Guided self-help via internet for panic disorder: Dissemination across countries

doi:10.1016/j.chb.2009.12.011

Computers in Human Behavior

Volume 26, Issue 4, July 2010, Pages 592-596

https://doi.org/10.1016/j.chb.2009.12.011 Get rights and content

Abstract

Guided self-help via Internet is a promising way of treating panic disorder (PD). The present study examined the effects of a self-help program via Internet with weekly therapist contact for PD after disseminated to a new country. Predictors of outcome were also examined. The study was an open trial with 27 participants with PD with or without agoraphobia as their primary diagnose. Medium to large effects on PD-symptoms were reported after treatment and at 6 months follow-up, with smaller effects on secondary outcome measures, i.e. depression, interpersonal problems, and sleep problem. The attrition rate of 30% in present study was higher than in Swedish studies. Predictor analysis showed that participants with longer duration of PD-symptoms had less improvement on all outcome measurers, whereas higher age predicted more improvement. The guided self-help program remained effective when disseminated to a new country, but the high attrition rate needs to be addressed in future studies.

Introduction

Panic disorder (PD) have a lifetime prevalence at nearly 5% in the adult population (Kessler et al., 2006a), resulting in substantial costs both for those with the diagnosis and for society (Deacon et al., 2008, Kessler et al., 2006b). There are several effective treatments for PD, but there is a challenge to make these available for those in need of treatment (Collins et al., 2004, McManus et al., 2008). Guided self-help treatment based on Cognitive Behavioural Therapy (CBT) delivered through the Internet is a promising way of helping those with PD (Kaltenthaler et al., 2004, Titov, 2007).

The effects of a CBT-based guided self-help program for PD developed by the Swedish research group led by Andersson and Carlbring have been reported in four randomized controlled trials (Carlbring et al., 2003, Carlbring et al., 2001, Carlbring et al., 2005, Carlbring et al., 2006). Within-group effect sizes on primary outcome measures in these studies are reported to be medium to large, and when compared with therapist delivered therapy between-group effect sizes are reported to be small (Carlbring et al., 2005). The primary aim of present study was to examine effects of the guided self-help program for PD developed by Andersson and Carlbring when disseminated to a new country (from Sweden to Norway). The second aim of the study was to examine effects on symptoms and problems additional to the targeted PD-symptoms. Effects on depressive symptoms and quality of life from this treatment have been reported (Carlbring et al., 2003, Carlbring et al., 2006), but outcome on sleep and interpersonal problems should also be of interest, as these are two domains in which those who suffers from PD often report problems (Hoffart, Hackmann, & Sexton, 2006). The third aim of the study was to examine possible predictors of outcome. There are few consistent findings regarding predictors of outcome in the novel field of guided self-help via Internet, and more research on predictors is needed (Andersson, Carlbring, & Grimund, 2008).

Section snippets

Recruitment and inclusion

Participants were recruited through an ad in the local newspaper and 87 persons responded during the recruitment period (3 days). Initially, telephone screening based on the following criteria was used to select persons for face-to-face interview: (1) positive on two of three opening questions on the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (First, Spitzer, Gibbon, & Williams, 1995), (2) regularly access to Internet,

Primary and secondary outcomes

Average changes from pre-treatment to post-treatment and 6-month follow-up respectively were statistically significant on all primary outcome measures. Table 1 shows medium to large within-group effect sizes from pre-treatment to post-treatment. No significant changes were observed from post-treatment to 6-month follow-up.

Secondary measures did change significantly from pre-treatment to post-treatment and changes remained stable or had further improvement at 6-month follow-up (Table 2).

Predictors of outcome

Table 3

Discussion

The results from present study indicate that the guided self-help program can be successfully disseminated from one country to another with a significant impact on primary and secondary symptoms. Medium to large effects on primary outcome measures were observed from pre- to post-treatment. Significant improvements were also observed in secondary measures from pre- to post-treatment, and the changes remained stable or had further improvement at 6-month follow-up. Longer duration of PD-symptoms

Acknowledgement

This study was supported financially by Western Norway Regional Health Authority.

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Indeed, therapists tend to favor anxiety management strategies and cognitive techniques at the expense of exposure when treating panic and anxiety-related disorders (Hipol & Deacon, 2013; Whiteside et al., 2016). Users of iCBT for panic disorder report especially liking breathing and relaxation exercises (Nordgreen et al., 2010). During a recent study of iCBT, participants used relaxation strategies almost twice as often as cognitive restructuring and four times more than exposure, with only 31 % of participants completing any exposure exercises at all (Arndt et al., 2020).
To compare the efficacy and acceptability of internet-delivered exposure therapy for panic disorder, to multi-component internet-delivered cognitive behavioral therapy (iCBT) that included controlled breathing, cognitive restructuring and exposure.
Participants with panic disorder, with or without agoraphobia, were randomized to internet-delivered exposure therapy (n = 35) or iCBT (n = 34). Both programs were clinician guided, with six lessons delivered over eight weeks. Outcomes included panic disorder and agoraphobia symptom severity, as well as depression symptom severity, functional impairment and days out of role.
Participants in both conditions displayed a large reduction in panic disorder symptom severity (ds >1.30) from pre- to post-treatment. Participants in both conditions displayed medium to large reduction in agoraphobia and depression symptom severity, functional impairment and days out of role. Effects were maintained at three- and six-month follow-up. There was no significant difference between the interventions in clinical outcomes, adherence or treatment satisfaction.
Internet-delivered exposure therapy appeared to be as acceptable and efficacious as more established iCBT, despite including less strategies. However, a fully powered replication is now needed to compare the two approaches.
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Cognitive behavioral therapy (CBT) is an established treatment for panic disorder (PD). Remote CBT (RCBT) is becoming increasingly popular and has the potential to enhance access to this treatment. The aim of this study was to examine the efficacy of RCBT for PD using a meta-analytic approach. An electronic database search was used to identify relevant articles and the references of previously completed reviews. Twenty-one studies (n = 1,604; mean age range: 31.9–43.9; mean female representation = 71 %) were included in the meta-analysis. 14/21 (67 %; n = 817 of the included studies were randomised controlled trials and 7/21 (33 %; n = 787) were open trials or non-randomised controlled trials. Pooled within-group effect sizes across all remote treatments for PD symptoms were large from pre-treatment to post-treatment (Hedges’ g = 1.18; 95 % CI: 0.99–1.36) and pre-treatment to follow-up (Hedges’ g = 1.51; 95 % CI: 1.22–1.79). Pooled between-group findings indicate that remote CBT treatments are more effective than passive control (Hedges’ g = 1.17; 95 % CI: 0.85–1.50), but are similar to other active treatments on measures of PD symptoms (e.g., face-to-face CBT) (Hedges’ g = 0.02; 95 % CI: −0.43 to 0.48). Internet-delivered CBT (Hedges’ g = 1.10, 95 % CI: 0.91–1.30), videoconferencing-delivered CBT (Hedges’ g = 1.40, 95 % CI: 0.85–1.95) and bibliotherapy-delivered CBT (Hedges’ g = 1.51, 95 % CI: 0.95–2.06) each produce large effect sizes on measures of PD symptoms. The results have important implications for the dissemination of entirely remote stepped-care treatments for PD.
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Guided Internet-based cognitive behavioural therapy (ICBT) is a recommended treatment for panic disorder promising to increase treatment availability, but there are some concerns regarding adherence, including adherence to the in vivo exposure given as home assignments. The aim of this study was to assess the feasibility of combining ICBT with physical exercise with the aim of improving adherence and treatment response to ICBT.
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90.9% of the participants was considered completers in the ICBT program and the average adherence to the physical exercise was 93.1%. The experience of participating was summarized as “Hard work but worth it”. Clinical outcomes effect sizes (d) ranged from 2.79 (panic severity) to .64 (Beck's anxiety index).
The sum results on adherence, qualitative and quantitative data all suggest that augmenting ICBT with an aerobic exercise protocol is feasible. We conclude that further research is warranted.
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Clinical trials have demonstrated the efficacy of internet delivered cognitive behaviour therapy (ICBT) for anxiety and depression. However, relatively little is known about the context, operations, and outcomes of ICBT when administered as part of routine care. This paper describes the setting, relationship to existing health services, procedures for referral, assessment, treatment, patients and outcomes of ICBT clinics in Sweden, Denmark, Norway, Canada and Australia.
All five clinics provide services free or at low cost to patients. All have systems of governance to monitor quality of care, patient safety, therapist performance and data security. All five clinics include initial assessments by clinicians and between 10 and 20 min of therapist support during each week. Published reports of outcomes all demonstrate large clinical improvement, low rates of deterioration, and high levels of patient satisfaction. Services that require a face to face assessment treat smaller numbers of patients and have fewer patients from remote locations.
The paper shows that therapist-guided ICBT can be a valuable part of mental health services for anxiety and depression. Important components of successful ICBT services are rigorous governance to maintain a high standard of clinical care, and the measurement and reporting of outcomes.
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This is in line with the procedures used in the Carlbring (2006 and 2007) studies. The ICBT program for PD used in the present study was piloted in 2008, and the pilot yielded moderate to large within-groups effect sizes (Nordgreen et al., 2010). The 12-session FtF CBT diagnosis-specific manuals for PD and SAD were developed for the present study.
The aim of this study was to assess the effectiveness of a cognitive behavioral therapy (CBT) stepped care model (psychoeducation, guided Internet treatment, and face-to-face CBT) compared with direct face-to-face (FtF) CBT. Patients with panic disorder or social anxiety disorder were randomized to either stepped care (n = 85) or direct FtF CBT (n = 88). Recovery was defined as meeting two of the following three criteria: loss of diagnosis, below cut-off for self-reported symptoms, and functional improvement. No significant differences in intention-to-treat recovery rates were identified between stepped care (40.0%) and direct FtF CBT (43.2%). The majority of the patients who recovered in the stepped care did so at the less therapist-demanding steps (26/34, 76.5%). Moderate to large within-groups effect sizes were identified at posttreatment and 1-year follow-up. The attrition rates were high: 41.2% in the stepped care condition and 27.3% in the direct FtF CBT condition. These findings indicate that the outcome of a stepped care model for anxiety disorders is comparable to that of direct FtF CBT. The rates of improvement at the two less therapist-demanding steps indicate that stepped care models might be useful for increasing patients’ access to evidence-based psychological treatments for anxiety disorders. However, attrition in the stepped care condition was high, and research regarding the factors that can improve adherence should be prioritized.

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Guided self-help via internet for panic disorder: Dissemination across countries

Abstract

Introduction

Section snippets

Recruitment and inclusion

Primary and secondary outcomes

Predictors of outcome

Discussion

Acknowledgement

Computers in Human Behavior

Journal of Behavior Therapy and Experimental Psychiatry

Behaviour Research and Therapy

Behavior Therapy

Research and Therapy

Journal of Anxiety Disorders