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The advantage of using traditional ways of delivering news

Abstract Several Internet interventions have been developed and tested for common mental disorders, and the evidence to date shows that these treatments often result in similar outcomes as in face-to-face psychotherapy and that they are cost-effective. In this paper, we first review the pros and cons of how participants in Internet treatment trials have been recruited.

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We then comment on the assessment procedures often involved in Internet interventions and conclude that, while online questionnaires yield robust results, diagnoses cannot be determined without any contact with the patient. We then review the role of the therapist and conclude that, although treatments including guidance seem to lead to better outcomes than unguided treatments, this guidance can be mainly practical and supportive rather than explicitly therapeutic in orientation.

Then we briefly describe the advantages and disadvantages of treatments for mood and anxiety disorders and comment on ways to handle comorbidity often associated with these disorders. Finally we discuss challenges when disseminating Internet interventions. In conclusion, there is now a large body of evidence suggesting that Internet interventions work.

Several research questions remain open, including how Internet interventions can be blended with traditional forms of care. Internet interventions, cognitive behaviour therapy, mood and anxiety disorders, dissemination Internet-based psychological treatments have a relatively short history, but extend on principles and evidence established by computerized interventions 1 and bibliotherapy 2.

Reflecting the evolving nature of the field, a broad range of terms have been used to describe Internet-delivered treatments, although consistency is emerging 3.

  1. However, more information is required about the rate and determinants of dropout and non-response, as well as on the potential benefits of sequencing ICBT with face-to-face psychotherapy.
  2. Internet-based self-help with therapist feedback and in-vivo group exposure for social phobia.
  3. The US senate is proposing a bill to regulate political advertising on the internet. To weigh the evidence, Freeman and a group of colleagues analyzed 225 studies of undergraduate STEM teaching methods.
  4. Indeed, at the Internet psychiatry unit in Stockholm, this is the case when patients are diagnosed at the clinic 22. Bower P, Gilbody S.

We will focus on psychological treatments delivered via the Internet. However, it should be noted that the Internet is also widely used by patients and their significant others to seek information about mental health issues 4and may also be used by patients to engage in online support groups 5.

Information seeking and online support groups are not the topic of this paper, but should be considered as important for psychiatry, since they may influence patient management 6. The model of Internet-delivered treatment for which there has been most research activity is Internet-delivered cognitive behaviour therapy ICBT 7.

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  3. However, there are disadvantages with not seeing the patient, and information may unavoidably be lost.

However, other models of psychotherapy e. During ICBT, patients login regularly to a secure website over a specified period to access, read and download online materials arranged into a series of lessons or modules 8. They receive homework assignments which they are expected to complete before the next module is available. They also regularly complete computer administered questionnaires relevant to their presenting problems, which allows a therapist to monitor progress, safety and outcomes.

Two dimensions which can be used to categorise ICBT are whether it involves therapist contact, and whether it aims to treat mental disorders or prevent their development.

Internet interventions that involve therapist contact can be further divided into those that involve real-time synchronous or delayed asynchronous interaction with patients.

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Examples of the former include contact via telephone, video, or messenger services 9while examples of the latter include secure e-mail communications. For pragmatic purposes, therapists may use a combination of synchronous and asynchronous communications during treatment. The amount of time therapists spend working with patients varies considerably between studies, with some requiring therapists to spend considerable time reading and responding to writing assignments 8.

Many programs, however, involve only minimal guidance via e-mail or secure asynchronous communication systemwhich requires considerably less time than face-to-face therapy 910. In this paper we discuss the advantages and disadvantages of Internet-delivered treatments for common mental disorders, with a focus on ICBT, although other forms of Internet interventions are also mentioned.

We examine a broad range of issues regarding recruitment, assessments, the role of the therapist in guided ICBT, treatments for mood and anxiety disorders, management of comorbidity, and dissemination. Allowing patients to self-refer to Internet interventions offers multiple advantages. It is a well-known fact that many persons with mood and anxiety disorders never reach specialist clinics and sometimes hesitate to even mention their problems when consulting general practitioners, and by means of online recruitment the treatment versus demand gap can decrease 12.

In other words, patients who may have remained untreated for many years may be given evidence-based psychological treatment for the first time. This is indeed an observation we have made, as research participants in our trials and clinics often have had their problems for example social anxiety disorder for decades. Furthermore, the format of Internet interventions makes it possible for prospective patients to reflect on the advantage of using traditional ways of delivering news treatment before they make an informed decision to commit to it.

Online recruitment and particularly patient self-referral has, however, raised questions about whether the characteristics of patients using online services are similar to those accessing traditional face-to-face clinics. This is important from the perspective of determining whether this model of service delivery can be provided at a public health level.

A common observation in Internet trials is that research participants tend to be better educated than the general population. This may reflect an artefact of the digital divide, i. However, it may be that, by virtue of increased levels of education and the self-selected nature of recruitment, online patients are more motivated to participate in treatment, and therefore are more responsive. Our experience is that patients who use Internet-delivered treatments represent a broad range of people. These include people with both low and high levels of education and different cultural groups.

This represents a challenge for the design and delivery of ICBT, though some initial steps have been taken in culturally adapting treatments 13. Patients also present with a spectrum of experiences with previous mental health services. Some have previously received traditional face-to-face treatments, while others have never sought treatment, despite years or decades of distressing symptoms.

There is relatively little research on patient characteristics in ICBT versus other trials and regular clinics, but there is evidence to suggest that participants in Internet trials are more similar to persons in the general population who have the same problems than patients who are seen in specialist clinics 1415. There is also now an increasing number of effectiveness trials on ICBT, i.

A recent review identified four controlled studies and eight open studies that had been conducted in regular clinics 16. All studies clearly showed that the promising effects of ICBT in trials with patients recruited via advertisements can also be observed when the treatment is transferred to regular clinics. An expanding literature concerned with how to collect patient data via the Internet has evolved 17and it is timely to highlight the pros and cons of online data collection.

We can conclude from several studies that questionnaire data can be collected without compromising psychometric characteristics 18 — 20but there is a need for a systematic review of this issue and it is commonly argued that norms need to be collected separately for paper-and-pencil and Internet administration 17. Advantages of Internet administration of questionnaires are that the risk of missing items can be reduced and that crucial items can be automatically highlighted for the clinicians e.

Moreover, summary scores can be automatically generated and algorithms developed to help therapists monitor progress and actively intervene in cases of suspected lapse. Automated administration also results in reduced costs associated with scoring and posting questionnaires.

The cons of Internet administration include first and foremost security issues. This is relevant not only to data storage, but also to methods of collection. While most researchers and clinicians comply with information security frameworks similar to online banking standards, the recent advent of mobile smartphones reminds us of evolving issues in security associated with new technology. An additional con is the difficulty of checking accuracy of responses and of obtaining additional information.

The former can be addressed to some extent by asking patients to confirm that responses are correct, while the latter can be managed by the adoption of clinical protocols that require telephone contact when clinically indicated.

These procedures must be implemented within a governance framework acknowledging legal and informed consent issues.

A more critical question concerns limits of diagnosing patients via the Internet. Clearly, the advantage of using traditional ways of delivering news would have many advantages, such as saving clinicians' time, but to date there is little to suggest that self-assessments can replace structured diagnostic interviews, and Internet administration does little to change this fact 21. On the other hand, if patients are required to first receive a diagnostic assessment at a face-to-face clinic, some of the advantages of Internet interventions may be reduced.

Indeed, at the Internet psychiatry unit in Stockholm, this is the case when patients are diagnosed at the clinic 22. In research, it is common to conduct structured psychiatric interviews such as the Mini-International Neuropsychiatric Interview 23 via telephone. This procedure is better than not obtaining any diagnoses at all and can generate valid findings 24.

However, there are disadvantages with not seeing the patient, and information may unavoidably be lost. Again, the adoption of pragmatic clinical protocols requiring face-to-face assessments in the presence of sufficient complexity of symptoms can address issues relating to diagnostic accuracy. In summary, online questionnaires work well, but psychiatric diagnoses cannot be reliably made using self-report only.

A compromise is to conduct interviews over the telephone. A secure online video conferencing platform could work as well, although research is needed to investigate the relative costs and benefits associated with this option.

Reviews of the literature consistently show that treatments that include guidance lead to better outcomes than unguided the advantage of using traditional ways of delivering news 26 — 28but there are occasional exceptions, and unguided treatments are emerging that can work by means of automated reminders and similar solutions 2930. The available evidence indicates that indeed any contact with a clinician may improve outcomes. While some data indicate that, when given choice, patients may be more likely to opt for unguided treatments, there are important advantages to guided treatments.

First, a therapist can make a diagnosis, to help determine the suitability of a treatment for a patient. Second, the intervention can be tailored and advice individualized following consultation with experienced clinicians: Third, there are clear indications that support increases adherence and prevents dropout, an important issue given that at least some unguided interventions have suffered from unacceptably high dropout rates 33.

Fourth, therapists can actively assist patients to access other services that may be required, including social, health and crisis services.

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However, there are also outstanding questions about the optimum frequency and form of support that should be provided. First, there the advantage of using traditional ways of delivering news no clear dose-response relation between support and outcome, and treatments in which substantial support is given do not appear to differ from treatments with minimal support e. Second, while studies indicate that equivalent clinical outcomes have been obtained whether support is provided by a professional psychologist or a coach, providing the latter is under careful clinical supervision and the ICBT is highly structured 34 — 36it is unclear whether similar outcomes would be obtained with less structured interventions.

Third, while guided Internet interventions are cost-effective 3738the advantage of using traditional ways of delivering news provision of guidance is indeed more costly than automated treatments, and unguided treatments with small effects can still be cost-effective 39.

Thus, from a public health perspective, the minimal costs of providing Internet interventions without guidance can in some cases be justified if they are safe. A fourth outstanding question relates to the limited knowledge about therapist factors which are widely held to be important in face-to-face treatments 40.

In addition to the findings regarding the role of technical versus more psychotherapeutic guidance 34 — 36there are a few studies in which the therapist factor has been studied showing no or small effects 4142.

On the other hand, the way guidance is provided seems to be important even if most of the communication tends to be of a supportive character 43. In a study in which the therapist correspondence was coded, it was found that a lenient attitude towards homework was associated with a worse outcome 10. Consistent with this, observations from our online research and clinical work indicate that better outcomes are associated with adherence to scripts which direct patients to key issues, while minimizing therapist drift.

Therapeutic alliance is another factor that is widely regarded as important in psychotherapy outcome research. Several studies on Internet interventions have collected data from patients on how they rate the therapeutic alliance with their online therapists 44. Most studies show no association with outcome, even if alliance ratings tend to be fairly high 4546.

There are, however, a few studies in which alliance early in the treatment predicted outcome 4748. In sum, and to date, most studies suggest that therapist contact is associated with better outcomes in Internet interventions.

However, provided the content of the Internet treatment is of appropriate quality and sufficiently engaging for patients, therapist expertise may be less important than in face-to-face therapies. Thus, depending on the degree of structure in the model of Internet intervention adopted, guidance can be mainly practical and supportive rather than explicitly therapeutic in orientation. This offers advantages in terms of fidelity and efficiency of patient and therapist time.

Indeed, the therapist can focus on supporting patients to master skills and overcome hurdles to the application of the intervention. In a surprisingly short time, treatments have been developed and tested for a range of anxiety disorders, including panic disorder 49social anxiety disorder 50 — 52generalized anxiety disorder 5354post-traumatic stress disorder 855obsessive-compulsive disorder 5657severe health anxiety 58and specific phobia 59.

Advantages and limitations of Internet-based interventions for common mental disorders

The majority of studies of mood disorders have examined major depression and have evaluated different forms of CBT 356364. In addition, several Internet intervention studies have evaluated other models of therapy, including psychodynamic psychotherapy 65 and physical activity 66. Direct comparisons of face-to-face CBT and ICBT have shown equivalent outcomes, with gains sustained in the long term 67and this pattern of results was replicated in effectiveness studies 16.

Several advantages and disadvantages are emerging. Advantages include improved access to evidence-based treatments for patients as well as cost-effectiveness compared to face-to-face treatment.