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Technology-based Cognitive Behavioral Therapy Interventions
... As shown in the RCT (Joubert et al., 2023), participants in the clinician-guided group demonstrated lower depression, anxiety and rumination scores both at post-treatment and follow-up, than the self-guided group; our analyses further show this group demonstrated larger reductions in RNT and distress lesson by lesson, and experienced reductions in RNT earlier in treatment than the self-guided group. These results are consistent with studies showing that therapist guidance and alliance is associated with stronger treatment outcomes and adherence in online treatments compared to unguided versions (Karyotaki et al., 2021;Musiat et al., 2022;Newby et al., 2024). Moderated mediation analysis in future studies could help elucidate the interaction between other predictor variables and clinician guidance, as some research shows the importance of therapist guidance relates particularly to patients with more severe baseline symptoms (e.g., Karyotaki et al., 2021;Newby et al., 2024)). ...
... These results are consistent with studies showing that therapist guidance and alliance is associated with stronger treatment outcomes and adherence in online treatments compared to unguided versions (Karyotaki et al., 2021;Musiat et al., 2022;Newby et al., 2024). Moderated mediation analysis in future studies could help elucidate the interaction between other predictor variables and clinician guidance, as some research shows the importance of therapist guidance relates particularly to patients with more severe baseline symptoms (e.g., Karyotaki et al., 2021;Newby et al., 2024)). ...
Background
Repetitive Negative Thinking (RNT) is a key transdiagnostic mechanism underlying anxiety and depressive disorders, and targeting RNT specifically leads to improved treatment outcomes. There is a lack of research however into mechanisms of change in RNT-focused interventions and factors that predict treatment response. The aim of this study was to examine the mediators and predictors of outcome (RNT, depression, anxiety, and distress) in a brief online intervention for RNT in adults.
Methods
This study used secondary data from a Randomised Controlled Trial of the Managing Rumination and Worry Program (Joubert et al. in Beh Res Therapy, 168:104378, 2023) in which N = 137 adults with elevated levels of RNT were randomly allocated to a 3-lesson clinician-guided or self-guided version of the program delivered over 6 weeks, or a treatment-as-usual (TAU) control condition. Self-report measures of depression, anxiety, distress, and RNT were administered at baseline, post-treatment, and 3-month follow-up; RNT and distress were also measured prior to each lesson.
Results
Intention-to-treat linear mixed models showed a gradual reduction in RNT and distress over treatment in both active conditions, with the largest reductions in RNT occurring after the lessons containing the active treatment strategies (2 and 3). Structural equation modelling mediation analyses showed that reductions in transdiagnostic RNT mediated reductions in distress between Lessons 2 and 3, and reductions in rumination specifically mediated reductions in distress and depression between post-treatment and follow-up, but there was no consistent pattern of mediation by RNT throughout treatment. Finally, higher baseline symptom severity (particularly rumination) significantly predicted poorer post-treatment outcomes, while higher treatment expectancy and clinician guidance significantly predicted better post-treatment outcomes.
Conclusion
This is one of the first studies to examine mediators and predictors of change in a brief, online RNT-focused intervention for adults with elevated RNT. Further research in larger samples is needed, examining additional possible mediating and predictor variables and across more time points, to better understand how and for whom this intervention reduces RNT, anxiety and depression.
Australian and New Zealand Clinical Trials Registration number: ACTRN 12620000959976. Date of registration: 25/09/2020.
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.
Background:
The global burden of anxiety and depression has created an urgent need for scalable approaches to increase access to evidence-based mental health care. The Screening and Treatment for Anxiety and Depression (STAND) system of care was developed to meet this need through the use of internet-connected devices for assessment and provision of treatment. STAND triages to level of care (monitoring only, digital therapy with coaches, digital therapy assisted by clinicians in training, and clinical care) and then continuously monitors symptoms to adapt level of care. Triaging and adaptation are based on symptom severity and suicide risk scores obtained from computerized adaptive testing administered remotely.
Objective:
This article discusses how the STAND system of care improves upon current clinical paradigms, and presents preliminary data on feasibility, acceptability, and effectiveness of STAND in a sample of US-based university students.
Methods:
US-based university students were recruited and enrolled in an open trial of the STAND system of care. Participants were triaged based on initial symptom severity derived from a computerized adaptive test and monitored over 40 weeks on anxiety, depression, and suicide risk to inform treatment adaptation and evaluate preliminary effectiveness.
Results:
Nearly 5000 students were screened and 516 received care. Depression and anxiety severity scores improved across all tiers (P<.001 in all cases). Suicide risk severity improved in the highest tier (ie, clinical care; P<.001). Acceptability and feasibility were demonstrated.
Conclusions:
STAND is a feasible and acceptable model of care that can reach large numbers of individuals. STAND showed preliminary effectiveness on all primary outcome measures. Current directions to improve STAND are described.
There has been a growing interest in the use of remote interventions based on cognitive-behavioral therapy (CBT)—the gold-standard treatment for obsessive-compulsive disorder (OCD), to deal with the barriers associated with face-to-face approaches. We performed a meta-analytic aggregation of the literature to characterize the efficacy of internet-based CBT (iCBT) in adult OCD patients. Our findings showed large effect sizes of iCBT in improving OCD symptoms in pre to post (g = 1.14), pre to follow-up (g = 1.16), and between control and experimental groups (g = 0.81). While iCBT seems a promising approach for reducing OCD symptoms, further research is needed to determine the feasibility and effectiveness of iCBT for OCD in contexts beyond clinical trials, that is, integrated in routine health care.
Providing therapist-guided cognitive behaviour therapy via the Internet (ICBT) has advantages, but a central research question is to what extent similar clinical effects can be obtained as with gold-standard face-to-face cognitive behaviour therapy (CBT). In a previous meta-analysis published in this journal, which was updated in 2018, we found evidence that the pooled effects for the two formats were equivalent in the treatment of psychiatric and somatic disorders, but the number of published randomized trials was relatively low (n=20). As this is a field that moves rapidly, the aim of the current study was to conduct an update of our systematic review and meta-analysis of the clinical effects of ICBT vs. face-to-face CBT for psychiatric and somatic disorders in adults. We searched the PubMed database for relevant studies published from 2016 to 2022. The main inclusion criteria were that studies had to compare ICBT to face-to-face CBT using a randomized controlled design and targeting adult populations. Quality assessment was made using the Cochrane risk of bias criteria (Version 1), and the main outcome estimate was the pooled standardized effect size (Hedges’ g) using a random effects model. We screened 5,601 records and included 11 new randomized trials, adding them to the 20 previously identified ones (total n=31). Sixteen different clinical conditions were targeted in the included studies. Half of the trials were in the fields of depression/depressive symptoms or some form of anxiety disorder. The pooled effect size across all disorders was g=0.02 (95% CI: –0.09 to 0.14) and the quality of the included studies was acceptable. This meta-analysis further supports the notion that therapist-supported ICBT yields similar effects as face-to-face CBT.
The estimated number of Substance Users (SU) globally has currently reached a very high number and is still increasing. This aspect necessitates appropriate interventions for prevention and specific treatments. The literature shows that digital treatments can be useful in the context of health services and substance abuse. This systematic review focuses mainly on research on the effectiveness of digital treatments for SU. Data sources included studies found on PsycINFO, PubMed, SCOPUS, and WebOfScience (WOS) database searches. The following keywords were used: TITLE (digital OR computer OR software OR tablet OR app OR videogame OR seriousgame OR virtualreality) AND ABSTRACT((mental AND health) AND (addiction OR dependence OR substance OR drug)). We focused on peer-reviewed articles published from 2010 through 2021 using PRISMA guidelines. A total of 18 studies met the inclusion criteria (i.e., type of intervention, efficacy in terms of misuse of substances and scored outcomes from questionnaire or toxicology tests, study methodology). The studies included investigations of specific digital treatments for SU of various kinds of drugs. The interventions were administered using personal computers, smartphones, or, in a few cases, tablets. Most of the interventions focused on the cognitive behavior therapy (CBT) model and/or on the use strategies, tips, or feedback. A minority provided information or training programs. The current review shows that digital treatments and interventions are effective in reducing the frequency of use, augmenting abstinence, or reducing the gravity of dependence for most of the studies at post-treatment. However, due to the heterogeneity of the variables (i.e., substance type, digital tool used, and treatment administered), there was a reduced generalizability of the results. This review highlights the need to continue the research in this field, and above all, to create effective digital protocols.
Background: Depression and anxiety have become the most common mental health disorders worldwide during the COVID-19 pandemic, and increasing interest in telemedicine has led to the innovation of using internet-based cognitive behavioral therapy (iCBT). Objective: This systematic review and meta-analysis aimed to evaluate the efficacy of iCBT for depression and anxiety among the global population during the COVID-19 pandemic. Methods: A literature search was conducted on PubMed, Scopus, Cochrane, ProQuest, Wiley, and Web of Science using the PRISMA framework, and only randomized controlled trials (RCTs) were included in the study. A critical appraisal was also performed using Cochrane’s Risk of Bias (RoB) 2. The meta-analysis used random-effects models to analyze pooled mean difference (MD) and its p-value. Results: Twelve RCTs were included for qualitative analysis and nine RCTs, which yielded 6778 patients with depression and 6556 patients with anxiety during the COVID-19 pandemic, were included for quantitative analysis. Despite high heterogeneity, all studies had a low risk of bias. Pre- and post-iCBT intervention in the depression forest plot depicts a significant effect (p < 0.00001) with a pooled MD of 4.73 (95% CI: 4.55–4.90), while the pre- and post-iCBT intervention depicts a significant effect (p < 0.00001) with a pooled MD of 4.50 (95% CI: 4.34–4.67). This demonstrates that iCBT was found to significantly decrease depression and anxiety scores in patients during the COVID-19 pandemic. However, substantial heterogeneity was also found (I2 = 93%; p < 0.00001 and I2 = 90%) for the pre-/post-depression and anxiety forest plots, respectively. Conclusions: This meta-analysis comprises an evidence-based result for iCBT to treat depression and anxiety in the COVID-19 population, as indicated by the significantly lower assessment scores. Delivering iCBT in this situation needs to be considered more extensively, as it has promising results and yields the benefits of technological advancement in psychotherapy.
Background: Veterans who did not seek and complete treatment as intended have been shown to have an elevated risk of experiencing and being exposed to post-traumatic stress disorder (PTSD). Internet-based interventions (IBIs) provide more confidentiality and fewer treatment barriers, and they are regarded as potential treatments to reduce PTSD in veterans. However, the effects of IBI for veterans with PTSD are inconclusive.
Objectives: IBI is defined as any internet-based series of psychosocial interventions, of which the internet works as a way of delivery. Psychosocial content and reduction of PTSD symptoms in veterans have been recognized as two core elements of this intervention. This study aimed to (1) examine the effects of IBI on veterans’ PTSD outcomes and (2) distinguish between the elements of IBI that play an important role for veterans with PTSD.
Methods: Web of Science, PubMed, EMBASE, PsycINFO, Cochrane, Wanfang Data, CNKI, and CQVIP databases were searched for randomized controlled trials (RCT) in IBI programs for veterans with PTSD, covering all studies in English and Chinese published from January 1990 to November 2020. Also, related studies tracking citations were identified. Studies met the following inclusion criteria of (1) being RCTs; (2) containing IBI in the full text; (3) having IBI conducted on veterans as participants; and (4) being on PTSD. All processes followed PRISMA. The risk of bias of the studies was assessed by the Cochrane Systematic Review Handbook. The confidence of outcomes of this review was valued according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation). The meta-analysis was done by RevMan 5.13. Two teams of reviewers independently searched the literature, made the assessment, and extracted the data.
Results: A total of 1,493 citations were identified after initial searching, of which the full texts of 66 studies were screened. Eventually, six RCT studies met the inclusion criteria. Beneficial effects of IBI were found on the overall PTSD outcome (−0.29; 95% CI–0.48 to −0.11, p<0.01). Particularly, IBI based on cognitive behavioral therapy (CBT) with peer support was found to be effective for PTSD outcomes (−0.36; 95% CI–0.61 to −0.11, p<0.01). The subgroup analysis demonstrated that scores of PTSD outcome measured by a PCL (PTSD Checklist) decreased to an average score of 0.38 (95% CI –0.60 to −0.15, p=0.001). The intervention had a positive effect on the PTSD outcome on veterans with comorbid psychological disorders (−0.30; 95% CI –0.61 to −0.11, p<0.01). Overall, the six studies included were evaluated with a low risk of bias, and the outcomes of the meta-analysis were proven with high confidence.
Conclusion: On the whole, IBIs have a positive effect on the overall PTSD outcome of veterans. The results encouraged us to focus on IBI with CBT with peer support for veterans, on specific instruments for veterans with PTSD, and on veterans with comorbid psychological disorders. This study, however, has limits. Only six studies with a Western population were included, which might result in cultural bias on IBI effects. In future, more high-qualified research and diverse cultural background of RCTs is needed to prove the effectiveness of IBI on veterans with PTSD.
The COVID-19 pandemic has potentially increased the risk for adolescent depression. Even pre-pandemic, <50% of youth with depression accessed care, highlighting needs for accessible interventions. Accordingly, this randomized-controlled trial (ClinicalTrials.gov: NCT04634903) tested online single-session interventions (SSIs) during COVID-19 in adolescents with elevated depression symptoms (N=2,452, ages 13-16). Adolescents from all 50 U.S. states, recruited via social media, were randomized to 1 of 3 SSIs: a behavioural activation SSI, an SSI teaching that traits are malleable, or a supportive control. We tested each SSI’s effects on post-intervention (hopelessness, agency) and 3-month outcomes (depression, hopelessness, agency, generalized anxiety, COVID-related trauma, restrictive eating). Versus control, both active SSIs reduced 3-month depressive symptoms (ds=0.18); decreased post-intervention and 3-month hopelessness (ds=0.16-0.28); increased post-intervention agency (ds=0.15-0.31); and reduced 3-month restrictive eating (ds=0.12-17). Several differences between active SSIs emerged. Results confirm the utility of free-of-charge, online SSIs for high-symptom adolescents, even in the high-stress COVID-19 context.
Providing accessible and effective healthcare solutions for people living in low- and middle-income countries, migrants, and indigenous people is central to reduce the global mental health treatment gap. Internet- and mobile-based interventions (IMI) are considered scalable psychological interventions to reduce the burden of mental disorders and are culturally adapted for implementation in these target groups. In October 2020, the databases PsycInfo, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for studies that culturally adapted IMI for mental disorders. Among 9438 screened records, we identified 55 eligible articles. We extracted 17 content, methodological, and procedural components of culturally adapting IMI, aiming to consider specific situations and perspectives of the target populations. Adherence and effectiveness of the adapted IMI seemed similar to the original IMI; yet, no included study conducted a direct comparison. The presented taxonomy of cultural adaptation of IMI for mental disorders provides a basis for future studies investigating the relevance and necessity of their cultural adaptation.
PROSPERO registration number: CRD42019142320.
Background:
Among the general public, there appears to be a growing need and interest in receiving digital mental health and well-being support. In response to this, mental health apps (MHapps) are becoming available for monitoring, managing, and promoting positive mental health and well-being. Thus far, evidence supports favorable outcomes when users engage with MHapps, yet there is a relative paucity of reviews on apps that support positive mental health and well-being.
Objective:
We aimed to systematically review the available research on MHapps that promote emotion regulation, positive mental health, and well-being in the general population aged 18-45 years. More specifically, the review aimed at providing a systematic description of the theoretical background and features of MHapps while evaluating any potential effectiveness.
Methods:
A comprehensive literature search of key databases, including MEDLINE (via Ovid), EMBASE (via Ovid), PsycINFO (via Ovid), Web of Science, and the Cochrane Register of Controlled Trials (CENTRAL), was performed until January 2021. Studies were included if they described standalone mental health and well-being apps for adults without a formal mental health diagnosis. The quality of all studies was assessed against the Mixed Methods Appraisal Tool. In addition, the Cochrane Risk-of-Bias tool (RoB-2) was used to assess randomized control trials (RCTs). Data were extracted using a modified extraction form from the Cochrane Handbook of Systematic Reviews. A narrative synthesis and meta-analysis were then undertaken to address the review aims.
Results:
In total, 3156 abstracts were identified. Of these, 52 publications describing 48 MHapps met the inclusion criteria. Together, the studies evaluated interventions across 15 countries. Thirty-nine RCTs were identified suggesting some support for the role of individual MHapps in improving and promoting mental health and well-being. Regarding the pooled effect, MHapps, when compared to controls, showed a small effect for reducing mental health symptoms (k=19, Hedges g=-0.24, 95% CI -0.34 to -0.14; P<.001) and improving well-being (k=13, g=0.17, 95% CI 0.05-0.29, P=.004), and a medium effect for emotion regulation (k=6, g=0.49, 95% CI 0.23-0.74, P<.001). There is also a wide knowledge base of creative and innovative ways to engage users in techniques such as mood monitoring and guided exercises. Studies were generally assessed to contribute unclear or a high risk of bias, or to be of medium to low methodological quality.
Conclusions:
The emerging evidence for MHapps that promote positive mental health and well-being suggests promising outcomes. Despite a wide range of MHapps, few apps specifically promote emotion regulation. However, our findings may position emotion regulation as an important mechanism for inclusion in future MHapps. A fair proportion of the included studies were pilot or feasibility trials (k=17, 33%), and full-scale RCTs reported high attrition rates and nondiverse samples. Given the number and pace at which MHapps are being released, further robust research is warranted to inform the development and testing of evidence-based programs.
Introduction
The Psychological Health Center of Excellence conducted a rapid review of the literature to investigate the effectiveness of behavioral health treatments (i.e., evidence-based psychotherapy and psychiatry) delivered in person compared to telehealth (TH; i.e., video teleconference and telephone).
Materials and Methods
The rapid review methods included a systematic search of a single database (PubMed), hand-searching of relevant systematic reviews, dual screening, single-person data abstraction verified by a second person, and dual risk of bias assessment. Due to heterogeneity across studies, no quantitative analyses were conducted.
Results
Twenty-two randomized controlled trials (RCTs), eight of which were non-inferiority trials, evaluated the effectiveness of TH via telephone or video teleconferencing compared to in-person (IP) delivery for patient populations with posttraumatic stress disorder, depression, and mixed diagnoses. The majority of RCTs and all but one of the eight non-inferiority trials found that clinical outcomes did not differ between TH and IP treatment delivery. Two studies found that subgroups with higher symptom severity (hopelessness and anxiety disorders, respectively) in the TH group had worse treatment-related outcomes than IP participants with similar symptom profiles. The majority of studies found no significant differences in satisfaction with care, quality of the therapeutic alliance, or study discontinuation between TH and IP groups.
Conclusion
Based on evidence from 22 RCTs, the use of TH platforms, including video conference and telephone modalities, generally produces similar outcomes as face-to-face provision of psychotherapy and psychiatry services.
Background
Digital mental health services (DMHS) provide highly accessible psychological supports and interventions that can supplement existing mental health services. Concerns about the mental health impact of the COVID-19 pandemic have been widespread and provide a unique impetus to examine the utility and responsivity of DMHS. This study examined the service utilisation and user characteristics of two DMHS (THIS WAY UP and Just a Thought) in Australia and New Zealand before and during the early pandemic period in these countries (March to June 2020).
Methods
Service use indices (website visits, course registrations and prescriptions, clinician registrations) were compared across different time periods before (12, 6 and 3 months) and during the pandemic in Australia and New Zealand. The demographic and clinical characteristics of course registrants (anxiety and depression symptom severity and psychological distress) were also compared across the pre- and during-COVID periods.
Results
Comparing pre-COVID to during-COVID time periods, we observed substantial increases across all service use indices in both DMHS (increases of >100% on the majority of service use indices). For example, in the 3 months prior to the pandemic, 2806 people registered for a THIS WAY UP course and 1907 people registered for a Just a Thought course, whereas 21,872 and 5442 registered for a THIS WAY UP and Just a Thought course, respectively, during the first 3 months of the COVID pandemic. Slight differences in the demographic and clinical profiles of course registrants were found between pre- and during-COVID time periods, with limited evidence of elevated anxiety and depression symptom severity in the COVID period.
Conclusions
Following the outbreak of COVID-19 in Australia and New Zealand, the volume of users accessing DMHS increased yet the demographic and clinical characteristics of course registrants remained stable. Results underscore how nimble and scalable DMHS can be during periods of high demand.
Introduction: Chronic loneliness has been linked to many
adverse outcomes, including mental health problems. Psychological treatment of loneliness can be effective, but the
evidence base is limited. Objective: To investigate the efficacy of 2 internet-based interventions based on cognitive
behavioral therapy (ICBT) and interpersonal psychotherapy
(IIPT) relative to a wait-list control group and each other.
Methods: A total of 170 participants were recruited and randomized to either 9 weeks of ICBT (n = 68), IIPT (n = 68), or a
wait-list condition (n = 34). The primary outcome was loneliness, measured using the UCLA Loneliness Scale before, during, and after treatment. Secondary measures of psychiatric
disorders and quality of life were administered before and
after treatment. Follow-up was conducted 4 months after
the treatment had ended. Primary outcome data were analyzed using growth curve modeling. Secondary outcomes
were analyzed using robust regression models. The trial was
preregistered (ClinicalTrials.gov ID: NCT03807154). Results:
The ICBT condition had a significantly greater impact on
loneliness compared to the wait-list and IIPT conditions. Effect sizes were moderate to large (Cohen d = 0.71) compared
to the wait-list and moderate (d = 0.53) compared to IIPT. The
IIPT condition did not differ significantly from the wait-list.
Both active treatments led to significant increases in quality
of life. Only the ICBT group had significantly lower symptoms
of depression and generalized anxiety compared to the waitlist group. Treatment gains were maintained but not improved at follow-up. Conclusions: ICBT can be an efficacious
option for alleviating loneliness. The IIPT intervention was
not as effective.
Background
Digital interventions for anxiety disorders are a promising solution to address barriers to evidence-based treatment access. Precise and powerful estimates of digital intervention effectiveness for anxiety disorders are necessary for further adoption in practice. The present systematic review and meta-analysis examined the effectiveness of digital interventions across all anxiety disorders and specific to each disorder v. wait-list and care-as-usual controls.
Methods
A systematic search of bibliographic databases identified 15 030 abstracts from inception to 1 January 2020. Forty-seven randomized controlled trials (53 comparisons; 4958 participants) contributed to the meta-analysis. Subgroup analyses were conducted by an anxiety disorder, risk of bias, treatment support, recruitment, location and treatment adherence.
Results
A large, pooled effect size of g = 0.80 [95% Confidence Interval: 0.68–0.93] was found in favor of digital interventions. Moderate to large pooled effect sizes favoring digital interventions were found for generalized anxiety disorder ( g = 0.62), mixed anxiety samples ( g = 0.68), panic disorder with or without agoraphobia ( g = 1.08) and social anxiety disorder ( g = 0.76) subgroups. No subgroups were significantly different or related to the pooled effect size. Notably, the effects of guided interventions ( g = 0.84) and unguided interventions ( g = 0.64) were not significantly different. Supplemental analysis comparing digital and face-to-face interventions (9 comparisons; 683 participants) found no significant difference in effect [ g = 0.14 favoring digital interventions; Confidence Interval: −0.01 to 0.30].
Conclusion
The precise and powerful estimates found further justify the application of digital interventions for anxiety disorders in place of wait-list or usual care.
Background:
There has been a recent rise in the use of eHealth treatments for a variety of psychological disorders, including eating disorders.
Objective:
This meta-analysis of randomized controlled trials is the first to evaluate the efficacy of eHealth interventions specifically for the treatment of binge eating disorder (characterized by compulsive overconsumption of food, in a relatively short period, and without compensatory behaviors such as purging or fasting).
Methods:
A search on the electronic databases PubMed, Web of Science, Embase, MEDLINE, and CINAHL was conducted for randomized controlled trials that compared the efficacy of eHealth treatment interventions with waitlist controls.
Results:
From the databases searched, 3 studies (298 participants in total) met the inclusion criteria. All interventions were forms of internet-based guided cognitive behavioral therapy. The results of the analysis demonstrated that when compared with waitlist controls, individuals enrolled in eHealth interventions experienced a reduction in objective binge episodes (standardized mean difference [SMD] -0.77, 95% CI -1.38 to -0.16) and eating disorder psychopathology (SMD -0.71, 95% CI -1.20 to -0.22), which included shape (SMD -0.61, 95% CI -1.01 to -0.22) and weight concerns (SMD -0.91, 95% CI -1.33 to -0.48). There was no significant difference in BMI between the eHealth interventions and controls (SMD -0.01, 95% CI -0.40 to 0.39).
Conclusions:
These findings provide promising results for the use of internet-based cognitive behavioral therapy for binge eating disorder treatment and support the need for future research to explore the efficacy of these eHealth interventions.
Background:
The prevalence of depressive and anxiety symptoms in patients with coronavirus disease 2019 (COVID-19) is higher than usual. Previous studies have shown that there are drug-to-drug interactions between antiretroviral drugs and antidepressants. Therefore, an effective and safe treatment method was urgently needed. Cognitive Behavior Therapy (CBT) is the first-line psychological therapy in clinical treatment. Computerized CBT (cCBT) was proven to be an effective alternative to CBT and does not require face-to-face therapy between a therapist and the patient, which suited the COVID-19 pandemic response.
Objective:
To evaluate the efficacy of the cCBT program we developed in improving depressive and anxiety symptoms among patients with COVID-19.
Methods:
We customized a cCBT program focused on improving depressive and anxiety symptoms among patients with COVID-19, and then we assessed its effectiveness. Screening was based on symptoms of depression and/or anxiety for patients who scored at or above 7 scores on the Hamilton Depression Rating Scale (HAMD17) and/or the Hamilton Anxiety Scale (HAMA). A total of 252 patients with COVID-19 at 5 sites were randomized into 2 groups: cCBT+ treatment as usual (TAU) (n = 126) and cCBT without TAU (n =126); the cCBT+TAU group received the cCBT intervention program for 1 week. The primary efficacy measures were the HAMD17 and HAMA scores. The secondary outcome measures were the Self-rating Depression Scale (SDS), Self-rating Anxiety Scale (SAS), and Athens Insomnia Scale (AIS). Assessments were carried out at pre- and post-intervention. The patients' symptoms of anxiety and depression in one of the centers were assessed again within 1 month after the post-intervention assessment.
Results:
The cCBT+TAU group displayed a significant decreased score on the HAMD17, HAMA, SDS, SAS, and AIS after the intervention, compared to that in the TAU group (all P < .001). A mixed-effects repeated-measures model revealed significant improvement in symptoms of depression (HAMD17 and SDS scores), anxiety (HAMA and SAS scores), and insomnia (AIS score) during the post-intervention and follow-up periods in the cCBT+TAU group (all P < .05, Bonferroni correction). Additionally, the improvement of insomia among the female and middle-school-educated populations in the CCBT+TAU group showed no significant differences when compared to the TAU group (both P > .05).
Conclusions:
The findings of this study suggest that the cCBT program we developed was an effective nonpharmacological treatment for symptoms of anxiety, depression, and insomnia among patients with COVID-19. Further research is warranted to investigate the long-term effects of cCBT for symptoms of anxiety, depression, and insomnia in patients with COVID-19.
Clinicaltrial:
Chinese Clinical Trial Registry Number: ChiCTR2000030084.
Background
Internet-delivered cognitive behavioral therapy (ICBT) is an effective treatment that can overcome barriers to mental health care. Various research groups have suggested that unguided ICBT (ie, ICBT without therapist support) and other eHealth interventions can be designed to enhance user engagement and thus outcomes. The persuasive systems design framework captures most design recommendations for eHealth interventions, but there is little empirical evidence that persuasive design is related to clinical outcomes in unguided ICBT.
Objective
This study aims to provide an updated meta-analysis of randomized controlled trials of unguided ICBT for depression and anxiety, describe the frequency with which various persuasive design principles are used in such interventions, and use meta-regression to explore whether a greater number of persuasive design elements predicts efficacy in unguided ICBT for depression and anxiety.
Methods
We conducted a systematic review of 5 databases to identify randomized controlled trials of unguided ICBT for depression and anxiety. We conducted separate random effects meta-analyses and separate meta-regressions for depression and anxiety interventions. Each meta-regression included 2 steps. The first step included, as a predictor, whether each intervention was transdiagnostic. For the meta-regression of ICBT for depression, the first step also included the type of control condition. The number of persuasive design principles identified for each intervention was added as a predictor in the second step to reveal the additional variance in effect sizes explained by persuasive design.
ResultsOf the 4471 articles we identified in our search, 46 (1.03%) were eligible for inclusion in our analyses. Our meta-analyses showed effect sizes (Hedges g) ranging from 0.22 to 0.31 for depression interventions, depending on the measures taken to account for bias in the results. We found a mean effect size of 0.45 (95% CI 0.33-0.56) for anxiety interventions, with no evidence that the results were inflated by bias. Included interventions were identified as using between 1 and 13 persuasive design principles, with an average of 4.95 (SD 2.85). The meta-regressions showed that a greater number of persuasive design principles predicted greater efficacy in ICBT for depression (R2 change=0.27; B=0.04; P=.02) but not anxiety (R2 change=0.05; B=0.03; P=.17).
Conclusions
These findings show wide variability in the use of persuasive design in unguided ICBT for depression and anxiety and provide preliminary support for the proposition that more persuasively designed interventions are more efficacious, at least in the treatment of depression. Further research is needed to clarify the role of persuasive design in ICBT.
Study objectives: Clinical guidelines recommend cognitive-behavioral therapy for insomnia (CBT-I) as first-line treatment. However, provision of CBT-I is limited due to insufficient time and expertise. Internet-delivered CBT-I might bridge this gap. This study aimed to estimate the cost-effectiveness of guided, internet-delivered CBT-I (i-Sleep) compared to care-as-usual for insomnia patients in general practice over 26 weeks from a societal perspective.
Methods: Primary outcomes were the Insomnia Severity Index (ISI, continuous score and clinically relevant response), and Quality-Adjusted Life Years (QALYs). Societal costs were assessed at baseline, and at 8 and 26 weeks. Missing data were imputed using multiple imputation. Statistical uncertainty around cost and effect differences was estimated using bootstrapping, and presented in cost-effectiveness planes and acceptability curves.
Results: The difference in societal costs between i-Sleep and care-as-usual was not statistically significant (-€318; 95% CI −1282 to 645). Cost-effectiveness analyses revealed a 95% probability of i-Sleep being cost-effective compared to care-as-usual at ceiling ratios of €450/extra point of improvement in ISI score and €7,000/additional response to treatment, respectively. Cost-utility analysis showed a 67% probability of cost-effectiveness for i-Sleep compared to care-as-usual at a ceiling ratio of 20,000 €/QALY gained.
Conclusions: The internet-delivered intervention may be considered cost-effective for insomnia severity in comparison with care-as-usual from the societal perspective. However, the improvement in insomnia severity symptoms did not result in similar improvements in QALYs.
Objective: This paper offers clinical insights and practical guidelines for clinicians about how internet-delivered cognitive behaviour therapy (iCBT) can be safely and effectively integrated into routine psychological therapy practice, in a 'blended' care model.
Method: For over a decade, the Clinical Research Unit for Anxiety and Depression (CRUfAD) has developed, tested, and disseminated iCBT programs for anxiety and depression, into routine care settings. This paper outlines examples of the available iCBT options for clinicians and details the advantages of integrating iCBT for anxiety and/or depression into psychological practice. We address common barriers to using iCBT, offer practical solutions based on our research and clinical experience, and present the lived experiences of ‘real-world’ clinicians using iCBT in their private practises and specialist clinics. Considerations associated with risk management, funding arrangements, and flexible models of care (e.g., stepped, blended and adjunct care) are discussed.
Results: Flexible and judicious use of iCBT in our outpatient routine care clinic has reduced treatment waitlists and enabled clinicians to dedicate more time to sophisticated therapeutic interventions (e.g., experiential work) and to support clients with complex needs.
Conclusion: iCBT can be safely and effectively integrated into routine psychological practice, and enhance client care.
KEY POINTS
What is already known about this topic:
(1) Internet cognitive behavioural therapy (iCBT) is effective for treating anxiety and depression.
(2) iCBT includes psychoeducation and core CBT components (e.g., thought challenging) delivered over the internet.
(3) To date, most iCBT programs have been used as stand-alone interventions, either as self-help or under guidance from a clinician.
What this paper adds:
(1) Outlines examples of iCBT options, their advantages and disadvantages, indications and contraindications.
(2) Outlines a variety of ways to integrate iCBT into routine clinical practice settings, including prequel to therapy, as an adjunct, and relapse prevention tool.
(3) Offers practical solutions to address common barriers and concerns to using iCBT in routine practice.
Importance
Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them.
Objective
To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information.
Data Sources
We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019.
Study Selection
Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization.
Data Extraction and Synthesis
We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression.
Main Outcomes and Measures
Patient Health Questionnaire–9 (PHQ-9) scores.
Results
Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-0 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, −0.8; 95% CI, −1.4 to −0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9.
Conclusions and Relevance
In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.
Aim
To determine the efficacy of Internet‐based interventions in decreasing the prevalence of postpartum depression in perinatal women.
Design
This review was conducted according to the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement.
Methods
We performed a systematic meta‐analysis of randomized controlled trials on the efficacy of Internet‐based interventions for postpartum depression. Studies (2008–2018) were identified through a search conducted on PubMed, EMBASE and the Cochrane Library. Risk ratios or weighted mean differences with 95% confidence intervals were calculated using a fixed‐effects model or a random‐effects model. Stata software 11.0 was used to perform the meta‐analysis.
Results
Most of the seven eligible studies were randomized controlled trials. The random‐effects model indicated that Internet‐based interventions significantly improved postpartum depression (d = 0.642, N = 7). Attrition rates ranged from 4.5%–86.9% and from 0%–87.1% for the intervention and control groups, respectively.
Study Objectives
Stressful life events contribute to insomnia, psychosocial functioning, and illness. Though individuals with a history of insomnia may be especially vulnerable during stressful life events, risk may be mitigated by prior intervention. This study evaluated the effect of prior digital cognitive-behavioral therapy for insomnia (dCBT-I) versus sleep education on health resilience during the COVID-19 pandemic.
Methods
COVID impact, insomnia, general- and COVID-related stress, depression, and global health were assessed in April 2020 in adults with a history of insomnia who completed a randomized controlled trial of dCBT-I (n = 102) versus sleep education control (n = 106) in 2016-2017. Regression analyses were used to evaluate the effect of intervention conditions on subsequent stress and health during the pandemic.
Results
Insomnia symptoms were significantly associated with COVID-19 related disruptions, and those previously received dCBT-I reported less insomnia symptoms, less general stress and COVID-related cognitive intrusions, less depression, and better global health than those who received sleep education. Moreover, the odds for resurgent insomnia was 51% lower in the dCBT-I versus control condition. Similarly, odds of moderate to severe depression during COVID-19 was 57% lower in the dCBT-I condition.
Conclusions
Those who received dCBT-I had increased health resilience during the COVID-19 pandemic in adults with a history of insomnia and ongoing mild to moderate mental health symptoms. These data provide evidence that dCBT-I is a powerful tool to promote mental and physical health during stressors, including the COVID-19 pandemic.
Background
Generalized anxiety disorder (GAD) is a highly prevalent, chronic disorder associated with impaired quality of life, societal burden, and poor treatment rates. Internet‐delivered interventions may improve the accessibility of treatments and are increasingly being used. This study aimed to update a previous meta‐analysis to determine the effectiveness of available Internet‐delivered interventions in treating symptoms of GAD.
Method
Systematic literature searches were conducted (through April 2020) using Embase, PubMed, PsychINFO, and Cochrane to find randomized controlled trials of Internet‐delivered interventions for GAD. Risk of bias was evaluated, and Hedge's g was calculated at posttreatment and follow‐up.
Results
Twenty studies met eligibility criteria and were included in the meta‐analysis. Random‐effect models detected large effect sizes for primary outcomes of anxiety (g = 0.79) and worry (g = 0.75), favoring treatment. Effect sizes for depression, functional impairment, and quality of life were moderate to large. Maintenance of effects at follow‐up seems likely.
Conclusions
Results support the effectiveness of Internet‐delivered treatments for GAD. Considerable heterogeneity between studies appeared moderated by variability in the interventions themselves, highlighting the importance of further investigation into the characteristics that may optimize treatment outcomes. Overall, Internet‐delivery appears to be a viable mode of treatment for GAD with potential to relieve existing gaps in the provision of treatment.
Virtual reality (VR) is an immersive technology capable of creating a powerful, perceptual illusion of being present in a virtual environment. VR technology has been used in cognitive behavior therapy since the 1990s and accumulated an impressive evidence base, yet with the recent release of consumer VR platforms came a true paradigm shift in the capabilities and scalability of VR for mental health. This narrative review summarizes the past, present, and future of the field, including milestone studies and discussions on the clinical potential of alternative embodiment, gamification, avatar therapists, virtual gatherings, immersive sto-rytelling, and more. Although the future is hard to predict, clinical VR has and will continue to be inherently intertwined with what are now rapid developments in technology, presenting both challenges and exciting opportunities to do what is not possible in the real world.
Background
Although there is evidence for the efficacy of internet-based cognitive behavioral therapy (iCBT), the generalizability of results to routine care is limited.
Objective
This study systematically reviews effectiveness studies of guided iCBT interventions for the treatment of depression or anxiety.
Methods
The acceptability (uptake, participants’ characteristics, adherence, and satisfaction), effectiveness, and negative effects (deterioration) of nonrandomized pre-post designs conducted under routine care conditions were synthesized using systematic review and meta-analytic approaches.
Results
A total of 19 studies including 30 groups were included in the analysis. Despite high heterogeneity, individual effect sizes of investigated studies indicate clinically relevant changes, with effect sizes ranging from Hedges’ g=0.42-1.88, with a pooled effect of 1.78 for depression and 0.94 for anxiety studies. Uptake, participants’ characteristics, adherence, and satisfaction indicate a moderate to high acceptability of the interventions. The average deterioration across studies was 2.9%.
Conclusions
This study provides evidence supporting the acceptability and effectiveness of guided iCBT for the treatment of depression and anxiety in routine care. Given the high heterogeneity between interventions and contexts, health care providers should select interventions that have been proven in randomized controlled clinical trials. The successful application of iCBT may be an effective way of increasing health care in multiple contexts.
Background
Cognitive behavioural therapy (CBT) is a widely used treatment for depression. However, limited resource availability poses several barriers to patients seeking access to care, including lengthy wait times and geographical limitations. This has prompted health care services to introduce electronically delivered CBT (eCBT) to facilitate access. Although previous reviews have compared the effects of eCBT to face-to-face CBT, there is an overall lack of adequately powered and up-to-date evidence in the literature to provide a reliable comparison between the two modes of administration. The purpose of this study is to evaluate the effects of eCBT compared to face-to-face CBT through a systematic review of the literature.
Methods
To be eligible for this review, studies needed to be randomized controlled trials evaluating the clinical effectiveness of any form of eCBT compared to face-to-face CBT. These encompassed studies evaluating a wide range of outcomes including severity of symptoms, adverse outcomes, clinically relevant outcomes, global functionality, participant satisfaction, quality of life, and affordability. There were no restrictions on participant age or sex.
We searched MEDLINE, EMBASE, Psych Info, Cochrane CENTRAL and CINAHL databases from inception to February 20th, 2020 using a comprehensive search strategy. All stages of literature screening and data extraction were completed independently in duplicate. Data extraction and risk of bias analyses, including GRADE ratings, were conducted on studies meeting inclusion criteria. Qualitative measures are reported in a narrative summary. We pooled quantitative data in meta-analyses to provide an estimated summary effect. This review adheres to PRISMA reporting guidelines.
Findings
In total, we included 17 studies in our analyses. Our results demonstrated that eCBT was more effective than face-to-face CBT at reducing depression symptom severity (Standardized mean difference [SMD]: −1.73; 95% confidence interval [CI]: −2.72, −0.74; GRADE: moderate quality of evidence). There were no significant differences between the two interventions on participant satisfaction (SMD 0.13 95%; CI −0.32, 0.59; GRADE: low quality of evidence). One RCT reported eCBT to be less costly than face-to-face CBT (GRADE: low quality of evidence). Results did not differ when stratified by subgroups such as participant age and study location.
Interpretation
Although we found eCBT to have moderate evidence of effectiveness in reducing symptoms of depression, high heterogeneity among studies precludes definitive conclusions for all outcomes. With the current reliance and accessibility of technology to increasing number of people worldwide, serious consideration in utilizing technology should be given to maximize accessibility for depression treatments. Our results found eCBT is at least as effective as face to face CBT, thus eCBT should be offered if preferred by patients and therapists.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Introduction:
Evidence on effects of Internet-based interventions to treat subthreshold depression (sD) and prevent the onset of major depression (MDD) is inconsistent.
Objective:
We conducted an individual participant data meta-analysis to determine differences between intervention and control groups (IG, CG) in depressive symptom severity (DSS), treatment response, close to symptom-free status, symptom deterioration and MDD onset as well as moderators of intervention outcomes.
Methods:
Randomized controlled trials were identified through systematic searches via PubMed, PsycINFO, Embase and Cochrane Library. Multilevel regression analyses were used to examine efficacy and moderators.
Results:
Seven trials (2,186 participants) were included. The IG was superior in DSS at all measurement points (posttreatment: 6-12 weeks; Hedges' g = 0.39 [95% CI: 0.25-0.53]; follow-up 1: 3-6 months; g = 0.30 [95% CI: 0.15-0.45]; follow-up 2: 12 months, g = 0.27 [95% CI: 0.07-0.47], compared with the CG. Significantly more participants in the IG than in the CG reached response and close to symptom-free status at all measurement points. A significant difference in symptom deterioration between the groups was found at the posttreatment assessment and follow-up 2. Incidence rates for MDD onset within 12 months were lower in the IG (19%) than in the CG (26%). Higher initial DSS and older age were identified as moderators of intervention effect on DSS.
Conclusions:
Our findings provide evidence for Internet-based interventions to be a suitable low-threshold intervention to treat individuals with sD and to reduce the incidence of MDD. This might be particularly true for older people with a substantial symptom burden.
Background
In a world of technological advancements, electronic devices and services seem to be a promising way to increase patients’ engagement in treatment and to help manage their symptoms. Here, we identified and analyzed the current evidence of RCTs to evaluate the effectiveness and acceptability of e-health interventions in the eating disorder (ED) field.
Methods
We screened an initial cluster of 581 papers. In the end, 12 RCTs in clinical ED cohorts were included.
Results
Some studies were conceived as stand-alone interventions, while others were presented as add-ons to ED-specific treatments. Studies varied in the type of EDs under investigation and in the e-health intervention applied (with vs. without therapist support vs. blended interventions; smartphone- vs. web-based). Only four studies reported explicit acceptability measures. Out of those, two reported high acceptability, one reported low acceptability, and one reported no significant difference in acceptability between groups. Four studies reported higher effectiveness of the e-health intervention compared to the control condition, e.g., reduction in maladaptive eating behaviors. Regarding control groups, three used a wait list design and nine had another kind of intervention (e.g., face-to-face CBT, or treatment as usual) as control.
Discussion
So far, the evidence for acceptability and effectiveness of e-health interventions in EDs is very limited. There is also a lack of studies in older patients, adolescents, men, sexual and ethnic minorities. Shame/stigma is discussed in the context of e-health interventions for EDs. It remains unclear how severity of EDs affects the effectiveness of e-health interventions, how patients can channel the knowledge they acquire from e-health interventions into their actual behaviors, and how such interventions can better fit the needs of the individual patient to increase acceptability and effectiveness.
Objective
Despite high rates of prenatal insomnia, efficacious treatment options for this population are quite limited. Early evidence from randomized controlled trials (RCTs) support the efficacy of face-to-face cognitive-behavioral therapy for insomnia (CBTI) for prenatal insomnia. Yet, as many patients are unable to access this specialist-driven care, a critical need exists to increase its accessibility. This RCT examined the efficacy internet-based digital CBTI in pregnant women with insomnia.
Methods
Single-site RCT. Ninety-one pregnant women (29.03±4.16 years) nearing/entering the third trimester who screened positive for clinical insomnia on the Insomnia Severity Index (ISI) were randomized to digital CBTI or digital sleep education control. The ISI, Pittsburgh Sleep Quality Index (PSQI), Edinburgh Postnatal Depression Scale (EPDS), and Pre-Sleep Arousal Scale’s Cognitive factor (PSAS-C) served as study outcomes, which were collected before treatment and after treatment during pregnancy, then 6 weeks after childbirth.
Results
From pre to posttreatment, CBTI patients reported reductions in ISI (-4.91 points, p<.001) and PSQI (-2.98 points, p<.001) and increases in nightly sleep duration by 32 minutes (p=.008). Sleep symptoms did not change during pregnancy in the control group. After childbirth, CBTI patients, relative to controls, slept longer by 40 minutes per night (p=.01) and reported better sleep maintenance. No pre or postnatal treatment effects on depression or cognitive arousal were observed.
Conclusions
Digital CBTI improves sleep quality and sleep duration during pregnancy and after childbirth. To better optimize outcomes, CBTI should be tailored to meet the changing needs of women as the progress through pregnancy and early parenting.
Name
Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum Depression
URL: clinicaltrials.gov. Registration: NCT03596879
This is the first pilot study to explore the feasibility, acceptability and preliminary efficacy of intensive cognitive behavioral therapy (CBT) for panic disorder and/or agoraphobia delivered via the internet. Ten participants who met DSM-5 criteria for panic disorder and/or agoraphobia (6 males; mean age = 43.40, SD = 15.25) completed The Intensive Panic Program: a six-lesson exposure-based CBT program, delivered online over seven days. Clinician support was provided via phone and email. All 10 participants completed the program (100% adherence) and high levels of satisfaction were reported. We found large and significant reductions in panic symptom severity at post-treatment (d = 1.40), which were maintained at two-month follow-up. We also found large reductions in agoraphobic avoidance (d = 0.92) and functional impairment (d = 1.04) at follow-up, and days out of role were halved. On average, 132 min (SD = 42, range: 47–183) of clinician time was spent per participant during the treatment week. The results provide promising preliminary evidence for the feasibility and acceptability of internet-delivered intensive CBT for panic disorder and/or agoraphobia. A larger, randomized control trial is now needed to evaluate the efficacy of this program compared to a control group and to explore long-term outcomes.
Clinical trial registration number
ACTRN12618001501235
Background:
Extensive literature has shown the effectiveness of cognitive behavioral therapy in treating perinatal depression, but little is known about the effectiveness of its technology-based version.
Aim:
The aim of this review was to examine the effectiveness of technology-based cognitive behavioral therapy in reducing depressive and anxiety symptoms in women suffering from or at risk of experiencing perinatal depression.
Methods:
Six electronic databases were searched until February 2023 for articles published in English. Random-effect meta-analyses were conducted. Heterogeneity was assessed using the I2 statistics and Cochran's Q chi-squared test. Sensitivity analyses and subgroup analyses were also performed, and quality appraisals at the study and outcome levels were conducted.
Results:
A total of 16 randomized controlled trials were included in the review. Results from meta-analyses suggest that technology-based cognitive behavioral therapy has a medium effect in reducing perinatal depressive symptoms and a small effect in reducing perinatal anxiety symptoms. Overall, women suffering from or at risk of perinatal depression may benefit from technology-based cognitive behavioral therapy.
Linking evidence to action:
Future interventions can be improved by addressing both perinatal depression and anxiety, paying more attention to antenatal women to prevent postnatal mental health issues, and using self-guided mobile applications for accessibility.
Background:
Rumination and worry, forms of repetitive negative thinking (RNT), are implicated in the onset, maintenance, severity, and relapse risk of depression and anxiety disorders. This randomised controlled trial evaluated an internet intervention targeting both rumination and worry in adults compared to treatment-as-usual (TAU) and compared treatment effects and adherence when delivered with and without clinician guidance.
Methods:
Adults (N = 137) with elevated RNT were randomly allocated to a 3-lesson clinician guided (n = 45) or self-help (n = 47) online program delivered over 6 weeks, or a TAU control group which waited 18 weeks to receive the program (n = 45). The clinician guided group received semi-structured phone support after each lesson. All three groups continued any pre-trial TAU. RNT, anxiety, depression, and psychological distress were assessed at baseline, post-treatment (week 7), and 3-month follow-up.
Results:
Intention-to-treat linear mixed models showed that participants in the self-help and clinician guided groups had significantly lower RNT, anxiety, depression, and distress at post-treatment and 3-month follow-up compared to TAU. Treatment effects were significantly larger in the clinician guided group compared to self-help (between-group gs = 0.41-0.97). No significant between-group differences were found in adherence/program completion (guided: 76%; self-guided: 79%) or treatment satisfaction (1-5 scale: guided: M = 4.17, SD = 1.20; self-guided: M = 3.89, SD = 0.93). Total time spent on clinician guidance was M = 48.64 min (SD = 21.28).
Conclusion:
This brief online intervention for RNT is acceptable and efficacious in reducing RNT, anxiety, depression, and distress in both clinician guided and self-help formats. The program appeared most effective when delivered with clinician guidance. Larger definitive trials comparing guided and self-guided programs are needed. Australian and New Zealand Clinical Trials Registration number: ACTRN12620000959976.
Study Objectives
Insomnia and anxiety are highly prevalent and frequently co-occur. Given limited therapeutic resources and time constraints, the aim of this study was to compare which treatment – internet CBT for insomnia or internet CBT for anxiety – leads to the best outcomes in individuals with comorbid insomnia and anxiety.
Methods
120 participants with comorbid insomnia and clinical anxiety (as defined by scores above the clinical cut off on the ISI and the GAD-7) were randomized to receive internet-based cognitive behavioral therapy (iCBT) for insomnia or iCBT for anxiety. The primary outcome measures were the insomnia severity index and the generalized anxiety disorder-7 item scale. Primary outcome measures were assessed before treatment, at mid-treatment, at post-treatment, and 3 months after treatment. Secondary outcome measures assessed depression symptoms, distress, and sleep diary parameters.
Results
Participants in both groups experienced large reductions in symptoms of insomnia, anxiety, depression, and distress, as well as improvements in sleep efficiency and total sleep time. Improvements were maintained at follow-up. Crucially, at the end of treatment, the insomnia treatment was more effective in reducing symptoms of insomnia than the anxiety treatment, and equally effective in reducing symptoms of anxiety. Treatment gains were maintained at 3-month follow-up, however, there were no differences between groups at that time point.
Conclusions
These results suggest that in the common case of a patient presenting with comorbid insomnia and anxiety, treatment for insomnia may be the most efficient treatment strategy.
Web-based interventions are increasingly used for the prevention, treatment and aftercare of mental disorders. A crucial factor to the efficacy of such online programmes is adherence to the intervention content and procedure. It has been frequently suggested that adherence in web-based interventions is low and little is known about which factors influence adherence. To increase intervention uptake and completion, studies increasingly include interventions with some form of guidance. Guided interventions have been shown to have higher efficacy, however, evidence for the impact on adherence is limited and mixed. This meta-analysis explored the impact of human guidance on intervention completion in web-based mental health interventions. A total of 22 studies were included with interventions primarily targeting symptoms of depression and anxiety disorders. Results showed that guidance significantly increases the average amount of intervention completion [ g = 0.29, 95% confidence interval (CI) 0.18–0.40] and the proportion of intervention completers [ log odds ratio (OR) = 0.50, 95% CI 0.34–0.66] with small effects. On average, full completion rates were 12% higher in guided intervention groups. This meta-analysis demonstrated that guidance in web-based mental health interventions does increase adherence, but more research is required to better understand the specific mechanisms between guidance, adherence and outcomes.
Background
Internet cognitive behavioural therapy (iCBT) for health anxiety has demonstrated efficacy but has not been evaluated during the COVID-19 pandemic. This study presents the first evaluation of the uptake and outcomes of iCBT for health anxiety during the COVID-19 pandemic.
Methods
THIS WAY UP is an Australian digital mental health service which delivers iCBT interventions to community members. We compared the uptake of THIS WAY UP’s iCBT course for health anxiety in an Australian adult sample who started the course before the pandemic (12th September 2019 to 11th March 2020) to during the pandemic (12th March to 11th June 2020). The course was accessible to Australian adults over 18 years old, with no inclusion criteria. Outcomes included course registrations and commencements, lesson and course completion, and self-reported health anxiety (Short Health Anxiety Inventory), depression (Patient Health Questionnaire 9-item) and distress (Kessler-10).
Results
From March to June 2020, we observed significant increases in course registrations (N=238 vs N=1057); and course commencements (N=126 vs. N= 778). Large, significant improvements in health anxiety (g= 0.89), and distress (K10: g=0.91), and medium improvements in depression (g=0.55) were found. Course completion during COVID was 30.5%.
Conclusions
iCBT improved health anxiety during the COVID-19 pandemic, and provides scalable intervention that can address increased demands for mental health services in the community.
Background
Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification.
Objective
The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements.
MethodsA meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis.
ResultsA random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=–0.27, 95% CI –0.36 to –0.17; P
Objective
Online cognitive behavioural therapy for insomnia (iCBT-I) provides scalable access to psychological interventions; however, the effectiveness of these courses during COVID-19 has not been examined. This study investigated the uptake and potential effectiveness of iCBT-I during the first 10 months of the pandemic in Australia (March- December 2020) and compared outcomes in the year prior.
Method
Two thousand six hundred and ninety-four adults commenced a four-lesson iCBT-I course (1,883 during the pandemic; 811 in the year before). Measures of insomnia and psychological distress were administered pre-, mid- and post-treatment.
Results
In the COVID-19 period, we observed a 140% increase in monthly course registrations compared to the year prior (with a peak increase of 257% from April-June 2020). Insomnia symptom severity was marginally lower for the during-COVID group compared to the pre-COVID group, although levels of psychological distress were similar. Before and during COVID-19, iCBT-I was associated with large effect size reductions in insomnia symptom severity (gs = .86–1.09) and small effect size improvements in psychological distress and wellbeing (gs = 0.34–0.41).
Conclusion
iCBT-I uptake substantially increased during the pandemic; treatment outcomes were similar. The findings demonstrate the scalability and potential effectiveness of iCBT-I.
Key Points
What is already known about this topic:
• Insomnia is a significant public health issue.
• Internet delivered cognitive behaviour therapy (iCBT) is effective in reducing insomnia symptom severity.
• The COVID-19 pandemic has had a large impact on mental health with higher estimated rates of insomnia during the pandemic.
What this topic adds:
• Uptake of an online insomnia course increased by >180% during COVID-19.
• The course was associated with large effect size reductions in insomnia symptoms.
• Results highlight the utility and scalability of digital mental health services.
Accessible, affordable cognitive behavioural therapy (CBT) options for Social Anxiety Disorder (SAD) that allow for rapid symptom improvement are needed. The present study investigated the first intensive, 7-day internet-based CBT for SAD. An open pilot trial was conducted to test the acceptability, feasibility and preliminary outcomes of the program in a sample of 16 participants (9 females, M age = 40.34, SD = 10.55) with a DSM-5 diagnosis of SAD. Participants were enrolled into the 6-lesson online program, and completed the Social Phobia Scale [SPS], Social Interaction Anxiety Scale [SIAS], Patient Health Questionnaire-9 (PHQ-9), and Work and Social Adjustment Scale (WSAS) at baseline, post and one month follow-up. We found support for the feasibility and acceptability of the program; 15 participants (93.8%) completed the program, and all participants reported the program was satisfactory. Large, significant reductions in social anxiety severity on both the SPS and SIAS (Hedges’ gs= 1.26-1.9) and functional impairment (WSAS; gs = 0.88-0.98) were found at post-treatment and follow-up. Medium, significant reductions in depressive symptom severity were also found (gs = 0.88-0.98 at post and follow-up, respectively). A third of participants scored below the clinical cut-off on both the SPS and SIAS at post-treatment and follow-up. A randomised controlled trial with longer follow-up, is needed to evaluate the efficacy of this intensive internet-based treatment for SAD. Implications and future research directions are discussed.
Importance
In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment.
Objective
To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder.
Design, Setting and Participants
A randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020.
Interventions
Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment.
Main Outcomes and Measures
The primary outcome was the masked assessor–rated Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS.
Results
Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, −∞ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group).
Conclusions and Relevance
Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings.
Trial Registration
ClinicalTrials.gov Identifier: NCT03263546
Background Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom.
Methods We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form
of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of
components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683.
Findings We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants’ weighted mean age was 42∙0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD –1∙83 [95% credible interval (CrI) –2∙90 to –0∙80]) and that relaxation might be harmful (1∙20 [95% CrI 0∙17 to 2∙27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0∙32 [95% CrI 0∙13 to 0∙93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components.
Interpretation The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package.
Funding Japan Society for the Promotion of Science.
Though therapist-guided Internet-based cognitive behavior therapy (ICBT) appears to be efficacious for depression, social anxiety disorder, and panic disorder, relatively little is known about real-world settings and predictors of treatment effects derived from cognitive-behavioral theory. We examined treatment effectiveness and predictors of improvement in a prospective cohort study where patients took part in 10 weeks of ICBT for depression (n = 114), social anxiety disorder (n = 150), or panic disorder (n = 106) at a teaching clinic. Patients self-reported symptoms before, during, and after treatment. Effect sizes were large for improvement in the primary symptom domain of each treatment group: depression (d = 1.48), social anxiety disorder (d = 1.01), and panic disorder (d = 1.15). In ICBT for depression, having no previous experience of psychological treatment (r = 0.21), and more frequent baseline negative automatic thoughts (r = 0.20) predicted larger improvement. In ICBT for panic disorder, having more baseline safety behaviors (r = 0.25) predicted larger improvement. Predictors remained significant when baseline symptoms were included in the statistical models. We conclude that ICBT can be effective in a real-world teaching clinic, and that patients with greater deficits at baseline benefit the most.
Social anxiety disorder (SAD) is one of the most common lifelong anxiety disorders. Although cognitive behavioural therapy (CBT) has proven to be effective in treating people with SAD, it may not be available for a considerable proportion of patients. Internet‐based CBT (ICBT) is more accessible than face‐to‐face treatment. This meta‐analysis evaluated the efficacy of ICBT in patients with SAD. We searched five databases, PubMed, Cochrane Central Register of Controlled Trials, Health Management Information Consortium, Ovid MEDLINE and EMBASE, and identified 20 eligible randomized controlled trials published from inception to 25 July 2020, with the outcome data from 1,743 participants. The results indicated that ICBT had a significant positive effect on patients with SAD compared with the control groups (g = −0.55). A subgroup analysis revealed that ICBT and CBT had an equal effect on treating patients with SAD (g = −0.18). There was also no difference between ICBT and ICBT plus other therapies in the treatment of patients with SAD (g = −0.07). The effect size of ICBT on patients with SAD was maintained at the 6‐month follow‐up (g = −0.08) and at the 12‐month follow‐up (g = −0.17). The findings of this review demonstrated that ICBT can significantly reduce SAD symptoms and that ICBT and face‐to‐face CBT produce equivalent effects. The results of this meta‐analysis contributed to the literature on ICBT for the treatment of patients with SAD, although numerous aspects of ICBT were identified for future investigations.
Objectives
Although cognitive behavioural therapy for insomnia (CBT-I) has been recommended the initial therapy for insomnia, its clinical usage remains limited due to the lack of therapists. Digital CBT-I (dCBT-I) can potentially circumvent this problem. This meta-analysis aims to evaluate the short-term and long-term efficacy of dCBT-I for adults with insomnia.
Methods
Systematic search of PubMed, EMBASE, PsycINFO and CENTRAL from inception till 5 March 2020 was conducted. Randomised controlled trials (RCTs) comparing dCBT-I with controls (wait-list/treatment-as-usual/online education) in adults with insomnia were eligible. The primary outcome was insomnia severity index (ISI) at post-intervention, short-term follow-up (ranging 4 weeks to 6 months) and 1-year follow-up. Mean differences were pooled using the random-effects model.
Results
94 articles were assessed full-text independently by two team members and 33 studies were included in this meta-analysis. 4719 and 4645 participants were randomised to dCBT-I and control respectively. dCBT-I significantly reduces ISI at post-intervention with mean difference -5.00 (95%CI -5.68 to -4.33, p<0.0001) (I²=79%) compared to control. The improvements were sustained at short-term follow-up, -3.99 (95%CI -4.82 to -3.16, p<0.0001) and 1-year follow-up, -3.48 (95% CI -4.21 to -2.76, p<0.0001). Compared to dCBT-I, face-to-face CBT-I produced greater improvement in ISI, 3.07 (95%CI 1.18 to 4.95, p=0.001). However, this was within the non-inferiority interval of 4 points on ISI.
Conclusion
This meta-analysis provides strong support for the effectiveness of dCBT-I in treating insomnia. dCBT-I has potential to revolutionise the delivery of CBT-I, improving the accessibility and availability of CBT-I content for insomnia patients worldwide.
Background
Internet-based psychological interventions have proven effective and yield advantages that make them a viable alternative to face-to-face therapy in many fields. Yet, the role of therapeutic alliance in technologically mediated interventions has been discussed critically. The aim of this meta-analysis is to summarize the association between therapeutic alliance and outcome in therapist-assisted online interventions.
Methods
A systematic search of the databases PubMed, Web of Science, PsycINFO and PubPsych was conducted for articles published before February 2020 that assess the association between therapeutic alliance and outcome in internet-based interventions involving remote therapist contact. Results were systematically screened and information on the alliance-outcome-association was extracted. A multilevel meta-analysis was conducted.
Results
Overall, 51 effect sizes were extracted from 20 included studies. The average weighted effect size is r = 0.203 (p < .0001). The correlation was larger when alliance was measured near the end of an intervention. There was no impact of therapist contact frequency or mode and availability of self-help content on the effect size.
Conclusions
Therapeutic alliance and outcome are significantly correlated in internet-based therapy. This points to the relevance of a stable alliance in internet-based interventions and suggests that fostering alliance might be beneficial to treatment success.
Virtual reality exposure therapy (VRET) has been recognized as an effective treatment for specific phobias and has the potential to overcome the limitations of traditional in vivo exposure therapy (e.g., acceptability). No past research has evaluated the efficacy of VRET for the treatment of blood-injection-injury (BII) phobias. Therefore, we conducted a randomized controlled trial to examine the acceptability and efficacy of a single-session VRET intervention for BII phobias. Participants who met DSM-5 criteria for BII phobia (N=43) were randomized to VRET or a waiting list control group, and completed self-report measures of BII severity (Medical Fear Survey [MFS] and Multidimensional Blood Phobia Inventory [MBPI]) and dental anxiety (Modified Dental Anxiety Scale), as well as clinician ratings of BII phobia severity and catastrophic cognitions at baseline, one-week post-treatment and 3-month follow-up. We found medium to large differences in catastrophic cognitions (probability [g=0.88] and cost [g=0.66] ratings), favouring VRET. We found moderate to large differences favouring VRET on the MBPI Injection and Injury fears subscales (g's=0.64-1.14) at one-week post-treatment and 3-month follow-up, and on the MBPI Fainting subscale (g=.84) and Injections subscale of the Medical Fear Survey (g=0.63) at follow-up. There were no other significant group differences. These findings provided some initial evidence to suggest that a single-session VRET may provide some improvements in fears of injections, injury and fainting. While it may be a useful adjunct or interim step before in vivo exposure therapy, it is not sufficient as a standalone treatment for BII phobias.
Internet-based acceptance and commitment therapy (iACT) primarily targets the process of psychological flexibility. Its accessibility and low-intensity delivery are applicable across different treatment and prevention scenarios. This transdiagnostic meta-analysis reviews the effectiveness of iACT on anxiety, depression, quality of life, and psychological flexibility across individuals with different psychological and somatic conditions/complaints, or undiagnosed complaints. Seven databases were searched for randomized controlled trials that reported on anxiety, depression, quality of life, and psychological flexibility outcomes from iACT in any adult population. Engagement with iACT was summarised and methodological and population-related variables were investigated as potential moderators of effectiveness. Across 25 studies, small pooled effects were found for all outcomes at post-assessment and maintained at follow-up time-points. Interventions with therapist guidance demonstrated greater effectiveness in improving depression and psychological flexibility outcomes compared to non-guided iACT, and populations defined by a psychological condition or symptoms (e.g. depressed samples) demonstrated greater improvements in anxiety compared to non-clinical or somatic populations (e.g. chronic pain samples or students). Participants completed on average 75.77% of iACT treatments. While we found iACT to be effective in improving and maintaining mental health outcomes across diverse populations, there was limited evidence of reliable, clinically significant effects. PROSPERO registration number: CRD42020140086.
A growing evidence base supports the efficacy of Internet-based cognitive behaviour therapy (iCBT) for obsessive compulsive disorder (OCD). However, very few studies have evaluated the effectiveness of iCBT for OCD in routine care settings which service the bulk of a population’s health needs. This study evaluated the treatment outcomes of 309 adults who enrolled in an online CBT course for their symptoms of OCD. Most patients (62.8%) enrolled in a self-help or unguided iCBT course, and the remainder were supported by a routine care, community clinician. The entire iCBT course was completed by 39.3% of participants, with 61.2% completing the majority of iCBT lessons. Higher baseline depression symptom severity predicted poorer adherence, while the presence of a supervising clinician was associated with greater adherence. Medium effect size reductions in OCD symptom severity (g= .61), depression symptom severity (g= .56), and psychological distress (g= .69) were observed from pre-to post-treatment. Pre-treatment OCD and depression symptom severity predicted post-treatment OCD symptom severity. Current results support the use of iCBT for OCD in routine care settings, and as health care resources are finite, iCBT for OCD may serve as a useful, low-intensity, and scalable addition to the existing healthcare infrastructure.
Importance: Health anxiety is a common and often chronic mental health problem associated with distress, substantial costs, and frequent attendance throughout the health care system. Face-to-face cognitive behavior therapy (CBT) is the criterion standard treatment, but access is limited.
Objective: To test the hypothesis that internet-delivered CBT, which requires relatively little resources, is noninferior to face-to-face CBT in the treatment of health anxiety.
Design, Setting, and Participants: This randomized noninferiority clinical trial with health economic analysis was based at a primary care clinic and included patients with a principal diagnosis of health anxiety who were self-referred or referred from routine care. Recruitment began in December 10, 2014, and the last treatment ended on July 23, 2017. Follow-up data were collected up to 12 months after treatment. Analysis began October 2017 and ended March 2020.
Interventions: Patients were randomized (1:1) to 12 weeks of internet-delivered CBT or to individual face-to-face CBT.
Main Outcomes and Measures: Change in health anxiety symptoms from baseline to week 12. Analyses were conducted from intention-to-treat and per-protocol (completers only) perspectives, using the noninferiority margin of 2.25 points on the Health Anxiety Inventory, which has a theoretical range of 0 to 54.
Results: Overall, 204 patients (mean [SD] age, 39 [12] years; 143 women [70%]) contributed with 2386 data points on the Health Anxiety Inventory over the treatment period. Of 204 patients, 102 (50%) were randomized to internet-delivered CBT, and 102 (50%) were randomized to face-to-face CBT. The 1-sided 95% CI upper limits for the internet-delivered CBT vs face-to-face CBT difference in change were within the noninferiority margin in the intention-to-treat analysis (B = 0.00; upper limit: 1.98; Cohen d = 0.00; upper limit: 0.23) and per-protocol analysis (B = 0.01; upper limit: 2.17; Cohen d = 0.00; upper limit: 0.25). The between-group effect was not moderated by initial symptom level, recruitment path, or patient treatment preference. Therapists spent 10.0 minutes per patient per week in the online treatment vs 45.6 minutes for face-to-face CBT. The net societal cost was lower in the online treatment (treatment period point difference: $3854). There was no significant group difference in the number of adverse events, and no serious adverse event was reported.
Conclusions and Relevance: In this trial, internet-delivered CBT appeared to be noninferior to face-to-face CBT for health anxiety, while incurring lower net societal costs. The online treatment format has potential to increase access to evidence-based treatment for health anxiety.
Trial Registration: ClinicalTrials.gov Identifier: NCT02314065
Background
Cognitive behavioral therapy (CBT) is a well-established treatment for panic disorder, but many fewer patients receive this treatment compared to medication-based therapy. Mobile app-based interactive CBT using a chatbot can increase patient access to CBT. We performed a preliminary study to determine whether short-term use of a newly developed chatbot is feasible and effective for relieving panic symptoms.
Method
Forty-one patients were randomly assigned to either a chatbot group (n = 21) or control group (n = 20) for a period of 4 weeks. The chatbot group was guided in the use of the chatbot application, while the control group was provided with a book on panic disorder.
Main results
The severity of panic disorder was significantly decreased in the chatbot group, but not in the control group. The social phobia score was significantly decreased and the control helplessness score was significantly increased in the chatbot group compared to the control group.
Discussion and conclusion
We found that mobile app-based interactive CBT using the chatbot was feasible and effective for reducing the severity of panic symptoms. Using this novel approach to provide CBT would allow clinicians to effect positive therapeutic outcomes with easy accessibility, interactivity, and self-management for patients with panic symptoms.
Clinical and research interest in the potential of mobile health apps for the management of mental health conditions has recently been given added impetus by growing evidence of consumer adoption. In parallel, there is now a developing evidence base that includes meta-analyses demonstrating reductions in symptoms of depression and anxiety, and reduction in suicidal ideation. While these findings are encouraging, recent research continues to identify a number of potential barriers to the widespread adoption of mental health apps. These challenges include poor data governance and data sharing practices; questions of clinical safety relating to the management of adverse events and potentially harmful content; low levels of user engagement and the possibility of ‘digital placebo’ effects; and workforce barriers to integration with clinical practice. Current efforts to address these include the development of new models of care, such as ‘digital clinics’ that integrate health apps. Other contemporary innovations in the field such as digital sensing and just-in-time adaptive interventions are showing early promise for providing accessible and personalised care.