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      Therapist behaviours in internet-based cognitive behaviour therapy (ICBT) for depressive symptoms

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          Abstract

          Internet-based cognitive behaviour therapy (ICBT) is efficacious for treating depression, with therapist guidance identified as important for favourable outcomes. We have limited knowledge, however, about the fundamental components of therapist guidance in ICBT. The purpose of this study was to systematically examine therapist messages sent to patients during the course of ICBT for depressive symptoms in order to identify common “therapist behaviours” and the extent to which these behaviours correlate with completion of modules and improvements in symptoms at post-treatment, one- and two-year follow-up. A total of 664 e-mails from 5 therapists to 42 patients were analysed using qualitative content analysis. The most frequent behaviour was encouraging that accounted for 31.5% of the total number of coded behaviours. This was followed by affirming (25.1%), guiding (22.2%) and urging (9.8%). Less frequently the therapists clarified the internet treatment framework, informed about module content, emphasised the importance of patient responsibility, confronted the patient and made self-disclosures. Six of the nine identified therapist behaviours correlated with module completion. Three behaviours correlated with symptom improvement. Affirming correlated significantly ( r = .42, p = .005) with improvement in depressive symptoms at post-treatment and after two years ( r = .39, p = .014). Encouraging was associated with outcome directly after treatment ( r = .52, p = .001). Self-disclosure was correlated with improvement in depressive symptoms at post-treatment ( r = .44, p = .003). The study contributes to a better understanding of therapist behaviours in ICBT for depressive symptoms. Future directions for research are discussed.

          Highlights

          • •

            Therapists in ICBT most frequently encouraged, affirmed and guided their patients.

          • •

            Encouragement, affirmation and self-disclosures from the therapist correlated with improvement.

          • •

            Seven behaviour categories correlated with adherence but only three correlated with improvement.

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          Most cited references25

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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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              A new self-rating scale for depression and anxiety states based on the Comprehensive Psychopathological Rating Scale.

              M Åsberg, P Svanborg (1993)
              Self-assessment scales have long been used in psychiatric research even if their validity has often been questioned, one reason being poor the concordance of expert ratings. In clinical practice the use of rating scales is restricted, since they are considered to be time-consuming and perhaps even to disrupt the clinician's rapport with the patient. In the present study, a self-assessment scale, the CPRS Self-rating Scale for Affective Syndromes (CPRS-S-A), was constructed by re-phrasing in a self-rating format 19 items from the original Comprehensive Psychopathological Rating Scale (CPRS) and covering depression, anxiety and obsessional symptoms. In a group of 30 patients with depression syndromes and anxiety syndromes, the CPRS-S-A and the original CPRS were both used on 2 occasions. The patient's Global Assessment of Functioning scores ranged from 30 to 76 (mean 58), which suggests a moderate severity of illness, as does the fact that the majority were outpatients. There was a high degree of concordance between the instruments for most items and for the scores on the subscales for both diagnostic groups (i.e., the Montgomery-Asberg Depression Rating Scale and the Brief Anxiety Scale, which are both subscales drawn from the CPRS). The time taken to complete the CPRS-S-A varied from 5 to 30 min (mean 19 min for depressive and 16 min for anxiety patients on the first occasion, 13 min for both groups on the second), and the self-rating procedure was readily accepted by both groups of patients. The CPRS-S-A would thus seem to be a promising instrument for quantitative rating of symptoms in ambulatory patients, both in clinical practice and in research.
              Article 0 comments Cited 108 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Fredrik Holländare
                Journal
                Journal ID (nlm-ta): Internet Interv
                Journal ID (iso-abbrev): Internet Interv
                Title: Internet Interventions
                Publisher: Elsevier
                ISSN (Electronic): 2214-7829
                Publication date PMC-release: 19 November 2015
                Publication date Collection: March 2016
                Publication date (Electronic): 19 November 2015
                Volume: 3
                Pages: 1-7
                Affiliations
                [a ]Psychiatric Research Centre, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
                [b ]School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
                [c ]Department of Psychology, Stockholm University, Stockholm, Sweden
                [d ]Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
                [e ]Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
                [f ]Department of Psychology, University of Regina, Regina, Canada
                Author notes
                [* ]Corresponding author at: Psychiatric Research Centre, Örebro University, Box 1613, 701 16 Örebro, Sweden. fredrik.hollandare@ 123456regionorebrolan.se
                Article
                Publisher ID: S2214-7829(15)00039-1
                DOI: 10.1016/j.invent.2015.11.002
                PMC ID: 6096119
                PubMed ID: 30135783
                SO-VID: e57af2ff-2afe-4480-a94f-c38b4fefd962
                Copyright © © 2015 The Authors
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 28 August 2015
                Date revision received : 13 November 2015
                Date accepted : 18 November 2015
                Categories
                Subject: Full length Article

                Keywords: therapist behaviour,internet,cognitive behaviour therapy,depression,patient adherence
                Data availability:
                Keywords: therapist behaviour, internet, cognitive behaviour therapy, depression, patient adherence

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