Internet-Based Early Intervention to Prevent Posttraumatic Stress Disorder in Injury Patients: Randomized Controlled Trial

Background

Posttraumatic stress disorder (PTSD) develops in 10-20% of injury patients. We developed a novel, self-guided Internet-based intervention (called Trauma TIPS) based on techniques from cognitive behavioral therapy (CBT) to prevent the onset of PTSD symptoms.

Objective

To determine whether Trauma TIPS is effective in preventing the onset of PTSD symptoms in injury patients.

Methods

Adult, level 1 trauma center patients were randomly assigned to receive the fully automated Trauma TIPS Internet intervention (n=151) or to receive no early intervention (n=149). Trauma TIPS consisted of psychoeducation, in vivo exposure, and stress management techniques. Both groups were free to use care as usual (nonprotocolized talks with hospital staff). PTSD symptom severity was assessed at 1, 3, 6, and 12 months post injury with a clinical interview (Clinician-Administered PTSD Scale) by blinded trained interviewers and self-report instrument (Impact of Event Scale—Revised). Secondary outcomes were acute anxiety and arousal (assessed online), self-reported depressive and anxiety symptoms (Hospital Anxiety and Depression Scale), and mental health care utilization. Intervention usage was documented.

Results

The mean number of intervention logins was 1.7, SD 2.5, median 1, interquartile range (IQR) 1-2. Thirty-four patients in the intervention group did not log in (22.5%), 63 (41.7%) logged in once, and 54 (35.8%) logged in multiple times (mean 3.6, SD 3.5, median 3, IQR 2-4). On clinician-assessed and self-reported PTSD symptoms, both the intervention and control group showed a significant decrease over time (P<.001) without significant differences in trend. PTSD at 12 months was diagnosed in 4.7% of controls and 4.4% of intervention group patients. There were no group differences on anxiety or depressive symptoms over time. Post hoc analyses using latent growth mixture modeling showed a significant decrease in PTSD symptoms in a subgroup of patients with severe initial symptoms (n=20) (P<.001).

Conclusions

Our results do not support the efficacy of the Trauma TIPS Internet-based early intervention in the prevention of PTSD symptoms for an unselected population of injury patients. Moreover, uptake was relatively low since one-fifth of individuals did not log in to the intervention. Future research should therefore focus on innovative strategies to increase intervention usage, for example, adding gameplay, embedding it in a blended care context, and targeting high-risk individuals who are more likely to benefit from the intervention.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 57754429; http://www.controlled-trials.com/ISRCTN57754429 (Archived by WebCite at http://webcitation.org/6FeJtJJyD).     

Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder

The authors report on changes in cognitions related to posttraumatic stress disorder (PTSD) among 54 female survivors of sexual and nonsexual assault with chronic PTSD who completed either prolonged exposure alone or in combination with cognitive restructuring. Treatment included 9-12 weekly sessions, and assessment was conducted at pretreatment, posttreatment, and a modal 12-month follow-up. As hypothesized, treatment that included prolonged exposure resulted in clinically significant, reliable, and lasting reductions in negative cognitions about self, world, and self-blame as measured by the Posttraumatic Cognitions Inventory. The hypothesis that the addition of cognitive restructuring would augment cognitive changes was not supported. Reductions in these negative cognitions were significantly related to reductions in PTSD symptoms. The addition of cognitive restructuring did not significantly augment the cognitive changes. Theoretical implications of the results are discussed.     

The effect of an Internet-based cognitive behavioral therapy intervention on social support in disaster evacuees

Introduction

Both exposure to a natural disaster and psychological symptoms may lead to decreases in social support. Few studies have examined ways to improve social support among victims of natural disasters.

Aims

The objective of the study was to assess emotional and tangible support following a 12-session Internet-based cognitive behavioral therapy (ICBT) targeting posttraumatic stress (PTS), insomnia, and depression symptoms and to examine the association between posttreatment symptoms and emotional and tangible support.

Materials and Methods

One hundred and seventy-eight wildfire evacuees with significant PTS, depression and/or insomnia symptoms were given access to the ICBT. They completed questionnaires at pre- and posttreatment to measure social support and symptom severity.

Results

Results show that completion of the treatment led to an improvement in emotional support. Lower posttreatment PTS and insomnia symptoms were associated with higher posttreatment emotional support.

Conclusion

ICBT may contribute to enhance emotional support through symptom improvement and probably more so when social support is address directly in treatment.     

Web-Based and Mobile Stress Management Intervention for Employees: A Randomized Controlled Trial

BackgroundWork-related stress is highly prevalent among employees and is associated with adverse mental health consequences. Web-based interventions offer the opportunity to deliver effective solutions on a large scale; however, the evidence is limited and the results conflicting.ObjectiveThis randomized controlled trial evaluated the efficacy of guided Web- and mobile-based stress management training for employees.MethodsA total of 264 employees with elevated symptoms of stress (Perceived Stress Scale-10, PSS-10≥22) were recruited from the general working population and randomly assigned to an Internet-based stress management intervention (iSMI) or waitlist control group. The intervention (GET.ON Stress) was based on Lazarus’s transactional model of stress, consisted of seven sessions, and applied both well-established problem solving and more recently developed emotion regulation strategies. Participants also had the opportunity to request automatic text messages on their mobile phone along with the iSMI. Participants received written feedback on every completed session from an e-coach. The primary outcome was perceived stress (PSS-10). Web-based self-report assessments for both groups were scheduled at baseline, 7 weeks, and 6 months. At 12 months, an extended follow-up was carried out for the iSMI group only.ResultsAn intention-to-treat analysis of covariance revealed significantly large effect differences between iSMI and waitlist control groups for perceived stress at posttest (F _1,261=58.08, P<.001; Cohen’s d=0.83) and at the 6-month follow-up (F _1,261=80.17, P<.001; Cohen’s d=1.02). The effects in the iSMI group were maintained at 12-month follow-up.ConclusionsThis Web- and mobile-based intervention has proven effective in reducing stress in employees in the long term. Internet-based stress management interventions should be further pursued as a valuable alternative to face-to-face interventions.

Trial Registration

German Clinical Trials Register (DRKS): 00004749; http://drks-neu.uniklinik-freiburg.de/ drks_web/setLocale_EN.do (Archived by WebCite at http://www.webcitation.org/6e8rl98nl)     

Cognitive processing therapy for veterans with military-related posttraumatic stress disorder

Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population.     

Treating complicated grief and posttraumatic stress in homicidally bereaved individuals: A randomized controlled trial

Homicidally bereaved individuals may experience symptoms of Complicated Grief (CG) and Posttraumatic Stress Disorder (PTSD). This Randomized Controlled Trial examined the effectiveness of an 8‐session treatment encompassing Cognitive Behavioural Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) to reduce self‐rated CG and PTSD symptoms in 85 Dutch adult homicidally bereaved men and women. We compared changes in symptoms of CG (assessed using the Inventory of Complicated Grief) and PTSD (assessed using the Impact of Event Scale) between an intervention group and a waitlist control group. The treatment was effective in reducing CG and PTSD symptoms, from pretreatment to posttreatment. It can be concluded that EMDR and CBT seem promising treatments for homicidally bereaved individuals for both men and women, and regardless of the time since the loss. Further research is needed to examine whether a combined treatment of EMDR and CBT together is of added value in situations where grief and trauma are intertwined over offering only one of the two treatment modalities.     

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

Objectives

Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans.

Methods

Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined.

Results

No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices.

Conclusions

The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.     

Racial Differences in the Associations of Posttraumatic Stress and Insomnia With Body Mass Index Among Trauma-Exposed Veterans

Posttraumatic stress is associated with increased body mass index (BMI) and rates of obesity. Black adults are at greater risk for obesity, trauma exposure, development of posttraumatic stress disorder, and comorbid sleep problems compared to White adults. Accordingly, Black adults with a history of trauma exposure may be at greater risk for elevated BMI associated with posttraumatic stress and insomnia. Multiple linear regression was used to examine race as a moderator of the relationship between posttraumatic symptoms and insomnia with BMI in a sample of Black and White trauma-exposed Veterans (N = 171), controlling for age and sex. There was a significant interaction of race with PTSD (p = 0.042) and insomnia symptoms (p = 0.045) on BMI. Simple slopes showed a significant positive association of posttraumatic stress and BMI among Black (p = 0.003), but not White Veterans (p = 0.590). Similarly, insomnia was significantly associated with greater BMI for Black (p = 0.023), but not White Veterans (p = 0.496). Posttraumatic stress and insomnia may play a particularly important role in the development of weight related health problems among Black Veterans. Early identification and treatment of these symptoms may reduce the risk of obesity among this vulnerable population.     

Efficacy of cognitive behavioral internet-based therapy in parents after the loss of a child during pregnancy: pilot data from a randomized controlled trial

The loss of a child during pregnancy can be a traumatic event associated with long-lasting grief and psychological distress. This study examined the efficacy of an internet-based cognitive behavioral therapy program for mothers after pregnancy loss. In a randomized controlled trial with a waiting list control group, 83 participants who had lost a child during pregnancy were randomly allocated either to 5 weeks of internet therapy or to a 5-week waiting condition. Within a manualized cognitive behavioral treatment program, participants wrote ten essays on loss-specific topics. Posttraumatic stress, grief, and general psychopathology, especially depression, were assessed pretreatment, posttreatment, and at 3-month follow-up. Intention-to-treat analyses and completer analyses were performed. Relative to controls, participants in the treatment group showed significant improvements in posttraumatic stress, grief, depression, and overall mental health, but not in anxiety or somatization. Medium to large effect sizes were observed, and the improvement was maintained at 3-month follow-up. This internet-based cognitive behavioral therapy program represents an effective treatment approach with stable effects for women after pregnancy loss. Implementation of the program can thus help to improve the health care provision for mothers in this traumatic loss situation.     

The additive benefit of hypnosis and cognitive-behavioral therapy in treating acute stress disorder

This research represents the first controlled treatment study of hypnosis and cognitive- behavioral therapy (CBT) of acute stress disorder (ASD). Civilian trauma survivors (N=87) who met criteria for ASD were randomly allocated to 6 sessions of CBT, CBT combined with hypnosis (CBT-hypnosis), or supportive counseling (SC). CBT comprised exposure, cognitive restructuring, and anxiety management. CBT-hypnosis comprised the CBT components with each imaginal exposure preceded by a hypnotic induction and suggestions to engage fully in the exposure. In terms of treatment completers (n=69), fewer participants in the CBT and CBT-hypnosis groups met criteria for posttraumatic stress disorder at posttreatment and 6-month follow-up than those in the SC group. CBT-hypnosis resulted in greater reduction in reexperiencing symptoms at posttreatment than CBT. These findings suggest that hypnosis may have use in facilitating the treatment effects of CBT for posttraumatic stress.     

Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling

Rape victims with posttraumatic stress disorder (PTSD; N = 45) were randomly assigned to one of four conditions: stress inoculation training (SIT), prolonged exposure (PE), supportive counseling (SC), or wait-list control (WL). Treatments consisted of nine biweekly 90-min individual sessions conducted by a female therapist. Measures of PTSD symptoms, rape-related distress, general anxiety, and depression were administered at pretreatment, posttreatment, and follow-up (M = 3.5 months posttreatment). All conditions produced improvement on all measures immediately post-treatment and at follow-up. However, SIT produced significantly more improvement on PTSD symptoms than did SC and WL immediately following treatment. At follow-up, PE produced superior outcome on PTSD symptoms. The implications of these findings and direction for treatment and future research are discussed.     

Effectiveness of a Web-Based Guided Self-help Intervention for Outpatients With a Depressive Disorder: Short-term Results From a Randomized Controlled Trial

BackgroundResearch has convincingly demonstrated that symptoms of depression can be reduced through guided Internet-based interventions. However, most of those studies recruited people form the general population. There is insufficient evidence for the effectiveness when delivered in routine clinical practice in outpatient clinics.ObjectiveThe objective of this randomized controlled trial was to study patients with a depressive disorder (as defined by the Diagnostic and Statistical Manual of Disorders, fourth edition), as assessed by trained interviewers with the Composite International Diagnostic Interview, who registered for treatment at an outpatient mental health clinic. We aimed to examine the effectiveness of guided Internet-based self-help before starting face-to-face treatment.MethodsWe recruited 269 outpatients, aged between 18 and 79 years, from outpatient clinics and randomly allocated them to Internet-based problem solving therapy (n=136), with weekly student support, or to a control condition, who remained on the waitlist with a self-help booklet (control group; n=133). Participants in both conditions were allowed to take up face-to-face treatment at the outpatient clinics afterward. We measured the primary outcome, depressive symptoms, by Center for Epidemiological Studies Depression scale (CES-D). Secondary outcome measures were the Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), Insomnia Severity Index questionnaire (ISI), and EuroQol visual analog scale (EQ-5D VAS). All outcomes were assessed by telephone at posttest (8 weeks after baseline).ResultsPosttest measures were completed by 184 (68.4%) participants. We found a moderate to large within-group effect size for both the intervention (d=0.75) and the control (d=0.69) group. However, the between-group effect size was very small (d=0.07), and regression analysis on posttreatment CES-D scores revealed no significant differences between the groups (b=1.134, 95% CI –2.495 to 4.763). The per-protocol analysis (≥4 sessions completed) results were also not significant (b=1.154, 95% CI –1.978 to 7.637). Between-group differences were small and not significant for all secondary outcomes. Adherence to the intervention was low. Only 36% (49/136) received an adequate dosage of the intervention (≥4 of 5 sessions). The overall treatment satisfaction was moderate.ConclusionsInternet-based problem solving therapy is not more effective in reducing symptoms of depression than receiving an unguided self-help book during the waitlist period at outpatient mental health clinics. The effect sizes are much smaller than those found in earlier research in the general population, and the low rates of adherence indicate that the acceptability of the intervention at this stage of treatment for depressed outpatients is low. However, taking into account that there is much evidence for the efficacy of Internet-based treatments, it is too early to draw firm conclusions about the effectiveness of these treatments in outpatient clinics as a whole.

Trial Registration

Netherlands Trial Register NTR2824; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2824 (Archived by WebCite at http://www.webcitation/ 6g3WEuiqH)     

Intraindividual variability in sleep schedule: effects of an internet-based cognitive-behavioral therapy for insomnia program and its relation with symptom remission

Study ObjectivesSleep schedule consistency is fundamental to cognitive-behavioral therapy for insomnia (CBT-I), although there is limited evidence suggesting whether it predicts treatment response. This analysis tested whether: (1) an Internet-based CBT-I program affects intraindividual variability (IIV) in sleep schedule and (2) sleep schedule IIV predicts insomnia symptom remission.MethodsThis secondary analysis compares participants (N = 303) randomized to an Internet-based CBT-I program (SHUTi—Sleep Healthy Using the Internet) or Internet-based patient education (PE). Participants reported daily bedtimes and rising times on 10 online sleep diaries collected over 2 weeks at baseline and 9-week post-intervention assessment. Participants completed the Insomnia Severity Index (ISI) at post-assessment and 6-month follow-up; symptom remission was defined by ISI < 8. Mixed effects location scale modeling was used to examine the effect of SHUTi on bedtime and rising time IIV; a novel two-staged analysis examined the effect of bedtime and rising time IIV on insomnia symptom remission.ResultsAt post-assessment, SHUTi participants reported about 30% less bedtime and 32% less rising time variability compared to PE (ps < 0.03). Bedtime and rising time IIV was not independently associated with likelihood of insomnia symptom remission at the subsequent time point (ps > 0.18), nor did sleep schedule IIV moderate treatment response (ps > 0.12).ConclusionsFindings demonstrate that an Internet-delivered CBT-I program can effectively increase users’ sleep schedule consistency relative to an educational control. This consistency, however, was not related to treatment outcome when defined by insomnia symptom remission, suggesting that enforcing rigid sleep schedules for patients may not be necessary for treatment success.Clinical Trial Registration{"type":"clinical-trial","attrs":{"text":"NCT00328250","term_id":"NCT00328250"}}NCT00328250     

An Internet-Based Guided Self-Help Intervention for Panic Symptoms: Randomized Controlled Trial

Background

Internet-based guided self-help is efficacious for panic disorder, but it is not known whether such treatment is effective for milder panic symptoms as well.

Objective

To evaluate the effectiveness of Don’t Panic Online, an Internet-based self-help course for mild panic symptoms, which is based on cognitive behavioral principles and includes guidance by email.

Methods

A pragmatic randomized controlled trial was conducted. Participants (N=126) were recruited from the general population and randomized to either the intervention group or to a waiting-list control group. Inclusion criteria were a Panic Disorder Severity Scale-Self Report (PDSS-SR) score between 5-15 and no suicide risk. Panic symptom severity was the primary outcome measure; secondary outcome measures were anxiety and depressive symptom severity. Measurements were conducted online and took place at baseline and 12 weeks after baseline (T1). At baseline, diagnoses were obtained by telephone interviews.

Results

Analyses of covariance (intention-to-treat) showed no significant differences in panic symptom reduction between groups. Completers-only analyses revealed a moderate effect size in favor of the intervention group (Cohen’s d=0.73, P=.01). Only 27% of the intervention group finished lesson 4 or more (out of 6). Nonresponse at T1 was high for the total sample (42.1%). Diagnostic interviews showed that many participants suffered from comorbid depression and anxiety disorders.

Conclusions

The Internet-based guided self-help course appears to be ineffective for individuals with panic symptoms. However, intervention completers did derive clinical benefits from the intervention.

Trial Registration

Nederlands Trial Register: NTR1639; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1639 (Archived by WebCite at http://www.webcitation.org/6ITZPozs9).     

Cost-utility and cost-effectiveness of internet-based treatment for adults with depressive symptoms: randomized trial

Background

The effectiveness of Internet-based treatments for depression has been demonstrated; their cost-effectiveness, however, has been less well researched.

Objective

Evaluating the relative cost-utility and cost-effectiveness of (1) Internet-based cognitive behavioral therapy, (2) Internet-based problem-solving therapy, and (3) a waiting list for adults with depressive symptoms.

Methods

A total of 263 participants with clinically significant depressive symptoms were randomized to Internet-based cognitive behavioral therapy (n = 88), Internet-based problem-solving therapy (n = 88), and a waiting list (n = 87). End points were evaluated at the 12-week follow-up.

Results

Cost-utility analysis showed that cognitive behavioral therapy and problem-solving therapy had a 52% and 61% probability respectively of being more acceptable than waiting when the willingness to pay is € 30,000 for one quality-adjusted life-year. When society is prepared to pay € 10,000 for a clinically significant change from depression, the probabilities of cognitive behavioral therapy and problem-solving therapy being more acceptable than waiting are 91% and 89%, respectively. Comparing both Internet-based treatments showed no clear preference for one or the other of the treatments.

Conclusions

Both Internet-based treatments have a high probability of being cost-effective with a modest value placed on clinically significant change in depressive symptoms.

Trial Registration

ISRCTN16823487; http://www.controlled-trials.com/ISRCTN16823487 (Archived by WebCite at http://www.webcitation.org/5u8slzhDE)     

A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder

Although the efficacy of exposure is well established in individual cognitive behavioral treatments for posttraumatic stress disorder (PTSD), some clinicians and researchers have expressed concerns regarding the use of in-session disclosure of trauma details through imaginal exposure in group cognitive behavioral therapy (GCBT) for PTSD. Thus, the aim of the present study was to conduct a systematic review of the empirical support for GCBT in the treatment of PTSD and to compare GCBT protocols that encourage the disclosure of trauma details via in-session exposure to GCBT protocols that do not include in-session exposure. Randomized controlled trials that assessed the efficacy of GCBT for PTSD were included in the meta-analysis. A total of 651 participants with PTSD were included in the 12 eligible GCBT treatment conditions (5 conditions included in-group exposure, 7 conditions did not include in-group exposure). The overall pre–post effect size of GCBT for PTSD (ES = 1.13 [SE = 0.22, 95% CI: 0.69 to 1.56, p  .001]). suggests that GCBT is an effective intervention for individuals with PTSD. No significant differences in effect sizes were found between GCBT treatments that included in-group exposure and those that did not. Although the attrition rate was higher in treatments that included exposure in-group, this rate is comparable to attrition rates in individual CBT treatments and pharmacotherapy for PTSD. The results from this meta-analysis suggest that concerns about the potentially negative impact of group exposure may be unwarranted, and support the use of exposure-based GCBT as a promising treatment option for PTSD.     

Posttraumatic stress disorder in parents of children with newly diagnosed type 1 diabetes

OBJECTIVE: To determine rates of posttraumatic stress disorder (PTSD) and symptoms in mothers and fathers of children with newly diagnosed type 1 diabetes. METHODS: Parents of 38 children with newly diagnosed type 1 diabetes were assessed with the Posttraumatic Diagnostic Scale 6 weeks after diagnosis. RESULTS: Twenty-four percent of the mothers and 22% of the fathers met full diagnostic criteria for current PTSD. In addition, 51% of the mothers and 41% of the fathers met criteria for partial or subclinical PTSD. Co-occurence of PTSD in couples was very low. Posttraumatic stress symptomatology did not correlate with age and gender of the child, socioeconomic status, family structure, or length of hospital stay. CONCLUSIONS: The findings support applicability of a posttraumatic stress model for investigating the psychological impact of type 1 diabetes on parents.     

An Internet-Based Intervention for Depression in Primary Care in Spain: A Randomized Controlled Trial

BackgroundDepression is the most prevalent cause of illness-induced disability worldwide. Face-to-face psychotherapeutic interventions for depression can be challenging, so there is a need for other alternatives that allow these interventions to be offered. One feasible alternative is Internet-based psychological interventions. This is the first randomized controlled trial (RCT) on the effectiveness of an Internet-based intervention on depression in primary health care in Spain.ObjectiveOur aim was to compare the effectiveness of a low-intensity therapist-guided (LITG) Internet-based program and a completely self-guided (CSG) Internet-based program with improved treatment as usual (iTAU) care for depression.MethodsMulticenter, three-arm, parallel, RCT design, carried out between November 2012 and January 2014, with a follow-up of 15 months. In total, 296 adults from primary care settings in four Spanish regions, with mild or moderate major depression, were randomized to LITG (n=96), CSG (n=98), or iTAU (n=102). Research completers at follow-up were 63.5%. The intervention was Smiling is Fun, an Internet program based on cognitive behavioral therapy. All patients received iTAU by their general practitioners. Moreover, LITG received Smiling is Fun and the possibility of psychotherapeutic support on request by email, whereas CSG received only Smiling is Fun. The main outcome was the Beck Depression Inventory-II at 3 months from baseline. Mixed-effects multilevel analysis for repeated measures were undertaken.ResultsThere was no benefit for either CSG [(B coefficient=-1.15; P=.444)] or LITG [(B=-0.71; P=.634)] compared to iTAU, at 3 months. There were differences at 6 months [iTAU vs CSG (B=-4.22; P=.007); iTAU vs LITG (B=-4.34; P=.005)] and 15 months [iTAU vs CSG (B=-5.10; P=.001); iTAU vs LITG (B=-4.62; P=.002)]. There were no differences between CSG and LITG at any time. Adjusted and intention-to-treat models confirmed these findings.ConclusionsAn Internet-based intervention for depression combined with iTAU conferred a benefit over iTAU alone in the Spanish primary health care system.

Trial Registration

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01611818","term_id":"NCT01611818"}}NCT01611818; https://register.clinicaltrials.gov/prs/app/action/SelectProtocol? selectaction=Edit&uid=U0001NPQ&ts=2&cx=gctdh2&sid=S0003KJ6 (Archived by WebCite at http://www.webcitation.org/6jbsUvUDz)     

Psychological consequences of war trauma and postwar social stressors in women in Bosnia and Herzegovina

Aim

To assess the consequences of psychotrauma in civilian women in Herzegovina who were exposed to prolonged and repetitive traumatic war events and postwar social stressors.

Methods

The study included a cluster sample of 367 adult women, divided into two groups. One group (n = 187) comprised women from West Mostar who were exposed to serious war and posttraumatic war events. The other group (n = 180) comprised women from urban areas in Western Herzegovina who were not directly exposed to war destruction and material losses, but experienced war indirectly, through military drafting of their family members and friends. Demographic data on the women were collected by a questionnaire created for the purpose of this study. Data on trauma exposure and posttraumatic stress disorder (PTSD) symptoms were collected by Harvard Trauma Questionnaire (HTQ) – Bosnia-Herzegovina version. General psychological symptoms were determined with Symptom Check List-90-revised (SCL-90-R). Data on postwar stressors were collected by a separate questionnaire.

Results

In comparison with the control group, women from Western Mostar experienced significantly more traumatic events (mean ± standard deviation [SD], 3.3 ± 3.2 vs 10.1 ± 4.9, respectively, t = 15.91; P<0.001) and had more posttraumatic symptoms (12.3 ± 10.3 vs 21.2 ± 10.9, respectively, t = 8.42; P<0.001). They also had significantly higher prevalence of PTSD (4.4% vs 28.3%, respectively; χ² = 52.56; P<0.001). The number of traumatic events experienced during the war was positively associated with postwar stressful events both in the West Mostar group (r = 0.223; P = 0.002) and control group (r = 0.276; P<0.001). Postwar stressful events contributed both to the number and intensity of PTSD symptoms and all general psychological symptoms measured with SCL-90 questionnaire, independently from the number of experienced traumatic war events.

Conclusion

Long-term exposure to war and postwar stressors caused serious psychological consequences in civilian women, with PTSD being only one of the disorders in the wide spectrum of posttraumatic reactions. Postwar stressors did not influence the prevalence of PTSD but they did contribute to the intensity and number of posttraumatic symptoms.There are few studies investigating how political violence in a community influences women, and those that do exist mostly deal with refugees (1,2). Epidemiologic research into consequences of war trauma established that posttraumatic stress disorder (PTSD), although the most frequent, was rarely the only psychological disorder among the general population of war-stricken countries (3-6) and that women had noticeably poorer mental health than the rest of the population (2,7). Studies investigating psychological consequences of military and civil trauma confirmed the correlation between the nature and intensity of trauma, previous traumatic experience, and psychological consequences (8-11).Because of its brutality, the war in Bosnia and Herzegovina has become the paradigm for traumatic experience, with the constant need for psychological and psychiatric help for victims long after its end. Previous research and local health care have mostly been focused on men, and preventive and therapeutic activities have targeted primarily the population of war veterans. However, there is no doubt that chronic war stress caused serious psychological problems in women in war-affected areas, although clinical experience about this problem is scarce. The reason why little is known about mental health of women in Bosnia and Herzegovina is that a relatively small number of psychotraumatized women seek psychiatric or psychological help (12). Previous research and local health care system dealt mostly with male population, which is the reason why most preventive and curative actions have been directed at veteran population. However, chronic war stress has doubtlessly had deep consequences on psychological health of women as well (13). Literature data and personal clinical experience indicate that clinical identification of PTSD is frequently hampered by gender prejudices, including the tendency to overlook traumatic nature of violence against women along with associated posttraumatic symptoms (14).The war did not affect all areas of Bosnia and Herzegovina equally. In some parts of the country, it was more intense and lasted longer than in others. The whole city of Mostar was a battlefield and suffered heavy destruction and human losses on everyday basis. Today, it is divided into Western Mostar and Eastern Mostar, and still struggles with devastated infrastructure and economic resources. On the other hand, urban areas in Western Herzegovina, although not too far from Mostar, were spared from everyday destruction and the civilian population was not directly exposed to life threatening situations. Also, postwar social and economic deprivation in that area has not been so pronounced as in Mostar.We expected that women exposed to war atrocities in Bosnia and Herzegovina would suffer posttraumatic psychological consequences and that a significant percentage of women in Mostar would develop posttraumatic disorders (PTSD, posttraumatic symptoms, and general psychological symptoms) as a reaction to traumatic experiences. We also expected that the percentage of women with posttraumatic disorders would be smaller in areas only indirectly affected by the war. Since postwar social stressors make the recovery more difficult, we also expected that women who were exposed to additional postwar social stressors would have more difficult recovery and more pronounced posttraumatic disorders.The aim of this study was to determine the degree of posttraumatic symptoms and symptoms of other mental disorders in women who were living in war-stricken areas for several years, determine the correlation between the number and intensity of posttraumatic symptoms and the intensity of psychotrauma, and establish the influence of postwar stressors on the manifestation and duration of posttraumatic and general psychological symptoms.     

Comparing In-Person to Videoconference-Based Cognitive Behavioral Therapy for Mood and Anxiety Disorders: Randomized Controlled Trial

Background

Cognitive-behavioral therapy (CBT) has demonstrated efficacy and effectiveness for treating mood and anxiety disorders. Dissemination of CBT via videoconference may help improve access to treatment.

Objective

The present study aimed to compare the effectiveness of CBT administered via videoconference to in-person therapy for a mixed diagnostic cohort.

Methods

A total of 26 primarily Caucasian clients (mean age 30 years, SD 11) who had a primary Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV-TR) diagnosis of a mood or anxiety disorder were randomly assigned to receive 12 sessions of CBT either in-person or via videoconference. Treatment involved individualized CBT formulations specific to the presenting diagnosis; all sessions were provided by the same therapist. Participants were recruited through a university clinic. Symptoms of depression, anxiety, stress, and quality of life were assessed using questionnaires before, after, and 6 weeks following treatment. Secondary outcomes at posttreatment included working alliance and client satisfaction.

Results

Retention was similar across treatment conditions; there was one more client in the videoconferencing condition at posttreatment and at follow-up. Statistical analysis using multilevel mixed effects linear regression indicated a significant reduction in client symptoms across time for symptoms of depression (P<.001, d=1.41), anxiety (P<.001, d=1.14), stress (P<.001, d=1.81), and quality of life (P<.001, d=1.17). There were no significant differences between treatment conditions regarding symptoms of depression (P=.165, d=0.37), anxiety (P=.41, d=0.22), stress (P=.15, d=0.38), or quality of life (P=.62, d=0.13). There were no significant differences in client rating of the working alliance (P=.53, one-tailed, d=–0.26), therapist ratings of the working alliance (P=.60, one-tailed, d=0.23), or client ratings of satisfaction (P=.77, one-tailed, d=–0.12). Fisher’s Exact P was not significant regarding differences in reliable change from pre- to posttreatment or from pretreatment to follow-up for symptoms of depression (P=.41, P=.26), anxiety (P=.60, P=.99), or quality of life (P=.65, P=.99) but was significant for symptoms of stress in favor of the videoconferencing condition (P=.03, P=.035). Difference between conditions regarding clinically significant change was also not observed from pre- to posttreatment or from pretreatment to follow-up for symptoms of depression (P=.67, P=.30), anxiety (P=.99, P=.99), stress (P=.19, P=.13), or quality of life (P=.99, P=.62).

Conclusions

The findings of this controlled trial indicate that CBT was effective in significantly reducing symptoms of depression, anxiety, and stress and increasing quality of life in both in-person and videoconferencing conditions, with no significant differences being observed between the two.

Trial Registration

Australian New Zealand Clinical Trials Registry ID: ACTRN12609000819224; http://www.anzctr.org.au/ACTRN12609000819224.aspx (Archived by WebCite at http://www.webcitation.org/6Kz5iBMiV).