Internet Treatment for Depression: A Randomized Controlled Trial Comparing Clinician vs. Technician Assistance

Background Internet-based cognitive behavioural therapy (iCBT) for depression is effective when guided by a clinician, less so if unguided. Question: Would guidance from a technician be 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 141 participants with major depressive disorder were randomized. Participants in the clinician- and technician-assisted groups received access to an iCBT program for depression comprising 6 online lessons, weekly homework assignments, and weekly supportive contact over a treatment period of 8 weeks. Participants in the clinician-assisted group also received access to a moderated online discussion forum. The main outcome measures were the Beck Depression Inventory (BDI-II) and the Patient Health Questionnaire-9 Item (PHQ-9). Completion rates were high, and at post-treatment, both treatment groups reduced scores on the BDI-II (p<0.001) and PHQ-9 (p<0.001) compared to the delayed treatment group but did not differ from each other. Within group effect sizes on the BDI-II were 1.27 and 1.20 for the clinician- and technician-assisted groups respectively, and on the PHQ-9, were 1.54 and 1.60 respectively. At 4-month follow-up participants in the technician group had made further improvements and had significantly lower scores on the PHQ-9 than those in the clinician group. A total of approximately 60 minutes of clinician or technician time was required per participant during the 8-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 depression. This form of treatment has potential to increase the capacity of existing mental health services.9 page(s

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.6 page(s

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

Internet-based trauma-focused cognitive behavioural therapy for PTSD with and without exposure components : a randomised controlled trial

Background: Internet-delivered trauma-focused cognitive behavioural therapy is efficacious for PTSD; however, no studies have investigated the roles of individual treatment components or the safety of online treatments. Aims: To compare the efficacy and safety of an online treatment for PTSD comprised of psychoeducation, stress management, cognitive restructuring and exposure components with the equivalent protocol without the exposure components, using a randomised controlled trial design. Methods: Sixty-six individuals were randomised to a non-exposure condition and 59 to the full protocol with exposure components. Treatment duration was 8 weeks and pre-, post-treatment and three-month follow-up outcomes were analysed using a mixed linear modelling approach. Results: Both groups achieved improvements in symptoms with no differences between groups on any primary or secondary outcome measures, diagnostic remission rates or adverse events. Limitations: The study included several secondary measures that have not been previously validated and treatments were not time matched in terms of number of lessons. Conclusions: These findings indicate that trauma-focused cognitive behavioural therapy for PTSD with or without exposure components can be safe and efficacious.8 page(s

An Internet administered treatment program for obsessive-compulsive disorder: A feasibility study

The present study evaluates efficacy of a new Internet-administered cognitive behavioral therapy (CBT) protocol, The OCD Program, designed to treat obsessive-compulsive disorder (OCD) remotely. This protocol comprises 8 online lessons delivered over 8 weeks and incorporates cognitive and behavioral techniques. Twenty-two individuals with a principal diagnosis of OCD received CBT-based online lessons, homework assignments, twice 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 21/21 (100%) and 19/21 (91%) participants, respectively. Participants improved significantly on the primary outcome measures, the Yale-Brown Obsessive Compulsive Scale and Obsessive Compulsive Inventory-Revised, with within-groups effect sizes (Cohen's d) at follow-up of 1.28 and 0.60, respectively. Participants rated the procedure as highly acceptable despite receiving an average of only 86 min (SD = 54.4 min) telephone contact with the therapist over the 8 weeks. These results provide preliminary support for efficacy of Internet-administered treatment for obsessive-compulsive disorder

An Internet administered treatment program for obsessive-compulsive disorder : a feasibility study

The present study evaluates efficacy of a new Internet-administered cognitive behavioral therapy (CBT) protocol, The OCD Program, designed to treat obsessive-compulsive disorder (OCD) remotely. This protocol comprises 8 online lessons delivered over 8 weeks and incorporates cognitive and behavioral techniques. Twenty-two individuals with a principal diagnosis of OCD received CBT-based online lessons, homework assignments, twice 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 21/21 (100%) and 19/21 (91%) participants, respectively. Participants improved significantly on the primary outcome measures, the Yale-B rown Obsessive Compulsive Scale and Obsessive Compulsive Inventory-Revised, with within-groups effect sizes (Cohen's d) at follow-up of 1.28 and 0.60, respectively. Participants rated the procedure as highly acceptable despite receiving an average of only 86 min (SD= 54.4. min) telephone contact with the therapist over the 8 weeks. These results provide preliminary support for efficacy of Internet-administered treatment for obsessive-compulsive disorder.6 page(s

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.10 page(s

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

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