E-therapy

[Lyubimova]

Therapist-assisted, Internet-based treatment for panic disorder: can general practitioners achieve comparable patient outcomes to psychologists?
Shandley K, Austin DW, Klein B, Pier C, Schattner P, Pierce D, Wade V.

Swinburne University of Technology, Faculty of Life and Social Sciences, Mail H31, PO Box 218, Hawthorn, Victoria 3122, Australia.

BACKGROUND: Mental illness is an escalating concern worldwide. The management of disorders such as anxiety and depression largely falls to family doctors or general practitioners (GPs). However, GPs are often too time constrained and may lack the necessary training to adequately manage the needs of such patients. Evidence-based Internet interventions represent a potentially valuable resource to reduce the burden of care and the cost of managing mental health disorders within primary care settings and, at the same time, improve patient outcomes. OBJECTIVE: The present study sought to extend the efficacy of a therapist-assisted Internet treatment program for panic disorder, Panic Online, by determining whether comparable outcomes could be achieved and maintained when Panic Online was supported by either GPs or psychologists. METHODS: Via a natural groups design, 96 people with a primary diagnosis of panic disorder (with or without agoraphobia) completed the Panic Online program over 12 weeks with the therapeutic assistance of their GP (n = 53), who had received specialist training in cognitive behavioral therapy, or a clinical psychologist (n = 43). Participants completed a clinical diagnostic telephone interview, conducted by a psychologist, and a set of online questionnaires to assess panic-related symptoms at three time periods (pretreatment, posttreatment, and 6 month follow-up). RESULTS: Both treatments led to clinically significant improvements on measures of panic and panic-related symptomatology from pretreatment to posttreatment. Both groups were shown to significantly improve over time. Improvements for both groups were maintained at follow-up; however, the groups did differ significantly on two quality of life domains: physical (F(1,82) = 9.13, P = .00) and environmental (F(1,82) = 4.41, P = .04). The attrition rate was significantly higher among those being treated by their GP (chi(2) (1) = 4.40, P = .02, N = 96). CONCLUSIONS: This study provides evidence that Internet-based interventions are an effective adjunct to existing mental health care systems. Consequently, this may facilitate and enhance the delivery of evidence-based mental health treatments to increasingly large segments of the population via primary care systems and through suitably trained health professionals.

PMID: 18487138 [PubMed - in process
J Med Internet Res. 2008 May 19;10(2):e14.



Internet-based treatment for adults with depressive symptoms: the protocol of a randomized controlled trial.
Warmerdam L, van Straten A, Cuijpers P.

Department of Clinical Psychology, Institute for Research in Extramural Medicine, VU University, Amsterdam, The Netherlands.

BACKGROUND: Depression is a highly prevalent condition, affecting more than 15% of the adult population at least once in their lives. Guided self-help is effective in the treatment of depression. The purpose of this study is to investigate the effectiveness of two Internet-based guided self-help treatments with adults reporting elevated depressive symptoms. Other research questions concern the identification of potential mediators and the search for subgroups who respond differently to the interventions. METHODS: This study is a randomized controlled trial with three conditions: two treatment conditions and one waiting list control group. The two treatment conditions are Internet-based cognitive behavior therapy and Internet-based problem-solving therapy. They consist of 8 and 5 weekly lessons respectively. Both interventions are combined with support by e-mail. Participants in the waiting list control group receive the intervention three months later.The study population consists of adults from the general population. They are recruited through advertisements in local and national newspapers and through banners on the Internet. Subjects with symptoms of depression (> or = 16 on the Center for Epidemiological Studies Depression scale) are included. Other inclusion criteria are having sufficient knowledge of the Dutch language, access to the Internet and an e-mail address.Primary outcome is depressive symptoms. Secondary outcomes are anxiety, quality of life, dysfunctional cognitions, worrying, problem solving skills, mastery, absence at work and use of healthcare. We will examine the following variables as potential mediators: dysfunctional cognitions, problem solving skills, worrying, anxiety and mastery. Potential moderating variables are: socio-demographic characteristics and symptom severity. Data are collected at baseline and at 5 weeks, 8 weeks, 12 weeks and 9 months after baseline. Analyses will be conducted on the intention-to-treat sample. DISCUSSION: This study evaluates two Internet-based treatments for depression, namely cognitive behavioral therapy and problem-solving therapy. The effectiveness of Internet-based problem-solving therapy suggest that this may be a worthwhile alternative to other more intensive treatment options. Strengths and limitations of this study are discussed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN16823487.

PMID: 18093331 [PubMed - indexed for MEDLINE]

BMC Psychiatry. 2007 Dec 19;7:72.




A randomized, controlled proof-of-concept trial of an Internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder.
Litz BT, Engel CC, Bryant RA, Papa A.

National Center for PTSD Boston VA Healthcare System and Boston University School of Medicine, 150 South Huntington Ave., Boston, MA 01230, USA.

OBJECTIVE: The authors report an 8-week randomized, controlled proof-of-concept trial of a new therapist-assisted, Internet-based, self-management cognitive behavior therapy versus Internet-based supportive counseling for posttraumatic stress disorder (PTSD). METHOD: Service members with PTSD from the attack on the Pentagon on September 11th or the Iraq War were randomly assigned to self-management cognitive behavior therapy (N=24) or supportive counseling (N=21). RESULTS: The dropout rate was similar to regular cognitive behavior therapy (30%) and unrelated to treatment arm. In the intent-to-treat group, self-management cognitive behavior therapy led to sharper declines in daily log-on ratings of PTSD symptoms and global depression. In the completer group, self-management cognitive behavior therapy led to greater reductions in PTSD, depression, and anxiety scores at 6 months. One-third of those who completed self-management cognitive behavior therapy achieved high-end state functioning at 6 months. CONCLUSIONS: Self-management cognitive behavior therapy may be a way of delivering effective treatment to large numbers with unmet needs and barriers to care.

PMID: 17974932 [PubMed - indexed for MEDLINE]
Am J Psychiatry. 2007 Nov;164(11):1676-83.



A 1.5-year follow-up of an Internet-based intervention for complicated grief.
Wagner B, Maercker A.

Department of Psychopathology & Clinical Intervention, University of Zurich, Switzerland.

Only recently have psychotherapeutic interventions for complicated grief been developed and evaluated in randomized controlled trials. These trials have reported significant reductions in complicated grief and related symptoms in response to treatment relative to control groups. However, little is known about the long-term outcomes of these treatments. The authors present an evaluation of a 1.5-year follow-up of an Internet-based cognitive-behavioral intervention for complicated grief. Treatment group patients (n = 22) were administered various assessments of complicated grief indicators, including the Impact of Event Scale, the anxiety and depression subscales of the Brief Symptom Inventory, and the SF-12. Results indicate that the reduction in symptoms of complicated grief observed at posttreatment was maintained at 1.5-year follow-up.

PMID: 17721955 [PubMed - indexed for MEDLINE]
J Trauma Stress. 2007 Aug;20(4):625-9.

[Lyubimova]

Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis.

Spek V, Cuijpers P, Nyklí; cek I, Riper H, Keyzer J, Pop V.

Department of Psychology and Health, Tilburg University, The Netherlands.

BACKGROUND: We studied to what extent internet-based cognitive behaviour therapy (CBT) programs for symptoms of depression and anxiety are effective. METHOD: A meta-analysis of 12 randomized controlled trials. RESULTS: The effects of internet-based CBT were compared to control conditions in 13 contrast groups with a total number of 2334 participants. A meta-analysis on treatment contrasts resulted in a moderate to large mean effect size [fixed effects analysis (FEA) d=0.40, mixed effects analysis (MEA) d=0.60] and significant heterogeneity. Therefore, two sets of post hoc subgroup analyses were carried out. Analyses on the type of symptoms revealed that interventions for symptoms of depression had a small mean effect size (FEA d=0.27, MEA d=0.32) and significant heterogeneity. Further analyses showed that one study could be regarded as an outlier. Analyses without this study showed a small mean effect size and moderate, non-significant heterogeneity. Interventions for anxiety had a large mean effect size (FEA and MEA d=0.96) and very low heterogeneity. When examining the second set of subgroups, based on therapist assistance, no significant heterogeneity was found. Interventions with therapist support (n=5) had a large mean effect size, while interventions without therapist support (n=6) had a small mean effect size (FEA d=0.24, MEA d=0.26). CONCLUSIONS: In general, effect sizes of internet-based interventions for symptoms of anxiety were larger than effect sizes for depressive symptoms; however, this might be explained by differences in the amount of therapist support.

PMID: 17112400 [PubMed - indexed for MEDLINE
Psychol Med. 2007 Aug;37(8):1211; author reply 1211-2.




Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial.
Knaevelsrud C, Maercker A.

Treatment Center for Torture Victims, Berlin, Germany.

BACKGROUND: The present study was designed to evaluate the efficacy of an internet-based therapy (Interapy) for Posttraumatic Stress Disorder (PTSD) in a German speaking population. Also, the quality of the online therapeutic relationship, its development and its relevance as potential moderator of the treatment effects was investigated. METHOD: Ninety-six patients with posttraumatic stress reactions were allocated at random to ten sessions of Internet-based cognitive behavioural therapy (CBT) conducted over a 5-week period or a waiting list control group. Severity of PTSD was the primary outcome. Secondary outcome variables were depression, anxiety, dissociation and physical health. Follow-up assessments were conducted at the end of treatment and 3 months after treatment. RESULTS: From baseline to post-treatment assessment, PTSD severity and other psychopathological symptoms were significantly improved for the treatment group (intent-to-treat group x time interaction effect size d = 1.40). Additionally, patients of the treatment condition showed significantly greater reduction of co-morbid depression and anxiety as compared to the waiting list condition. These effects were sustained during the 3-months follow-up period. High ratings of the therapeutic alliance and low drop-out rates indicated that a positive and stable therapeutic relationship could be established online. Significant improvement of the online working alliance in the course of treatment and a substantial correlation between the quality of the online relationship at the end of treatment and treatment outcome emerged. CONCLUSION: Interapy proved to be a viable treatment alternative for PTSD with large effect sizes and sustained treatment effects. A stable and positive online therapeutic relationship can be established through the Internet which improved during the treatment process. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN012606000401550.

PMID: 17442125 [PubMed - indexed for MEDLINE]
BMC Psychiatry. 2007 Apr 19;7:13.



Internet-based mental health programs: a powerful tool in the rural medical kit.
Griffiths KM, Christensen H.

Centre for Mental Health Research, The Australian National University, Canberra, Australian Capital Territory, Australia.

OBJECTIVE: To discuss, using two case examples, the potential utility of Internet-based depression information and automated therapy programs in rural regions. DESIGN: Systematic review of evaluations of two Australian web-based mental health programs: MoodGYM and BluePages Depression Information. SETTING: Community, school, university. PARTICIPANTS: A total of 12 papers and reports derived from nine separate studies of MoodGYM and BluePages involving sample sizes ranging from 78 to 19 607 people. OUTCOME MEASURES: Depressive symptoms, anxiety symptoms, dysfunctional thoughts, depression literacy, stigma, help seeking and cost-effectiveness. RESULTS: Internet-based applications were effective in reducing depressive symptoms and stigmatising attitudes to depression and in improving depression literacy. School-based programs also showed promise in decreasing depressive symptoms. CONCLUSIONS: Depression self-help and information programs can be delivered effectively by means of the Internet. As accessibility of face-to-face mental health services in rural areas is poor and as there is a strong culture of self-reliance and preference for self-managing health problems among rural residents, the Internet might offer an important platform for the delivery of help for depression in rural regions. Consideration should be given to developing programs tailored to rural settings and future research should evaluate the efficacy and effectiveness of such programs in rural settings.

PMID: 17441815 [PubMed - indexed for MEDLINE]
Aust J Rural Health. 2007 Apr;15(2):81-7.



Treatment of social phobia: randomised trial of internet-delivered cognitive-behavioural therapy with telephone support.
Carlbring P, Gunnarsdóttir M, Hedensjö L, Andersson G, Ekselius L, Furmark T.

Linköping University, Department of Behavioural Sciences, SE-581 83 Linköping, Sweden.

BACKGROUND: Although effective therapies for social phobia exist, many individuals refrain from seeking treatment owing to the embarrassment associated with help-seeking. Internet-based cognitive-behavioural self-help can be an alternative, but adherence is a problem. AIMS: To evaluate a 9-week programme of internet-based therapy designed to increase treatment adherence by the addition of short weekly telephone calls, nine in all, with a total duration of 95 min. METHOD: In a randomised controlled trial the effects of internet-based cognitive-behavioural therapy in the treatment group (n=29) were compared with a waiting-list control group (n=28). RESULTS: Compared with the control group the treated participants experienced greater reductions on measures of general and social anxiety, avoidance and depression. Adherence to treatment was high, with 93% finishing the complete treatment package. One year later all improvements were maintained. CONCLUSIONS: This study provides evidence to support the use of internet-based treatment supplemented by short, weekly telephone calls.

PMID: 17267928 [PubMed - indexed for MEDLINE]
Br J Psychiatry. 2007 Feb;190:123-8.


E-mailed standardized cognitive behavioural treatment of work-related stress: a randomized controlled trial.
Ruwaard J, Lange A, Bouwman M, Broeksteeg J, Schrieken B.

Interapy BV, Amsterdam, The Netherlands.

The aim of this study was to assess the effects of a 7-week standardized cognitive behavioural treatment of work-related stress conducted via e-mail. A total of 342 people applied for treatment in reaction to a newspaper article. Initial screening reduced the sample to a heterogeneous (sub)clinical group of 239 participants. Participants were assigned randomly to a waiting list condition (n = 62), or to immediate treatment (n = 177). A follow-up was conducted 3 years after inception of the treatment. The outcome measures used were the Depression Anxiety Stress Scales (DASS-42) and the Emotional Exhaustion scale of the Maslach Burnout Inventory - General Survey (MBI-GS). Fifty participants (21%) dropped out. Both groups showed statistically significant improvements. Intention-to-treat analysis of covariance (ANCOVAs) revealed that participants in the treatment condition improved significantly more than those in the waiting control condition (0.001<p < or = 0.025). In the treatment group, the effects were large to moderate (0.9 (stress) > or = d > or = 0.5 (anxiety)). The between-group effects ranged from d = 0.6 (stress) to d = 0.1 (anxiety). At follow-up, the effects were more pronounced, but this result requires replication in view of high attrition at follow-up. The results warrant further research on Internet-driven standardized cognitive behavioural therapy for work-related stress. Such research should include the direct comparison of this treatment with face-to-face treatment, and should address the optimal level of therapist contact in Internet-driven treatment.

PMID: 17852171 [PubMed - indexed for MEDLINE]
Cogn Behav Ther. 2007;36(3):179-92.

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[Lyubimova]

Internet administration of the Edinburgh Depression Scale.
Spek V, Nyklícek I, Cuijpers P, Pop V.

Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands.

BACKGROUND: Internet-based screening for depression is becoming increasingly important. The aim of this study is to validate the Edinburgh Depression Scale (EDS) for internet administration. METHODS: In 407 participants (64% women; 36% men) with subthreshold depression (mean age=55 years; S.D.=4.9) positive predictive values for a syndromal CIDI diagnosis of clinical depression were calculated and compared to those from paper and pencil validation studies. At one-year follow-up, internal consistency and convergent validity of the internet-based EDS were determined in 177 participants by Cronbach's alpha and correlations with the internet-administered BDI and SCL-90 subscales depression and anxiety. RESULTS: Positive predictive values ranged between 29% and 33% at cut-off scores of 12 to 14. Cronbach's alpha for the internet-administered EDS was 0.87. The EDS correlated significantly with the internet-administered BDI (r=.75; p<.001) and two internet-administered subscales of the SCL-90: depression (r=.77; p<.001) and anxiety (r=.72; p<.001). A major limitation is that the study was conducted without a control group of healthy subjects. CONCLUSION: The psychometric properties of the internet-administered EDS are comparable to those of the paper and pencil EDS.

PMID: 17689667 [PubMed - indexed for MEDLINE]
J Affect Disord. 2008 Mar;106(3):301-5. Epub 2007 Aug 8.

[Lyubimova]

A randomized controlled trial of an internet-based treatment for chronic headache.
Devineni T, Blanchard EB.

Conemaugh Health System, 122 Montour Street, Johnstown, PA 15905 2422, USA.

Chronic headache is a significant public health problem in Western nations. Although controlled trials demonstrate the efficacy and cost-effectiveness of face-to-face behavioral therapy, most headache sufferers have limited access to these treatments. Delivery of behavioral interventions using Internet technology has the potential to reach a larger number of headache sufferers and reduce the burden of disease. This randomized controlled study evaluated an Internet-delivered behavioral regimen composed of progressive relaxation, limited biofeedback with autogenic training, and stress management versus a symptom monitoring waitlist control. Treatment led to a significantly greater decrease in headache activity than symptom monitoring alone. Thirty-nine percent of treated individuals showed clinically significant improvement on self-report measures of headache symptoms at post-treatment. At two-month follow-up, 47% of participants maintained improvement. Treatment had a significant impact on general headache symptoms and headache-related disability. There was a 35% within-group reduction of medication usage among the treated subjects. The Internet program was more time-efficient than traditional clinical treatment. Treatment and follow-up dropout rates, 38.1% and 64.8%, respectively, were typical of behavioral self-help studies. This approach to self-management of headache is promising; however, several methodological and ethical challenges need to be addressed.

PMID: 15680926 [PubMed - indexed for MEDLINE]
Behav Res Ther. 2005 Mar;43(3):277-92.




Internet-based cognitive behavioral therapy for tinnitus.
Andersson G, Kaldo V.

Department of Psychology, Uppsala University, Sweden.

Tinnitus is a common otological problem that is often resistant to surgical or medical interventions. In common with chronic pain, cognitive-behavioral treatment has been found to alleviate the distress and improve the functioning of tinnitus patients. Recently, a self-help treatment has been developed for use via the Internet. In this article, we describe the self-help program and apply it to a middle-aged woman with tinnitus. We report the case formulation, which was done in a structured interview, and the treatment interactions, which were conducted via e-mail. The self-help program was presented on Web pages, and weekly diaries were submitted to follow progress and give feedback. The treatment was successful with reductions of tinnitus-related annoyance and anxious and depressive mood. Implications for Internet administration of self-help treatment are discussed. Copyright 2003 Wiley Periodicals, Inc.

PMID: 14724924 [PubMed - indexed for MEDLINE]
J Clin Psychol. 2004 Feb;60(2):171-8.

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Online counseling - “e-therapy” - is when a professional counselor or psychotherapist talks with you over the Internet, to give you emotional support, mental health advice or some other professional service. It could be one question, or an ongoing conversation; it could be by e-mail, chat, video or even Internet phone (voice-over-IP).

E-therapy is a viable alternative source of help when traditional psychotherapy is not accessible. It’s effective. It’s private. It’s conducted by skilled, qualified, ethical professionals. And for some people, it's the only way they can get help from a professional therapist.

E-therapy is not psychotherapy. It should not be compared to psychotherapy. It is not a substitute for traditional psychotherapy. Working with a therapist in person is still better. But many people cannot or will not see a therapist in person. E-therapy is a form of counseling which, though it falls short of full-fledged psychotherapy, is still a very effective source of help.

E-therapy directly addresses a major problem uncovered by the Surgeon General's Report on Mental Health (1999) which stated that while one American in five has a diagnosable psychological problem, nearly two-thirds of them never seek treatment.

Managed care and the mental health industry sometimes make it difficult for people to get the care they need. When traditional systems fail them, many people are turning to the Internet.
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Kenneth Drude, Ph.D. & Michael Lichstein, Ph.D.

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