Anxiety disorders have a pooled lifetime prevalence of 19.8% [1
]. This makes these disorders the most prevalent mental disorders for women, and the second most prevalent for men. Specific phobias are the most common form of anxiety disorders for both genders, with a total 12-month prevalence of 7.1%, followed by social phobia (4.8%) and agoraphobia without panic disorder (1.2%). Phobias are characterised by an excessive fear of situations or objects and are often treated by gradual exposure to the fear-inducing stimulus and/or cognitive behavioural therapy.
The economic burden of these conditions is considerable [2
], as is the negative impact on quality of life and psychosocial functioning [3
], especially if the patient is often confronted with the fear-inducing situation or object in life. In clinical populations this burden may have long-term effects on psychosocial functioning and well-being, as research suggests that often more than a decade passes between onset of symptoms and first therapy attendance [4
]. The prevalence and burden of phobic disorders call for effective and cost-effective treatment options and the Internet offers an accessible and widespread platform to disseminate low-threshold treatment for phobias.
Research has shown that guided self-help is effective for anxiety disorders [5
] and that it can be as effective as face-to-face (FTF) psychotherapy [6
]. Self-help programs adapted for the Internet have shown similar results [7
], e.g. for social anxiety disorder [9
], generalised anxiety disorder [10
] and severe health anxiety [11
]. The use of internet interventions for treating anxiety disorders has been well-established and deemed useful and acceptable in primary care and the general population [12
]. A recent small scale study found a large effect size of internet-based treatment for panic disorder in a psychiatric outpatient setting [13
] and internet-based cognitive behavioural therapy (CBT) for adolescent anxiety appeared to be as efficacious as clinic-based FTF psychotherapy [14
]. Apart from these studies, little is known about the clinical effectiveness or cost-effectiveness of internet-based CBT in psychiatric outpatient settings. Few studies have examined internet-based treatment of phobias in particular and these tended to focus on social phobia in the general population or primary care patients.
Waiting lists of varying lengths are ubiquitous in psychiatric outpatient clinics. As demand for psychotherapy often exceeds supply, patients cannot be treated immediately. Time otherwise ‘lost’ while a patient is on a waiting list could be spent more efficiently when a waiting list guided self-help intervention is offered that comprises elements common in FTF psychotherapy for phobias, e.g. psychoeducation, goal setting and exposure exercises. Offering patients a self-help intervention while on a waiting list for FTF treatment can be advantageous to both outpatient clinics and patients for several reasons.
Firstly, following the stepped-care model, the intervention may be sufficient treatment for some phobic disorders, cancelling the need for further psychotherapy and preventing inappropriate use of outpatient resources.
Secondly, being placed on a waiting list may be disappointing to patients who have been suffering from a phobia for a long time. This disappointment may lead to pre-treatment attrition, i.e., patients not starting FTF psychotherapy or 'no-show'. This has been shown to be relatively high in FTF settings, up to 30% in social phobia [15
]. Offering the intervention during the waiting period offers a mutual benefit of keeping the patient actively engaged in his or her treatment and thus possibly reducing this pre-treatment attrition.
Thirdly, depending on the uptake and effects of the guided self-help intervention, fewer FTF psychotherapy sessions might suffice when the waiting period has ended and FTF treatment is scheduled, thus lowering the pressure on psychiatric outpatient clinics. This can also lead to lower per-patient treatment costs.
As healthcare budgets stagnate or decline and demand for treatment for phobias increases, a larger number of patients will need to be treated at lower costs per patient.
Aims and hypotheses
The objective of this study is to establish the clinical and cost-effectiveness of an internet-based brief guided self-help intervention for phobic patients in outpatient clinics. We expect that patients are more satisfied as they can start treatment while on a waiting list and that outpatient clinics can reduce the number of costly FTF psychotherapy sessions due to the skills and knowledge already acquired by the patient in the guided self-help intervention. Furthermore, we expect that patients in the intervention group will recover more quickly than in the control group.