Online interventions for anxiety disorders.

REVIEW URRENT C OPINION

Online interventions for anxiety disorders Helen Christensen a, Philip Batterham b, and Alison Calear b

Purpose of review The present article updates knowledge regarding the evidence base for online interventions for anxiety disorders, and provides an overview of recent advances in online interventions for anxiety over the past 18 months. Recent findings Computerized self-help is an effective strategy for providing evidence-based treatments for symptoms of anxiety and depression. Online delivery has numerous advantages for clinicians and patients, including greater accessibility, anonymity, convenience and cost-effectiveness. These may be particularly important for populations experiencing anxiety, which may face more pronounced barriers to accessing care. Recent meta-analyses have confirmed that computerized cognitive behaviour therapy (CBT) for anxiety demonstrates comparable clinical outcomes as face-to-face psychotherapy for individuals with anxiety. This review updates the status of current knowledge by providing a focused review of randomized controlled trials of computerized (including Internet and portable device-delivered) treatments for anxiety. Summary Recent studies have confirmed the utility of computerized psychotherapy for anxiety. Future trials are required to elucidate the active constituents of effective programs, evaluate targeted approaches for specific groups, and to ascertain the optimal degree of guidance required. Clarification of these issues will assist in refining effective online programs operating within standalone virtual clinics or incorporated into cliniciansupported stepped care approaches. Keywords anxiety, guided, internet, online, self-help

INTRODUCTION Anxiety disorders are now recognized as a major contributor to the global burden of disease [1]. Anxiety is a key risk factor for the development of bipolar disorder, suicide and suicide attempt [2,3]. Online therapies are now considered a viable treatment option for anxiety disorders. The advantages of online anxiety programs include access to treatment for those not wishing to seek professional help, without access to services, including rural and remote dwellers, where waiting lists are long, and for those who prefer to seek help autonomously [4,5]. Additional advantages include lower cost, high availability (24/7) and capacity for rapid dissemination [6,7]. In recent years, governments of countries across the world, such as the United Kingdom, Sweden and Australia, have provided support for the use of these programs through primary care, or directly through online portals. For example, Fearfighter [8] and Beating the Blues [9] are recommended for use in the United Kingdom through primary care trusts. In Australia, the Department of Health and Ageing supports a portal that provides

access to evidence-based e-health applications (http://mindhealthconnect.org.au) [10] and funds open access, free evidence-based e-health applications for managing anxiety and depression, such as MyCompass (https://mycompass.com.au) and MoodGYM (https://moodgym.anu.edu.au). This article aims to identify new research examining the effectiveness and usefulness of Internet or computer-based programs for anxiety treatment and prevention. We review four meta-analyses of Internet-based treatment programs, which have been published since 2009 [7,11–13]. In addition, we have identified 29 new randomized controlled trials published in the past year (2012 – June 2013). In this a

Black Dog Institute, University of New South Wales, Randwick, New South Wales and bCentre for Mental Health Research, Australian National University, Canberra, Australia Correspondence to Professor Helen Christensen, Black Dog Institute, Hospital Road, Randwick, Sydney, NSW 2031, Australia. Tel: +61 02 9382 9285; e-mail: [emailprotected] Curr Opin Psychiatry 2014, 27:7–13 DOI:10.1097/YCO.0000000000000019

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article, we review the previous meta-analyses, the new effectiveness trials and identify current themes concerning online treatment for anxiety. These themes address evidence for the best type of therapy, the suitability of online interventions for the range of anxiety disorders, the extent to which clinician support is required, the relative effectiveness of faceto-face and online treatments, the use of these programs in adolescents and young people and the issue of adherence.

computerized CBT, all of the studies that focused on anxiety disorders involved Internet-based CBT (iCBT). The mean effect size was 0.92 for social phobia (n ¼ 8); 0.83 for panic disorder (n ¼ 6), and 1.12 for GAD (n ¼ 2). Two studies directly compared face-to-face treatment for anxiety disorder (panic disorder), and no differences were reported. Two other meta-analyses have since been reported, although neither focused exclusively on online anxiety programs or included all forms of online programs. The first by Lewis et al. [13] examined only self-help interventions for anxiety disorders, including websites, books, CDs and DVDs. The findings indicated large outcomes relative to waitlist control conditions for self-help interventions but negative effect sizes relative to therapist delivered interventions. Finally, Paul et al. [15] published a systematic review of web-based approaches to improving psychosocial health, or quality of life, in chronic physical and mental health conditions. However, the coverage of this review is broader than that of anxiety disorders, with its scope encompassing chronic health conditions, and it had a focus on improving well being and quality of life as outcomes of interest.

PREVIOUS SYSTEMATIC REVIEWS AND META-ANALYSES

EFFECTIVENESS TRIALS PUBLISHED IN THE PAST 12 MONTHS

Griffiths et al. [14] focused on Internet interventions for depression and anxiety disorders, uncovering 26 randomized controlled trials (RCTs), of which 16 targeted an anxiety disorder [panic disorder, five; social phobia, five; posttraumatic stress disorder (PTSD), four; unspecified anxiety, two] and two targeted both anxiety and depression. Independent of type of control condition, all anxiety interventions demonstrated positive results on at least one measure, with the exception of one SP study. Published effect sizes ranged from 0.29 to 1.74, with the majority above 0.65. Cuijpers et al. [7] reviewed RCTs of computerized psychotherapy for anxiety disorders, including Internet programs. Twentythree articles reporting on RCTs were identified, including phobia (n ¼ 10); panic disorder/agoraphobia, (n ¼ 9); PTSD, (n ¼ 3); and obsessive compulsive disorder (OCD) (n ¼ 1). The overall mean effect size was found to be 1.08. Based on 13 comparisons, face-to-face therapy did not differ from online delivery of CBT [7]. Effects persisted at 12-month follow-up. Andrews [11] identified 22 studies. Sixteen of these focused on anxiety disorders: panic disorder [6], social phobia [8] or generalized anxiety disorder (GAD) [2]; the remaining six dealt with major depression. Although two of the studies aimed at treating depression included clinic-based

Using search terms for anxiety disorders, RCTs, and computer-based studies we conducted a literature search in PsycInfo and PubMed to identify studies published in the past year (January 2012 to July 2013). Studies focussing on depression were included if anxiety was a secondary outcome. We also searched an existing database of peer-reviewed RCTs reporting on studies of mobile applications for mental health disorders for relevant articles from the past year [16]. A total of 77 articles were retrieved for full text coding from the past year. Twenty nine relevant RCTs were identified. These are summarized in Table 1. [17,18 ,19–21,22 ,23, 24 ,25 ,26–28,29 ,30,31 ,32,33 ,34 ,35–39,40 ,41 , 42 ,43–45]

KEY POINTS Computerized and Internet-delivered self-help CBT is highly effective for anxiety in adults, and shows comparable clinical outcomes as face-toface psychotherapy. CBT remains the dominant Internet therapy. Studies in adolescence and youth support the positive findings seen in outcome trials for adults. Adherence to online trials is comparable to other forms of psychotherapy.

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NOTEWORTHY THEMES AND ISSUES We identified several key themes that arose within the current literature, which we outline and discuss below.

Type of therapy The bulk of interventions used CBT. An example of these studies is that of Newby [40 ]. This study targeted mixed anxiety and depression, delivering &

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Online interventions for anxiety disorders Christensen et al. Table 1. Basic characteristics of studies included in current review Country conducted

Target population (Age)

Disorder targeted by intervention

Type of intervention

[17]

USA

Adults

Social anxiety

Bias modification

[18 ]

Sweden

Adults

Social anxiety

CBT

[19]

Sweden

Adults

GAD

Psychodynamic / CBT

[20]

Canada

Adults

Misc.

CBT/stress management

[21]

Adults

Anxiety disorders

CBT

[22 ]

Adults

Misc.

CBT

[23]

Sweden

Adults

Social anxiety

Bias modification

[24 ]

Germany

Adolescents

Misc.

CBT

[25 ]

Sweden

Adults

Misc.

CBT

[26]

Netherlands

Adolescents

Depression and anxiety

PST

[27]

Sweden

Adults

Depression

CBT

[28]

Netherlands

Adults

Misc.

CBT

[29 ]

Australia

Adolescents

Anxiety

CBT

[30]

Australia

Adults

Depression

Bias modification

[31 ]

Netherlands

Adolescents and Adults (16–25)

Depression

CBT

Reference

[32]

USA

Adults

Misc.

Social cognitive therapy/psychoeducation

[33 ]

Netherlands

Adolescents

Social anxiety

Bias modification

[34 ]

USA

Adults

Stress

Stress management

[35]

Australia

Adults

Social anxiety

Bias modification

[36]

Canada

N.R.

Misc.

CBT

[37]

Australia

Adults

Bipolar disorder

Psychoeducation

[38]

Adults

Misc.

CBT

[39]

Adults

Depressive symptoms

CBT

[40 ]

Australia

Adults

Anxiety and depression

CBT

[41 ]

Germany

Adults

Social anxiety

Bias modification

[42 ]

Adolescents

Depression

CBT

[43]

Adolescents

Depression

CBT

[44]

Sweden

Adults

Panic attacks

CBT

[45]

Italy

Adults

Stress

Stress management

Adolescents, 12–17 years; adults, 18–64 years; CBT, Cognitive Behaviour Therapy; GAD, generalized anxiety disorder; Misc, Miscellaneous conditions – included a range of conditions including disfigurement-related distress, eating disorder symptomatology, insomnia, maladaptive perfectionism, perfectionism, postdisaster trauma, severe health anxiety, wellbeing; NZ, New Zealand; N.R, Not reported; PST, problem solving therapy; UK, United Kingdom; US, United States.

a 10-week, therapist-assisted program. Findings indicated a relatively large between-group effect size of 0.8. This effect size is indicative of studies of this type, the mean effect size being 0.8 (range 0.2–1.6). Notably, the second most common type of intervention was bias modification. This may, in part, be a reflection of the critical role of attentional and cognitive biases in the development and maintenance of anxiety [20,46,47]. A notable example of a bias modification study is that of Neubauer [41 ]. This study is an RCT of Internet-delivered attention modification training for social phobia which examined the effectiveness of a 4.5-week intervention delivered to adults meeting criteria for social &

phobia. As was the trend for studies concerning bias modification in this review, no significant effects were found between the intervention and control groups at posttest or final follow-up (4 months in this case), and the effect size was fairly modest. Overall, the evidence for the efficacy of bias modification interventions for anxiety was somewhat lacking, with effect sizes for bias modification studies 0.07–0.42 and most/all effects nonsignificant. Three computerized stress-management interventions were evaluated. A good example of these is Rose [34 ]. This study tested a 6-week computer-based self-guided stress management and resilience training program that contained

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animated game-like activities focusing on day-today management of stress.

Type of anxiety

anxiety with a face-to-face CBT intervention for social anxiety with assessment only. There was no significant difference in reduction of social anxiety symptoms between the active conditions at posttest. The second study [22 ] compared an online intervention with standard face-to-face CBT for facialdisfigurement distress, and found both conditions differed from the control. &

The majority of studies meeting criteria for this review included anxiety as a secondary outcome to other mental health problems such as depression and depressive symptoms, bipolar disorder, anorexia, hypochondriasis, general mental well being and insomnia. Of the eight studies that focused primarily on anxiety, the major target was social phobia (five studies [1,10,30,37,44]), with only one study [44] targeting panic disorder, and two targeting symptoms of anxiety. New targets for online therapy were uncovered. The study by Fichter et al. [24 ] examined a 36-week CBT Internet-based prevention program for anorexia nervosa relapse. This study included a measure of phobic anxiety, finding that a significant difference between intervention and control groups in phobic anxiety at posttest, and an effect size of 0.22. Also of interest is the study by Bessel et al. [22 ] on the effectiveness of an 8-week computer-based CBT intervention for disfigurement-related distress and the study by Hedman et al. [25 ] of the long-term effectiveness of a 12-week iCBT course for severe health anxiety/hypochondriasis. &

Level of clinician support

New technologies Although there have been significant gains in technology afforded by the rise of smartphones and tablet devices, only one of the identified RCTs tested a mobile application [45]. This study was a small RCT of stress management for nurses (n ¼ 16), and reported significant improvements in anxiety for the treatment group [45].

Adolescence and youth Previous reviews [48,49] completed in 2010 identified only three online trials of two programs targeting youth: BRAVE-Online, a cognitive behavior therapy (CBT) program designed to treat anxiety in children and adolescents (7–14 years), and the CBT-based MoodGYM depression prevention program in an adolescent (13–17 years) school-based population. During the past 12 months, another five RCTs have been published [26,29 ,33 ,42 ,43] recruiting adolescents. Two of these trials [42 ,43] evaluated the effectiveness of the SPARX program, a CBT-based depression treatment program for adolescents (12–19 years). One of the trials [42 ] reported a significant effect for generalized anxiety at postintervention, while the other did not find an effect for anxiety [43]. Two [26,33 ] of the three remaining trials also did not report positive outcomes for anxiety, but these interventions used PST for mild anxiety or depression [26] and CBM for social and test anxiety [33 ]. As noted above (type of therapy) CBT interventions appear to be the most reliable in effecting positive outcomes. The final study evaluated the CBT-based Cool Teens program, which found a significant reduction in anxiety symptoms amongst adolescents (14–17 years) with a primary diagnosis of anxiety [29 ]. As with adults, online CBT appears to be the most reliable means to shift anxiety in adolescents using technology. &

The majority of identified studies were either solely or primarily self-help in conjunction with minimal therapist guidance (generally weekly, via E-Mail, with 24-h turnaround, concerning homework feedback and facilitating completion of intervention). Some studies featured unique types of guidance, for example peer support coaching by bipolar sufferers alongside psychoeducation [37], online group CBT sessions hosted by a therapist [31 ] and therapist support via telephone to both parents and adolescents [29 ]. The heterogeneity among the studies in amount and type of guidance made it difficult to draw consistent conclusions about the utility of clinician support. Andersson et al. [18 ] concluded that the degree of therapist experience in the delivery of Internet programs did not appear to make a difference to clinical outcome but might speed up protocol administration. &

Comparison with face-to-face Only two of the studies identified compared an online intervention with a face-to-face intervention. Sportel et al. [33 ] compared an online cognitive bias modification (CBM) intervention for social &&

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Adherence and dropout Among the 29 anxiety studies identified from the past year, 25 reported rates of dropout at posttest, with mean dropout of 18% (SD ¼ 14%, range Volume 27 Number 1 January 2014

Online interventions for anxiety disorders Christensen et al.

0–64%) and only five studies with dropout rates above 30%. These high rates of retention are comparable to those found in previous reviews of online anxiety interventions [7,11,50]. Definitional issues remain problematic [50–52]. Two of the identified studies focused on intervention adherence as an outcome [37,40 ]. One of these [37] found that adherence was greater when the online program included a peer support component, while females and older participants were also more likely to adhere to the program. The other [40 ] reported that adherence was high in a defined clinical population but lower in a primary care setting, despite large effect sizes. Adherence and dropout have also been examined as predictors of effectiveness. One study reported greater adherence was associated with greater intervention effectiveness [24 ], whereas another found no difference in outcomes for completers and noncompleters [26]. &

CONCLUSION Online therapies, particularly those using CBT, are effective for anxiety disorders and anxiety symptoms secondary to disorders such as major depression. However, there remain gaps in the literature. No direct comparisons have yet been published of anxiolytics/antidepressants and online therapies. Refinements in the type of intervention delivered are also required. Online programs for GAD and OCD are lacking with few research trials. Nevertheless, the evidence from previous work as well as from the current crop of RCTs remains strong enough to support the promotion of online programs to the public and to clinicians for use within their practice. There is also a need to switch the focus from efficacy and effectiveness studies to implementation trials within healthcare settings. This may involve the development of new models of care through ‘direct to the public’ virtual clinics, integration across healthcare systems in cliniciansupported stepped care models, or through workforce channels or school settings. New developments into the future will include training of General Practitioners in e-health, the escalation of e-health programs as part of ‘low intensity’ interventions in primary care, developments in General Practitioners’s prescription software to facilitate referral to online programs, and other developments linked with country-specific healthcare models. Both clinicians and the public recognize the importance of the information that is required to assure the quality of websites and programs. In response, the Beacon website at the Australian National University (https://beacon.anu.edu.au/) was established to summarize the features and

research evidence for online and mobile applications for mental health, including those targeting anxiety. We recommend this reference site for clinicians and the general public [53,54 ]. To date, most online interventions have focused on the treatment rather than the prevention of anxiety disorders. However, the Internet offers a solution to the delivery of prevention programs, given its capacity for rapid dissemination of evidence-based programs, at low cost [6]. A recent meta-analysis of anxiety prevention in youth [55] demonstrated an overall effect size at postintervention of 0.18. In light of these positive findings, the potential of online programs for broad reach and the fact that the majority of young people are active online [56] suggests that universal prevention of anxiety in schools through the Internet is likely to be a significant opportunity in the near future. &

Acknowledgements Many thanks are due to John Gosling, Katherine Petrie, and Kanupriya Kalia Hehir for undertaking the literature search, screening and coding process, and for their comments and assistance on article drafts. Conflicts of interest No conflicts of interest are reported.

REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study. Lancet 2012; 380: 2163–2196. 2. Batterham PJ, Christensen H, Calear AL. Anxiety symptoms as precursors of major depression and suicidal ideation. Depress Anxiety 2013; 30:908–916. 3. Nurnberger JI Jr, McInnis M, Reich W, et al. A high-risk study of bipolar disorder: childhood clinical phenotypes as precursors of major mood disorders. Arch Gen Psychiatry 2011; 68:1012–1020. 4. Griffiths KM, Christensen H. Internet-based mental health programs: a powerful tool in the rural medical kit. Aust J Rural Health 2007; 15:81–87. 5. Cuijpers P, Munoz RF, Clarke GN, Lewinsohn PM. Psychoeducational treatment and prevention of depression: the ‘Coping with Depression’ course thirty years later. Clin Psychol Rev 2009; 29:449–458. 6. Munoz RF. Using evidence-based internet interventions to reduce health disparities worldwide. J Med Internet Res 2010; 12:e60. 7. Cuijpers P, Marks IM, van Straten A, et al. Computer-aided psychotherapy for anxiety disorders: a meta-analytic review. Cogn Behav Ther 2009; 38:66– 82. 8. Marks IM, Mataix-Cols D, Kenwright M, et al. Pragmatic evaluation of computer-aided self-help for anxiety and depression. Br J Psychiatry 2003; 183:57–65. 9. Proudfoot J, Ryden C, Everitt B, et al. Clinical efficacy of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. Br J Psychiatry 2004; 185:46–54. 10. Ageing. DoHa. Mind Health Connect. 2012; http://www.mindhealthconnect.org.au/ [Accessed on 5 August 2013]. 11. Andrews G, Cuijpers P, Craske MG, et al. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical healthcare: a meta-analysis. PLoS One 2010; 5:e13196.

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Mood and anxiety disorders 12. Andersson G, Cuijpers P. Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cogn Behav Ther 2009; 38:196–205. 13. Lewis C, Pearce J, Bisson JI. Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: systematic review. Br J Psychiatry 2012; 200:15–21. 14. Griffiths KM, Farrer L, Christensen H. The efficacy of internet interventions for depression and anxiety disorders: a review of randomised controlled trials. Med J Aust 2010; 192:S4–S11. 15. Paul CL, Carey ML, Sanson-Fisher RW, et al. The impact of web-based approaches on psychosocial health in chronic physical and mental health conditions. Health Educ Res 2013; 28:450–471. 16. Donker T, Petrie K, Proudfoot J, et al. Smartphones for smarter delivery of mental health programs: a systematic review. J Med Internet Res . (in press). 17. Amir N, Taylor CT. Interpretation training in individuals with generalized social anxiety disorder: a randomized controlled trial. J Consult Clin Psychol 2012; 80:497–511. 18. Andersson G, Carlbring P, Furmark T, on behalf of the SOFIERG. Therapist && experience and knowledge acquisition in internet-delivered CBT for social anxiety disorder: a randomized controlled trial. PLoS ONE 2012; 7:e37411. This study is the first and to the authors’ knowledge, probably the largest ICBT study for social anxiety disorder in which therapists with varying degrees of experience were randomly allocated to participants, allowing examination of effects of therapist experience on clinical outcome. 19. Andersson G, Paxling B, Roch-Norlund P, et al. Internet-based psychodynamic versus cognitive behavioral guided self-help for generalized anxiety disorder: a randomized controlled trial. Psychother Psychosom 2012; 81:344–355. 20. Arpin-Cribbie C, Irvine J, Ritvo P. Web-based cognitive-behavioral therapy for perfectionism: a randomized controlled trial. Psychother Res 2012; 22:194– 207. 21. Bell CJ, Colhoun HC, Carter FA, Frampton CM. Effectiveness of computerised cognitive behaviour therapy for anxiety disorders in secondary care. Aust N Z J Psychiatry 2012; 46:630–640. 22. Bessell A, Brough V, Clarke A, et al. Evaluation of the effectiveness of Face IT, & a computer-based psychosocial intervention for disfigurement-related distress. Psychol Health Med 2012; 17:565–577. This is the first clinical trial to test (and demonstrate) the efficacy of an evidencebased e-mental health intervention in reducing anxiety and appearance-related distress in people with a facial disfigurement. This article builds a strong foundation for the future of online interventions for people with appearance-related distress as a first step in a stepped-care approach. 23. Carlbring P, Apelstrand M, Sehlin H, et al. Internet-delivered attention bias modification training in individuals with social anxiety disorder: a double blind randomized controlled trial. BMC Psychiatry 2012; 12:66. 24. Fichter MM, Quadflieg N, Nisslmuller K, et al. Does internet-based prevention & reduce the risk of relapse for anorexia nervosa? Behav Res Ther 2012; 50:180–190. This study examined a 36-week internet-based prevention program for anorexia nervosa relapse. This is the first study looking at an internet intervention for anorexia nervosa, and utilises online Cognitive Behavioural Therapy. This study included a measure of phobic anxiety, finding that a significant difference between intervention and control groups in phobic anxiety at posttest, and an effect size of 0.22. 25. Hedman E, Andersson E, Lindefors N, et al. Cost-effectiveness and long-term & effectiveness of internet-based cognitive behaviour therapy for severe health anxiety. Psychol Med 2013; 43:363–374. This study examined the long-term effectiveness of a 12-week iCBT course for severe health anxiety/hypochondriasis. This is of interest as it focuses on severe health anxiety, a less researched problem, and looks at long-term outcomes as well as cost-effectiveness. A between-group effect size at posttest of 1.62 was found, although this study did not find significant effects between intervention and control groups at posttest or final follow-up. 26. Hoek W, Schuurmans J, Koot HM, Cuijpers P. Effects of internetbased guided self-help problem-solving therapy for adolescents with depression and anxiety: a randomized controlled trial. PLoS One 2012; 7:e43485. 27. Johansson R, Sjoberg E, Sjogren M, et al. Tailored vs. standardized internetbased cognitive behavior therapy for depression and comorbid symptoms: a randomized controlled trial. PLoS One 2012; 7:e36905. 28. Lancee J, van den Bout J, van Straten A, Spoormaker VI. Internet-delivered or mailed self-help treatment for insomnia?: a randomized waiting-list controlled trial. Behav Res Ther 2012; 50:22–29. 29. Wuthrich VM, Rapee RM, Cunningham MJ, et al. A randomized controlled trial & of the Cool Teens CD-ROM computerized program for adolescent anxiety. J Am Acad Child Adolesc Psychiatry 2012; 51:261–270. This study featured a unique intervention comprising computerised CBT self-help for adolescents with primary anxiety disorder (DSM-IV diagnosis) and therapist telephone sessions to both adolescent and parents, with adolescents also supported by their parents who also received brief CBT handouts of core strategies to support their adolescent. This multifaceted intervention may be particularly suited to a younger age group, allowing for intensive support within their home environment as well as offering a degree of self-directed individual CBT learning too.

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30. Williams AD, Blackwell SE, Mackenzie A, et al. Combining imagination and reason in the treatment of depression: a randomized controlled trial of internet based cognitive-bias modification and internet-CBT for depression. J Consult Clin Psychol 2013; 81:793–799. 31. van der Zanden R, Kramer J, Gerrits R, Cuijpers P. Effectiveness of an online & group course for depression in adolescents and young adults: a randomized trial. J Med Internet Res 2012; 14:e86. This study is one of the first randomized controlled trials to date to investigate an online depression treatment for youth (majority of previous studies have focused on adults) and the first to feature an online group course (rather than an individual approach). 32. Steinmetz SE, Benight CC, Bishop SL, James LE. My disaster recovery: a pilot randomized controlled trial of an internet intervention. Anxiety Stress Coping 2012; 25:593–600. 33. Sportel BE, de Hullu E, de Jong PJ, Nauta MH. Cognitive bias modification && versus CBT in reducing adolescent social anxiety: a randomized controlled trial. PLoS One 2013; 8:e64355. This was the first clinical trial to test the efficacy of CBM in early intervention in a multidimensional CBM approach. 34. Rose RD, Buckey JC Jr, Zbozinek TD, et al. A randomized controlled trial of a & self-guided, multimedia, stress management and resilience training program. Behav Res Ther 2013; 51:106–112. Tested a novel 6-week computer-based self-guided stress management and resilience training program that contained animated game-like activities focusing on day-to-day management of stress, and for this reason it has been included for annotation. Of the three studies included in this review that dealt with stress management, two reported a between-group effect size – this study (e.s. ¼ 0.14) and Villani et al. 2011 (e.s. ¼ 0.67), demonstrating that there is need for further exploration in this area. 35. Rapee RM, MacLeod C, Carpenter L, et al. Integrating cognitive bias modification into a standard cognitive behavioural treatment package for social phobia: a randomized controlled trial. Behav Res Ther 2013; 51:207– 215. 36. Radhu N, Daskalakis ZJ, Arpin-Cribbie CA, et al. Evaluating a web-based cognitive–behavioral therapy for maladaptive perfectionism in university students. J Am Coll Health 2012; 60:357–366. 37. Proudfoot J, Parker G, Manicavasagar V, et al. Effects of adjunctive peer support on perceptions of illness control and understanding in an online psychoeducation program for bipolar disorder: a randomised controlled trial. J Affect Disord 2012; 142:98–105. 38. Powell J, Hamborg T, Stallard N, et al. Effectiveness of a web-based cognitivebehavioral tool to improve mental well being in the general population: randomized controlled trial. J Med Internet Res 2013; 15:e2. 39. Phillips R, Schneider J, Molosankwe I, et al. Randomized controlled trial of computerized cognitive behavioural therapy for depressive symptoms: effectiveness and costs of a workplace intervention. Psychol Med 2013; 1–12. 40. Newby JM, Mackenzie A, Williams AD, et al. Internet cognitive behavioural & therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care. Psychol Med 2013; 1–14. This study targeted mixed anxiety and depression, delivering a 10-week, therapistassisted program. Findings indicated a relatively large between-group effect size of 0.8, and this is fairly indicative of studies of this sort (i.e. CBT-based), making it of interest because it is representative of this area of research. 41. Neubauer K, von Auer M, Murray E, et al. Internet-delivered attention mod& ification training as a treatment for social phobia: a randomized controlled trial. Behav Res Ther 2013; 51:87–97. An RCT of internet delivered attention modification training for social phobia in which the effectiveness of a 4.5-week intervention delivered to adults meeting criteria for social phobia. As was the trend for studies concerning bias modification in this review, no significant effects were found between the intervention and control groups at posttest or final follow-up (4 months in this case), and the effect size was fairly modest at 0.31 [which was fairly representative of bias modification studies found, with the exception of Amir et al. (2012), who reported a very large effect]. This article has been chosen for annotation as it represents the bias modification literature included in this review fairly well. 42. Merry SN, Stasiak K, Shepherd M, et al. The effectiveness of SPARX, a && computerised self help intervention for adolescents seeking help for depression: randomised controlled noninferiority trial. BMJ 2012; 344: e2598. This study shows the effectiveness of a game SPARX for depression in adolescents in a well controlled noninferiority trial. Although this study targeted depression, rather than anxiety, it is of significance because it uses an interactive game, which was acceptable and appealed to adolescents, and showed effectiveness against current treatment provided through health providers. Moreover, it shows the type of research design that might be replicated for anxiety disorders as the primary target. 43. Fleming T, Dixon R, Frampton C, Merry S. A pragmatic randomized controlled trial of computerized CBT (SPARX) for symptoms of depression among adolescents excluded from mainstream education. Behav Cogn Psychother 2012; 40:529–541. 44. Silfvernagel K, Carlbring P, Kabo J, et al. Individually tailored internet-based treatment for young adults and adults with panic attacks: randomized controlled trial. J Med Internet Res 2012; 14:e65.

Volume 27 Number 1 January 2014

Online interventions for anxiety disorders Christensen et al. 45. Villani D, Grassi A, Cognetta C, et al. The effects of a mobile stress management protocol on nurses working with cancer patients: a preliminary controlled study. Stud Health Technol Inform 2012; 173:524–528. 46. Bar-Haim Y, Lamy D, Pergamin L, et al. Threat-related attentional bias in anxious and nonanxious individuals: a meta-analytic study. Psychol Bull 2007; 133:1–24. 47. Ouimet AJ, Gawronski B, Dozois DJ. Cognitive vulnerability to anxiety: a review and an integrative model. Clin Psychol Rev 2009; 29:459–470. 48. Calear AL, Christensen H. Review of internet-based prevention and treatment programs for anxiety and depression in children and adolescents. Med J Aust 2010; 192:S12–S14. 49. Richardson T, Stallard P, Velleman S. Computerised cognitive behavioural therapy for the prevention and treatment of depression and anxiety in children and adolescents: a systematic review. Clin Child Fam Psychol Rev 2010; 13:275–290. 50. Christensen H, Griffiths KM, Farrer L. Adherence in internet interventions for anxiety and depression. J Med Internet Res 2009; 11:e13.

51. Murray E, White IR, Varagunam M, et al. Attrition revisited: adherence and retention in a web-based alcohol trial. J Med Internet Res 2013; 15:e162. 52. Eysenbach G. The law of attrition. J Med Internet Res 2005; 7:e11. 53. Christensen H, Murray K, Calear AL, et al. Beacon: a web portal to high-quality mental health websites for use by health professionals and the public. Med J Aust 2010; 192:S40–S44. 54. Christensen H, Petrie K. State of the e-mental health field in Australia: where & are we now? Aust N Z J Psychiatry 2013; 47:117–120. This article provides a recent update of the contents of Beacon, a useful online resource that provides a compendium of evidence-based resources in anxiety and other mental health disorders. 55. Fisak BJ Jr, Richard D, Mann A. The prevention of child and adolescent anxiety: a meta-analytic review. Prev Sci 2011; 12:255–268. 56. Burns JM, Davenport TA, Durkin LA, et al. The internet as a setting for mental health service utilisation by young people. Med J Aust 2010; 192: S22–S26.

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