Alcohol and drug use among clients receiving internet-delivered cognitive behavior therapy for anxiety and depression in a routine care clinic - Demographics, use patterns, and prediction of treatment completion and outcomes.

BACKGROUND: Research shows that alcohol and drug use among mental health clients is common and has the potential to negatively impact treatment outcomes. Internet-delivered cognitive behavior therapy (ICBT) as a treatment for anxiety and depression is on the rise, but little is known about the prevalence of alcohol and drug use among clients and how this use affects treatment completion and outcomes. OBJECTIVE: The objective of the current study was to explore the prevalence of alcohol and drug use among clients in ICBT for depression and anxiety, and to investigate the impact of alcohol and drug use on treatment completion and symptom outcomes. MATERIAL AND METHODS: Data was collected from 1155 clients who participated in two randomized ICBT trials for depression and anxiety, conducted in a routine care clinic. Thirty-five individuals reporting severe substance use when applying to the trials were excluded. Demographic variables, and alcohol and drug use were measured at screening, and measures of depression and anxiety were administered at pre- and post-treatment. RESULTS: Four out of five clients reported having used alcohol in the past year, while one in five reported having used drugs in the past year. Around a third of clients had reported either problematic alcohol use, drug problems, or both. The analyses showed that drug problems, and combined alcohol and drug problems were negatively associated with treatment completion, but neither alcohol nor drug use had an impact on depression and anxiety outcomes. CONCLUSIONS: Alcohol and drug problems are likely to be present among a large proportion of patients using ICBT for anxiety and depression. This may not be a barrier to treatment benefit, at least when those with severe alcohol and drug problems have been excluded.

Brief online motivational interviewing pre-treatment intervention for enhancing internet-delivered cognitive behaviour therapy: A randomized controlled trial.

While the efficacy of therapist-guided internet-delivered cognitive behaviour therapy (iCBT) for anxiety and depression is well-established, a significant proportion of clients show little to no improvement with this approach. Given that motivational interviewing (MI) is found to enhance face-to-face treatment of anxiety, the current trial examined potential benefits of a brief online MI intervention prior to therapist-guided iCBT. Clients applying to transdiagnostic therapist-guided iCBT in routine care were randomly assigned to receive iCBT with (n = 231) or without (n = 249) the online MI pre-treatment. Clients rated motivation at screening and pre-iCBT and anxiety and depression at pre- and post-treatment and at 13- and 25-week follow-up after enrollment. Clients in the MI plus iCBT group made more motivational statements in their emails and were enrolled in the course for a greater number of days compared to clients who received iCBT only, but did not demonstrate higher motivation after completing the MI intervention or have higher course completion. Clients in both groups, at screening and pre-iCBT, reported high levels of motivation. No statistically significant group differences were found in the rate of primary symptom change over time, with both groups reporting large reductions in anxiety and depression pre- to post-treatment (Hedges' g range = 0.96-1.11). During follow-up, clients in the iCBT only group reported additional small reductions in anxiety, whereas clients in the MI plus iCBT group did not. The MI plus iCBT group also showed small increases in depression during follow-up, whereas improvement was sustained for the iCBT only group. It is concluded that online MI does not appear to enhance client outcomes when motivation at pre-treatment is high.

Mixed-method evaluation of an online motivational intervention as a pre-treatment to internet-delivered cognitive behaviour therapy: Immediate benefits and user feedback.

•An online MI intervention was recently developed to complement ICBT.•Intervention consists of videos, exercises, feedback to better simulate face-to-face MI.•Study evaluated intervention impact on motivation and perceptions of MI.•Ratings of motivation and MI perceptions significantly increased from pre- to post-MI.•Future research should explore longer term impact of online MI on ICBT.

Perceptions of Cognitive-Behavioral Therapy and Antidepressant Medication for Depression After Brief Psychoeducation: Examining Shifts in Attitudes.

The majority of people with depression in the United States either never seek treatment or gravitate exclusively to antidepressant medication (ADM), despite the existence of other effective treatments, such as cognitive-behavioral therapy (CBT). Reluctance to use psychotherapy is partly due to lack of appropriate mental health literacy and perceptions of low treatment acceptability (appropriateness for a given problem) and credibility (treatment logicalness, and whether the patient expects improvement). In the current investigation, we examined whether providing psychoeducation about CBT for depression would change participant perceptions of the treatment's acceptability and credibility. We recruited 554 (female n = 314; 57%) participants across two online studies, and assessed their baseline perceptions of CBT and ADM using modified Treatment Acceptability (TAAS) and Treatment Credibility and Expectancy (CEQ) scales. Participants were subsequently presented with evidence-based, expert-vetted psychoeducational materials describing CBT and ADM, and were asked to recomplete the TAAS and CEQ. In Study 1, participants endorsed significantly higher CBT-CEQ (credibility/expectancy) scores postpsychoeducation. In Study 2, participants endorsed significantly lower CBT-TAAS (acceptability), and among those with no exposure to depression treatments, endorsed significantly higher CBT-CEQ scores postpsychoeducation. In both studies, there were no perceptual changes of ADM after the psychoeducation. Finally, in Study 2, endorsement of a biological model of depression and depressive symptoms were negatively predictive of CBT's acceptability and credibility and expectancy postpsychoeducation. Perceptions of credibility and expectancy of CBT for depression appear malleable even after exposure to brief psychoeducation, whereas shifting perceptions of CBT's acceptability may require more extensive intervention.

What are Clients Asking Their Therapist During Therapist-Assisted Internet-Delivered Cognitive Behaviour Therapy? A Content Analysis of Client Questions.

BACKGROUND: Although internet-delivered cognitive behaviour therapy (ICBT) yields large clinical outcomes when accompanied by therapeutic support, a portion of clients do not benefit from treatment. In ICBT, clients review treatment materials online typically on a weekly basis. A key component of therapist-assistance involves answering questions as clients review and work on assignments related to the treatment materials. AIMS: The goal of this study was to enhance understanding of the nature of client questions posed during ICBT and examine potential associations between the number of questions asked and treatment outcomes in order to provide insight into how to improve ICBT for future users. METHOD: Content analysis was used to qualitatively analyse and identify questions that 80 clients asked their designated therapist over the course of an 8-week ICBT programme for anxiety and depression. RESULTS: On average, clients sent six emails during the course of treatment, of which less than two questions were asked. Of the 137 questions posed by clients, 46.72% reflected questions designed to enhance understanding and apply the material and techniques reviewed in the programme. Additional questions were categorized as clarifying the therapeutic process (22.62%), addressing technical challenges (18.25%), and seeking assistance with problems outside the scope of ICBT (12.41%). Number of client questions asked was not significantly correlated with the number of lessons completed, symptom change, or perceptions of therapeutic alliance. CONCLUSIONS: Findings can inform future practitioners who deliver ICBT of what to expect with this treatment approach and also assist in the development of future ICBT programmes.

Content of client emails in internet-delivered cognitive behaviour therapy: A comparison between two trials and relationship to client outcome.

Many Internet-delivered cognitive behavioural therapy (ICBT) programs include email communication between clients and therapists as a part of treatment; yet relatively little is known about the nature and impact of this communication. Previous research conducted by Svartvatten et al. (2015) has identified 10 themes in written correspondence by clients accessing ICBT for depression. The current study examined: (1) if previously identified themes in client emails would be present in a shorter ICBT program for depression and anxiety; and (2) whether themes in emails similarly correlated with symptom improvement, lesson completion, and perceptions of working alliance. Using 80 randomly selected clients from a published ICBT trial (ISRCTN42729166; Hadjistavropoulos et al., 2016), client emails (average 5.69 per client) were examined for the presence of the themes reported by Svartvatten et al. (2015) and correlated with symptom improvement, lesson completion, perceptions of working alliance. Although most themes developed by Svartvatten et al. (2015) were identified in client emails, the frequency of themes differed between studies. Most notably, emails in the current study were more often coded as involving alliance bolstering (~39% vs. 22% of statements) and identification of patterns and problem behaviours (~25% vs. 6% of statements). Greater frequency of tries alternative behaviour and identifies patterns and problem behaviours were correlated with a greater number of lessons completed. In terms of symptom change, greater frequency of maladaptive repetitive thinking and problems with treatment content in the emails were correlated with smaller improvements in anxiety, whereas observes positive consequences was correlated with larger improvements in anxiety. Similarly, greater frequency of maladaptive repetitive thinking was correlated with smaller improvements in depression. Regarding perceptions of working alliance, more frequent statements of observes positive consequences was correlated with higher alliance. The research provides clinicians and researchers with an improved understanding of the comparability and meaning of client communication in different ICBT programs. Experimental research is needed to better understand the role of client communication in ICBT.

Treatment acceptability and preferences for managing severe health anxiety: Perceptions of internet-delivered cognitive behaviour therapy among primary care patients.

BACKGROUND & OBJECTIVES: While cognitive behaviour therapy (CBT) is an established treatment for health anxiety, there are barriers to service access. Internet-delivered cognitive behaviour therapy (ICBT) has demonstrated effectiveness and has the potential to improve access to treatment. Nevertheless, it is unknown how patients perceive ICBT relative to other interventions for health anxiety and what factors predict ICBT acceptability. This study investigated these questions. METHODS: Primary care patients (N = 116) who reported elevated levels of health anxiety were presented three treatment vignettes that each described a different protocol for health anxiety (i.e., medication, CBT, ICBT). Acceptability and credibility of the treatments were assessed following the presentation of each vignette. Participants then ranked the three treatments and provided a rational for their preferences. RESULTS: The treatments were similarly rated as moderately acceptable. Relative to medication and ICBT, CBT was perceived as the most credible treatment for health anxiety. The highest preference ranks were for CBT and medication. Regression analyses indicated that lower computer anxiety, past medication use, and lower ratings of negative cognitions about difficulty coping with an illness significantly predicted greater ICBT acceptability. LIMITATIONS: Health anxiety was not assessed with a diagnostic interview. Primary care patients were recruited through a Qualtrics panel. Patients did not have direct experience with treatment but learned about treatment options through vignettes. CONCLUSIONS: Medication and CBT are preferred over ICBT. If ICBT is to increase treatment access, methods of improving perceptions of this treatment option are needed.

A randomized controlled trial of guided internet-delivered cognitive behaviour therapy for older adults with generalized anxiety.

This study aimed to establish the efficacy of guided Internet-delivered cognitive-behaviour therapy (ICBT) for older adults with generalized anxiety disorder (GAD) or subclinical GAD. Participants were randomized to receive seven modules of ICBT (n=24) or to a waiting list condition (WLC; n=22). Faster improvements in symptoms of anxiety and depression were observed for participants in the ICBT condition relative to the WLC, with large between-group effect sizes on the Generalized anxiety disorder-7 (d=.85) and the Patient health questionnaire (d=1.17) obtained at post-treatment. Further reduction in generalized anxiety symptoms was reported over the one-month follow-up. Treatment effects were replicated when control participants subsequently underwent treatment. Higher ratings of treatment credibility, but not expectancy, prior to ICBT predicted improvements over time. The results support the efficacy of ICBT as treatment for older adults with GAD.

Educating patients about Internet-delivered cognitive behaviour therapy: Perceptions among treatment seekers and non-treatment seekers before and after viewing an educational video.

Internet-delivered cognitive behaviour therapy (ICBT) is an efficacious, yet novel approach to the treatment of depression and anxiety. It has the potential to improve access to evidenced-based care, but only if potential patients are aware of, understand, and have positive expectations about this treatment. In order to establish whether the use of an educational video could improve favourable expectations of ICBT, two studies were conducted. The goal of the first study was to determine whether an educational video would improve perceptions of ICBT among individuals seeking ICBT treatment and to determine what type of information (client testimonials versus statistical information related to outcomes) facilitates the greatest increase in positive expectations of ICBT. Participants who visited an ICBT service (N = 71) website were invited to first complete brief questionnaires assessing initial perceptions of ICBT. They were then randomly assigned to watch one of two videos containing either client testimonials (n = 32) or statistical information related to outcomes (n = 39). Patient perceptions of ICBT were then reassessed. Perceptions of ICBT were significantly higher post-video than pre-video and the type of information did not impact perceptions of ICBT. In the second study, the research was extended by examining perceptions of ICBT before and after watching an educational video (including both statistical and narrative information as this had no impact on perceptions) in a sample of individuals (N = 94) who were experiencing anxiety and depression but were not specifically seeking ICBT. As with treatment seekers, perceptions of ICBT were significantly higher post-video than pre-video. Comparison of the treatment and non-treatment seekers revealed no differences in perceptions of ICBT between the samples. The findings suggest that educational videos are an effective way to increase expectations of ICBT. Future directions for research are described.