Increased skills usage statistically mediates symptom reduction in self-guided internet-delivered cognitive–behavioural therapy for depression and anxiety: a randomised controlled trial

Depression and anxiety are common conditions, whose symptoms can cause anything from mild discomfort to severe impairment. There is now a substantial evidence base showing the effectiveness of internet-delivered psychological treatments, such as internet-delivered Cognitive Behaviour Therapy (iCBT), for treating the symptoms of depression and anxiety. It is encouraging to see consumers and healthcare practitioners alike engaging with these treatments, as well as the increasing acceptance of the role that digital technologies can play for our health.

Although there is much evidence supporting the efficacy of iCBT, researchers are yet to arrive at any firm conclusions about how these treatments reduce symptoms. In other words, what is it about iCBT that makes it effective?

The answer is likely that there are several factors at play. However, in one of our recent research trials, we decided to investigate if changes in behaviour were playing a significant role. We set up a trial of iCBT for participants experiencing symptoms of anxiety and/or depression. Participants were randomly assigned to one of two conditions: (1) receiving an 8-week iCBT course; or (2) being on a waitlist control group during the 8-week period. Participants were assessed before and after the 8-week period. We were particularly interested in the frequency that participants engaged in helpful behaviours (such as planning rewarding activities, seeing friends, and challenging unrealistic thoughts) and whether the frequency of these behaviours changed over treatment. We also assessed symptoms of anxiety and depression, as well as life satisfaction.

Participants in the treatment group reported lower levels of depression and anxiety, and higher life satisfaction at the end of treatment. They also reported greater engagement in helpful behaviours compared with the control group. Further statistical analysis demonstrated that the increased frequency of helpful behaviours significantly accounted for the reduction in symptoms and increased life satisfaction. In other words, we found evidence that behavioural change in iCBT is an important mechanism for how these treatments achieve their effects.

In terms of practical application, this research suggests that online psychological interventions should have a significant focus on behavioural change. This includes teaching helpful behaviours to patients, but also using methods to help patients implement these behavioural changes. It further suggests that regularly performing helpful and rewarding behaviours is an effective way to increase satisfaction with life.

Future research should ask if different kinds of behaviours are more beneficial for different types of problems (e.g. is engaging in more social interactions more helpful for social anxiety?), and if different types of people benefit from different kinds of helpful behaviours.

Read the full paper: Terides, M. D., Dear, B. F., Fogliati, V. J., Gandy, M., Karin, E., Jones, M. P., & Titov, N. (in press). Increased skills usage statistically mediates symptom reduction in self-guided internet-delivered cognitive–behavioural therapy for depression and anxiety: a randomised controlled trial. Cognitive Behaviour Therapy. doi:10.1080/16506073.2017.1347195

Matthew Terides


Photo by: Kiran Jonnalagadda

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