Internet-delivered treatment for patients suffering from severe functional somatic disorders: Protocol for a randomized controlled trial

Background

Functional somatic disorders (FSDs) with symptoms from multiple organs, i.e., multi-system type, are common in the general population and may lead to disability and reduced quality of life. Evidence for efficient treatment programs has been established, however, there is a need for making treatments accessible to a larger group of patients. Internet-delivered therapy has become prevalent and has proven as effective as face-to-face therapy, while providing a flexible and easily accessible treatment alternative. The aim of the current study is to compare the efficacy of the therapist-assisted internet-delivered treatment program One step at a time (OneStep) with the internet-delivered self-help program Get started (GetStarted).

Methods

A total of 166 participants aged 18-60 years diagnosed with multi-system FSD will be assessed and randomized to either 1) OneStep: a 14-week program consisting of 11 treatment modules based on principles from cognitive behavioural therapy or 2) GetStarted consisting of 1 module on psychoeducation. The primary outcome is physical health, assessed by a Short Form Health Survey (SF-36) aggregate score of the subscales vitality, physical functioning, and bodily pain 3 months after end-of-treatment and self-reported improvement assessed by the Clinical Global Improvement Scale. Secondary outcomes include symptom load, depression, anxiety, and illness worry. Process measures include emotional distress, illness perception, illness behaviour, and symptom interference.

Conclusions

This study is the first study to test an internet-delivered treatment program for FSD, multi-system type and has the potential to show the importance of making evidence-based internet-delivered treatment for FSD more accessible.

Preference trial of internet-delivered cognitive behaviour therapy comparing standard weekly versus optional weekly therapist support

Emerging evidence from research trials suggests that Internet-delivered cognitive behaviour therapy (ICBT) produces similar symptom improvements whether patients receive weekly therapist support (standard support) or therapist support only when requested (optional support). It remains unknown, however, how many patients receiving ICBT as part of routine clinical care would prefer optional support compared to standard support and how outcomes compare when patients select their preferred treatment option. In this uncontrolled trial, we investigated patient preference and outcomes for standard versus optional support among patients with depression and or anxiety who were offered an 8-week transdiagnostic ICBT intervention in routine care. Of 401 patients accepted for ICBT, 22% selected optional support and 78% selected standard support. At assessment, patients who selected optional support had lower symptoms of anxiety and panic than patients who selected standard support. At post-treatment, both groups achieved similar large improvements in symptoms of anxiety and depression, with improvements sustained at 3-month follow-up. Patients receiving optional support sent and received fewer messages compared to patients receiving standard support. This study demonstrates the potential of optional therapist support to meet the needs and preferences of patients and to also reduce therapist costs in routine care.

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.

Randomized controlled trial of internet-delivered cognitive behaviour therapy comparing standard weekly versus optional weekly therapist support

Internet-delivered cognitive behaviour therapy (ICBT) is effective for treating anxiety and depression. The relative benefits of offering standard weekly compared to optional weekly therapist support in conjunction with ICBT within routine care has not been examined. Patients seeking ICBT for depression and or anxiety in routine care were randomized to standard (n=92) or optional (n=88) weekly support. The optional approach resulted in therapists receiving half as many messages from (1.70 vs. 3.96) and sending half as many messages to patients (3.62 vs. 7.29). Optional Support was associated with lower completion rates (56.6% versus 82.4%), but, similar to Standard Support, resulted in large reductions on the GAD-7 (within Cohen's d≥1.08; avg. reduction ≥47%) and PHQ-9 (within Cohen's d≥0.82; avg. reduction ≥43%) at post-treatment and 3-month follow-up. Optional weekly support appears clinically effective and acceptable for many patients and may reduce costs, but safety requires monitoring given lower completion rates.

Transdiagnostic Internet-delivered cognitive behaviour therapy in Canada: An open trial comparing results of a specialized online clinic and nonspecialized community clinics

Effects of Internet-delivered cognitive behaviour therapy (ICBT) for anxiety and depression are not well understood when delivered in non-specialized as compared to specialized clinic settings. This open trial (n=458 patients) examined the benefits of transdiagnostic-ICBT when delivered in Canada by therapists (registered providers or graduate students) working in either a specialized online clinic or one of eight nonspecialized community clinics. Symptoms of depression and anxiety were assessed at pre-treatment, post-treatment and at 3-month follow-up. Completion rates and satisfaction were high. Significant and large reductions (effect sizes 1.17-1.31) were found on symptom measures. Completion rates, satisfaction levels and outcomes did not differ whether ICBT was delivered by therapists working in a specialized online clinic or nonspecialized community clinics. Differences were also not found between registered providers and graduate students, or therapists trained in psychology or another discipline. The findings support the public health potential of ICBT.

Therapist-assisted Internet-delivered cognitive behavior therapy for depression and anxiety: translating evidence into clinical practice

This dissemination study examined the effectiveness of therapist-assisted Internet-delivered Cognitive Behavior Therapy (ICBT) when offered in clinical practice. A centralized unit screened and coordinated ICBT delivered by newly trained therapists working in six geographically dispersed clinical settings. Using an open trial design, 221 patients were offered 12 modules of ICBT for symptoms of generalized anxiety (n=112), depression (n=83), or panic (n=26). At baseline, midpoint and post-treatment, patients completed self-report measures. On average, patients completed 8 of 12 modules. Latent growth curve modeling identified significant reductions in depression, anxiety, stress and impairment (d=.65-.78), and improvements in quality of life (d=.48-.66). Improvements in primary symptoms were large (d=.91-1.25). Overall, therapist-assisted ICBT was effective when coordinated across settings in clinical practice, but further attention should be given to strategies to improve completion of treatment modules.