Transdiagnostic internet treatment for anxiety and depression: A randomised controlled trial
Highlights
► We compare the efficacy of transdiagnostic internet CBT vs. waitlist control. ► We examine changes in diagnosis and symptoms at post-treatment and at follow-up. ► Changes in the treatment group were superior to controls on all generic measures. ► Participants rated the procedure as highly acceptable. ► Transdiagnostic treatments could be administered via the internet.
Introduction
Depression and anxiety disorders are common, often chronic and disabling (Merikangas and Kalaydjian, 2007, Slade et al., 2009). These conditions can be treated effectively with disorder-specific treatment protocols (Andrews et al., 2003) but rates of treatment seeking amongst people with these conditions are often low. Barriers to treatment seeking include the limited number of mental health professionals and large waiting lists, particularly for public services, the direct and indirect costs of treatment, low mental health literacy, and stigma (Titov, 2011).
In recent years, several innovative approaches for improving access to evidence-based care have been proposed. One such approach is the use of unified or transdiagnostic treatments, which are designed to target the common elements of several disorders in one protocol (Barlow et al., 2004, Craske et al., 2009, Wilamowska et al., 2010). Interest in transdiagnostic treatments reflects pragmatic clinical considerations as well as arguments that anxiety and depressive disorders share similar symptoms and temperamental antecedents (negative affect or neuroticism) (Goldberg, 2010, Goldberg et al., 2009). The potential benefits to patients and clinicians of a single transdiagnostic treatment protocol compared to several disorder-specific protocols are considerable and include reduced waiting list times and the potential for patients to concurrently learn to manage co-morbid disorders. While based on a relatively small number of studies, recent meta-analyses of transdiagnostic treatments for the anxiety disorders (Norton & Price, 2007) and for anxiety combined with depression (McEvoy, Nathan, & Norton, 2009) are encouraging and indicate that transdiagnostic treatments may result in similar outcomes to disorder-specific treatments.
A complementary approach with the potential to improve access to evidence-based treatments for anxiety and depressive disorders is the use of internet-based cognitive behavioural therapy (iCBT) programs. iCBT involves patients systematically completing several online lessons that present the same information and skills typically taught in face-to-face CBT, often with support from a trained support person or clinician (Titov, 2011). Importantly, because of the increasing availability of the internet, iCBT has the potential to reduce barriers to treatment for both patients and clinicians. The results of recent meta-analyses of iCBT and computerised CBT indicate that these treatments produce superior effect sizes over control conditions (Andersson and Cuijpers, 2009, Andrews et al., 2010, Cuijpers et al., 2009).
Treatments that combine effective transdiagnostic treatment protocols with iCBT have considerable potential for improving access to evidence-based care. Recently Titov, Andrews, Johnston, Robinson, and Spence (2010) reported encouraging findings from a randomised controlled trial (RCT) evaluating a transdiagnostic iCBT treatment protocol designed to treat symptoms of generalised anxiety disorder (GAD), social phobia (SP) and panic disorder (with or without agoraphobia) (Pan/Ag). Using a RCT design, the present study explores the efficacy of a new transdiagnostic iCBT program (the Wellbeing program) that aims to treat depression as well as the three anxiety disorders (i.e., GAD, SP, Pan/Ag) treated in the aforementioned study. We hypothesised that Treatment group participants would show (1) significant improvements on generic measures of depression and anxiety, and on measures of neuroticism, and disability relative to waitlist Controls; (2) that these changes would be reflected in reduced numbers of those meeting criteria for diagnoses of major depressive disorder (DEP), GAD, SP, or Pan/Ag; and (3) that participants would rate the procedure as acceptable. Because quotas for each principal diagnosis were not set during recruitment strong a priori hypotheses about changes in disorder-specific measures were not established, although changes in disorder-specific measures were explored.
Section snippets
Design
A CONSORT revised compliant design compared an immediate Treatment group with a waitlist-deferred treatment Control group from pre to post treatment. The immediate Treatment group was followed through 3-month follow-up whereas the Control group received treatment following post-assessment. Power calculations indicated that a sample size of 36 participants in each group was sufficient to detect a between-groups effect size (ES) of 0.6 with power of 80%, which was the minimum expected based on
Baseline data
The mean age of participants was 43.9 years (SD = 14.6), and 54 (73%) were women. Additional demographic details are included in Table 1. A one-way ANOVA failed to identify any between-group difference for age (F1,72 = .31, p > .05) and chi-squared tests failed to find between-group differences in any other demographic characteristics in proportions of principal diagnosis or numbers of additional diagnoses (all ps > .05). However, one-way ANOVAs of pre-treatment scores indicated Treatment group
Discussion
This trial examined the efficacy of the Wellbeing program, a clinician-assisted transdiagnostic iCBT treatment program for depression and anxiety disorders. At intake all participants met DSM-IV diagnosis for major depressive disorder, GAD, social phobia, or panic disorder, and 81% met criteria for at least one additional disorder.
Outcomes for the Treatment group were superior to the Control group on the generic, disorder-specific, and secondary outcome measures, except the SP-12. Large
Conclusions
These findings provide preliminary support for the efficacy of a transdiagnostic iCBT protocol in the treatment of depression and anxiety disorders. Overall outcomes in the Treatment group were superior to those in the Control group, satisfaction with the protocol was high, and a modest amount of therapist time was required. Replication is required with larger samples and direct comparisons with disorder-specific programs are necessary to determine the relative benefits of each approach, with
Acknowledgements
The authors gratefully acknowledge the participants for their involvement and helpful comments. This research was enabled by funding from the Australian National Health and Medical Research Council Project Grant No. 630560.
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