Clinical and cost-effectiveness of therapist-guided internet-delivered cognitive behavior therapy for older adults with symptoms of depression: a randomized controlled trial.

UNLABELLED: Depression is a common and significant health problem among older adults. Unfortunately, while effective psychological treatments exist, few older adults access treatment. The aim of the present randomized controlled trial (RCT) was to examine the efficacy, long-term outcomes, and cost-effectiveness of a therapist-guided internet-delivered cognitive behavior therapy (iCBT) intervention for Australian adults over 60 years of age with symptoms of depression. Participants were randomly allocated to either a treatment group (n=29) or a delayed-treatment waitlist control group (n=25). Twenty-seven treatment group participants started the iCBT treatment and 70% completed the treatment within the 8-week course, with 85% of participants providing data at posttreatment. Treatment comprised an online 5-lesson iCBT course with brief weekly contact with a clinical psychologist, delivered over 8 weeks. The primary outcome measure was the Patient Health Questionnaire-9 Item (PHQ-9), a measure of symptoms and severity of depression. Significantly lower scores on the PHQ-9 (Cohen's d=2.08; 95% CI: 1.38 - 2.72) and on a measure of anxiety (Generalized Anxiety Disorder-7 Item) (Cohen's d=1.22; 95% CI: 0.61 - 1.79) were observed in the treatment group compared to the control group at posttreatment. The treatment group maintained these lower scores at the 3-month and 12-month follow-up time points and the iCBT treatment was rated as acceptable by participants. The treatment group had slightly higher Quality-Adjusted Life-Years (QALYs) than the control group at posttreatment (estimate: 0.012; 95% CI: 0.004 to 0.020) and, while being a higher cost (estimate $52.9l 95% CI: -23.8 to 128.2), the intervention was cost-effective according to commonly used willingness-to-pay thresholds in Australia. The results support the potential efficacy and cost-effectiveness of therapist-guided iCBT as a treatment for older adults with symptoms of depression. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12611000927921; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=343384.

Clinical and cost-effectiveness of therapist-guided internet-delivered cognitive behavior therapy for older adults with symptoms of anxiety: a randomized controlled trial.

UNLABELLED: There is preliminary support for internet-delivered cognitive behaviour therapy (iCBT) as a way of improving access to treatment among older adults with anxiety. The aim of this randomized controlled trial (RCT) was to examine the efficacy, long-term outcomes, and cost-effectiveness of an iCBT program for adults over 60 years of age with anxiety. Successful applicants were randomly allocated to either the treatment group (n=35) or the waitlist control group (n=37). The online treatment course was delivered over 8 weeks and provided with brief weekly contact with a clinical psychologist via telephone or secure email. Eighty-four percent of participants completed the iCBT course within the 8 weeks and 90% provided data at posttreatment. Significantly lower scores on measures of anxiety (Cohen's d=1.43; 95% CI: 0.89 - 1.93) and depression (Cohen's d=1.79; 95% CI: 1.21 - 2.32) were found among the treatment group compared to the control group at posttreatment. These lower scores were maintained at 3-month and 12-month follow-up and the treatment group rated the iCBT treatment as acceptable. The treatment group had slightly higher costs ($92.2; 95% CI: $38.7 to $149.2) and Quality-Adjusted Life-Years (QALYs=0.010; 95% CI: 0.003 to 0.018) than the control group at posttreatment and the intervention was found to have a greater than 95% probability of being cost-effective. The results support iCBT as an efficacious and cost-effective treatment option for older adults with symptoms of anxiety. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12611000929909; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12611000929909.

Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: randomised controlled trial.

BACKGROUND: Depression and anxiety are common, disabling and chronic. Self-guided internet-delivered treatments are popular, but few people complete them. New strategies are required to realise their potential. AIMS: To evaluate the effect of automated emails on the effectiveness, safety, and acceptability of a new automated transdiagnostic self-guided internet-delivered treatment, the Wellbeing Course, for people with depression and anxiety. METHOD: A randomised controlled trial was conducted through the website: www.ecentreclinic.org. Two hundred and fifty seven people with elevated symptoms were randomly allocated to the 8 week course either with or without automated emails, or to a waitlist control group. Primary outcome measures were the Patient Health Questionnaire 9-Item (PHQ-9) and the Generalized Anxiety Disorder 7-Item (GAD-7). RESULTS: Participants in the treatment groups had lower PHQ-9 and GAD-7 scores at post-treatment than controls. Automated emails increased rates of course completion (58% vs. 35%), and improved outcomes in a subsample with elevated symptoms. CONCLUSIONS: The new self-guided course was beneficial, and automated emails facilitated outcomes. Further attention to strategies that facilitate adherence, learning, and safety will help realise the potential of self-guided interventions. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610001058066.

Internet-delivered cognitive behavioural therapy for depression: a feasibility open trial for older adults.

BACKGROUND: Depression is an important health issue amongst older adults. Internet-delivered cognitive behaviour therapy (iCBT) may help to reduce barriers and improve access to treatment, but few studies have examined its use with older adults. The present study evaluated the efficacy, acceptability and feasibility of a brief iCBT program, the Managing Your Mood Program, to treat depression amongst adults aged 60 years and older. METHOD: Using an open trial design, 20 participants with elevated symptoms of depression (Patient Health Questionnaire 9-item (PHQ-9) total scores ≥ 10) received access to five educational lessons and homework summaries, additional resources, a moderated discussion forum and weekly telephone or email contact from a clinical psychologist. Eighty percent of the sample met diagnostic criteria for a major depressive episode at pre-treatment. RESULTS: Completion rates and response rates were high, with 16/20 participants completing the five lessons within the 8 weeks, and post-treatment and 3-month follow-up data being collected from 17/20 participants. Participants improved significantly on the PHQ-9 and Geriatric Depression Scale (GDS), with large within-group effect sizes (Cohen's d) at follow-up of 1.41 and 2.04, respectively. The clinician spent a mean time of 73.75 minutes (SD = 36.10 minutes) contacting participants within the trial and the program was rated as highly acceptable by participants. CONCLUSIONS: The results are encouraging and support the potential value of iCBT in the treatment of depressive symptoms amongst older adults.

Internet-delivered eye movement desensitization and reprocessing (iEMDR): an open trial.

Recent research indicates internet-delivered cognitive behavioural therapy (iCBT) can reduce symptoms of post traumatic stress disorder (PTSD). This study examined the efficacy of an internet-delivered treatment protocol that combined iCBT and internet-delivered eye movement desensitization and reprocessing (iEMDR), in an uncontrolled trial. Eleven of the 15 participants completed post-treatment questionnaires. Large effect sizes were found from pre-treatment to 3-month follow-up ( d = 1.03 - 1.61) on clinician-assessed and self-reported measures of PTSD, anxiety and distress, with moderate effect sizes ( d = 0.59 - 0.70) found on measures of depression and disability. At post-treatment, 55% of the participants no longer met criteria for PTSD and this was sustained at follow-up. Symptom worsening occurred in 3 of 15 (20%) of the sample from pre- to post-treatment; however, these participants reported overall symptom improvement by follow-up. Future research directions for iEMDR are discussed.

Brief internet-delivered cognitive behavioral therapy for anxiety in older adults: a feasibility trial.

This study examined the efficacy of an Internet-delivered cognitive-behavior therapy program developed for older adults. Twenty-two participants with elevated scores (≥8) on the Generalized Anxiety Disorder 7-Item Scale (GAD-7) participated in the course, which consisted of five lessons, homework tasks, additional resources, a moderated discussion forum, and weekly telephone support from a Clinical Psychologist. Ninety-five percent of the sample met diagnostic criteria for an anxiety disorder at pre-treatment. All participants completed the five lessons within the allotted eight weeks. Three-month follow-up data was collected from 95% of participants. Reductions in symptoms of anxiety and stress, with large within-group effect sizes (Cohen's d) were found on the GAD-7 (d=1.03) and the Depression, Anxiety and Stress Scales - 21 Items (d=0.98) at follow-up. Participants reported high levels of satisfaction with the program. These encouraging results provide tentative support for the online treatment of older adults with anxiety.

Self-perception and rumination in social anxiety.

The present study examined the relationship between perceptions of performance and post-event processing (PEP) following task feedback in individuals with social phobia and matched control participants. Groups of high and low socially anxious participants engaged in a structured 5-min conversation in groups of four people. Following the conversation, false feedback (given in the form of either high scores or moderate scores) was given and self-appraisals of performance, levels of positive and negative mood, and levels of PEP were assessed. Results showed that participants' perceptions of their own performance and levels of positive affect significantly predicted the degree to which they engaged in negative rumination about the task. The moderate score condition was found to be detrimental for socially anxious individuals' self-appraisals and PEP, whereas controls showed no significant difference in self-appraisal and PEP, regardless of feedback. The results are discussed in relation to current cognitive models of social phobia and both treatment implications and directions for future research are explored.

Culturally attuned Internet treatment for depression amongst Chinese Australians: a randomised controlled trial.

INTRODUCTION: Although depression can be treated effectively with Cognitive Behaviour Therapy (CBT), only a small percentage of Chinese Australians access evidence-based treatment due to practical and cultural barriers. The present study examined the efficacy and acceptability of an Internet delivered CBT (iCBT) program to treat Chinese Australians with depression. METHODS: The Chinese depression iCBT program (the Brighten Your Mood Program) is a culturally adapted version of the clinically efficacious Sadness iCBT Program. Fifty-five Chinese Australians with depression were randomly allocated to either an immediate treatment group or to a waitlist control group. Treatment consisted of an 8 week program with 6 CBT online educational lessons, homework assignments, additional resources presented in Chinese and English, and weekly telephone support with Mandarin/Cantonese-speaking support personnel. An intention-to-treat model was used for data analyses. RESULTS: Seventeen of twenty-five (68%) treatment group participants completed all lessons within the timeframe. Compared to controls, treatment group participants reported significantly reduced symptoms of depression on the Chinese versions of the Beck Depression Inventory (CBDI) and Patient Health Questionnaire-9 item (CB-PHQ-9). The within- and between-group effect sizes (Cohen's d) were 1.41 and 0.93 on the CBDI, and 0.90 and 0.50 on the CB-PHQ-9, respectively. Participants rated the procedure as acceptable, and gains were sustained at three-month follow-up. LIMITATIONS: The study included several subclinical participants and some measures that have not been previously validated with Chinese Australians. CONCLUSIONS: Results provide preliminary support for the efficacy and acceptability of an iCBT program at reducing symptoms of depression in Chinese Australians.

Characteristics and treatment preferences of people with symptoms of posttraumatic stress disorder: an internet survey.

BACKGROUND: Although Posttraumatic Stress Disorder (PTSD) is a severe and disabling anxiety disorder, relatively few people with this condition access evidence-based care. Barriers to treatment are multiple and complex, but the emerging field of Internet therapy for PTSD may improve access to evidence-based treatment. However, little is known about the characteristics of people with PTSD who seek online treatment, or whether they perceive internet treatment as an acceptable treatment option. METHODOLOGY: An online survey was used to collect information about the demographic and symptom characteristics of individuals with elevated levels of PTSD symptoms, and this was compared to data from corresponding sample from a national survey. Previous treatment experiences, perceived barriers to treatment and treatment preferences for Internet therapy and face-to-face treatment were also compared. PRINCIPAL FINDINGS: High levels of PTSD symptoms were reported by survey respondents. Psychological distress and disability was greater than reported by individuals with PTSD from a national survey. Half of the sample reported not having received treatment for PTSD; however, 88% of those who reported receiving treatment stated they received an evidence-based treatment. Primary barriers to treatment included cost, poor awareness of service availability, lack of prior treatment response and not perceiving personal distress as severe enough to warrant treatment. Most survey respondents indicated they were willing to try Internet treatment for PTSD. CONCLUSIONS: The Internet sample was symptomatically severe and multiple barriers existed to treatment. Internet therapy is an acceptable option for the treatment of PTSD in an internet sample.

Randomized controlled trial of Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a severe and disabling condition and few receive appropriate care. Internet-based treatment of PTSD shows promise in reducing barriers to care and preliminary evidence suggests it is efficacious in treating symptoms of PTSD. METHODOLOGY: Forty-two individuals with a diagnosis of PTSD confirmed by clinician interview completed a randomized controlled comparison of Internet-based cognitive behavioral therapy (CBT) with a waitlist control condition. PRINCIPLE FINDINGS: Large pre- to posttreatment effect sizes (ESs) were found for the Treatment group on measures of PTSD symptoms, depression, anxiety, and disability. A small between-group ES was found for PTSD symptoms and moderate between-group ESs were found for depression, anxiety, and disability. CONCLUSIONS: Results provide preliminary support for Internet-based CBT as an efficacious treatment for individuals with a confirmed primary diagnosis of PTSD.

Psychometric comparison of the PHQ-9 and BDI-II for measuring response during treatment of depression.

The Patient Health Questionnaire-9 Item (PHQ-9) and Beck Depression Inventory-II (BDI-II) are frequently used measures of depression severity, but little is known about their relative psychometric properties. The authors assessed psychometric properties of both measures during treatment for depression. The PHQ-9 and BDI-II scores from 172 depressed participants in two randomized controlled trials of treatment for depression were assessed and combined. Tests of internal consistency (Cronbach's α), factor analyses, correlational analyses, estimates of clinically significant change, and effect sizes (Cohen's d) were calculated after treatment and follow-up. Both scales demonstrated adequate internal consistency at pre- and posttreatment (PHQ-9 α = .74 and .81; BDI-II α = .87 and .90, respectively). Factor analysis failed to confirm the one-factor model previously reported for the PHQ-9, but two factors evidenced good fit for the BDI-II. Both scales converged more with each other than with the Sheehan Disability Scale at pre- but not at posttreatment. Responsiveness to change of PHQ-9 and BDI-II was similar at both posttreatment and follow-up. The consistency of agreement on indices of clinical significance was fair to moderate, but the BDI-II categorised a greater proportion of participants with severe depression than the PHQ-9. The BDI-II and PHQ-9 demonstrated adequate reliability, convergent/discriminant validity, and similar responsiveness to change. Differences were found in how they categorised severity. Pending the results of further studies, the attributes of the PHQ-9, of being shorter and based on the diagnostic criteria for depression, may indicate an advantage over the BDI-II.

The effect of attentional focus on social anxiety.

The aim of the present study was to examine the effect of attentional focus on social anxiety in a group of high and low blushing-anxious subjects. One hundred and fourteen psychology undergraduate students were screened using the Fear of Blushing subscale of the Blushing Questionnaire [Bögels, S. M., & Reith, W. (1999). Validity of two questionnaires to assess social fears: The Dutch social phobia and anxiety questionnaire and the blushing, trembling and sweating questionnaire. Journal of Psychopathology and Behavioral Assessment, 21, 51-66]. Those with the most extreme scores in the top and bottom 20% of the distribution were selected to form a high (n=22) and a low (n=22) blushing-anxious group. Subjects were randomly allocated to either a self-focused attention (SFA) condition or a task-focused attention (TFA) condition. They were asked to engage in a 5 min conversation with the first author, and were instructed to either self-focus (SFA condition) or task-focus (TFA condition). Levels of social anxiety and self-awareness were measured using visual analogue scales. Results suggest that the there was a significant condition by group interaction, with high blushing individuals showing considerably higher levels of social anxiety in the SFA condition compared to the TFA condition while low blushing individuals showed no significant difference across the two conditions.