Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: a randomized controlled non-inferiority trial.

Erik Hedman,Nils Lindefors,Gerhard Andersson,Brjánn Ljótsson,Erik Andersson,Christian Rück,Ewa Mörtberg,Antonio Verdejo García

doi:10.1371/journal.pone.0018001

Abstract

Background and AimsCognitive behavioral group therapy (CBGT) is an effective, well-established, but not widely available treatment for social anxiety disorder (SAD). Internet-based cognitive behavior therapy (ICBT) has the potential to increase availability and facilitate dissemination of therapeutic services for SAD. However, ICBT for SAD has not been directly compared with in-person treatments such as CBGT and few studies investigating ICBT have been conducted in clinical settings. Our aim was to investigate if ICBT is at least as effective as CBGT for SAD when treatments are delivered in a psychiatric setting.MethodsWe conducted a randomized controlled non-inferiority trial with allocation to ICBT (n = 64) or CBGT (n = 62) with blinded assessment immediately following treatment and six months post-treatment. Participants were 126 individuals with SAD who received CBGT or ICBT for a duration of 15 weeks. The Liebowitz Social Anxiety Scale (LSAS) was the main outcome measure. The following non-inferiority margin was set: following treatment, the lower bound of the 95 % confidence interval (CI) of the mean difference between groups should be less than 10 LSAS-points.ResultsBoth groups made large improvements. At follow-up, 41 (64%) participants in the ICBT group were classified as responders (95% CI, 52%–76%). In the CBGT group, 28 participants (45%) responded to the treatment (95% CI, 33%–58%). At post-treatment and follow-up respectively, the 95 % CI of the LSAS mean difference was 0.68–17.66 (Cohen’s d between group = 0.41) and −2.51–15.69 (Cohen’s d between group = 0.36) favoring ICBT, which was well within the non-inferiority margin. Mixed effects models analyses showed no significant interaction effect for LSAS, indicating similar improvement across treatments (F = 1.58; df = 2, 219; p = .21).ConclusionsICBT delivered in a psychiatric setting can be as effective as CBGT in the treatment of SAD and could be used to increase availability to CBT.Trial RegistrationClinicalTrials.gov NCT00564967

Highlights

Social anxiety disorder (SAD), or social phobia, is characterized by a persistent and debilitating fear of being evaluated by others
The following non-inferiority margin was set: following treatment, the lower bound of the 95 % confidence interval (CI) of the mean difference between groups should be less than 10 Liebowitz Social Anxiety Scale (LSAS)-points
At follow-up, 41 (64%) participants in the Internet-based cognitive behavior therapy (ICBT) group were classified as responders

Summary

Introduction

Social anxiety disorder (SAD), or social phobia, is characterized by a persistent and debilitating fear of being evaluated by others. Cognitive behavioral group therapy (CBGT) for SAD has proven to be effective in several randomized controlled trials (RCTs) over the last 20 years. While individually administered CBT has demonstrated large effects [10] and might be more efficacious than CBGT [11,12], this treatment format is even more dependent on the availability of trained therapists. Cognitive behavioral group therapy (CBGT) is an effective, well-established, but not widely available treatment for social anxiety disorder (SAD). Internet-based cognitive behavior therapy (ICBT) has the potential to increase availability and facilitate dissemination of therapeutic services for SAD. ICBT for SAD has not been directly compared with in-person treatments such as CBGT and few studies investigating ICBT have been conducted in clinical settings. Our aim was to investigate if ICBT is at least as effective as CBGT for SAD when treatments are delivered in a psychiatric setting

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