More than doubling the clinical benefit of each hour of therapist time: a randomised controlled trial of internet cognitive therapy for social anxiety disorder.

BACKGROUND: Cognitive therapy for social anxiety disorder (CT-SAD) is recommended by NICE (2013) as a first-line intervention. Take up in routine services is limited by the need for up to 14 ninety-min face-to-face sessions, some of which are out of the office. An internet-based version of the treatment (iCT-SAD) with remote therapist support may achieve similar outcomes with less therapist time. METHODS: 102 patients with social anxiety disorder were randomised to iCT-SAD, CT-SAD, or waitlist (WAIT) control, each for 14 weeks. WAIT patients were randomised to the treatments after wait. Assessments were at pre-treatment/wait, midtreatment/wait, posttreatment/wait, and follow-ups 3 & 12 months after treatment. The pre-registered (ISRCTN 95 458 747) primary outcome was the social anxiety disorder composite, which combines 6 independent assessor and patient self-report scales of social anxiety. Secondary outcomes included disability, general anxiety, depression and a behaviour test. RESULTS: CT-SAD and iCT-SAD were both superior to WAIT on all measures. iCT-SAD did not differ from CT-SAD on the primary outcome at post-treatment or follow-up. Total therapist time in iCT-SAD was 6.45 h. CT-SAD required 15.8 h for the same reduction in social anxiety. Mediation analysis indicated that change in process variables specified in cognitive models accounted for 60% of the improvements associated with either treatment. Unlike the primary outcome, there was a significant but small difference in favour of CT-SAD on the behaviour test. CONCLUSIONS: When compared to conventional face-to-face therapy, iCT-SAD can more than double the amount of symptom change associated with each therapist hour.

Early intervention in post-traumatic stress disorder without exposure to trauma memories using internet-delivered cognitive therapy: A pilot case series.

OBJECTIVES: Trauma-focussed psychological interventions are the treatments of choice for post-traumatic stress disorder (PTSD). As many clinical services receive high demand for PTSD interventions, strategies to improve treatment efficiency are needed. Some people seek help in the early phase post-trauma, including as soon as the first few months. It is unclear whether all components of trauma-focussed CBT are needed in this initial stage. Providing brief intervention in this early phase without work on trauma memories may be feasible and effective. This service evaluation study describes a case series of five participants experiencing PTSD following recent traumas. METHODS: Participants completed a shortened 6-week form of Internet-delivered Cognitive Therapy for PTSD (iCT-PTSD), which used fewer treatment modules and focussed primarily on psychoeducation about PTSD, and two key treatment components, 'reclaiming your life' and trigger discrimination. Unlike the full course of iCT-PTSD, this format did not include working directly with trauma memories. RESULTS: The intervention was associated with large reductions in symptoms of PTSD, depression and anxiety at the 6-week timepoint, which were maintained at 3-month follow-up. Scores on the composite PTSD measure showed an average reduction of 91% between baseline and end of follow-up. One client required an extension to the weekly phase of treatment and received further treatment modules. All were discharged after follow-up and did not require further treatment. CONCLUSIONS: The findings provide preliminary evidence that this briefer format of iCT-PTSD was of benefit for those seeking support following recent traumas. Further examination in a larger controlled study is required.

Living with loss: a cognitive approach to prolonged grief disorder - incorporating complicated, enduring and traumatic grief - ADDENDUM.

The subject of prolonged, complicated and traumatic grief has become more topical as a consequence of the Covid-19 pandemic. CBT practitioners have been asked to provide effective therapeutic responses for clients with enduring distressing grief reactions. These enduring grief conditions have now been categorised as Prolonged Grief Disorder in the two main mental health classification systems: in the ICD -11 in November 2020 and as a revision to the DSM-5 in 2021. In this paper we draw on our research and clinical experience in applying cognitive therapy for PTSD (CT-PTSD) to traumatic bereavement to derive lessons for the treatment of prolonged grief. During the pandemic the authors of this paper delivered several workshops on prolonged grief disorder (PGD) during which clinicians raised several thought-provoking questions; how do we differentiate between normal and abnormal or pathological grief; how do we categorise pathological grief; how effective are existing therapies and is there a role for CBT; and how do our experiences with Cognitive Therapy for PTSD help with conceptualisation and treatment of PGD. The purpose of this paper is to answer these important questions and in so doing, consider the historical and theoretical concepts relating to complex and traumatic grief, factors that differentiate normal grief from abnormal grief, maintenance factors for PGD and implications for CBT treatments.

Abstract thinking as a risk factor for the development of posttraumatic stress disorder symptoms in student paramedics.

cognitive processing is characterized by "why?" and "what if?" questions and associated with processes such as rumination and worry. The tendency to think abstractly in response to stress has not been examined as a longitudinal risk factor for later stress reactions. The present study evaluated the extent to which an abstract thinking style could represent a risk factor for posttraumatic stress disorder (PTSD) symptoms in student paramedics over a 6-month follow-up period. Student paramedics (N = 89) recruited from universities in the United Kingdom were assessed for baseline symptoms, abstract thinking, and cognitive responses to stressful memories; a follow-up assesment was conducted 6 months later in their training. All participants were exposed to a potentially traumatic event between baseline and follow-up. Baseline symptoms and trauma history accounted for 45% of the variation in follow-up posttraumatic symptoms, with abstract thinking style explaining an additional 2.5% over and above what could be predicted from initial symptom levels. Abstract thinking was moderately related to rumination in response to stressful memories, r = .45, and correlated with follow-up symptoms of PTSD, r = .49; anxiety, r = .40; and depression, r = .27. This study builds on previous work suggesting that abstract processing mode and abstract rumination are risk factors for PTSD. Abstract thinking in response to stress represents a potentially modifiable risk factor that could be targeted by a resilience-focused intervention for individuals likely to encounter traumatic events.

Effectiveness of psychosocial interventions in mitigating adverse mental health outcomes among disaster-exposed health care workers: A systematic review.

Health care workers worldwide are at an increased risk of a range of adverse mental health outcomes, including posttraumatic stress disorder (PTSD), following the unprecedented demand placed upon them during the COVID-19 pandemic. Psychosocial interventions offered to mitigate these risks should be based on the best available evidence; however, limited information regarding the comparative effectiveness of interventions is available. We undertook a systematic review of psychosocial interventions delivered to health care workers before, during, and after disasters. Eight databases were searched, including the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE, EMBASE, and PsycINFO. Our primary outcomes were changes in symptoms of PTSD, anxiety, depression, and sleep. We calculated effect sizes, where unreported, and reliable change indices to appraise intervention effectiveness. The study was registered with PROSPERO (CRD42020182774). In total, 12,198 papers were screened, 14 of which were included in the present review. Interventions based on evidence-based protocols, including individual and group-based cognitive behavioral therapy (CBT) for PTSD, anxiety, and depression were found to lead to reliable changes in PTSD and anxiety symptoms. Single-session debriefing and psychological first aid workshops showed limited efficacy. There is limited evidence on psychosocial interventions for health care workers faced with disasters, with the strongest evidence base for CBT-based approaches. Future research should include controlled evaluations of interventions and aim to target identified risk factors.

Post-traumatic stress disorder and major depression among frontline healthcare staff working during the COVID-19 pandemic.

OBJECTIVES: High rates of probable post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) have been reported for frontline healthcare staff during the COVID-19 pandemic. However, rates determined by diagnostic assessment are unknown, as are the onset of symptoms and associated index events. METHODS: We assessed frontline healthcare staff with the Structured Clinical Interview for DSM-5. RESULTS: Forty-four percent met criteria for PTSD and 39% met criteria for MDD. Twenty-four percent reported COVID-19 trauma as their index event, with the majority of staff reporting trauma that pre-dated the pandemic. While PTSD was likely to be pre-existing, MDD was more likely to develop during pandemic working. CONCLUSION: These findings indicate the propensity of healthcare staff to experience a range of occupational and personal trauma associated with PTSD and the need to assess index trauma when diagnosing psychopathology in order to best understand the needs of this workforce. PRACTITIONER POINTS: We found high diagnostic rates of PTSD (44%) and major depression (39%) among frontline healthcare staff working during the COVID-19 pandemic. Although major depression developed during the pandemic, PTSD was more likely to be pre-existing. When assessing pandemic-related psychopathology, it is important to assess the onset and index event related to symptoms. Healthcare workers appear to have high rates of PTSD related to occupational and personal trauma, which warrants specific focus in service planning.

Assessing panic disorder-specific competencies: evaluation of the Cognitive Therapy Competence Scale for panic disorder.

BACKGROUND: Evidence-based treatment for panic disorder consists of disorder-specific cognitive behavioural therapy (CBT) protocols. However, most measures of CBT competence are generic and there is a clear need for disorder-specific assessment measures. AIMS: To fill this gap, we evaluated the psychometric properties of the Cognitive Therapy Competence Scale (CTCP) for panic disorder. METHOD: CBT trainees (n = 60) submitted audio recordings of CBT for panic disorder that were scored on a generic competence measure, the Cognitive Therapy Scale - Revised (CTS-R), and the CTCP by markers with experience in CBT practice and evaluation. Trainees also provided pre- to post-treatment clinical outcomes on disorder-specific patient report measures for cases corresponding to their therapy recordings. RESULTS: The CTCP exhibited strong internal consistency (α = .79-.91) and inter-rater reliability (ICC = .70-.88). The measure demonstrated convergent validity with the CTS-R (r = .40-.54), although investigation into competence classification indicated that the CTCP may be more sensitive at detecting competence for panic disorder-specific CBT skills. Notably, the CTCP demonstrated the first indication of a relationship between therapist competence and clinical outcome for panic disorder (r = .29-.35); no relationship was found for the CTS-R. CONCLUSIONS: These findings provide initial support for the reliability and validity of the CTCP for assessing therapist competence in CBT for panic disorder and support the use of anxiety disorder-specific competence measures. Further investigation into the psychometric properties of the measure in other therapist cohorts and its relationship with clinical outcomes is recommended.

The impact of COVID-19 on the cancer care of adolescents and young adults and their well-being: Results from an online survey conducted in the early stages of the pandemic.

BACKGROUND: Because of the global spread of coronavirus disease 2019 (COVID-19), oncology departments across the world have rapidly adapted their cancer care protocols to balance the risk of delaying cancer treatments and the risk of COVID-19 exposure. COVID-19 and associated changes may have an impact on the psychosocial functioning of patients with cancer and survivors. This study was designed to determine the impact of the COVID-19 pandemic on young people living with and beyond cancer. METHODS: In this cross-sectional study, 177 individuals, aged 18 to 39 years, were surveyed about the impact of COVID-19 on their cancer care and psychological well-being. Participants also reported their information needs with respect to COVID-19. Responses were summarized with a content analysis approach. RESULTS: This was the first study to examine the psychological functioning of young patients and survivors during the first weeks of the COVID-19 pandemic. A third of the respondents reported increased levels of psychological distress, and as many as 60% reported feeling more anxious than they did before COVID-19. More than half also wanted more information tailored to them as young patients with cancer. CONCLUSIONS: The COVID-19 pandemic is rapidly evolving and changing the landscape of cancer care. Young people living with cancer are a unique population and might be more vulnerable during this time in comparison with their healthy peers. There is a need to screen for psychological distress and attend to young people whose cancer care has been delayed. As the lockdown begins to ease, the guidelines about cancer care should be updated according to this population's needs.

Mapping the needs and psychological outcomes of Slovenian adolescent and young adult cancer patients: An exploratory mixed-method study.

OBJECTIVE: With improving survival rates, it is becoming increasingly important to understand the psychological aspect and needs of young cancer patients and survivors. Our goal was to describe the self-reported levels of psychological distress, subjective illness experience and needs of young Slovenian cancer patients and survivors. METHODS: Seventy-nine participants, aged 19-39 years, answered questionnaires about anxiety, depression, mental defeat, cancer worry and their experience of learning the diagnosis and being treated. We used visualisations to demonstrate the relationship between anxiety and depression. The qualitative responses were summarised using a content analysis approach. RESULTS: Twenty-eight (35%) participants scored in the clinical range for anxiety and fifteen (19%) for depression. Cancer-related worry was common (85% reported at least one worry). Mental defeat was positively associated with measures of psychological distress. Those who felt negative about learning their diagnosis emphasised the need for more time, empathy and dignity. Psychological support during illness was seen as crucial. CONCLUSION: Anxiety and depression remain a problem for a subset of patients. Medical professionals working with young people with cancer should encourage a warm atmosphere as they attend to patients' needs and concerns.

Metabolomics for improved treatment monitoring of phenylketonuria: urinary biomarkers for non-invasive assessment of dietary adherence and nutritional deficiencies.

Management of phenylketonuria (PKU) requires lifelong restriction of phenylalanine (Phe) intake using specialized medical foods to prevent neurocognitive impairment in affected patients. However, dietary adherence is challenging to maintain while ensuring adequate nutrition, which can lead to sub-optimal clinical outcomes. Metabolomics offers a systematic approach to identify new biomarkers of disease progression in PKU when using urine as a surrogate for blood specimens that is more accurate than self-reported diet records. Herein, the plasma and urine metabolome of a cohort of classic PKU patients (median age = 11 years; n = 22) mainly prescribed (78%) a Phe-restricted diet were characterized using multisegment injection-capillary electrophoresis-mass spectrometry (MSI-CE-MS). Overall, there was good mutual agreement between plasma Phe and tyrosine (Tyr) concentrations measured from PKU patients when using an amino acid analyzer based on UPLC-UV as compared to MSI-CE-MS with a mean bias of 12% (n = 82). Longitudinal measurements of recently diagnosed PKU infants (n = 3) revealed good long-term regulation of blood Phe with dietary management, and only occasional episodes exceeding the recommended therapeutic range (>360 µM) unlike older PKU patients. Plasma metabolomic studies demonstrated that non-adherent PKU patients had lower circulating concentrations of Tyr, arginine, 2-aminobutyric acid, and propionylcarnitine (q < 0.05, FDR) that were inversely correlated to Phe (r ≈ -0.600 to -0.830). Nontargeted metabolite profiling also revealed urinary biomarkers associated with poor dietary adherence among PKU patients, including elevated concentrations of catabolites indicative of Phe intoxication (e.g., phenylpyruvic acid, phenylacetylglutamine, hydroxyphenylacetic acid). Additionally, PKU patients with poor blood Phe control had lower excretion of urinary compounds derived from co-metabolism of Tyr due to microbiota activity (e.g., cresol sulfate, phenylsulfate), as well as several metabolites associated with inadequate nutrient intake, including low carnitine and B vitamin status (e.g., folic acid, vitamin B12). Interestingly, an unknown urinary metabolite was strongly correlated with Phe excretion in PKU patients (r = 0.861), which was subsequently identified as imidazole lactic acid when using high resolution MS/MS. Overall, urine profiling offers a non-invasive approach for better treatment monitoring of individual PKU patients, which can also guide the design of novel therapies that improve adherence to Phe-restricted diets without acquired nutritional deficiencies.

Through the resident lens: examining knowledge and attitudes about midwifery among physician trainees.

Interprofessional collaboration optimizes maternal-newborn outcomes and satisfaction with care. Since 2002, midwives have provided an increasing proportion of maternity care in British Columbia (BC). Midwives often collaborate with and/or refer to physicians; but no study to date has explored Canadian medical trainees' exposure to, knowledge of, and attitudes towards midwifery practice. We designed an online cross-sectional questionnaire that included a scale to measure attitudes towards midwifery (13 items) and residents' knowledge of midwifery (94 items across 5 domains). A multi-disciplinary expert panel rated each item for importance, relevance, and clarity. The survey was distributed to family medicine (n = 338) and obstetric (n = 40) residents in BC. We analyzed responses from 114 residents. Residents with more favourable exposures to midwifery during their education had significantly more positive attitudes towards midwives (rs = 0.32, p = 0.007). We also found a significant positive correlation between residents' attitudes towards midwifery and four of five knowledge domains: scope of practice (rs = 0.41, p < 0.001); content of education (rs = 0.30, p = 0.002), equipment midwives carry to home births (rs = 0.30, p = 0.004) and tests that midwives can order (rs = 0.39, p < 0.001). The most unfavourable exposures were observing interprofessional conversations (66.2%), and providing inpatient consultations for midwives (61.4%). Findings suggest increased interprofessional education may foster improved midwife-physician collaboration. Abbreviations: BC - British Columbia; UBC - University of British Columbia.

Seeing Is Believing: Using Video Feedback in Cognitive Therapy for Social Anxiety Disorder.

Distorted negative self-images and impressions appear to play a key role in maintaining Social Anxiety Disorder (SAD). In previous research, McManus et al. (2009) found that video feedback can help people undergoing cognitive therapy for SAD (CT-SAD) to develop a more realistic impression of how they appear to others, and this was associated with significant improvement in their social anxiety. In this paper we first present new data from 47 patients that confirms the value of video feedback. Ninety-eighty percent of the patients indicated that they came across more favorably than they had predicted after viewing a video of their social interactions. Significant reductions in social anxiety were observed during the following week and these reductions were larger than those observed after control periods. Comparison with our earlier data (McManus et al., 2009) suggests we may have improved the effectiveness of video feedback by refining and developing our procedures over time. The second part of the paper outlines our current strategies for maximizing the impact of video feedback. The strategies have evolved in order to help patients with SAD overcome a range of processing biases that could otherwise make it difficult for them to spot discrepancies between their negative self-imagery and the way they appear on video.

SLEEP AND TREATMENT OUTCOME IN POSTTRAUMATIC STRESS DISORDER: RESULTS FROM AN EFFECTIVENESS STUDY.

BACKGROUND: Most patients with posttraumatic stress disorder (PTSD) suffer from sleep problems. Concerns have been raised about possible detrimental effects of sleep problems on the efficacy of psychological treatments for PTSD. In this study, we investigated the relation of session-to-session changes in PTSD symptoms and sleep, and tested whether sleep problems predicted poorer short- and long-term treatment outcome. METHODS: Self-reported sleep quality, sleep duration, and PTSD symptoms were assessed weekly in a consecutive sample of 246 patients who received cognitive therapy for PTSD (CT-PTSD; Ehlers & Clark, 2000), and at follow-up (mean = 247 days posttreatment). Additionally, moderating effects of medication use and comorbid depression were assessed. RESULTS: Sleep and PTSD symptoms improved in parallel. The relation was moderated by depression: Sleep problems at the start of therapy did not predict improvement in PTSD symptoms during treatment for patients without comorbid depression. Patients with comorbid depression, however, showed less rapid decreases in PTSD symptoms, but comparable overall outcome, if their sleep quality was poor. Residual sleep problems at the end of treatment did not predict PTSD symptoms at follow-up once residual PTSD symptoms were taken into account. CONCLUSIONS: CT-PTSD leads to simultaneous improvement in sleep and PTSD symptoms. Sleep problems may reduce the speed of recovery in PTSD patients with comorbid depression. For these patients, additional treatment sessions are indicated to achieve comparable outcomes, and additional interventions targeting sleep may be beneficial. For those without comorbid depression, self-reported sleep problems did not interfere with response to trauma-focused psychological treatment.

Cognitive appraisals, objectivity and coping in ambulance workers: a pilot study.

OBJECTIVES: Ambulance workers are regularly exposed to call-outs, which are potentially psychologically traumatic. The ability to remain objective and make adaptive appraisals during call-outs may be beneficial to this at-risk population. This pilot study investigated the links between cognitive appraisals, objectivity and coping in ambulance workers. METHODS: Forty-five ambulance workers from the London Ambulance Service, UK, were studied. Trauma exposure, post-traumatic stress disorder and depression symptoms were assessed using self-report measures. Positive and negative appraisals were measured in relation to two previous call-outs: one during which they coped well and one during which they did not. RESULTS: Enhanced coping was associated with making more positive appraisals during the call-out. Better coping was also related to greater levels of objectivity during these call-outs. Coping less well was associated with the use of more negative appraisals during the call-out. CONCLUSIONS: Ambulance workers may benefit from psychological interventions, which focus on cognitive reappraisal and enhancing objectivity to improve coping and resilience.

From loss to disorder: The influence of maladaptive coping on prolonged grief.

Research indicates that post-bereavement coping strategies can be adaptive or maladaptive. Understanding which strategies lead to poorer outcomes is an important clinical and theoretical question with the potential to guide intervention. The Oxford Grief - Coping Strategies scale was developed from interviews with bereaved people with and without prolonged grief disorder (PGD) to assess the frequency of maladaptive cognitive and behavioural strategies after bereavement. Factorial and psychometric validity were assessed using exploratory and confirmatory factor analysis (N = 676). A three-wave cross-lagged panel model (N = 275) was used to assess the predictive validity of the tool in explaining symptoms of PGD. Results supported a four-factor solution (Avoidance, Proximity Seeking, Loss Rumination, Injustice Rumination) with good psychometric properties. The OG-CS predicted prospective symptoms of PGD in the short-term (6-12 months) and long term (12-18 months), controlling for baseline symptoms and autocorrelations. Subscale analyses demonstrated that the use of coping strategies predicted ICD-11 PGD in both the short-term and the long-term. However, avoidance was not predictive of outcomes early in the grieving process. At 6-12 months, avoidance predicted PGD at 12-18 months.

Physician Associate/Assistant Program Medical Directors Are Important Advocates for the Physician Associate/Assistant Profession: Results From a National Pilot Study.

INTRODUCTION: This pilot study aimed to evaluate whether and how physician associate/assistant (PA) program medical directors play a role in advocating on behalf of PAs and what factors correlate with this. METHODS: The study used a mixed-methods grounded theory approach and was deemed institutional review board exempt. After literature review, a survey was developed and piloted by study personnel and faculty to affirm validity. Recruits with known email addresses were sent a link to a survey that included demographic information and 10 Likert scale questions. There were 69 respondents, and the response rate was 26%. Fisher's exact test and analysis of variance were performed using the R program. A P-value <.05 indicated significance. Thematic analysis of qualitative data was performed using ChatGPT, followed by iterative analysis by the research team. Consensus was achieved for each response. RESULTS: Most of the respondents had the following characteristics: MD degree, male, White, practicing clinically, and worked as PA medical directors 8 to 12 hours per week. Participants did not support PA title change, nor had they engaged in legislative efforts to support optimal team practice. Participants were strong PA advocates by promoting PA leadership positions, PA employment, improved attitudes in health care organizations toward PAs, and securing clinical rotations. Many respondents (41%) felt that none of their professional organizations supported them in their role as PA program medical director. DISCUSSION: Exploring ways to support continued advocacy by our valued PA program medical directors within PA professional organizations could be advantageous to PA program medical directors' professional growth and the PA profession.

Cost-effectiveness of therapist-assisted internet-delivered psychological therapies for PTSD differing in trauma focus in England: an economic evaluation based on the STOP-PTSD trial.

BACKGROUND: Although there are effective psychological treatments for post-traumatic stress disorder (PTSD), they remain inaccessible for many people. Digitally enabled therapy is a way to overcome this problem; however, there is little evidence on which forms of these therapies are most cost effective in PTSD. We aimed to assess the cost-effectiveness of the STOP-PTSD trial, which evaluated two therapist-assisted, internet-delivered cognitive behavioural therapies: cognitive therapy for PTSD (iCT-PTSD) and a programme focusing on stress management (iStress-PTSD). METHODS: In this health economic evaluation, we used data from the STOP-PTSD trial (n=217), a single-blind, randomised controlled trial, to compare iCT-PTSD and iStress-PTSD in terms of resource use and health outcomes. In the trial, participants (aged ≥18 years) who met DSM-5 criteria for PTSD were recruited from primary care therapy services in South East England. The interventions were delivered online with therapist support for the first 12 weeks, and three telephone calls over the next 3 months. Participants completed questionnaires on symptoms, wellbeing, quality of life, and resource use at baseline, 13 weeks, 26 weeks, and 39 weeks after randomisation. We used a cost-effectiveness analysis to assess cost per quality-adjusted life year (QALY) at 39 weeks post-randomisation, from the perspective of the English National Health Service (NHS) and personal social services and on the basis of intention-to-treat for complete cases. Treatment modules and the platform design were developed with extensive input from service users: service users also advised on the trial protocol and methods, including the health economic measures. This is a pre-planned analysis of the STOP-PTSD trial; the trial was registered prospectively on the ISRCTN Registry (ISRCTN16806208). FINDINGS: NHS costs were similar across treatment groups, but clinical outcomes were superior for iCT-PTSD compared with iStress-PTSD. The incremental cost-effectiveness ratio for NHS costs and personal social services was estimated as £1921 per QALY. iCT-PTSD had an estimated 91·6% chance of being cost effective at the £20 000 per QALY threshold. From the societal perspective, iCT-PTSD was cost saving compared with iStress-PTSD. INTERPRETATION: iCT-PTSD is a cost-effective form of therapist-assisted, internet-delivered psychological therapy relative to iStress-PTSD, and it could be considered for clinical implementation. FUNDING: Wellcome Trust and National Institute of Health Research Oxford Health Biomedical Research Centre.

A protocol for a pilot randomised controlled trial of unguided internet cognitive behaviour therapy for grief in adolescents.

Grief is highly prevalent in adolescents, however, there have been no studies investigating internet delivered cognitive behaviour therapy for grief in adolescents (ICBT-G-A). In this paper, the co-design of an unguided ICBT-G-A intervention is described, and a protocol outlined for a pilot randomised controlled trial of the intervention. Participants will be randomised to the intervention (delivered via eight modules over a four-week period) or a four-week waitlist control. Intervention participants will complete a follow-up assessment at one-month post-intervention (eight weeks from the pre-intervention assessment). The intervention outcomes assessed at pre-intervention, post-intervention and follow-up include wellbeing and symptoms of anxiety, depression, post-traumatic stress, and prolonged grief. User feedback on experiences and acceptability of the intervention will be sought and feasibility assessed via programmatic data on recruitment and attrition.

Internet-delivered cognitive therapy for social anxiety disorder: a development pilot series.

BACKGROUND: Randomized controlled trials have established that individual cognitive therapy based on the Clark and Wells (1995) model is an effective treatment for social anxiety disorder that is superior to a range of alternative psychological and pharmacological interventions. Normally the treatment involves up to 14 weekly face-to-face therapy sessions. AIM: To develop an internet based version of the treatment that requires less therapist time. METHOD: An internet-delivered version of cognitive therapy (iCT) for social anxiety disorder is described. The internet-version implements all key features of the face-to-face treatment; including video feedback, attention training, behavioural experiments, and memory focused techniques. Therapist support is via a built-in secure messaging system and by brief telephone calls. A cohort of 11 patients meeting DSM-IV criteria for social anxiety disorder worked through the programme and were assessed at pretreatment and posttreatment. RESULTS: No patients dropped out. Improvements in social anxiety and related process variables were within the range of those observed in randomized controlled trials of face-to-face CT. Nine patients (82%) were classified as treatment responders and seven (64%) achieved remission status. Therapist time per patient was only 20% of that in face-to-face CT. CONCLUSIONS: iCT shows promise as a way of reducing therapist time without compromising efficacy. Further evaluation of iCT is ongoing.