Using online-cognitive behaviour therapy (Online-CBT) to treat general anxiety and worry among older adults: Is it effective and does client engagement matter?

ISRCTN ISRCTN83626400
DOI https://doi.org/10.1186/ISRCTN83626400
Submission date
18/06/2013
Registration date
27/09/2013
Last edited
05/08/2021
Recruitment status
No longer recruiting
Overall study status
Completed
Condition category
Mental and Behavioural Disorders
Prospectively registered
Protocol
Statistical analysis plan
Results
Individual participant data

Plain English summary of protocol

Background and study aims
Anxiety is common among adults aged 60 years and older. Research shows that Cognitive Behaviour Therapy (CBT), a structured psychological therapy, is effective for treating anxiety; however, anxiety in older adults often goes untreated due to a lack of access to treatment providers, mobility difficulties in attending appointments, and the stigma of seeking help for mental health problems. To address this issue, researchers have developed therapist-assisted Online-CBT for the treatment of anxiety, depression and other mental health concerns. To date, there has been very little research studying the use of Online-CBT by adults aged 60 years and over. Therefore, this study will determine whether an Online-CBT program, made to meet the needs of an older population, is effective at reducing anxiety, worry and depression, and for improving quality of life. Because this service is newly available, this study will also look at older adults’ engagement with the treatment program and their therapists, and will collect feedback about their experiences to help improve the service for future seniors.

Who can participate?
This study aims to recruit adults aged 60 years or over living in the province of Saskatchewan who experience at least moderate general anxiety symptoms or meet criteria for generalized anxiety disorder.

What does the study involve?
All interested individuals will participate in a telephone screening to determine if Online-CBT matches their needs. The screening is a two-part process that takes 15 to 60 minutes and will ask questions about their anxiety and other mental health history. Following the screening, they will be randomly allocated to either receive Online-CBT immediately or after waiting 10 weeks. The Online-CBT program, titled GAD Online for Older Adults, is designed for treating older adults with generalized anxiety symptoms. The program consists of seven treatment modules containing CBT materials that are accessed online, as well as activities that are to be completed offline. The modules include information about generalized anxiety, how to monitor anxiety and worry, relaxation techniques, how to monitor thoughts and challenge them, how to reduce and control worry, and other coping strategies. Clients should engage in Online-CBT for about 7 to 10 weeks. All participants are asked to complete questionnaires at the start of the study and again 10 weeks later. Those who receive Online-CBT are also asked to complete a brief set of questionnaires one month after finishing treatment.

What are the possible benefits and risks of participating?
For participants assigned to receive Online-CBT and for those waiting list participants who opt to receive Online-CBT after the waiting period, there are potential benefits and challenges associated with the therapy delivered online. The potential benefits include: you do not need to schedule an appointment with Online-CBT, you avoid having to visit an office if things like transportation, stigma or your own availability are a concern, you can have more control over the pace of therapy, you can access the online material from the location of your choice at your convenience for up to four weeks after the end of therapy, you can e-mail your therapist at any time through our secure website, you may feel more comfortable disclosing personal information online than in person and this service is provided free of charge. For participants assigned to the waiting list, there are no anticipated risks associated with the online questionnaires. The only cost to you will be the time required to complete the questionnaires. This research may help participants to deal with their general anxiety more effectively in a variety of ways. Furthermore, if the treatment program is found to be effective, it may help other older adults who experience anxiety. The potential risks or challenges include: assessment and diagnosis may be more difficult when visual cues are not present; Online-CBT may require more self-motivation than other forms of therapy; without non-verbal cues, there is a greater potential for misinterpretation of e-mail messages between you and your therapist; there is a risk for breaches of confidentiality; there is potential for technology failures that may result in messages not being received by either you or your therapist; Online-CBT is a newer form of treatment, so there has been less research conducted when compared to other, more-established forms of treatment; Online-CBT is not meant to be a long-term form of therapy; Online-CBT is not meant for use in the event of an emergency.

Where is the study run from?
The study is run from the Online Therapy Unit for Service, Education, and Research, University of Regina, Canada.

When is study starting and how long is it expected to run for?
Recruitment for this study began in the winter of 2012 and is expected to be completed in the fall of 2013.

Who is funding the study?
Funding has been provided by the Canadian Institutes of Health Research, Canada.

Who is the main contact?
Ms Shannon Jones, jones23s@uregina.ca
Dr Heather D. Hadjistavropoulos, hadjista@uregina.ca

Study website

Contact information

Ms Shannon Jones
Scientific

Department of Psychology
University of Regina
3737 Wascana Parkway
Regina, Saskatchewan
S4S 0A2
Canada

Study information

Study designSingle-centre randomized controlled trial (waitlist control) using a between-subjects design
Primary study designInterventional
Secondary study designRandomised controlled trial
Study setting(s)Internet/virtual
Study typeTreatment
Participant information sheet Not available in web format, please use the contact details below to request a patient information sheet
Scientific titleAn efficacy trial of therapist-assisted internet cognitive behaviour therapy for older adults with generalized anxiety
Study objectives1. It is hypothesized that participants who receive Online-CBT will demonstrate significantly more improvement from pre- to post-treatment than waitlist participants on (a) primary outcome measures of generalized anxiety, anxiety symptom severity and worry; and, (b) secondary outcome measures of depressive symptoms and quality of life. Based on the percentage reported in a previous Online-CBT for GAD study (Titov et al., 2009), it is expected that around 80% of Online-CBT participants will report symptoms below the cut-off score on a measure of generalized anxiety (Generalized Anxiety Disorder-7) at post-treatment.
2. It is hypothesized that higher client engagement with Online-CBT will be associated with better treatment outcomes. More specifically, it is hypothesized that (a) clients who rated Online-CBT as credible and likely to be successful and had stronger belief in one’s ability to change at baseline, (b) clients who rate therapeutic alliance and treatment satisfaction high at post-treatment, and; (c) clients who access and use the website more frequently and complete lengthier emails and/or check-ins to their online therapist, will be associated with lower symptoms of anxiety, worry and depression at post-treatment.
Ethics approval(s)1. University of Regina; January 10, 2012; File #30S1112
2. University of Saskatchewan; March 7, 2012; BEH# 12-13
3. The Regina Qu'Appelle Health Region; March 1, 2012; REB-12-02
Health condition(s) or problem(s) studiedGeneralized anxiety disorder
InterventionComparing active treatment (therapist-assisted Online-CBT) to a non-active control group (waitlist)

The intervention is titled GAD Online for Older Adults, which is an Online-CBT program designed for treating older adults with generalized anxiety symptoms. The program consists of seven treatment modules containing CBT materials that are accessed online, as well as activities that are to be completed offline. The modules include information about generalized anxiety, how to monitor anxiety and worry, relaxation techniques, how to monitor thoughts and challenge them, how to reduce and control worry, and other coping strategies. Clients should engage in Online-CBT for approximately 7 to 10 weeks. GAD Online for Older Adults is therapist-assisted. Each client is assigned an online therapist who communicates with the client on a weekly basis via e-mail using the secure e-mail built into the program website. In the weekly e-mail, the therapist comments on the progress a client has made, addresses homework concerns, and answers any questions the client has for the therapist. The therapist’s role is also to provide support, encouragement and motivation for clients to continue with the program.

Participants who receive Online-CBT will be contacted one month after completing the program to be asked to complete follow-up measures.

Participants randomized to the waitlist control group will be offered the intervention upon completing the second set of questionnaires. They will then be followed for the duration of completing the intervention and the follow-up measures.
Intervention typeBehavioural
Primary outcome measure1. Generalized Anxiety Disorder-7 (GAD-7)
2. Patient Health Questionnaire-9 (PHQ-9)
3. Geriatric Anxiety Inventory (GAI)
4. Penn State Worry Questionnaire-Abbreviated (PSWQ-A)

These will be administered at baseline and post-treatment, as well as one-month follow-up for those randomized to receive the intervention.
Secondary outcome measures1. Geriatric Depression Scale (GDS)
2. WHO-Quality of Life-BREF (WHO-QOL-BREF)
3. Credibility/Expectancy Questionnaire (CEQ)
4. Anxiety Change Expectancy Scale (ACES)
5. Therapeutic Alliance Questionnaire (TAQ)
6. Treatment Satisfaction Questionnaire-Modified

Most measures are administered at baseline, post-treatment and one-month follow-up. Some are administered exclusively at post-treatment.

Baseline: Generalized Anxiety Disorder-7 item (GAD-7), Patient Health Questionnaire (PHQ-9), Geriatric Anxiety Inventory (GAI), Penn State Worry Questionnaire-Abbreviated (PSWQ-A), Geriatric Depression Scale (GDS), WHO-Quality of Life-BREF (WHOQOL-BREF), Credibility/Expectancy Questionnaires (CEQ), Anxiety Change Expectancy Scale (ACES)

Post-Treatment: Generalized Anxiety Disorder-7 item (GAD-7), Patient Health Questionnaire (PHQ-9), Geriatric Anxiety Inventory (GAI), Penn State Worry Questionnaire-Abbreviated (PSWQ-A), Geriatric Depression Scale (GDS), WHO-Quality of Life-BREF (WHOQOL-BREF), Anxiety Change Expectancy Scale (ACES), Treatment Satisfaction Questionnaire-Modified (TSQ-M), Therapeutic Alliance Questionnaire (TAQ), Client Feedback Open-Ended Questions

One-Month Follow-Up: Generalized Anxiety Disorder-7 item (GAD-7), Patient Health Questionnaire (PHQ-9), Geriatric Anxiety Inventory (GAI), Penn State Worry Questionnaire-Abbreviated (PSWQ-A), Geriatric Depression Scale (GDS)
Overall study start date01/03/2012
Completion date30/09/2013

Eligibility

Participant type(s)Patient
Age groupSenior
SexBoth
Target number of participantsThe goal is randomize at least 46 participants.
Total final enrolment46
Key inclusion criteria1. Resident of Saskatchewan
2. Aged 60 years of age or older, either sex
3. Meets DSM-IV-TR criteria for Generalized Anxiety Disorder or sub-clinical criteria
4. Has regular access to a computer, Internet and printer
5. Comfortable using the Internet and writing e-mails
Key exclusion criteria1. Not a resident of Saskatchewan
2. Less than 60 years of age
3. Has no regular access to a computer and/or the internet
4. Currently receiving psychotherapeutic treatment elsewhere or in some other form
5. Meets criteria for current substance abuse (drugs or alcohol)
6. Meets current criteria for a psychotic disorder or bipolar disorder, or severe symptoms of depression, including suicidal ideation
7. Reports having a serious medical condition that may account for anxiety symptoms or may interfere with treatment (i.e., untreated thyroid disorder or other endocrine disorder, Parkinson’s disease, recent stroke, acute cardiac disease)
8. Currently cognitively impaired
Date of first enrolment01/03/2012
Date of final enrolment30/09/2013

Locations

Countries of recruitment

  • Canada

Study participating centre

Department of Psychology
University of Regina
3737 Wascana Parkway
Regina
S4S 0A2
Canada

Sponsor information

University of Regina (Canada)
University/education

c/o Heather Hadjistavropoulos
Department of Psychology
3737 Wascana Parkway
Regina, Saskatchewan
S4S 0A2
Canada

Website http://www.onlinetherapyuser.ca
ROR logo "ROR" https://ror.org/03dzc0485

Funders

Funder type

Government

Canadian Institutes of Health Research (Canada) - Frederick Banting and Charles Best Canada Graduate Scholarship Doctoral Award ref:200910GSD-226274-190834

No information available

Results and Publications

Intention to publish date
Individual participant data (IPD) Intention to shareNo
IPD sharing plan summaryNot provided at time of registration
Publication and dissemination planNot provided at time of registration
IPD sharing plan

Study outputs

Output type Details Date created Date added Peer reviewed? Patient-facing?
Results article 02/11/2015 05/08/2021 Yes No

Editorial Notes

05/08/2021: The following changes have been made:
1. Publication reference added.
2. The final enrolment number has been added from the reference.