An open trial of a brief transdiagnostic internet treatment for anxiety and depression

Abstract

The present study evaluated the efficacy of a brief version of an internet-administered transdiagnostic CBT protocol, the Wellbeing Program (Titov et al., 2011), designed to treat three anxiety disorders and major depression within the same program. This brief version included the same core CBT skills as the original, but condensed the materials from 8 to 5 online lessons, reduced the duration of treatment from 10 to 8 weeks and did not include an online forum. Thirty-two individuals with a principal diagnosis of major depression, generalised anxiety disorder, panic disorder or social phobia received CBT-based online educational lessons, homework assignments, weekly contact from a clinical psychologist and automated emails. Eighty-one percent of participants completed the lessons within the 8 week program. Post-treatment and 3-month follow-up data were collected from 28/32 and 31/32 participants respectively. Participants improved significantly on the Depression Anxiety and Stress Scales – 21 Item, Patient Health Questionnaire – 9 Item, and Generalised Anxiety Disorder – 7 Item scales, with corresponding within-group effect sizes (Cohen’s d) at follow-up of 1.05, .73, and .95, respectively. Participants rated the procedure as highly acceptable with gains of a similar magnitude as those found for the original program, but less time was spent per participant by the clinician in the present trial (mean = 44.61 min, SD = 34.45) compared to the original program (mean = 84.76 min, SD = 50.37). These results provide additional support for the efficacy of transdiagnostic iCBT in the treatment of anxiety and depressive disorders and indicate that a brief version may be of benefit.

Introduction

The anxiety disorders and major depression are common mental disorders that frequently co-occur and are often associated with a chronic and disabling course (Goldberg, Krueger, Andrews, & Hobbs, 2009). Meta-analyses confirm that there are effective psychological treatments for these disorders (Butler, Chapman, Forman, & Beck, 2006). Unfortunately, many people with these conditions experience difficulty accessing mental health services (Burgess et al., 2009, Titov, 2011). Low mental health literacy, long waitlists, stigma and cost are common barriers to accessing evidence-based treatment.

Transdiagnostic treatments are one approach with potential to increase access to treatment for people with anxiety disorders and depression (Barlow et al., 2004, Craske et al., 2009, Wilamowska et al., 2010). Transdiagnostic treatments aim to treat more than one anxiety or depressive disorder in the same treatment protocol through the provision of core CBT skills relevant to the target disorders. Interest in this approach reflects a growing recognition that the internalising disorders are highly co-morbid, share similar symptoms and respond to similar treatments (Goldberg, 2010). The interest also reflects clinical and pragmatic considerations when trying to implement evidence-based treatment protocols (Craske et al., 2011, McHugh et al., 2009). For example, it has been argued that transdiagnostic treatments may provide a balance between treatment fidelity (e.g. clinician adherence to an evidence-based treatment) and the need for flexibility in frontline clinical service settings, where a broad range of clinical presentations are encountered and high level competency with multiple treatment protocols may not be feasible (McHugh et al., 2009). Transdiagnostic treatments may also treat co-morbid diagnoses concurrently, obviating the need for further treatment and thus conferring additional pragmatic advantages over disorder-specific protocols. Such advantages were recently reported in a large effectiveness trial of the Coordinated Anxiety Learning and Management (CALM) intervention, a collaborative care protocol involving a transdiagnostic CBT component, which produced encouraging findings on disorder-specific measures of anxiety compared with usual care (Craske et al., 2011). Consistent with this, recent meta-analyses of transdiagnostic treatments for anxiety disorders and depression also suggest that these types of treatments may result in similar outcomes to traditional disorder-specific treatments (McEvoy et al., 2009, Norton and Price, 2007).

Internet-delivery of cognitive behavioural therapy (iCBT) protocols are another innovative approach that may increase access to treatment. iCBT comprises the same treatment components as face-to-face cognitive behaviour therapy, but the information is provided over the internet with support provided via email, telephone or protocols may be self-guided. Importantly, while there is now reliable evidence for the effectiveness of internet-delivered psychological treatments (Andersson and Cuijpers, 2009, Andrews et al., 2010, Cuijpers et al., 2009, Titov, 2011), key questions remain about the effect of program parameters on adherence, compliance and clinical outcomes. These include questions about the optimum length of a program, the media that should be used to facilitate contact between patient and clinicians, and the essential treatment components. The answers to these questions have considerable implications not only for the clinical and cost-effectiveness of such programs but will also define how they are disseminated and integrated with existing services.

Two trials of combined transdiagnostic and internet-delivery treatment approaches have recently been reported. The first reported encouraging findings from a randomised controlled trial of a transdiagnostic iCBT protocol treating generalised anxiety disorder, social phobia and panic disorder (Titov, Andrews, Johnston, Robinson, & Spence, 2010). The second reported preliminary evidence from a randomised controlled trial for the efficacy of an internet-administered transdiagnostic cognitive behavioural therapy (iCBT) program to treat three anxiety disorders and major depressive disorder within the same program (the Wellbeing Program) (Titov et al., 2011). That treatment protocol comprised 8 online lessons with additional materials administered over 10 weeks. Relative to Waitlist Controls, Treatment group participants reported significantly reduced symptoms of anxiety, depression and disability with results sustained after 3 months.

The present study sought to explore the efficacy of a brief version of the same Wellbeing Program, which was shortened from 8 lessons to 5 lessons and administered over 8 weeks instead of 10. This brief version contained all the techniques and content described in the original. It also included weekly contact with a clinical psychologist via secure email and telephone, but omitted the online forum used in the RCT. This simulated the forms of contact likely to be provided by a clinician in everyday practice. This brief version was administered to participants in the Waitlist Control Group of the RCT that examined the efficacy of the original and longer version of the Wellbeing Program (Titov et al., 2011). It was hypothesised that participants would show (1) significant improvements on measures of depression, anxiety, neuroticism, and disability; (2) that these changes would be reflected in reduced numbers meeting criteria for diagnoses of major depressive disorder (DEP), generalised anxiety disorder (GAD), social phobia (SP) or panic with or without agoraphobia (Pan/Ag); and (3) that participants would rate the procedure as acceptable.