A systematic review of internet-based self-help therapeutic interventions to improve distress and disease-control among adults with chronic health conditions

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Highlights

  • Systematic review of online self-help interventions for chronic health conditions

  • Distress outcomes were favourable for IBS, tinnitus, and ‘other’ chronic illness.

  • Distress outcomes were moderately favourable for chronic pain.

  • Disease-outcomes were promising for all conditions, except diabetes.

  • The methodological quality, attrition and compliance continue to be sub-optimal.

Abstract

The evidence base of internet-based self-help interventions has been rapidly growing for mental health conditions over the past decade. However, to date a systematic review of the application of this technology to chronic health conditions has not been reported. The objective of the present review was to therefore critically appraise the research on the efficacy of internet self-help interventions for distress and disease outcomes in adults with physical health complaints. Electronic searches were conducted in Embase, CINAHL, MEDLINE and PsychINFO, and reference lists were examined. Twenty four studies met inclusion criteria, covering 8 health conditions. Across health conditions, consistent evidence was obtained that online therapeutic interventions were efficacious in improving disease-symptoms and control, with the exception of diabetes. Mixed evidence was obtained for distress outcomes: 3 health conditions demonstrated consistent benefit (irritable bowel syndrome, tinnitus, and one heterogeneous chronic illness population); one condition obtained moderate support (chronic pain); while results were not promising for diabetes. The limited research conducted among epilepsy, cancer, and chronic fatigue precluded conclusions from being drawn. Few studies met all methodological quality criteria. This review demonstrates that internet-based self-help interventions hold guarded promise in the amelioration of distress and disease-control, and further research implications are discussed.

Introduction

It is well established that physical health and psychological distress are strongly related, with one population-based survey indicating that one in four individuals reporting poor physical health also reports high to very-high psychological distress (Australian Institute of Health & Welfare, 2010). The incidence of mental disorders is approximately 10% higher among those with a diagnosed chronic health condition compared to those without (Mitchell, 2012), with these differences being more marked among females compared to males. One recent 12-month prevalence study found that chronic disease patients were more than twice as likely, when adjusting for sex and age, to have a mental disorder compared to healthy controls (odds ratio: 2.2) (Härter et al., 2007). Even among those without a diagnosable mental disorder, it has been estimated that up to 60% of physical health conditions have a psychological component to their presentation (Milgrom & Burrows, 2001). Psychiatric co-morbidity can result in increased symptom severity, length of hospital stay, health service utilisation, number of hospital visits, reduced treatment adherence, and delayed return to the workforce (Milgrom and Burrows, 2001, Mitchell, 2012). People with chronic health problems are generally more likely to be unemployed, employed part time, and to have significantly reduced ability to function in their day to day activities than those without chronic illness; this is amplified among those with comorbid mental health difficulties (Mitchell, 2012).

There is considerable research evidence supporting the efficacy of psychological interventions in (i) improving adjustment to diagnosis and resolving coping difficulties, (ii) improving compliance to medical regimes, (iii) reducing co-morbid psychiatric problems in these medical populations, such as anxiety and depression, and (iv) providing pain reduction and management strategies (Blyth et al., 2004, Steed et al., 2003). While these traditional face-to-face psychological therapies are demonstrably efficacious (Nathan & Gorman, 2007), there are numerous barriers to attendance. First, there are limited psychosocial services freely available in public health settings, and current capacity is not sufficient to meet the demand (Christensen, 2010, Ghahari et al., 2010, Ruehlman et al., 2012, Yates et al., 2001). This is particularly evident in rural and remote areas where access to psychological therapy is problematic. Second, even when services are offered in urban settings, research has demonstrated that less than 40% of those experiencing clinically significant psychological distress choose to attend (Christensen, 2010). In light of this, the past decade has seen a surge in the number of empirical studies investigating the online provision of psychological therapies. Online interventions overcome many of the attendance barriers relating to access and inequity, particularly for rural/remote areas, and have the advantages of being convenient, cost-effective, anonymous, and can be easily updated and provide links to other resources (Griffiths et al., 2010, Newman et al., 2011a).

Numerous reviews of these technology-assisted treatments have been published in recent years, demonstrating the efficacy of this service delivery format in treating depression and anxiety (Barak et al., 2008, Griffiths et al., 2010, Newman et al., 2011a, Van't Hof et al., 2009), and substance abuse/dependence (Newman, Szkodny, Llera, & Przeworski, 2011b). Two reviews have also documented the impact of degree of therapist-involvement, ranging from ‘pure’ to ‘guided’ self-help, on treatment outcomes. Self-help interventions involve an individual progressing unaided through print or online evidence-based therapeutic resources in their own time and at their own pace (Newman et al., 2011a, Newman et al., 2011b). When this process is supported through contact with a trained health professional, it is known as guided self-help. While pure- and predominantly self-help interventions are efficacious for motivated and moderately distressed individuals (Newman et al., 2011a, Newman et al., 2011b), guided self-help appears to be more efficacious for those who are less compliant, have clinical levels of depression (Newman et al., 2011a), and to extend and sustain improvements among those with addictive behaviour (Newman et al., 2011b). However, to date only one systematic review has been published on internet interventions for distress experienced by those with chronic physical health complaints (Cuijpers, van Straten, & Andersson, 2008). Given that chronic illnesses may limit the physical capacity of individuals to attend face-to-face psychological therapies, the potential applicability of online interventions to these populations is even more pronounced. Cuijpers et al. summarised the impact of internet-based cognitive behaviour therapy (iCBT) for pain, headache, tinnitus, physical disabilities, chronic diseases, breast cancer, insomnia, and paediatric brain injury. The reviewers summarised that iCBT for health conditions holds considerable promise, but the effect sizes were slightly below what has previously been reported for anxiety and depression (Cuijpers et al., 2008). The authors also identified gaps in the literature; chronic health conditions that have previously been successfully targeted using CBT had not yet been tested using the internet framework, such as multiple sclerosis, fibromyalgia, incontinence, and chronic fatigue.

In the intervening five years since this review was conducted (Cuijpers et al., 2008), there has been a surge in the literature on online interventions for health conditions, including several of those specified above. The purpose of the present article therefore is to update the evidence and review the application of the internet to the psychological treatment of distress among adult patients with chronic illnesses. The current review differs from Cuijpers et al. by focussing on studies that are self-guided, including any psychological therapy rather than being limited to CBT, and evaluating outcomes separately for (i) distress and (ii) disease/symptom control. Consistent with Newman et al., 2011a, Newman et al., 2011b, studies are organised by condition, and by degree of therapist- or moderator-involvement.

Section snippets

Methodological framework

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used (Moher, Liberati, Tetzlaff, Altman, & Group, 2009).

Data sources

Two methods of identifying primary studies were utilised. First, four electronic bibliographic databases were searched in OVID: Embase (1980 (database inception) to December 2011), MEDLINE (1980-December 2011), PsycINFO (1980 to December 2011), and CINAHL (1980 to December 2011). A list of keywords and MeSH terms were generated to identify

Results

A total of 1407 articles were identified from the electronic searches, after de-duplication. From this initial pool of screened titles and abstracts, 32 citations met initial inclusion criteria and underwent full-text review. A further 8 potential studies were identified from the reference lists of the initial full-texts reviewed. Of these 40 total citations, 16 studies were subsequently excluded during full-text analysis, because they were not an RCT (n = 3); biomedical rather than psychosocial

Discussion

This review sought to critically appraise the empirical evidence on the efficacy of online self-help interventions in reducing health-related distress among adults with chronic illnesses. Since 2000, 24 studies, using rigorous randomised controlled designs, have examined this topic. Over a third of these studies were published in the last two years, and over half of the included studies were published since the previous review of online CBT for health disorders (Cuijpers et al., 2008). Research

Acknowledgements

We acknowledge Melissa Atkinson, BPsych(Hons) for assistance with conducting the electronic searches.

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