Improving Adherence and Clinical Outcomes in Self-Guided Internet Treatment for Anxiety and Depression: A 12-Month Follow-Up of a Randomised Controlled Trial

Background: A recent paper reported the outcomes of a study examining a new self-guided internet-delivered treatment, the Wellbeing Course, for symptoms of anxiety or depression. This study found the intervention resulted in significant symptom reductions. It also found that automated emails increased treatment completion and clinical improvements in a subsample with elevated anxiety and depression. Aims: To examine the clinical outcomes and the effect of automated emails at 12 months post-treatment. Method: Participants, who were randomly allocated to a Treatment Plus Automated Emails Group (TEG; n = 100), a standard Treatment Group (TG; n = 106) or delayed-treatment Waitlist Control Group (Control; n = 51), were followed up at 12 months post-treatment. Eighty-one percent, 78% and 87% of participants in the TEG, TG and treated Waitlist Control Group provided symptom data at 12-month follow-up, respectively. The primary outcome measures were the Patient Health Questionnaire-9 Item Scale (PHQ-9) and the Generalized Anxiety Disorder-7 Item Scale (GAD-7).Results: Significant improvements in symptoms of anxiety and depression were observed over time in both the TEG and TG (Fs >69, ps .05), and were associated with large effect sizes. No statistically significant differences in symptoms were found between the TEG and TG at post-treatment, 3-month or 12-month follow-up. Previously reported symptom differences between TEG and TG participants with comorbid symptoms were no longer present at 12-month follow-up (ps >.70).Conclusions: The overall benefits of the Wellbeing Course were sustained at 12-month follow-up. Although automated emails facilitated Course completion and reductions in symptoms for participants with comorbid anxiety and depression from pre-post treatment, these differences were no longer observed at 12-month follow-up. The results indicate that automated emails promote more rapid treatment response for people with elevated and comorbid symptoms, but may not improve longer term outcomes

Prevalence and treatment of anxiety and depression in Arab people and the potential of Internet-delivered cognitive behavioural therapy

Empirical thesis.Bibliography: pages 213-260.1. A review of the literature -- 2. Study 1: Intergenerational and cross-cultural differences in emotional wellbeing, mental health service utilisation, treatment-seeking preferences and acceptability of psychological treatments for Arab Australians -- 3. Study 2: Acceptability of mental health services for anxiety and depression in an Arab sample -- 4. Study 3: Facebook as an effective recruitment strategy for mental health research of hard-to-reach populations -- 5. Study 4: A feasibility open trial of guided Internet-delivered cognitive behavioural therapy for anxiety and depression amongst Arab Australians -- 6. Study 5: A pilot study of self-guided Internet-delivered cognitive behavioural therapy for anxiety and depression among Arabs -- 7. Study 6: A pilot study of a clinician-guided Internet-delivered cognitive behavioural therapy for anxiety and depression among Arabs in Australia, presented in both English and Arabic languages -- 8. Discussion -- 9. References -- 10. Appendices.Little is known about the prevalence of anxiety and depressive disorders amongst Arab people. Furthermore, it is not clear if psychological treatments for disorders of anxiety and depression designed for Western populations are effective with Arab populations. This thesis aimed to: 1) Identify rates of psychological distress, barriers to treatment seeking, and acceptability of psychological treatments in Arab people; 2) Explore strategies for recruiting Arab people into psychological research; and 3) Determine the efficacy of Internet-delivered cognitive behavioural therapy (iCBT) for Arab people with symptoms of anxiety and depression. Using survey methodology, the results of Study 1 and 2 indicated that regardless of location, Arab people reported difficulty accessing treatment, high rates of psychological distress, but were willing to try face-to-face and online mental health services, such as iCBT. Study 3 found that Facebook was a more time-effective method for recruiting participants than traditional print and radio media. Using open trial designs, the results of Study 4 and 5 indicated that iCBT was efficacious and acceptable when administered in the English language to Arab people. Study 6, another open trial, found that iCBT was efficacious and acceptable for Arab people when administered in both the English and Arabic languages. The first two studies contribute to our understanding of the mental health needs of Arab people. Study 3 contributes to our understanding of effective recruitment methods for hard-to-reach populations. Studies 4, 5 and 6 contribute to data indicating that iCBT is efficacious for non-Western people with symptoms of anxiety and depressive disorders. Thus, in combination, these studies contribute to an emerging body of literature regarding the unmet mental health needs of Arab people and highlight the potential of iCBT for improving their access to evidence-based psychological treatments.Mode of access: World wide web1 online resource (271 pages) colour illustration

Fatal torment - from psychosis-driven index offence to trauma : a case study in forensic psychotherapy, trauma therapy and matricide

Objective: This paper presents the case of a forensic inpatient who was found ‘Not Guilty by Reason of Mental Illness’ for the murder of his mother and illustrates how psychotic symptoms can mask trauma symptoms, leading to neglect in the treatment of trauma in psychotherapy with forensic inpatients. Method: A case study of a forensic inpatient diagnosed with schizophrenia that as part of his rehabilitation program received 19 sessions of therapy (i.e. grief counselling, Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) and imagery rescripting). The following measures were administered pre- and post-treatment: (a) The Depression Anxiety Stress Scale (DASS), to measure symptoms of depression, anxiety and stress; (b) The Impact of Events Scale-Revised (IES-R), to measure post-traumatic stress symptoms; and (c) The Trauma Attachment and Beliefs Scale (TABS), to measure disruption in beliefs about self and others. Results: At completion of therapy, he showed a reduction in Post-Traumatic Stress Disorder (PTSD), depression, anxiety and stress symptoms. Conclusions: Trauma and PTSD-related symptoms in the forensic inpatient population must be assessed and treated alongside psychotic symptoms, where relevant. TF-CBT was effective in reducing PTSD symptoms in this current case study and should be considered as an intervention in forensic inpatient populations.5 page(s

Meta-analysis of the efficacy and acceptability of cognitive-behavioural therapy for Arab adult populations experiencing anxiety, depression or post-traumatic stress disorder

A meta-analysis of the literature of cognitive behaviour therapy (CBT) with Arab adult populations experiencing anxiety, depression or post-traumatic stress disorder (PTSD) was conducted. Nine studies (n = 536) met the eligibility criteria. Three of the nine studies (33%) were randomised control trials using waitlist control groups. All studies (100%) reported a statistically significant reduction in psychological symptoms at post-treatment with large effect sizes for anxiety (effect size, 95% confidence interval) (1.44 [1.29, 1.59]), depression (1.26 [1.16, 1.35]) and PTSD (2.08 [1.94, 2.23]). Six out of the nine studies (67%) collated follow-up data and reported that reductions of psychological symptoms were maintained at follow-up. An average dropout rate of 26% indicated good overall acceptability. Five out of nine (55%) of the trials reported diagnostic remission rates and of those trials the mean remission rate was 31%). Five of the nine eligible studies (55%) delivered remotely via Internet or telephone were found to have similar effect sizes as face-to-face CBT. The current meta-analysis indicates the potential of CBT, delivered either face-to-face or via internet, as efficacious and acceptable interventions for the treatment of anxiety, depression and PTSD for Arab adult populations

Building a bridge : a case report on communicating mental-health diagnoses to patients of a culturally and linguistically diverse background

Objective:This paper is based on a case report, describing a protocol to help practitioners communicate mental-health diagnosis to patients from culturally and linguistically diverse (CALD) backgrounds. The protocol was presented by integrating the DSM-5 Cultural Formulation Interview (CFI) and the SPIKES protocol for communicating the diagnosis of cancer, yielding a modified CFI-SPIKES protocol (i.e. S, Support; P, Perception using CFI; I, Invitation; K, Knowledge; E, Emotions). The protocol was demonstrated using a case report with a patient of a Middle-Eastern background experiencing generalised anxiety disorder.Conclusions:The CFI-SPIKES protocol for communicating mental-health diagnosis allows for a collaborative process, whereby the CALD patient and practitioner can address the stigma associated with communicating a mental-health diagnosis, ensuring patient engagement and informed shared decision making

Facebook as an effective recruitment strategy for mental health research of hard to reach populations

Recent reports indicate that Facebook (FB) may facilitate recruitment of hard to reach participants into mental health research. The present study aimed to contribute to this emerging literature by exploring recruitment data from a recently completed trial of online treatment for symptoms of anxiety and depression that targeted Arab people. The present study compared traditional recruitment strategies such as media releases, emails, and print advertisements with Facebook strategies including boosting posts, promoting websites, events and FB public fan pages. The main outcomes of interest were the number of started applications and the time and cost per application associated with the FB and traditional recruitment strategies. A target sample of 350 was sought and a total of 81 participants applied to participate over the 42-week recruitment period. Overall, 86% of the resultant applications occurred via FB recruitment and a Poisson regression analysis indicated the FB strategies were more time-effective, recruiting participants 2.5 times faster than the traditional strategies. However, there were no differences in cost-effectiveness for FB ($US37 per participant) and traditional strategies ($US40 per participant). The findings of the current study add to existing literature detailing the value of FB recruitment strategies, alongside more traditional strategies, as a way of recruiting hard-to-reach populations for research. However, more research is needed to explore alternative and optimal strategies for the successful recruitment of hard to reach populations via FB and other online social media platforms.10 page(s

Effectiveness of internet delivered cognitive behaviour therapy provided as routine care for people in the depressed phase of bipolar disorder treated with Lithium.

There is little research reporting the outcome of internet delivered cognitive behaviour therapy, (iCBT), which helps patients identify and modify unhelpful cognitions and behaviours, for the depressed phase of bipolar disorder as part of routine care. Demographic information, baseline scores and treatment outcomes were examined for patients of MindSpot Clinic, a national iCBT service who reported taking Lithium and their clinic records confirmed the diagnosis of bipolar disorder. Outcomes were completion rates, patient satisfaction and changes in measures of psychological distress, depression and anxiety measured by the Kessler-10 item (K-10), Patient Health Questionnaire 9 Item (PHQ-9), and Generalized Anxiety Disorder Scale 7 Item (GAD-7), compared to clinic benchmarks. Out of 21,745 people who completed a MindSpot assessment and enrolled in a MindSpot treatment course in a 7 year period, 83 reported taking Lithium and had a confirmed a diagnosis of bipolar disorder. Outcomes of reductions in symptoms were large on all measures (effect sizes > 1.0 on all measures, percentage change between 32.4% and 40%), and lesson completion and satisfaction with the course were also high. MindSpot treatments appear to be effective in treating anxiety and depression in people diagnosed with bipolar, and suggest that iCBT has the potential to overcome the under-use of evidence based psychological treatments of people with bipolar depression

A pilot study of a clinician-guided internet-delivered cognitive behavioural therapy for anxiety and depression among Arabs in Australia, presented in both English and Arabic languages

The present pilot study examined the efficacy and acceptability of an internet-delivered Cognitive Behaviour Therapy (iCBT) intervention delivered in both English and Arabic languages to Arab Australians, aged 18 and over, with symptoms of depression and anxiety. Thirteen participants with at least mild symptoms of depression on the (Patient Health Questionnaire 9-item; PHQ-9; total scores ≥5) or anxiety (Generalised Anxiety Disorder 7-item; GAD-7; total scores ≥5) accessed the online Arabic Wellbeing Course, which consisted of five online lessons delivered over eight weeks with weekly clinician support. Measures of depression, anxiety, distress and disability were administered at pre-treatment, post-treatment and 3-month follow-up. Data were analysed using generalised estimation equation (GEE) modelling. Seventy-seven percent (10/13) of participants completed the five lessons over eight weeks, with 10/13 providing post-treatment and 3-month follow-up data. Participants improved significantly across all outcome measures, with large within-group effect sizes based on estimated marginal means (Cohen's d) at post-treatment (d = 1.18 to 1.62) and 3-month follow-up (d = 1.28 to 1.72). In addition, 40% and 38% of participants obtained, at least, a 50% improvement in symptoms of both anxiety and depression at 3-month follow-up respectively. Participants rated the Arabic Wellbeing Course as acceptable, and 70% of those who completed follow-up questionnaires reported accessing the course in both English and Arabic languages. Notwithstanding the limitations of an open trial design, these results are encouraging and indicate that culturally modified clinician-guided internet-delivered versions of Western psychological interventions have the potential for increasing access to treatment for Arabic-speaking Australians, and potentially other groups

A feasibility open trial of guided Internet-delivered cognitive behavioural therapy for anxiety and depression amongst Arab Australians

The present study examined the preliminary efficacy and acceptability of a culturally modified therapist-guided cognitive behaviour therapy (CBT) treatment for Arab Australians, aged 18 years and over with symptoms of depression and anxiety. To facilitate ease of use, the treatment was delivered via the Internet (Internet CBT; iCBT). Eleven participants with at least mild symptoms of depression (Patient Health Questionnaire 9-item (PHQ-9) total scores  > 4 ) or anxiety (Generalised Anxiety Disorder 7-item (GAD-7) total scores > 4 ) accessed the online Arab Wellbeing Course, which consisted of five online lessons delivered over 8 weeks. Measures of depression, anxiety, distress and disability were gathered at pre-treatment, post-treatment and 3-month follow-up. Data were analysed using mixed-linear model analyses. Ninety-one percent (10/11) of participants completed the five lessons over 8 weeks, with 10/11 providing post-treatment and 3-month follow-up data. Participants improved significantly across all outcome measures, with large within-group effect sizes based on estimated marginal means (Cohen's d) at post-treatment (d = 1.08 to 1.74) and 3-month follow-up (d = 1.53 to 2.00). The therapist spent an average of 90.72 min (SD = 28.98) in contact, in total, with participants during the trial. Participants rated the Arab Wellbeing Course as acceptable. Caution is needed in interpreting the results of the current study given the small sample size employed, raising questions about the impact of levels of acculturation and the absence of a control group. However, the results are encouraging and indicate that, with minor modifications, western psychological interventions have the potential to be of benefit to English speaking Arab immigrants

Intergenerational and cross-cultural differences in emotional wellbeing, mental health service utilisation, treatment-seeking preferences and acceptability of psychological treatments for Arab Australians

BACKGROUND: Little is known about the intergenerational and cross-cultural differences in emotional wellbeing and acceptability of psychological treatments for Arab Australians. AIM: To contribute to the emerging data about the mental health status and needs of Arab Australians. METHOD: An Internet survey examined psychological distress and functional impairment as measured by the Kessler 10 Item scale (K-10) and the Sheehan Disability Scale (SDS) among Arab Australians. Additional questions enquired about their help-seeking behaviours, barriers to accessing psychological treatments and preferences for delivery of psychological treatments. A total of 252 participants were recruited through public talks, media and online promotions. RESULTS: Forty-three percent of the respondents reported moderate-to-severe functional impairment (M = 9.5; standard deviation (SD) = 1.8), 32% reported high psychological distress (M = 28.5; SD = 5.4) and 30% were born overseas. First-generation Arab Australians experiencing high psychological distress (i.e. K-10 ≥ 22), reported a greater preference for Internet-delivered treatment when compared to their second-generation counterparts. Only 18% of the sample reported seeking help from a mental health professional in the past year. The significant barriers reported by respondents with high psychological distress were poor mental health literacy, lack of time and stigma. Respondents preferred face-to-face (90%) over Internet-delivered treatment (55%). Finally, Arab Australians experienced higher psychological distress and underutilised mental health services when compared to the Australian population. CONCLUSION: Targeted public health campaigns that make culturally relevant interventions such as modifying existing Internet-delivered treatment for Arab Australians may reduce barriers and increase treatment options for this population.8 page(s