A 5-Year follow-up of internet-based cognitive behavior therapy for social anxiety disorder

Erik Hedman, Tomas Furmark, Per Carlbring, Brjánn Ljótsson, Christian Rück, Nils Lindefors, Gerhard Andersson, Erik Hedman, Tomas Furmark, Per Carlbring, Brjánn Ljótsson, Christian Rück, Nils Lindefors, Gerhard Andersson

Abstract

Background: Internet-based cognitive behavior therapy (CBT) has been shown to be a promising method to disseminate cognitive behavior therapy for social anxiety disorder (SAD). Several trials have demonstrated that Internet-based CBT can be effective for SAD in the shorter term. However, the long-term effects of Internet-based CBT for SAD are less well known.

Objective: Our objective was to investigate the effect of Internet-based CBT for SAD 5 years after completed treatment.

Method: We conducted a 5-year follow-up study of 80 persons with SAD who had undergone Internet-based CBT. The assessment comprised a diagnostic interview and self-report questionnaires. The main outcome measure was the Liebowitz Social Anxiety Scale-Self-Report (LSAS-SR). Additional measures of social anxiety were the Social Interaction Anxiety Scale (SIAS) and the Social Phobia Scale (SPS). Attrition rates were low: 89% (71/80) of the participants completed the diagnostic interview and 80% (64/80) responded to the questionnaires.

Results: Mixed-effect models analysis showed a significant effect of time on the three social anxiety measures, LSAS-SR, SIAS, and SPS (F(3,98-102) = 16.05 - 29.20, P < .001) indicating improvement. From baseline to 5-year follow-up, participants' mean scores on the LSAS-SR were reduced from 71.3 (95% confidence interval [CI] 66.1-76.5) to 40.3 (95% CI 35.2 - 45.3). The effect sizes of the LSAS-SR were large (Cohen's d range 1.30 - 1.40, 95% CI 0.77 - 1.90). Improvements gained at the 1-year follow-up were sustained 5 years after completed treatment.

Conclusions: Internet-based CBT for SAD is a treatment that can result in large and enduring effects.

Trial registration: Clinicaltrials.gov NCT01145690; https://ichgcp.net/clinical-trials-registry/NCT01145690 (Archived by WebCite at http://www.webcitation.org/5ygRxDLfK).

Conflict of interest statement

None declared

Figures

Figure 1
Figure 1
Participant flow
Figure 2
Figure 2
Improvement course on the primary outcome measure LSAS-SR during the follow-up period
Figure 3
Figure 3
Clinical Global Impression Improvement (CGI-I) scores at 5-year follow-up (dropouts are considered non-responders)

References

    1. Furmark T, Tillfors M, Everz P, Marteinsdottir I, Gefvert O, Fredrikson M. Social phobia in the general population: prevalence and sociodemographic profile. Soc Psychiatry Psychiatr Epidemiol. 1999 Aug;34(8):416–24.90340416.127
    1. Schneier FR, Heckelman LR, Garfinkel R, Campeas R, Fallon BA, Gitow A, Street L, Del Bene D, Liebowitz MR. Functional impairment in social phobia. J Clin Psychiatry. 1994 Aug;55(8):322–31.
    1. Reich J, Goldenberg I, Vasile R, Goisman R, Keller M. A prospective follow-along study of the course of social phobia. Psychiatry Res. 1994 Dec;54(3):249–58.
    1. Andersson G, Carlbring P, Holmström A, Sparthan E, Furmark T, Nilsson-Ihrfelt E, Buhrman M, Ekselius L. Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: a randomized controlled trial. J Consult Clin Psychol. 2006 Aug;74(4):677–86. doi: 10.1037/0022-006X.74.4.677.2006-09621-005
    1. Carlbring P, Gunnarsdóttir M, Hedensjö L, Andersson G, Ekselius L, Furmark T. Treatment of social phobia: randomised trial of internet-delivered cognitive-behavioural therapy with telephone support. Br J Psychiatry. 2007 Feb;190:123–8. doi: 10.1192/bjp.bp.105.020107. 190/2/123
    1. Furmark T, Carlbring P, Hedman E, Sonnenstein A, Clevberger P, Bohman B, Eriksson A, Hållén A, Frykman M, Holmström A, Sparthan E, Tillfors M, Ihrfelt EN, Spak M, Eriksson A, Ekselius L, Andersson G. Guided and unguided self-help for social anxiety disorder: randomised controlled trial. Br J Psychiatry. 2009 Nov;195(5):440–7. doi: 10.1192/bjp.bp.108.060996. 195/5/440
    1. Titov N, Andrews G, Schwencke G, Drobny J, Einstein D. Shyness 1: distance treatment of social phobia over the Internet. Aust N Z J Psychiatry. 2008 Jul;42(7):585–94. doi: 10.1080/00048670802119762.794820327
    1. Berger T, Hohl E, Caspar F. Internet-based treatment for social phobia: a randomized controlled trial. J Clin Psychol. 2009 Oct;65(10):1021–35. doi: 10.1002/jclp.20603.
    1. Titov N, Andrews G, Choi I, Schwencke G, Mahoney A. Shyness 3: randomized controlled trial of guided versus unguided Internet-based CBT for social phobia. Aust N Z J Psychiatry. 2008 Dec;42(12):1030–40. doi: 10.1080/00048670802512107.905606265
    1. Heimberg RG, Liebowitz MR, Hope DA, Schneier FR, Holt CS, Welkowitz LA, Juster HR, Campeas R, Bruch MA, Cloitre M, Fallon B, Klein DF. Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Arch Gen Psychiatry. 1998 Dec;55(12):1133–41.
    1. Clark DM, Ehlers A, McManus F, Hackmann A, Fennell M, Campbell H, Flower T, Davenport C, Louis B. Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. J Consult Clin Psychol. 2003 Dec;71(6):1058–67. doi: 10.1037/0022-006X.71.6.1058.2003-09784-011
    1. Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral treatment of anxiety disorders in children: long-term (6-year) follow-up. J Consult Clin Psychol. 2001 Feb;69(1):135–41.
    1. Heimberg RG, Salzman DG, Holt CS, Blendell KA. Cognitive-behavioral group treatment for social phobia: Effectiveness at five-year followup. Cognitive Ther Res. 1993;17:325–39.
    1. Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive behavioral treatment for childhood anxiety disorders: long-term effects on anxiety and secondary disorders in young adulthood. J Child Psychol Psychiatry. 2010 Aug;51(8):924–34. doi: 10.1111/j.1469-7610.2010.02242.x.JCPP2242
    1. Fava GA, Rafanelli C, Grandi S, Canestrari R, Morphy MA. Six-year outcome for cognitive behavioral treatment of residual symptoms in major depression. Am J Psychiatry. 1998 Oct;155(10):1443–5.
    1. Carlbring P, Nordgren LB, Furmark T, Andersson G. Long-term outcome of Internet-delivered cognitive-behavioural therapy for social phobia: a 30-month follow-up. Behav Res Ther. 2009 Oct;47(10):848–50. doi: 10.1016/j.brat.2009.06.012.S0005-7967(09)00147-8
    1. Michelson L, Mavissakalian M, Marchione K, Dancu C, Greenwald M. The role of self-directed in vivo exposure in cognitive, behavioral, and psychophysiological treatments of agoraphobia. Behav Ther. 1986;17:91–108.
    1. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition. New York, NY: Biometrics Research, New York State Psychiatric Institute; 2002.
    1. Fresco DM, Coles ME, Heimberg RG, Liebowitz MR, Hami S, Stein MB, Goetz D. The Liebowitz Social Anxiety Scale: a comparison of the psychometric properties of self-report and clinician-administered formats. Psychol Med. 2001 Aug;31(6):1025–35.
    1. Mattick RP, Clarke JC. Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behav Res Ther. 1998 Apr;36(4):455–70.S0005-7967(97)10031-6
    1. Svanborg P, Asberg M. A new self-rating scale for depression and anxiety states based on the Comprehensive Psychopathological Rating Scale. Acta Psychiatr Scand. 1994 Jan;89(1):21–8.
    1. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988 Dec;56(6):893–7.
    1. Frisch MB, Cornell J, Villanueva M, Retzlaff PJ. Clinical validation of the quality of life inventory. A measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment. 1992;4(1):92–101.
    1. Guy W. Clinical Global Impressions. Rockville, MD: US Department of Health and Human services; 1976.
    1. Tillfors M, Carlbring P, Furmark T, Lewenhaupt S, Spak M, Eriksson A, Westling BE, Andersson G. Treating university students with social phobia and public speaking fears: Internet delivered self-help with or without live group exposure sessions. Depress Anxiety. 2008;25(8):708–17. doi: 10.1002/da.20416.
    1. Clark DM, Wells A. A cognitive model of social phobia. In: Heimberg RG, Leibowitz M, Hope DA, Schneider FR, editors. Social Phobia: Diagnosis, Assessment and Treatment. New York, NY: Guilford Press; 1995. pp. 63–93.
    1. Crippa JA, de Lima Osório F, Del-Ben CM, Filho AS, da Silva Freitas MC, Loureiro SR. Comparability between telephone and face-to-face structured clinical interview for DSM-IV in assessing social anxiety disorder. Perspect Psychiatr Care. 2008 Oct;44(4):241–7. doi: 10.1111/j.1744-6163.2008.00183.x.PPC183
    1. Rohde P, Lewinsohn PM, Seeley JR. Comparability of telephone and face-to-face interviews in assessing axis I and II disorders. Am J Psychiatry. 1997 Nov;154(11):1593–8.
    1. Hedman E, Ljótsson B, Rück C, Furmark T, Carlbring P, Lindefors N, Andersson G. Internet administration of self-report measures commonly used in research on social anxiety disorder: A psychometric evaluation. Computers in Human Behavior. 2010;26:736–40. doi: 10.1016/j.chb.2010.01.010.
    1. Gueorguieva R, Krystal JH. Move over ANOVA: progress in analyzing repeated-measures data and its reflection in papers published in the Archives of General Psychiatry. Arch Gen Psychiatry. 2004 Mar;61(3):310–7. doi: 10.1001/archpsyc.61.3.310.61/3/310
    1. Hunt C, Andrews G. Long-term outcome of panic disorder and social phobia. J Anxiety Disord. 1998;12(4):395–406.S0887-6185(98)00023-1
    1. Titov N, Andrews G, Johnston L, Schwencke G, Choi I. Shyness programme: longer term benefits, cost-effectiveness, and acceptability. Aust N Z J Psychiatry. 2009 Jan;43(1):36–44. doi: 10.1080/00048670802534424.906738278
    1. Knaevelsrud C, Maercker A. Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC Psychiatry. 2007;7:13. doi: 10.1186/1471-244X-7-13. 1471-244X-7-13
    1. Heimberg RG, Dodge CS, Hope DA, Kennedy CR, Zollo LJ, Becker R. Cognitive behavioral group treatment for social phobia: Comparison with a credible placebo control. Cognitive Therapy and Research. 1990;14(1):1–23. doi: 10.1007/BF01173521.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren