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      Treating anxiety and depression in older adults: randomised controlled trial comparing guided v. self-guided internet-delivered cognitive–behavioural therapy

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          Abstract

          Background

          Symptoms of anxiety and depression are prevalent in older adults.

          Aims

          To compare clinician-guided and self-guided versions of a transdiagnostic internet-delivered cognitive–behavioural therapy (iCBT) intervention for adults aged 60 years and above.

          Method

          Adults ( n=433) with symptoms of anxiety and depression were randomly allocated to: (1) clinician-guided treatment ( n=153); (2) initial clinician interview followed by self-guided treatment ( n=140); or (3) self-guided treatment without interview ( n=140).

          Results

          Large reductions ( d ≥1.00) in symptoms of depression and anxiety were observed across groups, and sustained at follow-up. No differences were observed in clinical outcomes or satisfaction ratings. Age did not affect outcomes.

          Conclusions

          Carefully developed iCBT interventions may significantly reduce symptoms of anxiety and depression in older adults when delivered in either clinician-guided or self-guided formats.

          Declaration of interest

          N.T. and B.F.D. developed the Wellbeing Plus Course but derive no financial benefit from it.

          Copyright and usage

          © 2016 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

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          Most cited references19

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          Advantages and limitations of Internet-based interventions for common mental disorders.

          Gerhard Andersson, Nickolai Titov (2014)
          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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            Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost-effectiveness.

            Erik Hedman, Brjánn Ljótsson, Nils Lindefors (2012)
            Internet-based cognitive behavior therapy (ICBT) is a promising treatment that may increase availability of cognitive behavior therapy (CBT) for psychiatric disorders and other clinical problems. The main objective of this study was to determine the applications, clinical efficacy and cost-effectiveness of ICBT. The authors conducted a systematic review to identify randomized controlled trials investigating CBT delivered via the internet for adult patient populations. Searches to identify studies investigating cost-effectiveness of ICBT were also conducted. Evidence status for each clinical application was determined using the American Psychologist Association criteria for empirically supported treatments. Of 1104 studies reviewed, 108 met criteria for inclusion, of which 103 reported on clinical efficacy and eight on cost-effectiveness. Results showed that ICBT has been tested for 25 different clinical disorders, whereas most randomized controlled trials have been aimed at depression, anxiety disorders and chronic pain. Internet-based treatments for depression, social phobia and panic disorder were classified as well-established, that is, meeting the highest level of criteria for evidence. Effect sizes were large in the treatment of depression, anxiety disorders, severe health anxiety, irritable bowel syndrome, female sexual dysfunction, eating disorders, cannabis use and pathological gambling. For other clinical problems, effect sizes were small to moderate. Comparison to conventional CBT showed that ICBT produces equivalent effects. Cost-effectiveness data were relatively scarce but suggested that ICBT has more than 50% probability of being cost effective compared with no treatment or to conventional CBT when willingness to pay for an additional improvement is zero. Although ICBT is a promising treatment option for several disorders, it can only be regarded as a well-established treatment for depression, panic disorder and social phobia. It seems that ICBT is as effective as conventional CBT for respective clinical disorder, that is, if conventional CBT works then ICBT works. The large effects and the limited therapist time required suggest that the treatment is highly cost effective for well-established indications.
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              Improving Adherence and Clinical Outcomes in Self-Guided Internet Treatment for Anxiety and Depression: Randomised Controlled Trial

              Nickolai Titov, Blake Dear, Luke Johnston … (2013)
              Background Depression and anxiety are common, disabling and chronic. Self-guided internet-delivered treatments are popular, but few people complete them. New strategies are required to realise their potential. Aims To evaluate the effect of automated emails on the effectiveness, safety, and acceptability of a new automated transdiagnostic self-guided internet-delivered treatment, the Wellbeing Course, for people with depression and anxiety. Method A randomised controlled trial was conducted through the website: www.ecentreclinic.org. Two hundred and fifty seven people with elevated symptoms were randomly allocated to the 8 week course either with or without automated emails, or to a waitlist control group. Primary outcome measures were the Patient Health Questionnaire 9-Item (PHQ-9) and the Generalized Anxiety Disorder 7-Item (GAD-7). Results Participants in the treatment groups had lower PHQ-9 and GAD-7 scores at post-treatment than controls. Automated emails increased rates of course completion (58% vs. 35%), and improved outcomes in a subsample with elevated symptoms. Conclusions The new self-guided course was beneficial, and automated emails facilitated outcomes. Further attention to strategies that facilitate adherence, learning, and safety will help realise the potential of self-guided interventions. Trial Registration Australian and New Zealand Clinical Trials Registry ACTRN12610001058066
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                Author and article information

                Journal
                Journal ID (nlm-ta): BJPsych Open
                Journal ID (iso-abbrev): BJPsych Open
                Journal ID (publisher-id): bjporcpsych
                Journal ID (hwp): bjporcpsych
                Title: BJPsych open
                Publisher: The Royal College of Psychiatrists
                ISSN (Electronic): 2056-4724
                Publication date (Electronic): 1 February 2016
                Publication date Collection: January 2016
                Volume: 2
                Issue: 1
                Pages: 50-58
                Affiliations
                [1] Nickolai Titov, PhD
                [2] Vincent J. Fogliati, PhD
                [3] Lauren G. Staples, PhD
                [4] Milena Gandy, PhD
                [5] Luke Johnston, PhD, eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia
                [6] Bethany Wootton, PhD, School of Medicine (Psychology), University of Tasmania, Tasmania, Australia
                [7] Olav Nielssen, PhD
                [8] Blake F. Dear, PhD, eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia
                Author notes
                Correspondence: Blake F. Dear, PhD, eCentreClinic, Department of Psychology, Macquarie University, New South Wales, Australia. Email: blake.dear@ 123456mq.edu.au
                Article
                Publisher ID: bjporcpsych002139
                DOI: 10.1192/bjpo.bp.115.002139
                PMC ID: 4995559
                PubMed ID: 27703754
                SO-VID: a8650de7-3d1b-4814-895d-0dd0034edbfd
                Copyright © © 2016 The Royal College of Psychiatrists
                License:

                This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence ( http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 10 September 2015
                Date revision received : 9 November 2015
                Date accepted : 5 December 2015
                Categories
                Subject: Paper

                Data availability:

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