Publications by authors named "Heather D Hadjistavropoulos"

79 Publications

Brief online motivational interviewing pre-treatment intervention for enhancing internet-delivered cognitive behaviour therapy: A randomized controlled trial.

Internet Interv 2021 Sep 20;25:100394. Epub 2021 Apr 20.

MindSpot Clinic, Department of Psychology, Macquarie University, Sydney, Australia.

While the efficacy of therapist-guided internet-delivered cognitive behaviour therapy (iCBT) for anxiety and depression is well-established, a significant proportion of clients show little to no improvement with this approach. Given that motivational interviewing (MI) is found to enhance face-to-face treatment of anxiety, the current trial examined potential benefits of a brief online MI intervention prior to therapist-guided iCBT. Clients applying to transdiagnostic therapist-guided iCBT in routine care were randomly assigned to receive iCBT with ( = 231) or without ( = 249) the online MI pre-treatment. Clients rated motivation at screening and pre-iCBT and anxiety and depression at pre- and post-treatment and at 13- and 25-week follow-up after enrollment. Clients in the MI plus iCBT group made more motivational statements in their emails and were enrolled in the course for a greater number of days compared to clients who received iCBT only, but did not demonstrate higher motivation after completing the MI intervention or have higher course completion. Clients in both groups, at screening and pre-iCBT, reported high levels of motivation. No statistically significant group differences were found in the rate of primary symptom change over time, with both groups reporting large reductions in anxiety and depression pre- to post-treatment (Hedges' range = 0.96-1.11). During follow-up, clients in the iCBT only group reported additional small reductions in anxiety, whereas clients in the MI plus iCBT group did not. The MI plus iCBT group also showed small increases in depression during follow-up, whereas improvement was sustained for the iCBT only group. It is concluded that online MI does not appear to enhance client outcomes when motivation at pre-treatment is high.
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http://dx.doi.org/10.1016/j.invent.2021.100394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099490PMC
September 2021

Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data.

Lancet Psychiatry 2021 Jun 3;8(6):500-511. Epub 2021 May 3.

Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway.

Background: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom.

Methods: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683.

Findings: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components.

Interpretation: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package.

Funding: Japan Society for the Promotion of Science.
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http://dx.doi.org/10.1016/S2215-0366(21)00077-8DOI Listing
June 2021

Initial Outcomes of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy Tailored to Public Safety Personnel: Longitudinal Observational Study.

J Med Internet Res 2021 May 5;23(5):e27610. Epub 2021 May 5.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia.

Background: Canadian public safety personnel (PSP) experience high rates of mental health disorders and face many barriers to treatment. Internet-delivered cognitive behavioral therapy (ICBT) overcomes many such barriers, and is effective for treating depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms.

Objective: This study was designed to fill a gap in the literature regarding the use of ICBT tailored specifically for PSP. We examined the effectiveness of a tailored ICBT program for treating depression, anxiety, and PTSD symptoms among PSP in the province of Saskatchewan.

Methods: We employed a longitudinal single-group open-trial design (N=83) with outcome measures administered at screening and at 8 weeks posttreatment. Data were collected between December 5, 2019 and September 11, 2020. Primary outcomes included changes in depression, anxiety, and PTSD symptoms. Secondary outcomes included changes in functional impairment; symptoms of panic, social anxiety, and anger; as well as treatment satisfaction, working alliance, and program usage patterns.

Results: Clients reported large symptom reductions on measures of depression and anxiety, as well as moderate reductions on measures of PTSD and secondary symptoms, except for social anxiety. Most clients who reported symptoms above clinical cut-offs on measures of depression, anxiety, and PTSD during screening experienced clinically significant symptom reductions. Results suggested good engagement, treatment satisfaction, and working alliance.

Conclusions: Tailored, transdiagnostic ICBT demonstrated promising outcomes as a treatment for depression, anxiety, and PTSD among Saskatchewan PSP and warrants further investigation.

Trial Registration: Clinicaltrials.gov NCT04127032; https://www.clinicaltrials.gov/ct2/show/NCT04127032.
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http://dx.doi.org/10.2196/27610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8135031PMC
May 2021

Exploring the Role of Persuasive Design in Unguided Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Adults: Systematic Review, Meta-analysis, and Meta-regression.

J Med Internet Res 2021 Apr 29;23(4):e26939. Epub 2021 Apr 29.

Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden.

Background: Internet-delivered cognitive behavioral therapy (ICBT) is an effective treatment that can overcome barriers to mental health care. Various research groups have suggested that unguided ICBT (ie, ICBT without therapist support) and other eHealth interventions can be designed to enhance user engagement and thus outcomes. The persuasive systems design framework captures most design recommendations for eHealth interventions, but there is little empirical evidence that persuasive design is related to clinical outcomes in unguided ICBT.

Objective: This study aims to provide an updated meta-analysis of randomized controlled trials of unguided ICBT for depression and anxiety, describe the frequency with which various persuasive design principles are used in such interventions, and use meta-regression to explore whether a greater number of persuasive design elements predicts efficacy in unguided ICBT for depression and anxiety.

Methods: We conducted a systematic review of 5 databases to identify randomized controlled trials of unguided ICBT for depression and anxiety. We conducted separate random effects meta-analyses and separate meta-regressions for depression and anxiety interventions. Each meta-regression included 2 steps. The first step included, as a predictor, whether each intervention was transdiagnostic. For the meta-regression of ICBT for depression, the first step also included the type of control condition. The number of persuasive design principles identified for each intervention was added as a predictor in the second step to reveal the additional variance in effect sizes explained by persuasive design.

Results: Of the 4471 articles we identified in our search, 46 (1.03%) were eligible for inclusion in our analyses. Our meta-analyses showed effect sizes (Hedges g) ranging from 0.22 to 0.31 for depression interventions, depending on the measures taken to account for bias in the results. We found a mean effect size of 0.45 (95% CI 0.33-0.56) for anxiety interventions, with no evidence that the results were inflated by bias. Included interventions were identified as using between 1 and 13 persuasive design principles, with an average of 4.95 (SD 2.85). The meta-regressions showed that a greater number of persuasive design principles predicted greater efficacy in ICBT for depression (R change=0.27; B=0.04; P=.02) but not anxiety (R change=0.05; B=0.03; P=.17).

Conclusions: These findings show wide variability in the use of persuasive design in unguided ICBT for depression and anxiety and provide preliminary support for the proposition that more persuasively designed interventions are more efficacious, at least in the treatment of depression. Further research is needed to clarify the role of persuasive design in ICBT.
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http://dx.doi.org/10.2196/26939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8120424PMC
April 2021

Utilization, Patient Characteristics, and Longitudinal Improvements among Patients from a Provincially Funded Transdiagnostic Internet-delivered Cognitive Behavioural Therapy Program: Observational Study of Trends over 6 Years: Utilisation, caractéristiques des patients et améliorations longitudinales chez les patients d'un programme de thérapie cognitivo-comportementale financé par la province, transdiagnostique et dispensé par internet: Une étude observationnelle des tendances sur six ans.

Can J Psychiatry 2021 Apr 12:7067437211006873. Epub 2021 Apr 12.

eCentre Clinic, Department of Psychology, 7788Macquarie University, Sydney, Australia.

Objective: There is strong evidence supporting internet-delivered cognitive behaviour therapy (iCBT) and consequently growing demand for iCBT in Canada. Transdiagnostic iCBT that addresses both depression and anxiety is particularly promising as it represents an efficient method of delivering iCBT in routine care. The Online Therapy Unit, funded by the Saskatchewan government, has been offering transdiagnostic iCBT for depression and anxiety since 2013. In this article, to broadly inform implementation efforts, we examined trends in utilization, patient characteristics, and longitudinal improvements for patients receiving transdiagnostic iCBT over 6 years.

Methods: Patients who completed telephone screening between November 2013 and December 2019 were included in this observational study. Patients provided demographics and mental health history at screening and completed measures at pre-treatment, post-treatment and at 3- to 4-month follow-up. Treatment engagement and satisfaction were assessed.

Results: A total of 5,321 telephone screenings were completed and 4,283 of patients were accepted for treatment over the 6-year period (80.5% acceptance). The most common reason for referral to another service was high suicide risk/severe symptoms (47.1%). Examination of trends showed growing use of transdiagnostic iCBT over time (37% increase per year). There was remarkable stability in patient characteristics across years. Most patients were concurrently using medication (57.3%) with 11.9% reporting using iCBT while on a waiting list for face-to-face treatment highlighting the importance of integrating iCBT with other services. Consistent across years, large improvements in depression and anxiety symptoms were found and maintained at 3- to 4-month follow-up. There was strong patient engagement with iCBT and positive ratings of treatment experiences.

Conclusions: As there is growing interest in iCBT in Canada, this large observational study provides valuable information for those implementing iCBT in terms of likely user characteristics, patterns of use, and improvements. This information has potential to assist with resource allocation and planning in Canada and elsewhere.
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http://dx.doi.org/10.1177/07067437211006873DOI Listing
April 2021

Associations Between Burnout and Mental Disorder Symptoms Among Nurses in Canada.

Can J Nurs Res 2020 Dec 6:844562120974194. Epub 2020 Dec 6.

Department of Psychology, University of Regina, Regina, Canada.

Background: Nurses appear to be at a greater risk of burnout compared to other medical professionals. Higher levels of burnout are significantly associated with higher levels of anxiety, stress, and depression symptoms.

Purpose: The current study was designed to estimate levels of burnout among Canadian nurses, examine the association between burnout and mental disorder symptoms, and identify characteristics that may increase the risk for reporting symptoms of burnout.

Method: Canadian nurses ( = 3257; 94.3% women) were surveyed online in both English and French. The survey assessed current symptoms of burnout and mental disorders (i.e., Posttraumatic Stress Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, Panic Disorder).

Results: Most nurses (63.2%) reported at least some symptoms of burnout and many (29.3%) reported clinically significant levels of burnout. Age and years of service were the only demographic variables that explained burnout rates. Participants reporting clinically significant levels of burnout were significantly more likely than participants with no burnout to screen positive for all mental disorders, but particularly for Major Depressive Disorder.

Conclusions: Monitoring burnout may be an effective way to identify nurses at risk of developing symptoms of mental disorders. Younger and early-career nurses are an important group to target for prevention programs.
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http://dx.doi.org/10.1177/0844562120974194DOI Listing
December 2020

User characteristics and outcomes from a national digital mental health service: an observational study of registrants of the Australian MindSpot Clinic.

Lancet Digit Health 2020 11 19;2(11):e582-e593. Epub 2020 Oct 19.

MindSpot Clinic, Macquarie University, Sydney, NSW, Australia.

Background: Interest is growing in digital and telehealth delivery of mental health services, but data are scarce on outcomes in routine care. The federally funded Australian MindSpot Clinic provides online and telephone psychological assessment and treatment services to Australian adults. We aimed to summarise demographic characteristics and treatment outcomes of patients registered with MindSpot over the first 7 years of clinic operation.

Methods: We used an observational design to review all patients who registered for assessment with the MindSpot Clinic between Jan 1, 2013, and Dec 31, 2019. We descriptively analysed the demographics, service preferences, and baseline symptoms of patients. Among patients enrolled in a digital treatment course, we evaluated scales of depression (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder 7-Item Scale [GAD-7]), as primary measures of treatment outcome, from the screening assessment to post-treatment and a 3 month follow-up. The Kessler Psychological Distress 10-Item Plus Scale was also used to assess changes in general distress and disability, and course satisfaction was measured post-treatment.

Outcomes: A total of 121 652 screening assessments were started, of which 96 018 (78·9%) were completed. The mean age of patients was 35·7 years (SD 13·8) and 88 702 (72·9%) were women. Based on available assessment data, 36 866 (34·5%) of 106 811 participants had never previously spoken to a health professional about their symptoms, and most people self-reported symptoms of anxiety (88 879 [81·9%] of 108 494) or depression (78 803 [72·6%] of 108 494), either alone or in combination, at baseline. 21 745 patients started treatment in a therapist-guided online course, of whom 14 503 (66·7%) completed treatment (≥four of five lessons). Key trends in service use included an increase in the proportion of people using MindSpot primarily for assessment and information, from 52·6% in 2013 to 66·7% in 2019, while the proportion primarily seeking online treatment decreased, from 42·6% in 2013 to 26·7% in 2019. Effect sizes and percentage changes were large for estimated mean scores on the PHQ-9 and GAD-7 from assessment to post-treatment (PHQ-9, Cohen's d effect size 1·40 [95% CI 1·37-1·43]; and GAD-7, 1·45 [1·42-1·47]) and the 3 month follow-up (PHQ-9, 1·36 [1·34-1·38]; and GAD-7, 1·42 [1·40-1·44]); proportions of patients with reliable symptom deterioration (score increase of ≥6 points [PHQ-9] or ≥5 points [GAD-7]) were low post-treatment (of 13 058 respondents, 184 [1·4%] had symptom deterioration on the PHQ-9 and 282 [2·2%] on the GAD-7); and patient satisfaction rates were high (12 452 [96·6%] of 12 895 respondents would recommend the course and 12 433 [96·7%] of 12 860 reported the course worthwhile). We also observed small improvements in disability following treatment as measured by days out of role.

Interpretation: Our findings indicate improvement in psychological symptoms and positive reception among patients receiving online mental health treatment. These results support the addition of digital services such as MindSpot as a component in contemporary national mental health systems.

Funding: None.
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http://dx.doi.org/10.1016/S2589-7500(20)30224-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571905PMC
November 2020

Understanding Problems With Sleep, Sexual Functioning, Energy, and Appetite Among Patients Who Access Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Anxiety and Depression: Qualitative Exploratory Study.

JMIR Form Res 2020 Oct 13;4(10):e15037. Epub 2020 Oct 13.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia.

Background: Transdiagnostic internet-delivered cognitive behavioral therapy (T-ICBT) is an effective treatment for anxiety and depression, and nowadays, there is interest in exploring ways to optimize T-ICBT in routine care. T-ICBT programs are designed to address the primary cognitive-affective and behavioral symptoms of anxiety and depression (eg, low mood, worry, anhedonia, and avoidance). Treatment also has the potential to resolve other symptom concerns (eg, sleep disruption, sexual dysfunction, lack of energy, and appetite or weight changes). Having additional information regarding the extent of these concerns and how concerns change over time could prove beneficial for further development of T-ICBT in routine care.

Objective: This exploratory formative study aims to better understand sleep, sexual functioning, energy, and appetite concerns among T-ICBT clients seeking treatment for depression and anxiety. A qualitative analytic approach was used to identify themes in the symptom concerns reported by patients in the areas of sleep, sexual functioning, energy, and appetite at the time of enrollment. Patient responses to related items from screening measures for anxiety and depression were also examined pre- and posttreatment.

Methods: Patients in routine care who applied for a T-ICBT program for depression and anxiety over a 1-year period were included in this study. As part of the application and screening process, participants completed depression and anxiety symptom measures (ie, 9-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder scale). These same measures were administered posttreatment. Subsequently, they were asked if they were experiencing any problems with sleep, sexual activity, energy, or appetite (yes or no). If their response was yes, they were presented with an open-ended comment box that asked them to describe the problems they had experienced in those areas.

Results: A total of 462 patients were admitted to T-ICBT during the study period, of which 438 endorsed having some problems with sleep, sexual activity, energy, or appetite. The analysis of open-ended responses indicated that 73.4% (339/462) of patients reported sleep problems (eg, difficulty initiating or maintaining sleep), 69.3% (320/462) of patients reported problems with energy or motivation (eg, tiredness and low motivation), 57.4% (265/462) of patients reported appetite or body weight concerns (eg, changes in appetite and weight loss or gain), and 30.1% (139/462) of patients described concerns with sexual functioning (eg, loss of interest in sex and difficulty with arousal). Item analysis of symptom measures demonstrated that T-ICBT produced improvements in sleep, energy, and appetite in 8 weeks. Sexual dysfunction and weight changes were not represented in the screening measures, so it remains unclear what effect T-ICBT has on these symptoms.

Conclusions: Sleep disruption, lack of energy, appetite or weight changes, and sexual dysfunction are common concerns reported by clients enrolled in T-ICBT in routine practice and may deserve greater attention in T-ICBT program development and administration.
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http://dx.doi.org/10.2196/15037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592064PMC
October 2020

Exploring Perceptions of Internet-Delivered Cognitive Behaviour Therapy among Public Safety Personnel: Informing Dissemination Efforts.

Int J Environ Res Public Health 2020 08 19;17(17). Epub 2020 Aug 19.

Department of Psychology, University of Regina, 3737 Wascana Pkwy, Regina, SK S4S 0A2, Canada.

Public safety personnel (PSP) experience high rates of mental health disorders but have limited access to treatment. To improve treatment access, there is a growing interest in offering internet-delivered cognitive behaviour therapy (ICBT) to PSP. As attitudes towards ICBT can both impact and inform ICBT implementation efforts, this study examines perceptions of ICBT among PSP who viewed a poster (a commonly used method of advertising ICBT) or a poster supplemented with a story of a PSP who benefitted from ICBT. Participants ( = 132) from various PSP sectors were randomly assigned to view a poster or a poster and a story. Participants then completed an online survey assessing their perceptions of ICBT using both qualitative and quantitative questions. We used a mixed-methods approach to analyze the data. No differences in perceptions of ICBT were identified between the conditions. Ratings of credibility, treatment expectancy, anticipated treatment adherence, and acceptability suggested that PSP had positive perceptions of ICBT. Most participants (93%) reported that they would access ICBT if they needed help with mental health concerns. Participants ranked therapist-guided ICBT as their second most preferred treatment, with psychologists ranked first. Female participants found ICBT more credible than male participants. More experienced PSP reported lower acceptability and anticipated adherence to ICBT. The findings suggest that many PSP are likely to be receptive to ICBT even when a simple poster is used as a method of informing PSP of this treatment option. Further attention to improving the perceptions of ICBT among certain groups may be warranted.
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http://dx.doi.org/10.3390/ijerph17176026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7503620PMC
August 2020

The complex association of barriers and interest in internet-delivered cognitive behavior therapy for depression and anxiety: informing e-health policies through exploratory path analysis.

J Ment Health 2020 Jul 25:1-10. Epub 2020 Jul 25.

Johnson Shoyama Graduate School of Public Policy, University of Regina, Regina, Canada.

Background: Internet-delivered cognitive behavioral therapy (ICBT) provides critical remote access to mental health care to at-risk populations. However, to our knowledge, no investigation has been conducted to understand complex pathways through which barriers to care (i.e. structural, attitudinal and technological) correlate with patient interest in ICBT.

Aim: The objective of this study is to develop and test a pathway analysis framework using structural equation modeling to understand direct and mediating associations of barriers to care with interest in ICBT.

Methods: This cross-sectional observational study was conducted among adult (>18 years) urban and rural residents ( = 200) in Saskatchewan, Canada. An online survey assessed interest in ICBT, barriers to ICBT, demographics, and depression and anxiety symptoms. Utilizing structural equation modeling, a path analysis framework was developed.

Results: Path analysis results showed how associations between complex barriers and demographic variables correlate with interest in ICBT. For instance, the negative association of perceived financial concerns and life chaos on interest in ICBT was mediated by perceived access to care.

Conclusion: The findings identify specific barriers that could be addressed through targeted population health interventions to improve uptake of ICBT.
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http://dx.doi.org/10.1080/09638237.2020.1793125DOI Listing
July 2020

Mixed-method evaluation of an online motivational intervention as a pre-treatment to internet-delivered cognitive behaviour therapy: Immediate benefits and user feedback.

Internet Interv 2020 Apr 21;20:100311. Epub 2020 Feb 21.

Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada.

•An online MI intervention was recently developed to complement ICBT.•Intervention consists of videos, exercises, feedback to better simulate face-to-face MI.•Study evaluated intervention impact on motivation and perceptions of MI.•Ratings of motivation and MI perceptions significantly increased from pre- to post-MI.•Future research should explore longer term impact of online MI on ICBT.
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http://dx.doi.org/10.1016/j.invent.2020.100311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7052510PMC
April 2020

Stakeholder Perceptions of Internet-Delivered Cognitive Behavior Therapy as a Treatment Option for Alcohol Misuse: Qualitative Analysis.

JMIR Ment Health 2020 Mar 3;7(3):e14698. Epub 2020 Mar 3.

Online Therapy Unit, Department of Psychology, University of Regina, Regina, SK, Canada.

Background: Internet-delivered cognitive behavior therapy (ICBT) has been found to be effective for treating alcohol misuse in research trials, but it is not available as part of routine care in Canada. Recent recommendations in the literature highlight the importance of integrating perspectives from both patient and health care stakeholders when ICBT is being implemented in routine practice settings.

Objective: This study aimed to gain an understanding of how ICBT is perceived as a treatment option for alcohol misuse by interviewing diverse stakeholders. Specifically, the objectives were to (1) learn about the perceived advantages and disadvantages of ICBT for alcohol misuse and (2) elicit recommendations to inform implementation efforts in routine practice.

Methods: A total of 30 participants representing six stakeholder groups (ie, patients, family members, academic experts, frontline managers, service providers, and health care decision makers) participated in semistructured interviews. To be included in the study, stakeholders had to reside in Saskatchewan, Canada, and have personal or professional experience with alcohol misuse. Interviews were transcribed verbatim, anonymized, and analyzed using thematic analysis.

Results: Stakeholders identified numerous advantages of ICBT for alcohol misuse (eg, accessibility, convenience, privacy, relevance to technology-based culture, and fit with stepped care) and several disadvantages (eg, lack of internet access and technological literacy, isolation, less accountability, and unfamiliarity with ICBT). Stakeholders also provided valuable insight into factors to consider when implementing ICBT for alcohol misuse in routine practice. In terms of intervention design, stakeholders recommended a 6- to 8-week guided program that uses Web-based advertising, point-of-sale marketing, and large-scale captive audiences to recruit participants. With regard to treatment content, stakeholders recommended that the program focus on harm reduction rather than abstinence; be evidence based; appeal to the diverse residents of Saskatchewan; and use language that is simple, encouraging, and nonjudgmental. Finally, in terms of population characteristics, stakeholders felt that several features of the alcohol misuse population, such as psychiatric comorbidity, readiness for change, and stigma, should be considered when developing an ICBT program for alcohol misuse.

Conclusions: Stakeholders' insights will help maximize the acceptability, appropriateness, and adoption of ICBT for alcohol misuse and in turn contribute to implementation success. The methodology and findings from this study could be of benefit to others who are seeking to implement ICBT in routine practice.
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http://dx.doi.org/10.2196/14698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7078623PMC
March 2020

Audit and feedback of therapist-assisted internet-delivered cognitive behaviour therapy within routine care: A quality improvement case study.

Internet Interv 2020 Apr 6;20:100309. Epub 2020 Feb 6.

MindSpot Clinic and eCentreClinic, Department of Psychology, Macquarie University, Balaclava Road, North Ryde, NSW, Australia.

With the growing use of ICBT in routine care clinics there is a need for literature on how to monitor and improve the quality of therapist behaviours in clinical practice. In this paper, we first provide background literature on Audit and Feedback (A&F), a common quality improvement technique, and then present a case study regarding the use of A&F to improve quality of therapist behaviours in emails sent to patients provided with ICBT in routine care. The A&F measure used was derived from previous research on therapist's email behaviours in ICBT. Fifteen undesirable therapist behaviours (e.g., ) were audited in 1840 emails sent from eight therapists to 198 randomly selected patients, representing 18% of 1114 patients who started between one and five lessons of ICBT in the previous year and did not formally withdraw from treatment ( = 31 patients). The therapists who were audited were provided feedback four times over a one-year period from October 2018 to September 2019. Overall, in all audit periods, we found a low percentage of undesirable therapist behaviours (i.e., therapists displayed the behaviour in 12% or less of the total emails sent). For most therapist behaviours, we saw a trend towards improvement across the four audit cycles. Three therapist behaviours (i.e., , , ) did not follow this pattern and were flagged for clinical discussion to determine why behaviours were elevated and whether these behaviours represented unrealistic expectations. The process was valuable for monitoring and improving therapist behaviours and highlights the need for future research on standards for therapist behaviours (e.g., which behaviours to focus on, setting acceptable levels of undesirable behaviour).
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http://dx.doi.org/10.1016/j.invent.2020.100309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011000PMC
April 2020

Does concurrent medication usage affect patient response to internet-delivered cognitive behaviour therapy for depression and anxiety?

Internet Interv 2020 Mar 29;19:100302. Epub 2019 Dec 29.

Online Therapy Unit, Department of Psychology, University of Regina, Regina, SK, Canada.

Background: There is growing interest in Internet-delivered cognitive behavioural therapy (ICBT) as an alternative to face-to-face therapy for anxiety and depression because it reduces barriers to accessing traditional treatment (e.g., travel distance, cost, stigma). Extensive research has demonstrated that ICBT is an effective treatment for anxiety and depression and that it produces effect sizes comparable to medication and face-to-face therapy. In routine practice, however, ICBT patients commonly receive simultaneous pharmacological treatment, and few studies have examined how medication affects patient outcomes.

Objective: The objective of this study was to explore whether use of psychotropic medications predicts outcomes or adherence among patients receiving ICBT for depression and anxiety in a large community sample.

Methods: This study used data from 1201 patients who received an 8-week course of ICBT for anxiety and depression that included weekly therapist support as part of routine care. Patients reported medication usage and completed measures of depression and anxiety before treatment, after treatment, and at three-month follow-up.

Results: 60% of patients at pre-treatment reported regularly taking psychotropic medication. Common classes of medication reported included: (i) selective serotonin reuptake inhibitors (34%); (ii) anxiolytics (15%); (iii) serotonin and norepinephrine reuptake inhibitors (14%); (iv) antipsychotics (8%); and (v) norepinephrine-dopamine reuptake inhibitors (7%). At post-treatment and three-month follow-up, overall medication usage reduced slightly to 55%, with the greatest reduction seen in anxiolytics. Logistic regression revealed that none of the classes of medication commonly reported at pre-treatment were associated with study completion rates. A recursive partitioning algorithm found that usage of tetracyclic medication was related to smaller pre-to-post reductions in anxiety symptoms and did not identify any medication types that were related to differences in depressive symptom change. Patients on medication tended to report higher levels of anxiety symptoms at intake and experienced somewhat more modest symptom reductions than patients not taking medications; nevertheless, they still experienced large reductions in depression and anxiety over the course of treatment.

Conclusions: These results show that medication usage is very common in a diverse community sample of patients seeking ICBT for anxiety and depression. Patients reporting medication usage at intake are likely to benefit from treatment approximately as much as patients not taking medication. These results support the continued referral of patients receiving psychotropic medication to ICBT programs for anxiety and depression. Program designers might also consider providing information about the common medications (SSRIs, SNRIs, anxiolytics) used by this population alongside CBT materials.
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http://dx.doi.org/10.1016/j.invent.2019.100302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7016234PMC
March 2020

An Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Clients Referred and Funded by Insurance Companies Compared With Those Who Are Publicly Funded: Longitudinal Observational Study.

JMIR Ment Health 2020 Feb 4;7(2):e16005. Epub 2020 Feb 4.

MindSpot, Department of Psychology, Macquarie University, Sydney, Australia.

Background: Anxiety and depression are leading causes of disability but are often undertreated. Internet-delivered cognitive behavioral therapy (ICBT) improves access to treatment by overcoming barriers to obtaining care. ICBT has been found to be efficacious in research trials and routine care, but there is limited research of ICBT when it is recommended and funded by insurance companies for clients on or recently in receipt of disability benefits or accommodations.

Objective: The aim of this study was to examine ICBT engagement, treatment satisfaction, and effectiveness among individuals involved with 2 insurance companies. The 2 samples were benchmarked against published outcomes from a publicly funded (PF) ICBT clinic.

Methods: Individuals who were on or recently in receipt of disability benefits and were either insurance company (IC) employees (n=21) or IC plan members (n=19) were referred to ICBT funded by the respective insurance companies. Outcomes were benchmarked against outcomes of ICBT obtained in a PF ICBT clinic, with clients in the clinic divided into those who reported no involvement with insurance companies (n=414) and those who were on short-term disability (n=44). All clients received the same 8-week, therapist-assisted, transdiagnostic ICBT course targeting anxiety and depression. Engagement was assessed using completion rates, log-ins, and emails exchanged. Treatment satisfaction was assessed posttreatment. Depression, anxiety, and disability measures were administered pretreatment, posttreatment, and at 3 months.

Results: All samples showed high levels of ICBT engagement and treatment satisfaction. IC employees experienced significant improvement at posttreatment (depression d=0.77; anxiety d=1.13; and disability d=0.91) with outcomes maintained at 3 months. IC plan members, who notably had greater pretreatment disability than the other samples, experienced significant moderate effects at posttreatment (depression d=0.58; anxiety d=0.54; and disability d=0.60), but gains were not maintained at 3 months. Effect sizes at posttreatment in both IC samples were significantly smaller than in the PF sample who reported no insurance benefits (depression d=1.14 and anxiety d=1.30) and the PF sample who reported having short-term disability benefits (depression d=0.95 and anxiety d=1.07). No difference was seen in effect sizes among IC employees and the PF samples on disability. However, IC plan members experienced significantly smaller effects on disability d=0.60) compared with the PF sample with no disability benefits d=0.90) and those on short-term disability benefits d=0.94).

Conclusions: Many clients referred and funded by insurance companies were engaged with ICBT and found it acceptable and effective. Results, however, were not maintained among those with very high levels of pretreatment disability. Small sample sizes in the IC groups are a limitation. Directions for research related to ICBT funded by insurance companies have been described.
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http://dx.doi.org/10.2196/16005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058169PMC
February 2020

Guidance on defining the scope and development of text-based coaching protocols for digital mental health interventions.

Digit Health 2019 Jan-Dec;5:2055207619896145. Epub 2019 Dec 16.

Center for Behavioral Intervention Technologies, Northwestern University, Chicago, IL, USA.

A body of literature suggests that the provision of human support improves both adherence to and clinical outcomes for digital mental health interventions. While multiple models of providing human support, or coaching, to support digital mental health interventions have been introduced, specific guidance on how to develop coaching protocols has been lacking. In this Education Piece, we provide guidance on developing coaching protocols for text-based communication in digital mental health interventions. Researchers and practitioners who are tasked with developing coaching protocols are prompted to consider the scope of coaching for the intervention, the selection and training of coaches, specific coaching techniques, how to structure communication with clients and how to monitor adherence to guidelines, and quality of coaching. Our goal is to advance thinking about the provision of human support in digital mental health interventions to inform stronger, more engaging, and effective intervention designs.
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http://dx.doi.org/10.1177/2055207619896145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6920342PMC
December 2019

Negative effects associated with internet-delivered cognitive behaviour therapy: An analysis of client emails.

Internet Interv 2019 Dec 4;18:100278. Epub 2019 Sep 4.

MindSpot Clinic and eCentreClinic, Department of Psychology, Macquarie University, Balaclava Road, North Ryde, NSW, Australia.

Internet-delivered cognitive behaviour therapy (ICBT) is an efficacious form of treatment for anxiety and depression, yet it is still possible for clients to experience negative effects associated with treatment. In the ICBT literature, the term negative effects is broadly used to refer to all potentially adverse or unwanted events or experiences that are perceived as undesirable by the client and may or may not be associated with long-term symptoms or distress. Previous ICBT studies have asked clients to retrospectively describe negative effects at post-treatment; however, no research has examined the content of clients' emails to their therapist to see whether clients are reporting negative effects as they arise. In the current study, 96 clients (80 completers; 16 non-completers) were randomly selected from a published ICBT trial and directed content analysis was used to examine client emails for mention of negative effects. In addition, correlational analyses were used to examine the relationship between negative effects and: 1) demographic characteristics; 2) treatment engagement; 3) treatment satisfaction; 4) working alliance; and 5) symptom outcomes among completers. The results indicated that 61.5% of clients experienced at least one negative effect during treatment, although total number of negative effects was not significantly correlated with client demographic characteristics, lessons completed, working alliance, treatment satisfaction, or symptom outcomes. Among completers, , , and were the most commonly reported negative effects, whereas was the most commonly reported negative effect by non-completers. Negative effects that have been identified in previous research, such as symptom deterioration, novel symptoms, and severe adverse events, were not identified in client emails. The high incidence of negative effects in the current study suggests there may be value in systematically monitoring client emails for negative effects throughout treatment as a supplement to retrospective post-treatment reports. This will give therapists the opportunity to intervene as negative effects occur and potentially mitigate any impact they have on treatment outcomes. Future research, both qualitative and quantitative, is needed to gain a more nuanced understanding of negative effects associated with ICBT.
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http://dx.doi.org/10.1016/j.invent.2019.100278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926340PMC
December 2019

Development of the Internet-Delivered Cognitive Behaviour Therapy Undesirable Therapist Behaviours Scale (ICBT-UTBS).

Internet Interv 2019 Dec 18;18:100255. Epub 2019 Jun 18.

MindSpot Clinic and eCentreClinic, Department of Psychology, Macquarie University, Balaclava Road, North Ryde, NSW, Australia.

Internet-delivered cognitive behaviour therapy (ICBT) is often provided with therapist assistance via asynchronous secure emails, but there is limited research on undesirable behaviours exhibited by therapists in their correspondence with patients. In this study, an ICBT-Undesirable Therapist Behaviour Scale (ICBT-UTBS) was developed and used to assess the nature, frequency, and correlates of undesirable therapist behaviours in routine practice. Thematic analysis was used to identify undesirable therapist behaviours in 720 emails sent to 91 randomly selected patients in the context of a previous clinical trial of transdiagnostic ICBT for depression and anxiety. The following undesirable behaviours were identified, albeit infrequently, in therapist emails: (6.4%), (4.0%), (0.6%), (0.6%), (0.6%), and (0.3%). At least one undesirable behaviour was found in 10.7% of all emails coded. Moreover, 37.4% of patients received at least one email containing an undesirable therapist behaviour. Number of undesirable therapist behaviours was not correlated with patient engagement, working alliance, treatment satisfaction, or patient outcome variables. However, undesirable therapist behaviours were negatively correlated with patient gender and therapist characteristics (e.g., clinical setting, therapist profession). The results of the present study provide preliminary psychometric support for the ICBT-UTBS, a measure of ICBT treatment integrity. In the future, the ICBT-UTBS should be used in combination with the ICBT-Therapist Rating Scale (ICBT-TRS), a measure of desirable or recommended therapist behaviours, for training purposes and to monitor ICBT therapists in routine practice.
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http://dx.doi.org/10.1016/j.invent.2019.100255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926341PMC
December 2019

A systematic review of internet-delivered cognitive behavior therapy for alcohol misuse: study characteristics, program content and outcomes.

Cogn Behav Ther 2020 07 10;49(4):327-346. Epub 2019 Oct 10.

Department of Psychology, University of Regina , Regina, Saskatchewan, Canada.

Alcohol misuse is a common, disabling and costly issue worldwide. Internet-delivered cognitive behavior therapy (ICBT) has the potential to reduce the harms of alcohol misuse, particularly for individuals who are unable or unwilling to access face-to-face therapy. A systematic review was conducted using Medline, CINAHL, EMBASE and PsycINFO databases for all relevant articles published from 1980 to January 2019. Randomized controlled trials (RCTs) were included if (i) an ICBT intervention targeting alcohol misuse was delivered; (ii) participants were aged 18 years or older; and (iii) primary outcomes were quantity of drinking. A qualitative analysis was conducted on the content of the ICBT programs. Fourteen studies met inclusion criteria. Most studies included participants from the general population, while studies conducted within clinic settings with diagnosed individuals were rare. The programs were similar in terms of included modules. Small effects were seen in studies on self-guided ICBT, while therapist-guided ICBT rendered small to large effects. The current review indicates that ICBT has a significant effect in reducing alcohol consumption. Larger studies evaluating ICBT compared to active control groups especially within clinic settings are warranted.
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http://dx.doi.org/10.1080/16506073.2019.1663258DOI Listing
July 2020

From Research to Practice: Ten Lessons in Delivering Digital Mental Health Services.

J Clin Med 2019 Aug 17;8(8). Epub 2019 Aug 17.

MindSpot Clinic and Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia.

There is a large body of research showing that psychological treatment can be effectively delivered via the internet, and Digital Mental Health Services (DMHS) are now delivering those interventions in routine care. However, not all attempts to translate these research outcomes into routine care have been successful. This paper draws on the experience of successful DMHS in Australia and Canada to describe ten lessons learned while establishing and delivering internet-delivered cognitive behavioural therapy (ICBT) and other mental health services as part of routine care. These lessons include learnings at four levels of analysis, including lessons learned working with (1) consumers, (2) therapists, (3) when operating DMHS, and (4) working within healthcare systems. Key themes include recognising that DMHS should provide not only treatment but also information and assessment services, that DMHS require robust systems for training and supervising therapists, that specialist skills are required to operate DMHS, and that the outcome data from DMHS can inform future mental health policy. We also confirm that operating such clinics is particularly challenging in the evolving funding, policy, and regulatory context, as well as increasing expectations from consumers about DMHS. Notwithstanding the difficulties of delivering DMHS, we conclude that the benefits of such services for the broader community significantly outweigh the challenges.
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http://dx.doi.org/10.3390/jcm8081239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6722769PMC
August 2019

Facilitating access to iCBT: a randomized controlled trial assessing a translated version of an empirically validated program using a minimally monitored delivery model.

Behav Cogn Psychother 2020 Mar 16;48(2):185-202. Epub 2019 Aug 16.

École de Psychologie, Université de Moncton, Canada.

Background: Despite its established efficacy, access to internet-delivered CBT (iCBT) remains limited in a number of countries. Translating existing programs and using a minimally monitored model of delivery may facilitate its dissemination across countries.

Aims: This randomized control trial aims to evaluate the efficacy of an iCBT transdiagnostic program translated from English to French and offered in Canada using a minimally monitored delivery model for the treatment of anxiety and depression.

Method: Sixty-three French speakers recruited in Canada were randomized to iCBT or a waiting-list. A French translation of an established program, the Wellbeing Course, was offered over 8 weeks using a minimally monitored delivery model. Primary outcome measures were the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9), which were obtained pre-treatment, post-treatment and at 3-month follow-up.

Results: Mixed-effects models revealed that participants in the treatment group had significantly lower PHQ-9 and GAD-7 scores post-treatment than controls with small between-groups effect sizes (d = 0.34 and 0.37, respectively). Within-group effect sizes on primary outcome measures were larger in the treatment than control group. Clinical recovery rates on the PHQ-9 and GAD-7 were significantly higher among the treatment group (40 and 56%, respectively) than the controls (13 and 16%, respectively).

Conclusions: The provision of a translated iCBT program using a minimally monitored delivery model may improve patients' access to treatment of anxiety and depression across countries. This may be an optimal first step in improving access to iCBT before sufficient resources can be secured to implement a wider range of iCBT services.
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http://dx.doi.org/10.1017/S135246581900047XDOI Listing
March 2020

Patient perspectives of Internet-delivered cognitive behavior therapy for psychosocial issues post spinal cord injury.

Rehabil Psychol 2019 Aug 8;64(3):351-359. Epub 2019 Apr 8.

eCentreClinic, Department of Psychology, Macquarie University.

Purpose: Many individuals with a spinal cord injury (SCI) report significant symptoms of depression and/or anxiety post-SCI; however, access to mental health services can be limited. The purpose of this study was to evaluate patient perspectives on the acceptability of an 8-week guided Internet-delivered cognitive behavior therapy (ICBT) course (Chronic Conditions Course) for people with SCI. In particular, we sought to understand patient perceptions of facilitators and barriers of engaging in ICBT and strengths and weaknesses of ICBT program content.

Method: Semistructured interviews were conducted with 8 SCI patients after completion of the ICBT course. The interviews were audio-recorded, transcribed verbatim, and examined by means of thematic analysis by 2 coders.

Results: Eight participants (mean age = 53.2 years; males = 50%; paraplegia = 67.5%) were interviewed. Four major themes emerged when examining facilitators to completing the program: accessibility, flexibility, motivation, and guided support. Barriers to completing the program included course timeframe and physical health. Strengths of the course included effective skill development and mental health prioritization. Suggested changes to the course included improved breadth of case stories, development of extra resources, adjusting the course timeframe to account for the SCI, and more support from the guide.

Conclusions: ICBT was overall highlighted as an acceptable method of receiving care for people with SCI. The study provides direction for improving delivery of ICBT to ensure this method of treatment meets the needs of individuals with SCI. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/rep0000276DOI Listing
August 2019

Transdiagnostic, internet-delivered cognitive behavior therapy for depression and anxiety: Exploring impact on health anxiety.

Internet Interv 2019 Mar 18;15:60-66. Epub 2019 Jan 18.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia.

Health anxiety is associated with significant personal distress and economic cost; as such, widely available and effective treatment options are crucial. Several studies suggest that Internet-delivered cognitive behavior therapy (ICBT) programs that specifically target health anxiety are efficacious for this condition. However, no known studies have examined the impact of transdiagnostic ICBT, which emphasizes the acquisition of broad coping skills applicable to a variety of mental health concerns, on symptoms of health anxiety. The current study sought to explore changes in health anxiety symptoms by utilizing data available from a previously published study of 8-week transdiagnostic ICBT. Specifically, changes in symptoms of health anxiety in response to a transdiagnostic ICBT program that targeted broad symptoms of depression and anxiety, were examined in a subsample of individuals who endorsed elevated symptom scores on the Short Health Anxiety Inventory at pre-treatment ( = 72). Following treatment, large reductions in health anxiety symptoms (Cohen's  = 0.91; 20% improvement), depression (Cohen's  = 0.85; reduction = 38%), generalized anxiety (Cohen's  = 1.21; reduction = 42%), and disability (Cohen's  = 0.90; reduction = 35%) were reported. Furthermore, results showed that transdiagnostic ICBT was rated as acceptable to people with high health anxiety symptoms. Despite elevated pre-treatment health anxiety scores, email correspondence between clients and their therapist revealed very few mentions of health anxiety. These findings provide preliminary evidence for transdiagnostic ICBT for symptoms of health anxiety and suggest further research is warranted.
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http://dx.doi.org/10.1016/j.invent.2019.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350228PMC
March 2019

What are Clients Asking Their Therapist During Therapist-Assisted Internet-Delivered Cognitive Behaviour Therapy? A Content Analysis of Client Questions.

Behav Cogn Psychother 2019 Jul 26;47(4):407-420. Epub 2019 Jan 26.

Department of Psychology,Macquarie University,Sydney,Australia.

Background: Although internet-delivered cognitive behaviour therapy (ICBT) yields large clinical outcomes when accompanied by therapeutic support, a portion of clients do not benefit from treatment. In ICBT, clients review treatment materials online typically on a weekly basis. A key component of therapist-assistance involves answering questions as clients review and work on assignments related to the treatment materials.

Aims: The goal of this study was to enhance understanding of the nature of client questions posed during ICBT and examine potential associations between the number of questions asked and treatment outcomes in order to provide insight into how to improve ICBT for future users.

Method: Content analysis was used to qualitatively analyse and identify questions that 80 clients asked their designated therapist over the course of an 8-week ICBT programme for anxiety and depression.

Results: On average, clients sent six emails during the course of treatment, of which less than two questions were asked. Of the 137 questions posed by clients, 46.72% reflected questions designed to enhance understanding and apply the material and techniques reviewed in the programme. Additional questions were categorized as clarifying the therapeutic process (22.62%), addressing technical challenges (18.25%), and seeking assistance with problems outside the scope of ICBT (12.41%). Number of client questions asked was not significantly correlated with the number of lessons completed, symptom change, or perceptions of therapeutic alliance.

Conclusions: Findings can inform future practitioners who deliver ICBT of what to expect with this treatment approach and also assist in the development of future ICBT programmes.
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http://dx.doi.org/10.1017/S1352465818000668DOI Listing
July 2019

Evaluating a Web-Based Social Anxiety Intervention Among Community Users: Analysis of Real-World Data.

J Med Internet Res 2019 01 10;21(1):e11566. Epub 2019 Jan 10.

Department of Psychology, University of British Columbia, Vancouver, BC, Canada.

Background: Social anxiety is both harmful and prevalent. It also currently remains among the most undertreated major mental disorders, due, in part, to socially anxious individuals' concerns about the stigma and expense of seeking help. The privacy and affordability of computer-aided psychotherapy interventions may render them particularly helpful in addressing these concerns, and they are also highly scalable, but most tend to be only somewhat effective without therapist support. However, a recent evaluation of a new self-guided, 7-module internet-delivered cognitive behavioral therapy intervention called Overcome Social Anxiety found that it was highly effective.

Objective: The initial evaluation of Overcome Social Anxiety revealed that it led to significant reductions in symptom severity among university undergraduates. The aim of this study was to extend the results of the initial study and investigate their generalizability by directly evaluating the intervention's effectiveness among a general community sample.

Methods: While signing up for Overcome Social Anxiety, users consented to the usage of their anonymized outcome data for research purposes. Before and after completing the intervention, users completed the Fear of Negative Evaluation Scale (FNE), which we employed as the primary outcome measure. Secondary outcome measures included the Depression Anxiety Stress Scales (DASS) and 2 bespoke questionnaires measuring socially anxious thoughts (Thoughts Questionnaire) and avoidance behaviors (Avoidance Questionnaire).

Results: Participants who completed the intervention (102/369, 27.7%) experienced significant reductions in the severity of their symptoms on all measures employed, including FNE (P<.001; Cohen d=1.76), the depression subscale of DASS (P<.001; Cohen d=0.70), the anxiety subscale of DASS (P<.001; Cohen d=0.74), the stress subscale of DASS (P<.001; Cohen d=0.80), the Thoughts Questionnaire (P<.001; Cohen d=1.46), and the Avoidance Questionnaire (P<.001; Cohen d=1.42).

Conclusions: Our results provide further evidence that Overcome Social Anxiety reduces the severity of social anxiety symptoms among those who complete it and suggest that its effectiveness extends to the general community. The completion rate is the highest documented for a fully automated intervention for anxiety, depression, or low mood in a real community sample. In addition, our results indicate that Overcome Social Anxiety reduces the severity of symptoms of depression, physiological symptoms of anxiety, and stress in addition to symptoms of social anxiety.
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http://dx.doi.org/10.2196/11566DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329899PMC
January 2019

Internet-delivered cognitive behaviour therapy for chronic health conditions: a systematic review and meta-analysis.

J Behav Med 2019 04 1;42(2):169-187. Epub 2018 Nov 1.

Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK, S4S 0A2, Canada.

This systematic review and meta-analysis aims to evaluate the effectiveness of internet-delivered cognitive behavioural therapy (ICBT) on anxiety and depression among persons with chronic health conditions. A systematic database search was conducted of MEDLINE, CINAHL, PsycInfo, EMBASE, and Cochrane for relevant studies published from 1990 to September 2018. A study was included if the following criteria were met: (1) randomized controlled trial involving an ICBT intervention; (2) participants experienced a chronic health condition; (3) participants ≥ 18 years of age; and (4) effects of ICBT on anxiety and/or depression were reported. The Cochrane Risk of Bias tool was used to assess the risk of bias on the included studies. Pooled analysis was conducted on the primary and condition specific secondary outcomes. Twenty-five studies met inclusion criteria and investigated the following chronic health conditions: tinnitus (n = 6), fibromyalgia (n = 3), pain (n = 7), rheumatoid arthritis (n = 3), cardiovascular disease (n = 2), diabetes (n = 1), cancer (n = 1), heterogeneous chronic disease population (n = 1), and spinal cord injury (n = 1). Pooled analysis demonstrated small effects of ICBT in improving anxiety and depression. Moderate effects of therapist-guided approach were seen for depression and anxiety outcomes; while, self-guided approaches resulted in small effects for depression and moderate effects in anxiety outcomes. ICBT shows promise as an alternative to traditional face-to-face interventions among persons with chronic health conditions. Future research on long-term effects of ICBT for individuals with chronic health conditions is needed.Trial Registration PROSPERO registration number: CRD42018087292.
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http://dx.doi.org/10.1007/s10865-018-9984-xDOI Listing
April 2019

Content of client emails in internet-delivered cognitive behaviour therapy: A comparison between two trials and relationship to client outcome.

Internet Interv 2018 Mar 1;11:53-59. Epub 2018 Feb 1.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia.

Many Internet-delivered cognitive behavioural therapy (ICBT) programs include email communication between clients and therapists as a part of treatment; yet relatively little is known about the nature and impact of this communication. Previous research conducted by Svartvatten et al. (2015) has identified 10 themes in written correspondence by clients accessing ICBT for depression. The current study examined: (1) if previously identified themes in client emails would be present in a shorter ICBT program for depression and anxiety; and (2) whether themes in emails similarly correlated with symptom improvement, lesson completion, and perceptions of working alliance. Using 80 randomly selected clients from a published ICBT trial (ISRCTN42729166; Hadjistavropoulos et al., 2016), client emails (average 5.69 per client) were examined for the presence of the themes reported by Svartvatten et al. (2015) and correlated with symptom improvement, lesson completion, perceptions of working alliance. Although most themes developed by Svartvatten et al. (2015) were identified in client emails, the frequency of themes differed between studies. Most notably, emails in the current study were more often coded as involving (~39% vs. 22% of statements) and (~25% vs. 6% of statements). Greater frequency of and were correlated with a greater number of lessons completed. In terms of symptom change, greater frequency of and in the emails were correlated with smaller improvements in anxiety, whereas was correlated with larger improvements in anxiety. Similarly, greater frequency of was correlated with smaller improvements in depression. Regarding perceptions of working alliance, more frequent statements of was correlated with higher alliance. The research provides clinicians and researchers with an improved understanding of the comparability and meaning of client communication in different ICBT programs. Experimental research is needed to better understand the role of client communication in ICBT.
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http://dx.doi.org/10.1016/j.invent.2018.01.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6084818PMC
March 2018

Development and evaluation of a scale assessing therapist fidelity to guidelines for delivering therapist-assisted Internet-delivered cognitive behaviour therapy.

Cogn Behav Ther 2018 11 25;47(6):447-461. Epub 2018 Apr 25.

c MindSpot Clinic and eCentreClinic, Department of Psychology , Macquarie University , Sydney , Australia.

Internet-delivered cognitive behaviour therapy (ICBT) is often accompanied by therapist emails, but there is limited research on the quality of this therapist-assistance. In this study, an ICBT Therapist Rating Scale (ICBT-TRS) was developed and evaluated to assess whether therapist emails showed fidelity to specific therapist behaviours. Using data from a previous ICBT trial for depression and anxiety, the ICBT-TRS was used to rate 706 emails sent by 39 therapists to 91 randomly selected patients. Emails were rated for adherence (absent/present) and quality (inadequate/competent) on the following behaviours: Builds Rapport, Seeks Feedback, Provides Symptom Feedback, Provides Psychoeducation, Facilitates Understanding, Praises Effort, Encourages Practice, Clarifies Administrative Procedures, and Communicates Effectively. Inter-rater reliability was high. Most behaviours were identified as present in 72-100% of emails, with the exception of Provides Symptom Feedback and Facilitating Understanding which were only present in 54 and 61% of emails. The majority of emails were rated as high quality (88-98% of messages). While not related to symptom improvement, ICBT-TRS ratings were higher when patients were more engaged in ICBT (e.g. log-ins) and among therapists who specialized in ICBT or had a background in Psychology. The ICBT-TRS has potential to facilitate ICBT research and clinical training.
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http://dx.doi.org/10.1080/16506073.2018.1457079DOI Listing
November 2018

Patient and provider perceptions of Internet-delivered cognitive behavior therapy for recent cancer survivors.

Support Care Cancer 2018 02 15;26(2):597-603. Epub 2017 Sep 15.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, NSW, 2109, Australia.

Purpose: Although most cancer survivors adjust well, a subset experiences clinical levels of anxiety and depression following cancer treatment. Internet-delivered cognitive behavior therapy (iCBT) is a promising intervention for symptoms of anxiety and depression among survivors; however, patient and provider perceptions of iCBT have not been examined.

Methods: We employed an exploratory qualitative method and conducted semi-structured interviews with 13 cancer survivors and 10 providers to examine iCBT strengths and weaknesses, areas for improvement, and perceived barriers to program completion. A thematic content analysis approach was used to analyze the data.

Results: The majority of survivors liked the flexible, convenient, and private nature of the program. Many viewed the program as helping them feel less alone following cancer treatment. Areas of improvement included suggestions of additional information regarding cancer treatment side effects. Barriers to completing the program were identified by a minority of survivors and included finding time to complete the program and current symptoms. Providers liked the program's accessibility and its ability to provide support to patients after cancer treatment. All providers perceived the program as useful in their current work with survivors. Concerns around the fit of the program (e.g., for particular patients) were expressed by a minority of providers.

Conclusions: Results provide additional evidence for the acceptability of an iCBT program among recent cancer survivors and providers in oncology settings. The current study highlights the value of research exploring iCBT for cancer survivors and provides insights for other groups considering Internet-delivered care for survivors.
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http://dx.doi.org/10.1007/s00520-017-3872-8DOI Listing
February 2018

Treatment acceptability and preferences for managing severe health anxiety: Perceptions of internet-delivered cognitive behaviour therapy among primary care patients.

J Behav Ther Exp Psychiatry 2017 Dec 20;57:14-24. Epub 2017 Feb 20.

Department of Psychology, University of Regina, Regina, Canada. Electronic address:

Background & Objectives: While cognitive behaviour therapy (CBT) is an established treatment for health anxiety, there are barriers to service access. Internet-delivered cognitive behaviour therapy (ICBT) has demonstrated effectiveness and has the potential to improve access to treatment. Nevertheless, it is unknown how patients perceive ICBT relative to other interventions for health anxiety and what factors predict ICBT acceptability. This study investigated these questions.

Methods: Primary care patients (N = 116) who reported elevated levels of health anxiety were presented three treatment vignettes that each described a different protocol for health anxiety (i.e., medication, CBT, ICBT). Acceptability and credibility of the treatments were assessed following the presentation of each vignette. Participants then ranked the three treatments and provided a rational for their preferences.

Results: The treatments were similarly rated as moderately acceptable. Relative to medication and ICBT, CBT was perceived as the most credible treatment for health anxiety. The highest preference ranks were for CBT and medication. Regression analyses indicated that lower computer anxiety, past medication use, and lower ratings of negative cognitions about difficulty coping with an illness significantly predicted greater ICBT acceptability.

Limitations: Health anxiety was not assessed with a diagnostic interview. Primary care patients were recruited through a Qualtrics panel. Patients did not have direct experience with treatment but learned about treatment options through vignettes.

Conclusions: Medication and CBT are preferred over ICBT. If ICBT is to increase treatment access, methods of improving perceptions of this treatment option are needed.
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http://dx.doi.org/10.1016/j.jbtep.2017.02.002DOI Listing
December 2017