Clinician-Assisted Internet-Based Treatment is Effective for Generalized Anxiety Disorder: Randomized Controlled Trial
Abstract
Objective: The aim of the present study was to determine the efficacy of an Internet-based clinician-assisted computerized cognitive behavioural treatment (CaCCBT) programme for generalized anxiety disorder (the Worry programme). Methods: Forty-eight individuals meeting diagnostic criteria for generalized anxiety disorder (GAD) were randomly assigned to the Worry programme or to a waitlist control group. In the clinician-assisted Worry programme, participants complete six online lessons, weekly homework assignments, receive weekly email contact from a clinical psychologist, and contribute to a moderated online discussion forum with other participants. An intention-to-treat model was used for data analyses. The main outcome measures were Generalized Anxiety Disorder–7 Item Scale (GAD-7) and the Penn State Worry Questionnaire (PSWQ). Results: A total of 75% of treatment group participants completed all six lessons within the 9 week programme and post-treatment data were collected from 21/24 treatment group and 19/21 control group participants. Treatment group participants reported significantly reduced symptoms of worry as measured on the GAD-7 and PSWQ and reduced symptoms of depression as measured on the Patient Health Questionnaire–9 Item Scale (PHQ-9). Mean within- and between-groups effect sizes (Cohen's d) across the two measures of GAD were 1.3 and 1.1, respectively. Participants found the treatment programme acceptable and satisfactory. The clinician spent a total mean of 130 min per person over the programme. Conclusions: The Worry programme, the first randomized controlled trial of CaCCBT for GAD, resulted in clinically significant improvements. These results are consistent with literature indicating that Internet-based programmes, when combined with clinical guidance, can significantly reduce the symptoms of common mental disorders.
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Previous internet-delivered cognitive behavior therapy studies on generalized anxiety disorder indicate that internet-delivered cognitive behavior therapy can be effective.
“Previous ICBT studies on GAD indicate that ICBT can be effective.”
From Internet-delivered acceptance-based behavior therapy for generalized anxiety disorder: A pilot study (2016) · cites this paper as Titov et al., 2009
A number of studies have investigated the potential for internet-delivered treatments for GAD and reported significant post-treatment and follow-up gains similar to those found in face-to-face treatment studies.
“a number of studies have investigated the potential for internet-delivered treatments for GAD and they have reported significant post-treatment and follow-up gains [33,48-51] similar to those found in face-to-face treatment studies [52].”
From Low-intensity internet-delivered treatment for generalized anxiety symptoms in routine care: protocol for a randomized controlled trial (2014) · cites this paper as [51]
Only a handful of studies have investigated the efficacy and effectiveness of low-intensity internet-delivered treatments for GAD.
“However, only a handful of studies have investigated the efficacy and effectiveness of low-intensity internet-delivered treatments for GAD [33,48-51].”
From Low-intensity internet-delivered treatment for generalized anxiety symptoms in routine care: protocol for a randomized controlled trial (2014) · cites this paper as [51]
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“, with encouraging results recently reported from the first iCBT program for treating GAD”
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“Titov and colleagues 12 conducted an RCT of an online guided self-help intervention for GAD called ‘Worry’ with email guidance.”
InfluentialRozental, A., Boettcher, J., Andersson, G., Schmidt, B., & Carlbring, P. (2015) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2015.1008033 · Cited by 189 · see citing works
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InfluentialBerger, T., Boettcher, J., & Caspar, F. (2014) · Psychotherapy · doi:10.1037/a0032527 · Cited by 158 · see citing works
Carl, E., Witcraft, S. M., Kauffman, B. Y., Gillespie, E. M., Becker, E. S., Cuijpers, P., Van Ameringen, M., Smits, J. A. J., & Powers, M. B. (2020) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2018.1560358 · Cited by 151 · see citing works
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Self-citationTherapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults
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“In the trial by Titov et al. (2009), the dropout rate was larger (19%; 9/48) at posttreatment but, on the other hand, more participants completed the whole program.”
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Technological adjuncts to increase adherence to therapy: A review
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“To date email has been used predominately in psychotherapy as a replacement for traditional face to face therapy (e.g., Titov et al., 2009).”
MethodGuided internet-based CBT for common mental disorders
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“Generalized Anxiety Disorder There are only a few studies of guided iCBT for GAD.”
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“Four interventions were delivered in 6 modules of content over 8 to 10 weeks (Newby et al., 2013; Robinson et al., 2010; Titov et al., 2010; Titov et al., 2009).”
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“, 2009), generalized anxiety disorder (Titov et al., 2009), specific”
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“[6, 7] Two studies included in the review by Andrews et al (2010) focused on iCBT for GAD specifically.[8, 9] These studies found significant reductions in primary (GAD symptoms) and secondary outcomes (depression symptoms, psychological distress, and disability) for the treatment groups (effect sizes were all moderat…”
ResultSelf-citationComputer-Assisted Cognitive-Behavior Therapy and Mobile Apps for Depression and Anxiety
Wright, J. H., Mishkind, M., Eells, T. D., & Chan, S. R. (2019) · Current Psychiatry Reports · doi:10.1007/s11920-019-1031-2 · Cited by 93 · see citing works
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“Mean between-group effect size for the GAD measures was d ¼ 1.10 at post-treatment (Titov et al., 2009).”
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The Diagnosis and Treatment of Generalized Anxiety Disorder
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Psychotherapies for Generalized Anxiety Disorder in Adults
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“The average amount of time supporters spent per person over the course of their treatment was 77.04 min across the 15 studies providing this information, ranging from 18.15min (Newby et al., 2013) to 130min (Titov et al., 2009).”
BackgroundInfluentialMewton, L., Smith, J., Rossouw, P., & Andrews, G. (2014) · Psychology Research and Behavior Management · doi:10.2147/prbm.s40879 · Cited by 57 · see citing works
Self-citationRomijn, G., Batelaan, N., Kok, R., Koning, J., van Balkom, A., Titov, N., & Riper, H. (2019) · Journal of Medical Internet Research · doi:10.2196/11706 · Cited by 52 · see citing works
“When a general measure of anxiety was not available, we used a measure for specific anxiety symptoms (see Multimedia Appendix 2 [39-49] for the order of rating scales and Multimedia Appendix 3 [7,27-31,50-85] for the outcome measures we used for all studies).”
MethodSelf-citationInternet-delivered cognitive behavior therapy for anxiety and insomnia in a higher education context
Morris, J., Firkins, A., Millings, A., Möhr, C., Redford, P., & Rowe, A. (2015) · Anxiety Stress & Coping · doi:10.1080/10615806.2015.1058924 · Cited by 60 · see citing works
“Titov et al. (2009) found that participants receiving therapist-assisted iCBT for anxiety improved significantly relative to control.”
BackgroundAkkol‐Solakoglu, S., & Hevey, D. (2023) · Psycho-Oncology · doi:10.1002/pon.6097 · Cited by 55 · see citing works
Chen, T.-R., Huang, H., Hsu, J., Ouyang, W.-C., & Lin, K. (2019) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2019.08.014 · Cited by 60 · see citing works
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Self-citationAcceptability of Digital Mental Health Interventions for Depression and Anxiety: Systematic Review
Lau, C. K. Y., Saad, A., Camara, B., Rahman, D., & Bolea-Alamanac, B. (2024) · Journal of Medical Internet Research · doi:10.2196/52609 · Cited by 51 · see citing works
Digital interventions in mental health: Evidence syntheses and economic modelling
Gega, L., Jankovic, D., Saramago, P., Marshall, D., Dawson, S., Brabyn, S., Nikolaidis, G. F., Melton, H., Churchill, R., & Bojke, L. (2022) · Health Technology Assessment · doi:10.3310/rcti6942 · Cited by 48 · see citing works
Patient Expectations in Internet-Based Self-Help for Social Anxiety
Boettcher, J., Renneberg, B., & Berger, T. (2013) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2012.759615 · Cited by 47 · see citing works
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“Other studies of similar design and topic to that of the current piece of research have demonstrated statistically significant between group differences (Paxling et al., 2011; Titov et al., 2009; Robinson et al., 2010).”
ResultHadjistavropoulos, H. D., Thompson, M. J., Klein, B., & Austin, D. W. (2012) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2011.645550 · Cited by 41 · see citing works
“The trainer next presents research on therapist-assisted ICBT for depression, anxiety, and panic, describing research showing that clients receiving therapist-assisted ICBT improve to a significantly greater degree than clients on waiting lists (Klein et al, 2006 ; Perini et al, 2009 ; Titov et al, 2009 ), clients in…”
BackgroundMiller, C. B., Gu, J., Henry, A. L., Davis, M. L., Espie, C. A., Stott, R., Heinz, A. J., Bentley, K. H., Goodwin, G. M., Gorman, B. S., et al. (2021) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2020.101609 · Cited by 40 · see citing works
Is internet treatment for depressive and anxiety disorders ready for prime time?
Andrews, G., & Titov, N. (2010) · The Medical Journal of Australia · doi:10.5694/j.1326-5377.2010.tb03693.x · Cited by 37 · see citing works
Self-citationChan, C., West, S., & Glozier, N. (2017) · Journal of Medical Internet Research · doi:10.2196/jmir.5639 · Cited by 32 · see citing works
“A growing body of evidence shows that clinician-assisted CCBT results in significant improvements in patients with depressive [2,6] and anxiety disorders [2,7], with results comparable with those obtained from face-to-face treatment.”
Lorian, C. N., Titov, N., & Grisham, J. R. (2011) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2011.10.003 · Cited by 35 · see citing works
“The final number of participants in the treatment group and control groups was 24 and 20, respectively (see also Titov et al., 2009).”
BackgroundMethodInfluentialSelf-citationSaramago, P., Gega, L., Marshall, D. C., Nikolaidis, G. F., Janković, D., Melton, H., Dawson, S., Churchill, R. C., & Bojke, L. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.726222 · Cited by 33 · see citing works
“(65) [linked with (66)] Australia General–adults GAD diagnosis on MINI 34 NR 9 weeks GAD-7, K-10, PHQ-9, SDS”
BackgroundTRANSDIAGNOSTIC INTERNET TREATMENT FOR ANXIETY AND DEPRESSION
Titov, N., Dear, B. F., Johnston, L., & Terides, M. D. (2012) · Revista de Psicopatología y Psicología Clínica · Cited by 31 · see citing works
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“A noninferiority margin of a 1.8 change in GAD-7 total score was chosen based on previous literature [47-49] (see Methods S1 in Multimedia Appendix 1 for more details).”
InfluentialComputer-delivered cognitive behavioural therapy: effective and getting ready for dissemination
Titov, N., Andrews, G., & Sachdev, P. (2010) · F1000 Medicine Reports · doi:10.3410/m2-49 · Cited by 30 · see citing works
Self-citationRemote cognitive‐behavioral therapy for generalized anxiety disorder: A preliminary meta‐analysis
Trenoska Basile, V., Newton‐John, T., & Wootton, B. M. (2022) · Journal of Clinical Psychology · doi:10.1002/jclp.23360 · Cited by 28 · see citing works
Understanding adherence to web-based interventions
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Digitally Delivered Psychological Interventions for Anxiety Disorders: a Comprehensive Review
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Online Cognitive Behavioral Therapy for Depressed Primary Care Patients: A Pilot Feasibility Project
Whiteside, U. S., Richards, J. A., Steinfeld, B. I., Simon, G. E., Caka, S., Tachibana, C., Stuckey, S. J., & Ludman, E. J. (2014) · The Permanente Journal · doi:10.7812/tpp/13-155 · Cited by 27 · see citing works
Common mental health disorders.
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The Effect of the Draft DSM-5 Criteria for GAD on Prevalence and Severity
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“Efficacy and completion rates were similar to those seen for traditional face-to-face CBT programs [ 31 ].”
Internet-Delivered Cognitive Behaviour Therapy
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Treating people you never see: Internet-based treatment of the internalising mental disorders
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Internet-Based Cognitive Behavior Therapy
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“This CBT protocol has been validated in two randomized controlled trials (Robinson et al., 2010; Titov et al., 2009), two effectiveness studies (Mewton et al., 2012; Newby et al., 2017) and therapist guides are publicly available (Andrews et al., 2016).”
MethodSelf-citationYu, J. S., Szigethy, E., Wallace, M., Solano, F., & Oser, M. (2018) · Telemedicine and e-Health · doi:10.1089/tmj.2017.0280 · Cited by 15 · see citing works
“Furthermore, participants in studies of Internet-based CBT have typically completed 5 to 6 treatment modules within 8–9 weeks.”
InfluentialAre Trials of Computerized Therapy Generalizable? A Multidimensional Meta-analysis
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Internet-delivered acceptance-based behavior therapy for generalized anxiety disorder: A pilot study
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“The results showed large to moderate between group effect sizes on primary GAD measures as well as secondary outcomes (Titov et al., 2009).”
ResultThe Use of Telepsychology in Clinical Practice: Benefits, Effectiveness, and Issues to Consider
Godine, N., & Barnett, J. E. (2013) · International Journal of Cyber Behavior, Psychology and Learning · doi:10.4018/ijcbpl.2013100105 · Cited by 18 · see citing works
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“Although originally used as a screening tool for GAD, the GAD-7 has good sensitivity and specificity as a screen for panic disorder, social anxiety disorder, and post-traumatic stress disorder (Titov et al., 2009).”
MethodRichards, D., Timulak, L., Doherty, G., Sharry, J., McLoughlin, O., Rashleigh, C., Colla, A., & Joyce, C. (2014) · Trials · doi:10.1186/1745-6215-15-145 · Cited by 16 · see citing works
White, K. A. (2020) · Digital Scholarship - UNLV (University of Nevada Reno) · doi:10.34917/3276068 · Cited by 16 · see citing works
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“Several previous studies on internet-based treatments for GAD have used this approach resulting in positive effects (Andersson et al., 2012b; Paxling et al., 2011; Robinson et al., 2010; Titov et al., 2009).”
Zhang, W., Du, Y., Yang, X., Wang, E., Fang, J., Liu, Z., Wu, S., Liu, Q., & Hu, Y. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.832167 · Cited by 15 · see citing works
“(44) Australia GAD/DSM-IV 45 (21/24) no details no details ICBT 6 sessions GAD-7”
BackgroundGuided self-help for generalized anxiety disorder in older adults.
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“…these results are promising, but they are not clear if GSH is effective for GAD in older adults although there is evidence of the efficacy of CBT-GSH for GAD in younger adults (Paxling et al., 2011; Robinson et al., 2010; Titov, Andrews, Johnston, Robinson, & Spence, 2010; Titov et al., 2009).”
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“It is used widely as a screening tool for depression, and is frequently included as outcome measures in studies of online interventions (eg, [36,37]).”
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“…(Baumeister, Reichler, Munzinger & Lin, 2014; Richards & Richardson, 2012), but the nature, type, duration of any support are still largely unanswered as it seems that a variety of implementations of support can achieve the same outcomes (Richards & Richardson, 2012; Titov et al., 2009, 2010).”
BackgroundFinding Web-Based Anxiety Interventions on the World Wide Web: A Scoping Review
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“For This Way Up, a program targeted at generalized anxiety disorder, the intervention group participants showed significantly reduced symptoms of panic [81] and anxiety [82] at post-treatment compared to the control group.”
Rajeshkumar, L., Mishkind, M., Coleman, J. J., Pahwa, M., LaPreze, D., Solenske, S., & Wright, J. H. (2024) · Journal of Psychiatric Practice · doi:10.1097/pra.0000000000000815 · Cited by 7 · see citing works
“61 The Worry Program , 64 – 66 a similar form of CCBT from the same group in Australia, is designed to build CBT skills for GAD, including modi fi cation of cognitions about worry and graded exposure.”
Distance Treatment of Obsessive–Compulsive Disorder
Wootton, B., & Titov, N. (2010) · Behaviour change · doi:10.1375/bech.27.2.112 · Cited by 12 · see citing works
Self-citationWeb Based Interventions in Psychiatry: An Overview
Mehta, V. S., & Parakh, M. (2015) · International Journal of Mental Health & Psychiatry · doi:10.4172/2471-4372.1000108 · Cited by 10 · see citing works
“There is now evidence to suggest that Internet delivered CBT works for panic disorder [9,10], social anxiety disorder [11], generalized anxiety disorder [12], post-traumatic stress disorder [13], and specific phobia [8].”
BackgroundComputerised cognitive behavioural therapy: helping Ireland log on
Twomey, C., O'Reilly, G., & Byrne, M. (2013) · Irish Journal of Psychological Medicine · doi:10.1017/ipm.2012.5 · Cited by 11 · see citing works
- Authors
- Titov, N., Andrews, G., Robinson, E., Schwencke, G., Johnston, L., Solley, K., & Choi, I.
- Affiliations
- UNSW Sydney (AU)
- St Vincent's Hospital Sydney (AU)
- Corresponding author
- Titov, Nickolai
- Venue
- Australian & New Zealand Journal of Psychiatry
- Publisher
- SAGE Publications
- Published
- 2009-01-01
- Volume
- 43
- Issue
- 10
- Pages
- 905-912
- ISSN
- 0004-8674 (ISSN-L)
- 1440-1614
- OpenAlex
- W2102373238
- Semantic Scholar
- 0c00964dd9a9544f82e95160878f9726632ce6dc
- Cited by
- 147
- References
- 53
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 6 · 2023: 5 · 2022: 11 · 2021: 4 · 2020: 10 · 2019: 6 · 2018: 9 · 2017: 6 · 2016: 7 · 2015: 14 · 2014: 12 · 2013: 13 · 2012: 13
- FWCI
- 14.77
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Australian & New Zealand Journal of Psychiatry (publishedVersion)
- Funders
- Australian Rotary Health
- University of New South Wales
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Keywords
- generalized anxiety disorder, online therapy, worry, depression, treatment acceptability
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