Investigating trajectories of change in psychological distress amongst patients with depression and generalised anxiety disorder treated with internet cognitive behavioural therapy
Highlights
► We examine the effectiveness of internet based cognitive behavioural therapy. ► Change in psychological distress (K10) was modelled across six lessons. ► Psychological distress decreased in a quadratic trend. ► Two classes of individuals with different trajectories of change were identified. ► Internet cognitive behavioural therapy was effective for the majority of patients.
Introduction
Depression and anxiety are chronic conditions that if left untreated are responsible for high levels of distress, impairment, and disability, equal to chronic physical conditions such as diabetes, cancer, and arthritis (Mathers, Vos, Stevenson, & Begg, 2000). Treatments such as Cognitive Behavioural Therapy (CBT) are highly efficacious at treating anxiety and/or depression (Butler, Chapman, Forman, & Beck, 2006). Internet based CBT treatment programs, administered under the guidance of clinicians, have the potential to dramatically reduce many of the barriers to treatment that sufferers of these conditions face (Titov, 2007). To further validate the point, a meta-analysis of 22 randomised controlled trials has demonstrated the efficacy of internet based CBT programs to significantly reduce distress, disability, and symptom severity in comparison to waitlist controls (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010). With such evidence, it seems likely that initiatives designed to increase and improve access to internet based treatment for mental disorders will become the norm.
The CRUfAD clinic (www.crufadclinic.org), a not-for-profit initiative of St. Vincent's Hospital, Sydney, Australia, is one such approach to disseminate internet based CBT programs to the wider community. The primary target of the CRUfAD clinic was patients of GPs, psychologists, mental health nurses, and other specialist health workers, particularly those working in rural and remote parts of Australia. The programs were essentially designed to be used as an ‘intern in the practice’, meaning that internet based CBT could be used as a mechanism for GPs and mental health workers to provide cost effective and time efficient programs for treating their patients who suffer from anxiety and depression. Clinicians could then dedicate more therapeutic time to their severe patients who require additional attention and treatment. To date, the CRUfAD clinic has had 3600 patients enrol in one of their internet CBT courses, a large proportion of patients coming from rural areas of Australia. The efficacy of the courses has been established in multiple randomised controlled trials (e.g. Andrews et al., 2010; Perini, Titov, & Andrews, 2008; Perini, Titov, & Andrews, 2009; Robinson et al., 2010; Titov et al., 2009, 2010) but the true effectiveness of the internet treatment programs offered by the CRUfAD clinic, and more importantly the actual trajectory of change in psychological distress experienced by patients who complete treatment, has yet to be fully examined.
Consequently, the current study represents one facet of an ongoing quality assurance program for the CRUfAD clinic, which has the general aim to investigate the effectiveness of the internet based CBT courses as well as investigating the need for any significant improvements to the overall service. The current study aimed to investigate the trajectories of change in psychological distress amongst completers of two CRUfAD Clinic programs, one for depression and one for anxiety (Generalised Anxiety Disorder; GAD). A steadily decreasing trajectory of change across each of six lessons will demonstrate the effectiveness of the online depression and GAD courses across the wider community. It is also possible that certain groups of individuals within the total sample may experience little response to treatment and therefore improvements are required to better serve those sub-populations. Therefore, the secondary aims of the current study included: 1) to investigate the presence of any significant sub-classes of patients that exhibit different trajectories of change in psychological distress, and 2) to identify any significant factors, including socio-demographic and clinical characteristics, that may accurately predict class membership and facilitate with identifying individuals who may not benefit from online CBT programs.
Section snippets
Participants
The study comprised of participants admitted to Internet CBT courses for a primary diagnosis of either depression or GAD. The courses were developed and maintained by St Vincent's Hospital, Sydney, Australia. Patients were prescribed the online courses by their GP, psychologist, mental health nurse, or other mental health specialist and remained in the clinical care of their prescribing clinician for the entirety of the online course. The study examined patient data that was collected between
Growth modelling
The results of the growth modelling across lessons of both the depression and anxiety course are provided in Table 1 and Table 2, respectively. As demonstrated in the tables, for both courses the single class latent growth models with a quadratic growth function provided the best model fit as evidenced by BIC. The mean quadratic growth factors were highly significant in both of the course models (p < 0.001). Likewise other indices of model fit, such as the Comparative fit index (≥0.95), the
Discussion
The current study represented one facet of an ongoing quality assurance study to improve the performance and effectiveness of a series of internet based CBT treatment courses prescribed by GPs and mental health clinicians. By investigating the heterogeneity between individual groups in terms of their change across the six lessons, the current study is able to indicate that some individuals require further assistance and/or support in order to benefit from the online treatment courses for
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