Internet-Delivered CBT for Generalized Anxiety Disorder: Randomized Controlled Trial

Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for Generalized Anxiety Disorder (GAD). It typically involves several key components:

1. Psychoeducation about anxiety and worry
2. Cognitive restructuring to challenge and modify anxious thoughts
3. Relaxation techniques and mindfulness practices
4. Worry exposure and problem-solving training
5. Behavioral experiments to test anxious predictions
6. Gradual exposure to anxiety-provoking situations
7. Addressing intolerance of uncertainty

CBT helps individuals identify and change maladaptive thought patterns and behaviors that maintain anxiety. It teaches coping skills to manage worry and physical symptoms of anxiety.

Treatment usually occurs over 12-20 sessions, with homework assignments between sessions to practice new skills. CBT has been shown to produce significant and lasting reductions in GAD symptoms.

Trenoska Basile, V., Newton‐John, T., McDonald, S., & Wootton, B. M. (2023). Internet videoconferencing delivered cognitive behaviour therapy for generalized anxiety disorder: A randomized controlled trial. British Journal of Clinical Psychology. https://doi.org/10.1111/bjc.12482

Key Points

• Internet videoconferencing delivered cognitive behaviour therapy (VCBT) is an effective and acceptable treatment for generalized anxiety disorder (GAD), with large effect sizes observed on primary outcome measures.
• VCBT resulted in significant reductions in GAD symptoms from pre-treatment to post-treatment (d = 1.03) and pre-treatment to 3-month follow-up (d = 1.50).
• Large between-group effect sizes were observed at post-treatment when comparing VCBT to a waitlist control group (d = 0.80).
• 64.10% of VCBT participants no longer met diagnostic criteria for GAD at post-treatment, and 66.67% no longer met criteria at 3-month follow-up.
• 96% of participants reported being satisfied with the VCBT treatment.
• The study had limitations, including a predominantly female sample and lack of an active control group for comparison.
• VCBT may help overcome barriers to accessing treatment for GAD, such as geographical isolation or difficulty finding trained therapists.

Rationale

Generalized anxiety disorder (GAD) is a chronic mental health condition characterized by excessive and uncontrollable worry, affecting 3.7% of the global population in their lifetime (Ruscio et al., 2017).

While cognitive-behavioral therapy (CBT) has been shown to be an effective treatment for GAD (Carpenter et al., 2018), many individuals face barriers in accessing evidence-based care, including affordability, geographical isolation, and difficulty finding trained clinicians (Coles & Coleman, 2010; Goetter et al., 2020).

Remote treatments, particularly those delivered via videoconferencing (VCBT), may help overcome these barriers.

However, research on the efficacy of high-intensity remote treatments for GAD is limited, with existing studies having small sample sizes or focusing on specific populations (Bouchard & Renaud, 2001; Brenes et al., 2015).

The current study aims to address this gap by examining the efficacy and acceptability of VCBT for GAD using a randomized controlled trial design comparing an immediate treatment group to a waitlist control.

Method

Procedure

The study used a randomized controlled design comparing an immediate VCBT treatment group to a waitlist control group.

Participants completed an online screening followed by a telephone diagnostic interview. Eligible participants were randomly allocated to either the VCBT group or waitlist control group.

The VCBT group received 10 weekly 50-minute treatment sessions conducted via Zoom. Assessments were conducted at pre-treatment, mid-treatment, post-treatment, and 3-month follow-up.

Sample

78 adults (Mage = 36.92; SD = 12.92; 84.4% female) with a primary diagnosis of GAD were enrolled in the study. 39 participants were allocated to the VCBT group and 39 to the waitlist control group.

Measures

• Diagnostic Interview for Anxiety, Mood and Obsessive-Compulsive and Related Neuropsychiatric Disorders (DIAMOND): A structured clinical interview that assesses DSM-5 diagnostic criteria for various mental health disorders.
• Generalized Anxiety Disorder Questionnaire-7 item (GAD-7; primary outcome measure): A brief self-report measure assessing the severity of GAD symptoms.
• Generalized Anxiety Disorder Dimensional Scale (GAD-D): A 10-item measure evaluating the frequency of GAD symptoms over the past month.
• Penn State Worry Questionnaire-3 item (PSWQ-3): A short self-report questionnaire assessing the core features of worry in GAD.
• Patient Health Questionnaire-9 item (PHQ-9): A self-report measure of depressive symptoms severity.
• Overall Anxiety Severity and Impairment Scale (OASIS): A brief measure of anxiety-related severity and functional impairment across anxiety disorders.
• Intolerance of Uncertainty Scale (IUS-12): A questionnaire measuring responses to uncertainty, ambiguous situations, and the future.
• NIMH Clinician Global Impression (CGI) Scale: A single-item measure assessing overall illness severity and improvement in symptoms.
• Sheehan Disability Scale (SDS): A measure evaluating functional impairment in work, social, and family life due to symptoms.
• Client Satisfaction Questionnaire (CSQ): An 8-item measure assessing participant satisfaction with the treatment provided.
• Acceptability Questionnaire (AQ): A 10-item measure evaluating the acceptability of remote treatments, including satisfaction, perceived improvement, and likelihood of recommending the treatment.

Statistical measures

Mixed-linear models with an unstructured covariance structure were used for the main analyses. Multiple imputation was used to handle missing data.

Effect sizes using Cohen’s d were calculated for within-group and between-group differences.

Results

Hypothesis 1: VCBT would result in significant reductions in symptoms from pre-treatment to post-treatment and pre-treatment to 3-month follow-up with large within-group effect sizes.

This hypothesis was supported. On the primary outcome measure (GAD-7), significant reductions were observed from pre-treatment to post-treatment (d = 1.03, 95% CI: 0.55-1.50) and pre-treatment to 3-month follow-up (d = 1.50, 95% CI: 0.98-1.99).

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Hypothesis 2: VCBT would have significantly better outcomes at post-treatment when compared to the control group with large between-group effect sizes.

This hypothesis was supported. Large between-group effect sizes were observed at post-treatment on the GAD-7 (d = 0.80; 95% CI: 0.33-1.26) and GAD-D (d = 0.82; 95% CI: 0.35-1.28). Medium to large between-group effect sizes were observed on other secondary measures.

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Hypothesis 3: VCBT would be an acceptable treatment to individuals with GAD.

This hypothesis was supported. 96.43% of participants who completed post-treatment questionnaires reported being ‘satisfied’ or ‘extremely satisfied’ with the treatment. The mean score on the Client Satisfaction Questionnaire was 28.55 (SD = 3.60), indicating high satisfaction.

Additional findings:

• 64.10% of VCBT participants no longer met diagnostic criteria for GAD at post-treatment, and 66.67% at 3-month follow-up.
• Significant improvements were observed on secondary measures including worry, depression, and functional impairment.
• The dropout rate (25.6%) was comparable to other CBT trials for GAD.

Insight

This study provides strong evidence for the efficacy and acceptability of VCBT as a treatment for GAD.

The large effect sizes observed are comparable to those seen in meta-analyses of in-person CBT for GAD (Carpenter et al., 2018), suggesting that VCBT may be as effective as traditional face-to-face treatment.

The high satisfaction rates indicate that participants found the treatment acceptable despite the remote delivery format.

The study extends previous research by addressing limitations in earlier VCBT studies for GAD, such as small sample sizes or use of older technology.

By using modern videoconferencing platforms and allowing participants to receive treatment from their preferred location, this study better reflects real-world applications of VCBT.

Interestingly, while large effects were observed on GAD symptom measures, smaller effects were seen for worry and intolerance of uncertainty.

This aligns with previous research showing that worry measures often demonstrate smaller treatment effects than broader GAD symptom measures (Dear et al., 2011).

Future research could explore whether additional focus on worry exposure or addressing intolerance of uncertainty could enhance outcomes further.

The study also highlights the potential for VCBT to increase access to evidence-based treatment for GAD.

By removing geographical barriers and potentially increasing the reach of trained therapists, VCBT could help address the significant treatment gap that exists for anxiety disorders.

Further research directions could include:

1. Direct comparison of VCBT to in-person CBT for GAD
2. Examination of therapist and patient factors that influence VCBT outcomes
3. Investigation of VCBT efficacy for other anxiety disorders or transdiagnostic applications
4. Exploration of combined treatment approaches (e.g., VCBT plus smartphone apps)
5. Long-term follow-up studies to assess maintenance of gains from VCBT

Strengths

The study had many methodological strengths including:

1. Use of a randomized controlled design
2. Inclusion of a 3-month follow-up assessment
3. Use of both self-report and clinician-administered outcome measures
4. Assessment of diagnostic status pre- and post-treatment
5. Detailed reporting of effect sizes and confidence intervals
6. Use of modern videoconferencing technology reflecting real-world applications
7. Comprehensive assessment of treatment acceptability
8. Use of mixed-linear models and multiple imputation to handle missing data

Limitations

1. The sample was predominantly female (84.4%), which may limit generalizability to male populations with GAD.
2. The study used a waitlist control group rather than an active control, making it difficult to rule out non-specific treatment effects.
3. The follow-up period was relatively short at 3 months, limiting conclusions about long-term maintenance of gains.
4. The study did not assess treatment fidelity or therapist competence, which could influence outcomes.
5. Participants were required to have regular internet access and a computer with a camera, potentially excluding individuals without these resources.
6. The diagnostic interview was not administered post-treatment for the control group, limiting comparisons of diagnostic change between groups.

These limitations suggest caution in generalizing the results to all individuals with GAD and highlight the need for further research comparing VCBT to active treatments and assessing long-term outcomes.

Implications

The results of this study have significant implications for the treatment of GAD:

1. Clinical practice: VCBT appears to be an effective and acceptable treatment option for GAD, providing clinicians with an evidence-based remote treatment approach. This could be particularly valuable in situations where in-person treatment is not feasible or preferred by patients.
2. Access to care: VCBT has the potential to increase access to evidence-based treatment for individuals who face barriers to in-person care, such as those in rural areas or with mobility limitations.
3. Treatment delivery: The high acceptability of VCBT suggests that the therapeutic alliance can be effectively established and maintained through videoconferencing, challenging assumptions that remote therapy is inherently less personal or effective.
4. Cost-effectiveness: While not directly assessed in this study, the potential for VCBT to reduce travel time and associated costs for both patients and therapists could have implications for the cost-effectiveness of GAD treatment.
5. Therapist training: The efficacy of VCBT suggests that training programs for CBT therapists should incorporate skills for delivering treatment via videoconferencing.
6. Health policy: Evidence supporting the efficacy of VCBT could inform policy decisions about reimbursement for telehealth services and the integration of remote treatment options into mental health care systems.
7. Future research: This study provides a foundation for further research into remote treatments for anxiety disorders, potentially leading to the development of more accessible and flexible treatment options.

Variables that may influence the results and should be considered in future research include patient characteristics (e.g., severity of GAD, comorbidities, technology comfort), therapist factors (e.g., experience with VCBT, adherence to treatment protocol), and technological aspects (e.g., internet connectivity, platform usability).

References

Primary reference

Trenoska Basile, V., Newton‐John, T., McDonald, S., & Wootton, B. M. (2023). Internet videoconferencing delivered cognitive behaviour therapy for generalized anxiety disorder: A randomized controlled trial. British Journal of Clinical Psychology. https://doi.org/10.1111/bjc.12482

Other references

Bouchard, S., & Renaud, P. (2001). CBT in videoconference for panic disorder and generalized anxiety disorder. In 35th Annual Convention of the Association for Advancement of Behavioral Therapies, Philadelphia, Pennsylvania.

Brenes, G. A., Danhauer, S. C., Lyles, M. F., Hogan, P. E., & Miller, M. E. (2015). Telephone-delivered cognitive behavioral therapy and telephone-delivered nondirective supportive therapy for rural older adults with generalized anxiety disorder: a randomized clinical trial. JAMA psychiatry, 72(10), 1012-1020.

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta‐analysis of randomized placebo‐controlled trials. Depression and anxiety, 35(6), 502-514. https://doi.org/10.1002/da.22728

Coles, M. E., & Coleman, S. L. (2010). Barriers to treatment seeking for anxiety disorders: initial data on the role of mental health literacy. Depression and anxiety, 27(1), 63-71. https://doi.org/10.1002/da.20620

Dear, B. F., Titov, N., Sunderland, M., McMillan, D., Anderson, T., Lorian, C., & Robinson, E. (2011). Psychometric comparison of the generalized anxiety disorder scale-7 and the Penn State Worry Questionnaire for measuring response during treatment of generalised anxiety disorder. Cognitive behaviour therapy, 40(3), 216-227. https://doi.org/10.1080/16506073.2011.582138

Goetter, E. M., Frumkin, M. R., Palitz, S. A., Swee, M. B., Baker, A. W., Bui, E., & Simon, N. M. (2020). Barriers to mental health treatment among individuals with social anxiety disorder and generalized anxiety disorder. Psychological services, 17(1), 5.

Ruscio, A. M., Hallion, L. S., Lim, C. C., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., … & Scott, K. M. (2017). Cross-sectional comparison of the epidemiology of DSM-5 generalized anxiety disorder across the globe. JAMA psychiatry, 74(5), 465-475.

Keep Learning

1. How might the effectiveness of VCBT compare to in-person CBT for GAD, and what factors could influence any differences?
2. What ethical considerations arise when delivering psychological treatments via videoconferencing, and how can these be addressed?
3. How might the therapeutic alliance differ in VCBT compared to in-person therapy, and what strategies could therapists use to enhance rapport in remote sessions?
4. Given the predominantly female sample in this study, how might gender influence treatment outcomes or preferences for VCBT versus in-person therapy?
5. What modifications to VCBT might be necessary to make it more accessible to diverse populations, including those with limited technological resources or skills?
6. How could the principles of VCBT for GAD be adapted for use with other anxiety disorders or in transdiagnostic treatment approaches?
7. What role might VCBT play in stepped care models for anxiety treatment, and how could it be integrated with other interventions like self-help or medication management?