Internet-administered cognitive behavior therapy for health
problems: a systematic review
Pim Cuijpers Æ Æ Annemieke van Straten Æ Æ
Accepted: November 28, 2007/Published online: 29 December 2007
? The Author(s) 2007
extensively researched form of psychological treatment
and are increasingly offered through the Internet. Internet-
based interventions may save therapist time, reduce wait-
ing-lists, cut traveling time, and reach populations with
health problems who can not easily access other more
traditional forms of treatments. We conducted a systematic
review of twelve randomized controlled or comparative
trials. Studies were identified through systematic searches
in major bibliographical databases. Three studies focused
on patients suffering from pain, three on headache, and six
on other health problems. The effects found for Internet
interventions targeting pain were comparable to the effects
found for face-to-face treatments, and the same was true
for interventions aimed at headache. The other interven-
tions also showed some effects, although effects differed
across target conditions. Internet-delivered cognitive-
behavioral interventions are a promising addition and
complement to existing treatments. The Internet will most
likely assume a major role in the future delivery of
cognitive-behavioral interventions to patients with health
Cognitive-behavioral interventions are the most
behavior therapy ? Pain ? Migraine ? Headache
Systematic review ? Internet ? Cognitive
Cognitive-behavioral interventions are probably the most
extensively researched form of psychological treatment
(Butler et al. 2006). Cognitive-behavioral interventions are
aimed at challenging negative automatic thoughts and
dysfunctional underlying beliefs, and at changing behav-
ioral patterns which are related to the problem being tar-
geted in the therapy. More than 300 published controlled
outcome studies, and probably many more, have examined
the effects of cognitive-behavioral therapy (CBT) for a
wide range of disorders and health problems, ranging from
mental health disorders, such as depression (Hollon et al.
2002), anxiety disorders (Barlow 2002), schizophrenia
(Pilling et al. 2002), to health conditions such as chronic
pain (Morley et al. 1999), sleep problems (Morin et al.
1999), headache (Holroyd 2002), cancer (Moorey and
Greer 2002) and many others. Most of these studies have
shown that CBT has positive effects on these and several
other health conditions. CBT is not only the most exten-
sively researched form of psychotherapy, but also the most
widely applied type of psychotherapy (Norcross et al.
2005), and certainly the most widely applied ‘evidence-
based’ type of psychological therapy.
CBT is increasingly offered through the Internet. Internet-
based interventions may have several advantages over
other more traditional forms of delivery. They may save
therapist time, reduce waiting-lists, allow patients to work
at their own pace, abolish the need to schedule appoint-
ments with a therapist, save traveling time, reduce the
stigma of going to a psychologist or therapist, and facilitate
P. Cuijpers (&) ? A. van Straten
Department of Clinical Psychology, VU University Amsterdam,
Van der Boechorststraat 1, 1081 BT Amsterdam,
Department of Behavioural Sciences and Learning,
Linko ¨ping University, Linkoping, Sweden
Department of Clinical Neuroscience, Psychiatry Section,
Karolinska Institute, Stockholm, Sweden
J Behav Med (2008) 31:169–177
help for the hard-of-hearing as self-help treatments
typically work with visual rather than auditory information
(Marks et al. 2007). Furthermore, Internet-delivered self-
help may be programmed to enhance patients’ motivation
by presenting a wide range of attractive audiovisual
information with voices giving instructions in whichever
gender, age, accent, language and perhaps game format the
client prefers. It can also quickly and automatically report
patient progress and self-ratings.
Internet-based interventions may reach populations with
health problems, who can not be reached with other more
traditional forms of treatments. For example, a consider-
able proportion of the patients with mental disorders are
not reached with traditional forms of treatment (Bijl and
Ravelli 2000) because of the stigma associated with mental
disorder, prejudices about therapists, lack of willingness to
talk to a stranger about personal problems, or because of
physical obstacles like walking problems or long distances.
For patients with somatic conditions there may be barriers
to seek psychological treatment. Internet-guided interven-
tions may reach a segment of this population who cannot
be reached through traditional interventions.
Internet-based psychological interventions for many
health problems are commonly based on CBT techniques.
One reason is that the effects of CBT have been shown in
numerous trials. Another reason why CBT is often used in
internet-interventions is that these techniques lend them-
selves to be operationalized in text. CBT interventions can
very well be converted into a structured format, with
psychoeducation, homework assignments and registration
exercises presented via web pages (Ritterband et al. 2006).
Delivering CBT through the Internet does not, however,
only have advantages. An online programme may not be
suitable for technophobic patients and illiterates, nor can it
answer all the possible questions users may ask; it can not
detect subtle nonverbal and verbal clues to clients’ mis-
understandings; it may encourage clients to cherry-pick
from a range of homework options presented; and not all
clients find communicating via computers acceptable
(Marks et al. 2007). However, subtle text nuances may be
detected and somewhat surprisingly, Internet interventions
has been found to generate good working alliance between
the patient and the therapist (Knaevelsrud and Maercker
Furthermore, it is not yet very clear whether CBT
interventions which have been proven to be effective when
delivered in traditional format, are also effective when
delivered through the internet. Recent studies, however,
indicate that this might be the case for at least some
patients and some conditions (Carlbring et al. 2005).
Whether or not an internet-based CBT is effective
should be examined in randomized controlled trials, and
can obviously not be based on the effects of traditionally
delivered CBT (e.g., individual or group format). Since the
Internet has become available to the broad public in many
Western countries, several trials have examined the effects
of cognitive behavioral interventions in randomized trials.
In a recent meta-analysis, we examined the effects of
internet-based treatments for depression and anxiety dis-
orders, and found that these interventions had large effects
(Cohen’s d = 1.00) compared to control conditions, when
some kind of guidance was given to the patients receiving
the treatment (Spek et al. 2007). This latter observation
was also confirmed in a recent review in which a correla-
tion of rho = .75, P < .005 was obtained between amount
of contact spent with clients and the effect size (Palmqvist
et al. 2007). These large effect sizes suggest that Internet-
administered CBT is as effective as face-to-face CBT, and
that the format in which CBT is delivered may not be
related to the effect sizes found. It is not known, however,
whether Internet-administered CBT is also equally effec-
tive when other health problems are targeted.
In the current study, we will present the results of a
systematic review of Internet-delivered CBT for health
problems. In the review, we aim to establish for which
health problems Internet-based CBT has been developed,
and examined in randomized controlled or comparative
trials, and whether these interventions were effective. We
also examine the target groups and contents of these
intervention, as well the quality of the studies.
Search strategy and selection of studies
Studies were traced through several methods. First, we
conducted a comprehensive literature search in biblio-
graphical databases (from 1966 to February 2007). We
examined 1,608 abstracts in Pubmed (295 abstracts), Psy-
cinfo (109), Embase (330) and the Cochrane Central
Register of Controlled Trials (374). In order to find
unpublished studies, we also searched Digital Dissertations
(500 abstracts). We searched these databases by combining
terms indicative of effect studies (randomized trials, con-
trolled trials, clinical trials) and Internet (both keywords
and text words). Second, we examined the references of
earlier reviews of Internet-based interventions (Griffiths
et al. 2006; Wantland et al. 2004), and we reviewed the
reference lists of retrieved papers.
Studies were included if they met the following criteria:
(a) randomized controlled or comparative trials (b) exam-
ining interventions that were conducted through the Inter-
net (at least 50% of the intervention), (c) based on CBT
techniques, (d) aimed at behavior change (e) in patients
with an existing disorder or health problem. We excluded
170 J Behav Med (2008) 31:169–177
studies aimed at mental disorders, because another recent
systematic review was published about these studies (Spek
et al. 2007). We also excluded studies focusing on lifestyle
(smoking, obesity, exercise, nutrition), because the char-
acter of these interventions differs strongly because the
focus of these interventions is typically preventative.
There are at least 25 scales available to assess the validity
and quality of randomized controlled trials (Higgins and
Green 2005). There is no evidence, however, that these
scales provide more reliable assessments of validity. We
preferred therefore to use a simple approach for assessing
the validity of the studies, as suggested in the Cochrane
Handbook (Higgins and Green 2005).
In this context, the validity of a study can be defined as
the extent to which its design and conduct are likely to
prevent systematic errors (Moher 1995). Variation in
validity can explain variation in the results of the studies
included in a systematic review and may result in an
erroneous conclusions that an intervention is effective if
the less rigorous studies are biased toward overestimating
an intervention’s effectiveness (Higgins and Green 2005).
We assessed the validity of the studies using four basic
criteria: allocation to conditions is conducted by an inde-
pendent (third) party; adequacy of random allocation con-
cealment to respondents; blinding of assessors of outcomes;
and completeness of follow-up data.
We examined the characteristics of the target populations,
the interventions, and the design of the included studies.
We also examined which main outcome measures were
used for each study, and we calculated standardized effect
sizes for each of the main outcome measures. These effect
sizes (d) were calculated by subtracting (at post-test) the
average score of the control group (Mc) from the average
score of the experimental group (Me) and dividing the
result by the average of the standard deviations of the
experimental and control group (SDec). An effect size of
0.5 thus indicates that the mean of the experimental group
is half a standard deviation larger than the mean of the
control group. Effect sizes of 0.8 can be assumed to be
large, while effect sizes of 0.5 are moderate, and effect
sizes of 0.2 are small (Cohen 1988).
When sufficient effect sizes were available (at least
three effect sizes examining the same outcome measure in
the same health problem), we calculated pooled mean
effect sizes. For these analyses, we used the computer
program Comprehensive Meta-analysis (version 2.2.021),
developed for support in meta-analysis. As we expected
considerable heterogeneity, we decided to calculate mean
effect sizes with the random effects model. In the random
effects model, it is assumed that the included studies are
drawn from ‘populations’ of studies that differ from each
In these analyses, we tested whether there are genuine
differences underlying the results of the studies (hetero-
geneity), or whether the variation in findings is compatible
with chance alone (homogeneity; Higgins et al. 2003). As
an indicator of homogeneity, we calculated the Q-statistic.
We also calculated the I2-statistic which is an indicator of
heterogeneity in percentages as well. A value of 0% indi-
cates no observed heterogeneity, and larger values show
increasing heterogeneity, with 25% as low, 50% as mod-
erate, and 75% as high heterogeneity (Higgins et al. 2003).
A total of 61 papers which possibly met our inclusion
criteria were retrieved. Twelve studies (13 papers; two
papers were published about the same study) met our
inclusion criteria. The other studies were excluded because
they did not examine a cognitive-behavioral intervention
(30 papers), because they were not a randomized controlled
or comparative trial (11 papers), or because they did not
examine an Internet-based intervention (7 papers). Selected
characteristics of the target groups, the intervention, and
the general design of the twelve included studies are pre-
sented in Table 1.
In the twelve included studies, a total of 1,704 patients
participated, 841 in the Internet-CBT conditions, and 863
in the control conditions (mean number of respondents per
study: 142; standard deviation: 258.7). More than half of
these 1,704 patients (56%) participated in one study (Lorig
et al. 2006). In none of the other studies was the number of
patients per condition larger than 64.
Eleven studies compared an Internet-based CBT inter-
vention to a control condition, while one study compared
two types of Internet-based CBT to each other (one with
and one without weekly telephone calls). Nine of the ele-
ven controlled studies used a waiting list control group,
while one study used a care-as-usual control group, and the
other one used an information control group. In all studies,
participants were randomized to one of two conditions. In
none of the studies was Internet-based CBT compared to a
face-to-face intervention of another treatment. Six studies
only presented pre-post data, while the other six also had a
follow-up measurement (mean length of follow-up in these
six studies was 7.67 months; standard deviation 4.76).
J Behav Med (2008) 31:169–177171
Table 1 Selected characteristics of Internet-based cognitive behavioral interventions for health problems
Intervention and conditions
et al. 2003
24 Psychoeducation, applied
relaxation; problem solving;
E-mail (at request)
Weekly telephone calls
migraine-only ormixed headache
39 Progressive muscle
relaxation + cognitive stress
coping therapy (tension-
type), or autogenic training + PMR (migraine/
No therapist contact
Stro ¨m et al.
Recurrent headache Community
‡ 18 (37)
51 Psychoeducation, applied
relaxation; problem solving;
E-mail (at request)
pain + burn-out
in patients onlong-term sickleave
30 Films + texts;
+ cognitive self-treatment
(changing, coping with
shame and guilt, depression,
Real live introduction
meeting + weekly
20 weeks Pre, post,
Buhrman et al.
Chronic back pain
25 Applied relaxation; physical
exercise, coping strategies
E-mail (at request) weekly
Hicks et al.
25 Psychoeduation; relaxation;
(5 times) + telephone
contact (3 times)
et al. 2002
53 Psychoeducation; applied
relaxation; positive imagery;
advice on noise sensitivity; cognitive restructuring;
Weekly report on progress,
Hopps et al.
physical disabilities who
‡ 18 (34)
11 Psychoeducation on
verbalizations; social skills
Weekly sessions on the
12 weeks Pre, post,
172J Behav Med (2008) 31:169–177
Six studies were conducted in Sweden, four in the
United States, and two in Canada. All included studies
were conducted in the year 2000 or later (one in 2000 and
another one in 2002, two in 2003, in 2004, and in 2005, and
four in 2006).
The quality of studies varied. Three of the twelve studies
reported that allocation to conditions was conducted by an
independent party. Concealment of random allocation to
respondents was not possible in any of the studies, while
blinding of assessors was reported in none of the studies.
Drop-out numbers ranged from 2% to 61%. In only one of
the studies intention-to-treat analyses were conducted
(Hicks et al. 2006; the other studies were limited to
The target populations
Three studies focused on patients suffering from pain, three
on headache, and six on other health problems (tinnitus;
physical disabilities; chronic diseases; breast cancer;
insomnia; and pediatric brain injury). In ten of the twelve
studies, patients were recruited through announcements on
websites, referrals, and community recruitment. In the
other two studies patients were recruited through screening
of clinical samples. Ten studies were aimed at adults, two
at children. None of the interventions were aimed at older
adults, although three studies allowed older adults
(‡70 years) to participate. The other studies on adults only
included younger adults for participation or did not report
that they used an age limit.
The character of the interventions differed from each other.
One group of interventions consisted of self-help materials
on the Internet, with supporting e-mails or telephone calls
(5 studies). In two studies the intervention consisted of self-
help materials on the Internet, but without the supporting
e-mails or calls. In the other studies, the core of the
intervention consists of online contact between a therapist
or moderator and the patients (individual or in groups).
Most interventions contained psychoeducation on the spe-
cific problem, and different CBT modules such as cogni-
tive restructuring, relaxation techniques, and social skills
training. The duration of the interventions ranged between
4 and 20 weeks.
Effects of the interventions
The effects of the interventions on the main outcomes of
each included study at post-test are presented in Table 2.
We pooled the three studies in which Internet-based CBT
for pain was compared to control groups. The mean effect
Table 1 Continued
Intervention and conditions
Lorig et al.
(heart, lung, or
type 2 diabetes)
‡ 18 (57)
457 Exercise programs; relaxation;
psychoeducation; physician-patient communication;healthy eating; fatigue
Web-based bulletin board
Owen et al.
32 Psychoeducation; coping
advice for common physical
symptoms such as pain and
fatigue; structured coping-
skills training exercises
Bulletin board for
12 weeks Pre, post
Stro ¨m et al.
‡ 18 (44)
54 Psychoeducation; sleep
restriction, stimulus control,
E-mail (at request)
Wade et al.
behavior management skills;
Videocontact with therapist 14 weeks Pre, post
Abbreviations: I-CBT: Internet-CBT; NR: not reported
J Behav Med (2008) 31:169–177173
size on the main outcome measure was 0.58 (95% CI:
0.25–0.92; P < 0.001), indicating a moderate to large effect
of the interventions compared to the control groups at post-
test. Heterogeneity was very low (Q = 0.75, n.s.; I2= 0).
There were also three studies on headache, however one
did not use a true control group (but compared two active
interventions to each other). Therefore we did not pool the
results of these studies. The effect sizes of these inter-
ventions were small (d = 0.19; Stro ¨m et al. 2000) to
moderate (d = 56; Devineni et al. 2005).
The effect sizes of the other studies were in the small to
moderate range, varying from small (d = 0.10) for health
indicators in chronic diseases at one-year follow-up, to
somewhat larger for health-related quality of life in breast
cancer patients (d = 0.22) and from tinnitus sufferers
(d = 0.26), to moderate (loneliness in patients with physi-
cal disabilities; d = 0.46) and large (parental mental health
in pediatric brain injury; d = 0.70). Most effect sizes did
not significantly differ from zero because of the small
sample sizes in the majority of the studies.
This systematic review of controlled and comparative
studies of Internet-based CBT for health problems showed
that this field is developing fast. Since 2000, twelve ran-
domized studies have examined interventions for pain,
headache, and several other health problems. Half of these
trials were published in 2005 and 2006, and it can be
expected that the number of trials will rise sharply in the
next few years. Overall, findings are promising but effects
are slightly below the effect sizes found for Internet-deliv-
ered CBT for anxiety and depression (Spek et al. 2007).
Although several health problems were targeted in these
Internet-based studies, there are gaps in the literature in
terms of treatments for health problems which have been
found to improve by means of CBT. For example, several
studies have examined the effects of CBT for chronic
fatigue syndrome (Knoop et al. 2007), fibromyalgia
(Garcia et al. 2006), incontinence (Garley and Unwin
2006), or multiple sclerosis (Thomas et al. 2006), but these
Table 2 Main outcomes of studies on Internet-based cognitive behavioral interventions for health problems
Health conditionComparisonMain outcome Effect size 95% CI
Brattberg 2006 Chronic pain and
Rehabilitation course versus
waiting list control
Functional limitations 0.48 –0.03–0.99
Buhrman et al. 2004Chronic back pain Internet-guided self-help
versus waiting list control
Coping with pain0.790.22–1.36
Hicks et al. 2006 BPediatric recurrent
versus waiting list control
Pain 0.47 –0.24–1.18
Andersson et al. 2003 Headache Internet self-help with support
versus self-help only
Devineni and Blanchard 2005Chronic headacheInternet self-help versus
waiting list control
Stro ¨m et al. 2000 Recurrent headache Internet self-help versus
waiting list control
Andersson et al. 2002Tinnitus Internet CBT versus
waiting list control
Distress from tinnitus0.26 –0.23–0.75
Hopps et al. 2003Physical disabilitiesGoal-oriented CBT chat-group
teletherapy versus waiting
Lorig et al. 2006Chronic diseases Online CBT workshops
(only 1 year FU)
Owen et al. 2005Early-stage breast
Online CBT coping group
versus waiting list control
Stro ¨m et al. 2004 InsomniaInternet CBT versus waiting
Wade et al. 2006 Pediatric brain
Online family problem solving
therapy versus Internet
Parental mental health 0.700.05–1.35
aPooled with the random effects model; Z = 3.40, P < 0.001; Q = 0.75, n.s.; I2= 0
174J Behav Med (2008) 31:169–177
have not yet been transformed into a web based interven-
tion, although trials found positive effects of face-to-face
CBT for these problems. Because the promising results of
earlier studies, and because of the benefits of Internet-based
interventions, we can expect development of new programs
for these conditions in the future.
Our review does not cover the whole field of internet
interventions. While we focused on CBT for existing health
problems, several other studies have examined CBT for
mental health problems (Spek et al. 2007), on internet-
based preventive interventions aimed at a healthy lifestyle
(weight loss, smoking, exercise; e.g., Swartz et al. 2006;
Mun ˜oz et al. 2006; Oenema et al. 2001; Tate et al. 2006),
and interventions using non-CBT methods (McMahon
et al. 2005; Edwards et al. 2006; Gray et al. 2000). However,
as was shown in this review, research on CBT interventions
has been growing fast in the past few years. Because CBT
interventions are very well suited to be used through the
internet, it can be expected that research in this area will
continue to grow further in the next years.
The included studies do not yet allow us to draw definite
conclusions about whether CBT through the Internet are as
effective as face-to-face interventions. For most health
problems we found only one study examining the effects of
an Internet-based CBT study. In fact, it was only for pain
and headache did we find more than one studies. However,
the effects found for Internet-based interventions aimed at
pain are comparable to the effects found for face-to-face
treatments for pain (Morley et al. 1999), and the same is
most likely true for the Internet-interventions aimed at
headache (Bogaards and ter Kuile 1994). The other inter-
ventions also found some effects, although some effects
were stronger than others. It does seem clear, however, that
Internet-based CBT can have significant effects on some of
the health problems described in this review. For at least
one of the conditions—tinnitus—an effectiveness study has
been published showing better results then the first con-
trolled efficacy trial (Kaldo-Sandstro ¨m et al. 2004).
It has been suggested self-help interventions be used as
one of the first steps in stepped-care programs (Scogin
et al. 2003). Perhaps Internet-based interventions which are
used in healthcare settings should also be placed within
these stepped-care frameworks. In these cases, additional
care is available if the Internet-based intervention does not
reduce the problem of a patient sufficiently. On the other
hand, Internet interventions can develop as well, and might
at least for some patients be more suitable than face to face
CBT. As many health conditions such as chronic pain and
cancer require a multidisciplinary team approach for opti-
mal treatment, we assume that future Internet interventions
will take advantage of this possibility.
There is no consensus yet among researchers about the
way CBT should be presented on the Internet, although
standards are emerging. Most interventions used a guided
self-help format in which the treatment protocol is pre-
sented on the Internet and the patient works it through more
or less independently. The patients are supported by brief
contacts with therapists through e-mail or telephone.
However, other studies use a more traditional format in that
the patients go online at the same time as the therapist and
have a more or less regular treatment session. Group
treatments can also be delivered in such a way.
Another difference between interventions concerns the
additional elements on the Internet, apart from CBT. Some
interventions have combined the cognitive behavioral
interventions with other components, such as psychoedu-
cation, films and texts to read, and a forum for users of the
website. Other interventions do not provide such extras.
Our review showed up several other important limita-
tions of the current research in this area. First, most studies
used waiting list control groups, and only very few used a
care-as-usual or another control group. Subjects in waiting
list control groups probably do not take constructive action
to reduce their problems themselves during the waiting
period, because they are expecting professional help in the
future. This may result in an overestimation of the effects
of an intervention, because there may be less spontaneous
Second, most studies recruited participants through the
community and through other websites. This is not a
problem for interventions that target the general popula-
tion. But when such an intervention is effective this does
not automatically mean that it is also effective in clinical
settings. Subjects who are responding to community
recruitment are probably very motivated which may
improve their results compared to subjects who receive
Third, none of the twelve identified trials compared
Internet-based treatments to face-to-face or other treat-
ments. This is, however, an important issue, because only
direct comparisons can give evidence about the compara-
tive effects of Internet-based treatments compared to more
traditional treatments and the type of patients who can
benefit from it.
Fourth, most studies were aimed at adults. Only two
studies were aimed at children and adolescents, while these
groups are probably the most familiar with the Internet.
None of the studies were specifically aimed at older adults,
while they suffer most from health conditions.
Future research should focus on these limitations of
current research. More studies are needed with care-
as-usual or other control groups, clinical recruitment strat-
egies, comparisons with face-to-face treatments, and
children or older adults as target populations. More research
is also needed to examine how CBT should be presented on
the Internet, and to examine reasons and solutions to the
J Behav Med (2008) 31:169–177 175
relatively high drop-out rates in several studies. Finally, it
is also important to study how Internet-administered CBT
can be integrated in stepped-care models of care.
This review has several limitations. First, the number of
included studies is still very small. And the number of
studies examining specific health problems is too small to
integrate the results of these studies statistically into a
meta-analysis. Second, the quality of the included studies is
not optimal. Third, the drop-out rates reported are high in
some studies. This is a concern for this type of intervention,
as patients can very easily withdraw from the intervention.
Remarkably, the studies in which more traditional therapies
(live sessions with therapists) are delivered through the
Internet have the lowest drop-out rates.
Despite these limitations, however, there is no doubt that
the number of studies in this area will increase consider-
ably in the next few years, while the promising results of
the studies in this review indicate that the Internet will
assume a major role in the delivery of CBT to patients with
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