Mental illness is an escalating concern worldwide. The management of disorders such as anxiety and depression largely falls to family doctors or general practitioners (GPs). However, GPs are often too time constrained and may lack the necessary training to adequately manage the needs of such patients. Evidence-based Internet interventions represent a potentially valuable resource to reduce the burden of care and the cost of managing mental health disorders within primary care settings and, at the same time, improve patient outcomes.
The present study sought to extend the efficacy of a therapist-assisted Internet treatment program for panic disorder, Panic Online, by determining whether comparable outcomes could be achieved and maintained when Panic Online was supported by either GPs or psychologists.
Via a natural groups design, 96 people with a primary diagnosis of panic disorder (with or without agoraphobia) completed the Panic Online program over 12 weeks with the therapeutic assistance of their GP (n = 53), who had received specialist training in cognitive behavioral therapy, or a clinical psychologist (n = 43). Participants completed a clinical diagnostic telephone interview, conducted by a psychologist, and a set of online questionnaires to assess panic-related symptoms at three time periods (pretreatment, posttreatment, and 6 month follow-up).
Both treatments led to clinically significant improvements on measures of panic and panic-related symptomatology from pretreatment to posttreatment. Both groups were shown to significantly improve over time. Improvements for both groups were maintained at follow-up; however, the groups did differ significantly on two quality of life domains: physical (F1,82 = 9.13,
This study provides evidence that Internet-based interventions are an effective adjunct to existing mental health care systems. Consequently, this may facilitate and enhance the delivery of evidence-based mental health treatments to increasingly large segments of the population via primary care systems and through suitably trained health professionals.
Projections indicate that by the year 2020 mental health and neurological disorders will account for 15% of the global burden of disease [
Despite the high prevalence, up to 40% of people experiencing a mental health problem do not receive any mental health care within a given 12-month period [
In an attempt to address gaps in mental health care service provision in Australia, and in recognition of the critical role GPs play in service delivery, the government has expanded the number of Medicare (Australia’s universal health care system) rebate items for mental health consultations, and, in 2001, introduced the Better Outcomes in Mental Health Care (BOiMHC) initiative. The BOiMHC initiative includes educational activities and financial incentives to improve the capacity of GPs to deliver evidence-based psychological interventions such as cognitive behavioral therapy (CBT) [
Internet-based therapy (eTherapy) typically involves the interaction between a consumer and therapist (eTherapist) via the Internet [
Over the past decade, Internet-based treatments have been found effective for a variety of physical health conditions and mental health disorders, such as headache [
Panic disorder affects approximately 1.3% (with agoraphobia, 2.4%) of the Australian population annually [
CBT is a well established and highly effective treatment for panic disorder (with or without agoraphobia) [
Internet-based treatments largely address all of these barriers, and, indeed, panic disorder has been effectively treated via the Internet in a number of countries including Sweden [
Clinical trials have shown that PO, when paired with human support via email (provided by psychologist), is clinically superior to information-only control conditions or other forms of manual and telephone-based therapy [
To our knowledge, PO has not previously been trialled with professional support beyond that of a psychologist, except our own study [
A total of 193 people registered for the study, and after 97 were excluded on the basis of inclusion/exclusion criteria, a total of 96 individuals ultimately commenced treatment as part of this study: 43 were recruited into the PO plus psychologist support via email (PO+P) group and 53 into the PO plus face-to-face GP (PO+GP) group.
In total, 132 BOiMHC-trained (CBT-trained) GPs registered to participate in the study, of which 37 actively referred the 53 PO+GP patients and treated participants as per the standardized protocol. Seven psychologists (6 females; 1 male) were employed as eTherapists for the PO+P group and as assessors for both groups.
This study utilized three assessment phases (pretreatment, posttreatment, and 6-month follow-up after treatment). Each assessment included a clinical interview conducted over the telephone by a psychologist and the completion of a set of self-administered questionnaires accessed via the Internet. Recent studies have shown that the majority of validated paper-and-pencil questionnaires generally retain their psychometric qualities and produce equivalent results when administered in an online format [
The Anxiety Disorders Interview Schedule-IV (ADIS-IV) is a semistructured clinical interview designed to permit differential diagnosis among anxiety and mood disorders and to screen for other major disorders (eg, substance abuse, psychosis, somatoform disorders). It includes the “number of panic attacks in the last month” (PAMTH). The ADIS-IV has good-to-excellent reliability and validity [
The Anxiety Sensitivity Profile (ASP) [
The Depression Anxiety Stress Scale (DASS) [
The Mobility Inventory (MI) [
The Panic Disorder Severity Scale (PDSS) [
The Treatment Credibility Scale-Modified (TCS-M) [
The World Health Organization Quality of Life-BREF (WHOQOL-BREF) [
The present study employed a natural groups design open to all Australian residents who met the inclusion criteria (detailed below). Participants who were referred to the program by their GP were allocated back to their GP for treatment and were therefore in the PO+GP group. Participants who self-referred to the program (eg, found it via Web surfing, word-of-mouth) were allocated to receive PO supported by an eTherapist and were therefore in the PO+P group.
The study was advertised to the general public via participating GPs, Australian mental health websites, and local and national media. Study volunteers could register their interest on the PO website.
GPs were recruited in Victoria, South Australia, and New South Wales via BOiMHC-accredited training programs. Participating GPs were sent a project information package and subsequently were contacted by a research officer (either in person or via telephone) to discuss research protocols, PO program components, the manner in which PO was to be used, and the expected role of the GP and patient in the study. Additionally, regular consultative support was provided by the research officer throughout the duration of the study.
To be included in the study, participants were required to be Australian residents, have computer access, be 18 years or over, be fluent in English, have a primary diagnosis of panic disorder (with or without agoraphobia; as determined via the clinical telephone interview), and to agree not to undertake any other type of therapy for their panic disorder during the study. The request to refrain from other treatments did not cover the follow-up period. At post-assessment, all participants but one (whose data were removed from the analysis) had refrained from other treatments, as measured by self-report.
People were excluded if they reported a seizure disorder, stroke, schizophrenia, hyperthyroidism, organic brain syndrome, heart condition, or chronic hypertension as these are confounding variables with independent associations with panic attacks [
Study registrants were contacted by a psychologist who conducted a screening interview to determine whether they met the exclusionary criteria. When exclusionary criteria were met, volunteers were advised of the reason they could not participate and were referred to alternative services as appropriate. When exclusionary criteria were not met, an explanatory statement and consent form were emailed. Upon return of consent, a full clinical diagnostic assessment was conducted via telephone using the ADIS-IV, which took, on average, 90 minutes. Our interrater reliability for this procedure was .93. Following this, participants completed a set of online questionnaires. Upon assessment completion, participants were emailed a username and password with instructions on accessing the PO program. Posttreatment and follow-up assessments (clinical telephone interview and online questionnaires) were conducted at the end of week 12 and 6 months later. Psychologists did not provide therapy for any participant they assessed.
PO is a 12-week eTherapy program consisting of an introductory module, four learning modules, and a relapse prevention module. The program includes treatment methods commonly used in standard CBT for panic disorder, including instructions for controlled breathing, progressive muscle relaxation, cognitive restructuring, and interoceptive and situational exposure. Downloadable audio of isometric and progressive muscle relaxation and sequential photographic slide shows for two graduated exposure in vivo exercises (going to the supermarket and driving a car) were provided. An adjunct stress management program was also available to all participants (see Richards et al [
Communication between participants and psychologists occurred via email. No limitations were placed on email frequency; however, the assigned eTherapist was instructed to initiate contact if he or she had not received communication from a participant for approximately 1-2 weeks. On average, per participant, eTherapists sent 15.29 emails (SD 9.26; n = 31) and spent 378.62 minutes (SD 264.43; n = 29) emailing participants throughout the 12-week treatment. On average, each eTherapist provided support to 7.17 (range 2-19) participants.
Following assessment by a psychologist, participants allocated to the PO+GP condition were asked to make an appointment with their GP for their first PO consultation. The GP was then informed by the assessor that the patient could commence treatment. GPs and participants were encouraged to consult regularly (approximately once per week) throughout the treatment duration, while participants were using PO between consultations. On average, participants saw their GP (in a face-to-face consultation) 7.14 times (n = 31) throughout the 12-week treatment.
An independent groups
In addition to their primary diagnosis of panic disorder, 75 participants were also assessed with clinical levels of agoraphobia (30 in the PO+P group and 45 in the PO+GP group). See
Characteristics of participants at pretreatment assessment, by group
PO+P | PO+GP | Total | |||||||
Characteristic | No. | Mean | SD | No. | Mean | SD | No. | Mean | SD |
Age (years) | 43.5 | 12.4 | 38.7 | 10.9 | 40.9 | 11.8 | |||
Education (years) | 12.7 | 2.8 | 12.9 | 2.8 | 12.8 | 2.8 | |||
|
|||||||||
Male | 10 | 10 | 20 | ||||||
Female | 33 | 43 | 76 | ||||||
|
|||||||||
Yes | 19 | 31 | 50 | ||||||
No | 24 | 22 | 46 | ||||||
|
|||||||||
Panic disorder | 13 | 8 | 21 | ||||||
Panic disorder with agoraphobia | 30 | 45 | 75 | ||||||
|
|||||||||
Yes | 22 | 34 | 56 | ||||||
No | 21 | 19 | 40 | ||||||
|
|||||||||
Yes | 20 | 29 | 49 | ||||||
No | 23 | 24 | 47 |
Medication frequencies at pretreatment assessment, by group
Drug Class* | PO+P | PO+GP | Total |
SSRI | 1 | 14 | 15 |
Benzodiazepine | 9 | 4 | 13 |
SNRI | 5 | 2 | 7 |
SSRI + Benzodiazepine | 2 | 4 | 6 |
Tricyclic antidepressant | 1 | 2 | 3 |
Tricyclic antidepressant + SSRI | 1 | – | 1 |
SSRI + SNRI | – | 1 | 1 |
Benzodiazepine + SSRI + Antipsychotic | – | 1 | 1 |
SSRI + Antipsychotic | – | 1 | 1 |
RIMA + Benzodiazepine | – | 1 | 1 |
Anticonvulsant + Benzodiazepine + Antipsychotic | – | 1 | 1 |
19 | 31 | 50 |
*SSRI, selective serotonin reuptake inhibitor; SNRI, selective noradrenaline reuptake inhibitor; RIMA, reversible inhibitor of monoamine oxidase type A
Clinical comorbid condition frequencies at pretreatment assessment, by group*
Disorder | PO+P | PO+GP | Total |
Generalized anxiety disorder | 5 | 17 | 22 |
Depression | 9 | 13 | 22 |
Social anxiety disorder | 5 | 15 | 20 |
Specific disorder | 9 | 9 | 18 |
Dysthymia | 4 | 9 | 13 |
Posttraumatic stress disorder | 1 | 6 | 7 |
Hypochondriasis | 2 | 4 | 6 |
Obsessive compulsive disorder | – | 4 | 4 |
Alcohol dependence | 1 | 2 | 3 |
Substance abuse | – | 1 | 1 |
*Some participants were assessed as having multiple clinical comorbid conditions.
Attrition was defined as participants who withdrew, for reasons either known or unknown, from the research trial. The overall attrition rate for this study was 42.7% (41/96): 37.2% (16/43) and 47.2% (25/53) for the PO+P and PO+GP groups, respectively. This difference was not significant (
Reasons for attrition, by group
Reason | PO+P | PO+GP | Total |
Unknown | 9 | 9 | 18 |
Lost contact | 1 | 4 | 5 |
Commencing face-to-face counselling | 1 | 2 | 3 |
Computer problems | 1 | 2 | 3 |
Personal issues (nonspecific) | 2 | 1 | 3 |
GP difficulties | 2 | 2 | |
Cured | 1 | 1 | |
Health problem | 1 | 1 | |
Housing crisis | 1 | 1 | |
Language difficulties | 1 | 1 | |
Moved state | 1 | 1 | |
Personal issues (mental health) | 1 | 1 | |
Pregnancy | 1 | 1 | |
16 | 25 | 41 |
This study utilized intention-to-treat analyses. That is, pretreatment assessment scores for participants discontinuing their involvement during treatment were carried forward and used in both the posttreatment and follow-up assessments (11 for the PO+P group; 21 for the PO+GP group). Fisher exact test revealed no difference between the groups (
Nonnormally distributed dependent variables were transformed to satisfy normality assumptions. The DASS depression subscale and the MIA required a square root transformation, and PAMTH required a logarithmic transformation.
One-way analysis of variance (ANOVA) tests were conducted on all measures to test for pretreatment differences between groups. A significant pretreatment difference was found in the WHOQOL-BREF psychological domain, with the PO+P group reporting greater quality of life for this domain in comparison to the PO+GP group (
Results of evaluation of normality assumptions, homogeneity of variance-covariance matrices, and linearity were satisfactory. Additionally, Bartlett’s test of sphericity was conducted to confirm that the dependent variables in the MANOVA groupings were correlated at the
Variable* |
|
|
DASS depression | 2.521,89 | .12 |
DASS anxiety | 0.721,89 | .40 |
DASS stress | 1.601,89 | .21 |
WHOQOL-BREF physical | 3.611,87 | .06 |
WHOQOL-BREF psychological | 6.091,87 | .02 |
WHOQOL-BREF social | 1.941,87 | .17 |
WHOQOL-BREF environmental | 2.731,87 | .10 |
MIA | 0.411,84 | .53 |
MIB | 0.311,83 | .58 |
PAMTH | 0.381,94 | .54 |
ASP | 0.031,88 | .86 |
PDSS | 1.751,86 | .19 |
*DASS, Depression Anxiety Stress Scale; WHOQOL-BREF, World Health Organization Quality of Life-BREF; MIA, Mobility Inventory alone; MIB, Mobility Inventory accompanied; PAMTH, panic attacks in the last month; ASP, Anxiety Sensitivity Profile; PDSS, Panic Disorder Severity Scale.
An independent samples
For the panic symptoms grouping, repeated measures MANOVA revealed no significant interaction between time (pre, post, follow-up) and group (PO+P, PO+GP) or group main effect. However, a significant main effect for time was found from pretreatment to posttreatment assessment. Examination of the univariate tests for time and associated means revealed a significant decrease on all seven measures. Means and standard deviations are presented in
Means and standard deviations for treatment outcome measures at pretreatment, posttreatment, and follow-up treatment assessments, by group
PO+P | PO+GP | |||||
Variable* | No. | Mean | SD | No. | Mean | SD |
Clinician panic disorder rating | ||||||
Pre | 43 | 6.17 | 1.25 | 53 | 6.29 | 1.29 |
Post | 43 | 3.43 | 2.03 | 53 | 4.29 | 2.30 |
Follow-up | 43 | 3.02 | 2.42 | 53 | 3.84 | 2.65 |
Clinician agoraphobia rating | ||||||
Pre | 43 | 4.07 | 2.80 | 53 | 5.13 | 2.35 |
Post | 43 | 2.16 | 2.22 | 53 | 3.65 | 2.52 |
Follow-up | 43 | 2.40 | 2.34 | 53 | 3.40 | 2.69 |
PAMTH | ||||||
Pre | 43 | 6.33 | 7.99 | 53 | 9.85 | 14.83 |
Post | 42 | 2.67 | 5.48 | 53 | 4.27 | 8.12 |
Follow-up | 42 | 1.86 | 2.98 | 53 | 4.35 | 7.93 |
PDSS | ||||||
Pre | 38 | 14.62 | 4.40 | 50 | 16.05 | 5.45 |
Post | 38 | 9.71 | 5.65 | 52 | 12.00 | 6.24 |
Follow-up | 38 | 9.59 | 5.96 | 50 | 11.73 | 6.36 |
ASP | ||||||
Pre | 39 | 3.45 | 1.31 | 51 | 3.40 | 1.42 |
Post | 41 | 1.88 | 1.64 | 51 | 2.58 | 1.62 |
Follow-up | 41 | 1.83 | 1.61 | 52 | 2.50 | 1.59 |
MIA | ||||||
Pre | 41 | 2.15 | .93 | 45 | 2.26 | .88 |
Post | 39 | 1.78 | .87 | 40 | 2.11 | .91 |
Follow-up | 37 | 1.76 | .88 | 44 | 2.03 | .87 |
MIB | ||||||
Pre | 41 | 2.55 | 1.09 | 44 | 2.67 | .95 |
Post | 39 | 2.14 | 1.08 | 42 | 2.36 | .95 |
Follow-up | 37 | 2.16 | 1.12 | 45 | 2.34 | .93 |
DASS depression | ||||||
Pre | 41 | 12.24 | 9.83 | 50 | 16.45 | 12.86 |
Post | 40 | 7.15 | 9.76 | 51 | 13.52 | 12.90 |
Follow-up | 41 | 7.24 | 9.48 | 50 | 12.33 | 12.54 |
DASS anxiety | ||||||
Pre | 41 | 17.46 | 10.10 | 50 | 19.24 | 9.80 |
Post | 40 | 10.28 | 10.73 | 51 | 14.56 | 10.60 |
Follow-up | 41 | 10.23 | 10.33 | 50 | 13.64 | 10.43 |
DASS stress | ||||||
Pre | 41 | 19.26 | 10.35 | 50 | 21.98 | 10.06 |
Post | 40 | 12.23 | 10.84 | 51 | 17.24 | 11.79 |
Follow-up | 41 | 12.59 | 10.97 | 50 | 16.24 | 11.51 |
WHOQOL-BREF physical | ||||||
Pre | 40 | 59.05 | 16.81 | 49 | 51.59 | 19.60 |
Post | 37 | 69.53 | 13.85 | 50 | 58.54 | 21.13 |
Follow-up | 38 | 70.43 | 14.08 | 48 | 57.92 | 20.94 |
WHOQOL-BREF psychological | ||||||
Pre | 40 | 50.48 | 18.05 | 49 | 41.07 | 17.76 |
Post | 37 | 60.47 | 17.94 | 50 | 49.83 | 18.48 |
Follow-up | 38 | 60.96 | 17.45 | 48 | 48.83 | 19.75 |
WHOQOL-BREF social | ||||||
Pre | 40 | 55.00 | 25.09 | 49 | 47.19 | 27.21 |
Post | 37 | 61.49 | 22.85 | 50 | 52.17 | 27.12 |
Follow-up | 38 | 61.18 | 22.87 | 48 | 50.61 | 27.64 |
WHOQOL-BREF environment | ||||||
Pre | 40 | 63.38 | 16.92 | 49 | 57.65 | 15.76 |
Post | 37 | 67.00 | 15.01 | 50 | 60.58 | 15.76 |
Follow-up | 38 | 67.62 | 15.76 | 48 | 60.44 | 15.27 |
Treatment credibility | ||||||
Pre | 39 | 40.59 | 7.57 | 45 | 37.47 | 7.02 |
*PAMTH, panic attacks in the last month; PDSS, Panic Disorder Severity Scale; ASP = Anxiety Sensitivity Profile; MIA, Mobility Inventory alone; MIB, Mobility Inventory accompanied; DASS, Depression Anxiety Stress Scale; WHOQOL-BREF, World Health Organization Quality of Life-BREF.
Effects from the repeated measures MANOVA and ANCOVA analysis between groups*
Time Effect | Group Effect | Treatment × Time | ||||||||||
Variable | F |
|
Partial |
|
F |
|
Partial |
|
F |
|
Partial |
|
Panic symptoms | ||||||||||||
Post | 10.287,52 | .00 | .58 | 1.00 | 1.657,52 | .14 | .18 | .62 | 1.167,52 | .35 | .14 | .45 |
Follow-up | 2.167,58 | .05 | .21 | .77 | .907,58 | .52 | .10 | .35 | .877,58 | .53 | .10 | .34 |
Negative affect | ||||||||||||
Post | 18.043,86 | .00 | .39 | 1.0 | 1.693,86 | .48 | .06 | .42 | .803,86 | .50 | .03 | .22 |
Follow-up | .533,86 | .66 | .02 | .16 | .533,86 | .10 | .07 | .52 | 1.153,86 | .33 | .04 | .30 |
Quality of life | ||||||||||||
Post | 15.403,82 | .00 | .36 | 1.00 | 1.953,82 | .13 | .07 | .49 | .983,82 | .41 | .04 | .26 |
Follow-up | .583,80 | .63 | .02 | .17 | 2.973,80 | .04 | .10 | .68 | .013,80 | 1.00 | .00 | .05 |
WHOQOL-BREF psychological | ||||||||||||
Post | 2.161,83 | .15 | .03 | .31 | ||||||||
Follow-up | .001,80 | .95 | .00 | .05 | 2.891,80 | .09 | .04 | .39 | .231,80 | .63 | .23 | .08 |
*Panic symptoms MANOVA includes clinician-rated panic disorder and agoraphobia severity, PDSS, and PAMTH; negative affect MANOVA includes DASS subscales of depression, anxiety, and stress; quality of life MANOVA includes WHOQOL-BREF physical, social, and environmental domains.
Effects from univariate tests
Time Effect | Group Effect | |||||||
Variable | F |
|
Partial |
|
F |
|
Partial |
|
Panic disorder | 69.491,58 | .00 | .55 | 1.00 | ||||
PAMTH | 29.911,58 | .00 | .34 | 1.00 | ||||
ASP | 35.371,58 | .00 | .46 | 1.00 | ||||
PDSS | 50.141,58 | .00 | .46 | 1.00 | ||||
Agoraphobia | 37.231,58 | .00 | .39 | 1.00 | ||||
MIA | 15.161,58 | .00 | .21 | .97 | ||||
MIB | 21.791,58 | .00 | .27 | 1.00 | ||||
DASS depression | 41.181,88 | .00 | .32 | 1.00 | ||||
DASS anxiety | 47.981,88 | .00 | .35 | 1.00 | ||||
DASS stress | 44.661,88 | .00 | .34 | 1.00 | ||||
WHOQOL-BREF physical | 45.911,84 | .00 | .35 | 1.00 | ||||
WHOQOL-BREF social | 9.981,84 | .00 | .11 | .88 | ||||
WHOQOL-BREF environmental | 12.071,84 | .00 | .13 | .93 | ||||
WHOQOL-BREF physical | 9.131,82 | .00 | 1.00 | .85 | ||||
WHOQOL-BREF environmental | 4.411,82 | .04 | .05 | .55 |
*PAMTH, panic attacks in the last month; ASP, Anxiety Sensitivity Profile; PDSS, Panic Disorder Severity Scale; MIA, Mobility Inventory alone; MIB, Mobility Inventory accompanied; DASS, Depression Anxiety Stress Scale; WHOQOL-BREF, World Health Organization Quality of Life-BREF.
For the negative affect grouping, repeated measures MANOVA revealed no significant interaction between time and group or group main effect. However, a significant main effect for time was found from pretreatment to post treatment assessment (see
For the quality of life grouping, repeated measures MANOVA revealed no significant interaction between time and group. However, a significant main effect for time from pretreatment to posttreatment assessment and a significant main effect for group from posttreatment to follow-up assessment were found (see
An ANCOVA was conducted on the psychological domain of the WHOQOL-BREF from pretreatment to posttreatment and posttreatment to follow-up. No significant differences were detected (see
Panic-free status and high-end state functioning were examined at posttreatment and follow-up assessment. Panic-free status was defined as zero panic attacks reported during the month immediately prior to the assessment. At posttreatment assessment, panic-free status was achieved by 52.4% (22/42) of the PO+P group and 50.9% (27/53) of the PO+GP group; this difference was not significant (
High-end state functioning was defined as being panic free and having a clinician-rated panic disorder score ≤ 2. At posttreatment assessment, 28.6% (12/42) of the PO+P group and 26.4% (14/53) of the PO+GP group achieved high-end state functioning, but this difference was not statistically significant (
The purpose of the current study was to investigate whether the established efficacy of PO was affected by changing the form of therapist assistance from email support provided by psychologists (eTherapists) to face-to-face support provided by GPs, and, further, whether treatment improvements were maintained. The results of this study support findings from several previous studies examining Internet programs in primary care [
The recommended treatment for panic disorder includes CBT, medication (antidepressants and/or benzodiazepines), or a combination of both [
In this study, PO (whether supported by eTherapists or face-to-face GPs) led to significant improvements in panic attack frequency, depression, anxiety, stress, anxiety sensitivity, agoraphobia avoidance, and quality of life. Improvements were maintained at follow-up, with the only significant differences occurring on the WHOQOL-BREF physical and environmental domains. It is beyond the capacity of this study to ascertain definitively why the groups differed on these particular measures. It is possible to speculate, however, that the different dissemination processes (email vs face-to-face) created disparate learning experiences between the groups, resulting in the PO treatment information being used and retained in different manners. Further, while the groups did not significantly differ on any pretreatment assessment sociodemographic measure, the PO+GP group did have a higher degree of comorbidity and proportion of participants on medication. Consequently, it is possible that this study inherently measured two different cohorts.
Surprisingly, attrition from treatment was significantly higher for the PO+GP group. A number of possible reasons can be hypothesized. First, there was variation in the level of support throughout the duration of the trial. While participants in the PO+GP group were encouraged to regularly access their GP throughout treatment, this was not a requirement, and GP visitations could not be reasonably regulated within this study. By contrast, participants in the PO+P group were able to email their therapist as often as they wished, and their therapist was required to respond within 24 hours. Second, greater effort and planning are required to attend a medical practice in comparison to writing an email. Consequently, participants in the PO+P group may have experienced a greater level of continuous support and encouragement to adhere to the treatment. It is also worth noting that while treatment credibility was not significantly different between the groups, it did near significance, with the PO+P treatment appearing to be viewed more favorably than the PO+GP treatment. Finally, it is not known whether the content of GP visits focused specifically on panic disorder or incorporated consultation on other unrelated ailments. However, in comparison to other Internet-based studies [
It is noteworthy that the proportion of participants achieving high-end state functioning in both groups continued to increase from posttreatment to follow-up and that for the PO+P group, the increase was significant. These results not only support the durability of PO to maintain treatment outcomes but also indicate that it has the capacity to continue to have benefits beyond treatment completion.
There are several methodological issues and limitations to note. The primary limitation of this study was that it used a nonrandomized, natural groups design. Consequently, we can not speak to the direct comparability of these two treatments, and it is possible that the groups differed in ways not considered within this study. It should also be mentioned that all participating GPs were trained in delivering CBT. It is unknown whether non-CBT-trained GPs would achieve similar outcomes. This issue would benefit from further investigation as the accessibility to the program would be increased substantially if the evidence base indicated that all GPs were able to effectively support patients using the program. As discussed earlier, the treatments differed in terms of the supportive communication modality employed. This factor may have affected attrition and was not investigated. A final issue relates to PO access. Unfortunately, participant usage statistics (eg, number of times accessed PO, duration of time spent on PO) were not available. Consequently, it is possible that one group may have spent a proportionally greater period of time accessing and/or reading the PO material and therefore achieved and sustained greater benefits.
A number of implications for policy and practice can be derived from this study. While it is anticipated that there might be reluctance to adopt eTherapy into general practice [
This study demonstrates that when panic disorder sufferers are provided with accessible online treatment protocols, CBT-skilled GPs can achieve sustained patient outcomes comparable to best-practice treatments delivered by psychologists. Further research will be required to evaluate Internet-based programs for other mental health conditions and with non-CBT-trained GPs. Nevertheless, this study provides strong evidence that the use of Internet-based programs is an effective adjunct to existing mental health care services and may enable the delivery of evidence-based treatments to increasingly large numbers of patients via primary care with the support of suitably trained health professionals.
The authors wish to acknowledge the contribution of the late Professor Jeffrey Richards, instigator and former chief investigator of this research.
Funding for this research project was provided by the beyondblue Victoria Centre of Excellence in Depression and Related Disorders. Funding for the original development of the PO eTherapy program used in this study was granted to the original chief investigator, the late Professor Jeffrey Richards, by the Australian Rotary Health Research Fund.
None declared.
Anxiety Sensitivity Profile
Better Outcomes in Mental Health Care
cognitive behavioral therapy
Depression Anxiety Stress Scale
general practitioner
Mobility Inventory alone
Mobility Inventory accompanied
panic attacks in the last month
Panic Disorder Severity Scale
Panic Online
World Health Organization Quality of Life-BREF