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      Examining the Usage, User Experience, and Perceived Impact of an Internet-Based Cognitive Behavioral Therapy Program for Adolescents With Anxiety: Randomized Controlled Trial

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          Abstract

          Background

          Internet-based cognitive behavioral therapy (iCBT) increases treatment access for adolescents with anxiety; however, completion rates of iCBT programs are typically low. Understanding adolescents’ experiences with iCBT, what program features and changes in anxiety (minimal clinically important difference [MCID]) are important to them, may help explain and improve iCBT program use and impact.

          Objective

          Within a randomized controlled trial comparing a six-session iCBT program for adolescent anxiety, Being Real, Easing Anxiety: Tools Helping Electronically ( Breathe), with anxiety-based resource webpages, we aimed to (1) describe intervention use among adolescents allocated to Breathe or webpages and those who completed postintervention assessments ( Breathe or webpage respondents); (2) describe and compare user experiences between groups; and (3) calculate an MCID for anxiety and explore relationships between iCBT use, experiences, and treatment response among Breathe respondents.

          Methods

          Enrolled adolescents with self-reported anxiety, aged 13 to 19 years, were randomly allocated to Breathe or webpages. Self-reported demographics and anxiety symptoms (Multidimensional Anxiety Scale for Children—2nd edition [MASC-2]) were collected preintervention. Automatically-captured Breathe or webpage use and self-reported symptoms and experiences (User Experience Questionnaire for Internet-based Interventions) were collected postintervention. Breathe respondents also reported their perceived change in anxiety (Global Rating of Change Scale [GRCS]) following program use. Descriptive statistics summarized usage and experience outcomes, and independent samples t tests and correlations examined relationships between them. The MCID was calculated using the mean MASC-2 change score among Breathe respondents reporting somewhat better anxiety on the GRCS.

          Results

          Adolescents were mostly female (382/536, 71.3%), aged 16.6 years (SD 1.7), with very elevated anxiety (mean 92.2, SD 18.1). Intervention use was low for adolescents allocated to Breathe (mean 2.2 sessions, SD 2.3; n=258) or webpages (mean 2.1 visits, SD 2.7; n=278), but was higher for Breathe (median 6.0, range 1-6; 81/258) and webpage respondents (median 2.0, range 1-9; 148/278). Total user experience was significantly more positive for Breathe than webpage respondents ( P<.001). Breathe respondents reported program design and delivery factors that may have challenged (eg, time constraints and program support) or facilitated (eg, demonstration videos, self-management activities) program use. The MCID was a mean MASC-2 change score of 13.8 (SD 18.1). Using the MCID, a positive treatment response was generated for 43% (35/81) of Breathe respondents. Treatment response was not correlated with respondents’ experiences or use of Breathe ( P=.32 to P=.88).

          Conclusions

          Respondents reported positive experiences and changes in their anxiety with Breathe; however, their reports were not correlated with program use. Breathe respondents identified program design and delivery factors that help explain their experiences and use of iCBT and inform program improvements. Future studies can apply our measures to compare user experiences between internet-based interventions, interpret treatment outcomes and improve treatment decision making for adolescents with anxiety.

          Trial Registration

          ClinicalTrials.gov NCT02970734; https://clinicaltrials.gov/ct2/show/NCT02970734

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          Most cited references71

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          Measurement of health status. Ascertaining the minimal clinically important difference.

          In recent years quality of life instruments have been featured as primary outcomes in many randomized trials. One of the challenges facing the investigator using such measures is determining the significance of any differences observed, and communicating that significance to clinicians who will be applying the trial results. We have developed an approach to elucidating the significance of changes in score in quality of life instruments by comparing them to global ratings of change. Using this approach we have established a plausible range within which the minimal clinically important difference (MCID) falls. In three studies in which instruments measuring dyspnea, fatigue, and emotional function in patients with chronic heart and lung disease were applied the MCID was represented by mean change in score of approximately 0.5 per item, when responses were presented on a seven point Likert scale. Furthermore, we have established ranges for changes in questionnaire scores that correspond to moderate and large changes in the domains of interest. This information will be useful in interpreting questionnaire scores, both in individuals and in groups of patients participating in controlled trials, and in the planning of new trials.
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            Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort.

            If most adults with mental disorders are found to have a juvenile psychiatric history, this would shift etiologic research and prevention policy to focus more on childhood mental disorders. Our prospective longitudinal study followed up a representative birth cohort (N = 1037). We made psychiatric diagnoses according to DSM criteria at 11, 13, 15, 18, 21, and 26 years of age. Adult disorders were defined in the following 3 ways: (1) cases diagnosed using a standardized diagnostic interview, (2) the subset using treatment, and (3) the subset receiving intensive mental health services. Follow-back analyses ascertained the proportion of adult cases who had juvenile diagnoses and the types of juvenile diagnoses they had. Among adult cases defined via the Diagnostic Interview Schedule, 73.9% had received a diagnosis before 18 years of age and 50.0% before 15 years of age. Among treatment-using cases, 76.5% received a diagnosis before 18 years of age and 57.5% before 15 years of age. Among cases receiving intensive mental health services, 77.9% received a diagnosis before 18 years of age and 60.3% before 15 years of age. Adult disorders were generally preceded by their juvenile counterparts (eg, adult anxiety was preceded by juvenile anxiety), but also by different disorders. Specifically, adult anxiety and schizophreniform disorders were preceded by a broad array of juvenile disorders. For all adult disorders, 25% to 60% of cases had a history of conduct and/or oppositional defiant disorder. Most adult disorders should be reframed as extensions of juvenile disorders. In particular, juvenile conduct disorder is a priority prevention target for reducing psychiatric disorder in the adult population.
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              Advantages and limitations of Internet-based interventions for common mental disorders.

              Several Internet interventions have been developed and tested for common mental disorders, and the evidence to date shows that these treatments often result in similar outcomes as in face-to-face psychotherapy and that they are cost-effective. In this paper, we first review the pros and cons of how participants in Internet treatment trials have been recruited. We then comment on the assessment procedures often involved in Internet interventions and conclude that, while online questionnaires yield robust results, diagnoses cannot be determined without any contact with the patient. We then review the role of the therapist and conclude that, although treatments including guidance seem to lead to better outcomes than unguided treatments, this guidance can be mainly practical and supportive rather than explicitly therapeutic in orientation. Then we briefly describe the advantages and disadvantages of treatments for mood and anxiety disorders and comment on ways to handle comorbidity often associated with these disorders. Finally we discuss challenges when disseminating Internet interventions. In conclusion, there is now a large body of evidence suggesting that Internet interventions work. Several research questions remain open, including how Internet interventions can be blended with traditional forms of care. Copyright © 2014 World Psychiatric Association.
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                Author and article information

                Contributors
                Journal
                JMIR Ment Health
                JMIR Ment Health
                JMH
                JMIR Mental Health
                JMIR Publications (Toronto, Canada )
                2368-7959
                February 2020
                5 February 2020
                : 7
                : 2
                : e15795
                Affiliations
                [1 ] Department of Pediatrics University of Alberta Edmonton, AB Canada
                [2 ] Department of Psychiatry Dalhousie University Halifax, NS Canada
                [3 ] Department of Psychiatry Izaak Walton Killam Health Centre Halifax, NS Canada
                Author notes
                Corresponding Author: Amanda S Newton mandi.newton@ 123456ualberta.ca
                Author information
                https://orcid.org/0000-0003-1491-3516
                https://orcid.org/0000-0002-1484-9676
                https://orcid.org/0000-0003-4996-7784
                https://orcid.org/0000-0001-8341-3991
                https://orcid.org/0000-0003-3020-674X
                Article
                v7i2e15795
                10.2196/15795
                7055748
                32022692
                7dbf045b-1005-41ba-b5e5-3b33136a18a0
                ©Ashley D Dawn Radomski, Alexa Bagnell, Sarah Curtis, Lisa Hartling, Amanda S Newton. Originally published in JMIR Mental Health (http://mental.jmir.org), 05.02.2020.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/, as well as this copyright and license information must be included.

                History
                : 7 August 2019
                : 29 August 2019
                : 2 December 2019
                : 16 December 2019
                Categories
                Original Paper
                Original Paper

                internet,cognitive behavioral therapy,computer-assisted therapy,anxiety,adolescents,clinical effectiveness,satisfaction,minimal clinically important difference,treatment adherence

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