Optimizing internet-delivered cognitive behaviour therapy for alcohol misuse—a randomized factorial trial examining effects of a pre-treatment assessment interview and guidance

Evaluation of additional resources and stories within therapist-assisted internet-delivered cognitive behaviour therapy for alcohol misuse

Background

Additional resources and stories are sometimes incorporated into Internet-delivered cognitive behaviour therapy (ICBT) for alcohol misuse to enhance treatment. Little is known, however, about how patients use and evaluate additional resources and stories, and how use and evaluation of additional resources and stories relates to satisfaction and outcomes.

Methods

We examined patient use and evaluation of 8 additional resources and 8 stories among 121 patients who endorsed significant alcohol misuse and were enrolled in a 6-lesson ICBT course for alcohol misuse enhanced with additional resources and stories. The additional resources addressed anger, assertiveness and communication, cannabis use, cognitive coping, grief, PTSD, sleep, and worry. Stories varied by gender, ethnicity, occupation, and severity of alcohol problems. Primary drinking outcomes included the Timeline Follow-Back (TLFB) and heavy drinking days (HDD). Diverse secondary outcomes (e.g., depression, anxiety, cravings, anger, satisfaction) were also assessed.

Results

Large within-group effects for TLFB and HDD were found. Large effects were also observed for depression and cravings, with high treatment satisfaction. 63 % of patients accessed at least one resource (M = 2.27 resources), with anger (35 %), cognitive coping (35 %), sleep (34 %) and worry (30 %) being the most used. When accessed, patients found resources informative and/or helpful to varying degrees (25-67 %). In terms of stories, 85 % of patients indicated they read the stories, and 89 % of those found them worthwhile; 65 % felt less alone and 55 % found they gave them skills to improve wellbeing. Increased use and positive ratings of additional resources were not significantly related to outcomes or satisfaction. However, positive ratings of stories were associated with confidence in managing symptoms and an interest in future treatment. Additionally, reading stories was associated with larger improvements on several secondary outcomes, including PTSD, anger, insomnia, and work and social adjustment.

Conclusions

The findings suggest that adding resources and stories to ICBT is acceptable and worthwhile. A significant number of patients reviewed these materials and found them informative and/or helpful, which suggests it is likely valuable to retain these resources for those in need. Reading stories and positive ratings of stories, rather than use and positive ratings of additional resources, was associated with increased satisfaction and some larger improvements on secondary outcomes. Further research is warranted to identify strategies that will more effectively engage patients with additional resources tailored to their specific needs.

Active Components in Internet-Based Cognitive-Behavioral Therapy for Social Anxiety Disorder: A Randomized Full Factorial Trial

INTRODUCTION

Many studies have demonstrated that social anxiety disorder (SAD) can be effectively treated with psychotherapy, particularly cognitive-behavioral therapy (CBT), including internet-based CBT (ICBT). Despite evidence-based treatments, many individuals do not sufficiently benefit from them. Identifying the active components could help improve the effectiveness of SAD treatment. This study tested the effects of four treatment components (psychoeducation, cognitive restructuring, attention training, and exposure) within ICBT for SAD to investigate its active components.

METHODS

This randomized full factorial trial consisted of four factors (i.e., treatment components) and 16 conditions. A total of 464 adults with a diagnosed SAD were recruited from the community. The primary outcome was SAD symptoms at 8 weeks (post-assessment). Secondary outcomes included SAD diagnosis, SAD symptoms at follow-up (4 months after post), depression and anxiety symptoms, quality of life, client satisfaction, and adverse effects.

RESULTS

Conditions including psychoeducation and exposure were significantly more effective in reducing SAD symptoms at post compared to conditions without these components. Conditions including cognitive restructuring and attention training did not show superiority over conditions without them at post. However, all treatment conditions significantly reduced symptoms compared to the condition without a treatment component. At follow-up, the superiority of psychoeducation and exposure was not significant anymore due to the version without the respective components catching up.

CONCLUSION

The findings suggest that while all treatment components of ICBT for SAD are beneficial compared to no treatment, psychoeducation and exposure include specific active components that significantly improve treatment outcomes more quickly in ICBT for SAD.

INTRODUCTION

Many studies have demonstrated that social anxiety disorder (SAD) can be effectively treated with psychotherapy, particularly cognitive-behavioral therapy (CBT), including internet-based CBT (ICBT). Despite evidence-based treatments, many individuals do not sufficiently benefit from them. Identifying the active components could help improve the effectiveness of SAD treatment. This study tested the effects of four treatment components (psychoeducation, cognitive restructuring, attention training, and exposure) within ICBT for SAD to investigate its active components.

METHODS

This randomized full factorial trial consisted of four factors (i.e., treatment components) and 16 conditions. A total of 464 adults with a diagnosed SAD were recruited from the community. The primary outcome was SAD symptoms at 8 weeks (post-assessment). Secondary outcomes included SAD diagnosis, SAD symptoms at follow-up (4 months after post), depression and anxiety symptoms, quality of life, client satisfaction, and adverse effects.

RESULTS

Conditions including psychoeducation and exposure were significantly more effective in reducing SAD symptoms at post compared to conditions without these components. Conditions including cognitive restructuring and attention training did not show superiority over conditions without them at post. However, all treatment conditions significantly reduced symptoms compared to the condition without a treatment component. At follow-up, the superiority of psychoeducation and exposure was not significant anymore due to the version without the respective components catching up.

CONCLUSION

The findings suggest that while all treatment components of ICBT for SAD are beneficial compared to no treatment, psychoeducation and exposure include specific active components that significantly improve treatment outcomes more quickly in ICBT for SAD.

Research participation effects and where to find them: a systematic review of studies on alcohol

OBJECTIVES

The term 'research participation effects' (RPEs) is intended to capture features and artifacts of study design that may affect measured outcomes in ways that introduce bias into research findings, impacting inference and outcome validity. This systematic review aims to identify which RPEs have been studied in the context of alcohol research and provide an overview of estimates of RPEs on self-reported alcohol consumption.

STUDY DESIGN AND SETTING

This systematic review summarizes the available evidence on RPEs in alcohol research.

RESULTS

Twenty-seven reports were included in the review. The reports included randomized controlled trials (RCTs), studies-within-a-trial, between-subjects experiments, and qualitative investigations. A range of RPEs were addressed as follows: assessment reactivity (N = 15), being randomized to a waiting list control group (N = 3), the impact of obtaining informed consent (N = 2), experimentally induced social desirability (N = 3), and the Hawthorne effect, either specifically by name (N = 2, one quantitative, one qualitative) or described as general RPE presence (N = 2). The literature provided proportionally stronger evidence in favor of assessment reactivity and waiting list designs affecting alcohol outcomes, contrary to obtaining informed consent or inducing social desirability.

CONCLUSION

Variation in study quality, terminology, and outcome measures hinder comprehensive understanding and discussion of RPEs at present. Improved knowledge of RPEs and their potential long-term consequences in alcohol research, including a unified lexicon, would enhance trial design and improve the certainty of evidence in alcohol research.

Patient Perspectives on Blended Internet-Based and Face-to-Face Cognitive Behavioral Therapy for Alcohol Use Disorder: Qualitative Study

BACKGROUND

Harmful alcohol consumption has been identified as a major contributor to disease, mortality, and social harm, accounting for 5.3% of worldwide deaths annually. In Denmark, an estimated 150,000 people suffer from alcohol use disorder (AUD), but a low proportion seek treatment due to person- and treatment-related barriers. Internet-based cognitive behavioral therapy (iCBT) has shown positive effects on the treatment gap, with patients reporting benefits such as increased knowledge and flexibility. However, there is a lack of research on blended cognitive behavioral therapy (bCBT), which combines face-to-face CBT (FtF CBT) and iCBT for AUD.

OBJECTIVE

This study aims to investigate user experiences of bCBT. More specifically, it seeks to explore the advantages and disadvantages that users have experienced with bCBT for AUD, as well as their motivations for choosing this treatment format.

METHODS

A total of 30 patients who had participated in the Blend-A (Blending Internet Treatment into Conventional Face-to-Face Treatment for AUD) study and received the intervention were contacted and offered the opportunity to participate in semistructured individual telephone interviews. Of these, 12 patients consented to participate. Furthermore, an additional participant was approached at a municipal clinic and agreed to engage in an individual FtF interview. Thus, the final sample consisted of 13 patients. The interviews explored their background, experiences with digital technology, motivations for choosing internet-based treatment, and experiences with the program during AUD treatment. The interviews were audio-recorded and transcribed in full length and analyzed using thematic analysis. All data were anonymized and securely stored.

RESULTS

We found that users experienced several advantages of iCBT over a larger part of the treatment course, including increased anonymity and privacy. Most importantly, it offered flexibility, allowing patients to focus on their rehabilitation process at their own pace. Patients appreciated the availability of written text in the online program, finding it helpful for gaining knowledge and understanding of AUD and its impact on the individual with the condition. They emphasized how the assignments helped them fully engage in treatment by first acknowledging their problem with alcohol and then dedicating time to self-reflection before FtF sessions, allowing for more in-depth discussions with the therapist. They also appreciated the reminders, which motivated them to complete their assignments.

CONCLUSIONS

Overall, patients perceived more benefits than disadvantages in using bCBT. Essentially, bCBT offers a form of assisted autonomy that cannot be fully achieved through iCBT or FtF CBT alone. It is only through their combination that patients can fully appreciate the benefits of the treatment, as they have time for self-reflection, with guidance from the therapist between FtF CBT sessions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04535258; https://clinicaltrials.gov/ct2/show/NCT04535258.

Internet-delivered therapy for alcohol misuse: engagement, satisfaction, and outcomes when patients select their preference for therapist- or self-guided treatment

BACKGROUND

Alcohol misuse is common and causes substantial harm. Internet-delivered cognitive behaviour therapy (ICBT) is effective in reducing alcohol misuse; however, the literature investigating how treatment outcomes are impacted by patients' preferences for therapist- versus self-guided ICBT for alcohol misuse is sparse.

METHODS

In this preference trial, 74 eligible patients (who reported ≥ 14 drinks in the previous week and obtained scores suggesting hazardous or harmful drinking) chose between enrolling in either therapist- or self-guided ICBT for alcohol misuse. We investigated whether those who chose therapist- versus self-guided ICBT differed in their (a) drinking outcomes-as measured by Timeline Follow-Back (TLFB) and heavy drinking days (HDD) at post-treatment and 3-month follow-up-and (b) post-treatment ICBT engagement and satisfaction.

RESULTS

The majority (81.1%) of eligible patients chose therapist-guided ICBT. These patients reported higher psychotropic medication use, drinking difficulties, and anxiety symptoms. For both the therapist- and self-guided patients, a modified intention-to-treat analysis revealed large within-group treatment effects for TLFB (β =  - 2.64, SE 0.66; p < 0.001) and HDD (β =  - 0.34, SE 0.07; p < 0.001), with large pre-to-post-treatment Cohen's effect sizes of d = 0.97 (95% CI [0.49, 1.45]) for TLFB and d = 1.19 (95% CI [0.69, 1.68]) for HDD. The interaction comparing the effects of therapist- to self-guided ICBT over time was not significant for TLFB (p = 0.34) or HDD (p = 0.06). With treatment, for both therapist- and self-guided patients, there was a significant improvement in drinking difficulties, cravings, and confidence with controlling cravings, as well as in anxiety, depression, and functional impairment. Further, the majority (75.7%) of patients completed five or more lessons, as well as reported overall satisfaction with the treatment (88.9%) and increased confidence in managing their symptoms (86.7%); these outcomes also did not differ between therapist- and self-guided patients.

CONCLUSIONS

The current study shows that ICBT for alcohol misuse is associated with reduced drinking and comorbid mental health difficulties over time, irrespective of whether patients chose to complete the course on their own or with therapist guidance.

TRIAL REGISTRATION NUMBER

NCT04611854 ( https://clinicaltrials.gov/ct2/show/NCT04611854 ).

Investigating the added effects of guidance in digital psychological self-care for alcohol problems (ALVA)-protocol for a randomized factorial optimization trial

BACKGROUND

The continual development and implementation of effective digital interventions is one important strategy that may serve to bridge the well-known treatment gap related to problematic alcohol use. Research suggests that clinician guidance, provided in different ways during the digital intervention (i.e., written weekly messages, phone calls etc.), can boost intervention engagement and effects. Digital psychological self-care (DPSC) is a new delivery format wherein an unguided digital intervention is provided within the framework of a structured care process that includes initial clinical assessment and follow-up interviews. In a recent feasibility study, a DPSC intervention for problematic alcohol use, ALVA, provided without any extra guidance, was found safe and credible and to have promising within-group effects on alcohol consumption. The aim of the current study is to gather information on the effects and efficiency of different forms of guidance added to ALVA, in order to optimize the intervention.

METHODS

This protocol describes a randomized factorial trial where the effects of two different ways of providing guidance (mid-treatment interview, weekly written messages, respectively) in DPSC for problematic alcohol use are investigated. Optimization criteria will be applied to the results regarding how effective the intervention is at reducing alcohol consumption measured by the number of standard drinks per week together with the clinician time spent on guidance.

DISCUSSION

This study will investigate the added benefit of different forms of guidance to DPSC for problematic alcohol use. These added effects will be compared to the added cost of guidance, according to pre-defined optimization criteria.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT05649982. Registered on 06 December 2022. Prospectively registered.

Digital psychological self-care for problematic alcohol use: feasibility of a new clinical concept

BACKGROUND

Digital interventions based on cognitive-behavioural therapy and relapse prevention can increase treatment access for people with problematic alcohol use, but for these interventions to be cost-effective, clinician workload needs to remain low while ensuring patient adherence and effects. Digital psychological self-care is the provision of a self-guided digital intervention within a structured care process.

AIMS

To investigate the feasibility and preliminary effects of digital psychological self-care for reducing alcohol consumption.

METHOD

Thirty-six adults with problematic alcohol use received digital psychological self-care during 8 weeks, including telephone assessments as well as filling out self-rated questionnaires, before, directly after and 3 months after the intervention. Intervention adherence, usefulness, credibility and use of clinician time were assessed, along with preliminary effects on alcohol consumption. The study was prospectively registered as a clinical trial (NCT05037630).

RESULTS

Most participants used the intervention daily or several times a week. The digital intervention was regarded as credible and useful, and there were no reported adverse effects. Around 1 h of clinician time per participant was spent on telephone assessments. At the 3-month follow-up, preliminary within-group effects on alcohol consumption were moderate (standardised drinks per week, Hedge's g = 0.70, 95% CI = 0.19-1.21; heavy drinking days, Hedge's g = 0.60, 95% CI = 0.09-1.11), reflecting a decrease from 23 to 13 drinks per week on average.

CONCLUSIONS

Digital psychological self-care for reducing alcohol consumption appears both feasible and preliminarily effective and should be further optimised and studied in larger trials.

The Impacts of a Psychoeducational Alcohol Resource During Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety: Observational Study

BACKGROUND

Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown.

OBJECTIVE

This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety.

METHODS

All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients' use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients' alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into low-risk and hazardous drinking categories based on pretreatment Alcohol Use Disorders Identification Test (AUDIT) scores.

RESULTS

During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (P=.004) and separated, divorced, or widowed (P<.001). Reviewers also consumed more weekly drinks (P<.001), scored higher on the AUDIT (P<.001), and were more likely to exhibit hazardous drinking (P<.001). Regardless of their drinking level (ie, low risk vs hazardous), all clients showed a reduction in AUDIT-Consumption scores (P=.004), depression (P<.001), and anxiety (P<.001) over time; in contrast, there was no change in clients' drinks per week over time (P=.81). Reviewing alcohol resources did not predict changes in AUDIT-Consumption scores or drinks per week.

CONCLUSIONS

Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource.