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Article Critique Online Treatment 2

Summary
This article was about a study conducted in the Netherlands and it focused on the effectiveness of online cognitive behavioral therapy. The diagnosis that it addressed was: depression, panic disorder, posttraumatic stress and burnout. The study found that online therapy was effective in treating these disorders.
The article opens with a succinct abstract. It describes that randomized controlled trials have been proven to be effective in the treatment of common mental health disorders. It describes the objectives and design of the study. It gives a brief description of the participants and setting. The intervention of a manualized, web based cognitive behavior therapy is used. The measures used for each of the mental health disorders are listed and a summary of the results is stated.
The introduction opens the study by generally stating that there has been success in previous studies that “online interventions are feasible and efficacious in the prevention and treatment of a wide variety of common mental health disorders (Ruwaard et al). It asserts that in controlled research the benefit of an online intervention is established. It is less clear in routine clinical practice. This study presents the outcome of a therapist-assisted cognitive behavioral treatment.
The method was an uncontrolled and consisted of pre treatment, post treatment and follow-up. The researchers secured the data from for patients at Interapy, an online, Dutch, mental health clinic. The researchers continued to collect data until the reached exactly 1500 participants. The study ran from February 2002 until January 2008

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The participants were all adults. They were screened using internet administered assessments. A structured, telephone interview was next. Participants were not accepted if the had suicidal ideation, dissociation, psychosis, substance abuse or recent hospitalizations. Patients were also required to see a General Practitioner of health professional before beginning the study.
The therapists all held a master’s in clinical psychology and received training on cognitive behavioral therapy. Two licensed clinical psychologists oversaw the clinicians. If needed, a psychiatrist was available.
The intervention consisted of web-based CBT. There were four manualized treatments: depression; panic disorder; posttraumatic stress and burnout. The length of treatment depended on the diagnosis. The clinician would interact with the patient through the internet. It included specific homework assignments and CBT techniques. Therapists provided feedback and tailored strategies for individual needs.
The measures used in this study were dependent on the patient’s diagnosis. There was a pre-test, posttest, 6 week follow up and a one year follow up. For depression, Web-CBT for depression and the Beck Depression Inventory was used. Web-CBT for panic disorder and the Panic Disorder Severity Self-report was used. The Web-CBT for post-traumatic stress was used for posttraumatic stress and included the Impact of Event Scale. The Web-CBT for burnout used the Oldenberg Burnout Inventory.
Of the original 1500 participants, 1071 actually completed all of the steps of the study. Overall, there was a reduction in the severity of symptoms at posttest and long term follow up. The discussion states that the recovery rates of their study was comparable or better than those of

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previously controlled studies. They maintain that reduction of specific and general symptoms in 50% of patients and that patient satisfaction with the treatment was high.

The title was clear and appropriate. It described exactly what the study was about: the effectiveness of online cognitive behavioral treatment in routine clinical practice. There is other research that supports this idea. Studies have shown that online therapy has been beneficial for those suffering from depression and social anxiety disorder (Andersson).
The abstract was simple and direct. It adequately summarized the constructs of the study. Comparing the abstract to the actual body of the study, there were no discrepancies. It was well written and represents the content of the study accurately.
The introduction lays out the reasons for undertaking the study. Research from several other studies is references. These articles are footnoted and full disclosed at the end of the study. The authors state that, “While the benefits of online interventions have been firmly established in controlled research, the performance of these interventions in routine clinical practice is less clear” (Ruwaard et al). When I performed a search of journal articles related to online programs and clinical practice there were many. Many of these studies though had very narrow sights on specific mental illnesses and populations. This study used therapy for four different disorders in order to have enough participants for a decent sized study. Another disturbing problem was that two of the articles reviewed involved alcoholics. Alcoholics were clearly not invited to participate in this study. These references are misleading to include in this study.
They were able to begin with a population sample of 1500. This number reduced naturally over the course of the study to 1071. This high number of participants helps to find reliable

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statistics compared to a study that uses 10 participants. The therapists used in the study were trained in the online program and CBT. They were supervised by two senior, licensed clinicians.
The interventions used are all web based programs: Web-CBT for Depression; Web-CBT for Panic Disorder; Web-CBT for Posttraumatic Stress and Web-CBT for Burnout. They vary in lengths of time to complete 5 to 16 weeks. The therapists are on line with the clients for sessions to provide feedback and specific strategies. This feels as if the study was completed to sell this web based program. On one hand, using a consistent program across the study maintains consistency in results and comparisons. On the other hand, it comes across like an infomercial. The abstract does not mention the interventions used. There was difficulty in researching the Web-CBT in scholarly articles and online. This is confusing, is it a product that the team purchased and used or one that they developed.
The measures for used for pretesting, post-testing and at the 6 week and 1 year follows ups were all appropriate for this study. They were included with each of the internet programs that were used. The measures were used to determine the intensity of specific psychopathology for each of the four disorders. The second measure also measured patient satisfaction and changes in post-treatment psychopathology. This was accomplished with a patient survey.
The statistical analysis is clear and presented in diagrams and tables. The first shows the population of the study and how many of them completed the program at each measurement. The researchers used a multi-level mixed-model repeated measures model due to the timeline of the study. Upon closer inspection, it is stated, “Analyses were conducted on observed data of the full sample (N-1500, assuming no change in the patients, who did not complete the post test

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measurements) as well as the completer sample (those patients that completed the full treatment and post treatment assessment” ((Ruwaard et al).
The discussion includes the positive results of the study. It is claimed that 50% of the patients recovered and patient satisfaction was high. The tables of the results of the measures all display data that shows the patients on average experienced improvement. The authors clearly state the strength s weaknesses. They propose that since this program and the therapists were already carrying out Web-CBT, they were skilled at their performance and the study did not interfere with their therapy. They also used the same therapeutic procedures and measures as controlled trials. This allowed for direct comparison. The researchers do recognize that by not using a face to face interview with the participants and using The DSM-IV for diagnosis of the mental disorders. This would have given the study more strength. Also the withdrawal of participants and the nonresponse of some participants in the follow ups caused concern. The researchers admitted they should have tried to follow up more effectively.
Upon reading this study, it seems that online cognitive behavioral therapy is a dream come true for mental disorders such as depression, post-traumatic stress, anxiety and burnout. Reading the article with a little more scrutiny and doing some research to clarify misinformation or confusion. The principals of this study have completed many studies in the area of online CBT. The DSM-IV should have been used for initial diagnosis. This would have lent the study more credibility. The reader is also left wondering how patient satisfaction was gathered. Was a Likert scale used? Better follow up with the participants who left the study. Why were assumptions made in analyzing the data about these participants who left the study? They should have been eliminated from the study completely.

References:

Andersson, Gerhard (2009). Using the internet to provide cognitive behavior therapy.
Behavior Research and Therapy 47 (3). Retrieved from:
http://dx.doi.org/10.1016/j.brat.2009.01.010
Ruwaard, Jeroen, Lange, Alfred, Schrieken, Bart, Dolan, Conor & Emmelkamp, Paul (2012).
“The effectiveness of online cognitive behavioral treatment in routine clinical practice”.
PlosOne 7(7): e40089 doic:10.1371/journal.pone.0040089.