A pragmatic factorial randomized controlled trial of transdiagnostic internet-delivered cognitive behavioural therapy: Exploring benefits of homework reflection questionnaires and twice-weekly therapist support

Abstract

With the growing demand for internet-delivered cognitive behavioural therapy (iCBT), this pragmatic factorial (2 × 2 × 2) randomized controlled trial evaluated strategies for facilitating iCBT engagement and outcomes in routine care. Specifically, the benefits to patients and therapists of using homework reflection questionnaires and offering patients twice-weekly therapist support were examined. Patients ( n = 632) accepted into iCBT for depression and/or anxiety were randomly assigned to complete homework reflection questionnaires or not (factor 1), receive once- or twice-weekly support (factor 2), and to receive care from therapists employed in one of two settings (iCBT clinic or a community mental health clinic; factor 3). Outcomes were measured at pre-treatment, and 8, 12, and 24-weeks post-enrollment. Therapist time was tracked and a focus group was conducted to examine therapist experiences. No differences in patient outcomes were found between therapists employed in the two settings; as such, these two groups were combined for further analyses. In terms of engagement, homework reflection questionnaires were associated with fewer website log-ins and days accessing iCBT; twice-weekly support was associated with more patient emails sent to therapists. Despite engagement differences, homework reflection questionnaires and twice-weekly support did not significantly impact primary outcomes; all groups showed large improvements in depression and anxiety that were maintained at 24-week follow-up. Therapists perceived a number of benefits and challenges associated with responding to homework reflection questionnaires and offering twice-weekly support; most notably the strategies did not benefit all patients. Twice-weekly support was associated with increased therapist time and organizational challenges. It is concluded that neither completion of homework questionnaires nor offering twice-weekly support significantly improve iCBT in routine care.

Initial Outcomes of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy Tailored to Public Safety Personnel: Longitudinal Observational Study

“…Descriptively, these outcomes are comparable to the most recent published outcomes of the Wellbeing Course offered by the Online Therapy Unit to the general population of Saskatchewan [ 63 ]. Effect sizes, percentage changes, and reliable change rates were comparable for all available symptom measures with the possible exception of the SIAS-6/SPS-6, which appeared to show better outcomes for the Wellbeing Course.…”

“…Effect sizes, percentage changes, and reliable change rates were comparable for all available symptom measures with the possible exception of the SIAS-6/SPS-6, which appeared to show better outcomes for the Wellbeing Course. However, mean pretreatment social anxiety symptoms were considerably less severe in the present sample than in the Online Therapy Unit’s clients [ 63 ], and the smaller change in symptoms found in this study may be due, in part, to a floor effect. Of note, the present findings show that the PSP Wellbeing Course was moderately effective for treating anger, which has not been measured in research on the Wellbeing Course.…”

“…Of note, the present findings show that the PSP Wellbeing Course was moderately effective for treating anger, which has not been measured in research on the Wellbeing Course. PSP participating in this study reported concurrent use of psychotropic medication less frequently than clients of the Wellbeing Course [ 63 ]. Results concerning treatment satisfaction, working alliance, and engagement were similar across the two courses.…”

Utilization, Patient Characteristics, and Longitudinal Improvements among Patients from a Provincially Funded Transdiagnostic Internet-delivered Cognitive Behavioural Therapy Program: Observational Study of Trends over 6 Years

“…Therapists contact clients on a designated day once-weekly for 8 weeks, although in some trials the amount of contact has varied (e.g., optional, twice-weekly). 17 – 20 Most contact includes asynchronous secure emails, with therapists spending 15 to 20 minutes composing messages after reviewing patient iCBT progress, symptom measures, and messages. Therapists also phone patients when there is a large symptom increase, messages suggest suicide risk, patients have not logged in for a week, and or a phone call would more easily address patient concerns.…”

“…Past research on the Wellbeing Course has shown outcomes are strong whether delivered by therapists who specialise in iCBT or by therapists who primarily deliver face-to-face treatment. 15 , 16 Furthermore, outcomes are comparable with varying support (i.e., once-weekly support compares to optional support, 17 , 18 twice-weekly support, 19 and one-business-day support 20 ). Still, other trials have studied therapist behaviours in iCBT 21 – 23 and outcomes of iCBT for alcohol misuse, 24 for various chronic health conditions, 25 – 30 and for specific populations like postpartum depression/anxiety 31 or university students.…”