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 In a review of the emerging literature on the use of the Internet in the treatment of anxiety disorders in Current Opinion in Psychiatry, researchers from several universities in Sweden looked at whether Internet-delivered treatments for anxiety disorders are supported by the research literature and they asked if there is any evidence to suggest that Internet interventions might be more harmful than helpful. They looked at recent and ongoing studies on Internet-based formats that use cognitive behavioral interventions, mainly derived from the self-help literature that have been transferred to Internet-based formats for use in the treatment of panic disorder.
In general, cognitive behavioral therapies (CBTs) share some common features regardless of the form of administration. The first phase of treatment is usually psychoeducation. Here the client gets basic information on the diagnosis and nature of his or her problems as well as a description of CBT and the treatment rationale. The next step involves both cognitive and behavioral interventions. Cognitive interventions focus on the role of cognitions and how they affect feelings and behavior. After identification of a client's specific negative thoughts or interpretations, cognitive restructuring then aims to question these thoughts and to probe for alternative, more-balanced interpretations that better account for the client's experience. The various behavioral interventions focus on how behavior contributes to his or her problems, and how to change this. In anxiety disorders the primary behavioral intervention in is exposure, where the client is encouraged to expose him- or herself to anxiety-provoking stimuli and to do this multiple times so that habituation of anxiety can occur. The final step of CBT is usually relapse prevention, where the treatment is summarized and a plan for preventing relapse is established.
The authors attempt to clarify the difference between self-help versus minimal-contact treatments in the self-help literature. The majority of Internet applications for anxiety disorders are minimal-therapist-contact interventions, as e-mail contact is added routinely to a structured online self-help text, and tasks are completed on the web site. They make the following distinctions: (1) fully self-administered therapy or pure self-help, (2) predominately self-help (i.e. therapist assesses and provides initial rationale, and teaches how to use the self-help tool), (3) minimal-contact therapy (i.e. active involvement of a therapist, but to a lesser degree than traditional therapy, for example using e-mail), and (4) predominantly therapist-administered therapy (i.e. regular contact with therapist for a number of sessions, but in conjunction with self-help material). Most of the randomized controlled trails on Internet-based treatment could be referred to as minimal-contact therapy. In addition, in research projects structured psychiatric interviews may precede the treatment phase, and in other applications telephone contact, or even group sessions, might be included.
The researchers in general found that while there are only a few promising published studies on the use of the Internet in the treatment of anxiety disorders, there is additional research in progress that gives preliminary support for the use of the Internet in managing anxiety, and in particular panic disorder. The trials to-date have been small and with some limitations. There is a great need for large-scale trials showing that Internet interventions can be used with anxiety disorders, and there is also a need to evaluate stepped-care approaches. It was suggested that some clinicians feel uncomfortable with the perceived risk of not being able to help patients once they had received a self-help intervention. The authors found no evidence in the literature that this is the case, and they emphasize that Internet interventions in some circumstances can be as safe as face-to-face treatments, in particular when they are preceded by an in-session interview. For example, access to therapist feedback is facilitated by e-mail contact, but of course this is only useful if there are responsible clinicians at the other end of the connection who can take care of the responses and who can intervene when needed (e.g. in cases of suicidal ideation).
Some of the challenging issues that these researchers found in using Internet based treatment include patient access to the Internet (there is still a significant proportion of the population for which the Internet is not easily accessed) and managing the technical side of the interventions such as keeping the web sites up-to-date. The final issue that was quite interesting has to do with cost effectiveness. It is often claimed that Internet interventions are cost effective, but the research published so far has not included health economy calculations, which will be needed for such a claim to be supported. For example, the costs of developing and maintaining web sites need to be included in such calculations.
Related studies
Internet-based telehealth system for the treatment of agoraphobia
Treatment of panic disorder via the Internet: a randomized trial of CBT vs. applied relaxation
Common Treatments for Panic Disorder (including Internet-based Treatment)
Interapy. Treatment of posttraumatic stress through the Internet: a controlled trial (pdf)
A Comparison of Changes in Anxiety and Depression Symptoms of Spontaneous Users and Trial Participants of a Cognitive Behavior Therapy Website
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