Category: PHD

Examining motivational interviewing and booster sessions in Internet-delivered cognitive behaviour therapy for post-secondary students: An implementation trial

PhD Thesis Results, Vanessa Peynenburg 2022

Background: Nearly one-third of post-secondary students meet criteria for a mental disorder within any given year, with many students not receiving treatment. Internet-delivered cognitive behaviour therapy (ICBT) is an alternative to face-to-face services that is effective in general adult populations, but has been associated with high attrition rates and smaller effect sizes in student populations. Motivational interviewing (MI) is used by therapists in face-to-face settings and can help improve treatment completion and outcomes. Booster sessions are often used in face-to-face therapy to maintain long-term changes. To date, the use of online MI and booster sessions in ICBT for students has not been examined. In this implementation trial, the role of MI and booster sessions on treatment completion and outcomes was examined in Saskatchewan.

Methods: In this factorial trial (factor 1: presence of pre-treatment online MI); factor 2: presence of a booster lesson), a total of 308 clients were randomized to one of four groups: standard care, MI, booster, and MI + booster. All clients received a 5-week transdiagnostic ICBT course (the UniWellbeing Course) for symptoms of depression and anxiety. Primary outcomes included symptoms of depression, anxiety, and perceived academic functioning. All primary measures were administered at pre-treatment, post-treatment, and 1- and 3-month follow-up, Implementation outcomes (i.e., acceptability, adoption, and fidelity) were also examined.

Results:  Across all four groups, clients experienced large reductions in symptoms of depression and anxiety, as well as small improvements in perceived academic functioning. Changes were maintained at 1-month and 3-month follow-up. No benefit was found for the inclusion of MI on treatment completion, although clients who were assigned to MI had slightly larger improvements in symptoms of depression and anxiety at post-treatment. 30.9% of client assigned to one of the booster groups accessed the booster. When examining the booster groups as a whole, no benefits were found for improvements in depression, anxiety, or perceived academic functioning at 3-month follow-up. However, a sub-analysis of clients who accessed the booster found a small advantage in favour of the booster for depression. Overall, clients were satisfied with ICBT, although treatment completion remained low. Uptake of the ICBT course was highest at the two largest post-secondary institutions in Saskatchewan.

Conclusions: There is some evidence to suggest that including MI at pre-treatment results in greater symptom reduction, although these benefits do not persist to 1-month and 3-month follow-up. The inclusion of a self-guided booster lesson may also help with continued symptom management up to 3-month follow-up, but low uptake is a barrier to clients experiencing these benefits. Findings from this trial contribute to the literature on improving ICBT outcomes for post-secondary students.

Perceptions of and preferences for Internet-delivered cognitive behaviour therapy for anxiety and depression in post-secondary students

Masters Thesis Results, Vanessa Peynenburg 2019

Background: Anxiety and depression are prevalent mental health concerns experienced by post-secondary students. Rates of help-seeking are often low in this population, and students face several barriers to accessing psychological treatment. Internet-delivered cognitive behaviour therapy (ICBT) is an effective alternative to face-to-face therapy that addresses these barriers in adult populations with some evidence showing ICBT can also be effective with students. Additional research is necessary to identify students perceptions of and preferences for ICBT to assist with future implementation efforts in student populations. 

Methods: 314 Canadian post-secondary students completed an online survey and completed questionnaires about their symptoms of depression, anxiety, alcohol and drug use, and medical service utilization over the last 12 months. Students rated the acceptability and credibility of three treatment options (ICBT, face-to-face therapy, and medication) for the treatment of anxiety and depression. They also rated the utility of different kinds of content to be included in an ICBT course. 

Results: The three treatment options were rated as moderately acceptable and credible. Students expressed a preference for face-to-face services (44.6%), followed by medication (31.9%), and finally ICBT (23.5%). ICBT became more preferable once students would have to wait to receive face-to-face therapy. Students who were female and had less severe symptoms of depression had more positive perceptions of the use of ICBT in the treatment of anxiety and depression.

Conclusions: While many students expressed a preference for face-to-face therapy or medication over ICBT, a substantial number preferred ICBT. Students often have to wait to receive face-to-face therapy, so ICBT may also be more desirable in these circumstances. Implementation trials in student populations are necessary to identify barriers to implementation efforts.

Online motivational interviewing for enhancing internet-delivered cognitive behaviour therapy: A randomized controlled trial

Doctoral Dissertation Results, Joelle Soucy 2020

Background: Despite the fact that internet-delivered cognitive behaviour therapy (iCBT) can be used to effectively reduce symptoms of anxiety and depression, not all clients benefit from treatment. Opportunities exist to further enhance treatment outcomes in order to maximize the impact of iCBT. Motivational Interviewing (MI) is a clinical tool used by therapists to help facilitate clients’ motivation to change. Integrating MI and face-to-face therapy in the treatment of anxiety has been shown to result in better treatment response and completion relative to face-to-face therapy alone. Therefore, there is a possibility that combining iCBT with online MI can result in similar outcomes. This investigation sought to first develop a brief, interactive online MI pre-treatment that was designed to increase motivation to engage in iCBT for anxiety and depression. Once the protocol was developed and piloted, we examined the impact of the online MI pre-treatment on motivation levels, symptom change, and treatment engagement/completion.

Methods: A total of 480 clients applying to iCBT were randomly assigned to first receive the MI pre-treatment or no pre-treatment. The online MI pre-treatment consisted of a single lesson that comprised of videos, exercises, and feedback designed to increase intrinsic motivation to engage in iCBT. All clients then participated in an 8-week transdiagnostic iCBT program for anxiety and/or depression that consisted of 5 lessons aimed at providing psychoeducation and coping techniques for managing symptoms of anxiety and depression.    

Results: Contrary to prediction, little evidence of using online MI to further improve iCBT outcomes for anxiety and depression was found in the study. Engagement in iCBT was high across groups, with clients completing the same number of lessons and logging into the program a comparable number of times. Clients in both groups also reported high levels of motivation both prior to and following the MI period. Similarly, across groups, clients reported large reductions in anxiety and depression from pre- to post-treatment. During the 6-month follow-up, cliens in the iCBT only group continued to report small reductions in symptoms of anxiety, whereas clients in the MI plus iCBT group did not continue making improvements. The addition of MI to iCBT was also associated with minor increases in symptoms of depression during follow-up, wheras symptom improvements were maintained for clients in the iCBT only group.

Conclusions: Results from this study suggest that online MI may not enhance client outcomes when motivation at pre-treatment is high. In some instances, online MI may also prevent further treatment progress, especially among individuals with high motivation to engage in treatment. Moving forward, it will be important to determine if specific client populations benefit more from online MI.

Treatment acceptability and preference among primary care patients experiencing severe health anxiety: The role of internet-delivered cognitive behaviour therapy

Masters Thesis Results, Joelle Soucy 2016

Although cognitive behaviour therapy (CBT) is a helpful intervention for health anxiety, many individuals are unable to receive this treatment because of difficulties accessing it. Internet-delivered cognitive behaviour therapy (ICBT) is a new and accessible treatment that has been shown to successfully manage symptoms of health anxiety; however, it remains unclear whether ICBT would be used if in fact offered to individuals with health anxiety. The goal of this study was to see how patients perceive ICBT compared to other existing treatments for health anxiety. Primary care patients who were experiencing symptoms of health anxiety were presented with descriptions of three different treatments for health anxiety. The treatments were medication, CBT, and ICBT. Perceptions of the treatments were assessed following the presentation of each treatment description. Participants were also asked to rank the three treatments based on the likelihood wanting to receive that intervention for health anxiety. Results indicated that all three treatments were similarly rated as moderately acceptable. The highest preference ranks were for CBT and medication. That said, a small sample of participants ranked ICBT as the preferred intervention. While CBT and medication were the preferred treatments for health anxiety, the generally favourable perceptions of ICBT found in the study suggest that it would likely be considered a desirable treatment option by a number of potential users.

Efficacy of Internet-delivered cognitive behavioural therapy following an acute coronary event: A randomized controlled trial

Doctoral Dissertation Results, Luke Schneider 2019

Depression and anxiety are common after a heart attack or other acute cardiac event, however, evidence-based mental health interventions are not routinely available in cardiac rehabilitation programs. The focus of this study was to explore the effectiveness and acceptability of the Cardiac Wellbeing Course: an Internet-delivered cognitive behavioural therapy program to help survivors of cardiac events manage depression and anxiety.

The Cardiac Wellbeing Course was offered between August 2016 to April 2018 to Canadians who recently experienced a cardiac event (heart attack or unstable angina) in the last two years. A total of 25 participants were enrolled in the course and their levels of depression, anxiety, physical activity, and quality of life were compared to 28 participants who did not receive the course.

Results of the study were favourable, such that large and statistically significant improvements in depression and anxiety were observed among participants who received the course. A rise in physical activity levels and quality of life was also observed among participants who received the course. Satisfaction with the course was high and a majority of participants (92%) completed the course.

The results of this study highlight the potential of the Cardiac Wellbeing Course to help people who have experienced an acute cardiac event to manage depression and anxiety. Future research should look at evaluating the Cardiac Wellbeing Course in a larger sample, preferably in a cardiac rehabilitation setting.

Initial perceptions of Internet-based cognitive-behaviour therapy for chronic pain among potential users: Examining interest, perceived barriers, and strengths

Masters Thesis Results, Luke Schneider 2013

Background:

Chronic pain is an important area of study given that 15 to 18% of the Canadian population will develop a chronic pain condition during their lifetime. One difficulty in the self-management of chronic pain is the lack of resources available for those who suffer from this condition. Although preliminary research has demonstrated Internet Cognitive Behaviour Therapy (ICBT) for chronic pain to be a viable treatment option, potential users’ initial perceptions towards this mode of delivery may pose a barrier for participation in such programs. The purpose of the study was threefold:

1. To develop an ICBT perceptions questionnaire (ICBT-PQ) that captures the perceptions of potential users of the service
2. To examine variables that may predict early perceptions of ICBT (e.g., age, sex, computer self-efficacy)
3. To identify perceptions of what intervention features would be perceived by potential users as most desirable for ICBT

Methods:

Given the steps necessary to address the research questions, the overall project was divided into two studies. In study one, the ICBT-PQ was developed based on a comprehensive review of the literature and telephone interviews with 11 participants who had chronic pain. The preliminary version of the ICBT-PQ was then reviewed by researchers with ICBT experience and by a lay audience to ensure readability and acceptability.

In study two, a total of 129 people with chronic pain completed a web-based survey consisting of a demographic questionnaire, the finalized ICBT-PQ, and measures of computer self-efficacy and computer anxiety. Participants were predominantly female (82%), Caucasian (90%), middle-aged (average age = 47), and had chronic pain for an average of 12 years.

Results:

Through the factor analysis, the ICBT-PQ items were grouped into two categories: statements of potential ICBT strengtdhs and statements of potential ICBT limitations.

The majority of participants endorsed ICBT strength statements and disagreed with ICBT limitation statements.

ICBT strength statements that participants most agreed with

ICBT limitation statements that participants most disagreed with

“ICBT is important for patients who have difficulty moving or getting around” “ICBT is important for patients who have a hard time attending appointments for various reasons” “ICBT is important for patients who live in rural areas” “People with a high school education could use ICBT”

“If I used ICBT I would worry about the security of my personal information” “If I used ICBT I would worry about getting a computer virus” “ICBT is not necessary because there is already enough information available on chronic pain management on the Internet” “If I used ICBT I would worry about making a mistake using the computer” “Patients don’t really need extra information on how to manage chronic pain”

Conclusion:

Even though participants had no prior experience with ICBT, they generally had positive perceptions of ICBT such as accessibility and convenience. They did not perceive ICBT to have many negative limitations, such as computer concerns or concerns about the security of their personal information. The perceived strengths of ICBT outweighed the perceived limitations among study participants, which may indicate that ICBT may be well received if offered to Canadians with chronic pain.

Female participants and those with high computer self-efficacy were more likely to perceive ICBT favorably. Participants felt that it would be positive to include multimedia and group contact features in the ICBT program. Future research, however, needs to investigate whether these features are necessary and or improve the efficacy of ICBT.

Overall, the results of this study provide important information that could assist with future attempts to deliver ICBT to people with chronic pain.

Thank you to everyone for their participation in this research. The reserch findings have been submitted and accepted for publication in the academic journal Pain Research and Management.

A randomized trial of technician-guided and self-guided ICBT: Wellbeing After Cancer

Doctoral Dissertation Results, Dale Dirkse 2018

Internet-delivered  cognitive behviour therapy (ICBT) has only recently been used to treat  anxiety and depression within a cancer population but has demonstrated  promising results. The focus of this study was to assess the  effectiveness of two forms of non-therapist assisted ICBT for cancer  survivors with symptoms of depression and anxiety in a larger sample.  The Wellbeing After Cancer course was offered to Canadians from August 2016 to May 2017. In this study we were interested in the impact of Wellbeing After Cancer on symptoms of depression, anxiety, fear of cancer recurrence, and overall quality of life after the course.

Wellbeing After Cancer included education about depression and anxiety, strategies to identify  and modify unhelpful thoughts, manage physical symptoms of anxiety and  depression, overcome avoidance, cope with uncertainty, and maintain  improvements after treatment. The course was administered to a  randomized group of cancer survivors; 42 individuals who were guided by a  technician and 44 individuals who independently progressed through the  course.

The findings were very encouraging. The results of this  study showed that participants’ symptoms of anxiety and depression  improved significantly from pre to post treatment. Participants also  reported strong satisfaction ratings with the program.  Furthermore,  there was no difference in anxiety or depression symptom improvement or  overall satisfaction between those who were guided by a technician or  those who independently progressed through the course. Participants also  improved on secondary measures of fear of cancer recurrence and quality  of life.

Results from this study demonstrate the ability to  provide effective treatment to Canadian cancer survivors with symptoms  of anxiety and depression from one centralized site.  Providing ICBT has  the potential to change the mental health care landscape for cancer  survivors across Canada. Future research should focus on best practices  for implementation of ICBT. 

Linguistic analysis of communication in a therapist-assisted Internet-based cognitive behaviour therapy program for individuals with generalized anxiety disorder

Masters Thesis Results, Dale Dirkse 2014

Background: Therapist-assisted Internet-based Cognitive Behaviour Therapy (TAICBT) is an effective method of treating generalized anxiety disorder (GAD). In addition to the cognitive and behavioural elements found within face-to-face Cognitive Behaviour Therapy (CBT), TAICBT includes elements of expressive writing, through email communication with a therapist. Expressive writing has been associated with positive outcomes; furthermore, certain linguistic dimensions have been associated with psychological and physical health benefits.

Objective: The purpose of the present study was to understand how clients with symptoms of GAD are communicating with their online therapists, and explore whether their communication style was related to successful participation.

Method: Written communication submitted to therapists by 107 adult clients with symptoms of GAD during the course of a 12 module TAICBT program was analyzed along with symptom measures of anxiety, worry, and adjustment. Clients’ written communication was analyzed by a linguistic software (Linguistic Inquiry and Word Count Software) which categories words into several categories (e.g., negative emotion words, insight words).

Results: Negative emotion words, anxiety words, insight words, and past tense words were associated with symptom measures of anxiety and worry and they changed over time. A higher number of negative emotion and anxiety words differentiated clients that dropped out of the program earlier versus those that dropped later, and were associated with reduced therapeutic alliance and treatment satisfaction.

Discussion: Results suggest it may be useful to pay attention to linguistic categories as they can be used as indicators of client progress and well-being. Findings improve our understanding of the client experience of participating in TAICBT, with some linguistic trends being consistent with what clinicians would expect to see from a client’s successful participation in therapy. Other findings offer new insight into communication that may be particularly relevant to clients with symptoms of GAD. Findings confirm that clients are engaging with the program and opening up to their therapists.

Treating comorbid insomnia in patient enrolled in therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy for anxiety and depression: A randomized controlled trial

Doctoral Dissertation Results, Michael Edmonds 2023

Background: Transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) for patients experiencing anxiety and depression can produce large improvements in symptoms. Comorbid insomnia is common among individuals seeking treatment for anxiety and depression, yet transdiagnostic ICBT rarely targets insomnia and many ICBT patients report that symptoms of insomnia remain after treatment. This trial explored the impact of including a brief intervention for insomnia alongside an existing transdiagnostic ICBT course that included brief weekly therapist assistance.

Method: The current study used a two-group randomized controlled trial design. Patients were randomly assigned to receive one of two 8-week interventions: a Standard transdiagnostic course or a Sleep-Enhanced course, which included information on sleep restriction and stimulus control. Primary outcomes were assessed at pre-treatment, weekly during treatment, post-treatment, and three-month follow-up. Primary outcomes included symptoms of insomnia, depression, and anxiety.

Results: Patients reported significant, large reductions in all primary outcomes from pre-treatment to post-treatment, with changes maintained at 3-months. Patients assigned to the Sleep-Enhanced course reported larger reductions in insomnia than patients in the Standard transdiagnostic course at post-treatment but no significant group differences in any of the primary outcomes were found at follow-up. Patient-reported adherence to sleep restriction guidelines was associated with greater reductions in insomnia symptoms during the course.

Conclusions: Overall, patients who received the Sleep-Enhanced course were satisfied with the materials and most patients reported making sleep behaviour changes. The trial results demonstrate that including a brief intervention targeting insomnia can be beneficial for many patients who enroll in ICBT primarily for symptoms related to anxiety and depression.

Can patient characteristics at intake predict patient response to therapist-assisted transdiagnostic internet-delivered cognitive behavioural therapy?

Masters Thesis Results, Michael Edmonds 2018

Background: The Wellbeing Course is a transdiagnostic  online program designed to treat anxiety and depression. The five lesson  course teaches patients skills for managing anxiety and depression  based on principals of cognitive behavioural therapy and includes weekly  therapist contact via telephone or secure message. The program has been  shown to reduce symptoms in patients overall and, on average, patients  report a high degree of satisfaction. Although the program is effective  overall, only 75% of patients complete the program and only 50% of  patients complete the program and report a reliable reduction in either  anxiety or depression. The aim of this research was therefore to examine  patient outcomes further and look for relationships with patient  characteristics that might allow us to predict which patients are most  likely to benefit from online therapy.

Method: Patient case records from 1201 patients who enrolled in the Wellbeing Course were compiled and analyzed to look for relationships between patient  characteristics at intake and patient outcomes. Autoregressive latent  trajectory modeling was used to look for relationships between patient  characteristics and patient symptom change over time. Classification  trees were created to predict treatment dropout and overall treatment  success.

Results: Younger people were found to be at greater risk of  dropping out from online therapy. Higher initial severity of anxiety or  depression was related to greater improvement over the course of  therapy. Age and relationship status were related to anxiety symptom  trajectories, while education and initial psychological distress and  disability scores were related to depressive symptom trajectories.

Conclusions: Although some groups were identified as being at  higher risk of dropout or not improving, none of these effects were  strong enough to suggest that exclusion criteria for the program should  be changed. Instead, future research should look at how the program can  be modified to improve outcomes for at-risk groups.