Transdiagnostic Internet-delivered cognitive behaviour therapy with therapist support offered once-weekly or once-weekly supplemented with therapist support within one-business-day: Pragmatic randomized controlled trial

Abstract

In routine care, internet-delivered cognitive behaviour therapy (iCBT) regularly includes therapist support delivered via secure email, but the optimal response time to emails is unknown. In this study, we compared the benefits of therapists providing support once-weekly versus therapists providing support once-weekly supplemented with a one-business-day response to all patient emails. This pragmatic randomized controlled trial included therapists employed by a specialized iCBT clinic or community mental health clinics, where providing iCBT is a secondary service. Patients with depression and/or anxiety who enrolled in transdiagnostic iCBT (5 core lessons over 8 weeks) were randomized to: 1) once-weekly support supplemented with a one-business-day response to patient emails by specialized therapists ( n = 233); 2) once-weekly support also offered by specialized therapists ( n = 216); or 3) once-weekly support offered by community clinic therapists ( n = 226). Outcomes were measured at 8, 12, 24, and 52-weeks post-enrollment. Patient engagement and treatment experiences (e.g., treatment satisfaction, therapist alliance) were also assessed and a focus group was conducted with therapists. Supplementing once-weekly therapist support with a one-business-day response to patient emails resulted in therapists sending more emails to patients ( M : 13 versus 9) and required more therapist time over treatment ( M : 155 versus 109 min), but was not associated with improved outcomes, patient engagement or treatment experiences. All groups showed large improvements in symptoms of depression and anxiety maintained at 52-week follow-up, strong engagement and positive treatment experiences. Therapists viewed challenges of responding to patient emails within one-business-day to outweigh benefits. Contrary to expectations, supplementing once-weekly therapist support with a one-business-day response to all patient emails did not benefit patients and increased therapist time as well as therapist challenges when delivering iCBT in routine care.

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

“…% reduction ≥ 37%). Similar to our previous studies of iCBT in routine care (e.g., Hadjistavropoulos et al, 2016 , Hadjistavropoulos et al, 2020 ) satisfaction with the therapeutic alliance (all dimensions) and various ratings of treatment satisfaction were consistently positive (e.g., 97.5% would recommend iCBT to a friend) and unwanted negative effects of treatment were infrequent. Overall, it does not appear that HWRQs or 2W support garners substantial benefits for patients.…”

“…Overall, across all groups and consistent with past research on transdiagnostic iCBT (e.g., Dear et al, 2015 ; Hadjistavropoulos et al, 2016 , Hadjistavropoulos et al, 2019 , Hadjistavropoulos et al, 2020 ; Titov et al, 2015 , Titov et al, 2017 ), as well as research examining outcomes of iCBT in routine care (e.g., Etzelmueller et al, 2020 ; Romijn et al, 2019 ; Titov et al, 2018 ), patient outcomes were positive. Specifically, patients were engaged in treatment (73.7% completed all lessons) and demonstrated significant improvement in symptoms of depression (within Cohen's d = 0.69–1.00; avg.…”

“…Further challenges included perceptions that offering 2W resulted in an increased and unpredictable workload as well as discomfort related to having to provide this level of support when they perceived 2W as unwanted by patients. Of note, therapists in the iCBT clinic expressed that 2W support was preferable to a one-business-day response to patient emails which was trialed in a previous study ( Hadjistavropoulos et al, 2020 ). Supervisors identified organizational challenges related to offering support 2W including a greater likelihood of having to manage therapists missing patient contacts (e.g., due to vacation or sick time) and also having reduced capacity to offer patients iCBT in order to accommodate the increased time therapists needed to deliver 2W support.…”

“…Exclusion criteria included: 1) severe symptoms and high risk of suicide; 2) severe alcohol or drug problems; 3) weekly mental health treatment; 4) seeking help for a different mental health condition; and 5) self-reported medical condition that would interfere with treatment. Of note, iCBT was not limited to those who have scores on measures in the clinical range as past evidence suggests that patients in the nonclinical range show significant benefit from iCBT (e.g., Hadjistavropoulos et al, 2020 ). Also of note, we did not conduct diagnostic interviews but instead used primary and secondary measures below to examine patient symptom severity.…”

“…In that case, the optional support was found to result in lower completion rates than 1W support, although patient outcomes were still comparable ( Hadjistavropoulos et al, 2017b ). Recently, we examined whether 1W support supplemented with responding to patient emails in one-business-day conferred benefits over 1W support alone ( Hadjistavropoulos et al, 2020 ). No significant differences in patient engagement or outcomes were identified when patients were offered additional support.…”