Per Carlbring

Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: A randomized controlled trial.

Sixty-four individuals with social phobia (social anxiety disorder) were assigned to a multimodal cognitive-behavioral treatment package or to a waiting list control group. Treatment consisted of a 9-week, Internet-delivered, self-help program that was combined with 2 group exposure sessions in real life and minimal therapist contact via e-mail. Results were analyzed on an intention-to-treat basis, including all randomized participants. From pre- to posttest, treated participants in contrast to controls showed significant improvement on most measured dimensions (social anxiety scales, general anxiety and depression levels, quality of life). The overall within- and between-groups effect sizes were Cohens d = 0.87 and 0.70, respectively. Treatment gains were maintained at 1-year follow-up. The results from this study support the continued use and development of Internet-distributed, self-help programs for people diagnosed with social phobia.

Internet vs. paper and pencil administration of questionnaires commonly used in panic/agoraphobia research

The aim of this study was to investigate the psychometric properties of Internet administered questionnaires used in panic research. Included were 494 people who had registered for an Internet-based treatment program for panic disorder (PD). Participants were randomly assigned to fill in the questionnaires either on the Internet or the paper-and-pencil versions, and then to fill in the same questionnaires again the next day using the other format. The questionnaires were the body sensations questionnaire [BSQ; Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090-1097], agoraphobic cognitions questionnaire [ACQ; Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090-1097], mobility inventory [MI; Chambless, D. L., Caputo, G., Jasin, S., Gracely, E. J., & Williams, C. (1985). The mobility inventory for agoraphobia. Behaviour Research and Therapy, 23, 35-44], beck anxiety inventory [BAI; Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897], beck depression inventory II [Beck, A. T., & Steer, R. A. (1996). Beck Depression Inventory. Manual, Svensk version (Swedish version). Fagernes, Norway: Psykologiforlaget, AB], quality of life inventory [QOLI; Frisch, M. B., Cornell, J., Villanueva, M., & Retzlaff, P. J. (1992). Clinical validation of the quality of life inventory. A measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment, 4, 92-101], and montgomery Asberg depression rating scale [MADRS; Svanborg, P., & Asberg, M. (1994). A new self-rating scale for depression and anxiety states based on the comprehensive psychopathological rating scale. ACTA Psychiatrica Scandinavica, 89, 21-28]. Results showed largely equivalent psychometric properties for the two administration formats (Cronbachs @a between 0.79 and 0.95). The results also showed high and significant correlations between the Internet and the paper-and-pencil versions. Analyses of order effects showed an interaction effect for the BSQ and the MI (subscale Accompanied), a main effect was identified for ACQ, MI-Alone, BAI and BDI II. However, in contrast to previous research, the Internet version did not consistently generate higher scores and effect sizes for the differences were generally low. Given the presence of an interaction effect, we recommend that the administration format should be stable in research across measurement points. Finally, the findings suggest that Internet versions of questionnaires used in PD research can be used with confidence.

Treatment of panic disorder via the internet: A randomized trial of a self-help program *

This controlled study, evaluated an Internet-delivered self-help program plus minimal therapist contact via e-mail for people suffering front panic disorder. Out of the 500 individuals screened usi ...

Internet-delivered treatments with or without therapist input: does the therapist factor have implications for efficacy and cost?

Psychiatric problems such as mood and anxiety disorders are highly prevalent and are associated with high societal costs and individual suffering. Evidence-based psychological treatments obtain good results but are not available to the required extent due to the lack of practitioners with adequate training. One way to solve this problem is to provide minimal-contact self-help treatments, for example, with the assistance of computers. Recently, internet-delivered cognitive–behavioral treatment has been tested in a series of controlled trials. However, the interventions come in many forms with different levels and kinds of therapist input, which have implications for the costs of the treatments and possibly their effectiveness. In this review we found evidence for a strong correlation between therapist input and outcome. While emerging evidence attests to the efficacy of internet-delivered treatment when at least minimal therapist guidance is provided, most studies in the field have not included a formal evaluation of cost–effectiveness. Future research needs are discussed.

Treatment of panic disorder via the Internet: a randomized trial of CBT vs. applied relaxation.

A randomized trial was conducted of two different self-help programs for panic disorder (PD) on the Internet. After confirming the PD-diagnosis with an in-person structured clinical interview for DSM-IV (SCID) interview 22 participants were randomized to either applied relaxation (AR) or a multimodal treatment package based on cognitive behavioral therapy (CBT). Overall, the results suggest that Internet-administered self-help plus minimal therapist contact via e-mail has a significant medium to large effect (Cohens d=0.71 for AR and d=0.42 for CBT). The results from this study generally provide evidence to support the continued use and development of Internet-distributed self-help programs.

Internet administration of self-report measures commonly used in research on social anxiety disorder: A psychometric evaluation

The Internet has become increasingly popular as a way to administer self-report questionnaires, especially in the field of Internet delivered psychological treatments. Collecting questionnaire data over the Internet has advantages, such as ease of administration, and automated scoring. However, psychometric properties cannot be assumed to be identical to the paper-and-pencil versions. The aim of this study was to test the equivalence of paper-and-pencil and Internet administered versions of self-report questionnaires used in social phobia research. We analyzed data from two trials in which samples were recruited in a similar manner. One sample (N=64) completed the paper-and-pencil version of questionnaires and the second sample (N=57) completed the same measures online. We included the Liebowitz Social Anxiety Scale-self-assessment (LSAS-SR), the Social Interaction and Anxiety Scale (SIAS), and the Social Phobia Scale (SPS) as measures of social anxiety. Also included were the Montgomery Asberg Depression Rating Scale-self-assessment (MADRS-S), the Beck Anxiety Inventory (BAI), and the Quality of Life Inventory (QOLI). Results showed equivalent psychometric properties across administration formats. Cronbachs @a ranged between 0.77 and 0.94. There was an indication of a somewhat higher construct validity when participants filled out questionnaires using paper-and-pencil. We conclude that the LSAS-SR, SIAS, and SPS can be administered via the Internet with maintained psychometric properties.

Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression

Internet-delivered psychological treatment of major depression has been investigated in several trials, but the role of personalized treatment is less investigated. Studies suggest that guidance is important and that automated computerized programmes without therapist support are less effective. Individualized e-mail therapy for depression has not been studied in a controlled trial. Eighty-eight individuals with major depression were randomized to two different forms of Internet-delivered cognitive behaviour therapy (CBT), or to a waiting-list control group. One form of Internet treatment consisted of guided self-help, with weekly modules and homework assignments. Standard CBT components were presented and brief support was provided during the treatment. The other group received e-mail therapy, which was tailored and did not use the self-help texts i.e., all e-mails were written for the unique patient. Both treatments lasted for 8 weeks. In the guided self-help 93% completed (27/29) and in the e-mail therapy 96% (29/30) completed the posttreatment assessment. Results showed significant symptom reductions in both treatment groups with moderate to large effect sizes. At posttreatment 34.5% of the guided self-help group and 30% of the e-mail therapy group reached the criteria of high-end-state functioning (Beck Depression Inventory score below 9). At six-month follow-up the corresponding figures were 47.4% and 43.3%. Overall, the difference between guided self-help and e-mail therapy was small, but in favour of the latter. These findings indicate that both guided self-help and individualized e-mail therapy can be effective.

Guided and unguided self-help for social anxiety disorder : randomised controlled trial

BACKGROUND Internet-delivered self-help programmes with added therapist guidance have shown efficacy in social anxiety disorder, but unguided self-help has been insufficiently studied. AIMS To evaluate the efficacy of guided and unguided self-help for social anxiety disorder. METHOD Participants followed a cognitive-behavioural self-help programme in the form of either pure bibliotherapy or an internet-based treatment with therapist guidance and online group discussions. A subsequent trial was conducted to evaluate treatment specificity. Participants (n = 235) were randomised to one of three conditions in the first trial, or one of four conditions in the second. RESULTS Pure bibliotherapy and the internet-based treatment were better than waiting list on measures of social anxiety, general anxiety, depression and quality of life. The internet-based therapy had the highest effect sizes, but directly comparable effects were noted for bibliotherapy augmented with online group discussions. Gains were well maintained a year later. CONCLUSIONS Unguided self-help through bibliotherapy can produce enduring improvement for individuals with social anxiety disorder.

Internet-delivered attention bias modification training in individuals with social anxiety disorder - a double blind randomized controlled trial

BackgroundComputerized cognitive bias modification for social anxiety disorder has in several well conducted trials shown great promise with as many as 72% no longer fulfilling diagnostic criteria after a 4 week training program. To test if the same program can be transferred from a clinical setting to an internet delivered home based treatment the authors conducted a randomized, double-blind placebo-controlled trial.MethodsAfter a diagnostic interview 79 participants were randomized to one of two attention training programs using a probe detection task. In the active condition the participant was trained to direct attention away from threat, whereas in the placebo condition the probe appeared with equal frequency in the position of the threatening and neutral faces.ResultsResults were analyzed on an intention-to-treat basis, including all randomized participants. Immediate and 4-month follow-up results revealed a significant time effect on all measured dimensions (social anxiety scales, general anxiety and depression levels, quality of life). However, there were no time x group interactions. The lack of differences in the two groups was also mirrored by the infinitesimal between group effect size both at post test and at 4-month follow-up.ConclusionWe conclude that computerized attention bias modification may need to be altered before dissemination for the Internet.Trial registrationISRCTN01715124

Tailored vs. Standardized Internet-Based Cognitive Behavior Therapy for Depression and Comorbid Symptoms: A Randomized Controlled Trial

Background and Aims Major depression can be treated by means of cognitive behavior therapy, delivered via the Internet as guided self-help. Individually tailored guided self-help treatments have shown promising results in the treatment of anxiety disorders. This randomized controlled trial tested the efficacy of an Internet-based individually tailored guided self-help treatment which specifically targeted depression with comorbid symptoms. The treatment was compared both to standardized (non-tailored) Internet-based treatment and to an active control group in the form of a monitored online discussion group. Both guided self-help treatments were based on cognitive behavior therapy and lasted for 10 weeks. The discussion group consisted of weekly discussion themes related to depression and the treatment of depression. Methods A total of 121 participants with diagnosed major depressive disorder and with a range of comorbid symptoms were randomized to three groups. The tailored treatment consisted of a prescribed set of modules targeting depression as well as comorbid problems. The standardized treatment was a previously tested guided self-help program for depression. Results From pre-treatment to post-treatment, both treatment groups improved on measures of depression, anxiety and quality of life. The results were maintained at a 6-month follow-up. Subgroup analyses showed that the tailored treatment was more effective than the standardized treatment among participants with higher levels of depression at baseline and more comorbidity, both in terms of reduction of depressive symptoms and on recovery rates. In the subgroup with lower baseline scores of depression, few differences were seen between treatments and the discussion group. Conclusions This study shows that tailored Internet-based treatment for depression is effective and that addressing comorbidity by tailoring may be one way of making guided self-help treatments more effective than standardized approaches in the treatment of more severe depression. Trial Registration Clinicaltrials.gov NCT01181583