The clinical use of palmtop computers in the treatment of generalized anxiety disorder

Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts

INTRODUCTION

Generalized anxiety disorder (GAD) is common and disabling. Different versions of cognitive behavioral therapy (CBT) have been tested, but no treatment works for everyone. Therefore, researchers have attempted approaches to enhance CBT.

AREAS COVERED

The current narrative review examines meta-analyses and individual trials of CBT-based treatments for GAD. We focus on CBT and its cognitive and behavioral components as well as efforts to enhance CBT and its dissemination and generalizability. Enhancement efforts included interpersonal and emotional processing therapy, mindfulness-based CBT, emotion regulation therapy, intolerance of uncertainty therapy, the unified protocol, metacognitive therapy, motivational interviewing, and contrast avoidance targeted treatment. Emerging strategies to enhance dissemination have focused on technologically based treatments. Attempts at generalizability have included examination of efficacy within diverse racial and ethnic groups.

EXPERT OPINION

We conclude that CBT is efficacious, and a number of enhancement efforts have shown some promise in improving upon CBT in single trials. However, more research is needed, particularly efforts to determine which enhancements work best for which individuals and what are the mechanisms of change. Furthermore, few technological interventions have been compared to active treatments. Finally, much more attention needs to be paid to ethnic and racial diversity in randomized controlled trials.

A randomized controlled trial of a smartphone-based application for the treatment of anxiety

AbstractIntroduction: Generalized anxiety disorder (GAD) is prevalent among college students. Smartphone-based interventions may be a low-cost treatment method. Method: College students with self-reported GAD were randomized to receive smartphone-based guided self-help (n = 50), or no treatment (n = 50). Post-treatment and six-month follow-up outcomes included the Depression Anxiety Stress Scales-Short Form Stress Subscale (DASS Stress), the Penn State Worry Questionnaire (PSWQ-11), and the State-Trait Anxiety Inventory-Trait (STAI-T), as well as diagnostic status assessed by the GAD-Questionnaire, 4th edition. Results: From pre- to post-treatment, participants who received guided self-help (vs. no treatment) experienced significantly greater reductions on the DASS Stress (d = -0.408) and a greater probability of remission from GAD (d = -0.445). There was no significant between-group difference in change on the PSWQ-11 (d = -0.208) or STAI-T (d = -0.114). From post to six-month follow-up there was no significant loss of gains on DASS Stress scores (d = -0.141) and of those who had remitted, 78.6% remained remitted. Yet rates of remitted participants no longer differed significantly between conditions at follow-up (d = -0.229). Conclusion: Smartphone-based interventions may be efficacious in treating some aspects of GAD. Methods for improving symptom reduction and long-term outcome are discussed.

Advantages and disadvantages of online and blended therapy: Replication and extension of findings on psychotherapists' appraisals

Therapists hold a key role for the uptake of digital mental health interventions (DMHI) within regular care services but have demonstrated cautious attitudes towards such interventions. It is relevant to explore in detail what factors may positively influence therapists' perception when considering DMHI implementation within routine care. We recently assessed therapist views towards Internet-based and blended treatment in Austria (low implementation level). The present study aims at testing the reliability of previous findings, and moreover, it compares therapists' appraisals to a country with advanced DMHI implementation (Sweden). An online survey was conducted February through June of 2019. Respondents were recruited via email and social media. The survey assessed first-hand experience with Internet-based treatment (IT) and blended treatment (BT). To start, the survey presented a short informational video to half of the respondents, then assessed therapists' views on 17 advantages and 13 disadvantages of IT and BT on 6-point Likert scales. In total N = 300 therapists responded to the invitation, of which N = 165 provided full survey data (Germany 114/220, 52%; Sweden 51/80, 64%). German therapists rated the advantages of IT and BT as neutral (IT, M = 3.6; BT, M = 3.8) and to some extent agreed with disadvantages of IT (IT, M = 4.5; BT, M = 3.5). In comparison, Swedish therapists rated significantly greater advantages (IT, M = 4.6; BT, M = 4.5) and less disadvantages (IT, M = 3.2; BT, M = 2.8). Effect sizes ranged from d = 0.89 to d = 1.83; all P's < .001. Those with first-hand experience with DMHI reported more positive appraisals in both countries. No significant effect was found for exposure to the short informational video. The German sample represented essential characteristics of current German therapists; in comparison Swedish respondents skewed towards younger less experienced therapists (P's < .001). Those confounders accounted for a small non-significant proportion of variance (0.1-4.7%). We found that therapists considered blended treatment to have less disadvantages than Internet treatment, and that first-hand experience with DMHI, but not exposure to an acceptance facilitating video clip, predicted greater acceptability on individual level. The responses among German therapists closely resembled findings from our preceding study in Austria, indicating that reliable results can be achieved in small survey studies if sample and population parameters correspond. Swedish therapists held significantly more favorable attitudes towards both interventions. The comparison between countries, however, is limited by a number of potential confounding variables.

Development of an audio and computer cognitive behavioral therapy for depression in older adults

Background: The purpose of this paper is to discuss the development of two novel technology-based interventions for depression in older adults while comparing older adults' preferences for audio-based and computer-based cognitive behavioral therapy for depressive symptoms. The audio program consisted of eight compact discs and a workbook while the computer program consisted of 11 modules of similar duration provided on a tablet PC. Both interventions consisted of the following topics: 1) introduction, 2) identifying and changing unhelpful thoughts, 3) addressing feelings, 4) relaxation, 5) engaging in pleasant events, 6) assertiveness, and 7) problem-solving. Methods: Fifty-one older adults were recruited from medical settings and rural communities and randomly assigned to an immediate treatment group (computer or audio) with minimal contact or a four-week minimal contact delayed treatment control condition. Results: Participants rated computer-based and audio-based cognitive behavioral therapy fairly equally, with 75% of those who received audio treatment and 85% of those who received computer-based treatment indicating benefits to their mood.Discussion: Computer-based or audio-based cognitive behavioral treatments may be valuable, low-cost modalities to deliver psychotherapy to older adults with depressive symptoms within a health care setting. Both modalities seem to be accepted by older adults.

Effectiveness of mobile technologies delivering Ecological Momentary Interventions for stress and anxiety: a systematic review

OBJECTIVES

Mobile technologies may be suitable for delivering Ecological Momentary Interventions (EMI) to treat anxiety in real-time. This review aims to synthesize evidence on the effectiveness of EMI for treating anxiety conditions.

MATERIALS AND METHODS

Four databases and the reference lists of previous studies were searched. A total of 1949 abstracts were double screened for inclusion. Sufficient studies were available to undertake a quantitative meta-analysis on EMIs on generalized anxiety symptoms.

RESULTS

The 15 randomized trials and randomized controlled trials examined anxiety (n = 7), stress (n = 3), anxiety and stress (n = 2), panic disorder (n = 2), and social phobia (n = 1). Eight EMIs comprised self-monitoring integrated with therapy modules, seven comprised multimedia content, and three comprised self-monitoring only. The quality of studies presented high risk of biases. Meta-analysis (n = 7) demonstrated that EMIs reduced generalized anxiety compared to control and/or comparison groups (Effect Size (ES) = 0.32, 95% CI, 0.12-0.53). Most EMIs targeting stress were reported effective relative to control as were the two EMIs targeting panic disorders. The EMI targeting social phobia was not effective.

DISCUSSION

EMIs have potential in treating both anxiety and stress. However, few high-quality trials have been conducted for specific anxiety disorders. Further trials are needed to assess the value of EMI technologies for anxiety in enhancing existing treatments.

CONCLUSION

This study found a small significant effect of EMI studies on reducing generalized anxiety. Studies on stress demonstrated EMI was effective compared to control, with the small number of studies on panic and social phobia demonstrating mixed results.

Technological advances in psychotherapy: implications for the assessment and treatment of obsessive compulsive disorder

Obsessive compulsive disorder (OCD) is a prevalent and costly condition that causes significant functional impairment and reduced quality of life. Although treatments with demonstrated efficacy for OCD, such as cognitive behavior therapy and antidepressants, have existed for over three decades, many patients remain inadequately treated or untreated. Challenges encountered in the treatment of OCD include problems with homework compliance, frequent relapse, difficulties in simulating the spontaneous nature of intrusive thoughts, and infrequent treatment sessions. Accumulated research now indicates that computerized assessment and therapy tools can significantly improve the cost/time-effectiveness of conventional psychotherapeutic interventions for anxiety disorders such as OCD without impairing therapeutic progress and outcome. In this paper we examine the potential of such technology, address current challenges in the assessment and treatment of OCD, and provide a rationale for future research in the field. We outline the general utility of computer technology in psychotherapeutic interventions, critically evaluate the existing literature on computer-assisted assessment and treatment specific to OCD, as well as discuss potential implications of portable technology for OCD treatment delivery and outcomes.

Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence

BACKGROUND

Studies of cognitive behavioural therapy delivered by computer (cCBT) show clinical efficacy for treating anxiety and depression, but have not focused on barriers to uptake. Potential barriers include adverse consequences, accessibility and acceptability.

METHOD

An integrated systematic review was conducted of quantitative and qualitative studies and surveys from multiple electronic databases where computers delivered cCBT for anxiety or depression.

RESULTS

Substantial numbers of potential participants are lost prior to trials commencing with little explanation. Among trial participants, drop-outs may be higher in the cCBT groups (odds ratio 2.03, 95% confidence interval 0.81-5.09). Only a median of 56% completed a full course of cCBT and personal circumstance was a more common cause of drop-out than difficulties with the technology or social background. Risk was rarely assessed in the majority of programs. Significant staff time was needed to support clients. Therapists were more negative about cCBT than clients.

CONCLUSIONS

While cCBT is likely to be an effective and acceptable intervention for some people, there are barriers to its uptake that will substantially limit its impact if not addressed. These included investigating the outcome and attitudes of those who do not make it as far as cCBT trials and why so few finish a full course of cCBT.

Automatic classification of dysfunctional thoughts: a feasibility test

The identification of dysfunctional thoughts is a central effort in cognitive therapy. This paper describes the first version of a computer module that classifies dysfunctional thoughts automatically. It is part of COGNO, a system we are developing to give automatic feedback on dysfunctional thoughts. The system uses rules that were developed from language markers identified in a sample of 149 dysfunctional thoughts. The system was tested with an independent set of 112 example thoughts. The system detects the majority of dysfunctional thoughts, but works reliably only for some thought categories. Automatic thought classification may be a first step toward developing natural dialogue systems in cognitive therapy.

Computer-supported cognitive behavioral treatment of anxiety disorders

This article reviews the empirical literature pertaining to the use of computer-supported cognitive-behavioral treatment of anxiety disorders, including palmtop computers, virtual reality exposure therapy, and personal computer software programs. The advantages and disadvantages unique to each type of technology are described. The review concludes with a discussion of ethical issues, barriers to the use of technology by clinicians, and suggestions for a process by which scientists and practitioners can conceptualize how technology can advance our understanding of anxiety and our dissemination of effective treatments.

Computer treatment for common mental health problems

Perhaps the most complex and controversial role for the computer in clinical practice is as a treatment medium in which the computer effectively replaces the psychotherapist. This article outlines the historical development of computer treatment, from dialogue generators in the 1960s through to the interactive, multimedia programs of the 2000s. In evaluating the most recent developments in computer treatment, we present a small meta-analytic study demonstrating large effect sizes in favor of computer treatments for anxiety and depression for pre/post outcomes and treatment as usual/waitlist comparators. Next, we review studies of the cost effectiveness of computer treatments. Finally, we outline the implications for research, policy, and practice of this new generation of treatment options.

Self-help and minimal-contact therapies for anxiety disorders: Is human contact necessary for therapeutic efficacy?

Self-help materials, brief therapies, and treatments involving minimal therapist contact have all been proposed as effective and low-cost interventions for anxiety disorders. However, research also suggests that the therapeutic alliance is a central predictor of therapy outcome. Interestingly, amounts of therapist contact within and across "self-help" interventions vary greatly. It is therefore unclear how much therapist contact is necessary for a positive anxiety disorder treatment outcome. The present article reviews the literature on anxiety disorder treatments using self-help, self-administered, and decreased therapist-contact interventions. Treatment studies are grouped together by anxiety diagnosis as well as amount of therapist contact. It is concluded that self-administered treatments are most effective for motivated clients seeking treatment for simple phobias. Predominantly self-help therapies are efficacious for panic disorder and mixed anxiety samples. On the other hand, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses.