Journal of Behavior Therapy and Experimental Psychiatry
Efficacy of internet therapy for panic disorder
Introduction
Numerous clinical trials have shown that multi-element treatment protocols for panic disorder (PD), based on cognitive behavioural principles, enable 75–95% of patients to be panic-free following treatment and that these improvements are maintained for at least 2 years (e.g., Brown & Barlow, 1995; Craske, Brown, & Barlow, 1991; Margraf, Barlow, Clark, & Telch, 1993). However, several years ago it was suggested that the major challenges for cognitive behavioural panic treatment (CBT) are to increase its accessibility and affordability (Walker, Norton, & Ross, 1991). In response, considerable research has been conducted into the efficacy of self-help CBT manuals (often with limited therapist assistance) for PD.
Specifically, there is evidence that bibliotherapy may be as effective as face-to-face individual therapy for PD (Cote, Gauthier, Laberge, Cormier, & Plamondon, 1994; Febbraro, Clum, Roodman, & Wright, 1999; Gould & Clum, 1995; Gould, Clum, & Shapiro, 1993; Hecker, Losee, Fritzler, & Fink, 1996; Hecker, Losee, Roberson-Nay, & Maki, 2002; Lindren et al., 1994). Many of these studies have found that participants in the bibliotherapy-based conditions were significantly more improved than waitlist control conditions used (e.g., Febbraro et al., 1999; Gould & Clum, 1995; Gould et al., 1993; Lindren et al., 1994) and comparable to other treatment conditions investigated (e.g., guided imaginal coping, 4 or 8 weeks of group CBT, 12 or 17 sessions of therapist-directed CBT). However, these studies varied in the amount of therapist contact dispensed (i.e., ranging from no therapist contact to brief meetings or telephone calls). More recently, computer-based programs have been developed as another way of providing accessible CBT without the need for intensive therapist involvement. The participant can learn by reading and interacting with the treatment information on a computer program or website and limited therapist contact may also be involved.
In one of the first controlled evaluations of the incorporation of computers into panic treatment, Newman, Kenardy, Herman and Taylor (1997) found that four sessions of CBT utilising a palm-top computer was as effective as 12 sessions of standard face-to-face CBT, both at post-intervention assessment and at follow-up. Web-based programs have also been used to deliver CBT for various psychological disorders. These internet-based interventions have proved effective for body image concerns (Winzelberg et al., 2000), headaches (Strom, Pettersson, & Andersson, 2000), tinnitus (Andersson, Stromgren, Strom, & Lyttkens, 2002), phobias (Kenwright, Marks, Gega, & Mataix, 2004), and post-traumatic stress (Lange, van de Ven, & Schrieken, 2003).
Klein and Richards (2001) found that an internet-based panic information program, based on cognitive behavioural principles, for people with PD had greater positive effects on panic frequency, anticipatory fear of panic, general levels of anxiety, body vigilance, and self-efficacy for managing panic attacks than panic self-monitoring alone. Richards and Alvarenga (2002) developed Klein and Richards’ (2001) program into a five module internet-based program. At 3 months’ post-treatment, there were overall reductions in PD severity and more specifically, reductions in panic frequency and distress during panic attacks. However, this was a single group study without a control condition and attrition was relatively high at 36%.
Internet therapy for PD has also included limited therapist assistance via email. Carlbring, Westling, Ljungstrand, Ekselius, and Andersson (2001) found that participants in email therapist-assisted internet therapy demonstrated greater changes than waitlist controls in frequency, duration and intensity of full panic attacks per week, and on measures of agoraphobic cognitions, fear of bodily sensations, agoraphobic avoidance and general levels of anxiety and depression. Compared to 5% of the waitlist controls, 33% of those having internet therapy reached criterion for clinically significant improvement. Although no follow-up assessment was conducted, their results suggested that internet-based panic treatment, with minimal therapist contact via email, is a promising new treatment approach for people with PD.
It appears that self-help CBT manuals and internet-based treatments for PD are both efficacious but it is unclear how they compare to each other. The following study therefore compared a development of the internet-based CBT program, used by Klein and Richards (2001) and Richards and Alvarenga (2002) in treating PD to a self-help CBT manual (Mastery of Your Anxiety and Panic (MAP-3): Barlow & Craske, 2000) with limited therapist assistance.
This study is the first of its kind to directly compare two relatively efficacious forms of self-help treatment for panic and also builds upon previous investigations of internet-based treatment (e.g., Carlbring et al., 2001). It was predicted that the two forms of self-help treatment would be more efficacious than an information-only control condition; and that the internet-based intervention would be more effective than the self-help manual because it is more interactive and engaging.
Section snippets
Participants
One hundred and thirty individuals were recruited by contacts to our panic website, often via search engines or via links established with other mental health websites in Australia or through local and national print and electronic media.
Inclusion criteria for this study were that participants were Australian residents and had a Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) (American Psychiatric Association (APA), 1994) primary diagnosis of PD (with or without agoraphobia)
Attrition
Of the 55 people who commenced this study, nine discontinued during treatment. The attrition rate for the PO condition was 5% (1/19), 17% (3/18) in the MAN condition, and 28% (5/18) in the IC condition. A Fishers exact test revealed no differences in attrition rates between the three conditions (2, )=3.32, . Reasons given for discontinuing treatment were a reported relapse in a secondary bipolar disorder for the PO participant; in the MAN condition, participants reported either a lack
Discussion
The results of this study provide further evidence for the efficacy of reduced-therapist CBT for PD. The first hypothesis under consideration was that the active CBTs would be more efficacious than the IC condition on measures pertaining to panic symptomatology, panic cognition, negative affect, and self-rated physical health at post-treatment.
The two active treatments were indeed superior to the IC condition on all dependent variables at post-treatment. These findings are consistent with
Acknowledgement
We thank the Australian Rotary Health Research Fund in Australia for the grant they awarded us to conduct the study.
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