Key Points
Question
Is cognitive behavior therapy (CBT) delivered via the internet effective in the treatment of atopic dermatitis (AD)?
Findings
This randomized clinical trial of 102 adult participants with AD found that internet-delivered CBT produced significantly larger reductions of AD symptoms compared with a control group that received standard care instructions. The controlled effect size after treatment was moderate to large.
Meaning
Internet-delivered CBT yielded substantial improvements in AD symptoms while requiring minimal therapist resources and thus could drastically increase access to effective psychological treatment for this large patient group.
Abstract
Importance
Atopic dermatitis is a common and debilitating skin condition characterized by intense itching and chronic inflammation. Research on behavioral treatments with high accessibility is needed.
Objective
To investigate the efficacy of a highly scalable internet-delivered cognitive behavior therapy (CBT) for adults with atopic dermatitis.
Design, Setting, and Participants
This randomized clinical trial from a medical university in Stockholm, Sweden, included 102 adults with atopic dermatitis, recruited from across Sweden, who received 12 weeks of internet-delivered CBT (March 29, 2017, to February 16, 2018). The first participant provided screening data on November 27, 2016, and the last 1-year follow-up assessment was conducted on June 28, 2019.
Interventions
Participants were randomized in a 1:1 ratio to 12 weeks of therapist-guided internet-delivered CBT (n = 51) or a control condition (n = 51) that gave instructions about standard care.
Main Outcomes and Measures
The primary outcome was the between-group difference in mean reduction of atopic dermatitis symptoms as measured by the Patient-Oriented Eczema Measure and modeled intention to treat during the 12-week treatment period.
Results
A total of 102 participants (mean [SD] age, 37 [11] years; 83 [81%] female) were recruited and randomized. The primary analysis indicated that participants receiving internet-delivered CBT, relative to the controls, had a significantly larger mean weekly reduction in symptoms of atopic dermatitis as measured with the Patient-Oriented Eczema Measure (B = 0.32; 95% CI, 0.14-0.49; P < .001), with a moderate to large, controlled effect size after treatment (d = 0.75; 95% CI, 0.32-1.16). Secondary analyses indicated that internet-delivered CBT also produced significantly larger reductions in itch intensity, perceived stress, sleep problems, and depression. Gains were sustained at 12 months of follow-up. Treatment satisfaction was high, and therapists spent a mean (SD) of 39.7 (34.7) minutes per treated patient providing internet-delivered CBT.
Conclusions and Relevance
Internet-delivered CBT appears to be efficacious for reducing symptoms of atopic dermatitis, despite requiring minimal therapist resources. Thus, internet-delivered CBT has the potential to increase access to effective adjunct behavioral treatment for patients with this common skin condition.
Trial Registration
ClinicalTrials.gov Identifier: NCT03051958
This randomized clinical trial investigates the efficacy of a highly scalable internet-delivered cognitive behavior therapy for adults with atopic dermatitis.
Introduction
Atopic dermatitis (AD) is the most common inflammatory dermatologic disorder, affecting up to 10% of the general population.1 Patients with AD experience intense itching and chronic inflammation and are overrepresented with regard to numerous negative health outcomes, including depression and anxiety,2 suicidality,3 and cardiovascular problems.4
Several behavioral factors are likely to play a key role in exacerbating AD symptoms over time. First, itching may lead to scratching, which ruptures the skin barrier and causes increased inflammation. This inflammation, in turn, increases itching, which leads to further scratching, itching, and so on.5 Second, negative emotions, such as anxiety or low mood, may trigger scratching.6 Third, persons with AD often avoid situations or events (eg, stressful social situations or clothes of certain fabrics) associated with itch or skin symptoms, and such avoidance may paradoxically be associated with chronicity.7 Against this background, cognitive behavior therapy (CBT) based on exposure—systematic and sustained contact with stimuli related to AD symptoms and associated distress—seems to be a logical treatment option. Although a few trials8,9,10,11 have tested multicomponent or habit reversal CBT protocols, to our knowledge, only 1 previous study12 has investigated the clinical effects of exposure-based CBT for AD. That pilot clinical trial12 found that the treatment was feasible, acceptable, and associated with significant reductions of self-rated AD symptoms and general anxiety.
A major challenge for health care worldwide is the availability of psychological treatments. There are few mental health professionals in dermatologic care settings, and access to effective psychological interventions for AD is very limited.13 One path to further the dissemination of psychological therapies could be to deliver these via the internet.14 Important strengths of this approach include remote access to treatment and minimal therapist time.
The aim of this study was to investigate the clinical efficacy of internet-delivered CBT for adult patients with AD as an adjunct treatment to the recommendation of standard care. We hypothesized that the treatment would lead to larger reductions of AD symptoms, reduced itch, and increased quality of life compared with a control group given only the standard care recommendation. We also expected that internet-delivered CBT, compared with the control condition, would produce larger reductions of perceived stress, sleep problems, depressive symptoms, general anxiety, and improved self-rated health.
Methods
Trial Design
In this randomized clinical trial, 102 adults with AD were allocated in a 1:1 ratio to a 12-week (March 29, 2017, to February 16, 2018), internet-delivered, exposure-based CBT plus standard care (ie, instructions about emollient use) condition or to a control condition that received only standard care. The first participant provided screening data on November 27, 2016, and the last 1-year follow-up assessment was conducted on June 28, 2019. Assessments were conducted at baseline, after treatment, and at 6- and 12-month follow-up. Because participants in the control condition were crossed over to internet-delivered CBT after the initial 12-week phase, no between-group effects at 6- and 12-month follow-ups are reported. The trial was approved by the Regional Ethics Review Board in Stockholm, Sweden, and all participants provided written informed consent. All data were deidentified. The study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline. The trial protocol can be found in Supplement 1.
Participants
Individuals in all of Sweden could apply to the study through the project web portal. To be included in the trial participants had to (1) meet diagnostic criteria for AD15; (2) have AD symptoms of at least moderate severity, defined as a total score of at least 8 (range, 0-28) on the Patient Oriented Eczema Measure (POEM)16; (3) be 18 to 60 years of age; (4) have been on a stable dosage of an antidepressant or sleep medication for at least 1 month if taking such medication; (5) have an internet connection and be able to read and write Swedish; (6) and have the possibility to work with the treatment in practice (eg, not being away for a long period on travel). Reasons for exclusion were (1) ongoing cancer treatment, (2) severe psychiatric illness, (3) pregnancy, (4) regular use of benzodiazepines, (5) recent or ongoing psychological treatment, (6) psoriasis, (7) recent or ongoing UV light treatment, and (8) recent or ongoing oral treatment for AD. Applicants self-reported comprehensive information about their symptoms and information related to inclusion and exclusion criteria. A licensed psychologist (J.F. or A.B.), who was supervised by a dermatologist and who telephoned the applicant when deemed necessary, assessed whether the applicant met the criteria for inclusion.
Randomization
We used R, version 3.4.2 (R Foundation for Statistical Computing) to generate randomization sequences. All participants were randomized to internet-delivered CBT or to the control condition after inclusion and completion of baseline assessments, which ensured allocation concealment. It was thus not possible to have knowledge about forthcoming allocations.
Interventions
Internet-Based CBT
Internet-based intervention was a 12-week CBT for AD previously found to be feasible in a face-to-face format.12 This protocol is based on the assumption that AD symptoms and distress are influenced by learned aversive conditioning,17 and that, therefore, avoidance of situations or events associated with the disorder exacerbates AD symptoms. Furthermore, scratching is regarded as a key behavior hypothesized to be part of a vicious cycle in which itch leads to scratching, which is reinforced in the short term but leads to a damaged skin barrier and more skin inflammation.6,18 Against this backdrop, a central principle in this treatment is that breaking avoidance is key to reducing AD symptoms. The main component of the treatment is exposure to situations and events associated with AD in combination with response prevention (ie, refraining from behaviors that lead to short-term reduction of distress). A typical example would be to go to a party despite having AD symptoms, while refraining from scratching.
The treatment was delivered through a secure and encrypted internet-based treatment platform. The content of the treatment was provided through 10 modules to which participants were granted gradual access. Figure 1 presents an overview of the contents and homework assignments for each module. Therapists in the study were 4 licensed psychologists (M.B., M.L., O.M., and P.A.) who specialized in CBT. Typically, all therapist-participant contact was made through asynchronous text messages similar to email (ie, no face-to-face meetings in person or through video conferencing). The primary roles of the therapist were to provide feedback on the participant’s weekly homework assignments and to assist in tailoring the general treatment model to the participant’s problems. Therapists sent a mean (SD) of 15.9 (7.8) messages to the participants and received 13.2 (8.7).
Figure 1. Treatment Contents.
AD indicates atopic dermatitis; CBT, cognitive behavior therapy; UV, ultraviolet. This Figure is reproduced with permission from Hedman-Lagerlöf et al.12
Control Condition
Participants in the control condition received a letter that contained information about AD and how reduced efficiency of the skin barrier makes the skin more susceptible to bacteria, which can trigger inflammation. The participants also received information about the standard recommended treatment19 (ie, treatment as usual) for AD, which meant that they were instructed to use emollients at least twice per day and after contact with water to protect the skin barrier. Participants were informed that emollients should be used regularly (ie, also in the absence of AD symptoms) and that one can expect long-term benefits even if emollient use can cause skin irritation in the short term. In accordance with standard recommended treatment, participants were instructed to use anti-inflammatory treatments, such as topical corticosteroids, during flares (ie, daily use from debut of symptoms to 1 week after healed skin).
Outcomes
A detailed description of the outcome measures is provided in the eAppendix in Supplement 2. The primary outcome measure was the between-group difference in mean reduction of AD symptoms as measured by POEM,16 which measures core symptoms of AD, such as itch, bleeding, and cracked skin, on a scale of 0 to 28. We also administered the 5-D Itch Scale20 and visual analog scales (VASs) to assess itch intensity during the past 48 hours. We also administered the Perceived Stress Scale (PSS),21 the Patient Health Questionnaire 9 (PHQ-9),22 the Insomnia Severity Index (ISI),23 the Beck Anxiety Inventory (BAI),24 the Brunnsviken Brief Quality of Life Scale (BBQ),25 and the Dermatological Life Quality Index (DLQI).26 Self-rated health was measured with the single-item self-rated health status,27 and the Client Satisfaction Questionnaire28 was used to measure treatment satisfaction. Participants were also asked about occurrence of treatment-related adverse events after treatment through self-report.
Outcome measures were administered at baseline, after treatment, and at 6- and 12-month follow-ups. Both POEM and the VAS itch scale were also administered weekly during the initial 12-week phase.
Statistical Analysis
Statistical analyses were conducted on an intention-to-treat basis using Stata software, version 14.2 (StataCorp LLC). Continuous outcomes were analyzed with mixed-effects linear regression models with group, time, and group × time as fixed-effect factors associated with AD in the main analyses. Individual differences in baseline scores and change over time were included as random effects (ie, a random intercept and slope). In accordance with the empirically grounded recommendation of Schram et al,29 we defined treatment response on POEM as a baseline to posttreatment reduction of at least 4 points. Standardized effects were calculated as Cohen d: the observed mean difference divided by the pooled SD. Dichotomous outcomes were analyzed with logistic regression. As a sensitivity analysis, we reran the regression models using multiple imputations by chained equations to manage missing data. Given the small differences between analyses with and without imputations, we report only the main analyses in which no imputation was conducted. Power calculations showed that with an attrition of 10%, 100 participants would be required for 80% power to detect an expected effect size (d) of 0.6 in mean difference on the primary outcome measure, given an α of .05.
Results
This study included 102 participants (mean [SD] age, 37 [11] years; 83 [81%] female). Figure 2 displays a CONSORT flowchart of the trial. Of 204 participants who were assessed for eligibility, 102 were excluded, leaving 102 who were randomized in this trial. Participant characteristics are presented in Table 1.30 Participants in the internet-delivered CBT group reported spending a mean (SD) of 10.8 (9.8) hours reading the text material in the modules and 23.6 (23.7) hours conducting treatment exercises during the 12-week treatment phase. Therapists in the internet-delivered CBT group spent a mean (SD) of 39.7 (34.7) minutes per treated patient.
Figure 2. CONSORT Flowchart.
AD indicates atopic dermatitis; CBT, cognitive behavior therapy; UV, ultraviolet.
Table 1. Participant Baseline Characteristicsa.
| Characteristic | Internet-delivered CBT (n = 51) | Control condition (n = 51) | Total (N = 102) |
|---|---|---|---|
| Sex | |||
| Female | 41 (80) | 42 (82) | 83 (81) |
| Male | 10 (20) | 9 (18) | 19 (19) |
| Age, mean (SD) [range], y | 36 (11) [18-59] | 37 (11) [20-58] | 37 (11) [18-59] |
| Occupational status | |||
| Working | |||
| Full time | 33 (65) | 34 (67) | 67 (66) |
| Part time | 4 (8) | 7 (14) | 11 (11) |
| Student | 9 (18) | 4 (8) | 13 (13) |
| Other | 5 (10) | 6 (12) | 11 (11) |
| Married or de facto | 36 (71) | 39 (77) | 75 (74) |
| Parent | 29 (57) | 27 (53) | 56 (55) |
| Educational level | |||
| University | |||
| ≥3 y | 26 (51) | 28 (55) | 54 (53) |
| <3 y | 7 (14) | 9 (18) | 16 (16) |
| Upper secondary schoolb | 14 (28) | 9 (18) | 23 (23) |
| Other | 4 (8) | 5 (10) | 9 (9) |
| AD symptom severityc | |||
| Very severe | 7 (14) | 10 (20) | 17 (17) |
| Severe | 22 (43) | 23 (45) | 45 (44) |
| Moderate | 21 (41) | 18 (35) | 39 (38) |
| Mild | 1 (1) | 0 | 1 (1) |
| Duration of AD, y | |||
| >10 | 43 (84) | 46 (90) | 89 (87) |
| 1-9 | 8 (16) | 2 (4) | 10 (10) |
| <1 | 0 | 3 (6) | 3 (3) |
| AD treatments the past year | |||
| Emollients | 48 (94) | 51 (100) | 99 (97) |
| Cortisone cream | 47 (92) | 46 (90) | 93 (91) |
| Tacrolimus or pimecrolimus | 18 (35) | 17 (33) | 35 (34) |
| UV treatment | 7 (14) | 16 (31) | 23 (23) |
| Health foods | 8 (16) | 14 (28) | 22 (22) |
| Health products, external use | 8 (16) | 11 (22) | 19 (19) |
| Antibiotics | 10 (20) | 8 (16) | 18 (18) |
| Other | 3 (6) | 5 (10) | 8 (8) |
| Asthma | |||
| Yes | 19 (37) | 20 (39) | 39 (38) |
| No | 32 (63) | 31 (61) | 63 (35) |
| Previous psychological treatment | |||
| For AD | 0 | 0 | 0 |
| For other reasons than AD | 17 (33) | 23 (45) | 40 (39) |
Abbreviations: AD, atopic dermatitis; CBT, cognitive behavior therapy; UV, ultraviolet.
Data are presented as number (percentage) of patients unless otherwise indicated.
Upper secondary school indicates international standard classification of education level 3.
AD symptom severity classification follows the recommendation by Charman et al30 based on Patient-Oriented Eczema Measure ratings where 25 to 28 indicates very severe; 17 to 24, severe; 8 to 16, moderate; and 3 to 7, mild.
Primary Outcome
Figure 3 displays symptom trajectories based on the POEM scores during the treatment phase, and Table 2 presents means, SDs, and effect sizes for all outcomes. Mixed-effects linear regression analysis found a significant interaction effect of group × time on POEM, indicating a superior weekly reduction of AD symptoms in internet-delivered CBT compared with the control condition from baseline to after treatment (B = 0.32; 95% CI, 0.14-0.49; z = 3.49; P < .001), with a moderate to large standardized controlled effect after treatment (d = 0.75; 95% CI, 0.32-1.16). No significant within-group changes were found on the primary outcome measure from after treatment to 12-month follow-up in internet-delivered CBT (B = −0.20; 95% CI, −0.78 to 1.17; z = 0.39; P = .70). The baseline to 12-month follow-up within-group effect size was large, indicating that the treatment led to stable long-term improvement. Logistic regression analysis found a significant difference between groups in the odds of being a treatment responder (28 [65%] in internet-delivered CBT and 18 [37%] in the control condition), defined as an improvement of at least 4 points on POEM (odds ratio [OR], 3.11; 95% CI, 1.32-7.33; z = 2.60; P = .009).
Figure 3. Model Estimated and Observed Symptom Course on the Patient-Oriented Eczema Measure (POEM).
Vertical bars represent 95% CIs. CBT indicates cognitive behavior therapy; 6MFU, 6-month follow-up; 1YFU, 1-year follow-up.
Table 2. Study Outcome Findings.
| Measure (variable) | Observed data findings, mean (SD) | Standardized effect size (Cohen d) (95% CI) | |||||
|---|---|---|---|---|---|---|---|
| Before treatment | After treatment | 6MFU | 12MFU | Between and after treatment | Within | ||
| Before and after | Before 12MFU | ||||||
| Primary outcome | |||||||
| POEM (AD symptoms) | |||||||
| ICBT | 15.4 (6.9) | 9.4 (5.9) | 9.1 (6.4) | 9.4 (6.5) | 0.75 (0.32 to 1.16) | 0.93 (0.52 to 1.34) | 0.89 (0.50 to 1.28) |
| CC | 17.3 (6.1) | 14.4 (7.2) | NA | NA | NA | 0.44 (0.13 to 0.74) | NA |
| Secondary outcomes | |||||||
| 5D (AD symptoms) | |||||||
| ICBT | 8.9 (2.2) | 7.0 (2.0) | 6.8 (2.3) | 7.1 (2.2) | 0.76 (0.33 to 1.19) | 0.93 (0.49 to 1.37) | 0.84 (0.40 to 1.28) |
| CC | 9.2 (2.3) | 8.3 (1.7) | NA | NA | NA | 0.39 (0.01 to 0.78) | NA |
| VAS itch scale (AD symptoms) | |||||||
| ICBT | 4.8 (2.6) | 2.4 (2.1) | 2.3 (2.5) | 2.6 (2.2) | 0.42 (0.00 to 0.83) | 1.09 (0.63 to 1.56) | 0.96 (0.53 to 1.38) |
| CC | 4.8 (2.4) | 3.4 (2.6) | NA | NA | NA | 0.57 (0.22 to 0.93) | NA |
| PSS (stress) | |||||||
| ICBT | 26.1 (8.2) | 20.2 (8.4) | 18.4 (7.9) | 18.0 (9.2) | 0.56 (0.14 to 0.97) | 0.72 (0.41 to 1.03) | 0.93 (0.54 to 1.32) |
| CC | 25.6 (6.8) | 24.9 (8.6) | NA | NA | NA | 0.08 (−0.21 to 0.38) | NA |
| ISI (insomnia) | |||||||
| ICBT | 9.3 (5.9) | 6.0 (4.7) | 5.6 (4.5) | 5.6 (4.4) | 0.53 (0.11 to 0.94) | 0.61 (0.27 to 0.95) | 0.68 (0.32 to 1.03) |
| CC | 9.3 (5.8) | 9.1 (6.9) | NA | NA | NA | 0.03 (−0.25 to 0.31) | NA |
| PHQ-9 (depression) | |||||||
| ICBT | 6.8 (5.5) | 3.7 (3.4) | 3.0 (3.5) | 3.8 (4.3) | 0.43 (0.02 to 0.84) | 0.64 (0.27 to 1.02) | 0.61 (0.17 to 1.04) |
| CC | 6.4 (6.0) | 5.6 (5.2) | NA | NA | NA | 0.15 (−0.14 to 0.44) | NA |
| BAI (anxiety) | |||||||
| ICBT | 8.8 (9.4) | 6.1 (8.0) | 4.3 (5.4) | 4.4 (6.8) | 0.23 (−0.19 to 0.64) | 0.30 (0.10 to 0.49) | 0.51 (−0.18 to 0.84) |
| CC | 9.4 (7.6) | 7.8 (6.6) | NA | NA | NA | 0.22 (0.00 to 0.45) | NA |
| BBQ (quality of life) | |||||||
| ICBT | 52.5 (17.3) | 63.4 (16.5) | 65.4 (17.2) | 63.1 (17.3) | 0.52 (0.10 to 0.94) | 0.65 (0.30 to 0.99) | 0.61 (0.27 to 0.95) |
| CC | 54.9 (21.2) | 53.4 (21.0) | NA | NA | NA | 0.07 (−0.13 to 0.27) | NA |
| DLQI (quality of life) | |||||||
| ICBT | 8.7 (5.5) | 4.8 (3.4) | 3.9 (4.2) | 4.1 (4.9) | 0.71 (0.29 to 1.14) | 0.83 (0.37 to 1.29) | 0.88 (0.47 to 1.29) |
| CC | 11 (6.4) | 9.0 (7.5) | NA | NA | NA | 0.28 (−0.01 to 0.57) | NA |
| SRH (self-rated health) | |||||||
| ICBT | 2.9 (0.7) | 2.9 (0.8) | 3.2 (0.8) | 2.9 (0.8) | 0.10 (−0.31 to 0.52) | 0.06 (−0.20 to 0.31) | 0.11 (−0.21 to 0.42) |
| CC | 2.6 (1.0) | 2.8 (0.9) | -NA | NA | NA | 0.17 (−0.10 to 0.44) | NA |
Abbreviations: BAI, Beck Anxiety Inventory; BBQ, Brunnsviken Brief Quality of Life Inventory; CC, control condition; DLQI, Dermatological Life Quality Index; ICBT, internet-delivered cognitive behavior therapy; ISI, Insomnia Severity Index; NA, not applicable; PHQ-9, Patient Health Questionnaire 9; POEM, Patient-Oriented Eczema Measure; PSS, Perceived Stress Scale; SRH, self-rated health; 5D, 5-D Itch Scale; 6MFU, 6-month follow-up; 12MFU, 12-month follow-up.
Secondary Outcomes
Internet-delivered CBT, compared with the control condition, led to significantly larger improvements on the secondary AD symptom outcome measures, as shown by significant interaction effects of group × time on the 5-D Itch Scale (B = 1.20; 95% CI, 0.28-2.11; z = 2.55; P = .01) and the VAS itch scale (B = 0.10; 95% CI, 0.03-0.17; z = 2.97; P = .003). Similar patterns of results were found on most of the psychiatric outcome measures, with significantly larger baseline to posttreatment reductions of stress as measured by the PSS (B = 5.09; 95% CI, 1.96-8.21; z = 3.19; P = .001), sleep problems as measured by the ISI (B = 3.38; 95% CI, 1.28-5.48; z = 3.15; P = .002), and depressive symptoms as measured by the PHQ-9 (B = 2.42; 95% CI, 0.63-4.22; z = 2.65; P = .008) in internet-delivered CBT relative controls. No significant between-group difference was found in symptom course in general anxiety as measured by the BAI (B = 1.24; 95% CI, −0.82 to 3.30; z = 1.18; P = .24). As for quality of life, a significantly larger baseline to posttreatment improvement was found in internet-delivered CBT compared with the control condition on the general quality-of-life measure BBQ (B = 11.06; 95% CI, 4.81-17.32; z = 3.47, P = .001) but not on the disorder-specific DLQI (B = 2.07; 95% CI, −0.14 to 4.29; z = 1.83; P = .07). No significant between-group change was found on the 1-item single-rated health status that measured general self-rated health (B = 0.09; 95% CI, −0.21 to 0.39; z = 0.60; P = .55).
Participants receiving internet-delivered CBT were significantly more satisfied with treatment compared with the controls (B = 5.98; 95% CI, 4.06-7.90; P < .001). Of a possible total score of 32, the mean (SD) ratings were 25.5 (4.40) in the internet-delivered CBT group and 19.54 (4.65) in the control condition, indicating high overall treatment satisfaction in the former treatment group.
Parallel Treatments and Adverse Events
During the 12-week treatment phase, no significant difference was found between the groups in terms of initiated parallel psychological treatments (OR, 0.17; 95% CI, 0.02-1.51; P = .11). In the internet-delivered CBT group, 1 participant (2%) reported initiating such contact, and 6 participants (12%) in the control condition reported initiating such contract. In addition, no significant difference was found between groups in terms of change in medication (including emollient use) during the treatment phase (OR, 2.31; 95% CI, 0.95-5.64; P = .07). One participant in the internet-delivered CBT group and none in the control group reported starting systemic treatment during the treatment phase of the study. As for adverse events, a significant difference was found between groups (8 participants in the internet-delivered CBT group vs 1 in the control group) regarding reporting of such events during the 12-week treatment period (OR, 11.05; 95% CI, 1.32-92.61; P = .03).
Sensitivity Analyses
The analyses of the primary and secondary outcomes were rerun using multiple imputations to replace missing data (eTable in Supplement 2). Just as in the main analyses, the results indicated that internet-delivered CBT relative the control condition led to significantly larger improvements during the treatment phase on the primary outcome of POEM as well as on the secondary outcomes of the 5-D Itch Scale, VAS itch scale, PSS, ISI, PHQ-9, and BBQ.
Discussion
In this randomized clinical trial of an internet-delivered psychological treatment for AD, the addition of a 12-week exposure-based CBT to standard AD treatment recommendations led to significant improvements in AD symptoms, including itch, and reductions of perceived stress, sleep difficulties, and depressive symptoms. Participants receiving internet-delivered CBT were satisfied with the treatment and the substantial clinical effects achieved despite therapists spending only a mean of 39.7 minutes per treated patient. The findings of this randomized clinical trial are of clinical importance because they indicate that CBT via the internet is a scalable treatment that can yield meaningful clinical improvements on core symptoms of AD and reduce emotional distress.
Although AD is highly prevalent and has a clear behavioral component, few previous randomized clinical trials of CBT-based treatment protocols have been performed. Trials of habit reversal training conducted in the 1980s found promising results8,31 but suffered from small sample sizes, rendering uncertain effect estimates. Compared with more recent studies9,10,11 of face-to-face CBT for AD, the effects found in the current study seem to be on par or slightly higher. Previous research on internet-delivered treatment using exposure-based methods for other psychiatric and functional disorders indicates that this type of treatment is acceptable and effective.32,33,34,35
As mentioned in the Introduction, an important advantage of internet-delivered treatment is its potential to improve access to treatment. Although at the start of this study most participants were expected to be treatment naive (ie, without previous experience of psychological treatment for AD), it is striking that none of the included participants had received such treatment. This lack of treatment probably means that most patients with AD are typically not offered psychological treatment in primary or dermatologic care. Internet-delivered CBT could play an important role in the improvement of treatment services in this regard. An important question is where this type of treatment would fit in the health care system. This type of treatment most likely works best as a complement to standard care recommendations and should be viewed as a low-threshold treatment. In other words, internet-delivered treatment should not be regarded as a highly specialized treatment for the severe cases but should be offered to anyone with AD who is interested in testing whether symptom improvement can be achieved through behavior change. Ideally, this treatment would be implemented within dermatologic and primary care, where employed therapists could deliver the treatments and at the same time become an integral part of the dermatologic team, which would probably lead to further improvements of psychological treatments for AD. Because each therapist can have up to 80 patients in ongoing treatment, internet-delivered care may be highly promising to scale up access to psychological treatment in dermatologic care.
Although the treatment might be simple in principle, it should be emphasized that it certainly is not easy. In this trial, participants receiving internet-delivered CBT spent approximately 35 hours working with the treatment during the 12-week treatment phase. In addition, this work revolved around approaching situations associated with fear of increased symptoms, anxiety, and stress. In other words, this treatment requires much less from the health care professional compared with face-to-face therapy, but the patient needs to work just as hard. In line with this, the most commonly reported adverse event in the current study was increased stress or worry.
Strengths and Limitations
This trial has strengths and limitations. Central strengths of the study were the randomized, controlled design, yielding high internal validity; the fairly large sample size; the use of nationwide recruitment; the comprehensive assessments up to 12 months after treatment; and the weekly administration of the primary outcome during the treatment phase. The most central limitation was that a practitioner-administered measure of AD symptoms was not used. However, the primary outcome measure, POEM, has been reported to be reliable, valid, and highly correlated with practitioner assessment of AD symptoms.29,30
Conclusions
Internet-delivered, exposure-based CBT can be feasible, acceptable, and efficacious in the treatment of AD in adults. This treatment can yield substantial improvements in AD symptoms, perceived stress, sleep problems, and depressive symptoms while requiring minimal therapist resources.
Trial Protocol
eAppendix. Description of Outcomes
eTable. Means, Standard Errors, Effect Sizes (Cohen’s d), and Estimated Interaction Effects of Group and Time Based on Data set With Multiple Imputations of Missing Data
eReferences
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Trial Protocol
eAppendix. Description of Outcomes
eTable. Means, Standard Errors, Effect Sizes (Cohen’s d), and Estimated Interaction Effects of Group and Time Based on Data set With Multiple Imputations of Missing Data
eReferences
Data Sharing Statement