Self-guided behavioral therapy as impactful as clinician-guided in atopic dermatitis

Key takeaways:

• Both self- and clinician-guided therapy groups had nearly equal postintervention improvement scores (4.6 vs. 4.2).
• More self- vs. clinician-guided patients completed the therapy (81% vs. 67%).

Self-guided cognitive behavioral therapy was non-inferior in reducing atopic dermatitis symptom severity as clinician-guided cognitive behavioral therapy, according to a study.

“Cognitive behavioral therapy (CBT) is a very broad school in clinical psychology that focuses on behavior and the present,” Dorian Kern, PhD, researcher in the department of clinical neuroscience at the Karolinska Institute in Stockholm, told Healio. “This is in contrast to psychodynamic therapy where you focus on the past and come to terms with what happened in the past to move forward in the future.”

According to Kern, there are many different types of CBT, one of which is exposure-based and response prevention CBT, meaning patients undergoing this therapy need to face their fears. In the context of AD, some of these fears may include itching sensations or social stigma.

Although previously proven to be successful in mitigating symptoms, clinician-guided CBT therapy can be timely and expensive for patients. As a result, the authors evaluated the helpfulness of a brief, online self-guided CBT intervention.

The single-blind randomized clinical noninferiority study randomly assigned 168 adults (mean age, 39 years; 84.5% women) with a self-reported AD diagnosis to one of two 12-week programs — a self-guided CBT curriculum (n = 86) or a clinician-guided CBT curriculum (n = 82). The clinician-guided curriculum included 10 modules over the 12 weeks that required participants to read educational material, complete worksheets and report homework to the investigators. The self-guided curriculum included eight modules over 8 weeks, with the remaining 4 weeks dedicated to continued practice, and included the use of two digital tools, education and exercises.

According to the study, the main focuses of the modules for both programs were mindfulness training and exposure and response prevention. A key difference between the two programs was “significantly less text” in the self-guided modules, with a total of approximately 17,000 words vs. 111,000 words in the clinician-guided modules.

Kern described mindfulness as a technique that is used to focus on the present and not let the mind wander to various fears and catastrophic thoughts. For those with AD, mindfulness is used to train the mind to not distract itself from itching sensations, but instead face the sensation head on.

“Let’s say you put on an itchy sweater,” Kern said. “By design, you focus on how much it is itching you, but then you train yourself to say, ‘Oh, this is very uncomfortable but there is no catastrophe happening.’”

This can also apply to social stigma. Patients with AD in noticeable anatomical areas often avoid social gatherings due to potential embarrassment. However, Kern stated that CBT can teach patients to embrace and eventually overcome those feelings.

The study showed that the self-guided CBT curriculum was noninferior to clinician-guided CBT, with both groups having nearly equal postintervention improvement scores on the Patient-Oriented Eczema Measure (4.6 points; 95% CI, 2.57-6.64 vs. 4.2 points; 95% CI, 1.94-6.05, respectively). The estimated mean difference in change was 0.36 points, which was below the noninferiority margin of 3 points.

According to Kern, the self-guided CBT method offers benefits for both clinicians and patients with clinicians now having more time available to focus on others and patients having the flexibility to spend less time on simply reading the material.

This showed in the data, with 81% of the self-guided patients completing the therapy (defined as finishing five or more modules) vs. 67% of clinician-guided patients.

“You would expect that people who are guided and supported by someone would complete at a higher rate,” Kern said. “But I believe this finding was because of the length and number of worksheets in the clinician-guided condition.”

According to Kern, there is an important place for mental health in dermatologic care and clinicians should feel inclined to apply their mental health knowledge during appointments.

“In Sweden, many dermatologists say that they avoid asking about mental health or quality of life, because you can’t do anything about it,” Kern said. “I think that should be changed. You should certainly ask and then apply some of this CBT knowledge in your general advice to patients.”