Efficacy of a cognitive-behavioural therapy administered by videoconference for generalized anxiety disorder

CBT treatment delivery formats for panic disorder: a systematic review and network meta-analysis of randomised controlled trials

Several in-person and remote delivery formats of cognitive-behavioural therapy (CBT) for panic disorder are available, but up-to-date and comprehensive evidence on their comparative efficacy and acceptability is lacking. Our aim was to evaluate the comparative efficacy and acceptability of all CBT delivery formats to treat panic disorder. To answer our question we performed a systematic review and network meta-analysis of randomised controlled trials. We searched MEDLINE, Embase, PsycINFO, and CENTRAL, from inception to 1st January 2022. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO. We found a total of 74 trials with 6699 participants. Evidence suggests that face-to-face group [standardised mean differences (s.m.d.) -0.47, 95% confidence interval (CI) -0.87 to -0.07; CINeMA = moderate], face-to-face individual (s.m.d. -0.43, 95% CI -0.70 to -0.15; CINeMA = Moderate), and guided self-help (SMD -0.42, 95% CI -0.77 to -0.07; CINeMA = low), are superior to treatment as usual in terms of efficacy, whilst unguided self-help is not (SMD -0.21, 95% CI -0.58 to -0.16; CINeMA = low). In terms of acceptability (i.e. all-cause discontinuation from the trial) CBT delivery formats did not differ significantly from each other. Our findings are clear in that there are no efficacy differences between CBT delivered as guided self-help, or in the face-to-face individual or group format in the treatment of panic disorder. No CBT delivery format provided high confidence in the evidence at the CINeMA evaluation.

Remote cognitive-behavioral therapy for generalized anxiety disorder: A preliminary meta-analysis

BACKGROUND

Generalized anxiety disorder (GAD) is a chronic mental health condition that results in significant individual, societal, and economic burden. While cognitive behavioral therapy (CBT) is well established as an efficacious treatment for GAD, individuals have identified several logistical barriers to accessing face-to-face CBT. Remotely delivered treatments address many of these treatment barriers.

METHODS

The aim of the current study was to synthesize the current literature on the efficacy of remote CBT for GAD using a meta-analytic approach. Relevant articles were identified through an electronic database search and 10 studies (with 11 remote conditions and 1071 participants) were included in the meta-analysis.

RESULTS

Within-group findings indicate that remote CBT for GAD results in large effect sizes from pretreatment to posttreatment (g = 1.30; 95% confidence interval [CI]: 1.03-1.58). Both low intensity and high intensity remote CBT interventions were found to result in large effect sizes (g = 1.36; 95% CI: 1.11-1.61 and g = 0.83; 95% CI: 0.20-1.47, respectively), with no significant differences between the treatment formats (Q₁  = 2.28, p = 0.13). Between-group effect sizes were medium in size at posttreatment (g = 0.76; 95% CI: 0.47-1.06).

CONCLUSIONS

These findings have potential implications for the delivery of evidence-based treatment for GAD and the inclusion of remote methods in stepped care treatment approaches.

Internet videoconferencing delivered cognitive behavior therapy for generalized anxiety disorder: protocol for a randomized controlled trial

Background

Generalized anxiety disorder (GAD) is a chronic mental health condition that results in a significant individual and societal burden. While cognitive behavioral therapy (CBT) is well established as an efficacious treatment for GAD, many patients experience logistical barriers when accessing face-to-face CBT. Remotely delivered treatments remove many of these barriers. Despite emerging evidence demonstrating the efficacy of remotely delivered CBT for GAD, studies examining the efficacy of remote methods for GAD that are analogous to standard face-to-face treatment, in particular synchronous treatments such as CBT delivered via online videoconferencing (VCBT), are needed.

Methods

The authors propose a two-group randomized controlled trial comparing the efficacy of VCBT for GAD against a waitlist control group. The recruitment target will be 78 adults with primary GAD of at least moderate severity. The manualized high-intensity VCBT intervention will be delivered weekly over a 10-week period. After treatment completion, waitlist participants will receive the same VCBT delivered in a brief format (i.e., weekly over a 5-week period). Treatment for both groups will be delivered in real time via an online teleconferencing platform. Outcome measures will be administered at baseline, mid-treatment, post-treatment, and 3-month follow-up.

Discussion

This trial will report findings on the efficacy of a remote synchronous high-intensity VCBT intervention for GAD. The results have the potential to contribute towards advancing our knowledge on the evidence base for GAD, as well as increase the dissemination of VCBT for GAD.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12621000786897. Registered on 22 June 2021

Online Short-Term Mindfulness-Based Intervention During COVID-19 Quarantine in Italy: Effects on Wellbeing, Stress, and Anxiety

To limit the first spread of COVID-19 in March 2020, the Italian government imposed strict lockdown measures to the population. Despite necessary to reduce the virus transmission and the burden to the hospitals, social isolation has caused detrimental effects on psychological wellbeing and mental health. Moreover, during this period, it was also difficult to deliver psychological treatments and psychiatric assistance. A short (a weekly session for 9 weeks) mindfulness-based meditation program, named Integral Meditation (IM), was administered entirely online to healthy adults from Italy. This is a two-groups pre–post-quasi-experimental study in which the two groups, treated and control, were not randomized. Through matching procedures aimed at overcoming the absence of randomization, we analyzed a sample of 84 subjects (42 for each group). By applying linear mixed effect models, we tested the hypothesis of a beneficial effect of IM on wellbeing, perceived stress, and state anxiety, as measured by three self-reported questionnaires (WEMWBS, PSS, and STAI-X1, respectively), assuming that this effect could be different according to the level of baseline trait anxiety, as measured by STAI-X2. The results showed a statistically significant effect of STAI-X1 (β = −8.24 [95%CI −15.39; −1.09], p = 0.02) and WEMWBS (β = 4.61 [95%CI 0.94; 8.29], p = 0.01) in the higher trait anxiety subgroup only. No statistically significant effect of IM was observed for PSS. These results suggest that our IM, delivered online, may increase mental wellbeing and decrease anxiety specifically in subjects with higher trait anxiety.

Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19

The COVID-19 pandemic created significant mental stressors among patients, which had the potential to impede access to primary care behavioral health (PCBH) services through rapid unplanned shifts to telehealth. The authors utilized retrospective administrative data and patient surveys to assess the feasibility, acceptability, and clinical outcomes of Jefferson Health PCBH pre- and post-COVID pandemic onset (Cohort 1 in person-only visits and Cohort 2 telemedicine-only visits). Using a retrospective cohort comparison study, outcomes included number of patients receiving PCBH in both cohorts, frequency of visits, no-show and cancellation rates, change in mean PHQ-9 and GAD-7 scores for patients, changes in the levels of depression and anxiety severity using established severity levels, and patient satisfaction with telehealth (Cohort 2 only). Patients in Cohort 2 were significantly more likely to have an anxiety diagnosis, had a smaller average number of visits, and were more likely to have a cancelled appointment. Both cohorts had statistically significant improvements in PHQ-9 and GAD-7 scores. In regression analyses, treatment cohort was not a significant predictor of final PHQ-9 or GAD-7 score. More members of Cohort 2 reported severe anxiety at both initial and final measurements. Nearly all Cohort 2 patients agreed or strongly agreed that telehealth made it easier for them to obtain care, that the platform was easy to use, and the visit was effective. Overall, PCBH telehealth services post-COVID-19 onset were feasible, acceptable to patients, and yielded similar clinical improvements to in-person behavioral health visits conducted before the pandemic.

Couples Therapy Delivered Through Videoconferencing: Effects on Relationship Outcomes, Mental Health and the Therapeutic Alliance

Changing technology, and the pervasive demand created by a greater need in the population for access to mental health interventions, has led to the development of technologies that are shifting the traditional way in which therapy is provided. This study investigated the efficacy of a behavioral couples therapy program conducted via videoconferencing, as compared to face-to-face. There were 60 participants, in couples, ranging in age from 21 to 69 years old. Couples had been in a relationship for between 1 to 49 years. The 30 couples were randomly allocated to the face-to-face or videoconferencing group. They all took part in Couple CARE—a couples behavioral education program which promotes self-change in order to increase relationship satisfaction. The six session manualized intervention was offered in an identical manner to all clients, in each condition. Data analysis was based on several questionnaires completed by each couple at pre, post and 3-months follow-up. Results showed that therapeutic alliance ratings did not differ between groups, but increased significantly over time for both groups. Additionally, the results indicated improvements in relationship satisfaction, mental health, and all other outcome scores over time, which did not differ based on condition. This study uniquely contributes to the literature exploring the use of technology to provide therapy. Specifically, the study provides evidence for couples therapy via videoconferencing as a viable alternative to face-to-face interventions, especially for those couples who may not have access to the treatment they require. It is anticipated that the results of this study will contribute to the field of online therapy, and add to fostering confidence in agencies to allow expansion of services conducted via videoconferencing.

Review of the current empirical literature on using videoconferencing to deliver individual psychotherapies to adults with mental health problems

PURPOSE

The COVID-19 pandemic has resulted in a widespread adoption of videoconferencing as a communication medium in mental health service delivery. This review considers the empirical literature to date on using videoconferencing to deliver psychological therapy to adults presenting with mental health problems.

METHOD

Papers were identified via search of relevant databases. Quantitative and qualitative data were extracted and synthesized on uptake, feasibility, outcomes, and participant and therapist experiences.

RESULTS

Videoconferencing has an established evidence base in the delivery of cognitive behavioural therapies for post-traumatic stress disorder and depression, with prolonged exposure, cognitive processing therapy, and behavioural activation non-inferior to in-person delivery. There are large trials reporting efficacy for health anxiety and bulimia nervosa compared with treatment-as-usual. Initial studies show applicability of cognitive behavioural therapies for other anxiety and eating disorders and obsessive-compulsive spectrum disorders, but there has yet to be study of use in severe and complex mental health problems. Therapists may find it more difficult to judge non-verbal behaviour, and there may be initial discomfort while adapting to videoconferencing, but client ratings of the therapeutic alliance are similar to in-person therapy, and videoconferencing may have advantages such as being less confronting. There may be useful opportunities for videoconferencing in embedding therapy delivery within the client's own environment.

CONCLUSIONS

Videoconferencing is an accessible and effective modality for therapy delivery. Future research needs to extend beyond testing whether videoconferencing can replicate in-person therapy delivery to consider unique therapeutic affordances of the videoconferencing modality.

PRACTITIONER POINTS

Videoconferencing is an efficacious means of delivering behavioural and cognitive therapies to adults with mental health problems. Trial evidence has established it is no less efficacious than in-person therapy for prolonged exposure, cognitive processing therapy, and behavioural activation. While therapists report nonverbal feedback being harder to judge, and clients can take time to adapt to videoconferencing, clients rate the therapeutic alliance and satisfaction similarly to therapy in-person. Videoconferencing provides opportunities to integrate therapeutic exercises within the person's day-to-day environment.

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.

An Integrative Review of Contemporary Perspectives on Videoconference-Based Therapy-Prioritising Indigenous and Ethnic Minority Populations in the Global South

An integrative literature review was undertaken as a means of drawing together contemporary perspectives on the outcomes and affordances of videoconference-based therapy. This review was conducted in a way which placed emphasis on the need for mental healthcare strategies which are mindful of the cultural and social needs of indigenous and ethnic minority populations, particularly those situated in the Global South. The review was undertaken using an inverse funnelling approach which sought to prioritise literature on videoconference-based therapy literature which specifically focused on indigenous and ethnic minority populations. A series of general and population specific searches across relevant health databases were supplemented by a simultaneous search of Google Scholar. The PICOS search tool was used in developing the search terms, and data was processed using an inductive approach to thematic analysis. A final dataset of 43 articles were included in the review. This body of literature encompassed an international range of studies and included perspectives informed by quantitative, qualitative and mixed methods research. Four key themes were identified across the reviewed literature: indigenous and ethnic minority populations, therapeutic relationships, clinical outcomes and technical and logistical considerations. Based on our findings, there is reason to believe that videoconference-based therapy can be made to be just as effective as offline, face-to-face modes of delivery. However, research into the efficacy, impact and cultural implications of this technology in relation to indigenous and ethnic minority populations represents a significant gap within contemporary literature.

Videoconferencing psychological therapy and anxiety: a systematic review

BACKGROUND

The growing worldwide prevalence of individuals with anxiety disorders has increased needs for mental health services. Due to limited number of mental health providers and community resources, especially in low-income countries, individuals often seek services from primary care settings. Through collaborative care models, services via telemedicine address the mental health provider shortage. While previous reviews show telemedicine effectively treats mental illness, a gap exists for reviews on videoconferencing psychological therapy for anxiety treatment.

OBJECTIVE

This systematic review aims to summarize videoconferencing psychological therapy for anxiety disorder treatment.

METHODS

Database searches were performed with PubMed, PsychINFO and Embase. Inclusion criteria identified controlled and uncontrolled studies evaluating videoconferencing psychological therapy. Studies were appraised using the Effective Public Health Practice Project Quality Assessment tool. Data collected included research design, sample size, intervention details, outcome results, intervention effect size and differences between videoconferencing psychological therapy and face-to-face therapy.

RESULTS

The search revealed 1253 articles, with 21 meeting inclusion criteria. Sample sizes ranged from 1 to 121 participants; cognitive-behavioral therapy was most commonly evaluated. Participants' diagnoses included panic disorder with and without agoraphobia, generalized anxiety disorder, social anxiety disorder, social phobia and hypochondriasis. Three studies occurred in outpatient health care settings. Fourteen studies reported statistically significant improvement on anxiety measures; 11 reported clinically significant improvements. Effect sizes ranged from small to very large, and all controlled studies found no differences between videoconferencing and face-to face groups.

CONCLUSION

Results provide promise for evidence-based interventions delivered via videoconferencing psychological therapy. More rigorous research is needed in various settings and populations.

Internet-based treatment for panic disorder: A three-arm randomized controlled trial comparing guided (via real-time video sessions) with unguided self-help treatment and a waitlist control. PAXPD study results

A growing body of evidence suggests that Internet-based cognitive behavioral treatments (ICBT) are effective to treat anxiety disorders. However, the effect of therapist guidance in ICBT is still under debate and guided ICBT offered in a real-time audio-video communication format has not yet been systematically investigated. This three-arm RCT compared the efficacy of guided with unguided ICBT (12 weeks intervention) and a waitlist (WL). A total of 111 individuals meeting the diagnostic criteria for panic disorder (PD) were randomly assigned to one of three conditions. Primary outcomes were the severity of self-report panic symptoms and diagnostic status. Secondary outcomes were symptoms of depression, functional impairment, catastrophic cognitions, fear of sensations and body vigilance. At post-treatment, both active conditions showed superior outcomes regarding PD and associated symptoms (guided ICBT vs. WL: d = 1.04-1.36; unguided ICBT vs. WL: d = 0.70-1.06). At post-treatment, the two active conditions did not differ significantly in self-reported symptom reduction (d = 0.21-0.54, all ps > 0.05), but the guided treatment was superior to the unguided treatment in terms of diagnostic status (χ² (1) = 13.15, p < 0.01). Treatment gains were maintained at successive follow-ups and the guided treatment became superior to the unguided treatment at 6 months follow-up (d = 0.72-1.05, all ps < 0.05).

Internet-based treatment for Romanian adults with panic disorder: protocol of a randomized controlled trial comparing a Skype-guided with an unguided self-help intervention (the PAXPD study)

BACKGROUND

Efficacy of self-help internet-based cognitive behavior therapy (ICBT) for anxiety disorders has been confirmed in several randomized controlled trials. However, the amount and type of therapist guidance needed in ICBT are still under debate. Previous studies have shown divergent results regarding the role of therapist guidance and its impact on treatment outcome. This issue is central to the development of ICBT programs and needs to be addressed directly. The present study aims to compare the benefits of regular therapist guidance via online real-time audio-video communication (i.e. Skype) to no therapist guidance during a 12-week Romanian self-help ICBT program for Panic Disorder. Both treatments are compared to a waiting-list control group.

METHODS/DESIGN

A parallel group randomized controlled trial is proposed. The participants, 192 Romanian adults fulfilling diagnostic criteria for panic disorder according to a diagnostic interview, conducted via secured Skype or telephone, are randomly assigned to one of the three conditions: independent use of the internet-based self-help program PAXonline, the same self-help treatment with regular therapist support via secured Skype, and waiting-list control group. The primary outcomes are severity of self-report panic symptoms (PDSS-SR) and diagnostic status (assessors are blind to group assignment), at the end of the intervention (12 weeks) and at follow-up (months 3 and 6). The secondary measures address symptoms of comorbid anxiety disorders, depression, quality of life, adherence and satisfaction with ICBT. Additional measures of socio-demographic characteristics, personality traits, treatment expectancies, catastrophic cognitions, body vigilance and working alliance are considered as potential moderators and/ or mediators of treatment outcome.

DISCUSSION

To the best of our knowledge, the present study is the first effort to investigate the efficacy of a self-help internet-based intervention with therapist guidance via real-time video communication. A direct comparison between therapist guided versus unguided self-directed intervention for panic disorder will also be addressed for the first time. Findings from this study will inform researchers and practitioners about the added value of online video-therapy guidance sessions and the type of patients who may benefit the most from guided and unguided ICBT for Panic disorder.

TRIAL REGISTRATION

ACTRN12614000547640 (Australian New Zealand Clinical Trials Registry). Registered 22/05/2014.