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Short-Term Effectiveness of Web-Based Guided Self-Help for Phobic Outpatients: Randomized Controlled Trial
1Department of Clinical Psychology and the EMGO institute for Health and Care Research, VU University Amsterdam, Amsterdam, Netherlands
2National Institute for Mental Health Research, The Australian National University, Canberra, Australia
3Department of Psychiatry and the EMGO institute for Health and Care Research, VU University Medical Centre, Amsterdam, Netherlands
4Innovation Incubator, Division Health-Training.Online, Leuphana University, Lüneburg, Germany
Robin N Kok, MSc
Department of Clinical Psychology and the EMGO institute for Health and Care Research
VU University Amsterdam
van der Boechorststraat 1
Amsterdam, 1081 BT
Phone: 31 205983833
Fax: 31 205988756
Background: Internet-based guided self-help has been successfully used in the general population, but it is unknown whether this method can be effectively used in outpatient clinics for patients waiting for face-to-face psychotherapy for phobias.
Objective: The aim was to assess the clinical effectiveness of Phobias Under Control, an Internet-based intervention based on exposure therapy with weekly guidance.
Methods: We conducted a randomized controlled trial, recruiting 212 outpatients scheduled to receive face-to-face psychotherapy for any type of phobia at an outpatient clinic. Participants suffering from at least 1 DSM-IV or ICD-10 classified phobia (social phobia, agoraphobia with or without panic disorder, and/or specific phobia as ascertained by a telephone interview at baseline) were randomly allocated to either a 5-week Internet-based guided self-help program based on exposure therapy with weekly student support followed by face-to-face psychotherapy (n=105) or a wait-list control group followed by face-to-face psychotherapy (n=107). Primary outcome was the Fear Questionnaire (FQ). Secondary outcomes were the Beck Anxiety Inventory (BAI) and Center of Epidemiological Studies-Depression scale (CES-D). Assessments took place by telephone at baseline (T0) and on the Internet at posttest (T1, self-assessment at 5 weeks after baseline). Missing data at T1 were imputed.
Results: At posttest, analysis of covariance on the intention-to-treat sample showed significant but small effect sizes between intervention and control groups on the FQ (d=0.35, P=.02), CES-D (d=0.34, P=.03), and a nonsignificant effect size on the BAI (d=0.28. P=.05). Although initial acceptance was good, high nonresponse was observed, with 86 of 212 participants (40.5%) lost to follow-up at T1 and only 14 of 105 (13.3%) intervention participants finishing all 5 weeks.
Conclusions: Phobias Under Control is modestly effective in lowering phobic and depressive symptoms in a relatively short period and may be clinically beneficial when implemented in routine outpatient practice.
Trial Registration: Netherlands Trial Register NTR2233; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2233 (Archived by WebCite at http://www.webcitation.org/6O2ioOQSs).
(J Med Internet Res 2014;16(9):e226)
phobias; phobic disorders; anxiety disorders; Web-based intervention; Internet therapy; randomized controlled trial; outpatients
Phobias are among the most common mental disorders and the most common type of anxiety disorders . Specific phobias are the most common form of anxiety disorders for both genders, with a total 12-month prevalence of 7.1%, followed by social phobia (4.8%) and agoraphobia without panic disorder (1.2%). All phobias have a negative impact on quality of life and psychosocial functioning , and the societal burden of phobias is considerable [3,4]. Despite detrimental effects on quality of life, research has shown a substantial delay of more than 10 years between onset of symptoms and first therapy attendance . In a recent study, social phobia was found not only to have the earliest onset age, but also an even longer delay—on average 28 years—in seeking treatment . Notwithstanding the impact of a phobia on a patient’s quality of life [2,7], phobias are often not the primary reason for seeking treatment from an outpatient clinic [8,9] and it has been argued that commonly occurring comorbid disorders, such as depression, mask underlying social phobia leading to underdiagnosis in primary care . This suggests widespread undertreatment  for these disorders, even though there is robust evidence of efficacious psychological treatments for agoraphobia , social phobia , and specific phobias , most notably exposure therapy and cognitive behavioral therapy (CBT).
Internet-based interventions are increasingly popular adaptations of evidence-based psychotherapies as a replacement of, or adjunct to, traditional face-to-face therapies. Starting with computer-based, offline interventions (eg, [15,16]), existing therapies such as CBT, exposure therapy, systematic desensitization, and relaxation were found to be efficacious  and were rewritten to suit delivery on the Internet [18,19]. In past years, Internet interventions have been found efficacious for a number of anxiety disorders [17,18,20,21] and phobias, including agoraphobia , specific phobias [14,23,24], and social anxiety disorder [25-27]. Thus, Internet-delivered psychological treatments for anxiety and phobias are feasible, acceptable, and effective.
Typically, outpatients exhibit higher levels of anxiety and a greater number of comorbid and more complex diagnoses, as well as greater psychosocial impairment when compared with general and primary care populations . Previous research has primarily focused on self-referred participants from primary care settings or from the general population , and although some evidence exists on the effectiveness of routine psychological interventions in outpatients , only a limited number of trials have specifically evaluated Internet-based treatments in outpatient clinics and secondary care for common mental disorders [30-33]. To the best of our knowledge, there appear to be no large-scale high-quality trials evaluating the efficacy of Internet-based exposure therapy in phobic outpatients.
Because waiting lists are commonplace in outpatient clinics, time spent waiting for face-to-face treatment could be spent effectively by offering a (guided) self-help intervention to patients. Delegating the routine, basic elements of exposure treatment to a guided Internet-based situation could shorten face-to-face therapy and limit therapist involvement, making the treatment more cost-effective [19,34]. Previous research has indicated that Internet-based therapy for social phobia might be cost-effective relative to face-to-face therapy [35,36]. Furthermore, because pretreatment dropout is common in outpatient clinics , a second postulated benefit may be that continually engaging the patients in their treatments throughout the wait-list period will result in lower pretreatment attrition or “no shows.”
The objective of the current trial was to assess the short-term clinical effectiveness of offering Internet-based guided self-help to outpatients compared to a wait-list control. To our knowledge, this is the first large-scale randomized controlled trial of Internet-based treatment for phobias in outpatients. As such, it will also provide valuable information on the acceptability and feasibility of such an intervention in outpatient clinics. This paper describes the principal short-term outcomes of this multifaceted trial.
A full trial protocol is available elsewhere . This trial was approved by the Medical Ethics Committee of the VU Medical Centre, Amsterdam (registration number 2010/77) and registered with the Dutch Trial Registry (NTR2233). A total of 481 participants who recently applied for psychological treatment at an outpatient clinic consented to be contacted by our research group and were referred to the researchers from August 2010 to December 2013. After briefing the participants about the aims of the study, screening, and obtaining informed consent in writing, eligible participants (n=212) were administered a telephone baseline questionnaire and participants were randomized to either the intervention group (n=105) or treatment as usual (n=107). Patients who were ineligible (n=111), declined participation, or could not be contacted (n=153) remained on the waiting list for face-to-face treatment. The research did not interfere with the outpatient clinics’ wait-list duration or start of treatment and participants could start face-to-face psychotherapy after the intervention or control group period.
A total of 8 specialized anxiety disorder outpatient clinics in medium-to-large cities in the west of the Netherlands participated. Clinics were selected for a high monthly volume of patients for practical reasons. Participants were referred to the outpatient clinics by their general practitioners (GPs), briefly screened, and placed on a waiting list. Recruitment commenced in August 2010 and was stopped in December 2013 to allow for sufficient follow-up time. Waiting lists for outpatient psychotherapy are common in the Netherlands, and time spent on a waiting list is usually at least 6 weeks from first referral to first treatment session. At the start of the wait-list period, participants presenting with a phobia as a primary or secondary disorder were referred to the researchers and screened by telephone using the Composite International Diagnostic Interview (CIDI)  for presence of any phobia by master’s level students. Consequently, exclusion criteria were checked and baseline measures were administered. During this wait-list period, a nontherapeutic meeting with a health care professional from the outpatient clinic took place to ascertain treatment needs and to determine optimal face-to-face treatment for all participants. Additional details on recruitment are available elsewhere .
Eligibility Criteria for Participants
All computer-literate patients with a possible phobia (social phobia, agoraphobia with or without panic disorder, specific phobia) were referred to the researchers by the outpatient clinic even if a phobia was not the primary reason for seeking treatment at an outpatient clinic. Participants had to (1) be 18 years or older, (2) be currently enrolled to receive face-to-face psychotherapy at 1 of the participating outpatient clinics, and (3) have a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision; DSM-IV-TR) or International Classification of Diseases, Tenth Revision (ICD-10) diagnosis of any phobia as established by the CIDI. Psychotropic medication use was allowed if stable for at least the duration of the intervention or control group period. Patients presenting with psychotic disorders or at elevated risk for suicide were excluded from the trial, but remained on the waiting list for face-to-face psychotherapy at their outpatient clinics.
Internet-Based Guided Self-Help
The Internet-based intervention is an adaptation of an existing self-help book on phobias . The intervention is offered at no cost to the participant, takes 5 weeks to complete, and is based on psychoeducation and exposure therapy. The broad and nonspecific focus of the intervention is on identifying and correcting avoidance behavior by using exposure, a common and evidence-based therapeutic component of most phobia therapies . This broad focus facilitates using the intervention for the entire range of phobias. The intervention was presented to the prospective participants as a free-of-charge voluntary course to start reducing their phobic symptoms during the wait-list time. They were told that the intervention was based on evidence-based principles and that the elements they would encounter during the intervention would essentially be the same as in their upcoming face-to-face psychotherapy, allowing for a head start in their treatment. Participants were informed that face-to-face treatment would commence at the scheduled time, regardless of whether they enrolled in the study, and that their decision to participate or not would neither postpone nor advance their face-to-face treatment.
During the intervention, participants build a hierarchy (see Figure 1) of fear-inducing situations or stimuli and expose themselves to these situations or stimuli gradually. The participant completes exposure exercises as homework assignments and reports on his or her accomplishments to the coach each week. In the first weeks, the participant makes an inventory of his or her avoidance and safety behaviors and defines a focal point for exposure situations and a desired behavioral goal. The participant then plans a number of gradual exposure exercises to be executed for the upcoming week, with exposure exercises becoming gradually more challenging each week (see Figure 2). The coach monitors the fear hierarchy and planning and replies with a supportive message once a week for 5 weeks, relevant to the participant’s homework experiences through the secure online platform. All coaching was supervised by an experienced psychotherapist. The intervention is tunneled (ie, no new material is available to the participant until the participant has reported on that week’s achievements and the coach has provided feedback on these achievements). If applicable, the coach sends a standardized reminder message through the secure online platform if the participant did not use the website that week. All actions on the platform (eg, new feedback received, new exercise available) prompted an immediate automated email to the participant. Material from previous weeks remains accessible to the participant. Online coaching messages were delivered through a secured message system on the intervention website by trained and supervised master’s level students of clinical psychology. The participant completes exposure exercises alone and reports on completed exercises weekly. Throughout the intervention period, the participants were kept on the waiting list for face-to-face psychotherapy.
The website platform was migrated to an updated version during the recruitment period. This migration was performed to ensure continuing safety of participant data in accordance with Dutch law and to resolve or mitigate critical bugs and shortcomings in website functionality. Website content, however, remained unaltered throughout recruitment. No substantial website downtime was observed during recruitment.