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Internet-delivered cognitive behavioral therapy (ICBT) can improve access to mental health care for students, although high attrition rates are concerning and little is known about long-term outcomes. Motivational interviewing (MI) exercises and booster lessons can improve engagement and outcomes in face-to-face cognitive behavioral therapy.
This study aimed to examine the use of pretreatment MI exercises and booster lessons in ICBT for postsecondary students.
In this factorial trial (factor 1: web-based MI before treatment; factor 2: self-guided booster lesson 1 month after treatment), 308 clients were randomized to 1 of 4 treatment conditions, with 277 (89.9%) clients starting treatment. All clients received a 5-week transdiagnostic ICBT course (the
Overall, 54% (150/277) of students completed treatment and reported large improvements in symptoms of depression and anxiety and small improvements in academic functioning after treatment, which were maintained at the 1-month and 3-month follow-ups. Pretreatment MI did not contribute to better treatment completion or engagement, although small between-group effects favored MI for reductions in depression (Cohen
Rather than offering MI before treatment, clients may experience more benefits from MI exercises later in ICBT when motivation wanes. The low uptake of the self-guided booster limited our conclusions regarding its effectiveness. Future research should examine offering a booster for a longer duration after treatment, with therapist support and a longer follow-up period.
ClinicalTrials.gov NCT04264585; https://clinicaltrials.gov/ct2/show/NCT04264585
An estimated one-third of college students worldwide meet the criteria for mental health disorders in any given year [
Internet-delivered cognitive behavioral therapy (ICBT) is an effective alternative to face-to-face cognitive behavioral therapy (CBT) and may reduce the barriers that students face when trying to access treatment. In ICBT, clients receive structured web-based materials (eg, presentation slides, worksheets, and homework activities) based on cognitive behavioral strategies. Therapist-assisted ICBT courses typically involve weekly contact with a therapist either through secure messaging or telephone [
Another issue of ICBT for university students is high attrition rates [
The literature on adding MI to ICBT is limited, with only 2 studies exploring MI before clients initiate ICBT [
To date, no studies have examined the inclusion of pretreatment MI in ICBT for postsecondary students, a group known to be at risk of lower engagement and poorer outcomes. Given the promising findings of including MI in face-to-face CBT [
Booster sessions represent another strategy with the potential to improve ICBT outcomes. In face-to-face CBT, booster sessions are used to remind clients of strategies learned during treatment and offer clients the opportunity to problem solve any barriers faced since completing treatment [
The purpose of this study was to examine the effects of including pretreatment MI and a self-guided booster offered 1 month after transdiagnostic ICBT for postsecondary students. In particular, we were interested in whether including pretreatment MI would affect treatment completion, treatment engagement, and outcomes compared with ICBT without pretreatment MI. We hypothesized that clients assigned to either of the conditions with pretreatment MI would be more likely to complete treatment and be more engaged during treatment (ie, greater number of log-ins and more messages sent to their therapist) than clients who did not receive the pretreatment MI exercises (ie, only received the standard ICBT course or the ICBT course with a self-guided booster lesson). The study of the benefits of pretreatment MI for symptom improvement was considered exploratory in this specific population, given the null findings from both previous ICBT studies regarding the benefits of pretreatment MI [
This study used a 2×2 factorial design (factor 1: pretreatment web-based MI; factor 2: self-guided booster lesson 1 month after treatment), and was registered as a clinical trial (ClinicalTrials.gov NCT04264585).
The study was reviewed and received ethics approval from the University of Regina Research Ethics Board (REB: 2019-205).
The study was conducted at a routine care ICBT clinic (the Online Therapy Unit), which offers ICBT free of charge to residents of Saskatchewan. Examining client outcomes in a routine care setting is important as these clients typically present with greater levels of comorbidity and more diversity than in early phase randomized controlled trials [
Prospective clients could self-refer to the course using the Online Therapy Unit’s website. Clients found out about the
All clients were offered the
Clients who were accepted into the trial were randomized using REDCap (Research Electronic Data Capture; Vanderbilt University) to one of four treatment conditions (using block randomization) at the end of their telephone screen: standard
Clients who were randomized to 1 of the 2 conditions that included MI completed a series of 5 web-based exercises (the
In the trial by Soucy et al [
The exercises were based on common MI principles (ie, value clarification [
Clients who were randomized to the booster condition were offered a self-guided booster lesson 1 month after completing the
Each client was assigned to a therapist who provided weekly support during the 5-week course. Most of the therapist support was offered through personalized messages sent on the secure treatment portal on the same day each week. Therapists were instructed to spend 15 to 20 minutes per client each week. Telephone contact could be initiated if the client experienced a significant increase in symptoms of depression or anxiety (≥5 points on the PHQ-9 or GAD-7), if the client’s responses on the PHQ-9 or messages to their therapist suggested increased suicide risk, or if the client had not accessed the website for a week to encourage the client to continue working on the lessons. A total of 6 therapists provided support in the trial (n=2, 33% with backgrounds in psychology, and n=4, 67% in social work). Of the 6 therapists, 5 (83%) were registered with their respective regulatory colleges, and 1 (17%) was a supervised PhD student in clinical psychology. All 6 therapists received ICBT training, regular supervision, and auditing of their messages [
Primary outcome measures were administered before treatment, after treatment, and at the 1-month and 3-month follow-ups. Clients also completed these measures on a weekly basis during treatment as a way for therapists to monitor their symptoms.
The PHQ-9 [
The GAD-7 [
The Perceptions of Academic Functioning (PAF) was created for this study and comprises 3 items related to academic functioning over the past week. Using a scale ranging from 0 to 10, clients were asked how well they felt they were able to attend their classes or lectures, complete academic tasks (eg, assignments, papers, laboratory classes, and readings), and absorb information from readings or lectures. The PAF had good internal consistency (α=.81 to α=.93), and items were summed to create a total score, with higher scores indicating better perceived functioning.
Secondary outcome measures were administered at various time points, as described in the following sections:
The Sheehan Disability Scale (SDS) [
The Alcohol Use Disorder Identification Test (AUDIT) [
The Drug Use Disorder Identification Test (DUDIT) [
The 3-Item Change Questionnaire (CQ-3) [
The Treatment Satisfaction Questionnaire [
Descriptive statistics were used to summarize client characteristics at intake, including demographics and scores on each of the primary and secondary outcome measures. Modified intention-to-treat (ITT) analyses [
Patient flow from screening to the 3-month follow-up. ER: emergency room; MI: motivational interviewing.
In this trial, 308 clients were randomized (
Before treatment, the mean scores on the PHQ-9 and GAD-7 were 14.49 (SD 5.77) and 13.71 (SD 4.76), respectively. Over two-thirds of clients scored above the clinical cutoff (≥10) on both the PHQ-9 and GAD-7, and only a small subset of clients did not score within the clinical range on either the PHQ-9 or the GAD-7 (34/277, 12.3%). The mean score on the PAF was 17.36 (SD 6.46). In terms of mental health history and service use, 37.9% (105/277) reported having a mental health diagnosis, 27.4% (76/277) reported having some form of mental health support at screening, and 36.5% (101/277) reported having taken psychotropic medication for anxiety or depression in the previous 3 months. The mean score for the CQ-3 was 24.05 (SD 4.22) before treatment, suggesting relatively high levels of motivation.
Pretreatment demographic and clinical characteristics by group (N=277).
Variable | All groups | Standard (n=71) | MIa (n=67) | Booster (n=71) | MI+booster (n=68) | ||||||
Age (years), mean (SD; range) | 23.73 (5.95; 17-46) | 23.57 (6.11; 18-44) | 24.66 (6.58; 18-46) | 23.35 (5.86; 17-43) | 23.44 (5.28; 18-39) | ||||||
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Man | 45 (16.2) | 10 (14.1) | 6 (9.1) | 12 (18.2) | 17 (25) | |||||
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Woman | 224 (80.9) | 57 (80.3) | 58 (86.6) | 58 (81.7) | 51 (75) | |||||
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Nonbinary | 5 (1.8) | 2 (2.8) | 2 (3) | 1 (1.5) | 0 (0) | |||||
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Prefer not to disclose or not listed | 3 (1.1) | 2 (2.8) | 1 (1.5) | 0 (0) | 0 (0) | |||||
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Single or never married | 113 (41.5) | 31 (43.7) | 22 (33.3) | 31 (47) | 29 (42.6) | |||||
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Dating | 107 (38.6) | 26 (36.6) | 24 (35.8) | 29 (40.8) | 28 (41.2) | |||||
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Married or common law | 31 (11.4) | 8 (11.3) | 13 (19.7) | 5 (7.6) | 5 (7.4) | |||||
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Living with partner | 18 (6.4) | 4 (5.6) | 3 (4.5) | 5 (7.6) | 6 (8.8) | |||||
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Separated or divorced or widowed | 8 (3) | 2 (2.8) | 5 (7.6) | 1 (1.5) | 0 (0) | |||||
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Living with someone | 224 (80.9) | 55 (77.5) | 56 (83.6) | 57 (80.3) | 56 (82.4) | |||||
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University of Regina | 186 (67.1) | 47 (66.2) | 46 (70.1) | 47 (66.2) | 45 (66.2) | |||||
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University of Saskatchewan | 59 (21.3) | 14 19.7 () | 11 (16.4) | 18 (25.4) | 16 (23.5) | |||||
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Saskatchewan Polytechnic | 10 (3.6) | 1 (1.4) | 6 (9.1) | 1 (1.4) | 2 (2.9) | |||||
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Other | 22 (8.1) | 9 (12.7) | 3 (4.5) | 5 (7) | 5 (7.7) | |||||
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Full-time student | 235 (85.5) | 61 (87.1) | 53 (79.1) | 62 (87.3) | 59 (88.1) | |||||
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Part-time student | 40 (14.5) | 9 (12.9) | 14 (20.9) | 8 (12.7) | 8 (11.9) | |||||
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First-year undergraduate | 67 (24.6) | 19 (27.1) | 14 (21.2) | 21 (30.4) | 13 (19.4) | |||||
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Second-year undergraduate | 57 (21) | 13 (18.6) | 17 (25.8) | 8 (11.6) | 19 (28.4) | |||||
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Third-year undergraduate | 62 (22.8) | 18 (25.7) | 17 (25.8) | 16 (23.2) | 11 (16.4) | |||||
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Fourth-year undergraduate | 44 (16.2) | 10 (14.3) | 7 (10.6) | 15 (21.7) | 12 (17.9) | |||||
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Fifth or higher year undergraduate | 18 (6.6) | 3 (4.3) | 7 (10.6) | 4 (5.8) | 4 (6) | |||||
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Graduate or professional student | 26 (8.8) | 7 (10) | 4 (6.1) | 5 (7.2) | 8 (12) | |||||
International student, n (%) | 10 (3.6) | 3 (4.3) | 2 (3) | 1 (1.4) | 4 (5.9) | ||||||
English not the first language, n (%) | 24 (8.7) | 2 (2.8) | 5 (7.5) | 6 (8.6) | 11 (16.2) | ||||||
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Paid work | 135 (48.7) | 39 (54.9) | 32 (47.8) | 30 (44.1) | 30 (44.1) | |||||
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Unemployed | 142 (51.3) | 32 (45.1) | 35 (52.2) | 38 (55.9) | 38 (55.9) | |||||
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White | 201 (72.6) | 53 (74.6) | 49 (73.1) | 54 (76.1) | 45 (66.2) | |||||
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Indigenous | 20 (7.2) | 6 (8.5) | 8 (11.9) | 3 (4.2) | 3 (4.4) | |||||
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Asian | 26 (9.4) | 3 (4.2) | 4 (6) | 8 (11.2) | 11 (16.2) | |||||
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Other | 30 (10.8) | 9 (12.7) | 6 (9) | 6 (8.5) | 9 (13.2) | |||||
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Large city (>200,000) | 191 (69) | 49 (69) | 44 (65.7) | 52 (73.2) | 46 (67.6) | |||||
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Small to medium city | 23 (8.3) | 8 (11.3) | 6 (9) | 7 (9.9) | 2 (2.9) | |||||
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Small rural location (<10,000) | 63 (22.7) | 14 (19.7) | 17 (25.4) | 12 (16.9) | 20 (29.4) | |||||
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Physician or medical professional | 88 (31.9) | 19 (27.1) | 23 (34.3) | 22 (31) | 24 (35.3) | |||||
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Web-based source (eg, website or email) | 70 (25.4) | 19 (27.1) | 17 (25.4) | 20 (28.2) | 14 (20.6) | |||||
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Counseling services | 37 (13.4) | 10 (14.3) | 11 (16.4) | 6 (8.5) | 10 (14.7) | |||||
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Friend or family member or employer | 35 (12.7) | 6 (8.6) | 10 (14.9) | 12 (16.9) | 7 (10.3) | |||||
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Presentation | 12 (4.3) | 5 (7.1) | 2 (2.8) | 2 (2.8) | 3 (4.4) | |||||
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Printed poster or media | 4 (1.4) | 4 (5.7) | 0 (0) | 0 (0) | 1 (1.5) | |||||
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Other | 30 (10.9) | 7 (10) | 4 (6) | 9 (12.7) | 8 (11.8) | |||||
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Lifetime mental health service use | 158 (57) | 36 (50.7) | 47 (70.1) | 38 (53.5) | 37 (54.4) | |||||
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Lifetime hospitalization for mental health | 22 (7.9) | 3 (4.2) | 9 (13.4) | 7 (9.9) | 3 (4.4) | |||||
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Mental health diagnosis | 105 (37.9) | 27 (38) | 32 (47.8) | 27 (38) | 19 (27.7) | |||||
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Taking psychotropic medication in the past 3 months | 101 (36.5) | 20 (28.2) | 29 (43.3) | 23 (32.4) | 29 (42.6) | |||||
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Current mental health service use | 76 (27.4) | 19 (26.8) | 23 (34.3) | 12 (16.9) | 22 (32.4) | |||||
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Pretreatment GAD-7c ≥10 | 216 (78) | 58 (81.7) | 49 (73.1) | 55 (77.5) | 54 (79.4) | |||||
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Pretreatment PHQ-9d ≥10 | 213 (76.9) | 53 (74.6) | 52 (77.6) | 55 (77.5) | 53 (77.9) | |||||
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Pretreatment GAD-7 ≥10 and PHQ-9 ≥10 | 186 (67.1) | 48 (67.6) | 44 (65.7) | 47 (66.2) | 47 (69.1) | |||||
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No clinical scores | 34 (12.3) | 8 (11.3) | 10 (14.9) | 8 (11.3) | 8 (11.8) | |||||
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CEQe | 21.16 (4.19) | 20.63 (3.98) | 21.91 (4.09) | 20.90 (4.61) | 21.34 (4.09) | |||||
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CQ-3f | 24.05 (4.22) | 24.29 (3.64) | 23.39 (4.51) | 24.20 (4.46) | 24.35 (4.41) |
aMI: motivational interviewing.
bLocation is based on where the client was residing at intake.
cGAD-7: 7-item Generalized Anxiety Disorder.
dPHQ-9: 9-item Patient Health Questionnaire.
eCEQ: Credibility and Expectancy Questionnaire.
fCQ-3: 3-item Change Questionnaire.
The estimated marginal means, percentage reductions, and effect sizes for each of the primary outcome measures are presented in
Estimated marginal means, 95% CIs, percentage changes, and effect sizes (Cohen
Outcomes | Estimated marginal means, (SD) | Changes from pretreatment (%), 95% CI | Within-group effect sizes from pretreatment, 95% CI | |||||||||||||||||||||
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Pretreatment | Posttreatment | 1 month | 3 months | To posttreatment | To 1 month | To 3 months | To posttreatment | To 1 month | To 3 months | ||||||||||||||
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MI | 14.24 (5.56) | 6.90 (4.24) | 7.04 (4.92) | 7.41 (4.78) | 52 (46 to 57) | 51 (44 to 57) | 48 (42 to 54) | 1.48 (1.21 to 1.75) | 1.37 (1.10 to 1.63) | 1.31 (1.05 to 1.58) | ||||||||||||
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No MI | 14.72 (5.97) | 7.91 (4.54) | 7.73 (5.01) | 7.79 (5.31) | 46 (41 to 52) | 48 (41 to 54) | 47 (41 to 53) | 1.28 (1.02 to 1.54) | 1.27 (1.01 to 1.52) | 1.22 (0.97 to 1.48) | ||||||||||||
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Booster | 14.16 (5.16) | 7.77 (4.41) | 7.60 (5.00) | 7.59 (4.78) | 45 (40 to 51) | 46 (40 to 53) | 46 (40 to 53) | 1.33 (1.07 to 1.59) | 1.29 (1.03 to 1.55) | 1.32 (1.06 to 1.58) | ||||||||||||
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No booster | 14.80 (6.33) | 7.03 (4.41) | 7.16 (4.95) | 7.60 (5.33) | 53 (47 to 58) | 52 (45 to 58) | 49 (42 to 55) | 1.42 (1.16 to 1.69) | 1.34 (1.08 to 1.60) | 1.23 (0.97 to 1.48) | ||||||||||||
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MI | 13.51 (4.71) | 6.10 (3.89) | 6.78 (4.75) | 7.17 (5.42) | 55 (50 to 60) | 50 (43 to 56) | 47 (40 to 54) | 1.71 (1.43 to 1.99) | 1.42 (1.15 to 1.69) | 1.25 (0.98 to 1.51) | ||||||||||||
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No MI | 13.88 (4.82) | 7.14 (4.28) | 7.11 (4.94) | 7.51 (5.33) | 49 (43 to 54) | 49 (42 to 55) | 46 (39 to 53) | 1.47 (1.21 to 1.74) | 1.38 (1.12 to 1.64) | 1.25 (1.00 to 1.50) | ||||||||||||
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Booster | 13.66 (4.75) | 7.12 (4.19) | 7.34 (5.00) | 7.59 (5.42) | 48 (42 to 54) | 46 (40 to 53) | 44 (37 to 52) | 1.46 (1.19 to 1.72) | 1.29 (1.04 to 1.55) | 1.19 (0.93 to 1.44) | ||||||||||||
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No booster | 13.73 (4.80) | 6.12 (4.00) | 6.57 (4.68) | 7.10 (5.32) | 55 (50 to 60) | 52 (46 to 58) | 48 (41 to 55) | 1.72 (1.44 to 1.99) | 1.51 (1.24 to 1.77) | 1.31 (1.05 to 1.57) | ||||||||||||
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MI | 17.47 (6.27) | 19.63 (7.30) | 20.14 (6.73) | 19.76 (7.62) | 17 (7 to 28) | 21 (11 to 32) | 18 (7 to 30) | 0.32 (0.08, 0.56) | 0.41 (0.17 to 0.65) | 0.33 (0.09 to 0.57) | ||||||||||||
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No MI | 17.24 (6.67) | 19.24 (7.33) | 20.38 (6.09) | 19.12 (7.44) | 16 (5 to 27) | 25 (15 to 34) | 15 (4 to 26) | 0.28 (0.05 to 0.52) | 0.49 (0.25 to 0.73) | 0.27 (0.03 to 0.50) | ||||||||||||
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Booster | 17.29 (6.75) | 19.81 (6.94) | 20.52 (6.37) | 19.41 (7.36) | 20 (9 to 31) | 25 (16 to 35) | 17 (6 to 28) | 0.37 (0.13 to 0.61) | 0.49 (0.25 to 0.73) | 0.30 (0.06 to 0.54) | ||||||||||||
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No booster | 17.43 (6.19) | 19.05 (7.65) | 19.99 (6.45) | 19.48 (7.71) | 13 (2 to 24) | 20 (10 to 31) | 16 (5 to 28) | 0.23 (–0.01 to 0.47) | 0.40 (0.17 to 0.64) | 0.29 (0.06 to 0.53) | ||||||||||||
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MI | 19.28 (6.70) | 13.19 (6.79) | 11.99 (7.27) | 12.37 (7.46) | 32 (25 to 38) | 38 (31 to 45) | 36 (29 to 43) | 0.90 (0.65 to 1.15) | 1.04 (0.79 to 1.30) | 0.97 (0.72 to 1.22) | ||||||||||||
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No MI | 20.06 (5.75) | 15.63 (7.00) | 12.54 (7.09) | 12.24 (7.38) | 22 (16 to 28) | 37 (31 to 44) | 39 (32 to 46) | 0.69 (0.45 to 0.93) | 1.16 (0.91 to 1.41) | 1.18 (0.93 to 1.43) | ||||||||||||
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Booster | 19.58 (6.22) | 14.52 (6.53) | 12.27 (7.25) | 12.18 (7.13) | 26 (19 to 32) | 37 (30 to 44) | 38 (31 to 45) | 0.79 (0.55 to 1.03) | 1.08 (0.83 to 1.33) | 1.10 (0.85 to 1.35) | ||||||||||||
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No booster | 19.76 (6.26) | 14.20 (7.45) | 12.25 (7.12) | 12.43 (7.70) | 28 (21 to 35) | 38 (31 to 45) | 37 (30 to 44) | 0.81 (0.56 to 1.05) | 1.12 (0.86 to 1.37) | 1.04 (0.79 to 1.29) | ||||||||||||
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MI | 4.59 (4.86) | 3.08 (3.95) | —g | — | 33 (18 to 48) | — | — | 0.34 (0.10 to 0.58) | — | — | ||||||||||||
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No MI | 4.29 (4.06) | 3.52 (3.90) | — | — | 18 (2 to 34) | — | — | 0.19 (–0.04 to 0.43) | — | — | ||||||||||||
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Booster | 4.30 (4.28) | 3.28 (3.86) | — | — | 24 (7 to 40) | — | — | 0.25 (0.01 to 0.48) | — | — | ||||||||||||
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No booster | 4.58 (4.65) | 3.32 (4.00) | — | — | 28 (12 to 43) | — | — | 0.29 (0.05 to 0.53) | — | — | ||||||||||||
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MI | 2.32 (5.10) | 1.95 (4.72) | — | — | 16 (20 to 52) | — | — | 0.07 (–0.16 to 0.31) | — | — | ||||||||||||
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No MI | 2.90 (6.04) | 2.36 (5.21) | — | — | 19 (–12 to 49) | — | — | 0.10 (–0.14 to 0.33) | — | — | ||||||||||||
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Booster | 2.52 (5.09) | 1.66 (3.65) | — | — | 34 (8 to 60) | — | — | 0.19 (–0.04 to 0.43) | — | — | ||||||||||||
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No booster | 2.70 (6.09) | 2.66 (6.00) | — | — | 2 (–36 to 40) | — | — | 0.01 (–0.23 to 0.24) | — | — |
aMI: motivational interviewing.
bPHQ-9: 9-item Patient Health Questionnaire.
cGAD-7: 7-item Generalized Anxiety Disorder.
dPAF: Perceptions of Academic Functioning.
eSDS: Sheehan Disability Scale.
fAUDIT: Alcohol Use Disorder Identification Test.
gThe AUDIT and DUDIT were only administered before treatment and after treatment; thus, data are not available for the percentage change and effect sizes at the 1-month and 3-month follow-ups.
hDUDIT: Drug Use Disorder Identification Test.
A main effect was found for MI on the PHQ-9 (between-group Cohen
No main effects were found for those assigned to the booster versus those who were not assigned to any of the primary (
Between groups effect sizes (Cohen
Outcomes | After treatment, Cohen |
1-month follow-up, Cohen |
3-month follow-up, Cohen |
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PHQ-9b | 0.23 (−0.01 to 0.47) | 0.14 (−0.10 to 0.37) | 0.08 (−0.16 to 0.31) | |||
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GAD-7c | 0.25 (0.02 to 0.49) | 0.07 (−0.17 to 0.30) | 0.06 (−0.17 to 0.30) | |||
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PAFd | 0.05 (−0.18 to 0.29) | −0.04 (−0.27 to 0.20) | 0.09 (−0.15 to 0.32) | |||
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SDSe | 0.35 (0.12 to 0.59) | 0.08 (−0.16 to 0.31) | −0.02 (−0.25 to 0.22) | |||
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AUDITf | 0.11 (−0.12 to 0.35) | —g | — | |||
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DUDITh | 0.08 (−0.15 to 0.32) | — | — | |||
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PHQ-9 | −0.17 (−0.40 to 0.07) | −0.09 (−0.32 to 0.15) | 0.00 (−0.23 to 0.24) | |||
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GAD-7 | −0.24 (−0.48 to −0.01) | −0.16 (−0.39 to 0.08) | −0.09 (−0.33 to 0.14) | |||
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PAF | 0.10 (−0.13 to 0.34) | 0.08 (−0.15 to 0.32) | −0.01 (−0.25 to 0.23) | |||
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SDS | −0.05 (−0.28 to 0.19) | 0.00 (−0.24 to 0.23) | 0.03 (−0.20 to 0.27) | |||
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AUDIT | 0.00 (−0.23 to 0.24) | — | — | |||
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DUDIT | 0.20 (−0.03 to 0.44) | — | — |
aMI: motivational interviewing.
bPHQ-9: 9-item Patient Health Questionnaire.
cGAD-7: 7-item Generalized Anxiety Disorder.
dPAF: Perceptions of Academic Functioning.
eSDS: Sheehan Disability Scale.
fAUDIT: Alcohol Use Disorder Identification Test.
gThe AUDIT and DUDIT were only administered before treatment and after treatment; thus, data are not available for the percentage change and effect sizes at the 1-month and 3-month follow-ups.
hDUDIT: Drug Use Disorder Identification Test.
For MI, a small between-group effect was found after treatment, such that clients who received MI had larger improvements on the SDS than clients who did not receive MI (between-group Cohen
No main effects for randomization to the booster were found for the SDS (
After treatment, 47.7% (132/277) of all clients met the criteria for reliable recovery, 60.3% (167/277) met the criteria for reliable improvement, 1.9% (5/277) met the criteria for deterioration, and 37.9% (105/277) met the criteria for no change on the PHQ-9. For the GAD-7, the rate of reliable recovery was 56.6% (157/277), the rate of reliable improvement was 75.5% (209/277), the rate of deterioration was 2.2% (6/277), and the rate of no change was 22% (61/277). At all time points, no significant main effects were found for MI or booster (
Of the clients in one of the MI conditions, 88.9% (120/135) completed the MI exercises and started lesson 1 (MI: 60/67, 90%; MI+booster: 60/68, 88%). Overall, 66.8% (183/277) of the clients accessed at least three of the four lessons, and 54.2% (150/277) accessed all 4 lessons within the 5 weeks of treatment. Of the clients who were randomized to booster, 30.9% (43/139) accessed the booster. Across conditions, clients logged in an average of 12.95 (SD 9.15) times, received an average of 5.23 (SD 0.83) emails from their therapists, and sent an average of 1.98 (SD 1.71) emails to their therapists. There was an average of 29.05 (SD 19.16) days between the clients’ enrollment date and their last log-in to the treatment portal. No main effects were found for MI on any measure of treatment engagement (
Clients reported high rates of satisfaction overall, with 82.3% (158/192), 85.5% (165/193), and 84.5% (163/193) reporting that they were satisfied or very satisfied with the treatment, the treatment platform, and the lessons and do-it-yourself guides, respectively. Most clients felt that the treatment was worth their time (171/192, 89.1%) and that they would recommend it to a friend (176/193, 91.2%). Furthermore, 82.9% (160/193) of clients reported that their motivation to seek help if needed in the future either increased or greatly increased, and 76.2% (147/193) felt that their confidence in their ability to manage their symptoms either increased or greatly increased. No significant differences were found between treatment conditions on any of the treatment satisfaction measures (
Although ICBT is an effective treatment option for postsecondary students experiencing symptoms of anxiety or depression [
Some benefit was found for the inclusion of pretreatment MI on symptoms of depression, anxiety, and overall functioning after treatment. Clients who were randomized to one of the MI conditions reported larger improvements in symptoms of depression, anxiety, and overall functioning from before treatment to after treatment than those of clients who were not assigned MI. No benefit for MI was found at either the 1-month or 3-month follow-up; thus, it appears that pretreatment MI may only result in temporary benefits compared with ICBT without MI. MI did not contribute to higher rates of treatment completion or greater engagement (ie, more log-ins to the website, more days enrolled in the course, or more client messages sent to therapists). Findings from this trial replicate those of a previous trial that examined pretreatment MI before an 8-week ICBT program [
An explanation for why the MI exercises improved some outcomes despite no observable increase in treatment engagement is that the MI exercises helped elicit more change talk from the clients. Change talk was not examined directly in this study; however, a previous trial found that clients who completed pretreatment MI exercises included more change talk statements in messages with therapists than those who did not complete the exercises, despite no differences in treatment completion rates between the groups [
Pretreatment MI may not have led to higher treatment completion rates in both this trial and that of Soucy et al [
The inclusion of a self-guided booster lesson in ICBT for postsecondary students has not been previously examined; thus, no hypotheses were made regarding the proportion of clients who would make use of a booster. Overall, there were no significant differences between those assigned to the booster and those who were not. The lack of differences is likely, in part, related to the low use of the booster lesson. Booster use in this study was lower (43/134, 31.9%) than that in previous trials of boosters in ICBT (32/47, 68% in the study by Andersson et al [
Although findings related to MI and the booster condition were limited and completion rates were slightly above 50%, across the treatment conditions, clients experienced large reductions in both depression (Cohen
Treatment completion rates were similar between this study (150/277, 54.1%) and a previous trial (59%) [
Previous trials of the
It is challenging to compare the findings of this trial with the overall effects from meta-analyses of ICBT for postsecondary students [
Although the
There were several limitations to this study, which can inform future trials of ICBT for postsecondary students. One of the limitations was that the MI component was only offered before treatment, which may not have been the most beneficial time to offer MI to clients as clients may be starting treatment with high levels of motivation. In future trials of the
Future studies could also examine a
A limitation of the booster lesson was that it was offered only 1 month after treatment completion. Some clients may not have felt that they needed a booster lesson soon after treatment, which likely contributed to the low overall uptake of the booster. Among those who used the booster, there was preliminary evidence suggesting that the booster was associated with larger reductions in depression at the 3-month follow-up; however, these subanalyses were underpowered because of low uptake. Furthermore, we are unable to comment on the longer-term impacts of the booster lesson on symptoms of depression and anxiety, as well as subjective academic functioning, given that the final outcome measures were administered at the 3-month follow-up. Andersson et al [
It should be noted that all the clients enrolled in this trial started treatment during the COVID-19 pandemic. It is possible that clients experienced regression to the mean in terms of their symptom severity as they became accustomed to COVID-19 public health restrictions and the impact on their academic studies. As this is the first trial of the
A notable strength of this study is that we were able to replicate the findings of a previous trial on the
The findings from this factorial trial provide evidence for the efficacy of a 5-week transdiagnostic ICBT course for postsecondary students. Large effect sizes were found for reductions in symptoms of depression and anxiety, and small effect sizes were found for improvements in perceived academic functioning, with changes maintained up to the 3-month follow-up. There was some evidence for the benefit of pretreatment MI in improving depression, anxiety, and disability outcomes after treatment; however, no benefit was found for treatment completion or engagement. No main effects were found for the inclusion of a booster. However, although the booster was used by less than one-third of clients, there was some evidence for improved depression outcomes at the 3-month follow-up among booster users. Further research could explore whether it is possible to optimize ICBT for postsecondary populations by using variations of MI and booster lessons.
Estimated marginal means, 95% CIs, percentage changes, and effect sizes (Cohen
Alcohol Use Disorder Identification Test
cognitive behavioral therapy
3-item Change Questionnaire
Drug Use Disorders Identification Test
generalized anxiety disorder
7-item Generalized Anxiety Disorder
internet-delivered cognitive behavioral therapy
intention-to-treat
motivational interviewing
Perceptions of Academic Functioning
9-item Patient Health Questionnaire
Research Electronic Data Capture
Sheehan Disability Scale
The authors wish to acknowledge the clients, patient partners, screeners, therapists, research staff, and web developers from the Online Therapy Unit at the University of Regina, as well as the therapists from the Saskatchewan Health Authority for their contributions to this project.
This research was conducted by the Online Therapy Unit, which receives funding from the Saskatchewan Ministry of Health to provide internet-delivered cognitive behavioral therapy to residents of Saskatchewan. The funders had no involvement in the design of the paper and the collection, analysis, or interpretation of the data. NT and BD were funded by the Australian government to operate the MindSpot Clinic. NT and BD developed the
Data are not available because of confidentiality concerns.
None declared.