1. Williams et al. (2013) Combining imagination and reason in the treatment of depression: a randomised control trial of internet based cognitive bias modification and internet-CBT for depression.

2. Aim
to investigate the effectiveness of a brief 7 day internet-delivered imagery-based cognitive bias modification (CBM-I) …
as a “stand-alone” intervention for depression (bottom up intervention -inputting new information)
in combination with the more traditional top-down approach to CBT (scrutinising pre-existing thinking biases)
10 week iCBT program, delivered over the Internet
Would preparing Pps with the CBM-I optimise engagement with the more challenging iCBT components?

3. Design 69 people were randomized by an independent person to either
the intervention group (n = 38)
The wait-list control (WLC) group (n = 31). 
The WLC group completed iCBT after the intervention group had completed all study components

4. Ethics Approved by … All Pps gave electronic informed consent
the Human Research Ethics Committee (HREC) of St. Vincent’s Hospital in Sydney
the HREC of the University of New South Wales, Sydney.
All Pps gave electronic informed consent

5. Participants
69 Pps recruited via virtualclinic.org.au (Clinical Research Unit for Anxiety and Depression), a not-for-profit clinical and research unit in Sydney, Australia.
Applicants first completed online screening questionnaires

6. Materials: Primary Measures
to measure depression severity and distress …
telephoned for a diagnostic interview using the Mini International Neuropsychiatric Interview (MINI)
The Beck Depression Inventory–2nd edition (BDI-II)
nine-item Depression Scale of the Patient Health Questionnaire (PHQ-9)
The 10-item Kessler Psychological Distress Scale (K10) was used to index distress
Interpretation bias was measured with the Ambiguous Scenarios Test–Depression (AST-D) and an electronic version of the Scrambled Sentences Test (SST); two versions of the AST-D were presented in counterbalanced order.

7. Secondary measures
included degree of disability, anxiety and repetitive negative thinking) using…
the World Health Organization Disability Assessment Schedule–II (WHODAS-II),
the State Trait Anxiety Inventory–Trait Version (STAI-T)
the Repetitive Thinking Questionnaire (RTQ10  

8. Treatment Expectancy and Outcomes Questionnaire
contained three questions:
“At this point, how logical does the program offered to you seem? (0 = Not at all logical to 4 = Very logical)
“At this point, how useful do you think this treatment will be in reducing your depression symptoms?” (0 = Not at all useful to 4 = Very useful)
“Overall, how satisfied are you with your treatment?” (1 = Very dissatisfied to 5 = Very satisfied).

9. The interventions: CBM-I
CBM-I: seven sessions (20 min each)
imagery-focused CBM-I
completed daily over the course of 1 week;
repeatedly presented with ambiguous scenarios that are consistently resolved in a positive manner
to train the user to have an automatic positive bias with regard to the way that they interpret novel ambiguous information in their day-to-day lives

10. iCBT the Sadness Program six online lessons best practice CBT
regular HW assignments
access to supplementary resources
no face-to-face contact

11. The Design
All Pps completed baselines measures of their depression, distress, anxiety and thinking biases
Half the Pps then completed the 7-day CBM-I component, the other half were on the waiting list.
All patients then completed the primary measures after the 7-day intervention phase.
Next the experimental group completed the 10-week iCBT component, whilst the others were again “on the waiting list”.
All patients completed the baseline battery of questionnaires after 10 weeks.
The WLC group then commenced deferred treatment (iCBT but without CBM-I)

12. Results Measure Group Baseline After CBM-I After iCBT BDI -II
Intervention
27.97
18.96
10.40
Waiting List
28.00
24.82
20.54
PHQ-9
12.38
9.88
5.15
13.81
13.03
10.59
K10
29.26
24.11
17.40
28.62
28.33
24.45
AST-D
4.18
4.67
N/A
4.60
4.32

13. no significant group differences in any of the baseline measures or in age, gender, or medication use
no differences in patients’ ratings of treatment expectations,
standard contact did differ due to technical assistance required in the intervention group but the amount of personal contact with the research team did not vary
Following CBM-I, the reductions in BDI-II, PHQ-9, and K10 scores in the intervention group were all significant and corresponded to medium-large effects.
The intervention group showed improved scores on all measures, corresponding to medium effects.

14. Mean AST-D scores did not differ between groups, but the increase in mean scores (more positive interpretations) in the intervention group was significant, corresponding to a medium effect.
There was no significant change in the WLC group.
There was no main effect or interaction for SST-Negativity scores

15. Clinically significant change was evident in 27% (n = 7) of the intervention group compared to 0.07% (n = 2) in the WLC group
The direct effect of group on BDI-II was not significant (p = .09), but critically, the indirect effect of AST-D on the change in BDI-II scores was
Analyses of the combined intervention demonstrated significant reductions in all primary measures (BDI-II, PHQ-9, K10) in the intervention group, corresponding to large effects

16. Significant reductions were also observed in the WLC group corresponding to medium effects, but intervention group superiority was observed for all measures.
For WHODAS-II, STAI-T, and RTQ10, all scores were significantly lower in the intervention group relative to the WLC group, corresponding to medium-large effect sizes.
65% (n = 13) of patients in the intervention group evidenced clinically significant change on the BDI-II compared to 36% (n = 8) in the WLC

17. The majority of patients who completed the combined intervention indicated
the instructions were either easy or very easy to follow (77%)
that CBM-I was at least moderately logical (88%)
rated the quality of the combined intervention as good or excellent (84%)
Mean ratings of confidence in recommending the intervention to a friend with depression (1 = not at all confident to 10 = extremely confident) were 7.77 (SD = 2.10).

18. Conclusions
Internet-delivered CBM-I for depression can effect rapid symptom reduction over just 1 week, via seven 20-min sessions, and no additional “homework.”
the effect of the CBM-I intervention on symptoms of depression was at least partially mediated by the trained change in imagery-based interpretive bias (AST-D)
feasibility of integrating CBMi into existing iCBT treatment programs for depression
combined intervention was effective in reducing depressive symptoms, distress, disability, anxiety, and rumination in patients diagnosed with a major depressive episode.

19. Still people reading QuaN as QuaL!
Williams et al (2013) used many different self-report questionnaires to gather quaNtitative data in their study on internet-delivered CBT. With reference to data collected in this study, give ONE strength and ONE weakness of the use of quaNtitative data. (4)
Still people reading QuaN as QuaL!
One person only gave a strength and no weakness
People are not writing enough for the mark allocation
Too many people gave me two strengths and two weaknesses rather than one strength elaborated sufficiently for two marks

20. One strength for 2 marks
One strength of the quantitative data collected in standardised questionnaires such as the Beck Depression Inventory and the Patient Health Questionnaire is that data is easily analysed through counting up boxes ticked and numbers circled for example
this requires no interpretation on the part of the researcher meaning that the data analysis process is should be more objective and replicable and the findings can be checked for reliability.

21. One weakness
This said, a weakness of quantitative data to assess of the severity of someone’s depressive symptoms and distress is that the researcher is unable to collect data about contextual details, as the person is unable to expand upon when and why they may feel certain symptoms;
Now to elaborate on this…
Had an interview been used, the ability to collect this data through the use of open questions may have been beneficial in addressing the extent to which the cognitive bias modification and CBT had actually been effective.

22. Give examples from Williams (primary data)
Williams et al (2013) gathered primary data in their study from 69 participants. COMPARE the use of primary and secondary data in clinical psychology (3)
Too many people just described each type of data making no effort to compare them
Give examples from Williams (primary data)
Each and every sentence (there need to be three!) needs to contain both primary and secondary data
Each sentence needs to be either a similarity or a difference

23. Primary data is collected by the researcher for the purpose of exploring the specific hypothesis they have in mind, in this case whether a course of cognitive bias modification that is completed before computer delivered CBT enhances the success of the CBT whereas secondary data is data collected by other researchers potentially for an alternative purpose.

24. If Williams had used secondary data, she would not have had the opportunity to assess whether the Pps actually hit the criteria for depression in the first place and have to rely on the diagnosis provided in the first set of data which may have been erroneous. This means the validity of the conclusions of studies using secondary data may not be as good as those that collect primary data.

25. However the use of secondary data in a meta-analysis for example often allows for much larger data sets (Williams only had 69 Pps) to be analysed and this can improve the overall generalisability of the findings in contrast to primary data collection which use smaller samples due to the time it takes to carry out the data collection as well as analysis.

26. Evaluate the sample used in Williams et al (2013) (2)
still seeing people using reliability/validity when they mean generalisability
When talking about the sample and generalisability you need to always be talking about representativeness
Not enough people talking about the sampling technique (volunteer)
We learnt how to write chains of reason on G in our first few weeks!

27. One weakness of Williams sample is that they were recruited from virtualclinic.org.au and as such were a volunteer sample as people who have chosen to sign up for an online clinic may not be representative of people who would prefer to use face-to-face services and this means the findings that computer delivered CBT is effective may not be generalizable to people who prefer face to face services.

28. Furthermore the study was conducted in Sydney Australia suggesting most Pps were probably Australian, potentially meaning that online CBT may be less effective for Pps from cultures which are less individualistic and this cultural dimension has been shown to be relevant with regard to the experience of depression and cultural factors will also doubtless influence the efficacy of this form of treatment.

29. Williams et al (2013) had a complex experimental design combining elements of independent (between subjects) and repeated measures (within subjects) designs. This is known as a “mixed design”. Describe the design of Williams study and explain how it uses both experimental designs. (2)
Several people showed that they don’t reallt understand experimental design; if this is you listen up you need to practise!!!
Independent measures is when you compare two or more groups of different people
Repeated measures is when the DV is measured twice with one group of people

30. The aspect of the study which is repeated measures relates to the fact that Pps completed questionnaires relating to the severity of their depressive symptoms and distress before the interventions as well as afterwards. The aspect which relates to independent measures is the fact that there were two groups, randomly allocated by an independent person; the experimental group participated in the 11 week intervention (n=38) and the waiting list group (n=31) who did not participate in the intervention until after the other group had finished

31. Write a suitable directional experimental hypothesis for Williams looking at any element of the study that you like. (3)
There are still people not putting in the two groups/conditions that are compared (the two levels of the IV)
Marks were lost for not operationalising the IV and/or DV

32. Participants who have been diagnosed with depression who complete the 11 week computer delivered iCBT “Sadness Program” will experience less severe depressive symptoms as measured by the Beck Depression Inventory THAN depressed participants who do not complete the 11 week intervention.

33. People did not spot the it asked for the NULL!
Write a suitable non-directional null hypothesis for another element of the study. (3)
People did not spot the it asked for the NULL!
Similar problems to the previous hypothesis re lack of operationalisation:
There will be no significant difference in the severity of depressive symptoms, (measured using the Beck Depression Inventory) experienced by people with depression in the 11 week iCBT intervention group compared with those in the waiting group condition who did not participate in the computer delivered intervention and any difference that does arise will be due to chance alone.

34. Give ONE limitation of the use of self-reports in this study (2)
The limitation needed to relate to the fact the Pp is giving the data rather than an observer measuring behaviour for example
Needs to use proper terminology
Needs to elaborate one limitation for two marks not give two separate limitations
Needs to relate to the study (Williams et al)

35. One limitation with regard to the use of self-reports is the data could be deemed to lack validity as people may give socially desirable responses believing that the researchers expect them to feel better after the intervention and therefore demonstrating with demand characteristics.
This means that the use of self-reports may make iCBT appear more effective than it actually is. This may be particularly true of those in the intervention group who believe that they should be feeling better after giving up their time over the 11 weeks to engaging with the iCBT lessons and completing their HW exercises.

36. This study used questionnaires to gather the data
This study used questionnaires to gather the data. If Williams et al (2013) had used interviews instead, how might this have affected the analysis of the data (3)
Answers needed to demonstrate understanding of the use of qualitative methods of analysis such as grounded theory/ inductive content analysis

37. Interview data is usually in the form of a transcript or written verbatim record of exactly what was said in answer to open question, thus resulting in qualitative data.
Instead of counting up answers as in the quantitative analysis of data, a thematic analysis may follow, using the conventional inductive method whereby the researchers use ‘close reading’ to extract ‘coding units’ until they reach ‘data saturation’, at which point the codes are sorted into meaningful categories and the researcher attempts to explore how these categories are inter-related.
This technique is sometimes criticised as some researchers believe that the analysis is subjective and open to the interpretation of the researcher.

38. Needed to mention internal validity
Williams et al (2013) state that they randomly allocated their participants to either the intervention group or the waiting list control group. Explain how this is a strength of their design (2)
Disappointing number of people who did not pick up on the classic problem of independent measures design;
participant variables, which are eliminated through using random allocation to groups
Needed to mention internal validity

39. This is a strength of the study as it should improve the internal validity as it is a technique that is commonly used eliminate the effect of participant variables on the data.
For example, if all the Pps in the intervention group happened to have higher levels of social support available to them than all of those in the waiting list group and ended up with less severe symptoms over the course of 11 weeks it would not be possible to know whether it was the intervention or the social support that had helped.
Random allocation of Pps across the two groups should ensure that other factors relating to the Pps that might affect the severity of their symptoms should be equally distributed allowing for a clearer cause and effect statement to be drawn about the way the IV impacts the DV.

40. Williams et al (2013) required their Pps to complete the battery of self-report questionnaires three times, once at baseline, then post CBM-I and then again at the end of the study after the iCBT. Explain a potential weakness of this aspect of the design (2)

41. This aspect of the study has a repeated measures design and the results of studies of this nature can be subject to order effects which weaken internal validity. This means that the way that the questionnaire is filled in at time point 2 (after CBM –I) is affected the fact they have already filled the same questionnaire in one at time point 1 (the baseline), similarly at the end of the iCBT when they complete the questionnaire for the third time this may be affected by the fact they have already completed it at time 1 and 2. This means that measure of severity of symptoms might not simply be being affected by the interventions but that the measure is affected by the order in which the data has been gathered.

42. The following table shows the findings of the study
The following table shows the findings of the study. Determine three conclusions regarding the efficacy of CBM-I and iCBT that could be drawn from this data set (6)
Most people did not use the data from the table to substantiate their conclusions and instead simply copied the conclusions form the paper/handout
Command term “determine” says you cannot get the marks unless you use the data
We learnt this lesson from the tarantula question…but apparently have forgotten it!

43. You need to do this three times!
From the data table it can be concluded that the CBMi was effective in reducing depressive symptoms after just 7 days as the Beck Depression Inventory scores had decreased by approx. 9 points for the intervention group whereas the waiting list group only experienced a decline of just over 3 points.
You need to do this three times!

44. Evaluate Williams et al (2013) ensuring that you refer to at least one ethical issue in your answer (8) (think GRAVESOC)
This answer should have been easy as you should have had loads of evaluation points to make having completed the rest of the assessment.
ATCHOO(BC)
GRAVESOC