Abstract and Introduction
Spence SH, Donovan CL, March S, et al. A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety.J Consult Clin Psychol 2011;79:629–42
How effective is online delivery of cognitive-behaviour therapy (CBT) compared with clinic-based CBT for treatment of anxiety disorders in adolescents?
115 adolescents aged between 12 and 18 years with a primary diagnosis of separation anxiety disorder, social phobia, generalised anxiety disorder or specific phobia and at least one of their parents.
Three academic sites in Australia; from 2006 to 2008.
Internet-based CBT (NET), clinic-based CBT (CLIN) or wait list control (WLC). The NET group completed the 'BRAVEfor Teenagers – ONLINE' programme, which is designed to be equivalent to the clinic-based programme, 'BRAVE-CLINIC'. Sessions lasted about 60 min, and adolescents received 10 weekly sessions and their parents received five. A therapist monitored progress and provided email feedback following each NET session. The CLIN group received the programme via face-to-face sessions with their therapist within a clinic setting. Booster sections were given at 1 and 3 months. The WLC participants did not have any contact with the research team during the first 12 weeks of the study, then they were offered treatment.
Primary outcomes: primary or any anxiety diagnoses (Anxiety Disorders Interview Schedule – Child and Parent Versions, ADIS-C/P), clinical severity ratings (CSR) and clinician-rated global functioning.
93.2% NET, 90.9% CLIN and 88.9% WLC completed the 12-week follow-up; 84.1% NET and 81.8% CLIN completed 12-month follow-up. Intention to treat analyses (last observation carried forward) included 100% of participant
At 12 weeks, both the internet- (NET) and clinic- (CLIN) based CBT programmes increased the proportion of adolescents who no longer had their primary anxiety diagnosis compared with waiting list control (34.1% with NET vs 29.5% with CLIN vs 3.7% with WLC; NET vs WLC p=0.003; CLIN vs WLC p=0.008; completer analysis). There was no significant difference between internet and clinic groups for this outcome at 12 weeks (p=0.65). At 6 months, the proportion of participants free of their primary anxiety diagnosis increased to 54.5% with internet CBT and 50.0% with clinic CBT (p=0.67). A further increase was observed at 12 months, with 68.2% in both the internet and clinic groups (p=1.00). Similar results were seen in completer analyses, and in the outcome of freedom from any anxiety diagnosis. Both forms of CBT improved clinical severity and global functioning more than WLC over the first 12 weeks (p<0.001). Over the 12-month follow-up, there were no significant differences between internet-based and clinic-based CBT in improvement in clinical severity and global functioning.
Both internet-based and clinic-based CBT reduce anxiety disorders and improve functioning in adolescents more than waiting list control at 12 weeks. Internet- and clinic-based CBT are similarly effective for adolescent anxiety disorders at 12 weeks, and remain similarly effective at up to 12 months.
The study had 80% power to detect an effect size difference of 0.30 between the CBT groups at the 0.05 significance level.
Carol Newall, Jennifer L Hudson
Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, Australia
In the last two decades, a number of trials have been conducted to assess the applicability of cognitive behavioural therapy (CBT) to anxious youth. Overall, the empirical evidence supports the efficacy of CBT in children and adolescents. The efficacy of CBT specifically for adolescents is less well studied, as many trials focus on children aged 7 to 13 years old. Recruitment of adolescents is not only a problem for researchers but also reflects an important practical obstacle in adolescent mental health. Unlike children, adolescents have greater autonomy in decision-making than younger age groups and therefore, are more able to resist their parent's efforts at seeking treatment. Adolescents also often find it more difficult to engage in psychological treatment. Available evidence suggests that most young people do not seek treatment for anxiety problems.
Using a well-designed randomised controlled trial, Spence et al examined the efficacy of internet delivery of CBT in a sample of anxious adolescents to address this important gap. Internet-based CBT is a delivery format that may encourage adolescents to seek professional help and engage in therapy. A promising aspect of these findings is that internet delivery was as efficacious as face-to-face delivery of CBT for anxious youth and both treatment formats were superior to waiting list controls on diagnostic outcomes. Although the results from parent and child symptom measures were less convincing, the follow-up assessment points clearly showed that internet and face-to-face delivery demonstrated large effect sizes on both child and parent report measures. Parents and adolescents perceived internet delivery as equally credible as face-to-face treatments, however parents reported greater satisfaction with face-to-face than internet-delivered treatment. These findings have important implications, particularly for families for whom access to adequate mental health services is limited, suggesting that we can have confidence in delivering CBT via the