M. Ferwerda

Internet-based cognitive behavioral therapy for patients with chronic somatic conditions: a meta-analytic review

Background Patients with chronic somatic conditions face unique challenges accessing mental health care outside of their homes due to symptoms and physical limitations. Internet-based cognitive behavioral therapy (ICBT) has shown to be effective for various psychological conditions. The increasing number of recent trials need to be systematically evaluated and quantitatively analyzed to determine whether ICBT is also effective for chronic somatic conditions and to gain insight into the types of problems that could be targeted. Objective Our goal was to describe and evaluate the effectiveness of guided ICBT interventions for chronic somatic conditions on general psychological outcomes, disease-related physical outcomes, and disease-related impact on daily life outcomes. The role of treatment length was also examined. Methods PubMed, PsycINFO, and Embase were searched from inception until February 2012, by combining search terms indicative of effect studies, Internet, and cognitive behavioral therapy. Studies were included if they fulfilled the following six criteria: (1) randomized controlled trial, (2) Internet-based interventions, (3) based on cognitive behavioral therapy, (4) therapist-guided, (5) adult (≥18 years old) patients with an existing chronic somatic condition, and (6) published in English. 23 randomized controlled trials of guided ICBT were selected by 2 independent raters after reviewing 4848 abstracts. Demographic, clinical, and methodological variables were extracted. Standardized mean differences were calculated between intervention and control conditions for each outcome and pooled using random effects models when appropriate. Results Guided ICBT was shown to improve all outcome categories with small effect sizes for generic psychological outcomes (effect size range 0.17-0.21) and occasionally larger effects for disease-specific physical outcomes (effect size range 0.07 to 1.19) and disease-related impact outcomes (effect size range 0.17-1.11). Interventions with a longer treatment duration (>6 weeks) led to more consistent effects on depression. Conclusions Guided ICBT appears to be a promising and effective treatment for chronic somatic conditions to improve psychological and physical functioning and disease-related impact. The most consistent improvements were found for disease-specific outcomes, which supports the possible relevance of tailoring interventions to specific patient groups. Explorative analyses revealed that longer treatment length holds the promise of larger treatment effects for the specific outcome of depression. While the current meta-analysis focused on several chronic somatic conditions, future meta-analyses for separate chronic somatic conditions can further consolidate these results, also in terms of cost-effectiveness.

Tailored Therapist-Guided Internet-Based Cognitive Behavioral Treatment for Psoriasis: A Randomized Controlled Trial.

Objective: Patients with somatic conditions, such as psoriasis, frequently suffer from high burden of their disease in daily life and might benefit from internet-based cognitive behavioral therapy (ICBT) tailored to their adjustment problems. The aim of this multicenter randomized controlled trial was to examine the effects of therapist-guided, individually tailored ICBT in a clinical sample of patients with psoriasis. Methods: A total of 131 patients with psoriasis, who were screened for a psychological risk profile, were randomized to either care as usual (CAU, n = 66) or ICBT in addition to CAU (n = 65). Participants filled out standardized self-report questionnaires assessing physical and psychological functioning and impact on daily activities at baseline, posttreatment assessment, and 6-month follow-up. Results: In covariate-controlled linear mixed-model analyses, significantly larger improvements in ICBT compared to CAU were found in the primary outcomes physical functioning (p = 0.03, d = 0.36) and impact on daily activities (p = 0.04, d = 0.35), but not in psychological functioning (p = 0.32), up to 6 months after treatment compared to baseline. In explorative analyses, the working alliance measured at the beginning of ICBT treatment predicted improved physical (p = 0.02) and psychological (p < 0.001) outcomes. Conclusions: Results underline the promise of therapist-guided, individually tailored ICBT to improve physical functioning and reduce the impact of psoriasis on daily activities in patients with a psychological risk profile. Establishing a good therapeutic relationship early on may be an important factor that influences treatment outcomes in personalized ICBT interventions. Further research is needed to evaluate ICBT effectiveness in additional samples and to explore its underlying mechanisms.

A tailored-guided internet-based cognitive-behavioral intervention for patients with rheumatoid arthritis as an adjunct to standard rheumatological care: results of a randomized controlled trial

Abstract For patients with chronic pain conditions such as rheumatoid arthritis (RA), who experience elevated levels of distress, tailored-guided internet-based cognitive-behavioral treatment may be effective in improving psychological and physical functioning, and reducing the impact of RA on daily life. A multicenter, randomized controlled trial was conducted for RA patients with elevated levels of distress as assessed by a disease-specific measure. The control group (n = 71) received standard care and the intervention group (n = 62) additionally received an internet-based tailored cognitive-behavioral intervention. Main analyses were performed using a linear mixed model estimating differences between the intervention and control groups in scores of psychological functioning, physical functioning, and impact of RA on daily life at preassesment and postassessment, and at 3, 6, 9, and 12 months. Patients who received the internet-based intervention reported a larger improvement in psychological functioning compared with the control group, indicating less depressed mood (P < 0.001, d = 0.54), negative mood (P = 0.01, d = 0.38), and anxiety (P < 0.001, d = 0.48) during the course of the 1-year follow-up period. Regarding physical functioning, a trend was found for the intervention group reporting less fatigue than the control group (P = 0.06, d = 0.24), whereas no effect was found on pain. No effects were found for the impact of RA on daily life, except for the intervention group experiencing fewer role limitations due to emotional problems (P < 0.001, d = 0.53). Offering guided internet-based cognitive-behavioral therapy is a promising development to aid patients with psychological distress particularly in improving psychological functioning. Further research on adherence and specific intervention ingredients is warranted.

Predictors of perceived stigmatization in patients with psoriasis

The physical appearance of psoriasis can be cosmetically disfiguring, resulting in a substantial social burden for patients. An important aspect of this burden is the experience of stigmatization. While stigmatization is known to be disabling and stressful for patients, little is known about its correlates, and effective interventions are lacking.

Measuring the Therapeutic Relationship in Internet-Based Interventions

exists to measure internet-specific aspects of the therapeutic relationship during internet-based interventions. In this letter we describe the following: (1) the sensitivity to change, (2) the associations with pre-treatment patient characteristics and (3) the associations with patient-reported treatment outcome of an instrument to measure the therapeutic relationship during an internet intervention. We report on data from 98 psoriasis and rheumatoid arthritis patients who participated in the treatment arm of two ongoing trials between July 2010 and May 2014. Patients were asked to fill out a paper-and-pencil version of the Internet-Specific Therapeutic Relationship Questionnaire (ITRQ) together with the Dutch translation of the short form of the Working Alliance Inventory (WAIS) [8, 9] , firstly after an instruction session of the treatment website and again at treatment completion. The WAI-S is generally used for assessing the face-to-face treatment alliance. Also, at the pretreatment session several questionnaires on general well-being were assessed ( table 1 ). To assess whether the ITRQ may be related to treatment outcome, the patients were asked to rate their own progress on coping and complaints at the end of treatment and to give a general mark on a scale from 1 to 10 on treatment satisfaction. A full description of both trials and the inclusion criteria for participants were drawn from and can be found at http://www. trialregister.nl/trialreg/admin/rctsearch.asp (trial No. NTR2100 and NTR2436). Of the 98 patients, 72 pre-treatment and 75 posttreatment measurements of the questionnaire assessing internetspecific aspects of the treatment were available and 52 patients completed both questionnaires. Treatment consisted of an internet-based cognitive-behavioural treatment tailored to the individual’s goals and characteristics as established during one or two face-to-face intake sessions. Patients received online assignments from one to four treatment modules (pain or itch, fatigue, negative mood, or social functioning) and personalized feedback from the therapist. Treatment ended with a relapse prevention module. The ITRQ was constructed after a review of the literature on the specific characteristics of internet-based psychological treatments. For an overview of the English translation of the items on the questionnaire and results of the factor analysis, see Appendix. A team of psychologists, researchers and patient research partners aided in the generation of the items and the construction of the questionnaire. The ITRQ contains 9 items, consisting of two subscales of 4 items each. Because 1 item was highly associated with both subscales (item 7), this item was not included in either subscale. The first scale, including items on the time lag aspects in communication and receiving sufficient attention by the E-coach therapist, was termed ‘internet-specific time and attention’ (Cronbach’s α = 0.92). The second scale, including items reflecting the sharing of information with the therapist and the home as the treatment environment, was termed ‘internet-specific reflection and comfort’ (α = 0.87); the internal consistency of the total scale was also satisfactory (α = 0.89). The use of the internet for the provision of health care is on the rise, with increasing evidence of comparable effectiveness of psychological internet and face-to-face treatments [1, 2] . It is well known that the quality of the therapeutic relationship during faceto-face treatment contributes at least modestly to an effective treatment outcome [3] . A recent review [4] further suggests that the patient evaluation of the therapeutic relationship in internet-based therapy is comparable to that of face-to-face treatments. However, there might be specific issues of a therapeutic relationship during internet interventions that have been neglected so far. For example, patient evaluations and uptake of internet-based treatments suggest problems in building a therapeutic relationship during internetbased treatments [5] . Internet-based treatments may have incorporated fewer features to develop and maintain a therapeutic relationship compared to face-to-face treatments. On the other hand, internet-based treatments may offer unique characteristics that impact on the therapeutic relationship that face-to-face treatments do not provide [6] . Some studies have indicated that interventions with the support of a therapist to motivate patients have lower drop-out rates and may be more effective [7] . Finally, little is known about which patient pre-treatment characteristics contribute to a better therapeutic relationship during internet interventions. In previous studies on the therapeutic relationship in internet interventions, instruments were used that are commonly used in face-to-face treatment. To our knowledge, no instrument currently Received: March 21, 2015 Accepted after revision: June 15, 2015 Published online: November 27, 2015

Body attention, ignorance and awareness scale: assessing relevant concepts for physical and psychological functioning in psoriasis

A certain level of attention to bodily signals may be adaptive in the management of chronic skin conditions, as a lack of attention may lead to inadequate self-care behaviour and, consequently, may affect functioning and treatment outcomes. The purpose of this study was to develop a body awareness questionnaire and to investigate its psychometric properties and physical and psychological correlates in a cross-sectional study in patients with psoriasis (n = 475). The 16-item Body Attention, Ignorance and Awareness Scale demonstrated a 3-factor structure that could be interpreted as body ignorance, body attention, and body awareness (Cronbachs α of 0.73, 0.74, and 0.68, respectively). Higher body ignorance was significantly related to more physical symptoms and worse psychological functioning. Body attention and body awareness showed small significant correlations with coping and personality. Given the negative influence of impaired psychological functioning on treatment outcomes, it may be clinically important to screen for theses constructs of body awareness in chronic skin conditions.

Tailored, Therapist-Guided Internet-Based Cognitive Behavioral Therapy Compared to Care as Usual for Patients With Rheumatoid Arthritis: Economic Evaluation of a Randomized Controlled Trial

Background Internet-based cognitive behavioral therapy can aid patients with rheumatoid arthritis with elevated levels of distress to enhance their quality of life. However, implementation is currently lacking and there is little evidence available on the (cost-) effectiveness of different treatment strategies. Objective Cost-benefit ratios are necessary for informing stakeholders and motivating them to implement effective treatment strategies for improving health-related quality of life (HRQoL) of patients with rheumatoid arthritis. A cost-effectiveness study from a societal perspective was conducted alongside a randomized controlled trial on a tailored, therapist-guided internet-based cognitive behavioral therapy (ICBT) intervention for patients with rheumatoid arthritis with elevated levels of distress as an addition to care as usual (CAU). Methods Data were collected at baseline or preintervention, 6 months or postintervention, and every 3 months thereafter during the 1-year follow-up. Effects were measured in terms of quality-adjusted life years (QALYs) and costs from a societal perspective, including health care sector costs (health care use, medication, and intervention costs), patient travel costs for health care use, and costs associated with loss of labor. Results The intervention improved the quality of life compared with only CAU (Δ QALYs=0.059), but at a higher cost (Δ=€4211). However, this increased cost substantially reduced when medication costs were left out of the equation (Δ=€1863). Of all, 93% (930/1000) of the simulated incremental cost-effectiveness ratios were in the north-east quadrant, indicating a high probability that the intervention was effective in improving HRQoL, but at a greater monetary cost for society compared with only CAU. Conclusions A tailored and guided ICBT intervention as an addition to CAU for patients with rheumatoid arthritis with elevated levels of distress was effective in improving quality of life. Consequently, implementation of ICBT into standard health care for patients with rheumatoid arthritis is recommended. However, further studies on cost reductions in this population are warranted. Trial Registration Nederlands Trial Register NTR2100; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2100 (Archived by WebCite at http://www.webcitation.org/724t9pvr2)

OP0343-HPR An economic evaluation of a tailored guided internet-based cognitive behavioural intervention for patients with rheumatoid arthritisas an addition to usual care

Background Within the field of rheumatoid arthritis (RA), patients report decreased health-related quality of life (HRQoL) as a result of living with physical factors such as pain and psychological factors such as negative mood. As these factors are associated with the disease trajectory, health care utilisation, and workplace disability of patients, these factors lead to significant societal health expenses. In a recent randomised controlled trial, improvements in especially psychological functioning (e.g., depressed mood) were found by offering tailored, therapist guided cognitive behavioural therapy online.1 Although internet-based cognitive behavioural therapy holds promise for implementation and cost-reductions, scarce research is available on the cost-effectiveness of these treatments. Objectives A cost-effectiveness study from a societal perspective was conducted alongside a randomised controlled trial on a tailored and therapist-guided internet-based cognitive behavioural intervention (ICBT) for patients with elevated levels of distress, as an addition to usual care alone in order to inform stake-holders on implementation of this treatment. Methods Data were collected at baseline/pre-intervention, 6 months/post-intervention, and three-monthly thereafter during one year follow-up. Effects were measured in quality-adjusted life years (QALYs) and costs from a societal perspective including healthcare sector costs (including healthcare use, medication, and intervention costs), patient travel costs for healthcare use, and costs associated with loss of labour. Results The intervention improved quality of life compared to usual care alone (Δ QALYs=0.059), but also led to higher costs (Δ=€ 4.211,44), which reduced substantially when medication costs were left out of the equation (Δ=€ 1.862,72). Most (93%) of the simulated ICERS were in the north-east quadrant, suggesting a high probability that the intervention is effective in improving HRQoL, but at a greater monetary cost for society compared to usual care alone. Conclusions A positive effect on quality-adjusted life years is seen in the intervention group compared to the control group. However, cost-ratios show that this comes at a greater cost to society. The substantial costs in this population are generated by medication costs, for which no group differences could be found. The cost-benefit ratio improves when the costs for medication are not taken into account. Based on the effects for improvement of quality of life, implementation of the intervention is recommended, yet on the side of costs, further study is warranted. Reference [1] Ferwerda M, van Beugen S, van Middendorp H, Spillekom-van Koulil S, Donders ART, Visser H, Taal E, Creemers MCW, van Riel PCLM, Evers AWM. A tailored-guided internet-based cognitive-behavioural intervention for patients with rheumatoid arthritis as an adjunct to standard rheumatological care: Results of a randomized controlled trial. Pain2017;158(5):868–78. PMID: 28106666 Disclosure of Interest None declared

eHealth cognitieve gedragstherapie voor patiënten met chronische somatische aandoeningen

SamenvattingVeel patiënten met chronische somatische aandoeningen ervaren op zowel lichamelijk als psychologisch gebied beperkingen in het dagelijks leven. Een manier om patiënten hierbij te ondersteunen is het aanbieden van online zorgprogramma’s op basis van cognitieve gedragstherapie (eHealth cognitieve gedragstherapie; eCGt). Hoewel uit eerder onderzoek al is gebleken dat eCGt effectief kan zijn bij het verminderen van bijvoorbeeld depressieve klachten in het algemeen, loopt het onderzoek bij patiënten met chronische somatische aandoeningen daarbij nog wat achter. In de laatste jaren is er echter een toenemend aantal studies verschenen die de effectiviteit van eCGt bij diverse chronische somatische aandoeningen hebben onderzocht. Om de overkoepelende resultaten van deze studies te kunnen evalueren is er een meta-analyse uitgevoerd, waarvan de resultaten in dit artikel worden besproken. Hieruit blijkt dat eCGt ook bij chronische somatische aandoeningen effectief is, met kleine tot middelgrote effecten. Grote effecten werden soms gevonden bij ziektespecifieke klachten zoals symptomen van de aandoening en ziektespecifieke kwaliteit van leven. Ook werd gevonden dat een langere behandelduur enigszins samenhing met een grotere afname van depressieve klachten. In aanvulling op de resultaten van de meta-analyse wordt in dit artikel een overzicht gegeven van de recente literatuur over enkele klinisch relevante eCGt onderwerpen: kosteneffectiviteit, begeleiding versus zelfhulp, de rol van behandelduur, en optimaal ontwerp en implementatie van interventies.AbstractInternet-based cognitive behavioral therapy for patients with chronic somatic conditions Many patients with chronic somatic conditions regularly experience impairments in physical and psychological functioning in their daily life. A way to support these patients is to offer online programs based on cognitive behavioral therapy (Internet-based cognitive behavioral therapy; ICBT). Although a substantial evidence base already exists regarding the effectiveness of ICBT in treating, for example, depressive symptoms, research on ICBT for chronic somatic conditions is still upcoming. In recent years, a growing number of randomized controlled trials were published that examined the effectiveness of ICBT in various chronic somatic conditions. To systematically and quantitatively evaluate the results of these studies, a metaanalysis was conducted, the results of which are discussed in this article. Results indicated that ICBT is also overall effective for chronic somatic conditions, with small to moderate effect sizes. Larger effects were occasionally found for disease-specific outcomes such as disease symptoms and disease-specific quality of life. A longer treatment duration was found to be marginally related to a larger decrease in depressive symptoms. In addition to the results of the meta-analysis, this article provides an overview of the recent literature regarding several clinically relevant ICBT topics: cost-effectiveness, guided ICBT interventions versus self-help, the role of treatment duration, and optimal design and implementation of eHealth interventions.

The patient-therapist relationship as an indicator for treatment success in e-health treatments for patients with rheumatoid arthritis and psorias.

Background The popularity of E-health is rising and research has shown that E-health interventions can be effective [1]. However, they also offer new challenges and questions in clinical practice and research, for example about the role of the patient-therapist relationship [2,3]. In face-to-face treatments, a better patient-therapist relationship has often been reported as a predictor for improved treatment outcome. Objectives In an E-health cognitive-behavioral treatment for patients with rheumatoid arthritis and psoriasis, the patient-therapist relationship was assessed and related to patient-reported outcomes. Methods After a face-to-face intake, all patient-therapist contact was through e-mail. Patients rated the patient-therapist relationship pre and post treatment using the Working Alliance Inventory and internet-specific relationship questions. After treatment, patients were asked to rate improvement in symptoms and coping with these symptoms. Paired samples t-tests (patient-therapist relationship change during treatment) and regression analyses (association patient-therapist relationship and patient-reported outcome) were performed in a subsample of patients who had finished treatment. Results The patient-therapist relationship was rated positively and increased during treatment (p <.05) as generally found in face to face treatments. Both a better patient-therapist relationship and the specific internet related aspects (e.g., having time to think about the reply to the therapist) predicted patient-reported improvement in coping with disease problems, such as pain and fatigue (p-values <.05). At the end of treatment both relationship aspects are related to improvements in symptoms and coping with these symptoms (all p-values <.05). Conclusions These preliminary results indicate that the patient-therapist relationship is a possible predictor for self-reported improvements in E-health treatments, similar to the role of this patient-therapist relationship in face-to-face treatments. Future results need to demonstrate whether the patient-therapist relationship also contributes to the cost-effectiveness of this E-health treatment in the randomized controlled trial. References Cuijpers, P., Straten, A., & Andersson, G. Internet-administered cognitive behavior therapy for health problems: A systematic review. Journal of Behavioral Medicine 2008;31:169-77. Martin, D.J., Garske, J.P., & Davis, M.K. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Counseling and Clinical Psychology 2000;68:438-50. Preschl, B., Maercker, A., & Wagner, B. The working alliance in a randomized control trial comparing online with face-to-face cognitive behavioral therapy for depression. BMC Psychiatry 2011;11:189. Acknowledgements We would like to thank the patient representatives Henk van Duijn, Mariëtte Tomas, and Hen Ros for their contributions to the study, and ZonMw (The Netherlands Organisation for Health Research and Development) and Pfizer Inc. for their financial contribution to this research project. Disclosure of Interest M. Ferwerda Grant/research support from: Pfizer Inc., S. Spillekom: None Declared, H. van Middendorp: None Declared, S. van Beugen Grant/research support from: Pfizer Inc., W. Kievit: None Declared, J. Fransen: None Declared, H. Visser: None Declared, P. van Oijen: None Declared, E. Taal: None Declared, P. van Riel Consultant for: Roche, Abbott, Pfizer, E. de Jong: None Declared, P. van de Kerkhof: None Declared, M. van der Laar: None Declared, A. Evers Grant/research support from: Pfizer Inc., Consultant for: Roche