Mindfulness-enhanced internet-based cognitive behavioural therapy for anxiety and depression: Outcomes in routine care.

BACKGROUND: Clinical trials support the efficacy of mindfulness-enhanced, internet-based cognitive behavioural therapies (CBT) in reducing anxiety and depression symptom severity. However, it is unclear how effective these interventions are when delivered in routine clinical care settings. This study investigated the utilisation and treatment outcomes of an online mindfulness-enhanced CBT program in the general Australian community. METHODS: Over a one-year study period, 2187 adults commenced the online mindfulness-enhanced CBT program. The program consisted of six sequential lessons to be completed within 90 days. Participants (mean age= 39 ± 14 years, 68 % female) completed measures of symptom severity for anxiety, depression, and psychological distress at pre-, mid- and post-treatment. Treatment effects were assessed via intention-to-treat linear mixed models with Hedges' g effect size calculations. RESULTS: From pre- to post-treatment, the mindfulness-enhanced CBT program was associated with medium and large effect sized reductions in generalised anxiety symptom severity (g = 0.80, 95%CI: 0.74-0.86), depression symptom severity (g = 0.74, 95%CI: 0.68-0.80), and psychological distress (g = 0.97, 95%CI: 0.90-1.03). Program adherence was modest with approximately 30 % of participants completing all six lessons of the program. LIMITATIONS: This study is limited by its lack of a comparator condition, longer-term follow-up, and assessment of the reasons for participant non-adherence. The relative acceptability and effectiveness of mindfulness versus CBT components was not examined. CONCLUSION: This study supports the effectiveness of mindfulness-enhanced iCBT for symptoms of anxiety and depression when delivered in a routine care setting under the supervision of community health care practitioners.

Managing Rumination and worry: A randomised controlled trial of an internet intervention targeting repetitive negative thinking delivered with and without clinician guidance.

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.

Online cognitive behaviour therapy for maternal antenatal and postnatal anxiety and depression in routine care.

BACKGROUND: Perinatal depression and anxiety are associated with significant adverse effects for the mother and child. Online cognitive behavioural therapy (iCBT) can provide scalable access to psychological interventions to improve perinatal depression and anxiety, however, few studies have examined the effectiveness of these interventions in routine care. This study investigated the uptake and treatment outcomes of women living in the Australian community who enrolled in a pregnancy or postnatal iCBT program for their symptoms of depression and anxiety. METHODS: 1502 women commenced iCBT (529 pregnancy and 973 postnatal) and completed measures of anxiety and depression symptom severity, and psychological distress pre- and post-treatment. RESULTS: 35.0 % of women in the pregnancy program and 41.6 % in the postnatal program completed all 3 lessons, with lower pre-treatment depression symptom severity significantly associated with increased likelihood of perinatal program completion. Both iCBT programs were associated with medium pre- to post-treatment effect size reductions in generalised anxiety symptom severity (gs = 0.63 and 0.71), depression symptom severity (gs = 0.58 and 0.64), and psychological distress (gs = 0.52 and 0.60). LIMITATIONS: Lack of control group and long-term follow-up, as well as detailed information on nature of the sample (e.g., health status, relationship status). Additionally, the sample was limited to Australian residents. CONCLUSION: iCBT for perinatal anxiety and depression was associated with significant symptom improvement. Current findings support the use of iCBT in perinatal populations and its integration within routine healthcare provision.

Co-occurring insomnia and anxiety: a randomized controlled trial of internet cognitive behavioral therapy for insomnia versus internet cognitive behavioral therapy for anxiety.

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 cognitive behavioral therapy (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 cutoff on the insomnia severity index (ISI) and the generalized anxiety disorder 7-item scale (GAD-7)) were randomized to receive internet-based cognitive behavioral therapy (iCBT) for insomnia or iCBT for anxiety. The primary outcome measures were the ISI 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. TRIAL REGISTRATION: The trial was registered with the Australian and New Zealand Clinical Trials Registry, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001141235. Trial ID: ACTRN12618001141235. Trial name: a comparison of internet-based CBT for insomnia versus internet-based CBT for anxiety in a comorbid sample.

Internet-delivered cognitive behaviour therapy for post-traumatic stress disorder: a randomised controlled trial and outcomes in routine care.

BACKGROUND: Despite its potential scalability, little is known about the outcomes of internet-based cognitive behaviour therapy (iCBT) for post-traumatic stress disorder (PTSD) when it is provided with minimal guidance from a clinician. AIM: To evaluate the outcomes of minimally guided iCBT for PTSD in a randomised control trial (RCT, Study 1) and in an open trial in routine community care (Study 2). METHOD: A RCT compared the iCBT course (n=21) to a waitlist control (WLC, n=19) among participants diagnosed with PTSD. The iCBT group was followed up 3 months post-treatment. In Study 2, treatment outcomes were evaluated among 117 adults in routine community care. PTSD symptom severity was the primary outcome in both studies, with psychological distress and co-morbid anxiety and depressive symptoms providing secondary outcomes. RESULTS: iCBT participants in both studies experienced significant reductions in PTSD symptom severity from pre- to post-treatment treatment (within-group Hedges' g=.72-1.02), with RCT findings showing maintenance of gains at 3-month follow-up. The WLC group in the RCT also significantly improved, but Study 1 was under-powered and the medium between-group effect favouring iCBT did not reach significance (g=0.64; 95% CI, -0.10-1.38). CONCLUSIONS: This research provides preliminary support for the utility of iCBT for PTSD when provided with minimal clinician guidance. Future studies are needed to clarify the effect of differing levels of clinician support on PTSD iCBT outcomes, as well as exploring how best to integrate iCBT into large-scale, routine clinical care of PTSD.

Understanding the experience of rumination and worry: A descriptive qualitative survey study.

OBJECTIVES: Rumination and worry have been implicated in the onset, severity, maintenance and relapse risk of depression and anxiety disorders. Despite this, little research has examined individuals' personal experiences of these processes. This study investigates how individuals experience these processes, which will provide insight into these common features of mental disorders and inform the development of an online intervention specifically targeting rumination and worry. DESIGN: An online qualitative survey was conducted to gain insight into people's personal definitions, experiences with and understandings of rumination and worry. METHODS: Participants answered open- and close-ended questions about their personal understanding of rumination and worry, typical thought content, triggers, frequency, duration and coping strategies. Participant responses were coded into themes. Participants also completed self-report questionnaires of depression, anxiety and stress and repetitive negative thinking. RESULTS: Two hundred and seven adults completed the online survey (76% female; mean age = 28.2 years, range = 17-71), 51% of whom reported previously experiencing depression and anxiety. All participants were familiar with the concept of worry, whereas 28% of participants indicated they had never heard of rumination. Participants reported most commonly ruminating and/or worrying about personal relationships, past mistakes, negative experiences and conversations/social interactions. The most commonly reported triggers for rumination and/or worry were social situations/interpersonal interactions (25%) and negative events/experiences (24%). Distraction was the most common coping strategy (48%); however, 21% reported being unable to stop themselves from ruminating and/or worrying. CONCLUSIONS: The results provide a unique insight into the personal experiences and understandings of rumination and worry of potential end users of treatment programs targeting these processes.

The uptake and outcomes of Internet-based cognitive behavioural therapy for health anxiety symptoms during the COVID-19 pandemic.

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 2019-11 th 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.

A pilot study of intensive 7-day internet-based cognitive behavioral therapy for social anxiety disorder.

Accessible, affordable cognitive behavioral 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 randomized 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.

Internet-delivered exposure therapy versus internet-delivered cognitive behavioral therapy for panic disorder: A pilot randomized controlled trial.

AIM: To compare the efficacy and acceptability of internet-delivered exposure therapy for panic disorder, to multi-component internet-delivered cognitive behavioral therapy (iCBT) that included controlled breathing, cognitive restructuring and exposure. METHODS: Participants with panic disorder, with or without agoraphobia, were randomized to internet-delivered exposure therapy (n = 35) or iCBT (n = 34). Both programs were clinician guided, with six lessons delivered over eight weeks. Outcomes included panic disorder and agoraphobia symptom severity, as well as depression symptom severity, functional impairment and days out of role. RESULTS: Participants in both conditions displayed a large reduction in panic disorder symptom severity (ds >1.30) from pre- to post-treatment. Participants in both conditions displayed medium to large reduction in agoraphobia and depression symptom severity, functional impairment and days out of role. Effects were maintained at three- and six-month follow-up. There was no significant difference between the interventions in clinical outcomes, adherence or treatment satisfaction. CONCLUSIONS: Internet-delivered exposure therapy appeared to be as acceptable and efficacious as more established iCBT, despite including less strategies. However, a fully powered replication is now needed to compare the two approaches.

Commentary on: Understanding Breast Implant Illness.

BACKGROUND: Breast implant surgery is the most common plastic surgery procedure performed globally. A subset of women with breast implants report experiencing a myriad of disabling and distressing physical and psychological symptoms attributed to their implants. Social media groups have coined the condition "breast implant illness" (BII). Little to no scientific research currently exists for BII. OBJECTIVES: The aim of this study was to investigate the experiences of women with BII (both those with implants still in place and those who have explanted) and compare them with those of a control group of women with implants who do not report BII. METHODS: Women with self-reported BII and implants still in place (n = 51), self-reported BII who had explanted (n = 60), and women with implants in place without BII (n = 58) completed online self-report questionnaires about their symptoms, physical and mental health, health service use patterns, and lifestyle factors (eg, exercise, smoking, alcohol consumption). RESULTS: Women with BII, regardless of whether they had undergone explant surgery, reported experiencing more severe somatic symptoms, higher depression, anxiety and health anxiety, and poorer physical health than women without BII. CONCLUSIONS: These findings highlight the need for further investigation into the causes, risk factors, long-term effects, and potential interventions for women who experience BII.

Intensive one-week internet-delivered cognitive behavioral therapy for panic disorder and agoraphobia: A pilot study.

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.

A randomised controlled trial of computerised interpretation bias modification for health anxiety.

BACKGROUND AND OBJECTIVES: Health anxiety is characterised by a tendency to interpret benign bodily sensations as a sign of serious illness. This study aimed to examine whether computerised cognitive bias modification (CBM-I) training to facilitate benign interpretations of bodily symptoms could reduce these negative interpretations of bodily symptoms, health anxiety and comorbid symptoms. METHODS: Participants (N = 89) with clinical levels of health anxiety (Short Health Anxiety Inventory [SHAI] scores ≥20) were randomised to receive two internet-delivered 30-min sessions of either CBM-I interpretation training (Intervention) or control CBM-I training over 1-week. Participants were assessed at pre-treatment, post-treatment and 2-weeks follow-up on self-reported health anxiety, cognitions and attributions of bodily symptoms, and comorbid symptoms (e.g., depression). RESULTS: Results showed significantly reduced catastrophic attributions, health anxiety and related symptoms at post-treatment in both groups, which were maintained at 2-week follow-up. Although there were no significant group differences at post-treatment or follow-up, we found small non-significant effect sizes in favour of the CBM-I Intervention group on health anxiety and cognitions (Cohen's d's between-group effect sizes of 0.28 at post-treatment and d = 0.35 at follow-up on the 18-item Short Health Anxiety Inventory). LIMITATIONS: The study was conducted online, limiting control over the setting in which participants completed training. Additionally, training was not tailored to the specific symptoms or diseases that participants feared. CONCLUSIONS: This study is the first to evaluate the effect of internet-delivered CBM-I training targeting benign interpretations of bodily symptoms on health anxiety. Further research is needed before this intervention is disseminated.