An open trial of a brief transdiagnostic internet treatment for anxiety and depression.

The present study evaluated the efficacy of a brief version of an internet-administered transdiagnostic CBT protocol, the Wellbeing Program (Titov et al., 2011), designed to treat three anxiety disorders and major depression within the same program. This brief version included the same core CBT skills as the original, but condensed the materials from 8 to 5 online lessons, reduced the duration of treatment from 10 to 8 weeks and did not include an online forum. Thirty-two individuals with a principal diagnosis of major depression, generalised anxiety disorder, panic disorder or social phobia received CBT-based online educational lessons, homework assignments, weekly contact from a clinical psychologist and automated emails. Eighty-one percent of participants completed the lessons within the 8 week program. Post-treatment and 3-month follow-up data were collected from 28/32 and 31/32 participants respectively. Participants improved significantly on the Depression Anxiety and Stress Scales - 21 Item, Patient Health Questionnaire - 9 Item, and Generalised Anxiety Disorder - 7 Item scales, with corresponding within-group effect sizes (Cohen's d) at follow-up of 1.05, .73, and .95, respectively. Participants rated the procedure as highly acceptable with gains of a similar magnitude as those found for the original program, but less time was spent per participant by the clinician in the present trial (mean=44.61 min, SD=34.45) compared to the original program (mean=84.76 min, SD=50.37). These results provide additional support for the efficacy of transdiagnostic iCBT in the treatment of anxiety and depressive disorders and indicate that a brief version may be of benefit.

Transdiagnostic internet treatment for anxiety and depression: a randomised controlled trial.

Disorder-specific cognitive behavioural therapy programs delivered over the internet (iCBT) with clinician guidance are effective at treating specific anxiety disorders and depression. The present study examined the efficacy of a transdiagnostic iCBT protocol to treat three anxiety disorders and/or depression within the same program (the Wellbeing Program). Seventy-seven individuals with a principal diagnosis of major depression, generalised anxiety disorder, panic disorder, and/or social phobia were randomly assigned to a Treatment or 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. Eighty one percent of Treatment group participants completed all 8 lessons within the 10 week program. Post-treatment data were collected from 34/37 Treatment group and 35/37 Control group participants, and 3-month follow-up data were collected from 32/37 Treatment group participants. Relative to Controls, Treatment group participants reported significantly reduced symptoms of anxiety and depression as measured by the Depression Anxiety and Stress Scales-21 item, Patient Health Questionnaire-9 item, and Generalised Anxiety Disorder-7 item scales, with corresponding between-groups effect sizes (Cohen's d) at post treatment of.56,.58, and.52, respectively. The clinician spent a mean time of 84.76 min (SD=50.37) per person over the program. Participants rated the procedure as highly acceptable, and gains were sustained at follow-up. These results provide preliminary support for the efficacy of transdiagnostic iCBT in the treatment of anxiety and depressive disorders.

Randomized controlled trial of Internet cognitive behavioural treatment for social phobia with and without motivational enhancement strategies.

OBJECTIVE: The present study (Shyness 7) has two aims: Firstly, to replicate an earlier trial showing that a self-guided Internet treatment for social phobia is efficacious, and secondly, to examine whether the addition of self-guided motivational enhancement strategies improves completion rates and clinical outcomes. METHOD: Randomized controlled trial (RCT) of self-guided Internet-based cognitive behavioural treatment (iCBT), or iCBT plus self-guided motivational enhancement strategies (iCBT+MS), was conducted. An intention-to-treat and last observation carried forward model was used for data analyses. The participants consisted of 108 volunteers with social phobia. The iCBT intervention consisted of two online lessons about symptoms and treatment of anxiety disorders and six lessons about management of social phobia (the Shyness programme) with complex automated reminders. The motivational intervention was based on traditional techniques including understanding and exploring ambivalence about change using a cost­benefit analysis, developing and resolving discrepancy between values and symptoms, and enhancing self-efficacy for change. The main outcome measures were the Social Interaction Anxiety Scale and Social Phobia Scale. RESULTS: More iCBT+MS group participants completed the eight lessons than iCBT group participants (75% versus 56%, respectively), but there were no between-group differences in outcome measures at post-treatment or at 3 month follow up. Large mean within-groups effect sizes (Cohen's d) for the two social phobia measures were found for both the iCBT and iCBT+ MS groups (1.1 and 0.95, respectively), which were sustained at 3 month follow up (1.06 and 1.07, respectively). Both iCBT and iCBT+MS group participants reported that the procedures were highly acceptable. CONCLUSIONS: Both self-guided versions of the Shyness programme were reliably efficacious, confirming that people with social phobia may significantly benefit from a highly structured self-guided intervention. The addition of motivational techniques increased completion rates but did not improve clinical outcomes or acceptability.

Internet treatment for generalized anxiety disorder: a randomized controlled trial comparing clinician vs. technician assistance.

BACKGROUND: Internet-based cognitive behavioural therapy (iCBT) for generalized anxiety disorder (GAD) has been shown to be effective when guided by a clinician. The present study sought to replicate this finding, and determine whether support from a technician is as effective as guidance from a clinician. METHOD: Randomized controlled non-inferiority trial comparing three groups: Clinician-assisted vs. technician-assisted vs. delayed treatment. Community-based volunteers applied to the VirtualClinic (www.virtualclinic.org.au) research program and 150 participants with GAD were randomized. Participants in the clinician- and technician-assisted groups received access to an iCBT program for GAD comprising six online lessons, weekly homework assignments, and weekly supportive contact over a treatment period of 10 weeks. Participants in the clinician-assisted group also received access to a moderated online discussion forum. The main outcome measures were the Penn State Worry Questionnaire (PSWQ) and the Generalized Anxiety Disorder-7 Item (GAD-7). Completion rates were high, and both treatment groups reduced scores on the PSWQ (p<0.001) and GAD-7 (p<0.001) compared to the delayed treatment group, but did not differ from each other. Within group effect sizes on the PSWQ were 1.16 and 1.07 for the clinician- and technician-assisted groups, respectively, and on the GAD-7 were 1.55 and 1.73, respectively. At 3 month follow-up participants in both treatment groups had sustained the gains made at post-treatment. Participants in the clinician-assisted group had made further gains on the PSWQ. Approximately 81 minutes of clinician time and 75 minutes of technician time were required per participant during the 10 week treatment program. CONCLUSIONS: Both clinician- and technician-assisted treatment resulted in large effect sizes and clinically significant improvements comparable to those associated with face-to-face treatment, while a delayed treatment/control group did not improve. These results provide support for large scale trials to determine the clinical effectiveness and acceptability of technician-assisted iCBT programs for GAD. This form of treatment has potential to increase the capacity of existing mental health services. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609000563268.

Shyness programme: longer term benefits, cost-effectiveness, and acceptability.

OBJECTIVE: In two randomized controlled trials Titov et al. demonstrated significant benefit from an Internet- and email-based treatment programme for social phobia: the Shyness programme. Data are presented about the longer term outcomes (6 months after treatment), cost-effectiveness relative to face-to-face treatment, and the acceptability of the programme to participants. METHOD: Participants completed outcome and acceptability questionnaires at 6 months after treatment. Repeated measures analyses of variance were calculated using an intention-to-treat design. Cost-effectiveness in years lived with disability averted were calculated based on between-group effect sizes. RESULTS: A total of 59% of treatment group participants completed the 6 month follow-up questionnaires. Between post-treatment and 6 month follow up participants continued to make improvements in symptoms of social phobia, while maintaining improvements in mood, psychological distress, and disability. At 6 month follow up the mean within-group effect size (Cohen's d) for the two social phobia measures increased from 1.2 to 1.4. Cost-effectiveness in years lived with disability (YLD) averted was calculated as one-quarter that of face-to-face group treatment, or $AUD1495 for one YLD gained, compared to $AUD5686/YLD gained. Participants rated the Internet treatment to be as effective and helpful as face-to-face treatment. CONCLUSIONS: The present results confirm the reliability of the short-term findings reported in the first two Shyness programmes. The procedure appears to be very cost-effective, and acceptable to participants. These data provide further support for the development of Internet-based virtual clinics for common mental disorders.

Shyness 3: randomized controlled trial of guided versus unguided Internet-based CBT for social phobia.

OBJECTIVE: In two previous randomized controlled trials Titov et al. demonstrated significant benefit from an Internet- and email-based treatment programme for social phobia. The present study (Shyness 3) explores whether participants are able to complete this programme independently. METHOD: A total of 98 individuals with social phobia were randomly assigned to a clinician-assisted computerized cognitive behavioural treatment (CaCCBT) group, a self-guided computerized CBT (CCBT) group, or to a waitlist control group. CaCCBT group participants completed the usual Shyness programme consisting of six online lessons, cognitive behavioural homework assignments, email contact with a therapist, and participation in an online discussion forum. CCBT group participants accessed the same resources except for therapist emails. An intention-to-treat model was used for data analyses. RESULTS: A total of 77% of CaCCBT and 33% of CCBT group participants completed all lessons. Significant differences were found after treatment between CaCCBT and control groups (mean between-groups effect size (ES) for the social phobia measures=1.04), and between the CaCCBT and CCBT groups (mean between-groups ES for the social phobia measures=0.66). No significant differences were found after treatment between the CCBT and control groups (mean between-groups ES for the social phobia measures=0.38). CCBT participants, however, who completed the six lessons made good progress (mean within-group ES for the social phobia measures=0.62). Quantitative and qualitative data indicate that both the CaCCBT and CCBT procedures were acceptable to participants. CONCLUSIONS: The reliability of this Internet-based treatment programme for social phobia has been confirmed. The therapist-guided condition was superior to the self-guided condition, but a subgroup of participants still benefited considerably from the latter. These data confirm that self-guided education or treatment programmes for common anxiety disorders can result in significant improvements.

Shyness 1: distance treatment of social phobia over the Internet.

OBJECTIVE: The purpose of the present study was to examine the effectiveness of an Internet-based clinician-assisted computerized cognitive behavioural therapy programme for social phobia. METHOD: A total of 105 individuals with social phobia were randomly assigned to a six-lesson cognitive behavioural treatment programme or to a waitlist control group. Treatment consisted of four components: six online lessons; homework assignments; participation in an online discussion forum; and regular email contact with a therapist. An intention-to-treat model was used for data analyses. RESULTS: A total of 78% of treatment group participants completed all lessons, and post-treatment data were obtained from 93/105 participants. Significant post-treatment differences between treatment and waitlist participants were found on two measures of symptoms of social phobia. Mean within- and between-group effect sizes (Cohen's d) for the primary social phobia outcome measures were 1.15, and 0.95, respectively. CONCLUSIONS: These results were comparable with those obtained in exemplary face-to-face treatment programmes. They provide further positive data about the utility of Internet-based guided self-help programmes for people with common mental disorders.

Shyness 2: treating social phobia online: replication and extension.

OBJECTIVE: In a randomized controlled trial Titov et al. (2008) demonstrated significant benefit from an Internet- and email-based treatment programme for social phobia. The present study (Shyness 2) seeks to replicate that finding and compares results with benchmark data. METHOD: Eighty-eight individuals with social phobia were randomly assigned to a clinician-assisted computerized cognitive behavioural treatment programme or to a waitlist control group. Participants completed the same treatment programme used in Shyness 1, consisting of six online lessons, cognitive behavioural homework assignments, email contact with a therapist, and participation in an online discussion forum. An intention-to-treat model was used for data analyses. RESULTS: A total of 80% of treatment group participants completed all lessons, and post-treatment data were obtained from 78/81 participants. Treatment group participants each had an average of 127 min of therapist contact over the 10 week programme, including an average of 22 email contacts plus therapist responses to forum postings. Pre- to post-treatment differences were seen between treatment and waitlist participants across two measures of symptoms of social phobia, and across a measure of disability. Mean within- and between-group effect sizes (Cohen's d) across the two primary outcome measures were 1.18, and 1.20, respectively. Quantitative and qualitative data indicate that the procedure is very acceptable to participants. CONCLUSIONS: These results closely replicate those obtained in Shyness 1, indicating that the treatment procedure is reliable. These results compare favourably with outcomes reported in benchmarking studies from high-quality face-to-face treatment programmes for social phobia. These results provide further positive data about the utility of Internet-based guided self-help programmes for people with social phobia.