Online cognitive behavior therapy for adolescents with excessive worry: a multiple baseline design feasibility study

Initial effectiveness of an ICBT-protocol for GAD in psychiatric care - A feasibility-pilot study

Generalized Anxiety Disorder (GAD) is a common and debilitating anxiety disorder with a chronic course and a low rate of spontaneous remission. Previous internet-delivered treatments for GAD in clinical routine care has been shown to be effective but tend to use a mix of many different treatment components, often based in several theoretical models. Another approach could be to instead develop more focused and theory driven treatments, potentially allowing the protocol to be shorter and less demanding for patients. In this pilot-feasibility-trial we implemented a treatment focusing on one target core construct (intolerance of uncertainty) at the internet psychiatry clinic in Stockholm. The treatment was administered to 22 individuals with GAD. We found a significant reduction in GAD symptoms of similar effect size to previous studies of CBT and ICBT for GAD in routine clinical care. Patients rated overall high levels of treatment satisfaction and treatment credibility. Only two patients dropped out from the treatment. Among the remaining patients a median of 7.5 out of 8 modules were completed. We conclude that the treatment protocol is preliminarily effective, acceptable to patients and clinicians, and feasible to implement in routine psychiatric care.

Are you Lonesome Tonight? Ecological Momentary Assessment of Evening Loneliness, Worry, and Actigraphic Sleep in Adolescents

OBJECTIVES

This study aims to evaluate the association between ecological assessment experience of loneliness and nocturnal sleep in a sample of healthy adolescents and to investigate the potential mediating role of pre-sleep worry in this relationship.

METHODS

Each evening, participants completed an electronic diary including items assessing loneliness and worry. The time of diary administration was set on an individual basis to capture the actual pre-bed experience. Sleep parameters were assessed using actigraphy.

RESULTS

Analyses were conducted on 72 participants (53.9% boys; Mage = 15.65; SD = 1.32) and 535 nights. Multilevel structural equation modeling indicated that within person loneliness fluctuations over the assessment period predicted shorter sleep duration through the mediation of high pre-sleep worry (B = -1.634, p = .027); More specifically, at the within level, loneliness was significantly and positively related to worry (B = .131, p = .001), which in turn was negatively related to sleep duration (B = -12.502, p = .028).One step increase in loneliness-associated pre-sleep worry predicted a decrease of 12 minutes in sleep duration. The mediation path was not influenced by anxiety and gender differences in the adjusted analysis. Results on other sleep parameters were not significant.

CONCLUSIONS

Findings suggest that adolescents' loneliness experienced at bedtime may influence sleep duration through worry. Sleep-promoting interventions in adolescents may benefit from targeting loneliness and pre-sleep cognitions.

Effectiveness of internet-delivered cognitive behavioural therapy for anxiety and obsessive-compulsive disorders within routine clinical care in rural Sweden

Few studies have evaluated the implementation of ICBT in regular child and adolescent mental health services (CAMHS). This study aimed to explore the acceptability, feasibility, and effectiveness of ICBT for children and adolescents with anxiety disorders and obsessive-compulsive disorder (OCD) within a rural CAMHS. The study also explored outcome predictors and long-term outcomes. Eighty-three participants were consecutively recruited from a non-specialized CAMHS in Region Jämtland Härjedalen in northern Sweden. Therapist-guided ICBT was offered during 12 weeks to children aged 8-17 with an anxiety disorder or OCD. Acceptability and feasibility measures included treatment adherence, treatment satisfaction, and adverse events. The primary outcome measure was the Clinical Global Impression-Severity. Secondary measures of effectiveness included clinician-, self-, and parent-ratings of symptom severity and functional impairment. Assessments were completed at baseline, post-treatment, and three-month follow-up (primary endpoint). A two-year follow up was conducted using medical records. Potential predictors included both patient characteristics and treatment variables. Results indicated that ICBT was both acceptable and feasible according to study measures. Statistically significant improvements were found from baseline to the three-month follow-up on clinician rated severity (B [SE] = -0.92 [0.09]; p < .001), as well as on all secondary measures. Forty-three percent of participants no longer fulfilled criteria for their principal disorder at the three-month follow-up. No serious adverse events were reported. Clinical improvement was highest among children with higher functioning at baseline (B [SE] = -0.05 [0.02]; p < .05). Forty-six percent of participants had been in contact with CAMHS during the two-year follow-up period, mainly for reasons other than their initial diagnosis. Findings suggest that ICBT could be an acceptable and feasible treatment option for young people with anxiety disorders and OCD in rural non-specialized CAMHS settings. Further studies are needed to confirm treatment effectiveness in this setting. Trial registration: NCT02926365.

Do single-case experimental designs lead to randomised controlled trials of cognitive behavioural therapy interventions for adolescent anxiety and related disorders recommended in the National Institute of Clinical Excellence guidelines? A systematic review

Background

Although Cognitive Behavioural Therapy (CBT) is effective for 60% of adolescents with anxiety disorders, only 36% are in remission post-intervention. This indicates that more effective treatments are needed which should be reflected in the NICE guidelines. We hypothesised that Single-case experimental designs (SCEDs) may provide a framework for accelerating the development of novel interventions. The primary purpose of this review was to investigate whether SCEDs are currently followed by randomised controlled trials (RCTs) of CBT intervention for adolescent anxiety disorders named in the NICE guidelines. The secondary objective was to investigate whether using SCEDs prior to RCTs could be a helpful approach.

Method

For the primary search of SCEDs five databases were used (PsycINFO, PubMed, PsycArticles, Web of Science and ProQuest). Nineteen articles met eligibility criteria including a total of 107 participants. For the secondary search of RCTs named in the NICE guidelines for adolescent anxiety disorders 53 articles met inclusion criteria and were included in the systematic review.

Results

The 19 SCED studies included in the review were conducted with participants with a diverse range of anxiety disorders and across a range of CBT formats. Two of the SCEDs were followed by RCTs, but neither of these were named in the NICE guidelines for anxiety disorders. All of the SCEDs identified were rated as low quality with none meeting the criteria for the highest or second highest quality rating. From the secondary searches, none of the RCTs named in the NICE guide were preceded by SCEDs.

Conclusions

It was concluded that currently SCEDs were not followed by RCTs of CBT interventions named in the NICE guidelines for adolescent anxiety disorders. However, it was suggested that SCEDs may provide an important framework for the development of more effective interventions for adolescents with anxiety.

Italia Ti Ascolto [Italy, I am listening]: an app-based group psychological intervention during the COVID-19 pandemic

The onset of the coronavirus disease 2019 (COVID-19) pandemic impacted individuals' psychological wellbeing resulting in heightened perceived stress, anxiety, and depression. However, a significant issue in accessing psychological care during a lockdown is the lack of access to in-person interventions. In this regard, research has shown the efficacy and utility of psychological app-based interventions. 'Italia Ti Ascolto' (ITA) has been developed as a population tailored internet-based intervention to offer an online professional solution for psychological support needs. The ITA app is available on iOS and Android systems. Users completed a baseline assessment on emotion regulation strategies (cognitive reappraisal and expressive suppression), psychological stress, anxiety, depression, and perceived social support. Participants could select among several one-hour long clinical groups held by expert psychotherapists. After every session, people were asked to complete a quick users' satisfaction survey. Our contribution presents ITA's intervention protocol and discusses preliminary data on psychological variables collected at baseline. Data showed significant associations between emotion regulation strategies, symptoms of depression and anxiety, and level of stress. Moreover, the role of perceived social support is considered. Future developments and implications for clinical practice and treatment are discussed.

Experiences of online exposure-based treatment with parental support for teenagers with excessive worry

Worry is a common symptom that can become excessive and is related to several negative health outcomes. Our research group recently developed an online treatment for teenagers with excessive worry with a parallel programme for their parents. The treatment is characterized by a specific focus on exposure to uncertainty and other avoided stimuli, and includes a substantial amount of parental involvement. The aim of this study was to explore how teenagers and their parents experienced the treatment, especially how they perceived working independently with exposure tasks, parental involvement in the treatment programme, and a fixed treatment format. An experienced, independent clinical psychologist interviewed eight teenagers and nine parents in total. The verbatim transcripts were analysed with thematic analysis and two main themes emerged: ‘Seeing the worry in a new light’ and ‘Changing within a set format’, which both consisted of three subthemes. Based on the analysis, we concluded that teenagers can work actively with exposure and experience it as helpful even though it can be difficult and strange at first, and that parental involvement can be perceived as beneficial by both teenagers and their parents. While the online format placed a substantial responsibility on the families, and some would have wanted additional therapist support, working independently with one’s difficulties was acceptable.

Key learning aims

(1)