ترکیب رایانه ای درمان خانگی برای اختلال اضطراب فراگیر: برنامه اصلاح توجه و درمان رفتاری شناختی

Generalized anxiety disorder (GAD) is a common and disabling condition associated with significant personal and societal costs. Although efficacious treatments exist for GAD, the majority of these individuals fail to access our most effective treatments. In the current paper, we report the results of an open trial that examined the efficacy of a computer-delivered home-based treatment program for GAD. Twenty-one individuals seeking treatment for GAD received a self-administered program over 6 weeks that comprised two components: (1) an Attention Modification Program (AMP) designed to facilitate attentional disengagement from threat-relevant stimuli and (2) brief computer-delivered cognitive and behavioral treatment modules (CCBT). Fourteen of the 21 enrolled participants (67%) completed the treatment program. Intent-to-treat and completer analyses revealed that AMP + CCBT resulted in significant reductions in clinician- and self-rated symptoms of anxiety, worry, depression, and functional impairment. Moreover, treatment completers displayed significant reductions in attentional bias for threat from pre- to postassessment. Change in attentional bias for threat from pre- to postassessment was associated with change in worry symptoms. Finally, 79% of participants no longer met DSM-IV criteria for GAD at postassessment and 36% were classified as remitted (Hamilton Rating Scale for Anxiety ≤ 7; Rickels et al., 2006). These results suggest that computer-delivered AMP + CCBT may serve as an effective and easily accessible treatment option for individuals with GAD.

Generalized anxiety disorder (GAD) is a common and debilitating psychiatric condition associated with medical overutilization, poor perceived health, low ratings of quality of life, and impairment at work that result in a significant economic and public health impact (Ballenger et al., 2001, Hoffman et al., 2008 and Wittchen, 2002). GAD has a high lifetime prevalence (5.7%, Kessler et al., 2005; 8.5% in primary care settings, Roy-Byrne & Wagner, 2004) and is chronic, running an unremitting and disabling course (i.e., mean duration of 20 years; Ninan, 2001). Although efficacious psychosocial and pharmacological treatments exist for GAD (for reviews see Gould et al., 2004, Gould et al., 1997, Lydiard and Monnier, 2004 and Nutt et al., 2002), the majority of these individuals do not access our most effective treatments (Collins, Westra, Dozois, & Burns, 2004). Moreover, even when individuals with GAD eventually access treatment, treatment-seeking delays are longer for GAD relative to all other anxiety and mood disorders (i.e., 14 years from the time of onset; Kessler, Olfson, & Berglund, 1998). Considered together, the substantial delays in treatment seeking, failure to access evidence-based treatments, and overutilization of medical services results in prolonged personal and economic costs. These findings highlight the need to develop efficient and cost-effective treatments that have the potential to be widely accessible to individuals with GAD. Although the translation of evidence-based treatments developed in tightly controlled research settings into easily accessible interventions has many challenges, two of the most common obstacles include (a) treatment fidelity and (b) acceptability of evidence-based treatment approaches to clinicians and community health organizations (Chambless et al., 1996, Hollon et al., 2002, Persons, 1995 and Wilson, 1995). Accordingly, the National Institute of Mental Health (NIMH) Psychosocial Intervention Development Workgroup recommended the “development of user-friendly interventions and non-traditional delivery methods to increase access to evidence-based interventions” (Hollon et al., 2002, p. 625). Consistent with these recommendations, researchers have increasingly used computer-based technologies to facilitate transportability of empirically supported treatments into the community. These procedures have the potential to overcome many barriers to accessing traditional forms of therapy, including cost, convenience, and limited availability of evidence-based therapies in routine clinical care (Przeworski & Newman, 2006). Moreover, such interventions can be delivered systematically and reliably to large segments of the public outside of clinical settings, thereby increasing accessibility among populations that would otherwise not seek or receive adequate treatment. Computer-based interventions have similar rates of patient satisfaction, acceptability, and attrition compared to standard clinic treatment (Marks & Cavanagh, 2009; Przeworski & Newman), suggesting they may provide a feasible cost-effective alternative for individuals who may otherwise not access evidence-based treatments. Although computerized treatments may reduce treatment barriers that are common across a number of psychiatric conditions, these interventions may be particularly relevant for individuals with GAD who tend to exhibit the longest treatment-seeking delays relative to other anxiety and mood disorders (Kessler et al., 1998). The most commonly used strategy to date involves the translation of empirically supported psychosocial strategies (e.g., cognitive and behavioral techniques, applied relaxation) into computer-delivered formats such as the internet, palmtop or desktop computers, i.e., computerized-CBT (CCBT; Andersson, 2009, Marks and Cavanagh, 2009, Newman et al., 2003, Proudfoot, 2004 and Przeworski and Newman, 2006). More recently, our program of research (e.g., Amir, Beard, Burns and Bomyea, 2009 and Amir et al., 2008) and others (Schmidt, Richey, Buckner, & Timpano, 2009) have adapted experimental procedures used in cognitive science to develop a computerized Attention Modification Program (AMP) designed to target central cognitive mechanisms implicated in the maintenance of anxiety (Mathews & MacLeod, 2005). In the current paper, we describe our ongoing efforts to create an integrated computer-delivered treatment program (AMP + CCBT) that can be self-administered in the home (or other community settings) for individuals suffering from GAD. The treatment program described in the current study comprises two components: AMP and CCBT. AMP is based on cognitive theories of anxiety that propose a causal role for selective attention to threat-relevant information in the maintenance of anxiety (e.g., Mathews and MacLeod, 2005 and Williams et al., 1997). Consistent with these theories, 25 years of research provides evidence demonstrating that patients meeting diagnostic criteria for an anxiety disorder, including GAD (see Mogg & Bradley, 2005), preferentially attend to threat-relevant stimuli over neutral stimuli when the two compete for processing resources (for a review and meta-analysis see Bar-Haim, Lamy, Pergamin, Bakermans-Kranenburg, & van IJzendoorn, 2007). More relevant to the causality hypothesis, recent studies have demonstrated that experimentally manipulating attentional allocation in the presence of threatening information confers differential susceptibility to anxiety under stress (e.g., Amir et al., 2008, Clarke et al., 2008 and MacLeod et al., 2002). To modify attention, individuals complete a variant of the traditional probe detection task (MacLeod, Mathews, & Tata, 1986) that guides their attention away from threat-relevant cues by requiring them to respond to a visual probe that consistently follows benign (nonthreat) cues (e.g., couch) when these cues compete for processing resources with threat-relevant stimuli (e.g., illness). To our knowledge, three published studies have examined the efficacy of AMP in reducing symptoms in treatment-seeking individuals meeting diagnostic criteria for an anxiety disorder; two in generalized social phobia (GSP; Amir, Beard, Burns and Bomyea, 2009 and Schmidt et al., 2009) and one in generalized anxiety disorder (GAD; Amir, Beard, Burns, & Bomyea, 2009). All three studies were randomized placebo-controlled double-blind trials. The placebo group (Attention Control Condition, ACC) was identical to AMP except that the probe replaced the threatening and neutral stimuli with equal frequency. Participants completed AMP or ACC twice weekly for 4 weeks. Each training session was approximately 20 minutes in duration. Across the three RCTs, AMP participants exhibited significantly larger reductions in clinician- and self-rated symptoms of anxiety and functional impairment relative to the ACC group. The magnitude of treatment effects was within the range of those obtained for existing empirically supported cognitive and behavioral and pharmacological treatments for anxiety (Barlow, 2007). Most relevant to the current study, in a sample of 29 individuals seeking treatment for GAD (Amir, Beard, Burns, et al., 2009), participants who completed AMP displayed large pre- to postassessment changes on the primary outcome measure, the interviewer-rated Hamilton Rating Scale for Anxiety (HRSA; Hamilton, 1959; Cohen's d = 1.36; see also Hazen, Vasey, & Schmidt, 2009). Moreover, a significantly larger proportion of participants in the AMP group (50%) no longer met diagnostic criteria for GAD at postassessment compared to the ACC group (13%). Finally, a mediation analysis ( Mackinnon, Lockwood, Hoffman, West, & Sheets, 2002) revealed that change in attentional bias for threat accounted for the reduction in interviewer-rated anxiety from pre- to postassessment. Although most previous studies examined the efficacy of AMP in controlled laboratory settings, AMP possesses several unique features that support its transportability from the laboratory to real-world settings. First, AMP can be implemented in a consistent, highly reliable manner across settings. Administration of AMP is straightforward, requiring little technical knowledge or the need of specialized treatment settings, suggesting that it can be easily accessed from any location where the individual has access to a computer (e.g., home or work). Moreover, standardization of treatment delivery as well as implementation by participants also reduces the likelihood of variability and potential error in application of the intervention (cf. psychosocial treatments; Persons, 1995 and Wilson, 1995). Accordingly, researchers have begun testing the effects of transporting AMP into real-world environments. For example, See, MacLeod, and Bridle (2009) administered a home-based internet-delivered AMP to a group of high school students during the 2 weeks prior to a naturalistic stressor (i.e., relocating overseas for university). Students who completed AMP prior to relocation exhibited significantly greater reductions in trait anxiety scores and attenuated state anxiety responses immediately following relocation relative to a control training group. These findings suggest that administering AMP in a home-based setting may have clinical value in reducing symptoms of anxiety. To our knowledge, however, studies have yet to examine the efficacy of a home-based AMP in individuals meeting diagnostic criteria for an anxiety disorder. Another unique advantage of AMP is that at least one primary, theory-driven outcome, change in attentional bias for threat, is not a self-report or clinician-rated measure and therefore is less likely to be influenced by demand characteristics. Thus, although less ideal than the gold-standard randomized controlled trial (RCT), AMP lends itself very well to single-group designs (e.g., open trials) because the investigator can use change on a behavioral measure of attentional bias (i.e., change in response latency) as a measure of treatment response. Moreover, by presenting participants with a different set of stimuli during the pre- and postassessment as well as training sessions, it is possible to test the generalizability of change in attentional bias from stimuli used during training to a distinct set of GAD-related threat-relevant stimuli (Amir, Beard, Burns and Bomyea, 2009 and MacLeod et al., 2009). The second component of our program involves computer-delivered CBT. Research supports the efficacy of computer-based cognitive and behavioral treatments for anxiety (for reviews see Andersson, 2009, Andersson et al., 2007, Cuijpers et al., 2009, Marks and Cavanagh, 2009, Przeworski and Newman, 2006 and Reger and Gahm, 2009). A recent meta-analysis of 19 RCTs found that computer-based treatments for individuals meeting diagnostic criteria for an anxiety disorder were superior to wait-list and placebo groups (Cohen's d = .49 – 1.14; Reger & Gahm). Moreover, clinical effects of computer-based procedures did not differ relative to treatment-as-usual (TAU) with direct therapist contact. We are aware of one published clinical trial that examined the effects of computer-delivered clinician-assisted CBT for individuals seeking treatment for GAD specifically ( Titov et al., 2009). Consistent with previous studies, participants in the CBT group displayed significantly larger reductions in symptoms of worry and depression from pre- to posttreatment relative to a wait-list condition. The goal of the current study was to test the feasibility and efficacy of a home-based, self-administered computerized treatment program for GAD that integrated AMP and basic CBT didactic modules. Individuals seeking treatment for GAD were invited to take part in an initial diagnostic intake session followed by a brief tutorial intended to orient them to the program. Participants were then provided with the computer-based program that comprised AMP and 12 brief video-delivered CBT modules. The program was designed to be completed over 6 weeks, and participants received standardized weekly email contact. Feasibility of the program was assessed through (a) treatment completion rates, (b) treatment adherence (i.e., number of modules completed), and (c) amount of weekly contact. We also examined the effects of the program on clinician- and self-rated symptoms of anxiety, depression, and functional impairment as well as behavioral assessment of attentional bias for threat and worry.