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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

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

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.

Perceptions of client stories in internet-delivered cognitive behaviour therapy: A mixed-methods evaluation

Internet-delivered Cognitive-Behavioural Therapy (ICBT) aims to support people with mental health concerns using online treatment materials. Client stories (either real or a composite based on many clients) are often used in ICBT to facilitate learning. However, these stories remain understudied in terms of how they are perceived by clients, as well as their relationship to ICBT engagement, satisfaction, and outcomes. Among a sample of 324 clients enrolled in transdiagnostic ICBT targeting symptoms of depression and anxiety, we examined client perceptions of stories through mixed-method qualitative (open-ended) and quantitative (closed-ended) data collection. Specifically, 234 (72.22 %) clients responded to questions about stories at 4 weeks and 221 (68.21 %) responded to questions at 8 weeks. Most clients who responded to questions endorsed reviewing at least some stories (79.06 % at 4 weeks, 71.95 % at 8 weeks). Moreover, they rated stories positively in terms of being relatable, making clients feel less alone, increasing knowledge, providing ideas for how to use skills, and motivating clients to use skills. These perceptions of stories remained stable over the course of treatment. Stories were perceived more positively among those with lower symptom severity at 8 weeks as well as those who were more satisfied with ICBT at 8 weeks. Story perceptions at 4 weeks were predictive of decreased post-treatment anxiety symptom severity but not depression while controlling for baseline scores, age, and education. 26.49 % of clients at 4 weeks who reviewed stories and 33.33 % at 8 weeks provided suggestions about how to improve stories. In a qualitative analysis, we found 5 categories of suggestions including increasing the variety of issues and relatability of stories, ensuring the stories are realistic, refining the formatting, and making the stories shorter. Overall, this study provides insights into how client stories could be improved to play a more significant role in future ICBT programs.

Effectiveness of Internet-based cognitive-behavioural therapy for obsessive-compulsive disorder (OCD-NET) and body dysmorphic disorder (BDD-NET) in the Swedish public health system using the RE-AIM implementation framework

Objectives

Therapist-guided internet-delivered cognitive behaviour therapy (ICBT) is an efficacious treatment for obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD), but it is unclear if the results obtained in controlled trials can be reproduced in clinical settings. We evaluated the implementation of ICBT for OCD (OCD-NET) and BDD (BDD-NET) in the Swedish public health system.

Methods

Consecutive referrals to an outpatient psychiatric clinic providing ICBT, with a primary diagnosis of OCD or BDD, were included in the study. Four hundred and thirty-four participants started OCD-NET and 163 started BDD-NET. The primary outcome measures were the Yale Brown Obsessive Compulsive Scale (Y-BOCS) and the Y-BOCS for BDD (BDD-YBOCS), respectively. Participants were assessed before treatment, weekly during treatment, and after treatment. The study used the RE-AIM implementation framework, and the elements of reach, effectiveness, adoption, and implementation for the evaluation.

Results

Intention to treat analysis of the OCD-NET sample (n = 434) showed a significant decrease in OCD symptoms from pre-treatment to post-treatment (mean reduction = -8.77 [95 % CI -9.48 to -8.05] p < .001, d = 1.94 [95 % CI 1.75 to 2.13]). Forty-nine percent (95 % CI 43 % to 56 %) of the participants in OCD-NET were classified as treatment responders and 21 % (95 % CI 16 % to 27 %) were in remission. Participants in BDD-NET (n = 163) also showed a significant decrease in BDD symptoms from pre-post treatment (mean reduction = -11.37 [95 % CI -12.9 to -9.87] p < .001, d = 2.07 [95 % CI 1.74 to 2.40]) and 69 % (95 % CI 58 % to 79 %) of the participants were classified as treatment responders and 48 % (95 % CI 38 % to 58 %) were in full or partial remission. Eighty-seven percent of the participants in OCD-NET and 78 % in BDD-NET were treatment completers and participants in both treatment groups reported a high treatment satisfaction at post treatment (OCD-NET = 87 %, BDD-NET = 79 %). The most reported negative effects attributed to the treatments were transient experiences of unpleasant feelings (52 %) and anxiety (50 %). The implementation also influenced treatment delivery and dramatically decreased the mean number of patients waiting to receive face-to-face treatment at the clinic.

Conclusions

Our results indicate that OCD-NET and BDD-NET are suitable treatments for implementation in a Swedish public health service.

Internet-delivered cognitive behaviour therapy for chronic health conditions: self-guided versus team-guided

There is growing interest in offering Internet-delivered cognitive behaviour therapy (ICBT) to individuals with chronic health conditions, with this process often being guided by a single clinician. Due to lack of full time personnel, it is sometimes necessary to have multiple clinicians offer guidance or for no guidance to be offered. In this randomized trial, we compared team-guided ICBT (n = 90) to self-guided ICBT (n = 88). Participants completed measures at pre-, post-, and 3-months post-ICBT. Both groups showed similar rates of treatment completion and large improvements on depression and anxiety at post-treatment and follow-up. Unexpectedly, more participants in the self-guided versus team-guided condition showed clinically significant improvement on depression at post-treatment (76.5% vs 49.2%) and follow-up (70% vs 45.6%). Thus, team-guided ICBT may not provide significant benefits compared to self-guided ICBT. However, it may be an alternative approach to consider among a population of high risk individuals that wants or requires closer monitoring of symptoms.

Trail registration TRN: NCT03500237; Date: April 18, 2018.

Improving internet-delivered cognitive behaviour therapy for alcohol misuse: Patient perspectives following program completion

Although Internet-delivered cognitive behaviour therapy (ICBT) for alcohol misuse is efficacious in research trials, it is not routinely available in practice. Moreover, there is considerable variability in engagement and outcomes of ICBT for alcohol misuse across studies. The Alcohol Change Course (ACC) is an ICBT program that is offered free of charge by an online clinic in Saskatchewan, Canada, which seeks to fill this service gap, while also conducting research to direct future improvements of ICBT. As there is limited qualitative patient-oriented research designed to improve ICBT for alcohol misuse, in this study, we describe patient perceptions of the ACC post-treatment. Specifically, post-treatment feedback was obtained from 191 of 312 patients who enrolled in the ACC. Qualitative thematic analysis was used to examine post-treatment written comments related to what patients liked and disliked about the course, which skills were most helpful for them, and their suggestions for future patients. The majority of patients endorsed being very satisfied or satisfied with the course (n = 133, 69.6%) and 94.2% (n = 180) perceived the course as being worth their time. Worksheets (n = 61, 31.9%) and reflections of others (n = 40, 20.9%) received the most praise. Coping with cravings (n = 63, 33.0%), and identifying and managing risky situations (n = 46, 24.1%) were reported as the most helpful skills. Several suggestions for refining the course were provided with the most frequent recommendation being a desire for increased personal interaction (n = 24, 12.6%) followed by a desire for wanting more information (n = 22, 11.5%). Many patients offered advice for future ACC patients, including suggestions to make a commitment (n = 47, 24.6%), do all of the work (n = 29, 15.2%), and keep a consistent approach to the course (n = 24, 12.6%). The results provide valuable patient-oriented directions for improving ICBT for alcohol misuse.

Experiences from implementation of internet-delivered cognitive behaviour therapy for insomnia in psychiatric health care: a qualitative study applying the NASSS framework

BACKGROUND

Insomnia is a common diagnosis among patients in psychiatric health care and effective treatments are highly demanded. Previous research suggests that internet-delivered cognitive behavioural therapy for insomnia (ICBT-i) is helpful for a variety of patients and may be effective for psychiatric health care patients. Little is known about implementation of ICBT-i in psychiatric health care. The aim of this study was to explore experiences among therapists and managers who participated in a pilot implementation of ICBT-i in outpatient psychiatric health care, and to identify determinants for the implementation.

METHODS

Semi-structured interviews were conducted with 7 therapists and 5 managers working in outpatient psychiatric health care and directly involved with the pilot implementation. Data were analysed using qualitative content analysis guided by the NASSS framework, combining inductive and deductive approaches.

RESULTS

The analysis revealed 32 facilitators, 21 barriers, and 2 determinants that were both a barrier and a facilitator, organised in 1-5 themes under each of the 7 NASSS domains. Key facilitators included: meeting a demand for treatment options with the ICBT-i programme, the experienced benefits of ICBT-i as a treatment option for insomnia, training and support, engagement and support from managers and the wider system, and a long-term organisation for maintenance of the technology. Key barriers included: low interest in ICBT-i among therapists, difficulty in recruiting patients, perceived low ability in therapists to deliver treatment online, technical problems, and therapists' competing demands leading to low priority of ICBT-i. Complexity analysis assessed two NASSS domains as simple, four as complicated, and one as complex.

CONCLUSIONS

The study contributes new knowledge and insights into the implementation process of ICBT-i in psychiatric health care. Our findings highlight the importance of providing training, support, and guidance in online treatment for therapists when implementing a technological innovation. Technical problems should be minimised and the maintenance and demand-side value for the technology must be clear. Support from managers at all levels is crucial, particularly support to therapists in everyday prioritisation among competing demands. Besides taking the identified determinants into account, managing complexity is important for successful scale-up implementation.

Audit and feedback of therapist-assisted internet-delivered cognitive behaviour therapy within routine care: A quality improvement case study

With the growing use of ICBT in routine care clinics there is a need for literature on how to monitor and improve the quality of therapist behaviours in clinical practice. In this paper, we first provide background literature on Audit and Feedback (A&F), a common quality improvement technique, and then present a case study regarding the use of A&F to improve quality of therapist behaviours in emails sent to patients provided with ICBT in routine care. The A&F measure used was derived from previous research on therapist's email behaviours in ICBT. Fifteen undesirable therapist behaviours (e.g., Did Not Message, Unresponsive to Symptom Increase, Does Not Address Patient Concern) were audited in 1840 emails sent from eight therapists to 198 randomly selected patients, representing 18% of 1114 patients who started between one and five lessons of ICBT in the previous year and did not formally withdraw from treatment (n = 31 patients). The therapists who were audited were provided feedback four times over a one-year period from October 2018 to September 2019. Overall, in all audit periods, we found a low percentage of undesirable therapist behaviours (i.e., therapists displayed the behaviour in 12% or less of the total emails sent). For most therapist behaviours, we saw a trend towards improvement across the four audit cycles. Three therapist behaviours (i.e., Failure to Ask One Question to the Patient, Poor Instructions, Not Linking Email to Course Content) did not follow this pattern and were flagged for clinical discussion to determine why behaviours were elevated and whether these behaviours represented unrealistic expectations. The process was valuable for monitoring and improving therapist behaviours and highlights the need for future research on standards for therapist behaviours (e.g., which behaviours to focus on, setting acceptable levels of undesirable behaviour).

A randomized controlled trial of internet-delivered cognitive behaviour therapy to prevent the development of depressive disorders in older adults with multimorbidity

BACKGROUND

Multimorbidity, which commonly impacts older adults is associated with higher rates of depression. We aimed to investigate whether internet delivered cognitive-behaviour therapy (iCBT) could prevent depressive disorders in older adults with multimorbidity who were not currently depressed.

METHOD

302 primary care and community participants aged 65 years and over, who had multimorbidity but did not meet criteria for a depressive disorder were randomised to an intervention group who received an eight-week, five session iCBT (n = 150) or to a control group (n = 152) who received treatment as usual. Diagnostic interviews were conducted at baseline, and three and six months after the intervention period, where indicated, and the presence of depressive disorder was the primary outcome.

RESULTS

The intention to treat, chi-square analyses indicated there were significantly fewer cases of depressive disorder in the treatment group compared to the control group by six-month follow-up (χ²(1,302) = 5.21, p = .02).

LIMITATIONS

The main limitations of this RCT are a short follow up period and low proportion of participants who developed depressive disorders. Participants were relatively well educated, with a majority having English as their first language.

CONCLUSIONS

These results indicate that depressive disorder was prevented in the first six months following iCBT with three times the number of cases of depressive disorder in the control group compared to the treatment group. Further research is required to determine whether iCBT can be effective for preventing depressive disorder in this population over a longer time period.

Negative effects associated with internet-delivered cognitive behaviour therapy: An analysis of client emails

Internet-delivered cognitive behaviour therapy (ICBT) is an efficacious form of treatment for anxiety and depression, yet it is still possible for clients to experience negative effects associated with treatment. In the ICBT literature, the term negative effects is broadly used to refer to all potentially adverse or unwanted events or experiences that are perceived as undesirable by the client and may or may not be associated with long-term symptoms or distress. Previous ICBT studies have asked clients to retrospectively describe negative effects at post-treatment; however, no research has examined the content of clients' emails to their therapist to see whether clients are reporting negative effects as they arise. In the current study, 96 clients (80 completers; 16 non-completers) were randomly selected from a published ICBT trial and directed content analysis was used to examine client emails for mention of negative effects. In addition, correlational analyses were used to examine the relationship between negative effects and: 1) demographic characteristics; 2) treatment engagement; 3) treatment satisfaction; 4) working alliance; and 5) symptom outcomes among completers. The results indicated that 61.5% of clients experienced at least one negative effect during treatment, although total number of negative effects was not significantly correlated with client demographic characteristics, lessons completed, working alliance, treatment satisfaction, or symptom outcomes. Among completers, technical difficulties, implementation problems, and negative emotional states were the most commonly reported negative effects, whereas dropout was the most commonly reported negative effect by non-completers. Negative effects that have been identified in previous research, such as symptom deterioration, novel symptoms, and severe adverse events, were not identified in client emails. The high incidence of negative effects in the current study suggests there may be value in systematically monitoring client emails for negative effects throughout treatment as a supplement to retrospective post-treatment reports. This will give therapists the opportunity to intervene as negative effects occur and potentially mitigate any impact they have on treatment outcomes. Future research, both qualitative and quantitative, is needed to gain a more nuanced understanding of negative effects associated with ICBT.

Development of the Internet-Delivered Cognitive Behaviour Therapy Undesirable Therapist Behaviours Scale (ICBT-UTBS)

Internet-delivered cognitive behaviour therapy (ICBT) is often provided with therapist assistance via asynchronous secure emails, but there is limited research on undesirable behaviours exhibited by therapists in their correspondence with patients. In this study, an ICBT-Undesirable Therapist Behaviour Scale (ICBT-UTBS) was developed and used to assess the nature, frequency, and correlates of undesirable therapist behaviours in routine practice. Thematic analysis was used to identify undesirable therapist behaviours in 720 emails sent to 91 randomly selected patients in the context of a previous clinical trial of transdiagnostic ICBT for depression and anxiety. The following undesirable behaviours were identified, albeit infrequently, in therapist emails: inadequate detail (6.4%), unaddressed content (4.0%), unsupportive tone (0.6%), missed correspondence (0.6%), inappropriate self-disclosure (0.6%), and unmanaged risk (0.3%). At least one undesirable behaviour was found in 10.7% of all emails coded. Moreover, 37.4% of patients received at least one email containing an undesirable therapist behaviour. Number of undesirable therapist behaviours was not correlated with patient engagement, working alliance, treatment satisfaction, or patient outcome variables. However, undesirable therapist behaviours were negatively correlated with patient gender and therapist characteristics (e.g., clinical setting, therapist profession). The results of the present study provide preliminary psychometric support for the ICBT-UTBS, a measure of ICBT treatment integrity. In the future, the ICBT-UTBS should be used in combination with the ICBT-Therapist Rating Scale (ICBT-TRS), a measure of desirable or recommended therapist behaviours, for training purposes and to monitor ICBT therapists in routine practice.

ICBT in routine care: A descriptive analysis of successful clinics in five countries

Clinical trials have demonstrated the efficacy of internet delivered cognitive behaviour therapy (ICBT) for anxiety and depression. However, relatively little is known about the context, operations, and outcomes of ICBT when administered as part of routine care. This paper describes the setting, relationship to existing health services, procedures for referral, assessment, treatment, patients and outcomes of ICBT clinics in Sweden, Denmark, Norway, Canada and Australia. All five clinics provide services free or at low cost to patients. All have systems of governance to monitor quality of care, patient safety, therapist performance and data security. All five clinics include initial assessments by clinicians and between 10 and 20 min of therapist support during each week. Published reports of outcomes all demonstrate large clinical improvement, low rates of deterioration, and high levels of patient satisfaction. Services that require a face to face assessment treat smaller numbers of patients and have fewer patients from remote locations. The paper shows that therapist-guided ICBT can be a valuable part of mental health services for anxiety and depression. Important components of successful ICBT services are rigorous governance to maintain a high standard of clinical care, and the measurement and reporting of outcomes.

Development and evaluation of a scale assessing therapist fidelity to guidelines for delivering therapist-assisted Internet-delivered cognitive behaviour therapy

Internet-delivered cognitive behaviour therapy (ICBT) is often accompanied by therapist emails, but there is limited research on the quality of this therapist-assistance. In this study, an ICBT Therapist Rating Scale (ICBT-TRS) was developed and evaluated to assess whether therapist emails showed fidelity to specific therapist behaviours. Using data from a previous ICBT trial for depression and anxiety, the ICBT-TRS was used to rate 706 emails sent by 39 therapists to 91 randomly selected patients. Emails were rated for adherence (absent/present) and quality (inadequate/competent) on the following behaviours: Builds Rapport, Seeks Feedback, Provides Symptom Feedback, Provides Psychoeducation, Facilitates Understanding, Praises Effort, Encourages Practice, Clarifies Administrative Procedures, and Communicates Effectively. Inter-rater reliability was high. Most behaviours were identified as present in 72-100% of emails, with the exception of Provides Symptom Feedback and Facilitating Understanding which were only present in 54 and 61% of emails. The majority of emails were rated as high quality (88-98% of messages). While not related to symptom improvement, ICBT-TRS ratings were higher when patients were more engaged in ICBT (e.g. log-ins) and among therapists who specialized in ICBT or had a background in Psychology. The ICBT-TRS has potential to facilitate ICBT research and clinical training.

Content of client emails in internet-delivered cognitive behaviour therapy: A comparison between two trials and relationship to client outcome

Many Internet-delivered cognitive behavioural therapy (ICBT) programs include email communication between clients and therapists as a part of treatment; yet relatively little is known about the nature and impact of this communication. Previous research conducted by Svartvatten et al. (2015) has identified 10 themes in written correspondence by clients accessing ICBT for depression. The current study examined: (1) if previously identified themes in client emails would be present in a shorter ICBT program for depression and anxiety; and (2) whether themes in emails similarly correlated with symptom improvement, lesson completion, and perceptions of working alliance. Using 80 randomly selected clients from a published ICBT trial (ISRCTN42729166; Hadjistavropoulos et al., 2016), client emails (average 5.69 per client) were examined for the presence of the themes reported by Svartvatten et al. (2015) and correlated with symptom improvement, lesson completion, perceptions of working alliance. Although most themes developed by Svartvatten et al. (2015) were identified in client emails, the frequency of themes differed between studies. Most notably, emails in the current study were more often coded as involving alliance bolstering (~39% vs. 22% of statements) and identification of patterns and problem behaviours (~25% vs. 6% of statements). Greater frequency of tries alternative behaviour and identifies patterns and problem behaviours were correlated with a greater number of lessons completed. In terms of symptom change, greater frequency of maladaptive repetitive thinking and problems with treatment content in the emails were correlated with smaller improvements in anxiety, whereas observes positive consequences was correlated with larger improvements in anxiety. Similarly, greater frequency of maladaptive repetitive thinking was correlated with smaller improvements in depression. Regarding perceptions of working alliance, more frequent statements of observes positive consequences was correlated with higher alliance. The research provides clinicians and researchers with an improved understanding of the comparability and meaning of client communication in different ICBT programs. Experimental research is needed to better understand the role of client communication in ICBT.

Two-year outcome of internet-based relapse prevention for partially remitted depression

The objective of the study was to investigate the long-term effects of internet-based relapse prevention for sufferers of partially remitted depression. Eighty-four individuals with partially remitted unipolar depression were randomized to either internet-based CBT (iCBT) or to a control group. After the ten week intervention period the participants were followed for 24 months and diagnostic interviews conducted to detect relapse. The intervention and monthly self-ratings of depressive symptoms were administered via an internet-based platform that ensured secure communication with all participants. Significantly fewer participants in the iCBT group had experienced a relapse compared with those in the control group two years after the internet-based intervention. The relapse rate in the iCBT group was 13.7% (CI 95%=2.5-24.9) and in the control group it was 60.9% (CI 95%=44.8-77). Furthermore, a significantly larger proportion of the iCBT group experienced remission two years after the intervention compared with the control group. Internet-based CBT seems promising for preventing relapse in sufferers of partially remitted depression.