Guided and unguided self-help for social anxiety disorder: randomised controlled trial

The efficacy of psychotherapy for social anxiety disorder, a systematic review and meta-analysis

BACKGROUND

Given the growth in research examining the effects of psychotherapy on social anxiety disorder (SAD), an up-to-date comprehensive meta-analysis in this field is needed.

METHODS

We selected studies from a database of randomized trials (RCTs) on psychotherapies for anxiety disorders (last updated search of PubMed, PsycINFO, Embase, and Cochrane (CENTRAL): 1 January 2024) We included RCTs comparing psychotherapy to a control condition for adults with SAD and conducted random effects meta-analyses to examine the efficacy of psychotherapy compared to control conditions at post-treatment.

RESULTS

Sixty-six RCTs were included with 5560 participants and 98 comparisons between psychotherapy and control groups. Psychotherapy was effective in reducing SAD symptoms, with a large effect size (g = 0.88; 95 % CI: 0.76 to 1.0; I2 = 74 %; 95 % CI: 69 to 79, NNT = 3.8). Effects remained robust across sensitivity analyses. However, there was evidence for significant risk of bias in the included trials. The multivariable meta-regression indicated significant differences in treatment delivery formats, type of recruitment strategy, target group, and number of sessions.

CONCLUSION

Psychotherapy is an effective treatment for SAD, with moderate to large effect sizes across all treatment types and formats. Future research is needed to determine the long-term effects.

Guided and unguided internet-delivered psychodynamic therapy for social anxiety disorder: A randomized controlled trial

Social Anxiety Disorder (SAD) is highly prevalent and debilitating disorder. Treatments exist but are not accessible and/or helpful for all patients, indicating a need for accessible treatment alternatives. The aim of the present trial was to evaluate internet-delivered psychodynamic therapy (IPDT) with and without therapist guidance, compared to a waitlist control condition, in the treatment of adults with SAD. In this randomized, clinical trial, we tested whether IPDT was superior to a waitlist control, and whether IPDT with therapeutic guidance was superior to unguided IPDT. Participants were recruited nationwide in Sweden. Eligible participants were ≥ 18 years old and scoring ≥ 60 on the Liebowitz Social Anxiety Scale self-report (LSAS-SR) whilst not fulfilling any of the exclusion criteria. Included participants were randomly assigned to IPDT with guidance (n = 60), IPDT without guidance (n = 61), or waitlist (n = 60). The IPDT intervention comprised eight self-help modules based on affect-focused dynamic therapy, delivered over 8 weeks on a secure online platform. The primary outcome was SAD symptoms severity measured weekly by the LSAS-SR. Primary analyses were calculated on an intention-to-treat sample including all participants randomly assigned. Secondary outcomes were depressive symptoms, generalized anxiety, quality of life, emotion regulation and defensive functioning. At post-treatment, both active treatments were superior to the waitlist condition with guided treatment exhibiting larger between group effects than unguided treatment (d = 1.07 95% CI [0.72, 1.43], p < .001 and d = 0.61, 95% CI [0.25, 0.98], p = .0018) on the LSAS-SR respectively. Guided IPDT lead to larger improvements than unguided IPDT (d = 0.46, 95% CI [0.11, 0.80], p < .01). At post-treatment, guided IPDT was superior to waitlist on all secondary outcome measures. Unguided IPDT was superior to waitlist on depressive symptoms and general anxiety, but not on emotion regulation, self-compassion or quality of life. Guided IPDT was superior to unguided PDT on depressive symptoms, with a trend towards superiority on a measure of generalized anxiety. At six and twelve month follow-up there were no significant differences between guided and unguided IPDT. In conclusion, IPDT shows promising effects in the treatment of SAD, with larger benefits from guided IPDT compared to non-guided, at least at post-treatment. This finding increases the range of accessible and effective treatment alternatives for adults suffering from SAD. The study was prospectively registered at ClinicalTrials (NCT05015166).

Remote cognitive behaviour therapy for social anxiety disorder: A meta-analysis

Remote cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) has the potential to improve access to treatment by reducing economic, geographic, and psychological barriers. The aim of this study was to use a meta-analytic approach to examine the efficacy of the different remote CBT methods for treating SAD. A systematic electronic database search was used to identify 31 studies (n = 2905; mean age range: 24.73-41.65 years; mean female representation = 60.2 %). Pooled within-group analyses indicated large effect sizes from pre-treatment to post-treatment (Hedges' g = 1.06; 95 % CI: 0.96-1.16) and pre-treatment to follow up (g = 1.18; 95 % CI: 1.03-1.33) for remote CBT. Internet-delivered CBT (g = 1.08; 95 % CI: 0.98-1.19) and application-delivered CBT (g = 1.19; 95 % CI: 0.75-1.64) produced large within-group effect sizes. Bibliotherapy-delivered CBT (g = 0.79; 95 % CI: 0.45-1.13) produced medium within-group effect sizes. Pooled between-group findings indicate that remote CBT treatments were more effective than passive control (g = 0.87; 95 % CI: 0.70-1.03) and non-CBT remote treatments (g = 0.41; 95 % CI: 0.17-0.66), and were at least as effective, or slightly more effective, than face-to-face CBT treatments (g = 0.34; 95 % CI: 0.14-0.54). These findings have important implications for the dissemination of remote and stepped-care treatments for SAD.

Internet-Delivered Cognitive Behavioral Therapy Tailored to Spouses and Significant Others of Public Safety Personnel: Formative Evaluation Study

BACKGROUND

Spouses and significant others (SSOs) of public safety personnel (PSP) are affected by the risks and requirements of these occupations. Internet-delivered cognitive behavioral therapy (ICBT) provides a convenient and accessible treatment format that can be tailored to the needs of SSOs of PSP.

OBJECTIVE

This study aimed to assess the initial use and client perceptions (eg, likes, helpfulness, and areas for improvement) of a self-guided, transdiagnostic ICBT course designed for Canadian SSOs of PSP and identify opportunities to further tailor ICBT for this group.

METHODS

SSOs were invited to complete a 5-lesson, self-guided, transdiagnostic ICBT course. Descriptive statistics were used to analyze the demographic and clinical characteristics of participants. Content analysis was used to analyze the data from open-ended survey responses and interviews to understand their experiences with ICBT.

RESULTS

Clients (N=118) endorsed various mental health concerns (eg, depression, anxiety, posttraumatic stress symptoms, and relationship concerns) with a range of severity levels. Most clients identified as White (110/116, 94.8%) and women (108/116, 91.5%), with a mean age of 42.03 (SD 9.36) years. Of the 26 clients who were interviewed, 89% (23/26) reported believing that ICBT is helpful and 92% (24/26) reported finding at least 1 skill helpful. Clients provided suggestions for course improvements. On the basis of this feedback and quantitative data, changes were made to areas such as the delivery of materials, content, case stories, and timelines. Overall, the results indicated that many SSOs of PSP had positive perceptions of ICBT tailored to their needs and found several aspects of the course helpful, supporting the continued delivery of tailored ICBT to this population. However, there remains a need for continued promotion of the course and outreach to diverse groups of SSOs of PSP.

CONCLUSIONS

Findings from this formative evaluation provide insight into the unique experiences and needs of SSOs of PSP and provide preliminary evidence for the use of tailored ICBT to support the mental health of this group in Canada.

Scheduled Support Versus Support on Demand in Internet-Delivered Cognitive Behavioral Therapy for Social Anxiety Disorder: Randomized Controlled Trial

Objectives

Clinician-supported internet-delivered cognitive behavioral therapy (ICBT) can be an effective treatment option when treating social anxiety disorder (SAD). Unguided ICBT is often found to be less effective. One possible solution to reduce the costs of clinician support is to provide support on demand. In this format of guidance, participants have the option to contact their clinician if needed. In a few studies, this mode of support has been compared favorably to scheduled support.

Method

Participants in a previously reported controlled trial on SAD who had been in a waitlist control group were randomly allocated to ICBT with either on-demand guidance or scheduled weekly therapist guidance. A total of 99 participants were included. Data were collected weekly on the primary outcome measure, the Liebowitz Social Anxiety Scale self-report (LSAS-SR), and at pre- and post-treatment for secondary measures. Data were analyzed in accordance with the intention-to-treat principle using mixed-effects models.

Results

Both groups improved significantly during the treatment according to the LSAS-SR ratings. The groups did not differ in their estimated change during the treatment period, with a between-group effect of d = 0.02, 95% CI [-0.37, 0.43]. Both groups experienced similar improvement also on the secondary outcome measures, with small between-group effect sizes on all outcomes.

Conclusions

The findings indicate that support on demand can be an effective way of providing guidance in ICBT for SAD, although more research on this topic is needed. A limitation of the study is that it was conducted in 2009, and the findings were in the file drawer. Subsequent published studies support our initial findings, but more research is needed.

The effect of internet-delivered cognitive behavioral therapy for depression and anxiety on quality of life: A meta-analysis of randomized controlled trials

Although numerous studies have examined the effects of internet-delivered cognitive behavioral therapy (iCBT) for depression and anxiety on quality of life, no meta-analysis has yet been conducted to integrate the results of these studies. We conducted systematic searches in PubMed, Cochrane, and PsycInfo, which included terms for treatment type, modality of delivery, condition, and main outcome. We included studies that met the following inclusion criteria: (a) randomized controlled trials, (b) patients allocated to some form of the control condition, (c) patients receiving some type of treatment of anxiety and/or depression involving Internet-delivered Cognitive Behavioral Therapy, (d) use of a validated outcome measure assessing the level of quality of life, (e) conducted with adult participants diagnosed with anxiety disorder and/or unipolar depression, (f) papers written in English. We analyzed 40 randomized controlled trials with a total of 4289 participants that met inclusion criteria. The pooled between-group effect size for the quality of life overall score was small (g = 0.35, 95 % CI: 0.26-0.44, p = .0001), favoring iCBT over the control conditions. Regarding the distinct quality of life domains measured by the World Health Organization Quality of Life Assessment, a statistically significant difference between iCBT and control conditions was found only for the physical health domain (g = 0.56, 95 % CI: 0.06-1.07, p = .029), in favor of iCBT. In both cases, heterogeneity was moderate. While the effect on the quality of life is small (the overall quality of life score) to moderate (the physical health domain score), we conclude that iCBT for depression and anxiety may be a promising approach for improving the quality of life of patients.

Baseline Severity as a Moderator of the Waiting List-Controlled Association of Cognitive Behavioral Therapy With Symptom Change in Social Anxiety Disorder: A Systematic Review and Individual Patient Data Meta-analysis

Importance

Social anxiety disorder (SAD) can be adequately treated with cognitive behavioral therapy (CBT). However, there is a large gap in knowledge on factors associated with prognosis, and it is unclear whether symptom severity predicts response to CBT for SAD.

Objective

To examine baseline SAD symptom severity as a moderator of the association between CBT and symptom change in patients with SAD.

Data Sources

For this systematic review and individual patient data meta-analysis (IPDMA), PubMed, PsycInfo, Embase, and the Cochrane Library were searched from January 1, 1990, to January 13, 2023. Primary search topics were social anxiety disorder, cognitive behavior therapy, and randomized controlled trial.

Study Selection

Inclusion criteria were randomized clinical trials comparing CBT with being on a waiting list and using the Liebowitz Social Anxiety Scale (LSAS) in adults with a primary clinical diagnosis of SAD.

Data Extraction and Synthesis

Authors of included studies were approached to provide individual-level data. Data were extracted by pairs of authors following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline, and risk of bias was assessed using the Cochrane tool. An IPDMA was conducted using a 2-stage approach for the association of CBT with change in LSAS scores from baseline to posttreatment and for the interaction effect of baseline LSAS score by condition using random-effects models.

Main Outcomes and Measures

The main outcome was the baseline to posttreatment change in symptom severity measured by the LSAS.

Results

A total of 12 studies including 1246 patients with SAD (mean [SD] age, 35.3 [10.9] years; 738 [59.2%] female) were included in the meta-analysis. A waiting list-controlled association between CBT and pretreatment to posttreatment LSAS change was found (b = -20.3; 95% CI, -24.9 to -15.6; P < .001; Cohen d = -0.95; 95% CI, -1.16 to -0.73). Baseline LSAS scores moderated the differences between CBT and waiting list with respect to pretreatment to posttreatment symptom reductions (b = -0.22; 95% CI, -0.39 to -0.06; P = .009), indicating that individuals with severe symptoms had larger waiting list-controlled symptom reductions after CBT (Cohen d = -1.13 [95% CI, -1.39 to -0.88] for patients with very severe SAD; Cohen d = -0.54 [95% CI, -0.80 to -0.29] for patients with mild SAD).

Conclusions and Relevance

In this systematic review and IPDMA, higher baseline SAD symptom severity was associated with greater (absolute but not relative) symptom reductions after CBT in patients with SAD. The findings contribute to personalized care by suggesting that clinicians can confidently offer CBT to individuals with severe SAD symptoms.

INTERNET-DELIVERED LOW-INTENSITY CBT FOR PEOPLE WITH SOCIAL ANXIETY DISORDER IN A PERIOD OF COVID-19: RESULTS OF PILOT RESEARCH

OBJECTIVE

The aim: The study aims to provide evidence of the effectiveness of online low-intensity CBT-based psychological interventions on the psychological well-being of people with social anxiety disorders and related impairments in the COVID-19 pandemic.

PATIENTS AND METHODS

Materials and methods: 222 volunteers aged 18-35 years included in study: low-intensity CBT group (n=106) and control group (n=116). To assess the mental health prob¬lems were used International Neuropsychiatric Interview (MINI) and a set of IAPT scales. Analyses considered levels of pre-post intervention effect sizes and clinically significant improvement of symptoms of social anxiety disorder, generalized anxiety disorder, depression, and distress in maintaining general and work activity scores.

RESULTS

Results: Comparisons between the low-intensity interventions group and control (self-help guide psychological care as usual) indicated more reduction in the severity of symp¬toms of social anxiety disorder and comorbid impairments associated with depression or generalized anxiety disorder. Changes for social phobia and other outcomes indicate that the odds of relapse or exacerbation of symptoms in the control group are more significant than those after a CBT-based low-intensity psychosocial care program. Analysis showed a significant interaction between outcomes scores and the number of sessions: more than five online sessions and homework with a self-help guide improved outcome.

CONCLUSION

Conclusions: This pilot trial provides initial evidence that low-intensity online interventions based on CBT result in reductions in psychological problems for persons with a social anxiety disorder during the COVID-19 pandemic.

What I missed from my online therapist: A survey-based qualitative investigation of patient experiences of therapist contact in guided internet interventions

Background

The effectiveness of internet-delivered cognitive behavioral therapy (ICBT) in alleviating symptoms of psychological disorders has been demonstrated across qualitative and quantitative studies. Generally, guided ICBT is considered more effective than unguided ICBT. Yet, what therapist contact and guidance specifically add to the treatment is less clear. There is a need for more knowledge about how patients experience the relationship with their therapist in guided ICBT. The aim of the study was to explore what patients missed in the contact with their therapist in guided ICBT in routine care.

Methods

The study used a qualitative design to explore patients´ experiences of the therapist contact in guided ICBT for social anxiety disorder, panic disorder and major depressive disorder. Following treatment, 579 patients received a survey with the open-ended question "What did you miss in the contact with your therapist?" The responses were explored thematically using qualitative content analysis.

Results

A total of 608 unique responses were provided. Of these, 219 responses gave voice to some degree of perceived lack or limitation in their interaction with the therapist or the treatment in general. The analysis yielded three main categories: The first theme, Therapist-ascribed shortcomings, concerned experiences of something missing or lacking in the contact with the ICBT therapist. More specifically, the patients expressed a need for more emotionally attuned and tailored interaction. The second theme was Program obstacles, encompassing expressed wishes for increased therapist responsivity and more contact face-to-face. Self-attributed limitations, the third category, concerned patient experiences of barriers to treatment engagement as originating in themselves.

Conclusion

This study sheds light on what patients receiving guided ICBT in routine care missed in the contact with their therapist. The patients who expressed that something was missing in the contact with their therapist constituted a small part of the responses in the sample, even after being directly asked. The themes that emerged point to significant experiences of being inadequately related and responded to, both with potential adverse consequences for the treatment. These findings give new insights to the role of the guidance in ICBT and have implications for the training and supervision of guided ICBT therapists.

Development of social anxiety cognition scale for college students: Basing on Hofmann's model of social anxiety disorder

Introduction

To develop the Chinese version of the Social Anxiety Cognition Scale for College Students (SACS-CS) based on Hofmann's model of social anxiety disorder and examine its reliability and validity.

Methods

Based on literature analysis and structured interviews, a theoretical model was constructed and behavioral examples were collected. According to the results of participants' and experts' evaluations, the initial SACS-CS was developed. The study data were collected from a total of 500 valid participants, randomly divided into two samples. Sample 1 (n = 200) and sample 2 (n = 300) were considered for exploratory factor analysis and confirmatory factor analysis (CFA), respectively. Internal reliability and validity were examined using all 500 participants, and temporal reliability was established using sample 3 (n = 70), who completed the scale again after 4 weeks.

Results

The SACS-CS consists of 21 items, grouped under four factors: self-perception, social skills, emotional control, and cost estimation. The four-factor model fits well. The internal consistency coefficient of the scale and the four factors ranged from 0.87 to 0.96, and the test-retest reliability ranged from 0.76 to 0.84. The scores of the scale and the four factors were significantly correlated with the score of the Interaction Anxiousness Scale (r = 0.54-0.64).

Discussion

The SACS-CS possesses good reliability and validity and can be applied in the cognitive assessment of college students' social anxiety. The scale could help people with different social anxiety disorder conditions receive more personalized interventions.

A Preliminary Examination of Treatment Barriers, Preferences, and Histories of Women with Symptoms of Social Anxiety Disorder

Social anxiety disorder (SAD) is a common mental health condition that is characterised by a persistent fear of social or performance situations. Despite effective treatments being available, many individuals with SAD do not seek treatment or delay treatment seeking for many years. The aim of the present study was to examine treatment barriers, treatment histories, and cognitive behavioural therapy (CBT) delivery preferences in a sample of women with clinically relevant SAD symptoms. Ninety-nine women (Mage = 34.90, SD = 11.28) completed the online questionnaires and were included in the study. Participants were recruited from advertisements on community noticeboards and posts on social media. The results demonstrated that less than 5% of those who received psychological treatment in the past were likely to have received best-practice CBT. The most commonly cited barriers to accessing treatment for women with SAD related to direct costs (63%) and indirect costs (e.g., transport/childcare) (28%). The most preferred treatment delivery method overall was individual face-to-face treatment (70%). The study demonstrates a need to provide a variety of treatment options in order to enhance access to empirically supported treatment for women with SAD.

Two decades of digital interventions for anxiety disorders: a systematic review and meta-analysis of treatment effectiveness

BACKGROUND

Digital interventions for anxiety disorders are a promising solution to address barriers to evidence-based treatment access. Precise and powerful estimates of digital intervention effectiveness for anxiety disorders are necessary for further adoption in practice. The present systematic review and meta-analysis examined the effectiveness of digital interventions across all anxiety disorders and specific to each disorder v. wait-list and care-as-usual controls.

METHODS

A systematic search of bibliographic databases identified 15 030 abstracts from inception to 1 January 2020. Forty-seven randomized controlled trials (53 comparisons; 4958 participants) contributed to the meta-analysis. Subgroup analyses were conducted by an anxiety disorder, risk of bias, treatment support, recruitment, location and treatment adherence.

RESULTS

A large, pooled effect size of g = 0.80 [95% Confidence Interval: 0.68-0.93] was found in favor of digital interventions. Moderate to large pooled effect sizes favoring digital interventions were found for generalized anxiety disorder (g = 0.62), mixed anxiety samples (g = 0.68), panic disorder with or without agoraphobia (g = 1.08) and social anxiety disorder (g = 0.76) subgroups. No subgroups were significantly different or related to the pooled effect size. Notably, the effects of guided interventions (g = 0.84) and unguided interventions (g = 0.64) were not significantly different. Supplemental analysis comparing digital and face-to-face interventions (9 comparisons; 683 participants) found no significant difference in effect [g = 0.14 favoring digital interventions; Confidence Interval: -0.01 to 0.30].

CONCLUSION

The precise and powerful estimates found further justify the application of digital interventions for anxiety disorders in place of wait-list or usual care.

Burnout syndrome, doctor-patient relationship and family support of pediatric medical staff during a COVID-19 Local outbreak in Shanghai China: A cross-sectional survey study

OBJECTIVES

To explore burnout syndrome (BOS) incidence, doctor-patient relationship, and family support on pediatric medical staff in Shanghai comprehensive hospitals during a COVID-19 local outbreak.

METHODS

A cross-sectional survey of pediatric medical staff from 7 comprehensive hospitals across Shanghai was conducted from March to July 2022. The survey included BOS, doctor-patient relationships, family support, and the related factors of COVID-19. The T-test, variance, the LSD-t test, Pearson's r correlation coefficient, and multiple regression analyses examined the data.

RESULTS

Using Maslach Burnout Inventory-General Survey (MBI-GS), 81.67% of pediatric medical staff had moderate BOS, and 13.75% were severe. The difficult doctor-patient relationship was positively correlated with emotional exhaustion(EE), cynicism(Cy), and negatively with personal accomplishment(PA). When medical staff need help, the greater the support provided by the family, the lower the EE and CY, and the higher the PA.

CONCLUSION

"In our study, the pediatric medical staff in Shanghai comprehensive hospitals had significant BOS during a COVID-19 local outbreak." We provided the potential steps that can be taken to reduce the increasing rate of BOS in pandemics. These measures include increased job satisfaction, psychological support, maintaining good health, increased salary, lower intent to leave the profession, regularly carrying out COVID-19 prevention training, improving doctor-patient relations, and strengthening family support.

Self-compassion training for individuals with social anxiety disorder: a preliminary randomized controlled trial

Self-compassion is the ability to offer oneself kindness and compassion in response to failure, suffering, or insecurity. Learning how to be self-compassionate through self-compassion training appears effective for improving psychological well-being in community samples and promising for clinical populations. The current randomized controlled trial was designed to (a) examine the effectiveness of a self-guided self-compassion training program; and (b) determine whether self-compassion training can help mitigate social anxiety disorder (SAD) symptoms. Adults with SAD (n = 63; Mage = 34.3, SD = 11.4; 67.8% female; 84.7% Caucasian) were randomized to a waitlist control condition, a self-guided self-compassion training condition, or a self-guided applied relaxation training condition for six weeks. Outcome measures of SAD symptoms and self-compassion were completed pre-, mid-, and post-treatment, as well as at 3-months follow-up. Multilevel linear modelling results suggested the self-compassion training program was statistically superior at improving outcome measures relative to the waitlist control condition (ps < .05; η²_ps = .12-.33), but not relative to the applied relaxation training condition (ps > .05; η²_ps = .01-.05). Self-compassion training produced greater clinically significant gains in self-compassion and reductions in fear of self-compassion compared to both the waitlist condition and applied relaxation training. The current trial provides preliminary evidence for the effectiveness of a self-help self-compassion training program and provides evidence that self-compassion training may be beneficial for managing clinically significant SAD symptoms.

Long-term outcomes of cognitive behavioural therapy for social anxiety disorder: A meta-analysis of randomised controlled trials

Cognitive Behavioural Therapy (CBT) is effective in treating Social Anxiety Disorder (SAD). However, less is known about whether gains achieved in disorder-specific and secondary outcomes (e.g., depression, general anxiety, quality of life, and self-esteem) are maintained 12 months or longer. A systematic literature search yielded 25 relevant studies that administered CBT to participants with SAD. Multivariate meta-analyses of post-treatment assessments, found that CBT was superior to control conditions in reducing social anxiety (g =.74), depression (g =.52), general anxiety (g =.69) and improving quality of life (g =.39). The within-groups effect sizes revealed that 12 months or more after CBT treatment, symptoms continued to improve for social anxiety (g_av =.23) and quality of life (g_av =.17), and gains were maintained for depressive (g_av =.06) and general anxiety symptoms (g_av =.03). However, meta-analyses of long-term outcomes lack comparison groups. Moderation was non-significant for the treatment model, format, number of sessions, treatment duration, or inclusion of booster sessions. Future research may investigate what drives improvement after treatment cessation and how CBT affects other co-occurring symptomatology. Taken together, CBT produces many benefits for SAD and individuals with co-occurring symptoms can benefit from extant SAD-focused treatments.

Serotonin and dopamine transporter availability in social anxiety disorder after combined treatment with escitalopram and cognitive-behavioral therapy

Selective serotonin reuptake inhibitors (SSRIs) and internet-based cognitive behavioral therapy (ICBT) are recommended treatments of social anxiety disorder (SAD), and often combined, but their effects on monoaminergic signaling are not well understood. In this multi-tracer positron emission tomography (PET) study, 24 patients with SAD were randomized to treatment with escitalopram+ICBT or placebo+ICBT under double-blind conditions. Before and after 9 weeks of treatment, patients were examined with positron emission tomography and the radioligands [¹¹C]DASB and [¹¹C]PE2I, probing the serotonin (SERT) and dopamine (DAT) transporter proteins respectively. Both treatment combinations resulted in significant improvement as measured by the Liebowitz Social Anxiety Scale (LSAS). At baseline, SERT-DAT co-expression was high and, in the putamen and thalamus, co-expression showed positive associations with symptom severity. SERT-DAT co-expression was also predictive of treatment success, but predictor-outcome associations differed in direction between the treatments. After treatment, average SERT occupancy in the SSRI + ICBT group was >80%, with positive associations between symptom improvement and occupancy in the nucleus accumbens, putamen and anterior cingulate cortex. Following placebo+ICBT, SERT binding increased in the raphe nuclei. DAT binding increased in both groups in limbic and striatal areas, but relations with symptom improvement differed, being negative for SSRI + ICBT and positive for placebo + ICBT. Thus, serotonin-dopamine transporter co-expression exerts influence on symptom severity and remission rate in the treatment of social anxiety disorder. However, the monoamine transporters are modulated in dissimilar ways when cognitive-behavioral treatment is given concomitantly with either SSRI-medication or pill placebo.

The relationship between negative life events and mental health of overseas Chinese left-behind children: A moderated mediation model

To examine the factors influencing the mental health and sociality of overseas Chinese left-behind children, and to identify the protective mechanisms of their mental health, the current study investigated 568 overseas Chinese left-behind children. The age distribution of the sample ranges from 10 to 16 years, with an average age of 13.51 years and a standard deviation of 1.11. Using the Adolescent Self-Rating Life Events Checklist, Perceived Social Support Scale, General Self-Efficacy Scale and Mental Health Inventory of Middle-school Students, results showed that: (1) Perceived social support played a moderate mediate role in the relationship between negative life events and mental health. (2) The effect of negative life events on perceived social support was moderated by general self-efficacy. Negative life events of overseas Chinese left-behind children with higher self-efficacy were more likely to experience negative mental health. Conclusion: Perceived social support plays a moderating mediating role in the relationship between negative life events and mental health of overseas Chinese left-behind children.

Improving adherence to a web-based cognitive-behavioural therapy program for social anxiety with group sessions: A randomised control trial

Individuals with social anxiety disorder (SAD) commonly receive non-evidence based, ineffective treatments. Cognitive behaviour therapy (CBT) has been demonstrated to be the gold standard treatment for treating SAD. Scalable web-based CBT programs ensure evidence-based treatment procedures, but low treatment adherence remains problematic. This study aimed to test whether adding group sessions to a fully automated web-based CBT program, Overcome Social Anxiety (OSA), would increase treatment adherence. A total of 69 participants were provided access to a web-based program, and randomly allocated to three conditions: 1) An experimental condition involving an addition of three online group psychoeducation sessions; 2) a placebo condition involving an addition of three online progressive muscle relaxation (PMR) group sessions, or 3) a control condition where participants did not receive group sessions. Adherence was operationalised as number of OSA modules completed. Treatment adherence significantly differed between the conditions. On average, participants assigned to the placebo condition completed significantly more of the program compared to those in the control condition. Further, all conditions produced a significant improvement in BFNE and QOLS. No significant difference in treatment efficacy was found between groups on the SIAS, BFNE or QOLS. The current results indicate PMR can improve treatment adherence for scalable social anxiety interventions.

Involving Crowdworkers with Lived Experience in Content-Development for Push-Based Digital Mental Health Tools: Lessons Learned from Crowdsourcing Mental Health Messages

Digital tools can support individuals managing mental health concerns, but delivering sufficiently engaging content is challenging. This paper seeks to clarify how individuals with mental health concerns can contribute content to improve push-based mental health messaging tools. We recruited crowdworkers with mental health symptoms to evaluate and revise expert-composed content for an automated messaging tool, and to generate new topics and messages. A second wave of crowdworkers evaluated expert and crowdsourced content. Crowdworkers generated topics for messages that had not been prioritized by experts, including self-care, positive thinking, inspiration, relaxation, and reassurance. Peer evaluators rated messages written by experts and peers similarly. Our findings also suggest the importance of personalization, particularly when content adaptation occurs over time as users interact with example messages. These findings demonstrate the potential of crowdsourcing for generating diverse and engaging content for push-based tools, and suggest the need to support users in meaningful content customization.

Moment-to-Moment Brain Signal Variability Reliably Predicts Psychiatric Treatment Outcome

BACKGROUND

Biomarkers of psychiatric treatment response remain elusive. Functional magnetic resonance imaging (fMRI) has shown promise, but low reliability has limited the utility of typical fMRI measures (e.g., average brain signal) as harbingers of treatment success. Notably, although historically considered a source of noise, temporal brain signal variability continues to gain momentum as a sensitive and reliable indicator of individual differences in neural efficacy, yet has not been examined in relation to psychiatric treatment outcomes.

METHODS

A total of 45 patients with social anxiety disorder were scanned twice (11 weeks apart) using simple task-based and resting-state fMRI to capture moment-to-moment neural variability. After fMRI test-retest, patients underwent a 9-week cognitive behavioral therapy. Multivariate modeling and reliability-based cross-validation were used to perform brain-based prediction of treatment outcomes.

RESULTS

Task-based brain signal variability was the strongest contributor in a treatment outcome prediction model (total r_{ACTUAL,PREDICTED} = 0.77), outperforming self-reports, resting-state neural variability, and standard mean-based measures of neural activity. Notably, task-based brain signal variability showed excellent test-retest reliability (intraclass correlation coefficient = 0.80), even with a task length less than 3 minutes long.

CONCLUSIONS

Rather than a source of undesirable noise, moment-to-moment fMRI signal variability may instead serve as a highly reliable and efficient prognostic indicator of clinical outcome.

Social Support, Mindfulness, and Job Burnout of Social Workers in China

In the last 20 years, amid extensive social and economic reforms, China’s social structure and community life have changed considerably. A large number of social workers are needed to provide many more social services to community residents. The central government has issued many policies to rapidly develop human service organizations and increase the number of social workers. Thus, by the end of 2019, the number of social workers has reached more than 1.5 million in China. At the same time, local governments have issued many policies to promote an increase in the number of social workers. According to statistics from the Chengdu Civil Affairs Bureau, from 2010 to 2021, the number of social workers in Chengdu City increased, remarkably, from 553 to 17,622. Although the number of social workers has increased rapidly, some problems still exist. According to a survey by the Chengdu Social Workers Association, the turnover rate of social workers has reached approximately 20% in Chengdu City in 2018. Therefore, we aim to determine what influences social workers’ job burnout. Through regression analysis and mediation effect tests, we found the following: First, when controlling for gender, age, education, and workday, social support of social workers had a significant negative impact on job burnout (β = − 0.376). Second, the mindfulness of social workers had a significant negative impact on job burnout (β = − 0.320). Third, the mindfulness of social workers played a mediating role between social support and job burnout. The mediating effect was −0.116 (p < 0.001). Fourth, among the three dimensions of social support, mindfulness played a partially mediating role in family support and other support. The mediating effect between other support, which is the support from leaders and colleagues, and job burnout was the strongest, with a mediating effect of −0.109 (p < 0.001). In other words, the support provided by agency leaders and colleagues can maximize the level of mindfulness of social workers, thereby reducing social workers’ job burnout most effectively. We can thus reduce social workers’ job burnout by improving their level of mindfulness and the social support for them in China.

Effects of self-guided stress management interventions in college students: A systematic review and meta-analysis

BACKGROUND

College students face several sources of stress. Self-guided stress management interventions offer an excellent opportunity for scaling up evidence-based interventions for self-management of these stresses. However, little is known about the overall effects of these interventions. Increasing this understanding is essential because self-guided stress management interventions might be a cost-effective and acceptable way of providing help to this important segment of the population during a critical life course stage.

METHODS

We carried out a systematic literature search of bibliographical databases (PubMed, PsycINFO, Embase, and Cochrane Library) for randomized controlled trials (RCTs) of self-guided stress management interventions published up through April 2020. We conducted two separate meta-analyses for perceived stress, depression, and anxiety. The first included interventions for general college student samples. The second included studies for students with high levels of perceived stress.

RESULTS

The first meta-analysis included 26 studies with 29 intervention-control comparisons based on a total of 4468 students. The pooled effect size was small but statistically significant (g = 0.19; 95% CI [0.10, 0.29]; p < 0.001). Results showed moderate heterogeneity across studies [I ² = 48%; 95% CI (19, 66%)]. The second meta-analysis, included four studies based on a total of 491 students with high levels of stress. The pooled effect size was small but statistically significant (g = 0.34; 95% CI [0.16, 0.52]; p < 0.001). Results showed no heterogeneity across studies (I ² = 0%; 95% CI [0, 79%]), but risk of bias was substantial.

DISCUSSION

Our results suggest that self-guided stress management programs may be effective when compared to control conditions, but with small average effects. These programs might be a useful element of a multi-component intervention system. Given the psychological barriers to treatment that exist among many college students, self-help interventions might be a good first step in facilitating subsequent help-seeking among students reluctant to engage in other types of treatment. More studies should be conducted to investigate these interventions, sample specifications, mediating effects, and individual-level heterogeneity of effects.

Can We Boost Treatment Adherence to an Online Transdiagnostic Intervention by Adding Self-Enhancement Strategies? Results From a Randomized Controlled Non-inferiority Trial

Background: Internet-delivered psychotherapy represents an impactful large-scale solution for addressing psychological disorders. In spite of its flexibility and scalability, the fact that the ones in need have to initiate and sustain the curse of the treatment by themselves comes with considerable downsides in terms of treatment adherence. One solution could be to increase the ease of use and attractivity of the strategies and assignments from such programs. The present study aims to address this issue by incorporating a series of self-oriented strategies to the validated internet-delivered short version of the Unified Protocol (UP). By this mean we intend to complement the symptom-focused assignments, which may be more suitable in a therapist assisted context, with ones designed for self-enhancement, which may be easier approached as self-initiated. Based on a randomized controlled non-inferiority trial we compared the modified version of the UP with the standard short version. Method: The trial design was factorial, with two parallel arms and three measurement moments (baseline, post-intervention and 6-months follow-up). A total of 284 participants were randomly assigned to the intervention or the active control groups. The intervention group (baseline n = 142) received the self-enhanced nine modules of the UP (Self-enhanced 9UP) while the active control (baseline n = 142) received the standard nine modules (9UP). The newly added techniques were inspired by the acceptance and commitment therapy and were specific for self-concepts such as self-compassion or unconditional self-acceptance. Both programs lasted for 9 weeks. The non-inferiority of the Self-enhanced 9UP was tested against a margin of d = -0.35, on the following primary outcome measures: Patient Health Questionnaire 9 (PHQ9) - operationalization for depression; Generalized Anxiety Disorder 7 (GAD7) - operationalization for generalized anxiety or worry; Social Phobia Inventory (SPIN) - operationalization for social phobia; and Panic Disorder Severity Scale-Self Report (PDSS-SR) - that showed participants' level of panic. Treatment adherence was assessed through the drop-out analyses and the engagement in completing the homework assignments. Secondary outcome measures included several self-concept measures: Self-Compassion Scale (SCS); Rosenberg Self-Esteem Scale (RSES); Unconditional Self-Acceptance Questionnaire (USAQ); New General Self-Efficacy Scale (NGSE); and Self-Concept Clarity Scale (SCCS). On the secondary outcomes we explored the potential boost of effectiveness produced by the newly added self-enhancement components. Results: The dropout rates were similar in both groups (approximately 45%) and high overall. Adherence to treatment assignments was also modest and similar between groups (on average participants completed approximately half of the tasks), without a statistically significant bias toward the self-enhancement ones. Overall, both the intention-to-treat and completers analyses yielded no significant group by time interactions for any of the post-intervention and follow-up measurements, but a few non-inferiority analyses suggested that the Self-enhanced 9UP had a significantly weaker effectiveness than the standard 9UP. Within-group analyses showed significant alleviations on all the primary and secondary outcomes for both groups. The effect size estimates were mainly medium and high, and their magnitude tended to be kept also at 6-months follow-up. Discussion: We failed to increase treatment adherence, but we found support with some exceptions, for the non-inferiority hypothesis. Hence, the alterations performed to the 9UP protocol, although they did not boost the treatment attractiveness, they also did not decrease the treatment effectiveness as suggested by most non-inferiority analyses. Likewise, the gain on self-concepts was produced by both groups. Hence, the short version of the UP seems to have the potential of effectively alleviating a larger palette of psychological variables associated with mental health symptoms than previously known. Even though our main objective was only partially achieved, these secondary results are insightful and could open new avenues of research. Clinical Trial Registration: This trial has been registered at ClinicalTrials.Gov (NCT03917550; 17 April 2019; https://clinicaltrials.gov/ct2/show/NCT03917550).

Predicting Treatment Outcomes in Guided Internet-Delivered Therapy for Anxiety Disorders-The Role of Treatment Self-Efficacy

Aim: Guided Internet-delivered therapy has shown to be an effective treatment format for anxiety disorders. However, not all patients experience improvement, and although predictors of treatment outcome have been identified, few are consistent over time and across studies. The current study aimed to examine whether treatment self-efficacy (self-efficacy regarding the mastery of obstacles during treatment) in guided Internet-delivered therapy for anxiety disorders in adults could be a predictor of lower dropout rates and greater symptom reduction. Method: The analyzed data comes from an open effectiveness study including 575 patients receiving guided Internet-delivered therapy for panic disorder or social anxiety disorder. Treatment self-efficacy was measured at pre-treatment. Symptom reduction was measured at 10 measurement points, including a 6-month follow-up. A mixed linear model was applied in the analysis. Results: The results showed that high treatment self-efficacy was a predictor of both lower dropout rates and greater symptom reduction. Significant interaction effects between time and treatment self-efficacy were found for several of the nine modules that constitutes the treatment program, suggesting that treatment self-efficacy could be a moderator of symptom reduction. Three of nine modules in the panic disorder treatment and six of nine in the social anxiety disorder treatment showed significant interaction effects. Conclusion: The results suggest that measuring treatment self-efficacy may be a valuable tool to identify patients at risk of dropping out, and that treatment self-efficacy could be a predictor and moderator of symptom reduction in guided Internet-delivered therapy. The implications of the results are discussed.

The Use of Task Shifting to Improve Treatment Engagement in an Internet-Based Mindfulness Intervention Among Chinese University Students: Randomized Controlled Trial

BACKGROUND

Traditional in-person psychotherapies are incapable of addressing global mental health needs. Use of computer-based interventions is one promising solution for closing the gap between the amount of global mental health treatment needed and received.

OBJECTIVE

Although many meta-analyses have provided evidence supporting the efficacy of self-guided, computer-based interventions, most report low rates of treatment engagement (eg, high attrition and low adherence). The aim of this study is to investigate the efficacy of an adjunctive treatment component that uses task shifting, wherein mental health care is provided by nonspecialist peer counselors to enhance engagement in an internet-based, self-directed, evidence-based mindfulness intervention among Chinese university students.

METHODS

From 3 universities across China, 54 students who reported at least mild stress, anxiety, or depression were randomly assigned to a 4-week internet-based mindfulness intervention (MIND) or to the intervention plus peer counselor support (MIND+), respectively. Be Mindful delivers all the elements of mindfulness-based cognitive therapy in an internet-based, 4-week course. Participants completed daily monitoring of mindfulness practice and mood, as well as baseline and posttreatment self-reported levels of depression, anxiety, stress, and trait mindfulness. We screened 56 volunteer peer counselor candidates who had no former training in the delivery of mental health services. Of these, 10 were invited to participate in a day-long training, and 4 were selected. Peer counselors were instructed to provide 6 brief (15-20 minute) sessions each week, to help encouraging participants to complete the internet-based intervention. Peer counselors received weekly web-based group supervision.

RESULTS

For both conditions, participation in the internet-based intervention was associated with significant improvements in mindfulness and mental health outcomes. The pre-post effect sizes (Cohen d) for mindfulness, depression, anxiety, and stress were 0.55, 0.95, 0.89, and 1.13, respectively. Participants assigned to the MIND+ (vs MIND) condition demonstrated significantly less attrition and more adherence, as indicated by a greater likelihood of completing posttreatment assessments (16/27, 59% vs 7/27, 26%; χ²₁=6.1; P=.01) and a higher percentage of course completion (72.6/100, 72.6% vs 50.7/100, 50.7%; t₅₂=2.10; P=.04), respectively. No significant between-group differences in daily frequency and duration of mindfulness practice were observed. Multilevel logistic growth models showed that MIND+ participants reported significantly greater pre-post improvements in daily stress ratings (interaction estimate 0.39, SE 0.18; t₃₁₇=2.29; P=.02) and depression (interaction estimate 0.38, SE 0.16; t₃₃₀=2.37; P=.02) than those in the MIND condition.

CONCLUSIONS

This study provides new insights into effective ways of leveraging technology and task shifting to implement large-scale mental health initiatives that are financially feasible, easily transportable, and quickly scalable in low-resource settings. The findings suggest that volunteer peer counselors receiving low-cost, low-intensity training and supervision may significantly improve participants' indices of treatment engagement and mental health outcomes in an internet-based mindfulness intervention among Chinese university students.

The effect of depression on treatment outcome in social anxiety disorder: an individual-level meta-analysis

Social anxiety disorder (SAD) is highly comorbid with depression. In the present meta-analysis, we conducted the first individual-level examination of the association between pre-treatment depression and improvement in social anxiety symptoms during treatment. We identified eligible studies on cognitive behavior therapy (CBT) and pharmacotherapy for SAD and contacted authors to obtain individual-level data. We obtained these data from 41 studies, including 46 treatment conditions (n = 4,381). Our results showed that individuals who had high levels of depression at pre-treatment experienced greater decreases in social anxiety symptoms from pre- to post-treatment, but not at follow-up. When analyzing treatment modalities (individual CBT, group CBT, internet-delivered CBT, and pharmacotherapy), we found that depressive symptoms were associated with better post-treatment outcomes for individual CBT and internet-delivered CBT, but not for pharmacotherapy or group CBT. Our findings suggest that depression does not negatively affect treatment outcome in SAD and may even lead to improved outcomes in some treatment formats. Clinical implications of these findings are discussed.

Implementation of Telemental Health Services Before COVID-19: Rapid Umbrella Review of Systematic Reviews

BACKGROUND

Telemental health care has been rapidly adopted for maintaining services during the COVID-19 pandemic, and a substantial interest is now being devoted in its future role. Service planning and policy making for recovery from the pandemic and beyond should draw on both COVID-19 experiences and the substantial research evidence accumulated before this pandemic.

OBJECTIVE

We aim to conduct an umbrella review of systematic reviews available on the literature and evidence-based guidance on telemental health, including both qualitative and quantitative literature.

METHODS

Three databases were searched between January 2010 and August 2020 for systematic reviews meeting the predefined criteria. The retrieved reviews were independently screened, and those meeting the inclusion criteria were synthesized and assessed for risk of bias. Narrative synthesis was used to report these findings.

RESULTS

In total, 19 systematic reviews met the inclusion criteria. A total of 15 reviews examined clinical effectiveness, 8 reported on the aspects of telemental health implementation, 10 reported on acceptability to service users and clinicians, 2 reported on cost-effectiveness, and 1 reported on guidance. Most reviews were assessed to be of low quality. The findings suggested that video-based communication could be as effective and acceptable as face-to-face formats, at least in the short term. Evidence on the extent of digital exclusion and how it can be overcome and that on some significant contexts, such as children and young people's services and inpatient settings, was found to be lacking.

CONCLUSIONS

This umbrella review suggests that telemental health has the potential to be an effective and acceptable form of service delivery. However, we found limited evidence on the impact of its large-scale implementation across catchment areas. Combining previous evidence and COVID-19 experiences may allow realistic planning for the future implementation of telemental health.

Exploring the Role of Persuasive Design in Unguided Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Adults: Systematic Review, Meta-analysis, and Meta-regression

BACKGROUND

Internet-delivered cognitive behavioral therapy (ICBT) is an effective treatment that can overcome barriers to mental health care. Various research groups have suggested that unguided ICBT (ie, ICBT without therapist support) and other eHealth interventions can be designed to enhance user engagement and thus outcomes. The persuasive systems design framework captures most design recommendations for eHealth interventions, but there is little empirical evidence that persuasive design is related to clinical outcomes in unguided ICBT.

OBJECTIVE

This study aims to provide an updated meta-analysis of randomized controlled trials of unguided ICBT for depression and anxiety, describe the frequency with which various persuasive design principles are used in such interventions, and use meta-regression to explore whether a greater number of persuasive design elements predicts efficacy in unguided ICBT for depression and anxiety.

METHODS

We conducted a systematic review of 5 databases to identify randomized controlled trials of unguided ICBT for depression and anxiety. We conducted separate random effects meta-analyses and separate meta-regressions for depression and anxiety interventions. Each meta-regression included 2 steps. The first step included, as a predictor, whether each intervention was transdiagnostic. For the meta-regression of ICBT for depression, the first step also included the type of control condition. The number of persuasive design principles identified for each intervention was added as a predictor in the second step to reveal the additional variance in effect sizes explained by persuasive design.

RESULTS

Of the 4471 articles we identified in our search, 46 (1.03%) were eligible for inclusion in our analyses. Our meta-analyses showed effect sizes (Hedges g) ranging from 0.22 to 0.31 for depression interventions, depending on the measures taken to account for bias in the results. We found a mean effect size of 0.45 (95% CI 0.33-0.56) for anxiety interventions, with no evidence that the results were inflated by bias. Included interventions were identified as using between 1 and 13 persuasive design principles, with an average of 4.95 (SD 2.85). The meta-regressions showed that a greater number of persuasive design principles predicted greater efficacy in ICBT for depression (R2 change=0.27; B=0.04; P=.02) but not anxiety (R2 change=0.05; B=0.03; P=.17).

CONCLUSIONS

These findings show wide variability in the use of persuasive design in unguided ICBT for depression and anxiety and provide preliminary support for the proposition that more persuasively designed interventions are more efficacious, at least in the treatment of depression. Further research is needed to clarify the role of persuasive design in ICBT.

Adapting Clinical Skills to Telehealth: Applications of Affirmative Cognitive-Behavioral Therapy with LGBTQ+ Youth

Online social work services (e.g., telemental health; telebehavioral health; virtual care; telehealth) present significant opportunities for clinical social workers to provide effective care to marginalized populations, such as LGBTQ+ youth. The COVID-19 pandemic has led to an increased focus on telehealth, and while there are excellent resources to guide ethics, standards, and legal decisions (NASW, n.d.), there is less guidance in the literature to specifically inform the adaptation of offline clinical skills to telehealth, particularly for LGBTQ+ youth. To address this gap, we present examples from our experience offering AFFIRM, an affirmative cognitive behavioral therapy (CBT) group intervention now being delivered through telehealth. Specifically, this paper will: (a) describe the key considerations for the delivery of CBT via telehealth to youth; (b) detail specific clinical skills and strategies to enable successful online implementation; (c) describe the adaptation approach through a case study of cognitive restructuring with a transgender youth; (d) and offer specific guidance to support clinicians to adapt their clinical skills to the virtual environment.

AFFIRM Online: Utilising an Affirmative Cognitive-Behavioural Digital Intervention to Improve Mental Health, Access, and Engagement among LGBTQA+ Youth and Young Adults

Digital mental health interventions may enable access to care for LGBTQA+ youth and young adults that face significant threats to their wellbeing. This study describes the preliminary efficacy of AFFIRM Online, an eight-session manualised affirmative cognitive behavioural group intervention delivered synchronously. Participants (Mage = 21.17; SD = 4.52) had a range of sexual (e.g., queer, lesbian, pansexual) and gender (e.g., non-binary, transgender, cisgender woman) identities. Compared to a waitlist control (n = 50), AFFIRM Online participants (n = 46) experienced significantly reduced depression (b = -5.30, p = 0.005, d = 0.60) and improved appraisal of stress as a challenge (b = 0.51, p = 0.005, d = 0.60) and having the resources to meet those challenges (b = 0.27, p = 0.059, d = 0.39) as well active coping (b = 0.36, p = 0.012, d = 0.54), emotional support (b = 0.38, p = 0.017, d = 0.51), instrumental support (b = 0.58, p < 0.001, d = 0.77), positive framing (b = 0.34, p = 0.046, d = 0.42), and planning (b = 0.41, p = 0.024, d = 0.49). Participants reported high acceptability. This study highlights the potential of digital interventions to impact LGBTQA+ youth mental health and explores the feasibility of digital mental health to support access and engagement of youth with a range of identities and needs (e.g., pandemic, lack of transportation, rural locations). Findings have implications for the design and delivery of digital interventions for marginalised youth and young adults.

Assessing the Efficacy and Acceptability of a Web-Based Intervention for Resilience Among College Students: Pilot Randomized Controlled Trial

BACKGROUND

College students are at elevated risk for developing mental health problems and face specific barriers around accessing evidence-based treatment. Web-based interventions that focus on mental health promotion and strengthening resilience represent one possible solution. Providing support to users has shown to reduce dropout in these interventions. Further research is needed to assess the efficacy and acceptability of these interventions and explore the viability of automating support.

OBJECTIVE

This study investigated the feasibility of a new web-based resilience program based on positive psychology, provided with human or automated support, in a sample of college students.

METHODS

A 3-armed closed pilot randomized controlled trial design was used. Participants were randomized to the intervention with human support (n=29), intervention with automated support (n=26), or waiting list (n=28) group. Primary outcomes were resilience and well-being, respectively measured by the Connor-Davidson Resilience Scale and Pemberton Happiness Index. Secondary outcomes included measures of depression and anxiety, self-esteem, and stress. Outcomes were self-assessed through online questionnaires. Intention-to-treat and per-protocol analyses were conducted.

RESULTS

All participants demonstrated significant improvements in resilience and related outcomes, including an unexpected improvement in the waiting list group. Within- and between-group effect sizes ranged from small to moderate and within-group effects were typically larger for the human than automated support group. A total of 36 participants began the program and completed 46.46% of it on average. Participants were generally satisfied with the program and found it easy to use.

CONCLUSIONS

Findings support the feasibility of the intervention. Preliminary evidence for the equal benefit of human and automated support needs to be supported by further research with a larger sample. Results of this study will inform the development of a full-scale trial, from which stronger conclusions may be drawn.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN) 11866034; http://www.isrctn.com/ISRCTN11866034.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.invent.2019.100254.

Effects of Internet-Based Cognitive Behavioral Therapy in Routine Care for Adults in Treatment for Depression and Anxiety: Systematic Review and Meta-Analysis

Background

Although there is evidence for the efficacy of internet-based cognitive behavioral therapy (iCBT), the generalizability of results to routine care is limited.

Objective

This study systematically reviews effectiveness studies of guided iCBT interventions for the treatment of depression or anxiety.

Methods

The acceptability (uptake, participants’ characteristics, adherence, and satisfaction), effectiveness, and negative effects (deterioration) of nonrandomized pre-post designs conducted under routine care conditions were synthesized using systematic review and meta-analytic approaches.

Results

A total of 19 studies including 30 groups were included in the analysis. Despite high heterogeneity, individual effect sizes of investigated studies indicate clinically relevant changes, with effect sizes ranging from Hedges’ g=0.42-1.88, with a pooled effect of 1.78 for depression and 0.94 for anxiety studies. Uptake, participants’ characteristics, adherence, and satisfaction indicate a moderate to high acceptability of the interventions. The average deterioration across studies was 2.9%.

Conclusions

This study provides evidence supporting the acceptability and effectiveness of guided iCBT for the treatment of depression and anxiety in routine care. Given the high heterogeneity between interventions and contexts, health care providers should select interventions that have been proven in randomized controlled clinical trials. The successful application of iCBT may be an effective way of increasing health care in multiple contexts.

Do depressive symptoms affect the outcome of treatments for SAD? A meta analysis of randomized controlled trials

Individuals with social anxiety disorder (SAD) typically have elevated depressive symptoms. In the present meta-analysis, we reviewed the treatment outcome literature in SAD and examined whether depressive symptoms predict treatment outcome. We focused on randomized controlled trials of cognitive behavior therapy (individual face-to-face, group format, and internet-delivered format) and randomized controlled trials of pharmacotherapy. After implementing exclusion criteria, 108 studies with 133 treatment conditions (n = 12,913 participants) were included in the meta-analysis. Our findings indicated that treatments for SAD were efficacious and significantly reduced social anxiety symptoms across all treatment modalities. Exclusion of individuals with MDD or high levels of depression did not affect outcome at post-treatment or at follow-up. However, we found that elevated depressive symptoms were associated with greater reductions in social anxiety symptoms from pre-treatment to post-treatment. Importantly, this effect was above and beyond pre-treatment levels of social anxiety. Finally, analyzing treatment modalities separately, we found that depressive symptoms were associated with better post-treatment outcomes in individual face-to-face CBT but not in other modalities. Clinical and research implications of these findings are discussed.

Effectiveness of a culturally adapted cognitive behavioural therapy-based guided self-help (CACBT-GSH) intervention to reduce social anxiety and enhance self-esteem in adolescents: a randomized controlled trial from Pakistan

BACKGROUND

Social anxiety is common among adolescents in Pakistan and is associated with low self-esteem. Among the recommended treatments, cognitive behavioural therapy (CBT) is effective, and self-help approaches are encouraged.

AIM

To determine the effectiveness of culturally adapted CBT-based guided self-help (CACBT-GSH) intervention, using a manual 'Khushi aur Khatoon', for treating social anxiety when added to treatment as usual (TAU) compared with TAU only.

METHOD

A total of 76 adolescents with social anxiety aged 13-16 years from six schools in Multan, Pakistan were recruited into this randomized controlled trial. Participants were divided into intervention and control groups in a 1:1 ratio. Social anxiety, self-esteem and fear of negative evaluation were assessed through the Liebowtiz Social Anxiety Scale for children and adolescents, the Rosenberg Self-Esteem Scale and the Brief Fear of Negative Evaluation, respectively, at baseline and at the end of the study. Guided self-help using culturally adapted CBT (CACBT)-based self-help manual (eight sessions, one session per week) was provided to the intervention group. The effect of the CACBT-GSH intervention was analysed with ANCOVA.

RESULTS

There was a statistically significant difference between the intervention and the control groups in favour of intervention. Participants in the intervention group showed reduced symptoms of social anxiety (p < .001), fear of negative evaluation (p < .001) and enhanced self-esteem (p < .001).

CONCLUSION

The study demonstrated the effectiveness of CACBT-based guided self-help intervention in treating social anxiety and addressing the symptoms associated with it.

Treatment Options for Fear of Blushing

PURPOSE OF REVIEW

To review mechanisms of blushing and fear of blushing from physiological, neuropharmacological and psychological viewpoints, and to evaluate current forms of treatment for blushing-related fear.

RECENT FINDINGS

Blushing appears to be driven primarily by sympathetic adrenomedullary and neural vasodilator discharge, possibly in association with secondary neurovascular inflammation. Psychological risk factors for fear of blushing include social anxiety, coupled with heightened self-focused attention and inflated beliefs about the likelihood and social costs of blushing. In addition, schemas of emotional inhibition, social isolation and alienation may underlie blushing-related fears. Established psychological treatments for fear of blushing include task concentration training, exposure, cognitive therapy, social skills training, psychoeducation and applied relaxation. More novel approaches include mindfulness and mindful self-compassion, video feedback and imagery rescripting. There are no established pharmacological treatments specifically for fear of blushing. However, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are effective treatments for social anxiety disorder and may thus help some patients manage their fear of blushing. A reactive sympathetic nervous system may interact with psychological predispositions to intensify fear of blushing. These physiological and psychological risk factors could be promising targets for treatment.

Internet-delivered mental health treatment systems in Scandinavia - A usability evaluation

Mental health problems are a major public health concern worldwide. Approximately 50% of the population will experience mental problems during their life. Traditional treatment is based on psychopharmacotherapy or psychotherapy, with face-to-face interaction between the patient and the therapist. New technologies such as Internet-delivered treatments are seen as an opportunity to offer more scalable and cost-efficient treatments in the field of mental health. Despite the growing interest and new evidence supporting the effect of Internet-delivered treatments is it remarkably little research on how the technology and the usability of Internet-delivered treatment programs affects the treatment. In this paper, we propose a set of evaluation criteria for evaluating the usability and the responsive design of Internet-delivered treatment systems. By our knowledge we are the first to include usability and universal design principles in the evaluation of Internet-delivered treatment systems. Our findings indicate that despite the good treatment results and proven clinical effects, the systems in general have several issues regarding usability, universal design and outdated technology. Based on our findings we propose that there should be established guidelines for testing the usability and technology of Internet-delivered treatment systems.

Neuroimaging, genetic, clinical, and demographic predictors of treatment response in patients with social anxiety disorder

BACKGROUND

Correct prediction of treatment response is a central goal of precision psychiatry. Here, we tested the predictive accuracy of a variety of pre-treatment patient characteristics, including clinical, demographic, molecular genetic, and neuroimaging markers, for treatment response in patients with social anxiety disorder (SAD).

METHODS

Forty-seven SAD patients (mean±SD age 33.9 ± 9.4 years, 24 women) were randomized and commenced 9 weeks' Internet-delivered cognitive behavior therapy (CBT) combined either with the selective serotonin reuptake inhibitor (SSRI) escitalopram (20 mg daily [10 mg first week], SSRI+CBT, n = 24) or placebo (placebo+CBT, n = 23). Treatment responders were defined from the Clinical Global Impression-Improvement scale (CGI-I ≤ 2). Before treatment, patients underwent functional magnetic resonance imaging and the Multi-Source Interference Task taxing cognitive interference. Support vector machines (SVMs) were trained to separate responders from nonresponders based on pre-treatment neural reactivity in the dorsal anterior cingulate cortex (dACC), amygdala, and occipital cortex, as well as molecular genetic, demographic, and clinical data. SVM models were tested using leave-one-subject-out cross-validation.

RESULTS

The best model separated treatment responders (n = 24) from nonresponders based on pre-treatment dACC reactivity (83% accuracy, P = 0.001). Responders had greater pre-treatment dACC reactivity than nonresponders especially in the SSRI+CBT group. No other variable was associated with clinical response or added predictive accuracy to the dACC SVM model.

LIMITATIONS

Small sample size, especially for genetic analyses. No replication or validation samples were available.

CONCLUSIONS

The findings demonstrate that treatment outcome predictions based on neural cingulate activity, at the individual level, outperform genetic, demographic, and clinical variables for medication-assisted Internet-delivered CBT, supporting the use of neuroimaging in precision psychiatry.

Predictors of treatment outcomes and adherence in internet-based cognitive behavioral therapy for social anxiety in China

BACKGROUND

Although internet-based cognitive behaviour therapy (ICBT) is an effective treatment for social anxiety disorder (SAD), a substantial proportion of patients do not achieve clinically significant improvement. More research is needed to identify which factors predict treatment adherence and outcomes.

AIMS

The aims of this study were to (1) identify demographic and clinical factors associated with treatment adherence and outcomes in ICBT for social anxiety in China, and (2) explore whether low-intensity therapist support results in improved treatment adherence or outcomes.

METHOD

Participants were assigned to either therapist-guided (N = 183) or self-guided ICBT (N = 72). Level of social anxiety was measured at both pre- and post-treatment. Treatment adherence and outcomes were analysed using a two-step linear and logistic regression approach. Clinical and demographic characteristics were examined.

RESULTS

No significant group differences were found for treatment adherence or outcomes between the therapist-guided and self-guided conditions. Participants diagnosed with SAD were significantly less likely to drop out (OR 0.531, p = .03) compared with subclinical participants with social anxiety symptoms. Older participants (B = 0.17, SE = 0.04, p = .008) and participants with a diagnosis of SAD (B = 0.16, SE = 0.44, p = .01) tended to complete more modules. Participants who completed more modules (B = 0.24, SE = 0.03, p = .01) and participants who identified as female (B = -0.20, SE = 0.18, p = .04) reported greater reductions in SAD symptoms.

CONCLUSIONS

Understanding of factors related to adherence and outcome is necessary to prevent drop-out and optimize outcome.

Improvement in indices of cellular protection after psychological treatment for social anxiety disorder

Telomere attrition is a hallmark of cellular aging and shorter telomeres have been reported in mood and anxiety disorders. Telomere shortening is counteracted by the enzyme telomerase and cellular protection is also provided by the antioxidant enzyme glutathione peroxidase (GPx). Here, telomerase, GPx, and telomeres were investigated in 46 social anxiety disorder (SAD) patients in a within-subject design with repeated measures before and after cognitive behavioral therapy. Treatment outcome was assessed by the Liebowitz Social Anxiety Scale (self-report), administered three times before treatment to control for time and regression artifacts, and posttreatment. Venipunctures were performed twice before treatment, separated by 9 weeks, and once posttreatment. Telomerase activity and telomere length were measured in peripheral blood mononuclear cells and GPx activity in plasma. All patients contributed with complete data. Results showed that social anxiety symptom severity was significantly reduced from pretreatment to posttreatment (Cohen's d = 1.46). There were no significant alterations in telomeres or cellular protection markers before treatment onset. Telomere length and telomerase activity did not change significantly after treatment, but an increase in telomerase over treatment was associated with reduced social anxiety. Also, lower pretreatment telomerase activity predicted subsequent symptom improvement. GPx activity increased significantly during treatment, and increases were significantly associated with symptom improvement. The relationships between symptom improvement and putative protective enzymes remained significant also after controlling for body mass index, sex, duration of SAD, smoking, concurrent psychotropic medication, and the proportion of lymphocytes to monocytes. Thus, indices of cellular protection may be involved in the therapeutic mechanisms of psychological treatment for anxiety.

A New Mental Health Mobile App for Well-Being and Stress Reduction in Working Women: Randomized Controlled Trial

BACKGROUND

Although the availability and use of mobile mental health apps has grown exponentially in recent years, little data are available regarding their efficacy.

OBJECTIVE

This study aimed to evaluate the effectiveness of an app developed to promote stress management and well-being among working women compared with a control app.

METHODS

Female employees at a private hospital were invited to participate in the study via mailing lists and intranet ads. A total of 653 individuals self-enrolled through the website. Eligible participants were randomized between control (n=240) and intervention (n=250) groups. The well-being mobile app provides an 8-week program with 4 classes per week (including a brief theoretical portion and a 15-min guided practice). The active control app also provided 4 assessments per week that encouraged participants to self-observe how they were feeling for 20 min. We also used the app to conduct Web-based questionnaires (10-item Perceived Stress Scale and 5-item World Health Organization Well-Being Index) and ask specific questions to assess subjective levels of stress and well-being at baseline (t₁), midintervention (t₄=4 weeks after t₁) and postintervention (t₈=8 weeks after t₁). Both apps were fully automated without any human involvement. Outcomes from the control and intervention conditions at the 3 time points were analyzed using a repeated measures analysis of variance.

RESULTS

Among the randomized participants (n=490), 185 participants were excluded at the 4-week follow-up and another 79 at the 8-week follow-up because of noncompliance with the experimental protocol. Participants who did not complete t₄ and t₈ assessments were equally distributed between groups (t₄: control group=34.6% [83/240] and intervention group=40.8% [102/250]; P=.16; t₈: control group=29.9% [47/157] and intervention group=21.6% [32/148]; P=.10). Both groups showed a significant increase in general well-being as a function of time (F_2,426=5.27; P=.006), but only the intervention group presented a significant increase in work-related well-being (F_2,426=8.92; P<.001), as well as a significant reduction in work-related and overall stress (F_2,426=5.50; P=.004 and F_2,426=8.59; P<.001, respectively).

CONCLUSIONS

The well-being mobile app was effective in reducing employee stress and improving well-being.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02637414; https://clinicaltrials.gov/ct2/show/NCT02637414.

Processes in cognitive behavior therapy for social anxiety disorder: Predicting subsequent symptom change

Although cognitive behavior therapy (CBT) is an effective treatment for social anxiety disorder, little is known about the processes during treatment that bring about change. The aim of this study was to investigate whether the proposed processes of change according to the cognitive model of social anxiety disorder predicted subsequent symptom reduction in CBT delivered as therapist-guided bibliotherapy. We analyzed data from patients with social anxiety disorder (N = 61) who participated in an effectiveness trial of CBT in primary care. Seven putative processes and outcome (i.e., social anxiety) were assessed on a weekly basis throughout treatment. We used linear mixed models to analyze within-person relations between processes and outcome. The results showed a unidirectional effect of reduced avoidance on subsequent decrease in social anxiety. Further, we found support for reciprocal influences between four of the proposed processes (i.e., estimated probability and cost of adverse outcome, self-focused attention, and safety behaviors) and social anxiety. The remaining two processes, (i.e., anticipatory and post-event processing) did not predict subsequent social anxiety, but were predicted by prior symptom reduction. The findings support that several of the change processes according to the cognitive model of social anxiety disorder are involved in symptom improvement.

Supplementing stuttering treatment with online cognitive behavior therapy: An experimental trial

PURPOSE

It is now well established that adults who present to speech clinics for help with stuttering will have an increased risk of having an anxiety disorder, particularly social anxiety disorder. Concomitant psychological problems are known to interfere with the maintenance of the benefits of behavioral speech treatments for stuttering. The current team has developed and trialed a cognitive behavior therapy (CBT) program designed specifically to reduce anxiety in adults who stutter, and trials have shown promise for both an in-clinic version and a standalone internet-based version. The aim of the present study is to determine whether iGlebe, the internet-based version of the team's internet CBT treatment (previously known as CBTPsych), enhances the benefits of behavioral stuttering treatment.

METHOD

Participants were 32 adults seeking treatment for stuttering. The design was a two-arm randomized experimental trial with blinded outcome assessments at 6 and 12 months post-randomization. Both arms received basic speech-restructuring training to reduce stuttering, without any anxiolytic (anxiety reducing) components. The experimental arm also received 5 months access to iGlebe.

RESULTS

There was evidence that, at 12 months post-randomization, iGlebe added clinically significant improvements to self-reported stuttering severity and quality of life. The present experimental trial provides the first evidence that the addition of CBT to speech restructuring improves speech outcomes.

CONCLUSIONS

The present results will be the basis for the development of a comprehensive, internet-based treatment program for anxiety associated with stuttering. Ultimately, it may be possible for such an economical, scalable, and translatable comprehensive treatment model to supplement standard speech-language pathology treatment practices for those who stutter.

Efficacy and cost-effectiveness of an unguided, internet-based self-help intervention for social anxiety disorder in university students: protocol of a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) is highly prevalent among university students, but the majority of affected students remain untreated. Internet- and mobile-based self-help interventions (IMIs) may be a promising strategy to address this unmet need. This study aims to investigate the efficacy and cost-effectiveness of an unguided internet-based treatment for SAD among university students. The intervention is optimized for the treatment of university students and includes one module targeting fear of positive evaluations that is a neglected aspect of SAD treatment.

METHODS

The study is a two arm randomized controlled trial in which 200 university students with a primary diagnosis of SAD will be assigned randomly to either a wait-list control group (WLC) or the intervention group (IG). The intervention consists of 9 sessions of an internet-based cognitive-behavioral treatment, which also includes a module on fear of positive evaluation (FPE). Guidance is delivered only on the basis of standardized automatic messages, consisting of positive reinforcements for session completion, reminders, and motivational messages in response to non-adherence. All participants will additionally have full access to treatment as usual. Diagnostic status will be assessed through Structured Clinical Interviews for DSM Disorders (SCID). Assessments will be completed at baseline, 10 weeks and 6-month follow-up. The primary outcome will be SAD symptoms at post-treatment, assessed via the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Secondary outcomes will include diagnostic status, depression, quality of life and fear of positive evaluation. Cost-effectiveness and cost-utility analyses will be evaluated from a societal and health provider perspective.

DISCUSSION

Results of this study will contribute to growing evidence for the efficacy and cost-effectiveness of unguided IMIs for the treatment of SAD in university students. Consequently, this trial may provide valuable information for policy makers and clinicians regarding the allocation of limited treatment resources to such interventions.

TRIAL REGISTRATION

DRKS00011424 (German Clinical Trials Register (DRKS)) Registered 14/12/2016.

Efficacy of an unguided internet-based self-help intervention for social anxiety disorder in university students: A randomized controlled trial

OBJECTIVES

Internet- and mobile-based interventions (IMIs) offer the opportunity to deliver mental health treatments on a large scale. This randomized controlled trial evaluated the efficacy of an unguided IMI (StudiCare SAD) for university students with social anxiety disorder (SAD).

METHODS

University students (N = 200) diagnosed with SAD were randomly assigned to an IMI or a waitlist control group (WLC) with full access to treatment as usual. StudiCare SAD consists of nine sessions. The primary outcome was SAD symptoms at posttreatment (10 weeks), assessed via the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Secondary outcomes included depression, quality of life, fear of positive evaluation, general psychopathology, and interpersonal problems.

RESULTS

Results indicated moderate to large effect sizes in favor of StudiCare SAD compared with WLC for SAD at posttest for the primary outcomes (SPS: d = 0.76; SIAS: d = 0.55, p < 0.001). Effects on all secondary outcomes were significant and in favor of the intervention group.

CONCLUSION

StudiCare SAD has proven effective in reducing SAD symptoms in university students. Providing IMIs may be a promising way to reach university students with SAD at an early stage with an effective treatment.

Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis

Background

Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects.

Objective

This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome.

Methods

We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials.

Results

We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls.

Conclusions

iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients’ greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings.

Interrelations between participant and intervention characteristics, process variables and outcomes in online interventions: A protocol for overarching analyses within and across seven clinical trials in ICare

BACKGROUND

It is well known that web-based interventions can be effective treatments for various conditions. Less is known about predictors, moderators, and mediators of outcome and especially interrelations between participant and interventions characteristics, process variables and outcomes in online interventions. Clinical trials often lack statistical power to detect variables that affect intervention effects and their interrelations. Within ICare, we can investigate the interrelation of potential predictor and process variables in a large sample.

METHOD

The ICare consortium postulated a model of interrelations between participant and intervention characteristics, process variables and outcomes in online interventions. We will assess general and disorder-specific interrelations between characteristics of the intervention, characteristics of the participants, adherence, working alliance, early response, and intervention outcomes in a sample of over 7500 participants from seven clinical trials evaluating 15 online interventions addressing a range of mental health conditions and disorders, using an individual participant data meta-analyses approach.

DISCUSSION/CONCLUSION

Existing research tends to support the efficacy of online mental health interventions, but the knowledge base regarding factors that affect intervention effects needs to be expanded. The overarching analyses using data from the ICare intervention trials will add considerably to the evidence.

In the Absence of Effects: An Individual Patient Data Meta-Analysis of Non-response and Its Predictors in Internet-Based Cognitive Behavior Therapy

Background: Negative effects of psychological treatments have recently received increased attention in both research and clinical practice. Most investigations have focused on determining the occurrence and characteristics of deterioration and other adverse and unwanted events, such as interpersonal issues, indicating that patients quite frequently experience such incidents in treatment. However, non-response is also negative if it might have prolonged an ongoing condition and caused unnecessary suffering. Yet few attempts have been made to directly explore non-response in psychological treatment or its plausible causes. Internet-based cognitive behavior therapy (ICBT) has been found effective for a number of diagnoses but has not yet been systematically explored with regard to those patients who do not respond. Methods: The current study collected and aggregated data from 2,866 patients in 29 clinical randomized trials of ICBT for three categories of diagnoses: anxiety disorders, depression, and other (erectile dysfunction, relationship problems, and gambling disorder). Raw scores from each patient variable were used in an individual patient data meta-analysis to determine the rate of non-response on the primary outcome measure for each clinical trial, while its potential predictors were examined using binomial logistic regression. The reliable change index (RCI) was used to classify patients as non-responders. Results: Of the 2,118 patients receiving treatment, and when applying a RCI of z ≥ 1.96, 567 (26.8%) were classified as non-responders. In terms of predictors, patients with higher symptom severity on the primary outcome measure at baseline, Odds Ratio (OR) = 2.04, having a primary anxiety disorder (OR = 5.75), and being of male gender (OR = 1.80), might have higher odds of not responding to treatment. Conclusion: Non-response seems to occur among approximately a quarter of all patients in ICBT, with predictors related to greater symptoms, anxiety disorders, and gender indicating increasing the odds of not responding. However, the results need to be replicated before establishing their clinical relevance, and the use of the RCI as a way of determining non-response needs to be validated by other means, such as by interviewing patients classified as non-responders.