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Internet cognitive behavioural therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care

Published online by Cambridge University Press:  18 February 2013

J. M. Newby ,
A. Mackenzie ,
A. D. Williams ,
K. McIntyre ,
S. Watts ,
N. Wong  and
G. Andrews
J. M. Newby*
Affiliation:
Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
A. Mackenzie
Affiliation:
Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
A. D. Williams
Affiliation:
Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
K. McIntyre
Affiliation:
Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
S. Watts
Affiliation:
Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
N. Wong
Affiliation:
Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
G. Andrews
Affiliation:
Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
*
*Address for correspondence: J. M. Newby, Ph.D., MRC Cognition and Brain Sciences Unit, 15 Chaucer Road, Cambridge CB2 7EF, UK. (Email: [email protected])
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Abstract

Background

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) have the highest co-morbidity rates within the internalizing disorders cluster, yet no Internet-based cognitive behavioural therapy (iCBT) programme exists for their combined treatment.

Method

We designed a six-lesson therapist-assisted iCBT programme for mixed anxiety and depression. Study 1 was a randomized controlled trial (RCT) comparing the iCBT programme (n = 46) versus wait-list control (WLC; n = 53) for patients diagnosed by structured clinical interview with MDD, GAD or co-morbid GAD/MDD. Primary outcome measures were the Patient Health Questionnaire nine-item scale (depression), Generalized Anxiety Disorder seven-item scale (generalized anxiety), Kessler 10-item Psychological Distress scale (distress) and 12-item World Health Organization Disability Assessment Schedule II (disability). The iCBT group was followed up at 3 months post-treatment. In study 2, we investigated the adherence to, and efficacy of the same programme in a primary care setting, where patients (n = 136) completed the programme under the supervision of primary care clinicians.

Results

The RCT showed that the iCBT programme was more effective than WLC, with large within- and between-groups effect sizes found (>0.8). Adherence was also high (89%), and gains were maintained at 3-month follow-up. In study 2 in primary care, adherence to the iCBT programme was low (41%), yet effect sizes were large (>0.8). Of the non-completers, 30% experienced benefit.

Conclusions

Together, the results show that iCBT is effective and adherence is high in research settings, but there is a problem of adherence when translated into the ‘real world’. Future efforts need to be placed on developing improved adherence to iCBT in primary care settings.

Keywords

Anxietycognitive behaviour therapydepressioneffectivenessInternettransdiagnostic treatmentstreatment outcome
Type
Original Articles
Information
Psychological Medicine , Volume 43 , Issue 12 , December 2013 , pp. 2635 - 2648
Copyright
Copyright © Cambridge University Press 2013 

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References

Andersson, G, Cuijpers, P (2009). Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cognitive Behaviour Therapy 38, 196–205.CrossRefGoogle ScholarPubMed
Andersson, G, Estling, F, Jakobsson, E, Cuijpers, P, Carlbring, P (2011). Can the patient decide which modules to endorse? An open trial of tailored Internet treatment of anxiety disorders. Cognitive Behaviour Therapy 40, 57–64.CrossRefGoogle ScholarPubMed
Andrews, G (1990). Classification of neurotic disorders. Journal of the Royal Society of Medicine 83, 606–607.CrossRefGoogle ScholarPubMed
Andrews, G, Cuijpers, P, Craske, MG, McEvoy, P, Titov, N (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS One 5, e13196.CrossRefGoogle ScholarPubMed
Andrews, G, Henderson, S, Hall, W (2001). Prevalence, comorbidity, disability and service utilisation. Overview of the Australian National Mental Health Survey. British Journal of Psychiatry 178, 145–153.CrossRefGoogle ScholarPubMed
Andrews, G, Kemp, A, Sunderland, M, Von Korff, M, Ustun, TB (2009). Normative data for the 12 item WHO Disability Assessment Schedule 2.0. PLoS One 4, e8343.CrossRefGoogle ScholarPubMed
Barlow, DH, Allen, LB, Choate, ML (2004). Toward a unified treatment for emotional disorders. Behavior Therapy 35, 205–230.CrossRefGoogle Scholar
Beck, AT, Steer, RA, Ball, R, Ranieri, WF (1996 a). Comparison of Beck Depression Inventories-IA and -II in psychiatric outpatients. Journal of Personality Assessment 67, 588–597.CrossRefGoogle Scholar
Beck, AT, Steer, RA, Brown, GK (1996 b). Manual for Beck Depression Inventory-II. The Psychological Corporation: San Antonio, TX.Google Scholar
Brown, TA, Antony, MM, Barlow, DH (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy 30, 33–37.CrossRefGoogle Scholar
Brown, TA, Campbell, LA, Lehman, CL, Grisham, JR, Mancill, RB (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology 110, 585–599.CrossRefGoogle Scholar
Chorpita, BF, Daleiden, EL (2009). Mapping evidence-based treatments for children and adolescents: application of the distillation and matching model to 615 treatments from 322 randomized trials. Journal of Consulting and Clinical Psychology 77, 566–579.CrossRefGoogle ScholarPubMed
Chu, BC (2012). Translating transdiagnostic approaches to children and adolescents. Cognitive and Behavioral Practice 19, 1–4.CrossRefGoogle Scholar
Costa, PTJ, McCrae, RR (1985). The NEO Personality Inventory Manual. Psychological Assessment Resources: Odessa, FL.Google Scholar
Cuijpers, P, van Straten, A, Andersson, G, van Oppen, P (2008). Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology 76, 909–922.CrossRefGoogle ScholarPubMed
Cuijpers, P, van Straten, A, Donker, M (2005). Personality traits of patients with mood and anxiety disorders. Psychiatry Research 133, 229–237.CrossRefGoogle ScholarPubMed
Cuijpers, P, van Straten, A, van Schaik, A, Andersson, G (2009). Psychological treatment of depression in primary care: a meta-analysis. British Journal of General Practice 59, e51–e60.CrossRefGoogle ScholarPubMed
Dear, BF, Titov, N, Schwencke, G, Andrews, G, Johnston, L, Craske, MG, McEvoy, P (2011). An open trial of a brief transdiagnostic internet treatment for anxiety and depression. Behaviour Research and Therapy 49, 830–837.CrossRefGoogle ScholarPubMed
Furukawa, T, Kessler, R, Slade, T, Andrews, G (2003). The performance of the K6 and K10 screening scales for psychological distress in the Australian National Survey of Mental Health and Well-Being. Psychological Medicine 33, 357–362.CrossRefGoogle ScholarPubMed
Gueorguieva, R, Krystal, J (2004). Move over ANOVA: progress in analyzing repeated-measures data and its reflection in papers published in the Archives of General Psychiatry. Archives of General Psychiatry 61, 310–317.CrossRefGoogle ScholarPubMed
Hedman, E, Andersson, E, Ljótsson, B, Andersson, G, Rück, C, Lindefors, N (2011). Cost-effectiveness of Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: results from a randomized controlled trial. Behaviour Research and Therapy 49, 729–736.CrossRefGoogle ScholarPubMed
Hettema, JM, Neale, MC, Myers, JM, Prescott, CA, Kendler, KS (2006). A population-based twin study of the relationship between neuroticism and internalizing disorders. American Journal of Psychiatry 163, 857–864.CrossRefGoogle ScholarPubMed
Hilvert-Bruce, Z, Rossouw, PJ, Wong, N, Sunderland, M, Andrews, G (2012). Adherence as a determinant of effectiveness of internet cognitive behavioural therapy for anxiety and depressive disorders. Behaviour Research and Therapy 50, 463–468.CrossRefGoogle ScholarPubMed
Hollandare, F, Andersson, G, Engstrom, I (2010). A comparison of psychometric properties between internet and paper versions of two depression instruments (BDI-II and MADRS-S) administered to clinic patients. Journal of Medical Internet Research 12, e49.CrossRefGoogle ScholarPubMed
Jacobson, NS, Truax, P (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology 59, 12–19.CrossRefGoogle ScholarPubMed
Kessler, R, Andrews, G, Colpe, L, Hiripi, E, Mroczek, D, Normand, S, Walters, E, Zaslavsky, A (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine 32, 959–976.CrossRefGoogle ScholarPubMed
Kessler, RC, DuPont, RL, Berglund, P, Wittchen, H-U (1999). Impairment in pure and comorbid generalized anxiety disroder and major depression at 12 months in two national surveys. American Journal of Psychiatry 156, 1915–1923.CrossRefGoogle Scholar
Kessler, RC, Ustün, TB (2004). The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). International Journal of Methods in Psychiatry Research 13, 93–121.CrossRefGoogle ScholarPubMed
Kroenke, K, Spitzer, R, Williams, J (2001). The PHQ-9: valdity of a brief depression severity measure. Journal of General Internal Medicine 16, 606–613.CrossRefGoogle Scholar
Kroenke, K, Spitzer, RL, Williams, JBW, Monahan, PO, Löwe, B (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine 146, 317–325.CrossRefGoogle ScholarPubMed
Lumpkin, PW, Silverman, WK, Weems, CF, Markham, MR, Kurtines, WM (2002). Treating a heterogeneous set of anxiety disorders in youths with group cognitive behavioral therapy: a partially nonconcurrent multiple-baseline evaluation. Behavior Therapy 33, 163–177.CrossRefGoogle Scholar
McEvoy, PM, Nathan, P, Norton, PJ (2009). Efficacy of transdiagnostic treatments: a review of published outcome studies and future research directions. Journal of Cognitive Psychotherapy 23, 20–33.CrossRefGoogle Scholar
Mewton, L, Wong, N, Andrews, G (2012). The effectiveness of internet cognitive behavioural therapy for generalized anxiety disorder in clinical practice. Depression and Anxiety 29, 843–849.CrossRefGoogle ScholarPubMed
Meyer, TJ, Miller, ML, Metzger, RL, Borkovec, TD (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy 28, 487–495.CrossRefGoogle ScholarPubMed
Newman, MG, Przeworski, A, Fisher, AJ, Borkovec, TD (2010). Diagnostic comorbidity in adults with generalized anxiety disorder: impact of comorbidity on psychotherapy outcome and impact of psychotherapy on comorbid diagnoses. Behavior Therapy 41, 59–72.CrossRefGoogle ScholarPubMed
Nolen-Hoeksema, S, Wisco, BE, Lyubomirsky, S (2008). Rethinking rumination. Perspectives on Psychological Science 3, 400–424.CrossRefGoogle ScholarPubMed
Norton, PJ (2008). An open trial of a transdiagnostic cognitive-behavioral group therapy for anxiety disorder. Behavior Therapy 39, 242–250.CrossRefGoogle ScholarPubMed
Norton, PJ (2012). A randomized clinical trial of transdiagnostic cognitve-behavioral treatments for anxiety disorder by comparison to relaxation training. Behavior Therapy 43, 506–517.CrossRefGoogle ScholarPubMed
Page, AC, Hooke, GR (2003). Outcomes for depressed and anxious inpatients discharged before or after group cognitive behavior therapy: a naturalistic comparison. Journal of Nervous Mental Disease 191, 653–659.CrossRefGoogle ScholarPubMed
Perini, S, Titov, N, Andrews, G (2009). Clinician-assisted Internet-based treatment is effective for depression: randomized controlled trial. Australian and New Zealand Journal of Psychiatry 43, 571–578.CrossRefGoogle ScholarPubMed
Robinson, E, Titov, N, Andrews, G, McIntyre, K, Schwencke, G, Solley, K (2010). Internet treatment for generalized anxiety disorder: a randomized controlled trial comparing clinician vs. technician assistance. PLoS One 5, e10942.CrossRefGoogle ScholarPubMed
Salim, A, Mackinnon, A, Christensen, H, Griffiths, K (2008). Comparison of data analysis strategies for intent-to-treat analysis in pre-test–post-test designs with substantial dropout rates. Psychiatry Research 160, 335–345.CrossRefGoogle ScholarPubMed
Schulz, KF, Altman, DG, Moher, D, for the CONSORT Group (2010). CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. PLoS Med 7, e1000251.CrossRefGoogle ScholarPubMed
Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, Hergueta, T, Baker, R, Dunbar, GC (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59 (Suppl. 20), 22–33.Google ScholarPubMed
Spitzer, RL, Kroenke, K, Williams, JB, Lowe, B (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine 166, 1092–1097.CrossRefGoogle ScholarPubMed
Stewart, RE, Chambless, DL (2009). Cognitive–behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology 77, 595–606.CrossRefGoogle ScholarPubMed
Titov, N, Andrews, G, Johnston, L, Robinson, E, Spence, J (2010). Transdiagnostic Internet treatment for anxiety disorders: a randomized controlled trial. Behaviour Research and Therapy 48, 890–899.CrossRefGoogle ScholarPubMed
Titov, N, Dear, BF, Schwencke, G, Andrews, G, Johnston, L, Craske, MG, McEvoy, P (2011). Transdiagnostic internet treatment for anxiety and depression: a randomised controlled trial. Behaviour Research and Therapy 49, 441–452.CrossRefGoogle ScholarPubMed
van Balkom, AJ, van Boeijen, CA, Boeke, AJ, van Oppen, P, Kempe, PT, van Dyck, R (2008). Comorbid depression, but not comorbid anxiety disorders, predicts poor outcome in anxiety disorders. Depression and Anxiety 25, 408–415.CrossRefGoogle Scholar
Waller, R, Gilbody, S (2009). Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence. Psychological Medicine 39, 705–712.CrossRefGoogle Scholar
Weisz, JR, Chorpita, BF, Palinkas, LA, Schoenwald, SK, Miranda, J, Bearman, SK, Daleiden, EL, Ugueto, AM, Ho, A, Martin, J, Gray, J, Alleyne, A, Langer, DA, Southam-Gerow, MA, Gibbons, RD (2012). Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: a randomized effectiveness trial. Archives of General Psychiatry 69, 274–282.CrossRefGoogle ScholarPubMed
Williams, AD, Andrews, G (in press). The effectiveness of internet cognitive behavioural therapy (iCBT) for depression in primary care: a quality assurance study. PLoS One.Google Scholar
Wittkampf, KA, Naeije, L, Schene, AH, Huyser, J, van Weert, HC (2007). Diagnostic accuracy of the mood module of the Patient Health Questionnaire: a systematic review. General Hospital Psychiatry 29, 388–395.CrossRefGoogle ScholarPubMed
WHO (2001). World Health Organization Disability Assessment Schedule II (WHO-DAS II) (http://www.who.int/classifications/icf/WHODAS2.0_12itemsSELF.pdf). Accessed 28 January 2013.Google Scholar