Cognitive-behaviour therapy in the treatment of chronic, occupational pain of the upper limbs: a 2 yr follow-up.

Nineteen Ss who experienced chronic, occupational pain of the upper limbs and who had previously completed a programme of either individual or group cognitive-behaviour therapy were followed up 2 yr later. Significant improvements on measures of depression, anxiety, coping strategies and interference in daily living were found following treatment. Such improvements were not evident for the waiting list control Ss and no difference was found between group vs individual applications of therapy. A 2 yr follow-up, significant improvements from pre-treatment levels were evident for depression, coping strategies, significant other report of disability, self monitored pain and distress caused by pain. While there was generally little evidence of relapse, a significant decline from post-treatment levels was found for the individual therapy condition compared to the group therapy condition on measures of self monitored pain and interference caused by pain. Since post-treatment levels tended to be somewhat superior for the individual therapy condition, the overall finding at 2 yr follow-up was of minimal difference in outcome for group vs individual forms of cognitive-behaviour therapy. Despite improvements from pre-treatment levels, the vast majority of Ss still reported significant and distressing levels of pain at 2 yr follow-up.     

Responsiveness of measures of attentional bias to clinical change in social phobia

This study examined responsiveness of the dot probe measure of attentional bias to standard cognitive-behaviour group therapy (CBGT) for social phobia. People who met criteria for social phobia were randomly allocated to either an immediate treatment condition or a waiting list control (WLC). All participants completed self-report measures of social anxiety, depression, and anxiety sensitivity, a verbal dot probe and a facial dot-probe task before and after eight weeks of standard CBGT was undertaken by the treatment group. On the first measurement occasion the two groups had similar scores on all measures. On the second measurement occasion the self-report scores for the CBGT group were lower than those of the WLC group. Performance on the dot-probe tasks for the CBGT group had also changed. The treatment group appeared to direct their attention away from social threat words and threatening faces after CBGT.     

Internet-Based Cognitive Behaviour Therapy for Tinnitus Patients Delivered in a Regular Clinical Setting: Outcome and Analysis of Treatment Dropout

Cognitive behaviour therapy (CBT) can reduce tinnitus distress but is not available for most patients. Therapist guided, internet-based CBT (ICBT) increase availability and has been shown to be effective. However, the initial positive results need to be replicated in larger samples, and treatment dropout has not been thoroughly studied. Moreover, it has not been evaluated if a low-intensity version of ICBT without therapist contact could be an alternative for patients who do not need or are able to manage the full ICBT-program. This study evaluated two parallel interventions delivered in regular care: ICBT for tinnitus distress (n = 293) and a low-intensity version of ICBT (n = 81) for patients with lower levels of tinnitus distress. We also explored predictors of dropout from ICBT and if dropout influences outcome. Tinnitus Reaction Questionnaire (Wilson, Henry, Bowen, & Haralambous, 1991) was used as the primary outcome. Secondary outcomes were measures of depression, anxiety, sleep, and sound sensitivity. Significant reductions following ICBT were found on all measures after treatment and also at a three-month follow-up. Patients receiving low-intensity ICBT showed a significant reduction in distress, even when they had low levels of distress initially. Treatment dropout was preceded by an increase in days spent at each treatment step but not by an increased distress. Early dropout was related to worse outcome. ICBT can be used in a regular clinical setting to reduce tinnitus distress. Early dropouts may need additional management. For help-seeking patients with lower distress, a low-intensity version of ICBT can be used.     

Implementing Group CBT for Depression Among Latinos in a Primary Care Clinic

Depression in low-income Latino populations can be treated using group cognitive behavioral therapy (GCBT). However, effective delivery of GCBT for depression in primary care settings is often impeded by high dropout rates and poor homework adherence. In this study, we describe the structure, processes, and outcomes (including attendance, homework completion, and symptom measures) of GCBT for Spanish-speaking Latino patients with depression in an urban public sector primary care setting. For this study, 96 Latino patients in a primary care clinic participated in at least 1 session of GCBT. Although depressive symptoms among these patients, as measured by the PHQ-9, significantly decreased during treatment, attendance and homework completion were limited. Even with a strategy in place to allow patients to continue in treatment after missing several sessions, 23% of patients dropped out of therapy following their initial session, and approximately half of all patients completed less than 50% (or 8) therapy sessions. Homework was only completed 23% of the time it was checked. Greater session attendance prospectively predicted lower depressive symptoms over time. We discuss potential strategies to increase engagement, treatment effects, and symptom reduction for depression in primary care settings.     

Rational-emotive therapy and the reduction of interpersonal anxiety in junior high school students

This study evaluated the effectiveness of rational-emotive therapy and rational-emotive imagery. Fifty-nine junior high school students who volunteered to participate in treatment for interpersonal anxiety were randomly assigned to rational-emotive therapy without imagery (RET), rational-emotive therapy with imagery (REI), relationship-oriented counseling (ROC), and waiting-list control (WLC) groups. Groups met for seven 50-minute treatment sessions during a three-week period. Assessments were conducted at pretreatment, posttreatment, and three-week follow-up. Both self-report and sociometric measures were used to evaluate treatment outcome. At postassessment, both the RET and REI groups were rated on sociometric measures as significantly less interpersonally anxious than the WLC group. Mean scores favored the RET and REI groups, but no significant differences between these groups and the ROC group were obtained. The self-report measure did not significantly differentiate between groups, but the REI group demonstrated significant pre- to follow-up changes. Both the RET and REI groups yielded greater reductions in irrational thinking than did the ROC and WLC groups. In addition, the pattern of the results supported the use of rational-emotive imagery as a component of rational-emotive therapy. The practical implications of these findings are discussed.     

Overcoming procrastination: one-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy

Procrastination is a common self-regulatory failure that can have a negative impact on well-being and performance. However, few clinical trials have been conducted, and no follow-up has ever been performed. The current study therefore aimed to provide evidence for the long-term benefits and investigate predictors of a positive treatment outcome among patients receiving Internet-based cognitive behavior therapy (ICBT). A total of 150 self-recruited participants were randomized to guided or unguided ICBT. Self-report measures of procrastination, depression, anxiety, and quality of life were distributed at pre-treatment assessment, post-treatment assessment, and one-year follow-up. Mixed effects models were used to investigate the long-term gains, and multiple linear regression for predictors of a positive treatment outcome, using the change score on the Irrational Procrastination Scale as the dependent variable. Intention-to-treat was implemented for all statistical analyses. Large within-group effect sizes for guided and unguided ICBT, Cohen’s d = .97–1.64, were found for self-report measures of procrastination, together with d = .56–.66 for depression and anxiety. Gains were maintained, and, in some cases, improved at follow-up. Guided and unguided ICBT did not differ from each other, mean differences ?.31–1.17, 95% CIs [?2.59–3.22], and none of the predictors were associated with a better result, bs ?1.45–1.61, 95% CIs [?3.14–4.26]. In sum, ICBT could be useful and beneficial in relation to managing procrastination, yielding great benefits up to one year after the treatment period has ended, with comparable results between guided and unguided ICBT.     

Group Cognitive Behavior Therapy for Chronic Posttraumatic Stress Disorder: An Initial Randomized Pilot Study

Individuals with posttraumatic stress disorder (PTSD) related to a serious motor vehicle accident were randomly assigned to either group cognitive behavioral treatment (GCBT) or a minimum contact comparison group (MCC). Compared to the MCC participants (n = 16), individuals who completed GCBT (n = 17) showed significant reductions in PTSD symptoms, whether assessed using clinical interview or a self-report measure. Among treatment completers, 88.3% of GCBT participants did not satisfy criteria for PTSD at posttreatment assessment, relative to 31.3% of the MCC participants. Examination of anxiety, depression, and pain measures did not show a unique advantage of GCBT. Treatment-related gains were maintained over a 3-month follow-up interval. Patients reported satisfaction with GCBT, and attrition from this treatment was comparable with individually administered CBTs. Results are discussed in light of modifications necessitated by the group treatment format, with suggestions for future study of this group intervention.     

Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder

Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3-4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.     

Internet-Based Therapy for Mild to Moderate Depression in Swedish Primary Care: Short Term Results from the PRIM-NET Randomized Controlled Trial

Depression presents a serious condition for the individual and a major challenge to health care and society. Internet-based cognitive behavior therapy (ICBT) is a treatment option supported in several trials, but there is as yet a lack of effective studies of ICBT in “real world” primary care settings. We examined whether ICBT differed from treatment-as-usual (TAU) in reducing depressive symptoms after 3 months. TAU comprised of visits to general practitioner, registered nurse, antidepressant drugs, waiting list for, or psychotherapy, or combinations of these alternatives. Patients, aged ≥ 18 years, who tentatively met criteria for mild to moderate depression at 16 primary care centers in the south-western region of Sweden were recruited and then assessed in a diagnostic interview. A total of 90 patients were randomized to either TAU or ICBT. The ICBT treatment included interactive elements online, a workbook, a CD with mindfulness and acceptance exercises, and minimal therapist contact. The treatment period lasted for 12 weeks after which both groups were assessed. The main outcome measure was Beck Depression Inventory-II (BDI-II). Additional measures were Montgomery Åsberg Depression Rating Scale – self rating version (MADRS-S) and Beck Anxiety Inventory (BAI). The analyses revealed no significant difference between the two groups at post treatment, neither on BDI-II, MADRS-S, nor BAI. Twenty patients (56%) in the ICBT treatment completed all seven modules. Our findings suggest that ICBT may be successfully delivered in primary care and that the effectiveness, after 3 months, is at par with TAU.     

A Case Study Illustrating Therapist-Assisted Internet Cognitive Behavior Therapy for Depression

Randomized controlled trials show that therapist-assisted Internet cognitive behavior therapy (ICBT) is efficacious in the treatment of depression. Given that this is a novel way of delivering cognitive behavior therapy, however, clinical service providers may have questions about how to provide therapist-assisted ICBT in clinical practice, particularly with respect to therapist assistance. To exemplify this approach, we present a case study of an older adult male who received 12 modules of therapist-assisted ICBT for depression over the course of 5 months. Highlights of the therapeutic exchanges that occurred over email are provided to illustrate the type of information clients may share with therapists and the nature of therapist assistance. Treatment progress was assessed via self-report questionnaires measuring depression, anxiety, and adjustment. Consistent with the research evidence, significant improvement was observed on all symptom measures at posttreatment. Satisfaction with the therapist-assisted ICBT program and a strong therapeutic alliance was also reported. The case will expand clinician understanding of therapist-assisted ICBT and may serve to stimulate clinician interest in the provision of therapist-assisted ICBT. Future research directions stemming from this case are presented.     

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

ABSTRACT

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.     

Cost-effectiveness of Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: results from a randomized controlled trial

Social anxiety disorder (SAD) is highly prevalent and associated with a substantial societal economic burden, primarily due to high costs of productivity loss. Cognitive behavior group therapy (CBGT) is an effective treatment for SAD and the most established in clinical practice. Internet-based cognitive behavior therapy (ICBT) has demonstrated efficacy in several trials in recent years. No study has however investigated the cost-effectiveness of ICBT compared to CBGT from a societal perspective, i.e. an analysis where both direct and indirect costs are included. The aim of the present study was to investigate the cost-effectiveness of ICBT compared to CBGT from a societal perspective using a prospective design. We conducted a randomized controlled trial where participants with SAD were randomized to ICBT (n = 64) or CBGT (n = 62). Economic data were assessed at pre-treatment, immediately following treatment and six months after treatment. Results showed that the gross total costs were significantly reduced at six-month follow-up, compared to pre-treatment in both treatment conditions. As both treatments were equivalent in reducing social anxiety and gross total costs, ICBT was more cost-effective due to lower intervention costs. We conclude that ICBT can be more cost-effective than CBGT in the treatment of SAD and that both treatments reduce societal costs for SAD.     

Dissemination of therapist-assisted internet cognitive behaviour therapy: development and open pilot study of a workshop

There is considerable research suggesting that therapist-assisted Internet cognitive behaviour therapy (ICBT) is efficacious in the treatment of depression and anxiety. Given this research, there is a growing interest in training students in therapist-assisted ICBT in order to assist with the dissemination of this emerging modality into routine clinical practice. In this study, we developed, delivered, and evaluated a therapist-assisted ICBT workshop for clinical psychology graduate students (n?=?20). The workshop provided both research evidence and practical information related to the delivery of therapist-assisted ICBT. The workshop also incorporated an experiential component with students working on and discussing responses to client e-mails. Before and after the workshop, we measured knowledge of therapist-assisted ICBT research and professional practice issues, as well as attitudes towards and confidence in delivering therapist-assisted ICBT. Statistically significant changes were observed in all areas. Eighty-five per cent of students are now offering therapist-assisted ICBT under supervision. We conclude by discussing future research directions related to disseminating therapist-assisted ICBT.     

Cognitive behavior therapy vs exposure in vivo in the treatment of panic disorder with agoraphobia (corrected from agrophobia)

Seventy-three psychiatric outpatients with DSM-IV diagnosis of panic disorder with agoraphobia were assessed with a battery of independent assessor, self-observation, self-report and behavioral measures before and after therapy, and at a 1-yr follow-up. They were randomly assigned to Exposure in vivo (E; n = 25), Cognitive Behavior Therapy (CBT; n = 26), or a Wait-list control (WLC; n = 22) and received 12-16 individual therapy sessions, once weekly. The treatments yielded significant improvements, both on panic/agoraphobia measures and on measures of general anxiety, depression, social adjustment and quality of life, which were maintained at follow-up. However, there were no significant differences between E and CBT. The three criteria of clinically significant improvement were achieved by 67% of the E-patients and 79% of the CBT-patients at post-treatment, and 74% and 76%, respectively, at follow-up. The conclusion that can be drawn is that adding cognitive therapy to exposure did not yield significantly better results than for exposure alone.     

The implementation of guided Internet-based cognitive behaviour therapy for panic disorder in a routine-care setting: effectiveness and implementation efforts

Panic disorder is a common mental disorder. Guided Internet-based cognitive behavioural therapy (Guided Internet-based cognitive behaviour therapy (ICBT)) is a promising approach to reach more people in need of help. In the present effectiveness study, we investigated the outcome of guided ICBT for panic disorder after implementation in routine care. A total of 124 patients were included in the study, of which 114 started the treatment. Large within-group effect sizes were observed on the primary panic disorder symptoms (post-treatment: d = 1.24; 6-month follow-up: d = 1.39) and moderate and large effects on secondary panic disorder symptoms and depressive symptoms at post-treatment and follow-up (d = .55–1.13). More than half (56.1%) of the patients who started treatment recovered or improved at post-treatment. Among treatment takers (completed at least five of the nine modules), 69.9% recovered or improved. The effectiveness reported in the present trial is in line with previous effectiveness and efficacy trials of guided ICBT for panic disorder. This provides additional support for guided ICBT as a treatment alternative in routine care.     

Dissemination of Therapist-Assisted Internet Cognitive Behaviour Therapy: Development and Open Pilot Study of a Workshop

There is considerable research suggesting that therapist-assisted Internet cognitive behaviour therapy (ICBT) is efficacious in the treatment of depression and anxiety. Given this research, there is a growing interest in training students in therapist-assisted ICBT in order to assist with the dissemination of this emerging modality into routine clinical practice. In this study, we developed, delivered, and evaluated a therapist-assisted ICBT workshop for clinical psychology graduate students (n = 20). The workshop provided both research evidence and practical information related to the delivery of therapist-assisted ICBT. The workshop also incorporated an experiential component with students working on and discussing responses to client e-mails. Before and after the workshop, we measured knowledge of therapist-assisted ICBT research and professional practice issues, as well as attitudes towards and confidence in delivering therapist-assisted ICBT. Statistically significant changes were observed in all areas. Eighty-five per cent of students are now offering therapist-assisted ICBT under supervision. We conclude by discussing future research directions related to disseminating therapist-assisted ICBT.     

Money talks in attention bias modification: Reward in a dot-probe task affects attentional biases

Attention bias modification (ABM) aimed at correcting dysfunctional biases in anxiety patients has met with only mild success. Inspired by recent studies showing large effects of financial reward upon attention shifts, we contrasted effects of traditional dot-probe ABM and reward upon attention biases in a between-subject 2 × 2 design. Twenty-seven participants in group cognitive behavioural therapy (GCBT) for social anxiety disorder (SAD) were randomly assigned to undergo six sessions of a dot-probe task consisting of ABM or placebo ABM along with random or high reward following neutral stimuli. There was no influence of ABM on participants' attention bias over and above the influence of GCBT. Reward, however, had a strong influence on attention bias. Neither ABM nor reward reduced SAD symptoms over and above the effects of GCBT. The results add to the growing evidence that benefits of ABM through dot-probe training are unreliable but suggest on the other hand that rewarding attention may strongly influence dysfunctional attention biases.     

Predicting Treatment Outcomes From Internet-Based Cognitive Behavior Therapy for Obsessive–Compulsive Disorder

Internet-based cognitive-behavioral therapy (ICBT) with therapist support shows promise as a treatment for obsessive-compulsive disorder (OCD). Yet, not all patients respond to ICBT. It is therefore important to identify predictors of ICBT outcomes to determine who is likely to benefit. Relative to the large literature on predictors of outcomes for in-person CBT for OCD, very few studies have investigated ICBT predictors. Therefore, we analyzed predictors of outcome in an open trial (n = 30) of ICBT for OCD using the OCD-NET platform, which consists of 10 online modules delivered with therapist support. The Yale-Brown Obsessive-Compulsive Scale (YBOCS) was administered by independent raters as the primary outcome measure at baseline and posttreatment. In this sample, greater baseline OCD severity and OCD-related avoidance behaviors were associated with higher end-state OCD symptoms (i.e., poorer outcome). Patients with a past history of face-to-face CBT for OCD also had worse outcomes. Although these results require replication, these factors may identify individuals at risk for poor ICBT outcomes.     

An Evaluation of Two Types of Cognitive Intervention in the Management of Chronic Tinnitus

Abstract

Fifty-four subjects with chronic distressing tinnitus were randomly allocated to one of four experimental treatment conditions: (1) attention control and imagery training (AC1); (2) cognitive restructuring (CR); (3) combined attention control and imagery training plus cognitive restructuring (ACI + CR); and (4) a waiting list control (WLC). Significant overall improvements were found on measures of distress associated with tinnitus, and on a number of other measures of cognition and coping strategies. These improvements were maintained at the six-month follow-up. Relative to the WLC, the three treatment conditions (combined) were associated with improvements in tinnitus-related distress, reductions in tinnitus-related dysfunctional cognitions and an increase in the frequency of use of coping strategies. There was a significant effect in favour of the ACI group compared to the CR group on the measure of irrational beliefs. The analyses also revealed that the combined treatment condition (ACI + CR) showed significantly greater improvement on a measure of psychological distress and achieved a higher clinical response rate compared to the two single treatments. There were significant improvements from pretreatment to follow-up on some measures, although the mean scores revealed that some of the gains had been lost at this stage on the main measure of tinnitus-related distress. There were no significant group X time effects for any of the dependent variables at the six-month follow-up. The results were interpreted as supporting the practice of combining the two cognitive approaches.     

Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis

During the last two decades, Internet-delivered cognitive behavior therapy (ICBT) has been tested in hundreds of randomized controlled trials, often with promising results. However, the control groups were often waitlisted, care-as-usual or attention control. Hence, little is known about the relative efficacy of ICBT as compared to face-to-face cognitive behavior therapy (CBT). In the present systematic review and meta-analysis, which included 1418 participants, guided ICBT for psychiatric and somatic conditions were directly compared to face-to-face CBT within the same trial. Out of the 2078 articles screened, a total of 20 studies met all inclusion criteria. Results showed a pooled effect size at post-treatment of Hedges g = .05 (95% CI, ?.09 to .20), indicating that ICBT and face-to-face treatment produced equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there have been few studies of the individual psychiatric and somatic conditions so far, and for the majority, guided ICBT has not been compared against face-to-face treatment. Thus, more research, preferably with larger sample sizes, is needed to establish the general equivalence of the two treatment formats.