Self‐help and minimal‐contact therapies for anxiety disorders: Is human contact necessary for therapeutic efficacy?

Self-help materials, brief therapies, and treatments involving minimal therapist contact have all been proposed as effective and low-cost interventions for anxiety disorders. However, research also suggests that the therapeutic alliance is a central predictor of therapy outcome. Interestingly, amounts of therapist contact within and across "self-help" interventions vary greatly. It is therefore unclear how much therapist contact is necessary for a positive anxiety disorder treatment outcome. The present article reviews the literature on anxiety disorder treatments using self-help, self-administered, and decreased therapist-contact interventions. Treatment studies are grouped together by anxiety diagnosis as well as amount of therapist contact. It is concluded that self-administered treatments are most effective for motivated clients seeking treatment for simple phobias. Predominantly self-help therapies are efficacious for panic disorder and mixed anxiety samples. On the other hand, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses.     

Therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care

Panic disorder with or without agoraphobia is a prevalent clinical disorder which places heavy demands on treatment resources in primary care. The efficiency of delivery of psychological treatments for this disorder is therefore important. Previous research has focused on psychological treatments delivered with reduced therapist contact but methodological problems preclude firm conclusions. The present study investigated the relevance of therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia, taking account of previous methodological problems. One hundred and four patients suffering from DSM III‐R panic disorder with or without agoraphobia were randomly allocated to receive cognitive behaviour therapy with either, ‘standard’ therapist contact, ‘minimum’ therapist contact or as a bibliotherapy. All patients were seen by the same therapist and all received an identical treatment manual. Treatment response, as measured by patient and therapist report scales of anxiety, depression, and agoraphobic avoidance, was analysed in terms of both traditional statistical significance and clinical significance of outcome. At treatment end‐point the ‘standard’ therapist contact and ‘minimum’ therapist contact groups showed significant reductions pre‐ to post‐treatment on all measures. Pre‐ to post‐treatment reductions for the bibliotherapy group were significant on therapist‐ and patient‐rated measures of anxiety only. The ‘standard’ therapist contact group was consistently significantly improved in comparison to the bibliotherapy group. Significant differences between the ‘standard’ and ‘minimum’ therapist contact groups were found on therapist‐rated anxiety only. Assessment of clinical significance of treatment outcome showed further differences between treatment groups with the ‘standard’ therapist contact group showing the largest proportion of patients achieving clinically significant change on all measures both at treatment end‐point and at 6‐month follow‐up. Copyright © 2000 John Wiley & Sons, Ltd.     

Behavioral treatment parameters with primary dysmenorrhea

Fourteen women with primary dysmenorrhea were administered four sessions of systematic desensitization (SD) by either a male or a female therapist. The following measures were taken during the flow periods before and after treatment and at a 6-month follow-up: menstrual symptom checklist, medication usage, invalid hours, and menstrual attitudes. At pretreatment, menstrually distressed women had significantly higher scores on all measures compared to a normative group and an explicitly nondistressed group. At posttreatment, treated women's scores on the dependent variables were significantly reduced. All indices were reduced to a nondistressed level at posttreatment and at 6-month follow-up. Type of dysmenorrhea (congestive vs. spasmodic), trait anxiety level, and therapist sex did not predict differential responsiveness to SD. SD did not affect frontalis EMG, peripheral blood flow, or pain threshold. A Retrospective Symptom Scale of menstrual distress was found to be highly reliable, valid, and sensitive.     

A review of technology-assisted self-help and minimal contact therapies for anxiety and depression: is human contact necessary for therapeutic efficacy?

Technology-based self-help and minimal contact therapies have been proposed as effective and low-cost interventions for anxiety and mood disorders. The present article reviews the literature published before 2010 on these treatments for anxiety and depression using self-help and decreased therapist-contact interventions. Treatment studies are examined by disorder as well as amount of therapist contact, ranging from self-administered therapy and predominantly self-help interventions to minimal contact therapy where the therapist is actively involved in treatment but to a lesser degree than traditional therapy and predominantly therapist-administered treatments involving regular contact with a therapist for a typical number of sessions. In the treatment of anxiety disorders, it is concluded that self-administered and predominantly self-help interventions are most effective for motivated clients. Conversely, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses when accounting for both attrition and compliance. Additionally, predominantly self-help computer-based cognitive and behavioral interventions are efficacious in the treatment of subthreshold mood disorders. However, therapist-assisted treatments remain optimal in the treatment of clinical levels of depression. Although the most efficacious amount of therapist contact varies by disorder, computerized treatments have been shown to be a less-intensive, cost-effective way to deliver empirically validated treatments for a variety of psychological problems.     

Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: a randomized controlled trial

Sixty-four individuals with social phobia (social anxiety disorder) were assigned to a multimodal cognitive-behavioral treatment package or to a waiting list control group. Treatment consisted of a 9-week, Internet-delivered, self-help program that was combined with 2 group exposure sessions in real life and minimal therapist contact via e-mail. Results were analyzed on an intention-to-treat basis, including all randomized participants. From pre- to posttest, treated participants in contrast to controls showed significant improvement on most measured dimensions (social anxiety scales, general anxiety and depression levels, quality of life). The overall within- and between-groups effect sizes were Cohen's d = 0.87 and 0.70, respectively. Treatment gains were maintained at 1-year follow-up. The results from this study support the continued use and development of Internet-distributed, self-help programs for people diagnosed with social phobia.     

Reducing therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care: global measures of outcome in a randomised controlled trial.

BACKGROUND: Panic disorder, with and without agoraphobia, is a prevalent condition presenting in general practice. Psychological treatments are effective but are limited by restricted availability. Interest has grown in methods by which the efficiency and thus availability of psychological treatments can be improved, with particular emphasis on reduced therapist contact formats. AIM: To evaluate the relative efficacy in a primary care setting of a cognitive behaviour therapy (CBT) delivered at three levels of therapist contact: standard contact, minimum contact, and bibliotherapy. METHOD: A total of 104 patients were randomly allocated to receive standard therapist contact, minimum therapist contact or bibliotherapy, with 91 patients completing treatment. All patients received an identical treatment manual and were seen by the same psychologist therapist. Outcome was reported in terms of brief global ratings of severity of illness, change in symptoms, and levels of social disruption. These brief measures were chosen to be suitable for use in general practice and were used at treatment entry and endpoint. RESULTS: The standard therapist contact group had the strongest and most comprehensive treatment response, showing significant differences from the bibliotherapy group on all, and the minimum therapist contact group on some, endpoint measures. Some reduction in efficacy was therefore found for the reduced therapist contact groups. CONCLUSION: The standard therapist contact group showed the greatest treatment efficacy in the present study. As it was of notably shorter duration than many other current formulations of CBT, it represents a useful and efficient treatment for panic disorder and agoraphobia in primary care.     

Introduction to the special section on stepped care models in psychotherapy

Not all patients need the same type and intensity of intervention. Some may be helped greatly by reading a self-help book, watching an instructional video, or using a computer program. Others could benefit from a brief psychoeducational group conducted by a paraprofessional, and still others may require long-term individual treatment from a highly trained professional therapist with specialized expertise. In an environment of limited resources, it makes sense to provide all the time, expertise, and individual attention a patient needs, but not more. Stepped care models represent attempts to maximize the effectiveness and efficiency of decisions about allocation of resources in therapy. This article introduces a special section addressing these resource allocation issues in the context of prevalent disorders (e.g., generalized anxiety disorder, panic disorder, eating disorders, and alcohol dependence) for which empirically supported psychosocial treatments are available.     

Comparative efficacy of biofeedback and stress inoculation for stress reduction

Evaluated the comparative effectiveness of frontalis electromyographic (EMG) biofeedback, a primarily somatic intervention, and stress inoculation, a self-instructional form of cognitive-behavior therapy. Both treatments were compared with a waiting list control group on systolic and diastolic blood pressure, the Taylor Manifest Anxiety Scale, and the Teaching Anxiety Scale (N = 24). Multivariate assessment on all four dependent measures indicated that both the frontalis feedback and stress inoculation groups improved significantly more than the no treatment control, but did not differ overall from one another. The stress inoculation group showed more improvement in self-reported anxiety than the EMG group, while the EMG group tended to do better than the stress inoculation group on blood pressure measures. The untreated control group regressed somewhat across all measures. It was proposed that each treatment may have specific effects that might suggest which treatment would be indicated for a particular client.     

Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis

BACKGROUND: We studied to what extent internet-based cognitive behaviour therapy (CBT) programs for symptoms of depression and anxiety are effective. METHOD: A meta-analysis of 12 randomized controlled trials. RESULTS: The effects of internet-based CBT were compared to control conditions in 13 contrast groups with a total number of 2334 participants. A meta-analysis on treatment contrasts resulted in a moderate to large mean effect size [fixed effects analysis (FEA) d=0.40, mixed effects analysis (MEA) d=0.60] and significant heterogeneity. Therefore, two sets of post hoc subgroup analyses were carried out. Analyses on the type of symptoms revealed that interventions for symptoms of depression had a small mean effect size (FEA d=0.27, MEA d=0.32) and significant heterogeneity. Further analyses showed that one study could be regarded as an outlier. Analyses without this study showed a small mean effect size and moderate, non-significant heterogeneity. Interventions for anxiety had a large mean effect size (FEA and MEA d=0.96) and very low heterogeneity. When examining the second set of subgroups, based on therapist assistance, no significant heterogeneity was found. Interventions with therapist support (n=5) had a large mean effect size, while interventions without therapist support (n=6) had a small mean effect size (FEA d=0.24, MEA d=0.26). CONCLUSIONS: In general, effect sizes of internet-based interventions for symptoms of anxiety were larger than effect sizes for depressive symptoms; however, this might be explained by differences in the amount of therapist support.     

Efficacy of cognitive behavioural therapy for internet gaming disorder

Cognitive behavioural therapy (CBT) is considered to be an effective treatment for internet gaming disorder (IGD). This study examined the effectiveness of CBT in treating impulsivity, anxiety, avoidance, and family and environmental problems in patients. A total of 101 patients completed the CBT programme, and 104 completed the supportive therapy. The CBT programme consisted of fourteen 90‐min sessions with one therapist and four to five patients, once or twice a week. The supportive therapy group visited a psychiatric outpatient department once or twice a week until they completed 14 visits. Outcomes were measured in terms of improvement in IGD, psychological symptoms, and social interaction. The CBT group (improvement: 67 [66.3%] versus non‐improvement: 34 [33.7%]) showed more improvement in IGD compared with the supportive therapy group. The CBT group also showed a greater decrease in internet addiction, anxiety, impulsivity, and social avoidance. In the CBT group, among patients who improved, the greatest improvements were in internet addiction, attention, depression, anxiety, impulsivity, social avoidance, and family cohesion. Our CBT programme may be more effective than supportive therapy with regard to improvement in IGD symptoms by controlling anxiety, impulsivity, and social avoidance. In addition, CBT‐related improvements in patients with IGD could be enhanced by controlling anxiety, social avoidance, and family cohesion.     

戴力新治疗功能性胃肠病109例疗效观察

目的探讨戴力新对功能性胃肠病（FGID）的治疗作用。方法选取我院186例FGID患者,分为治疗组和对照组,每组根据是否伴随焦虑抑郁等症状,以及患者为FD或IBS进行分组。治疗组在常规治疗的基础上加用戴力新,每次1片,每天早上及中午各1次;统计分析各组的有效率和无效率。结果在伴有明显精神症状的患者中,FD患者经戴力新治疗后有效率明显高于对照组,P〈0.01;IBS患者治疗组有效率明显高于对照组,P〈0.01。在不伴有精神症状但经常规治疗无效的FD患者治疗组有效率达75%,IBS患者治疗组有效率达68.7%。结论戴力新是治疗FGID患者的有效且安全的精神类药物,对于伴有明显抑郁或焦虑的FGID患者可在治疗初期即加用戴力新,对于不伴有抑郁或焦虑紧张但是经常规治疗无效的患者可加用戴力新治疗。     

Internet‐based treatment for social phobia: a randomized controlled trial

In this study conducted in the French‐speaking part of Switzerland, 52 individuals with social phobia were randomly assigned either to an Internet‐based cognitive–behavioral treatment with minimal contact with therapists via e‐mail or to a waiting‐list control group. Significant differences between the two groups were found at posttreatment on all primary outcome measures (social anxiety measures) and on two of the secondary outcome measures (general symptomatology, therapy goal attainment). On average, within‐groups effect sizes were large for the primary outcomes (Cohen's d=0.82) and for secondary outcomes (Cohen's d=1.04). Moreover, subjects in the treatment group fulfilled the criteria of clinically significant improvement significantly more often than subjects in the control group on all measured dimensions (58% vs. 20%). Users' acceptance of the program was high. The results from the present study lend further support to the hypothesis that Internet‐delivered interventions with minimal therapist contact are a promising treatment approach to social phobia. © 2009 Wiley Periodicals, Inc. J Clin Psychol 65:1–15, 2009.     

Exposure in vivo of agoraphobics: contributions of diazepam, group exposure, and anxiety evocation.

Fifty-seven chronic agoraphobic outpatients were treated by 12 hours of exposure in vivo on four days over two weeks to check the effects of oral diazepam versus placebo during group exposure, group versus individual exposure, and high versus medium anxiety arousal during individual exposure. The controlled parallel design allowed comparative evaluation of each treatment condition to six months follow-up. Assessment was blind with respect to drug and psychological treatment. Patients in all treatment conditions improved significantly in phobias and in related life areas. Outcome to group exposure on phobias and other measures was similar in all three drug conditions (placebo, waning diazepam, peak diazepam) with no significant differences between them. Diazepam patients had significantly less discomfort than placebo patients during group exposure treatment. Group exposure patients improved slightly but significantly more than individual exposure patients on non-phobic measures, though group exposure was accompanied by more panics during treatment yet was easier to run by the therapist. Individual exposure under high anxiety arousal was no more therapeutic than with lower anxiety. Diazepam is a mild palliative during group exposure but does not facilitate outcome to treatment. Group exposure in vivo is mildly facilitatory for outcome compared with individual exposure. Anxiety evocation during treatment was not therapeutically helpful.     

Effects of psychotherapy for anxiety in children and adolescents: a meta-analytic review

This paper provides a comprehensive quantitative review of high quality randomized controlled trials of psychological therapies for anxiety disorders in children and young people. Using a systematic search for randomized controlled trials which included a control condition and reported data suitable for meta-analysis, 55 studies were included. Eligible studies were rated for methodological quality and outcome data were extracted and analyzed using standard methods. Trial quality was variable, many studies were underpowered and adverse effects were rarely assessed; however, quality ratings were higher for more recently published studies. Most trials evaluated cognitive behavior therapy or behavior therapy and most recruited both children and adolescents. Psychological therapy for anxiety in children and young people was moderately effective overall, but effect sizes were small to medium when psychological therapy was compared to an active control condition. The effect size for non-CBT interventions was not significant. Parental involvement in therapy was not associated with differential effectiveness. Treatment targeted at specific anxiety disorders, individual psychotherapy, and psychotherapy with older children and adolescents had effect sizes which were larger than effect sizes for treatments targeting a range of anxiety disorders, group psychotherapy, and psychotherapy with younger children. Few studies included an effective follow-up. Future studies should follow CONSORT reporting standards, be adequately powered, and assess follow-up. Research trials are unlikely to address all important clinical questions around treatment delivery. Thus, careful assessment and formulation will remain an essential part of successful psychological treatment for anxiety in children and young people.     

Training parents as therapists: A comparison between individual parent-child interaction training and parent group didactic training

Children with home behavior problems frequently are treated via training their parents to become behavior therapists for their own children. One well-established approach has been to use didactic group training. Another approach involves parent training in specific parent-child interaction patterns through the use of modeling, in vivo practice, and immediate feedback. In this study, the effectiveness of these two methods was compared via multiple outcome measures, which included both direct therapist observation and parent report. Twenty-nine children between the ages of 4 and 9 were divided into didactic group-treatment, individual mother-child interaction training, and controls. After five training sessions, therapist observation revealed improvement in the facilitative behavior of the mothers who received individual, in-vivo instruction, as well as improvement in the children's behavior. No significant changes were observed in the group treatment or control conditions. Specific home management behaviors were improved in all three groups according to mothers' reports. The individually trained mothers expressed significantly more satisfaction with the program. It is suggested that direct observation of mother-child behavior, with immediate feedback, reinforcement, and further practice, may be related to the superiority of the individual training method.     

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.     

Effectiveness of a videotaped behavioral intervention in reducing anxiety in emergency oral surgery patients

This study evaluated the effectiveness of a videotaped behavioral treatment program in reducing dental anxiety in emergency oral surgery patients. It compared a videotaped placebo program and a no-treatment control condition. Anxiety, measured for two periods during the study (an anticipatory phase just before oral surgery and a post oral surgery phase), was evaluated by means of self-report, physiological, and behavioral observation measures. Results revealed significant treatment group as well as Group X Sex interaction effects for the heart rate index of physiological arousal. Results also revealed that the treatment program was reported by subjects to be significantly more helpful than the placebo program. Overall, these results suggest that a short, videotaped behavioral intervention can have a positive effect on the oral surgery patient, and that the sex of the subject may be an important variable to be incorporated in evaluating the effectiveness of this type of treatment program.     

Clinical Effects of Xinmailong Therapy in Patients with Chronic Heart Failure

In the last 100 years, intensive studies have been done on the identification of the systematic approaches to find the cure for the chronic heart failure, however the mystery remains unresolved due to its complicated pathogenesis and ineffective early diagnosis. The present investigation was aimed to evaluate the potential effects of the traditional chinese medicine, Xinmailong, on the chronic heart failure (CHF) patients as compared to the standard western medical treatment available so far. In our study, we selected two groups of voluntary CHF patients at the Xiangya Hospital, which were allowed to administrate Xinmailong or standard treatments, respectively. Another group of voluntary healthy individuals were recruited as the control group. The treatment effectiveness was measured by five symptomatic factors, i.e. angiotensin II (Ang_II), high sensitivity C-reactive protein (hs_CRP), Left Ventricular End Systolic Volume Index (LVESVI), left ventricular ejection fraction (LVEF) and pro-B-type natriuretic peptide (NT_proBNP), between the control group and the CHF patients at different stages of drug administration and in different treatment groups. The timeline for the full dose administration was set to 15 days and five measurements as indicated above were taken on every 0, 7th and 15th day of the drug administration respectively. In the conducted study, similar symptomatic measurements were observed on day 0 in both treatment groups, and slight improvements were observed on 7th day. It was observed that after a full course of drug administration for 15 days, both of the treatment groups achieved statistically significant improvements in all the five measures, but Xinmailong was found to be more (almost double) statistically significant as compared with the available drug treatments for chronic heart failure.     

The efficacy of acupuncture combined with Bailemian capsule in the treatment of cervical spondylosis accompanied by headache,anxiety, and depression

ObjectiveThe present study aimed to investigate the efficacy of using acupuncture combined with Bailemian capsule to treat cervical spondylosis by observing the improvement in the degree of headache, anxiety, and depression suffered by patients.MethodsA total of 100 patients with cervical spondylosis of the cervical type were equally divided into a combination group and a control group using the random number table method. The patients in the combination group were treated with acupuncture combined with the oral administration of Bailemian capsule, while those in the control group were only treated with acupuncture. Patient self-assessment was conducted, comprising the visual analogue scale, the self-assessment scale for anxiety, and the self-assessment scale for depression. Before treatment and on the14th and 28th days of treatment, the therapeutic effects of the two treatment modalities on the cervical spondylosis and accompanying headache, anxiety, and depression were analyzed using the Hamilton anxiety scale, the Hamilton depression scale, the Pittsburgh sleep quality inventory, and the Neck Disability Index (%).ResultsThere were statistically significant differences between the two groups in all seven indicators at the different treatment time points (p < 0.01). The seven indicators were significantly reduced in both groups on the 14th and 28th days of treatment compared with before the treatment. Moreover, except for the Neck Disability Index results at 14 days, which did not differ between the groups (p = 0.37), all the other indicators were significantly lower in the combination group than in the control group on the 14th and 28th days of treatment (p < 0.01), and at the end of the treatment, the therapeutic effect was significantly better in the combination group than in the control group (p = 0.006).ConclusionBoth acupuncture combined with Bailemian Capsule and acupuncture alone were effective in the treatment of cervical spondylosis, but the combination therapy was better than the acupuncture alone in improving the accompanying negative symptoms of headache, anxiety, and depression.     

Self-help treatment of anxiety disorders: a meta-analysis and meta-regression of effects and potential moderators

Self-help treatments have the potential to increase the availability and affordability of evidence-based treatments for anxiety disorders. Although promising, previous research results are heterogeneous, indicating a need to identify factors that moderate treatment outcome. The present article reviews the literature on self-help treatment for anxiety disorders among adults, with a total sample of 56 articles with 82 comparisons. When self-help treatment was compared to wait-list or placebo, a meta-analysis indicated a moderate to large effect size (g=0.78). When self-help treatment was compared to face-to-face treatment, results indicated a small effect that favored the latter (g=-0.20). When self-help was compared to wait-list or placebo, subgroup analyses indicated that self-help treatment format, primary anxiety diagnosis and procedures for recruitment of subjects were related to treatment outcome in bivariate analyses, but only recruitment procedures remained significant in a multiple meta-regression analysis. When self-help was compared to face-to-face treatment, a multiple meta-regression indicated that the type of comparison group, treatment format and gender were significantly related to outcome. We conclude that self-help is effective in the treatment of anxiety disorders, and should be offered as part of stepped care treatment models in community services. Implications of the results and future directions are discussed.