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Literature Review for Internet- and Computer-based CBT for GAD

A Literature Review on the Effectiveness of Internet- and Computerbased Cognitive Behavioral Therapy for Generalized Anxiety Disorder
Jay Key
Wake Forest University

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Literature Review for Internet- and Computer-based CBT for GAD

Abstract
Introduction: Generalized Anxiety Disorder (GAD) is characterized by excessive worrying and
other physical symptoms associated with anxiety. Cognitive Behavioral Therapy (CBT) has
proven effectiveness in treating GAD, but can be expensive. Internet- and computer-based CBT
could be more cost-effective than in-person CBT, while remaining an effective treatment.
Method: Reviews were made in data bases for studies utilizing internet- and computer-based
CBT in treatment for GAD. Further searches were made to find supplementary journals and
books.
Results: Six studies were identified that used diverse methods of internet- or computer-based
CBT in treating GAD. Statistically significant differences in pre- and post-treatment levels of
GAD were found, in both individual and group treatments, and compared to no treatment
controls and other forms of treatment controls.

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Literature Review for Internet- and Computer-based CBT for GAD

Introduction:
Generalized anxiety disorder (GAD) is characterized by The Diagnostic and Statistical Manual
of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) as excessive
anxiety and worry (apprehensive expectation), occurring more days than not for at least 6
months, about a number of events or activities (such as work or school performance.)
(American Psychiatric Association, 2013, p. 222) Unlike other anxiety disorders, the worrying is
about everyday circumstances that is out of proportion to the likelihood or impact of the
anticipated event. (2013, p. 222) This worrying is difficult to control, lasts longer than nondisorder anxiety, and is more likely to be associated with physical symptoms such as
restlessness or feeling keyed up or on edge or muscle tension. (2013, p. 222-223) At least
three or more of the following symptoms are also necessary for GAD: 1. Restlessness or feeling
keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4.
Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or
restless, unsatisfying sleep). (2013, p. 222) Generalized anxiety disorder also cannot be better
explained by either another anxiety disorder (such as social phobia or panic disorder) or by a
substance or medical condition (such as drug abuse or hyperthyroidism). (2013, p. 222) In the
United States, the 12-month prevalence of GAD is 2.9% among adults, and the lifetime morbid
risk is 9.0%. (2013, p. 223) Around the world, the 12-month prevalence is somewhere between
0.4% and 3.6% (2013, p. 223) Individuals of European descent are more likely to exhibit GAD
than individuals of non-European descent, and individuals from developed countries also exhibit
GAD at a higher rate than individuals from non-developed countries. (2013, p. 223) The median
age at onset for GAD is 30 years old, which is later than for other anxiety disorders, although the
range for age at onset is broad. (2013, p. 223) Generalized anxiety disorder is associated with

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Literature Review for Internet- and Computer-based CBT for GAD

temperamental and genetic and physiological factors, and although some aspects of childhood
have been associated with GAD, no environmental factors have been identified as special to only
GAD and not other disorders or to specifically causing GAD. (2013, p. 224) Females are more
frequently diagnosed with GAD than males, at a rate of 55-60% in clinical settings and around
66% in epidemiological studies. There is likely comorbidity between GAD and other anxiety
and unipolar depressive disorders, although comorbidity with substance use, conduct,
psychotic, neurodevelopmental, and neurocognitive disorders is less common. (2013, p. 226)
Generalized anxiety disorder can effect both home and work life, as [e]xcessive worrying
impairs the individuals capacity to do things quickly and efficiently. (2013, p. 225) Finding
effective treatment for GAD is important not only to decrease the primary symptoms of the
disorder, but also to decrease the secondary symptoms, such as financial costs, of GAD.
Generalized anxiety disorder accounts for 110 million disability days per annum in the U.S.
population. (2013, p. 225) Evidence has also shown to indicate that untreated anxiety can lead
to greater medical illness, medical utilization, disabilityand some of the highest health care
costs. (Newman, 2000, p. 551) While cognitive behavioral therapy (CBT) has been
demonstrated as an effective treatment for GAD, it can be expensive. (Deacon & Abramowitz,
2004) In 1995 it was estimated that the costs for CBT, the treatment of focus for this literature
review, were $2,181 per client and on average require 23.2 billable hours of therapist contact.
(Newman, Przeworski, Consoli, & Taylor, 2014) Internet- and computer-based CBT might be a
more cost-effective alternate to in-person CBT.
Method:
To identify articles, searches were conducted in the PsychINFO, PubMed, and Wake Forest
University ZSR Library databases. The original search was conducted for articles that had been

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Literature Review for Internet- and Computer-based CBT for GAD

published since 2004 and whose participants were adults. Further criteria that were used were
delineating between journal articles or books and between unspecified methodology and metaanalyses. Effective search terms included Anxiety AND Internet cognitive behavior therapy,
generalized anxiety disorder AND CBT AND internet, and generalized anxiety disorder AND
assessment. Due to inconsistencies in nomenclature, acronyms (e.g. GAD for generalized
anxiety disorder, CBT for cognitive behavioral therapy, iCBT for internet-based cognitive
behavioral therapy) used in addition to written out names rather than in place of them are
suggested for future searches. After initial articles were found, further sources were located from
the reference pages of the initial articles. Studies that focused on other forms of anxiety or did
not specifically focus on GAD were excluded. It is suggested to start with a broad search, find
one article that matches what future researchers are looking for, and use that article both as a
sounding board for future searches (i.e. doing a broad search for anxiety and CBT, finding an
article on anxiety and internet-based CBT, and doing subsequent searches on anxiety and
internet-based CBT) as well as using references from that article.
Results:
Internet CBT for Anxiety
The literature has indicated first that there are multiple forms of Internet- and computer-based
CBT for GAD. Mora, Nevid, and Chaplin identified four different internet-based treatments email, individual chat, group chat, and videoconferencing that can be used when planning a CBT
treatment. (2008, p. 3052) Newman et al. further proposed the option of CBT that is supplied
through software, either on a computer or a phone, as an alternative to both in-person CBT and to
CBT supplied through the internet. (2014, p. 199) Draper et al, a case study and one of the
earliest studies of internet-based CBT on GAD, used the Internet-based intervention, What?

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Literature Review for Internet- and Computer-based CBT for GAD

Me Worry!?! that combines traditional CBT elements with techniques that target intolerance
of uncertainty, metacognitive beliefs, and acceptance and mindfulness. (2008, p. 233) Two
studies used the Worry programme a clinician-assisted computerized cognitive behavioral
therapy (CaCCBT) that consists of the following components: six online lessons; a
summary/homework assignment for each lesson an online discussion forum for each lesson; and
instant messaging to allow secure email-type messages with a clinician. (Robinson et al., 2010;
Titov et al., 2009, p. 206) Robinson et al also tested how training of the person who administers
the treatment can effect outcomes, dividing treatment groups into those receiving treatment from
a clinician (clinician-assisted (CA)) and those receiving treatment from a non-clinician
(technician-assisted (TA)). (2010, p. 2) The treatment used by Paxling et al consisted of eight
text-based treatment modules delivered on a weekly basis for 8 weeks. (2011, p. 163) This
program included psycheducation, homework, and access to a therapist who was in the final
year of psychologist training. (2011, p. 163) Communication was conducted over email, and
therapist time devoted to each client ranged from 10 to 15 min per week, totaling 71 h and 5
min for all patients in the trial and a mean of 97 minper patient. (2011, p. 164) Mewton,
Wong, and Andrews intervention consisted of six fully automated, unassisted online lessons
involving components such as psychoeducation, behavioral activation, cognitive restructuring,
problem solving, graded exposure, relapse prevention, and assertiveness skills. Homework was
required after each lesson. (2012, p. 844) Unlike other studies, Newman et al used a palmtop
computer that already had software installed as the delivery method for their group CBT
treatment. (2014, pp. 201, 202) Methods delivered through the palmtop computer included a
CBT model and rationaletraining in self-monitoring of environmental, somatic imaginal, and
thoughtcures that trigger anxiety spirals [and] formal progressive relaxation. (2014, p. 202)

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Literature Review for Internet- and Computer-based CBT for GAD

Therapy was limited to 6 group sessions to reduce cost, and contact with therapist was recorded
at 4 hours per person. (2014, pp. 202, 204)
Measures
It is beyond the scope of this literature review to list and review every item used to assess anxiety
and its related symptoms. However, Table 3.1 of Rygh and Sandersons Treating Generalized
Anxiety Disorder lists multiple GAD Assessment methods. (2004, p. 29) Notable measures
include: the Structured Clinical Interview for DSM-IV (SCID), which can be used to establish
the diagnosis of GAD (Paxling et al., 2011, p. 161); the Penn State Worry Questionnaire
(PSWQ), a self-report questionnaire used to measure worry. It was designed to discriminate
individuals with GAD from those with other anxiety disorders (Rygh & Sanderson, 2004, p.
36); the Generalized Anxiety Disorder Questionnaire-IV (GADQ-IV), a revised self-report
diagnostic measure of GAD based on the DSM-IV criteria. (2004, p. 36); the GAD-7, a brief
screening tool for GAD (Mewton et al., 2012, p. 845); the Meta-Cognitions Questionnaire
Short Form (MCQ-30), a questionnaire used to specifically measure metacognitive variables
related to anxiety (Draper et al., 2008, pp. 232, 239); the State Trait Anxiety Inventory-Trait
Version (STAI-T), which is used to measure trait anxiety (Newman et al., 2014, p. 200); and
the Hamilton Anxiety Rating Scale (HARS), a clinician administered scale [that] provides a
rating of severity of each overarching anxiety symptom cluster. (2014, p. 200)
Draper et al. made use of the PSWQ, the GAD-Q-IV, and the MCQ-30, to measure GAD. (2008,
p. 232) Titov et al used the GAD-7 and the PSWQ as primary measures for GAD. (2009)
Robinson et al used the PSWQ and the GAD-7 as primary measures for GAD. (2010) Paxling
used the PSWQ, the GAD-Q-IV, and the SCID-I as primary measures for GAD. (2011) For

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Literature Review for Internet- and Computer-based CBT for GAD

Mewton et al, the primary outcome measure of GAD was the GAD-7 (2012) And Newman et al
used the STAI-T, the HARS and the PSWQ. (2014)
Treatment Outcomes
Using both the PSWQ and the GADQ-IV as measurements for GAD, Draper et als treatment led
to no less than reliable improvement in [participant] scores of worry intensity. In addition, by
the end of the study, none of the participants met the DSM-IV diagnostic criteria for GAD as
measured by GADQ-IV. (2008, p. 239) Titov et als study showed improvements in GAD
through the GAD-7 and PSWQ, with over half of participants showing a remission in GAD
symptoms, compared to less than 15% remission for the control group. (2009, p. 910) In
Robinson et als study, both the technician-assisted (TA) and the clinician-assisted (CA) groups
showed statistically significant differences from the control group in PSWQ and GAD-7 scores,
although they did not show differences from each other. (2010, pp. 45) These scores also
indicated a large percentage of recovery from GAD based on GAD-7 scores, with 56% of TA
group meeting criteria for recovery, and 70% of CA group meeting criteria for recovery, with
these scores remaining relatively consistent at a 3 month follow up. (2010, pp. 67) Paxling et
als study revealed statistically significant decreases in anxiety based on PSWQ, GAD-7, STAI-S
and STAI-T scores, which changes relatively consistent during 1- and 3-year follow-ups. (2011)
Mewton et als study resulted in over 60% of their treatment sample who had a probabl[e]
diagnosis of GAD at baseline no longer would receive that diagnosis after treatment based off
of GAD-7 scores. (2012, pp. 846847) While not all participants showed reliable improvement
(posstreatment GAD-7 scores at least 6.12 points lower than baseline GAD-7 scores), only
0.9% of their sample showed reliable deterioration (GAD-7 score[s] at least 6.12 points higher
than baseline.) (2012, p. 847) Newman et als study showed that while their internet-based

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Literature Review for Internet- and Computer-based CBT for GAD

therapy (CAGT6) was more effective (meaning percentage of participants who achieved change
on at least 2/3 GAD-specific measures) than individuals in their six session treatment (CBGT6),
there were no significant differences with their 12 session treatment (CBGT12) at initial
posttreatment according to the combination of HARS, PSWQ, and STAI-T scores. (2014, pp.
203204) At both 6-month and 12-month follow-ups there were not significant differences
between CAGT6, CBGT6, and CBGT12. (2014, p. 204)
Discussion:
These findings indicate that, in multiple settings and with different measures for change and
methods of delivery, internet- and computer-based CBT can be more effective than doing nothing
in treating GAD and can be just as, or more effective than in-person CBT. Initial interest in
internet- and computer-based CBT was due to helping clients in harder to reach places and
decreasing the cost of therapy, and at least one study estimated savings of over a thousand
dollars per client, even after factoring in the cost of the technology. (Newman et al., 2014, p.
204)
Limitations and Future Areas of Study:
The primary limitation noted by this literature review is the lack of a consistent or primary
definition or procedure of what internet- or computer-based CBT is. While all treatments are
based off cognitive-behavioral theory, both the methods and delivery system are inconsistent
among the studies. Further research is required to determine if and how method and delivery
system effect treatment effectiveness. There is also a general lack of consistency for measures for
GAD. Although every study used measures specifically designed for GAD as their primary
measures, only two studies used the exact same measures for GAD. (Robinson et al., 2010; Titov

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Literature Review for Internet- and Computer-based CBT for GAD

et al., 2009) Studies also used different comparison groups to the internet- or computer-based
CBT, with some using control groups with no treatment and others using other forms of
treatment as a comparison group. Other limitations include whether results are applicable to all
populations. Sample sizes were small (with only one being more than 150 people), and most
participants were of European decent and well educated. Further research is required for more
diverse populations, for those with lower levels of education, and to see if there is an interaction
between treatment effectiveness and socio-economic status. It is also unclear how popular this
form of CBT is and whether it will be used more extensively or not, despite its level of
effectiveness. (Mora et al., 2008) Lastly, future research should examine the relationship between
the therapeutic alliance and CBT conducted not in person.

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Literature Review for Internet- and Computer-based CBT for GAD

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Deacon, B. J., & Abramowitz, J. S. (2004). Cognitive and behavioral treatments for anxiety
disorders: A review of meta-analytic findings. Journal of Clinical Psychology, 60(4),
429441. doi:10.1002/jclp.10255
Draper, M., Rees, C. S., & Nathan, P. R. (2008). Internet-based self-management of generalised
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doi:10.1375/bech.25.4.229
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Literature Review for Internet- and Computer-based CBT for GAD

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