Background: Anxiety and depression are common during pregnancy and associated with adverse outcomes for the mother and infant if left untreated. Despite the need to improve treatment accessibility and uptake in this population, no studies have investigated internet-delivered cognitive behavioural therapy (iCBT) for antenatal anxiety and depression. In a randomised controlled trial, we examined the efficacy and acceptability of a brief, unguided iCBT intervention – the MUMentum Pregnancy program – in pregnant women with anxiety and/or depression. Methods: Participants meeting clinical threshold on validated self-report measures of generalised anxiety and/or depression were recruited online and randomised to iCBT (n=43) or a treatment as usual (TAU) control (n=44). Outcomes were assessed at baseline, post-treatment and four-week follow-up; and included anxiety, depression, psychological distress, antenatal bonding, quality of life, and treatment acceptability. Results: Of the 36 women who started iCBT, 26 completed all three lessons of treatment (76% adherence rate). iCBT produced moderate to large effect size reductions for anxiety on the GAD-7 (Hedges’ g=0.76) and psychological distress on the Kessler-10 (g=0.88) that were superior to TAU. Only small nonsignificant differences were found for depression outcomes (g=<0.35). Participants reported that iCBT was an acceptable treatment for antenatal anxiety and/or depression. Limitations: Lack of an active control condition and long-term postpartum follow-up. Conclusions: This is the first study to evaluate brief unguided iCBT for antenatal anxiety and depression. While our findings are promising, particularly for anxiety reduction, additional RCTs are required to establish treatment efficacy.

Clinician-guided internet-delivered cognitive behavioral therapy (iCBT) is an effective treatment for depression and anxiety disorders. However, few studies have examined the effectiveness of completely unguided iCBT. The current research investigated adherence to, and the effects of two brief unguided iCBT programs on depression and anxiety symptom severity, and psychological distress. Study 1 evaluated a four-lesson transdiagnostic iCBT program for anxiety and depression (N = 927). Study 2 then evaluated a three-lesson version of the same program (N = 5107) in order to determine whether reducing the duration of treatment would influence adherence and treatment effects. Cross-tabulations and independent t-tests were used to examine the extent to which users adhered and remitted with treatment. Linear mixed models were used to evaluate the effects of treatment in the entire sample, and stratified by gender and completer-type (e.g., users who completed some but not all lessons vs. those who completed all lessons of treatment). Among those who began treatment, 13.83% completed all four lessons in Study 1. Shortening the course to three lessons did not improve adherence (e.g., 13.11% in Study 2). In both studies, users, on average, experienced moderate to large effect size reductions in anxiety and depressive symptom severity, as well as psychological distress. This pattern of results was robust across gender and for those who did and did not complete treatment. Approximately two-thirds of those who completed treatment experienced remission. These data show that unguided iCBT programs, which have the capacity to attract large numbers of individuals with clinically significant symptoms of depression and anxiety, and psychological distress, can produce significant improvements in wellbeing.

Introduction: Randomised controlled trials have shown that internet-delivered cognitive behavioural treatment (iCBT) is an effective treatment for health anxiety, but the effectiveness of these programs in routine care has not been investigated. This study examined the effectiveness of iCBT for health anxiety symptoms in routine care settings in the community. Methods: Using an open-trial design, we investigated adherence to, and effectiveness of a 6-lesson iCBT program for health anxiety symptoms amongst individuals (n=391, mean age 41 years, 64% female) who enrolled in the program either self-guided (n=312) or under the supervision of community clinicians (general practitioners, psychologists and other allied health professionals) (n=79). Primary outcome was health anxiety severity on the Short Health Anxiety Inventory (SHAI), and secondary outcomes were depression severity on the Patient Health Questionnaire 9-item (PHQ-9) (depression) and distress (Kessler-10: K-10). Results: Adherence to the iCBT program was modest (45.6% in the clinician-supervised group, 33.0% in the unguided group), but within-subjects effect sizes were large (SHAI: g=1.66, 95%CI: 1.45–1.88; PHQ-9: g=1.12, 95%CI: 0.92–1.32; K-10: g=1.35, 95%CI: 1.15–1.56). Limitations: No control group, lack of follow-up data. Conclusions: iCBT is an effective treatment for health anxiety symptoms in routine care, but methods to increase adherence are needed to optimise benefits to participants. Randomised controlled effectiveness trials with long-term follow-up are needed.

Computerised cognitive behavioural therapy (CCBT) has been shown to be an efficacious treatment for depression. A recent meta-analysis of 9 studies showed a large mean effect size superiority over control group (effect size=0.86, number needed to treat=2), good adherence (69%) and benefits were evident at follow-up at a median of 26 weeks. In contrast, REEACT, a major study which compared usual general practitioner (GP) care versus usual GP care plus access to 1 of 2 pioneering CCBT courses detected no differences between the groups. We present the results and discuss possible explanations for these findings. In all 3 groups, usual care was extensive (9 visits in 12 months, 80% on medication, 8–23% getting psychological sessions). Adherence to CCBT courses was very poor (17%). Perhaps the surfeit of services meant there was no need for CCBT. Perhaps neither of the 2 CCBT courses encouraged adherence. What is certain is that this study did not test the potential of these CCBT courses to produce change in patients with depression presenting in primary care.

Background: The use of maladaptive behaviors by individuals with generalized anxiety disorder (GAD) is theoretically important and clinically meaningful. However, little is known about the specificity of avoidant behaviors to GAD and how these behaviors can be reliably assessed. Aims: This study replicated and extended the psychometric evaluation of the Worry Behaviors Inventory (WBI), a brief self-report measure of avoidant behaviors associated with GAD. Method: The WBI was administered to a hospital-based sample of adults seeking treatment for symptoms of anxiety and/or depression (n = 639) and to a community sample (n = 55). Participants completed measures of symptom severity (GAD, depression, panic disorder, health anxiety, and personality disorder), and measures of checking, reassurance-seeking and behavioral inhibition. Analyses evaluated the factor structure, convergent, divergent, incremental, and discriminant validity, as well the temporal stability and treatment sensitivity of the WBI. Results: The two-factor structure found in the preliminary psychometric evaluation of the WBI was replicated. The WBI was sensitive to changes across treatment and correlated well with measures of GAD symptom severity and maladaptive behaviors. The WBI was more strongly related to GAD symptom severity than other disorders. The WBI discriminated between clinical and community samples. Conclusions: The WBI provides clinicians and researchers with a brief, clinically meaningful index of problematic behaviors that may guide treatment decisions and contribute to our understanding of maintaining factors in GAD.

Cognitive theories of generalised anxiety disorder (GAD) posit that cognitive and behavioural factors maintain the disorder. This study examined whether avoidance and safety behaviours mediated the relationship between cognitive factors and GAD symptoms. We also examined the reverse mediation model; that is, whether cognitive factors mediated the relationship between maladaptive behaviours and GAD symptoms. Undergraduate psychology students (N = 125 and N = 292) completed the Worry Behaviours Inventory (a recently developed measure of maladaptive behaviours associated with GAD), in addition to measures of intolerance of uncertainty, cognitive avoidance, metacognitive beliefs, and symptoms of GAD and depression. Analyses supported the reliability and validity of the WBI. We consistently found that engagement in maladaptive behaviours significantly mediated the relationship between cognitive factors and symptoms of GAD. The reverse mediation model was also supported. Our results are consistent with the contention that cognitive and behavioural factors contribute to GAD symptom severity.

Recent research has sought to identify maladaptive behaviors that are associated with generalized anxiety disorder (GAD). Although maladaptive behaviors may contribute to the maintenance of the disorder, little is known about how these behaviors change during the course of cognitive behavior therapy and whether such changes relate to treatment outcomes. This study examined changes in maladaptive behaviors, symptoms of GAD and depression, and disability across internet-based cognitive behavior therapy (iCBT) for GAD in two large clinical samples (N = 206 and 298). Assessments were completed at pre and post-treatment. Significant reductions in patients' maladaptive behaviors (WBI), GAD and depression severity (GAD-7 and PHQ-9), and disability (WHODAS-II) were observed following iCBT. Reductions in maladaptive behaviors predicted post-treatment GAD symptom severity after controlling for pre-treatment GAD symptom severity and reductions in depression and disability. Findings provide further support for the importance of maladaptive behaviors in contemporary conceptualizations of GAD and highlight the need for experimental investigations to examine the possible causal relationships between maladaptive behaviors and GAD.

Background: Cognitive models of generalized anxiety disorder (GAD) suggest that maladaptive behaviours may contribute to the maintenance of the disorder; however, little research has concentrated on identifying and measuring these behaviours. To address this gap, the Worry Behaviors Inventory (WBI) was developed and has been evaluated within a classical test theory (CTT) approach. Aims: As CTT is limited in several important respects, this study examined the psychometric properties of the WBI using an Item Response Theory approach. Method: A large sample of adults commencing treatment for their symptoms of GAD (n = 537) completed the WBI in addition to measures of GAD and depression symptom severity. Results: Patients with a probable diagnosis of GAD typically engaged in four or five maladaptive behaviours most or all of the time in an attempt to prevent, control or avoid worrying about everyday concerns. The two-factor structure of the WBI was confirmed, and the WBI scales demonstrated good reliability across a broad range of the respective scales. Together with previous findings, our results suggested that hypervigilance and checking behaviours, as well as avoidance of saying or doing things that are worrisome, were the most relevant maladaptive behaviours associated with GAD, and discriminated well between adults with low, moderate and high degrees of the respective WBI scales. Conclusions: Our results support the importance of maladaptive behaviours to GAD and the utility of the WBI to index these behaviours. Ramifications for the classification, theoretical conceptualization and treatment of GAD are discussed.

Objective: To investigate the reliability, validity and utility of DSM-5 illness anxiety disorder (IAD) and somatic symptom disorder (SSD), and explore their overlap with DSM-IV Hypochondriasis in a health anxious sample. Methods: Treatment-seeking patients with health anxiety (N = 118) completed structured diagnostic interviews to assess DSM-IV Hypochondriasis, DSM-5 IAD, SSD, and comorbid mental disorders, and completed self-report measures of health anxiety, comorbid symptoms, cognitions and behaviours, and service utilization. Results: IAD and SSD were more reliable diagnoses than Hypochondriasis (kappa estimates: IAD: 0.80, SSD: 0.92, Hypochondriasis: 0.60). 45% of patients were diagnosed with SSD, 47% with IAD, and 8% with comorbid IAD/SSD. Most patients with IAD fluctuated between seeking and avoiding care (61%), whereas care-seeking (25%) and care-avoidant subtypes were less common (14%). Half the sample met criteria for DSM-IV Hypochondriasis; of those, 56% met criteria for SSD criteria, 36% for IAD, and 8% for comorbid IAD/SSD. Compared to IAD, SSD was characterized by more severe health anxiety, somatic symptoms, depression, and higher health service use, and higher rates of major depressive disorder, panic disorder and agoraphobia. Conclusions: DSM-5 IAD and SSD classifications reliably detect more cases of clinically significant health anxiety than DSM-IV Hypochondriasis. The differences between IAD and SSD appear to be due to severity. Future research should explore the generalizability of these findings to other samples, and whether diagnostic status predicts treatment response and long-term outcome.

Objective: Chronic pain is a prevalent and burdensome condition. Reboot Online was developed to address treatment barriers traditionally associated with accessing face-to-face chronic pain management programs. It is a comprehensive multidisciplinary online treatment program, based on an existing and effective face-to-face multidisciplinary pain program (the Reboot program). Design & Participants: A CONSORT-compliant randomized controlled trial was conducted, enrolling adults who had experienced pain for three months or longer. Methods: Participants were randomly allocated to either an eight-lesson multidisciplinary pain management program, Reboot Online (N=41), or to a usual care (UC) control group (N=39). Clinical oversight was provided by a multidisciplinary team remotely, including physiotherapists and clinical psychologists. Participants were measured at baseline, post-treatment (week 16), and three-month follow-up (week 28). Results: Intention-to-treat analyses revealed that Reboot Online was significantly more effective than UC at increasing pain self-efficacy (g=0.69) at post-treatment, and these gains were maintained at follow-up. Similarly, Reboot Online was significantly more effective than UC on several secondary measures at post-treatment and follow-up, including movement-based fear avoidance and pain-related disability, but it did not significantly reduce pain interference or depression compared with UC. Clinician input was minimal, and adherence to Reboot Online was moderate, with 61% of participants (N=25) completing all eight lessons. Conclusions: Reboot Online presents a novel approach to multidisciplinary pain management and offers an accessible, efficacious alternative and viable treatment option for chronic pain management.