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Individually tailored internet-based cognitive behavioural therapy for anxiety disorders
Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Skräddarsydd internetförmedlad kognitiv beteendeterapi för ångestproblematik (Swedish)
Abstract [en]

Fear is an innate emotion and an adaptive response to provide protection from potential harm. When fear is excessive and out of proportion in relation to the confronted situation, it can lead to the development of an anxiety disorder. Many individuals feel anxious at some point, but not all experience clinical anxiety or meet the diagnostic criteria of an anxiety disorder. Still, anxiety disorders are the most prevalent form of psychiatric disorder in the general population. More often than not people suffering from one anxiety disorder also present other psychiatric conditions. As of today, cognitive and behavioural treatments have been tested and found to positively affect anxiety disorders, making them the treatment of choice. Nevertheless, many patients do not seek or receive adequate treatment.

One common critique of the research trials from which the recommendations for treatments stem is the use of a single protocol targeting only one diagnosis. This is because many people suffer from comorbidities. Another problem connected to the recommendation that cognitive behavioural therapy (CBT) should be the treatment of choice for anxiety disorders is the lack of therapists with adequate training. One possible way of dealing both with the shortcoming of therapists and making CBT more accessible is the use of the Internet. Internet-based CBT (ICBT) has been tested in numerous trials during the last 15 years, showing positive outcomes for a large variety of disorders. Many ICBT trials also make use of a single protocol. Another way of dealing with comorbidities might be to tailor the treatment to let characteristics and preferences of the patient guide the design of the protocol. Little is known about possible effects of tailoring the ICBT, the effects of therapeutic relationships in ICBT, and the effectiveness and cost-effectiveness of these treatments. This thesis is based on three studies on two separate randomized controlled trials (RCTs) using the same set of modules accessible for the tailored protocol.

Study I was an RCT investigating treatment effects up to two-year after completion, showing favourable outcomes of the treatment in a self-recruited sample at all measure points. Study II was a secondary analysis exploring possible relations between working alliance and treatment outcome for participants in the treatment group recruited for Study I indicating that working alliance predict outcome in this tailored treatment. The second RCT was an effectiveness trial (Study III) analysing treatment effects and cost-effectiveness of the treatment up to one year post treatment in a primary-care population. This study showed positive treatment effects both regarding symptom reduction and cost-effectiveness, and that effects were sustained at one year post treatment. Conclusions drawn from these studies are that individually tailored ICBT seems to be a feasible approach for patients with anxiety disorders regardless of comorbidities, and a responsible choice in terms of societal costs.

Abstract [sv]

Rädsla är en medfödd känsla och en adaptiv respons för att skydda organismen från potentiell skada. När rädslan blir överdriven och oproportionerlig i relation till den konfronterade situationen, kan det leda till utvecklandet av ångestsyndrom. Många personer upplever någon gång ångest, men inte alla upplever klinisk ångest eller uppfyller de diagnostiska kriterierna för något ångestsyndrom. Trots detta är ångest det vanligaste psykiatriska tillståndet i befolkningen i stort och oftast uppfyller personer som lider av ett ångestsyndrom även andra  psykiatriska tillstånd. Till dags dato har både kognitiva och beteendeinriktade behandlingar testats och visat sig verksamma vid ångestproblem, vilket gjort dem till de behandlingar som rekommenderas för dessa tillstånd. Trots god effekt av behandling söker många patienter ändå inte hjälp, alternativt erhåller inte adekvat behandling.

En vanlig kritik mot den forskning från vilka behandlingsrekommendationerna för ångestsyndrom stammar är att många använt en manual eller ett protokoll som riktar sig mot bara en diagnos. Detta på grund av den stora komorbiditeten. Ett annat problem kopplat till rekommendationerna att kognitiv beteendeterapi (KBT) ska vara förstahandsval vid behandling av ångest är bristen på behandlare med adekvat utbildning. Ett möjligt sätt att göra KBT mer tillgängligt är att använda Internet. Internet- förmedlad KBT (IKBT) har prövats i ett stort antal studier de senaste 15 åren dessa har visat positiva resultat vid ett stort antal psykiatriska tillstånd. Flertalet av dessa studier har dock använt ett enda behandlingsprotokoll. En annan möjlighet att hantera komorbiditet kan vara att skräddarsy behandlingen för att låta patientens egenskaper och preferenser vara med och styra utformningen av behandlingsprotokollet. Möjliga effekter av att skräddarsy IKBT är relativt lite undersökt, likaså effekterna av terapeutiska relationer i IKBT samt klinisk effektivitet och kostnadseffektiviteten för dessa behandlingar. Denna avhandling bygger på tre studier från två randomiserade kontrollerade studier med samma uppsättning av moduler tillgängliga för att skräddarsy behandlingsprotokollen.

I Studie I undersöktes behandlingseffekter upp till två år efter avslutad behandling i en självrekryterad grupp patienter. Studie II var en sekundäranalys av behandlingsgruppen från Studie I där eventuella samband mellan arbetsallians och behandlingsresultat undersöktes. Den andra randomiserade kontrollerade studien var en prövning av huruvida denna behandling var effektiv för en klinisk population (Studie III) rekryterad via primärvården. Förutom behandlingseffekter undersöktes även kostnadseffektiviteten upp till ett år efter behandlingsavslut. De slutsatser som dras utifrån dessa studier är att skräddarsydd IKBT verkar vara en framkomlig väg för patienter med ångest oavsett komorbiditet, att arbetsalliansen kan vara en faktor som påverkar utfallet, samt att det är ett ansvarsfullt val vad gäller samhälleliga kostnader.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 72 p.
Series
Linköping Studies in Arts and Science, ISSN 0282-9800 ; 598Linköping Studies in Behavioural Science, ISSN 1654-2029 ; 180
Keyword [en]
Anxiety, anxiety disorders, comorbidities, individually tailored Internet-based cognitive behavioural therapy, primary care, effectiveness, cost-effectiveness, working alliance, follow-up, long-term follow-up
Keyword [sv]
Ångest, ångestproblematik, komorbiditet, skräddarsydd internetförmedlad kognitiv beteendeterapi, primärvård, behandlingseffekt, kostnadseffekt, arbetsallians, uppföljning, långtidsuppföljning
National Category
Psychology
Identifiers
URN: urn:nbn:se:liu:diva-100969DOI: 10.3384/diss.diva-100969ISBN: 978-91-7519-459-2 (print)OAI: oai:DiVA.org:liu-100969DiVA: diva2:664494
Public defence
2013-12-20, 101, Hus I, Campus Valla, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2013-11-15 Created: 2013-11-15 Last updated: 2014-11-28Bibliographically approved
List of papers
1. Individually-tailored, Internet-based treatment for anxiety disorders: A randomized controlled trial
Open this publication in new window or tab >>Individually-tailored, Internet-based treatment for anxiety disorders: A randomized controlled trial
Show others...
2011 (English)In: BEHAVIOUR RESEARCH AND THERAPY, ISSN 0005-7967, Vol. 49, no 1, 18-24 p.Article in journal (Refereed) Published
Abstract [en]

Previous studies on Internet-based treatment with minimal to moderate therapist guidance have shown promising results for a number of specific diagnoses. The aim of this study was to test a new approach to Internet treatment that involves tailoring the treatment according to the patients unique characteristics and comorbidities. A total of 54 participants, regardless of specific anxiety diagnosis, were included after an in-person, semi-structured diagnostic interview and randomized to a 10 week treatment program or to a control group. Treatment consisted of a number of individually-prescribed modules in conjunction with online therapist guidance. Significant results were found for all dependent measures both immediately following treatment and at 1 and 2 year intervals. Mean between-group effect size including measures of anxiety, depression and quality of life was Cohens d = 0.69 at post-treatment, while the mean within-group effect size was d = 1.15 at post-treatment and d = 1.13 and d = 1.04 at 1 and 2 year follow-up respectively. The tentative conclusion drawn from these results is that tailoring the Internet-based therapy can be a feasible approach in the treatment of anxiety in a homogeneous population.

Place, publisher, year, edition, pages
Elsevier Science B.V., Amsterdam., 2011
Keyword
Anxiety, Depression, Effectiveness, Internet-based treatment
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-66957 (URN)10.1016/j.brat.2010.10.002 (DOI)000287061500003 ()
Available from: 2011-03-23 Created: 2011-03-23 Last updated: 2014-11-28
2. Role of the Working Alliance on Treatment Outcome in Tailored Internet-Based Cognitive Behavioural Therapy for Anxiety Disorders: Randomized Controlled Pilot Trial
Open this publication in new window or tab >>Role of the Working Alliance on Treatment Outcome in Tailored Internet-Based Cognitive Behavioural Therapy for Anxiety Disorders: Randomized Controlled Pilot Trial
2013 (English)In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 15, no 1Article in journal (Refereed) Published
Abstract [en]

Background: Internet-based cognitive behavioral therapy (ICBT) is a form of guided self-help that has been found to be effective for addressing several problems. The target for this type of therapy is usually restricted to one specific disorder. Tailoring the treatment widens the scope of ICBT in that it can address comorbid conditions directly.

Objectives: The working, or therapeutic, alliance has been found to predict outcome in studies of face-to-face therapy. The extent to which these findings apply to ICBT is largely unknown. We therefore decided to find out whether the working alliance could predict outcome in tailored ICBT for anxiety disorders.

Methods: Data were obtained from the treatment group (n=27) in a randomized controlled trial aiming to test the effects of tailored ICBT for anxiety disorders. The forthcoming study was designed to test the hypothesis that the working alliance measured both pre-treatment and early in treatment (week 3) can predict treatment outcome as measured by the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) in a heterogeneous group of patients with anxiety disorders (n=27).

Results: Working alliance measured at week 3 into the treatment correlated significantly with the residual gain scores on the primary outcome measure (r=-.47, P=.019, n=25), while expected working alliance pre-treatment did not (r=-.17, P=.42, n=27).

Conclusions: These results raise questions about the importance of working alliance in ICBT treatments, and suggest that the working alliance could be important in ICBT.

Place, publisher, year, edition, pages
Journal of Medical Internet Research / Gunther Eysenbach, 2013
Keyword
tailored Internet-based cognitive behavioural therapy, anxiety disorders, working alliance, prediction
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-90686 (URN)10.2196/resprot.2292 (DOI)000315113200008 ()
Note

Funding Agencies|Swedish Council for Working Life and Social Research|2008-1145|

Available from: 2013-04-05 Created: 2013-04-03 Last updated: 2017-12-06Bibliographically approved
3. Effectiveness and cost-effectiveness of individually tailored Internet-delivered cognitive behavior therapy for anxiety disorders in a primary care population: A randomized controlled rial
Open this publication in new window or tab >>Effectiveness and cost-effectiveness of individually tailored Internet-delivered cognitive behavior therapy for anxiety disorders in a primary care population: A randomized controlled rial
Show others...
2014 (English)In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 59, 1-11 p.Article in journal (Other academic) Published
Abstract [en]

A significant proportion of the general population suffers from anxiety disorders, often with comorbid psychiatric conditions. Internet-delivered cognitive behavior therapy (ICBT) has been found to be a potent treatment for patients with specific psychiatric conditions. The aim of this trial was to investigate the effectiveness and cost-effectiveness of ICBT when tailoring the treatment to address comorbidities and preferences for primary-care patients with a principal anxiety disorder. One hundred participants were recruited through their primary-care contact and randomized to either treatment or an active control group. The treatment consisted of 7–10 weekly individually assigned modules guided by online therapists. At post-treatment, 46% of the treatment group had achieved clinically significant improvement on the primary outcome measure (CORE-OM) and between-group effect sizes at ranged from d = 0.20 to 0.86, with a mean effect of d = 0.59. At one-year follow-up, within-group effect sizes varied between d = 0.53 to 1.00. Cost analysis showed significant reduction of total costs for the ICBT group, the results were maintained at one-year follow-up and the incremental  costeffectiveness ratio favored ICBT compared to control group. Individually tailored ICBT is an effective and cost-effective treatment for primary-care patients with anxiety disorders with or without comorbidities.

Place, publisher, year, edition, pages
Elsevier, 2014
Keyword
Primary care, anxiety, depression, comorbidity, Internet-administered cognitive behaviour therapy, cognitive behavior therapy, cost-effectiveness
National Category
Psychology
Identifiers
urn:nbn:se:liu:diva-100964 (URN)10.1016/j.brat.2014.05.007 (DOI)000340224000001 ()
Available from: 2013-11-15 Created: 2013-11-15 Last updated: 2017-12-06Bibliographically approved

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