Disorder-specific internet-based cognitive-behavioral therapy in treating panic disorder, comorbid symptoms and improving quality of life: A meta-analytic evaluation of randomized controlled trials

App-Based Psychotherapy of Panic Disorder With Self-Guided Exposure in Virtual Reality—A Randomized Controlled Trial

BACKGROUND

Patients with panic disorder often suffer from tempo rary unavailability of care. The smartphone app Invirto (IVT) provides digital treatment for panic disorder comprising self-guided exposure in virtual reality. The aim of this trial was to assess the efficacy of Invirto.

METHODS

In a randomized, controlled, non-blinded trial, IVT was compared with care as usual (CAU) in patients with panic disorder (preregistration: DRKS00027585). The endpoints were assessed online before treatment (t0) and at 3 months (t1). The primary endpoint was the change in symptoms of anxiety, as measured with the Beck Anxiety Inventory (BAI), between the groups. The secondary endpoints were the patients' scores on the following assessment instruments, all in their German versions: the Panic and Agoraphobia Scale (PAS), the Beck Depression Inventory (BDI-II), a questionnaire on patient satisfaction (Client Satisfaction Questionnaire, CSQ-8), the Acceptance and Action Questionnaire (AAQ-II), and quality of life as a global item in the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF).

RESULTS

One hundred twenty-four participants were included. The intention-to-treat analysis revealed greater improvement with IVT than with CAU with respect to both the primary endpoint (BAI, d = -0.46; 95% confidence interval [-0.87; -0.04]) and the secondary endpoints (PAS, d = -0.63 [-1.05; -0.22]; BDI-II, d = -0.44 [-0.86; -0.02]; AAQ-II, d = -0.42 [-0.84; -0.01]), except for WHOQOL-BREF (p = 0.216).

CONCLUSION

A digital treatment with virtual exposure can lessen anxiety, panic, and depressive symptoms and improve mental flexibility. In further studies, IVT should be compared with an active control group.

Easing Panic: The Effect of an Online Psychoeducational Program on Panic Symptoms, Anxiety, and Quality of Life Among People Experiencing Panic Attacks

Panic attacks (PAs) are intense episodes of anxiety with severe physical symptoms that can impair an individual's social and occupational functions. Psychoeducation, a structured educational intervention, aims to improve various health aspects, including mental disorders. Delivering psychoeducation via the Internet can overcome barriers to accessing mental health treatment. This study examined the effectiveness of online psychoeducation on panic symptoms, anxiety, and quality of life (QOL) among people experiencing PAs. In this quasi-experimental design, 157 participants with PAs were recruited, and 136 eligible participants were allocated to treatment and control groups. The treatment group received an eight-session online psychoeducational program over 8 weeks, while the control group received reading materials. Outcome variables, including panic symptoms, anxiety, and QOL, were measured at baseline, 1-week post-intervention, and at 8-week follow-up using the Panic Disorder Dimensional (PD-D) scale, the Generalized Anxiety Disorder (GAD-7) scale, and the World Health Organization Quality of Life-BREF (WHOQOL-BREF), respectively. In the treatment group, the split-plot ANOVA showed a significant reduction in panic symptoms [F(1, 98) = 18.86, p < 0.01] and anxiety [F(1, 98) = 18.241, p < 0.01] compared to the control group. However, the intervention did not significantly affect QOL [F(1, 98) = 0.278, MSE = 153.007, p > 0.05]. The online psychoeducational program effectively reduced panic symptoms and anxiety levels but did not significantly impact QOL. Internet-based interventions, including psychoeducation, can improve access to mental health treatment, potentially reducing the treatment gap and enhancing overall mental health outcomes.

Internet-Based Cognitive Behavioural Treatments for Obsessive-Compulsive Disorder: A Systematic Review and Meta-Analysis

Obsessive-compulsive disorder (OCD) is a common mental health condition characterized by distressing, intrusive thoughts (obsessions) and repetitive behaviours (compulsions) aimed at reducing anxiety. Internet-based cognitive behavioural therapy (ICBT) has emerged as an effective treatment modality for various mental health disorders. This meta-analysis evaluates the efficacy of guided self-help ICBT (GSH ICBT) and unguided self-help ICBT (SH ICBT) against active and passive control conditions in adults with OCD. A comprehensive systematic literature search yielded 12 randomized controlled trials (RCTs) comprising 15 comparison arms (N = 1416) that met the inclusion criteria. Results indicate that GSH ICBT significantly reduced OCD symptomatology posttreatment compared to active controls (g = 0.378, k = 9), with no significant effects maintained at follow-up (g = 0.153, k = 4). GSH ICBT was also found to be as effective as active CBT interventions in reducing comorbid anxiety and depression symptoms posttreatment (g = 0.278, k = 6) and at follow-up (g = 0.124, k = 4). However, improvements in quality of life were not significant posttreatment (g = 0.115, k = 4) nor at follow-up (g = 0.179, k = 3). Combined GSH and SH ICBT demonstrated large effects on reducing OCD symptoms (g = 0.754, k = 6), medium effects on comorbid symptoms (g = 0.547, k = 6) and small effects on quality of life (g = 0.227, k = 2) when compared to inactive controls. No significant differences were found between GSH and SH ICBT in all measured outcomes posttreatment (OCD: g = 0.098, k = 3; AD: g = 0.070, k = 3; QoL: g = -0.030, k = 1) and at follow-up (OCD: g = 0.265, k = 2; AD: g = 0.084, k = 2; QoL: g = 0.00, k = 1). Sample size was identified as a significant moderator of treatment effects. This paper further explores clinical significance, treatment adherence, therapist time investment and moderator influences of the ICBT. The limitations of the study and recommendations for future research are thoroughly discussed.

Clinical and cognitive insight in panic disorder: phenomenology and treatment effects in internet cognitive behavior therapy

Clinical observations suggest that individuals with panic disorder (PD) vary in their beliefs about the causes of their panic attacks. Some attribute these attacks to psychological factors, while others to physiological or medical factors. These beliefs also extend to whether individuals perceive panic attacks as dangerous. In other areas of psychiatric nosology, these phenomena are commonly called clinical insight (recognition of disorder and the need for treatment) and cognitive insight (the ability to reflect on one's beliefs). Despite its importance, limited research exists on insight in PD and its relation to symptoms and treatment outcomes. This study examines clinical and cognitive insight in 83 patients with PD who received internet-based cognitive behavioral therapy, investigating their relationship with symptoms, treatment outcomes, and changes in insight. We assessed patients using interview and self-report measures of insight and symptoms. Clinical and cognitive insight were correlated and both constructs improved significantly during treatment. Good clinical insight pretreatment was positively correlated with more severe pretreatment symptoms. Pretreatment clinical and cognitive insight were not correlated with symptom change or attrition. Greater change in clinical and cognitive insight was related to greater change in symptoms. The findings highlight the significance of clinical and cognitive insight in PD, and the importance of distinguishing between them. This suggests the need to develop interventions according to patients' level of insight, particularly focusing on those lacking insight. Further research is essential to advance our understanding of the relationship between insight and the phenomenology and treatment of PD.

Internet-Based Cognitive-Behavioral Therapy for Individuals Experiencing Panic Attacks: A Scoping Literature Review

Panic attacks (PAs) are prevalent and highly comorbid with various physical and psychological disorders. Cognitive-behavioral therapy (CBT) is a well-established psychosocial intervention. Internet-delivered CBT (ICBT) presents a promising avenue to overcome barriers and provide evidence-based support to those in need. The current scoping review aimed to systematically map the existing literature and identify knowledge gaps regarding the impact of ICBT on outcome measures for individuals experiencing PAs. The PRISMA guidelines for scoping reviews were used. A total of 3,044 records were retrieved, and 18 studies from 2013 to 2023 were ultimately included in the analysis. ICBT demonstrated effectiveness as a psychosocial intervention for improving panic symptoms and anxiety in individuals with PAs. However, the impact of ICBT on quality of life (QOL) remains inconclusive. All studies included in this review focused on assessing the severity of panic symptoms, with limited emphasis on measuring QOL. This scoping review holds significant implications for research and practice. However, further addressing the research needs identified in this review will enhance our understanding and improve treatment outcomes for PAs. [Journal of Psychosocial Nursing and Mental Health Services, 62(4), 9-15.].

Internet-delivered cognitive behaviour therapy for affective disorders, anxiety disorders and somatic conditions: An updated systematic umbrella review

Background

Internet-delivered cognitive behaviour therapy (ICBT), which can involve guidance from a clinician, continues to be a way to deliver psychological treatments. A previous umbrella review identified moderate-to-large effect sizes favouring ICBT compared to control conditions when treating major depression and anxiety disorders. Given the rapid developments in the field, an updated umbrella review of available meta-analyses can show other conditions and subpopulations for which ICBT is effective. The aim of the study was to provide an expanded overview of the efficacy of ICBT for a broader range of adult psychiatric and somatic conditions.

Methods

We conducted an updated search of the literature since the publication of the previous umbrella review back in 2019 and up until March 2024. Five different search engines were used (Medline (OVID), Scopus, Web of Science, Cochrane library and CINAHL). The search was expanded to include additional psychiatric conditions (e.g., suicidal ideation) and somatic conditions (e.g., tinnitus and chronic pain).

Results

Of the 6509 identified articles, 39 meta-analyses met the inclusion criteria. In these meta-analyses 19 unique outcomes were represented. The most common outcome was symptoms of major depressive disorder, followed by symptoms of anxiety. Effect sizes for the comparisons against control conditions ranged between small (e.g., SMD = 0.10 for stress in employees) to large (e.g., SMD = 1.20 for depressive symptoms among older adults).

Conclusions

ICBT can generally reduce symptoms of a wide range of conditions including both psychiatric and somatic conditions, as well as other mental health problems. This updated review of available meta-analyses also indicated that ICBT has been successful in treating symptoms in different subpopulations such as older adults and students. However, some knowledge gaps remain, including the use of ICBT for psychotic disorders, and the quality of the available meta-analyses' points to a need for more stringent methodological procedures.

[Prescription-based digital interventions in psychiatry : Methodology, possible areas of application, and legal framework of digital tools for panic disorder and agoraphobia available in Germany]

In 2020, prescription-based digital interventions were introduced in Germany. These digital courses have to meet safety and data privacy requirements and must prove positive effects on symptoms and/or other outcome parameters. Interventions are available for a range of mental disorders. For patients with panic disorder and agoraphobia, several applications based on cognitive behavioral therapy have been developed. Within these digital courses, patients can typically access psychoeducational content and practice psychotherapeutic strategies such as exposure therapy. Recent meta-analyses prove the effectiveness of such interventions when compared with waitlist control conditions. According to current German guidelines, digital courses can be used to prepare psychotherapy and as an accompanying tool during psychotherapy. In Germany, physicians and psychotherapist can prescribe digital interventions for outpatients and as a post-hospital treatment..

Psychosocial treatment for panic disorder: An umbrella review of systematic reviews and meta-analyses

BACKGROUND

Panic disorder is a common and disabling psychiatric condition marked by sudden onset of physiological sensations that are appraised as dangerous. A number of studies and reviews have examined the efficacy of psychosocial treatments for PD; however, there is a lack of overarching reports that discuss the strength of evidence for the different psychosocial treatments for PD. This umbrella review provides an overview of systematic reviews and meta-analyses on psychosocial treatments for PD.

METHODS

A systematic search and review of the literature was conducted according to PRISMA guidelines.

RESULTS

A total of 38 reviews (31 meta-analyses and 7 systematic reviews) were included in the umbrella review. Most of the 38 reviews were focused on the use of CBT, both in-person and internet-based, to treat PD among adults, generally finding it to be an efficacious treatment compared to control conditions. A limited number of the 38 reviews included other age ranges or examined other forms of psychosocial treatments. The methodological quality of most included reviews was rated as critically low according to the AMSTAR-2 rating system.

CONCLUSIONS

Future reviews should focus on improving their methodological quality. Although the included reviews supported CBT as an efficacious treatment for reducing panic symptoms among adults, future research could focus on how CBT compares to other psychosocial treatments and the efficacy of CBT for PD among other populations (e.g., children and adolescents) and among diverse cultural groups.

User evaluation of a therapist-guided internet-delivered treatment program for anxiety disorders: A qualitative study

Therapist-guided internet-based cognitive behaviour therapy (ICBT) has been proposed as a potential means to increase individuals' access to quality mental health care and effective treatment. Guided ICBT aims to increase a patient's knowledge and competence to better cope with their disorder. Despite the growing evidence supporting the effects of guided ICBT, there is remarkably little research on the different factors that are important for patients to achieve effects from using such digital treatment interventions. Thus, the aim of this study was to conduct a user evaluation of a therapist-guided ICBT program using the updated DeLone and McLean (D&M) model for measuring information systems (IS) success or effectiveness. This model includes the following six dimensions: system quality, information quality, service quality, intention to use and use, user satisfaction, and net benefits (impacts or effect). Ten users of a Norwegian therapist-guided ICBT program for treating anxiety disorders named 'Assisted Self-Help' (Assistert Selvhjelp) participated in phone-based individual interviews. Data were analysed using directed content analysis. Results showed that the participants were quite satisfied with the program's system quality and information quality. However, participants suggested improvements, including in-program instruction, improved visibility of system status, more flexibility regarding automated measurement surveys, and the inclusion of more videos with patient stories. Further, the results indicated a need for improvement in the service quality of guided ICBT introduction, instruction, follow-up, guidance, and support from therapists. The results showed that user friendliness and high educational content might not be sufficient for a therapist-guided ICBT program to be perceived as effective. It might also be necessary for therapists to provide follow-up, guidance, and support that are more in line with individual patient needs. Thus, the results suggest that guided ICBT requires active participation from all involved in the process, including the therapist.