Internet-based cognitive behavioural treatment (iCBT) represents a means of improving accessibility of mental health services to people who struggle to attend in-person appointments; saving resources and utilising the growing technology use among the general population. Access to remote treatment can be especially important for people with anxiety disorders who might have difficulties leaving home. Several studies have found iCBT to be effective in treating anxiety disorders (Hedman et al, 2013; Ruwaard et al, 2012).
iCBT can be delivered in an unguided format, with no therapist support, or guided format including communication with the therapist. These formats convey different advantages such as better social support in guided treatment and the possibility to revisit content in unguided format. There is currently evidence for the effectiveness of both guided and unguided iCBT in reducing anxiety symptoms although the evidence suggests greater effectiveness of the guided format (Andersson & Titov, 2014; Fogliati et al., 2016).
However, most research has dealt with guided treatment using asynchronous communication where patients and therapists respond to each other at different moments in time, for example via emails. In contrast, guided iCBT uses synchronous communication with therapist and client communicating in the same moment, for example via video conference.
There has not been any research that directly compares the efficacy of unguided and guided iCBT using synchronous communication. Ciuca et al. (2018) therefore investigated iCBT for panic disorder in unguided and therapist-guided formats (i.e. Skype videoconference with real-time audio-video communication).
Ciuca et al (2018) aimed to answer the following questions:
- What is the efficacy of internet-based self-help treatment program for panic disorder?
- Is guided format superior to the unguided format of iCBT?
The study recruited 111 Romanian adults (age 18-65) who were diagnosed with Panic disorder (PD) and randomly allocated them into three treatment groups:
- Unguided treatment: participants followed the 12-week PAXonline Program for Panic Disorder (PAXPD) which was an internet-based self-help program using 16 modules based on cognitive behavioural therapy (CBT)
- Guided treatment: This group followed the same PAXPD program with 10 additional video sessions (15-45 min) with a licensed psychotherapist
- Waitlist control: No intervention
After the treatment, the three groups were compared on the severity of their panic symptoms, their diagnostic status, and five other outcomes (e.g. symptoms of depression).
- The results showed that both guided and unguided intervention were more effective compared to being on a wait-list at reducing panic disorder, depression symptoms, panic attack cognitions, catastrophic cognitions, attentional biases and functional impairment.
- There were no differences between the effect of guided compared to unguided internet intervention on the symptoms after the treatment. However, the overall improvement when combining the different symptoms measures appeared to be greater in the guided intervention group compared to the unguided group.
- The guided intervention was more effective in reducing panic disorder symptoms in the period between 1 to 6 months after the treatment compared to the unguided intervention.
- Fewer participants met the diagnostic criteria for panic disorder after the treatment in the guided intervention group compared to the unguided intervention and wait-list groups.
- Participants in the guided condition spent more time using the internet program and completed more modules and more of them completed follow-up measures than the participants in the unguided treatment group.
- Overall, participants were on average satisfied with both the guided and unguided interventions.
The results of this small trial confirm the previous findings that iCBT is effective in treating panic disorder. While both guided and unguided iCBT were more effective in reducing multiple symptom and functioning measures compared to waiting list control. The guided iCBT was found to be superior to the unguided iCBT in the measures of overall beneficial effect, longer maintenance of the improvement, greater engagement with the intervention and smaller loss to follow-up.
Strength and limitations
The authors developed an accessible intervention for panic disorder and investigated its efficacy using sound methodology. It was successfully shown that although guided treatment boosts learning new skills to cope with panic, panic symptoms can be reduced even without a therapist guidance.
However, a number of limitations mean that we should use caution when interpreting these findings:
- Attrition bias: The high number of participants that dropped out might positively skew the results, especially since those participants that dropped out had more severe symptoms at the start of the treatment. In total, 30 participants (27%) failed to complete the post-treatment assessment (7 in the guided treatment condition, 12 in the unguided treatment condition and 11 in the control group).
- Selection bias: The authors could not reach the target number of participants due to financial difficulties. Participants were approached via communities, which can make it difficult for the results to be generalised to the public rather than population. Wrong sample size bias may also be an issue.
- The researchers became aware of participants’ therapy type during follow-up, since patients shared information about their treatments. This can cause researchers to make judgments based on their expectations. Failure to implement blinding can lead to performance bias (differences in how the treatment regimes are delivered) and observer bias (affecting the assessment of outcomes).
This study found that people with panic disorder can be successfully treated with a newly-developed iCBT intervention (i.e. PAXPD program), which supports the promise of iCBT in reducing the treatment gap in mental health care. This is especially applicable to the low and middle-income countries where the majority of people in need of mental health care do not receive any treatment. The effective iCBT program could potentially serve as an alternative in treating people with panic disorder. Given the global rise of internet use, iCBT could be accessed by more people who are in need and reduce the costs for all stakeholders, including the therapist. Therefore, policy makers should encourage the development and large-scale testing of web-based treatments.
As guided iCBT was superior to the unguided treatment in terms of its long-term benefit, future studies are encouraged to examine the effect of different types of therapist guidance (e.g. real-time audio-video versus asynchronous email) and their related cost-effectiveness ratios. Another direction of future studies could be the development of the iCBT intervention with a more personalised and tailored approach by identifying which patients would benefit most from which treatment format.
Thanks to the UCL Mental Health MSc students who wrote this blog: Ivana Hezelyova, Zsofia Dombi, Zsofia Sophansay, Karen Chan, Elnaz Gültekin, Stanislava Stashchenko, Isabelle Goehre, Jasper Ho (@Conscience_Psyc), Clementine Pizzey-Gray (@pizzeygray), and Mariam Riaz.
Conflicts of interest
None of the authors have any conflict of interest in the publication of this blog.
UCL MSc in Mental Health Studies
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Ciuca, A. M., Berger, T., Crişan, L. G., & Miclea, M. (2018). Internet-based treatment for panic disorder: A three-arm randomized controlled trial comparing guided (via real-time video sessions) with unguided self-help treatment and a waitlist control. PAXPD study results. Journal of Anxiety Disorders, 56, 43-55. https://doi.org/10.1016/j.janxdis.2018.03.009
Andersson, G., & Titov, N. (2014). Advantages and limitations of Internet‐based interventions for common mental disorders. World Psychiatry, 13(1), 4-11.
Hedman, E., Andersson, E., Andersson, G., Lindefors, N., Lekander, M., Rück, C., & Ljótsson, B. (2013). Mediators in internet-based cognitive behavior therapy for severe health anxiety. PLoS One, 8(10), e77752.
Ruwaard, J., Lange, A., Schrieken, B., Dolan, C. V., & Emmelkamp, P. (2012). The effectiveness of online cognitive behavioral treatment in routine clinical practice. PLoS One, 7(7), e40089.
Titov, N., Fogliati, V. J., Staples, L. G., Gandy, M., Johnston, L., Wootton, B., … & Dear, B. F. (2016). Treating anxiety and depression in older adults: randomised controlled trial comparing guided v. self-guided internet-delivered cognitive–behavioural therapy. BJPsych open, 2(1), 50-58.