A pragmatic factorial randomized controlled trial of transdiagnostic internet-delivered cognitive behavioural therapy: Exploring benefits of homework reflection questionnaires and twice-weekly therapist support

H D Hadjistavropoulos; V Peynenburg; D L Thiessen; M Nugent; K Adlam; K M B Owens; E Karin; B F Dear; N Titov

doi:10.1016/j.invent.2020.100357

A pragmatic factorial randomized controlled trial of transdiagnostic internet-delivered cognitive behavioural therapy: Exploring benefits of homework reflection questionnaires and twice-weekly therapist support

Internet Interv. 2020 Dec 1:22:100357. doi: 10.1016/j.invent.2020.100357. eCollection 2020 Dec.

Authors

H D Hadjistavropoulos¹, V Peynenburg¹, D L Thiessen², M Nugent¹, K Adlam¹, K M B Owens³, E Karin⁴, B F Dear⁴, N Titov⁵

Affiliations

¹ Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada.
² Department of Mathematics & Statistics, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada.
³ Adult Therapy Program, Regina Mental Health Clinic, Saskatchewan Health Authority, 2110 Hamilton St, Regina, SK S4P 2E3, Canada.
⁴ eCentreClinic, Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia.
⁵ MindSpot Clinic, eCentreClinic, Department of Psychology, Macquarie University, Australian Hearing Hub Building, Sydney, NSW 2109, Australia.

Abstract

With the growing demand for internet-delivered cognitive behavioural therapy (iCBT), this pragmatic factorial (2 × 2 × 2) randomized controlled trial evaluated strategies for facilitating iCBT engagement and outcomes in routine care. Specifically, the benefits to patients and therapists of using homework reflection questionnaires and offering patients twice-weekly therapist support were examined. Patients (n = 632) accepted into iCBT for depression and/or anxiety were randomly assigned to complete homework reflection questionnaires or not (factor 1), receive once- or twice-weekly support (factor 2), and to receive care from therapists employed in one of two settings (iCBT clinic or a community mental health clinic; factor 3). Outcomes were measured at pre-treatment, and 8, 12, and 24-weeks post-enrollment. Therapist time was tracked and a focus group was conducted to examine therapist experiences. No differences in patient outcomes were found between therapists employed in the two settings; as such, these two groups were combined for further analyses. In terms of engagement, homework reflection questionnaires were associated with fewer website log-ins and days accessing iCBT; twice-weekly support was associated with more patient emails sent to therapists. Despite engagement differences, homework reflection questionnaires and twice-weekly support did not significantly impact primary outcomes; all groups showed large improvements in depression and anxiety that were maintained at 24-week follow-up. Therapists perceived a number of benefits and challenges associated with responding to homework reflection questionnaires and offering twice-weekly support; most notably the strategies did not benefit all patients. Twice-weekly support was associated with increased therapist time and organizational challenges. It is concluded that neither completion of homework questionnaires nor offering twice-weekly support significantly improve iCBT in routine care.

Keywords: Cognitive behaviour therapy; Internet-delivered; Therapist support, homework.