Video-based cognitive-behavioral intervention for COVID-19 anxiety: a randomized controlled trial

Abstract Objective Cognitive-behavioral interventions can be effective for relieving anxiety associated with coronavirus disease 2019 (COVID-19), but complications such as social distancing, quarantine, a shortage of experts, and delayed care provisions have made it difficult to access face-to-face therapeutic interventions. The purpose of this study was to investigate the efficacy of a video-based cognitive-behavioral intervention for reducing COVID-19 anxiety. Method In the present randomized controlled trial, 150 college students with severe COVID-19 anxiety were randomly assigned to either an intervention (n = 75) or a waiting list control (n = 75) group. The intervention group participated in a video-based cognitive-behavioral program consisting of nine 15-20-minute sessions (three days a week for three weeks). Dependent measures included the COVID-19 Anxiety Questionnaire, Short Health Anxiety Inventory, Anxiety Sensitivity Index-3, Somatosensory Amplification Scale, Experience of Parasocial Interaction Scale, and Source Credibility Scale. Results Participants who were randomly assigned to the cognitive-behavioral program reported high parasocial interaction, source credibility, and satisfaction with the intervention. Eighty percent reported that the video-based intervention was a beneficial alternative to traditional face-to-face therapeutic intervention. At post-treatment evaluation, the video-based cognitive-behavioral intervention group showed a significant reduction in COVID-19 anxiety, health anxiety, anxiety sensitivity, and somatosensory amplification when compared to the wait-listed control group. Conclusions This study suggests that video-based cognitive-behavioral interventions can be an affordable, feasible, and effective method to reduce anxiety during a large-scale pandemic.


Introduction
Health anxiety, or distress related to fears of contracting a disease, is a widespread problem associated with a range of psychological and behavioral symptoms. 1 While health anxiety is already common, there is evidence that such distress is intensified and more widespread during public health crises, such as the Ebola 2 and coronavirus disease 2019 (COVID- 19) outbreaks. 3,4 Cognitive-behavioral therapies show excellent efficacy for the treatment of health anxiety. 5 However, during a public health crisis, it may be difficult to access traditional therapy due to a number of barriers, including the need for social distancing to prevent disease transmission, a lack of therapists to meet increased mental health needs, financial limitations, and stigma over seeking mental health treatment.

Cognitive-behavioral video-based interventions can
potentially alleviate the increased mental health needs during public health crises. The present study tests the efficacy of a cognitive-behavioral video-based intervention program for health anxiety during the COVID-19 epidemic in Iran.
Health anxiety is characterized by a preoccupation with physiological cues or "symptoms" that leads some to believe that they are suffering from, or will acquire, a serious illness. 1 Health anxiety may be manifested in health-related behaviors such as excessive investigation into health conditions, maladaptive avoidance of situations or substances deemed unhealthy, and frequent and unnecessary visits to health care facilities. Individuals with health anxiety often persist in the belief that they have a serious illness despite medical assurance of the opposite. 1,6 Indeed, health anxiety results in significant costs due to unnecessary use of medical services, 7 which can result in financial hardship. In addition, those who suffer from health anxiety often experience occupational and social problems 8 and generally low quality of life. 9 Therefore, the costs of health anxiety extend well beyond immediate psychological distress.
Health anxiety may be amplified in large populations during disease outbreaks. There is evidence that diseases such as Ebola and COVID-19 are associated with a widespread collective fear that is out of proportion to the actual physical threat for many people. Anxiety sensitivity and somatosensory amplification contribute to health anxiety. 12,13 Anxiety sensitivity is characterized by fear of arousal-related sensations 14 and is considered a risk factor for health anxiety in cognitive-behavioral models of health anxiety. 12 Furthermore, somatosensory amplification, or the tendency to experience normal somatic and visceral sensations as intense, noxious, and disturbing, 15 plays a prominent role in the development of health anxiety. 13 There is evidence that communities have experienced elevated levels of anxiety sensitivity and somatosensory amplification during the COVID-19 outbreak. These symptoms are likely to contribute to widespread health anxiety in response to COVID-19. [16][17][18] Theoretical models based on cognitive-behavioral therapy (CBT) have been successfully applied to treat health anxiety, showing evidence of cognitive, affective, and behavioral symptom domains. 19 People with health anxiety show an attentional focus on threatening healthrelated information (cognitive). They have a tendency to interpret benign body sensations as dangerous signs of illness, which results in negative emotions (affective).
Finally, those exhibiting health anxiety show behavioral avoidance of situations perceived to be health threats (behavioral). Therapies focused on the cognitivebehavioral model have been successfully developed and tested for health anxiety. 5 CBT has proved to be quite effective for anxiety in general 20 and for health anxiety in particular (5).
Meta-analyses on the efficacy of CBT for health anxiety have shown that CBT reduces health anxiety levels more effectively than waiting list control groups, treatment-as-usual groups, medication groups, and a variety of other therapies. 5,21 Moreover, the effects of CBT for health anxiety tend to reduce other types of psychological distress, such as depression, and the therapy has shown lasting post-treatment effects in 6-and 12-month follow-up studies. 5 Therefore, CBT appears to be an appropriate and effective therapeutic approach for the management of health anxiety. There has been little research on self-administered video-based programs for health anxiety. Research findings are also difficult to interpret given the diversity in the administration and content of programs. Selfadministered video-based CBT-based programs have shown effectiveness for sexual anxiety and pain 22 and insomnia. 23 Hedman et al. 24 examined the efficacy of an Internet-based CBT therapy program for severe health anxiety and found reductions in anxiety and depression among those who participated in the program compared to a control group. However, that program was administered using self-help text-based modules with access to a web-based therapist. 24 Therefore, more This study and its trial protocol were approved by Department of Psychology of Guilan University, Iran.
Ethical considerations such as participant satisfaction, data retention and destruction, and informed participation were taken into account in accordance with the Declaration of Helsinki. Additionally, written informed consent was obtained from each participant.
In order to be included in the study, participants were required to: 1) report COVID-19 anxiety symptoms as assessed using the COVID-19 Anxiety Questionnaire (CVAQ) and DSM-5 criteria for illness anxiety disorder 25 ; 2) have access to a personal computer with Internet service; 3) be between 18 and 40 years old; and 4) provide written consent.
Respondents were excluded from participation if they: 1) reported severe psychological or bodily impairments; 2) reported severe visual and hearing defects; 3) were currently participating in other psychological or physical treatments; 4) missed more than one session; or 5) were reluctant to cooperate.

Procedure
Participants were recruited using an online advertisement posted in a college student social network.
The advertisement explained that the study examined a video-based cognitive-behavioral intervention for COVID-19 anxiety. Respondents (n = 237) were initially interviewed in order to introduce the study, explain the procedure, and assess participant inclusion criteria.
Participants who met the inclusion criteria (n = 152) were randomly assigned to either an experimental or a waiting list control group. After coding each participant with a number, a computer-generated list of random numbers was used to generate the random allocation.
Two participants were excluded from the sample following randomization, based on exclusion criteria, resulting in a final sample of 150 participants (Figure 1), of which 77 were women and 73 were men. The mean age of participants was 24.7 years (standard deviation [SD] = 5.4). Also, 127 were undergraduate students and the rest were graduate students (n = 23).

Design
The present study employed a one-way, randomized, pretest/post-test experimental design to examine the efficacy of an intervention intended to reduce COVID-19 anxiety. Participants were randomly assigned to one of two levels of the independent variable: they either received a video-based, cognitive-behavioral intervention or had their names added to a waiting list and did not receive the intervention during the period of data collection. Prior to manipulation of the independent variable, all participants completed an emailed pre-test that included CVAQ, Short Health Anxiety Inventory (SHAI), 26 Anxiety Sensitivity Index-3 (ASI-3), 27 and Somatosensory Amplification Scale (SSAS). 28 After manipulation of the independent variable, all participants completed an emailed post-test that was identical to the pre-test, with the following additional tests for the cognitive-behavioral intervention group: Experience of Parasocial Interaction Scale (EPSI), 29 Source Credibility Scale, 30 a satisfaction item, and an alternative to traditional face-to-face service item. These items were used as a manipulation check to assess the degree to which the participants in the intervention group were engaged with the video-based intervention and judged the source of the information to be credible.

COVID-19 Anxiety Questionnaire (CVAQ)
To measure COVID-19 anxiety, we adapted items from an existing survey measuring anxiety in the swine flu epidemic (Swine Flu Inventory 31

Short Health Anxiety Inventory (SHAI)
The SHAI 26 is used to measure exaggerated estimates of the likelihood and severity of having an illness. The

18-item SHAI is a shorter version of the 64-item Health
Anxiety Inventory (HAI), which measures respondents' perceived illness likelihood, illness severity, and body vigilance. Each question in SHAI consists of a group of four statements that are scored from 0 to 3. Total scores may range from 0 to 54, with higher scores representing more health anxiety. Salkovskis et al. 26 reported satisfactory reliability, validity, and sensitivity to treatment for SHAI; convergent, divergent, and predictive validity have been confirmed by Abramowitz, et al. 34 Previous studies confirmed the capability of SHAI to evaluate health anxiety across samples. 35 In the present sample, the alpha reliability was 0.81.

Anxiety Sensitivity Index-3 (ASI-3)
The ASI-3 27 assesses concern associated with possible negative consequences of anxiety-related symptoms. The ASI-3 is derived from the Anxiety and summed to create a total score (0-72). The ASI-3 has shown satisfactory convergent validity, divergent validity, and reliability. 27 Petrocchi et al. 36 confirmed the three-factor structure of the ASI-3. They reported Cronbach's alphas of 0.87, 0.83, 0.81 and 0.90 for physical concerns, social concerns, cognitive concerns, and total index, respectively. In the present study, the ASI-3 showed good internal consistency (α = 0.83).

Somatosensory Amplification Scale (SSAS)
The SSAS is a 10-item self-assessment instrument with response options rated on a scale from 1 to 5 and the total score ranging from 10 to 50. The SSAS evaluates the tendency to experience normal somatosensory sensations as intense. Validity, testretest reliability (r = 0.79; p < .0001), and internal consistency (α = 0.82) of the SSAS were shown to be adequate by Barsky et al. 28 Previous studies confirm suitable psychometric properties of SSAS in Japanese, 37 Turkish, 38 and Iranian 39 populations. In this study, Cronbach's alpha was 0.81.

Satisfaction item
Satisfaction with the video-based cognitivebehavioral intervention was measured using the following question: "How satisfied were you with the intervention?" The respondent rated satisfaction on a 10-point Likert scale (1 = from not at all; to 10 = very much).

Alternative to traditional face-to-face service item
The participants were also asked to respond to the following question: "Do you experience the videobased cognitive-behavioral intervention as a beneficial alternative to traditional face-to-face service?" Participants answered the question with yes or no.

Video-based cognitive-behavioral intervention
Participants randomly assigned to the video-based cognitive-behavioral intervention group received a self-help package, including nine video clips (153 minutes of video in total) and a 25-page online booklet.
Participants were instructed to first watch a video clip and case illustration. 50

Statistical analysis
This study was a randomized controlled trial comparing an intervention group and a waiting list control group to evaluate the efficacy of the intervention.
The data obtained were analyzed using the Statistical Package for the Social Sciences (SPSS) version 24.
Multivariate analysis of covariance (MANCOVA) was used to investigate pre-vs. post-treatment differences.

Ethics statement
The present study was conducted in coordination with the Department of Psychology of Guilan University, Iran. All ethical considerations such as personal satisfaction, data retention and destruction, and informed participation were taken into account in accordance with the Declaration of Helsinki.  The results of Table 2 show the effect of the independent variable on the dependent variables. The intervention and waiting list control groups showed a significant difference in at least one of the variables of COVID-19 anxiety, health anxiety, anxiety sensitivity, and somatosensory amplification. Sixty-three percent of total variances of the experimental and waiting list control groups were due to the independent variable.

Results
The statistical power of the test was also equal to 1, indicating adequacy of the sample size. However, in order to determine which domains were significant, univariate analysis of covariance was used in the MANCOVA, the results of which are reported in Table 3.
There was a significant difference between the intervention and control groups in COVID-19 anxiety Cohen 51 suggested that small, medium, and large

Discussion
To the best of our knowledge, this study was the   Additionally, participants considered the videobased intervention to be informative and interesting.
The participants showed strong parasocial bonds with the TV performer. They also evaluated the intervention as a valid, satisfactory, and appropriate alternative to face-to-face intervention. These findings indicate that participants showed strong engagement with the video and associated text, which contributed to the experimental realism of the intervention.
We regard the findings of the present study to be of high relevance from a clinical perspective. First, COVID-19 has led to widespread health anxiety that may carry long-term physical and psychological consequences. Second, a cognitive-behavioral model can be used to help individuals interpret and understand COVID-19 anxiety. Third, video-based cognitivebehavioral intervention is a low-cost, feasible and effective service that can lead to significant reduction in COVID-19 anxiety, health anxiety, anxiety sensitivity, and somatosensory amplification.
Our study had several important limitations. Our initial selection of participants was opportunistic.
Participants were students, i.e., they do not represent the diversity found in broader community populations.
The measurements were not masked completely, and therefore may have been subject to participant demand characteristics. Only self-report measurements were used, which made it difficult to assess the degree to which reported reductions in anxiety may have affected behavior. Not measuring adherence metrics such as video clips watched, pages of the booklet read, and days used was another limitation of our study. Our effect sizes were relatively low. Since the effects of CBT demonstrate a dose-response relationship, 21 we can guess that more than nine sessions could have produced larger effects. It would also be desirable to have followup measures to examine for how long reductions in anxiety were maintained. Finally, our intervention was tested only against a wait-listed control group. While this design showed that the intervention was effective, we cannot be sure of which aspects of the intervention were the most important or whether an alternative intervention (e.g., non-CBT based) could have been equally effective. However, previous research 5 has compared CBT to a variety of control conditions (e.g., waiting list, other psychotherapies, and medication) and found it to be highly effective for health anxiety, even at > 1 year post-therapy.

Conclusion
Video-based interventions give individuals the opportunity to learn cognitive-behavioral strategies for overcoming COVID-19 anxiety at home, during times that are best suited for their schedules. Given the high prevalence of health anxiety and barriers to intervention during large-scale public health crises, our results show that video-based cognitive-behavioral intervention could benefit individuals and societies during times of widespread panic.