A 5-Year follow-up of internet-based cognitive behavior therapy for social anxiety disorder

Improvements in emotion regulation during cognitive behavior therapy predict subsequent social anxiety reductions

Individuals with social anxiety disorder (SAD) experience overall emotion regulation difficulties, but less is known about the long-term role of such difficulties in cognitive behavior therapy (CBT) for SAD. Forty-six patients with SAD receiving internet-delivered CBT, and matched healthy controls (HCs; n = 39), self-reported the Difficulties in Emotion Regulation Scale (DERS), Liebowitz Social Anxiety Scale (LSAS-SR), and participated in anticipatory speech anxiety behavioral experiments. Patients were measured at seven time points before, during and after CBT over a total period of 28 months, and HCs at two timepoints. Disaggregated growth curve models with a total of 263 observations were used, as well as intra-class correlation coefficients and regression models. Patients' LSAS-SR and DERS ratings were reliable (ICC = .83 and .75 respectively), and patients, relative to controls, showed larger difficulties in emotion regulation at pre-treatment (p < .001). During CBT, within-individual improvements in emotion regulation significantly predicted later LSAS-SR reductions (p = .041, pseudo-R2 = 43%). Changes in emotion regulation may thus be important to monitor on an individual level and may be used to improve outcomes in future developments of internet-delivered CBT.

Acceptance of a Web-Based Intervention in Individuals Who Committed Sexual Offenses Against Children: Cross-Sectional Study

BACKGROUND

Individuals who have committed sexual offenses against children often have difficulties finding treatment, despite its potential effectiveness. Although the development of web-based interventions could enhance therapeutic supply, up to now the acceptance thereof among this target group is unknown.

OBJECTIVE

For the first time, this study assesses the acceptance of a web-based intervention among individuals who committed sexual offenses against children and analyzes variables that predict acceptance. Following the Unified Theory of Acceptance and Use of Technology (UTAUT), it is assumed that acceptance of web-based interventions in individuals who have committed sexual offenses against children follows the same mechanisms as for individuals in general psychiatry.

METHODS

This cross-sectional study is based on the data from an ongoing clinical trial (@myTabu) evaluating the effectiveness of a web-based intervention in individuals who committed sexual offenses against children (N=113). Acceptance level was measured using a questionnaire based on the UTAUT and modified for the target group. Furthermore, predictors of acceptance from the UTAUT (performance expectancy, effort expectancy, and social influence [SI]), attitudes toward web-based interventions, and internet anxiety were assessed at baseline.

RESULTS

Most participants (61.1%, 69/113), reported high acceptance, while 36.3% (41/113) of them indicated moderate acceptance, and 2.7% (3/113) of them expressed low acceptance. In a linear regression model, the predictors explained 41.2% of the variance (F11,101=9.055; P=.01). Attitudes toward web-based interventions (B=0.398, 95% CI 0.16-0.64; P=.001) and SI (B=0.183, 95% CI 0.03-0.38; P=.04) significantly predicted acceptance. Post hoc explorative analysis showed that the participants' belief that people close to them would recommend the use of a web-based intervention is a predictor of acceptance. In contrast, the belief that their community supervisor would recommend the use thereof was not predictive in this respect.

CONCLUSIONS

For the participants of this study, we identified high acceptance of web-based interventions for the majority of participants. SI and the participants' attitudes toward web-based interventions were important in predicting acceptance.

TRIAL REGISTRATION

German Clinical Trial Registration (DRKS, Deutsches Register Klinischer Studien) DRKS 00021256; https://drks.de/search/de/trial/DRKS00021256.

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

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

Scheduled Support Versus Support on Demand in Internet-Delivered Cognitive Behavioral Therapy for Social Anxiety Disorder: Randomized Controlled Trial

Objectives

Clinician-supported internet-delivered cognitive behavioral therapy (ICBT) can be an effective treatment option when treating social anxiety disorder (SAD). Unguided ICBT is often found to be less effective. One possible solution to reduce the costs of clinician support is to provide support on demand. In this format of guidance, participants have the option to contact their clinician if needed. In a few studies, this mode of support has been compared favorably to scheduled support.

Method

Participants in a previously reported controlled trial on SAD who had been in a waitlist control group were randomly allocated to ICBT with either on-demand guidance or scheduled weekly therapist guidance. A total of 99 participants were included. Data were collected weekly on the primary outcome measure, the Liebowitz Social Anxiety Scale self-report (LSAS-SR), and at pre- and post-treatment for secondary measures. Data were analyzed in accordance with the intention-to-treat principle using mixed-effects models.

Results

Both groups improved significantly during the treatment according to the LSAS-SR ratings. The groups did not differ in their estimated change during the treatment period, with a between-group effect of d = 0.02, 95% CI [-0.37, 0.43]. Both groups experienced similar improvement also on the secondary outcome measures, with small between-group effect sizes on all outcomes.

Conclusions

The findings indicate that support on demand can be an effective way of providing guidance in ICBT for SAD, although more research on this topic is needed. A limitation of the study is that it was conducted in 2009, and the findings were in the file drawer. Subsequent published studies support our initial findings, but more research is needed.

The Impact of a Gamified Mobile Mental Health App (eQuoo) on Resilience and Mental Health in a Student Population: Large-Scale Randomized Controlled Trial

BACKGROUND

With many digital mental health interventions failing to engage clients for enough time to demonstrate substantive changes to their well-being and with only 2% of all digital solutions on app stores having undergone randomized controlled trials, the rising demand for mental health prevention and early intervention care is not being met. Young adults in particular struggle to find digital well-being apps that suit their needs.

OBJECTIVE

This study explored the effects of eQuoo, an evidence-based mental health game that teaches psychological skills through gamification, on resilience, depression, anxiety, and attrition in a student population.

METHODS

In total, 1165 students from 180 universities in the United Kingdom participated in a 5-week, 3-armed randomized controlled trial. Participants were randomly allocated into 1 of 3 groups: eQuoo users, users of a treatment-as-usual evidence-based cognitive behavioral health app called Sanvello, and a no-intervention waitlist. The Rugged Resilience Scale, Generalized Anxiety Disorder-7, and Patient Health Questionnaire-8 were administered to all participants at baseline and every 7 days until completion.

RESULTS

A repeated measures-ANOVA revealed statistically significant increases in resilience scores in the test group (P<.001) compared with both control groups (Sanvello: P=.10 and waitlist: P=.82) over 5 weeks. The app also significantly decreased anxiety and depression scores (both P<.001). With 64.5% (251/389) adherence, the eQuoo group retained 42% more participants than the control groups.

CONCLUSIONS

Digital health interventions such as eQuoo are effective, scalable, and low-cost solutions for supporting young adults and are available on all leading mobile platforms. Further investigation could clarify the extent to which specific elements of the eQuoo app (including gamification) led to better outcomes.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00027638; https://drks.de/search/en/trial/DRKS00027638.

PROTOCOL: Effects of virtual reality exposure therapy versus in vivo exposure in treating social anxiety disorder in adults: A systematic review and meta-analysis

This is the protocol for a Campbell systematic review. The objectives are as follows: (a) to quantify the effect sizes for virtual reality exposure therapy (VRET) in the treatment of social anxiety disorder (SAD), targeting primary social anxiety symptoms, comorbid anxiety and depression symptoms and improvements in quality of life, when compared to WL, information control, care-as-usual and placebo; (b) to compare VRET to in vivo cognitive and cognitive-behavioral interventions in treating SAD, at posttest and follow-up, using between-group design; (c) to identify the key features which are linked to beneficial outcomes in the two formats in treating SAD and (d) to collect and interpret information on differences in treatment uptake, adherence and attrition, as well as clinical significance and therapist-time in both treatment formats.

Transitioning From In-Person to Telehealth Cognitive-Behavioral Therapy for Social Anxiety Disorder During the COVID-19 Pandemic: A Case Study in Flexibility in an Adverse Context

Social anxiety disorder (SAD) is a condition in which people consistently and persistently experience significant fear and/or anxiety about one or more social situations in which they may be scrutinized and negatively evaluated. SAD has historically been found to respond well to cognitive-behavioral therapy (CBT) delivered both in-person and via telehealth; however, comparatively little information is available regarding response to treatment in the context of Coronavirus Disease 2019 (COVID-19) pandemic social and physical distancing guidelines, which have affected the way in which behavioral health services are delivered, as well as opportunities for interpersonal interactions which are either spontaneous or assigned as exposures. The current case study describes "Jennifer" (a pseudonym), a college student with a primary diagnosis of SAD, who was treated with primarily CBT interventions for 18 individual sessions over the course of approximately 6 months, which included treatment with a psychologist and a graduate student, implemented both in-person and via telehealth, both before and during the COVID-19 pandemic. Jennifer responded well to treatment, as evidenced by her self-report and decreases in symptom measure scores, engaged in CBT adapted to pandemic restrictions, and was able to utilize strategies learned during SAD treatment to address generalized anxiety and pandemic-related concerns. This case study demonstrates the feasibility of transitioning SAD care between providers and formats, as well as the robustness and flexibility of CBT strategies in the face of significant change, stress, and limitations of the external environment.

Internet-Delivered Versus Face-to-Face Cognitive Behavior Therapy for Anxiety Disorders: Systematic Review and Meta-Analysis

Background:

Over the last 20 years, internet-delivered cognitive behavior therapy (ICBT) has been tested in a large number of randomized controlled trials, often with positive results. However, it is not widely known about the efficacy of ICBT as compared to face-to-face cognitive behavior therapy (CBT).

Methods:

In the present systematic review and meta-analysis, ICBT for treatment of anxiety disorders was directly compared to face- to-face CBT within the same trial. This study aimed to reinvestigate the effect of ICBT compared to face-to-face CBT for anxiety disorders. A total of 8 studies out of the 236 articles screened met all the inclusion criteria. The included studies targeting five different anxiety disorders, social anxiety disorder, adolescent anxiety, panic disorder, spider phobia, and fear of public speaking, had been carried out in Australia, Spain, and Sweden. The total number of participants was 348 in ICBT and 316 in face-to-face conditions.

Results:

The results of our meta-analysis are interesting both from theoretical and practical standpoints, which showed a pooled effect size posttreatment with Hedges' g = 0.01 (95% CI: −0.16 to 0.18),

Conclusions:

ICBT and face-to-face CBT created equivalent overall effects. in treatment of anxiety disorders. Since there have been similar systematic reviews about anxiety disorders so far, and in majority of them, ICBT has not been compared against face-to-face treatment. More research is needed to establish the general equivalence of the two treatment formats. Also, understanding what makes ICBT work is a challenge for future research.

Mental Health Screening in General Practices as a Means for Enhancing Uptake of Digital Mental Health Interventions: Observational Cohort Study

Background

Digital mental health interventions stand to play a critical role in managing the mental health impact of the COVID-19 pandemic. Thus, enhancing their uptake is a key priority. General practitioners (GPs) are well positioned to facilitate access to digital interventions, but tools that assist GPs in identifying suitable patients are lacking.

Objective

This study aims to evaluate the suitability of a web-based mental health screening and treatment recommendation tool (StepCare) for improving the identification of anxiety and depression in general practice and, subsequently, uptake of digital mental health interventions.

Methods

StepCare screens patients for symptoms of depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder scale) in the GP waiting room. It provides GPs with stepped treatment recommendations that include digital mental health interventions for patients with mild to moderate symptoms. Patients (N=5138) from 85 general practices across Australia were invited to participate in screening.

Results

Screening identified depressive or anxious symptoms in 43.09% (1428/3314) of patients (one-quarter were previously unidentified or untreated). The majority (300/335, 89.6%) of previously unidentified or untreated patients had mild to moderate symptoms and were candidates for digital mental health interventions. Although less than half were prescribed a digital intervention by their GP, when a digital intervention was prescribed, more than two-thirds of patients reported using it.

Conclusions

Implementing web-based mental health screening in general practices can provide important opportunities for GPs to improve the identification of symptoms of mental illness and increase patient access to digital mental health interventions. Although GPs prescribed digital interventions less frequently than in-person psychotherapy or medication, the promising rates of uptake by GP-referred patients suggest that GPs can play a critical role in championing digital interventions and maximizing the associated benefits.

Acceptability and Effectiveness of Artificial Intelligence Therapy for Anxiety and Depression (Youper): Longitudinal Observational Study

Background

Youper is a widely used, commercially available mobile app that uses artificial intelligence therapy for the treatment of anxiety and depression.

Objective

Our study examined the acceptability and effectiveness of Youper. Further, we tested the cumulative regulation hypothesis, which posits that cumulative emotion regulation successes with repeated intervention engagement will predict longer-term anxiety and depression symptom reduction.

Methods

We examined data from paying Youper users (N=4517) who allowed their data to be used for research. To characterize the acceptability of Youper, we asked users to rate the app on a 5-star scale and measured retention statistics for users’ first 4 weeks of subscription. To examine effectiveness, we examined longitudinal measures of anxiety and depression symptoms. To test the cumulative regulation hypothesis, we used the proportion of successful emotion regulation attempts to predict symptom reduction.

Results

Youper users rated the app highly (mean 4.36 stars, SD 0.84), and 42.66% (1927/4517) of users were retained by week 4. Symptoms decreased in the first 2 weeks of app use (anxiety: d=0.57; depression: d=0.46). Anxiety improvements were maintained in the subsequent 2 weeks, but depression symptoms increased slightly with a very small effect size (d=0.05). A higher proportion of successful emotion regulation attempts significantly predicted greater anxiety and depression symptom reduction.

Conclusions

Youper is a low-cost, completely self-guided treatment that is accessible to users who may not otherwise access mental health care. Our findings demonstrate the acceptability and effectiveness of Youper as a treatment for anxiety and depression symptoms and support continued study of Youper in a randomized clinical trial.

Unguided low intensity cognitive behaviour therapy for anxiety and depression during the COVID-19 pandemic: A randomised trial

The COVID-19 pandemic has had a severe impact on mental health worldwide, with increased rates of anxiety and depression widely documented. The aim of this study was to examine unguided low intensity cognitive behaviour therapy for anxiety and depression during the pandemic. A sample of 225 individuals in Australia and the United Kingdom (M age 37.79, SD = 14.02, range 18–80 years; 85% female) were randomised into intervention or waitlist control. The intervention group demonstrated significant decreases in anxiety (d = 0.36 [0.18, 0.54]) and depression (d = 0.28 [0.11, 0.45]) compared to controls. The majority of participants (96%) rated the intervention as useful, and most (83%) reported they spent 30 min or less reading the guide, with 83% agreeing the intervention was easy to read. The results indicate that low intensity cognitive behaviour therapy has efficacy in reducing anxiety and depression during the COVID-19 pandemic. There is an urgent need to disseminate low intensity psychological therapies to improve mental health in this challenging time.

Efficacy of an Internet-based cognitive-behavioural grief therapy for people bereaved by suicide: a randomized controlled trial

Background: The loss of a loved one due to suicide can be a traumatic event associated with prolonged grief and psychological distress. Objective: This study examined the efficacy of an Internet-based cognitive-behavioural grief therapy (ICBGT) specifically for people bereaved by suicide. Methods: In a randomized controlled trial, 58 participants with prolonged grief disorder (PGD) symptoms who had lost a close person to suicide were randomly allocated either to the intervention group (IG) or waitlist-control group (WCG). The 5-week intervention comprised ten writing assignments in three phases: self-confrontation, cognitive restructuring, and social sharing. Symptoms of PGD, common grief reactions after suicide, depression, and general psychopathology were assessed at pre-, post-test and follow-up. Results: Between-group effect sizes were large for the improvement of PGD symptoms in treatment completers (d_ppc2 = 1.03) and the intent-to-treat analysis (d_ppc2 = 0.97). Common grief reactions after suicide and depressive symptoms also decreased in the IG compared to the WCG (moderate to large effects). The results are stable over time. Only for general psychopathology, there was no significant time by group interaction effect found. Conclusions: The ICBGT represents an effective treatment approach for people suffering from PGD symptoms after bereavement by suicide. Considering the effect sizes, the small treatment dose, duration, and the stability of the results, the ICBGT constitutes an appropriate alternative to face-to-face grief interventions.

The Effect of Shame on Patients With Social Anxiety Disorder in Internet-Based Cognitive Behavioral Therapy: Randomized Controlled Trial

BACKGROUND

Prior research has demonstrated the efficacy of internet-based cognitive behavioral therapy (ICBT) for social anxiety disorder (SAD). However, it is unclear how shame influences the efficacy of this treatment.

OBJECTIVE

This study aimed to investigate the role shame played in the ICBT treatment process for participants with SAD.

METHODS

A total of 104 Chinese participants (73 females; age: mean 24.92, SD 4.59 years) were randomly assigned to self-help ICBT, guided ICBT, or wait list control groups. For the guided ICBT group, half of the participants were assigned to the group at a time due to resource constraints. This led to a time difference among the three groups. Participants were assessed before and immediately after the intervention using the Social Interaction Anxiety Scale (SIAS), Social Phobia Scale (SPS), and Experience of Shame Scale (ESS).

RESULTS

Participants' social anxiety symptoms (self-help: differences between pre- and posttreatment SIAS=-12.71; Cohen d=1.01; 95% CI 9.08 to 16.32; P<.001 and differences between pre- and posttreatment SPS=11.13; Cohen d=0.89; 95% CI 6.98 to 15.28; P<.001; guided: SIAS=19.45; Cohen d=1.20; 95% CI 14.67 to 24.24; P<.001 and SPS=13.45; Cohen d=0.96; 95% CI 8.26 to 18.64; P<.001) and shame proneness (self-help: differences between pre- and posttreatment ESS=7.34; Cohen d=0.75; 95% CI 3.99 to 10.69; P<.001 and guided: differences between pre- and posttreatment ESS=9.97; Cohen d=0.88; 95% CI 5.36 to 14.57; P<.001) in both the self-help and guided ICBT groups reduced significantly after treatment, with no significant differences between the two intervention groups. Across all the ICBT sessions, the only significant predictors of reductions in shame proneness were the average number of words participants wrote in the exposure module (β=.222; SE 0.175; t₉₆=2.317; P=.02) and gender (β=-.33; SE 0.002; t₇₇=-3.13; P=.002). We also found a mediation effect, wherein reductions in shame fully mediated the relationship between the average number of words participants wrote in the exposure module and reductions in social anxiety symptoms (SIAS: β=-.0049; SE 0.0016; 95% CI -0.0085 to -0.0019 and SPS: β=-.0039; SE 0.0015; 95% CI -0.0075 to -0.0012).

CONCLUSIONS

The findings of this study suggest that participants' engagement in the exposure module in ICBT alleviates social anxiety symptoms by reducing the levels of shame proneness. Our study provides a new perspective for understanding the role of shame in the treatment of social anxiety. The possible mechanisms of the mediation effect and clinical implications are discussed.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900021952; http://www.chictr.org.cn/showproj.aspx?proj=36977.

Do depressive symptoms affect the outcome of treatments for SAD? A meta analysis of randomized controlled trials

Individuals with social anxiety disorder (SAD) typically have elevated depressive symptoms. In the present meta-analysis, we reviewed the treatment outcome literature in SAD and examined whether depressive symptoms predict treatment outcome. We focused on randomized controlled trials of cognitive behavior therapy (individual face-to-face, group format, and internet-delivered format) and randomized controlled trials of pharmacotherapy. After implementing exclusion criteria, 108 studies with 133 treatment conditions (n = 12,913 participants) were included in the meta-analysis. Our findings indicated that treatments for SAD were efficacious and significantly reduced social anxiety symptoms across all treatment modalities. Exclusion of individuals with MDD or high levels of depression did not affect outcome at post-treatment or at follow-up. However, we found that elevated depressive symptoms were associated with greater reductions in social anxiety symptoms from pre-treatment to post-treatment. Importantly, this effect was above and beyond pre-treatment levels of social anxiety. Finally, analyzing treatment modalities separately, we found that depressive symptoms were associated with better post-treatment outcomes in individual face-to-face CBT but not in other modalities. Clinical and research implications of these findings are discussed.

Guided Self-Help Works: Randomized Waitlist Controlled Trial of Pacifica, a Mobile App Integrating Cognitive Behavioral Therapy and Mindfulness for Stress, Anxiety, and Depression

Background

Despite substantial improvements in technology and the increased demand for technology-enabled behavioral health tools among consumers, little progress has been made in easing the burden of mental illness. This may be because of the inherent challenges of conducting traditional clinical trials in a rapidly evolving technology landscape.

Objective

This study sought to validate the effectiveness of Pacifica, a popular commercially available app for the self-management of mild-to-moderate stress, anxiety, and depression.

Methods

A total of 500 adults with mild-to-moderate anxiety or depression were recruited from in-app onboarding to participate in a randomized waitlist controlled trial of Pacifica. We conducted an all-virtual study, recruiting, screening, and randomizing participants through a Web-based participant portal. Study participants used the app for 1 month, with no level of use required, closely mimicking real-world app usage. Participants in the waitlist group were given access to the app after 1 month. Measurements included self-reported symptoms of stress, anxiety, depression, and self-efficacy. We performed an intent-to-treat analysis to examine the interactive effects of time and condition.

Results

We found significant interactions between time and group. Participants in the active condition demonstrated significantly greater decreases in depression, anxiety, and stress and increases in self-efficacy. Although we did not find a relationship between overall engagement with the app and symptom improvement, participants who completed relatively more thought record exercises sustained improvements in their symptoms through the 2-month follow-up to a greater degree than those who completed fewer. In addition, we found that participants who reported concomitantly taking psychiatric medications during the trial benefitted less from the app, as measured by the symptoms of anxiety and stress.

Conclusions

This study provides evidence that Pacifica, a popular commercially available self-help app, is effective in reducing self-reported symptoms of depression, anxiety, and stress, particularly among individuals who utilize thought records and are not taking psychiatric medication.

Trial Registration

ClinicalTrials.gov NCT03333707; https://clinicaltrials.gov/ct2/show/NCT03333707 (Archived by WebCite at http://www.webcitation.org/78YE07ADB)

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)].

Patient Perspectives on Strengths and Challenges of Therapist-Assisted Internet-Delivered Cognitive Behaviour Therapy: Using the Patient Voice to Improve Care

Therapist-assisted internet-delivered cognitive behaviour therapy (T-ICBT) involves patients reading online treatment materials, completing relevant exercises, and receiving therapist support. This study aimed to understand the preferences and recommendations of 225 patients enrolled in a T-ICBT course for depression and anxiety via an online therapy unit in collaboration with community mental health clinics dispersed across one Canadian province. An open-ended survey asked participants their opinions of the course and responses were analyzed using a content analysis approach. Patient comments addressed many strengths of the course (64%), with some opportunities for improvement (36%). Most-appreciated features included ability to download content for future use, reading other patients' experiences, and content of lessons. Patients made suggestions for improving the breadth of patient stories, timeline of the course, and matching availability of the therapist to patient need. Patient feedback regarding preferences provides valuable information for improving the patient-centered nature of T-ICBT.

The Pain Course: 12- and 24-Month Outcomes From a Randomized Controlled Trial of an Internet-Delivered Pain Management Program Provided With Different Levels of Clinician Support

Little is known about the long-term outcomes of emerging Internet-delivered pain management programs. The current study reports the 12- and 24-month follow-up data from a randomized controlled trial (n = 490) of an Internet-delivered pain management program, the Pain Course. The initial results of the trial to the 3-month follow-up have been reported elsewhere. There were significant improvements in disability, depression, anxiety, and pain levels across 3 treatment groups receiving different levels of clinician support compared with a treatment as the usual control. No marked or significant differences were found between the treatment groups either after treatment or at the 3-month follow-up. The current study obtained long-term follow-up data from 78% and 79% of participants (n = 397) at the 12-month and 24-month follow-up marks, respectively. Clinically significant decreases (average percent reduction; Cohen's d effect sizes) were maintained at the 12- and 24-month follow-ups for disability (average reduction ≥27%; d ≥ .67), depression (average reduction ≥36%; d ≥ .80), anxiety (average reduction ≥38%; d ≥ .66), and average pain levels (average reduction ≥21%; d ≥ .67). No marked or consistent differences were found among the 3 treatment groups. These findings suggest that the outcomes of Internet-delivered programs may be maintained over the long term. PERSPECTIVE: This article presents the long-term outcome data of an established Internet-delivered pain management program for adults with chronic pain. The clinical improvements observed during the program were found to be maintained at the 12- and 24-month follow-up marks. This finding indicates that these programs can have lasting clinical effects.

Digital Technologies in the Treatment of Anxiety: Recent Innovations and Future Directions

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of the efficacy, limitations, and future of e-health treatments for anxiety. Within this, we provide detail on "first-generation" e-health approaches, such as computerized therapies. Additionally, we assess the emergence and early efficacy of newer methods of treatment delivery, including smartphone apps and virtual reality interventions, discussing the potential and pitfalls for each.

RECENT FINDINGS

There is now substantial clinical research demonstrating the efficacy of internet-delivered cognitive behavioral therapy in the treatment of anxiety. However, the ability of these interventions for engaging patients in "real-world" settings is unclear. Recently, smartphone apps for anxiety have presented a more popular and ubiquitous method of intervention delivery, although the evidence base supporting these newer approaches drastically falls behind the extensive marketing and commercialization efforts currently driving their development. Meanwhile, the increasing availability of novel technologies, such as "virtual reality" (VR), introduces further potential of e-health treatments for generalized anxiety and anxiety-related disorders such as phobias and obsessive compulsive disorder, while also creating additional challenges for research. Although still in its infancy, e-health research is already presenting several promising avenues for delivering effective and scalable treatments for anxiety. Nonetheless, several important steps must be taken in order for academic research to keep pace with continued technological advances.

Effect of Religious Cognitive Behavioral Therapy on Religious Obsessive-compulsive Disorder (3 and 6 months Follow-up)

Background:

Obsessive-compulsive disorder (OCD) is a chronic disorder that strongly affects one's life and social, emotional, and occupational functioning. Due to the effect of religious beliefs on phenomenology of OCD, in this paper, we assess the effectiveness of religious cognitive behavioral therapy (CBT) within 3 and 6 months follow-up.

Materials and Methods:

This study is a clinical trial with follow-ups which last 2 months consisting eight sessions of 1.5 h of religious CBT. The research is conducted in a group of 40, with pre- and post-test after 3 and 6 months. Used Yale-Brown OCD symptom scale, before, the end, after 3 months and after 6 months of intervention. Treatment is carried out by a psychiatrist and a clergyman through religious CBT. The trial is held in OCD clinic affiliated with Noor Hospital. Results are analyzed by ANOVA repeated measure with SPSS18.

Results:

The results showed a considerable decrease in OCD symptoms which remained almost persistent after 3 and 6 months (F = 3/54. P = 0/024). It also shows that religious CBT can leave substantial effect on OCD symptoms; permanency of this intervention after 3 and 6 months is noticeable (P < 0/001). In Conclusion this therapy could be helpful for OCD patients with religious content.

Conclusion:

RCBT have a positive effect on people with religious obsessive -compulsive.

Gender Differences in and the Relationships Between Social Anxiety and Problematic Internet Use: Canonical Analysis

Background

The cognitive-behavioral model of problematic Internet use (PIU) proposes that psychological well-being is associated with specific thoughts and behaviors on the Internet. Hence, there is growing concern that PIU is associated with psychological impairments.

Objective

Given the proposal of gender schema theory and social role theory, men and women are predisposed to experience social anxiety and engage in Internet use differently. Thus, an investigation of gender differences in these areas is warranted. According to the cognitive-behavioral model of PIU, social anxiety is associated with specific cognitions and behaviors on the Internet. Thus, an investigation of the association between social anxiety and PIU is essential. In addition, research that takes into account the multidimensional nature of social anxiety and PIU is lacking. Therefore, this study aimed to explore multivariate gender differences in and the relationships between social anxiety and PIU.

Methods

Participants included 505 college students, of whom 241 (47.7%) were women and 264 (52.3%) were men. Participants’ ages ranged from 18 to 22 years, with a mean age of 20.34 (SD=1.16). The Social Anxiety Scale and Problematic Internet Use Scale were used in data collection. Multivariate analysis of variance (MANOVA) and canonical correlation analysis were used.

Results

Mean differences between men and women were not statistically significant in social anxiety (λ=.02, F3,501=2.47, P=.06). In all three PIU dimensions, men scored higher than women, and MANOVA shows that multivariate difference was statistically significant (λ=.94, F3,501=10.69, P<.001). Of the canonical correlation functions computed for men, only the first was significant (Rc=.43, λ=.78, χ29=64.7, P<.001) and accounted for 19% of the overlapping variance. Similarly, only the first canonical function was significant for women (Rc=.36, λ=.87, χ29=33.9, P<.001), which accounted for 13% of the overlapping variance.

Conclusions

On the basis of the findings, we conclude that enhanced educational opportunities for women and their increasing role in the society have led women to become more active and thus closed the gap in social anxiety levels between men and women. We found that men showed more difficulties than women in terms of running away from personal problems (ie, social benefit), used the Internet more excessively, and experienced more interpersonal problems with significant others due to Internet use. We conclude that men are under a greater risk of social impairments due to PIU. Our overall conclusion is that there is a substantial amount of association between social anxiety and PIU and the association is stronger for men than it is for women. We advise that future research continue to investigate PIU and social anxiety as multidimensional constructs.

Internet-Assisted Cognitive Behavioral Therapy

Internet-assisted cognitive-behavioral therapy (ICBT) is a way to deliver cognitive-behavioral therapy (CBT) that has been found to generate similar effects as face-to-face CBT in some studies. Results have been replicated by different research groups. This article presents the treatment format and reviews evidence for mood and anxiety disorders. Future developments are discussed, including the lack of theories specific for the treatment format and ways to handle comorbidity. Although some programs have been implemented there is a need for further studies in clinical settings. Overall, clinician-assisted ICBT is becoming one of the most evidence-based forms of psychological treatment.

[Can we do therapy without a therapist? Active components of computer-based CBT for depression]

OBJECTIVES

Computer-delivered Cognitive Behavioral Therapies (C-CBT) are emerging as therapeutic techniques which contribute to overcome the barriers of health care access in adult populations with depression. The C-CBTs provide CBT techniques in a highly structured format comprising a number of educational lessons, homework, multimedia illustrations and supplementary materials via interactive computer interfaces. Programs are often administrated with a minimal or regular support provided by a clinician or a technician via email, telephone, online forums, or during face-to-face consultations. However, a lot of C-CBT is provided without any therapeutic support. Several reports showed that C-CBTs, both guided or unguided by a therapist, may be reliable and effective for patients with depression, and their use was recommended as part of the first step of the clinical care. The aim of the present qualitative review is to describe the operational format and functioning of five of the most cited unguided C-CBT programs for depression, to analyze their characteristics according to the CBT's principles, and to discuss the results of the randomized clinical trials (RCT) conducted to evaluate its effectiveness, adherence and user's experience.

METHODS

We analyzed five C-CBTs: Beating The Blues (BTB), MoodGYM, Sadness, Deprexis and Overcoming Depression on the Internet (ODIN) and 22 randomized controlled studies according to 5 dimensions: General characteristics; Methodology, structure and organization; Specific modules, themes and techniques: Clinical indications, recruitment mode, type of users with depression, type and mode of therapist's support, overall therapeutic effects, adherence and user's experience.

RESULTS

The C-CBT have a secured free or pay-to-use access in different languages (English, German, Dutch, and Chinese) but not in French. The programs may be accessed at a medical center or at home via a CD-ROM or via an Internet connection. Some C-CBTs are very close to textual self-helps provided via an E-learning mode (Sadness, MoodGYM, ODIN), others adopt interactive software technologies (Deprexis, BTB), but their interactivity and the possibility of personalization is low. The C-CBTs use similar principles and techniques as in face-to -face CBT (e.g. self-evaluation, psychoeducation, cognitive restructuring, cognitive restructuring of schema, behavioral activation and agenda setting, problem solving techniques, communication and crisis management techniques, relaxation, principles of positive psychology and relapse prevention, positive reinforcement methods, motivational feedbacks, social learning, homework assignments and progress monitoring). The results of the 22 RCSs showed that both the effectiveness and the adherence of the unguided C-CBT is high with self-referred active help-seekers with major depression, but the latter is low with users who are depressed out-patients referred by general practitioners or clinicians. The presence of therapist support improves the effectiveness and the adherence of the C-CBT, especially in clinical out-patients.

CONCLUSIONS

In light of the existing insight of the advantages and the inconvenient of the C-CBT, the actual challenge is to find its optimal clinical indication and the modality of its effective use in clinical populations.

Long-term effects of internet-supported cognitive behaviour therapy

INTRODUCTION

Internet-supported and therapist-guided cognitive behaviour therapy (ICBT) is effective for a range of problems in the short run, but less is known about the long-term effects with follow-ups of two years or longer. Areas covered: This paper reviews studies in which the long-term effects of guided ICBT were investigated. Following literature searches in PubMed and other sources meta-analytic statistics were calculated for 14 studies involving a total of 902 participants, and an average follow-up period of three years. Studies were from Sweden (n = 11) or the Netherlands (n = 3). Long-term outcome studies were found for panic disorder, social anxiety disorder, generalized anxiety disorder, depression, mixed anxiety and depression, obsessive-compulsive disorder, pathological gambling, stress and chronic fatigue. The duration of the treatments was usually short (8-15 weeks). The pre-to follow-up effect size was Hedge's g = 1.52, but with a significant heterogeneity. The average symptom improvement across studies was 50%. Treatment seeking in the follow-up period was not documented and few studies mentioned negative effects. Expert commentary: While effects may be overestimated, it is likely that therapist-supported ICBT can have enduring effects. Long-term follow-up data should be collected for more conditions and new technologies like smartphone-delivered treatments.

Social anxiety and Internet socialization in Indian undergraduate students: An exploratory study

BACKGROUND

Social Anxiety Disorder (SAD) is a globally prevalent, chronic, debilitating psychiatric disorder affecting youth. With comorbidities including major depression, substance abuse, lower educational and work attainment, and increased suicide risk, it has a significant public health burden. The objective of this study was to estimate the prevalence of SAD in urban Indian undergraduate students and to study their Facebook (FB) usage patterns.

METHODS

In this exploratory cross-sectional study, 316 undergraduate students were screened for social anxiety using validated instruments, Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS), and divided into two groups based on scores obtained. The groups were then compared with regards to behaviors and attitudes toward Facebook, obtained from a self-report questionnaire.

RESULTS

SAD was estimated to be a significant, prevalent (7.8%) disorder in otherwise productive youth, and showed female preponderance. Higher specific social phobia scores were associated with the inability to reduce Facebook use, urges toward increasing use, spending more time thinking about Facebook, negative reactions to restricting use, and using it to forget one's problems.

CONCLUSIONS

SAD was estimated to have a prevalence of 7.8% in our study, and was associated with stronger FB usage attitudes and patterns. We recommend that the relationship between social anxiety and Internet use be explored further, to study the possibility of Internet-based screening and intervention strategies having wider reach and appeal in socially anxious individuals.

Internet-Delivered Acceptance-Based Cognitive-Behavioral Intervention for Social Anxiety Disorder With and Without Therapist Support: A Randomized Trial

Social anxiety disorder (SAD) is one of the most prevalent psychiatric disorders in the United States. Although evidenced-based behavioral treatments are available, less than 20% of those with SAD receive treatment. Internet-based interventions can address barriers to treatment access, and guided Internet-based treatments have been demonstrated to be effective for SAD. However, the optimal role (if any) of the therapist in such programs remains unclear. We examined the acceptability and efficacy of a novel Internet-based cognitive-behavior therapy for SAD that utilizes traditional behavioral interventions (e.g., exposure) within the context of a model emphasizing mindfulness and psychological acceptance. Forty-two participants were randomized to an eight-module self-help intervention with ( n = 20) or without ( n = 22) adjunctive therapist support; the therapist support was delivered through 10 to 15 min of weekly videoconferencing and daily text messages. Both groups experienced a significant reduction in SAD symptoms and improvements in functioning and quality of life, with no significant differences between groups in both completer-only and intent-to-treat analyses. However, the therapist support group evidenced lower attrition than the minimal support group (20% vs. 50%). Implications for dissemination and future directions are discussed.

Web-based stress management for newly diagnosed cancer patients (STREAM-1): a randomized, wait-list controlled intervention study

BACKGROUND

Being diagnosed with cancer causes major psychological distress, yet the majority of newly diagnosed cancer patients lack psychological support. Internet interventions overcome many barriers for seeking face-to-face support and allow for independence in time and place. We assess efficacy and feasibility of the first web-based stress management intervention (STREAM: STREss-Aktiv-Mindern) for newly diagnosed, German-speaking cancer patients.

METHODS/DESIGN

In a prospective, wait-list controlled trial 120 newly diagnosed cancer patients will be included within 12 weeks of starting anti-cancer treatment and randomized between an immediate (intervention group) or delayed (control group) 8-week, web-based intervention. The intervention consists of eight modules with weekly written feedback by a psychologist ("minimal-contact") based on well-established stress management manuals including downloadable audio-files and exercises. The aim of this study is to evaluate efficacy in terms of improvement in quality of life (FACT-F), as well as decrease in anxiety and depression (HADS), as compared to patients in the wait-list control group. A sample size of 120 patients allows demonstrating a clinically relevant difference of nine points in the FACT score after the intervention (T2) with a two-sided alpha of 0.05 and 80 % power. As this is the first online stress management intervention for German-speaking cancer patients, more descriptive outcomes are equally important to further refine the group of patients with the largest potential for benefit who then will be targeted more specifically in future trials. These descriptive endpoints include: patients' characteristics (type of cancer, type of treatment, socio-demographic factors), dropout rate and dropout reasons, adherence and satisfaction with the program.

DISCUSSION

New technologies open new opportunities: minimal-contact psychological interventions are becoming standard of care in several psychological disorders, where their efficacy is often comparable to face-to-face interventions. With our study we open this field to the population of newly diagnosed cancer patients. We will not only assess clinical efficacy but also further refine the target population who has the most potential to benefit. An internet-based minimal-contact stress management program might be an attractive, time- and cost-effective way to effectively deliver psychological support to newly diagnosed cancer patients and an opportunity to include those who currently are not reached by conventional support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02289014 .

Internet-delivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: a systematic review and meta-analysis of randomized controlled trials

Anxiety and depressive disorders are often comorbid. Transdiagnostic and tailored treatments seem to be promising approaches in dealing with comorbidity. Although several primary studies have examined the effects of Internet-delivered cognitive behavior therapy (iCBT) for anxiety and depression, no meta-analysis including different types of iCBT that address comorbidity has been conducted so far. We conducted systematic searches in databases up to 1 July 2016. Only randomized trials comparing transdiagnostic/tailored iCBT for adult anxiety and/or depression with control groups were included. Nineteen randomized trials with a total of 2952 participants that met inclusion criteria were analyzed. The quality of the studies was high, however the blinding criteria were not fulfilled. The uncontrolled effect size (Hedges' g) of transdiagnostic/tailored iCBT on anxiety and depression outcomes was large and medium for quality of life. The controlled effect size for iCBT on anxiety and depression outcomes was medium to large (anxiety: g = .82, 95% CI: .58-1.05, depression: g = .79, 95% CI: .59-1.00) and medium on quality of life (g = .56, 95% CI: .37-.73). Heterogeneity was small (quality of life) to moderate (anxiety, depression). There was a large effect on generic outcome measures and a moderate effect on comorbidities. When compared to disorder-specific treatments there were no differences on anxiety and quality of life outcomes, however there were differences in depression outcomes. Transdiagnostic and tailored iCBT are effective interventions for anxiety disorders and depression. Future studies should investigate mechanisms of change and develop outcome measures for these interventions.

Overcoming procrastination: one-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy

Procrastination is a common self-regulatory failure that can have a negative impact on well-being and performance. However, few clinical trials have been conducted, and no follow-up has ever been performed. The current study therefore aimed to provide evidence for the long-term benefits and investigate predictors of a positive treatment outcome among patients receiving Internet-based cognitive behavior therapy (ICBT). A total of 150 self-recruited participants were randomized to guided or unguided ICBT. Self-report measures of procrastination, depression, anxiety, and quality of life were distributed at pre-treatment assessment, post-treatment assessment, and one-year follow-up. Mixed effects models were used to investigate the long-term gains, and multiple linear regression for predictors of a positive treatment outcome, using the change score on the Irrational Procrastination Scale as the dependent variable. Intention-to-treat was implemented for all statistical analyses. Large within-group effect sizes for guided and unguided ICBT, Cohen's d = .97-1.64, were found for self-report measures of procrastination, together with d = .56-.66 for depression and anxiety. Gains were maintained, and, in some cases, improved at follow-up. Guided and unguided ICBT did not differ from each other, mean differences -.31-1.17, 95% CIs [-2.59-3.22], and none of the predictors were associated with a better result, bs -1.45-1.61, 95% CIs [-3.14-4.26]. In sum, ICBT could be useful and beneficial in relation to managing procrastination, yielding great benefits up to one year after the treatment period has ended, with comparable results between guided and unguided ICBT.

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

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

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

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

Psychometric properties of the Mini-Social Phobia Inventory (Mini-SPIN) in a large online treatment-seeking sample

The Mini-Social Phobia Inventory (Mini-SPIN) is a brief, three-item measure designed as a screening tool for social anxiety disorder (SAD). This study investigated the Mini-SPIN's psychometric properties in a series of trials of Internet-delivered treatment. Participants were 993 people seeking Internet-delivered cognitive behavioural therapy for a range of anxiety and mood disorders. Participants completed the Mini-SPIN, and were diagnosed using the Mini International Neuropsychiatric Interview Version 5.0.0 (MINI). They also completed measures of depression, general anxiety, panic, neuroticism and general impairment. The Mini-SPIN's ability to discriminate between people with and without SAD, within a large sample of people seeking treatment for a range of psychological disorders, was assessed at initial assessment and three-month follow-up. The Mini-SPIN's criterion group validity, internal consistency, test-retest reliability, construct validity and responsiveness to treatment were also examined. Results demonstrated that the Mini-SPIN has an excellent ability to discriminate between those with and without SAD in a highly comorbid clinical sample, and also has good criterion group validity. The Mini-SPIN also exhibited excellent internal consistency, good test-retest reliability, and was responsive to treatment. These results highlight the Mini-SPIN's potential as an efficient and reliable measure of SAD in heterogeneous populations.

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.

Predicting Response to Therapist-Assisted Internet-Delivered Cognitive Behavior Therapy for Depression or Anxiety Within an Open Dissemination Trial

Therapist-assisted Internet-delivered cognitive behavior therapy (ICBT) is efficacious for treating anxiety and depression, but predictors of response to treatment when delivered in clinical practice are not well understood. In this study, we explored demographic, clinical, and program variables that predicted modules started and symptom improvement (i.e., Generalized Anxiety Disorder-7 or Patient Health Questionnaire-9 total scores over pre-, mid-, and posttreatment) within a previously published open dissemination trial (Hadjistavropoulos et al., 2014). The sample consisted of 195 patients offered 12 modules of therapist-assisted ICBT for depression or generalized anxiety; ICBT was delivered by therapists working in six geographically dispersed clinics. Consistent across ICBT for depression or generalized anxiety, starting fewer modules was associated with more phone calls from therapists reflecting that therapists tended to call patients who did not start modules as scheduled. Also consistent for both ICBT programs, greater pretreatment condition severity and completion of more modules was associated with superior ICBT-derived benefit. Other predictors of response to treatment varied across the two programs. Younger age, lower education, taking psychotropic medication, being in receipt of psychiatric care and lower comfort with written communication were associated with either fewer program starts or lower symptom improvement in one of the two programs. It is concluded that monitoring response to ICBT may be particularly important in patients with these characteristics. Research directions for identifying patients who are less likely to benefit from ICBT are discussed.

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.

Long-term effectiveness and outcome predictors of therapist-guided internet-based cognitive-behavioural therapy for social anxiety disorder in routine psychiatric care

OBJECTIVES

Although the short-term outcome of therapist-guided internet-based cognitive-behavioural therapy (ICBT) for treating social anxiety disorder (SAD) has been well studied, little research has been undertaken on the sustainability of treatment gains, especially under clinically representative conditions. Further, there is some debate whether delivering psychological treatment via the internet may be suitable for more severely ill patients.

DESIGN

Longitudinal multilevel growth-modelling of long-term (1-4 years) follow-up cohort data.

SETTING

An outpatient psychiatric clinic specialised in internet interventions.

PARTICIPANTS

446 adults having been treated for SAD.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were estimated improvement rate and Cohen's d effect size on the self-rated Liebowitz Social Anxiety Disorder Scale. Secondary outcome measures were change in comorbid depressive symptoms and health-related quality of life.

RESULTS

A large treatment effect was observed on the primary outcome measure after treatment (d=0.8 (95% CI 0.7 to 0.9)), with continued long-term improvements (d=1.2 (95% CI 1.0 to 1.3)). However, the rate of change varied significantly between individuals over time. A faster rate of improvement was observed among patients with higher illness severity, whereas having a family history of social anxiety was related to worse response. Long-term improvements were also observed in comorbid depressive symptoms (d=0.7 (95% CI 0.5 to 0.8)) and health-related quality of life (d=-0.3 (95% CI -0.4 to -0.1)).

CONCLUSIONS

These findings provide evidence for the long-term effectiveness of ICBT for SAD in routine clinical practice, even for more severe cases.

The Resilience Program: preliminary evaluation of a mentalization-based education program

In order to manage with the burden of mental health problems in the world we need to develop cost-effective and safe preventive interventions. Education about resilience to support the ability to cope with life challenges in general, may be a useful strategy. We consider the concepts of Theory of Mind and Mentalization to be relevant in this context. In this paper we describe a simple modular intervention program based on these concepts which can be tailored to specific needs and situations in individual therapy as well as group levels. The program has shown promising results in pilot studies and is now tested in controlled trials in settings such as schools and educational institutions, adults diagnosed with ADHD, and children in care.

Predicting long-term outcome of Internet-delivered cognitive behavior therapy for social anxiety disorder using fMRI and support vector machine learning

Cognitive behavior therapy (CBT) is an effective treatment for social anxiety disorder (SAD), but many patients do not respond sufficiently and a substantial proportion relapse after treatment has ended. Predicting an individual's long-term clinical response therefore remains an important challenge. This study aimed at assessing neural predictors of long-term treatment outcome in participants with SAD 1 year after completion of Internet-delivered CBT (iCBT). Twenty-six participants diagnosed with SAD underwent iCBT including attention bias modification for a total of 13 weeks. Support vector machines (SVMs), a supervised pattern recognition method allowing predictions at the individual level, were trained to separate long-term treatment responders from nonresponders based on blood oxygen level-dependent (BOLD) responses to self-referential criticism. The Clinical Global Impression-Improvement scale was the main instrument to determine treatment response at the 1-year follow-up. Results showed that the proportion of long-term responders was 52% (12/23). From multivariate BOLD responses in the dorsal anterior cingulate cortex (dACC) together with the amygdala, we were able to predict long-term response rate of iCBT with an accuracy of 92% (confidence interval 95% 73.2-97.6). This activation pattern was, however, not predictive of improvement in the continuous Liebowitz Social Anxiety Scale-Self-report version. Follow-up psychophysiological interaction analyses revealed that lower dACC-amygdala coupling was associated with better long-term treatment response. Thus, BOLD response patterns in the fear-expressing dACC-amygdala regions were highly predictive of long-term treatment outcome of iCBT, and the initial coupling between these regions differentiated long-term responders from nonresponders. The SVM-neuroimaging approach could be of particular clinical value as it allows for accurate prediction of treatment outcome at the level of the individual.

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.

Guided Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis

Internet-delivered cognitive behavior therapy (ICBT) has been tested in many research trials, but to a lesser extent directly compared to face-to-face delivered cognitive behavior therapy (CBT). We conducted a systematic review and meta-analysis of trials in which guided ICBT was directly compared to face-to-face CBT. Studies on psychiatric and somatic conditions were included. Systematic searches resulted in 13 studies (total N=1053) that met all criteria and were included in the review. There were three studies on social anxiety disorder, three on panic disorder, two on depressive symptoms, two on body dissatisfaction, one on tinnitus, one on male sexual dysfunction, and one on spider phobia. Face-to-face CBT was either in the individual format (n=6) or in the group format (n=7). We also assessed quality and risk of bias. Results showed a pooled effect size (Hedges' g) at post-treatment of -0.01 (95% CI: -0.13 to 0.12), indicating that guided ICBT and face-to-face treatment produce equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there are still few studies for each psychiatric and somatic condition and many conditions for which guided ICBT has not been compared to face-to-face treatment. Thus, more research is needed to establish equivalence of the two treatment formats.