Transdiagnostic Internet treatment for anxiety disorders: A randomized controlled trial

ArticleinBehaviour Research and Therapy 48(9):890-9 · September 2010with62 Reads
Impact Factor: 3.85 · DOI: 10.1016/j.brat.2010.05.014 · Source: PubMed
Abstract

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

Full-text

Available from: Luke Johnston, Sep 05, 2015
Transdiagnostic Internet treatment for anxiety disorders: A randomized
controlled trial
Nickolai Titov
a
,
*
, Gavin Andrews
a
, Luke Johnston
a
, Emma Robinson
b
, Jay Spence
b
a
School of Psychiatry, University of New South Wales, Sydney, Australia
b
Clinical Psychologist, St Vincents Hospital, Sydney, Australia
article info
Article history:
Received 23 March 2010
Received in revised form
13 May 2010
Accepted 18 May 2010
Keywords:
Internet cognitive behavioural therapy
(iCBT)
Randomized controlled trial (RCT)
Anxiety
Transdiagnostic
Treatment
Internet
abstract
Clinician-guided Internet-based cognitive behavioural therapy (iCBT) programs are clinically effective at
treating specic anxiety disorders. The present study examined the efcacy of a transdiagnostic Internet-
based cognitive behavioural treatment (iCBT) program to treat more than one anxiety disorder within
the same program (the Anxiety Program). Eighty six individuals meeting diagnostic criteria for general-
ized anxiety disorder (GAD), panic disorder, and/or social phobia were randomly assigned to a treatment
group, or to a waitlist control group. Treatment consisted of CBT based online educational lessons and
homework assignments, weekly email or telephone contact from a clinical psychologist, access to
a moderated online discussion forum, and automated emails. An intention-to-treat model using the
baseline-observation-carried-forward principle was employed for data analyses. Seventy-ve percent of
treatment group participants completed all 6 lessons within the 8 week program. Post-treatment data
was collected from 38/40 treatment group and 38/38 control group participants, and 3-month follow-up
data was collected from 32/40 treatment group participants. Relative to controls, treatment group
participants reported signicantly reduced symptoms of anxiety as measured by the Generalized Anxiety
Disorder e 7 Item, Social Phobia Screening Questionnaire, and the Panic Disorder Severity Rating Scale e
Self Report Scale, but not on the Penn State Worry Questionnaire, with corresponding between-groups
effect sizes (Cohens d) at post-treatment of 0.78, 0.43, 0.43, and 0.20, respectively. The clinician spent
a total mean time of 46 min per person over the program, participants rated the procedure as moderately
acceptable, and gains were sustained at follow-up. Modications to the Anxiety program, based on post-
treatment feedback from treatment group participants, were associated with improved outcomes in the
control group. These results indicate that transdiagnostic programs for anxiety disorders may be
successfully administered via the Internet.
Crown Copyright Ó 2010 Published by Elsevier Ltd. All rights reserved.
Introduction
Anxiety disorders are common, affecting 1 in 7 adults. By
themselves, these conditions result in considerable disability and
distress (Australian Bureau of Statistics, 2008). However, anxiety
disorders frequently co-occur, and comorbidity is associated with
increased distress, disability, and service utilization (Andrews,
Slade, & Issakidis, 2002).
Anxiety disorders can be effectively treated with disorder-
specic treatment plans (Andrews et al., 2003) or, as indicated by
an emerging literature, transdiagnostic or unied programs that
target the common elements and symptoms across disorders
(Barlow, Allen, & Choate, 2004). The potential benets to patients
and clinicians of requiring only one transdiagnostic program
compared to numerous disorder-specic programs are consider-
able. For example, patients with different disorders may be treated
with the same program, thus reducing waiting list times for
disorder-specic programs, while patients with comorbid anxiety
disorders or depression may concurrently learn to manage multiple
disorders. Recent meta-analyses of transdiagnostic treatment for
the anxiety disorders (Norton & Price, 2007), and for anxiety
combined with depression (McEvoy, Nathan, & Norton, 2009),
while based on a relatively small number of studies, indicate that
transdiagnostic treatment can result in similar outcomes to
disorder-specic treatment.
Despite the existence of effective disorder-specic or trans-
diagnostic treatments, fewer than 50% of people with anxiety seek
treatment and less than one quarter receive evidence-based
*
Correspondence to: Dr Nickolai Titov, CRUFAD at St Vincents Hospital, 299
Forbes Street, Darlinghurst, NSW 2010, Australia. Tel.: þ61 2 8382 1732; fax: þ61 2
8382 1721.
E-mail address: nickt@unsw.edu.au (N. Titov).
Contents lists available at ScienceDirect
Behaviour Research and Therapy
journal homepage: www.elsevier.com/locate/brat
0005-7967/$ e see front matter Crown Copyright Ó 2010 Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2010.05.014
Behaviour Research and Therapy 48 (2010) 890e899
Page 1
treatment (Andrews et al., 2002). Barriers to treatment include the
direct and indirect costs of treatment, stigma, the belief that
treatment wont work, and difculty accessing treatment by people
in non-metropolitan regions or by those unable to attend treatment
during usual working hours (Marks & Cavanagh, 2009; Spek et al.,
20 07; Titov, 2007).
One promising strategy for improving access to treatment
involves administering psychological treatments via the Internet.
Such programs are increasingly common, often based on cognitive
behavioural therapy (CBT), and highly structured. Internet-based
CBT (iCBT) programs comprise several components including
online lessons, homework assignments, and regular communica-
tion with a therapist via email, telephone, or online forums
(Andersson & Cuijpers, 2009; Titov, 2007). The treatment efcacy or
effectiveness of iCBT programs has been demonstrated for
depression (Andersson et al., 2005; Perini, Titov, & Andrews, 2009;
Ruwaard et al, 2009; Titov et al., in press; Vernmark et al., 2010),
panic disorder (Carlbring et al., 2005; Kiropoulos et al., 2008; Klein,
Richards, & Austin, 2006; Shandley et al., 2008; Wims, Titov,
Andrews, & Choi, 2010), generalized anxiety disorder (Robinson
et al., in press; Titov, Andrews, Robinson, et al., 2009), and social
phobia (Andersson et al., 2006; Berger, Hohl, & Caspar, 2009;
Carlbring, Gunnarsdottir et al., 2007; Titov, Andrews, Choi,
Schwencke, & Johnston, 2009; Titov, Andrews, Choi, Schwencke,
& Mahoney, 2009; Titov, Andrews, & Schwencke, 2008; Titov,
Andrews, Schwencke, Drobny, & Einstein, 2008; Titov, Andrews,
Schwencke, et al., 2009). Recent meta-analyses of iCBT and
computerized CBT for anxiety (Cuijpers et al., 2009) and depression
(Andersson & Cuijpers, 2009) reported that the effect size superi-
ority over control conditions is large in anxiety disorders (23
studies, Cohens d ¼ 1.1), and moderate in depression (12 studies,
d ¼ 0.41). However, the relatively low effect size superiority in
studies of iCBT for depression reected a signicant difference
between assisted (d ¼ 0.61) and unassisted programs (d ¼ 0.25).
The benets of an effective transdiagnostic program that can be
delivered remotely are considerable. The present study extends the
literature on transdiagnostic treatments of anxiety and CBT by
exploring the efcacy of a clinician-assisted transdiagnostic iCBT
program for anxiety disorders, the Anxiety program, using
a CONSORT-Revised compliant randomized controlled trial design
(Moher, Schulz, & Altman, for the CONSORT Group, 2001). Partici-
pants included people with a DSM-IV (American Psychiatric
Association, 2000) diagnosis of generalized anxiety disorder
(GAD), panic disorder (with or without agoraphobia; Pan/Ag), and/
or social phobia (SP). We hypothesised that treatment group
participants would show signicant improvements on general and
disorder-speci
c measures of anxiety, depression, neuroticism, and
disability
relative to waitlist controls; and, that participants would
rate the procedure as acceptable. However, given the challenges of
constructing efcacious transdiagnostic interventions suitable for
different disorders, it was expected that the Anxiety program
would be improved based on post-treatment feedback obtained
from the treatment group. Thus, a secondary aim was to examine
whether additional benets would be reported by the waitlist
control group after modifying the program.
Method
Participants and recruitment
Applicants applied online to www.virtualclinic.org.au, and the
details of participant ow are in Fig. 1. During the 7 weeks of
recruitment in mid 2009, 152 individuals applied for this program
and 114 met the following inclusion criteria: (i) A resident of
Australia; (ii) at least 18 years of age; (iii) had access to a computer,
the Internet, and use of a printer; (iv) not currently participating in
CBT; (v) not using illicit drugs or consuming more than three
standard drinks/day; (vi) not currently experiencing a psychotic
mental illness or severe symptoms of depression (dened as a total
score > 23 or responding > 2 to Question 9 (suicidal ideation) on
the Patient Health Questionnaire e 9 Item (PHQ-9) (Kroenke,
Spitzer, & Williams, 2001)); (vii) if taking medication (people
taking benzodiazepines were excluded), had been taking the same
dose for at least 1 month and did not intend to change that dose
during the course of the program; and (viii) met DSM-IV diagnostic
criteria for GAD, social phobia, and/or panic disorder. Applicants
who did not meet these criteria were informed via an on-screen
message and email thanking them for their application, and
encouraging them to discuss their symptoms with their physician.
Participants who met the inclusion criteria then completed a 25
item questionnaire enquiring about demographic details and
treatment history.
One hundred and eight individuals were contacted and were
administered the Mini International Neuropsychiatric Interview
Version 5.0.0 (MINI) (Sheehan et al., 1998) during a telephone
interview to determine whether they meet DSM-IV criteria for an
anxiety or affective disorder. Eighty six applicants met all inclusion
criteria and were randomized by NT via a true randomization
process (www.random.org) to either the treatment (n ¼ 42) or
control (n ¼ 44) groups (Table 1). Allocation preceded the screening
phone call. The unsuccessful applicants were advised about more
appropriate treatment options. The study was approved by the
Human Research Ethics Committee (HREC) of St Vincents Hospital
(Sydney, Australia) and the HREC of the University of New South
Wales (Sydney, Australia), and the trial was registered as
ACTRN12609000501246.
Design
A CONSORT-R revised compliant design was employed
comparing an immediate treatment group (treatment) with
a waitlist-treatment control group (control). A wide range of
outcome measures (see below) were used to examine change in
diagnosis-specic symptoms, in higher-order factors common
across anxiety disorders, and in symptoms of depression and
disability. Measures of treatment satisfaction and adherence were
also administered. Based on our previous experience administering
iCBT programs, to reduce risk of non-completion, the total number
of questionnaire items was limited to 110, so abbreviated measures
were used when possible.
Outcome measures
These included the Generalized Anxiety Disorder 7-Item Scale,
(GAD-7) (Spitzer, Kroenke, Williams, & Löwe, 2006), the Penn State
Worry Questionnaire (PSWQ) (Meyer, Miller, Metzger, & Borkovec,
1990),
the Social Phobia Screening Questionnaire (SPSQ) (Furmark
et al., 1999), the Panic Disorder Severity Scale e Self Rating
(PDSS-SR) (Houck, Spiegel, Shear, & Rucci, 2002), the PHQ-9, the
Kessler-10 item (K-10) (Kessler et al., 2002), the Sheehan Disability
Scales (SDS) (Sheehan, 1983), the Depression Anxiety Stress Scales
e 21 Item (DASS-21) (Lovibond & Lovibond, 1995), and the 12-item
Neuroticism Subscale (NEO-FFI-N) of the NEO-Five Factor Inventory
(Costa & McCrae, 1985). The GAD-7 is a brief measure of the
symptoms and severity of GAD based on the DSM-IV diagnostic
criteria for GAD. However, a total score of 10 on the GAD-7 has also
been identied as an important threshold for identifying DSM-IV
congruent GAD, social phobia, or panic disorder with increasing
scores indicating greater severity of symptoms (Löwe et al., 2008).
The PSWQ is a well recognized clinical measure of worry, the SPSQ
N. Titov et al. / Behaviour Research and Therapy 48 (2010) 890e899 891
Page 2
is a brief measure based on the DSM-IV criteria for social phobia,
and the PDSS-SR is a brief measure of panic disorder severity
(Houck et al., 2002). The PHQ-9 is a brief measure based on the
DSM-IV criteria for depression, the K-10 and SDS are measures of
psychological distress and disability, respectively, and the NEO-FFI-
N is a higher-order risk factor for anxiety and depression (Cuijpers,
van Straten, & Donker, 2005; Spinhoven, de Rooij, Heiser, Smit, &
Penninx, 2009). The DASS-21 is a widely used measure of severity
of symptoms of anxiety, stress, and depression, and is also often
used to measure change in higher-order, or common symptoms
across anxiety and depressive disorders. All of these measures are
considered reliable, valid, and appropriate for clinical and research
purposes, with recent research indicating that online administra-
tion of questionnaires results in acceptable reliability of responses
(Carlbring, Brunt, et al., 2007; Garb, 20 07).
Change in the GAD-7 was considered the primary anxiety
outcome measure. The GAD-7 is increasingly used in research
(Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007) and in large
scale dissemination studies as a generic measure of change in
anxiety symptoms (Clark et al., 2009; Richards & Suckling, 2009).
Changes in the PHQ-9, K-10, SDS, NEO-FFI-N, and DASS-21 were the
secondary outcome measures, and changes in the PSWQ, GAD-7,
SPSQ, PDSS-SR were the disorder-specic measures. At post-treat-
ment, all participants also completed a 7-item treatment
152 individuals applied to participate within timeframe (22/06/09 - 02/08/09)
108 individuals completed telephone interview with MINI 5.0
Total excluded before diagnostic interview (n = 38):
Not Australian residents (n=4)
Could not be contacted (n=23)
High PHQ-9 scores (n=8)
Did not provide valid email address (n=2)
Current substance use
(
n=1
)
114 individuals met inclusion criteria
Total excluded before interview (n=6):
Applied for other Programs (n=2)
Withdrew application (n=4)
Total excluded from study (n=22):
Current use of benzodiazepines (n=6)
Changed medication in past month (n=2)
Current bipolar disorder (n=1)
Current substance use (n=3)
Did not meet criteria for an anxiety disorder (n=5)
Currently receiving CBT (n=2)
Did not complete consent form (n=1)
Withdrew application (n=2)
86 participants met all inclusion criteria and were randomized into Treatment or Control Groups
30 participants completed all 6 Lessons (1
withdrew at lesson 2, 2 withdrew at Lesson 4),.
34 completed Lesson 5, 38 completed Lesson 4,
39 completed Lesson 3, and all participants
completed Lessons 1 and 2.
Completed Mid-Treatment Questionnaires n= 30
Completed Post-Treatment Questionnaires n= 36
Completed Post-Treatment Questionnaires n= 36
Completed Mid-Treatment Questionnaires n= 34
Completed 3 month follow up Questionnaires n= 32
Treatment Group (n = 42) Control Group (n = 44)
Completed Pre-Treatment Questionnaires (n = 40)
Completed Pre-Treatment Questionnaires (n = 38)
Withdrew before
Program began (n = 2)
Withdrew before Program
began (n = 5)
Did not complete Pre-
Treatment Questionnaires
(n=1)
Fig. 1. Anxiety study ow chart. PHQ-9, Patient Health Questionnaire e 9 Item; MINI 5.0.0, Mini International Neuropsychiatric Interview.
N. Titov et al. / Behaviour Research and Therapy 48 (2010) 890e899892
Page 3
satisfaction questionnaire based on the Credibility/Expectancy
Questionnaire (Devilly & Borkovec, 2000). Treatment group
participants completed the outcomes measures at the following
time points: Pre-treatment (Time 1); one-week post-treatment
(Time 2); and 3-month post-treatment (Time 3). The control group
completed the outcome measures at the same times as the treat-
ment group, and began the program after treatment group partic-
ipants completed the post-treatment questionnaires (Time 2).
Control group participants did not have a 3-month post-treatment
follow-up, and the Time 3 administration of questionnaires
occurred when the control group completed the program. Col-
lecting post-treatment results for the control group enabled
exploration of whether changes to the Anxiety program, based on
feedback and observations from the therapist and participants in
the treatment groups performance, improved outcomes.
Intervention
The Anxiety program is based on evidence-based principles of
CBT (Andrews et al., 2003) and contains materials from existing
disorder-specic iCBT programs for GAD (Titov, Andrews, Robinson,
et al., 2009), social phobia (Titov, Andrews, Schwencke, Drobny,
et al., 2008), and panic disorder (Wims et al., 2010). The Anxiety
program comprises the following components: Six online lessons;
a summary/homework assignment for each lesson; an online
discussion forum for each lesson; regular automatic reminder and
notication emails, and instant messaging to allow secure email-
type messages with a clinician. Participants also had access to
additional written resources. These included guidelines about
assertiveness, health anxiety, and answers to frequently asked
questions about the application of skills described in the lessons
and summaries. Part of the content of each lesson was presented in
the form of illustrated stories about people with either GAD, panic,
or social phobia who, with the help of a clinical psychologist,
successfully begin to gain mastery over their symptoms. Lesson 1
provides education about the symptoms and treatment of anxiety,
Lesson 2 provides instructions about controlling physical symp-
toms and the importance of lifestyle factors, Lesson 3 describes the
basic principles of cognitive therapy, Lesson 4 provides education
and guidelines about practicing graded exposure, Lesson 5 provides
education and guidelines about communication and assertiveness
skills, while Lesson 6 includes information about relapse preven-
tion. Participants were encouraged to complete one Lesson each
week and to complete the six lessons within 8 weeks.
Therapist
One clinical psychologist (ER) provided all clinical contact with
treatment group participants and another clinical psychologist (JS)
provided all clinical contact with the control group. A research
assistant provided administrative support to collate data. Every
contact with each participant was recorded as was the total ther-
apist time spent per participant. Therapists were encouraged to
actively engage with participants in treatment, but advised to limit
weekly contact time to approximately 10 min per participant,
except if more time was clinically indicated.
Hypotheses
Three hypotheses were tested: Firstly, that relative to controls,
treatment group participants would show signicant improvement
on the general measure of anxiety (GAD-7), on disorder-specic
measures (PSWQ, SPSQ, PDSS-SR), and on measures of common
factors (NEO-FFI-N and DASS-21); secondly, that treatment group
participants with primary diagnoses of GAD, panic, or social phobia
would show signicant improvement on relevant disorder-specic
measures (PSWQ, SPSQ, PDSS-SR) relative to controls with the
same primary diagnosis; and thirdly, that gains would be sustained
at 3-month follow-up and that participants would rate the proce-
dure as acceptable.
Statistical methods
Group differences in demographic data and pre-treatment
measures were analyzed with one-way ANOVAs and chi-square
tests. All post-treatment analyses involved an intention-to-treat
(ITT) design and missing data was addressed by carrying forward
the rst available data (baseline-observation-carried-forward;
BOCF). Pre- to post-treatment changes in treatment group partici-
pants q
uestionnaire scores were analyzed using univariate anal-
yses of covariance (ANCOVAs). This approach is recommended as
a robust and reliable statistical strategy for analyzing the results of
RCTs (Vickers, 2005a, 2005b). Effect sizes (Cohens d) were calcu-
lated for within- and between-group changes, based on the pooled
standard deviation.
Two measures of clinical signicance were employed. Pre-
treatment and post-treatment GAD-7 scores were compared with
clinical cut-offs to provide an index of remission. This was dened as
the proportion of participants who initially scored above the
optimum cut-off (GAD-7 total score of 8 or more) and subsequently
scored below this cut-off, as described in Clark et al. (2009).An
estimate of recovery was made by identifying the proportion of
Table 1
Demographics characteristics of treatment and control groups, and overall sample.
Variable Treatment
group (n ¼ 40)
Control
(n ¼ 38)
Total
(n ¼ 78)
n % n % n %
Gender
Male 11 27.5 14 36.8 25 32.1
Female 29 72.5 24 63.2 53 67.9
Age
Mean age (SD) 38.6 (12.0) 40.5 (14.1) 39.5 (13.0)
Range 19e74 18e73 18e74
Marital status
Single/never married 11 27.5 15 39.5 26 33.3
Married/de facto 26 65 15 39.5 41 52.6
Separated/divorced 3 7.5 8 21 11 14.1
Education
High school 5 12.5 11 28.9 16 20.5
Tertiary 24 60 19 50 43 55.1
Other certicate 11 27.5 5 13.2 16 20.5
None 0 0 3 7.9 3 3.9
Employment status
Part time/student 20 50 18 47.4 38 48.7
Full time 13 32.5 13 34.2 26 33.3
Unemployed, retired
or disabled
7 17.5 7 18.4 14 18
Previously discussed
symptoms with health
professional
35 87.5 32 84.2 67 85.9
Taking medication 17 42.5 20 52.6 37 47.4
Hours/week of internet use
0e10 21 52.5 19 50 40 51.3
11þ 19 47.5 19 50 38 48.7
Condence using computers and internet
Very condent 26 65 26 68.4 52 66.7
Condent 9 22.5 8 21.1 17 21.8
Average 5 12.5 3 7.9 8 10.3
Mildly condent 0 0 1 2.6 1 1.2
Not condent 0 0 0 0 0 0
N. Titov et al. / Behaviour Research and Therapy 48 (2010) 890e899 893
Page 4
participants in each group who demonstrated a signicant reduc-
tion in their symptoms (dened here, as a reduction of 50% of pre-
treatment GAD-7 scores), as described in recent dissemination
studies (Richards & Suckling, 2009).
Results
Participant ow
The ow is shown in Fig. 1. Two treatment and 6 control group
participants did not complete the pre-treatment questionnaires
resulting in 40 treatment and 38 control group participants eligible
for analysis.
Baseline data
The mean age of participants was 40 years ( SD ¼ 13.0), 53 (68%)
were women, 41 (53%) were married or in a de facto relationship,
59 (76%) had post-secondary education or training, and 26 (33%)
were in full time employment. Sixty-seven (86%) participants
reported having previously talked to a health professional about
their symptoms of anxiety, and 37 (47%) reported taking medica-
tion for mood and/or anxiety. Thirty-eight (49%) participants
reported using the Internet more than 10 h per week
(mean ¼ 15.24 h, SD ¼ 11.95), and 69 (89%) reported they were
condent or very condent using computers and the Internet. No
between-group differences on demographic characteristics or pre-
treatment measures were observed using one-way ANOVAs (F
1,
76
¼ 0.00e0.71, p > 0.05) or chi-squared tests (p > 0.05), except that
the treatment group reported signicantly highly qualications
than the control group (
c
2
¼ 6.70, df ¼ 1, p < 0.01). Table 1 shows
the demographic characteristics of the treatment and control
groups, and the overall sample.
Diagnoses
At interview 18 (45.0%) treatment and 16 (42.1%) control group
participants received a primary diagnosis of GAD (43.6% of the
overall sample). Ten (25.0%) treatment and 11 (28.9%) control group
participants received a primary diagnosis of panic disorder with or
without agoraphobia (26.9% of the overall sample). Twelve (30.0%)
treatment and 11 (28.9%) control group participants received
a primary diagnosis of social phobia (29.5% of the overall sample).
Thirty-one treatment (77.5%) and 28 (73.7%) control participants
had a comorbid anxiety or depressive disorder (75.6% of the overall
sample). Chi-square tests for independence analyses revealed that
groups did not differ at pre-treatment in proportions of primary
diagnosis or type of comorbid disorder (all p > 0.05). Statistical
analyses were not conducted regarding the number of additional
diagnoses due to small number of participants with 3 or 4 comorbid
disorders; however Tables 2 and 3 indicate the proportion of
additional diagnoses is similar between groups and that comor-
bidity is high.
Treatment group results
Completion rate and numbers analyzed
Thirty (75%) treatment group participants completed the six
lessons within the eight weeks of the program. Post-treatment data
(Time 2) was collected from 38/40 (95%) treatment group partici-
pants and 38/38 (100%) control group participants. Three-month
follow-up data was collected from 32/40 (80%) treatment group
participants. In accordance with the ITT and BOCF principles, the
pre-treatment scores of participants who did not complete the
post-treatment or follow-up questionnaires were replicated as
their post-treatment or follow-up scores.
Overall primary and disorder-specic outcome measures
Univariate ANCOVAs on post-treatment GAD-7, SPSQ, and PDSS-
SR scores, controlling for pre-treatment scores revealed that the
treatment group had signicantly lower post-treatment scores than
the control group (F
1, 75
¼ 17.15, p < 0.001), (F
1, 75
¼ 5.93, p < 0.02),
(F
1, 75
¼ 8.42, p < 0.005), respectively. A univariate ANCOVA on post-
treatment PSWQ scores, controlling for pre-treatment scores (see
Tables 4 and 5), failed to reveal differences between treatment and
control group participants (F
1, 75
¼ 2.55, p < 0.11).
Overall secondary outcome measures
Univariate ANCOVAs were also conducted on the PHQ-9, SDS, K-
10, DASS-21, and NEO-FFI-N post-treatment scores, controlling for
pre-treatment scores, and revealed signicant differences between
treatment and control groups (F
1, 75
¼ 6.49, p < 0.01), (F
1, 75
¼ 10.18,
p < 0.002), (F
1, 75
¼ 9.67, p < 0.003), (F
1, 75
¼ 6.49, p < 0.01), and (F
1,
75
¼ 6.47, p < 0.01), respectively (see Table 5).
Disorder-specic outcome measures
Treatment and control group participants were then divided by
primary diagnoses (Table 4), and univariate ANCOVAs were con-
ducted on the disorder-specic measures, controlling for pre-
Table 2
Primary and secondary diagnoses at assessment (percentage).
Disorder Treatment group
(n ¼ 40)
Control group
(n ¼ 38)
Total
(n ¼ 78)
Primary diagnosis
GAD 18 (45.0%) 16 (42.1%) 34 (43.6%)
Pan/Ag 10 (25.0%) 11 (28.9%) 21 (26.9%)
SP 12 (30.0%) 11 (28.9%) 23 (29.5%)
Comorbid disorder
None 9 (22.5%) 10 (26.3%) 19 (24.4%)
Anxiety only 12 (29.3%) 10 (26.3%) 22 (28.2%)
Affective only 8 (19.5%) 8 (21.1%) 16 (20.5%)
Anxiety and affective 11 (26.8%) 10 (26.3%) 21 (26.9%)
Number of additional diagnoses
0 9 (22.5%) 10 (26.3%) 19 (24.4%)
1 14 (35.0%) 14 (36.8%) 28 (35.9%)
2 13 (32.5%) 9 (23.7%) 22 (28.2%)
3 3 (7.5%) 5 (13.2%) 8 (10.3%)
4 1 (2.5%) 0 (0.0%) 1 (1.3%)
Total additional diagnoses 40 38 78
Abbreviations: GAD, Generalized Anxiety Disorder; Pan/Ag, panic disorder with or
without agoraphobia; SP, social phobia.
Table 3
Pre-treatment diagnostic data by group.
Additional diagnosis Primary diagnosis
Treatment (n ¼ 40) Control (n ¼ 38)
GAD
(n ¼ 18)
Pan/Ag
(n ¼ 10)
SP
(n ¼ 12)
GAD
(n ¼ 16)
Pan/Ag
(n ¼ 11)
SP
(n ¼ 11)
GAD e 65e 66
Pan/Ag 6 e 12e 1
SP 9 2 e 53e
PTSD 300122
OCD 100000
MDE/DYS 9 4 6 10 4 4
Total 28 12 12 18 15 13
Abbreviations: GAD, Generalized Anxiety Disorder; Pan/Ag, panic disorder with or
without agoraphobia; SP, social phobia; PTSD, Posttraumatic Stress Disorder; OCD,
Obsessive Compulsive Disorder; MDE/DYS, Major Depressive Episode and/or
Dysthymia.
N. Titov et al. / Behaviour Research and Therapy 48 (2010) 890e899894
Page 5
treatment scores. For participants with a primary diagnosis of GAD,
no differences were found between treatment and control partici-
pants on the PSWQ (F
1, 31
¼ 0.16, p > ns). For participants with
a primary diagnosis of SP, no differences were found on the SPSQ
(F
1, 20
¼ 3.13, p > ns). For participants with a primary diagnosis of
Pan/Ag, signicant differences were found between treatment and
control participants on the PDSS-SR (F
1, 18
¼ 7.94, p < 0.01).
Effect sizes
Within- and between-group effect sizes for the outcome
measures are included in Tables 4 and 5. From pre- to post-treat-
ment, a large within-group effect size was found for the treatment
group on the GAD-7 (0.81), moderate within-group effects were
found on the DASS-21 (0.76), PDSS-SR (0.62), PSWQ (0.60), NEO-
FFI-N (0.55), SPSQ (0.54), and SDS (0.54) with small within-group
effect sizes on the K-10 (0.49) and PHQ-9 (0.45). Moderate to small
between-group effect sizes were found on the DASS-21 (0.78),
GAD-7 (0.78), SDS (0.70), NEO-FFI-N (0.50), PHQ-9 (0.49), SPSQ
(0.43), and PDSS-SR (0.43).
From pre- to 3-month follow-up, moderate within-group effect
sizes were found for the treatment group on the PSWQ (0.79), GAD-
7 (0.73), PDSS-SR (0.68), DASS-21 (0.67), SPSQ (0.64), and SDS
(0.54), with small within-group effect sizes on the NEO-FFI-N
(0.42), PHQ-9 (0.42) and K-10 (0.38).
Clinical signicance
At pre-treatment 29/40 (73%) of treatment group and 25/38
(66%) of control group participants had a GAD-7 score at or above
the clinical cut-off. At post-treatment (using the ITT and BOCF
design), 16/40 (40%) of treatment group and 3/38 (8%) of control
group participants met the criteria for remission (pre-treatment
GAD-7 score of 8 or above and a post-treatment GAD-7 score below
8). Based on the criteria for recovery (a reduction of pre-treatment
GAD-7 scores of at least 50%) at post-treatment, 16/40 (40%) of
treatment group, and 4/38 (11%) of control group participants were
classied as recovered. At follow-up (using the ITT and BOCF
design), 15/40 (38%) of treatment group participants met the
criteria for both remission and recovery.
Treatment satisfaction
Treatment group participants who completed the post-treatment
satisfaction questionnaires reported a moderate level of satisfaction
with the overall program, with 27/38(71%) reporting beingeither very
satised or mostly satised, and 11/38 (29%) neutral/somewhat satised,
with no participants rating the program as unsatisfactory. Twenty-six
participants (68%) rated the quality of the treatment modules as
excellent or good; 25/38 (66%) participants rated the quality of Internet
correspondence with the therapist as excellent or good, 11/38 (29%)
rated it as satisfactory, and 2/38 (5%) rated it as unsatisfactory.
When asked to provide a rating from 1 to 10, where 10 indicates
a high level of agreement, the average treatment group participant
rated the treatment as logical (8/10); they reported feeling
moderately condent that the treatment would be successful at
teaching them techniques for managing their symptoms (7/10);
and they reported a moderate level of condence in recommending
this treatment to a friend with anxiety (8/10).
Table 4
Results of disorder-specic outcome measures: means, standard deviations, and pooled effect sizes (Cohens d) for each group (intention to treat).
Outcome measure n Time 1 Time 2 Time 3 Effect sizes
M SD M SD M SD Within Between
Time 1
minus
Time 2
Time 1
minus
Time 3
Time 2
minus
Time 2
Time 3
minus
Time 3
PSWQ
Treatment group total 40 64.28 9.97 57.65 11.89 55.60 11.85 0.60 0.79 0.20 0.26
GAD subgroup 18 66.17 8.77 60.94 9.40 57.06 10.66 0.58 0.93
SP subgroup 12 62.17 9.04 54.33 13.35 56.83 12.10 0.69 0.50
Pan/Ag subgroup 10 63.40 13.12 55.70 13.69 51.50 13.77 0.57 0.88
Control group total 38 62.74 11.75 60.11 12.98 52.53 11.50 0.21 0.88
GAD subgroup 16 65.19 9.78 61.94 11.16 55.25 10.62 0.31 0.97
SP subgroup 11 61.09 14.67 57.27 15.97 48.18 13.43 0.25 0.92
Pan/Ag subgroup 11 60.82 11.63 60.27 12.95 52.90 10.36 0.04 0.72
SPSQ
Treatment group 40 13.78 9.80 8.78 8.73 8.23 7.50 0.54 0.64 0.43 0.08
GAD subgroup 18 12.94 8.03 8.17 8.04 5.94 4.60 0.59 1.07
SP subgroup 12 20.00 9.49 13.25 10.69 14.75 9.05 0.67 0.57
Pan/Ag subgroup 10 7.80 9.60 4.50 4.55 4.50 4.55 0.44 0.44
Control group 38 13.66 10.38 12.87 10.25 7.61 8.44 0.08 0.64
GAD subgroup 16 10.44 7.48 9.75 5.95 4.88 5.26 0.10 0.86
SP subgroup 11 18.45 9.34 18.36 11.91 10.18 9.31 0.01 0.89
Pan/Ag subgroup 11 13.55 13.62 11.91 12.01 9.00 10.67 0.13 0.37
PDSS-SR
Treatment group 40 11.03 6.64 6.88 6.79 6.50 6.77 0.62 0.68 0.43 0.09
GAD subgroup 18 8.44 6.26 6.67 7.21 4.94 6.15 0.26 0.56
SP subgroup 12 13.42 6.39 6.50 8.34 7.50 7.93 0.93 0.82
Pan/Ag subgroup 10 12.80 6.55 7.70 3.97 8.10 6.44 0.94 0.72
Control group 38 10.16 7.07 9.95 7.60 5.87 6.54 0.03 0.63
GAD subgroup 16 7.69 6.46 6.94 6.16 3.19 5.43 0.12 0.75
SP subgroup 11 8.73 7.11 9.27 8.30 5.55 6.55 0.07 0.47
Pan/Ag subgroup 11 15.18 5.67 15.00 6.72 10.09 6.32 0.03 0.85
Time 1: pre-treatment for treatment and control groups. Time 2: post-treatment for the treatment group. Time 3: 3-month follow-up for the treatment group, and post-
treatment for the control group.
PSWQ, Penn State Worry Questionnaire; SPSQ, Social Phobia Screening Questionnaire; PDSS-SR, Panic Disorder Severity Scale-Self Report.
N. Titov et al. / Behaviour Research and Therapy 48 (2010) 890e899 895
Page 6
Time spent/contact events per participant
The mean total therapist time per treatment group participant
was 46 min (SD ¼ 16 min) including monitoring of the discussion
forum, sending and reading instant messages, and telephoning
participants. An additional average 30 min per participant was
required for administrative purposes, including the diagnostic
telephone interview. During the program, treatment group partic-
ipants received a total of 765 automatic emails (mean ¼ 19.1 per
participant), with the clinician sending a mean of 4.5 additional
personal instant messages per participant. The clinician also made
a total of 215 telephone calls (mean ¼ 5 telephone calls per
participant) and made 22 forum postings to the entire group.
Control group results
Based on feedback from the treatment group therapist and
participants, the Anxiety program was revised and modied prior
to the control group beginning the program. The main modication
involved exchanging the order of Lesson 2, which is concerned with
controlling physical symptoms and lifestyle factors, with that of
Lesson 3, which describes basic principles of cognitive therapy.
Completion rate and numbers analyzed
Thirty-six control group participants commenced the active
treatment phase of the Anxiety program. Of these participants, 29
(80.6%) participants completed the six lessons within the eight
weeks of the program. Post-treatment data (Time 3) was collected
from 33/36 (92%) control group participants. In accordance with the
ITT and BOCF paradigm, the pre-treatment scores of participants
who did not complete the post-treatment questionnaires were
replicated as their post-treatment scores.
Change in outcome measures
Paired samples t-tests revealed that the control group had signif-
icantly lower scores at Time 3 (i.e., post-treatment) compared with at
Time 1 on all measures (GAD-7, DASS-21, PHQ-9, PSWQ, SPSQ, PDSS-
SR, NEO-FFI-N, SDS, K-10) (t(37) ¼ 3.18e6.85, p < 0.001e0.003).
Effect sizes
Comparing control group results at post-treatment (Time 3)
with their pre-treatment scores (Time 1) revealed large within-
group effect sizes on the GAD-7 (0.97), DASS-21 (0.96), and PSWQ
(0.88), while moderate within-group effects were found on the SDS
(0.73), NEO-FFI-N (0.66), PDSS-SR (0.63), PHQ-9 (0.65), SPSQ (0.64),
and K-10 (0.51) (see Tables 4 and 5).
Treatment satisfaction
Control group participants who completed the post-treatment
satisfaction questionnaires reported a high level of satisfaction with
the overall program, with 31/33 (94%) reporting being either very
satised or mostly satised, and 2/33 (6%) neutral/somewhat satised.
Twenty-nine participants (88%) rated the quality of the treatment
modules as excellent or good; 29/33 (88%) rated the quality of
Internet correspondence with the therapist as excellent or good, and
4/33 (12%) rated it as satisfactory.
When asked to provide a rating from 1 to 10, where 10 indicates
a high level of agreement, the average control participant rated the
treatment as logical (9/10); they reported feeling con
dent that the
trea
tment would be successful at teaching them techniques for
managing their symptoms (9/10); and they reported condence in
recommending this treatment to a friend with anxiety (9/10).
Time spent/contact events per participant
The mean total therapist time per control group participant was
48 min (SD ¼ 21 min) including the monitoring of the discussion
forum, instant messages, and telephone calls. An additional average
30 min per participant was required for administrative purposes,
including the diagnostic telephone interview. During the program,
the control group participants received a total of 700 automatic
emails (mean ¼ 19.4 per participant), with the clinician sending
Table 5
Results of primary and secondary outcome measures: means, standard deviations, and pooled effect sizes (Cohens d) for each group (intention to treat).
Outcome
measure
n Time 1 Time 2 Time 3 Effect sizes
M SD M SD M SD Within Between
Time 1
minus
Time 2
Time 1
minus
Time 3
Time 2
minus
Time 2
Time 3
minus
Time 3
GAD-7
Treatment 40 11.33 4.98 7.43 4.70 7.75 4.83 0.81 0.73 0.78 0.33
Control 38 11.34 5.48 11.42 5.55 6.08 5.42 0.01 0.97
PHQ-9
Treatment 40 10.77 5.20 8.28 5.90 8.43 6.03 0.45 0.42 0.49 0.27
Control 38 10.84 6.26 11.47 6.99 6.76 6.25 0.09 0.65
SDS
Treatment 40 14.45 6.94 10.48 7.69 10.40 8.07 0.54 0.54 0.70 0.08
Control 38 15.87 7.94 16.42 9.14 9.71 8.83 0.09 0.73
K-10
Treatment 40 27.78 8.18 23.70 8.39 24.55 8.98 0.49 0.38 0.41 0.25
Control 38 26.87 8.86 27.45 9.76 22.32 9.00 0.06 0.51
DASS-21
Treatment 40 51.65 25.93 33.15 22.69 34.05 26.82 0.76 0.67 0.78 0.29
Control 38 52.00 27.27 53.42 28.78 26.58 25.51 0.05 0.96
NEO-FFI-N
Treatment 40 32.65 7.45 28.40 7.86 29.18 9.16 0.55 0.42 0.50 0.14
Control 38 34.16 9.33 32.74 9.51 27.82 9.90 0.15 0.66
Time 1: pre-treatment for treatment and control groups. Time 2: post-treatment for the treatment group. Time 3: 3-month follow-up for the treatment group, and post-
treatment for the control group.
GAD-7, Generalized Anxiety Disorder e 7-Item Scale; PHQ-9, Patient Health Questionnaire e 9 Item; SDS, Sheehan Disability Scale; K-10, Kessler-10 Item; DASS-21,
Depression Anxiety and Stress Scale e 21 Item; NEO-FFI-N, NEO-Five Factor Inventory Neuroticism Subscale.
N. Titov et al. / Behaviour Research and Therapy 48 (2010) 890e899896
Page 7
a mean of 4.8 additional personal instant messaging messages per
participant. The clinician also made a total of 150 telephone calls
(mean ¼ 4 telephone calls per participant) and made 27 forum
postings to the entire group.
Discussion
This trial examined the efcacy of the Anxiety program, a clini-
cian-assisted transdiagnostic iCBT program for anxiety disorders.
At intake all participants met DSM-IV diagnosis for GAD, social
phobia, or panic disorder, and 72% met criteria for at least one
additional disorder.
Overall outcomes for the treatment group were superior to the
control group on all primary and disorder-specic outcome
measures, except the PSWQ. Consistent with this, the within-
groups ESs for the treatment group on the primary outcome
measure (GAD-7) and the disorder-specic measures (SPSQ, PDSS-
SR, PSWQ) ranged from large (GAD-7, ES ¼ 0.81) to moderate (SPSQ,
ES ¼ 0.54). Compared to the control group, improvements were
also observed on measures of disability and depression, and on the
two measures of higher-order risk factors (DASS-21, NEO-FFI-N),
indicating generalized benets, and a reduction in risk factors for
anxiety or depression. At post-treatment 40% of participants in the
treatment group were classied as in remission compared to 8% of
controls, while 40% of participants in the treatment group were
classied as recovered compared to 11% of controls. Furthermore,
consistent with the third hypothesis, the treatment group reported
moderate levels of satisfaction with the program and therapist
contact, and gains were maintained at 3-month follow-up. These
overall results indicate the program appears efcacious and
acceptable and the magnitude of improvements reported here, is
broadly consistent with those reported in recent meta-analyses of
face-to-face transdiagnostic anxiety programs (McEvoy et al., 2009;
Norton & Price, 2007), and disorder-specic computerized CBT
programs for anxiety (Cuijpers et al., 2009).
However, not all results were as expected: The second hypoth-
esis, that treatment group participants would show signicant
improvements on the disorder-specic measures relevant to their
primary diagnosis, was only partially supported. Signicant
differences at post-treatment between treatment and control
group participants were found only for participants with a primary
diagnosis of panic disorder on the PDSS-SR. Relative to controls, at
post-treatment, treatment group participants with a primary
diagnosis of social phobia did not report a signicant reduction in
their SPSQ scores, and participants with a primary diagnosis of GAD
did not report a signicant reduction in post-treatment PSWQ
scores relative to controls. These disorder-specic results indicate
that the Anxiety program may not be as efcacious as disorder-
specic iCBT programs, with similar ndings reported elsewhere.
For example, a program aiming to treat panic disorder and the most
severe comorbid condition was reported as less efcacious than
a similar program treating panic disorder alone (Craske et al.,
20 07). Likewise, a recent study of iCBT for people with a primary
diagnosis of GAD reported a within-group effect size on the PSWQ
of 1.0, considerably larger than reported here (Robinson et al., in
press
). Importantly, the same therapist (ER) was employed in
bo
th studies, indicating that therapist variables are unlikely to
account for the differences.
Based on post-treatment feedback from the therapist and
participants of the treatment group, the Anxiety program was
revised before the control group started. On the primary measure
(GAD-7) the control group obtained a within-group almost ES 0.2
larger than those obtained by the treatment group. Importantly,
control group participants with a primary diagnosis of GAD
obtained a within-groups ES on the PSWQ of 0.97, considerably
larger than those in the treatment group (0.60) and consistent with
those observed in previous iCBT disorder-specic programs for GAD
(Robinson, et al., in press; Titov, Andrews, Robinson, et al., 2009),
with improvements also seen on the SPSQ but not on the PDSS-SR.
Furthermore, while only 71% of treatment group participants rated
their satisfaction with the program as either very or mostly satised,
94% of control group participants gave these ratings. Importantly,
the total amount of time required the therapist of the treatment
group per participant (46 min) was approximately the same as that
by the therapist in the control group (48 min).
Although the post-treatment results of the control group need
to be interpreted with caution, they provide some evidence that
careful attention should be spent on the design of transdiagnostic
interventions. In this example, changes to the order of content
appeared to considerably improve the acceptability and outcomes
for the control group, but the mechanisms accounting for these
improvements are unclear. Our therapists reported that changing
the order of the content for the control group provided those
participants with more engaging content earlier in the program,
which sustained their motivation and enthusiasm for participating,
hence the higher completion rates and improved outcomes.
Although these are speculative comments, they indicate that clin-
ical skill and careful evaluation is required in the design and staging
of therapeutic content for iCBT programs.
Limitations
The practical and methodological limitations of the present
study are relevant to other studies in the emerging eld of trans-
diagnostic treatment. For example, while the sample size selected
for this study was sufcient to detect overall differences between
groups, it is insufcient to detect differences when secondary
analyses are conducted based on primary diagnosis. The sample
sizes required for secondary analyses are considerable and prob-
ably unrealistic for most research teams, unless trial results were
pooled together or studies treated one disorder at a time.
A second important limitation is the statistical and practical
challenges of managing comorbidity. As indicated earlier, 72% of
participants in this study met DSM-IV criteria for at least one other
anxiety disorder or depression. Thus, analysis by primary diagnosis
could be contaminated by the secondary or tertiary diagnoses,
adding to the difculty already present with small sample sizes. A
third critical limitation concerns the choice of general and disorder-
specic measures. Currently there is no consensus about the most
appropriate outcome measures, and the temptation to add addi-
tional measures must be balanced with the risk of reducing
adherence and completion by participants. We have attempted to
include a wide range of measures, with details reported in Tables 4
and 5, to assist readers in interpreting these results. A related
limitation is the relatively small dose of therapeutic content (6
lessons) and clinician contact (under 1 h per participant) provided
during this program. Limited exposure to therapeutic materials
may have limited the magnitude of clinical gains, which must be
balanced with the risk of overwhelming participants with excessive
content and clinician contact, as discussed by Erickson, Janeck, and
Tallman (2007). To address some of these limitations, a second RCT
using the Anxiety program is underway, with a larger sample,
comprising additional lessons and providing participants with
more time to complete the program.
Conclusions
To our knowledge, this is the rst attempt at providing Internet-
based transdiagnostic treatment for anxiety disorders. This
preliminary randomized controlled trial revealed overall outcomes
N. Titov et al. / Behaviour Research and Therapy 48 (2010) 890e899 897
Page 8
for the treatment group to be superior to a waitlist control condi-
tion. Outcomes by primary diagnosis appeared lower than those
obtained in disorder-specic programs. However, modications to
the Anxiety program based on feedback from the treatment group
appeared to result in improved outcomes for the control group on
the primary outcome measure and across all disorder-specic
measures, with improvements comparable to diagnosis-specic
studies. Replication of this effect is required, and further studies
need to explore questions about the optimum amount and nature
of the content of transdiagnostic programs, the amount and type of
clinician contact, to compare different clinical outcome measures,
and to explore statistical strategies for evaluating the role of
comorbidity. Direct comparisons between transdiagnostic and
disorder-specic programs are required to determine the relative
benets of these approaches.
Anxiety disorders are frequently comorbid, chronic and
disabling. Transdiagnostic treatment programs that can concur-
rently treat more than one disorder are desirable, as are treatment
modalities that can reduce barriers to treatment.
Acknowledgements
The authors gratefully acknowledge the participants for their
involvement and helpful comments, and the Australian Rotary
Health Research Fund and the New South Wales Institute of
Psychiatry for contributing to the funding of this study. We also
wish to gratefully acknowledge the contributions to the develop-
ment of the VirtualClinic program by Mr Jason Hando, and Mr
Daniel Winter.
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    • "Because half of all lifetime cases of mental disorders start by age 14 years and the median age of onset for anxiety is 11 years [1] , it should be mentioned that ICBT shows promising results not just for adults, but also for treating anxiety and depression in youth [23, 24]. Anxiety disorders seem to be one of the most approachable and treatable types of mental disorder through online therapy25262728293031. Panic disorder (PD) with or without agoraphobia is one of the conditions for which ICBT programs have been developed since the late 1990s and there are several empirical studies supporting their efficacy and effectiveness [13, 17, 19,3233343536373839404142. In Romania, only one internet-based treatment has been tested so far, the Swedish program Sofie [43]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Efficacy of self-help internet-based cognitive behavior therapy (ICBT) for anxiety disorders has been confirmed in several randomized controlled trials. However, the amount and type of therapist guidance needed in ICBT are still under debate. Previous studies have shown divergent results regarding the role of therapist guidance and its impact on treatment outcome. This issue is central to the development of ICBT programs and needs to be addressed directly. The present study aims to compare the benefits of regular therapist guidance via online real-time audio-video communication (i.e. Skype) to no therapist guidance during a 12-week Romanian self-help ICBT program for Panic Disorder. Both treatments are compared to a waiting-list control group. Methods/Design A parallel group randomized controlled trial is proposed. The participants, 192 Romanian adults fulfilling diagnostic criteria for panic disorder according to a diagnostic interview, conducted via secured Skype or telephone, are randomly assigned to one of the three conditions: independent use of the internet-based self-help program PAXonline, the same self-help treatment with regular therapist support via secured Skype, and waiting-list control group. The primary outcomes are severity of self-report panic symptoms (PDSS-SR) and diagnostic status (assessors are blind to group assignment), at the end of the intervention (12 weeks) and at follow-up (months 3 and 6). The secondary measures address symptoms of comorbid anxiety disorders, depression, quality of life, adherence and satisfaction with ICBT. Additional measures of socio-demographic characteristics, personality traits, treatment expectancies, catastrophic cognitions, body vigilance and working alliance are considered as potential moderators and/ or mediators of treatment outcome. Discussion To the best of our knowledge, the present study is the first effort to investigate the efficacy of a self-help internet-based intervention with therapist guidance via real-time video communication. A direct comparison between therapist guided versus unguided self-directed intervention for panic disorder will also be addressed for the first time. Findings from this study will inform researchers and practitioners about the added value of online video-therapy guidance sessions and the type of patients who may benefit the most from guided and unguided ICBT for Panic disorder. Trial registration ACTRN12614000547 640 (Australian New Zealand Clinical Trials Registry). Registered 22/05/2014.
    Full-text · Article · Dec 2016 · BMC Psychiatry
    • "Meta-analyses on Internet interventions for anxiety disorders mostly yield moderate to large effect sizes (Andersson & Hedman, 2013; Griffiths, Farrer, & Christensen, 2010; Saddichha, Al-Desouki, Lamia, Linden, & Krausz, 2014). Transdiagnostic iCBT programs for various anxiety disorders (Johnston, Titov, Andrews, Spence, & Dear, 2011; Titov, Andrews, Johnston, Robinson, & Spence, 2010) and comorbid depression (Titov et al., 2011, Titov, Dear, Staples, & Bennett-Levy, et al., 2015, Titov, Dear, Staples, & Terides, et al., 2015) show promising results. Recent studies in the field of Internet interventions may further suggest that transdiagnostic approaches have similar effects to disorder-specific approaches (Berger et al., 2014; Dear et al., 2015; Fogliati et al., 2015), but more research is needed. "
    [Show abstract] [Hide abstract] ABSTRACT: Many individuals with anxiety disorders do not receive professional treatment. Internet interventions have shown to be effective in the treatment of anxiety. The present randomized controlled trial was designed to examine the effectiveness of a short-term (4-week) Internet intervention in treating panic disorder, agoraphobia, social anxiety disorder, and specific phobias (‘ConfID’). We addressed the questions of whether this transdiagnostic program would affect these disorders to varying degrees and whether there would be moderators of effectiveness. Adults who were recruited in online forums for anxiety underwent an online baseline assessment (N = 179) and were randomized either to the intervention group (ConfID) or the control group (care as usual). Online post-assessment took place 4 weeks later. The primary outcome was assessed with the Beck Anxiety Inventory (BAI); the secondary outcomes targeted the disorder-specific symptoms, depression, and somatization. Participants in the intervention group showed a significantly stronger anxiety reduction compared to participants receiving care as usual (small-to-medium effect size between groups in intention-to-treat analysis). The treatment effect was similar for the different disorders and was moderated by participants’ attitudes towards Internet interventions. Secondary outcomes yielded effect sizes in the medium range. Limitations: Moderate treatment adherence, lack of measures beyond online self-reports, and unavailability of long-term results. The study provides further evidence that transdiagnostic Internet interventions are promising in reducing the existing treatment gap in individuals with panic disorder and phobias. Results extend previous findings by showing that significant effects can also be reached by comprehensive short-term programs and that the effects might be moderated by participants’ attitudes towards Internet interventions.
    No preview · Article · May 2016 · Journal of Behavior Therapy and Experimental Psychiatry
    • "Moreover, the present study demonstrates that low-threshold interventions, such as psychoeducation and a (meta-)cognitive self-help manual, are not able to substitute psychotherapy but could act as an important complementary tool in the framework of comprehensive (e.g., stepped-care) treatment programs for OCD. In fact, there is accumulating evidence of generally positive attitudes towards self-help both from patients (e.g., Carlbring, Bohman et al., 2006, Carlbring, Nilsson-Ihrfelt et al., 2006 Titov, Andrews, Johnston, Robinson, & Spence, 2010) as well as from mental health practitioners (e.g., MacLeod, Martinez, & Williams, 2009; Nordgreen et al., 2012 ). It has been shown that a greater understanding of OCD and the potential gravity of the disorder may enhance treatment seeking in this under-treated group (Belloch, Valle, Morillo, Carrió, & Cabedo, 2009; Levy, McLean, Yadin, & Foa, 2013). "
    [Show abstract] [Hide abstract] ABSTRACT: Effective treatment strategies exist for obsessive-compulsive disorder (OCD), however, many individuals do not receive professional help. Media-delivered self-help is increasingly sought to narrow the treatment gap. Previous studies included personal contact with a clinician, making it difficult to delineate the specific effect of the medium. We developed "myMCT" for OCD, a (meta-)cognitive manual for self-application. We conducted a randomized-controlled trial with 128 OCD participants receiving myMCT versus psychoeducation, adopting low-threshold recruitment approaches without any face-to-face contact. Diagnoses were verified with telephone interviews paralleling online surveys at pre, post (4 weeks) and follow-up (6 months). Participants benefited significantly from both interventions. MyMCT showed stronger reduction of OCD symptoms on Y-BOCS total score (p=.023, η2partial=.04), obsessions (p=.002, η2partial=.07), depression (BDI: p=.022, η2partial=.04), and cognitive biases (OBQ: p=.016, η2partial=.05) after 4 weeks. After 6 months, individuals with myMCT showed decreased levels of cognitive biases (OBQ). The current study provides further evidence that myMCT is a promising approach to target OCD-related psychopathology as mere self-help. Although effect sizes were below those usually found in (therapist-)guided self-help, myMCT could be of value for the large subgroup of individuals without treatment.
    Full-text · Article · Apr 2016 · Journal of Obsessive-Compulsive and Related Disorders
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