JOURNAL OF MEDICAL INTERNET RESEARCH

Matsumoto et al

Original Paper

Internet-Based Cognitive Behavioral Therapy With Real-Time
Therapist Support via Videoconference for Patients With
Obsessive-Compulsive Disorder, Panic Disorder, and Social
Anxiety Disorder: Pilot Single-Arm Trial
Kazuki Matsumoto1,2, MPH; Chihiro Sutoh3, MD, PhD; Kenichi Asano2, PhD; Yoichi Seki1,2, PhD; Yuko Urao1,2,
PhD; Mizue Yokoo2, PhD; Rieko Takanashi2, PhD; Tokiko Yoshida2, MPH; Mari Tanaka2, PhD; Remi Noguchi2,
PhD; Shinobu Nagata2, PhD; Keiko Oshiro2, PhD; Noriko Numata1,2, PhD; Motohisa Hirose2, PhD; Kensuke
Yoshimura4, MD, MPH; Kazue Nagai5, PhD; Yasunori Sato6, PhD; Taishiro Kishimoto7, MD, PhD; Akiko Nakagawa1,2,
MD, PhD; Eiji Shimizu2,3, MD, PhD
1

United Graduate School of Child Development, Osaka University, Kanazawa University, Hamamatsu University School of Medicine, Chiba University
and University of Fukui, Osaka, Japan
2

Research Center for Child Mental Development, Graduate School of Medicine, Chiba University, Chiba, Japan3

Department of Cognitive Behavioral Physiology, Graduate School of Medicine, Chiba University, Chiba, Japan

4

Research Center for Medical Economics Administration, Chiba University Hospital, Chiba, Japan

5

Reseach and Education Center of Health Sciences, Gunma University Graduate School of Health Sciences, Gunma, Japan

6

Department of Preventive Medicine and Public Health, Keio University, Tokyo, Japan

7

Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

Corresponding Author:
Chihiro Sutoh, MD, PhD
Department of Cognitive Behavioral Physiology
Graduate School of Medicine
Chiba University
1-8-1, Chuo-ku, Chiba-shi
Chiba,
Japan
Phone: 81 43 226 2027
Email: csutoh@graduate.chiba-u.jp
Related Article:
Comment in: https://www.jmir.org/2020/8/e13234

Abstract
Background: Cognitive behavioral therapy (CBT) is the first-line treatment for adults with obsessive-compulsive disorder(OCD), panic disorder (PD), and social anxiety disorder (SAD). Patients in rural areas can access CBT via the internet. The
effectiveness of internet-delivered cognitive behavioral therapy (ICBT) has been consistently shown, but no clinical studies havedemonstrated the feasibility of ICBT with real-time therapist support via videoconference for OCD, PD, and SAD at the sametime.
Objectives: This study aimed to evaluate the feasibility of videoconference-delivered CBT for patients with OCD, PD, or SAD.
Methods: A total of 30 Japanese participants (mean age 35.4 years, SD 9.2) with OCD, SAD, or PD received 16 sessions ofindividualized videoconference-delivered CBT with real-time support of a therapist, using tablet personal computer (Apple iPad
Mini 2). Treatment involved individualized CBT formulations specific to the presenting diagnosis; all sessions were provided
by the same therapist. The primary outcomes were reduction in symptomatology, using the Yale-Brown obsessive-compulsive
scale (Y-BOCS) for OCD, Panic Disorder Severity Scale (PDSS) for PD, and Liebowitz Social Anxiety Scale (LSAS) for SAD.
The secondary outcomes included the EuroQol-5 Dimension (EQ-5D) for Quality of Life, the Patient Health Questionnaire(PHQ-9) for depression, the Generalized Anxiety Disorder (GAD-7) questionnaire for anxiety, and Working Alliance
Inventory-Short Form (WAI-SF). All primary outcomes were assessed at baseline and at weeks 1 (baseline), 8 (midintervention),
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Matsumoto et al

and 16 (postintervention) face-to-face during therapy. The occurrence of adverse events was observed after each session. For the
primary analysis comparing between pre- and posttreatments, the participants’ points and 95% CIs were estimated by the pairedt tests with the change between pre- and posttreatment.
Results: A significant reduction in symptom of obsession-compulsion (Y-BOCS=−6.2; Cohen d=0.74; 95% CI −9.4 to −3.0,
P=.002), panic (PDSS=−5.6; Cohen d=0.89; 95% CI −9.83 to −1.37; P=.02), social anxiety (LSAS=−33.6; Cohen d=1.10; 95%
CI −59.62 to −7.49, P=.02) were observed. In addition, depression (PHQ-9=−1.72; Cohen d=0.27; 95% CI −3.26 to −0.19; P=.03)
and general anxiety (GAD-7=−3.03; Cohen d=0.61; 95% CI −4.57 to −1.49, P<.001) were significantly improved. Although
there were no significant changes at 16 weeks from baseline in EQ-5D (0.0336; Cohen d=-0.202; 95% CI −0.0198 to 0.00869;
P=.21), there were high therapeutic alliance (ie, WAI-SF) scores (from 68.0 to 73.7) throughout treatment, which significantly
increased (4.14; 95% CI 1.24 to 7.04; P=.007). Of the participants, 86% (25/29) were satisfied with videoconference-delivered
CBT, and 83% (24/29) preferred videoconference-delivered CBT to face-to-face CBT. An adverse event occurred to a patientwith SAD; the incidence was 3% (1/30).
Conclusions: Videoconference-delivered CBT for patients with OCD, SAD, and SAD may be feasible and acceptable.
(J Med Internet Res 2018;20(12):e12091) doi: 10.2196/12091
KEYWORDS
clinical trial; cognitive behavioral therapy; feasibility study; obsessive-compulsive disorder; panic disorder; social anxiety disorder;
videoconference

Introduction
BackgroundObsessive-compulsive disorder (OCD), panic disorder (PD),and social anxiety disorder (SAD) are the most common mental
disorders and incur a huge burden throughout the lifespan [1-4].
Cognitive behavioral therapy (CBT) has been found to beeffective in treating all of the 3 disorders [5-16]. Although CBT
is an effective treatment, it is difficult for all patients to receive
CBT because of problems of access to treatment such as
expensive specialized medical treatment, lack of therapists, anduneven urban distribution. Known as telemental health, a new
therapeutic approach, born out of technological innovation after
the internet revolution, has solved these problems. A patient
can now receive treatment from remote distance via the internet,
regardless of physical or psychological barriers such as time,
distance, and stigma from remote distance by the internet[17,18]. For example, in internet-delivered CBT (ICBT), users
can receive their programmed treatment at any time, 24 hours
a day. In addition, the therapist’s involvement with the patient
can be reduced, optimizing treatment costs. Furthermore, atherapist guide can be employed via remote treatment, by using
videoconference in real time, without compromising linguistic
and nonverbal communication with the patient as much as
possible.
ICBT has been shown to be effective for OCD, PD, and SAD
from several randomized controlled trials [19-35]. A recent
systematic review and meta-analyses using 20 studies comparing
ICBTs and face-to-face CBTs showed that ICBT andface-to-face treatment produced equivalent overall effects [36].
Target diseases in this meta-analysis included SAD, PD, anddepression. In the other meta-analyses, comparing theeffectiveness of ICBT and face-to-face CBT with anxiety
disorders including OCD (defined according to the Diagnostic
and Statistical Manual of Mental Disorder III [37], III-R [38],
IV [39], and IV-TR or the International Classification of
Diseases 9 or 10 [40-42]), there were no clear differences
between them [43]. ICBT can be roughly divided into the 3
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categories depending on how the therapist participates in the
program [44]: programs with no therapist assistance [45];programs with assistance, where the therapists assistance isminimal [46]; and live conversations on the internet, where thetherapist is fully involved using videoconference [47,48].
Although the effectiveness of ICBT has been suggested, there
is little knowledge about ICBT including videoconference. In
telemental health, which is an important theme when considering
the optimization of social resources, the effectiveness of ICBT
should be examined based on the therapist’s degree of
involvement. In this study, we examined the feasibility of ICBTwith real-time videoconference, where the therapists were fully
involved in treatment.

Videoconference-Delivered Cognitive Behavioral
Therapy
In videoconference-delivered CBT, the therapist and patientuse video and audio links to have a therapeutic conversation,
as in face-to-face CBT, which includes nonverbal informationsuch as expressions, body language, voice volume, and tone.
Therefore, among the ICBT options, this allows the patient andthe therapist to have the strongest therapeutic relevance. In asituation where real-time communication with the patient isimportant, it is considered to be a powerful approach; forexample, when the therapist can enhance motivation throughrole playing by performing internal sensory exposure in frontof a patient with serious panic PD.
Mental health services for remote populations via
videoconferences have yielded high satisfaction [17,49-52]. A
systematic review of videoconference-delivered CBT trials,
using 20 controlled studies, uncontrolled studies, case series,
and case studies for anxiety disorders including posttraumaticstress disorder (PTSD) using the criteria of the Diagnostic andStatistical Manual of Mental Disorders (DSM-IV-TR), suggested
a medium to large effect size [53]. At the same time, there wereno clinical studies about videoconference-delivered CBT for
all of OCD, PD, and SAD. Comorbidity has often been seen
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additional
remotesystemstodeterminevideoconference-delivered CBT adaptation to normal clinicalscenes are thus meaningful. A randomized controlled trial
compared OCD using professional videoconferencing equipment(n=10) with self-help (n=10) and wait-list (n=10) controls [51].
The results indicated large effect sizes (Cohen d=2.1-2.5); in
addition, 60% (6/10) of participants in the videoconference
condition achieved clinically significant changes at
posttreatment and 50% (5/10) did so at a 3-month follow-up.
Another controlled trial compared manualized CBT for PD andagoraphobia by videoconference (n=11) with in-person CBT(n=10) [52]. The results indicated no significant difference
between the conditions, but 81% (9/11) of participants in thevideoconferencing condition were panic-free at posttreatment
and 91% (10/11) at a 9-month follow-up; this indicated a verylarge effect size for all panic and agoraphobia symptoms. An
uncontrolled trial, using 24 participants with SAD, applied
acceptance-based behavioral therapy via videoconference [50]and found that 54% (13/24) of participants did not meet
DSM-IV-TR criteria for SAD at posttreatment. Large effectsizes for all social anxiety symptoms (Cohen d=1.23-1.91) wereobtained at post-therapy and at a 3-month follow-up. In addition,
it is known that videoconference-delivered therapy can develop
a similarly strong therapeutic alliance with psychotherapy clientsas in-person therapy [49,55].

Ethics and Dissemination

Nevertheless, during this trial, the only national university
hospital with a CBT specialized outpatient in Japan was at ourfacility alone, the Chiba University; most patients do not haveaccess to this treatment. For patients in Japan to receive CBT
via the internet, it was necessary to examine the feasibility ofvideoconference-delivered CBT.

Inclusion criteria for this study included informed consent toparticipate in the study; having a primary diagnosis of OCD,
PD, or SAD; aged between 19 and 65 years, and having accessto the internet at home. Comorbid mental disorders—including
major depressive disorder, other anxiety disorders, and eating
disorders—were permitted if they were clearly secondary,considering that this trial should reflect routine clinical practice.
The exclusion criteria were organic brain damage, dementia,
psychotic disorders, serious drug dependence, recurrent suicidal
and antisocial behaviors, and severe somatic conditions.
Participants, who used psychotropic drugs, including selective
serotonin reuptake inhibitors and benzodiazepines, were asked
to report all of changes regarding pharmacotherapy during thestudy period.

Objective of This Study
Previous studies have consistently demonstrated theeffectiveness of videoconference-delivered CBT, but they havesmall samples sizes and were conducted in Western countries.
Therefore, this pilot study utilized an open trial to examine thefeasibility and preliminary effectiveness of in-home CBT via
videoconference for Japanese adults with OCD [49], PD, andSAD. It was hypothesized that videoconference-delivered CBT
would be effective to reduce the symptomatology for eachdisorder from pre- to posttreatment and acceptable to Japaneseparticipants.

Methods
Study Design
This study was conducted as a single-arm, open trial at theacademic outpatient clinic of the Cognitive Behavioral Therapy
Center of Chiba University Hospital between March 2017 andMarch 2018. Since this trial was the first to employ an individual
videoconference-delivered CBT intervention design against
OCD, PD and SAD in Japan, a single-arm trial examining
baseline predictors rather than effectiveness was considered to
be an appropriate design [56].

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This trial was approved by the Institutional Review Board of
Chiba University Hospital (reference number: G28038). The
clinical trial registration number was UMIN000026609.
If an individual wished to participate in the trial, they had tocontact the study trial office, where they were informed about
the study objectives and asked to confirm whether they werewilling to participate. Furthermore, they were assured absolute
anonymity. They had to fill out an informed consent form forparticipation in this study. All participants were informed thatthey could continue receiving conventional drug treatmentsfrom their primary doctors. We practiced videoconferencing
twice with participants.

Participants and Eligibility Criteria
The study participants were recruited through posters andleaflets placed at medical institutions in Chiba Prefecture,through the official Web-based advertisements at the Cognitive
Behavioral Therapy Center of Chiba University Hospital andby referrals from their primary care doctors or psychiatrists.
After email or telephone screening through Web-based app, theparticipants visited our center and were diagnosed with OCD,
SAD, or PD using the Mini-International NeuropsychiatricInterview [57,58].

Intervention
The participants entered a Web conference room by clicking a
URL in an email sent from their therapists. The intervention
was conducted at a 50-min session once a week for 16 weeks.
The modules were derived from previous studies on in-person
CBT for OCD [59], PD [60], and SAD [61] in Japan andincluded psychoeducation, exposure exercises, behavioral
experiments, and homework assignments.

Therapists and Therapy Quality Control
Videoconference-delivered CBT was delivered by 12 therapists,
who were experienced in face-to-face CBT for patients with
OCD, PD, and/or SAD (including 7 clinical psychologists, 2
psychiatric social workers, 1 nurse, 1 psychiatric pharmacist,and 1 psychiatrist). Therapists were trained in CBT programsfor patients with OCD, PD, and SAD and attended weekly
group-supervision sessions with other therapists as well as
undergoing individual supervision by a senior supervisor. Alltherapists had completed a CBT training course (Chiba
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Improving Access to Psychological Therapies project:
Chiba-IAPT) [62]. Of the therapists, 6 were female, with anaverage age of 43.5 years (SD 7.5) and an average of 2.2 yearsof clinical experience (SD 6.4) at the beginning of the study.
Senior supervisors assessed the quality of thevideoconference-delivered CBT sessions using the Cognitive
Therapy Scale-Revised [63,64], a revision of the Cognitive
Therapy Scale designed by Young and Beck (unpublished data
[65,66]).

Visual Aids
The use of visual aids facilitates the learning process byenhancing motivation and understanding of complex matters[67]. Therefore, visual aids were used in each program toenhance the participants’ understanding. The visual aids
consisted of several slides including key concepts of CBT. The
therapists conducted CBT sessions with the visual aids by using
the screen-sharing function of the videoconference software,
sending them to the participants as password-protected
homework slides by email after each session.

Hardware
The therapists used 2 Surface Pro 2 computers―2-in-1
detachable produced by Microsoft , running Windows 10 Pro(Microsoft Corporation, US). The display size was 10.6 inches
and a resolution of 1920×1080 pixels. Each participant was lentan iPad Mini 2 (Apple Inc, US) with a 7.9-inch display and a
2048×1536-pixel resolution.

Software for Videoconference
A total of 3 licenses for videoconference software (Cisco
WebEx, Milpitas, CA, USA) were used in this trial. This system
has been awarded ISO27001 certification (regarding handlingof information security) and SSAE16 (Statement of Standards
for Attestation Engagements No. 16: former SAS 70)
compliance certification (issued by a third party). It also
complies with the United States Health Insurance Portability
and Accountability Act. WebEx’s use of a switching network
along with a 128-bit Secure Sockets Layer encryption and public
key infrastructure is regarded by the Japan Ministry of Health,
Labor and Welfare to have solved the problem of safety, asreported in their “Guidelines on Safety Management of Medical
Information System Version 4.3” in March 2016 [68]. Since
the stability and safety of the software are excellent and it
sufficiently protects personal information, we judged WebEx
to be sufficiently reliable for this study.

Measures of Primary Outcomes
The most commonly used scales to measure symptoms of eachdisorder were used as follows: the Yale-Brown
Obsessive-Compulsive Scale (Y-BOCS) for OCD symptoms[69,70], the Panic Disorder Severity Scale (PDSS) for PD
symptoms [71,72], and the Liebowitz Social Anxiety Scale(LSAS) for SAD symptoms [73,74].
To calculate responsiveness to treatment and the remission rate
after the intervention, the criteria of the previous studies
regarding the severity rating scale of each disorder was used
[62,64,65]. For OCD, treatment response was defined as a 35%
or greater reduction in the total Y-BOCS score, and remission
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Matsumoto et al
was defined as a final Y-BOCS score of ≤14 [75]. For PD,
treatment response was defined as a 40% or greater reduction
in total PDSS score, and remission was defined as a final PDSS
score of ≤5 [76]. For SAD, treatment response was defined asa 31% or greater reduction in total LSAS score, and remission
was defined as a final LSAS score of ≤36 [73].

Measures of Secondary Outcomes
We used the EuroQol-5 Dimension (EQ-5D) to measure
health-related quality of life [77,78]. This trial measured thepsychological bond between therapist and participant using theWorking Alliance Inventory-Short Form (WAI-SF) [79],depressive symptoms using the Patient Health Questionnaire-9(PHQ-9) [80,81], and generalized anxiety symptoms using theGeneralized Anxiety Disorder-7 (GAD-7) [82,83]. The
definition of the response in PHQ-9 and GAD-7 was defined
as a 50% reduction in total score. We used 7-point Likert scale
format to measure participants’ satisfaction about
videoconference-delivered CBT as follows: “Very dissatisfied,”“Dissatisfied,” “Slightly dissatisfied,” “Neutral,” “Slightly
satisfied,” “Satisfied,” and “Very satisfied.” In addition, theparticipants
were
asked
about
preferenceofvideoconference-delivered CBT or face-to-face CBT as follows:“If you could choose in the future, would you wish to receive
treatment with either face-to-face or videoconference CBT?”
Participants answered using a 7-point Likert scale as follows:“Clearly prefer face-to-face,” “Prefer face-to-face,” “Slightly
preferface-to-face,”“Neutral,”“Slightly
prefervideoconference-delivered
CBT,”“Prefervideoconference-delivered CBT,” and “Clearly prefervideoconference-delivered CBT.”

Data Setting and Locations
Participant and therapists used the Numbers app for iOS to run
the digital questionnaires, and the therapist asked eachparticipant to answer them by themselves on the tablet PC atweeks 1, 8, and 16. Each participant sent an email with thecompleted questionnaires of all primary outcomes (Y-BOCS,
PDSS, and LSAS) and part of secondary outcomes (EQ-5D,
PHQ-9, and GAD-7) to their therapist before each session andsent an email with the completed questionnaires of the secondary
outcomes (WAI-SF and satisfaction/preference) attached after
session. The therapist checked outcomes and evaluated thesymptoms during the session, collaborating with the participant.
The collected data were registered to the server of DATATRAKONE (DATATRAK International Inc, US) as Web caseregistration system by the lead author and managed by the data
management office of Chiba University. This study adhered to
the CONSORT-EHEALTH guidelines for improving andstandardizing the report of Web-based and mobile healthinterventions [84].

Adverse Events
To confirm the occurrence of adverse events after intervention,
the therapist asked the patient about their physical and mental
condition at the end of each session and instructed allparticipants to report all adverse events by email.

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Statistical Analysis
Statistical analysis and reporting of this trial were conducted inaccordance with the CONSORT-EHEALTH guidelines [84].
All statistical analyses were described in the statistical analysis
plan, which was fixed before the database lock. All efficacy
analyses were primarily based on the full analysis set, which
included all patients who had received at least one session of
the videoconference-delivered CBT treatment. For baselinevariables, summary statistics were constructed, employing
frequencies and proportions for categorical data and means andSDs for continuous variables. Baseline variables were comparedusing the Fisher exact test for categorical outcomes and theunpaired t test for continuous variables. For the primary analysis
comparing between pre- and posttreatments, the points and their
95% CIs were estimated by the paired t tests with the change
at week 16 from baseline in EQ-5D index scores for all of thepatients in Y-BOCS for OCD, PDSS for PD, and in LSAS for
SAD. For comparison among the 3 disorders, a one-way analysis
of variance was used. Analyses of secondary outcomes were
performed in the same manner as the primary analysis.
In addition, we calculated Cohen d pre-post effect sizes by
calculating the mean differences between pre- andposttreatments, dividing by the pooled SDs. We also adopted
the criteria that a Cohen d of >0.20 was a small effect, that of>0.50 was a medium effect, and that of >0.80 was a large effect[85]. All P values were two-sided; a value of P<.05 wasconsidered statistically significant. Statistical analyses were
performed using SAS software version 9.4 (SAS Institute, Cary,
North Carolina, USA) and the R statistical program version
2.13 (The R Foundation, Vienna, Austria).

Results
Recruitment
Figure 1 shows the participant flow. A total of 37 patients
applied to participate through our website. After email or
telephone screening, 6 patients were excluded; 1 did not meet
one of the inclusion criteria due to epilepsy and 5 declined toparticipate because of long distance to our hospital. After thescreening, 31 attended the face-to-face baseline assessment, andone did not meet one of the inclusion criteria due to high riskof suicide. Finally, 30 patients were enrolled to the study.

Attrition
Of the participants eligible to take part in the study, 1 SAD
participant with major depressive disorder dropped out after 9
sessions because of worsening of his depressive state. The
remaining 97% (29/30) completed the full course ofvideoconference-delivered CBT. All data at point each

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Matsumoto et alassessment (screening, session 1, session 8, and session 16)
were statistically analyzed.

Clinical and Demographic Characteristics
The sample included 30 participants (6 males and 24 females),aged 20 to 54 years (mean 35.4 years, SD 9.2), education 10 to
19 years (mean 14.8 years, SD 2.1). Apart from primary
diagnoses, a summary of the participants’ demographic anddiagnostic information is presented in Table 1. Moreover, 15participants continued to receive pharmacotherapy during thetrial (4 fluvoxamine, 2 escitalopram, 1 sertraline, 1 paroxetinehydrochloride, 1 duloxetine, 1 mirtazapine, 1 trazodone, 1 ethyl
loflazepate, 1 alprazolam, and 1 clotiazepam).

Primary Outcomes
There were significant reductions for each symptoms ofobsession-compulsion (Y-BOCS=−6.2; Cohen d=0.74; 95% CI−9.4 to −3.0; P=.002), panic (PDSS=−5.6; Cohen d=0.89; 95%
CI −9.83 to −1.37; P=.02), and social anxiety (LSAS=−33.3;
Cohen d=1.10; 95% CI −59.62 to −7.49; P=.02). Of theparticipants with OCD, 20% (2/10) showed a treatment response,
whereas 40% (4/10) went into remission [75]. Of the participants
with PD, 60% (6/10) showed a treatment response and 50%(5/10) went into remission [76]. Of the participants with SAD,
44% (4/9) showed a treatment response and 22% (2/9) went
into remission [73].

Secondary Outcomes
Figure 2 shows the change in the primary outcomes. Table 2
shows the mean change in the EQ-5D scores, at 16 sessions
from baseline. The adjusted mean changes of the EQ-5D for allof the 3 disorders was 0.0336 (95% Cl −0.0198 to 0.0869;
P=.21), which showed that it was not significant and showed asmall effect size (Cohen d=- 0.202).
Figure 3 also shows the change in the secondary outcomes. The
mean changes in the PHQ-9 and GAD-7 scores reflectedsignificant decreases in total participants for the 3 disorders(Table 3). The mean change in the WAI-SF reflected asignificant increase for the total sample. Table 4 shows
participants’ satisfaction with and preferences forvideoconference-delivered CBT. As the ratings “very satisfied”
and “satisfied” were combined, the majority of participants(86%,
25/29)
reportedbeing
satisfiedwithvideoconference-delivered CBT. In that case, the ratings“slightly prefer videoconference-delivered CBT,” “prefervideoconference-delivered CBT,” and “clearly prefervideoconference-delivered CBT” were combined; 83% (24/29)
of the participants preferred videoconference-delivered CBT toface-to-face CBT. Conversely, 7% (2/29) of them preferredface-to-face CBT to videoconference-delivered CBT.

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Figure 1. Participant flow.

Table 1. Clinical and demographic characteristics of participants (N=30).
Characteristics

All

OCDa

PDb

SADc

Age (years), mean (SD)35.4 (9.2)

37.7 (6.9)

38.8 (9.8)

29.7 (8.6)

Male

6 (20)

2 (6)

0 (0)

4 (13)

Female24 (80)8 (27)

10 (33)6 (20)

Employment, n (%)

11 (36)5 (17)2 (6)

4 (13)

Combined pharmacotherapy, n (%) 15 (50)

6 (20)

5 (17)

4 (13)

Videophone use experience, n (%)

15 (50)4 (13)

6 (20)

5 (17)

Depression

5 (17)

1 (3)

1 (3)

3 (10)

Panic/agoraphobia

2 (6)

2 (6)

N/Ad

N/A

PTSDe

1 (3)

N/A

1 (3)

N/A

Alcohol dependence

1 (3)

N/A

N/A

1 (3)

Bulimia nervosa

1 (3)

N/A

N/A

1 (3)

GADf

3 (10)

2 (6)

N/A

1 (3)

Sex, n (%)

Comorbid disorders, n (%)

a

OCD: obsessive-compulsive disorder.

b

PD: panic disorder.

c

SAD: social anxiety disorder.

d

N/A: not applicable.

e

PTSD: posttraumatic stress disorder.

f

GAD: generalized anxiety disorder.

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Figure 2. Change of primary outcomes. LSAS: Liebowitz Social Anxiety Scale; PDSS: Panic Disorder Severity Scale; Y-BCOS: Yale-Brown
Obsessive-Compulsive Scale.

Table 2. Mean change in EuroQol-5 Dimension score.

a

DisorderMean change (95% CI)

P value (paired t test)

P value (F test)

All (n=29)

0.0336 (−0.0198 to 0.0869)

.21

N/Aa

OCDb (n=10)0.0488 (−0.0577 to 0.1553)

.33

.91

PDc (n=10)0.0305 (−0.0393 to 0.1003)

.35

.91

SADd (n=9)

0.0201 (−0.1188 to 0.1591)

.75

.91

N/A: not applicable.

b

OCD: obsessive-compulsive disorder.

c

PD: panic disorder.

d

SAD: social anxiety disorder.

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Figure 3. Change of secondary outcomes. EQ-5D-5L: EuroQol-5 Dimension; GAD-7: Generalized Anxiety Disorder-7; PHQ-9: Patient Health
Questionnaire-9; WAI-SF: Working Alliance Inventory-Short Form.

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Table 3. Mean changes in secondary outcomes.
Measures and Disorder

Mean change, t value (95% CI)

P value (paired t test)

P value (F test)

All (n=29)−1.72 (−3.26 to −0.19)

.03

N/Ab

OCDc (n=10)−1.70 (−4.52 to 1.12)

.21

.27

PDd (n=10)−0.30 (−1.65 to 1.05)

.63

.27

SADe (n=9)−3.33 (−7.56 to 0.89)

.11

.27

All (n=29)−3.03 (−4.57 to −1.49)

<.001

N/A

OCD (n=10)−.50 (−6.37 to −0.63)

.002

.68

PD (n=10)−2.10 (−3.43 to 0.77)

.006

.68

SAD (n=9)−3.56 (−8.02 to 0.91)

.10

.68

All (n=29)

4.14 (1.24 to 7.04)

.007

N/A

OCD (n=10)

3.00 (−1.77 to 7.77)

.19

.85

PD (n=10)

4.80 (−0.42 to 10.02)

.07

.85

SAD (n=9)4.67 (−2.66 to 11.99)

.18

.85

PHQ-9aGAD-7f

WAI-SFga

PHQ-9: Patient Health Questionnaire-9.

b

N/A: not applicable.

c

OCD: obsessive-compulsive disorder.

d

PD: panic disorder.

e

SAD: social anxiety disorder.

f

GAD-7: Generalized Anxiety Disorder-7.

g

WAI-SF: Working Alliance Inventory-Short Form.

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Table 4. Satisfaction and preference.
Answer optionsn (%)

Satisfaction
Very dissatisfied

0 (0)Dissatisfied

0 (0)Slightly dissatisfied

1 (3)Neutral0 (0)Slightly satisfied

3 (10)

Satisfied

9 (31)

Very satisfied

16 (55)PreferenceaClearly prefer face-to-face

0 (0)Prefer face-to-face

1 (3)Slightly prefer face-to-face

1 (3)Neutral3 (10)

Slightly prefer videoconference-delivered CBTa

10 (34)Prefer videoconference-delivered CBT

6 (21)

Clearly prefer videoconference-delivered CBT

8 (28)

CBT: cognitive behavioral therapy.

Adverse Events
A total of 3 patients reported adverse events, including
depression relapse, headache, and feeling of exhaustion. The
depressive symptoms of 1 SAD patient with depressive disorderworsened between the ninth and tenth sessions, when he wastravelling with his friend. We identified this as a serious adverse
event at the tenth session. He wanted to decline continuing withvideoconference-delivered CBT and dropped out of the trial atthat time. At 6 months after he received pharmacotherapy fromhis psychiatrist, he recovered the depressive episode. In addition,
1 PD participant reported a headache at the fourth session but
recovered in the same day. Furthermore, 1 OCD patient reported
a feeling of exhaustion after the 4th session but recovered in
the same day.

Discussion
Principal Findings
This study examined the feasibility of videoconference-delivered
CBT in adult patients with mild to severe OCD, PD, and SAD.
Interventions based on CBT were conducted for each groupdivided by primary diagnosis, and examination of symptom
improvement and acceptance of patients was conducted before
and after the intervention. We use different criteria for eachdisease looking at the rate of responders to treatment (defined
as a 35% reduction in Y-BOCS obsessive-compulsive
symptoms, a 40% reduction in PDSS panic symptoms, and a
31% reduction in LSAS social anxiety symptoms); patients’satisfaction were also confirmed by using therapeutic allianceand patients’ treatment acceptance. Improvement of thesymptoms was confirmed in 3 disorders; it was found that thetherapeutic alliance was achieved at a high level, and patients’
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satisfaction was extremely high. Therefore, this study showed
the feasibility of ICBT with real-time support of therapists toJapanese patients except for depression [86].

Feasibility of Videoconference-Delivered Cognitive
Behavioral Therapy
Regarding the other primary outcomes, the calculated Cohen dfor pre- to posttreatment were 0.74 for the Y-BOCS, 0.89 for
the PDSS, and 1.10 for the LSAS. The Cohen d scores wereclassified as medium and large. Though it is difficult to compare
these studies because the characteristics of the patients and/or
the methods were different, these results seem similar to thoseof our face-to-face CBT studies [59-61]. These medium andlarge effect sizes were also found in the previous studies ofvideoconference-delivered CBT (Cohen d=1.4-2.5) [50-52]. A
previous videoconference-delivered CBT study for OCD
reported that the treatment response rate was 60% (6/10).
According to a systematic review about face-to-face CBT studies
conducted between 2000 and 2014, the response rates were
43.3% for OCD, 53.2% for PD, and 45.3% for SAD [87]. The
response rates in this study were 20% (2/10) for OCD, 60%(6/10) for PD, and 44% (4/9) for SAD. Previous
videoconference-delivered CBT studies reported that theremission rate for PD was 81% (9/11) [52] and that for SAD
was 54% (13/24) [50]. The remission rates in our studies were40% (4/10) for OCD, 50% (5/10) for PD, and 22% (2/9) for
SAD. Although comparisons of these results must be done withcaution, the response and remission rates of this study werecomparable with those in the previous studies of in-person CBTand videoconference-delivered CBT. In the future, it will benecessarytoverifytheeffectivenessof
ourvideoconference-delivered CBT through a randomized
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JOURNAL OF MEDICAL INTERNET RESEARCH
face-to-face CBT or videoconference-delivered CBT withdifferent methodology.
There was no significant change (P=.21) in the EQ-5D scoresfor all of the 3 disorders, the calculated Cohen d from pre- to
posttreatment was −0.202 and classified as small. In addition,
there were no significant differences in changes of the EQ-5D
score among the 3 disorder groups (P=.91). As described by
the previous reports [88], our findings suggested that the EQ-5D
was responsive in videoconference-delivered CBT for OCD,
PD, and SAD.
For the PHQ-9, a significant reduction between pre- andposttreatment was observed for the entire sample (P=.03) There
were no significant differences in the PHQ-9 changes amongthe 3 disorders (P=.27). The effect size for the 3 disorders was
small (Cohen d=0.27). After dividing each disorder, the effectsizes ranged from small to medium (OCD: Cohen d=0.23; PD:
Cohen d=0.07; SAD: Cohen d=0.64). As for the GAD-7, asignificant reduction pre- and posttreatment was observed forthe entire sample (P<.001). Although the change reflected a
medium effect size for the entire sample (Cohen d= 0.61), allwere medium for each disorder (OCD: Cohen d=0.75; PD:
Cohen d=0.79; SAD: Cohen d=0.67). There were significant
differences in changes between the OCD and PD groups (OCD:
P=.002; PD: P=.006; SAD: P=.10) at week 16. A previous study
reported a response rate in GAD-7 of 50.9% following acomputerized CBT program, for 1062 adults who had GAD-7
scores of 10 or more at baseline [89] including 75 patients with
GAD, 47 with PD, 40 with SAD, and 18 with PTSD. In thisstudy, the treatment response rate for the GAD-7 was 45%(13/29). The response rates of PHQ-9 and GAD-7 in this study
were similar to those in a prior study [89]. Taken together, ourresults suggest that videoconference-delivered CBT for OCD,
PD, and SAD might secondarily ameliorate symptoms forgeneralized anxiety and depression.
More than half of the participants (55%, 16/29) who completed
the videoconference-delivered CBT reported the highest levelof satisfaction (“very satisfied”) with treatment via
videoconferencing, whereas 31% (9/29) reported that they were“satisfied” (the second highest level). In other words, 86%(25/29) of participants reported being satisfied withvideoconference-delivered CBT. These results are consistent
with those of previous studies [50,90]. Furthermore, 83% (24/29)
of the participants preferred videoconference-delivered CBT toface-to-face CBT. Conversely, 7% (2/29) preferred face to face
CBT to videoconference-delivered CBT. Taken together, theseresults indicated that videoconference-delivered CBT was
generally accepted by Japanese participants with OCD andanxiety disorders.
The therapeutic alliance indicated by the total scores of WAI-SF
significantly improved throughout the treatment, from 68.9 (SD12.3) at week 1 to 77.9 (SD 7.7) at week 16 (P=.007). The meanscores of the WAI-SF items were 5.7 (SD 0.97) at pretreatment,
6.1 (SD 0.95) at midtreatment, and 6.5 (SD 0.63) atposttreatment. These results were comparable with those of aprevious study on videoconference-delivered CBT, where the
WAI-SF scores increased from 5.22 (SD 0.42) to 5.60 (SD 0.90)
in patients with SAD [50] and were 5.80 (SD 0.90) in patients
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Matsumoto et alwith OCD [51]. Furthermore, these therapeutic alliance scores
were comparable with those in a previous study on in-person
CBT, where the WAI-SF scores increased from 5.78 (SD 0.94)
to 5.93 (SD 0.90) in patients with PD and from 5.32 (SD 0.87)
to 5.57 (SD 0.85) in patients with SAD [90]. Considering thatlower alliance is known to be associated with dropout [90], thehigh alliance scores in this study can explain low dropout rate
(3%, 1/30).
The dropout rate of this study was 3% (1/30), as 97% (29/30)
completed the videoconference-delivered CBT treatment.
Dividing the 3 disorders, the dropout rate of 10% (1/10) ofparticipants with SAD was comparable with that of a previous
study of videoconference-delivered CBT (17%, 4/24) [50] as
well as a previous meta-analysis of 587 studies of in-person
CBT between 1990 and 2010 (18%) [91]. The dropout rate of
0% for OCD was comparable with that of a previous study ofvideoconference-delivered CBT (0%, 0/10) [51] as well as theresults of a meta-analysis of studies on in-person CBT publishedbetween 1993 and 2014 (15%) [92]. The dropout rate of 0% forPD was similarly comparable with a previous study onvideoconference-delivered CBT (0%, 0/11) [52] as well as ameta-analysis of in-person CBT studies published between 1993
and 2002 (12.7%) [93].

Limitations
This study has some limitations, including its small sample size,lack of a control group, unstandardized outcomes(satisfaction/preference of videoconference-delivered CBT),and long-term follow-up. Without a placebo control group andpharmacotherapy group, it remains unknown whether theobserved improvements in symptom severity were merely thenatural course, a result of the drug, or the effect of theintervention. Future studies should employ psychologicalplacebo conditions and pharmacotherapy conditions. Thus, a3-armed randomized controlled trial comparing pill placebo as
the control group, videoconference-delivered CBT patients on
antidepressants, and videoconference-delivered CBT patients
who are drug-free should be designed and performed. We havebeen conducting a randomized controlled trial that includes thepharmacotherapy condition to provide greater insight into thisCBT for PD since December 2016. In addition, we intend to
conduct similar trials for OCD and SAD in the near future.

Conclusions
This study demonstrated the feasibility of CBT with real-time
support by the therapist to remotely treat adult patients withsymptoms of obsessive-compulsion or anxiety, examining the
reduction in symptoms before and after the intervention, andpatient acceptance. As it was found that the mutual relationshipbetween therapists and patients can be built on a high level by
patients and that patients felt satisfaction about remote treatment
with real-time therapist support via videoconference, we believethat videoconference-delivered CBT can be easily implemented
on a larger scale in present Japan where the internet is easily
accessible. Future research should aim at increasing the reachof intervention and determining whether the intervention isindeed more approachable to people who are young patients or
those with a low socioeconomic status. Related to this matter,because a patient’s understanding level and information
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JOURNAL OF MEDICAL INTERNET RESEARCH
communication skills probably influence the effectiveness of
remote treatment, future studies should be made on designs that

Matsumoto et alconsider the contents of support of the therapist beyond theabsence or presence of guides.

Acknowledgments
The authors would like to thank Ms Ota and Ms Suwabe, nurses at the Cognitive Behavior Therapy Center, Chiba University
Medical School Hospital for the smooth coordination between the therapists and the patients. They also thank Professor Hanaoka,
Mr Oki, Ms Yamasaki, and other staff of the Clinical Research Center, Chiba University Medical School Hospital for ensuring
the rigor of the study plan. Accurate data management was carried out thanks to Ms Shin and Professor Hanawa in the DataManagement Center, Chiba University Medical School Hospital. The authors express their heartfelt appreciation to everyone for
their cooperation.
This study was funded by the Japan Agency for Medical Research and Development (AMED; “Medical Digital Revolution
Realization Project”; Second Public Inquiry, “Study on Database Infrastructure Construction for Medical Images and Others,”
aimed at utilization of Information Communication Technology and Artificial Intelligence, Clinical Research Evidence of DistantPsychiatric Medicine to establish guideline through the accumulation of databases and database construction for data utilization;
grant 16929962). The AMED played no role in the collection, management, analysis, or interpretation of data and will not have
any impact on the trial and the publication of the results.

Conflicts of Interest
None declared.

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Abbreviations
AMED: Agency for Medical Research and Development
CBT: cognitive behavioral therapy
DSM: Diagnostic and Statistical Manual of Mental Disorders
EQ-5D: EuroQol-5 Dimension
GAD-7: Generalized Anxiety Disorder-7
ICBT: internet-delivered CBT
LSAS: Liebowitz Social Anxiety Scale
OCD: obsessive-compulsive disorder
PD: panic disorder
PDSS: Panic Disorder Severity Scale
PHQ-9: Patient Health Questionnaire-9
PTSD: posttraumatic stress disorder
SAD: social anxiety disorder
WAI-SF: Working Alliance Inventory-Short Form
Y-BOCS: Yale-Brown Obsessive-Compulsive Scale

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Matsumoto et al

Edited by C Eichenberg; submitted 05.09.18; peer-reviewed by K Mathiasen, E Aboujaoude, M Ak; comments to author 26.09.18;
revised version received 29.10.18; accepted 11.11.18; published 17.12.18
Please cite as:
Matsumoto K, Sutoh C, Asano K, Seki Y, Urao Y, Yokoo M, Takanashi R, Yoshida T, Tanaka M, Noguchi R, Nagata S, Oshiro K,
Numata N, Hirose M, Yoshimura K, Nagai K, Sato Y, Kishimoto T, Nakagawa A, Shimizu E
Internet-Based Cognitive Behavioral Therapy With Real-Time Therapist Support via Videoconference for Patients With
Obsessive-Compulsive Disorder, Panic Disorder, and Social Anxiety Disorder: Pilot Single-Arm Trial
J Med Internet Res 2018;20(12):e12091
URL: http://www.jmir.org/2018/12/e12091/
doi: 10.2196/12091
PMID: 30559094©Kazuki Matsumoto, Chihiro Sutoh, Kenichi Asano, Yoichi Seki, Yuko Urao, Mizue Yokoo, Rieko Takanashi, Tokiko Yoshida,
Mari Tanaka, Remi Noguchi, Shinobu Nagata, Keiko Oshiro, Noriko Numata, Motohisa Hirose, Kensuke Yoshimura, Kazue
Nagai, Yasunori Sato, Taishiro Kishimoto, Akiko Nakagawa, Eiji Shimizu. Originally published in the Journal of Medical Internet
Research (http://www.jmir.org), 17.12.2018. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The
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