Luke Johnston

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.

Transdiagnostic Internet treatment for anxiety disorders: A randomized controlled trial

Clinician-guided Internet-based cognitive behavioural therapy (iCBT) programs are clinically effective at treating specific anxiety disorders. The present study examined the efficacy of a transdiagnostic Internet-based cognitive behavioural treatment (iCBT) program to treat more than one anxiety disorder within the same program (the Anxiety Program). Eighty six individuals meeting diagnostic criteria for generalized anxiety disorder (GAD), panic disorder, and/or social phobia were randomly assigned to a treatment group, or to a 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. An intention-to-treat model using the baseline-observation-carried-forward principle was employed for data analyses. Seventy-five percent of treatment group participants completed all 6 lessons within the 8 week program. Post-treatment data was collected from 38/40 treatment group and 38/38 control group participants, and 3-month follow-up data was collected from 32/40 treatment group participants. Relative to controls, treatment group participants reported significantly reduced symptoms of anxiety as measured by the Generalized Anxiety Disorder - 7 Item, Social Phobia Screening Questionnaire, and the Panic Disorder Severity Rating Scale - Self Report Scale, but not on the Penn State Worry Questionnaire, with corresponding between-groups effect sizes (Cohens d) at post-treatment of 0.78, 0.43, 0.43, and 0.20, respectively. The clinician spent a total mean time of 46min per person over the program, participants rated the procedure as moderately acceptable, and gains were sustained at follow-up. Modifications to the Anxiety program, based on post-treatment feedback from treatment group participants, were associated with improved outcomes in the control group. These results indicate that transdiagnostic programs for anxiety disorders may be successfully administered via the Internet.

Clinician-Assisted Internet-Based Treatment is Effective for Generalized Anxiety Disorder: Randomized Controlled Trial

Objective: The aim of the present study was to determine the efficacy of an Internet-based clinician-assisted computerized cognitive behavioural treatment (CaCCBT) programme for generalized anxiety disorder (the Worry programme). Methods: Forty-eight individuals meeting diagnostic criteria for generalized anxiety disorder (GAD) were randomly assigned to the Worry programme or to a waitlist control group. In the clinician-assisted Worry programme, participants complete six online lessons, weekly homework assignments, receive weekly email contact from a clinical psychologist, and contribute to a moderated online discussion forum with other participants. An intention-to-treat model was used for data analyses. The main outcome measures were Generalized Anxiety Disorder–7 Item Scale (GAD-7) and the Penn State Worry Questionnaire (PSWQ). Results: A total of 75% of treatment group participants completed all six lessons within the 9 week programme and post-treatment data were collected from 21/24 treatment group and 19/21 control group participants. Treatment group participants reported significantly reduced symptoms of worry as measured on the GAD-7 and PSWQ and reduced symptoms of depression as measured on the Patient Health Questionnaire–9 Item Scale (PHQ-9). Mean within- and between-groups effect sizes (Cohens d) across the two measures of GAD were 1.3 and 1.1, respectively. Participants found the treatment programme acceptable and satisfactory. The clinician spent a total mean of 130 min per person over the programme. Conclusions: The Worry programme, the first randomized controlled trial of CaCCBT for GAD, resulted in clinically significant improvements. These results are consistent with literature indicating that Internet-based programmes, when combined with clinical guidance, can significantly reduce the symptoms of common mental disorders.

Randomized controlled trial of web-based treatment of social phobia without clinician guidance

Objective: The aim of the present study was (Shyness 4) to determine which level of reminder best facilitated a clinician-free Internet treatment for social phobia. Method: A pragmatic randomized controlled trial of an enhanced Internet treatment, with and without weekly telephone reminders, was done. Participants consisted of 163 volunteers with social phobia, who completed six lessons of computerized cognitive behaviour therapy for social phobia with complex automated reminders. Main outcome measures were the Social Interaction Anxiety Scale and Social Performance Scale. Results: Social phobia improved in both groups. Adherence (68% vs 81%) and improvement in social phobia (effect size = 0.86 vs 1.15) was better in the group with the added telephone reminders. Conclusions: Enhanced Internet-based cognitive behaviour therapy without clinician guidance is a strong treatment for social phobia. Telephone reminders further improve outcome. Because both interventions are effective, it is a pragmatic decision for a practice or a service as to whether the 33% increase in efficacy justifies 1 h of practice nurse or receptionist time.

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.

An RCT Comparing Effect of Two Types of Support on Severity of Symptoms for People Completing Internet-Based Cognitive Behaviour Therapy for Social Phobia

Objective: The present study (Shyness 6) compares the benefits and acceptability of two types of guidance on severity of symptoms during Internet treatment for social phobia. Methods: Non-inferiority randomized controlled trial of Internet treatment, supplemented with weekly telephone calls from a technician (computerized cognitive-behavioural treatment (CCBT + Tel), or regular access to a clinician-moderated online discussion forum (CCBT + Forum), was carried out. An intention-to-treat model was used for data analyses. The participants consisted of 82 volunteers with social phobia. The intervention consisted of six lessons of CCBT for social phobia (the Shyness programme) with complex automated reminders. The main outcome measures were the Social Interaction Anxiety Scale and Social Phobia Scale. Results: A total of 79% of CCBT + Tel and 79% of CCBT + Forum group participants completed all six lessons. Large mean within-groups effect sizes (Cohens d) for the two social phobia measures were found for the CCBT + Tel and CCBT + Forum groups (1.31 and 1.54, respectively). Each participant in the CCBT + Tel group received a mean total of 38 min of technician time over the 8 week programme, while participants in the CCBT + Forum group received a mean total of 37 min of clinician time. Quantitative and qualitative data indicate that both the CCBT + Tel and CCBT + Forum procedures were equally and highly acceptable to participants. Conclusions: The Shyness programme with either telephone support or access to a clinician-moderated online forum resulted in good clinical outcomes with equivalent patient acceptability. These results confirm that people with social phobia may significantly benefit from a highly structured education programme administered by clinical or non-clinical staff.

Randomized controlled trial of Internet‐delivered cognitive behavioral therapy for posttraumatic stress disorder

Background: Posttraumatic stress disorder (PTSD) is a severe and disabling condition and few receive appropriate care. Internet‐based treatment of PTSD shows promise in reducing barriers to care and preliminary evidence suggests it is efficacious in treating symptoms of PTSD. Methodology: Forty‐two individuals with a diagnosis of PTSD confirmed by clinician interview completed a randomized controlled comparison of Internet‐based cognitive behavioral therapy (CBT) with a waitlist control condition. Principle Findings: Large pre‐ to posttreatment effect sizes (ESs) were found for the Treatment group on measures of PTSD symptoms, depression, anxiety, and disability. A small between‐group ES was found for PTSD symptoms and moderate between‐group ESs were found for depression, anxiety, and disability. Conclusions: Results provide preliminary support for Internet‐based CBT as an efficacious treatment for individuals with a confirmed primary diagnosis of PTSD. Depression and Anxiety, 2011.

Shyness programme: longer term benefits, cost-effectiveness, and acceptability

Objective: In two randomized controlled trials Titov et al. demonstrated significant benefit from an Internet- and email-based treatment programme for social phobia: the Shyness programme. Data are presented about the longer term outcomes (6 months after treatment), cost-effectiveness relative to face-to-face treatment, and the acceptability of the programme to participants. Method: Participants completed outcome and acceptability questionnaires at 6 months after treatment. Repeated measures analyses of variance were calculated using an intention-to-treat design. Cost-effectiveness in years lived with disability averted were calculated based on between-group effect sizes. Results: A total of 59% of treatment group participants completed the 6 month follow-up questionnaires. Between post-treatment and 6 month follow up participants continued to make improvements in symptoms of social phobia, while maintaining improvements in mood, psychological distress, and disability. At 6 month follow up the mean within-group effect size (Cohens d) for the two social phobia measures increased from 1.2 to 1.4. Cost-effectiveness in years lived with disability (YLD) averted was calculated as one-quarter that of face-to-face group treatment, or