A pilot trial of the iCanADAPT Advanced Program, an internet Cognitive Behaviour Therapy (iCBT) program for the treatment of depression and anxiety in ambulatory advanced-stage cancer patients.

INTRODUCTION The Clinical Research Unit for Anxiety and Depression (CRUfAD) have developed an online cognitive behavioural therapy (CBT) intervention for anxiety and depression in advanced-stage cancer patients. It is called iCanADAPT Advanced. Aspects of existing online interventions for anxiety and depression were adapted to the cancer context in the development of the iCanADAPT Advanced program. iCanADAPT Advanced is a 12 week self-managed mixed anxiety and depression program that is tailored to unique aspects of the cancer context, such as adapting to illness, fear of cancer progression and end-of-life concerns. PROPOSAL The proposed study will explore the outcomes of the clinician-guided iCBT program for people experiencing anxiety and/or depression symptoms who have been diagnosed with advanced-stage cancer. ALLOCATION Participants with elevated anxiety and depression scores who have been diagnosed with advanced-stage cancer will be recruited. They will complete online screening questionnaires on CRUfAD's clinical trials website (www.virtualclinic.org.au) to assess eligibility to participate and provide informed consent, before being interviewed over the telephone to assess eligibility for inclusion into the study. OVERVIEW OF PROGRAM The iCanADAPT Advanced program consists of six 'Modules' based on cognitive behavioural therapy (CBT). They include all treatment components typically seen in face-to-face CBT (the first-line treatment for depression and anxiety in people diagnosed with advanced-stage cancer). Each of the six 'Modules' can be considered as a discrete package. Each of the 'Modules' contains: - A Lesson (consists of a comic based, easy to read story, pertinent to all participants) - An associated Lesson Summary (consists of more dense reading material, likely pertinent to all participants) - Any additional resources for that Module (which may not be needed by all participants) - Any additional worksheets for that part (pertinent to all participants) THEMES OF THE MODULES The overriding messages in each ‘Module’ i.e. the each ‘Lesson’ and it’s associated ‘Lesson Summary’, and any additional resources is arranged by themes. The main themes are: Lesson 1: Learning about Depression and Anxiety Lesson 2: Adjusting to change Lesson 3: Identifying and Tackling Thoughts Lesson 4: Tackling unhelpful Behaviours Lesson 5: Facing your fears Lesson 6: Maintaining your skills EXAMPLE OF A MODULE Hence, for ‘Module 4’ the theme is “Tackling Unhelpful Behaviours”, hence the Lesson shows the characters addressing their unhelpful behaviours in a comic based, easy to follow story. Further specific, more detailed, writing is contained in the Lesson summary, in this case under the following headings: 1. Tackling Low Activity 2. Before starting activity scheduling and physical activity 3. Daily Activity Scheduling 4. Physical Activity 5. Your Checklist 6. Summary HOW TO WORK THROUGH THE PROGRAM Participants will be asked to complete the Lesson (including the questionnaires beforehand for that lesson). Each lesson will take approximately 45-60 minutes to complete. They may go through all the slides in a single sitting, or they may take multiple sittings to get to the end. Once they have completed the Lesson, the computer system automatically releases the associated Lesson Summary (i.e., it becomes available for download on completion of the lesson). The participants are asked to practice any associated skills/activities over the course of the following 14 days. Furthermore, upon completion of the Lesson, the extra resources for that part of the course, or 'Module'', similar become available. We ask participants to aim for an additional 3 hours per week to read these associated resources and to put into practice the CBT skills. TIMING OF EACH MODULE There is a purposeful lock-out time of 5 days between release of the subsequent 'Module' i.e., next Lesson and Lesson Summary etc. The 5-day lock-out refers to specific time points for the release of the next lesson and it's associated Lesson Summary. For example, if a participant undertook Lesson 3 in one sitting and hence downloaded the Lesson 3 Summary on 01st of the month, we purposely do not allow them to start 'Module 4' i.e., Lesson 4, until at least 5 days later, the 05th of the month. We will recommend instead that they spend up to two weeks (until the 14th of the month) reflecting and working through the prior Module i.e., Lesson 3, Lesson 3 Summary/recommendations. However, as some patients prefer to progress at a quicker pace we do not necessitate the full 14 day period. Instead a five day minimum is set; to ensure that the patient does not get information overload and to encourage them to reflect and undertake activities for at least a short time period. CONTACT Routine email contact from the clinician (registered clinical psychologist or psychiatry registrar/medical officer) after completion of the first two lessons will occur. Further email contact will occur then as required. The participant is also able to email or phone the clinician at any point during the trial as required. The participant completes a measure of psychological distress before each lesson and if their scores increase by one or more standard deviations the clinician is automatically alerted and initiates contact with the participant by phone or email. ADHERENCE Strategies used to improved adherence to intervention protocols and procedures for monitoring adherence include: automated email reminders, monitoring the downloading of homework, collection of data on how long participants spent reading lessons and practicing skills.