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Cited by 69Digital Mental Health InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesTelemedicine and Telehealth Implementation

Individually Tailored Internet-Based Treatment for Young Adults and Adults With Panic Attacks: Randomized Controlled Trial

Open access
Silfvernagel, Kristin, Carlbring, Per, Kabo, Julia, Edström, Sara, Eriksson, Jenny, Månson, Lisa, Andersson, Gerhard·2012·Journal of Medical Internet Research
DOI 10.2196/jmir.1853PMC PMC3414867
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Abstract

BACKGROUND: Previous studies on Internet-based treatment with minimal therapist guidance have shown promising results for several specific diagnoses. OBJECTIVE: To (1) investigate the effects of a tailored, therapist-guided, Internet-based treatment for individuals with reoccurring panic attacks, and (2) to examine whether people in different age groups (18-30 years and 31-45 years) would respond differently to the treatment. METHODS: We recruited 149 participants from an online list of individuals having expressed an interest in Internet treatment. Screening consisted of online questionnaires followed by a telephone interview. A total of 57 participants were included after a semistructured diagnostic interview, and they were randomly assigned to an 8-week treatment program (n = 29) or to a control condition (n = 28). Treatment consisted of individually prescribed cognitive behavior therapy text modules in conjunction with online therapist guidance. The control group consisted of people on a waitlist who later received treatment. RESULTS: All dependent measures improved significantly immediately following treatment and at the 12-month follow-up. The between-group effect size on the primary outcome measure, the Panic Disorder Severity Scale, was d = 1.41 (95% confidence interval 0.81-1.95) at posttreatment. The within-group effect size from pretreatment to 12-month follow-up was d = 1.66 (95% confidence interval 1.14-2.35). Age group had no effect, suggesting that age did not influence the outcome. CONCLUSIONS: Tailoring an Internet-based treatment can be a feasible approach in the treatment of panic symptoms and comorbid anxiety and depressive symptoms. Younger adults benefit as much as adults over 30 years and up to 45 years of age. TRIAL REGISTRATION: Clinicaltrials.gov NCT01296321; http://www.clinicaltrials.gov/ct2/show/NCT01296321 (Archived by WebCite at http://www.webcitation.org/65wddsqlL).

AI snapshot

Written from the paper’s full text.

TL;DR

In a randomized controlled trial, individually tailored therapist-guided internet-based CBT reduced panic, anxiety, and depressive symptoms and improved quality of life compared with a waitlist control in adults with recurrent panic attacks. Treatment gains were maintained at 12-month follow-up, and age group did not influence outcome.

Key findings

  • On the primary outcome, the Panic Disorder Severity Scale (PDSS), the between-group effect size at posttreatment was d = 1.41 (95% CI 0.81–1.95); the within-group effect size from pretreatment to 12-month follow-up was d = 1.66 (95% CI 1.14–2.35).
  • Secondary outcomes also showed significant treatment interactions at posttreatment: CORE-OM d = 1.01, BAI d = 0.57, MADRS-S d = 0.71, and QOLI d = 0.54.
  • Clinically, 16 of 24 (67%) treated participants versus 3 of 27 (11%) controls achieved a 40% PDSS improvement (χ²₁ = 16.1, P < .001); at 12 months, 14 of 20 (70%) treated participants met that improvement threshold and 16 of 20 (80%) no longer met their pretreatment diagnosis.
  • Age group had no effect across measures; treatment completion was limited, with 7 of 29 (24%) completing all prescribed modules and a mean of 5.0 (SD 2.6) completed modules.

Methods

  • Participants were recruited from an online list; 149 expressed interest, and 57 were included after online screening and telephone SCID-I/PDSS interviews, then randomized to an 8-week tailored iCBT program (n = 29) or waitlist control (n = 28), with age groups 18–30 and 31–45 balanced across conditions.
  • Treatment used 19 CBT modules, with fixed introduction and relapse-prevention modules plus 17 optional therapist-prescribed modules; the aim was 6–8 modules over 8 weeks with online therapist guidance, while controls received treatment after 10 weeks.
  • Analyses used mixed-effects models with unstructured covariance for missing data; between- and within-group Cohen’s d were calculated from estimated means and observed pooled standard deviations, plus a prespecified 40% PDSS reduction analysis.

Limitations

  • The authors state that module prescription may have been unreliable because it relied on SCID-I and clinical impression by relatively inexperienced clinicians; the waitlist control cannot determine nonspecific factors; there was no comparison group at 12-month follow-up; the sample was small, limiting generalizability; participants had self-selected into iCBT and motivation was not measured; and the study was underpowered to detect age differences.
  • The authors also note that 83% of participants met criteria for panic disorder with agoraphobia despite the aim to target panic symptoms more broadly.
  • Evident from the text: only 24% completed all prescribed modules, so conclusions about optimal treatment dose and adherence are constrained.

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

Integrity signals

Registry

Crossref · 10.2196/jmir.1853

Cites

38 of 38 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 24 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    A mixed-models analysis of the immediate results of the primary outcome measure, PDSS, showed a significant interaction (F 1,47.3 = 29.6, P < .001, d = 1.41, d young adult = 1.59, d adult = 1.20).

    “A mixed-models analysis of the immediate results of the primary outcome measure, PDSS, showed a significant interaction (F 1,47.3 = 29.6, P < .001, d = 1.41, d young adult = 1.59, d adult = 1.20; see Figure 2).”
    Quote in the paperSubstantial claim
  • Findingown data

    The mean number of completed modules for the whole group was 5.0 (SD 2.6).

    “The mean number of completed modules for the whole group was 5.0 (SD 2.6).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The within-group effect size from pretreatment to 12-month follow-up was d = 1.66 (95% confidence interval 1.14-2.35).

    “The within-group effect size from pretreatment to 12-month follow-up was d = 1.66 (95% confidence interval 1.14–2.35).”
    Quote in the paperSubstantial claim
  • Findingown data

    Of the 29 participants in the treatment group, 7 (24%) completed all prescribed modules (6-8) within the 8-week treatment period.

    “Of the 29 participants in the treatment group, 7 (24%) completed all prescribed modules (6–8) within the 8-week treatment period.”
    Quote in the paperNot a substantial claim
  • Findingown data

    The between-group effect size on the primary outcome measure, the Panic Disorder Severity Scale, was d = 1.41 (95% confidence interval 0.81-1.95) at posttreatment.

    “The between-group effect size on the primary outcome measure, the Panic Disorder Severity Scale, was d = 1.41 (95% confidence interval 0.81–1.95) at posttreatment.”
    Quote in the paperSubstantial claim
  • May combine two claims. 19
  • Classified as probably not a substantial claim. 20

  • May combine two claims.

    Findingown data

    For the secondary outcome measure CORE-OM, there was a significant interaction effect and a moderate to large between-group effect size (F 1,46.7 = 10.8, P < .01, d = 1.01, d young adult = 1.24, d adult = 0.80).

    “CORE-OM (F 1,46.7 = 10.8, P < .01, d = 1.01, d young adult = 1.24, d adult = 0.80)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For the secondary outcome measure BAI, there was a significant interaction effect and a moderate to large between-group effect size (F 1,49.6 = 4.6, P = .04, d = 0.57, d young adult = 0.93, d adult = 0.28).

    “BAI (F 1,49.6 = 4.6, P = .04, d = 0.57, d young adult = 0.93, d adult = 0.28)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A total of 17 participants (59%) completed 50% of the prescribed modules and 14 (48%) completed 75% of the prescribed modules.

    “A total of 17 participants (59%) completed 50% of the prescribed modules and 14 (48%) completed 75% of the prescribed modules.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    All dependent measures improved significantly immediately following treatment and at the 12-month follow-up.

    “All dependent measures improved significantly immediately following treatment and at the 12-month follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The treatment was superior to the control condition with significant interactions on all measures.

    “As is evident in Table 3, the treatment was superior to the control condition with significant interactions on all measures.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The mean number of completed modules in the young adult group was 5.15 (SD 2.34) and the corresponding number in the adult group was 4.19 (SD 3.16).

    “The mean number of completed modules in the young adult group was 5.15 (SD 2.34) and the corresponding number in the adult group was 4.19 (SD 3.16).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For the secondary outcome measure MADRS-S, there was a significant interaction effect and a moderate to large between-group effect size (F 1,47.5 = 4.5, P = .04, d = 0.71, d young adult = 0.88, d adult = 0.60).

    “MADRS-S (F 1,47.5 = 4.5, P = .04, d = 0.71, d young adult = 0.88, d adult = 0.60)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For the secondary outcome measure QOLI, there was a significant interaction effect and a moderate to large between-group effect size (F 1,48.8 = 5.2, P = .03, d = 0.54, d young adult = 0.76, d adult = 0.32).

    “QOLI (F 1,48.8 = 5.2, P = .03, d = 0.54, d young adult = 0.76, d adult = 0.32)”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Effect sizes across all measures showed a tendency for larger effects among young adults.

    “The effect sizes across all measures showed a tendency for larger effects among the young adults”
    Quote in the paperNot a substantial claim

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

    Findingown data

    There was an interaction of time and age group for BAI (F 1,49.6 = 7.7, P < .01).

    “There was, however, an interaction of time and age group for BAI (F 1,49.6 = 7.7, P < .01)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Adherence was high in this trial, with no difference between the age groups.

    “adherence was high in this trial, with no difference between the age groups.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    At 1-year follow-up, there was a significant time effect for CORE-OM (F(1,23.9)=9.7, P<.001, estimated mean 1.65, SE 0.10, SD 0.45, d=0.07), but the effect size was small.

    “The exception was the CORE-OM (F 1,23.9 = 9.7, P < .001, estimated mean 1.65, SE 0.10, SD 0.45, d = 0.07).”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Panic attacks are common across psychiatric conditions, but far from all persons with panic attacks develop panic disorder.

    “Panic attacks are common across psychiatric conditions, but far from all persons with panic attacks develop panic disorder [19].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] Goodwin, RD, 2003, J Clin Epidemiol source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    One limitation of many previous iCBT trials on anxiety and depression is that they targeted specific disorders and that comorbid disorders could either be affected without being directly addressed or remain undetected and unchanged.

    “One limitation of many previous iCBT trials on anxiety and depression is that they targeted specific disorders and that comorbid disorders could either be affected without being directly addressed or remain undetected and unchanged [15].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Guided iCBT has been found to be effective for numerous specific disorders such as panic disorder, generalized anxiety disorder, social anxiety disorder, posttraumatic stress disorder, specific phobia, major depression, stress, and somatic health problems such as irritable bowel syndrome.

    “Guided iCBT has been found to be effective for numerous specific disorders such as panic disorder [4,5], generalized anxiety disorder [6,7], social anxiety disorder [8-10], posttraumatic stress disorder [11], specific phobia [12], major depression [3], stress [13], and somatic health problems such as irritable bowel syndrome [14].”
    Quote in the paperSubstantial claim0 of 7 sources checked
    • cites [4] source

      Not checked in the free run.

    • cites [5] source

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    • cites [6] source

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    • cites [7] source

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    • cites [8] source

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    • cites [9] source

      Not checked in the free run.

    • cites [10] source

      Not checked in the free run.

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

    Study design and conductcitation

    The SCID-I interview has been shown to have good psychometric properties when administered over telephone.

    “the same accounts for administrating the SCID-I interview over telephone [30]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Rohde, P, 1997, Am J Psychiatry source

      Not checked in the free run.

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

    Study design and conductnone given

    The principal investigator along with a psychiatrist further checked the SCID-I protocols and PDSS assessments for the participants before they enrolled in the trial.

    “The principal investigator along with a psychiatrist further checked the SCID-I protocols and PDSS assessments for the participants before they enrolled in the trial.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    A few previous trials have been conducted on iCBT for younger persons with anxiety disorders.

    “A few previous trials have been conducted on iCBT for younger persons with anxiety disorders.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [20] source

      Not checked in the free run.

    • cites [21] source

      Not checked in the free run.

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

    Study design and conductnone given

    The therapists were instructed to check whether the participants had completed the assignments associated with each module and to provide individual feedback within 24 hours.

    “The therapists were instructed to check whether the participants had completed the assignments associated with each module and to provide individual feedback within 24 hours.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    The blocked randomization process was conducted through an online true random number-generation service (random.org) independent of the investigators and therapists.

    “The blocked randomization process was conducted through an online true random number-generation service (random.org) independent of the investigators and therapists.”
    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

    A prespecified analysis of a 40% reduction from baseline on PDSS based on observed data was used, which is equivalent to the participant being much improved, according to the guidelines by Furukawa et al.

    “We also present a prespecified analysis of a 40% reduction from baseline on PDSS based on observed data, which is equivalent to the participant being much improved, according to the guidelines by Furukawa et al [36].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] 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 conductnone given

    The project was approved by the regional ethics committee in Linköping and registered at ClinicalTrials.gov (NCT01296321).

    “The project was approved by the regional ethics committee in Linköping and registered at ClinicalTrials.gov (NCT01296321).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Two studies found effects of iCBT for social anxiety disorder in high school students and university students, but adherence to treatment was poor.

    “While these two studies found effects, adherence to treatment was poor.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [20] source

      Not checked in the free run.

    • cites [21] source

      Not checked in the free run.

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

    Study design and conductnone given

    At posttreatment participants were instructed via email to complete the follow-up questionnaires and to participate in a semistructured telephone interview carried out by a blinded assessor who had no earlier contact with the participants.

    “At posttreatment participants were instructed via email to complete the follow-up questionnaires and to participate in a semistructured telephone interview carried out by a blinded assessor who had no earlier contact with the participants.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    The participants were divided into two groups so that the two predetermined age groups 18-30 years and 31-45 years were equally represented in each condition.

    “The participants were divided into two groups so that the two predetermined age groups 18–30 years (young adults) and 31–45 years(adults) were equally represented in each condition.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    The therapists in this trial were not aware of the participants' age group.

    “The therapists in this trial were not aware of the participants’ age group.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    The therapists were supervised by experienced clinical psychologists (senior authors).

    “The therapists were three clinical psychology MSc students who had completed their clinical training and who were supervised by experienced clinical psychologists (senior authors).”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    It is possible that small but clinically meaningful differences would have been detected with a larger sample.

    “and it is possible that small but clinically meaningful differences would have been detected with a larger sample.”
    Quote in the paperNot a substantial claim

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

    Study design and conductreasoning

    Participants in this study may have been highly motivated to undergo treatment because they had expressed an interest in iCBT for their problems.

    “The forth limitation is that the participants in this study had expressed an interest in iCBT for their problems and therefore the participants may have been highly motivated to undergo treatment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The interaction of time and age group for BAI was caused by a slightly lower pretreatment value in the adult control group and thus did not reflect differential treatment effects.

    “which was caused by a slightly lower pretreatment value in the adult control group and thus not reflecting differential treatment effects.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    Individually tailored iCBT can broaden the use of iCBT to address comorbidity in anxiety disorder, allow for more flexibility, and emphasize the role of the clinician.

    “Individually tailored iCBT can broaden the use of iCBT to address comorbidity in anxiety disorder, allow for more flexibility, and emphasize the role of the clinician.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    The size of the study affects the generalizability of the results.

    “A third limitation is the size of the study, which in turn affects the generalizability of the results.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    The study did not measure how highly motivated the participants were.

    “However, we did not measure how highly motivated the participants were.”
    Quote in the paperNot a substantial claim
33 of 33

  • The paper relies on this without support.

    No trials have tested iCBT specifically for persons presenting with panic attacks regardless of the presence of a diagnosis such as panic disorder and social anxiety disorder.

    “However, no trials have tested iCBT specifically for persons presenting with panic attacks regardless of the presence of a diagnosis such as panic disorder and social anxiety disorder.”

  • The paper relies on this without support.

    Persons with recurrent panic attacks may have other conditions that they want to address in treatment along with their panic symptoms, such as sleep problems, worry, low mood, and other symptoms.

    “Persons with recurrent panic attacks may, however, have other conditions that they want to address in treatment along with their panic symptoms, such as sleep problems, worry, low mood, and other symptoms.”

  • The paper relies on this without support.

    Tailoring iCBT according to the participant’s needs and symptoms with transdiagnostic components can increase the scope of iCBT and possibly increase motivation and improve treatment outcome.

    “The idea is to address specific problems and comorbidities with the aim of increasing the scope of iCBT, and possibly increasing motivation and improving treatment outcome.”

  • The paper relies on this without support.

    Structured or diagnosis-specific iCBT treatments leave little room for clinician and patient preferences.

    “Structured or diagnosis-specific iCBT treatments are also limited in that they leave little room for clinician and patient preferences.”

  • The paper relies on this without support.

    A 40% improvement on PDSS is a clinically meaningful criterion for treatment response.

    “fulfilled the criteria of a 40% improvement on PDSS”
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?

  • Individually tailored ICBT has proven efficacy compared with control for mixed anxiety and for depression with high comorbid anxiety.

    “Recent results exist proving the efficacy compared with control for mixed anxiety [25,27] and in the treatment of depression with a high amount of comorbid anxiety [26].”

    From Internet-based psychological treatments for depression (2012) · cites this paper as [27]

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Related

Authors
Silfvernagel, K., Carlbring, P., Kabo, J., Edström, S., Eriksson, J., Månson, L., & Andersson, G.
Affiliations
  • Linköping University (SE)
  • Umeå University (SE)
Corresponding author
Silfvernagel, Kristin
ORCID
Venue
Journal of Medical Internet Research
Publisher
JMIR Publications Inc.
Published
2012-06-26
Volume
14
Issue
3
Pages
e65
ISSN
1438-8871 (ISSN-L)
DOI
10.2196/jmir.1853
PMC
PMC3414867
OpenAlex
W2158611346
Cited by
69
References
38
Citations by year
2026: 3 · 2025: 2 · 2024: 4 · 2023: 2 · 2022: 3 · 2021: 7 · 2020: 3 · 2019: 5 · 2018: 5 · 2017: 6 · 2016: 7 · 2015: 5 · 2014: 5 · 2013: 9 · 2012: 3
FWCI
9.86
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Journal of Medical Internet Research (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
Forskningsrådet för Arbetsliv och Socialvetenskap
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
online therapy, panic attacks, panic disorder, cognitive behavioral therapy, personalized treatment, young adults, age differences in treatment response, anxiety comorbidity, depressive symptoms, medication adherence
MeSH terms
Adolescent, Adult, Female, Humans, Male, Middle Aged, Cognitive Behavioral Therapy, Panic Disorder, Internet, Young Adult

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