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.     

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.     

Examining How CBT Interventions for Anxious Youth Are Delivered Across Settings

Most efforts to assess treatment integrity—the degree to which a treatment is delivered as intended—have conflated content (i.e., therapeutic interventions) and delivery (i.e., strategies for conveying the content, such as modeling). However, there may be value in measuring content and delivery separately. This study examined whether the quantity (how much) and quality (how well) of delivery strategies for individual cognitive behavioral therapy (ICBT) for youth anxiety varied when the same evidence-based treatment was implemented in research and community settings. Therapists (N = 29; 69.0% White; 13.8% male) provided ICBT to 68 youths (M age = 10.60 years, SD = 2.03; 82.4% white; 52.9% male) diagnosed with a principal anxiety disorder in research or community settings. Training and supervision protocols for therapists were comparable across settings. Two independent teams of trained coders rated 744 sessions using observational instruments designed to assess the quantity and quality of delivery of interventions found in ICBT approaches. Overall, both the quantity and quality of delivery of interventions found in ICBT approaches were significantly lower in the community settings. The extent to which didactic teaching, collaborative teaching, and rehearsal were used systematically varied over the course of treatment. In general, differences in the quantity and quality of delivery observed between settings held when differences in youth characteristics between settings were included in the model. Our findings suggest the potential relevance of measuring how therapists deliver treatment separate from the content.     

Predicting Response to Therapist-Assisted Internet-Delivered Cognitive Behavior Therapy for Depression or Anxiety Within an Open Dissemination Trial

Therapist-assisted Internet-delivered cognitive behavior therapy (ICBT) is efficacious for treating anxiety and depression, but predictors of response to treatment when delivered in clinical practice are not well understood. In this study, we explored demographic, clinical, and program variables that predicted modules started and symptom improvement (i.e., Generalized Anxiety Disorder-7 or Patient Health Questionnaire-9 total scores over pre-, mid-, and posttreatment) within a previously published open dissemination trial (Hadjistavropoulos et al., 2014). The sample consisted of 195 patients offered 12 modules of therapist-assisted ICBT for depression or generalized anxiety; ICBT was delivered by therapists working in six geographically dispersed clinics. Consistent across ICBT for depression or generalized anxiety, starting fewer modules was associated with more phone calls from therapists reflecting that therapists tended to call patients who did not start modules as scheduled. Also consistent for both ICBT programs, greater pretreatment condition severity and completion of more modules was associated with superior ICBT-derived benefit. Other predictors of response to treatment varied across the two programs. Younger age, lower education, taking psychotropic medication, being in receipt of psychiatric care and lower comfort with written communication were associated with either fewer program starts or lower symptom improvement in one of the two programs. It is concluded that monitoring response to ICBT may be particularly important in patients with these characteristics. Research directions for identifying patients who are less likely to benefit from ICBT are discussed.     

Acceptability,Feasibility, and Effectiveness of Internet-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in New York

Cognitive-behavioral therapy (CBT), consisting of exposure and response prevention (EX/RP), is both efficacious and preferred by patients with obsessive–compulsive disorder (OCD), yet few receive this treatment in practice. This study describes the implementation of an Internet-based CBT program (ICBT) developed in Sweden in individuals seeking OCD treatment in New York. After translating and adapting the Swedish ICBT for OCD, we conducted an open trial with 40 adults with OCD. Using the RE-AIM implementation science framework, we assessed the acceptability, feasibility, and effectiveness of ICBT. The Yale–Brown Obsessive Compulsive Scale (Y-BOCS) was the primary outcome measure. Of 40 enrolled, 28 participants completed the 10-week ICBT. In the intent-to-treat sample (N = 40), Y-BOCS scores decreased significantly over time (F = 28.12, df = 2, 49, p < . 001). Depressive severity (F = 5.87, df = 2, 48, p < . 001), and quality of life (F = 12.34, df = 2, 48, p < . 001) also improved. Sensitivity analyses among treatment completers (N = 28) confirmed the intent-to-treat results, with a large effect size for Y-BOCS change (Cohen’s d = 1.38). ICBT took less time to implement than face-to face EX/RP and participants were very to mostly satisfied with ICBT. On a par with results in Sweden, the adapted ICBT program reduced OCD and depressive symptoms and improved quality of life among individuals with moderate to severe OCD. Given its acceptability and feasibility, ICBT deserves further study as a way to increase access to CBT for OCD in the United States.     

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.     

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.     

Violent, nonviolent, and substance-related offending over the life course in a cohort of males and females treated for substance misuse as youths

Most studies on adolescent offending heterogeneity are based on general population samples, and few include individuals with substance misuse or look specifically at substance-related offending. It is also unclear how offender subtypes develop after young adulthood or how offending heterogeneity varies between genders. This study aimed to identify subgroups of offending among adolescents with misuse problems and to examine associations with offending in adulthood. The study included 1,992 females and males that consulted a clinic for adolescents with misuse problems between 1968 and 1971. Latent Class Analyses were conducted to identify subgroups based on violent and nonviolent offending before age 20. Participants were then followed until age 50 and reexamined regarding violent, nonviolent, and substance-related crimes. Associations between subgroups before age 20 and subgroups age 21-50 were examined. Before age 20, three subgroups were identified among the females and six among the males. Males were more specialized in their offending and demonstrated higher levels of offending. Results pointed to both stability and decrease of violent and nonviolent offending, and to the emergence of substance-related offending in adulthood in both genders. The connection between substance-related crimes and general delinquency in adulthood among individuals treated for substance misuse suggests that interventions should also address substance misuse for reducing the overall volume of crime. This study also highlights the importance of including females in research on offending heterogeneity.     

Efficacy of an internet-based intervention for burnout: a randomized controlled trial in the German working population

Background and Objectives: Internet-based interventions are a viable treatment option for various mental problems. However, their effects on the burnout syndrome yielded mixed results. In this paper, we examine the efficacy of a structured and therapist-guided internet intervention, based on solution-focused and cognitive-behavioral therapy, for individuals with symptoms of burnout.

Design: Two-arm, Internet-based, randomized, wait-list controlled trial (RCT).

Methods: Participants were recruited through in-house events and online advertising. They were randomly assigned to the intervention or a wait-list. Group comparison was conducted three months after randomization. Outcomes were the burnout level according to the Maslach Burnout Inventory (MBI-GS) and the levels of depression, anxiety and stress according to the DASS-21.

Results: Thirty-nine participants were included in the trial; 36 (92.3%) took part at the 3-months-follow-up. Intention-to-treat analyses revealed significant group differences in favor of the intervention group in depression (d?=?0.66), cynicism (d?=?0.87) and personal accomplishment (d?=?0.75).

Conclusions: The intervention helped ameliorate symptoms of work-related stress and burnout. Although limited by a small sample size, the study suggests that the program provides effective support for affected individuals. However, further studies with bigger sample sizes should be conducted to examine the effects of such programs more precisely.     

Physical activity and posttraumatic growth: A systematic review of quantitative and qualitative studies

ObjectivesThis systematic review aimed to examine the relationships between physical activity and posttraumatic growth (PTG) following a highly stressful life event.DesignA systematic review was conducted to identify eligible articles. A meta-analysis was conducted for quantitative studies and a meta-ethnographic synthesis was conducted for qualitative studies.MethodAfter systematic searches of five databases and literature screening, 20 quantitative studies and 12 qualitative studies were included in the final review. A meta-analysis of 14 quantitative studies was conducted to examine association between leisure-time physical activity and PTG. A meta-ethnographic synthesis of 10 qualitative studies was conducted to examine the relationship between physical activity and the experience of PTG.ResultsThe meta-analysis revealed a positive, yet small, association between leisure-time physical activity and PTG (average correlation = 0.120; 95% confidence interval: 0.071 to 0.168; p < 0.001). The effect sizes did not differ by measurements of PTG and participants’ age and gender but were smaller in studies with a binary variable of physical activity, a sample of participants with moderate or advanced diseases, and a longer period since the stressful event. The meta-ethnographic synthesis identified potential processes linking physical activity and PTG, including perceptions of self, social experiences, philosophical re-evaluation, and health effects.ConclusionsThis review suggest physical activity is a behavioral factor that may facilitate PTG. It highlights methodological considerations for further research.     

Stimulated brains and meditative minds: A systematic review on combining low intensity transcranial electrical stimulation and meditation in humans

BackgroundLow intensity transcranial electrical stimulation (tES) and meditation are two promising, yet variable, non-pharmacological interventions. Growing research is investigating combined effects of both techniques on one's cognitive, emotional, and physical health.ObjectiveThis article reviews the current research that combines tES and meditation interventions in healthy and diseased participants. The review considers the intervention parameters and their effects in a well-organized manner.MethodA systematic search for clinical and experimental published studies was conducted in the PubMed, Cochrane, and transcranial direct current stimulation (tDCS) databases using common keywords for tES and for meditation techniques well defined by previous studies. Unpublished ongoing studies were identified with the ClinicalTrials.gov and DRKS.de clinical trial websites.Results20 published studies and 13 ongoing studies were included for qualitative analysis. 13 published articles studied patients with chronic pain, psychological disorders, cognitive impairment, and movement disorders. Anodal tDCS was the only tES technique while mindfulness meditation was the most common meditation type. Eight studies had a main group effect, with outcome improvement in the active combined intervention. However, most published studies showed improvements after at least one combined intervention with variable effects.ConclusionPairing anodal tDCS with meditation shows promising improvements of the physical, mental, and emotional aspects of daily life. Further studies are required to confirm the relevance of this combination in the clinic.     

Treating Procrastination Using Cognitive Behavior Therapy: A Pragmatic Randomized Controlled Trial Comparing Treatment Delivered via the Internet or in Groups

Procrastination is a common problem among university students, with at least half of the population reporting great difficulties initiating or completing tasks and assignments. Procrastination can have a negative impact on course grades and the ability to achieve a university degree, but can also lead to psychological distress. Cognitive behavior therapy (CBT) is believed to reduce procrastination, but few studies have investigated its effectiveness in a regular clinical setting. The current study explored its effects using a pragmatic randomized controlled trial comparing treatment delivered during 8 weeks as self-guided CBT via the Internet (ICBT) or as group CBT. In total, 92 university students with severe procrastination were included in the study (registered as a clinical trial on Clinicaltrials.gov: NCT02112383). Outcome measures on procrastination, depression, anxiety, and well-being were distributed at pre- and posttreatment as well as 6-month follow-up. An outcome measure of procrastination was administered weekly. Linear mixed and fixed effects models were calculated, along with improvement and deterioration rates. The results showed large within-group effect sizes on procrastination, Cohen’s d of 1.29 for ICBT, 95% Confidence Interval (CI) [0.81, 1.74], and d of 1.24 for group CBT, 95% CI [0.76, 1.70], and small to moderate benefits for depression, anxiety, and well-being. In total, 33.7% were regarded as improved at posttreatment and 46.7% at follow-up. No differences between conditions were observed after the treatment period, however, participants in group CBT continued or maintained their improvement at follow-up, while participants in self-guided ICBT showed some signs of deterioration. The findings from the current study suggest that CBT might be an effective treatment for those struggling with severe procrastination, but that a group format may be better for some to sustain their benefits over time and that the clinical significance of the results need to be investigated further.     

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.     

A systematic review of interventions for adults who stutter

PurposeTo examine the effectiveness of (i) face to face interventions (ii) models of service delivery and (iii) psychological treatments combined with speech-focused interventions for adults who stutter.MethodsFive electronic databases and three clinical trial registries were searched. Systematic reviews, randomised controlled trials (RCTs) and studies that applied an intervention with adults who stutter were included. Pharmaceutical interventions were excluded. Primary outcomes included a measure of stuttering severity. Risk of bias assessment was conducted on included studies and overall quality of the evidence was graded.ResultsFive RCTS, four registered trials and three systematic reviews met inclusion criteria. Intervention approaches included speech restructuring programs (e.g. Camperdown Program) and transcranial direct current stimulation (tDCS). One study investigated cognitive behaviour therapy (CBT) alongside speech restructuring. Overall, studies were classified low risk of bias and good quality. Speech restructuring was included in all but one study (tDCS study) and had the most evidence i.e. supported by the greatest number of RCTs. On average, stuttering frequency was reduced by 50–57 % using speech restructuring approaches. No study reduced stuttering to the same level as community controls who don’t stutter. The study on tDCS reduced stuttering frequency by 22–27 %. Speech restructuring delivered via telehealth was non-inferior to face-to-face intervention. One study reported CBT was an effective adjunct to speech restructuring interventions.ConclusionSpeech restructuring interventions were found to reduce stuttering in adults, however degree and maintenance of fluency varied. The body of evidence surrounding tDCS and psychological interventions is limited. Replication studies should be considered.     

Stigmatisation intériorisée et consommation de substances psychoactives : revue systématique de la littérature

IntroductionSubstance use is a very stigmatized condition all over the world. Moreover, lots of people who use drugs or alcohol tend to internalize these stigmas, which can lead to harmful consequences. Corrigan's progressive model of self-stigma suggest that individuals go through four stages to internalize the stigma (aware, agree, apply, harm) and then undergo a stage of resignation and lack of hope and energy called “why try”. Research seems to be increasingly interested in this phenomenon, so we wonder, where we stand in the comprehension of internalized stigma for substances users?ObjectiveThis work aims to systematically review ten-past years studies about self-stigma in substance addiction in order to assess the status of curr ent works in this area.MethodThis systematic review was led inspired by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statements on the electronic databases PubMed, PsycInfo and PsycArticle. The inclusion criteria were: references published between 2010 and 2020, in French or English language which shows results about self-stigma for psychoactives substances users. A total of 39 studies met the eligibility criteria for inclusion in this review.ResultsSynthesizing findings across the studies revealed some important topics. First, the progressive model seems to be statistically valid among drug and/or alcohol users. Nevertheless, self-stigma of drugs and/or alcohol is not the only condition that entails users. A varieties of other factors (i.e. HIV, sex work) are to be considered in the understanding of stigmatization. In the studies, negative consequences due to self-stigma in substance use were observed such as depression or anxiety symptoms, lower self-esteem and negatives emotions as fear and shame.ConclusionAll these results are to be considered within their limits. In light of these findings, the knowledge acquired will allow professionals to develop new interventions to prevent and to reduce self-stigma of drug and/or alcohol users.     

Psychological counseling as an adjunct to stuttering treatment: Clients’ experiences and perceptions

PurposeStuttering can trigger anxiety and other psychological and emotional reactions, and limit participation in society. It is possible that psychological counseling could enhance stuttering treatment outcomes; however, little is known about how clients view such counseling. The purpose of this study was to gain an understanding of clients’ experiences with, and perceptions of, a psychological counseling service that was offered as an optional adjunct to speech therapy for stuttering.MethodNine individuals who stutter (13-38 years old) participated in semi-structured interviews. Six participants had taken part in psychological counseling; three participants did not do so. Interview data were analyzed using grounded theory as a guiding framework.ResultsFour thematic clusters emerged from participants’ accounts: insights into personal decision-making, why others may not participate in counseling, psychological counseling as a worthwhile part of therapy, and counseling as a necessary component in a stuttering treatment program.ConclusionIn addition to experiencing barriers and facilitators to help-seeking that are reported in related fields, participants accounts also revealed novel facilitators (i.e., a ‘why not’ mentality and the importance of having a pre-existing relationship with the clinician who offered the service) and barriers (i.e., viewing the service as a ‘limited resource,’ and, the overwhelming nature of intensive stuttering treatment programs). Findings suggest that clients value the option to access psychological counseling with trained mental health professionals to support the stuttering treatment provided by speech-language pathologists. Participants made recommendations for the integration of psychological counseling into stuttering treatment programs.     

History,literature, and philosophy: A systematic review of positive functioning

ABSTRACT

The humanities are instrumental to human development and happiness and are an integral part of our lives. However, a lack of empirical research limits our current understanding of the role the humanities play in the well-being of individuals, communities, and societies. Through a systematic search of the literature, we identify and review empirical studies that investigate whether engagement with history, literature, and philosophy influences individual’s well-being (i.e. psychological well-being, subjective well-being, and virtues). The results suggest that studies investigating such influences are limited and mainly conducted in pedagogical settings. At the same time, these studies provide initial evidence for the positive effects of engagement in the humanities on individual well-being. Through this review, we identify gaps in the literature and provide recommendations for future research.     

Psychological and physiological stress in non-competitive and competitive esports settings: A systematic review

ObjectivesCompetition is related to psychophysiological stress responses and is a key aspect of esports. Yet, while competition may indeed have an impact on performance, little is known about competition-related psychophysical stress responses in esports. Accordingly, this review aims to investigate whether playing esports in competitive (and non-competitive) settings is related to psychological and/or physiological stress.DesignA systematic literature review was performed. Study inclusion criteria included: assessment of psychological and/or physiological stress in esports, study of healthy individuals over 12 years of age, and published in peer-reviewed journals in English or German.MethodThe literature search comprised EBSCOhost, PubMed, and Web of Science up until August 2019. An additional search was performed on Science Direct, Google Scholar, and Sponet.ResultsSeventeen studies met inclusion criteria. In publications investigating the non-competitive setting, it can be assumed that merely playing esports games is unrelated to psychophysiological stress reactions. While three out of five studies on stress in competitive settings demonstrated no hormonal reaction, one study reported an increase in anxiety levels in winners as well as an increase cortisol levels from baseline to postgame conditions, and two studies found an activation of the sympathetic nervous system. Overall, the studies revealed theoretical and methodological limitations, which are discussed in the present review.ConclusionsAlthough the existing literature contributes to an initial understanding of psychophysiological stress in esports, further in-depth studies of stress responses in actual competition are needed.