Deborah Brauser

May 29, 2013

SAN FRANCISCO — Cognitive-behavioral therapy (CBT) delivered via email is an effective treatment alternative for patients with general anxiety disorder (GAD) — especially those who live in rural areas or places with a shortage of therapists, new research suggests.

The study of 62 adults with GAD in Iran showed that those who received 12 email-based sessions of CBT had significantly lower anxiety symptom scores 6 and 12 months later than did those who did not receive any treatment.

Lead author Nazanin Alavi, MD, from the Department of Psychiatry at Queen's University in Kingston, Ontario, Canada, told Medscape Medical News that when the active treatment group was asked how they felt about their sessions, answers included that it had less stigma "because it was something online that was just between them and their psychotherapist."

"They also said that when they were going through stuff, it was easier to write it down instead of telling someone in person in their office."

Dr. Alavi presented the findings here at the American Psychiatric Association's (APA's) 2013 Annual Meeting.

Jeffrey Borenstein, MD, chair of the Council on Communications for the APA, noted that, as a field, "We don't yet know how to best use new technology."

"But certainly at this point I think there's the potential for [email-based CBT] as an adjunct treatment, especially for people who are in an area that is difficult to reach," said Dr. Borenstein.

Treatment Barriers

According to the investigators, previous research has shown that CBT is "superior to no treatment and nonspecific control conditions" in improving symptoms of GAD in both the short and long term.

However, several barriers exist to delivering this type of treatment, including long wait times in urban areas, a lack of access in remote areas, and cultural differences faced by immigrants who may feel more comfortable working with a clinician from their home country or who at least speaks their language.

"Therefore, using alternative methods to overcome these barriers seems necessary," write the researchers.

Dr. Alavi noted that she was born in and received her medical degree in Iran before moving to Canada. So she has become especially concerned with the obstacles that many immigrants face in receiving psychotherapy.

Dr. Nazanin Alavi

"When you move to a new country, there are lots of stressors, including financial problems as you try to find a job and not being around your family, which means being without support. So sometimes depression or anxiety can develop," she said.

"I've seen many people who were thinking about seeing a psychotherapist but preferred to see someone with the same cultural background."

Dr. Alavi noted that because Internet use continues to rise, "I thought about online psychotherapy as a new method of delivering treatment."

For this study, 62 adults with access to the Internet between the ages of 20 and 40 years were enrolled. The preferred language for all was Farsi. In addition, all had GAD, as assessed via a 1-hour online chat interview.

Half of the participants were randomly assigned to receive 12 email-based CBT sessions, and the other half received no treatment (control group).

All were asked to complete the Beck Anxiety Inventory (BAI) at baseline and immediately after final treatment, as well as at 6-month and 1-year follow-up.

Lower Symptom Scores

Results showed that the group that received email-based CBT had significantly lower BAI scores at end of treatment, at 6-month follow-up, and at 12-month follow-up compared with the control group. The symptom scores for the CBT group also decreased significantly at each checkpoint compared with their baseline scores.

The control group did not show any significant changes in BAI scores at any of the evaluation points.

Dr. Alavi noted that limitations with this treatment delivery method include not being able to see a patient's face and that not everyone has Internet access.

"We can't say right now whether this should be a first-line treatment. But we want to do more research comparing online CBT with live CBT — and also find out which one patients prefer."

When asked during the Q&A session after her presentation whether using an online video service such as Skype might help to give a better experience, she said "maybe," noting its own limitations, including taking more time and providing more complications due to scheduling or time zone differences.

Nevertheless, Dr. Borenstein, who is also president and CEO of Brain and Behavior Research Foundation, answered that technology such as Skype might work well as a desirable adjunct delivery option.

"That will clearly allow you to hear the voice of the patient and to be able to see each other. And I think that could be very powerful. It's not quite like being in the same room, but it's much closer," he said.

More Opportunities

Dr. Borenstein told Medscape Medical News that he applauds research that examines ways for psychiatrists to provide treatment to more people — including those individuals who may be afraid to come into a mental health office because of fears of stigma.

"I do think efforts to reduce stigma and prejudice, to educate the public, and to encourage people not to suffer in silence and to seek treatment are worthwhile initiatives. And for people who are more remote, making use of other technologies, such as the phone, Skype, etc, are ways to help them to get treatment," he said.

"The more opportunities for more people to get treatment and to get improvement in their condition, the better."

The study authors and Dr. Borenstein have disclosed no relevant financial relationships.

The American Psychiatric Association's 2013 Annual Meeting. Abstract NR7-20. Presented May 20, 2013.

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