Internet-versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial

Jan Bergström, Gerhard Andersson, Brjánn Ljótsson, Christian Rück, Sergej Andréewitch, Andreas Karlsson, Per Carlbring, Erik Andersson, Nils Lindefors, Jan Bergström, Gerhard Andersson, Brjánn Ljótsson, Christian Rück, Sergej Andréewitch, Andreas Karlsson, Per Carlbring, Erik Andersson, Nils Lindefors

Abstract

Background: Internet administered cognitive behaviour therapy (CBT) is a promising new way to deliver psychological treatment, but its effectiveness in regular care settings and in relation to more traditional CBT group treatment has not yet been determined. The primary aim of this study was to compare the effectiveness of Internet-and group administered CBT for panic disorder (with or without agoraphobia) in a randomised trial within a regular psychiatric care setting. The second aim of the study was to establish the cost-effectiveness of these interventions.

Methods: Patients referred for treatment by their physician, or self-referred, were telephone-screened by a psychiatric nurse. Patients fulfilling screening criteria underwent an in-person structured clinical interview carried out by a psychiatrist. A total of 113 consecutive patients were then randomly assigned to 10 weeks of either guided Internet delivered CBT (n = 53) or group CBT (n = 60). After treatment, and at a 6-month follow-up, patients were again assessed by the psychiatrist, blind to treatment condition.

Results: Immediately after randomization 9 patients dropped out, leaving 104 patients who started treatment. Patients in both treatment conditions showed significant improvement on the main outcome measure, the Panic Disorder Severity Scale (PDSS) after treatment. For the Internet treatment the within-group effect size (pre-post) on the PDSS was Cohen's d = 1.73, and for the group treatment it was d = 1.63. Between group effect sizes were low and treatment effects were maintained at 6-months follow-up. We found no statistically significant differences between the two treatment conditions using a mixed models approach to account for missing data. Group CBT utilised considerably more therapist time than did Internet CBT. Defining effect as proportion of PDSS responders, the cost-effectiveness analysis concerning therapist time showed that Internet treatment had superior cost-effectiveness ratios in relation to group treatment both at post-treatment and follow-up.

Conclusions: This study provides support for the effectiveness of Internet CBT in a psychiatric setting for patients with panic disorder, and suggests that it is equally effective as the more widely used group administered CBT in reducing panic-and agoraphobic symptoms, as well as being more cost effective with respect to therapist time.

Trial registration: ClinicalTrials.gov NCT00845260.

Figures

Figure 1
Figure 1
Flowchart of study participants, point of random assignment, and dropouts.
Figure 2
Figure 2
Cost-effectiveness plane for results at post-treatment.
Figure 3
Figure 3
Cost-effectiveness plane for results at follow-up.

References

    1. Taylor CB. Panic disorder. BMJ. 2006;332(7547):951–955. doi: 10.1136/bmj.332.7547.951.
    1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders-4th edition (DSM-IV). text revision edition edition. 4. Washington DC: American Psychiatric Press; 2000.
    1. Mitte K. A meta-analysis of the efficacy of psycho-and pharmacotherapy in panic disorder with and without agoraphobia. J Affect Disord. 2005;88(1):27–45. doi: 10.1016/j.jad.2005.05.003.
    1. Westen D, Morrison K. A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: an empirical examination of the status of empirically supported therapies. J Consult Clin Psychol. 2001;69(6):875–899. doi: 10.1037/0022-006X.69.6.875.
    1. Milrod B, Leon AC, Busch F, Rudden M, Schwalberg M, Clarkin J, Aronson A, Singer M, Turchin W, Klass ET. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry. 2007;164(2):265–272. doi: 10.1176/appi.ajp.164.2.265.
    1. Furukawa TA, Watanabe N, Churchill R. Combined psychotherapy plus antidepressants for panic disorder with or without agoraphobia. Cochrane Database Syst Rev. 2007. p. CD004364.
    1. Postel MG, de Haan HA, De Jong CA. E-therapy for mental health problems: a systematic review. Telemed J E Health. 2008;14(7):707–714. doi: 10.1089/tmj.2007.0111.
    1. Telch MJ, Lucas JA, Schmidt NB, Hanna HH, LaNae Jaimez T, Lucas RA. Group cognitive-behavioral treatment of panic disorder. Behav Res Ther. 1993;31(3):279–287. doi: 10.1016/0005-7967(93)90026-Q.
    1. Wade WA, Treat TA, Stuart GL. Transporting an empirically supported treatment for panic disorder to a service clinic setting: a benchmarking strategy. J Consult Clin Psychol. 1998;66(2):231–239. doi: 10.1037/0022-006X.66.2.231.
    1. Lidren DM, Watkins PL, Gould RA, Clum GA, Asterino M, Tulloch HL. A comparison of bibliotherapy and group therapy in the treatment of panic disorder. J Consult Clin Psychol. 1994;62(4):865–869. doi: 10.1037/0022-006X.62.4.865.
    1. Carlbring P, Westling BE, Ljungstrand P, Ekselius L, Andersson G. Treatment of panic disorder via the internet: A randomized trial of a self-help program. Behavior Therapy. 2001;32(4):751–764. doi: 10.1016/S0005-7894(01)80019-8.
    1. Schneider AJ, Mataix-Cols D, Marks IM, Bachofen M. Internet-guided self-help with or without exposure therapy for phobic and panic disorders. Psychother Psychosom. 2005;74(3):154–164. doi: 10.1159/000084000.
    1. Carlbring P, Bohman S, Brunt S, Buhrman M, Westling BE, Ekselius L, Andersson G. Remote treatment of panic disorder: a randomized trial of internet-based cognitive behavior therapy supplemented with telephone calls. Am J Psychiatry. 2006;163(12):2119–2125. doi: 10.1176/appi.ajp.163.12.2119.
    1. Klein B, Richards JC, Austin DW. Efficacy of internet therapy for panic disorder. J Behav Ther Exp Psychiatry. 2006;37(3):213–238. doi: 10.1016/j.jbtep.2005.07.001.
    1. Shandley K, Austin DW, Klein B, Pier C, Schattner P, Pierce D, Wade V. Therapist-assisted, Internet-based treatment for panic disorder: can general practitioners achieve comparable patient outcomes to psychologists? J Med Internet Res. 2008;10(2):e14. doi: 10.2196/jmir.1033.
    1. Bergström J, Andersson G, Karlsson A, Andréewitch S, Rück C, Carlbring P, Lindefors N. An open study of the effectiveness of Internet treatment for panic disorder delivered in a psychiatric setting. Nord J Psychiatry. 2009;63(1):44–50. doi: 10.1080/08039480802191132.
    1. Lutz W. Efficacy, effectiveness, and expected treatment response in psychotherapy. J Clin Psychol. 2003;59(7):745–750. doi: 10.1002/jclp.10169.
    1. Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 2005.
    1. Roberge P, Marchand A, Reinharz D, Savard P. Cognitive-behavioral treatment for panic disorder with agoraphobia: a randomized, controlled trial and cost-effectiveness analysis. Behav Modif. 2008;32(3):333–351. doi: 10.1177/0145445507309025.
    1. Andersson G, Bergström J, Carlbring P, Lindefors N. The use of the Internet in the treatment of anxiety disorders. Curr Opin Psychiatry. 2005;18(1):73–77.
    1. Carlbring P, Nilsson-Ihrfelt E, Waara J, Kollenstam C, Buhrman M, Kaldo V, Soderberg M, Ekselius L, Andersson G. Treatment of panic disorder: live therapy vs. self-help via the Internet. Behav Res Ther. 2005;43(10):1321–1333. doi: 10.1016/j.brat.2004.10.002.
    1. Kiropoulos LA, Klein B, Austin DW, Gilson K, Pier C, Mitchell J, Ciechomski L. Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT? J Anxiety Disord. 2008;22(8):1273–1284. doi: 10.1016/j.janxdis.2008.01.008.
    1. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22–33. quiz 34-57.
    1. Shear MK, Brown TA, Barlow DH, Money R, Sholomskas DE, Woods SW, Gorman JM, Papp LA. Multicenter collaborative panic disorder severity scale. Am J Psychiatry. 1997;154(11):1571–1575.
    1. Guy W. ECDEU Manual, US Dept of Health and Human Services. Rockville, MD: NIMH; 1976. Clinical Global Impressions; pp. 217–222.
    1. Montgomery S, Asberg M. A new depression scale designed to be sensitive to change. The British Journal of Psychiatry. 1979;134(4):382–389. doi: 10.1192/bjp.134.4.382.
    1. Reiss S, Peterson RA, Gursky DM, McNally RJ. Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behav Res Ther. 1986;24(1):1–8. doi: 10.1016/0005-7967(86)90143-9.
    1. Leon AC, Olfson M, Portera L, Farber L, Sheehan DV. Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. Int J Psychiatry Med. 1997;27:93–105.
    1. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA. 2000;283(19):2529–2536. doi: 10.1001/jama.283.19.2529.
    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;61(3):310–317. doi: 10.1001/archpsyc.61.3.310.
    1. Barlow DH, Craske MG. Mastery of your anxiety and panic (MAP-3) San Antonio: The Psychological Corporation; 2000.
    1. Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med. 2008;148(4):295–309.
    1. Wampold BE. The great psychotherapy debate. Models, methods, and findings. Mahaw, New Jersey: Lawrence Erlbaum; 2001.
    1. Brown H, Prescott R. Applied mixed models in medicine. New York: Oxford University Press; 1999.
    1. Barlow DH. Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic. 2. New York: Guilford Press; 2002.
    1. Internet Usage in Europe-Sweden. Retrieved 14 january, 2010.
    1. Spek V, Cuijpers P, Nyklicek I, Riper H, Keyzer J, Pop V. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med. 2007;37(3):319–328. doi: 10.1017/S0033291706008944.
    1. Farvolden P, Denisoff E, Selby P, Bagby RM, Rudy L. Usage and longitudinal effectiveness of a Web-based self-help cognitive behavioral therapy program for panic disorder. J Med Internet Res. 2005;7(1):e7. doi: 10.2196/jmir.7.1.e7.

Source: PubMed

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