Treating comorbid insomnia in patients enrolled in therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy for anxiety and depression: A randomized controlled trial

Transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) for patients experiencing anxiety and depression can produce large improvements in symptoms. Comorbid insomnia is common among individuals seeking treatment for anxiety and depression, yet transdiagnostic ICBT rarely targets insomnia and many ICBT patients report that symptoms of insomnia remain after treatment. This trial explored the impact of including a brief intervention for insomnia alongside an existing transdiagnostic ICBT course that included brief weekly therapist assistance. Patients were randomly assigned to receive either the Standard transdiagnostic (n = 75) or a Sleep-Enhanced course (n = 142), which included information on sleep restriction and stimulus control. Intent-to-treat analyses using generalized estimating equation (GEE) showed significant, large reductions in all primary outcomes (insomnia: d = 0.96, 95 % CI [0.68, 1.24]; depression: d = 1.04, 95 % CI [0.76, 1.33]; and anxiety: d = 1.23, 95 % CI [0.94, 1.52]) from pre-treatment to post-treatment, with changes maintained at 3-months. Patients assigned to the Sleep-Enhanced course reported larger reductions in insomnia than patients in the Standard transdiagnostic course (Cohen's d = 0.31, 95 % CI [0.034, 0.60]) at post-treatment but no significant between-group differences in any of the primary outcomes were found at follow-up. Patient-reported adherence to sleep restriction guidelines (p = .03), but not stimulus control instructions (p = .84) was associated with greater reductions in insomnia symptoms during the course. Overall, patients who received the Sleep-Enhanced course were satisfied with the materials and most patients reported making sleep behaviour changes. The trial results demonstrate that including a brief intervention targeting insomnia can be beneficial for many patients who enroll in ICBT primarily for symptoms related to anxiety and depression.

Acceptability and effectiveness study of therapist-assisted internet-delivered cognitive behaviour therapy for agriculture producers

Agriculture producers are less likely to seek or to receive mental health services compared to the general population. Additional research is needed to identify effective and accessible mental health interventions for this underserved population. This study used a mixed-methods approach and open trial design to examine the acceptability and effectiveness of therapist-assisted internet-delivered cognitive behaviour therapy (ICBT) supplemented with an additional agricultural resource for clients from agricultural backgrounds receiving ICBT in routine care. Clients (n = 34) participated in an online, five-lesson course that provided psychoeducation and strategies for dealing with symptoms of anxiety and depression, with weekly therapist assistance. Clients also received a tailored resource (developed with input from those with an agricultural background) providing culturally specific information and case stories pertinent to agricultural communities. Intent-to-treat analyses showed that the ICBT program was effective in reducing anxiety and depression symptoms among the agricultural population. Large within-group pre-to-post-treatment Cohen's effect sizes of d = 1.14, 95 % CI [0.41, 1.86] and d = 1.15, 95 % CI [0.42, 1.87] were found for depression and anxiety, respectively and comparable to the same program offered to the general population. Clients also experienced reductions in perceived stress and significant improvements in resiliency from pre- to post-treatment. Semi-structured interviews conducted at post-treatment with the agricultural clients (n = 31) on their experiences with ICBT identified four main themes: perceived strengths of ICBT and the tailored resource, suggestions to improve service delivery for agriculture producers, clients experienced internal and external challenges to participating in ICBT, and the positive impact of the course reached beyond the client. Very high satisfaction rates were found. These results provide support for the acceptability and effectiveness of ICBT with a tailored resource offered in routine care among agriculture producers.

Cost-effectiveness of varying degrees and models of therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy: Evidence from a randomized controlled trial

In routine care, Internet-delivered Cognitive Behaviour Therapy (ICBT) is often delivered with therapist support via emails/phone calls, but the cost-effectiveness of varying amounts of therapist support or having therapists specialized in ICBT is not known. This study compared the cost-effectiveness of specialized therapists providing ICBT support once-weekly (1WS) versus providing support once-weekly supplemented with a one-business-day response to patient emails (1W/1BD-S). We further compared the cost-effectiveness of 1W support offered by therapists employed in a specialized clinic (1WS) versus community clinics where therapists primarily deliver face-to-face therapy (1WC). Patients were randomly allocated to groups: 1WS group (n = 216), 1W/1BD-S group (n = 233), and 1WC group (n = 226). At baseline, 12, 24 and 52-week follow-up, patients completed the Treatment Inventory of Costs in Patients with Psychiatric Disorders questionnaire (TiC-P) adapted for use in Canada to assess healthcare use and productivity losses. Additionally, to assess Quality Adjusted Life Years (QALYs) gained, patients completed the EQ-5D-5L at the same time periods. We quantified uncertainties by one-way and probabilistic sensitivity analysis and reported Incremental cost-effectiveness ratios (ICER), cost-effectiveness planes and acceptability curves. Cost-effectiveness over 52 weeks was CAD 3072/QALY for 1WC, CAD 3244/QALY for 1W/1BD-S, and CAD 3528/QALY for 1WS. Our model suggests that 1WS is the best strategy since the incremental cost per QALY is below the $50,000 threshold (ICER is CAD 42,328/QALY compared to the next most effective, 1WC). 1W/1BD-S is dominated by the other strategies. The cost-effectiveness acceptability curves suggest that the 1WS group has a higher probability for cost-effectiveness (38 %) than 1W/1BD-S (30 %) and 1WC (32 %) when the willingness to pay is $50,000 per QALY. These results have important implications for health policymakers deciding on delivery of ICBT for the treatment of anxiety and/depressive disorders.

A randomized factorial trial of internet-delivered cognitive behavioural therapy: An 8-week program with or without extended support and booster lesson

While internet-delivered cognitive behavioural therapy (ICBT) is effective, some patients suggest extended support post-treatment could improve care. In this randomized factorial trial, we examined the benefits of an 8-week therapist-assisted ICBT program offered with or without an optional 4-week extension of support (Factor 1) and with or without an optional booster lesson (Factor 2). Patients screened for ICBT for depression and/or anxiety were randomly assigned to the conditions (N = 434) and we examined the use of the extension and booster, differences between those who did or did not use extension or booster, and the impact of the extension or booster on outcomes, engagement, and satisfaction at 26-weeks post-enrollment. Therapists recorded time and observations with offering support during the extension and booster. In the extension group, 54.4% (n = 56) requested the extension, while in the booster group 50.9% (n = 56) accessed the booster, and in the combined group, 41.6% (n = 47) requested the extension and 51.3% (n = 58) accessed the booster. Those who requested the extension were older, and more likely to report medication and mental health service use and severe mental health-related disability at pre-treatment; they also reported putting less effort into ICBT and finding skills more difficult. The booster was more often used among those with lower symptom severity, and those who put more effort into and had more positive experiences with ICBT. As expected, those assigned to extension sent more messages to their therapist, and those assigned to booster logged in more often. Therapists also took more time to deliver ICBT with an extension (>18 min) or booster (>13 min) compared to the 8-week program, and perceived extension and booster as beneficial for some, but not all patients. Treatment satisfaction was high across conditions, and effect sizes were large from pre-treatment to 26-week follow-up on most measures. No significant group differences were found in this study. Lack of group differences, however, could reflect low use of the extension and booster. Results provide helpful information about the demand for extensions and boosters, and provide directions for future research.

Corrigendum to "Transdiagnostic internet-delivered cognitive behaviour therapy with therapist-support offered once-weekly or once-weekly supplemented with therapist support within one-business-day: Pragmatic randomized controlled trial" [Internet Interv. 22 (2020) 1-16/100347]

[This corrects the article DOI: 10.1016/j.invent.2020.100347.].

A pragmatic factorial randomized controlled trial of transdiagnostic internet-delivered cognitive behavioural therapy: Exploring benefits of homework reflection questionnaires and twice-weekly therapist support

With the growing demand for internet-delivered cognitive behavioural therapy (iCBT), this pragmatic factorial (2 × 2 × 2) randomized controlled trial evaluated strategies for facilitating iCBT engagement and outcomes in routine care. Specifically, the benefits to patients and therapists of using homework reflection questionnaires and offering patients twice-weekly therapist support were examined. Patients (n = 632) accepted into iCBT for depression and/or anxiety were randomly assigned to complete homework reflection questionnaires or not (factor 1), receive once- or twice-weekly support (factor 2), and to receive care from therapists employed in one of two settings (iCBT clinic or a community mental health clinic; factor 3). Outcomes were measured at pre-treatment, and 8, 12, and 24-weeks post-enrollment. Therapist time was tracked and a focus group was conducted to examine therapist experiences. No differences in patient outcomes were found between therapists employed in the two settings; as such, these two groups were combined for further analyses. In terms of engagement, homework reflection questionnaires were associated with fewer website log-ins and days accessing iCBT; twice-weekly support was associated with more patient emails sent to therapists. Despite engagement differences, homework reflection questionnaires and twice-weekly support did not significantly impact primary outcomes; all groups showed large improvements in depression and anxiety that were maintained at 24-week follow-up. Therapists perceived a number of benefits and challenges associated with responding to homework reflection questionnaires and offering twice-weekly support; most notably the strategies did not benefit all patients. Twice-weekly support was associated with increased therapist time and organizational challenges. It is concluded that neither completion of homework questionnaires nor offering twice-weekly support significantly improve iCBT in routine care.

Transdiagnostic Internet-delivered cognitive behaviour therapy with therapist support offered once-weekly or once-weekly supplemented with therapist support within one-business-day: Pragmatic randomized controlled trial

In routine care, internet-delivered cognitive behaviour therapy (iCBT) regularly includes therapist support delivered via secure email, but the optimal response time to emails is unknown. In this study, we compared the benefits of therapists providing support once-weekly versus therapists providing support once-weekly supplemented with a one-business-day response to all patient emails. This pragmatic randomized controlled trial included therapists employed by a specialized iCBT clinic or community mental health clinics, where providing iCBT is a secondary service. Patients with depression and/or anxiety who enrolled in transdiagnostic iCBT (5 core lessons over 8 weeks) were randomized to: 1) once-weekly support supplemented with a one-business-day response to patient emails by specialized therapists (n = 233); 2) once-weekly support also offered by specialized therapists (n = 216); or 3) once-weekly support offered by community clinic therapists (n = 226). Outcomes were measured at 8, 12, 24, and 52-weeks post-enrollment. Patient engagement and treatment experiences (e.g., treatment satisfaction, therapist alliance) were also assessed and a focus group was conducted with therapists. Supplementing once-weekly therapist support with a one-business-day response to patient emails resulted in therapists sending more emails to patients (M: 13 versus 9) and required more therapist time over treatment (M: 155 versus 109 min), but was not associated with improved outcomes, patient engagement or treatment experiences. All groups showed large improvements in symptoms of depression and anxiety maintained at 52-week follow-up, strong engagement and positive treatment experiences. Therapists viewed challenges of responding to patient emails within one-business-day to outweigh benefits. Contrary to expectations, supplementing once-weekly therapist support with a one-business-day response to all patient emails did not benefit patients and increased therapist time as well as therapist challenges when delivering iCBT in routine care.

Efficacy of internet-delivered cognitive behavioural therapy following an acute coronary event: A randomized controlled trial

Depression and anxiety are common among people who have experienced an acute coronary event (e.g., heart attack). Multidisciplinary cardiac rehabilitation programs often focus on reducing risk factors associated with future cardiac events, however, mental health interventions are not routinely available. Given known difficulties with access to mental health treatment, the present study sought to explore the efficacy and acceptability of an Internet-delivered cognitive behavioural therapy program (Cardiac Wellbeing Course) among participants who experienced an acute coronary event. The five-lesson course was delivered over eight weeks and was provided with brief weekly contact, via telephone and secure email with a guide. Participants were randomized to the Cardiac Wellbeing Course (n = 25) or waiting-list control group (n = 28). Symptoms were assessed at pre-treatment, post-treatment, and four-week follow-up. Completion rates (84%) and satisfaction ratings (95%) were high. Statistically significant between-group improvements were observed for the treatment group on primary measures of general anxiety (Cohen's d = 1.62; 67% reduction), depression (Cohen's d = 1.09; 61% reduction), and physical activity levels (Cohen's d = 0.27; 70% increase). Statistically significant improvements were also observed on secondary measures of distress (Cohen's d = 0.98; 51% reduction), cardiac anxiety (Cohen's d = 0.92; 34% reduction), and mental-health quality of life (Cohen's d = 0.23; 24% improvement). The changes were maintained at four-week follow-up. The current findings add to the existing literature and highlight the potential of Internet-delivered cognitive behavioural therapy programs among participants who have experienced an acute coronary event.

Influence of an acid soil on the herbage yield and nodulation of five annual pasture legumes

Balansa, persian and subterranean clover and barrel and murex medic were grown in acidic sandy loam in pots in a glasshouse. Four lime treatments (0, 1, 2, 3.5 t/ha) resulted in pH levels of 4.2, 4.7, 5.1 and 6.0 (1:5 CaCl2). After addition of plant nutrients, total exchangeable cations in the nil lime treatment averaged 2.197 cmol(+)/kg, increasing to 4.738 cmol(+)/kg at pH 6.0. With increasing pH, aluminium saturation of the soil exchange was 38, 14, 4 and 3%. The effect of soil acidity on dry matter production was compared between legumes by determining relative yield (yield/maximum yield) responses over the pH range. Subterranean clover was the most tolerant legume, followed by murex medic and balansa clover (similar), persian clover and then barrel medic. All legumes except barrel medic produced at least 90% of maximum yield at pH 4.7; only subterranean clover produced more than 90% of maximum yield at pH 4.2. Establishment of nodules was more sensitive to acidity than indicated by relative yields of dry matter, especially in murex medic and persian clover. Average nodule weight usually increased at lower pH. The dry matter yields of murex medic and persian clover at lower pH were probably reliant on compensatory increases in nodule volume as nodule number declined with increasing acidity.