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Long-term effects of Internet-supported cognitive behavior therapy
Expert Review of Neurotherapeutics
Abstract
Introduction: Internet-supported and therapist-guided cognitive behaviour therapy (ICBT) is effective for a range of problems in the short run, but less is known about the long-term effects with follow-ups of two years or longer.
Areas covered: This paper reviews studies in which the long-term effects of guided ICBT were investigated. Following literature searches in PubMed and other sources meta-analytic statistics were calculated for 14 studies involving a total of 902 participants, and an average follow-up period of three years. Studies were from Sweden (n=11) or the Netherlands (n=3). Long-term outcome studies were found for panic disorder, social anxiety disorder, generalized anxiety disorder, depression, mixed anxiety and depression, obsessive-compulsive disorder, pathological gambling, stress and chronic fatigue. The duration of the treatments was usually short (8-15 weeks). The pre-to follow-up effect size was Hedge’s g = 1.52, but with a significant heterogeneity. The average symptom improvement across studies was 50%. Treatment seeking in the follow-up period was not documented and few studies mentioned negative effects.
Expert commentary: While effects may be overestimated, it is likely that therapist-supported ICBT can have enduring effects. Long-term follow-up data should be collected for more conditions and new technologies like smartphone-delivered treatments.
... In recent years, internet-delivered CBT (iCBT) has been recognized as a viable alternative to traditional face-face CBT, and it holds particular promise for its capacity to help address longstanding and pervasive issues pertaining to provider shortages and access problems (Mohr et al., 2021). Several studies have demonstrated both the effectiveness of iCBT in treating depression and anxiety (e.g., Andrews et al., 2018;Richards et al., 2020;Wright et al., 2019), and its capacity to produce remission rates that are comparable to face-to-face delivered CBT treatments (Andersson et al., 2018;Andrews et al., 2018;Karyotaki et al., 2018). However, very little is known to date about relapse rates following a course of iCBT. ...
... However, very little is known to date about relapse rates following a course of iCBT. While meta-analyses have shown that there is indeed a maintenance of effects for up to 18 months after iCBT treatment (Andersson et al., 2018;Andrews et al., 2018), these have only explored the durability of effects at an aggregated group-level, and as such, they have not provided any information on relapse rates at an individual-level. Two studies have investigated relapse rates after acute-phase treatment for lowintensity interventions, including but not limited to iCBT, in the Improving Access to Psychological Treatments (IAPT) stepped-care model in the United Kingdom. ...
... We did not have a control group at follow up, which prevents us attributing the observed maintenance of the effects solely to the iCBT intervention. However, reductions of symptoms during follow-up have been shown in previous iCBT studies (Andersson et al., 2018;Andrews et al., 2018). The design of the study allowed us to follow up patients up to 9 months post-treatment, which prevents us from comparing results at a later time, when relapse rates might be higher. ...
Objective
To investigate post‐treatment relapse and remission rates 3, 6 and 9 months after completion of an acute phase of a clinician‐supported internet‐delivered cognitive‐behavioural therapy (iCBT) for anxiety and depressive symptoms, within a routine care setting.
Method
Secondary analysis from a 12‐month pragmatic randomized‐controlled trial delivered within the Improving Access to Psychological Therapies (IAPT) programme in England. Participants in the intervention arm were included if they met criteria for reliable recovery from depression (PHQ‐9) and anxiety (GAD‐7) at post‐treatment assessment. Survival analysis was used to assess durability of treatment effects and determine predictors to relapse at 3‐, 6‐ and 9‐month follow‐up. Hazard ratios predicting time‐to‐relapse were estimated with semi‐parametric Cox proportional hazards model.
Results
Of the 241 participants in the intervention arm, 89 participants met the criteria for reliable recovery from depression and anxiety at the post‐treatment assessment. Of these 89 eligible cases, 29.2% relapsed within the 9‐month period, with 70.8% remaining in remission at 9 months post‐treatment. Of those who relapsed, 53.8% experienced a relapse of depression and anxiety; 7.7% experienced a relapse of depression only; and 38.4% experienced a relapse of anxiety only. Younger age, having a long‐term condition, and residual symptoms of anxiety at end‐of‐treatment were all significant predictors of relapse.
Conclusions
This study is the first to explore the remission and relapse rates after an acute phase of iCBT treatment, within a routine, stepped‐care setting. The results add to the scarce literature on the durability of the effects of iCBT treatment in routine care settings, where patients are not typically followed up after receiving a completed course of treatment.
... One way to increase access to psychological treatment is to deliver the treatment using information technology, and in particular internet-delivered psychological treatments have been found to work as a complement and sometimes replacement for face-to-face treatments [3]. Using the internet to provide guided self-help for depression has been around for about 25 years, and there are studies suggesting that guided internet-delivered cognitive behavioral therapy (ICBT) works as well as face-to-face CBT [4] and yields long term effects [5]. Guided treatments usually involve human contact from a distance via e-mail or other means of communication and should be distinguished from pure self-help with no or automated contact [3]. ...
... The time for the follow-ups was set at ≥8 weeks after post treatment measurements, with follow-up periods ranging from 2 months to 1 year post treatment. In contrast to a previous review on the long-term effects of ICBT (2 years or more), this review focused on controlled trials which the previous review did not [5]. Mamukashvili-Delau et al.. (2023) could include 15 studies (with 17 samples) and the overall results across all time points was a medium between standardized mean group difference (SMD) effect size of 0.43 favoring the treatment groups (based on 1689 participants and 9 RCTs). ...
Introduction:
Internet-based psychological treatments for depression have been around for more than 20 years. There has been a continuous line of research with new research questions being asked and studies conducted.
Areas covered:
In this paper, the author reviews studies with a focus on papers published from 2020 and onwards based on a Medline and Scopus search. Internet-based cognitive behavior therapy (ICBT) programs have been developed and tested for adolescents, older adults, immigrant groups and to handle a societal crisis (e.g. COVID-19). ICBT works in regular clinical settings and long-term effects can be obtained. Studies on different treatment orientations and approaches such as acceptance commitment therapy, unified protocol, and tailored treatments have been conducted. Effects on quality-of-life measures, knowledge acquisition and ecological momentary assessment as a research tool have been reported. Factorial design trials and individual patient data meta-analysis are increasingly used in association with internet intervention research. Finally, prediction studies and recent advances in artificial intelligence are mentioned.
Expert opinion:
Internet-delivered treatments are effective, in particular if therapist guidance is provided. More target groups have been covered but there are many remaining challenges including how new tools like artificial intelligence will be used when treating depression.
... Although psychological symptoms and fatigue have clinical interactions, they are distinct phenomena, and post-COVID-19 fatigue cannot be explained by psychological problems (25). It has been suggested that patients with chronic fatigue and mental health problems can benefit from cognitive behavior therapy (26), which can also be admitted via the Internet and smartphones (26). ...
... Although psychological symptoms and fatigue have clinical interactions, they are distinct phenomena, and post-COVID-19 fatigue cannot be explained by psychological problems (25). It has been suggested that patients with chronic fatigue and mental health problems can benefit from cognitive behavior therapy (26), which can also be admitted via the Internet and smartphones (26). ...
Background: Long COVID is a major manifestation of long-lasting symptoms experienced by the survivors of the coronavirus infection that may influence patients’ physical and mental health. Objectives: This study aimed to evaluate the association of the physical symptoms of COVID-19 (fatigue, breathlessness, and pain) and the level of physical activity with the physical and mental health of survivors in the post-COVID-19 period. Methods: This was a cross-sectional study conducted on 152 hospitalized and non-hospitalized adults infected with COVID-19 aged between 18 and 65 years at the post-infection period with follow-up times greater than 6 months. Standardized instruments, such as the SF12, International Physical Activity Questionnaire (IPAQ), Multidimensional Fatigue Inventory (MFI-20), and visual analog scale (VAS), were used for measuring pre-and post-COVID-19 painful symptoms, fatigue, and breathlessness. The severity of the coronavirus infection was judged based on hospitalization or ICU admission. Data were analyzed with linear regression analysis. Results: The results showed that, at a mean duration of 6 months post-discharge, only fatigue was associated with lower physical (F = 2.84, explained variance = 15.3%) and mental health (F = 1.88, explained variance = 10.6%) Conclusions: Considering the negative impact of fatigue on the physical and mental health of patients during the post-COVID period, it is suggested to monitor and manage fatigue for a longer period post-COVID-19.
... Reductions in loneliness were maintained two years after the conclusion of the active treatment (Käll et al., 2020a). There is however a need to understand what makes internet interventions work and how they maintain their effects over time, which has been seen to be the case for ICBT in general (Andersson et al., 2018). While the focus on the mechanisms of change that contribute to symptom reductions has received increasing attention in psychotherapy research (Hofmann & Hayes, 2018), another aspect of CBT is how the didactic component of the treatment relate to treatment outcome. ...
... The third aim of the study was to investigate if knowledge ratings at posttreatment would be associated with to long-term change two years later. The effects of CBT have been suggested to be enduring for many disorders (van Dis et al., 2020), and a meta-analysis of the long-term efficacy of ICBT showed lasting positive outcomes in studies with a long-term follow-up period of at least two years after the conclusion of treatment (Andersson et al., 2018). The lasting benefits of CBT have been attributed to the role of learning and acquiring knowledge about how to deal with relapses and setbacks should they appear (Hollon et al., 2006). ...
Background and objectives:
Knowledge about a condition and how to treat it is part of most cognitive behavioural therapies. This is particularly relevant for self-help treatments such as internet-based CBT, which is commonly delivered in the form of didactic materials. The role of knowledge acquisition in treatment outcomes is an understudied area. The present study sought to investigate knowledge acquisition as part of an ICBT trial targeting loneliness and discern its role in the outcome of treatment.
Methods:
We used secondary data from a randomised controlled trial of ICBT targeting loneliness with 73 participants. A knowledge test including certainty ratings was constructed and used to investigate whether knowledge increased for the treatment group in comparison to the control group, whether changes in knowledge predicted changes in loneliness during the treatment phase, and how the acquired knowledge related to outcomes at a two-year follow-up. Multiple linear regression models were used to analyse the data.
Results:
The treatment group had significantly higher knowledge scores compared to the waitlist group at posttreatment, both in terms of correct answers (Cohen's d = 0.73) and certainty-weighted sum scores (Cohen's d = 1.20). Acquired knowledge did not predict reductions in loneliness in the short-term, and neither loneliness ratings nor use of treatment techniques in the long-term.
Limitations:
The sample size was relatively small, which limits the statistical inferences.
Conclusions:
Knowledge of treatment relevant principles increase as part of the treatment in ICBT for loneliness. This increase was not related to other short- and long-term outcomes.
... Systematic reviews have found the effect of guided ICBT for depression and anxiety disorders to be no different from that of face-to-face CBT [17][18][19]. Guided ICBT for depression and anxiety is found to work well in routine care clinics and tends to replicate results found in efficacy studies in Sweden, Denmark, Norway, Canada, and Australia [20][21][22][23][24] and to have long-term effects [25]. However, the implementation of guided ICBT in specialist mental health care has been slow, partly due to lack of knowledge, prejudice, and negative attitudes among health care professionals and general practitioners (GPs) [26]. ...
Background
Therapist-guided, internet-delivered cognitive behavioral therapy (guided ICBT) appears to be efficacious for depression, panic disorder (PD), and social anxiety disorder (SAD) in routine care clinical settings. However, implementation of guided ICBT in specialist mental health services is limited partly due to low referral rates from general practitioners (GP), which may stem from lack of awareness, limited knowledge of its effectiveness, or negative attitudes toward the treatment format. In response, self-referral systems were introduced in mental health care about a decade ago to improve access to care, yet little is known about how referral pathways may affect treatment outcomes in guided ICBT.
Objective
This study aims to compare the overall treatment effectiveness of GP referral and self-referral to guided ICBT for patients with depression, PD, or SAD in a specialized routine care clinic. This study also explores if the treatment effectiveness varies between referral pathways and the respective diagnoses.
Methods
This naturalistic open effectiveness study compares treatment outcomes from pretreatment to posttreatment and from pretreatment to 6-month follow-up across 2 referral pathways. All patients underwent module-based guided ICBT lasting up to 14 weeks. The modules covered psychoeducation, working with negative or automatic thoughts, exposure training, and relapse prevention. Patients received weekly therapist guidance through asynchronous messaging, with therapists spending an average of 10‐30 minutes per patient per week. Patients self-reported symptoms before, during, immediately after, and 6 months posttreatment. Level and change in symptom severity were measured across all diagnoses.
Results
In total, 460 patients met the inclusion criteria, of which 305 were GP-referred (“GP” group) and 155 were self-referred (“self” group). Across the total sample, about 60% were female, and patients had a mean age of 32 years and average duration of disorder of 10 years. We found no significant differences in pretreatment symptom levels between referral pathways and across the diagnoses. Estimated effect sizes based on linear mixed modeling showed large improvements from pretreatment to posttreatment and from pretreatment to follow-up across all diagnoses, with statistically significant differences between referral pathways (GP: 0.97‐1.22 vs self: 1.34‐1.58, P <.001-.002) and for the diagnoses separately: depression (GP: 0.86‐1.26, self: 1.97‐2.07, P <.001-.02), PD (GP: 1.32‐1.60 vs self: 1.64‐2.08, P =.06-.02) and SAD (GP: 0.80‐0.99 vs self: 0.99‐1.19, P= .18-.22).
Conclusions
Self-referral to guided ICBT for depression and PD appears to yield greater treatment outcomes compared to GP referrals. We found no difference in outcome between referral pathway for SAD. This study underscores the potential of self-referral pathways to enhance access to evidence-based psychological treatment, improve treatment outcomes, and promote sustained engagement in specialist mental health services. Future studies should examine the effect of the self-referral pathway when it is implemented on a larger scale.
... It causes disruptions in normal functioning and has objective and physical signs associated with anxiety that are clinically significant [8]. Beck included numbness and tingling as well as other physical symptoms like trembling in the legs, dizziness, nausea, tremors in the hands and body, inability to calm down, shaking, palpitations, shortness of breath, suffocation, heat, , and fear of a bad accident [9]. These individuals hold this belief for a reason, even in the absence of supporting data [10][11]. ...
The efficient treatment of anxiety-related disorders and memory recall is significant, regarding the occurrence of these disorders and their relationship with poor psychology operational. Thus, this study aims to measure the modern evidence on the efficacy of CBT on anxiety- disorders and memory recall in elderly in Amman, Jordan. Quasi-experimental intervention was conducted combined with qualitative approach. Purposive sampling method was used to sample 46 elderly resident in Amman. Feedback and observation were used to collect qualitative data. The tests of “The State-Trait Anxiety Inventory” (STAI), “Rey Auditory Verbal Learning Test” (RAVLT), and Narrative Recall Assessment (NRA) were used to collect the data. SPSS 25.0 and NVivo software analyzed the data. The findings show that the Cognitive Behavioral Therapy program has a positive effect on anxiety decreasing, memory function and recalling in elderly people. Three major themes emerged “improved coping, increased confidence, positive engagement”. The positive findings highlight the importance of personalized CBT interventions in improving mental health among elderly people residing within an institutionalized care setting. The study contributions, recommendations, and future directions were explained at the end of the study.
... Although their meta-analysis included all cancer patients, it also provides some reference value for breast cancer patients. Some studies suggest that the long-term intervention effect of ICBT is not ideal (44). Therefore, we conducted a subgroup analysis based on a 12-week cutoff and found that, for depression, the results were not significant regardless of whether the intervention period exceeded 12 weeks. ...
Background
Internet-based cognitive behavioral therapy(ICBT) improves the impact of breast cancer through online platforms, modular learning, goal setting, relaxation exercises, and other techniques. Compared to traditional cognitive behavioral therapy (CBT), ICBT offers advantages such as the convenience of flexible time and location choices and reduced manpower requirements. In recent years, research exploring the impact of ICBT on breast cancer patients has been increasing, with conflicting results across different studies. Therefore, the purpose of this study was to comprehensively examine the impact of ICBT on the psychological health and quality of life of breast cancer patients through a systematic review and meta-analysis.
Methods
We searched ten databases in both English and Chinese, with the search period extending from the inception of the databases to December 30, 2023. Literature screening, bias risk assessment, data extraction, and evidence level evaluation were independently conducted by two researchers. All the data were analyzed using RevMan 5.4 and Stata 17.0 software.
Results
A total of 2079 breast cancer patients were included in this study, of which 1171 patients received ICBT treatment. The results show that ICBT can reduce anxiety [SMD=-0.19, 95%CI (-0.37, -0.01), P=0.0008] and depression [SMD=-0.20, 95%CI (-0.37, -0.02), P=0.001], alleviate fatigue [SMD=-0.34, 95%CI (-0.67, -0.01), P=0.04], and improve quality of life [SMD=0.20, 95% CI (0.03, 0.38), P=0.02] in breast cancer patients. However, the intervention effects of ICBT on insomnia [SMD=-0.44, 95%CI (-0.93, 0.06), P=0.08] and sleep quality [SMD=-0.14, 95%CI (-0.30, 0.01), P=0.06] in breast cancer patients are not significant. The subgroup analysis showed that when the intervention period is longer than 8 weeks, the number of intervention modules exceeds 6, and a waitlist control group is included, there is a significant effect on reducing patients’ anxiety and depression. However, the method of guidance and whether the intervention period exceeds 12 weeks are not related.
Conclusion
ICBT can alleviate anxiety and depression in breast cancer patients, with the intervention effects being independent of the guidance method. Significant results were obtained when the intervention period was >8 weeks and the number of modules was >6. ICBT can reduce fatigue and improve quality of life in breast cancer patients, but its impact on sleep quality was not significant. More high-quality research is needed in the future.
Systematic review registration
PROSPERO, identifier CRD42024494744.
... Various Internet-Based Cognitive Behavioral Therapy (ICBT) programmes have demonstrated significant improvement in symptoms of mental health problems, such as anxiety and depression [8]. In a meta-analysis Hedman-Lagerlöf et al. [9] found that therapist-supported ICBT for psychiatric and somatic disorders yielded similar effects as face-to-face CBT. ...
Background
Posttraumatic stress disorder (PTSD) is a common mental disorder. However, many cases of PTSD remain untreated because of limited healthcare resources and other treatment-seeking barriers. Effective internet-based interventions could help to improve access to PTSD treatments. Therefore, the main objective of the planned randomized controlled trial is to evaluate the efficacy of the Lithuanian version of the guided internet-based self-help programme (Spring) in reducing ICD-11 PTSD symptoms.
Methods
The planned sample size is 50 participants exposed to different traumatic experiences. Participants eligible for the study will be randomized into two study groups: the immediate treatment group and the delayed treatment control group. Both groups will receive guided trauma-focused ICBT intervention, but the delayed treatment group will receive access to the programme five months after randomization. The International Trauma Interview (ITI) will be used for the assessment of ICD-11 PTSD symptoms at pre-treatment, post-treatment, and at a 3-month follow-up. Changes in disturbances in self-organization, depression and anxiety levels, as well as posttraumatic cognitions and trauma-related shame, will also be evaluated. In addition, associations between changes in symptoms of PTSD and readiness for treatment, treatment expectations and working alliance will be explored. Changes in treatment outcomes will be evaluated using multiple Latent Change Models.
Discussion
This study is expected to contribute to valuable knowledge on the efficacy of internet-based interventions for posttraumatic stress disorder.
Trial registration
ClinicalTrials.gov NCT06475716. Registered on 25 June 2024.
... It causes disruptions in normal functioning and has objective and physical signs associated with anxiety that are clinically significant [8]. Beck included numbness and tingling as well as other physical symptoms like trembling in the legs, dizziness, nausea, tremors in the hands and body, inability to calm down, shaking, palpitations, shortness of breath, suffocation, heat, , and fear of a bad accident [9]. These individuals hold this belief for a reason, even in the absence of supporting data [10][11]. ...
The efficient treatment of anxiety-related disorders and memory recall is significant, regarding the occurrence of these disorders and their relationship with poor psychology operational. Thus, this study aims to measure the modern evidence on the efficacy of CBT on anxiety-disorders and memory recall in elderly in Amman, Jordan. Quasi-experimental intervention was conducted combined with qualitative approach. Purposive sampling method was used to sample 46 elderly resident in Amman. Feedback and observation were used to collect qualitative data. The tests of “The State-Trait Anxiety Inventory”(STAI),“Rey Auditory Verbal Learning Test”(RAVLT), and Narrative Recall Assessment (NRA) were used to collect the data. SPSS 25.0 and NVivo software analyzed the data. The findings show that the Cognitive Behavioral Therapy program has a positive effect on anxiety decreasing, memory function and recalling in elderly people. Three major themes emerged “improved coping, increased confidence, positive engagement”. The positive findings highlight the importance of personalized CBT interventions in improving mental health among elderly people residing within an institutionalized care setting. The study contributions, recommendations, and future directions were explained at the end of the study.
... Недавние исследования показывают, что когнитивноповеденческая терапия (КПТ) может играть определенную роль в лечении СХУ и иметь долгосрочные преимущества при хронической усталости [71], но пока доказательств недостаточно, в связи с чем КПТ необходимо использовать с большой осторожностью, чтобы избежать дистресса [72]. Также следует понимать, что данный метод терапии является поддерживающим, а не лечебным [73]. ...
Fatigue is an extremely disabling symptom both in healthy people and in various diseases. Physical fatigue is characterized by limitations in physical functioning, while mental/cognitive fatigue involves difficulties in concentrating and performing cognitive tasks. Mental and physical fatigue exist in both pathological and physiological fatigue. Fatigue is primarily an adaptive physiological process. It is a signal to have a rest and helps conserve energy to prevent injury, which can be useful after intense work, or when the body’s defenses need to be redistributed, for example, during infectious disease. It is important to distinguish between fatigue or tiredness and chronic fatigue syndrome in clinical practice. Chronic fatigue syndrome has multisystem manifestations and affects millions of people globally. Although the exact aetiology of chronic fatigue syndrome is uncertain, the studies point to neurological, immunological, autonomic and energy disorders. The main sings of chronic fatigue syndrome are debilitating fatigue that is worsened by activity, poor exercise tolerance, unrefreshing sleep and cognitive impairment. Reduced information processing speed is the most common cognitive impairment in chronic fatigue syndrome. Other manifestations include decreased reaction time, working memory, and attention. These symptoms must persist for at least 3–6 months for a diagnosis to be made. As there are no specific tests for chronic fatigue syndrome, a diagnosis can be established on the basis of a medical history and physical examination.
Although there are no standards-based methods specific to chronic fatigue syndrome, clinicians can reduce the severity of symptoms using pharmacological and non-pharmacological treatment approaches that have proved their efficacy in clinical practice. In particular, nootropics are widely used in asthenic conditions and chronic fatigue syndrome. Fonturacetam is a nootropic drug that directly activates brain integration activities, promotes memory consolidation, and improves concentration and mental activity.
... negligible disadvantages for iCBT due to the remote guidance [26]. Only the most urgent and convenient support is provided by psychiatrists or administrator, such as minimal therapeutic support, the usage of application, register and login of website, routine supervision and administration and encouraging messages [27]. CBT is widely approved and used in psychological clinical practice but the use of iCBT is not mentioned in the published clinical guidelines due to the uncertain e cacy of iCBT [17]. ...
Background
Depression is a high prevalence mental disorder and the global disease burden is substantial. Internet-based Cognitive Behavior Therapy (iCBT) is a means to compensate for the lack of accessibility of Cognitive Behavior Therapy (CBT) which is an effective therapeutic measure for depression. However, the characteristic of remote guidance combined with the absence of professional guidance of iCBT leads to an uncertain efficacy for depression.
Methods
We searched PubMed, Embase, The Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science from inception to May 2023. The Randomized Controlled Trials (RCTs) that iCBT with the absence of professional guidance for depression patients were selected. We assessed the risk of bias according to the Rob 2.0. Standardized mean difference (SMD), mean difference (MD) or risk ratio (RR) as well as their 95% confidence interval (CI) were calculated to evaluate the effect sizes by the software of R 5.4.1. The sources of heterogeneity were explored by subgroup analysis and meta regression.
Results
30 studies involving 10,659 participants were included. Intervention group showed a statistically significant reduction compared with control group for the posttreatment depression symptom scores (SMD: -0.54; 95% CI: -0.64 to -0.44, P < 0.01) and for the depressive symptom scores after the follow-up period (SMD: -0.38; 95% CI: -0.53 to -0.23, P < 0.01). In addition, the depressive symptom scores continued to decrease statistically significantly after the follow-up period (SMD: 0.18; 95% CI: 0.09 to 0.26, P < 0.01) compared with the scores before the follow-up period in intervention group. The drop-out rate of intervention group is higher statistically significantly (Risk Ratio: 1.51; 95% CI: 1.26 to 1.80, P < 0.01) compared with control group. The subgroup and meta regression showed that the covariate of control condition was the main source of heterogeneity to primary outcome 1 and the covariate of support content to primary outcome 3.
Conclusions
ICBT with the absence of professional guidance can relieve symptoms of depression patients and also can maintain a long-term efficacy. In addition, depression patients have a high level of satisfaction with the intervention of iCBT with the absence of professional guidance. However, the drop-out rate of intervention group is higher than control group.
... Em meio a esse contexto, o campo de pesquisa das intervenções on-line vem crescendo rapidamente nos últimos anos, já estando bem documentado que essas intervenções possuem eficácia similar às intervenções presenciais e contam com protocolos para os mais variados tipos de transtornos, incluindo mindfulness para redução da ansiedade e do estresse (Andersson et al., 2018). O braço mais recente dessas pesquisas são as intervenções fornecidas por smartphones, que, embora não disponham do mesmo número de pesquisas para intervenções realizadas via computador, já possuem trabalhos documentando sua efetividade para protocolos de mindfulness na redução da ansiedade e do estresse (Economides et al., 2018;Flett et al., 2019;Huberty et al., 2019;Victorson et al., 2020). ...
... Our results on primary outcomes are in line with previous research of internet interventions for anxiety and depression, where symptom reductions are maintained in long-term follow-ups, but with lower effect sizes over time. For anxiety and depression, long-term effect sizes have been identified at a mean Hedge's g of 1.52 (Andersson et al., 2018), while in our study, participants in the high intensity intervention showed within-group effect sizes of g = 0,38-0.59 and in the low intensity intervention, participants showed effect sizes of g = 0.75-1.04. ...
Alcohol Use Disorders (AUD) are widespread and have serious consequences, but are among the most undertreated mental disorders. Internet interventions have been found effective in treating AUD, but we know little about long-term outcomes, two years or more after treatment. This study explored 12- and 24-month outcomes in alcohol consumption following initial 6-month improvements after a therapist-guided high-intensity internet intervention and an unguided low-intensity internet intervention among individuals with alcohol use disorder. Between-group comparisons were analyzed, as well as within-group comparisons with (1) pre-treatment measurements (2) post-treatment measurements. Participants consisted of a general population sample of internet help-seekers in Sweden. A total of 143 adults (47% men) with a score of 14 (women)/16 (men) or more on the Alcohol Use Disorders Identification Test, alcohol consumption of 11 (women)/14 (men) or more standard drinks the preceding week and ≥ 2 DSM-5 alcohol use disorder (AUD) criteria based on a diagnostic interview were included. The high- and low-intensity internet interventions (n = 72 and n = 71 respectively) consisted of modules based on relapse prevention and cognitive-behavioral therapy. The primary outcome was self-reported alcohol consumption in the preceding week measured as (1) number of standard drinks and (2) number of heavy drinking days. Attrition from self-reported questionnaires was 36% at the 12-month follow-up and 53% at the 24-month follow-up. No significant between-group differences occurred in outcomes at either long-term follow-up. Regarding within-group differences, compared to pre-treatment, alcohol consumption was lower in both high- and low-intensity interventions at both long-term follow-ups [within-group standard drinks effect sizes varied between g = 0.38-1.04 and heavy drinking days effect sizes varied between g = 0.65-0.94]. Compared to post-treatment, within-group alcohol consumption in the high intensity intervention increased at both follow-ups; for the low-intensity intervention, within-group consumption decreased at 12-month follow-up, but did not differ compared to post-treatment at 24 months. Both high- and low-intensity internet interventions for AUD were thus associated with overall reductions in alcohol consumption at long term follow-ups, with no significant differences between the two. However, conclusions are hampered by differential and non-differential attrition.
... Notably, the effectiveness of internet-based interventions for mental health problems has been widely established [38][39][40]. Although less is known about the long-term effects (eg, follow-ups of 2 years or longer) of these interventions, a recent meta-analysis summarizing studies that have examined the long-term effects of internet-supported CBT showed diminished but large effects sizes over an average follow-up period of 3 years [41]. Internet-based or web-based solutions often utilize pre-recorded content, are self-guided, or involve smartphone apps [42]. ...
BackgroundA growing literature supports the use of internet-based interventions to improve mental health outcomes. However, most programs target specific symptoms or participant groups and are not tailored to facilitate improvements in mental health and well-being or do not allow for needs and preferences of individual participants. The Be Well Plan, a 5-week group-facilitated, internet-based mental health and well-being group intervention addresses these gaps, allowing participants to select a range of activities that they can tailor to their specific characteristics, needs, and preferences.
Objective
This study aims to test whether the Be Well Plan program was effective in improving primary outcomes of mental well-being, resilience, anxiety, and depression compared to a waitlist control group during the COVID-19 pandemic; secondary outcomes included self-efficacy, a sense of control, and cognitive flexibility. The study further seeks to examine participants’ engagement and satisfaction with the program.
MethodsA randomized controlled trial (RCT) was conducted with 2 parallel arms, an intervention and a waitlist control group. The intervention involved 5 weekly 2-hour sessions, which were facilitated in group format using Zoom videoconferencing software. University students were recruited via social media posts, lectures, emails, flyers, and posters.
ResultsUsing an intentional randomization 2:1 allocation strategy, we recruited 215 participants to the trial (n=126, 58.6%, intervention group; n=89, 41.4%, waitlist control group). Of the 126 participants assigned to the intervention group, 75 (59.5%) commenced the program and were included in modified intention-to-treat (mITT) analyses. mITT intervention participants attended, on average, 3.41 sessions (SD 1.56, median 4); 55 (73.3%) attended at least 4 sessions, and 25 (33.3%) attended all 5 sessions. Of the 49 intervention group participants who completed the postintervention assessment, 47 (95.9%) were either very satisfied (n=31, 66%) or satisfied (n=16, 34%). The mITT analysis for well-being (F1,162=9.65, P=.002, Cohen d=0.48) and resilience (F1,162=7.85, P=.006, Cohen d=0.44) showed significant time × group interaction effects, suggesting that both groups improved over time, but the Be Well Plan (intervention) group showed significantly greater improvement compared to the waitlist control group. A similar pattern of results was observed for depression and anxiety (Cohen d=0.32 and 0.37, respectively), as well as the secondary outcomes (self-efficacy, Cohen d=0.50; sense of control, Cohen d=0.42; cognitive flexibility, Cohen d=0.65). Larger effect sizes were observed in the completer analyses. Reliable change analysis showed that the majority of mITT participants (58/75, 77.3%) demonstrated a significant reliable improvement in at least 1 of the primary outcomes.
Conclusions
The Be Well Plan program was effective in improving mental health and well-being, including mental well-being, resilience, depression, and anxiety. Participant satisfaction scores and attendance indicated a high degree of engagement and satisfaction with the program.
Trial RegistrationAustralian New Zealand Clinical Trial Registry ACTRN12621000180819; https://tinyurl.com/2p8da5sk
... Internet-delivered, therapist-assisted psychological interventions are becoming increasingly popular and are as efficacious as face-to-face therapy [6]. The outcome is often also maintained after several years [7]. A recent updated metaanalysis with a total number of 20 randomized controlled trials finds a pooled effect size (g = 0.05; 95% CI: − 0.09 to 0.20), suggesting that therapist-supported and internet-based cognitive behavioral therapy are as efficacious as face-toface therapy for both patients with psychiatric disorders and patients with anxiety and depression with comorbid somatic disease [8]. ...
Purpose of Review
This review focuses on the efficacy of internet-based psychological interventions for patients with cardiovascular disease (CVD) and comorbid anxiety and depression. Anxiety and depression comprise barriers for treatment adherence and are associated with poorer patient-reported and clinical outcomes, and greater health care costs.
Recent Findings
Internet-based, therapist-assisted interventions targeting anxiety and depression can be as efficacious as face-to-face therapy and may have some advantages, as patients can do it from their own laptop/smartphone at home at a time of their convenience, which may facilitate a better integration in their lives.
Summary
To enhance the field of internet-based therapy for patients with CVD, we need to involve patients in the development of interventions, focus on developing standards for adherence and assessment of fidelity, and assess and augment health literacy in patients to safeguard equality in health care.
... ICBTs may reduce the threshold to seek treatment and provide cost-efficient [10,11] and highly scalable access to scientifically evaluated treatment programs [12]. Recent empirical data shows that internet-based cognitive behavioral treatments can be as effective as traditional face-to-face therapy [12,13] and also reach favorable long-term outcomes [12,14]. Stott et al. [15] for example were able to show that an online treatment program, based on the Clark and Wells approach, offered through a website, was significantly reducing SADrelated symptoms. ...
Background:
There is growing evidence that Internet-based cognitive behavioral therapy (ICBT) is as effective as a stand-alone treatment and helps facilitating access to treatment. Given the complexity of the treatment, we argue that the effect of ICBT could be even greater if guided by a therapist, as this could increase treatment adherence. We modified an established and well-evaluated treatment approach and developed a mobile application for treating social anxiety disorder (SAD). In the present study, we compare the efficacy of app use alone (APP) with video-based, therapist-guided app use (TG-APP) and with a wait-list control group (WLC) in terms of symptom reduction, and various secondary outcomes such as increase in quality of life or decrease of general psychological distress.
Methods/design:
A within-between interaction design with randomization to one of three conditions will be used. In the APP condition, patients receive only the app without any additional contact with therapists, while in the TG-APP condition, therapists provide 8 sessions of video-based treatment in addition to using the app. The study will be conducted in two university outpatient treatment centers with reliably diagnosed SAD patients. The primary outcome will be defined as change in SAD symptoms, as measured by the Liebowitz Social Anxiety Scale (expert rating). Furthermore, a wide range of self-reports and clinician ratings for other symptoms (depression, general psychopathology) or quality of life will be used. A simulation-based power analysis for a 3 × 2 interaction effect (group × time) on the primary outcome in a linear mixed model resulted in a total sample size of N = 165.
Discussion:
The present study will be one of the first to examine the additional benefit of therapist-guided video sessions regarding the use of an app treating SAD. Study results are pivotal to future treatment application in SAD.
... We note that the follow-up results at two year follow-up overall suggest that treatment effects were maintained, which is in line with previous ICBT research (Andersson, Rozental, Shafran, & Carlbring, 2018), but also note that there were no differential effects based on our independent variables with the exception of a small effect on the BBQ in favour of the clinician-tailored group. ...
Even if much is known regarding the effects of internet-delivered cognitive behaviour therapy (ICBT) for depression there are several topics that have not been studied. In this factorial design trial with 197 participants we investigated if clients in ICBT could select treatment modules themselves based on a selection of 15 tailored treatment modules developed for use in ICBT for depression. We contrasted this against clinician-tailored module selection. We also investigated if support on demand (initiated by the client) could work as well as scheduled support. Finally, we tested if clients that were mentioned in supervision would improve more than clients not mentioned (with the exception of acute cases). The treatment period lasted for 10 weeks, and we measured effects at post-treatment and two-year follow-up. Measures of depression and secondary outcomes were collected at pre-treatment, post-treatment and two-year follow-up. Overall, within-group effects were large across conditions (e.g., d = 1.73 on the BDI-II). We also found a small but significant difference in favour of self-tailored treatment over clinician-tailored (d = 0.26). Within-group effects for the secondary measures were all moderate to large including a test of knowledge about CBT. The other two contrasts support on demand and supervision yielded mostly non-significant differences, with the exception of a larger dropout rate in support on demand. There were few negative effects (2.2%). Effects were largely maintained at a two-year follow-up. We conclude that clients can choose treatment modules and that support on demand may work. The role of supervision is not yet clear as advice can be transferred across clients.
... Two of these programs were compared to passive control groups, with one resulting as superior (Dincer & Inangil, 2021) and the other equivalent (Hosseinzadeh Asl, 2021); follow-up assessments were included in two studies, with none of them reflecting significant effects on stress (Divya et al., 2021;Hosseinzadeh Asl, 2021). These findings do not go in line with previous research which reported that the changes produced by guided interventionsnot 'third wave'-based-were maintained in the long term for different clinical populations (Andersson et al., 2018). ...
Aims
To evaluate the effectiveness of eHealth interventions to reduce stress and promote mental health in healthcare professionals, and to compare the efficacy of different types of programs (guided vs. self‐guided; ‘third‐wave’ psychotherapies vs. other types).
Background
Healthcare workers present high levels of stress, which constitutes a risk factor for developing mental health problems such as depression and anxiety. eHealth interventions have been designed to reduce these professional's stress considering that the characteristics of this delivery method make it a cost‐effective and very appealing alternative because of its fast and easy access.
Design
A systematic review of quantitative studies.
Methods
A comprehensive database search for quantitative studies was conducted in PubMed, EMBASE and Cochrane (until 1 April 2022). The systematic review was conducted in accordance with the PRISMA and SWiM reporting guidelines. The quality of the studies was assessed using the National Heart, Lung and Blood Institute tools.
Results
The abstracts of 6349 articles were assessed and 60 underwent in‐depth review, with 27 fulfilling the inclusion criteria. The interventions were classified according to their format (self‐guided vs. guided) and contents (‘third‐wave’ psychotherapies vs. others). Twenty‐two interventions emerged, 13 of which produced significant posttreatment reductions in stress levels of health professionals (9 self‐guided, 8 ‘third wave’ psychotherapies). Significant effects in improving depressive symptomatology, anxiety, burnout, resilience and mindfulness, amongst others, were also found.
Conclusion
The evidence gathered in this review highlights the heterogeneity of the eHealth interventions that have been studied; self‐guided and ‘third‐wave’ psychotherapy programs are the most common, often with promising results, although the methodological shortcomings of most studies hinder the extraction of sound conclusions.
Protocol registration
PROSPERO CRD42022310199. No Patient or Public Contribution.
... [6,7] Presently, Internet-based cognitive-behavioral therapies, backed with vigorous evidence, have been provided for most psychological issues. [8,9] Axline [10] proposes eight principles for play therapy: (i) developing a warm and friendly relationship with the child, (ii) accepting the child, (iii) establishing a comfortable nurturing atmosphere for the child, (iv) recognizing and reflecting the feeling of the child, (v) not interfering with the child's actions and allowing the child to do what he or she wants, (vii) recognizing that play has a progressive path, and (viii) establishing some limitations to support a real therapy. [3] Training to improve computer-based health behaviors that can be used through the web, for the more than 100 health programs in the system, nothing has been done yet, and the introduction of training in its new form is a completely new program and for the first time used in the system. ...
BACKGROUND: Play therapy is an intelligent tool in cognitive–behavioral therapies. In today's world, the Internet and technology play a key role in all aspects of people's life including mental health. The present study explores the feasibility of using Internet-assisted play therapy to solve children's psychological issues in primary healthcare systems.
MATERIALS AND METHODS: The present qualitative research was conducted by the content analysis approach on 20 experts working in the healthcare centers, who were selected purposefully. The sample was saturated with these 20 participants. Data were collected through semi-structured interviews and were coded manually. Then, they were analyzed in the Atlas.ti software package.
RESULTS: The results revealed 15 themes and 10 sub-themes. The themes included (1) safety, (2) efficiency, (3) client-orientedness, (4) organizational growth, (5) time, (6) effectiveness, (7) justice-orientedness, (8) access, (9) feedback, (10) analysis, (11) children's computer game room, (12) reward, (13) group game, and (14) capability to be integrated into other electronic programs.
CONCLUSION: It seems that Internet-based play therapy is plausible to be used as a service in primary healthcare to tackle the psychological problems of children in the target population if the challenges related to the exploratory themes are taken care of.
... The literature has shown that iCBT for emotional disorders is accessible [7], easy to disseminate [8], safe [9], and effective in both short-and long-term periods. Regarding long-term outcomes, several studies have been carried out that support the long-term effectiveness and efficacy of iCBT at 1-year follow-up [10] or longer periods [11]; for example, Eriksson et al [10] reported 1-year follow-up outcomes of a randomized controlled trial (RCT) that evaluated an iCBT program compared with treatment as usual (TAU) for depression in primary care, with results that supported its effectiveness. In another study, Wootton et al [12] showed that a self-guided iCBT program for obsessive-compulsive disorder (OCD) was effective in reducing OCD symptoms and that these gains were maintained at 1-year follow-up. ...
Background: Transdiagnostic internet-delivered cognitive behavioral therapy (iCBT) for emotional disorders has been shown to be effective in specialized care in the short term. However, less is known about its long-term effects in this specific setting. In addition, predictors of long-term effectiveness may help to identify what treatments are more suitable for certain individuals.
Objective: This study aimed to analyze the long-term effectiveness of transdiagnostic iCBT compared with that of treatment as usual (TAU) in specialized care and explore predictors of long-term effectiveness.
Methods: Mixed models were performed to analyze the long-term effectiveness and predictors of transdiagnostic iCBT (n=99) versus TAU (n=101) in public specialized mental health care. Outcomes included symptoms of depression and anxiety, health-related quality of life (QoL), behavioral inhibition and behavioral activation, comorbidity, and diagnostic status (ie, loss of principal diagnosis) from baseline to 1-year follow-up. Sociodemographic characteristics (sex, age, and education) and clinical variables (principal diagnosis, comorbidity, and symptom severity at baseline) were selected as predictors of long-term changes.
Results: Compared with baseline, transdiagnostic iCBT was more effective than TAU in improving symptoms of depression (b=–4.16, SE 1.80, 95% CI –7.68 to –0.67), health-related QoL (b=7.63, SE 3.41, 95% CI 1.00-14.28), diagnostic status (b=–0.24, SE 0.09, 95% CI –1.00 to –0.15), and comorbidity at 1-year follow-up (b=–0.58, SE 0.22, 95% CI –1.00 to –0.15). From pretreatment assessment to follow-up, anxiety symptoms improved in both transdiagnostic iCBT and TAU groups, but no significant differences were found between the groups. Regarding the predictors of the long-term effectiveness of transdiagnostic iCBT compared with that of TAU, higher health-related QoL at follow-up was predicted by a baseline diagnosis of anxiety, male sex, and the use of psychiatric medication; fewer comorbid disorders at follow-up were predicted by older age and higher baseline scores on health-related QoL; and fewer depressive symptoms at follow-up were predicted by baseline diagnosis of depression. However, this pattern was not observed for baseline anxiety diagnoses and anxiety symptoms.
Conclusions:The results suggest that transdiagnostic iCBT is more effective than TAU to target depressive symptoms among patients with emotional disorders. Anxiety symptoms remained stable at 1-year follow-up, with no differences between the groups. Results on predictors suggest that some groups of patients may obtain specific gains after transdiagnostic iCBT. Specifically, and consistent with the literature, patients with baseline depression improved their depression scores at follow-up. However, this pattern was not found for baseline anxiety disorders. More studies on the predictor role of sociodemographic and clinical variables in long-term outcomes of transdiagnostic iCBT are warranted. Future studies should focus on studying the implementation of transdiagnostic iCBT in Spanish public specialized mental health care.
... Our meta-analysis indicated that ICBT interventions lasting for ≤12 weeks seemed to be more effective on improving anxiety and depressive symptoms than interventions lasting for>12 weeks. Relevant studies have shown that ICBT can only relieve patients' anxiety and depressive symptoms in the short term, and the long-term improvement effect is not significant [27,45,46]. The short-term improvement effect may be due to the high compliance of patients when they start receiving ICBT and anticipate the effect of the new treatment. ...
Purpose
This meta-analysis was to critically evaluate the effects of Internet-based cognitive behavioral therapy (ICBT) on the symptoms of anxiety and depression in cancer patients.
Methods
Eight Chinese and English databases (CNKI, Wanfang, VIP, CBM, Cochrane Library, PubMed, Embase, and PsycINFO) were systematically searched from the inception of databases to May 2022 for relevant randomized controlled trials (RCTs). According to the Cochrane Collaboration criteria, two reviewers independently assessed the risk of bias and extract data from included studies. All analyses were performed with Review Manager 5.4.
Results
Thirteen qualified studies were included in the meta-analysis, twelve of which reported the effect of ICBT on anxiety in 2079 cancer patients; thirteen of the studies reported the effect of ICBT on depression in 2179 patients. The meta-analysis indicated that ICBT was effective in improving anxiety [SMD = -0.37, 95%CI (−0.62, −0.12), P < 0.01, I² = 86%] and depression [SMD = -0.27, 95%CI (−0.44, −0.09), P < 0.01, I² = 72%] symptoms in cancer patients, especially those undergoing anti-cancer treatment. Therapist-guided ICBT was more effective than self-directed ICBT. ICBT lasting for ≤12 weeks could relieve anxiety and depressive symptoms of cancer patients. ICBT with number of modules ≥5 had a small effect on anxiety and depression relief while ICBT with number of modules <5 was found to be ineffective.
Conclusions
ICBT lasting for ≤12 weeks, especially therapist-directed, helps relieve the anxiety and depressive symptoms of cancer patients. The ideal number of modules for ICBT and its long-term efficacy need to be validated by more studies of higher-quality.
... The literature has shown that iCBT for emotional disorders is accessible [7], easy to disseminate [8], safe [9], and effective in both short-and long-term periods. Regarding long-term outcomes, several studies have been carried out that support the long-term effectiveness and efficacy of iCBT at 1-year follow-up [10] or longer periods [11]; for example, Eriksson et al [10] reported 1-year follow-up outcomes of a randomized controlled trial (RCT) that evaluated an iCBT program compared with treatment as usual (TAU) for depression in primary care, with results that supported its effectiveness. In another study, Wootton et al [12] showed that a self-guided iCBT program for obsessive-compulsive disorder (OCD) was effective in reducing OCD symptoms and that these gains were maintained at 1-year follow-up. ...
Background: Transdiagnostic Internet-delivered Cognitive Behavioral Therapy (iCBT) for emotional disorders has been shown to be effective in specialized care in the short term. However, less is known about its long-term effects in this specific setting. In addition, predictors of long-term effectiveness may help to identify what treatments are more suitable for certain individuals.
Objective: In this study we aimed to a) analyze the long-term effectiveness of transdiagnostic iCBT compared to treatment as usual in specialized care, and b) to explore predictors of long-term effectiveness.
Methods: Mixed models were performed to analyze the long-term effectiveness and predictors of transdiagnostic iCBT (EmotionRegulation) (n= 99) versus treatment as usual (n = 101) in public specialized mental health care. Outcomes included symptoms of depression and anxiety, health-related quality of life (QoL), behavioral inhibition/behavioral activation, comorbidity, and diagnostic status (i.e., loss of principal diagnosis) from baseline to one-year follow-up. Sociodemographic characteristics (sex, age, education), and clinical variables (principal diagnosis, comorbidity, and symptom severity at baseline) were selected as predictors of long-term changes.
Results: compared to baseline, EmotionRegulation was more effective than treatment as usual (TAU) in improving symptoms of depression (b= -4.16, s.e. = 1.80, 95% CI [-7.68, -.67]) , health-related QoL (b= 7.63, s.e. = 3.41, 95% CI [1.00, 14.28]), diagnosis status (b= -.24, s.e. = .09, 95% CI [-1.00, -.15]), and comorbidity at one-year follow-up (b= -.58, s.e. = .22, 95% CI [-1.00, -.15]). Pre-treatment to follow-up anxiety symptoms improved in both EmotionRegulation and TAU, but no significant differences were found between groups. Regarding the predictors of long-term effectiveness, compared to treatment as usual, a) higher health-related QoL at follow-up was predicted by a baseline diagnosis of anxiety, male sex, and the use of psychiatric medication; b) fewer comorbid disorders at follow-up were predicted by older age and higher baseline scores on health-related QoL; and c) fewer depressive symptoms at follow-up were predicted by baseline diagnosis of depression. However, this pattern was not observed for baseline anxiety diagnoses and anxiety symptoms.
Conclusions: The results support that transdiagnostic iCBT is more effective than treatment as usual to target depressive symptoms among patients with emotional disorders. Anxiety symptoms remained stable at one-year follow-up, with no differences between groups. Results on predictors suggest that some groups of patients may obtain specific gains after transdiagnostic iCBT. Specifically, and consistent with the literature, patients with baseline depression improved their depression scores at follow-up. However, this pattern was not found for baseline anxiety disorders. More studies on the predictor role of sociodemographic and clinical variables in long-term outcomes of transdiagnostic iCBT are warranted. Future studies should focus on studying the implementation of transdiagnostic iCBT in Spanish public specialized mental healthcare.
CLINICALTRIAL
Trial Registration: ClinicalTrials.gov NCT02345668, 27 July 2015
... Global technological progress has generated alternatives for psychological assistance, both for the evaluation and for the treatment of different emotional disorders. Evidence suggests that Internet-based treatments are effective for the treatment of anxiety and depression disorders (12)(13)(14). Likewise, the metaanalysis data reveal that these interventions are as effective as face-to-face treatments (15,16). ...
Global technological progress has generated alternatives for psychological assistance, both for the evaluation and for the treatment of different emotional disorders. Evidence suggests that Internet-based treatments are effective for the treatment of anxiety and depression disorders. However, in Latin America online treatments are still scarce compared to developed countries and have similar problems as developed countries, such as high dropout rate. One possible solution to help decrease the dropout rate is to design and develop online interventions based on the needs and characteristics of the users. The user-centered design (UCD) is a fundamental concept to develop successful online interventions. The objective of this article is to provide a perspective overview on how UCD could improve the impact of self-applied psychological interventions in low- or middle-income countries in Latin America; however this proposal can also be applied in low- and middle-income countries in other regions of the world. The literature on UCD has demonstrated its efficacy when properly applied in online interventions; however, it is not common to see how this methodology has been applied in research in online interventions, and regarding Latin America, this is even more scarce with a very limited number of articles implementing the principles of UCD.
... To illustrate, among pregnant women and young mothers, higher health anxiety was associated with delaying or canceling routine health assessments [16]. To counterbalance the negative consequences of skipping on-site routine medical checks and counseling, telemedicine and online psychotherapeutic interventions were established as valuable and useful alternatives: In fact, such internet-assisted interventions showed identical results compared to traditional face-to-face psychotherapeutic interventions [17][18][19][20][21][22][23]. However, such online interventions mental health issues of individuals with ED. ...
Plain English summary The COVID-19 pandemic and the consequent lockdowns have significantly impacted people's mental health and mental status worldwide. Remarkably, people with pre-existing illnesses (e.g., eating disorders) were affected by the COVID-19-related restrictions. Thus, gathering information and data would significantly help researchers and physicians provide better future therapy and support for people with ED. Moreover, the use of online surveys to evaluate the mental status of people with ED has grown hugely in the era of the COVID-19 pandemic, which could be used as a promising way of communicating with these people in the future. Considering the growing number of studies that reported the status of individuals with ED in the COVID-19 era, we aimed to conduct a comprehensive review to summarize the current literature. Our findings show that, of all individuals participating in the surveys, 59.65% of them experienced exacerbations in their ED symptoms and 9.37% experienced improved ED symptoms. Altogether, this emphasizes the challenges to maintaining well-being in individuals with ED during the pandemic.
Posttraumatic stress disorder (PTSD) is a common mental disorder. However, only a part of people with PTSD receive the necessary treatment. Digital interventions could provide a more accessible alternative to the traditional face-to-face therapies. ‘Spring’ is an internet-based guided self-help intervention developed at Cardiff University (UK). It is based on the principles of trauma-focused cognitive behavioural therapy and has been developed with the objective to reduce mild to moderate PTSD symptoms associated with a single traumatic experience. The aim of this pilot study was to assess changes in the mental health indicators of individuals with PTSD after using the Lithuanian version of ‘Spring’. Data from seven women with PTSD who used the ‘Spring’ intervention were analysed. The mean age of the participants was 41 years (SD = 15). The results showed a significant reduction in posttraumatic stress, depression and anxiety symptoms, and an increase in psychological well-being after the intervention. The reduction in PTSD symptoms was statistically reliable for all participants, and six of the seven participants showed changes corresponding with a loss of their probable PTSD diagnosis after undergoing ‘Spring’. Overall satisfaction with the intervention was high. The early results from this pilot study of the Lithuanian version of ‘Spring’ guided internet-based intervention show that it can be a promising PTSD treatment method. More research is still needed to evaluate the efficaciousness of ‘Spring’ in larger samples.
Background
This study aimed to evaluate the effectiveness of Internet-based Cognitive Behavioral Therapy (ICBT) in reducing anxiety and depressive symptoms among patients with cardiovascular diseases (CVDs) and to explore how intervention characteristics, such as module number and program duration, influence treatment outcomes.
Methods
A systematic review and meta-analysis were conducted by searching eight databases, including PubMed, Embase, and Cochrane Library, for randomized controlled trials (RCTs) published up to December 2023. Studies involving adult CVD patients with anxiety or depressive symptoms who underwent ICBT interventions were included. Statistical analyses used random-effects models, with subgroup analyses performed to assess the impact of intervention format, module number, and program duration. Sensitivity and publication bias assessments ensured the robustness of the findings.
Results
Eight RCTs with 1177 participants were included. ICBT significantly reduced depressive symptoms (SMD = -0.32, 95% CI [-0.56, -0.08], p < 0.015) and anxiety symptoms (SMD = -0.37, 95% CI [-0.68, -0.06], p < 0.001). Subgroup analysis indicated that self-guided ICBT was more effective than therapist-guided ICBT. Programs with fewer than eight modules were more effective for anxiety, while those with eight or more modules were more effective for depression. Shorter programs (< 9 weeks) were better for anxiety, whereas longer programs (≥ 9 weeks) were more effective for depression.
Conclusions
ICBT is an effective intervention for managing anxiety and depression in CVD patients. Tailoring ICBT interventions based on symptom type, module number, and program duration can optimize outcomes. Future research should explore personalized, long-term strategies to enhance effectiveness and safety.
Against the increasing prevalence of mental health disorders globally, digitally delivered interventions have sought to alleviate the pressures on service delivery due to shortages of trained professionals, geographical and ability barriers, financial constraints, and stigma. There is good evidence for digital interventions for depression and anxiety, and treatment guidelines recommend them as a first-line intervention. Cognitive behavior and social rhythms therapy are proving salient in program development and delivery for bipolar disorder (BD), and their evidence base should be further developed. Alongside further evidence generation, the challenges around implementing digitally delivered interventions in the real world for patient benefit will need to be addressed. The future of these interventions will likely leverage machine learning algorithms and connected devices for remote monitoring in real-time and ecological approaches for on-time interventions that may contribute to preventing relapses and enhancing monitoring for recovery-orientated living with bipolar disorder.
Although the short-term efficacy of internet-delivered cognitive-behavioral therapy (i-CBT) is well-established, its long-term efficacy remains understudied. Robust variance estimation meta-analysis was thus conducted across guided and self-guided i-CBT, synthesizing data from 154 randomized controlled trials (N = 45,335) with ≥ 12-month follow-ups. For binary outcomes, guided (52.3% vs. 38.6%; log-risk ratio [LOG-RR] = 1.15 95% confidence interval [1.04, 1.26]) yielded higher remission, reliable improvement, and response rates, and lower suboptimal treatment outcome rates (9.3% vs. 10.8%; LOG-RR = 0.63 [0.45, 0.80]) than treatment-as-usual, active controls, and waitlists at ≥ 12 months. Insufficient studies precluded testing the efficacy between self-guided i-CBT and controls for binary outcomes. For baseline-to-12-month dimensional outcomes, guided i-CBT produced greater reductions in anxiety, depressive, post-traumatic stress disorder (PTSD) symptoms, and repetitive negative thinking (Hedge’s g = -1.86 to -0.31), and self-guided i-CBT yielded stronger reductions in depressive symptoms (g = -0.51) than all controls. For outcome scores aggregated at ≥ 12-month follow-ups, guided i-CBT alleviated anxiety, depression, distress, insomnia, PTSD symptoms, role impairment, emotion regulation, and quality of life (g = -0.31 to 0.26), and self-guided i-CBT yielded lower anxiety and depressive symptoms (g = -0.16 to -0.09) than all controls. No significant differences in efficacy emerged between guided and self-guided i-CBT when sufficient studies existed for a meta-analysis. There was no evidence for publication bias. Long-term efficacy was similar to short-term efficacy for most outcomes. Implementing scalable i-CBTs should entail transparency about their long-term benefits and drawbacks.
Background
Compared to efficacy research, studies investigating the processes of change in psychological therapy are rare, especially for internet-based interventions. While many online therapies are based on face-to-face therapy protocols, it is unknown whether the processes of clinical improvement differ between these treatment formats.
Objective
To examine candidate change processes in an online therapist-guided cognitive therapy intervention for social anxiety disorder (iCT-SAD), and compare the results to the corresponding face-to-face therapy (CT-SAD).
Methods
Data from a randomised controlled trial (n = 99) were analysed using Multilevel Structural Equation Models, incorporating the temporal precedence of the process variable, and disaggregating the within- and between-subject components of the predictors. These examined three candidate change processes: self-focused attention, negative social cognitions, and depressed mood. Moderated mediation models provided an additional test of the moderating effect of treatment format.
Results
Negative social cognitions and self-focused attention were supported as significant mediators of clinical improvement in both CT-SAD and iCT-SAD. Effects were of similar strength and moderated mediation was not observed. There was also evidence of cyclical relationships between social anxiety symptoms and these process variables. Depressed mood also emerged as a significant but weak mediator in CT-SAD, but not in iCT-SAD. Moderated mediation was not observed.
Conclusion
The online format of therapy showed a similar pattern of change processes to face-to-face treatment, with self-focused attention and negative social cognitions mediating clinical improvement in both treatments. Efforts to improve the efficacy and efficiency of SAD interventions by targeting these factors may therefore be equally applicable to online and face-to-face interventions.
This narrative historical review examines the development of internet-based cognitive behavioral therapy (ICBT) in Sweden, describing its progression within both academic and routine care settings. The review encompasses key publications, significant scientific findings, and contextual factors in real-world settings. Over 25 years ago, Sweden emerged as a pioneering force in internet-delivered treatment research for mental health. Since then, Swedish universities, in collaboration with research partners, have produced substantial research demonstrating the efficacy of ICBT across various psychological problems, including social anxiety disorder, panic disorder, generalized anxiety disorder, and depression. Although research conducted in clinical settings has been less frequent than in academic contexts, it has confirmed the effectiveness of therapist-supported ICBT programs for mild-to-moderate mental health problems in routine care. Early on, ICBT was provided as an option for patients at both the primary care level and in specialized clinics, using treatment programs developed by both public and private providers. The development of a national platform for delivering internet-based treatment and the use of procurement in selecting ICBT programs and providers are factors that have shaped the current routine care landscape. However, gaps persist in understanding how to optimize the integration of digital treatment in routine care, warranting further research and the use of specific implementation frameworks and outcomes. This historical perspective on the research and delivery of ICBT in Sweden over two decades offers insights for the international community into the development and broad dissemination of a specific digital mental health intervention within a national context.
Background
Internet-based Cognitive Behavior Therapy (ICBT) and mindfulness interventions are commonly used to treat elevated levels of stress. There are however few high-quality studies that examine ICBT with integrated mindfulness components for symptoms of stress and exhaustion, and the role of mindfulness exercises in digital treatment.
Method
The aim of the present study was to evaluate if a mindfulness-focused ICBT-program could reduce symptoms of stress and exhaustion, and increase quality of life, in a randomized controlled trial including 97 self-referred participants between 18 and 65 years who experienced elevated levels of stress.
Results
The intervention group had significantly reduced symptoms of stress and exhaustion, and increased quality of life, compared to the control group. Compared with the controls, participants in the intervention group showed a significant improvement with moderate to large effects on the primary outcome measure perceived stress ( d = 0.79), and the secondary outcomes, exhaustion ( d = 0.65), and quality of life ( d = 0.40). Participants in the ICBT group also increased their level of mindfulness ( d = 0.66) during the program. The amount of mindfulness training was significantly associated with an increased level of mindfulness, which in turn was significantly associated with reduced stress symptoms.
Conclusions
Mindfulness-focused ICBT can be an effective method to reduce stress-related mental health problems and the amount of mindfulness training seems to be of importance to increase the level of experienced mindfulness after treatment.
Guided self-help is an evidence-based intervention used globally. Self-help is a fundamental part of the stepped care model of mental health services that enables the efficient use of limited resources. Despite its importance, there is little information defining the role of the guide and the key competences required. In this context, the guide is defined as the person who facilitates and supports the use self-help materials. This article sets out the role of the guide in guided self-help. It considers practical issues such as the importance of engagement to motivate clients for early change, personalising the intervention, structuring sessions, how best to use routine outcome monitoring and supervision requirements. Key competences are proposed, including generic competences to build the relationship as well as specific competences such as being able to clearly convey the role of the guide to clients. Guides should be prepared for “self-help drift”, a concept akin to therapist drift in more traditional therapies. Knowing how to identify mental health problems, use supervision and manage risk and comorbidity are all key requirements for guides. The paper concludes by calling for increased recognition and value of the role of the guide within mental health services.
Purpose: Online group-based interventions are widely adopted, but their efficacy, when compared with similar face-to-face (F2F) psychosocial group interventions, has not been sufficiently examined. Methods: This systematic review included randomly controlled trials (RCTs) that compared an intervention/model delivered in both F2F and online formats. The review adhered to PRISMA guidelines and was registered with PROSPERO. Results: The search yielded 15 RCTs. Effect sizes ranged from small to exceptionally large. Between-condition effect sizes yielded nonsignificant differences in effectiveness except for three studies that reported superior effectiveness in outcomes for F2F interventions. High heterogeneity was found where only two studies integrated rigorous designs, thus limiting opportunity for a meta-analysis evaluation. Conclusions: Most studies showed comparable outcomes in both F2F and online modalities. However, given the heterogeneity of samples and outcomes, it is premature to conclude that online treatment is as effective as F2F for all challenges and populations.
Background
Depressive symptoms in patients with cardiovascular disease (CVD) can lead to increased healthcare use. In a randomized controlled trial (ClinicalTrials.gov, NCT02778074), we reported that a 9-week internet-delivered cognitive behavioural therapy (iCBT) program (n = 72) compared to an online discussion forum (ODF) (n = 72) had moderate to large effect on depression in CVD outpatients. In this secondary analysis, we aimed to describe and compare the effect of iCBT compared to ODF regarding healthcare use and to identify factors impacting healthcare use in these groups.
Methods
Data on healthcare use were retrieved from care data registries in five hospitals in Southeastern Sweden.
Results
The year prior to intervention, the iCBT group had a mean of 31 outpatient clinic/primary care contacts per patient compared with 21 contacts the year after. The corresponding numbers for the ODF group were 37 and 25. The decrease was 32 % in both groups and did not differ significantly (p = 0.261 and p = 0.354) between the groups. Regarding hospital admissions, the iCBT group had 0.8 admissions per patient the year before and 0.6 the year after the intervention, a decrease by 25 %, whereas the ODF group had 1.1 and 0.6 admissions respectively, a decrease by 45 %. The difference was not statistically significant (p = 0.270 and p = 0.883) between the groups. Improvement in depressive symptoms post intervention were significantly (Beta = 0.459, p = 0.047) associated with a decrease in number of outpatient contacts in the iCBT group. In the ODF group, better mental health-related quality of life post intervention was significantly (Beta = −0.429, p = 0.045) associated with a decrease in number of hospital admissions.
Conclusion
Reduced depressive symptom scores following intervention were associated with lower outpatient service use, but iCBT was not superior compared to ODF. This implicates that reducing depression in CVD patients, regardless of the type of internet-delivered intervention used, is important since it may reduce healthcare use in these patients.
The COVID-19 pandemic influence mental health in both infected and non-infected populations. In this study we examined if individually tailored internet-based cognitive behavioral therapy (ICBT) could be an effective treatment for psychological symptoms related to the pandemic. Following recruitment we included 76 participants who were randomized to either a treatment group (n = 37) or a waitlist control group (n = 39). The treatment group received 8 modules (out of 16 possible) during 8 weeks with weekly therapist support. We collected data on symptoms of depression, experienced quality of life, anxiety, stress, anger, insomnia, PTSD, and alcohol use before, after the treatment and at one year follow-up. Using multiple regression analysis, group condition was found to be a statistically significant predictor for a decrease, favoring the treatment group, in symptoms of depression, insomnia, and anger with small to moderate effect sizes. The improvements remained at one year follow-up. Group condition did not significantly predict changing symptoms regarding experienced quality of life, anxiety, stress, PTSD and alcohol use. Findings indicate that ICBT is an effective intervention for some psychological symptoms associated with the COVID-19 pandemic. There is a need for further studies on mechanisms of change and on tailored ICBT for problems associated with crises like the pandemic.
This study aimed to test the effectiveness and the sustained effect (follow-up) of a four-week mindfulness intervention in reducing anxiety and stress in a group of Brazilian university students. The intervention was adapted to be made available through the Neurosaúde application, created as part of this work to serve as a platform for the intervention. The research took place in a virtual environment, with 48 participants recruited, who were randomly allocated to the intervention group or to the waiting list control group. Measures were used to access the levels of mindfulness, anxiety, and stress before and after the intervention and at the 4-week follow-up. Applying the intention-to-treat analysis, we found significant differences between the groups regarding the measurement of anxiety in the follow-up, with a large effect size (F(2, 92) = 10.275, p = .000, η² = 0.183). The results suggest that the 4-week mindfulness intervention through a mobile application was able to act as a protective factor against the anxiety developed by university students during the COVID-19 pandemic. While the treatment group maintained reduced levels of anxiety the control group demonstrated a continuous increase in anxiety in the post-test and follow-up that coincided with the first wave of COVID-19 in the region where the participants lived.
Although numerous studies have examined the effects of internet-delivered cognitive behavioral therapy (iCBT) for depression and anxiety on quality of life, no meta-analysis has yet been conducted to integrate the results of these studies. We conducted systematic searches in PubMed, Cochrane, and PsycInfo, which included terms for treatment type, modality of delivery, condition, and main outcome. We included studies that met the following inclusion criteria: (a) randomized controlled trials, (b) patients allocated to some form of the control condition, (c) patients receiving some type of treatment of anxiety and/or depression involving Internet-delivered Cognitive Behavioral Therapy, (d) use of a validated outcome measure assessing the level of quality of life, (e) conducted with adult participants diagnosed with anxiety disorder and/or unipolar depression, (f) papers written in English. We analyzed 40 randomized controlled trials with a total of 4289 participants that met inclusion criteria. The pooled between-group effect size for the quality of life overall score was small (g = 0.35, 95 % CI: 0.26-0.44, p = .0001), favoring iCBT over the control conditions. Regarding the distinct quality of life domains measured by the World Health Organization Quality of Life Assessment, a statistically significant difference between iCBT and control conditions was found only for the physical health domain (g = 0.56, 95 % CI: 0.06-1.07, p = .029), in favor of iCBT. In both cases, heterogeneity was moderate. While the effect on the quality of life is small (the overall quality of life score) to moderate (the physical health domain score), we conclude that iCBT for depression and anxiety may be a promising approach for improving the quality of life of patients.
To our knowledge, no systematic review has been conducted on predictors or moderators of treatment outcome across diagnoses in guided internet-based interventions (IBIs) for adults. To identify who benefits from this specific format and therein inform future research on improving patient-treatment fit, we aimed to aggregate results of relevant studies. 2100 articles, identified by searching the databases PsycInfo, Ovid Medline, and Pubmed and through snowballing, were screened in April/May 2021 and October 2022. Risk of bias and intra- and interrater reliability were assessed. Variables were grouped by predictor category, then synthesized using vote counting based on direction of effect. N = 60 articles were included in the review. Grouping resulted in 88 predictors/moderators, of which adherence, baseline symptoms, education, age, and gender were most frequently assessed. Better adherence, treatment credibility, and working alliance emerged as conclusive predictors/moderators for better outcome, whereas higher baseline scores predicted more reliable change but higher post-treatment symptoms. Results of all other predictors/moderators were inconclusive or lacked data. Our review highlights that it is currently difficult to predict, across diagnoses, who will benefit from guided IBIs. Further rigorous research is needed to identify predictors and moderators based on a sufficient number of studies. PROSPERO registration: CRD42021242305.
Internet-delivered CBT interventions effectively improve different aspects of mental health, although the therapist’s role remains unclear. The aim of this trial was to evaluate the efficacy of a therapist-supported 6-week internet-delivered intervention in improving stress recovery among healthcare workers compared to a group with optional therapist support. A total of 196 participants were recruited and randomly allocated to regular therapists’ support or optional therapists’ support groups. The primary outcome measure was the Recovery Experiences Questionnaire (REQ), developed to assess four components of stress recovery: psychological detachment, relaxation, mastery, and control. Secondary outcomes measured perceived stress (PSS-10), anxiety (GAD-7), depression (PHQ-9), and psychological well-being (WHO-5). All four stress recovery skills improved significantly after participating in the intervention at a 3-month follow-up, with small to medium effects (0.27–0.65) in both groups. At follow-up, we also found a significant reduction in perceived stress, depression, and anxiety in both groups, as well as an improvement in psychological well-being. The results indicate that ICBT can be effective in improving stress recovery skills among healthcare workers with optional support from the therapist, provided at the participants’ request. This RCT suggests that optional therapist support could meet participants’ needs and reduce resources needed in routine care.
Objective
Text-based communication is becoming an increasingly salient feature of the psychotherapeutic landscape. Yet little is known about the factors distinguishing high- and low-quality therapeutic conversations taking place over this modality. Prior research on therapist effects has outlined several common factors associated with better clinical outcomes. But these common factors can only be researched in the context of text-based communication if they can be measured. Accordingly, we developed and validated a new behavioral task and coding system: the Facilitative Interpersonal Skills Performance Task for Text (FIS-T) to measure therapists’ messaging quality across eight dimensions of facilitative interpersonal skill.
Methods
1150 survey-takers rated the interpersonal dynamics and response difficulty of the FIS-T Task’s text-based stimuli. The FIS-T was then administered to 64 therapists.
Results
The FIS-T stimuli displayed similar interpersonal dynamics to those elicited by the original FIS task, demonstrated a similar range of difficulties to those of the video-based stimuli of the original FIS Task, and showed high inter-rater reliability.
Conclusions
The text-based FIS-T Task demonstrates high reliability and convergent validity with the original FIS Task, making it appropriate for use in assessing the common factors in text-based therapy. Future directions in the quality assessment of internet-delivered psychotherapies are discussed.
Internet-delivered interventions are generally effective for psychological problems. While the presence of a clinician guiding the client via text messages typically leads to better outcomes, the characteristics of what constitutes high-quality communication are less well investigated. This study aimed to identify how an internet therapist most effectively communicates with clients in internet-delivered cognitive behavioral therapy (ICBT). Using data from a treatment study of depressed adolescents with a focus on participants who had a positive outcome, messages from therapists were analyzed using thematic analysis. The study focused on the therapist's 1) encouragement and 2) affirmation, and how the therapists used 3) personal address. The analysis resulted in a total of twelve themes (Persistence Wins, You Are a Superhero, You Make Your Luck, You Understand, Hard Times, You Are Like Others, My View on the Matter, Time for a Change, Welcome In, Let Me Help You, You Affect Me, and I Am Human). Overall, the themes form patterns where treatment is described as hard work that requires a motivated client who is encouraged by the therapist. The findings are discussed based on the cognitive behavioral theoretical foundation of the treatment, prior research on therapist behaviors, and the fact that the treatment is provided over the internet.
Background
Eating disorders (ED) are severe psychiatric conditions, characterized by decreased quality of life and high mortality. However, only a minority of patients with ED seek care and very few receive treatment. Internet-delivered cognitive behavioral therapy (ICBT) has the potential to increase access to evidence-based treatments.
Aims
The aims of the present study were to (1) develop and evaluate the usability of an Internet-delivered guided self-help treatment based on Enhanced Cognitive Behavioral Therapy (ICBT-E) for patients with full or subthreshold bulimia nervosa (BN) or binge eating disorder (BED) with a user centered design process, and (2) to evaluate its feasibility and preliminary outcome in a clinical environment.
Method
The study was undertaken in two stages. In Stage I, a user-centered design approach was applied with iterative phases of prototype development and evaluation. Participants were eight clinicians and 30 individuals with current or previous history of ED. In Stage II, 41 patients with full or subthreshold BN or BED were recruited to a single-group open trial to evaluate the feasibility and preliminary outcome of ICBT-E. Primary outcome variables were diagnostic status and self-rated ED symptoms.
Results
The user-centered design process was instrumental in the development of the ICBT-E, by contributing to improvements of the program and to the content being adapted to the needs and preferences of end-users. The overall usability of the program was found to be good. ICBT-E targets key maintaining factors in ED by introducing healthy eating patterns and addressing over-evaluation of weight and shape. The results indicate that ICBT-E, delivered in a clinical setting, is a feasible and promising treatment for full or subthreshold BN or BED, with a high level of acceptability observed and treatment completion of 73.2 %. Participation in ICBT-E was associated with significant symptom reductions in core ED symptomology, functional impairment as well as depressive symptoms, and the results were maintained at the 3-month follow-up.
Conclusions
ICBT-E was developed with end-users' preferences in mind, in accordance with the identified recommendations, and the program was perceived as usable by end-users. The study demonstrated the potential of ICBT-E, which marks a step forward in the effort to make powerful, empirically supported psychological interventions targeting ED more widely available and accessible.
Background:
Australians living in rural and remote areas are at elevated risk of mental health problems and must overcome barriers to help seeking, such as poor access, stigma, and entrenched stoicism. e-Mental health services circumvent such barriers using technology, and text-based services are particularly well suited to clients concerned with privacy and self-presentation. They allow the client to reflect on the therapy session after it has ended as the chat log is stored on their device. The text also offers researchers an opportunity to analyze language use patterns and explore how these relate to mental health status.
Objective:
In this project, we investigated whether computational linguistic techniques can be applied to text-based communications with the goal of identifying a client’s mental health status.
Methods:
Client-therapist text messages were analyzed using the Linguistic Inquiry and Word Count tool. We examined whether the resulting word counts related to the participants’ presenting problems or their self-ratings of mental health at the completion of counseling.
Results:
The results confirmed that word use patterns could be used to differentiate whether a client had one of the top 3 presenting problems (depression, anxiety, or stress) and, prospectively, to predict their self-rated mental health after counseling had been completed.
Conclusions:
These findings suggest that language use patterns are useful for both researchers and clinicians trying to identify individuals at risk of mental health problems, with potential applications in screening and targeted intervention.
Background:
Australians living in rural and remote areas are at elevated risk of mental health problems and must overcome barriers to help seeking, such as poor access, stigma, and entrenched stoicism. e-Mental health services circumvent such barriers using technology, and text-based services are particularly well suited to clients concerned with privacy and self-presentation. They allow the client to reflect on the therapy session after it has ended as the chat log is stored on their device. The text also offers researchers an opportunity to analyze language use patterns and explore how these relate to mental health status.
Objective:
In this project, we investigated whether computational linguistic techniques can be applied to text-based communications with the goal of identifying a client's mental health status.
Methods:
Client-therapist text messages were analyzed using the Linguistic Inquiry and Word Count tool. We examined whether the resulting word counts related to the participants' presenting problems or their self-ratings of mental health at the completion of counseling.
Results:
The results confirmed that word use patterns could be used to differentiate whether a client had one of the top 3 presenting problems (depression, anxiety, or stress) and, prospectively, to predict their self-rated mental health after counseling had been completed.
Conclusions:
These findings suggest that language use patterns are useful for both researchers and clinicians trying to identify individuals at risk of mental health problems, with potential applications in screening and targeted intervention.
Background and objectives:
This two-year follow-up study evaluated the long-term outcomes of two early interventions that aimed at reducing social and test anxiety in young adolescents at risk for developing social anxiety disorder.
Methods:
In this RCT, moderately socially anxious adolescents (N=240, mean age 13.6 years) were randomly assigned to a 10-week internet-based multifaceted cognitive bias modification training (CBM), a 10-week school-based cognitive behavioral group training (CBT), or a no-intervention control condition. Using multiple imputation, this study examined the changes in primary and secondary outcome measures from pretest to follow-up in a repeated measures design.
Results:
Primary outcome: Self-reported social and test anxiety generally decreased from pre-test to two-year follow-up, regardless of treatment condition. The percentage of adolescents who developed a social anxiety disorder was very low (6%) and similar across conditions. Secondary outcome: There were beneficial changes in self-esteem, self-reported prosocial behaviors, and fear of negative evaluation, but none of these were related to treatment condition. Automatic social-threat associations did not significantly change. The CBM intervention was effective in changing interpretative bias as indexed by the Recognition Task but this long-term effect did not transfer to the Adolescent Interpretation and Belief Questionnaire.
Limitations:
There was a substantial (50%) though seemingly non-selective attrition at follow-up.
Conclusions:
This RCT does not support the longer-term efficacy of school-based CBT or CBM as an early intervention for social and test anxiety. Rather, it emphasizes the positive 'natural' course of highly socially anxious adolescents over two years.
Objectives
To evaluate the long-term effects of two non-face-to-face treatment programmes for stress urinary incontinence (SUI) based on pelvic floor muscle training (PFMT).Subjects and Methods
Randomised controlled trial with online recruitment of 250 community-dwelling women aged 18-70 years with SUI ≥1/week. Diagnosis based on validated self-assessed questionnaires, 2-day bladder diary, and telephone interview with a urotherapist. Consecutive computer-generated block-randomisation with allocation by an independent administrator to 3 months of treatment with either an Internet-based treatment programme (n=124) or a programme sent by post (n=126). Both interventions focused mainly on PFMT; the Internet group received continuous e-mail support from a urotherapist, whereas the postal group trained on their own. Follow-up was performed after 1 and 2 years via self-assessed postal questionnaires. The primary outcomes were symptom severity (International Consultation on Incontinence Questionnaire Short Form, ICIQ-UI SF) and condition-specific quality of life (ICIQ-Lower Urinary Tract Symptoms Quality of Life, ICIQ-LUTSqol). Secondary outcomes were the Patient's Global Impression of Improvement, health-specific quality of life (EQ-Visual Analogue Scale), use of incontinence aids, and satisfaction with treatment. There was no face-to-face contact with the participants at any time. Analysis was based on intention-to-treat.ResultsWe lost 32.4% (81/250) of participants to follow-up after 1 year and 38.0% (95/250) after 2 years. With both interventions, we observed highly significant (p<0.001) improvements with large effect sizes (>0.8) for symptoms and condition-specific quality of life after 1 and 2 years, respectively. No significant differences were found between the groups. The mean changes (SD) in symptom score were 3.7 (3.3) for Internet and 3.2 (3.4) for postal (p=0.47) after 1 year, and 3.6 (3.5) for Internet and 3.4 (3.3) for postal (p=0.79) after 2 years. The mean changes (SD) of condition-specific quality of life were 5.5 (6.5) for Internet and 4.7 for postal (6.5) (p=0.55) after 1 year, and 6.4 (6.0) for Internet and 4.8 (7.6) for postal (p=0.28) after 2 years. The proportions of participants perceiving they were much or very much improved were similar in both intervention groups after 1 year (Internet 31.9% (28/88), postal 33.8% (27/80) p=0.82), but after 2 years significantly more participants in the Internet group reported this level of improvement (39.2% (29/74) vs. 23.8% (19/80), p=0.03). Health-specific quality of life improved significantly in the Internet group after 2 years (mean change EQ-VAS 3.8 (11.4), p=0.005). We found no other significant improvements in this measure. One year after treatment, 69.8% (60/86) of participants in the Internet group and 60.5% (46/76) of participants in the postal group reported that they were still satisfied with the treatment result. After 2 years, the proportions were 64.9% (48/74) and 58.2% (46/79), respectively.Conclusion
Non-face-to-face treatment of SUI with PFMT provides significant and clinically relevant improvements in symptoms and condition-specific quality of life 1 and 2 years after treatment.This article is protected by copyright. All rights reserved.
Internet-delivered cognitive behavior therapy (ICBT) has been tested in many research trials, but to a lesser extent directly compared to face-to-face delivered cognitive behavior therapy (CBT). We conducted a systematic review and meta-analysis of trials in which guided ICBT was directly compared to face-to-face CBT. Studies on psychiatric and somatic conditions were included. Systematic searches resulted in 13 studies (total N=1053) that met all criteria and were included in the review. There were three studies on social anxiety disorder, three on panic disorder, two on depressive symptoms, two on body dissatisfaction, one on tinnitus, one on male sexual dysfunction, and one on spider phobia. Face-to-face CBT was either in the individual format (n=6) or in the group format (n=7). We also assessed quality and risk of bias. Results showed a pooled effect size (Hedges' g) at post-treatment of -0.01 (95% CI: -0.13 to 0.12), indicating that guided ICBT and face-to-face treatment produce equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there are still few studies for each psychiatric and somatic condition and many conditions for which guided ICBT has not been compared to face-to-face treatment. Thus, more research is needed to establish equivalence of the two treatment formats.
Introduction
The aim of this study was to systematically review the impact of guidance on the efficacy of Internet-based interventions.
Methods
Included were RCTs with a comparison of (1) guided vs. unguided interventions, (2) different doses of guidance, (3) different qualification levels of e-coaches, and (4) synchronous vs. asynchronous communication mode. Outcomes were symptom severity, completer rates and number of completed intervention modules. A systematic search of MEDLINE, CENTRAL and PsycINFO, PsycARTICLES and Psyndex (search date 4th June 2013) was conducted, as well as a hand search of trial-registers and the reference lists of included articles. Methodological quality was rated using the Cochrane Risk of Bias tool. Relevant study characteristics and outcome data were extracted. Random-effects analyses were conducted if appropriate.
Results
5,328 articles were retrieved of which 14 fulfilled inclusion criteria. Guided interventions were significantly superior to unguided interventions (symptom severity: standardized mean difference (SMD) = -.27 [95%CI:-.45;-.10]),n = 8; completed modules: SMD = .52 [.37;.67],n = 7; completer rate: OR = 2.76 [1.68;4.53],n = 6). The four trials that examined different levels of e-coach qualification showed no significant differences on either of the outcome measures. Only one trial each examined the remaining two research questions, without significant effects on either of the outcome measures.
Conclusions
Guidance is a beneficial feature of Internet-based interventions, although its effect is smaller than reported before when compared to unguided interventions. The qualification of the e-coaches seems of minor importance. However, methodological limitations need to be considered when interpreting these findings. Overall, the number of studies was small and mainly limited to depression and social phobia restricting the generalizability of the findings.
The current study is a qualitative follow-up of a study on guided internet-delivered cognitive behaviour therapy (ICBT) for social anxiety disorder (SAD), conducted four years after treatment completion. The main aim was to capture participants’ description of their experiences of the treatment, their view on treatment effects, memories of the treatment, and whether they continued using the gained knowledge after treatment. Sixty participants were selected from the original study’s treatment group. A criterion based sampling approach was used based on the obtained treatment effect, and with a minimum of five completed treatment modules. E-mail invitations were sent, with information about the follow-up and the instruction to respond if interested in participating. Twelve semi-structured interviews were made and the material was analysed using an approach based on grounded theory. The results showed that all participants found the treatment to have some effect, but they also found it to be demanding, difficult, and hard. Many appreciated to hear of the experiences of other participants in the online forum. Under the theme of memory, most could describe the setup of the treatment in general terms. The exposure module was mentioned by all, cognitive restructuring by most, and some also reported memories of the psychoeducation. A core process was identified which involved how the attained treatment effect was viewed over the time, and how this view changed from treatment completion to current time. The findings outlined in this study describes how treatment effects can be sustained via an active approach to the treatment and the symptoms of SAD.
Background:
As relapse after completed cognitive behavior therapy (CBT) for obsessive-compulsive disorder (OCD) is common, many treatment protocols include booster programs to improve the long-term effects. However, the effects of booster programs are not well studied. In this study, we investigated the long-term efficacy of Internet-based CBT (ICBT) with therapist support for OCD with or without an Internet-based booster program.
Method:
A total of 101 participants were included in the long-term follow-up analysis of ICBT. Of these, 93 were randomized to a booster program or no booster program. Outcome assessments were collected at 4, 7, 12 and 24 months after receiving ICBT.
Results:
The entire sample had sustained long-term effects from pre-treatment to all follow-up assessments, with large within-group effect sizes (Cohen's d = 1.58-2.09). The booster group had a significant mean reduction in OCD symptoms compared to the control condition from booster baseline (4 months) to 7 months, but not at 12 or 24 months. Participants in the booster group improved significantly in terms of general functioning at 7, 12 and 24 months, and had fewer relapses. Kaplan-Meier analysis also indicated a significantly slower relapse rate in the booster group.
Conclusions:
The results suggest that ICBT has sustained long-term effects and that adding an Internet-based booster program can further improve long-term outcome and prevent relapse for some OCD patients.
Internet interventions have great potential for alleviating emotional distress, promoting mental health, and enhancing well-being. Numerous clinical trials have demonstrated their effectiveness for a number of psychiatric conditions, and interventions delivered via the Internet will likely become a common alternative to face-to-face treatment. Meanwhile, research has paid little attention to the negative effects associated with treatment, warranting further investigation of the possibility that some patients might deteriorate or encounter adverse events despite receiving best available care. Evidence from research of face-to-face treatment suggests that negative effects afflict 5-10% of all patients undergoing treatment in terms of deterioration. However, there is currently a lack of consensus on how to define and measure negative effects in psychotherapy research in general, leaving researchers without practical guidelines for monitoring and reporting negative effects in clinical trials. The current paper therefore seeks to provide recommendations that could promote the study of negative effects in Internet interventions with the aim of increasing the knowledge of its occurrence and characteristics. Ten leading experts in the field of Internet interventions were invited to participate and share their perspective on how to explore negative effects, using the Delphi technique to facilitate a dialogue and reach an agreement. The authors discuss the importance of conducting research on negative effects in order to further the understanding of its incidence and different features. Suggestions on how to classify and measure negative effects in Internet interventions are proposed, involving methods from both quantitative and qualitative research. Potential mechanisms underlying negative effects are also discussed, differentiating common factors shared with face-to-face treatments from those unique to treatments delivered via the Internet. The authors conclude that negative effects are to be expected and need to be acknowledged to a greater extent, advising researchers to systematically probe for negative effects whenever conducting clinical trials involving Internet interventions, as well as to share their findings in scientific journals.
Objective:
Cognitive behavioral therapy (CBT) is known to be an effective treatment of adolescents with chronic fatigue syndrome (CFS), but its availability is limited. Fatigue in Teenagers on the Internet (FITNET), an Internet-based CBT program for adolescents with CFS, has been developed as an alternative to face-to-face CBT. Recently, its short-term effectiveness has been proven in a randomized clinical trial. Here we aimed to assess the long-term outcome of CFS in adolescents after FITNET treatment and after usual care. In addition, factors related to recovery at long-term follow-up (LTFU) for adolescents treated with the FITNET program were investigated.
Methods:
The study was an LTFU of participants of the FITNET trial. Data were completed for 112 (88.2%) of 127 approached FITNET study participants. Primary outcomes were fatigue severity (Checklist Individual Strength-20), physical functioning (87-item Child Health Questionnaire), and school/work attendance.
Results:
After a mean follow-up of 2.7 years, 66 (58.9%) adolescents had recovered from CFS. Most adolescents who recovered directly after treatment with FITNET were still recovered at LTFU. At LTFU there was no difference between the recovery rates for the different treatment strategies (original randomization: FITNET [64%] versus any form of usual care [52.8%]). Per additional month of "pretreatment disease duration," the odds for recovery were 4% lower (odds ratio: 0.96; 95% confidence interval: 0.93-0.99; P = .016), and per added point on "focus on bodily symptoms" (Body Consciousness Scale) of the mother (0-20 points) the odds for recovery were 11% lower (odds ratio: 0.89; 95% confidence interval: 0.80-0.99; P = .029).
Conclusions:
The short-term effectiveness of Internet-based CBT on adolescent CFS is maintained at LTFU. At LTFU, usual care led to similar recovery rates, although these rates were achieved at a slower pace.
Objectives
Although cognitive behaviour therapy (CBT) and pharmacotherapy are equally effective in the acute treatment of adult depression, it is not known how they compare across the longer term. In this meta-analysis, we compared the effects of acute phase CBT without any subsequent treatment with the effects of pharmacotherapy that either were continued or discontinued across 6–18 months of follow-up.
Design
We conducted systematic searches in bibliographical databases to identify relevant studies, and conducted a meta-analysis of studies meeting inclusion criteria.
Setting
Mental healthcare.
Participants
Patients with depressive disorders.
Interventions
CBT and pharmacotherapy for depression.
Outcome measures
Relapse rates at long-term follow-up.
Results
9 studies with 506 patients were included. The quality was relatively high. Short-term outcomes of CBT and pharmacotherapy were comparable, although drop out from treatment was significantly lower in CBT. Acute phase CBT was compared with pharmacotherapy discontinuation during follow-up in eight studies. Patients who received acute phase CBT were significantly less likely to relapse than patients who were withdrawn from pharmacotherapy (OR=2.61, 95% CI 1.58 to 4.31, p<0.001; numbers-needed-to-be-treated, NNT=5). The acute phase CBT was compared with continued pharmacotherapy at follow-up in five studies. There was no significant difference between acute phase CBT and continued pharmacotherapy, although there was a trend (p<0.1) indicating that patients who received acute phase CBT may be less likely to relapse following acute treatment termination than patients who were continued on pharmacotherapy (OR=1.62, 95% CI 0.97 to 2.72; NNT=10).
Conclusions
We found that CBT has an enduring effect following termination of the acute treatment. We found no significant difference in relapse after the acute phase CBT versus continuation of pharmacotherapy after remission. Given the small number of studies, this finding should be interpreted with caution pending replication.
Guided internet-delivered cognitive behavior therapy (ICBT) has been tested in several trials on social anxiety disorder (SAD) with moderate to large effects. The aims of this study were threefold. First, to compare the effects of ICBT including online discussion forum with a moderated online discussion forum only. Second, to investigate if knowledge about SAD increased following treatment and third to compare the effects of inexperienced versus experienced therapists on patient outcomes.
A total of 204 participants with a primary diagnosis of SAD were included and randomized to either guided ICBT or the control condition. ICBT consisted of a 9-week treatment program which was guided by either psychology students at MSc level (n = 6) or by licensed psychologists with previous experience of ICBT (n = 7). A knowledge test dealing with social anxiety was administered before and after treatment. Measures of social anxiety and secondary outcomes dealing with general anxiety, depression, and quality of life were administered before and after treatment. In addition, a 1-year follow-up was conducted on the treated individuals.
Immediately following treatment, the ICBT group showed superior outcome on the Liebowitz Social Anxiety Scale self-report version with a between group posttreatment Hedges g effect size of g = 0.75. In addition, significant differences on all the secondary outcomes were observed. Gains were well maintained one year later. Knowledge, as assessed by the knowledge test, increased following treatment with little gain in the control group. Therapist experience did not result in different outcomes, but experienced therapists logged in less frequently compared to the inexperienced therapists, suggesting that they needed less time to support patients.
We conclude that guided ICBT reduce symptoms of SAD, increase knowledge about SAD and that therapist experience does not make a difference apart from the finding that experienced therapist may require less time to guide patients.
UMIN.ac.jp UMIN000001383.
Effective therapies for pathological gambling exist, but their use is limited to about 10% of the target population. In an attempt to lower the barriers for help, Internet-based cognitive behavioural therapy (ICBT) has been shown to be effective when delivered to a non-depressed sample with pathological gambling. This study sought to extend this finding to a larger, more representative population, and also test a model to predict responder status. Following advertisement, a total of 284 participants started an 8-week ICBT programme with minimal therapist contact via e-mail and weekly telephone calls of less than 15 min. The average time spent on each participant, including telephone conversations, e-mail, and administration, was 4 h. In addition to a mixed effects model to evaluate the effectiveness of the treatment, two logistic regression analyses were performed with the following eight pre-defined response predictor variables: work-life satisfaction, primary gambling activity, debts due to gambling, social support, personal yearly salary, alcohol consumption, stage of change, and dissociative gambling. ICBT resulted in statistically significant reductions in the scores of pathological gambling, anxiety, and depression as well as an increase in quality of life compared to pre-treatment levels. Follow-ups carried out in the treatment group at 6, 18, and 36 months indicated that treatment effects were sustained. Using the eight predictor variable model rendered an acceptable predictive ability to identify responders both at post-test (AUC = .72, p < .01) and at 36-month follow-up (AUC = .70, p < .01). We conclude that ICBT for pathological gamblers, even if depressed, can be effective and that outcome can partly be predicted by pre-treatment characteristics.
Internet-based cognitive behavior therapy (CBT) has been shown to be a promising method to disseminate cognitive behavior therapy for social anxiety disorder (SAD). Several trials have demonstrated that Internet-based CBT can be effective for SAD in the shorter term. However, the long-term effects of Internet-based CBT for SAD are less well known.
Our objective was to investigate the effect of Internet-based CBT for SAD 5 years after completed treatment.
We conducted a 5-year follow-up study of 80 persons with SAD who had undergone Internet-based CBT. The assessment comprised a diagnostic interview and self-report questionnaires. The main outcome measure was the Liebowitz Social Anxiety Scale-Self-Report (LSAS-SR). Additional measures of social anxiety were the Social Interaction Anxiety Scale (SIAS) and the Social Phobia Scale (SPS). Attrition rates were low: 89% (71/80) of the participants completed the diagnostic interview and 80% (64/80) responded to the questionnaires.
Mixed-effect models analysis showed a significant effect of time on the three social anxiety measures, LSAS-SR, SIAS, and SPS (F(3,98-102) = 16.05 - 29.20, P < .001) indicating improvement. From baseline to 5-year follow-up, participants' mean scores on the LSAS-SR were reduced from 71.3 (95% confidence interval [CI] 66.1-76.5) to 40.3 (95% CI 35.2 - 45.3). The effect sizes of the LSAS-SR were large (Cohen's d range 1.30 - 1.40, 95% CI 0.77 - 1.90). Improvements gained at the 1-year follow-up were sustained 5 years after completed treatment.
Internet-based CBT for SAD is a treatment that can result in large and enduring effects.
Clinicaltrials.gov NCT01145690; http://clinicaltrials.gov/ct2/show/NCT01145690 (Archived by WebCite at http://www.webcitation.org/5ygRxDLfK).
Background:
Internet-delivered cognitive behavior therapy (ICBT) for major depression has been tested in several trials, but only with follow-ups up to 1.5 years.
Aim:
The aim of this study was to evaluate the outcome of ICBT 3.5 years after treatment completion.
Methods:
A total of 88 people with major depression were randomized to either guided self-help or e-mail therapy in the original trial. One-third was initially on a waiting-list. Treatment was provided for eight weeks and in this report long-term follow-up data were collected. Also included were data from post-treatment and six-month follow-up. A total of 58% (51/88) completed the 3.5-year follow-up. Analyses were performed using a random effects repeated measures piecewise growth model to estimate trajectory shape over time and account for missing data. Results Results showed continued lowered scores on the Beck Depression Inventory (BDI). No differences were found between the treatment conditions. A large proportion of participants (55%) had sought and received additional treatments in the follow-up period. A majority (56.9%) of participants had a BDI score lower than 10 at the 3.5-year follow-up.
Conclusions:
People with mild to moderate major depression may benefit from ICBT 3.5-years after treatment completion.
BACKGROUND: Cognitive behaviour therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD) but access to CBT is limited. Internet-based CBT (ICBT) with therapist support is potentially a more accessible treatment. There are no randomized controlled trials testing ICBT for OCD. The aim of this study was to investigate the efficacy of ICBT for OCD in a randomized controlled trial.Method
Participants (n=101) diagnosed with OCD were randomized to either 10 weeks of ICBT or to an attention control condition, consisting of online supportive therapy. The primary outcome measure was the Yale-Brown Obsessive Compulsive Scale (YBOCS) administered by blinded assessors. RESULTS: Both treatments lead to significant improvements in OCD symptoms, but ICBT resulted in larger improvements than the control condition on the YBOCS, with a significant between-group effect size (Cohen's d) of 1.12 (95% CI 0.69-1.53) at post-treatment. The proportion of participants showing clinically significant improvement was 60% (95% CI 46-72) in the ICBT group compared to 6% (95% CI 1-17) in the control condition. The results were sustained at follow-up. CONCLUSIONS: ICBT is an efficacious treatment for OCD that could substantially increase access to CBT for OCD patients. Replication studies are warranted.
The development of a 21-item self-report inventory for measuring the severity of anxiety in psychiatric populations is described. The initial item pool of 86 items was drawn from three preexisting scales: the Anxiety Checklist, the Physician’s Desk Reference Checklist, and the Situational Anxiety Checklist. A series of analyses was used to reduce the item pool. The resulting Beck Anxiety Inventory (BAI) is a 21-item scale that showed high internal consistency (α = .92) and test—retest reliability over 1 week, r (81) = .75. The BAI discriminated anxious diagnostic groups (panic disorder, generalized anxiety disorder, etc.) from nonanxious diagnostic groups (major depression, dysthymic disorder, etc). In addition, the BAI was moderately correlated with the revised Hamilton Anxiety Rating Scale, r (150) = .51, and was only mildly correlated with the revised Hamilton Depression Rating Scale, r (153) = .25.
Generalized anxiety disorder (GAD) has been effectively treated with cognitive behavioural therapy (CBT) in face-to face settings. Internet-delivered CBT could be a way to increase the accessibility and affordability of CBT for people suffering from GAD. The aim of this study was to evaluate the efficacy of guided Internet-delivered CBT for GAD in a controlled trial with a wait-list control group. A total of 89 participants were included following online screening and a structured psychiatric telephone interview. Participants were randomized to either an 8-week treatment group (n = 44) or a wait-list control group (n = 45). Treatment consisted of a self-help program based on CBT principles and applied relaxation along with therapist guidance. The main outcome measure was the Penn State Worry Questionnaire. Ratings of clinical improvement and symptoms were included as well as secondary outcome measures dealing with anxiety, depression, and quality of life. Among the treatment group participants, 13.6% did not complete the posttreatment measures. The treatment group showed significant improvement compared with the control group on all outcome measures. Large effect sizes (Cohen's d > 0.8) were found both within the treatment group and between the groups in favor of the treatment on all outcome measures except on a measure of quality of life. Results at 1- and 3-year follow-up indicated that treatment results improved or were maintained. The authors conclude that Internet-delivered CBT with therapist support can reduce symptoms and problems related to GAD.
Cognitive behavioral group therapy (CBGT) is an effective, well-established, but not widely available treatment for social anxiety disorder (SAD). Internet-based cognitive behavior therapy (ICBT) has the potential to increase availability and facilitate dissemination of therapeutic services for SAD. However, ICBT for SAD has not been directly compared with in-person treatments such as CBGT and few studies investigating ICBT have been conducted in clinical settings. Our aim was to investigate if ICBT is at least as effective as CBGT for SAD when treatments are delivered in a psychiatric setting.
We conducted a randomized controlled non-inferiority trial with allocation to ICBT (n=64) or CBGT (n=62) with blinded assessment immediately following treatment and six months post-treatment. Participants were 126 individuals with SAD who received CBGT or ICBT for a duration of 15 weeks. The Liebowitz Social Anxiety Scale (LSAS) was the main outcome measure. The following non-inferiority margin was set: following treatment, the lower bound of the 95 % confidence interval (CI) of the mean difference between groups should be less than 10 LSAS-points.
Both groups made large improvements. At follow-up, 41 (64%) participants in the ICBT group were classified as responders (95% CI, 52%-76%). In the CBGT group, 28 participants (45%) responded to the treatment (95% CI, 33%-58%). At post-treatment and follow-up respectively, the 95 % CI of the LSAS mean difference was 0.68-17.66 (Cohen's d between group=0.41) and -2.51-15.69 (Cohen's d between group=0.36) favoring ICBT, which was well within the non-inferiority margin. Mixed effects models analyses showed no significant interaction effect for LSAS, indicating similar improvement across treatments (F=1.58; df=2, 219; p=.21).
ICBT delivered in a psychiatric setting can be as effective as CBGT in the treatment of SAD and could be used to increase availability to CBT.
ClinicalTrials.gov NCT00564967.
We hypothesized that people with type 2 diabetes in an online diabetes self-management program, compared with usual-care control subjects, would 1) demonstrate reduced A1C at 6 and 18 months, 2) have fewer symptoms, 3) demonstrate increased exercise, and 4) have improved self-efficacy and patient activation. In addition, participants randomized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement.
A total of 761 participants were randomized to 1) the program, 2) the program with e-mail reinforcement, or 3) were usual-care control subjects (no treatment). This sample included 110 American Indians/Alaska Natives (AI/ANs). Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups.
At 6 months, A1C, patient activation, and self-efficacy were improved for program participants compared with usual care control subjects (P < 0.05). There were no changes in other health or behavioral indicators. The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects. The subgroup with initial A1C >7% demonstrated stronger improvement in A1C (P = 0.01). At 18 months, self-efficacy and patient activation were improved for program participants. A1C was not measured. Reinforcement showed no improvement.
An online diabetes self-management program is acceptable for people with type 2 diabetes. Although the results were mixed they suggest 1) that the program may have beneficial effects in reducing A1C, 2) AI/AN populations can be engaged in and benefit from online interventions, and 3) our follow-up reinforcement appeared to have no value.
Internet-delivered self-help programmes with added therapist guidance have shown efficacy in social anxiety disorder, but unguided self-help has been insufficiently studied.
To evaluate the efficacy of guided and unguided self-help for social anxiety disorder.
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.
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.
Unguided self-help through bibliotherapy can produce enduring improvement for individuals with social anxiety disorder.
The field of Internet-supported therapeutic interventions has suffered from a lack of clarity and consistency. The absence of professional leadership and of accepted governing approaches, terminology, professional standards, and methodologies has caused this field to be diffused and unstructured. Numerous terms have been used to label and describe the activities conducted over the Internet for mental and physical health purposes: web-based therapy, e-therapy, cybertherapy, eHealth, e-Interventions, computer-mediated interventions, and online therapy (or counseling), among others.
Following a comprehensive review, we conceptualized Internet-supported interventions, using four categories based on prime practice approaches: web-based interventions, online counseling and therapy, Internet-operated therapeutic software, and other online activities (e.g., as supplements to face-to-face therapy). We provide a working definition and detailed description of each category, accompanied by numerous examples.
These categories may now serve as guiding definitions and related terminologies for further research and development in this emerging field.
No meta-analytical study has examined whether the quality of the studies examining psychotherapy for adult depression is associated with the effect sizes found. This study assesses this association.
We used a database of 115 randomized controlled trials in which 178 psychotherapies for adult depression were compared to a control condition. Eight quality criteria were assessed by two independent coders: participants met diagnostic criteria for a depressive disorder, a treatment manual was used, the therapists were trained, treatment integrity was checked, intention-to-treat analyses were used, N >or= 50, randomization was conducted by an independent party, and assessors of outcome were blinded.
Only 11 studies (16 comparisons) met the eight quality criteria. The standardized mean effect size found for the high-quality studies (d=0.22) was significantly smaller than in the other studies (d=0.74, p<0.001), even after restricting the sample to the subset of other studies that used the kind of care-as-usual or non-specific controls that tended to be used in the high-quality studies. Heterogeneity was zero in the group of high-quality studies. The numbers needed to be treated in the high-quality studies was 8, while it was 2 in the lower-quality studies.
We found strong evidence that the effects of psychotherapy for adult depression have been overestimated in meta-analytical studies. Although the effects of psychotherapy are significant, they are much smaller than was assumed until now, even after controlling for the type of control condition used.
Although effective therapies for pathological gambling exist, their uptake is limited to 10% of the target population. To lower the barriers for help seeking, the authors tested an online alternative in a randomized trial (N = 66). The participants were pathological gamblers not presenting with severe comorbid depression. A wait-list control was compared with an 8-week Internet-based cognitive behavior therapy program with minimal therapist contact via e-mail and weekly telephone calls of less than 15 min. Average time spent on each participant, including phone conversations, e-mail, and administration, was 4 hr. The Internet-based intervention resulted in favorable changes in pathological gambling, anxiety, depression, and quality of life. Composite between-group effect size (Cohen's d) at posttreatment was 0.83. Follow-ups carried out in the treatment group at 6, 18, and 36 months indicated that treatment effects were sustained (ds = 2.58, 1.96, and 1.98). This evidence is in support of Internet-delivered treatment for pathological gamblers. However, it is not clear how effective the treatment is for more severely depressed individuals.
Although effective therapies for social phobia exist, many individuals refrain from seeking treatment owing to the embarrassment associated with help-seeking. Internet-based cognitive-behavioural self-help can be an alternative, but adherence is a problem.
To evaluate a 9-week programme of internet-based therapy designed to increase treatment adherence by the addition of short weekly telephone calls, nine in all, with a total duration of 95 min.
In a randomised controlled trial the effects of internet-based cognitive-behavioural therapy in the treatment group (n=29) were compared with a waiting-list control group (n=28).
Compared with the control group the treated participants experienced greater reductions on measures of general and social anxiety, avoidance and depression. Adherence to treatment was high, with 93% finishing the complete treatment package. One year later all improvements were maintained.
This study provides evidence to support the use of internet-based treatment supplemented by short, weekly telephone calls.
Aims
The standardised mean difference (SMD) is one of the most used effect sizes to indicate the effects of treatments. It indicates the difference between a treatment and comparison group after treatment has ended, in terms of standard deviations. Some meta-analyses, including several highly cited and influential ones, use the pre-post SMD, indicating the difference between baseline and post-test within one (treatment group).
Methods
In this paper, we argue that these pre-post SMDs should be avoided in meta-analyses and we describe the arguments why pre-post SMDs can result in biased outcomes.
Results
One important reason why pre-post SMDs should be avoided is that the scores on baseline and post-test are not independent of each other. The value for the correlation should be used in the calculation of the SMD, while this value is typically not known. We used data from an ‘individual patient data’ meta-analysis of trials comparing cognitive behaviour therapy and anti-depressive medication, to show that this problem can lead to considerable errors in the estimation of the SMDs. Another even more important reason why pre-post SMDs should be avoided in meta-analyses is that they are influenced by natural processes and characteristics of the patients and settings, and these cannot be discerned from the effects of the intervention. Between-group SMDs are much better because they control for such variables and these variables only affect the between group SMD when they are related to the effects of the intervention.
Conclusions
We conclude that pre-post SMDs should be avoided in meta-analyses as using them probably results in biased outcomes.
Objective:
The MindSpot Clinic provides online mental health services to Australian adults with anxiety and depression. This paper describes users of MindSpot between January 2013 and June 2015. Outcomes are considered against three key objectives: improving access to mental health services, improving public awareness of how to access services and providing evidence-based treatments.
Method:
Website traffic data were examined to determine patterns of use. Demographic characteristics, past service utilisation and reasons for contacting MindSpot were analysed. Outcomes for patients enrolled in a MindSpot treatment course were also analysed. Primary outcomes were scores on the 9-Item Patient Health Questionnaire, Generalised Anxiety Disorder 7-Item, Yale-Brown Obsessive Compulsive Scale and Post-Traumatic Stress Disorder Checklist-Civilian Version, administered at assessment, post-treatment and 3-month follow-up.
Results:
The website was visited by almost 500,000 Australians, of which 33,990 adults started assessments, and 25,469 people completed assessment and were eligible for analysis. Mean age was 36.4 years (standard deviation = 13.3 years; range = 18-94 years), and 72% were female. The proportion living in rural or remote regions and who identified as Aboriginal and Torres Strait Islander closely matched national statistics. The majority (82%) reported that they were not currently in contact with mental health services. Most patients sought an assessment, information about treatment options, or referral to another service, and only 24% of those completing an assessment commenced a MindSpot treatment course. Of these, large clinical effects (d: 0.7-2.4; average symptom reductions: 25.5% to 61.6%) were found from assessment to follow-up on all outcome measures. Deterioration ranged from 1.0% to 4.3%.
Conclusion:
Based on the number of website visits, completed assessments and treatment outcomes, MindSpot achieved its three programme objectives. This model of service provision has considerable value as a complement to existing services, and is proving particularly important for improving access for people not using existing services.
During the past 15 years, much progress has been made in developing and testing Internet-delivered psychological treatments. In particular, therapistguided Internet treatments have been found to be effective for a wide range of psychiatric and somatic conditions in well over 100 controlled trials. These treatments require (a) a secure web platform, (b) robust assessment procedures, (c) treatment contents that can be text based or offered in other formats, and (d) a therapist role that differs from that in face-to-face therapy. Studies suggest that guided Internet treatments can be as effective as face-to-face treatments, lead to sustained improvements, work in clinically representative conditions, and probably are cost-effective. Despite these research findings, Internet treatment is not yet disseminated in most places, and clinical psychologists should consider using modern information technology and evidence-based treatment programs as a complement to their other services, even though there will always be clients for whom face-to-face treatment is the best option. Expected final online publication date for the Annual Review of Clinical Psychology Volume 12 is March 28, 2016. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
Generalized anxiety disorder (GAD) can be treated effectively with either disorder-specific cognitive behavior therapy (DS-CBT) or transdiagnostic CBT (TD-CBT). The relative benefits of DS-CBT and TD-CBT for GAD and the relative benefits of delivering treatment in clinician guided (CG-CBT) and self-guided (SG-CBT) formats have not been examined. Participants with GAD (n=338) were randomly allocated to receive an internet-delivered TD-CBT or DS-CBT intervention delivered in either CG-CBT or SG-CBT formats. Large reductions in symptoms of GAD (Cohen's d≥1.48; avg. reduction≥50%) and comorbid major depressive disorder (Cohen's d≥1.64; avg. reduction≥45%), social anxiety disorder (Cohen's d≥0.80; avg. reduction≥29%) and panic disorder (Cohen's d≥0.55; avg. reduction≥33%) were found across the conditions. No substantive differences were observed between DS-CBT and TD-CBT or CG-CBT and SG-CBT, highlighting the public health potential of carefully developed TD-CBT and SG-CBT.
• The Yale-Brown Obsessive Compulsive Scale was designed to remedy the problems of existing rating scales by providing a specific measure of the severity of symptoms of obsessivecompulsive disorder that is not influenced by the type of obsessions or compulsions present. The scale is a clinician-rated, 10-item scale, each item rated from 0 (no symptoms) to 4 (extreme symptoms) (total range, 0 to 40), with separate subtotals for severity of obsessions and compulsions. In a study involving four raters and 40 patients with obsessive-compulsive disorder at various stages of treatment, interrater reliability for the total Yale-Brown Scale score and each of the 10 individual items was excellent, with a high degree of internal consistency among all item scores demonstrated with Cronbach's α coefficient. Based on pretreatment assessment of 42 patients with obsessive-compulsive disorder, each item was frequently endorsed and measured across a range of severity. These findings suggest that the Yale-Brown Scale is a reliable instrument for measuring the severity of illness in patients with obsessive-compulsive disorder with a range of severity and types of obsessive-compulsive symptoms.
Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in the treatment of mild to moderate depression, but there have been no direct comparisons with the more established group-based CBT with a long-term follow-up.
Participants with mild to moderate depression were recruited from the general population and randomized to either guided ICBT (n=33) or to live group treatment (n=36). Measures were completed before and after the intervention to assess depression, anxiety, and quality of life. Follow-ups were conducted at one-year and three-year after the treatment had ended.
Data were analysed on an intention-to-treat basis using linear mixed-effects regression analysis. Results on the self-rated version of the Montgomery-Åsberg Depression Scale showed significant improvements in both groups across time indicating non-inferiority of guided ICBT, and there was even a tendency for the guided ICBT group to be superior to group-based CBT at three year follow-up. Within-group effect sizes for the ICBT condition at post-treatment showed a Cohen's d=1.46, with a similar large effect at 3-year follow-up, d=1.78. For the group CBT the corresponding within-group effects were d=0.99 and d=1.34, respectively.
The study was small with two active treatments and there was no placebo or credible control condition.
Guided ICBT is at least as effective as group-based CBT and long-term effects can be sustained up to 3 years after treatment.
The objective of the study was to investigate the long-term effects of internet-based relapse prevention for sufferers of partially remitted depression. Eighty-four individuals with partially remitted unipolar depression were randomized to either internet-based CBT (iCBT) or to a control group. After the ten week intervention period the participants were followed for 24 months and diagnostic interviews conducted to detect relapse. The intervention and monthly self-ratings of depressive symptoms were administered via an internet-based platform that ensured secure communication with all participants. Significantly fewer participants in the iCBT group had experienced a relapse compared with those in the control group two years after the internet-based intervention. The relapse rate in the iCBT group was 13.7% (CI 95% = 2.5-24.9) and in the control group it was 60.9% (CI 95% = 44.8-77). Furthermore, a significantly larger proportion of the iCBT group experienced remission two years after the intervention compared with the control group. Internet-based CBT seems promising for preventing relapse in sufferers of partially remitted depression.
Understanding the process by which problem gamblers recover without formal treatment may improve both formal treatments and assist those who wish to modify their gambling behavior without seeking treatment. Study 1 assessed the recovery process in problem gamblers who had recovered for at least 6 months without formal treatment from those who had recovered with the assistance of formal treatment. The treated recovered gamblers generally had a more severe gambling problem than did untreated recovered gamblers, as indicated by a long problem gambling career and more gambling-related negative consequences (e.g., family, health). Study 2 compared two samples of untreated gamblers, those who had recovered without treatment with a comparable sample of active gamblers who also had never received treatment. The active, untreated gamblers had higher lifetime rates of anxiety and personality disorder. Recovered gamblers may match the behaviorally conditioned problem gamblers as described in Blaszczynski's Pathways Model.
The absence of laboratory tests and clear criteria to identify homogeneous (sub)groups in patients presenting with unexplained fatigue, and to assess clinical status and disability in these patients, calls for further assessment methods. In the present study, a multi-dimensional approach to the assessment of chronic fatigue syndrome (CFS) is evaluated. Two-hundred and ninety-eight patients with CFS completed a set of postal questionnaires that assessed the behavioural, emotional, social, and cognitive aspects of CFS. By means of statistical analyses nine relatively independent dimensions of CFS were identified along which CFS-assessment and CFS-research can be directed. These dimensions were named: psychological well-being, functional impairment in daily life, sleep disturbances, avoidance of physical activity, neuropsychological impairment, causal attributions related to the complaints, social functioning, self-efficacy expectations, and subjective experience of the personal situation. A description of the study sample on these dimensions is presented.
To investigate whether Internet-based cognitive behaviour therapy (CBT) can prevent relapse in persons with partially remitted major depression after previous treatment.
Seventy-one women and 13 men (N = 84) with partially remitted major depression after treatment were randomly assigned to either 10 weeks of Internet-based CBT or to a control group. Self-help material was used in combination with e-mail contact with a personal therapist. Monthly self-ratings of depressive symptoms were made, and diagnostic interviews were conducted before and after the treatment period, as well as 6 months later.
Significantly fewer participants in the CBT group experienced relapse (4/38 or 10.5%) compared with those in the control group (14/37 or 37.8%). The difference in relapse rates between groups occurred early in the study period and was still apparent after 6 months. A trend towards a larger reduction in depressive symptoms was observed at post-treatment in the participants who received CBT compared with controls. Reduction in depressive symptoms reduced the risk of relapse. A trend towards a higher remission rate was found in the CBT group at the 6 month follow-up.
Internet-based CBT seems promising in preventing relapse in persons with partially remitted major depression after previous treatment.
Previous studies on Internet-based treatment with minimal to moderate therapist guidance have shown promising results for a number of specific diagnoses. The aim of this study was to test a new approach to Internet treatment that involves tailoring the treatment according to the patient's unique characteristics and comorbidities. A total of 54 participants, regardless of specific anxiety diagnosis, were included after an in-person, semi-structured diagnostic interview and randomized to a 10 week treatment program or to a control group. Treatment consisted of a number of individually-prescribed modules in conjunction with online therapist guidance. Significant results were found for all dependent measures both immediately following treatment and at 1 and 2 year intervals. Mean between-group effect size including measures of anxiety, depression and quality of life was Cohen's d = 0.69 at post-treatment, while the mean within-group effect size was d = 1.15 at post-treatment and d = 1.13 and d = 1.04 at 1 and 2 year follow-up respectively. The tentative conclusion drawn from these results is that tailoring the Internet-based therapy can be a feasible approach in the treatment of anxiety in a homogeneous population.
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.
Internet-delivered guided cognitive behaviour therapy for social anxiety disorder has been found to generate promising short-term results, up to one year posttreatment. No study has however documented longer follow-up periods. In this 30-month follow-up we contacted 57 participants from the original study of which 77.2% (44/57) responded to the Internet-administered outcome measures and 66.7% (38/57) completed a telephone interview. Results showed large pretreatment to follow-up within-group effect sizes for the primary outcome measures (Cohen's d 1.10-1.71), and a majority (68.4%; 26/38) reported improvements in the interview. The findings suggest that the long-term effects seen in previous live treatment CBT trials can occur in Internet-delivered treatment as well.
The present report describes the development of the Penn State Worry Questionnaire to measure the trait of worry. The 16-item instrument emerged from factor analysis of a large number of items and was found to possess high internal consistency and good test-retest reliability. The questionnaire correlates predictably with several psychological measures reasonably related to worry, and does not correlate with other measures more remote to the construct. Responses to the questionnaire are not influenced by social desirability. The measure was found to significantly discriminate college samples (a) who met all, some, or none of the DSM-III-R diagnostic criteria for generalized anxiety disorder and (b) who met criteria for GAD vs posttraumatic stress disorder. Among 34 GAD-diagnosed clinical subjects, the worry questionnaire was found not to correlate with other measures of anxiety or depression, indicating that it is tapping an independent construct with severely anxious individuals, and coping desensitization plus cognitive therapy was found to produce significantly greater reductions in the measure than did a nondirective therapy condition.
The Yale-Brown Obsessive Compulsive Scale was designed to remedy the problems of existing rating scales by providing a specific measure of the severity of symptoms of obsessive-compulsive disorder that is not influenced by the type of obsessions or compulsions present. The scale is a clinician-rated, 10-item scale, each item rated from 0 (no symptoms) to 4 (extreme symptoms) (total range, 0 to 40), with separate subtotals for severity of obsessions and compulsions. In a study involving four raters and 40 patients with obsessive-compulsive disorder at various stages of treatment, interrater reliability for the total Yale-Brown Scale score and each of the 10 individual items was excellent, with a high degree of internal consistency among all item scores demonstrated with Cronbach's alpha coefficient. Based on pretreatment assessment of 42 patients with obsessive-compulsive disorder, each item was frequently endorsed and measured across a range of severity. These findings suggest that the Yale-Brown Scale is a reliable instrument for measuring the severity of illness in patients with obsessive-compulsive disorder with a range of severity and types of obsessive-compulsive symptoms.
The Liebowitz social anxiety scale (LSAS) is a commonly used clinician-administered instrument. The present study reports on the properties of a self-report version of the LSAS (LSAS-SR). About 175 participants diagnosed with social phobia participated in the study. The LSAS-SR showed overall good psychometric properties as indicated by the results of test-retest reliability, internal consistency, and convergent and discriminant validity. Furthermore, the scale was sensitive to treatment change. The construct validity of the LSAS-SR, however, remains to be further explored. These findings support the utility of the LSAS-SR, which has the advantage of saving valuable clinician time compared to the clinician-administered version.
The interview-administered Panic Disorder Severity Scale (PDSS) has been demonstrated to be a reliable and valid measurement of panic disorder severity. The purpose of this paper is to report on the reliability and usefulness of the self-report form (PDSS-SR). The PDSS and PDSS-SR were administered to 108 psychiatric outpatients with and without panic disorder. The internal consistency of the instruments was analyzed with Cronbach's alpha. Test-retest reliability was assessed on 25 of these subjects by using intraclass correlation coefficient (ICC). In addition, decrease in panic symptoms was measured after cognitive-behavioral treatment (CBT) treatment on 27 subjects. Cronbach's alpha was.917 for PDSS-SR and.923 for the PDSS. The PDSS-SR had good test-retest reliability (ICC=0.81) and was sensitive to change with treatment, with a mean decrease of 7.3 (S.D.=5.1). The self-report version of the PDSS is a reliable format, which could be useful in clinical and research settings.
Recent studies suggest that cognitive and behavioral interventions have enduring effects that reduce risk for subsequent symptom return following treatment termination. These enduring effects have been most clearly demonstrated with respect to depression and the anxiety disorders. It remains unclear whether these effects are a consequence of the amelioration of the causal processes that generate risk or the introduction of compensatory strategies that offset them and whether these effects reflect the mobilization of cognitive or other mechanisms. No such enduring effects have been observed for the psychoactive medications, which appear to be largely palliative in nature. Other psychosocial interventions remain largely untested, although claims that they produce lasting change have long been made. Whether such enduring effects extend to other disorders remains to be seen, but the capacity to reduce risk following treatment termination is one of the major benefits provided by the cognitive and behavioral interventions with respect to the treatment of depression and the anxiety disorders.