A controlled trial of internet-based cognitive-behavioural therapy for panic disorder with face-to-face support from a general practitioner or email support from a psychologist

Background: Panic disorder (PD) is one of the most common anxiety disorders seen in general practice, but provision of evidence-based cognitive-behavioural treatment (CBT) is rare. Many Australian GPs are now trained to deliver focused psychological strategies, but in practice this is time consuming and costly.

Objective: To evaluate the efficacy of an internet-based CBT intervention (Panic Online) for the treatment of PD supported by general practitioner (GP)-delivered therapeutic assistance.

Design: Panic Online supported by GP-delivered face-to-face therapy was compared to Panic Online supported by psychologist-delivered email therapy.

Methods: Sixty-five people with a primary diagnosis of PD (78% of whom also had agoraphobia) completed 12 weeks of therapy using Panic Online and therapeutic assistance with his/her GP (n = 34) or a clinical psychologist (n = 31). The mean duration of PD for participants allocated to these groups was 59 months and 58 months, respectively. Participants completed a clinical diagnostic interview delivered by a psychologist via telephone and questionnaires to assess panic-related symptoms, before and after treatment.

Results: The total attrition rate was 20%, with no group differences in attrition frequency. Both treatments led to significant improvements in panic attack frequency, depression, anxiety, stress, anxiety sensitivity and quality of life. There were no statistically significant differences in the two treatments on any of these measures, or in the frequency of participants with clinically significant PD at post assessment.

Conclusions: When provided with accessible online treatment protocols, GPs trained to deliver focused psychological strategies can achieve patient outcomes comparable to efficacious treatments delivered by clinical psychologists. The findings of this research provide a model for how GPs may be assisted to provide evidence-based mental healthcare successfully.

Motivational interviewing and cognitive behaviour therapy in the treatment of adolescent overweight and obesity : study design and methodology

Background

Despite the high prevalence and negative physical and psychosocial consequences of overweight and obesity in adolescents, very little research has evaluated treatment in this population. Consequently, clinicians working with overweight and obese adolescents have little empirical research on which to base their practise. Cognitive behavioural therapy has demonstrated efficacy in promoting behaviour change in many treatment resistant disorders. Motivational interviewing has been used to increase motivation for change and improve treatment outcomes. In this paper we describe the rationale and design of a randomised controlled trial testing the efficacy of motivational interviewing and cognitive behaviour therapy in the treatment of overweight and obese adolescents.
Methods

Participants took part in a motivational interview or a standard semi-structured assessment interview and were then randomly allocated to a cognitive behavioural intervention or a wait-list control condition. The cognitive behavioural intervention, the CHOOSE HEALTH Program, consisted of 13 individual treatment sessions (12 face-to-face, 1 phone call) followed by 9 maintenance sessions (7 phone calls, 2 face-to-face). Assessments were conducted prior to participation, after the treatment phase and after the maintenance phase of intervention. Improvement in body composition was the primary outcome; secondary outcomes included improved cardiovascular fitness, eating and physical activity habits, family and psychosocial functioning.
Conclusion

Despite the demonstrated effectiveness of motivational interviewing and cognitive behavioural therapy in the long-term management of many treatment resistant disorders, these approaches have been under-utilised in adolescent overweight and obesity treatment. This study provides baseline data and a thorough review of the study design and treatment approach to allow for the assessment of the efficacy of motivational interviewing and cognitive behavioural therapy in the treatment of adolescent overweight and obesity. Data obtained in this study will also provide much needed information about the behavioural and psychosocial factors associated with adolescent overweight and obesity.

Dissemination of therapist-assisted internet cognitive behaviour therapy : development and open pilot study of a workshop

There is considerable research suggesting that therapist-assisted Internet cognitive behaviour therapy (ICBT) is efficacious in the treatment of depression and anxiety. Given this research, there is a growing interest in training students in therapist-assisted ICBT in order to assist with the dissemination of this emerging modality into routine clinical practice. In this study, we developed, delivered, and evaluated a therapist-assisted ICBT workshop for clinical psychology graduate students (n = 20). The workshop provided both research evidence and practical information related to the delivery of therapist-assisted ICBT. The workshop also incorporated an experiential component with students working on and discussing responses to client e-mails. Before and after the workshop, we measured knowledge of therapist-assisted ICBT research and professional practice issues, as well as attitudes towards and confidence in delivering therapist-assisted ICBT. Statistically significant changes were observed in all areas. Eighty-five per cent of students are now offering therapist-assisted ICBT under supervision. We conclude by discussing future research directions related to disseminating therapist-assisted ICBT.

Internet cognitive behavioural therapy for panic disorder : does the inclusion of stress management information improve end-state functioning?

Previous research has established Internet-based cognitive behavioural therapy (CBT) for panic disorder (PD) as effective in reducing panic severity and frequency. There is evidence, however, that such programs are less effective at improving overall end-state functioning, defined by a PD clinician severity rating of ≤2 and panic free. In order to test the effect on end-state functioning of the incorporation of stress management material within a CBT program for PD, 32 people with PD were randomised to either Internet-based CBT (PO1), Internet-based CBT plus stress management (PO2) or an Internet-based information-only control condition (IC). Both CBT treatments were more effective at posttreatment assessment than the control condition in reducing PD severity, panic and agoraphobia-related cognition, negative affect and self-ratings of health. PO2 was more effective than PO1 at posttreatment assessment on PD severity and general anxiety, although at 3-month follow-up these differences were no longer apparent. This study provides further support for the efficacy of Internet-based CBT for PD and suggests that although the incorporation of stress management material confers short-term advantages over a standard program, it is not associated with any longer term improvements on panic severity and related cognitions, negative affect, general wellbeing and end-state functioning.

Obsessive compulsive disorder : integration of cognitive-behaviour therapy and clinical psychology care into the primary care context

In primary care, evidence-based psychological treatments for obsessive compulsive disorder (OCD), such as cognitive behaviour therapy (CBT), have not been readily available. We aimed to develop models of care for OCD that account for barriers to access and can be integrated into general practice settings. Multiple methodologies and sources were utilised, including literature reviews, a reference group, focus groups, interviews and questionnaire responses from consumers, psychologists and/or GPs. It was found that there were similarities and some differences among stakeholders in attitudes and knowledge about OCD, and views about treatment and assessment in primary care. Three models of care for patients with OCD were developed and integrated into a treatment program operating through a division of general practice. Participating GPs preferred referral to a specialist clinic, irrespective of participation in an educational program about OCD. Based on these findings, it is suggested that effective integration of specialist CBT treatments for OCD into primary care is possible if the needs and views of all stakeholders are accounted for.

The role of the therapeutic alliance in internet-delivered cognitive-behaviour therapy

My research tested the importance of the client–practitioner relationship to therapeutic outcomes, utilising an Internet-based treatment for panic disorder. Results indicate that, while the relationship remains important when shared online, it matters less than in face-to-face settings. This calls into question conventional models of what makes psychological treatments effective.

Investigation of consumer satisfaction with cognitive-behaviour therapy and sertraline in the treatment of adolescent depression

Objective: A new instrument, the Adolescent Depression Treatment Satisfaction Questionnaire (ADTSQ) was devised to measure the consumer satisfaction of depressed adolescents and their parents. The objectives of the paper were to present the psychometric proper ties ofthe ADTSQ and to investigate the relative consumer satisfaction with cognitive-behavioural therapy (CBT), sertraline (SRT) and a combined treatment of CBT and SRT (COMBINED) for the treatment of adolescent depression. In addition, participants were asked to rank their most preferred treatment from the following approaches: medication, individual counselling, group program and family therapy.Method: Thirty-eight adolescents with a unipolar depressive disorder and 37 parents who participated in a randomized clinical trial of CBT versus SRT versus COMBINED completed the ADTSQ following the completion of acute treatment.Results: The ADTSQ was found to have high internal consistency and exploratory factor analysis detected three underlying factors. High levels of consumer satisfaction were reported by both adolescents and parents in all three treatments. Those treated with CBT treatments reported higher levels of skill acquisition than those treated with SRT. Of the four treatment approaches, most parents and adolescentsrated individual counsellingas their first preference.Conclusions: The ADTSQ is a useful measure of consumer satisfaction for depressed adolescents and their parents. CBT, SRT and COMBINED were shown to have high consumer satisfaction with CBT's higher skills training content reflected in the participants' reports. Individual counselling was perceived as the most favourable choice of treatment for adolescent depression. Although limitations associated with the measurement of consumer satisfaction and of the study are acknowledged, it is recommended that the inclusion of consumer satisfaction measures be considered in clinical trials that examine treatment efficacy.

Cognitive-reminiscence therapy for the treatment of depression in young adults

 This thesis aimed to evaluate a novel psychotherapy for young adults with depressive symptoms, cognitive-reminiscence therapy, and the underlying mechanisms of change. The results from a clinical trial showed large effects in reducing depressive symptoms, evidence for the mechanisms of change, and that young adults found this treatment helpful and appealing

Study protocol for a randomised controlled trial of internet-based cognitive-behavioural therapy for obsessive-compulsive disorder.

Obsessive-Compulsive Disorder (OCD) is a common chronic psychiatric disorder that constitutes a leading cause of disability. Although Cognitive-Behaviour Therapy (CBT) has been shown to be an effective treatment for OCD, this specialised treatment is unavailable to many due to access issues and the social stigma associated with seeing a mental health specialist. Internet-based psychological treatments have shown to provide effective, accessible and affordable treatment for a range of anxiety disorders, and two Randomised Controlled Trials (RCTs) have demonstrated the efficacy and acceptability of internet-based CBT (iCBT) for OCD, as compared to waitlist or supportive therapy. Although these initial findings are promising, they do not isolate the specific effect of iCBT. This paper details the study protocol for the first randomised control trial evaluating the efficacy of therapist-assisted iCBT for OCD, as compared to a matched control intervention; internet-based therapist-assisted progressive relaxation training (iPRT). It will aim to examine whether therapist-assisted iCBT is an acceptable and efficacious treatment, and to examine how effectiveness is influenced by patient characteristics.