Strategies to improve access to cognitive behavioral therapies for anxiety disorders: A scoping review

Cognitive Behavioral Immersion for Depression: Protocol for a Three-Arm Randomized Controlled Trial of Peer-Based Coaching in the Metaverse

BACKGROUND

Depression and anxiety are among the most common mental health concerns globally. Efficacious treatments such as cognitive behavioral therapy exist but remain difficult to access and scale. Cognitive behavioral immersion (CBI)-a cognitive behavioral skills training intervention delivered by peer coaches in the metaverse-has been developed to address these barriers. CBI can be used through a virtual reality headset or via flat-screen devices such as phones, tablets, or computers. Pilot data have established its usability among participants with clinical levels of depression and anxiety. However, more research is needed to determine whether CBI causes decreases in these symptoms and how delivery via virtual reality compares to flat-screen devices.

OBJECTIVE

This protocol aims to conduct a randomized controlled trial evaluating the efficacy of immersive CBI accessed via a virtual reality headset (CBI-VR) as compared to a less immersive (but more accessible) CBI condition accessed via a flat-screen device (CBI-FS) and each to a delayed access control (DAC).

METHODS

A total of 306 adults experiencing clinical levels of depressive symptoms are being recruited nationally to participate in this web-based trial. Participants will be randomized according to a 1:1:1 ratio to one of three conditions: (1) CBI-VR, (2) CBI-FS, and (3) DAC. The CBI program consists of eight weekly 60-minute group sessions led by trained peer coaches who teach cognitive behavioral skills. The acute period of each condition will last 8 weeks with a follow-up period of 6 months. The primary outcome is depressive symptoms; secondary outcomes are anxiety symptoms and quality of life. Outcomes will be assessed once at baseline, weekly during the course of the intervention, and monthly during follow-ups. We will use hierarchical linear models to assess differences in the rate of symptom change among conditions. We will also explore potential prognostic (demographics and immersion) and prescriptive (cognitive behavioral skills, group alliance, and program engagement) predictors, as well as potential mechanisms (cognitive change and social support) of response.

RESULTS

We hypothesize that participants randomized to either CBI group will experience greater symptom improvement than those in DAC and that CBI-VR participants will improve more than CBI-FS participants. This study was funded in September 2023. Data collection began in February 2024. As of January 2025, all 306 participants have been enrolled. Data collection should conclude by September 2025. Data have not yet been analyzed. Expected results to be submitted for publication in the winter of 2025.

CONCLUSIONS

This trial will determine if CBI via either device is efficacious as compared to DAC and whether virtual reality enhances outcomes. Findings will contribute to the literature on using the metaverse and virtual reality to facilitate effective accessible mental health interventions, particularly for depression.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06418997; https://clinicaltrials.gov/study/NCT06418997.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/65970.

Benzos (as) needed: research into as-needed and intermittent benzodiazepines for anxiety is required for comprehensive best prescribing practices

The medical and public health communities are divided around the use of benzodiazepine ("benzo") pharmacotherapy for anxiety disorders. Recent years have seen increased attention to benzo overprescription and its risks, leading to a pervasive emphasis on deprescribing. Some have resisted this trend, arguing that the balance of evidence supports the safety and efficacy of benzo pharmacotherapy for both short-term and long-term treatment of anxiety disorders. Given that rising rates of anxiety disorders and benzo misuse are both serious public health concerns, there is an urgent need for comprehensive evidence-based best practices for the prescription of benzos for anxiety. At present, however, major scientific gaps make it impossible to formulate such guidance. Most concerning is the lack of research into as-needed and intermittent prescription and use, which are both what benzos are best suited for, and likely, how they are most commonly administered. Further research into the safety and efficacy of both long-term daily and intermittent, as-needed benzo prescription and use are badly needed. But a roundly "anti-benzo" sentiment may be causing problematic underprescription of benzos, particularly when superior alternatives like cognitive-behavioral therapy are not widely available.

Effectiveness of internet-based cognitive behavioral therapy in reducing suicidality among high-risk patients with depression: A multicenter randomized controlled trial in Korea

OBJECTIVES

To compare the effectiveness of Internet-based cognitive behavioral therapy (iCBT) + treatment as usual (TAU) to TAU in patients with major depressive disorder (MDD) and suicidal risk.

DESIGN

This study was a multicenter, 1:1 single-blind randomized controlled trial (RCT) in which only the assessors were blinded.

SETTING

5 tertiary hospitals in Korea.

PARTICIPANTS

190 patients with depression aged 18-44 years who had suicidal ideation at baseline or had attempted suicide within the past month.

INTERVENTION

iCBT, consisted of five sessions over 4 weeks, and TAU including psychotherapy and pharmacotherapy. Data were collected through assessments and self-reports at baseline and at 6, 16, and 28 weeks after randomization.

RESULTS

200 patients were randomized, while 10 patients withdrew their consent to the study. (iCBT + TAU = 97, TAU = 93). 39 patients in iCBT + TAU group and 30 patients in TAU group completed final follow-up. Suicidal attempt was observed in 3 patients in iCBT + TAU group and 2 patients in TAU group.

CONCLUSION

No significant difference presented in the number of suicide attempts between groups during the follow-up period. However, iCBT + TAU showed faster improvements in suicidal ideation intensity, depressive symptoms, and social stress than TAU in the short term, but were not sustained at the long-term follow-up.

Correction: Strategies to improve access to cognitive behavioral therapies for anxiety disorders: A scoping review

[This corrects the article DOI: 10.1371/journal.pone.0264368.].

Impact of Empowerment Theory-Based Nursing Intervention on the Quality of Life and Negative Emotions of Patients Diagnosed with Brain Metastasis Post Breast Cancer Surgery

Objective

This study explores the impact of a nursing intervention grounded in empowerment theory, focusing on behavioral change, on brain metastasis patients post-breast cancer surgery.

Methods

Between June 2021 and June 2023, 102 patients diagnosed with brain metastasis after breast cancer surgery at Bao Ding No.1 Central Hospital were randomized into two groups. The control group (51 patients) received standard nursing care, while the observation group (51 patients) participated in a behavioral change nursing intervention influenced by empowerment theory. The evaluation metrics included measures of negative emotions, compliance with treatment protocols, overall quality of life, and nursing satisfaction, assessed at multiple time points during the study period.

Results

The intervention led to significant reductions in negative emotions for all patients when compared to their pre-intervention statuses, with the observation group exhibiting notably lower depression and anxiety scores at one and three months post-intervention (P < 0.05). Additionally, this group achieved higher compliance scores and demonstrated greater improvements in quality of life than the control group (P < 0.05). Nursing satisfaction was also significantly higher in the observation group, with 96.08% reporting high satisfaction compared to 80.39% in the control group (P < 0.05).

Conclusion

Implementing a nursing intervention that emphasizes behavioral changes and leverages empowerment theory significantly enhances the quality of life, reduces negative emotions, boosts compliance with treatment, and increases nursing satisfaction among patients with brain metastasis following breast cancer surgery. This suggests that such interventions could be a valuable component of postoperative care for this patient population.

Effect of adding systematic desensitization to goal-directed paradigm on risk of falling in patients with stroke: a randomized controlled trial

Background

Improvement in rehabilitation outcomes for patients suffering from chronic stroke can be attained through systematic desensitization of their fear of falling, which in turn reduces the risk of falling.

Purpose

This study aimed to examine the effect of adding systematic desensitization to a goal-directed paradigm on functional performance, balance, risk of falling, and fear of falling among chronic ischemic stroke patients.

Methodology

Two equally sized groups, each comprising 40 stroke patients of both sexes, were randomly divided. For 8 weeks, Group A received three sessions per week of combined treatment consisting of systematic desensitization and a goal-directed paradigm, while Group B received only the goal-directed paradigm. The Timed Up and Go (TUG) test and Dynamic Gait Index (DGI) were used to assess function performance; the Berg Balance Scale (BBS) and the Biodex Fall Risk Index (FRI) were used to evaluate balance; and the 16-item Fall Efficacy Scale-International (FES-I) was used to evaluate fear of falling. At baseline and after the treatment, all measurements were obtained.

Results

Both groups (A and B) revealed a substantial increase in functional performance through a decrease in TUG scores and an increase in DGI. Additionally, there was a decrease in the risk of falling through an increase in the BBS scores and a decrease in the FRI. Furthermore, there was a decrease in the fear of falling, as measured using the FES-I, after treatment, with superior improvement in Group A with a p-value of <0.001.

Conclusion

Systematic desensitization combined with a goal-directed paradigm has a superior effect on improving functional performance and reducing the risk of falling and the fear of falling in patients with stroke compared to a goal-directed paradigm alone.

Australian men's help-seeking intentions for anxiety symptoms: The impact of masculine norm conformity and gender role conflict

Research highlights a discrepancy between the number of men experiencing mental illness and those seeking professional help, particularly for anxiety. Conformity to masculine norms (CMN) and gender role conflict (GRC) have been recognised as barriers to men's mental health help-seeking, but few studies have examined these relationships for anxiety. This study aimed to examine the relationship between anxiety severity and help-seeking intentions in Australian men, and the additional impact of CMN and GRC. A total of 610 Australians aged 18-89 years (M = 46.02, SD = 17.14) participated in an online survey, which included demographic information and four standardised questionnaires measuring anxiety, help-seeking intentions, CMN, and GRC. CMN but not GRC was found to fully mediate the relationship between anxiety severity and anxiety-related help-seeking intentions. The results have theoretical implications for the study of masculinity and clinical implications for therapeutic approaches for men with anxiety symptoms.

Demand management processes to improve access to cognitive-behavioral therapies for anxiety disorders: a grounded theory study

Introduction

Anxiety disorders are impactful mental health conditions for which evidence-based treatments are available, notably cognitive-behavioral therapies (CBTs). Even when CBTs are available, demand-side factors limit their access, and actors in a position to perform demand management activities lack a framework to identify context-appropriate actions.

Methods

We conducted a constructivist grounded theory study in Quebec, Canada, to model demand management targets to improve access to CBTs for anxiety disorders. We recruited key informants with diverse experiences using purposeful, then theoretical sampling. We analyzed data from 18 semi-directed interviews and 20 documents through an iterative coding process centered around constant comparison.

Results

The resulting model illustrates how actors can target clinical-administrative processes fulfilling the demand management functions of detection, evaluation, preparation, and referral to help patients progress on the path of access to CBTs.

Discussion

Modeling clinical-administrative processes is a promising approach to facilitate leveraging the competency of actors involved in demand management at the local level to benefit public mental health.

SuRxgWell: study protocol for a randomized controlled trial of telemedicine-based digital cognitive behavioral intervention for high anxiety and depression among patients undergoing elective hip and knee arthroplasty surgery

BACKGROUND

Mood disorders (anxiety, depression), sleep disorders, and catastrophizing lead to increased post-operative pain perception, increase in postoperative opioid consumption, decreased engagement with physical activity, and increased resource utilization in surgical patients. Psychosocial disorders significantly affect postoperative outcome. Unfortunately, studies focused on perioperative psychological assessment and treatment are scarce. We propose to test whether digital cognitive behavioral intervention (dCBI) can help surgical patients. dCBI such as RxWell™ is a proven treatment for mood disorders in medical patients such as reducing depression in patients with inflammatory bowel disease. We hypothesize that RxWell™ will also be effective in surgical patients. This study aims to test whether RxWell™ can improve preoperative mood disorders and subsequently reduce postoperative pain and opioid requirement in patients scheduled for primary total hip and knee arthroplasty (THA, TKA). We named the trial as the SuRxgWell trial.

METHODS

This is a randomized, controlled trial that will enroll primary and unilateral THA or TKA patients with anxiety and/or depression symptoms before surgery to receive the SuRxgWell dCBI program and investigate its impact on postoperative outcomes including postoperative pain, anxiety, depression, sleep disorder, and catastrophizing. After signing an informed consent, subjects will be screened using the PROMIS questionnaires, and subjects with a T-score of ≥ 60 on the short Patient-Reported Outcomes Measurement Information System (PROMIS) 4a Anxiety and/or short PROMIS 4a Depression questionnaires will be randomized to either usual care (control group) or the cognitive behavioral intervention, RxWell™, plus usual care (intervention group). The control group will receive information on how to locate tools to address anxiety and depression, whereas the intervention group will have access to SuRxgWell 1 month prior to surgery and up to 3 months after surgery. The allocation will be 3:1 (intervention to control). Investigators will be blinded, but research coordinators approaching patients and research subjects will not. The primary outcome will be day of surgery anxiety or depression symptoms measured with the PROMIS Short Form v1.0 -Anxiety 4a/Depression and Generalized Anxiety Disorder Measure (GAD-7) and Patient Health Questionnaire (PHQ-8). Secondary end points include measuring other health-related quality of life outcomes including sleep disturbance, fatigue, ability to participate in social roles, pain interference, cognitive function, pain catastrophizing, and physical function. Other secondary outcomes include collecting data about preoperative and postoperative pain scores, and pain medication usage, and orthopedic functional recovery at baseline, day of surgery, and 1, 2, and 3 months after the surgery with the Pain Catastrophizing Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip injury and Osteoarthritis Outcome Score (HOOS). In addition, subjects will be asked to complete a GAD-7 and PHQ-8 questionnaires bi-weekly (via the RxWell™ app for the interventional group or REDCAP for the control group). Data about postsurgical complications, and resource utilization will also be recorded. We will also receive monthly reports measuring the usage and engagement of RxWell use for each participant randomized to that arm. The primary hypotheses will be assessed with intention-to-treat estimates, and differences in primary outcome will be tested using independent two sample t-tests. This trial is registered to the ClinicalTrials.gov database (NCT05658796) and supported by the DAPM, UPMC Health Plan, and the NIH.

DISCUSSION

Our trial will evaluate the feasibility of digital cognitive behavioral intervention as a perioperative tool to improve anxiety and depression before and after major orthopedic surgery in comparison to education. If digital cognitive behavioral intervention proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcomes.

Telemedicine-Based Digital Cognitive Behavioral Intervention for Perioperative Anxiety and Depression for Total Knee Arthroplasty

Introduction

Preoperative anxiety and depression have been shown to increase postoperative pain and opioid consumption by up to 50% in patients undergoing primary unilateral Total Knee Arthroplasty (TKA). We hypothesized that the use of a telemedicine-based digital Cognitive Behavioral Intervention program (RxWell®) started one month prior to surgery would control anxiety and depression prior to surgery.

Materials and methods

This was a randomized, controlled trial that enrolled patients undergoing primary unilateral TKA. At least a month prior to surgery, patients who gave consent to participate were asked to complete PROMIS® (Patient-Reported Outcomes Measurement Information System) emotional anxiety short form 8a and PROMIS® emotional depression short form-8a questionnaires. Patients with T-scores of ≥ 57 were randomized to either a no intervention (control group) or a RxWell® program (treatment group) for a month prior to surgery. The primary outcome of this proof-of-concept study was the ability of the RxWell® to normalize patients' PROMIS anxiety T scores.

Results

T scores for anxiety and depression among patients randomized to the RxWell® group significantly decreased from 64.3 ± 3.0 at the time of randomization to 58.5 ± 2.6 prior to surgery (n=5, p=0.006), whereas no changes in T scores were recorded in the control group (59.4 ± 4.2 at the time of randomization vs. 57.7 ± 6.2; n=6, p=0.559).

Conclusion

These preliminary data suggest that the use of a RxWell® program represents an effective approach to control anxiety and depression prior to surgery. In contrast, it seems that in the absence of treatment, anxiety level remains similar over a month prior to surgery.