رفتاردرمانی شناختی به کمک درمانگر برای افسردگی و اضطراب با ارائه اینترنت؛ ترجمه شواهد در امور بالینی

This dissemination study examined the effectiveness of therapist-assisted Internet-delivered Cognitive Behavior Therapy (ICBT) when offered in clinical practice. A centralized unit screened and coordinated ICBT delivered by newly trained therapists working in six geographically dispersed clinical settings. Using an open trial design, 221 patients were offered 12 modules of ICBT for symptoms of generalized anxiety (n = 112), depression (n = 83), or panic (n = 26). At baseline, midpoint and post-treatment, patients completed self-report measures. On average, patients completed 8 of 12 modules. Latent growth curve modeling identified significant reductions in depression, anxiety, stress and impairment (d = .65–.78), and improvements in quality of life (d = .48–.66). Improvements in primary symptoms were large (d = .91–1.25). Overall, therapist-assisted ICBT was effective when coordinated across settings in clinical practice, but further attention should be given to strategies to improve completion of treatment modules.

Depression and anxiety are highly prevalent and associated with significant morbidity for the individual and substantial burden for the health care system (Eaton et al., 2008). Internet-delivered cognitive behavior therapy (ICBT) represents a pragmatic approach that may address common treatment barriers such as limited access to mental health providers, unwillingness to disclose mental health concerns, and challenges seeking care due to limited time, rural or remote residence, and or mobility difficulties (Andersson, 2009). ICBT involves reviewing psychoeducational materials presented in modules over the Internet and is commonly paired with therapist-assistance provided by phone or secure messaging. Over the past decade, research has demonstrated the efficacy of ICBT for the treatment of depression and anxiety disorders. In a meta-analysis of 22 controlled studies that compared ICBT for depression and anxiety with or without therapist assistance to a waiting list control condition, effect size superiority over the control group was 0.88 and symptom improvement was shown to be maintained after 26-weeks on average post-treatment (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010). Results also indicated high levels of accessibility, adherence, and satisfaction with this modality. Even more impressive is that several studies reported similar treatment outcomes when comparing therapist-assisted ICBT to face-to-face therapy for depression and anxiety disorders (Andersson, Cuijpers, Carlbring, Riper, & Hedman, in press). Although the benefits of ICBT have been firmly established in controlled studies, the performance of this approach remains understudied when delivered in routine clinical practice. Efficacy trials are typically conducted using strict protocols and delivered by a small number of therapists within specialized treatment settings. These trials often utilize extensive and strict exclusion criteria that are not representative of conditions evident in routine clinical practice. For wide-scale dissemination to occur, it is critical to demonstrate the effectiveness of ICBT outside of highly controlled clinical trials (Streiner, 2002). Preliminary evidence is encouraging regarding the effectiveness of ICBT in routine clinical practice. For example, in a large study, 1500 community patients were treated through a Dutch clinic offering therapist-assisted ICBT for depression, panic, posttraumatic stress, and burnout (Ruwaard, Lange, Schrieken, Dolan, & Emmelkamp, 2012). Results indicated that effect sizes and recovery rates were comparable to, or somewhat superior than, those observed in previous controlled trials, and similar to those of face-to-face CBT. Moreover, patients reported high satisfaction with the programs, with over 71% completing their programs, and symptom improvement sustained up to one year post-treatment. Ruwaard and colleagues (2012) noted the importance of examining ICBT in other clinical contexts. In a recent review of effectiveness studies, it was found that ICBT appears to be effective when delivered in clinical practice (Andersson & Hedman, 2013). The review included 4 controlled trials and 8 open studies, involving a total of 3888 patients. However, studies have only been conducted in Sweden, Australia, and the Netherlands, indicating a need to evaluate ICBT in other countries and settings. In the present research, we describe the utilization and effectiveness of ICBT programs for depression, generalized anxiety, and panic disorder when delivered in clinical practice. The model of delivery was unique with a centralized unit responsible for developing and maintaining the ICBT web application, training and monitoring community therapists or supervised graduate students working in one of six geographically dispersed clinics, and screening and assigning self-referred or provider-referred patients to therapists (Hadjistavropoulos et al., 2011). A centralized model was implemented as this was considered more cost-efficient with a higher degree of oversight and quality control than if each clinic worked independently. ICBT represented a new model of service delivery in all clinics and hence the trial can be described as a dissemination project. The ICBT program content was licensed from an established virtual clinic in Australia (Klein, Meyer, Austin, & Kyrios, 2011). The objective of the study was to determine the external validity of the ICBT programs when delivered in clinical practice in this manner. We expected that the treatment programs would produce moderate to large effects (Andersson & Hedman, 2013). We also hypothesized that treatment satisfaction would be high. This research is likely to assist with the transfer of knowledge to clinical practice and may encourage other community clinics to consider implementing ICBT in clinical practice.

While countries such as Sweden, Australia, and the Netherlands are increasingly offering ICBT in clinical practice, provision of therapist-assisted ICBT in Canada has been infrequent. The findings of this study are promising and are expected to have an impact on both clinicians and health system decision-makers. Dissemination projects, such as this one, are valuable as they serve to demonstrate the applicability of ICBT to the Canadian context. The study also serves to highlight important issues for consideration in delivering ICBT in clinical practice, such as whether the same exclusion criteria should be applied in clinical practice as research trials and the importance of gathering outcome data from all patients regardless of program completion, despite the added challenges associated with this task in clinical practice. While additional research is needed in this area to further improve the implementation of ICBT in clinical practice, the present research illustrates that many patients were interested in this service, engaged with the treatment, experienced large improvements, and reported high levels of satisfaction. The results are particularly encouraging in that they were obtained when therapists were new to the provision of ICBT. This study also serves to highlight a unique model of coordinating ICBT that may be of interest to other organizations, whereby therapist-assisted ICBT was coordinated by a centralized unit with treatment offered by community therapists and graduate students working in diverse geographically dispersed settings.