The Diagnostic Assessment Research Tool in action: A preliminary evaluation of a semistructured diagnostic interview for DSM-5 disorders.

This article describes the initial validation of the Diagnostic Assessment Research Tool (DART), a modular semistructured interview to facilitate diagnosis of various disorders among adults corresponding with the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). In this study, the construct, convergent, and discriminant validity of DART modules for anxiety disorders, depressive disorders, obsessive-compulsive disorder, posttraumatic stress disorder, and substance-related and addictive disorders was assessed among a sample of 610 participants in a clinical outpatient setting. The data indicated excellent construct validity among DART modules assessed. Individuals with and without DSM-5 diagnoses identified via the DART had significant between-group differences on self-report measures corresponding to these diagnoses. Follow-up logistic regressions supported convergent validity for all diagnostic categories assessed. Discriminant validity was established for the majority of diagnostic categories assessed. High rates of interrater agreement in a small subsample (n = 15) were observed for the various diagnostic categories of the DART (88% average agreement). The results of the present study provide initial support for the DART as a useful tool to aid in the assessment of several major diagnostic categories corresponding with DSM-5 disorders. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Five-year observational study of Internet-delivered cognitive behavioural pain management when offered as routine care by an online therapy clinic.

BACKGROUND: Internet-delivered cognitive behavioural pain management programmes (PMPs) are effective, but less is known about their use outside of research trials. Five years of data from offering the Internet-delivered cognitive behavioural PMP in an online therapy clinic was examined to assess effectiveness, acceptability and predictors of outcomes. METHODS: Patients (N = 293) were offered a previously validated 8-week Internet-delivered cognitive behavioural PMP and administered measures at pre-treatment, post-treatment and 3 months. RESULTS: There was growth in demand for an Internet-delivered cognitive behavioural PMP over time (n = 64 first year to n = 133 fifth year). Moderate-to-large improvements on depression (post-treatment 35% reduction; 3-month 41% reduction) and anxiety (post-treatment 37% reduction; 3-month 41% reduction), and small-to-moderate improvements on disability (post-treatment 19% reduction; 3-month 20% reduction) were found. Lesson completion and satisfaction were high. Lower pain acceptance, lower pain self-efficacy and higher pain intensity were associated with lower improvements on depression, anxiety and disability. CONCLUSIONS: This longitudinal observational study provides support for Internet-delivered cognitive behavioural PMPs when offered as routine care by an online therapy clinic. SIGNIFICANCE: This 5-year observational study provides support for Internet-delivered cognitive behavioural pain management programs (PMPs) offered as routine care in an online therapy clinic. Interest in the service grew over 5 years. Outcomes, engagement and satisfaction were strong. Higher pain acceptance, pain self-efficacy and lower pain severity were associated with greater post-treatment improvements on depression, anxiety and disability.

Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data.

BACKGROUND: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom. METHODS: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683. FINDINGS: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. INTERPRETATION: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package. FUNDING: Japan Society for the Promotion of Science.

Transdiagnostic, internet-delivered cognitive behavior therapy for depression and anxiety: Exploring impact on health anxiety.

Health anxiety is associated with significant personal distress and economic cost; as such, widely available and effective treatment options are crucial. Several studies suggest that Internet-delivered cognitive behavior therapy (ICBT) programs that specifically target health anxiety are efficacious for this condition. However, no known studies have examined the impact of transdiagnostic ICBT, which emphasizes the acquisition of broad coping skills applicable to a variety of mental health concerns, on symptoms of health anxiety. The current study sought to explore changes in health anxiety symptoms by utilizing data available from a previously published study of 8-week transdiagnostic ICBT. Specifically, changes in symptoms of health anxiety in response to a transdiagnostic ICBT program that targeted broad symptoms of depression and anxiety, were examined in a subsample of individuals who endorsed elevated symptom scores on the Short Health Anxiety Inventory at pre-treatment (n = 72). Following treatment, large reductions in health anxiety symptoms (Cohen's d = 0.91; 20% improvement), depression (Cohen's d = 0.85; reduction = 38%), generalized anxiety (Cohen's d = 1.21; reduction = 42%), and disability (Cohen's d = 0.90; reduction = 35%) were reported. Furthermore, results showed that transdiagnostic ICBT was rated as acceptable to people with high health anxiety symptoms. Despite elevated pre-treatment health anxiety scores, email correspondence between clients and their therapist revealed very few mentions of health anxiety. These findings provide preliminary evidence for transdiagnostic ICBT for symptoms of health anxiety and suggest further research is warranted.

Development of the Internet-Delivered Cognitive Behaviour Therapy Undesirable Therapist Behaviours Scale (ICBT-UTBS).

Internet-delivered cognitive behaviour therapy (ICBT) is often provided with therapist assistance via asynchronous secure emails, but there is limited research on undesirable behaviours exhibited by therapists in their correspondence with patients. In this study, an ICBT-Undesirable Therapist Behaviour Scale (ICBT-UTBS) was developed and used to assess the nature, frequency, and correlates of undesirable therapist behaviours in routine practice. Thematic analysis was used to identify undesirable therapist behaviours in 720 emails sent to 91 randomly selected patients in the context of a previous clinical trial of transdiagnostic ICBT for depression and anxiety. The following undesirable behaviours were identified, albeit infrequently, in therapist emails: inadequate detail (6.4%), unaddressed content (4.0%), unsupportive tone (0.6%), missed correspondence (0.6%), inappropriate self-disclosure (0.6%), and unmanaged risk (0.3%). At least one undesirable behaviour was found in 10.7% of all emails coded. Moreover, 37.4% of patients received at least one email containing an undesirable therapist behaviour. Number of undesirable therapist behaviours was not correlated with patient engagement, working alliance, treatment satisfaction, or patient outcome variables. However, undesirable therapist behaviours were negatively correlated with patient gender and therapist characteristics (e.g., clinical setting, therapist profession). The results of the present study provide preliminary psychometric support for the ICBT-UTBS, a measure of ICBT treatment integrity. In the future, the ICBT-UTBS should be used in combination with the ICBT-Therapist Rating Scale (ICBT-TRS), a measure of desirable or recommended therapist behaviours, for training purposes and to monitor ICBT therapists in routine practice.

Development and evaluation of a scale assessing therapist fidelity to guidelines for delivering therapist-assisted Internet-delivered cognitive behaviour therapy.

Internet-delivered cognitive behaviour therapy (ICBT) is often accompanied by therapist emails, but there is limited research on the quality of this therapist-assistance. In this study, an ICBT Therapist Rating Scale (ICBT-TRS) was developed and evaluated to assess whether therapist emails showed fidelity to specific therapist behaviours. Using data from a previous ICBT trial for depression and anxiety, the ICBT-TRS was used to rate 706 emails sent by 39 therapists to 91 randomly selected patients. Emails were rated for adherence (absent/present) and quality (inadequate/competent) on the following behaviours: Builds Rapport, Seeks Feedback, Provides Symptom Feedback, Provides Psychoeducation, Facilitates Understanding, Praises Effort, Encourages Practice, Clarifies Administrative Procedures, and Communicates Effectively. Inter-rater reliability was high. Most behaviours were identified as present in 72-100% of emails, with the exception of Provides Symptom Feedback and Facilitating Understanding which were only present in 54 and 61% of emails. The majority of emails were rated as high quality (88-98% of messages). While not related to symptom improvement, ICBT-TRS ratings were higher when patients were more engaged in ICBT (e.g. log-ins) and among therapists who specialized in ICBT or had a background in Psychology. The ICBT-TRS has potential to facilitate ICBT research and clinical training.

Effectiveness, acceptability and feasibility of an Internet-delivered cognitive behavioral pain management program in a routine online therapy clinic in Canada.

BACKGROUND: Access to face-to-face cognitive behavioral pain management programs is very limited. Internet-delivered cognitive behavioral pain management has potential to improve client access to care but is not readily available in Canada. AIMS: The present study explored the effectiveness, acceptability, and feasibility of a previously validated Internet-delivered cognitive behavioral pain management course, the Pain Course, when offered in a publicly funded provincial Online Therapy Clinic. The five-lesson course was delivered over 8 weeks and was accompanied by brief weekly contact from a coach via weekly telephone calls and secure online messages. METHODS: A single-group open trial design (ISRCTN15509834) was employed (n = 55). Effectiveness was assessed by examining symptom measures at pretreatment, posttreatment, and 3-month follow-up. Completion rates and satisfaction ratings were used to examine acceptability. Feasibility was assessed by examining time required for service delivery. RESULTS: Results were highly comparable to past studies of the Pain Course showing improvements on primary measures of disability (Cohen's d = 0.45; 18% reduction), depression (Cohen's d = 0.85; 36% reduction), and anxiety (Cohen's d = 0.52; 32% reduction) at posttreatment that were maintained at follow-up. Completion rates (76%) and course satisfaction ratings (85% would recommend course) were high. Coach time per week was estimated as M = 12.67 (SD = 6.53) min. CONCLUSIONS: The findings add to existing literature on the Pain Course demonstrating for the first time the effectiveness, acceptability, and feasibility of Internet-delivered cognitive behavioral pain management programs for adults with chronic pain in a routine online therapy clinic.

Contexte: L'accès aux programmes de prise en charge cognitivo-comportementale de la douleur en mode présentiel est très limité. La prise en charge cognitivo-comportementale de la douleur par Internet a le potentiel d'améliorer l'accès aux soins, mais elle n'est pas facilement disponible au Canada.Buts: Cette étude portait sur l'efficacité, l'acceptatbilité et la faisabilité d'un cours de prise en charge cognitivo-comportementale de la douleur par Internet précédemment validé, le Pain Course, offert par une clinique de traiement en ligne financée par des fonds publics. Ce cours en cinq lessons, qui s'est déroulé sur une période de huit semaines, s'accompagnait d'un bref contact hebdomadaire avec un coach par le biais d'appels téléphoniques et de messages en ligneMéthodes: Un devis d'essai ouvert à un seul groupe (ISRCTN15509834) a été utilisé (n = 55). L'efficacicté a été évaluée par la mesure des symptômes avant le traitement, après le traitement et lors d'un suivi trois mois aprés le cours. Les taux d'achèvement et de satisfaction ont été utilisés pour évaluer l'acceptabilité. La faisaibilité a été évaluée en mesurant le temps requis pour la prestation du service.Résultats: Les résultats étaient fortement comparables aux études antérieures sur le Pain Course et ont démontré des améliorations dans les principales mesures de l'incapacité (d de Cohen = 0,45; réduction de 18 %), de la dépression (d de Cohen = 0,85; réduction de 36 %), et de l'anxieté (d de Cohen = 0,52; réduction de 32 %) après le traitement, et qui étaient toujours présentes lors du suivi. Les taux d'achètevement (76 %) et de satisfaction à l'égard du cours (85 % des personnes recommenderaient le cours) étaient élevés. Le temps d'encadrement a été estimé à M = 12,67 (écart type = 6,53) minutes par semaine.Conclusions: Ces résultats enrichissent la littérature existante sur le Pain Couse en démontrant pour la première fois l'efficacité, l'acceptabilité et la faisabilité de programmes de prise en charge cognitivo-comportementale de la douleur par Internet destinés aux adultes souffrant de douleur chronique dans le cadre d'une clinique de traitement de routine en ligne.

Examination of an Internet-Delivered Cognitive Behavioural Pain Management Course for Adults with Fibromyalgia: A Randomized Controlled Trial.

Fibromyalgia (FM) is a common and often debilitating chronic pain condition. Research shows that symptoms of depression and anxiety are present in up to three quarters of individuals with FM. Of concern, most adults with FM cannot access traditional face-to-face cognitive behavioural pain management programs, which are known to be beneficial. Given known difficulties with treatment access, the present study sought to explore the efficacy and acceptability of a previously developed Internet-delivered cognitive behavioural pain management course, the Pain Course, for adults with FM. The five-lesson course was delivered over eight weeks and was provided with brief weekly contact, via telephone and secure email, with a guide throughout the course. Participants were randomized either to the Pain Course (n = 30) or to a waiting-list control group (n = 30). Symptoms were assessed at pre-treatment, post-treatment and 4-week follow-up. Completion rates (87%) and satisfaction ratings (86%) were high. Improvements were significantly greater in treatment group participants compared to waiting-list group participants on measures of FM (Cohen's d =.70; 18% reduction), depression (Cohen's d =.63-.72; 20-28% reduction), pain (Cohen's d =.87; 11% improvement) and fear of pain (Cohen's d =1.61; 12% improvement). Smaller effects were also observed on measures of generalized anxiety and physical health. The changes were maintained at four-week follow-up. The current findings add to existing literature and highlight the specific potential of Internet-delivered cognitive behavioural pain management programs for adults with FM, especially as a part of stepped-care models of care. Future research directions are described.

Internet-delivered Cognitive Behaviour Therapy for Depressive Symptoms: An Exploratory Examination of Therapist Behaviours and their Relationship to Outcome and Therapeutic Alliance.

BACKGROUND: A previous study of therapist-assisted Internet-delivered cognitive behaviour therapy (ICBT) for generalized anxiety (Paxling et al., 2013) identified eight distinct therapist behaviours in ICBT (task reinforcement, self-efficacy shaping, task prompting, alliance bolstering, psychoeducation, empathetic utterances, deadline flexibility, and self-disclosure). It is unknown how generalizable these behaviours are across ICBT programs. AIMS: We systematically examined the frequency of these eight therapist behaviours and additional newly identified behaviours in e-mails sent to patients during the course of ICBT for depressive symptoms. We also conducted exploratory analyses to examine relationships between therapist behaviours, symptom improvement, and therapeutic alliance. METHOD: Data was obtained from a previously published open trial (Hadjistavropoulos et al., 2014). A total of 1013 e-mails sent from therapists (n = 24) to patients (n = 41) during ICBT for depressive symptoms were analyzed. Therapist behaviours were correlated with symptom change scores and ratings of therapeutic alliance at mid- and post-treatment. RESULTS: Therapist behaviours described by Paxling et al. were reliably identified in the e-mails using qualitative content analysis; the frequencies of these behaviours differed, however, from the Paxling et al. study and three additional therapist behaviours were identified (administrative statements, questionnaire feedback, asking clarifying questions). Several therapist behaviours (e.g. administrative statements, task prompting) were associated with lower symptom improvement at post-treatment. Questionnaire feedback and task reinforcement were associated with higher patient ratings of therapeutic alliance. CONCLUSIONS: The study provides partial support for the generalizability of therapist-assistance across ICBT programs. Experimental research is needed to examine the impact of varying therapist-assistance on patient outcomes.

When in doubt, ask the audience: potential users' perceptions of Internet-delivered cognitive behavioural therapy for chronic pain.

BACKGROUND: Although research has demonstrated that Internet-delivered cognitive behavioural therapy (ICBT) for chronic pain helps with adjustment to pain, it remains unclear how this treatment option would initially be perceived by individuals with chronic pain. OBJECTIVES: To explore initial perceptions of ICBT and to examine variables that correlate with an expressed interest in ICBT as a treatment option among individuals with chronic pain. METHODS: A total of 129 individuals with chronic pain completed a survey assessing perceptions of ICBT and individual difference variables that could be correlated with expressed interest in ICBT (eg, demographic characteristics, pain, computer self-efficacy). RESULTS: Results showed that most participants perceived ICBT as a potentially valuable service with multiple benefits. Being female, having greater pain severity and interference, and having greater computer self-efficacy and lower computer anxiety were positively correlated with interest in receiving ICBT. CONCLUSIONS: Combined with previous research on treatment efficacy of ICBT for chronic pain, the results should serve to stimulate further research on integrating ICBT within existing health care services.