Elizabeth Mason’s research while affiliated with St. Vincent's Hospital and other places

Insomnia is a highly prevalent sleep disorder, which has negative consequences on almost all aspects of physical and psychological health. The gold-standard treatment for insomnia disorder is cognitive behavioral therapy for insomnia (CBT-I). While CBT-I is efficacious, access to this therapy is limited. Digital forms of therapy for insomnia, including CBT-I and mindfulness-based therapy for insomnia are emerging, with growing evidence of their efficacy for reducing insomnia severity and other symptoms of the disorder (e.g., pre-sleep arousal) and improving mental health. This chapter describes the evidence for the effectiveness of these therapies, as well as factors that may influence response to treatment. The role of digital therapies for insomnia in stepped-care models is also discussed. Ultimately, digital therapeutics for insomnia will help address the poor sleep endemic faced by modern society, with potential positive flow-on effects for other aspects of health and well-being.

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.

Objectives: A key feature of blood-injection-injury (BII) phobia is activation of disgust responses, in addition to fear. Yet, standard treatments have largely neglected addressing disgust responses. The disorder is further complicated by fainting in 75% of sufferers. Moreover, treatments have been traditionally delivered in an individual format, which may not be as efficient as group treatment. The aim of this study was to develop a group-based programme for BII phobia, with components targeting fear, disgust, and fainting, to determine feasibility and effectiveness of such an intervention. Methods: Participants took part in an 8-session, group-based Cognitive Behavioural Therapy (CBT) programme for BII phobia (N = 40). The key outcome measure was the Multidimensional Blood/Injury Phobia Inventory, which assesses a range of phobic stimuli and responses (including fear, disgust, and fainting). Results: There were significant improvements, with large effect sizes, across symptoms over the course of treatment. Participants with higher disgust sensitivity reported higher pre-treatment symptom severity and greater life interference than those with lower disgust scores. Despite this, neither pre-treatment disgust sensitivity nor fainting history impacted on treatment response. For the first time, however, we showed that greater reductions in disgust to BII stimuli were associated with greater overall symptom reductions, highlighting the importance of disgust in the treatment of this disorder, and potentially others. Conclusion: Despite the heterogeneous nature of BII phobia, this group-based, modified CBT intervention was effective in reducing a variety of phobic responses, including fear, disgust, and fainting. Practitioner points: Disgust is a key maintaining factor in blood-injection-injury phobia, which clinicians should consider in their assessment and treatment of this disorder. There is little in the existing literature to guide clinicians in this regard. This study examined a novel group treatment for blood-injection-injury phobia which included strategies to target disgust, in addition to traditional CBT strategies to address fear and fainting. The treatment was feasible and acceptable. Symptoms of fear, disgust, and fainting reduced significantly over treatment. Changes in disgust symptoms were associated with overall symptom changes, however a control group is needed to determine the effects of individual treatment components and to make more robust conclusions about the benefits of this enhanced approach.

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.

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.

Little is known about the prevalence and impact on treatment of comorbid personality disorders for adults undertaking online cognitive behaviour therapy (internet-delivered or internet-based cognitive behaviour therapy (iCBT)) for anxiety and depressive disorders. This study explored how common comorbid personality difficulties were in a large sample of consecutive patients (N = 1 132) seeking iCBT for their symptoms of anxiety and depression in routine care settings. Patients completed the Standardized Assessment of Personality-abbreviated Scale Self-Report prior to commencing an iCBT programme, as well as completing assessments of anxiety and depression symptom severity and psychological distress pre-iCBT and post-iCBT. Consistent with previous studies, a high proportion of the sample (62.6%) reported experiencing comorbid personality difficulties. However, comorbid personality difficulties were not significantly associated with poorer treatment adherence or higher post-treatment symptom severity or psychological distress (controlling for baseline symptom severity, demographic characteristics and treatment variables). Current findings support an inclusive approach to iCBT provision where comorbid personality difficulties do not appear to be a contraindication for treatment. © 2021 John Wiley & Sons, Ltd.

Introduction: Randomised controlled trials have shown that internet-delivered cognitive behavioural treatment (iCBT) is an effective treatment for health anxiety, but the effectiveness of these programs in routine care has not been investigated. This study examined the effectiveness of iCBT for health anxiety symptoms in routine care settings in the community. Methods: Using an open-trial design, we investigated adherence to, and effectiveness of a 6-lesson iCBT program for health anxiety symptoms amongst individuals (n = 391, mean age 41 years, 64% female) who enrolled in the program either self-guided (n = 312) or under the supervision of community clinicians (general practitioners, psychologists and other allied health professionals) (n = 79). Primary outcome was health anxiety severity on the Short Health Anxiety Inventory (SHAI), and secondary outcomes were depression severity on the Patient Health Questionnaire 9-item (PHQ-9) (depression) and distress (Kessler-10: K-10). Results: Adherence to the iCBT program was modest (45.6% in the clinician-supervised group, 33.0% in the unguided group), but within-subjects effect sizes were large (SHAI: g = 1.66, 95%CI: 1.45-1.88; PHQ-9: g = 1.12, 95%CI: 0.92-1.32; K-10: g = 1.35, 95%CI: 1.15-1.56). Limitations: No control group, lack of follow-up data. Conclusions: iCBT is an effective treatment for health anxiety symptoms in routine care, but methods to increase adherence are needed to optimise benefits to participants. Randomised controlled effectiveness trials with long-term follow-up are needed.

Objective: To examine the efficacy of an Internet-delivered cognitive-behavioral therapy (iCBT) program for health anxiety compared to an active psychoeducation control group. Method: Individuals (N = 86, mean age: 30 years, 87% female) with a Diagnostic and Statistical Manual of Mental Disorders (5th ed.) diagnosis of illness anxiety disorder or somatic symptom disorder with health anxiety were randomized to either a 6-lesson clinician-guided iCBT program for health anxiety (n = 45) or an active control group who received anxiety psychoeducation, clinical support, and monitoring (control, n = 41) over a 12-week period. Results: Both groups experienced significant improvements between baseline and posttreatment on self-report measures of health anxiety, depression, general anxiety, and functional impairment. Intention-to-treat analyses indicated that the iCBT group experienced greater improvements in health anxiety on the Short Health Anxiety Inventory (SHAI) compared to controls (between-groups effect size = 1.39, 95% confidence interval [0.87, 1.93]), and a greater proportion of the iCBT group showed clinically reliable change on the SHAI (84% vs. 34% in the control group). Similarly, the iCBT group outperformed the control group on secondary measures of depression, generalized anxiety, functional impairment, maladaptive cognitions, body hypervigilance, safety behaviors and avoidance, and intolerance of uncertainty. Gains were maintained at 3-month follow-up in the iCBT group. Conclusion: iCBT for health anxiety is more effective than psychoeducation, clinical support, and monitoring, and presents an efficacious and accessible treatment option for people with health anxiety. (PsycINFO Database Record

Clinician-guided internet-delivered cognitive behavioral therapy (iCBT) is an effective treatment for depression and anxiety disorders. However, few studies have examined the effectiveness of completely unguided iCBT. The current research investigated adherence to, and the effects of two brief unguided iCBT programs on depression and anxiety symptom severity, and psychological distress. Study 1 evaluated a four-lesson transdiagnostic iCBT program for anxiety and depression (N = 927). Study 2 then evaluated a three-lesson version of the same program (N = 5107) in order to determine whether reducing the duration of treatment would influence adherence and treatment effects. Cross-tabulations and independent t-tests were used to examine the extent to which users adhered and remitted with treatment. Linear mixed models were used to evaluate the effects of treatment in the entire sample, and stratified by gender and completer-type (e.g., users who completed some but not all lessons vs. those who completed all lessons of treatment). Among those who began treatment, 13.83% completed all four lessons in Study 1. Shortening the course to three lessons did not improve adherence (e.g., 13.11% in Study 2). In both studies, users, on average, experienced moderate to large effect size reductions in anxiety and depressive symptom severity, as well as psychological distress. This pattern of results was robust across gender and for those who did and did not complete treatment. Approximately two-thirds of those who completed treatment experienced remission. These data show that unguided iCBT programs, which have the capacity to attract large numbers of individuals with clinically significant symptoms of depression and anxiety, and psychological distress, can produce significant improvements in wellbeing.