Blake F. Dear

Improving Adherence and Clinical Outcomes in Self-Guided Internet Treatment for Anxiety and Depression: Randomised Controlled Trial

Background Depression and anxiety are common, disabling and chronic. Self-guided internet-delivered treatments are popular, but few people complete them. New strategies are required to realise their potential. Aims To evaluate the effect of automated emails on the effectiveness, safety, and acceptability of a new automated transdiagnostic self-guided internet-delivered treatment, the Wellbeing Course, for people with depression and anxiety. Method A randomised controlled trial was conducted through the website: www.ecentreclinic.org. Two hundred and fifty seven people with elevated symptoms were randomly allocated to the 8 week course either with or without automated emails, or to a waitlist control group. Primary outcome measures were the Patient Health Questionnaire 9-Item (PHQ-9) and the Generalized Anxiety Disorder 7-Item (GAD-7). Results Participants in the treatment groups had lower PHQ-9 and GAD-7 scores at post-treatment than controls. Automated emails increased rates of course completion (58% vs. 35%), and improved outcomes in a subsample with elevated symptoms. Conclusions The new self-guided course was beneficial, and automated emails facilitated outcomes. Further attention to strategies that facilitate adherence, learning, and safety will help realise the potential of self-guided interventions. Trial Registration Australian and New Zealand Clinical Trials Registry ACTRN12610001058066

Transdiagnostic internet treatment for anxiety and depression: A randomised controlled trial

Disorder-specific cognitive behavioural therapy programs delivered over the internet (iCBT) with clinician guidance are effective at treating specific anxiety disorders and depression. The present study examined the efficacy of a transdiagnostic iCBT protocol to treat three anxiety disorders and/or depression within the same program (the Wellbeing Program). Seventy-seven individuals with a principal diagnosis of major depression, generalised anxiety disorder, panic disorder, and/or social phobia were randomly assigned to a Treatment or Waitlist Control group. Treatment consisted of CBT-based online educational lessons and homework assignments, weekly email or telephone contact from a clinical psychologist, access to a moderated online discussion forum, and automated emails. Eighty one percent of Treatment group participants completed all 8 lessons within the 10 week program. Post-treatment data were collected from 34/37 Treatment group and 35/37 Control group participants, and 3-month follow-up data were collected from 32/37 Treatment group participants. Relative to Controls, Treatment group participants reported significantly reduced symptoms of anxiety and depression as measured by the Depression Anxiety and Stress Scales-21 item, Patient Health Questionnaire-9 item, and Generalised Anxiety Disorder-7 item scales, with corresponding between-groups effect sizes (Cohens d) at post treatment of.56,.58, and.52, respectively. The clinician spent a mean time of 84.76 min (SD=50.37) per person over the program. Participants rated the procedure as highly acceptable, and gains were sustained at follow-up. These results provide preliminary support for the efficacy of transdiagnostic iCBT in the treatment of anxiety and depressive disorders.

The Acceptability of Internet-Based Treatment and Characteristics of an Adult Sample with Obsessive Compulsive Disorder: An Internet Survey

Background Obsessive-compulsive disorder (OCD) is a disabling anxiety disorder, but most individuals delay seeking treatment. Internet-based cognitive behavioural therapy (iCBT) is an innovative service delivery method that may help to improve access to care, but the acceptability to consumers of such programs has not yet been established. Methodology People with symptoms of OCD were invited to complete an online survey enquiring about demographic characteristics, symptom severity, and acceptability of Internet-based treatment. Demographic and symptom severity data were compared with people with OCD identified in a national epidemiological survey and with a sample of patients with OCD from a specialist outpatient anxiety clinic. Participants 129 volunteers to an online Internet survey, 135 patients at a specialist anxiety disorders outpatient clinic, and 297 cases identified in a national epidemiological survey. Main Measures Demographic characteristics, and severity of symptoms as measured by the Kessler 10-Item scale, the 12-item World Health Organisation Disability Assessment Schedule - Second Edition and the Yale Brown Obsessive Compulsive Scale - Self Report Version. Principal Findings The Internet sample was similar demographically but reported more severe symptoms than the comparison groups, although had similar severity of symptoms of OCD compared with other clinical samples reported in the literature. Participants reported Internet-based treatment for OCD would be highly acceptable. Conclusions Internet-based treatment may reduce barriers to accessing treatment to people with OCD. Individuals in this study were similar demographically to other samples and had similar severity of symptoms as those identified in other clinical samples, suggesting that Internet-based treatment using techniques employed in face-to-face treatment may be effective in this group. Internet-based treatments for OCD need to be developed and evaluated.

Psychometric Comparison of the PHQ-9 and BDI-II for Measuring Response during Treatment of Depression

The Patient Health Questionnaire-9 Item (PHQ-9) and Beck Depression Inventory–II (BDI-II) are frequently used measures of depression severity, but little is known about their relative psychometric properties. The authors assessed psychometric properties of both measures during treatment for depression. The PHQ-9 and BDI-II scores from 172 depressed participants in two randomized controlled trials of treatment for depression were assessed and combined. Tests of internal consistency (Cronbachs α), factor analyses, correlational analyses, estimates of clinically significant change, and effect sizes (Cohens d) were calculated after treatment and follow-up. Both scales demonstrated adequate internal consistency at pre- and posttreatment (PHQ-9 α = .74 and .81; BDI-II α = .87 and .90, respectively). Factor analysis failed to confirm the one-factor model previously reported for the PHQ-9, but two factors evidenced good fit for the BDI-II. Both scales converged more with each other than with the Sheehan Disability Scale at pre- but not at posttreatment. Responsiveness to change of PHQ-9 and BDI-II was similar at both posttreatment and follow-up. The consistency of agreement on indices of clinical significance was fair to moderate, but the BDI-II categorised a greater proportion of participants with severe depression than the PHQ-9. The BDI-II and PHQ-9 demonstrated adequate reliability, convergent/discriminant validity, and similar responsiveness to change. Differences were found in how they categorised severity. Pending the results of further studies, the attributes of the PHQ-9, of being shorter and based on the diagnostic criteria for depression, may indicate an advantage over the BDI-II.

Psychometric Comparison of the Generalized Anxiety Disorder Scale-7 and the Penn State Worry Questionnaire for Measuring Response during Treatment of Generalised Anxiety Disorder

The Penn State Worry Questionnaire (PSWQ) is a widely used measure of the worry characteristic of generalised anxiety disorder (GAD). The 7-item Generalized Anxiety Disorder Scale (GAD-7) is a new brief screening tool for GAD, which is being increasingly used in research and clinical practice. The present study sought to provide comparison data on the relative psychometric properties of these two scales. The data of 195 adults who met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for GAD and who participated in two randomised treatment controlled trials were used. Factor analyses, internal consistency, correlational analyses, responsiveness to change, and agreement between the scales based on indentified clinical cutoffs were conducted. Factor analyses confirmed a one-factor structure for the GAD-7 and a three-factor structure involving two method factors for the PSWQ. Both the GAD-7 and the PSWQ demonstrated adequate internal consistency (Cronbachs alpha: .79–.91 and .86–.91, respectively), and moderate correlations (r = .51–.71) were observed between the scales across the treatment time points. The scales exhibited small correlations with the Sheehan Disability Scale at pretreatment (GAD-7 r = .38; PSWQ r = .26), but moderate correlations at posttreatment and follow-up (r = .59–.79). Agreement between the scales was limited using various clinical cutoffs identified within the literature. Both measures were sensitive to change, although the GAD-7 appeared to be more sensitive and may, therefore, confer some advantages in clinical work.

A RCT of a transdiagnostic internet-delivered treatment for three anxiety disorders : examination of support roles and disorder-specific outcomes

Background Anxiety disorders share common vulnerabilities and symptoms. Disorder-specific treatment is efficacious, but few access evidence-based care. Administering transdiagnostic cognitive-behavioral therapy via the internet (iCBT) may increase access to evidence-based treatment, with a recent randomized controlled trial (RCT) providing preliminary support for this approach. This study extends those findings and aims to answer three questions: Is a transdiagnostic iCBT program for anxiety disorders efficacious and acceptable? Does it result in change for specific disorders? Can good clinical outcomes be obtained when guidance is provided via a Coach rather than a Clinician? Method RCT (N = 131) comparing three groups: Clinician-supported (CL) vs. Coach-supported (CO) vs. waitlist control (Control). Individuals met DSM-IV criteria for a principal diagnosis of generalized anxiety disorder (GAD), social phobia (SP) or panic disorder with or without agoraphobia (Pan/Ag). Treatment consisted of an 8-lesson/10 week iCBT program with weekly contact from a Clinician or Coach, and follow-up at 3-months post-treatment. Results Outcomes for the pooled treatment groups (CL+CO) were superior to the Control group on measures of anxiety, depression and disability, were associated with medium to large effect sizes (Cohens d = .76 – 1.44) (response rate = 89–100%), and were maintained at follow-up. Significant reductions were found on disorder-specific outcomes for each of the target diagnoses, and were associated with large effect sizes. CO participants achieved similar outcomes to CL participants at post-treatment, yet had significantly lower symptom severity scores on general anxiety, panic-disorder, depression and disability at follow-up (d = .45 – .46). Seventy-four percent of CO and 76% of CL participants completed the program. Less than 70 minutes of Clinician or Coach time was required per participant during the program. Discussion This transdiagnostic iCBT course for anxiety appears to be efficacious, associated with significant change for three target disorders, and is efficacious when guided by either a Clinician or Coach. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12610000242022

The Pain Course: A randomised controlled trial of a clinician-guided Internet-delivered cognitive behaviour therapy program for managing chronic pain and emotional well-being

&NA; Examination of a clinician‐guided Internet‐delivered cognitive behaviour therapy program for chronic pain found significant improvements in disability, anxiety, depression, and average pain ratings. &NA; The present study evaluated the efficacy of a clinician‐guided Internet‐delivered cognitive behaviour therapy (iCBT) program, the Pain Course, to reduce disability, anxiety, and depression associated with chronic pain. Sixty‐three adults with chronic pain were randomised to either a Treatment Group or waitlist Control Group. Treatment consisted of 5 iCBT‐based lessons, homework tasks, additional resources, weekly e‐mail or telephone contact from a Clinical Psychologist, and automated e‐mails. Twenty‐nine of 31 Treatment Group participants completed the 5 lessons during the 8‐week program, and posttreatment and 3‐month follow‐up data were collected from 30/31 and 29/31 participants, respectively. Treatment Group participants obtained significantly greater improvements than Control Group participants in levels of disability, anxiety, depression, and average pain levels at posttreatment. These improvements corresponded to small to large between‐groups effect sizes (Cohen’s d) at posttreatment for disability (d = .88), anxiety (d = .38), depression (d = .66), and average pain (d = .64), respectively. These outcomes were sustained at follow‐up and participants rated the program as highly acceptable. Overall, the clinician spent a total mean time of 81.54 minutes (SD 30.91 minutes) contacting participants during the program. The results appear better than those reported in iCBT studies to date and provide support for the potential of clinician‐guided iCBT in the treatment of disability, anxiety, and depression for people with chronic pain.

Is there a potential role for attention bias modification in pain patients? Results of 2 randomised, controlled trials

Summary Attention bias modification resulted in positive outcomes compared to placebo in 2 randomised, controlled trials in patients with acute and chronic pain. Abstract Potential applications of attention bias modification (ABM) for acute and chronic pain patients are investigated. In study 1, 54 acute back pain patients (46 of whom completed the study) were recruited at their initial physiotherapy session and randomised to receive 1 session of ABM or placebo. Patients were followed up 3 months later. Participants who were randomised to receive ABM reported less average (P = 0.001) and current pain (P = 0.008) and experienced pain for fewer days (P = 0.01) than those who received placebo. In study 2, 34 chronic pain patients were recruited and randomly assigned to receive either 4 sessions of ABM (n = 22) or placebo (n = 12), followed by 8 sessions of cognitive behavioural treatment (CBT). After ABM, there was a significant group‐by‐time effect for disability. By 6‐month follow‐up, differences had emerged between the 2 training groups, such that the ABM group had shown greater reductions in anxiety sensitivity and disability than the placebo group. Although the results of these studies show that there is potential in the application of ABM to pain conditions, the mechanisms of treatment could not be established. Neither group showed an initial bias towards the word stimuli or a training effect, and only in the acute pain group were changes in biases related to outcome. Nonetheless, the fact that 2 independent samples showed a positive effect of ABM on clinical outcomes suggests that ABM is worthy of future study as an intervention for pain patients.

Clinical and Cost-Effectiveness of Therapist-Guided Internet-Delivered Cognitive Behavior Therapy for Older Adults With Symptoms of Anxiety: A Randomized Controlled Trial

UNLABELLED There is preliminary support for internet-delivered cognitive behaviour therapy (iCBT) as a way of improving access to treatment among older adults with anxiety. The aim of this randomized controlled trial (RCT) was to examine the efficacy, long-term outcomes, and cost-effectiveness of an iCBT program for adults over 60 years of age with anxiety. Successful applicants were randomly allocated to either the treatment group (n=35) or the waitlist control group (n=37). The online treatment course was delivered over 8 weeks and provided with brief weekly contact with a clinical psychologist via telephone or secure email. Eighty-four percent of participants completed the iCBT course within the 8 weeks and 90% provided data at posttreatment. Significantly lower scores on measures of anxiety (Cohens d=1.43; 95% CI: 0.89 - 1.93) and depression (Cohens d=1.79; 95% CI: 1.21 - 2.32) were found among the treatment group compared to the control group at posttreatment. These lower scores were maintained at 3-month and 12-month follow-up and the treatment group rated the iCBT treatment as acceptable. The treatment group had slightly higher costs (

Culturally attuned Internet treatment for depression amongst Chinese Australians: a randomised controlled trial.

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