An Efficacy Trial of Therapist-Assisted Internet-Delivered Cognitive-Behaviour Therapy for Older Adults with Generalized Anxiety

Abstract

Generalized anxiety disorder (GAD) and subclinical anxiety symptoms are prevalent among adults aged 60 years and older. While cognitive-behaviour therapy (CBT) is efficacious for treating GAD, under treatment of GAD remains a problem in this age group. Therapist-assisted Internet-delivered CBT (TAICBT) has been developed and tested to increase accessibility to psychological treatment. TAICBT presents psychoeducational materials and CBT techniques using structured, interactive web pages, and involves a therapist who provides support via e-mail and/or telephone. The purpose of the current study was to: (1) establish the efficacy of TAICBT for treating GAD in adults aged 60 years and older, (2) examine how client engagement factors, such as website use, are related to treatment outcomes, and; (3) obtain and analyze feedback on participants’ experiences in using TAICBT. Using a randomized controlled trial design, 46 community-dwelling older adults were randomized to receive seven modules of TAICBT (n = 24) or were placed on a 10-week waiting list (n = 22). All participants completed outcome measures on anxiety, worry, depression, and quality of life after randomization and again 10 weeks later. Data was also gathered on client engagement and at four-week follow-up. TAICBT participants responded to open-ended questions to obtain feedback regarding their experience with TAICBT. Data was analyzed using longitudinal mixed models analyses and repeated measures analyses of variance (ANOVA) to establish efficacy. Multiple linear regression was used to analyze the association between client engagement factors and treatment outcomes. Responses to open-ended questions were analyzed using thematic analysis. As compared to the waiting list control group, TAICBT was efficacious at reducing general anxiety, worry, and depressive symptoms and for improving physical, psychological, and environmental quality of life over time. Large between-group effect sizes (Cohen’s d) were observed on the primary outcome measures, Generalized Anxiety Disorder-7 (GAD-7: .85) and the Patient Health Questionnaire-9 (1.17). About 86% of the TAICBT group reported GAD-7 scores ≤ 10 at post-treatment, a cut-off score suggesting a probable diagnosis of GAD. TAICBT participants in this study experienced continued symptom improvement at four-week follow-up on all outcome measures. Higher credibility of treatment ratings at pre-treatment predicted faster rates of decline in anxiety symptoms; however, expectancy of change, treatment satisfaction, and therapeutic alliance were not strong predictors of anxiety or depressive symptoms. Regarding website use, completing more treatment modules and writing more e-mails and lengthier Check-In responses to the therapist were associated with reduced anxiety, whereas taking longer to complete the program and writing lengthier e-mails to the therapist were linked to higher anxiety at follow-up. Thematic analysis revealed that older adults typically reported having positive experiences with TAICBT but also identified several challenges with TAICBT, including difficulties with the amount of content and the short timeframe to complete the program. Participants varied in their preferences for the program material versus contact with the online therapist. Overall, the results of this RCT provides evidence that TAICBT is a feasible and efficacious way of reaching and providing mental health services to adults aged 60 years and older, while also enriching our knowledge of how we may better address older adults’ needs in the design of future therapy programs for this age group.