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Karpov B, Lipsanen JO, Ritola V, Rosenström T, Saarni S, Pihlaja S, Stenberg JH, Laizane P, Joffe G. The Overall Anxiety Severity and Impairment Scale as an Outcome Measure in Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders: Observational Study. J Med Internet Res 2023; 25:e45362. [PMID: 37590055 PMCID: PMC10472172 DOI: 10.2196/45362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 06/20/2023] [Accepted: 06/30/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Internet-delivered cognitive behavioral therapy (iCBT) is effective in the treatment of anxiety disorders. iCBT clinical trials use relatively long and time-consuming disorder-specific rather than transdiagnostic anxiety measurements. Overall Anxiety Severity and Impairment Scale (OASIS) is a brief self-report scale that could offer a universal, easy-to-use anxiety measurement option in disorder-specific and transdiagnostic iCBT programs. OBJECTIVE We aimed to investigate relationships between OASIS and disorder-specific instruments in iCBT. We expected these relationships to be positive. METHODS We investigated patients in original nationwide iCBT programs for generalized anxiety disorder (GAD), obsessive-compulsive disorder, panic disorder, and social anxiety disorder, which were administered by Helsinki University Hospital, Finland. In each program, anxiety symptoms were measured using both disorder-specific scales (the 7-item Generalized Anxiety Disorder scale, Penn State Worry Questionnaire, revised Obsessive-Compulsive Inventory, Panic Disorder Severity Scale, and Social Phobia Inventory) and by OASIS. A general linear model for repeated measures (mixed models) and interaction analysis were used for investigating the changes and relationships in the mean scores of OASIS and disorder-specific scales from the first session to the last one. RESULTS The main effect of linear mixed models indicated a distinct positive association between OASIS and disorder-specific scale scores. Interaction analysis demonstrated relatively stable associations between OASIS and the revised Obsessive-Compulsive Inventory (F822.9=0.09; 95% CI 0.090-0.277; P=.32), and OASIS and the Panic Disorder Severity Scale (F596.6=-0.02; 95% CI -0.108 to -0.065; P=.63) from first the session to the last one, while the 7-item Generalized Anxiety Disorder scale (F4345.8=-0.06; 95% CI -0.109 to -0.017; P=.007), Penn State Worry Questionnaire (F4270.8=-0.52; 95% CI -0.620 to -0.437; P<.001), and Social Phobia Inventory (F862.1=-0.39; 95% CI -0.596 to -0.187; P<.001) interrelated with OASIS more strongly at the last session than at the first one. CONCLUSIONS OASIS demonstrates clear and relatively stable associations with disorder-specific symptom measures. Thus, OASIS might serve as an outcome measurement instrument for disorder-specific and plausibly transdiagnostic iCBT programs for anxiety disorders in regular clinical practice.
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Affiliation(s)
- Boris Karpov
- Department of Psychiatry, Helsinki University Hospital, Helsinki, Finland
| | | | - Ville Ritola
- Department of Psychiatry, Helsinki University Hospital, Helsinki, Finland
| | - Tom Rosenström
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Suoma Saarni
- Department of Psychiatry, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Satu Pihlaja
- Department of Psychiatry, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jan-Henry Stenberg
- Department of Psychiatry, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Grigori Joffe
- Department of Psychiatry, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Rosenström TH, Ritola V, Saarni S, Joffe G, Stenberg JH. Measurement Invariant but Non-Normal Treatment Responses in Guided Internet Psychotherapies for Depressive and Generalized Anxiety Disorders. Assessment 2023; 30:618-632. [PMID: 34905968 PMCID: PMC9999284 DOI: 10.1177/10731911211062500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Assessment of treatment response in psychotherapies can be undermined by lack of longitudinal measurement invariance (LMI) in symptom self-report inventories, by measurement error, and/or by wrong model assumptions. To understand and compare these threats to validity of outcome assessment in psychotherapy research, we studied LMI, sum scores, and Davidian Curve Item Response Theory models in a naturalistic guided internet psychotherapy treatment register of 2,218 generalized anxiety disorder (GAD) patients and 3,922 depressive disorder (DD) patients (aged ≥16 years). Symptoms were repeatedly assessed by Generalized Anxiety Disorder Assessment-7 (GAD-7) or Beck Depression Inventory. The symptom self-reports adhered to LMI under equivalence testing, suggesting sum scores are reasonable proxies for disorder status. However, the standard LMI assumption of normally distributed latent factors did not hold and inflated treatment response estimates by 0.2 to 0.3 standard deviation units compared with sum scores. Further methodological research on non-normally distributed latent constructs holds promise in advancing LMI and mental health assessment.
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Affiliation(s)
- Tom H. Rosenström
- University of Helsinki, Finland
- Tom H. Rosenström, Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, PL 21 (Haartmaninkatu 3), 00014 Helsinki, Finland.
| | - Ville Ritola
- University of Helsinki, Finland
- Helsinki University Hospital, Finland
| | - Suoma Saarni
- University of Helsinki, Finland
- Helsinki University Hospital, Finland
| | - Grigori Joffe
- University of Helsinki, Finland
- Helsinki University Hospital, Finland
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Mylläri S, Saarni SE, Ritola V, Joffe G, Stenberg JH, Solbakken OA, Czajkowski NO, Rosenström T. Text Topics and Treatment Response in Internet-Delivered Cognitive Behavioral Therapy for Generalized Anxiety Disorder: Text Mining Study. J Med Internet Res 2022; 24:e38911. [DOI: 10.2196/38911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/08/2022] [Accepted: 09/28/2022] [Indexed: 11/11/2022] Open
Abstract
Background
Text mining methods such as topic modeling can offer valuable information on how and to whom internet-delivered cognitive behavioral therapies (iCBT) work. Although iCBT treatments provide convenient data for topic modeling, it has rarely been used in this context.
Objective
Our aims were to apply topic modeling to written assignment texts from iCBT for generalized anxiety disorder and explore the resulting topics’ associations with treatment response. As predetermining the number of topics presents a considerable challenge in topic modeling, we also aimed to explore a novel method for topic number selection.
Methods
We defined 2 latent Dirichlet allocation (LDA) topic models using a novel data-driven and a more commonly used interpretability-based topic number selection approaches. We used multilevel models to associate the topics with continuous-valued treatment response, defined as the rate of per-session change in GAD-7 sum scores throughout the treatment.
Results
Our analyses included 1686 patients. We observed 2 topics that were associated with better than average treatment response: “well-being of family, pets, and loved ones” from the data-driven LDA model (B=–0.10 SD/session/∆topic; 95% CI –016 to –0.03) and “children, family issues” from the interpretability-based model (B=–0.18 SD/session/∆topic; 95% CI –0.31 to –0.05). Two topics were associated with worse treatment response: “monitoring of thoughts and worries” from the data-driven model (B=0.06 SD/session/∆topic; 95% CI 0.01 to 0.11) and “internet therapy” from the interpretability-based model (B=0.27 SD/session/∆topic; 95% CI 0.07 to 0.46).
Conclusions
The 2 LDA models were different in terms of their interpretability and broadness of topics but both contained topics that were associated with treatment response in an interpretable manner. Our work demonstrates that topic modeling is well suited for iCBT research and has potential to expose clinically relevant information in vast text data.
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Stenberg JH, Ritola V, Joffe G, Saarni S, Rosenström T. Effectiveness of mobile-delivered, therapist-assisted cognitive behavioral therapy for insomnia in nationwide routine clinical care in Finland. J Clin Sleep Med 2022; 18:2643-2651. [PMID: 35929590 PMCID: PMC9622989 DOI: 10.5664/jcsm.10186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Internet-delivered cognitive behavioral therapies (iCBTs) are efficacious for insomnia. Few studies have as yet reported their effectiveness in routine care. The objective of this study was to examine the effectiveness of the new Finnish 7-session HUS Helsinki University Hospital-iCBT for Insomnia (HUS-iCBTI) program in nationwide routine care. METHODS We studied 2,464 physician-referred patients in therapist-supported iCBTI. Treatment was free of charge for patients. The primary measure was the Insomnia Severity Index (ISI); the Patient Health Questionnaire, 4-item version (PHQ-4), and the Alcohol Use Disorders Identification Test (AUDIT-C) were also administered. RESULTS As many as 75.4% completed the treatment, with the ISI scores declining, on average, by -7.04 points during treatment. Altogether, 91.1% of the completers improved in terms of having a lower ISI score in phase 7 than in phase 1 and 34.0% of the completers achieved remission by phase 7 (ISI score < 8); 46.0% responded to treatment (ISI-score reduction of ≥ 8 points from phase 1). The Cohen's effect size (ISI-score decline) was d = -1.449, showing a large effect. CONCLUSIONS We observed large benefits for this publicly funded therapist-supported treatment in its naturalistic setting as a part of routine care. Effect sizes were comparable to randomized controlled trials reported earlier. HUS-iCBTI appears to be effective as a treatment for insomnia and may also reduce the risk of other adverse health consequences associated with poor sleep. CITATION Stenberg J-H, Ritola V, Joffe G, Saarni S, Rosenström T. Effectiveness of mobile-delivered, therapist-assisted cognitive behavioral therapy for insomnia in nationwide routine clinical care in Finland. J Clin Sleep Med. 2022;18(11):2643-2651.
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Affiliation(s)
- Jan-Henry Stenberg
- Department of Psychiatry, Helsinki University Hospital, Helsinki, Finland
| | - Ville Ritola
- Department of Psychiatry, Helsinki University Hospital, Helsinki, Finland
| | | | - Suoma Saarni
- Department of Psychiatry, Helsinki University Hospital, Helsinki, Finland
| | - Tom Rosenström
- Department of Psychiatry, Helsinki University Hospital, Helsinki, Finland
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
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Ritola V, Lipsanen JO, Pihlaja S, Gummerus EM, Stenberg JH, Saarni S, Joffe G. Internet-Delivered Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Nationwide Routine Care: Effectiveness Study. J Med Internet Res 2022; 24:e29384. [PMID: 35323119 PMCID: PMC8990365 DOI: 10.2196/29384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/30/2021] [Accepted: 12/16/2021] [Indexed: 12/21/2022] Open
Abstract
Background Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficacious for generalized anxiety disorder (GAD), but few studies are yet to report its effectiveness in routine care. Objective In this study, we aim to examine whether a new 12-session iCBT program for GAD is effective in nationwide routine care. Methods We administered a specialized, clinic-delivered, therapist-supported iCBT for GAD in 1099 physician-referred patients. The program was free of charge for patients, and the completion time was not predetermined. We measured symptoms with web-based questionnaires. The primary measure of anxiety was the GAD 7-item scale (GAD-7); secondary measures were, for pathological worry, the Penn State Worry Questionnaire and, for anxiety and impairment, the Overall Anxiety Severity and Impairment Scale. Results Patients completed a mean 7.8 (SD 4.2; 65.1%) of 12 sessions, and 44.1% (485/1099) of patients completed all sessions. The effect size in the whole sample for GAD-7 was large (Cohen d=0.97, 95% CI 0.88-1.06). For completers, effect sizes were very large (Cohen d=1.34, 95% CI 1.25-1.53 for GAD-7; Cohen d=1.14, 95% CI 1.00-1.27 for Penn State Worry Questionnaire; and Cohen d=1.23, 95% CI 1.09-1.37 for Overall Anxiety Severity and Impairment Scale). Noncompleters also benefited from the treatment. Greater symptomatic GAD-7–measured relief was associated with more completed sessions, older age, and being referred from private or occupational care. Of the 894 patients with a baseline GAD-7 score ≥10, approximately 421 (47.1%) achieved reliable recovery. Conclusions This nationwide, free-of-charge, therapist-supported HUS Helsinki University Hospital–iCBT for GAD was effective in routine care, but further research must establish effectiveness against other treatments and optimize the design of iCBT for GAD for different patient groups and individual patients.
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Affiliation(s)
- Ville Ritola
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jari Olavi Lipsanen
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - Satu Pihlaja
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eero-Matti Gummerus
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jan-Henry Stenberg
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Suoma Saarni
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Grigori Joffe
- Department of Psychiatry, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Pihlaja S, Lahti J, Lipsanen JO, Ritola V, Gummerus EM, Stenberg JH, Joffe G. Scheduled Telephone Support for Internet Cognitive Behavioral Therapy for Depression in Patients at Risk for Dropout: Pragmatic Randomized Controlled Trial. J Med Internet Res 2020; 22:e15732. [PMID: 32706658 PMCID: PMC7413288 DOI: 10.2196/15732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/20/2019] [Accepted: 04/21/2020] [Indexed: 12/19/2022] Open
Abstract
Background Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficient in the treatment of depression. However, the optimal mode and intensity of therapist support remain to be identified. Scheduled telephone support (STS) may improve adherence and outcomes but, as it is time- and resource-consuming, should be reserved for patients for whom the usual support may be insufficient. Objective This paper aims to reveal whether add-on STS for patients at risk of dropping out improves treatment adherence and symptoms in iCBT for depression. Methods Among patients participating in an ongoing large observational routine clinical practice study of iCBT for depression delivered nationwide by Helsinki University Hospital (HUS-iCBT), those demonstrating a ≥14-day delay in initiation of treatment received invitations to this subsidiary STS study. A total of 100 consenting patients were randomly allocated to either HUS-iCBT as usual (control group, n=50) or HUS-iCBT plus add-on STS (intervention group, n=50). Proportions of those reaching midtreatment and treatment end point served as the primary outcome; secondary outcomes were change in Beck Depression Inventory (BDI)–measured depressive symptoms and time spent in treatment. Results Add-on STS raised the proportion of patients reaching midtreatment compared with HUS-iCBT as usual (29/50, 58% vs 18/50, 36%; P=.045) and treatment end point (12/50, 24% vs 3/50, 6%; P=.02). Change in BDI score also favored add-on STS (3.63 points vs 1.1 points; P=.049), whereas duration of treatment did not differ. Conclusions Add-on STS enhances adherence and symptom improvement of patients at risk of dropping out of iCBT for depression in routine clinical practice. Trial Registration International Standard Randomised Controlled Trial Number (ISRCTN) 55123131; http://www.isrctn.com/ISRCTN55123131.
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Affiliation(s)
- Satu Pihlaja
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Hospital District of Helsinki and Uusimaa, Helsinki, Finland
| | - Jari Lahti
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Olavi Lipsanen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Ville Ritola
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Hospital District of Helsinki and Uusimaa, Helsinki, Finland
| | - Eero-Matti Gummerus
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Hospital District of Helsinki and Uusimaa, Helsinki, Finland
| | - Jan-Henry Stenberg
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Hospital District of Helsinki and Uusimaa, Helsinki, Finland
| | - Grigori Joffe
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Hospital District of Helsinki and Uusimaa, Helsinki, Finland
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Pihlaja S, Stenberg JH, Joutsenniemi K, Mehik H, Ritola V, Joffe G. Therapeutic alliance in guided internet therapy programs for depression and anxiety disorders - A systematic review. Internet Interv 2018; 11:1-10. [PMID: 30135754 PMCID: PMC6084872 DOI: 10.1016/j.invent.2017.11.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/11/2017] [Accepted: 11/15/2017] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE The role of internet therapy programs for mental disorders is growing. Those programs employing human support yield better outcomes than do those with no such support. Therapeutic alliance may be a critical element in this support. Currently, the significance of therapeutic alliance in guided, internet-delivered cognitive behavioral therapy programs (iCBT) remains unknown. This review aims to determine whether the therapeutic alliance influences outcome of iCBTs and if it does, what plausible factors underlie this association. METHOD Towards that goal searches were made in PubMed, PsycINFO, SCOPUS, The Cochrane Library and CINAHL in May 2016 and January 2017. RESULTS From the 1658 relevant studies, only six studied the relationship of therapeutic alliance and outcome. All six studies showed a high level of client-therapist alliance; in the three most recent studies, the alliance was directly associated with outcome. No studies reported alliance-adherence associations. CONCLUSIONS Alliance research in iCBT for mental disorders is scarce. Therapeutic alliance seems to associate with outcomes. More studies are necessary to define the optimal support to strengthen alliance. iCBT is a feasible environment for alliance research both practically and theoretically. The impact of alliance on adherence to iCBT requires study.
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Affiliation(s)
| | | | | | | | | | - Grigori Joffe
- Hospital District of Helsinki and Uusimaa, Department of Psychiatry, University of Helsinki and Helsinki University Hospital, P.O. Box 590, 00029 HUS, Finland
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