As evidenced by several trials, cognitive-behavioral therapy (CBT) is a highly effective treatment for panic disorder (PD) (Taylor, 2000). However, only about 25% seek treatment (Lidren et al., 1994). The National Institute of Health (1991) postulated that barriers such as accessibility and affordability often prevented people suffering from PD from taking advantage of CBT. Lidren et al. (1994) suggested that bibliotherapy could be a way of overcoming these barriers.
In an attempt to provide a cost-effective treatment for these individuals, Carlbring, Westling, Ljungstrand, Ekselius, and Andersson (2001) developed an Internet-delivered self-help program and provided minimal therapist contact via e-mail. The program was recently evaluated in a randomized controlled trial which showed that the participants, compared to the waiting-list, achieved significant improvement in diary measurements of frequency of panic attacks, total intensity of each attack, total duration of each attack, and daily anxiety. Moreover, bodily sensations associated with the arousal accompanying anxiety were reduced, as well as anticipatory and catastrophic thoughts, agoraphobic avoidance, severity of anxiety symptoms, and depression. Finally, perceived life satisfaction was increased following treatment. With the exception of two dependent measurements, the treated participants reached a higher degree of clinical significant improvement compared to the waiting-list group. The results from this experiment generally provide evidence to support the continued use and development of self-help programs for PD distributed via the Internet. In addition, previous trials on other conditions suggest that the Internet can be used for administration of self-help treatments (e.g., Andersson, Strömgren, Ström, & Lyttkens, 2002; Lange, van den Ven, Schrieken, & Emmelkamp, 2001; Ström, Pettersson, & Andersson, 2001; Klein & Richards, 2000). A question that came up in our previous panic trail was if the time the therapist spent on each subject (approx. 90 min in total) could be reduced even more, and how important therapist monitoring of the patient's progress was. The present study deliberately minimized the time spent on each subject by using one of about 25 different standardized e-mail messages in response to questions. Furthermore, no time limit for the completion of the different treatment steps was set.
Instead of using a waiting-list control, which in an earlier study showed no improvement over time, a second treatment condition was employed. The choice of applied relaxation (AR; Öst, 1987) was made because it, at least in some studies, is equally effective as CBT (Öst & Westling, 1995). Furthermore, the delivery of this treatment is less demanding on the therapist and previous studies have shown that it can be delivered via the Internet (e.g. Ström et al., 2001; Andersson et al., 2002).
