Internet-Delivered Cognitive Behaviour Therapy for Public Safety Personnel

Internet-Delivered Cognitive Behaviour Therapy (ICBT) for Public Safety Personnel (PSP): Examination of Engagement, Outcomes, Strengths and Challenges

This study evaluates a transdiagnostic Internet-delivered cognitive behavioural therapy (ICBT) recently tailored for Canadian public safety personnel (PSP) reporting symptoms of depression, anxiety, or posttraumatic stress. Outcomes of interest include engagement with the intervention, changes in symptoms and functioning, and strengths and limitations of implementing ICBT with Canadian PSP.

Background: Public Safety Personnel (PSP) is a term that broadly encompasses personnel who ensure the safety and security of Canadians across jurisdictions, including, but not necessarily limited to, public safety communications officials (e.g., call centre operators/dispatchers), correctional employees, firefighters, paramedics, border services personnel, operational and intelligence personnel, search and rescue personnel, and police officers. As a function of their vocations, PSP are frequently exposed to traumatic events (e.g., threatened or actual physical assaults, sexual violence, fires, and explosions) and are at risk of post-traumatic stress injuries. Results from a recent survey with a large Canadian PSP sample showed 44.5% screened positive for one or more mental health disorders, which is much higher than the 10.1% diagnostic rate among the Canadian general public. For many Canadian PSP access to in-person evidence-based care is impeded for several reasons, including preference to self-manage symptoms, geographic barriers (e.g., difficulty accessing care while deployed to remote locations), logistical barriers (e.g., shift work limits access to standard service hours), stigma (e.g., perceptions of being evaluated negatively for having mental health concerns), growing waiting-lists, and limited resources (e.g., insufficient access to mental health care coverage). Transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) represents a convenient method for PSP to access care for mental health concerns, such as depression, anxiety, and post-traumatic stress. In transdiagnostic ICBT, clients receive access to standardized lessons that provide the same information and skills as traditional face-to-face CBT. Divergent mental health symptoms are targeted within transdiagnostic ICBT by educating clients in strategies that apply to multiple conditions (e.g., cognitive restructuring, graded exposure); this helps to ensure multiple concerns are addressed in an efficient manner. This is important given high rates of mental health comorbidity. In addition to weekly lessons, clients are encouraged to complete homework assignments to facilitate learning. Research shows that transdiagnostic ICBT is effective at reducing symptoms of anxiety, depression and trauma and there is also evidence that the findings of research trials translate into routine clinic settings. Most commonly, ICBT is delivered with brief once weekly e-therapist assistance (~20 minutes) via the telephone or secure email over ~8 weeks. There are also encouraging research results that clients can benefit with lower levels of support, such as when treatment is largely self-directed but with automated reminder emails, e-therapist monitoring and optional e-therapist support as needed by clients. Research purpose: The purpose of the current research project is to explore outcomes of a transdiagnostic ICBT course that is specifically tailored for PSP (e.g., case examples are relevant to PSP), referred to as the PSP Wellbeing Course. Of particular interest in this study are: 1) the usage of the PSP Wellbeing Course among PSP who are informed about the PSP Wellbeing Course (e.g., # enrolling, completion rates, use of e-therapist support); 2) outcomes of the PSP Wellbeing Course with respect to diverse outcome measures (e.g., depression, anxiety, trauma, disability) measured at 8, 26, and 52 week follow-up (and at 16 weeks for clients still engaged in treatment at that time); and 3) strengths and challenges of the PSP Wellbeing Course when offered to Canadian PSP. In order to take part, PSP will first complete an online questionnaire and telephone screening to assess whether they meet the following inclusion criteria: 1) 18 years of age or older; 2) Saskatchewan or Quebec resident; 3) endorsing symptoms of anxiety, depression, post-traumatic stress, but not high suicide risk or recent suicide attempts in the past year; 4) able to access and comfortable using computers and the internet; 5) not seeking help primarily for alcohol and or drugs, bipolar disorder, or psychotic symptoms; and 6) willing to provide an emergency contact. The PSP Wellbeing Course will be delivered by trained providers with graduate training in psychology or social work or graduate students under supervision. Of note, the program will first be offered in Saskatchewan, and when this is underway, materials will be translated to French and the program will be offered to PSP who reside in Quebec as well (update: recruitment in Quebec began on September 23, 2020). The program was also expanded to PSP in Nova Scotia, New Brunswick, and Prince Edward Island in February 2022. Of note, a purely self-guided version of the PSP Wellbeing Course (i.e., without therapist guidance) was made available to PSP anywhere in Canada on December 1st, 2021. The primary research questions to be answered include: ENGAGEMENT: How many PSP will enroll in and complete the PSP Wellbeing Course? What will be the uptake of optional e-therapist support, versus 1x week or 2x week e-therapist support? What will be the length of support selected (8 week-16 week)? OUTCOMES: What will be the impact of the PSP Wellbeing Course on symptom improvement and functioning at 8, 26, and 52 weeks post-enrollment (and at 16 weeks for clients still engaged in treatment at that time)? What factors will predict outcomes (e.g., symptom severity, demographics, engagement)? IMPLEMENTATION: What are stakeholder experiences, positive and negative, with the PSP Wellbeing Course? What are the suggested improvements to ICBT to meet the needs of PSP? Significance: This project will provide information that will inform future use of ICBT to assist PSP with common mental health concerns. Data will be extracted and analyzed on a quarterly basis in order to provide a preliminary evaluation of engagement, outcomes and implementation experiences and determine if adjustments to ICBT are required. Once adjustments are completed or deemed unnecessary, data will be extracted and analyzed biannually.

Therapist-guided, Internet-delivered cognitive behavioral therapy tailored specifically for Canadian public safety personnel.

A tailored ICBT intervention will be delivered to public safety personnel who report symptoms of depression, anxiety, or posttraumatic stress. Clients will choose whether they prefer weekly therapist support, twice-weekly support, or monitored optional support. The intervention is designed to be completed in 8 weeks, but clients will be able to extend their treatment by an additional 8 weeks (i.e., up to 16 weeks in total).

Patient Health Questionnaire - 9 Item (PHQ-9). Higher total scores indicate greater severity of depression. Scores range from 0 to 27. Note: this measure is only administered at 9, 10, 11, 12, 13, 14, 15, and 16 weeks for clients who are still engaged in treatment at those timepoints.

Generalized Anxiety Disorder - 7 Item (GAD-7). Higher total scores indicate greater severity of anxiety. Scores range from 0 to 21. Note: this measure is only administered at 9, 10, 11, 12, 13, 14, 15, and 16 weeks for clients who are still engaged in treatment at those timepoints.

PTSD Checklist for DSM-5 (PCL-5). Higher total scores indicate greater severity of posttraumatic stress. Scores range from 0 to 80. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time.

Abbreviated PTSD Checklist - Civilian Version (PCL-C). Higher total scores indicate greater severity of posttraumatic stress. Scores range from 5 to 30. Note: this measure is only administered at 9, 10, 11, 12, 13, 14, and 15 weeks for clients who are still engaged in treatment at those timepoints.

Panic Disorder Severity Scale (PDSS). Higher total scores indicate greater severity of panic symptoms. Scores range from 0 to 28. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time.

Social Interaction Phobia Scale (SIPS). Higher total scores indicate greater severity of social anxiety. Scores range from 0 to 56. This measure is administered only to clients of the French version of the PSP Wellbeing Course. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time. Note: this measure was added on September 23, 2020.

Social Phobia Scale - 6 Item (SPS-6). Higher total scores indicate greater severity of social anxiety. Scores range from 0 to 24. This measure is administered only to clients of the English version of the PSP Wellbeing Course. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time.

Social Interaction Anxiety Scale - 6 Item (SIAS-6). Higher total scores indicate greater severity of social anxiety. Scores range from 0 to 24. This measure is administered only to clients of the English version of the PSP Wellbeing Course. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time.

Dimensions of Anger Reactions (DAR-5) scale. Higher total scores indicate greater severity of anger problems. Scores range from 0 to 20. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time.

Insomnia Severity Index (ISI). Higher total scores indicate greater severity of sleep problems. Scores range from 0 to 28. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time. Note: this measure was added on December 3, 2020.

SLEEP-50 Questionnaire. This questionnaire consists of 50 items spanning 9 subscales. However, instead of administering and scoring the entire questionnaire, we are administering only 21 items for descriptive purposes. Note: this measure was added on December 3, 2020.

Alcohol Use Disorders Identification Test (AUDIT). Higher scores indicate greater alcohol consumption and alcohol-related problems. Scores ranger from 0 to 40.

Drug Use Disorders Identification Test (DUDIT). Higher scores indicate greater drug use and drug-related problems. Scores ranger from 0 to 44.

Sheehan Disability Scale (SDS). Higher total scores indicate a greater degree of impairment. Total scores range from 0 to 30. Scores in each of 3 specific life domains range from 0 to 10. Note: this measure is only administered at 9, 10, 11, 12, 13, 14, 15, and 16 weeks for clients who are still engaged in treatment at those timepoints. Note: prior to December 3, 2020, this measure was only administered at screening and 8, 16, 26, and 52 weeks.

Brief Resiliency Scale (BRS). Higher total scores indicate greater resiliency. Total scores represent mean scores across the six items of the scale and range from 0 to 5. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time. Note: this measure was added on December 3, 2020.

Canadian Adapted Treatment Inventory of Costs in Patients with psychiatric disorders (TiC-P). This questionnaire is adapted from the TiC-P to assess use of health services and productivity loss due to health problems. Each item contributes uniquely to an estimate of the costs associated with a psychiatric condition. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time.

Treatment Satisfaction Questionnaire. A bespoke questionnaire consisting of 19 items with varying response formats measuring treatment satisfaction and perceived treatment credibility. Items are not designed to be combined into a unitary measure. An abbreviated (10-item) version of this questionnaire will be administered at 16 weeks. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time.

Working Alliance Inventory - Short Revised (WAI-SR). Higher scores indicate greater working alliance. Scores in three distinct domains of working alliance each range from 4 to 20. Note: this measure is only administered at 16 weeks for clients who are still engaged in treatment at that time.

Life Events Checklist for DSM-5 (LEC-5). A checklist of common traumatic events used to establish the nature of the traumatic events a respondent has experienced. This questionnaire is not intended to be scored.

Worst Traumatic Event Questionnaire. A checklist of common traumatic events used to establish the nature of the single worst traumatic event a respondent has experienced. This questionnaire is not intended to be scored.

Homework Reflection. A bespoke questionnaire consisting of 8 items with varying response formats, designed to measure engagement with treatment tasks and help alert therapists to any challenges clients face. Items are not designed to be combined into a unitary measure. Note: this measure is only administered at 9, 10, 11, 12, 13, 14, 15, and 16 weeks for clients who are still engaged in treatment at those timepoints.

Inclusion Criteria: 18 years of age or older residing in Saskatchewan or Quebec for the duration of the intervention endorsing symptoms of anxiety, depression, or post-traumatic stress able to access a computer and internet service willing to provide a physician as emergency contact Exclusion Criteria: high suicide risk suicide attempt or hospitalization in the last year primary problems with psychosis, alcohol or drug problems, mania currently receiving regular psychological treatment for anxiety or depression not present in Canada during treatment concerns about ICBT

Hadjistavropoulos HD, McCall HC, Thiessen DL, Huang Z, Carleton RN, Dear BF, Titov N. Initial Outcomes of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy Tailored to Public Safety Personnel: Longitudinal Observational Study. J Med Internet Res. 2021 May 5;23(5):e27610. doi: 10.2196/27610.