Abstract
BackgroundIn the context of the COVID-19 pandemic, legislations are being modified around the world to allow patients to receive mental health services through telehealth. Unfortunately, there are no large clinical trial available to reliably document the efficacy of delivering videoconferencing psychotherapy (VCP) for people with panic disorder and agoraphobia (PDA) and whether basic psychotherapeutic processes are altered.MethodsThis 2-arm intent-to-treat non-inferiority study reports on a clinical trial on VCP and documents how therapeutic working alliance and motivation toward psychotherapy are associated to treatment outcome. We hypothesized that VCP would not be inferior to standard face-to-face (FF) cognitive behavior therapy for PDA. No specific hypothesis was stated to address working alliance and treatment mechanisms. VCP was compared to a gold-standard psychotherapy treatment for PDA, which was delivered either in person or in videoconference, with a strict tolerance criterion of about 2 points on the primary outcome measure. Seventy one adult patients were recruited. Measures of working alliance were collected after the first, fifth, and last session. Motivation toward therapy at pre-treatment and working alliance after the fifth therapy session were used as predictors of treatment outcome and compared with change in dysfunctional beliefs toward bodily sensations.ResultsPanic disorder, agoraphobia, fear of sensations and depressed mood all showed significant improvements and large effect-sizes from pre to post-treatment. Gains were maintained at follow-up. No significant differences were found between VCP and FF, and effect sizes were trivial for three of the four outcome measures. Non-inferiority tests confirmed that VCP was no less effective than FF therapy on the primary outcome measure and two of the three secondary outcome measures. Working alliance was very strong in VCP and did not statistically differ from FF. Working alliance and motivation did not predict treatment outcome, which was significantly predicted by the reduction in dysfunctional beliefs. The strength of the therapeutic bond was correlated with change in dysfunctional beliefs.ConclusionMental health professionals can use VCP to provide services to patients with PDA. Building and maintaining a sound working alliance should not be a source concern. Practical recommendations are formulated.ISRCTN Trial Registration NumberISRCTN76456442.
Highlights
Telemedicine and telepsychotherapy have long been considered solutions to provide health services to people living in rural areas, but legislations are being modified around the world to allow people to receive services from home due to measures implemented to face the COVID-19 pandemic
People with panic disorder and agoraphobia (PDA), or at risk of developing PDA, may be more sensitive to the apprehension of suffering from harmful diseases, experiencing symptoms associated with COVID-19, wearing facial masks that may induce the feeling that breathing is difficult, being restricted in mobility because of rules for confinement and physical distancing, having panic attacks induced by the increase in arousal caused by adapting to this situation or by co-morbid anxiety disorders, etc
This is especially relevant for cognitive-behavior therapy (CBT) of PDA, as patients feel reassured by the presence of the therapist during exposure
Summary
Telemedicine and telepsychotherapy have long been considered solutions to provide health services to people living in rural areas, but legislations are being modified around the world to allow people to receive services from home due to measures implemented to face the COVID-19 pandemic. Many people are sensitive to these measures, including some anxious patients and those fearful of physical distancing and confinement In this context, there is a need for accessible empirical evidences about the efficacy and predictors of outcome of telehealth for each specific mental disorder. People with PDA, or at risk of developing PDA, may be more sensitive to the apprehension of suffering from harmful diseases, experiencing symptoms associated with COVID-19 (e.g., shortness of breath, dizziness), wearing facial masks that may induce the feeling that breathing is difficult, being restricted in mobility because of rules for confinement and physical distancing, having panic attacks induced by the increase in arousal caused by adapting to this situation or by co-morbid anxiety disorders, etc. There are no large clinical trial available to reliably document the efficacy of delivering videoconferencing psychotherapy (VCP) for people with panic disorder and agoraphobia (PDA) and whether basic psychotherapeutic processes are altered
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