social capital play a role in decreasing fears of being judged by others, general fears in social interactions and interpersonal problems.

CONCLUSION

Guided digital social support interventions result in open and flexible access to various resources through supportive social networks, for patients and their family members/carers.

Evaluating the quality and safety of health-related apps and e-tools: Adapting the Mobile App Rating Scale and developing a quality assurance protocol

BACKGROUND

Whilst apps and e-tools have tremendous potential as low-cost, scalable mental health intervention and prevention tools, it is essential that consumers and health professionals have a means by which to evaluate their quality and safety.

OBJECTIVE

This study aimed to: 1) adapt the original Mobile App Rating Scale (MARS) in order to be appropriate for the evaluation of both mobile phone applications as well as e-tools; 2) test the reliability of the revised scale; and 3) develop a quality assurance protocol for identifying and rating new apps and e-tools to determine appropriateness for use in clinical practice.

METHODS

The MARS was adapted to include items specific to health-related apps and e-tools, such as the availability of resources, strategies for self-management, and quality information. The 41 apps and e-tools in the standard youth configuration of the InnoWell Platform, a digital tool designed to support or enhance mental health service delivery, were independently rated by two expert raters using the A-MARS. Cronbach's alpha was used to calculate the internal consistency and interclass correlation coefficients were used to calculate interrater reliability.

RESULTS

The A-MARS was shown to be a reliable scale with acceptable to excellent internal consistency and moderate to excellent interrater reliability across the subscales. Given the ever-increasing number of health information technologies on the market, a protocol to identify and rate new apps and e-tools for potential clinical use is presented.

CONCLUSIONS

Whilst the A-MARS is a useful tool to guide health professionals as they explore available apps and e-tools for potential clinical use, the training, time, and skill required to use it effectively may be prohibitive. As such, health professionals and services are likely to benefit from including a digital navigator as part of the care team to assist in selecting and rating apps and e-tools, increasing the usability of the data, and technology troubleshooting. When selecting, evaluating and/or recommending apps and e-tools to consumers, it is important to consider: 1) the availability of explicit strategies to set, monitor and review SMART goals; 2) the accessibility of credible, user friendly information and resources from reputable sources; 3) evidence of effectiveness; and 4) interoperability with other health information technologies.

Assessing the Efficacy and Acceptability of a Web-Based Intervention for Resilience Among College Students: Pilot Randomized Controlled Trial

BACKGROUND

College students are at elevated risk for developing mental health problems and face specific barriers around accessing evidence-based treatment. Web-based interventions that focus on mental health promotion and strengthening resilience represent one possible solution. Providing support to users has shown to reduce dropout in these interventions. Further research is needed to assess the efficacy and acceptability of these interventions and explore the viability of automating support.

OBJECTIVE

This study investigated the feasibility of a new web-based resilience program based on positive psychology, provided with human or automated support, in a sample of college students.

METHODS

A 3-armed closed pilot randomized controlled trial design was used. Participants were randomized to the intervention with human support (n=29), intervention with automated support (n=26), or waiting list (n=28) group. Primary outcomes were resilience and well-being, respectively measured by the Connor-Davidson Resilience Scale and Pemberton Happiness Index. Secondary outcomes included measures of depression and anxiety, self-esteem, and stress. Outcomes were self-assessed through online questionnaires. Intention-to-treat and per-protocol analyses were conducted.

RESULTS

All participants demonstrated significant improvements in resilience and related outcomes, including an unexpected improvement in the waiting list group. Within- and between-group effect sizes ranged from small to moderate and within-group effects were typically larger for the human than automated support group. A total of 36 participants began the program and completed 46.46% of it on average. Participants were generally satisfied with the program and found it easy to use.

CONCLUSIONS

Findings support the feasibility of the intervention. Preliminary evidence for the equal benefit of human and automated support needs to be supported by further research with a larger sample. Results of this study will inform the development of a full-scale trial, from which stronger conclusions may be drawn.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN) 11866034; http://www.isrctn.com/ISRCTN11866034.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.invent.2019.100254.

A Web- and Mobile App-Based Mental Health Promotion Intervention Comparing Email, Short Message Service, and Videoconferencing Support for a Healthy Cohort: Randomized Comparative Study

BACKGROUND

The rapid increase in mental health disorders has prompted a call for greater focus on mental health promotion and primary prevention. Web- and mobile app-based interventions present a scalable opportunity. Little is known about the influence of human support on the outcomes of these interventions.

OBJECTIVE

This study aimed to compare the influence of 3 modes of human support on the outcomes (ie, mental health, vitality, depression, anxiety, stress, life satisfaction, and flourishing) of a 10-week, Web- and mobile app-based, lifestyle-focused mental health promotion intervention among a healthy adult cohort.

METHODS

Participants were recruited voluntarily using a combination of online and offline advertising. They were randomized, unblinded into 3 groups differentiated by human support mode: Group 1 (n=201): standard-fully automated emails (S); Group 2 (n=202): standard plus personalized SMS (S+pSMS); and Group 3 (n=202): standard plus weekly videoconferencing support (S+VCS), hosted by 1 trained facilitator. Participants accessed the intervention, including the questionnaire, on a Web-based learning management system or through a mobile app. The questionnaire, administered at pre- and postintervention, contained self-reported measures of mental well-being, including the "mental health" and "vitality" subscales from the Short Form Health Survey-36, Depression Anxiety and Stress Scale-21, Diener Satisfaction With Life Scale (SWLS), and Diener Flourishing Scale.

RESULTS

Of 605 potential participants, 458 (S: n=157, S+pSMS: n=163, and S+VCS: n=138) entered the study by completing registration and the preintervention questionnaire. At post intervention, 320 out of 458 participants (69.9%; S: n=103, S+pSMS: n=114, and S+VCS: n=103) completed the questionnaire. Significant within-group improvements were recorded from pre- to postintervention in all groups and in every outcome measure (P≤.001). No significant between-group differences were observed for outcomes in any measure: mental health (P=.77), vitality (P=.65), depression (P=.93), anxiety (P=.25), stress (P.57), SWLS (P=.65), and Flourishing Scale (P=.99). Adherence was not significantly different between groups for mean videos watched (P=.42) and practical activity engagement (P=.71). Participation in videoconference support sessions (VCSSs) was low; 37 out of 103 (35.9%) participants did not attend any VCSSs, and only 19 out of 103 (18.4%) attended 7 or more out of 10 sessions. Stratification within the S+VCS group revealed that those who attended 7 or more VCSSs experienced significantly greater improvements in the domains of mental health (P=.006; d=0.71), vitality (P=.005; d=0.73), depression (P=.04; d=0.54), and life satisfaction (P=.046; d=0.50) compared with participants who attended less than 7.

CONCLUSIONS

A Web- and mobile app-based mental health promotion intervention enhanced domains of mental well-being among a healthy cohort, irrespective of human support. Low attendance at VCSSs hindered the ability to make meaningful between-group comparisons. Supplementing the intervention with VCSSs might improve outcomes when attendance is optimized.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): 12619001009101; http://www.anzctr.org.au/ACTRN12619001009101.aspx.

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.

Efficacy and cost-effectiveness of an unguided, internet-based self-help intervention for social anxiety disorder in university students: protocol of a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) is highly prevalent among university students, but the majority of affected students remain untreated. Internet- and mobile-based self-help interventions (IMIs) may be a promising strategy to address this unmet need. This study aims to investigate the efficacy and cost-effectiveness of an unguided internet-based treatment for SAD among university students. The intervention is optimized for the treatment of university students and includes one module targeting fear of positive evaluations that is a neglected aspect of SAD treatment.

METHODS

The study is a two arm randomized controlled trial in which 200 university students with a primary diagnosis of SAD will be assigned randomly to either a wait-list control group (WLC) or the intervention group (IG). The intervention consists of 9 sessions of an internet-based cognitive-behavioral treatment, which also includes a module on fear of positive evaluation (FPE). Guidance is delivered only on the basis of standardized automatic messages, consisting of positive reinforcements for session completion, reminders, and motivational messages in response to non-adherence. All participants will additionally have full access to treatment as usual. Diagnostic status will be assessed through Structured Clinical Interviews for DSM Disorders (SCID). Assessments will be completed at baseline, 10 weeks and 6-month follow-up. The primary outcome will be SAD symptoms at post-treatment, assessed via the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Secondary outcomes will include diagnostic status, depression, quality of life and fear of positive evaluation. Cost-effectiveness and cost-utility analyses will be evaluated from a societal and health provider perspective.

DISCUSSION

Results of this study will contribute to growing evidence for the efficacy and cost-effectiveness of unguided IMIs for the treatment of SAD in university students. Consequently, this trial may provide valuable information for policy makers and clinicians regarding the allocation of limited treatment resources to such interventions.

TRIAL REGISTRATION

DRKS00011424 (German Clinical Trials Register (DRKS)) Registered 14/12/2016.

Efficacy of an unguided internet-based self-help intervention for social anxiety disorder in university students: A randomized controlled trial

OBJECTIVES

Internet- and mobile-based interventions (IMIs) offer the opportunity to deliver mental health treatments on a large scale. This randomized controlled trial evaluated the efficacy of an unguided IMI (StudiCare SAD) for university students with social anxiety disorder (SAD).

METHODS

University students (N = 200) diagnosed with SAD were randomly assigned to an IMI or a waitlist control group (WLC) with full access to treatment as usual. StudiCare SAD consists of nine sessions. The primary outcome was SAD symptoms at posttreatment (10 weeks), assessed via the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Secondary outcomes included depression, quality of life, fear of positive evaluation, general psychopathology, and interpersonal problems.

RESULTS

Results indicated moderate to large effect sizes in favor of StudiCare SAD compared with WLC for SAD at posttest for the primary outcomes (SPS: d = 0.76; SIAS: d = 0.55, p < 0.001). Effects on all secondary outcomes were significant and in favor of the intervention group.

CONCLUSION

StudiCare SAD has proven effective in reducing SAD symptoms in university students. Providing IMIs may be a promising way to reach university students with SAD at an early stage with an effective treatment.

Digitally Delivered Psychological Interventions for Anxiety Disorders: a Comprehensive Review

Digital interventions for anxiety disorders have been well-researched over the past two decades. However, reviews to date have focused on internet-based cognitive behavioural therapy (iCBT), whereas other psychological interventions have received less attention. The aim of this review was therefore to evaluate the effectiveness of digitally delivered psychological therapies (CBT, Attention Bias Modification, Exposure Therapy, Applied Relaxation, Bibliotherapy, Psychodynamic Therapy, Mindfulness, Behavioural Stress Management, Counselling) compared with control conditions and/or other psychological interventions for anxiety disorders (Social Anxiety Disorder (SAD), Health Anxiety, Obsessive-Compulsive Disorder (OCD), Post-traumatic Stress Disorder (PTSD), Specific Phobias, Panic Disorder (PD), Generalised Anxiety Disorder (GAD)]. 68 randomised controlled trials (RCTs) were reviewed. SAD was the anxiety disorder for which the most RCTs were conducted. Overall, findings support the effectiveness of iCBT for SAD; for the remaining interventions, although some RCTs indicated significant improvement (within groups) at post-treatment and/or follow up, between group findings were less consistent and overall, methodological differences across trials failed to provide strong supporting evidence. Finally, the level of therapist contact or expertise did not appear to affect much treatment effectiveness. Additional large, methodologically rigorous trials are needed to investigate further whether different digitally delivered psychological interventions are equally effective for anxiety disorders. Moreover, further studies are pertinent in order to examine the maintenance of therapy gains after the end of treatments and understand how these work [(e.g. the influence of therapist factors, user engagement and/or satisfaction, potential access barriers and treatments with diverse population groups (e.g. BME groups)].

Internet- and mobile-based interventions for anxiety disorders: A meta-analytic review of intervention components

BACKGROUND

Although the efficacy of Internet- and mobile-based interventions (IMIs) for anxiety is established, little is known about the intervention components responsible for therapeutic change. We conducted the first comprehensive meta-analytic review of intervention components of IMIs for adult anxiety disorders.

METHODS

Randomized controlled trials (RCTs) comparing IMIs for anxiety disorders to active online control groups, or IMIs to dismantled variations of the same intervention (± specific components) were identified by a systematic literature search in six databases. Outcomes were validated observer-rated or self-report measures for anxiety symptom severity and treatment adherence (number of completed modules and completer rate). This meta-analytic review is registered with PROSPERO (CRD42017068268).

RESULTS

We extracted the data of 34 RCTs (with 3,724 participants) and rated the risk of bias independently by two reviewers. Random-effects meta-analyses were performed on 19 comparisons of intervention components (i.a., different psychotherapeutic orientations, disorder-specific vs. transdiagnostic approaches, guidance factors). IMIs had a large effect when compared to active online controls on symptom severity (standardized mean difference [SMD] of -1.67 [95% CI: -2.93, -0.42]; P = 0.009). Thereby, guided IMIs were superior to unguided interventions on symptom severity (SMD of -0.39 [95% CI: -0.59, -0.18]; P = 0.0002) and adherence (SMD of 0.38 [95% CI: 0.10, 0.66]; P = 0.007).

CONCLUSIONS

Overall, the results of this meta-analysis lend further support to the efficacy of IMIs for anxiety, pointing to their potential to augment service supplies. Still, future research is needed to determine which ingredients are essential, as this meta-analytic review found no evidence for incremental effects of several single intervention components apart from guidance.

Internet-based cognitive behavioral therapy of perfectionism: Comparing regular therapist support and support upon request

Perfectionism may be a clinically relevant problem on its own or as part of the etiology and maintenance of psychiatric disorders, e.g., anxiety disorders, depression, and eating disorders. Cognitive behavior therapy has been shown to be a promising treatment for managing perfectionism and its associated problems, including when being administered via the Internet, i.e., Internet-based cognitive behavioral therapy (ICBT). In the current study, seventy-eight self-referred participants underwent ICBT after an initial eight-week wait-list period, i.e., second wave of treatment. These were randomized to receive regular support from a therapist (ICBT-support) or ICBT with support on request (ICBT-request), in an eight-week treatment of perfectionism. Assessments of perfectionism were made at pre-, mid-, and post-treatment, as well as six-month follow-up, using the Frost Multidimensional Perfectionism Scale, subscale Concern over Mistakes. Mixed effects models revealed large symptom reductions for both conditions; Concern over Mistakes, Cohen's d = 1.40, 95% Confidence Interval (CI) [0.85, 1.95] for ICBT-support, and d = 1.00, 95% CI [0.51, 1.47] for ICBT-request. The effects were maintained at six-month follow-up and there were no differences between the conditions in terms of the results, opened modules, or completed exercises. A total of 28 out of 70 participants (42.4%; ICBT-support, 37.8%; ICBT-request) were classified as improved at post-treatment. Both types of ICBT may thus be beneficial in treating perfectionism, suggesting that just having the opportunity to ask for support from a therapist, when regular support is not provided, could be sufficient for many participants undergoing ICBT. However, the study was underpowered to detect differences between the conditions. The lack of a cutoff also makes it difficult to differentiate a dysfunctional from a functional population in terms of perfectionism. In addition, the study design could have affected the participants' motivational level from start, given their initial eight-week wait-list period. Recommendations for future studies include recruiting a larger sample size, a clearer cutoff for perfectionism, and the use of a non-inferiority test with a predetermined margin of change.

School mental healthcare services using internet-based cognitive behaviour therapy for young male athletes in Japan

AIM

Preventive intervention and treatment using internet-based cognitive behaviour therapy (iCBT) can be easily administered to school students, as they are quite familiar with internet tools. This study aims to investigate the effectiveness and contribution of iCBT to mental healthcare in a school setting.

METHODS

Eighty Japanese high school boys who were participating in a sports specialist course were enrolled in this study. The participants were randomly assigned to either the iCBT intervention group or the control group. Both programmes were administered for 4 weeks. To evaluate the effects, physical and mental health problems and self-efficacy were assessed.

RESULTS

The mean number of times that the iCBT website was accessed during the intervention period was 16.9, and the mean access frequency (percentage of the number of times the website was accessed during the intervention period) was 40.1% in the iCBT group. A statistically significant interaction between group and time in favour of the iCBT group was observed based on the Kessler-6 (K6) scale for depression and anxiety.

CONCLUSIONS

The results suggest that a school mental healthcare programme using iCBT is suitable for students and useful for coping with stress and reducing depressed mood and anxiety in young people, especially athletes, who are regarded as needing special mental health support.

Impact of telephone prompts on the adherence to an Internet-based aftercare program for women with bulimia nervosa: A secondary analysis of data from a randomized controlled trial

INTRODUCTION

Poor adherence is a common challenge in self-directed mental health interventions. Research findings indicate that telephone prompts may be useful to increase adherence.

METHOD

Due to poor adherence in a randomized controlled trial evaluating an Internet-based aftercare program for women with bulimia nervosa we implemented regular short telephone prompts into the study protocol halfway through the trial period. Of the 126 women in the intervention group, the first 63 women were not prompted by telephone (unprompted group) and compared with 63 women who subsequently enrolled into the study and were attempted to prompt bimonthly by a research assistant (telephone prompt group). Completed telephone calls took less than 5 min and did not include any symptom-related counseling.

RESULTS

Most of the women in the telephone prompt group (67%) were reached only once or twice during the intervention period. However, overall adherence in the telephone prompt group was significantly higher than in the unprompted group (T = - 3.015, df = 124, p = 0.003).

CONCLUSION

Our findings from this secondary analysis suggest that telephone prompts can positively affect adherence to an Internet-based aftercare intervention directed at patients with bulimia nervosa.

A scoping review of human-support factors in the context of Internet-based psychological interventions (IPIs) for depression and anxiety disorders

Internet-based psychological interventions (IPIs) may provide a highly accessible alternative to in-person psychotherapy. However, little is known about the role of human-support in IPIs for depression and anxiety disorders. The purpose of this study was to evaluate the evidence in the literature regarding the role of human-support in IPIs for depression and anxiety disorders; identify research gaps; and provide recommendations. A scoping review of randomized controlled trials was conducted using seven databases. Two reviewers screened citations, selected studies, and extracted data. Data was analyzed and summarized by common human-support factors. Seven categories for support factors were identified from 19 studies: guided versus unguided IPIs, level of therapist expertise, human versus automated support, scheduled versus unscheduled contact, mode of communication, synchronicity of communication, and intensity of support. Only one feature had a significant effect on treatment outcomes, with scheduled support resulting in better outcomes than unscheduled support. There were mixed findings regarding guided versus unguided interventions and human versus automated support. Providing structured support in a fixed-interval schedule is recommended to enhance the utilization of IPIs for depression and anxiety disorders. Findings should be interpreted with caution due to the limited available research. Further research is needed to draw robust conclusions.

Internet-Delivered Health Interventions That Work: Systematic Review of Meta-Analyses and Evaluation of Website Availability

BACKGROUND

Due to easy access and low cost, Internet-delivered therapies offer an attractive alternative to improving health. Although numerous websites contain health-related information, finding evidence-based programs (as demonstrated through randomized controlled trials, RCTs) can be challenging. We sought to bridge the divide between the knowledge gained from RCTs and communication of the results by conducting a global systematic review and analyzing the availability of evidence-based Internet health programs.

OBJECTIVES

The study aimed to (1) discover the range of health-related topics that are addressed through Internet-delivered interventions, (2) generate a list of current websites used in the trials which demonstrate a health benefit, and (3) identify gaps in the research that may have hindered dissemination. Our focus was on Internet-delivered self-guided health interventions that did not require real-time clinical support.

METHODS

A systematic review of meta-analyses was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO Registration Number CRD42016041258). MEDLINE via Ovid, PsycINFO, Embase, Cochrane Database of Systematic Reviews, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched. Inclusion criteria included (1) meta-analyses of RCTs, (2) at least one Internet-delivered intervention that measured a health-related outcome, and (3) use of at least one self-guided intervention. We excluded group-based therapies. There were no language restrictions.

RESULTS

Of the 363 records identified through the search, 71 meta-analyses met inclusion criteria. Within the 71 meta-analyses, there were 1733 studies that contained 268 unique RCTs which tested self-help interventions. On review of the 268 studies, 21.3% (57/268) had functional websites. These included evidence-based Web programs on substance abuse (alcohol, tobacco, cannabis), mental health (depression, anxiety, post-traumatic stress disorder [PTSD], phobias, panic disorders, obsessive compulsive disorder [OCD]), and on diet and physical activity. There were also evidence-based programs on insomnia, chronic pain, cardiovascular risk, and childhood health problems. These programs tended to be intensive, requiring weeks to months of engagement by the user, often including interaction, personalized and normative feedback, and self-monitoring. English was the most common language, although some were available in Spanish, French, Portuguese, Dutch, German, Norwegian, Finnish, Swedish, and Mandarin. There were several interventions with numbers needed to treat of <5; these included painACTION, Mental Health Online for panic disorders, Deprexis, Triple P Online (TPOL), and U Can POOP Too. Hyperlinks of the sites have been listed.

CONCLUSIONS

A wide range of evidence-based Internet programs are currently available for health-related behaviors, as well as disease prevention and treatment. However, the majority of Internet-delivered health interventions found to be efficacious in RCTs do not have websites for general use. Increased efforts to provide mechanisms to host "interventions that work" on the Web and to assist the public in locating these sites are necessary.

The Efficacy of Internet-Based Mindfulness Training and Cognitive-Behavioral Training With Telephone Support in the Enhancement of Mental Health Among College Students and Young Working Adults: Randomized Controlled Trial

Background

College students and working adults are particularly vulnerable to stress and other mental health problems, and mental health promotion and prevention are needed to promote their mental health. In recent decades, mindfulness-based training has demonstrated to be efficacious in treating physical and psychological conditions.

Objective

The aim of our study was to examine the efficacy of an Internet-based mindfulness training program (iMIND) in comparison with the well-established Internet-based cognitive-behavioral training program (iCBT) in promoting mental health among college students and young working adults.

Methods

This study was a 2-arm, unblinded, randomized controlled trial comparing iMIND with iCBT. Participants were recruited online and offline via mass emails, advertisements in newspapers and magazines, announcement and leaflets in primary care clinics, and social networking sites. Eligible participants were randomized into either the iMIND (n=604) or the iCBT (n=651) condition. Participants received 8 Web-based sessions with information and exercises related to mindfulness or cognitive-behavioral principles. Telephone or email support was provided by trained first tier supporters who were supervised by the study’s research team. Primary outcomes included mental and physical health-related measures, which were self-assessed online at preprogram, postprogram, and 3-month follow-up.

Results

Among the 1255 study participants, 213 and 127 completed the post- and 3-month follow-up assessment, respectively. Missing data were treated using restricted maximum likelihood estimation. Both iMIND (n=604) and iCBT (n=651) were efficacious in improving mental health, psychological distress, life satisfaction, sleep disturbance, and energy level.

Conclusions

Both Internet-based mental health programs showed potential in improving the mental health from pre- to postassessment, and such improvement was sustained at the 3-month follow-up. The high attrition rate in this study suggests the need for refinement in future technology-based psychological programs. Mental health professionals need to team up with experts in information technology to increase personalization of Web-based interventions to enhance adherence.

Trial Registration

Chinese Clinical Trial Registry (ChiCTR): ChiCTR-TRC-12002623; https://www2.ccrb.cuhk.edu.hk/ registry/public/191 (Archived by WebCite at http://www.webcitation.org/6kxt8DjM4).

Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis

BACKGROUND

The need for effective interventions to improve mental health and emotional well-being at a population level are gaining prominence both in the United Kingdom and globally. Advances in technology and widespread adoption of Internet capable devices have facilitated rapid development of Web-delivered psychological therapies. Interventions designed to manage a range of affective disorders by applying diverse therapeutic approaches are widely available.

OBJECTIVE

The main aim of this review was to evaluate the evidence base of acceptance and commitment therapy (ACT) in a Web-based delivery format.

METHOD

A systematic review of the literature and meta-analysis was conducted. Two electronic databases were searched for Web-delivered interventions utilizing ACT for the management of affective disorders or well-being. Only Randomized Controlled Trials (RCTs) were included.

RESULTS

The search strategy identified 59 articles. Of these, 10 articles met the inclusion criteria specified. The range of conditions and outcome measures that were identified limited the ability to draw firm conclusions about the efficacy of Web-delivered ACT-based intervention for anxiety or well-being.

CONCLUSIONS

ACT in a Web-based delivery format was found to be effective in the management of depression. Rates of adherence to study protocols and completion were high overall suggesting that this therapeutic approach is highly acceptable for patients and the general public.

Meta-analysis of technology-assisted interventions for social anxiety disorder

This meta-analysis investigated the efficacy of technology-assisted interventions for individuals with social anxiety disorder (SAD). A systematic literature search in the databases Medline, PsychInfo, and Web of Science revealed 37 randomized controlled trials (2991 participants) that were grouped into internet delivered cognitive behavior therapy (ICBT; 21 trials), virtual reality exposure therapy (VRET; 3 trials), and cognitive bias modification (CBM; 13 trials). Patients undergoing ICBT and VRET showed significantly less SAD symptoms at postassessment than passive control conditions (g=0.84 and 0.82, respectively). Compared to active control conditions, ICBT had a small advantage (g=0.38) and VRET showed comparable effects (p>0.05). CBM was not more effective than passive control conditions, except when delivered in the laboratory (g=0.35). While the efficacy of CBM was limited, substantial evidence for ICBT and preliminary evidence for VRET suggests that both can effectively reduce SAD symptoms indicating the potential of technology-assisted interventions for SAD.

Usage and Dose Response of a Mobile Acceptance and Commitment Therapy App: Secondary Analysis of the Intervention Arm of a Randomized Controlled Trial

Background

Mobile phone apps offer a promising medium to deliver psychological interventions. A mobile app based on Acceptance and Commitment Therapy (ACT) was developed and studied in a randomized controlled trial (RCT).

Objective

To study usage metrics of a mobile ACT intervention and dose-response relationship between usage and improvement in psychological flexibility.

Methods

An RCT was conducted to investigate the effectiveness of different lifestyle interventions for overweight people with psychological stress. This paper presents a secondary analysis of the group that received an 8-week mobile ACT intervention. Most of the analyzed 74 participants were female (n=64, 86%). Their median age was 49.6 (interquartile range, IQR 45.4-55.3) years and their mean level of psychological flexibility, measured with the Acceptance and Action Questionnaire II, was 20.4 (95% confidence interval 18.3-22.5). Several usage metrics describing the intensity of use, usage of content, and ways of use were calculated. Linear regression analyses were performed to study the dose-response relationship between usage and the change in psychological flexibility and to identify the usage metrics with strongest association with improvement. Binary logistic regression analyses were further used to assess the role of usage metrics between those who showed improvement in psychological flexibility and those who did not. In addition, associations between usage and baseline participant characteristics were studied.

Results

The median number of usage sessions was 21 (IQR 11.8-35), the number of usage days was 15 (IQR 9.0-24), and the number of usage weeks was 7.0 (IQR 4.0-8.0). The participants used the mobile app for a median duration of 4.7 (IQR 3.2-7.2) hours and performed a median of 63 (IQR 46-98) exercises. There was a dose-response relationship between usage and the change in psychological flexibility. The strongest associations with psychological flexibility (results adjusted with gender, age, and baseline psychological variables) were found for lower usage of Self as context related exercises (B=0.22, P=.001) and higher intensity of use, described by the number of usage sessions (B=−0.10, P=.01), usage days (B=−0.17, P=.008), and usage weeks (B=−0.73, P=.02), the number of exercises performed (B=−0.02, P=.03), and the total duration of use (B=−0.30, P=.04). Also, higher usage of Acceptance related exercises (B=−0.18, P=.04)

was associated with improvement. Active usage was associated with female gender, older age, and not owning a smart mobile phone before the study.

Conclusions

The results indicated that active usage of a mobile ACT intervention was associated with improved psychological flexibility. Usage metrics describing intensity of use as well as two metrics related to the usage of content were found to be most strongly associated with improvement.

Trial Registration

ClinicalTrials.gov NCT01738256; https://clinicaltrials.gov/ct2/show/NCT01738256 (Archived by WebCite at http://www.webcitation.org/6iTePjPLL)

A sorrow shared is a sorrow halved? A three-arm randomized controlled trial comparing internet-based clinician-guided individual versus group treatment for social anxiety disorder

A growing body of evidence suggests that internet-based cognitive behavioural treatments (ICBT) are effective to treat social anxiety disorder (SAD). Whereas the efficacy of clinician-guided ICBT has been established, ICBT in a group format has not yet been systematically investigated. This three-arm RCT compared the efficacy of clinician-guided group ICBT (GT) with clinician guided individual ICBT (IT) and a wait-list (WL). A total of 149 individuals meeting the diagnostic criteria for SAD were randomly assigned to one of three conditions. Primary endpoints were self-report measures of SAD and diagnostic status taken at baseline, after the twelve-week intervention and at six-month follow-up. Secondary endpoints were symptoms of depression, interpersonal problems and general symptomatology. At post-treatment, both active conditions showed superior outcome regarding SAD symptoms (GT vs. WL: d = 0.84-0.74; IT vs. WL: d = 0.94-1.22). The two active conditions did not differ significantly in symptom reduction (d = 0.12-0.26, all ps > 0.63), diagnostic response rate or attrition. Treatment gains were maintained at follow-up. The group format reduced weekly therapist time per participant by 71% (IT: 17 min, GT: 5 min). Findings indicate that a clinician-guided group format is a promising approach in treating SAD.

Adherence to Internet-Based Mobile-Supported Stress Management: A Pooled Analysis of Individual Participant Data From Three Randomized Controlled Trials

Background

Nonadherence to treatment is a prevalent issue in Internet interventions. Guidance from health care professionals has been found to increase treatment adherence rates in Internet interventions for a range of physical and mental disorders. Evaluating different guidance formats of varying intensity is important, particularly with respect to improvement of effectiveness and cost-effectiveness. Identifying predictors of nonadherence allows for the opportunity to better adapt Internet interventions to the needs of participants especially at risk for discontinuing treatment.

Objective

The goal of this study was to investigate the influence of different guidance formats (content-focused guidance, adherence-focused guidance, and administrative guidance) on adherence and to identify predictors of nonadherence in an Internet-based mobile-supported stress management intervention (ie, GET.ON Stress) for employees.

Methods

The data from the groups who received the intervention were pooled from three randomized controlled trials (RCTs) that evaluated the efficacy of the same Internet-based mobile-supported stress management intervention (N=395). The RCTs only differed in terms of the guidance format (content-focused guidance vs waitlist control, adherence-focused guidance vs waitlist control, administrative guidance vs waitlist control). Adherence was defined by the number of completed treatment modules (0-7). An ANOVA was performed to compare the adherence rates from the different guidance formats. Multiple hierarchical linear regression analysis was conducted to evaluate predictors of nonadherence, which included gender, age, education, symptom-related factors, and hope for improvement.

Results

In all, 70.5% (93/132) of the content-focused guidance sample, 68.9% (91/132) of the adherence-focused guidance sample, and 42.0% (55/131) of the participants in the administrative guidance sample completed all treatment modules. Guidance had a significant effect on treatment adherence (F_2,392=11.64, P<.001; ω²=.05). Participants in the content-focused guidance (mean 5.70, SD 2.32) and adherence-focused guidance samples (mean 5.58, SD 2.33) completed significantly more modules than participants in the administrative guidance sample (mean 4.36, SD 2.78; t₂₂₃=4.53, P<.001; r=.29). Content-focused guidance was not significantly associated with higher adherence compared to adherence-focused guidance (t₂₆₂=0.42, P=.67; r=.03). The effect size of r=.03 (95% CI –0.09 to 0.15) did not pass the equivalence margin of r=.20 and the upper bound of the 95% CI lay below the predefined margin, indicating equivalence between adherence-focused guidance and content-focused guidance. Beyond the influence of guidance, none of the predictors significantly predicted nonadherence.

Conclusions

Guidance has been shown to be an influential factor in promoting adherence to an Internet-based mobile-supported stress management intervention. Adherence-focused guidance, which included email reminders and feedback on demand, was equivalent to content-focused guidance with regular feedback while requiring only approximately a quarter of the coaching resources. This could be a promising discovery in terms of cost-effectiveness. However, even after considering guidance, sociodemographic, and symptom-related characteristics, most interindividual differences in nonadherence remain unexplained.

Clinical Trial

DRKS00004749; http://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL _ID=DRKS00004749 (Archived by WebCite at http://www.webcitation.org/6QiDk9Zn8); DRKS00005112; http://drks-neu.uniklinik-freiburg. de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005112 (Archived by WebCite at http://www.webcitation.org/6QiDysvev); DRKS00005384; http://drks-neu.uniklinik-freiburg.de/ drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005384 (Archived by WebCite at http://www.webcitation.org/6QiE0xcpE)

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.

Prevention and early intervention of anxiety problems in young children: A pilot evaluation of Cool Little Kids Online

Anxiety disorders are common, debilitating, and begin early in life. Early intervention to prevent anxiety disorders in children who are at risk could have long-term impact. The 'Cool Little Kids' parenting group program has previously been shown to be efficacious in preventing anxiety disorders in temperamentally inhibited young children. Wider dissemination of the program could be achieved with an internet-based delivery platform, affording greater accessibility and convenience for parents. The aim of this study was to evaluate 'Cool Little Kids Online', a newly developed online version of the existing parenting group program. Fifty-one parents of children aged 3-6 years were recruited to evaluate the online program's acceptability and preliminary efficacy in reducing inhibited young children's anxiety problems. Parents were randomized to receive either a clinician-supported version or an unsupported version of the program. Parents had 10 weeks to access the program and completed questionnaires at baseline and post-intervention. Both groups showed medium-to-large reductions in children's anxiety symptoms, emotional symptoms, number of child anxiety diagnoses, and improvements in life interference from anxiety. The effect of clinician support was inconsistent and difficult to interpret. Parents reported high levels of satisfaction with the program. These encouraging results indicate that the online version is acceptable and useful for parents with temperamentally inhibited young children. Cool Little Kids Online may be a promising direction for improving access to an evidence-based prevention and early intervention program for child anxiety problems. A large randomized trial is warranted to further evaluate efficacy.

The relationship between persuasive technology principles, adherence and effect of web-Based interventions for mental health: A meta-analysis

BACKGROUND

Research has shown that web-based interventions concerning mental health can be effective, although there is a broad range in effect sizes. Why some interventions are more effective than others is not clear. Persuasive technology is one of the aspects which has a positive influence on changing attitude and/or behavior, and can contribute to better outcomes. According to the Persuasive Systems Design Model there are various principles that can be deployed. It is unknown whether the number and combinations of principles used in a web-based intervention affect the effectiveness. Another issue in web-based interventions is adherence. Little is known about the relationship of adherence on the effectiveness of web-based interventions.

OBJECTIVE

This study examines whether there is a relationship between the number and combinations of persuasive technology principles used in web-based interventions and the effectiveness. Also the influence of adherence on effectiveness of web-based interventions is investigated.

METHODS

This study elaborates on the systematic review by [37] and therefore the articles were derived from that study. Only web-based interventions were included that were intended to be used on more than one occasion and studies were excluded when no information on adherence was provided. 48 interventions targeted at mental health were selected for the current study. A within-group (WG) and between-group (BG) meta-analysis were performed and subsequently subgroup analyses regarding the relationship between the number and combinations of persuasive technology principles and effectiveness. The influence of adherence on the effectiveness was examined through a meta-regression analysis.

RESULTS

For the WG meta-analysis 40 treatment groups were included. The BG meta-analysis included 19 studies. The mean pooled effect size in the WG meta-analysis was large and significant (Hedges' g=0.94), while for the BG meta-analysis this was moderate to large and significant (Hedges' g=0.78) in favor of the web-based interventions. With regard to the number of persuasive technology principles, the differences between the effect sizes in the subgroups were significant in the WG subgroup analyses for the total number of principles and for the number of principles in the three categories Primary Task Support, Dialogue Support, and Social Support. In the BG subgroup analyses only the difference in Primary Task Support was significant. An increase in the total number of principles and Dialogue Support principles yielded larger effect sizes in the WG subgroup analysis, indicating that more principles lead to better outcomes. The number of principles in the Primary Task Support (WG and BG) and Social Support (WG) did not show an upward trend but had varying effect sizes. We identified a number of combinations of principles that were more effective, but only in the WG analyses. The association between adherence and effectiveness was not significant.

CONCLUSIONS

There is a relationship between the number of persuasive technology principles and the effectiveness of web-based interventions concerning mental health, however this does not always mean that implementing more principles leads to better outcomes. Regarding the combinations of principles, specific principles seemed to work well together (e.g. tunneling and tailoring; reminders and similarity; social learning and comparison), but adding another principle can diminish the effectiveness (e.g. tunneling, tailoring and reduction). In this study, an increase in adherence was not associated with larger effect sizes. The findings of this study can help developers to decide which persuasive principles to include to make web-based interventions more persuasive.

Internet-based treatment for Romanian adults with panic disorder: protocol of a randomized controlled trial comparing a Skype-guided with an unguided self-help intervention (the PAXPD study)

BACKGROUND

Efficacy of self-help internet-based cognitive behavior therapy (ICBT) for anxiety disorders has been confirmed in several randomized controlled trials. However, the amount and type of therapist guidance needed in ICBT are still under debate. Previous studies have shown divergent results regarding the role of therapist guidance and its impact on treatment outcome. This issue is central to the development of ICBT programs and needs to be addressed directly. The present study aims to compare the benefits of regular therapist guidance via online real-time audio-video communication (i.e. Skype) to no therapist guidance during a 12-week Romanian self-help ICBT program for Panic Disorder. Both treatments are compared to a waiting-list control group.

METHODS/DESIGN

A parallel group randomized controlled trial is proposed. The participants, 192 Romanian adults fulfilling diagnostic criteria for panic disorder according to a diagnostic interview, conducted via secured Skype or telephone, are randomly assigned to one of the three conditions: independent use of the internet-based self-help program PAXonline, the same self-help treatment with regular therapist support via secured Skype, and waiting-list control group. The primary outcomes are severity of self-report panic symptoms (PDSS-SR) and diagnostic status (assessors are blind to group assignment), at the end of the intervention (12 weeks) and at follow-up (months 3 and 6). The secondary measures address symptoms of comorbid anxiety disorders, depression, quality of life, adherence and satisfaction with ICBT. Additional measures of socio-demographic characteristics, personality traits, treatment expectancies, catastrophic cognitions, body vigilance and working alliance are considered as potential moderators and/ or mediators of treatment outcome.

DISCUSSION

To the best of our knowledge, the present study is the first effort to investigate the efficacy of a self-help internet-based intervention with therapist guidance via real-time video communication. A direct comparison between therapist guided versus unguided self-directed intervention for panic disorder will also be addressed for the first time. Findings from this study will inform researchers and practitioners about the added value of online video-therapy guidance sessions and the type of patients who may benefit the most from guided and unguided ICBT for Panic disorder.

TRIAL REGISTRATION

ACTRN12614000547640 (Australian New Zealand Clinical Trials Registry). Registered 22/05/2014.

The Effectiveness of Prompts to Promote Engagement With Digital Interventions: A Systematic Review

Background

Digital interventions have been effective in improving numerous health outcomes and health behaviors; furthermore, they are increasingly being used in different health care areas, including self-management of long-term conditions, mental health, and health promotion. The full potential of digital interventions is hindered by a lack of user engagement. There is an urgent need to develop effective strategies that can promote users’ engagement with digital interventions. One potential method is the use of technology-based reminders or prompts.

Objective

To evaluate the effectiveness of technology-based strategies for promoting engagement with digital interventions.

Methods

Cochrane Collaboration guidelines on systematic review methodology were followed. The search strategy was executed across 7 electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, the Education Resources Information Center (ERIC), PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Databases were searched from inception to September 13, 2013, with no language or publication type restrictions, using three concepts: randomized controlled trials, digital interventions, and engagement. Gray literature and reference lists of included studies were also searched. Titles and abstracts were independently screened by 2 authors, then the full texts of potentially eligible papers were obtained and double-screened. Data from eligible papers were extracted by one author and checked for accuracy by another author. Bias was assessed using the Cochrane risk of bias assessment tool. Narrative synthesis was performed on all included studies and, where appropriate, data were pooled using meta-analysis. All findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

A total of 14 studies were included in the review with 8774 participants. Of the 14 studies, 9 had sufficient data to be included in the meta-analyses. The meta-analyses suggested that technology-based strategies can potentially promote engagement compared to no strategy for dichotomous outcomes (relative risk [RR] 1.27, 95% CI 1.01-1.60, I²=71%), but due to considerable heterogeneity and the small sample sizes in most studies, this result should be treated with caution. No studies reported adverse or economic outcomes. Only one study with a small sample size compared different characteristics; the study found that strategies promoting new digital intervention content and those sent to users shortly after they started using the digital intervention were more likely to engage users.

Conclusions

Overall, studies reported borderline positive effects of technology-based strategies on engagement compared to no strategy. However, the results have to be interpreted with caution. More research is needed to replicate findings and understand which characteristics of the strategies are effective in promoting engagement and how cost-effective they are.

A randomized controlled trial of guided internet-delivered cognitive behaviour therapy for older adults with generalized anxiety

This study aimed to establish the efficacy of guided Internet-delivered cognitive-behaviour therapy (ICBT) for older adults with generalized anxiety disorder (GAD) or subclinical GAD. Participants were randomized to receive seven modules of ICBT (n=24) or to a waiting list condition (WLC; n=22). Faster improvements in symptoms of anxiety and depression were observed for participants in the ICBT condition relative to the WLC, with large between-group effect sizes on the Generalized anxiety disorder-7 (d=.85) and the Patient health questionnaire (d=1.17) obtained at post-treatment. Further reduction in generalized anxiety symptoms was reported over the one-month follow-up. Treatment effects were replicated when control participants subsequently underwent treatment. Higher ratings of treatment credibility, but not expectancy, prior to ICBT predicted improvements over time. The results support the efficacy of ICBT as treatment for older adults with GAD.

Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for generalized anxiety disorder and comorbid disorders: A randomized controlled trial

Generalized anxiety disorder (GAD) can be treated effectively with either disorder-specific cognitive behavior therapy (DS-CBT) or transdiagnostic CBT (TD-CBT). The relative benefits of DS-CBT and TD-CBT for GAD and the relative benefits of delivering treatment in clinician guided (CG-CBT) and self-guided (SG-CBT) formats have not been examined. Participants with GAD (n=338) were randomly allocated to receive an internet-delivered TD-CBT or DS-CBT intervention delivered in either CG-CBT or SG-CBT formats. Large reductions in symptoms of GAD (Cohen's d ≥ 1.48; avg. reduction ≥ 50%) and comorbid major depressive disorder (Cohen's d ≥ 1.64; avg. reduction ≥ 45%), social anxiety disorder (Cohen's d ≥ 0.80; avg. reduction ≥ 29%) and panic disorder (Cohen's d ≥ 0.55; avg. reduction ≥ 33%) were found across the conditions. No substantive differences were observed between DS-CBT and TD-CBT or CG-CBT and SG-CBT, highlighting the public health potential of carefully developed TD-CBT and SG-CBT.

Internet- und Mobilebasierte Interventionen in der Psychotherapie

Strukturelle Versorgungslücken und niedrige Inanspruchnahmeraten therapiebedürftiger Menschen beschränken eine bedarfsgerechte psychotherapeutische Versorgung. Internet- und Mobilebasierte Interventionen (IMIs) können als ort- und zeitunabhängige Angebote dazu beitragen, die psychotherapeutische Versorgung zu verbessern. Der vorliegende Beitrag gibt einen Überblick zum Gegenstandsbereich, der Evidenzbasierung sowie den Implementierungsmöglichkeiten von IMIs.

Using a digital game for training desirable behavior in cognitive-behavioral therapy of burnout syndrome: a controlled study

Burnout is a globally increasing illness, and as a result, many forms of burnout therapy have arisen. The use of digital games can be psychotherapeutically effective because they can transform exercises that are by themselves unattractive into intrinsically motivated action. This pilot study aims to test whether a specially designed game contributes to patients learning desired behavior and achieving other specific therapeutic goals in an online cognitive-behavioral therapy (CBT)-based burnout treatment context. In total, 101 participants took part in the experiment, under four conditions: (a) Game+Therapy, (b) Therapy Only, (c) Game Only, and (d) No Game+No Therapy. Pre- and postmeasures were taken online. Results showed that the two therapy conditions (Game+Therapy and Therapy Only) showed a greater decrease in complaints and disengagement, and a stronger increase in coping skills than the nontherapy conditions (Game Only and No Game+No Therapy). As expected, the Game+Therapy condition outperformed the Therapy Only condition on combined improvement measures of burnout symptoms. However, analyses of individual measures showed no effects. It can be cautiously concluded that the therapeutic digital game may be a useful tool when embedded in a therapeutic burnout treatment program and is probably more efficient than CBT, as it is used in current practice.

How to Increase Reach and Adherence of Web-Based Interventions: A Design Research Viewpoint

Nowadays, technology is increasingly used to increase people's well-being. For example, many mobile and Web-based apps have been developed that can support people to become mentally fit or to manage their daily diet. However, analyses of current Web-based interventions show that many systems are only used by a specific group of users (eg, women, highly educated), and that even they often do not persist and drop out as the intervention unfolds. In this paper, we assess the impact of design features of Web-based interventions on reach and adherence and conclude that the power that design can have has not been used to its full potential. We propose looking at design research as a source of inspiration for new (to the field) design approaches. The paper goes on to specify and discuss three of these approaches: personalization, ambient information, and use of metaphors. Central to our viewpoint is the role of positive affect triggered by well-designed persuasive features to boost adherence and well-being. Finally, we discuss the future of persuasive eHealth interventions and suggest avenues for follow-up research.

Comparing human and automated support for depression: Fractional factorial randomized controlled trial

Web-based interventions for people with depressive symptoms are needed and show promising effects. However, it is a consistent finding that human support is needed and this makes implementation costly. This study investigates the adherence and effectiveness of a human-supported and automated-supported web-based intervention for people with mild to moderate depressive symptomatology, and studies the impact of four persuasive technology components. People with mild to moderate depressive symptoms according to the Center of Epidemiological Studies depression scale self-report questionnaire were included, but no diagnosis was made for the study. Participants (n = 239) were randomized into one of eight intervention arms, where each level of each component is present in half of the intervention arms. On clinical outcomes, there was a significant interaction effect between support condition and time, but there was no difference on the extent of improvement from baseline to follow-up, only a difference in the time-path of improvement. Effect sizes from baseline to follow-up were 0.89 for automated and 1.00 for human support. There was no significant difference on adherence between support condition. We conclude that an automated-supported web-based intervention for treatment of depression with persuasive technology may achieve similar adherence and effectiveness as the same intervention with human support.

Enhancing Web-based mindfulness training for mental health promotion with the health action process approach: randomized controlled trial

Background

With increasing evidence demonstrating the effectiveness of Web-based interventions and mindfulness-based training in improving health, delivering mindfulness training online is an attractive proposition.

Objective

The aim of this study was to evaluate the efficacy of two Internet-based interventions (basic mindfulness and Health Action Process Approach enhanced mindfulness) with waitlist control. Health Action Process Approach (HAPA) principles were used to enhance participants’ efficacy and planning.

Methods

Participants were recruited online and offline among local universities; 321 university students and staff were randomly assigned to three conditions. The basic and HAPA-enhanced groups completed the 8-week fully automated mindfulness training online. All participants (including control) were asked to complete an online questionnaire pre-program, post-program, and at 3-month follow-up.

Results

Significant group by time interaction effect was found. The HAPA-enhanced group showed significantly higher levels of mindfulness from pre-intervention to post-intervention, and such improvement was sustained at follow-up. Both the basic and HAPA-enhanced mindfulness groups showed better mental well-being from pre-intervention to post-intervention, and improvement was sustained at 3-month follow-up.

Conclusions

Online mindfulness training can improve mental health. An online platform is a viable medium to implement and disseminate evidence-based interventions and is a highly scalable approach to reach the general public.

Trial Registration

Chinese Clinical Trial Registry (ChiCTR): ChiCTR-TRC-12002954; http://www.chictr.org/en/proj/show.aspx?proj=3904 (Archived by WebCite at http://www.webcitation.org/6VCdG09pA).

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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