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Cited by 16Digital Mental Health InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychological Treatments and Assessments

Low-intensity internet-delivered treatment for generalized anxiety symptoms in routine care: protocol for a randomized controlled trial

Open access
Richards, Derek, Timulak, Ladislav, Doherty, Gavin, Sharry, John, McLoughlin, Orla, Rashleigh, Chuck, Colla, Amy, Joyce, Ciara·2014·Trials
DOI 10.1186/1745-6215-15-145PMC PMC4017809
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Abstract

BACKGROUND: Worldwide prevalence of generalized anxiety disorder (GAD) is considered high; in Europe lifetime prevalence has been estimated at 4.3 to 5.9%. High levels of anxiety disorders have been reported in university students, affecting 25 to 30% of the population. Young adults are some of the most vulnerable for the onset of mental health disorders and any stressors may act as a catalyst for their onset. The absence of resources can often mean that many do not seek treatment. Other factors that impede access to resources include such things as a lack of trained professionals, personal stigma, and waiting lists. Anxiety disorders can be treated successfully; indeed brief forms of cognitive-behavior therapy have been recommended. One potential avenue for research and development is that of delivering low-intensity interventions online for students with GAD. Therefore, the current study seeks to investigate the potential effectiveness for a low-intensity online CBT-based treatment for GAD in a service-based setting; implemented as one step in a stepped-care model. METHODS/DESIGN: The research is a service-based effectiveness study utilizing a randomized waiting-list controlled design. The active intervention consists of six weekly modules of online CBT. Participants are assigned a supporter who provides weekly post-session feedback on progress and exercises. Participants will complete the GAD-7 as the primary outcome measure. Secondary outcomes include pathological worry, depression and measures of well-being. At three-months follow-up data will be collected using the GAD-7, BDI-II, PSWQ, ED-Q5 and WSAS. Post-session data will be collected on significant in-session events in treatment (HAT). A satisfaction with treatment measure will be administered post-treatment (SAT). DISCUSSION: The study will be a contribution to the potential for a low-intensity internet-delivered program implemented in a service-based setting; implemented as one step in a stepped-care model. The study will be a contribution to the already established work in online treatments for anxiety worldwide. The study will assess the utility of an innovative digital health solution (SilverCloud) to deliver such interventions. TRIAL REGISTRATION: Current Controlled Trials ISRCTN16303842.

AI snapshot

Written from the paper’s full text.

TL;DR

This is a protocol for a service-based randomized waiting-list controlled trial testing a six-module, supporter-assisted online CBT program ("Calming Anxiety," delivered via the SilverCloud platform) for generalized anxiety symptoms in university students at Trinity College Dublin. It reports no outcome data; it specifies the design, measures, sample-size calculation, and planned analyses.

Key findings

  • No trial results are reported; the paper states the hypothesis that participants in the active condition will show significant decreases in GAD symptoms post-intervention with corresponding positive change in pathological worry and quality of life.
  • Sample-size calculation: using power of 0.80 and alpha of 0.05, 50 subjects per arm are needed to detect a moderate (d = 0.50) post-treatment difference on the main outcomes.
  • Cited prior evidence: a meta-analysis of internet-delivered treatments for GAD showed large post-treatment effects for GAD symptoms (d = 0.91) and pathological worry (d = 0.73) favoring active interventions over waiting-list controls; prior similar-protocol online GAD studies reported post-treatment effect sizes of 0.79–1.67 and follow-up effects of 0.69–1.65 from samples of 10–97.
  • Trial registration: Current Controlled Trials ISRCTN16303842; the trial began January 2014 and a second round of recruitment was beginning at the time of writing.

Methods

  • Design: service-based effectiveness study using a randomized waiting-list controlled design; participants randomized (via computer algorithms scoring baseline screening instruments, managed by a person independent of the research group) to the supported internet intervention or a waiting-list control that receives access at week seven.
  • Sample: registered students at the University of Dublin, Trinity College, aged at least 18, with a DSM-IV-congruent GAD-7 score of 10 or above; comorbid disorders included if GAD is primary; those attending face-to-face counseling excluded. Recruitment via email advertising and an informational website, with online informed consent.
  • Intervention and measures: six weekly online CBT modules based on the Avoidance Model of Worry, with an assigned supporter providing weekly asynchronous post-session feedback (10–15 minutes per participant per session). Primary outcome is the GAD-7; secondary outcomes are PSWQ, BDI-II, EQ-5D, WSAS, plus HAT (post-session) and SAT (post-treatment); engagement/usage data collected continuously. Planned analysis is intention-to-treat with Last Observation Carried Forward for missing data, repeated measures ANOVA for the primary outcome and ANOVAs for secondary measures, effect sizes (Cohen's d), remission/recovery and clinically meaningful change analyses, and qualitative analysis of HAT, SAT, and dropout data.

Limitations

  • Stated by the paper: results may not be generalizable to the wider community in Ireland, though they may give insight into low-intensity internet-delivered interventions within a stepped-care model in routine primary care.
  • Evident from the text: this is a protocol only, so no effectiveness, satisfaction, or dropout findings are yet available; the design relies on self-report outcome measures; the waiting-list control is not an active comparator; and the planned use of LOCF for missing data is a conservative but potentially biased approach to attrition, which the paper itself identifies as a persistent concern for online treatments.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/1745-6215-15-145

Cites

103 of 103 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 77 cited sources checked · 0 supported · 0 flagged

  • Premisecitation

    Only a very small percentage of people with GAD seek treatment.

    “In Europe the lifetime prevalence of GAD has been estimated at 4.3 to 5.9%, with a 12-month prevalence of 1.2 to 1.9%, yet only a very small percentage seek treatment [7].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] Wittchen HU: Met and unmet need for interventions in community cases with anxiety disorders. Unmet Need in Psychiatry: Problems, Resources, Responses. Edited by: Andrews G, Henderson S. 2000, Cambridge: Cambridge University Press, 256-276. source

      Not checked in the free run.

  • Premisecitation

    Young adults aged between 17 and 25 are at high risk of developing a serious mental illness such as an anxiety disorder.

    “young adults aged between 17 and 25 are at high risk of developing a serious mental illness such as an anxiety disorder”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Royal College of Psychiatrists: Mental health of students in higher education. 2011, London: Royal College of Psychiatrists, 97-

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  • Premisecitation

    CBT is highly suitable to being delivered as a low-intensity intervention within a model of stepped-care.

    “CBT is highly suitable to being delivered as a low-intensity intervention within a model of stepped-care [35].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [35] Bennett-Levy J, Richards DA, Farrand P, Christensen H, Griffiths KM, Kavanagh DJ, Klein B, Lau MA, Proudfoot J: Low intensity CBT interventions. Oxford guide to low intensity CBT interventions. Edited by: Bennett-Levy J, Richards DA, Farrand P, Christensen H, Griffiths KM, Kavanagh DJ, Klein B, Lau MA, Proudfoot J, Ritterband L, White J, Williams C. 2010, Oxford: Oxford University Press source

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  • Premisecitation

    Ireland is far behind its European neighbors in developing and implementing stepped-care models for mental health service delivery that involve both low-intensity and high-intensity interventions, despite it being recommended as best practice and its demonstrated success.

    “Ireland is far behind its European neighbors in developing and implementing stepped-care models for mental health service delivery that involve both low-intensity (such as bibliotherapy) and high-intensity (such as face-to-face therapy) interventions, despite it being recommended as best practice [36] and its demonstrated success to date [37].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [36] National Institute for Health and Clinical Excellence: Computerised cognitive behaviour therapy for depression and anxiety. Technology Appraisal 97. 2006, London: National Institute for Health and Clinical Excellence

      Not checked in the free run.

    • cites [37] Clark DM, Layard R, Smithies R, Richards DA, Suckling R, Wright B: Improving access to psychological therapy: initial evaluation of two UK demonstration sites. Behav Res Ther. 2009, 47: 910-920. 10.1016/j.brat.2009.07.010. source

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  • Premisecitation

    CBT has been shown to be a highly effective treatment for GAD.

    “By far the most extensively researched psychological treatment for GAD is cognitive-behavior therapy (CBT) which has been shown to be a highly effective treatment for GAD [22].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Mitte K: Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: a comparison with pharmacotherapy. Psychol Bull. 2005, 131: 785-795. source

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  • Classified as probably not a substantial claim. 27
  • May combine two claims. 17

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The prevalence of anxiety in high school and university students has been reported to be between 25 and 30%, in response to academic demands.

    “The prevalence of anxiety in high school and university students has been reported to be between 25 and 30%, in response to their academic demands [13,14].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [13] McDonald AS: The prevalence and effects of test anxiety in school children. Educ Psychol. 2001, 21: 89-101. 10.1080/01443410020019867. source

      Not checked in the free run.

    • cites [14] Wachelka D, Katz RC: Reducing test anxiety and improving academic self-esteem in high school and college students with learning disabilities. J Behav Ther Exp Psychiatry. 1999, 30: 191-198. 10.1016/S0005-7916(99)00024-5. source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In Europe, the lifetime prevalence of GAD has been estimated at 4.3 to 5.9%, with a 12-month prevalence of 1.2 to 1.9%.

    “In Europe the lifetime prevalence of GAD has been estimated at 4.3 to 5.9%, with a 12-month prevalence of 1.2 to 1.9%, yet only a very small percentage seek treatment [7].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Wittchen HU: Met and unmet need for interventions in community cases with anxiety disorders. Unmet Need in Psychiatry: Problems, Resources, Responses. Edited by: Andrews G, Henderson S. 2000, Cambridge: Cambridge University Press, 256-276. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A recent Irish survey of young adult students using DASS-21 showed levels of clinical anxiety at 36% and clinical symptoms of stress at 30%.

    “showed levels of clinical anxiety at 36% (8% in the mild range, 15% in the moderate range, 5% in the severe and a further 9% in the very severe range) and 30% with clinical symptoms of stress”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16] Dooley B, Fitzgerald A: My world survey. 2012, Dublin: Headstrong

      Not checked in the free run.

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    Premisecitation

    CBT as a brief psychological intervention has demonstrated its efficacy and has the potential to significantly reduce the burden of anxiety disorders.

    “CBT as a brief psychological interventions has demonstrated its efficacy and has the potential to significantly reduce the burden of anxiety disorders [34].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] National Institute for Clinical Excellence: Clinical guidelines 22: anxiety. 2004, London

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    Premisecitation

    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].”
    Quote in the paperSubstantial claim0 of 6 sources checked
    • cites [33] Titov N, Dear BF, Schwencke G, Andrews G, Johnston L, Craske MG, McEvoy P: Transdiagnostic internet treatment for anxiety and depression: a randomised controlled trial. Behav Res Ther. 2011, 49: 441-452. 10.1016/j.brat.2011.03.007. source

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    • cites [48] Dear BF, Titov N, Schwencke G, Andrews G, Johnston L, Craske MG, McEvoy P: An open trial of a brief transdiagnostic internet treatment for anxiety and depression. Behav Res Ther. 2011, 49: 830-837. 10.1016/j.brat.2011.09.007. source

      Not checked in the free run.

    • cites [49] Paxling B, Almlov J, Dahlin M, Carlbring P, Breitholtz E, Eriksson T, Andersson G: Guided Internet-delivered cognitive behavior therapy for generalized anxiety disorder: A randomized controlled trial. Cogn Behav Ther. 2011, 40: 159-173. 10.1080/16506073.2011.576699. source

      Not checked in the free run.

    • cites [50] Robinson E, Titov N, Andrews G, McIntyre K, Schwencke G, Solley K: Internet treatment for generalized anxiety disorder: a randomized controlled trial comparing clinician vs technician assistance. PLoS One. 2010, 5: e10942-10.1371/journal.pone.0010942. source

      Not checked in the free run.

    • cites [51] Titov N, Andrews G, Robinson E, Schwencke G, Johnston L, Solley K, Choi I: Clinician-assisted Internet-based treatment is effective for generalized anxiety disorder: randomised controlled trial. Aust N Z J Psychiatry. 2009, 43: 905-912. 10.1080/00048670903179269. source

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    • cites [52] Donegan E, Dugas MJ: Generalized anxiety disorder: a comparison of symptom change in adults receiving cognitive-behavioral therapy or applied relaxation. J Consult Clin Psychol. 2012, 80: 490-496. source

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    Premisecitation

    Both AMW and IUM have gathered supporting empirical evidence for their central constructs and have developed and researched treatment protocols based on their model.

    “Both have gathered supporting empirical evidence for their central constructs and have developed and researched treatment protocols based on their model [26].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Behar E, DiMarco ID, Hekler EB, Mohlman J, Staples AM: Current theoretical models of generalized anxiety disorder (GAD): conceptual review and treatment implications. J Anxiety Disord. 2009, 23: 1011-1023. 10.1016/j.janxdis.2009.07.006. source

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    Premisecitation

    Pharmacological and psychological treatments for GAD have demonstrated their efficacy.

    “Treatments for GAD include pharmacological and psychological and both have demonstrated their efficacy [21].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Gould RA, Otto MW, Pollack MH, Yap L: Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: a preliminary meta-analysis. Behav Ther. 1997, 28: 285-305. 10.1016/S0005-7894(97)80048-2. source

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    Premisecitation

    The Avoidance Model of Worry and GAD (AMW) and the Intolerance of Uncertainty Model (IUM) are the most well-defined and empirically supported theoretical models for GAD.

    “Perhaps the most well-defined and empirically supported of these are the Avoidance Model of Worry and GAD (AMW) [27] and the Intolerance of Uncertainty Model (IUM) [28].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [27] Borkovec TD, Alcaine O, Behar E: Avoidance theory of worry and generalized anxiety disorder. Generalized anxiety disorder: advances in research and practice. Edited by: Heimberg RG, Turk CL, Mennin DS. 2004, New York: Guilford Press

      Not checked in the free run.

    • cites [28] Dugas MJ, Gagnon F, Ladouceur R, Freeston MH: Generalized anxiety disorder: a preliminary test of a conceptual model. Behav Res Ther. 1998, 36: 215-226. 10.1016/S0005-7967(97)00070-3. source

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    Premisecitation

    Internet-delivered treatment programs have been developed and employed in the treatment of a range of disorders and their results support their efficacy.

    “Programs have been developed and employed in the treatment of a range of disorders and their results support their efficacy [39-42].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [39] Andrews G, Cuijpers P, Craske M, McEvoy P, Titov N: Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS One. 2010, 5: e13196-10.1371/journal.pone.0013196. source

      Not checked in the free run.

    • cites [40] Cuijpers P, Marks I, van Straten A, Cavanagh K, Gega L, Andersson G: Computer-aided psychotherapy for anxiety disorders: a meta-analytic review. Cogn Behav Ther. 2009, 38: 66-82. 10.1080/16506070802694776. source

      Not checked in the free run.

    • cites [41] Reger M, Gahm G: A meta-analysis of the effects of Internet-and computer-based cognitive-behavioral treatments for anxiety. J Clin Psychol. 2009, 65: 53-75. 10.1002/jclp.20536. source

      Not checked in the free run.

    • cites [42] Richards D, Richardson T: Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clin Psychol Rev. 2012, 32: 329-342. 10.1016/j.cpr.2012.02.004. source

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  • May combine two claims.

    Premisecitation

    Additional barriers to accessing treatment include lack of available trained professionals, waiting lists, lack of motivation for change, negative perception of psychological treatments, indirect costs of treatment, personal difficulty such as stigma, and low mental health literacy.

    “Additional barriers to accessing treatment exist, such as a lack of available trained professionals, waiting lists, lack of motivation for change, negative perception of psychological treatments, indirect costs of treatment (and direct costs in some cases), personal difficulty such as stigma, and low mental health literacy.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [32] Kohn R, Saxena S, Levav I, Saraceno B: The treatment gap in mental health care. Bull World Health Organ. 2004, 82: 858-866.

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    • cites [33] Titov N, Dear BF, Schwencke G, Andrews G, Johnston L, Craske MG, McEvoy P: Transdiagnostic internet treatment for anxiety and depression: a randomised controlled trial. Behav Res Ther. 2011, 49: 441-452. 10.1016/j.brat.2011.03.007. source

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    Premisecitation

    Internet-delivered treatments for anxiety disorders have included interventions for panic disorder, SAD, SP, and posttraumatic stress and have established findings that support their potential effectiveness and efficacy.

    “Internet-delivered treatments for anxiety disorders have included interventions for panic disorder, SAD, SP, and posttraumatic stress and they have established findings that support their potential effectiveness and efficacy [43-47].”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [43] Andersson G: Using the internet to provide cognitive behaviour therapy. Behav Res Ther. 2009, 47: 175-180. 10.1016/j.brat.2009.01.010. source

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    • cites [44] Carlbring P, Bohman S, Brunt S, Buhrman M, Westling B, Ekselius L, Andersson G: Remote treatment of panic disorder: a randomized trial of internet-based cognitive behavior therapy supplemented with telephone calls. Am J Psychiatry. 2006, 163: 2119-2125. 10.1176/appi.ajp.163.12.2119. source

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    • cites [45] Furmark T, Carlbring P, Hedman E, Sonnenstein A, Clevberger P, Bohman B, Eriksson A, Hållén A, Frykman M, Holmström A, Sparthan E, Tillfors M, Ihrfelt E, Spak M, Eriksson A, Ekselius L, Andersson G: Guided and unguided self-help for social anxiety disorder: randomised controlled trial. Br J Psychiatry. 2009, 195: 440-447. 10.1192/bjp.bp.108.060996. source

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    • cites [46] Lange A, Van den Ven JP, Schrieken B, Hudcovicova M, Rietdijk D, Hudcovicova M, EmmelKamp P: Interapy: a controlled randomized trail of the standard treatment of posttraumatic stress through the internet. J Consult Clin Psychol. 2003, 71: 901-909. source

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    • cites [47] Titov N, Gibson M, Andrews G, McEvoy P: Internet treatment for social phobia reduces comorbidity. Aust N Z J Psychiatry. 2009, 43: 754-759. 10.1080/00048670903001992. source

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    Premisecitation

    Anxiety can be treated successfully through disorder specific treatment plans or treatments that target common elements and symptoms across anxiety disorders.

    “Anxiety can be treated successfully through disorder specific treatment plans or treatments that target common elements and symptoms across anxiety disorders [19,20].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [19] Andrews G, Creamer M, Crino R, Hunt C, Lampe L, Page A: The treatment of anxiety disorders: clinician guides and patient manuals. 2003, Cambridge: Cambridge University Press, 2

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    • cites [20] Barlow DH, Allen LB, Choate ML: Toward a unified treatment for emotional disorders. Behav Ther. 2004, 35: 205-230. 10.1016/S0005-7894(04)80036-4. source

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    Premisecitation

    Many with anxiety disorders have no diagnosis nor seek treatment.

    “It is the case that many with anxiety disorders have no diagnosis nor seek treatment [29,30].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [29] Andrews G, Sanderson K, Slade T, Issakidis C: Why does the burden of disease persist? relating the burden of anxiety and depression to effectiveness of treatment. Bulletin World Health Organisation, Volume 78. 2000, Switzerland: World Health Organisation, 446-454.

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    • cites [30] Wittchen HU, Jacobi F: Size and burden of mental disorders in Europe-a critical review and appraisal of 27 studies. Eur Neuropsychopharmacol. 2005, 15: 357-376. 10.1016/j.euroneuro.2005.04.012. source

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    Study design and conductcitation

    The BDI-II manual states that a cutoff score of 17 has yielded a 93% specificity and 18% sensitivity for the presence of major depression.

    “The BDI-II manual states that a cutoff score of 17 has yielded a 93% specificity and 18% sensitivity for the presence of major depression (Beck et al.[73]).”
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    • cites [73] Beck AT, Steer RA, Brown GK: Manual for the BDI-II. 1996, San Antonio: Psychological Corporation

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    Study design and conductcitation

    The BDI-II has been found to have an excellent internal consistency and test-retest reliability with a diverse range of samples.

    “The BDI-II has been found to have an excellent internal consistency and test–retest reliability with a diverse range of samples [73,75,76].”
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    • cites [73] Beck AT, Steer RA, Brown GK: Manual for the BDI-II. 1996, San Antonio: Psychological Corporation

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    • cites [75] Arnau RC, Meagher MW, Norris MP, Bramson R: Psychometric evaluation of the Beck Depression Inventory-II with primary care medical patients. Health Psychol. 2001, 20: 112-119. source

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    • cites [76] Steer RA, Rissmiller DJ, Beck AT: Use of the Beck Depression Inventory-II with depressed geriatric inpatients. Behav Res Ther. 2000, 38: 311-318. 10.1016/S0005-7967(99)00068-6. source

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    Interpretationreasoning

    Internet-delivered treatments are a valuable alternative.

    “therefore internet-delivered treatments are a valuable alternative.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The demand for psychological treatments will never be met from high-intensity therapy.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for GAD; it is considered congruent of DSM-IV as a clinical case for GAD.

    “Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for GAD; it is considered congruent of DSM-IV as a clinical case for GAD [67].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [67] Spitzer RL, Kroenke K, Williams JW, Löwe B: A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006, 166: 1092-1097. 10.1001/archinte.166.10.1092. source

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  • May combine two claims.

    Premisecitation

    Previous studies of online interventions for GAD that have used a CBT protocol similar to the intervention in the current study have reported post-treatment effect sizes of between 0.79 and 1.67, and follow-up effects of between 0.69 and 1.65, based on sample sizes ranging from 10 to 97.

    “Previous studies of online interventions for GAD that have used a CBT protocol similar to the intervention in the current study have reported post-treatment effect sizes of between 0.79 and 1.67, and follow-up effects of between 0.69 and 1.65, based on sample sizes ranging from 10 to 97 [33,48-50].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [33] Titov N, Dear BF, Schwencke G, Andrews G, Johnston L, Craske MG, McEvoy P: Transdiagnostic internet treatment for anxiety and depression: a randomised controlled trial. Behav Res Ther. 2011, 49: 441-452. 10.1016/j.brat.2011.03.007. source

      Not checked in the free run.

    • cites [48] Dear BF, Titov N, Schwencke G, Andrews G, Johnston L, Craske MG, McEvoy P: An open trial of a brief transdiagnostic internet treatment for anxiety and depression. Behav Res Ther. 2011, 49: 830-837. 10.1016/j.brat.2011.09.007. source

      Not checked in the free run.

    • cites [49] Paxling B, Almlov J, Dahlin M, Carlbring P, Breitholtz E, Eriksson T, Andersson G: Guided Internet-delivered cognitive behavior therapy for generalized anxiety disorder: A randomized controlled trial. Cogn Behav Ther. 2011, 40: 159-173. 10.1080/16506073.2011.576699. source

      Not checked in the free run.

    • cites [50] Robinson E, Titov N, Andrews G, McIntyre K, Schwencke G, Solley K: Internet treatment for generalized anxiety disorder: a randomized controlled trial comparing clinician vs technician assistance. PLoS One. 2010, 5: e10942-10.1371/journal.pone.0010942. source

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    Premisecitation

    The WSA is a five-item self-report measure that provides an experiential impact of a disorder from the patient's point of view.

    “It is a five-item self-report measure that provides an experiential impact of a disorder from the patient’s point of view.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [79] Mundt JC, Marks IM, Shear MK, Greist JM: The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry. 2002, 180: 461-464. 10.1192/bjp.180.5.461. source

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    Study design and conductnone given

    The study protocol, information on the study, informed consent and related materials received ethical approval from the School of Psychology, Trinity College Dublin (22 November 2013).

    “The study protocol, information on the study, informed consent and related materials received ethical approval from the School of Psychology, Trinity College Dublin (22 November 2013).”
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    Premisecitation

    The EuroQol 5D (EQ-5D) questionnaire is a generic instrument of health-related quality of life.

    “The EuroQol 5D (EQ-5D) questionnaire [78] is a generic instrument of health-related quality of life.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [78] Rabin R, Oemar M, Oppe M: EQ-5D-3 L User Guide: basic information on how to use the EQ-5D-3 L instrument. 2011, Rotterdam: EuroQol Group, 40

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    Premisecitation

    Some previous research has assessed the relevance of low-intensity internet-delivered treatments for anxiety disorders in service-based settings.

    “Some previous research has assessed the relevance of low-intensity internet-delivered treatments for anxiety disorders in service-based settings [56-58].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [56] Cavanagh K, Seccombe N, Lidbetter N: The implementation of computerized cognitive behavioural therapies in a service user-led, third sector self-help clinic. Behav Cogn Psychother. 2011, 39: 427-442. 10.1017/S1352465810000858. source

      Not checked in the free run.

    • cites [57] Cavanagh K, Shapiro DA, Van Den Berg S, Swain S, Barkham M, Proudfoot J: The effectiveness of computerized cognitive behavioural therapy in routine care. Br J Clin Psychol. 2006, 45: 499-514. 10.1348/014466505X84782. source

      Not checked in the free run.

    • cites [58] Ruwaard J, Lange A, Schrieken B, Dolan CV, Emmelkamp P: The effectiveness of online cognitive behavioral treatment in routine clinical practice. PLoS One. 2012, 7: e40089-10.1371/journal.pone.0040089. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The research is a service-based effectiveness study utilizing a randomized controlled trial design of an internet intervention for the treatment of GAD symptoms.

    “The research is a service-based effectiveness study utilizing a randomized controlled trial design of an internet intervention for the treatment of GAD symptoms.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Some studies have collected information regarding dropout, suggesting difficulties using the computer, negative features of the program, perceiving the course as too demanding, poor clinical progress, receiving alternative treatment, feeling better, lack of time, and problems understanding the computer program.

    “Some studies have collected information regarding dropout, suggesting difficulties using the computer, negative features of the program, perceiving the course as too demanding, poor clinical progress, receiving alternative treatment, feeling better, lack of time, and problems understanding the computer program [42,62].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [42] Richards D, Richardson T: Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clin Psychol Rev. 2012, 32: 329-342. 10.1016/j.cpr.2012.02.004. source

      Not checked in the free run.

    • cites [62] Warmerdam L, van Straten A, Twisk J, Riper H, Cuijpers P: Internet-based treatment for adults with depressive symptoms: randomized controlled trial. J Med Internet Res. 2008, 10: e44-10.2196/jmir.1094. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Work and Social Adjustment (WSA) questionnaire is a simple, reliable, and valid measure of impaired functioning.

    “The Work and Social Adjustment (WSA) questionnaire [79] is a simple, reliable, and valid measure of impaired functioning.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [79] Mundt JC, Marks IM, Shear MK, Greist JM: The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry. 2002, 180: 461-464. 10.1192/bjp.180.5.461. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The BDI-II has demonstrated a good convergent validity with other measures of depression among clinical and nonclinical adult samples.

    “The BDI-II has demonstrated a good convergent validity with other measures of depression among clinical and nonclinical adult samples [77].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [77] Beck AT, Steer RA, Garbin MG: Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev. 1988, 8: 77-100. 10.1016/0272-7358(88)90050-5. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Helpful Aspects of Therapy Form (HAT) is an instrument that assesses the most significant events in the therapy.

    “The Helpful Aspects of Therapy Form (HAT) [80,81] is an instrument that assesses the most significant events in the therapy.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [80] Elliott R, Slatick E, Urman M: Qualitative change process research on psychotherapy: alternative strategies. Qualitative psychotherapy research: methods and methodology. Edited by: Frommer J, Rennie DL. 2001, Lengerich: Pabst Science Publishers, 69-111.

      Not checked in the free run.

    • cites [81] Llewelyn SP, Elliott R, Shapiro DA, Hardy G, Firth-Cozens J: Client perceptions of significant events in prescriptive and exploratory periods of individual therapy. Br J Clin Psychol. 1988, 27: 105-114. 10.1111/j.2044-8260.1988.tb00758.x. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The GAD-7 has good internal consistency (0.89) and good convergent validity with other anxiety scales.

    “The GAD-7 has good internal consistency (0.89) and good convergent validity with other anxiety scales [68].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [68] Kroenke K, Spitzer RL, Williams JBW, Löwe B: The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry. 2010, 32: 345-359. 10.1016/j.genhosppsych.2010.03.006. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Participants will be randomized into two groups: the internet-delivered intervention with clinical support and a waiting list control group.

    “Participants will be randomized into two groups: the internet-delivered intervention with clinical support and a waiting list control group.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The randomization procedure will be managed by a person independent of the research group.

    “The randomization procedure will be managed by a person independent of the research group.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Psychometric evaluations of the PSWQ have revealed a high internal consistency (α = 0.86 to 0.95) and test-retest reliability over four weeks (r = 0.74 to 0.93).

    “Psychometric evaluations have revealed a high internal consistency (α = 0.86 to 0.95) and test-retest reliability over four weeks (r = 0.74 to 0.93) [71].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [71] Molina S, Borkovec TD: The Penn State Worry Questionnaire: psychometric properties and associated characteristics. Worrying: perspectives on theory, assessment and treatment. Edited by: Davey G, Tallis F. 1994, New York: Wiley, 265-283.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

    Premisenone given

    Completing the entire course will benefit users.

    “it is suggested that completing the entire course will benefit users”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [61] Richards D, Timulak L, Hevey D: A comparison of two online cognitive-behavioural interventions for symptoms of depression in a student population: The role of therapist responsiveness. Couns Psychother Res. 2013, 3: 184-193. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    The results may not be generalizable to the wider community in Ireland.

    “The results may not be generalizable to the wider community in Ireland”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationnone given

    The results may give insight into the usefulness of low-intensity internet-delivered interventions within a stepped-care model in routine primary care.

    “but perhaps may give insight into the usefulness of low-intensity internet-delivered interventions within a stepped-care model in routine primary care.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Adult students are high users of the internet and related tools.
    • Rests on an assumption: The possibility of accessing traditional services is difficult, prohibitive due to waiting lists, costs, and personal stigma.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Session time estimation will always be an imperfect calculation, as users may be interrupted or take breaks within a session, and may not formally log out of the system.

    “Session time estimation will always be an imperfect calculation, as users may be interrupted or take breaks within a session, and may not formally log out of the system.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Satisfaction with Treatment (SAT) questionnaire establishes a net promoter score that serves as a tool to gauge customer satisfaction.

    “The Satisfaction with Treatment (SAT) questionnaire [82] establishes a net promoter score that serves as a tool to gauge customer satisfaction.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [82] Richards D, Timulak L: Satisfaction with therapist-delivered vs. self-administered online cognitive-behavioural treatments for depression symptoms in college students. Br J Guid Couns. 2012, 41: 193-207. source

      Not checked in the free run.

36 of 36

  • The paper relies on this without support.

    Online technologies can deliver treatment incrementally and in an engaging way.

    “Online technologies can deliver treatment incrementally and in an engaging way.”

  • The paper relies on this without support.

    The demand for psychological treatments will never be met from high-intensity therapy.

    “The demand for psychological treatments will never be met from high-intensity therapy”

  • The paper relies on this without support.

    The primary outcome measure (GAD-7) is a well-established measure and has been used in previous trials involving internet-delivered and face-to-face treatments.

    “The primary outcome measure (GAD-7) that will assess anxiety symptoms is a well-established measure and has been used in previous trials involving internet-delivered and face-to-face treatments.”

  • The paper relies on this without support.

    Adult students are high users of the internet and related tools.

    “who are high users of the internet and related tools”

  • The paper relies on this without support.

    The possibility of accessing traditional services is difficult, prohibitive due to waiting lists, costs, and personal stigma.

    “the possibility of accessing traditional services is difficult, prohibitive due to waiting lists, costs, and personal stigma.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The online CBT programme 'Space for Anxiety and Depression' is fully validated, delivering evidence-based content and adapted to integrate and deliver to NICE standards of care.

    “This is a fully validated online CBT programme, delivering evidence-based content and adapted to integrate and deliver to NICE standards of care [16, 17].”

    From Internet-based cognitive behavioural therapy programme as an intervention for people diagnosed with adult-onset, focal, isolated, idiopathic cervical dystonia: A feasibility study protocol (2020) · cites this paper as [16]

    The Methods/Design section describes an online programme called “Calming Anxiety” and says its modules follow evidence-based CBT principles for generalized anxiety disorder. The paper is a trial protocol, not evidence that the programme is fully validated; our copy also does not identify it as “Space for Anxiety and Depression” or say it was adapted to deliver care to NICE standards. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • The SilverCloud platform can be used to deliver a range of programs (eg, depression and anxiety).

    “The sample platform can be used to deliver a range of programs (eg, depression [36] and anxiety [37]).”

    From Analyzing Engagement in a Web-Based Intervention Platform Through Visualizing Log-Data (2014) · cites this paper as [37]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • G-Power citation points to the PSWQ paper

    Minor

    The cited reference is a paper on the Penn State Worry Questionnaire, not G-Power software.

  • EuroQol version differs between table and description

    Minor

    The measures table specifies EQ-5D-5 L, while the measure description says each domain has three severity levels.

  • PSWQ minimum score is misstated

    Minor

    With 16 items scored from 1 to 5, the minimum sum is 16, not 0.

    Reported 0 · recomputed 16

  • Meta-analysis citation points to an internet-use report

    Minor

    Reference 53 is titled as a report on internet use and online health-information seeking, not a meta-analysis of GAD treatments.

  • BDI-II remission cutoff cites a CES-D reference

    Minor

    The reference attached to the BDI-II remission cutoff describes the CES-D Scale, a different measure.

5 of 5

Cites

Flagged first, then by citations

2 of the 105 references couldn’t be matched to a known paper.

Research works printed but not linked: 7

  1. Royal College of Psychiatrists: Mental health of students in higher education. 2011, London: Royal College of Psychiatrists, 97-
  2. Dooley B, Fitzgerald A: My world survey. 2012, Dublin: Headstrong
  3. Dugas MJ, Robichaud M: Cognitive-behavioral treatment for generalized anxiety disorder. 2007, New York: Routledge
  4. National Institute for Clinical Excellence: Clinical guidelines 22: anxiety. 2004, London
  5. National Institute for Health and Clinical Excellence: Computerised cognitive behaviour therapy for depression and anxiety. Technology Appraisal 97. 2006, London: National Institute for Health and Clinical Excellence
  6. Beck AT, Steer RA, Brown GK: Manual for the BDI-II. 1996, San Antonio: Psychological Corporation
  7. Rabin R, Oemar M, Oppe M: EQ-5D-3 L User Guide: basic information on how to use the EQ-5D-3 L instrument. 2011, Rotterdam: EuroQol Group, 40

Cited by

Sorted by citations

Related

Authors
Richards, D., Timulak, L., Doherty, G., Sharry, J., McLoughlin, O., Rashleigh, C., Colla, A., & Joyce, C.
Affiliations
  • Trinity College Dublin (IE)
  • Mater Misericordiae University Hospital (IE)
  • SilverCloud (Ireland) (IE)
Corresponding author
Richards, Derek
ORCID
Venue
Trials
Publisher
Springer Science and Business Media LLC
Published
2014-04-27
Volume
15
Issue
1
Pages
145-145
ISSN
1745-6215 (ISSN-L)
DOI
10.1186/1745-6215-15-145
PMC
PMC4017809
OpenAlex
W2160303473
Semantic Scholar
f617b6277096f93d80a2a82d60658ed0c05e4430
Cited by
16
References
105
Citations by year
2025: 1 · 2024: 1 · 2023: 1 · 2021: 1 · 2020: 2 · 2019: 1 · 2018: 1 · 2017: 1 · 2016: 3 · 2015: 3 · 2014: 1
FWCI
4.15
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Trials (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Arrow@dit (Dublin Institute of Technology) (submittedVersion, cc-by-nc-sa)
  • Trinity's Access to Research Output (TARA) (Trinity College Dublin) (submittedVersion)
  • Lenus, The Irish Health Repository (Dr Steevens Hospital Library) (submittedVersion)
Funders
Trinity College Dublin
Topics
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
Keywords
generalized anxiety disorder, internet-based cognitive behavioral therapy, low-intensity treatment, stepped care, university students, young adults, digital mental health interventions, treatment supporters, pathological worry, depression, well-being, treatment satisfaction, access to mental health care
MeSH terms
Anxiety Disorders, Clinical Protocols, Humans, Ireland, Psychiatric Status Rating Scales, Surveys and Questionnaires, Research Design, Students, Therapy, Computer-Assisted, Time Factors, Cognitive Behavioral Therapy, Treatment Outcome, Internet, Feedback, Psychological

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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