title: Predictors of Symptomatic Change and Adherence in Internet-Based Cognitive Behaviour Therapy for Social Anxiety Disorder in Routine Psychiatric Care.
abstract: OBJECTIVE
  A central goal of health care is to improve patient outcomes. Although several studies have demonstrated the effectiveness of therapist guided internet-based cognitive behaviour therapy (ICBT) for social anxiety disorder (SAD), a significant proportion of patients do not respond to treatment. Consequently, the aim of this study was to identify individual characteristics and treatment program related factors that could help clinicians predict treatment outcomes and adherence for individuals with SAD.
  
  
  METHODS
  The sample comprised longitudinal data collected during a 4-year period of adult individuals (N = 764) treated for SAD at a public service psychiatric clinic. Weekly self-rated Liebowitz Social Anxiety Scale (LSAS-SR) scores were provided. Rates of symptomatic change during treatment and adherence levels were analysed using multilevel modelling. The following domains of prognostic variables were examined: (a) socio-demographic variables; (b) clinical characteristics; (c) family history of mental illness; and (d) treatment-related factors.
  
  
  RESULTS
  Higher treatment credibility and adherence predicted a faster rate of improvement during treatment, whereas higher overall functioning level evidenced a slower rate of improvement. Treatment credibility was the strongest predictor of greater adherence. Having a family history of SAD-like symptoms was also associated with greater adherence, whereas Attention-Deficit/Hyperactivity Disorder (ADHD)-like symptoms, male gender, and family history of minor depression predicted lower adherence. Also, the amount of therapist time spent per treatment module was negatively associated with adherence.
  
  
  CONCLUSIONS
  Results from a large clinical sample indicate that the credibility of ICBT is the strongest prognostic factor explaining individual differences in both adherence level and symptomatic improvement. Early screening of ADHD-like symptoms may help clinicians identify patients who might need extra support or an adjusted treatment. Therapist behaviours that promote adherence may be important for treatment response, although more research is needed in order to determine what type of support would be most beneficial.
authors.affiliation: Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Samir
authors.initials: S
authors.lastname: El Alaoui
authors.affiliation: Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Brjánn
authors.initials: B
authors.lastname: Ljótsson
authors.affiliation: Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Erik
authors.initials: E
authors.lastname: Hedman
authors.affiliation: Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Viktor
authors.initials: V
authors.lastname: Kaldo
authors.affiliation: Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Evelyn
authors.initials: E
authors.lastname: Andersson
authors.affiliation: Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Christian
authors.initials: C
authors.lastname: Rück
authors.affiliation: Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden; Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
authors.forename: Gerhard
authors.initials: G
authors.lastname: Andersson
authors.affiliation: Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Nils
authors.initials: N
authors.lastname: Lindefors
mesh_terms: D000328:Adult; D001008:Anxiety Disorders / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D000068237:Distance Counseling / Q000379:methods*; D005260:Female; D006801:Humans; D020407:Internet; D008137:Longitudinal Studies; D008297:Male; D008605:Mental Health Services / Q000458:organization & administration; D010349:Patient Compliance; D011237:Predictive Value of Tests; D011379:Prognosis; D012923:Social Class; D011795:Surveys and Questionnaires; D016896:Treatment Outcome