Making Internet-delivered cognitive behaviour therapy scalable for cancer survivors: a randomized non-inferiority trial of self-guided and technician-guided therapy.

PURPOSE: To compare the effectiveness and acceptability of two low-intensity methods of offering a transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) intervention for treating symptoms of anxiety and depression among cancer survivors. METHODS: Cancer survivors with symptoms of anxiety or depression (n = 86) were randomly assigned to receive a transdiagnostic ICBT programme (Wellbeing After Cancer) that was either guided by a technician (n = 42) or self-guided (n = 44). Measures of anxiety, depression, fear of cancer recurrence, and quality of life were completed at pre-treatment, post-treatment, and 4 weeks following treatment completion. RESULTS: Large within-group effect sizes were observed on measures of depression, anxiety, and mental health-related quality of life (d range, 0.98-1.86) at post-treatment. Medium effects were found for reductions in fear of cancer recurrence (d range, 0.65-0.78). Non-inferiority was established for the primary outcome measures of anxiety and depression. All participants reported high satisfaction ratings of the programme; however, technician-guided participants were slightly more satisfied with their level of support (d = 0.57, p = .014). CONCLUSIONS: The Wellbeing After Cancer Course was associated with improved levels of anxiety, depression, fear of cancer recurrence, and quality of life, regardless of how ICBT was offered. IMPLICATIONS FOR CANCER SURVIVORS: ICBT is emerging as an accessible and effective treatment for depression, anxiety, and fear of cancer recurrence in cancer survivors. The success of non-therapist-guided options increases the potential scalability of ICBT, which is particularly valuable for cancer survivors from rural areas who have less access to mental health services.

Randomized controlled trial of internet-delivered cognitive behaviour therapy comparing standard weekly versus optional weekly therapist support.

Internet-delivered cognitive behaviour therapy (ICBT) is effective for treating anxiety and depression. The relative benefits of offering standard weekly compared to optional weekly therapist support in conjunction with ICBT within routine care has not been examined. Patients seeking ICBT for depression and or anxiety in routine care were randomized to standard (n=92) or optional (n=88) weekly support. The optional approach resulted in therapists receiving half as many messages from (1.70 vs. 3.96) and sending half as many messages to patients (3.62 vs. 7.29). Optional Support was associated with lower completion rates (56.6% versus 82.4%), but, similar to Standard Support, resulted in large reductions on the GAD-7 (within Cohen's d≥1.08; avg. reduction ≥47%) and PHQ-9 (within Cohen's d≥0.82; avg. reduction ≥43%) at post-treatment and 3-month follow-up. Optional weekly support appears clinically effective and acceptable for many patients and may reduce costs, but safety requires monitoring given lower completion rates.

Implementation of internet-delivered cognitive behavior therapy within community mental health clinics: a process evaluation using the consolidated framework for implementation research.

BACKGROUND: Depression and anxiety are prevalent and under treated conditions that create enormous burden for the patient and the health system. Internet-delivered cognitive behavior therapy (ICBT) improves patient access to treatment by providing therapeutic information via the Internet, presented in sequential lessons, accompanied by brief weekly therapist support. While there is growing research supporting ICBT, use of ICBT within community mental health clinics is limited. In a recent trial, an external unit specializing in ICBT facilitated use of ICBT in community mental health clinics in one Canadian province (ISRCTN42729166; registered November 5, 2013). Patient outcomes were very promising and uptake was encouraging. This paper reports on a parallel process evaluation designed to understand facilitators and barriers impacting the uptake and implementation of ICBT. METHODS: Therapists (n = 22) and managers (n = 11) from seven community mental health clinics dispersed across one Canadian province who were involved in implementing ICBT over ~2 years completed an online survey (including open and closed-ended questions) about ICBT experiences. The questions were based on the Consolidated Framework for Implementation Research (CFIR), which outlines diverse constructs that have the potential to impact program implementation. RESULTS: Analyses suggested ICBT implementation was perceived to be most prominently facilitated by intervention characteristics (namely the relative advantages of ICBT compared to face-to-face therapy, the quality of the ICBT program that was delivered, and evidence supporting ICBT) and implementation processes (namely the use of an external facilitation unit that aided with engaging patients, therapists, and managers and ICBT implementation). The inner setting was identified as the most significant barrier to implementation as a result of limited resources for ICBT combined with greater priority given to face-to-face care. CONCLUSIONS: The results contribute to understanding facilitators and barriers to using ICBT within community mental health clinics and serve to identify recommendations for improving uptake and implementation of ICBT in clinic settings.

Shame, guilt, and communication in lung cancer patients and their partners.

Lung cancer patients report the highest distress levels of all cancer groups. In addition to poor prognosis, the self-blame and stigma associated with smoking might partially account for that distress and prevent patients from requesting help and communicating with their partners. The present study used innovative methods to investigate potential links of shame and guilt in lung cancer recovery with distress and marital adjustment. A specific emphasis was an examination of the impact of shame on partner communication. Lung cancer patients (n = 8) and their partners (n = 8) completed questionnaires and interviews that were videotaped. We report descriptive statistics and Spearman correlations between shame and guilt, relationship talk, marital satisfaction, distress, and smoking status. We coded the interviews for nonverbal expressions of shame. Greater self-reported shame was associated with decreased relationship-talk frequency and marital satisfaction, and with increased depression and smoking behaviour. Nonverbal shame behaviour also correlated with higher depression and increased smoking behaviour. Guilt results were more mixed. More recent smoking behaviour also correlated with higher depression. At a time when lung cancer patients often do not request help for distress, possibly because of shame, our preliminary study suggests that shame can also disrupt important partner relationships and might prevent patients from disclosing to physicians their need for psychosocial intervention and might increase their social isolation. Even if patients cannot verbally disclose their distress, nonverbal cues could potentially give clinicians an opportunity to intervene.