Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: a randomized controlled non-inferiority trial

Erik Hedman, Gerhard Andersson, Brjánn Ljótsson, Erik Andersson, Christian Rück, Ewa Mörtberg, Nils Lindefors, Erik Hedman, Gerhard Andersson, Brjánn Ljótsson, Erik Andersson, Christian Rück, Ewa Mörtberg, Nils Lindefors

Abstract

Background and aims: Cognitive behavioral group therapy (CBGT) is an effective, well-established, but not widely available treatment for social anxiety disorder (SAD). Internet-based cognitive behavior therapy (ICBT) has the potential to increase availability and facilitate dissemination of therapeutic services for SAD. However, ICBT for SAD has not been directly compared with in-person treatments such as CBGT and few studies investigating ICBT have been conducted in clinical settings. Our aim was to investigate if ICBT is at least as effective as CBGT for SAD when treatments are delivered in a psychiatric setting.

Methods: We conducted a randomized controlled non-inferiority trial with allocation to ICBT (n=64) or CBGT (n=62) with blinded assessment immediately following treatment and six months post-treatment. Participants were 126 individuals with SAD who received CBGT or ICBT for a duration of 15 weeks. The Liebowitz Social Anxiety Scale (LSAS) was the main outcome measure. The following non-inferiority margin was set: following treatment, the lower bound of the 95 % confidence interval (CI) of the mean difference between groups should be less than 10 LSAS-points.

Results: Both groups made large improvements. At follow-up, 41 (64%) participants in the ICBT group were classified as responders (95% CI, 52%-76%). In the CBGT group, 28 participants (45%) responded to the treatment (95% CI, 33%-58%). At post-treatment and follow-up respectively, the 95 % CI of the LSAS mean difference was 0.68-17.66 (Cohen's d between group=0.41) and -2.51-15.69 (Cohen's d between group=0.36) favoring ICBT, which was well within the non-inferiority margin. Mixed effects models analyses showed no significant interaction effect for LSAS, indicating similar improvement across treatments (F=1.58; df=2, 219; p=.21).

Conclusions: ICBT delivered in a psychiatric setting can be as effective as CBGT in the treatment of SAD and could be used to increase availability to CBT.

Trial registration: ClinicalTrials.gov NCT00564967.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Participant flow and reasons for…
Figure 1. Participant flow and reasons for dropping out throughout the trial.
Abbreviations: ICBT, Internet-based cognitive behavior therapy; CBGT, Cognitive behavioral group therapy; SAD, Social anxiety disorder; Received, completed at least 5 modules (ICBT) or 5 sessions (CBGT).
Figure 2. Weekly change on LSAS-SR during…
Figure 2. Weekly change on LSAS-SR during treatment and LSAS scores at each assessment point.
Abbreviations: ICBT, Internet-based cognitive behavior therapy; CBGT, Cognitive behavioral group therapy; LSAS, Liebowitz Social Anxiety Scale; -SR, Self-report; CA, Clinician administered; Pre, Before treatment; Post, Post-treatment; 6MFU, Six months after treatment.
Figure 3. CGI-I scores at post-treatment and…
Figure 3. CGI-I scores at post-treatment and six-month follow-up.
Abbreviations: ICBT, Internet-based cognitive behavior therapy; CBGT, Cognitive behavioral group therapy; CGI-I, Clinical Global Impression Improvement Scale.

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