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

Internet videoconferencing delivered cognitive behaviour therapy for generalized anxiety disorder: A randomized controlled trial

OBJECTIVE

Generalized anxiety disorder (GAD) is a chronic mental health condition that results in significant individual and societal burden. Cognitive-behaviour therapy (CBT) therapy is an effective treatment for GAD, however, many individuals experience logistical barriers when accessing evidence-based care. Remote treatments may help to reduce these barriers, however, currently, there are few studies examining the efficacy of high-intensity remote methods for GAD treatment. The current study aims to examine the efficacy of CBT delivered via videoconferencing (VCBT) for GAD using a randomized controlled trial design comparing an immediate treatment group to a waitlist control.

METHOD

Seventy-eight adults (M age = 36.92; SD = 12.92; 84.4% female) with GAD were enrolled in the study.

RESULTS

Those in the treatment group demonstrated a statistically significant reduction in GAD symptoms from pre-treatment to post-treatment (d = 1.03) and pre-treatment to 3-month follow-up (d = 1.50). Large between-group effect sizes were also observed at post-treatment (d = .80). Twenty-five participants (64.10%) in the VCBT group no longer met diagnostic criteria for GAD at post-treatment, and 26/39 (66.67%) no longer met criteria at 3-month follow-up. Ninety-six per cent of participants were satisfied with the treatment.

CONCLUSION

The results contribute towards advancing our knowledge on the efficacy and acceptability of VCBT for patients with GAD.

Acceptability of Digital Mental Health Interventions for Depression and Anxiety: Systematic Review

BACKGROUND

Depression and anxiety disorders are common, and treatment often includes psychological interventions. Digital health interventions, delivered through technologies such as web-based programs and mobile apps, are increasingly used in mental health treatment. Acceptability, the extent to which an intervention is viewed positively, has been identified as contributing to patient adherence and engagement with digital health interventions. Acceptability, therefore, impacts the benefit derived from using digital health interventions in treatment. Understanding the acceptability of digital mental health interventions among patients with depression or anxiety disorders is essential to maximize the effectiveness of their treatment.

OBJECTIVE

This review investigated the acceptability of technology-based interventions among patients with depression or anxiety disorders.

METHODS

A systematic review was performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PROSPERO (International Prospective Register of Systematic Reviews) guidelines. We searched PubMed, Web of Science, and Ovid in May 2022. Studies were included if they evaluated digital interventions for the treatment of depression or anxiety disorders and investigated their acceptability among adult patients. Studies were excluded if they targeted only specific populations (eg, those with specific physical health conditions), investigated acceptability in healthy individuals or patients under the age of 18 years, involved no direct interaction between patients and technologies, used technology only as a platform for traditional care (eg, videoconferencing), had patients using technologies only in clinical or laboratory settings, or involved virtual reality technologies. Acceptability outcome data were narratively synthesized by the direction of acceptability using vote counting. Included studies were evaluated using levels of evidence from the Oxford Centre for Evidence-Based Medicine. The risk of bias was assessed using a tool designed for this review and GRADE (Grading of Recommendations, Assessment, Development, and Evaluation).

RESULTS

A total of 143 articles met the inclusion criteria, comprising 67 (47%) articles on interventions for depression, 65 (45%) articles on interventions for anxiety disorders, and 11 (8%) articles on interventions for both. Overall, 90 (63%) were randomized controlled trials, 50 (35%) were other quantitative studies, and 3 (2%) were qualitative studies. Interventions used web-based programs, mobile apps, and computer programs. Cognitive behavioral therapy was the basis of 71% (102/143) of the interventions. Digital mental health interventions were generally acceptable among patients with depression or anxiety disorders, with 88% (126/143) indicating positive acceptability, 8% (11/143) mixed results, and 4% (6/143) insufficient information to categorize the direction of acceptability. The available research evidence was of moderate quality.

CONCLUSIONS

Digital mental health interventions seem to be acceptable to patients with depression or anxiety disorders. Consistent use of validated measures for acceptability would enhance the quality of evidence. Careful design of acceptability as an evaluation outcome can further improve the quality of evidence and reduce the risk of bias.

TRIAL REGISTRATION

Open Science Framework Y7MJ4; https://doi.org/10.17605/OSF.IO/SPR8M.

Psychotherapies for Generalized Anxiety Disorder in Adults: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

Importance

Generalized anxiety disorder (GAD) is one of the most common mental disorders in adults. Psychotherapies are among the most recommended treatments for GAD, but which should be considered as first-line treatment needs to be clarified.

Objective

To use a network meta-analysis to examine the short- and long-term associations of different psychotherapies with outcomes of effectiveness and acceptability in adults with GAD.

Data Sources

MEDLINE, Embase, PsycINFO, and the Cochrane Register of Controlled Trials were searched from database inception to January 1, 2023, to identify randomized clinical trials (RCTs) of psychotherapies for adults with GAD.

Study Selection

RCTs comparing any type of psychotherapy against another or with a control condition for the treatment of adults (≥18 years, both sexes) with a primary diagnosis of GAD were eligible for inclusion.

Data Extraction and Synthesis

This study followed Cochrane standards for extracting data and assessing data quality and used the PRISMA guideline for reporting. Risk of bias of individual studies was assessed using the second version of the Cochrane risk of bias tool, and the Confidence in Network Meta-Analysis was used to rate the certainty of evidence for meta-analytical results.

Main Outcomes and Measures

Eight psychotherapies were compared against one another and with 2 control conditions. Primary outcomes were severity of GAD symptoms and acceptability of the psychotherapies. Random-effects model pairwise and network meta-analyses were conducted. For effectiveness, standardized mean differences (SMDs) were pooled, and for acceptability, relative risks with 95% CIs were calculated.

Results

Data from 65 RCTs were included. Effect size estimates on data from 5048 participants (mean [SD], 70.9% [11.9%] women; mean [SD] age, 42.2 [12.5] years) suggested that third-wave cognitive behavior therapies (CBTs) (SMD, -0.76 [95% CI, -1.15 to -0.36]; certainty, moderate), CBT (SMD, -0.74 [95% CI, -1.09 to -0.38]; certainty, moderate), and relaxation therapy (SMD, -0.59 [95% CI, -1.07 to -0.11]; certainty, low) were associated with reduced GAD symptoms vs treatment as usual. Relative risks for all-cause discontinuation (indication of acceptability) signaled no differences compared with treatment as usual for all psychotherapies (eg, relative risk, 1.04 [95% CI, 0.64-1.67] for CBT vs treatment as usual). When excluding studies at high risk of bias, relaxation therapy lost its superiority over treatment as usual (SMD, -0.47; 95% CI, -1.18 to 0.23). When considering anxiety severity at 3 to 12 months after completion of the intervention, only CBT remained significantly associated with greater effectiveness than treatment as usual (SMD, -0.60; 95% CI, -0.99 to -0.21).

Conclusions and Relevance

Given the evidence in this systematic review and network meta-analysis for its associations with both acute and long-term effectiveness, CBT may represent the first-line therapy of GAD. Third-wave CBTs and relaxation therapy were associated with short-term effectiveness and may also be offered.

A meta-analysis on the efficacy of low-intensity cognitive behavioural therapy for generalised anxiety disorder

BACKGROUND

Low-intensity cognitive behavioural therapy (LICBT) has been recommended as a primary intervention in the tiered care for mild to moderate generalised anxiety disorder. However, LICBT for generalised anxiety disorder are markedly diverse and efficacy data on various outcomes have not been systematically reviewed. This meta-analysis aimed to synthesise effect sizes of three NICE-recommended LICBT for generalised anxiety disorder: non-facilitated self-help, guided self-help, and psychoeducational groups.

METHODS

A systematic literature review of randomised controlled trials (RCTs) examining LICBT for generalised anxiety disorder in the last 23 years (2000-2023) was conducted. Efficacy data for anxiety, depression, and worry outcomes were separately meta-analysed. The study was reported following the PRISMA guidelines.

RESULTS

The systematic review identified 12 RCTs out of 1205 papers. The three meta-analyses consisted of 12 (anxiety), 11 (depression), and 9 (worry) effect sizes respectively, including total sample sizes of 1201 (anxiety), 1164 (depression), and 908 (worry). The adjusted effect sizes for reductions in anxiety (g = -0.63), depression (g = -0.48), and worry (g = -0.64) were all in the medium range, favouring LICBT over control conditions. Between-study heterogeneity was significant on anxiety and worry, with no specific moderators identified by meta-regression.

CONCLUSIONS

LICBT has shown promise as an effective and efficient treatment modality for individuals with generalised anxiety disorder. Future research comparing various LICBT subtypes and treatment components will further inform clinical practice.

TRIAL REGISTRATION

This systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO; record ID CRD42021285590).

BodyThink program-based body image education improves Korean adolescents' attitudes toward cosmetic surgery: randomized controlled trial

BACKGROUND

The aims of this study were to modify the widely used BodyThink program to suit the circumstances of Korean schools and determine its effects on body esteem, body image, appearance stress, depression, and attitudes toward cosmetic surgery.

METHODS

Participants were 184 third-grade students from two middle schools in Korea, who were randomly assigned to a control or intervention group. Two of the participants dropped out; hence, data from 182 students were analyzed. The control group received the existing curriculum for 4 sessions, and the experimental group was provided with 4 sessions of the revised BodyThink program. Before and after the intervention, all participants completed questionnaires.

RESULTS

In the BodyThink group, improved body image, decreased depression, and positive improvements in attitudes toward cosmetic plastic surgery were observed after the intervention.

DISCUSSION

These results suggest that school health nurses can utilize interventions based on BodyThink program in their curricula to improve the physical and emotional health of adolescents.

TRIAL REGISTRATION

This study has been retrospectively registered with the Clinical Research information Service (CRIS) in Korea on October 5, 2023 (KCT0008839).

Internet-delivered cognitive behavioural therapy for depression and anxiety in breast cancer survivors: Results from a randomised controlled trial

OBJECTIVE

Depression and anxiety symptoms are common among breast cancer survivors. Access to evidence-based psychological therapy remains a major challenge. Despite the proven effectiveness of internet-delivered cognitive behavioural therapy (iCBT) in reducing depression and anxiety, the research with cancer survivors is still limited. This study evaluated the effectiveness of an iCBT intervention on depression and anxiety, quality of life, fear of recurrence, active and avoidant coping, and perceived social support in breast cancer survivors.

METHODS

Seventy-two participants were randomised to a 7-module guided iCBT intervention or treatment-as-usual (TAU). Depression and anxiety symptoms were measured using the Hospital Anxiety and Depression Scale total score (HADS-T). The secondary measures included the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC-QLQ), Breast Cancer Worry Scale (CWC), Brief Coping Orientation to Problems Encountered (Brief COPE), Medical Outcomes Study Social Support Survey (MOS-SSS). All were completed at baseline, post-intervention, and 2-month follow-up. Groups were compared using linear mixed models.

RESULTS

Although non-significant, iCBT group had lower HADS-T scores than TAU at post-intervention. This difference was statistically significant at 2-month follow-up (Hedge's g = -0.094). No significant group-by-time interaction effects were found for quality of life, fear of recurrence, active coping, avoidant coping, and perceived social support. The intervention adherence was acceptable; 52.8% (n = 28) completed all seven modules.

CONCLUSIONS

iCBT intervention demonstrated its preliminary effectiveness in reducing distress in breast cancer survivors.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

DISCUSSION

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

Remote cognitive-behavioral therapy for generalized anxiety disorder: A preliminary meta-analysis

BACKGROUND

Generalized anxiety disorder (GAD) is a chronic mental health condition that results in significant individual, societal, and economic burden. While cognitive behavioral therapy (CBT) is well established as an efficacious treatment for GAD, individuals have identified several logistical barriers to accessing face-to-face CBT. Remotely delivered treatments address many of these treatment barriers.

METHODS

The aim of the current study was to synthesize the current literature on the efficacy of remote CBT for GAD using a meta-analytic approach. Relevant articles were identified through an electronic database search and 10 studies (with 11 remote conditions and 1071 participants) were included in the meta-analysis.

RESULTS

Within-group findings indicate that remote CBT for GAD results in large effect sizes from pretreatment to posttreatment (g = 1.30; 95% confidence interval [CI]: 1.03-1.58). Both low intensity and high intensity remote CBT interventions were found to result in large effect sizes (g = 1.36; 95% CI: 1.11-1.61 and g = 0.83; 95% CI: 0.20-1.47, respectively), with no significant differences between the treatment formats (Q₁  = 2.28, p = 0.13). Between-group effect sizes were medium in size at posttreatment (g = 0.76; 95% CI: 0.47-1.06).

CONCLUSIONS

These findings have potential implications for the delivery of evidence-based treatment for GAD and the inclusion of remote methods in stepped care treatment approaches.

Increased Risk of Generalized Anxiety Disorder According to Frequent Sedentary Times Based on the 16th Korea Youth Risk Behavior Web-Based Survey

This study aimed to identify the association between sedentary behavior and anxiety disorders in 53,510 Korean adolescents. It analyzed data from the 16th (2020) Korea Youth Risk Behavior Web-based Survey (KYRBS). The dependent variable was the generalized anxiety disorder-7 (GAD-7). The GAD-7 scores were divided into normal, mild, moderate, and severe levels. The independent variables were sedentary time for learning, other sedentary times, total sedentary time, and regular physical activity. The confounding variables were sex, grade, stress, depression, substance abuse, suicidal thoughts, violent victimization, drinking, smoking, sleep satisfaction, and smartphone addiction. A chi-squared test, one-way analysis of variance, and logistic regression analysis were used for analysis. After adjusting for all confounding variables, the risk of severe level in GAD-7 increased by 1.045 times each time the sedentary time for learning based on increased by one hour. In other sedentary time and total sedentary time, the risk of severe level in GAD-7 increased by 1.025 times and 1.045 times per hour, respectively. However, in regular physical activity, after adjusting for the confounding variables, there was no significant association with the GAD-7 levels. Therefore, to prevent generalized anxiety disorders in Korean adolescents, it is necessary to reduce the overall sedentary times including sedentary time for learning.

Information technology-based versus face-to-face cognitive-behavioural therapy for anxiety and depression: A systematic review and meta-analysis

BACKGROUND

We aimed to systematically review the efficacy of information technology-based cognitive behavioural therapy (ICBT) versus face-to-face cognitive behavioural therapy (FCBT) for management of anxiety and depression in adult patients.

METHODS

Systematic literature search for clinical trials comparing ICBT to FCBT in adults diagnosed with anxiety or depression was conducted. Quantitative analyses were performed to examine the efficacy of ICBT versus FCBT. Primacy outcome was change in symptom severity.

RESULTS

A total of 11 publications (10 studies and 896 participants) were included. The pooled effect size of ICBT versus FCBT did not find significant difference for post-treatment anxiety or depressive symptoms severity (Hedges' g = -0.07; 95% CI = -0.20 to 0.06), and ICBT was non-inferior to FCBT (at Cohen's d = 0.3). Maintenance of treatment efficacy also showed no significant difference between ICBT and FCBT at 6 months (g = -0.14, 95% CI = -0.42 to 0.14) and 12 months (g = -0.05, 95% CI = -0.41 to 0.32) post-treatment. Adherence rate was lower in ICBT than FCBT but did not achieve statistically significance (61% vs 88%; RR = 0.86, 95% CI = 0.74 to1.00). Results were not affected by study quality.

LIMITATIONS

The examination of study heterogeneity was limited by the small number of studies.

CONCLUSIONS

We found non-inferior performance of ICBT versus FCBT in reducing symptoms in patients diagnosed of anxiety or depressive disorders. With the social-distancing measures amid COVID-19 pandemic, service providers should give serious consideration with great caution in the decision-making process of offering ICBT to patients.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Systematic Review Registration

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

Worry-specific versus self-tailored internet-based treatments for generalized anxiety disorder, with scheduled support or support on demand: A pilot factorial design trial

Studies suggest that internet-delivered cognitive behaviour therapy (ICBT) can be effective when treating generalized anxiety disorder (GAD). This pilot factorial design study examined the effects of two types of ICBT (worry-specific and self-tailored treatment), and two support types (scheduled weekly support and support on demand), on measures of worry, anxiety, and depressive symptoms. Participants (N = 85) were randomized into four treatment groups. Post-treatment measures were completed by 76.5% after eight weeks (n = 65). Intention to treat analysis showed significant improvements, with moderate to large within-group effects on the primary outcome measure, Penn State Worry Questionnaire (Cohen's d = 0.77-1.43). Minor to large effects on the secondary measures were found in all groups (Cohen's d = 0.13-1.66). No significant differences in outcome measures were found between the groups. Receiving scheduled support and self-tailored treatment was rated as more positive than receiving support on demand and the worry-specific program. A limitation is the low number of participants. The pilot results suggest that GAD can be treated with both worry-specific and self-tailored treatments, and that ICBT can be supported both with scheduled and support on demand.

Antecedents and consequences of internet addiction among school and college students: evidence from India

Purpose

Internet addiction (IA) has become a global health problem. As the research on IA has progressed, this study aims to explore the antecedents and consequences of IA, particularly in the Indian context. A conceptual model was developed, and hypotheses were formulated based on the conceptual model and the hypotheses were tested.

Design/methodology/approach

This study investigated 752 schools and collected students from the southern part of India. First, psychometric properties of the survey instrument were tested, and hierarchical regression was used to test the hypotheses.

Findings

The results revealed that time spent on the internet every day is positively related to IA, internet experience in terms of years is positively related to IA, income and gender moderates the relationship between time spent every day on the internet and internet experience and IA and IA is positively related to time spent on networking, video streaming, short video apps, educational apps, chat apps, online shopping apps, money-involved apps, etc.

Practical implications

The outcomes of this study are essential for the school and college students and their parents. As IA has become chronic in the present-day digital world, it is necessary to take rectification measures to avoid facing the perils of IA. The conceptual model provides a simple framework of explaining how young students spend their time on the internet to become addicted gradually. Furthermore, this study highlights the importance of controlling the younger generation's behavior, particularly regarding internet use.

Originality/value

This study is unique and innovative to the extent that it explores the antecedents of IA and the moderating role of gender and income in the relationship between the time spent on the internet and the IA. To the best of the authors’ knowledge, developing a conceptual model is the first of its kind to study school and college students in India.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Digital interventions in mental health: evidence syntheses and economic modelling

BACKGROUND

Economic evaluations provide evidence on whether or not digital interventions offer value for money, based on their costs and outcomes relative to the costs and outcomes of alternatives.

OBJECTIVES

(1) Evaluate and summarise published economic studies about digital interventions across different technologies, therapies, comparators and mental health conditions; (2) synthesise clinical evidence about digital interventions for an exemplar mental health condition; (3) construct an economic model for the same exemplar mental health condition using the previously synthesised clinical evidence; and (4) consult with stakeholders about how they understand and assess the value of digital interventions.

METHODS

We completed four work packages: (1) a systematic review and quality assessment of economic studies about digital interventions; (2) a systematic review and network meta-analysis of randomised controlled trials on digital interventions for generalised anxiety disorder; (3) an economic model and value-of-information analysis on digital interventions for generalised anxiety disorder; and (4) a series of knowledge exchange face-to-face and digital seminars with stakeholders.

RESULTS

In work package 1, we reviewed 76 economic evaluations: 11 economic models and 65 within-trial analyses. Although the results of the studies are not directly comparable because they used different methods, the overall picture suggests that digital interventions are likely to be cost-effective, compared with no intervention and non-therapeutic controls, whereas the value of digital interventions compared with face-to-face therapy or printed manuals is unclear. In work package 2, we carried out two network meta-analyses of 20 randomised controlled trials of digital interventions for generalised anxiety disorder with a total of 2350 participants. The results were used to inform our economic model, but when considered on their own they were inconclusive because of the very wide confidence intervals. In work package 3, our decision-analytic model found that digital interventions for generalised anxiety disorder were associated with lower net monetary benefit than medication and face-to-face therapy, but greater net monetary benefit than non-therapeutic controls and no intervention. Value for money was driven by clinical outcomes rather than by intervention costs, and a value-of-information analysis suggested that uncertainty in the treatment effect had the greatest value (£12.9B). In work package 4, stakeholders identified several areas of benefits and costs of digital interventions that are important to them, including safety, sustainability and reducing waiting times. Four factors may influence their decisions to use digital interventions, other than costs and outcomes: increasing patient choice, reaching underserved populations, enabling continuous care and accepting the 'inevitability of going digital'.

LIMITATIONS

There was substantial uncertainty around effect estimates of digital interventions compared with alternatives. This uncertainty was driven by the small number of studies informing most comparisons, the small samples in some of these studies and the studies' high risk of bias.

CONCLUSIONS

Digital interventions may offer good value for money as an alternative to 'doing nothing' or 'doing something non-therapeutic' (e.g. monitoring or having a general discussion), but their added value compared with medication, face-to-face therapy and printed manuals is uncertain. Clinical outcomes rather than intervention costs drive 'value for money'.

FUTURE WORK

There is a need to develop digital interventions that are more effective, rather than just cheaper, than their alternatives.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018105837.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 1. See the NIHR Journals Library website for further project information.

Digital Interventions for Generalized Anxiety Disorder (GAD): Systematic Review and Network Meta-Analysis

Background: Generalized anxiety disorder is the most common mental health condition based on weekly prevalence. Digital interventions have been used as alternatives or as supplements to conventional therapies to improve access, patient choice, and clinical outcomes. Little is known about their comparative effectiveness for generalized anxiety disorder. Methods: We conducted a systematic review and network meta-analysis of randomized controlled trials comparing digital interventions with medication, non-digital interventions, non-therapeutic controls, and no intervention. Results: We included 21 randomized controlled trials with a total of 2,350 participants from generalized anxiety disorder populations. Pooled outcomes using analysis of Covariance and rankograms based on the surface under the cumulative ranking curves indicated that antidepressant medication and group therapy had a higher probability than digital interventions of being the "best" intervention. Supported digital interventions were not necessarily "better" than unsupported (pure self-help) ones. Conclusions: Due to very wide confidence intervals, network meta-analysis results were inconclusive as to whether digital interventions are better than no intervention and non-therapeutic active controls, or whether they confer an additional benefit to standard therapy. Future research needs to compare digital interventions with one-to-one therapy and with manualized non-digital self-help and to include antidepressant medication as a treatment comparator and effect modifier.

Implementation of Telemental Health Services Before COVID-19: Rapid Umbrella Review of Systematic Reviews

BACKGROUND

Telemental health care has been rapidly adopted for maintaining services during the COVID-19 pandemic, and a substantial interest is now being devoted in its future role. Service planning and policy making for recovery from the pandemic and beyond should draw on both COVID-19 experiences and the substantial research evidence accumulated before this pandemic.

OBJECTIVE

We aim to conduct an umbrella review of systematic reviews available on the literature and evidence-based guidance on telemental health, including both qualitative and quantitative literature.

METHODS

Three databases were searched between January 2010 and August 2020 for systematic reviews meeting the predefined criteria. The retrieved reviews were independently screened, and those meeting the inclusion criteria were synthesized and assessed for risk of bias. Narrative synthesis was used to report these findings.

RESULTS

In total, 19 systematic reviews met the inclusion criteria. A total of 15 reviews examined clinical effectiveness, 8 reported on the aspects of telemental health implementation, 10 reported on acceptability to service users and clinicians, 2 reported on cost-effectiveness, and 1 reported on guidance. Most reviews were assessed to be of low quality. The findings suggested that video-based communication could be as effective and acceptable as face-to-face formats, at least in the short term. Evidence on the extent of digital exclusion and how it can be overcome and that on some significant contexts, such as children and young people's services and inpatient settings, was found to be lacking.

CONCLUSIONS

This umbrella review suggests that telemental health has the potential to be an effective and acceptable form of service delivery. However, we found limited evidence on the impact of its large-scale implementation across catchment areas. Combining previous evidence and COVID-19 experiences may allow realistic planning for the future implementation of telemental health.

Feasibility and efficacy of a digital CBT intervention for symptoms of Generalized Anxiety Disorder: A randomized multiple-baseline study

BACKGROUND AND OBJECTIVES

Cognitive behavioral therapy (CBT) is a first-line treatment for anxiety, but it is not widely available as clinical guidelines recommend. We examined the feasibility and efficacy of a novel smartphone-based fully automated digital CBT intervention, 'Daylight™', to improve symptoms of Generalized Anxiety Disorder (GAD).

METHODS

In this multiple-baseline design, 21 adults (20 F; mean age 43yrs. range 19-65yrs.) with moderate-to-severe symptoms of GAD were randomized to one of three baseline durations (2-, 4-, or 6-weeks) and then received access to digital CBT. Participants completed daily ratings of anxiety and worry, weekly measures of anxiety, depressive symptoms, and sleep, and measures of anxiety, worry, wellbeing, quality of life, CBT skill acquisition, and work performance at initial assessment prior to baseline randomization, post-intervention, and follow-up.

RESULTS

Digital CBT was found to be feasible in terms of engagement, satisfaction, and safety. For preliminary efficacy, improvements were detected in daily and weekly outcomes of anxiety for most participants. Despite individual differences, significant improvements occurred with the introduction of digital CBT and not during baseline. Overall, 70% of participants no longer had clinically significant symptoms of GAD, 61% no longer had significant depressive symptoms, and 40% no longer had significant sleep difficulty at post-intervention.

LIMITATIONS

The study sample was recruited using the internet and was mostly female, limiting the generalizability of the findings.

CONCLUSIONS

Findings support the feasibility and efficacy of Daylight. Further examination in randomized controlled trials is now warranted.

The effectiveness of Internet-delivered treatment for generalized anxiety disorder: An updated systematic review and meta-analysis

BACKGROUND

Generalized anxiety disorder (GAD) is a highly prevalent, chronic disorder associated with impaired quality of life, societal burden, and poor treatment rates. Internet-delivered interventions may improve the accessibility of treatments and are increasingly being used. This study aimed to update a previous meta-analysis to determine the effectiveness of available Internet-delivered interventions in treating symptoms of GAD.

METHOD

Systematic literature searches were conducted (through April 2020) using Embase, PubMed, PsychINFO, and Cochrane to find randomized controlled trials of Internet-delivered interventions for GAD. Risk of bias was evaluated, and Hedge's g was calculated at posttreatment and follow-up.

RESULTS

Twenty studies met eligibility criteria and were included in the meta-analysis. Random-effect models detected large effect sizes for primary outcomes of anxiety (g = 0.79) and worry (g = 0.75), favoring treatment. Effect sizes for depression, functional impairment, and quality of life were moderate to large. Maintenance of effects at follow-up seems likely.

CONCLUSIONS

Results support the effectiveness of Internet-delivered treatments for GAD. Considerable heterogeneity between studies appeared moderated by variability in the interventions themselves, highlighting the importance of further investigation into the characteristics that may optimize treatment outcomes. Overall, Internet-delivery appears to be a viable mode of treatment for GAD with potential to relieve existing gaps in the provision of treatment.

A randomised controlled trial comparing internet-delivered cognitive behavioural therapy (iCBT) with and without main carer access versus treatment-as-usual for depression and anxiety among breast cancer survivors: Study protocol

BACKGROUND

Depression and anxiety are common problems among breast cancer survivors. Carer support is one of the most important determinants of women's psychological wellbeing. Survivors' distress can be alleviated by giving carers access to survivors' evidence-based treatment, which will help carers understand what survivors have been going through and help survivors feel more supported. Given the limited access to evidence-based treatments, an adapted internet-delivered cognitive behavioural therapy (iCBT) intervention for breast cancer survivors, but also open for carers' access, has the potential to decrease survivors' depression and anxiety symptoms and improve cancer-related communication and relationship quality between survivors and carers.

OBJECTIVES

This study evaluates (1) the effectiveness of a guided iCBT intervention for depression and/or anxiety symptoms among breast cancer survivors with and without main carer access, and (2) the acceptability and satisfaction with the iCBT programme.

METHOD

In this pilot study comparing the effectiveness of an adapted 7-week iCBT without main carer access against the iCBT with main carer access and treatment-as-usual control, 108 breast cancer survivors will be recruited and then randomised to either (1) treatment (n = 72) or (2) treatment-as-usual control group (n = 36) with a 2:1 ratio. The participants in the treatment group will be assigned to either iCBT alone or iCBT with the main carer also having access to the same content based on their preference. The primary outcome measure is the Hospital Anxiety and Depression Scale, and alongside secondary measures such as Cancer-Related Quality of Life, Breast Cancer Worry Scale, Brief COPE, and Medical Outcomes Study Social Support Survey will be completed by the survivors at baseline, post-treatment, and 2-month follow-up. Survivors who have carers will also complete Survivor-Carer Cancer Communication and Relationship Quality measures to provide insights into the effects of carer access. To assess the acceptability and satisfaction with the programme, survivors and their main carers will fill out the Helpful Aspects of Therapy Form (HAT) and Satisfaction with Online Treatment (SAT). Programme effectiveness and the effects of carer access on primary and secondary outcome measures will be evaluated on intention-to-treat and per-protocol basis using Linear-Mixed-Models.

DISCUSSION

This is the first trial comparing the effectiveness and acceptability of iCBT with and without carer access for depression and anxiety among breast cancer survivors. The findings of this study will provide novel data on the acceptability of iCBT programmes for breast cancer survivors and the impact of carer access on them and their carers.

Pharmacological and psychological interventions for generalized anxiety disorder in adults: A network meta-analysis

Generalized anxiety disorder (GAD) is a significant and common mental illness with a lifetime prevalence of 3.7%. Regardless of the complexity of treatment decisions for GAD, few studies have conducted systematic comparisons of the efficacies of varying interventions. Thus, this study performed a valid network meta-analysis (NMA) of randomized controlled trials (RCTs) to synthesize direct and indirect evidence for alternative interventions for GAD. We searched four major bibliographic databases, the Cochrane Central Register of Controlled Trials, Embase, PsycINFO, and PubMed, for published RCTs of adult patients with a diagnosis of GAD and allowed for all comorbidities. A total of 91 articles (14,812 participants) were identified in the final NMA. The results showed that all pharmacological treatments except for serotonin modulators and second-generation antipsychotics had greater effects than placebo: norepinephrine-dopamine reuptake inhibitors (standardized mean difference (SMD) -1.84, 95% credible interval -3.05 to -0.62), noradrenergic and specific serotonergic antidepressants (-0.91, -1.62 to -0.20), melatonergic receptor agonists (-0.68, -1.15 to -0.21), selective serotonin reuptake inhibitors (SSRIs; -0.67, -0.90 to -0.43), azapirones (-0.58, -1.00 to -0.17), anticonvulsants (-0.56, -0.85 to -0.28), serotonin-norepinephrine reuptake inhibitors (SNRIs; -0.54, -0.79 to -0.30), and benzodiazepines (BZDs; -0.40, -0.65 to -0.15). Most psychological and self-help interventions exerted greater effects than the waitlist group. However, no psychological interventions had greater effects compared with the psychological placebo. Overall, most pharmacological interventions had larger effect sizes than psychological interventions, and most psychological interventions showed larger effect sizes than self-help interventions.

Protocol for the Yapatjarrathati project: a mixed-method implementation trial of a tiered assessment process for identifying fetal alcohol spectrum disorders in a remote Australian community

Background

Fetal alcohol spectrum disorder (FASD) is a highly prevalent neurodevelopmental disorder associated with prenatal alcohol exposure. Early identification can improve functioning for individuals and reduce costs to society. Gold standard methods of diagnosing FASD rely on specialists to deliver intensive, multidisciplinary assessments. While comprehensive, prevalence rates highlight that this assessment model cannot meet demand, nor is it feasible in remote areas where specialist services are lacking. This project aims to expand the capabilities of remote practitioners in north Queensland, Australia, where 23–94% of the community identify as First Nations people. Integrating cultural protocols with the implementation science theories of Knowledge-To-Action, Experience-Based Co-Design, and RE-AIM, remote practitioners with varying levels of experience will be trained in a co-designed, culturally appropriate, tiered neurodevelopmental assessment process that considers FASD as a potential outcome. This innovative assessment process can be shared between primary and tertiary health care settings, improving access to services for children and families. This project aims to demonstrate that neurodevelopmental assessments can be integrated seamlessly with established community practices and sustained through evidence-based workforce development strategies.

Methods

The Yapatjarrathati project (named by the local First Nations community and meaning ‘to get well’) is a mixed-method implementation trial of a tiered assessment process for identifying FASD within a remote Australian community. In collaboration with the community, we co-designed: (a) a culturally sensitive, tiered, neurodevelopmental assessment process for identifying FASD, and (b) training materials that up-skill remote practitioners with varying levels of expertise. Qualitative interviews for primary, secondary and end users will be undertaken to evaluate the implementation strategies. RE-AIM will be used to evaluate the reach, effectiveness, adoption, implementation and maintenance of the assessment and training process.

Discussion

Co-designed with the local community, integrated with cultural protocols, and based on implementation science theories, the assessment and training process from this project will have the potential to be scaled-up across other remote locations and trialed in urban settings. The Yapatjarrathati project is an important step towards increasing the availability of neurodevelopmental services across Australia and empowering remote practitioners to contribute to the FASD assessment process.

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.

Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis

BACKGROUND

Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects.

OBJECTIVE

This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome.

METHODS

We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials.

RESULTS

We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls.

CONCLUSIONS

iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients' greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings.

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)].

Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials

The purpose of this meta-analysis was to provide updated pooled effect sizes of evidence-based psychotherapies and medications for generalized anxiety disorder (GAD) and to investigate potential moderators of outcomes. Seventy-nine randomized controlled trials (RCT) including 11,002 participants with a diagnosis of GAD were included in a meta-analysis that tested the efficacy of psychotherapies or medications for GAD. Psychotherapy showed a medium to large effect size (g = 0.76) and medication showed a small effect size (g = 0.38) on GAD outcomes. Psychotherapy also showed a medium effect on depression outcomes (g = 0.64) as did medications (g = 0.59). Younger age was associated with a larger effect size for psychotherapy (p < 0.05). There was evidence of publication bias in psychotherapy studies. This analysis found a medium to large effect for empirically supported psychotherapy interventions on GAD outcomes and a small effect for medications on GAD outcomes. Both groups showed a medium effect on depression outcomes. Because medication studies had more placebo control conditions than inactive conditions compared to psychotherapy studies, effect sizes between the domains should not be compared directly. Patient age should be further investigated as a potential moderator in psychotherapy outcomes in GAD.

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

Objective:

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

Method:

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

Results:

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

Conclusion:

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

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

Implementation of a Guided, Digital Cognitive Behavioral Program for Anxiety in Primary Care: Preliminary Findings of Engagement and Effectiveness

BACKGROUND

Implementation of digital behavioral health programs in primary care (PC) can improve access to care for patients in need.

INTRODUCTION

This study provides preliminary data on user engagement and anxiety symptom change among patients referred by their PC provider to a guided, mobile cognitive behavioral program, Lantern.

MATERIALS AND METHODS

Adults aged 20-65 years with at least mild anxiety (GAD-7 ≥ 5) during routine clinical screening in two PC practices were offered Lantern. The primary outcome was self-reported anxiety collected at baseline and 2 months. Linear mixed effects modeling was used to examine anxiety symptom reduction from baseline to 2 months. Post hoc analyses evaluated how number of units completed, number of techniques practiced, and days of usage impacted symptom change.

RESULTS

Sixty-three participants signed up for Lantern and had both baseline and 2- month GAD-7. A mixed effects model adjusted for age, gender, medical complexity score, and physical health found a significant effect of time on GAD-7 (β = -2.08, standard error = 0.77, t(62) = -2.71, p = 0.009). Post hoc analyses indicated that mean number of units, techniques, and usage days did not significantly impact GAD-7 change over 2 months. However, there was significantly greater improvement in anxiety in participants who completed at least three techniques.

DISCUSSION

Results benchmark to previous studies that have found statistically significant symptom change among participants after 4-9 weeks of face-to-face or Internet-based cognitive behavioral therapy (CBT).

CONCLUSIONS

This study suggests that use of Lantern is associated with anxiety reduction and provides proof-of-concept for the dissemination and implementation of guided, CBT-based mobile behavioral health interventions in PC settings.

Evaluation of a computerized cognitive behavioural therapy programme, MindWise (2.0), for adults with mild-to-moderate depression and anxiety

OBJECTIVES

To investigate the acceptability and utility of a newly developed computerized cognitive behavioural therapy (cCBT) programme, MindWise (2.0), for adults attending Irish primary care psychology services.

METHOD

Adult primary care psychology service users across four rural locations in Ireland were invited to participate in this study. A total of 60 service users participated in the MindWise (2.0) treatment group and compared to 22 people in a comparison waiting list control group. Participants completed pre- and post-intervention outcome measures of anxiety, depression, and work/social functioning.

RESULTS

At post-intervention, 25 of 60 people in the MindWise (2.0) condition had fully completed the programme and 19 of 22 people in the waiting list condition provided time 2 data. Relative to those in the control group, the MindWise (2.0) participants reported significantly reduced symptoms of anxiety and no change in depression or work/social functioning.

CONCLUSIONS

The newly developed cCBT programme, MindWise (2.0), resulted in significant improvements on a measure of anxiety and may address some barriers to accessing more traditional face-to-face mental health services for adults in a primary care setting. Further programme development and related research appears both warranted and needed to lower programme drop-out, establish if gains in anxiety management are maintained over time, and support people in a primary care context with depression.

PRACTITIONER POINTS

There is a growing evidence base that computerized self-help programmes can assist in a stepped-care approach to adult mental health service provision. These programmes require further development to address issues such as high dropout, the development of equally effective transdiagnostic content, and greater effectiveness in the country of origin. This study evaluated the acceptability and utility of a brief online CBT programme for adults referred due to anxiety or low mood to primary care psychology services in the national health service in Ireland. Results indicate that 42% of people completed the programme and experienced a significant reduction in anxiety but not depression and no improvement in work or social adjustment compared to similar adults on a waiting list for services. This study suggests the programme warrants further development and research and may in time become a useful and suitable intervention within the national health service in Ireland.

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

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

Commencing and Persisting With a Web-Based Cognitive Behavioral Intervention for Insomnia: A Qualitative Study of Treatment Completers

Background

Computerized cognitive behavioral therapy for insomnia (CCBT-I) has a growing evidence base as a stand-alone intervention, but it is less clear what factors may limit its acceptability and feasibility when combined with clinical care.

Objective

The purpose of this study was to explore barriers and facilitators to use of an adjunctive CCBT-I program among depressed patients in a psychiatric clinic by using both quantitative and qualitative approaches.

Methods

We conducted the qualitative component of the study using face-to-face or telephone interviews with participants who had enrolled in a clinical trial of a CCBT-I program as an adjunctive treatment in a psychiatric clinical setting. In line with the grounded theory approach, we used a semistructured interview guide with new thematic questions being formulated during the transcription and data analysis, as well as being added to the interview schedule. A range of open and closed questions addressing user experience were asked of all study participants who completed the 12-week trial in an online survey.

Results

Three themes emerged from the interviews and open questions, consistent with nonadjunctive CCBT-I implementation. Identification with the adjunctive intervention’s target symptom of insomnia and the clinical setting were seen as key reasons to engage initially. Persistence was related to factors to do with the program, its structure, and its content, rather than any nonclinical factors. The survey results showed that only the key active behavioral intervention, sleep restriction, was rated as a major problem by more than 15% of the sample. In this clinical setting, the support of the clinician in completing the unsupported program was highlighted, as was the need for the program and clinical treatment to be coordinated.

Conclusions

The use of a normally unsupported CCBT-I program as an adjunctive treatment can be aided by the clinician’s approach. A key behavioral component of the intervention, specific to insomnia treatment, was identified as a major problem for persistence. As such, clinicians need to be aware of when such components are delivered in the program and coordinate their care accordingly, if the use of the program is to be optimized.

ClinicalTrial

Australian and New Zealand Clinical Trials Registry ACTRN12612000985886; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362875&isReview=true (Archived by WebCite at http://www.webcitation.org/6njjhl42X)

Effectiveness of an internet-delivered intervention for generalized anxiety disorder in routine care: A randomised controlled trial in a student population

BACKGROUND

Cognitive behavioural therapy is one of the main and preferred treatments for generalized anxiety disorder. Numerous barriers can hinder an individual from seeking or receiving appropriate treatment; internet-delivered CBT interventions offer a relatively new means of increasing access to treatment.

METHODS

A service-based effectiveness randomised waiting list control trial examined the impact of an internet-delivered CBT intervention, Calming Anxiety, amongst Irish university students (N = 137). Primary outcome was self-reported GAD and secondary outcomes included depression and work and social functioning.

RESULTS

Analyses returned inconclusive results. Both treatment and waiting list conditions displayed significant decreases in anxiety symptoms post-treatment, but we did not observe a significant between-group effect (p = 0.076). Significant within-group differences from pre to post time points were observed for depression (BDI-II) and work and social functioning (WASA), and between group differences were also significant for depression (d = 0.46) and functioning (d = 0.36). Both groups demonstrated cases of remission and recovery from anxiety, however differences in the number of cases reaching clinically meaningful change between conditions were non-significant.

CONCLUSIONS

Several explanations regarding the results are presented, examining issues related to active waiting lists, study limitations and treatment expectancies.Trial registration: Current Controlled Trials ISRCTN16303842.

How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence

We report the current best estimate of the effects of cognitive behavior therapy (CBT) in the treatment of major depression (MDD), generalized anxiety disorder (GAD), panic disorder (PAD) and social anxiety disorder (SAD), taking into account publication bias, the quality of trials, and the influence of waiting list control groups on the outcomes. In our meta-analyses, we included randomized trials comparing CBT with a control condition (waiting list, care-as-usual or pill placebo) in the acute treatment of MDD, GAD, PAD or SAD, diagnosed on the basis of a structured interview. We found that the overall effects in the 144 included trials (184 comparisons) for all four disorders were large, ranging from g=0.75 for MDD to g=0.80 for GAD, g=0.81 for PAD, and g=0.88 for SAD. Publication bias mostly affected the outcomes of CBT in GAD (adjusted g=0.59) and MDD (adjusted g=0.65), but not those in PAD and SAD. Only 17.4% of the included trials were considered to be high-quality, and this mostly affected the outcomes for PAD (g=0.61) and SAD (g=0.76). More than 80% of trials in anxiety disorders used waiting list control groups, and the few studies using other control groups pointed at much smaller effect sizes for CBT. We conclude that CBT is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still uncertain and should be considered with caution.

Guided self-help for generalized anxiety disorder in older adults

OBJECTIVE

The main objective of this study was to examine the efficacy of a guided self-help treatment based on cognitive behavioral principles (CBT-GSH) for generalized anxiety disorder (GAD) in older adults.

METHODS

Three older adults aged from 66 to 70 and diagnosed with GAD were included in a single-case experimental multiple-baseline protocol. Data were collected using daily self-monitoring, standardized clinician ratings, and self-report questionnaires at pretest, posttest, and 6-month and 12-month follow-ups. Treatment consisted of awareness training, worry interventions, relaxation training, pleasant activities scheduling, and relapse prevention. Participants used a manual presenting weekly readings and at-home practice exercises. They also received weekly supportive phone calls from a therapist.

RESULTS

At posttest, participants showed improvement on worries and GAD severity, on psychological process variables targeted by treatment (intolerance of uncertainty, negative problem orientation, cognitive avoidance, and perceived usefulness of worry), and on secondary variables associated with GAD (anxiety, depression, sleep difficulties, cognitive functioning, and disability). These results were generally maintained at 12 months after the end of treatment. Participants had favorable opinions toward the treatment.

CONCLUSION

The results of this study suggest that CBT-GSH is both feasible and effective for the treatment of GAD in older adults.

Internet-delivered acceptance-based behavior therapy for generalized anxiety disorder: A pilot study

OBJECTIVE

Internet-delivered cognitive behavior therapy (ICBT) has been developed and tested for treating persons with generalized anxiety disorder (GAD). A new form of CBT focuses on acceptance (of internal experiences or difficult psychological content), mindfulness and valued actions. To date this form of CBT has not been delivered via the internet for persons with GAD. The aim of this study was to describe the functionality of a new internet-delivered acceptance-based behavior therapy for GAD, and to test the effect of the intervention in an open pilot trial.

METHODS

Following exclusion of two patients we included 14 patients diagnosed with GAD from two primary care clinics. At 2-3 months follow-up after treatment 10 patients completed the outcome measures. The treatment lasted for an average of 15 weeks and consisted of acceptance-based techniques, behavior therapy components and homework assignments.

RESULTS

A majority of participants completed all modules during the treatment. Findings on the Penn State Worry Questionnaire showed a within-group improvement of Cohen's d = 2.14 at posttreatment. At the follow-up results were maintained. Client satisfaction ratings were high.

CONCLUSIONS

We conclude that internet-delivered acceptance-based behavior therapy potentially can be a promising new treatment for GAD. A controlled trial of the program has already been completed.

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.

Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults

BACKGROUND

Cognitive behavioural therapy (CBT) is an evidence-based treatment for anxiety disorders. Many people have difficulty accessing treatment, due to a variety of obstacles. Researchers have therefore explored the possibility of using the Internet to deliver CBT; it is important to ensure the decision to promote such treatment is grounded in high quality evidence.

OBJECTIVES

To assess the effects of therapist-supported Internet CBT (ICBT) on remission of anxiety disorder diagnosis and reduction of anxiety symptoms in adults as compared to waiting list control, unguided CBT, or face-to-face CBT. Effects of treatment on quality of life and patient satisfaction with the intervention were also assessed.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) to 16 March 2015. The CCDANCTR includes relevant randomised controlled trials from MEDLINE, EMBASE, PsycINFO and CENTRAL. We also searched online clinical trial registries and reference lists of included studies. We contacted authors to locate additional trials.

SELECTION CRITERIA

Each identified study was independently assessed for inclusion by two authors. To be included, studies had to be randomised controlled trials of therapist-supported ICBT compared to a waiting list, attention, information, or online discussion group; unguided CBT (that is, self-help); or face-to-face CBT. We included studies that treated adults with an anxiety disorder (panic disorder, agoraphobia, social phobia, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, obsessive compulsive disorder, and specific phobia) defined according to the Diagnostic and Statistical Manual of Mental Disorders III, III-R, IV, IV-TR or the International Classification of Disesases 9 or 10.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of included studies and judged overall study quality. We used data from intention-to-treat analyses wherever possible. We assessed treatment effect for the dichotomous outcome of clinically important improvement in anxiety using a risk ratio (RR) with 95% confidence interval (CI). For disorder-specific and general anxiety symptom measures and quality of life we assessed continuous scores using standardized mean differences (SMD). We examined statistical heterogeneity using the I(2) statistic.

MAIN RESULTS

We screened 1736 citations and selected 38 studies (3214 participants) for inclusion. The studies examined social phobia (11 trials), panic disorder with or without agoraphobia (8 trials), generalized anxiety disorder (5 trials), post-traumatic stress disorder (2 trials), obsessive compulsive disorder (2 trials), and specific phobia (2 trials). Eight remaining studies included a range of anxiety disorder diagnoses. Studies were conducted in Sweden (18 trials), Australia (14 trials), Switzerland (3 trials), the Netherlands (2 trials), and the USA (1 trial) and investigated a variety of ICBT protocols. Three primary comparisons were identified, therapist-supported ICBT versus waiting list control, therapist-supported versus unguided ICBT, and therapist-supported ICBT versus face-to-face CBT.Low quality evidence from 11 studies (866 participants) contributed to a pooled risk ratio (RR) of 3.75 (95% CI 2.51 to 5.60; I(2) = 50%) for clinically important improvement in anxiety at post-treatment, favouring therapist-supported ICBT over a waiting list, attention, information, or online discussion group only. The SMD for disorder-specific symptoms at post-treatment (28 studies, 2147 participants; SMD -1.06, 95% CI -1.29 to -0.82; I(2) = 83%) and general anxiety symptoms at post-treatment (19 studies, 1496 participants; SMD -0.75, 95% CI -0.98 to -0.52; I(2) = 78%) favoured therapist-supported ICBT; the quality of the evidence for both outcomes was low.One study compared unguided CBT to therapist-supported ICBT for clinically important improvement in anxiety at post-treatment, showing no difference in outcome between treatments (54 participants; very low quality evidence). At post-treatment there were no clear differences between unguided CBT and therapist-supported ICBT for disorder-specific anxiety symptoms (5 studies, 312 participants; SMD -0.22, 95% CI -0.56 to 0.13; I(2) = 58%; very low quality evidence) or general anxiety symptoms (2 studies, 138 participants; SMD 0.28, 95% CI -2.21 to 2.78; I(2) = 0%; very low quality evidence).Compared to face-to-face CBT, therapist-supported ICBT showed no significant differences in clinically important improvement in anxiety at post-treatment (4 studies, 365 participants; RR 1.09, 95% CI 0.89 to 1.34; I(2) = 0%; low quality evidence). There were also no clear differences between face-to-face and therapist supported ICBT for disorder-specific anxiety symptoms at post-treatment (7 studies, 450 participants; SMD 0.06, 95% CI -0.25 to 0.37; I(2) = 60%; low quality evidence) or general anxiety symptoms at post-treatment (5 studies, 317 participants; SMD 0.17, 95% CI -0.35 to 0.69; I(2) = 78%; low quality evidence).Overall, risk of bias in included studies was low or unclear for most domains. However, due to the nature of psychosocial intervention trials, blinding of participants and personnel, and outcome assessment tended to have a high risk of bias. Heterogeneity across a number of the meta-analyses was substantial, some was explained by type of anxiety disorder or may be meta-analytic measurement artefact due to combining many assessment measures. Adverse events were rarely reported.

AUTHORS' CONCLUSIONS

Therapist-supported ICBT appears to be an efficacious treatment for anxiety in adults. The evidence comparing therapist-supported ICBT to waiting list, attention, information, or online discussion group only control was low to moderate quality, the evidence comparing therapist-supported ICBT to unguided ICBT was very low quality, and comparisons of therapist-supported ICBT to face-to-face CBT were low quality. Further research is needed to better define and measure any potential harms resulting from treatment. These findings suggest that therapist-supported ICBT is more efficacious than a waiting list, attention, information, or online discussion group only control, and that there may not be a significant difference in outcome between unguided CBT and therapist-supported ICBT; however, this latter finding must be interpreted with caution due to imprecision. The evidence suggests that therapist-supported ICBT may not be significantly different from face-to-face CBT in reducing anxiety. Future research should explore heterogeneity among studies which is reducing the quality of the evidence body, involve equivalence trials comparing ICBT and face-to-face CBT, examine the importance of the role of the therapist in ICBT, and include effectiveness trials of ICBT in real-world settings. A timely update to this review is needed given the fast pace of this area of research.

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

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

Internet-Delivered Psychological Treatments

During the past 15 years, much progress has been made in developing and testing Internet-delivered psychological treatments. In particular, therapist-guided Internet treatments have been found to be effective for a wide range of psychiatric and somatic conditions in well over 100 controlled trials. These treatments require (a) a secure web platform, (b) robust assessment procedures, (c) treatment contents that can be text based or offered in other formats, and (d) a therapist role that differs from that in face-to-face therapy. Studies suggest that guided Internet treatments can be as effective as face-to-face treatments, lead to sustained improvements, work in clinically representative conditions, and probably are cost-effective. Despite these research findings, Internet treatment is not yet disseminated in most places, and clinical psychologists should consider using modern information technology and evidence-based treatment programs as a complement to their other services, even though there will always be clients for whom face-to-face treatment is the best option.

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.

Are Trials of Computerized Therapy Generalizable? A Multidimensional Meta-analysis

BACKGROUND

Previous meta-analyses have established that computerized cognitive behavioral therapy (cCBT) is an effective, acceptable, and efficient method of delivering treatment for anxiety and depression. However, the potential generalizability of these conclusions to nonresearch settings has not yet been investigated.

MATERIALS AND METHODS

We conducted a multidimensional meta-analysis of randomized controlled trials of cCBT for anxiety and/or depressive disorders quantifying generalizability by examining the relationship between participant exclusion and treatment outcome. Thirty-six trials of cCBT were identified through systematic searches in six databases. The number of exclusion criteria and exclusion rate served as indices of participant exclusion. Outcome variables included between- and within-group effect sizes in addition to rates of clinically significant improvement.

RESULTS

Analyses were performed for all studies, depression studies (n = 11), and anxiety studies (n = 23). Pooling across all studies, we found a between-group effect size of 0.85 (95% confidence interval, 0.77-0.94). The mean number of exclusionary criteria was 12 (range, 2-24), and the mean exclusion rate was 0.49 (range, 0.08-0.92). Risk for suicide was the most common criterion for exclusion. Correlation analyses revealed a large relationship between number of exclusion criteria and proportion clinically changed in the treatment group for anxiety studies (r = 0.70). Results provide evidence for the limited effectiveness of cCBT for anxiety disorders in nonresearch samples.

CONCLUSIONS

As computerized therapy is developed to address barriers to dissemination, future trials should examine the effectiveness of cCBT for anxiety for patients with more complex clinical presentations.

Internet-delivered cognitive behavior therapy for anxiety and insomnia in a higher education context

BACKGROUND AND OBJECTIVES

Anxiety and insomnia can be treated with internet-delivered Cognitive Behavioral Therapy (iCBT). iCBT may be well-suited to students who are known to be poor help-seekers and suffer these symptoms. iCBT can offer easy access to treatment and increase service availability. The aim of this study was to evaluate the efficacy of anxiety and insomnia iCBT programs in students.

DESIGN

A randomized, controlled study.

METHODS

Students were randomly allocated to intervention ("Anxiety Relief": n = 43; "Insomnia Relief": n = 48; control: n = 47). Interventions lasted six weeks. Outcome measures were the State-Trait Anxiety Inventory and the Pittsburgh Sleep Quality Index.

RESULTS

Significant within-group reductions in anxiety (t(31) = 2.00, p = .03) with moderate between-groups (compared to control) effect size (d = .64) and increases in sleep quality (t(31) = 3.46, p = .002) with a moderate between-groups effect size (d = .55) were found for completers of the anxiety program from pre- to post-intervention. Significant within-group increases in sleep quality were found for completers of the insomnia program from pre- to post-intervention (t(35) = 4.28, p > .001) with a moderate between-groups effect size (d = .51).

CONCLUSIONS

Findings support the use of iCBT for anxiety and insomnia in students, and indicate that further research is needed.

A mobile phone and web-based intervention for improving mental well-being in young people with type 1 diabetes: design of a randomized controlled trial

Background

Young people with type 1 diabetes experience elevated levels of emotional distress that impact negatively on their diabetes self-care, quality of life, and disease-related morbidity and mortality. While the need is great and clinically significant, a range of structural (eg, service availability), psychological (eg, perceived stigma), and practical (eg, time and lifestyle) barriers mean that a majority of young people do not access the support they need to manage the emotional and behavioral challenges of type 1 diabetes.

Objective

The aim of this study is to examine the effectiveness of a fully-automated cognitive behavior therapy-based mobile phone and Web-based psychotherapeutic intervention (myCompass) for reducing mental health symptoms and diabetes-related distress, and improving positive well-being in this vulnerable patient group.

Methods

A two-arm randomized controlled trial will be conducted. Young people with type 1 diabetes and at least mild psychological distress will be recruited via outpatient diabetes centers at three tertiary hospitals in Sydney, Australia, and referred for screening to a study-specific website. Data will be collected entirely online. Participants randomized to the intervention group will use the myCompass intervention for 7 weeks, while at the same time a control group will use an active placebo program matched to the intervention on duration, mode of delivery, and interactivity.

Results

The primary outcome will be mental well-being (ie, depression, anxiety, diabetes-related distress, and positive well-being), for which data will be collected at baseline, post-intervention, and after 3 months follow-up. Secondary outcomes will be functional (work and social functioning and diabetes self-care), biochemical measures (HbA1c), and mental health self-efficacy. We aim to recruit 280 people into the study that will be conducted entirely online. Group differences will be analyzed on an intention-to-treat basis using mixed models repeated measures.

Conclusions

We hypothesize that scores on the outcome measures will improve significantly for young people who use the mobile phone and Web-based intervention compared to the control group. myCompass is a public health intervention that is broadly available and free to use. If effective, the program has the capacity to provide convenient and accessible evidenced-based care to the large group of young people with type 1 diabetes who do not currently access the psychosocial support they need.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12614000974606; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366607 (Archived by WebCite at http://www.webcitation.org/6YGdeT0Dk).

Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults

BACKGROUND

Cognitive behavioural therapy (CBT) is an evidence-based treatment for anxiety disorders. Many people have difficulty accessing treatment, due to a variety of obstacles. Researchers have therefore explored the possibility of using the Internet to deliver CBT; it is important to ensure the decision to promote such treatment is grounded in high quality evidence.

OBJECTIVES

To assess the effects of therapist-supported Internet CBT on remission of anxiety disorder diagnosis and reduction of anxiety symptoms in adults as compared to waiting list control, unguided CBT, or face-to-face CBT. Effects of treatment on quality of life and patient satisfaction with the intervention were also assessed.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialized Register (CCDANCTR) to 12 April 2013. The CCDANCTR includes relevant randomised controlled trials from EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We also searched online clinical trial registries and reference lists of included studies. We contacted authors to locate further trials. An update of an initial search (April 2013), conducted in September 2014, identified seven new completed studies, seven previously ongoing studies now completed, and four new ongoing studies. This is a fast-moving area; we plan to update this review shortly, incorporating these new studies.

SELECTION CRITERIA

Each identified study was independently assessed for inclusion by two authors. To be included, studies had to be randomised controlled trials of therapist-supported ICBT compared to a waiting list, attention, information, or online discussion group; unguided CBT (that is, self-help); or face-to-face CBT. We included studies that treated adults with an anxiety disorder (panic disorder, agoraphobia, social phobia, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, obsessive compulsive disorder, and specific phobia) defined according to the Diagnostic and Statistical Manual of Mental Disorders III, III-R, IV, IV-TR or the International Classification of Disesases 9 or 10.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of included studies and judged overall study quality. We used data from intention-to-treat analyses wherever possible. We assessed treatment effect for the dichotomous outcome of clinically important improvement in anxiety using a risk ratio (RR) with 95% confidence interval (CI). For disorder-specific and general anxiety symptom measures and quality of life we assessed continuous scores using standardized mean differences (SMD). We examined statistical heterogeneity using the I(2) statistic.

MAIN RESULTS

We screened 1000 citations and selected 30 studies (2181 participants) for inclusion. The studies examined social phobia (11 trials), panic disorder with or without agoraphobia (8 trials), generalized anxiety disorder (4 trials), post-traumatic stress disorder (1 trial), and specific phobia (1 trial). Five remaining studies included a range of anxiety disorder diagnoses. Studies were conducted in Sweden (15 trials), Australia (12 trials), Switzerland (2 trials), and the Netherlands (1 trial) and investigated a variety of ICBT protocols. Three primary comparisons were identified, experimental versus waiting list control, experimental versus unguided ICBT, and experimental versus face-to-face CBT.Moderate quality evidence from 9 studies (644 participants) contributed to a pooled RR of 4.18 (95% CI 2.42 to 7.22) for clinically important improvement in anxiety at post-treatment, favouring therapist-supported ICBT over a waiting list, attention, information, or online discussion group only. Similarly, the SMD for disorder-specific symptoms at post-treatment (22 studies, 1573 participants; SMD -1.12, 95% CI -1.39 to -0.85) and general anxiety symptoms at post-treatment (14 studies, 1004 participants; SMD -0.79, 95% CI -1.10 to -0.48) favoured therapist-supported ICBT. The quality of the evidence for both outcomes was low.One study compared unguided CBT to therapist-supported ICBT for clinically important improvement in anxiety at post-treatment, showing no difference in outcome between treatments (54 participants; very low quality evidence). At post-treatment there were no clear differences between unguided CBT and therapist-supported ICBT for disorder-specific anxiety symptoms (4 studies, 253 participants; SMD -0.24, 95% CI -0.69 to 0.21; low quality evidence) or general anxiety symptoms (two studies, 138 participants; SMD 0.28, 95% CI -2.21 to 2.78; low quality evidence).Compared to face-to-face CBT, therapist-supported ICBT showed no significant differences in clinically important improvement in anxiety at post-treatment (4 studies, 365 participants; RR 1.09, 95% CI 0.89 to 1.34; moderate quality evidence). There were also no clear differences between face-to-face and therapist supported ICBT for disorder-specific anxiety symptoms at post-treatment (6 studies, 424 participants; SMD 0.09, 95% CI -0.26 to 0.43; low quality evidence) or general anxiety symptoms at post-treatment (5 studies, 317 participants; SMD 0.17, 95% CI -0.35 to 0.69; low quality evidence).Overall, risk of bias in included studies was low or unclear for most domains. However, due to the nature of psychosocial intervention trials, blinding of participants and personnel, and outcome assessment tended to have a high risk of bias. Heterogeneity across a number of the meta-analyses was substantial, some was explained by type of anxiety disorder or may be meta-analytic measurement artefact due to combining many assessment measures. Adverse events were rarely reported.

AUTHORS' CONCLUSIONS

Therapist-supported ICBT appears to be an efficacious treatment for anxiety in adults. The evidence comparing therapist-supported ICBT to waiting list, attention, information, or online discussion group only control was low to moderate quality, the evidence comparing therapist-supported ICBT to unguided ICBT was low to very low quality, and comparisons of therapist-supported ICBT to face-to-face CBT was low to moderate quality. Further research is needed to better define and measure any potential harms resulting from treatment. These findings suggest that therapist-supported ICBT is more efficacious than a waiting list, attention, information, or online discussion group only control, and that there may not be a significant difference in outcome between unguided CBT and therapist-supported ICBT; however, this latter finding must be interpreted with caution due to imprecision. The evidence suggests that therapist-supported ICBT may not be significantly different from face-to-face CBT in reducing anxiety. Future research should involve equivalence trials comparing ICBT and face-to-face CBT, examine the importance of the role of the therapist in ICBT, and include effectiveness trials of ICBT in real-world settings. A timely update to this review is needed given the fast pace of this area of research.