Effectiveness of a transdiagnostic internet-based protocol for the treatment of emotional disorders versus treatment as usual in specialized care: study protocol for a randomized controlled trial

Efficacy of a transdiagnostic internet-based program for adolescents with emotional disorders: A randomized controlled trial

OBJECTIVE

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) is a well-established transdiagnostic cognitive-behavioral therapy (T-CBT) intervention. The aim of the present study was to examine the efficacy of the program Learn to Manage your Emotions [Aprende a Manejar tus Emociones] (AMtE), a self-applied transdiagnostic internet-delivered program based on the Spanish version of the UP-A. This is the first transdiagnostic internet-based program designed for the treatment of emotional disorders in adolescents.

METHOD

A sample of Spanish adolescents with a primary diagnosis of an anxiety and/or depressive disorder (n = 58; age range = 12-18 years; 78.3% girls; 90% Caucasian) were randomly allocated to receive AMtE (n = 28) or the UP-A via videocall (n = 30). Pre-treatment, post-treatment and 3-month follow-up data were collected using self-reports and clinician-rated measures of anxiety, depression, positive and negative affect, anxiety sensitivity and emotional avoidance.

RESULTS

Based on generalized estimating equations (GEE) models, both intervention programs were effective in significantly reducing self-reported anxiety and depressive disorder symptoms and clinician-rated severity of anxiety and depression, as well as self-reported transdiagnostic outcome variables.

CONCLUSIONS

Data provide empirical support for the efficacy of AMtE as a transdiagnostic online CBT treatment for anxiety and depressive disorders in adolescents. No marked nor consistent differences were observed between the UP-A and AMtE, highlighting the potential usefulness of the online self-administered AMtE program.

The Overall Anxiety Severity and Impairment Scale as an Outcome Measure in Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders: Observational Study

BACKGROUND

Internet-delivered cognitive behavioral therapy (iCBT) is effective in the treatment of anxiety disorders. iCBT clinical trials use relatively long and time-consuming disorder-specific rather than transdiagnostic anxiety measurements. Overall Anxiety Severity and Impairment Scale (OASIS) is a brief self-report scale that could offer a universal, easy-to-use anxiety measurement option in disorder-specific and transdiagnostic iCBT programs.

OBJECTIVE

We aimed to investigate relationships between OASIS and disorder-specific instruments in iCBT. We expected these relationships to be positive.

METHODS

We investigated patients in original nationwide iCBT programs for generalized anxiety disorder (GAD), obsessive-compulsive disorder, panic disorder, and social anxiety disorder, which were administered by Helsinki University Hospital, Finland. In each program, anxiety symptoms were measured using both disorder-specific scales (the 7-item Generalized Anxiety Disorder scale, Penn State Worry Questionnaire, revised Obsessive-Compulsive Inventory, Panic Disorder Severity Scale, and Social Phobia Inventory) and by OASIS. A general linear model for repeated measures (mixed models) and interaction analysis were used for investigating the changes and relationships in the mean scores of OASIS and disorder-specific scales from the first session to the last one.

RESULTS

The main effect of linear mixed models indicated a distinct positive association between OASIS and disorder-specific scale scores. Interaction analysis demonstrated relatively stable associations between OASIS and the revised Obsessive-Compulsive Inventory (F822.9=0.09; 95% CI 0.090-0.277; P=.32), and OASIS and the Panic Disorder Severity Scale (F596.6=-0.02; 95% CI -0.108 to -0.065; P=.63) from first the session to the last one, while the 7-item Generalized Anxiety Disorder scale (F4345.8=-0.06; 95% CI -0.109 to -0.017; P=.007), Penn State Worry Questionnaire (F4270.8=-0.52; 95% CI -0.620 to -0.437; P<.001), and Social Phobia Inventory (F862.1=-0.39; 95% CI -0.596 to -0.187; P<.001) interrelated with OASIS more strongly at the last session than at the first one.

CONCLUSIONS

OASIS demonstrates clear and relatively stable associations with disorder-specific symptom measures. Thus, OASIS might serve as an outcome measurement instrument for disorder-specific and plausibly transdiagnostic iCBT programs for anxiety disorders in regular clinical practice.

Long-term Effectiveness and Predictors of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Emotional Disorders in Specialized Care: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Transdiagnostic internet-delivered cognitive behavioral therapy (iCBT) for emotional disorders has been shown to be effective in specialized care in the short term. However, less is known about its long-term effects in this specific setting. In addition, predictors of long-term effectiveness may help to identify what treatments are more suitable for certain individuals.

OBJECTIVE

This study aimed to analyze the long-term effectiveness of transdiagnostic iCBT compared with that of treatment as usual (TAU) in specialized care and explore predictors of long-term effectiveness.

METHODS

Mixed models were performed to analyze the long-term effectiveness and predictors of transdiagnostic iCBT (n=99) versus TAU (n=101) in public specialized mental health care. Outcomes included symptoms of depression and anxiety, health-related quality of life (QoL), behavioral inhibition and behavioral activation, comorbidity, and diagnostic status (ie, loss of principal diagnosis) from baseline to 1-year follow-up. Sociodemographic characteristics (sex, age, and education) and clinical variables (principal diagnosis, comorbidity, and symptom severity at baseline) were selected as predictors of long-term changes.

RESULTS

Compared with baseline, transdiagnostic iCBT was more effective than TAU in improving symptoms of depression (b=-4.16, SE 1.80, 95% CI -7.68 to -0.67), health-related QoL (b=7.63, SE 3.41, 95% CI 1.00-14.28), diagnostic status (b=-0.24, SE 0.09, 95% CI -1.00 to -0.15), and comorbidity at 1-year follow-up (b=-0.58, SE 0.22, 95% CI -1.00 to -0.15). From pretreatment assessment to follow-up, anxiety symptoms improved in both transdiagnostic iCBT and TAU groups, but no significant differences were found between the groups. Regarding the predictors of the long-term effectiveness of transdiagnostic iCBT compared with that of TAU, higher health-related QoL at follow-up was predicted by a baseline diagnosis of anxiety, male sex, and the use of psychiatric medication; fewer comorbid disorders at follow-up were predicted by older age and higher baseline scores on health-related QoL; and fewer depressive symptoms at follow-up were predicted by baseline diagnosis of depression. However, this pattern was not observed for baseline anxiety diagnoses and anxiety symptoms.

CONCLUSIONS

The results suggest that transdiagnostic iCBT is more effective than TAU to target depressive symptoms among patients with emotional disorders. Anxiety symptoms remained stable at 1-year follow-up, with no differences between the groups. Results on predictors suggest that some groups of patients may obtain specific gains after transdiagnostic iCBT. Specifically, and consistent with the literature, patients with baseline depression improved their depression scores at follow-up. However, this pattern was not found for baseline anxiety disorders. More studies on the predictor role of sociodemographic and clinical variables in long-term outcomes of transdiagnostic iCBT are warranted. Future studies should focus on studying the implementation of transdiagnostic iCBT in Spanish public specialized mental health care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02345668; https://clinicaltrials.gov/ct2/show/NCT02345668.

Efficacy of a transdiagnostic guided internet-delivered intervention for emotional, trauma and stress-related disorders in Mexican population: study protocol for a randomized controlled trial

BACKGROUND

Emotional and stress-related disorders show high incidence, prevalence, morbidity, and comorbidity rates in Mexico. In recent decades, research findings indicate that cognitive behavioral interventions, from a disorder-specific perspective, are the effective front-line treatment for anxiety and depression care. However, these treatments are not often used. Reasons include limited access and low availability to effective interventions and comorbidity between mental disorders. Emotional deregulation of negative affectivity has been found to be a mediating factor in addressing emotional disorders from a transdiagnostic perspective, aimed at two or more specific disorders. In addition, technological advancement has created alternatives for psychological assistance, highlighting the possibilities offered by technologies since Internet-supported intervention programs have been empirically tested for effectiveness, efficiency and efficacy and can be key to ensuring access to those who are inaccessible. The aim of the study is to evaluate the efficacy, moderators of clinical change and acceptability of a transdiagnostic guided Internet-delivered intervention versus a transdiagnostic self-guided Internet-delivered intervention for emotional, trauma and stress-related disorders, and waiting list in community sample.

METHODS

A three-armed, parallel group, superiority randomized controlled clinical trial with repeated measurements at four times: pretest, posttest, follow-up at 3, 6 and 12 months. Outcomes assessor, participant, care provider and investigator will be blinded. Participants aged 18 to 70 years will be randomly allocated 1:1:1 to one of three study arms: a) Transdiagnostic guided internet-delivered intervention with synchronous assistance, b) Transdiagnostic self-guided internet-delivered intervention, c) Waiting list group. Based on sample size estimation, a minimum of 207 participants (69 in each intervention group) will be included.

DISCUSSION

The study could contribute to improving the efficacy of transdiagnostic internet-delivered interventions to promote the dissemination of evidence-based treatments and eventually, to decrease the high prevalence of emotional and trauma-related disorders in the Mexican population.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT05225701 . Registered February 4, 2022.

Dropout From an Internet-Delivered Cognitive Behavioral Therapy Intervention for Adults With Depression and Anxiety: Qualitative Study

BACKGROUND

Treatment dropout continues to be reported from internet-delivered cognitive behavioral therapy (iCBT) interventions, and lower completion rates are generally associated with lower treatment effect sizes. However, evidence is emerging to suggest that completion of a predefined number of modules is not always necessary for clinical benefit or consideration of the needs of each individual patient.

OBJECTIVE

The aim of this study is to perform a qualitative analysis of patients' experiences with an iCBT intervention in a routine care setting to achieve a deeper insight into the phenomenon of dropout.

METHODS

A total of 15 purposively sampled participants (female: 8/15, 53%) from a larger parent randomized controlled trial were interviewed via telephone using a semistructured interview schedule that was developed based on the existing literature and research on dropout in iCBT. Data were analyzed using a descriptive-interpretive approach.

RESULTS

The experience of treatment leading to dropout can be understood in terms of 10 domains: relationship to technology, motivation to start, background knowledge and attitudes toward iCBT, perceived change in motivation, usage of the program, changes due to the intervention, engagement with content, experience interacting with the supporter, experience of web-based communication, and termination of the supported period.

CONCLUSIONS

Patients who drop out of treatment can be distinguished in terms of their change in motivation: those who felt ready to leave treatment early and those who had negative reasons for dropping out. These 2 groups of participants have different treatment experiences, revealing the potential attributes and nonattributes of dropout. The reported between-group differences should be examined further to consider those attributes that are strongly descriptive of the experience and regarded less important than those that have become loosely affiliated.

Predicting response to transdiagnostic iCBT for emotional disorders from patient and therapist involvement

BACKGROUND

Transdiagnostic iCBT has been shown to be effective for the treatment of emotional disorders. Less is known about the optimal level of therapist and patient involvement in these interventions. Specific characteristics of Internet-delivered interventions include treatment adherence (e.g., amount of review of the materials) and guidance (e.g., amount of therapist support). Exploring the importance of these elements in treatment outcome may help to maximize the efficiency of Internet-delivered psychological interventions.

AIM

In this study, we aimed to analyze the relationship between patient and therapist involvement (i.e., platform usage and amount of therapist guidance) in a sample of patients with emotional disorders who received transdiagnostic iCBT in Spanish public specialized mental healthcare services.

METHOD

This is a secondary analysis of a randomized controlled trial. The sample included 63 patients who completed transdiagnostic iCBT for emotional disorders. Platform usage metrics included number of logins into the platform and number of times the participants reviewed the modules. Therapist guidance was measured as the number of support phone calls with a therapist and their total duration (minutes). Logistic regressions and ROC analyses were performed to explore the predictive value of platform usage and therapist guidance in symptom reduction. Clinical outcomes included depressive and anxiety symptoms assessed at baseline and post-intervention. The bivariate relationship between the platform usage and therapist guidance variables was also explored.

RESULTS

Overall, platform usage and therapist guidance were not associated with symptom improvement. However, the patient and therapist involvement parameters were intercorrelated. Specifically, the number of calls and their duration were associated with a greater number of logins (r = 0.61; p < .001) and more frequent reviews of the modules (0.46 ≤ r ≤ 0.60; p < .001). Higher baseline depression and anxiety were, respectively, associated with greater improvements in depression (r = -0.37, p = .003) and anxiety after treatment completion (r = -0.48, p < .001).

DISCUSSION

The results suggest that there is no reliable cut-off point for platform usage and therapist guidance in predicting optimal symptom reduction. However, significant associations were found between platform usage and guidance variables that warrant additional research. More research on this topic is necessary to further clarify the role of these and other platform usage and guidance variables in Internet-delivered iCBT outcomes.

The primary care assessment and research of a telephone intervention for neuropsychiatric conditions with education and resources study: Design, rationale, and sample of the PARTNERs randomized controlled trial

While most patients with depression, anxiety, or at-risk drinking receive care exclusively in primary care settings, primary care providers experience challenges in diagnosing and treating these common problems. Over the past two decades, the collaborative care model has addressed these challenges. However, this model has been adopted very slowly due to the high costs of care managers; inability to sustain their role in small practices; and the perceived lack of relevance of interventions focused on a specific psychiatric diagnosis. Thus, we designed an innovative randomized clinical trial (RCT), the Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study (PARTNERs). This RCT compared the outcomes of enhanced usual care and a novel model of collaborative care in primary care patients with depressive disorders, generalized anxiety, social phobia, panic disorder, at-risk drinking, or alcohol use disorders. These conditions were selected because they are present in almost a third of patients seen in primary care settings. Innovations included assigning the care manager role to trained lay providers supported by computer-based tools; providing all care management centrally by phone - i.e., the intervention was delivered without any face-to-face contact between the patient and the care team; and basing patient eligibility and treatment selection on a transdiagnostic approach using the same eligibility criteria and the same treatment algorithms regardless of the participants' specific psychiatric diagnosis. This paper describes the design of this RCT and discusses the rationale for its main design features.

Emotion Network Analysis During COVID-19 Quarantine - A Longitudinal Study

Introduction: The coronavirus disease 2019 (COVID-19) emergency has imposed important challenges in the lives of individuals, particularly since the restriction of free movement. In Spain, this mandatory home confinement started on March 14, 2020. In this scenario, some calls have been made to better understand the exact impact of the quarantine on the emotional status of individuals across time. Materials and Methods: On the first day that the Spanish government imposed the quarantine, our team launched an online longitudinal study to monitor emotional responses to the COVID-19 emergency over time. For 2 weeks, 187 people have responded to a daily diary on emotion functioning. An emotion network analysis was performed to study the network structure of 30 mood states and its changes during the first 2 weeks of the quarantine. Results: The emotional network showed critical changes in the interactions of emotions over time. An analysis of mean emotional levels did not show statistically significant changes in mood over time. Interestingly, two different network patterns were found when the sample was divided between those with favorable responses and those with unfavorable responses. Discussion: This new approach to the study of longitudinal changes of the mood state network of the population reveals different adaptation strategies reflected on the sample's emotional network. This network approach can help identify most fragile individuals (more vulnerable to external stressors) before they develop clear and identifiable psychopathology and also help identify anti-fragile individuals (those who improve their functioning in the face of external stressors). This is one of the first studies to apply an emotional network approach to study the psychological effects of pandemics and might offer some clues to psychologists and health administrators to help people cope with and adjust to this critical situation.

Clinical Utility of an Internet-Delivered Version of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (iUP-A): A Pilot Open Trial

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) has been shown to be effective for reducing symptoms of anxiety and depression in adolescents with emotional disorders. Internet-delivered psychological treatments have great potential to improve access to evidence-based psychological therapy since they are associated with reduced human and economic costs and less social stigma. Recently, our group developed an online version of the UP-A (the iUP-A) for the treatment of emotional disorders in adolescents. The aim of this pilot trial was to test the clinical utility of the iUP-A in a small sample (n = 12) of adolescents with elevated anxiety and/or depressive symptoms. Intention-to-treat and completer analyses revealed pre- to post-intervention self-reported decreases of anxiety and depressive symptoms, anxiety sensitivity, emotional avoidance, panic disorder symptoms, panic disorder severity, generalized anxiety disorder symptoms, pathological worry, and major depressive disorder symptoms. We found high feasibility and acceptability of the program with all participants and responsible parents reporting an improvement in the adolescents’ ability to cope with emotions. Results suggest that the iUP-A may provide a new approach to improve access to treatment for anxious and depressive adolescents in Spain; however, further research must be conducted before firm conclusions can be drawn.

Effectiveness of a Transdiagnostic Guided Internet-Delivered Protocol for Emotional Disorders Versus Treatment as Usual in Specialized Care: Randomized Controlled Trial

Background

Anxiety disorders and depression (emotional disorders) are highly prevalent mental disorders. Extensive empirical evidence supports the efficacy of cognitive behavioral therapy (CBT) for the treatment of these disorders. However, there are still some barriers related to their dissemination and implementation, which make it difficult for patients to receive these treatments, especially in public health care settings where resources are limited. Recent advances in improving CBT dissemination encompass different perspectives. One is the transdiagnostic approach, which offers treatment protocols that can be used for a range of emotional disorders. Another approach is the use of the internet to reach a larger number of people who could benefit from CBT.

Objective

This study aimed to analyze the effectiveness and acceptability of a transdiagnostic internet-delivered protocol (EmotionRegulation) with human and automated guidance in patients from public specialized mental health care settings.

Methods

A 2-armed randomized controlled trial (RCT) was conducted to compare the effectiveness of EmotionRegulation with treatment as usual (TAU) in specialized mental health care. In all, 214 participants were randomly assigned to receive either EmotionRegulation (n=106) or TAU (n=108). Measurement assessments were conducted at pre- and postintervention and at a 3-month follow-up.

Results

The results revealed the superiority of EmotionRegulation over TAU on measures of depression (d=0.41), anxiety (d=0.35), and health-related quality of life (d=−0.45) at posttreatment, and these gains were maintained at the 3-month follow-up. Furthermore, the results for expectations and opinions showed that EmotionRegulation was well accepted by participants.

Conclusions

EmotionRegulation was more effective than TAU for the treatment of emotional disorders in the Spanish public mental health system. The implications of this RCT, limitations, and suggestions for future research are discussed.

Trial Registration

ClinicalTrials.gov NCT02345668; https://clinicaltrials.gov/ct2/show/NCT02345668

Unified protocol for anxiety disorders in two cities of Mexico measuring gamma activity: Study protocol for a randomized controlled trial

BACKGROUND

The Unified Protocol for Emotional Disorders (UP) for emotional regulation manifests effective results in a broad range of mental disorders. The UP efficacy was tested in several countries, but it has not been tested within Mexican population. It is crucial to do more research and implement effective protocols to intervene Mexican population with Anxiety Disorders (AD).

OBJECTIVE

This study aims to examine and describe the research procedures and treatment interventions of the UP in a Randomized Controlled Trial (RCT), to approach and treat AD in patients in 2 Mexican borderland cities, by applying the UP and an Electroencephalogram (EGG) neuro screening.

METHODS

The enrolled patients will be randomized in a two-arm control trial with repeated measures, comprising between 18 and 60 years, that were diagnosed with an AD, and low scored in depression symptoms and suicidal ideation. The study will comprise of two conditions: an intervention group clinical trial with the UP or a waiting list control. The primary outcome measures will be applied on AD quantitative self-reports and a gamma activity by EGG before and after the intervention and in follow-ups of 3 and 6 months. The participants in the waiting list group, will receive the treatment after the trial first group completes the treatment.

CONCLUSIONS

Processes and outcomes of this project, will provide evidence in order to apply the UP in a broader population with AD and other mental disorders also covered by this protocol, such as depression and borderline personality disorder in a broader Mexican population, a country that suffers with a major health issue with an increasing rate of mental disorders and scarce psychological and health coverage.

New Technologies for the Understanding, Assessment, and Intervention of Emotion Regulation

In the last decades, emotion regulation (ER) received increasing attention and became one of the most studied topics within the psychological field. Nevertheless, this construct has not been fully updated with the latest technological advancements. In this perspective, we will show how diverse technologies, such as virtual reality (VR), wearable biosensors, smartphones, or biofeedback techniques, can be applied to the understanding, assessment, and intervention of ER. After providing a brief overview of the currently available technological developments, we will discuss the benefits of incorporating new technologies in ER field, including ecological validity, intervention personalization, and the integration of understudied facets of ER, such as the implicit and interpersonal dimension.

Internet-Delivered Psychological Treatment Options for Panic Disorder: A Review on Their Efficacy and Acceptability

BACKGROUND

Internet-delivered psychological treatments have been suggested as a chance to expand the access to professional help. However, little is known about the usefulness of different support formats and approaches of digital treatments for panic disorder among clinicians.

OBJECTIVE

This narrative review aimed to explore the recent evidence base on the efficacy and acceptability of different internet-delivered treatments for adults with panic disorder.

METHODS

A systematic search in electronic databases (Pubmed/Medline, PSYNDEX) and a hand search were performed to identify articles on randomized controlled trials published within the past five years (2012/12/10-2017/12/12) in English peer-reviewed journals.

RESULTS

Eight studies (1,013 participants) involving 10 interventions met the inclusion criteria. Nine interventions were primarly based on Cognitive Behavioral Therapy principles. Most interventions were effective, when compared to a control condition (6 of 8 comparisons). Minimal guidance was associated with improved outcomes in one study and adherence in two studies (3 comparisons). Furthermore, no differences were found based on treatment approach (2 comparisons). Regarding acceptability, the attrition rates were moderate to high, ranging from 9.8% to 42.1% of randomized participants. Adherence rates also varied largely (7.8-75%), whereas participant satisfaction of program completers was assessed overall high (5 studies).

CONCLUSION

Diverse effective internet-delivered treatments are available for the self-management of panic symptoms. Especially selfguided and transdiagnostic Cognitive Behavioral Therapy approaches appear being efficient options for the dissemination in routine care. However, due to the limited evidence base, further efforts are required to improve the actual uptake of internet-delivered treatments and identify moderators of outcomes.

A brief online transdiagnostic measure: Psychometric properties of the Overall Anxiety Severity and Impairment Scale (OASIS) among Spanish patients with emotional disorders

The Overall Anxiety Severity and Impairment Scale (OASIS) is a self-report questionnaire designed to evaluate the severity and functional impairment associated with anxiety. Given its transdiagnostic nature, it can be used indistinctly across anxiety and depressive disorders. In this study, the psychometric properties of the online version of the OASIS were evaluated in a Spanish clinical sample with emotional disorders. Patients (n = 583) with anxiety (n = 250) and depression (n = 333) with a mean age of 37.21 (SD = 12.22), underwent a diagnostic interview and questionnaires assessing anxiety, depression, positive and negative affect, and quality of life. Factorial structure, internal consistency, convergent and discriminant validity, cutoff scores, and sensitivity to change were analyzed. Confirmatory Factor Analysis yielded a unidimensional factor structure, consistent with previous validations of the instrument. The analyses showed good internal consistency and adequate convergent and discriminant validity, as well as sensitivity to change. A cutoff score of 7.5 was found to meet the criteria used in this study to select the optimal cutoff point. Overall, in this study, the psychometric properties of the online version of the OASIS were found to be appropriate. The brevity and ease of use of the OASIS support its adequacy as a valid measure of anxiety severity and impairment in Spanish clinical samples with anxiety and depression.

Dropping out of a transdiagnostic online intervention: A qualitative analysis of client's experiences

INTRODUCTION

An important concern in Internet-based treatments (IBTs) for emotional disorders is the high dropout rate from these protocols. Although dropout rates are usually reported in research studies, very few studies qualitatively explore the experiences of patients who drop out of IBTs. Examining the experiences of these clients may help to find ways to tackle this problem.

METHOD

A Consensual Qualitative Research study was applied in 10 intentionally-selected patients who dropped out of a transdiagnostic IBT.

RESULTS

22 categories were identified within 6 domains. Among the clients an undeniable pattern arose regarding the insufficient support due to the absence of a therapist and the lack of specificity of the contents to their own problems.

CONCLUSIONS

The analyzed content has direct impact on the clinical application of IBTs. A more tailored manage of expectations as well as strategies to enhance the therapeutic relationship in certain clients are identified as the two key elements in order to improve the dropout in IBTs. Going further, in the mid and long run, ideographic interventions would be vital. The present study permits to better grasp the phenomenon of dropout in IBTs and delineate specific implications both in terms of research, training and practice.