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Major depression is highly prevalent, and is associated with high societal costs and individual suffering. Evidence-based psychological treatments obtain good results, but access to these treatments is limited. One way to solve this problem is to provide internet-based psychological treatments, for example, with therapist support via email. During the last decade, internet-delivered cognitive-behavioral therapy (ICBT) has been tested in a series of controlled trials. However, the ICBT interventions are delivered with different levels of contact with a clinician, ranging from nonexisting to a thorough pretreatment assessment in addition to continuous support during treatment. In this review, the authors have found an evidence for a strong correlation between the degree of support and outcome. The authors have also reviewed how treatment content in ICBT varies among treatments, and how various therapist factors may influence outcome. Future possible applications of ICBT for depression and future research needs are also discussed.
Content may be subject to copyright.
10.1586 /ERN.12.63 861
ISSN 1473-7175
© 2012 Expert Reviews Ltd
Robert Johansson1 and
Gerhard Andersson*1,2
1Department of Behavioural Sciences
and Learning, Linköping University,
SE-58183 Linköping, Sweden
2Department of Clinical Neuroscience,
Psychiatry Section,
Karolinska Institutet, Sweden
*Author for correspondence:
Major depression is highly prevalent, and is associated with high societal costs and individual
suffering. Evidence-based psychological treatments obtain good results, but access to these
treatments is limited. One way to solve this problem is to provide internet-based psychological
treatments, for example, with therapist support via email. During the last decade, internet-
delivered cognitive-behavioral therapy (ICBT) has been tested in a series of controlled trials.
However, the ICBT interventions are delivered with different levels of contact with a clinician,
ranging from nonexisting to a thorough pretreatment assessment in addition to continuous
support during treatment. In this review, the authors have found an evidence for a strong
correlation between the degree of support and outcome. The authors have also reviewed how
treatment content in ICBT varies among treatments, and how various therapist factors may
influence outcome. Future possible applications of ICBT for depression and future research
needs are also discussed.
Internet-based psychological
treatments for depression
Expert Rev. Neurother. 12( 7) , 8 61– 870 (2012)
Keywor ds: cognitive-behavioral therapy • depression • internet delivered • self-help • therapist factors
Expert Review of Neurotherapeutics
© 2012 Expert Reviews Ltd
Internet-based psychological treatments for depression
Johansson & Andersson
Expert Rev. Neurother.
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Expert Rev. Neurother. 12(7), (2012)
Review CME
Major depression is a worldwide health problem, which low-
ers the quality of life for the individual and generates huge
costs for society [1,2]. In a 2003 survey, approximately half of
the 12-month cases in the USA were receiving treatment for
depression, and only 18–25% were adequately treated [3]. Several
forms of psychotherapy have been found to be effective in the
treatment of depression [4], and treatments that are structured
follow a treatment manual and are time limited and in general
equally effective in the treatment of mild-to-moderate depression.
Such treatments include cognitive-behavioral therapy (CBT),
behavioral activation, interpersonal psychotherapy, short-term
psychodynamic therapy and problem-solving therapy. These
structured psychological treatments seem to work better than
unstructured, nondirective therapeutic approaches [5]. CBT has
a strong empirical base for depression [4], with the largest number
of controlled trials among different psychotherapies. In short,
CBT is an umbrella term for various treatments using cognitive
and behavioral techniques.
CBT has been found to be transferable to the internet format,
especially in the form of guided self-help [6]. Guided self-help is
a format of treatment delivery that presents structured self-help
materials (e.g., via the internet) together with therapist contact
(e.g., by email). The role of the therapist is to provide support,
encouragement and occasionally direct therapeutic activities [6].
In 2006, a summary of current research on internet-based
CBT (ICBT) for depression was published [7]. The field was
quite new then, but the results were regarded as promising. By
then, only five controlled ICBT studies existed that had tar-
geted depression. Hence, no firm conclusions could be drawn
regarding the overall efficacy and whether therapist support was
crucial. Since then, the field has evolved very rapidly and the
need for an update of the previous review is evident. The aim
of this review is to provide an updated summary of research on
ICBT for depression. The authors have focused on four main
issues in this paper: the overall effect of ICBT for depression,
the role of support in ICBT, how treatment content varies in
ICBT and the role of the therapist. The authors conclude by
discussing future research needs and further topics concerning
ICBT for depression.
The overall effect of ICBT for depression
Initially, the authors provide a summary of a selection of previous
reviews. In a meta-analysis from 2009, the overall effect of
internet-based and computerized treatments for depression was
investigated [8], but not restricted only to ICBT even if the majority
of studies can be categorized as ICBT. The authors included
15 comparisons and found that the overall effect size (Cohen’s d)
was d = 0.41 (95% CI: 0.29–0.54). Importantly, this effect size
was significantly moderated by a difference between guided
(d = 0.61; 95% CI: 0.45–0.77) and unguided (d = 0.25;
95% CI: 0.14–0.35) treatments. This result was mirrored by
a meta-analysis on self-guided psychological treatments (not
necessarily internet based or computer based) [9], which found an
overall effect size of d = 0.28 (95% CI: 0.14–0.42). Another meta-
analysis, which focused on ICBT for both depression and anxiety
disorders, found an overall effect size (Hedges’s g) of g = 0.78 for
the depression studies [10] . These average effect sizes indicate that
guided ICBT for depression may be on a par with face-to-face
treatment. This claim was also supported by a meta-analysis on
ICBT and guided self-help treatments for depression and anxiety
disorders [11] . In this analysis, 21 randomized controlled trials
were included, in which participants were randomized to either
guided self-help or face-to-face treatment. The overall between-
group effect size was d = -0.03, indicating no difference between
internet-based and face-to-face treatments in general. In summary,
there is mounting support for a difference between guided and
unguided ICBT, but no evidence for a difference between guided
ICBT and face-to-face therapy.
Financial & competing interests disclosure
ublish er
Elisa Manzotti
Publisher, Future Science Group, London, UK.
Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.
Laurie Barclay
Freelance writer and reviewer, Medscape, LLC.
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
rEdEn tiAls
Robert Johansson, MSc
Department of Behavioural Sciences and Learning, Linköping University, Sweden.
Disclosure: Robert Johansson, MSc, has disclosed no relevant financial relationships.
Gerhard Andersson, PhD
Department of Behavioural Sciences and Learning, Linköping University, Sweden; Department of Clinical Neuroscience, Psychiatry Section,
Karolinska Institutet, Sweden.
Disclosure: Gerhard Andersson, PhD, has disclosed the following relevant financial relationships: This paper was sponsored in part by the Swedish
research council and Linköping University (Professor contract).
Johansson & Andersson
The present review
The authors were able to include data from a total of 25 con-
trolled trials. In eight of these trials, more than one treatment
was compared with a control condition, resulting in a total of
33 comparisons with a control (such as waiting list or care as
usual). The studies included were located via Medline, refer-
ence lists and a search for ongoing studies conducted by active
researchers in the field. An overview of the located studies is
given in Tab le 1. As seen in the table, effect sizes range between
0.10 and 1.20. As the aim of this report was not to conduct a
formal meta-analysis, the mean effect size is not reported. While
three studies formally contained other treatments than CBT
(problem-solving therapy [1 2 ,1 3] and psychoeduction [14] ), they
were regarded as relevant for the review.
How important is guidance in guided ICBT?
As mentioned in the previous paragraph, there is evidence that
guided ICBT is more effective than unguided, but the question
is debated as unguided treatments cost less and can reach more
people, whereas guided treatments appear to be more effective but
have a narrower target group. There are also some inconsistencies
on how guidance has been defined. Traditionally, guidance or
support is provided during treatment. It is, however, unknown
how contact before or after treatment affects the outcome [15] .
In this review, the included published studies were categorized
according to the type of support provided. By support, the authors
mean contact with a human and not an automated system that
may handle screening, measures and automated reminders. The
degree of support was designed as 0 when there was no human
contact before, during or after the treatment period. Category 1
was assigned when there was contact only before the treatment.
Category 2 was coded when there was contact mainly during the
treatment. Finally, the degree of support was defined as 3 when
there was a contact with the research staff or clinicians before,
during and after the treatment period.
As indicated in Figur e 1, the between-group effect sizes vary
depending on the degree of support. The average effect sizes
for the respective categories were d = 0.21, 0.44, 0.58 and 0.76.
A Spearman correlation of ρ = 0.64 (p < 0.01) was obtained
between degree of support and effect size, indicating that more
support yields larger effects. In Figure 1, all 33 comparisons to a
control condition are illustrated. However, as two effect sizes
overlap in the figure, only 31 comparisons are visible.
This opens up more fine-grained differences between ICBT
treatments for speculation. For example, two recent studies on
unguided treatments showed medium-to-large effects when
including a contact by telephone before treatment [16,17]. In
one case, these telephone contacts were a structured diagnostic
interview and in the other an eligibility screening, but in both
studies it was provided by trained staff. However, this is in contrast
to two previous studies on unguided treatment, where face-to-face
contact was provided before treatment. These studies had low [18] or
close to nonexisting effects compared with a control condition [19 ] .
Figur e 1 indicates that a pretreatment contact could enhance
guided treatments, which do not have a telephone or face-to-face
contact before treatment. This pretreatment contact is often in
the form of a structured diagnostic interview [20,21], and probably
results in more reliable diagnostic categories for inclusion in a
trial. However, no trial exists in which this condition is directly
manipulated. Future studies could use meta-analytical tools to
explore how pretreatment contact including structured diagnostic
procedures moderates treatment outcome.
The effect of pretreatment contact in unguided and guided
internet-based treatments is a topic for further research. An
exploration of this issue will also open up questions concerning
the nature of such contacts. For example, it is unclear whether
contacts that focus on motivation to complete the treatment will
be more effective than other contacts in the treatment of depres-
sion [22] . In addition, reliable diagnostic procedures may also
enhance overall treatment effects, for example, by ensuring that
the patients included in the treatment present with problems, that
the treatment is intended to treat.
The effect of a clear deadline is related to the effect of pre-
treatment contacts. This has not been tested explicitly in ICBT
for depression, but there is some evidence from bibliotherapy on
panic disorder. In a study, 40 patients diagnosed with panic disor-
der were randomized to self-help treatment with a clear deadline
or to a waiting list [15] . After 10 weeks, all patients completed a
telephone interview, which had been scheduled when the treat-
ment started. The treatment had an average effect size of d = 1.0,
indicating that the treatment was highly effective and that a clear
deadline scheduled in advance was enough to motivate the partici-
pants to complete the treatment on their own. How this could be
generalized to ICBT for depression is a topic for future research.
In conclusion, there is now a strong support for the claim that
guided internet-based psychological treatments are more effective
than unguided treatments. The categorization of studies after
degree of support indicates that the effect of guidance may be
moderated by whether pretreatment contact is available. Further
exploration of these moderators is a topic for future meta-analyses.
Does treatment content in ICBT matter?
With a few exceptions, all published studies considered in this
review have been based on CBT. One Australian study [14]
included a psychoeducational intervention and two studies from
The Netherlands tested the efficacy of an internet-based problem-
solving therapy [12,13] . Both these treatments seem to be com-
parable in efficacy to CBT [1 3, 14 ] . These results are mirrored by
the fact that there are few indications of differences in efficacy
between various face-to-face psychological treatments for depres-
sion [4]. This also indicates that psychological treatments other
than CBT may be possible to deliver via the internet. For exam-
ple, the authors’ research group has recently completed a trial
on internet-based psychodynamic treatment for depression where
the between-group effect size, compared with an active control,
was d = 1.11 (95% CI: 0.67–1.56). In this study, the active con-
trol condition consisted of psychoeducation and weekly support
contacts online. These studies suggest that psychological treat-
ments other than CBT can be delivered through the internet and
open up a mixture of various treatment approaches, for example,
Internet-based psychological treatments for depression
Expert Rev. Neurother. 12(7), (2012)
Review CME
Table 1. Overview of controlled trials of internet-delivered cognitive-behavioral therapy for depression.
Country Comment Contact
Condition n Main
Measure Effect
et al. (2005)
Sweden None Email 1. CBT 57 1 > 2 BDI and
0.88 [43]
2. WL + DG 60
Berger et al.
Switzerland Guided ICBT (1)
versus nonguided
ICBT (2)
Phone Email 1. CBT 25 1 = 2 > 3 BDI 1.14 [16]
None 2. CBT 25 0.66
3. WL 26
Calear et al.
Australia ICBT for
None None 1. CBT 563 1 = 2 CES-D 0 .15 [4 4]
2. WL 914
Choi et al.
Australia ICBT for Chinese
Phone Email 1. CBT 25 1 > 2 BDI and
0.72 [33]
2. WL 30
et al. (2004)
Australia None Phone 1. CBT 182 1 = 2 > 3 CES-D 0.36 [14]
Phone 2. PE 165 0.33
3. PLA 178
Clarke et al.
USA None None 1. CBT 144 1 = 2 CES-D 0.00 [45]
2. CAU 155
Clarke et al.
USA PCs and
PHs made
None None: PC 1. CBT 75 1 + 2 > 3 CES-D 0.31 [46]
None: PHs 2. CBT 80 0.25
3. CAU 100
Clarke et al.
USA ICBT for young
None None 1. CBT 83 1 > 2 PHQ-9 0.17 [47]
2. CAU 77
de Graaf
et al. (2009)
Live None 1. CBT 100 1 = 2 BDI 0.05 [19]
2. CAU 103
Farrer et al.
Australia Guided ICBT (1)
versus nonguided
ICBT (2)
Phone Email 1. CBT 45 1 = 2 > 3 CES-D 1.07 [1 7]
None 2. CBT 38 0.78
3. CAU 35
et al. ( 2011)
Sweden Relapse
Phone Email 1. CBT 42 1 = 2 BDI and
0.31 [29]
2. CAU 42
et al. (2012)
Sweden Tailored ICBT (1)
versus nontailored
Phone Email 1. CBT 39 1 = 2 > 3 BDI and
0.82 [26 ]
Email 2. CBT 40 0.58
3. WL + DG 42
Kessler et al.
UK Phone and
Chat 1. CBT +
149 1 > 2 BDI 0.61 [28]
2. CAU 148
Meyer et al.
Germany None None 1. CBT 320 1 > 2 BDI 0.64 [23]
2. WL 76
et al. (2006)
Australia ICBT for
None None 1. CBT 35 1 = 2 CES-D 0 .10 [48]
2. CAU 24
et al. (2009)
Australia ICBT for
adolescent girls
None None 1. CBT 67 1 > 2 CES-D 0 .18 [49]
2. CAU 90
Effect size: Between-group Cohen’s d. This estimate is pooled if several measures of depression are used.
BDI: Beck’s Depression Inventory; CAU: Care as usual; CBT: Cognitive-behavioral therapy; CES-D: Center for Epidemiologic Studies Depression Scale; DG: Discussion
group; ICBT: Internet-delivered cognitive-behavioral therapy; MADRS-S: Montgomery–Åsberg Depression Rating Scale – Self-rated; MDI: Major Depression Inventory;
PC: Post card; PE: Psychoeducation; PH: Phone call; PHQ-9: 9-item Patient Health Questionnaire Depression Scale; PLA: Placebo treatment; PST: Problem-solving
therapy; SCL-90-R-D: Depression subscale of the Symptom Checklist-90-Revised; WL: Waiting list.
Johansson & Andersson
Table 1. Overview of controlled trials of internet-delivered cognitive-behavioral therapy for depression
Country Comment Contact
Condition n Main
Measure Effect
Perini et al.
Australia Phone Email 1. CBT 27 1 > 2 BDI and
0.76 [20 ]
2. WL 18
et al. (2009)
None Email 1. CBT 36 1 > 2 BDI and
0.94 [5 0]
2. WL 18
Spek et al.
ICBT for adults
>50 years old
Live None 1. CBT 102 1 > 2 BDI 0.27 [18]
2. WL 100
Titov et al.
(2010 )
Australia Clinician-assisted
(1) versus
assisted (2)
Phone Email and
1. CBT 47 1 = 2 > 3 BDI and
1.20 [37]
Email and
2. CBT 43 1.18
3. WL 40
Titov et al.
Australia Transdiagnostic
Phone Email and
1. CBT
2. WL
1 > 2 PHQ-9 0.58 [24]
et al. ( 2011)
Type 1 and Type 2
Phone Email 1. CBT 125 1 > 2 CES-D 0.29 [31]
2. WL 130
van Straten
et al. (2008)
None Email 1. PST 107 1 > 2 CES-D and
0.50 [12 ]
2. WL 106
et al. (2010 )
Sweden Email therapy (1)
versus guided
self-help (2)
Live Email 1. CBT 29 1 = 2 > 3 BDI and
0.89 [21]
Email 2. CBT 27 0.46
3. WL 29
et al. (2008)
None Email 1. CBT 88 1 = 2 > 3 CES-D 0.55 [1 3]
Email 2. PST 87 0.47
3. WL 87
Effect size: Between-group Cohen’s d. This estimate is pooled if several measures of depression are used.
BDI: Beck’s Depression Inventory; CAU: Care as usual; CBT: Cognitive-behavioral therapy; CES-D: Center for Epidemiologic Studies Depression Scale; DG: Discussion
group; ICBT: Internet-delivered cognitive-behavioral therapy; MADRS-S: Montgomery–Åsberg Depression Rating Scale – Self-rated; MDI: Major Depression Inventory;
PC: Post card; PE: Psychoeducation; PH: Phone call; PHQ-9: 9-item Patient Health Questionnaire Depression Scale; PLA: Placebo treatment; PST: Problem-solving
therapy; SCL-90-R-D: Depression subscale of the Symptom Checklist-90-Revised; WL: Waiting list.
by including treatment components from non-CBT treatments
within a CBT framework. Deprexis, the treatment tested by
Meyer et al. [23] and Berger et al. [16] , is an example of such a
blend as it includes positive psychology interventions, dreamwork
and emotion-focused interventions above more traditional cogni-
tive and behavioral techniques. Future studies evaluating such
component-based treatments could include process measures to
investigate the specific effects of various components.
As pointed out earlier, the amount of guidance varies between
treatments (i.e., guided vs unguided treatments). Besides, the
treatments investigated also vary in scope (e.g., if the treatment
specifically targets depression or has a general scope to also target
for example, comorbid anxiety disorders), which phase of depres-
sion treatment is in focus (e.g., treatment in the acute phase or
relapse prevention after recovery), and if the treatment is given as
a standalone treatment or is given as a complement to regular care.
Recently, there have been examples of treatments targeting a
broader scope than depression. An Australian team has explored
a transdiagnostic ICBT intervention in the treatment of depres-
sion and anxiety disorders [2 4]. This treatment appears to be
effective both in the treatment of depression and anxiety. A
transdiagnostic treatment conceptualizes a psychological prob-
lem in general terms and provides general treatment ingredients,
assumed to be able to target multiple conditions. The primary
benefit of this kind of ‘one size fits all’ treatment is that it makes
the procedure of treatment selection less demanding. This may,
for example, be of benefit in treatment contexts where time
and/or competence for thorough assessment is missing, for
example, in primary care.
In Sweden, there are recent examples of individually tailored
ICBT treatments for depression and anxiety disorders [25, 26] .
Instead of providing the same material to all participants, a
Internet-based psychological treatments for depression
Expert Rev. Neurother. 12(7), (2012)
Review CME
treatment package is tailored from a pool of different treatment
modules. For example, a patient with a diagnosis of depression
and generalized anxiety disorder (GAD) may receive a treatment
based on behavioral activation, cognitive restructuring and inter-
ventions targeting worry (e.g., worry time and exposure to worry).
Recent results exist proving the efficacy compared with control
for mixed anxiety [25 ,27] and in the treatment of depression with
a high amount of comorbid anxiety [26] . The study by Johansson
et al. included a comparison between tailored and nontailored
treatment for depression and provided data that indicate that
tailored treatment is superior to nontailored treatment for patients
with more severe forms of depression [26] . This study is one of the
few that provides some indications of differential efficacy between
active treatments.
Instead of providing ICBT as a standalone treatment, there are
examples of studies investigating the efficacy of ICBT added to
care as usual (CAU). One example is a large primary care study
from the UK where real-time online CBT was added to CAU
[28] . The CBT plus CAU intervention outperformed CAU alone,
measured by the amount of patients who recovered from depres-
sion. This study is an example of how ICBT can enhance regular
treatment in terms of efficacy. In another study, adding ICBT to
CAU did not improve the outcome [19] . However, despite similar
delivery context and study design, there are important differ-
ences between the therapist-supported intervention in the study
by Kessler et al. [28] and the nonguided intervention in the study
by de Graaf et al. [19] .
The majority of ICBT treatments for
depression have been conducted on depres-
sion in the acute phase. One exception is
that the treatment developed by Holländare
et al., where people suffering from partially
remitted depression after previous treat-
ment were randomized to ICBT or to a
control condition [29] . Significantly, fewer
participants receiving ICBT experienced
relapse compared with those in the con-
trol group (10.5 compared with 37.8%),
which is in line with previous face-to-face
studies [3 0].
Recently, there have been examples on
how ICBT has been adapted for depression
in specific populations. A study from The
Netherlands tested ICBT for depression in
a population with Type 1 and Type 2 dia-
betic patients with depressive symptoms
[31] . The ICBT intervention had a small
to medium effect on depressive symp-
toms, which was the primary outcome.
Another recent attempt to reach out to
specific populations is the study by Smith
et al., in which an internet-based psych-
oeducational intervention was tested for
patients with bipolar disorder [32] . In the
study, there were no significant differences
on any of the outcome measures between the intervention and
the control group. However, there was a difference in a sub-
scale measuring psychological quality of life. Despite few dif-
ferences between treatment and control, this study represents
a proof-of-concept that it is possible to deliver an ICBT inter-
vention to patients with bipolar disorder. Finally, there is an
Australian study on a culturally attuned ICBT intervention for
depressed Chinese Australians [33] . The program was translated
to Mandarin/Cantonese and had the content culturally adapted,
in terms of text and exercises. On average, the between-group
effect for the ICBT intervention compared with control was
In summary, as the field of ICBT treatments for depression
expands rapidly, examples of other treatment approaches than
CBT have begun to emerge. With the exception of study by
Johansson et al., no study exists where differences in efficacy
between ICBT treatments are observed [26] . Differences in work-
ing mechanisms and efficacy are topics for future research. As
depression continues to be a worldwide health problem, ICBT
has proven to be a way to reach out to new populations.
Is it important who the therapist is & what the
therapist does?
Despite many new studies on ICBT for depression, including
meta-analyses proving the importance of guidance, little is known
about the role of therapist factors in internet-based treatments. Two
Swedish studies exist that have specifically investigated the therapist
d = 0.21
Degree of support
Between-group effect size (Cohen’s d)
d = 0.44
d = 0.58
d = 0.76
Figure 1. Categories of degree of support. The degrees of support are defined as
follows: 0, no therapist contact either before nor during treatment; 1, contact before
treatment only; 2, contact during treatment only; and 3, contact both before and during
treatment. The large dots represent effect sizes (Cohen’s d) between internet-delivered
cognitive-behavioral therapy conditions and controls. The horizontal lines between the
smaller dots lines represent the average effect size per category of degree of support.
Johansson & Andersson
Key issues
Internet-based psychological treatments are effective and provide an important treatment alternative to face-to-face psychological
treatments and medication.
Guided internet-delivered cognitive-behavioral therapy (ICBT) treatments are more effective than unguided ICBT.
Contact before and/or after the treatment may potentially enhance both guided and unguided ICBT.
Unified and tailored ICBT approaches provide a promising treatment development that may broaden the scope of ICBT.
Little is known about the therapist factor in ICBT. There are some indications that nonclinicians may be able to provide ICBT.
Modern technology, such as smartphones and artificial intelligence, may potentially enhance ICBT.
effect in ICBT for depression and anxiety disorders, respectively
[34 ,35] . In these studies, the patients’ measurements were modeled to
be clustered within a specific therapist. Using these two-level mod-
els, the therapist effects were measured by the intraclass correlation,
which is a measure of the variability due to the clustering. Small
intraclass correlations are found on some measures, indicating
nonexisting or small therapist effects in ICBT [34 ,35] .
Another way of studying therapist effects in ICBT is to search
for specific therapist behaviors in text conversations. This was
done in a recent study on ICBT for GAD [3 6] . Results showed that
therapist behavior, such as deadline flexibility, was negatively cor-
related to change scores on the main outcome measure. Further
results showed that behaviors, such as task reinforcement, task
prompting and making empathic utterances, were all correlated
with module completion [3 6] . This study opens the way for micro-
analyses of therapist behavior in ICBT, which may enhance ICBT
for depression and other conditions.
Three Australian studies on ICBT, for depression, social anxi-
ety disorder and GAD, compared treatment outcome when the
therapist was either a psychologist or a computer technician [37–39].
While each study only had one therapist and one technician, the
data give no support for differences in treatment outcome between
therapists in ICBT.
One factor that is known to vary bet ween therapists is therapeutic
alliance. A recent study explored alliance in ICBT and face-to-face
therapy for depression [4 0]. While alliance was present and compa-
rable in the two groups, it could not predict treatment outcome in
any of the two treatment groups. This is mirrored in the study by
Knaevelsrud and Maercker, in which therapeutic alliance was found
important in ICBT for post-traumatic stress disorder [4 1] . However,
while the authors found high patient ratings of alliance, associa-
tions with treatment outcome were modest. This finding mirrors
unpublished data from the authors’ research group on alliance in
ICBT. Although high alliance ratings have been found in the trials,
we cannot predict treatment outcome using alliance ratings.
In summary, little is known about the role of therapist factors in
ICBT. The Australian studies indicate that it is possible to specify
the therapist behavior as certain ‘roles’, which even nonclinical staff
can adhere to. Studies on therapeutic microprocesses may reveal
effective and ineffective therapist behavior, and the importance of
adequate self-help texts should also be investigated [42].
Expert commentary & five-year view
Major depression is a worldwide health problem for which cost-
effective interventions are needed. Recent reviews conclude that
internet-based psychological treatments are important treat-
ment alternatives that can be as effective as face-to-face CBT.
This review has explored how contact before and after treatment
may moderate treatment outcomes in both unguided and guided
ICBT. Future controlled trials and meta-analytic reviews should
investigate the specific effect of this kind of support. As ICBT
begins to reach out to healthcare providers, for example, primary
care, where time may be very limited, more detailed knowledge
about the role of therapist contact is needed. For example, an
unguided self-help program with a thorough assessment and
clear deadline may be easier to implement in primary care than a
treatment that requires continuous therapist support. As pretreat-
ment interviews often involve diagnostic procedures, the time
invested could also prevent prescribing ICBT to patients who
drop out immediately or receive a treatment that does not suit
their problem profile.
Future research should explore how to make guided and
unguided ICBT even more effective. It is reasonable to believe that
ICBT could be enhanced if integrated with day-to-day techno logy,
such as modern mobile telephones (smartphones). For example,
a technique such as activity scheduling seems optimal for using
a smartphone with automatic reminders. ICBT may be further
enhanced by integrating more recently developed technology
from computer science, such as the field of artificial intelligence.
This kind of technology could be used for automatic feedback,
intelligent adaption and tailoring of treatment material, among
other things. Using modern technology, it is not unreasonable to
believe that unguided ICBT could be as effective as guided ICBT.
Moreover, not all patients require much support, and the dissemi-
nation of ICBT would be helped by systems that could identify
when human support is needed to prevent treatment failure.
Papers of special note have been highlighted as:
• of interest
• of considera ble interest
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• ImportantstudyofICBTinanew
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assisted internet-based treatment is
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Internet administered guided self-help
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48(5), 368–376 (2010).
22 Titov N, Andrews G, Schwencke G,
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• UnguidedICBTprovestobeunusually
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• TransdiagnosticICBTfordepressionand
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26 Johansson R, Sjöberg E, Sjögren M et al.
Tailored vs. standardized internet-based
cognitive behavior therapy for depression
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• IndicationsthattailoredICBTmaywork
27 Silfvernagel K, Carlbring P, Kabo J et al.
Individually tailored internet-based
treatment of young adults and adults with
panic symptoms: a randomized controlled
trial. J. Med. Internet Res. 14(3), e65. (2012).
28 Kessler D, Lewis G, Kaur S et al. Therapist-
delivered internet psychotherapy for
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• DeliversICBTonalargesca le.
29 Holländare F, Johnsson S, Randestad M
et al. Randomized trial of internet-based
relapse prevention for partially remitted
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285–294 (2011).
• InvestigateshowICBTcanprevent
30 Vittengl JR, Clark LA, Dunn TW, Jarrett
RB. Reducing relapse and recurrence in
unipolar depression: a comparative
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31 van Bastelaar KM, Pouwer F, Cuijpers P,
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Johansson & Andersson
32 Smith DJ, Griffiths E, Poole R et al.
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• ICBTforbipolardisorder.
33 Choi I, Zou J, Titov N et al. Culturally
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• ICBTinaChinesepopulation.
34 Almlöv J, Carlbring P, Berger T, Cuijpers
P, Andersson G. Therapist factors in
internet-delivered cognitive behavioural
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Cogn. Behav. Ther. 38(4), 247–254 (2009).
35 Almlöv J, Carlbring P, Källqvist K, Paxling
B, Cuijpers P, Andersson G. Therapist
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for anxiety disorders. Behav. Cogn.
Psychother. 39(3), 311–322 (2011).
36 Paxling B, Lundgren S, Norman A et al.
Therapist behaviours in internet-delivered
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generalized anxiety disorder. Behav. Cogn.
Psychother. doi:10 .1017/S1352465812 000240
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• Novelanalysisoftherapistbehavior
37 Titov N, Andrews G, Davies M, McIntyre
K, Robinson E, Solley K. Internet
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• Indicatesthatatechnicianca ndeliver
ICBTwithpreservedef cacy.
38 Robinson E, Titov N, Andrews G,
Mcintyre K, Schwencke G, Solley K.
Internet treatment for generalized anxiety
disorder: a randomized controlled trial
comparing clinician vs. technician
assistance. PLoS ONE 5(6), e10942
39 Titov N, Andrews G, Schwencke G, Solley
K, Johnston L, Robinson E. An RCT
comparing two types of support on severity
of symptoms for people completing
internet-based cognitive behavior therapy
for social phobia. Aust. NZ J. Psychiatry
43(10), 920–926 (2009).
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working alliance in a randomized controlled
trial comparing online with face-to-face
cognitive-behavioral therapy for depression.
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Internet-based psychological treatments for depression
Expert Rev. Neurother. 12(7), (2012)
Review CME
Internet-based psychological treatments for depression
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1. Based on the review by Drs. Johansson and Andersson, which of the following statements about the overall effect
of internet-delivered cognitive-behavioral therapy (ICBT) for depression is most likely correct?
£AICBT is significantly less effective for depression than face-to-face treatments
£BICBT is as effective as face-to-face treatments for anxiety
£CFor depression, ICBT provides an important treatment alternative to face-to-face psychological treatments and
£DMost internet-based therapy involves problem-solving therapy
2. Your patient is a 48-year-old woman with depression. Based on the review by Drs. Johansson and Andersson,
which of the following statements about the importance of guidance to outcomes of ICBT is most likely correct?
£AGuided and unguided ICBT treatments are about equally effective
£BContact before and/or after ICBT does not affect the efficacy of guided or unguided ICBT
£CDegree of human support was significantly correlated with effect size
£DThe specific focus of the human contact does not appear to affect ICBT efficacy
3. Based on the review by Drs. Johansson and Andersson, which of the following statements about the effect of
treatment content and other variables on outcomes of ICBT for the patient described in question 2 would most
likely be correct?
£AStudies have shown that efficacy of ICBT is best when it is performed by a therapist
£BSmartphones, artificial intelligence, and other modern technology methods may potentially enhance ICBT
£CTherapeutic alliance is a significant, dramatic predictor of treatment outcome in ICBT
£DAll studies have shown that tailored ICBT is superior to non-tailored ICBT regardless of depression severity
Johansson & Andersson
... For instance, clinicians encounter difficulty with executing novel workflow processes [50][51][52][53][54], such as creating login accounts for patients and "teaching" them to use apps [40,55,56], often impacting adoption of these treatments [52,57,58]. A second challenge is that patients often need human support to effectively engage in digital therapeutics [53,54,[59][60][61][62]. Successful implementations must provide support to patients to help them engage in use of apps, without overburdening primary care teams [51,53,54,59,63]. ...
... Coaching is an effective strategy for engaging patients in digital therapeutics [53,54,[59][60][61]. ...
Full-text available
Background Experts recommend that treatment for substance use disorder (SUD) be integrated into primary care. The Digital Therapeutics for Opioids and Other SUD (DIGITS) Trial tests strategies for implementing reSET® and reSET-O®, which are prescription digital therapeutics for SUD and opioid use disorder, respectively, that include the community reinforcement approach, contingency management, and fluency training to reinforce concept mastery. This purpose of this trial is to test whether two implementation strategies improve implementation success (Aim 1) and achieve better population-level cost effectiveness (Aim 2) over a standard implementation approach. Methods/Design The DIGITS Trial is a hybrid type III cluster-randomized trial. It examines outcomes of implementation strategies, rather than studying clinical outcomes of a digital therapeutic. It includes 22 primary care clinics from a healthcare system in Washington State and patients with unhealthy substance use who visit clinics during an active implementation period (up to one year). Primary care clinics implemented reSET and reSET-O using a multifaceted implementation strategy previously used by clinical leaders to roll-out smartphone apps (“standard implementation” including discrete strategies such as clinician training, electronic health record tools). Clinics were randomized as 21 sites in a 2x2 factorial design to receive up to two added implementation strategies: (1) practice facilitation, and/or (2) health coaching. Outcome data are derived from electronic health records and logs of digital therapeutic usage. Aim 1’s primary outcomes include reach of the digital therapeutics to patients and fidelity of patients’ use of the digital therapeutics to clinical recommendations. Substance use and engagement in SUD care are additional outcomes. In Aim 2, population-level cost effectiveness analysis will inform the economic benefit of the implementation strategies compared to standard implementation. Implementation is monitored using formative evaluation, and sustainment will be studied for up to one year using qualitative and quantitative research methods. Discussion The DIGITS Trial uses an experimental design to test whether implementation strategies increase and improve the delivery of digital therapeutics for SUDs when embedded in a large healthcare system. It will provide data on the potential benefits and cost-effectiveness of alternative implementation strategies. Identifier: NCT05160233 (Submitted 12/3/2021).
... Because the sample excluded participants who had more severe forms of mental illness (e.g., active suicidality, schizophrenia, bipolar I), these results may generalize best to people with mild, moderate, or moderately severe levels of depression symptoms. Second, this study may only generalize to therapist-supported DMHIs, which have been shown to be associated with higher levels of engagement and more positive outcomes compared to self-guided, text-based, and automated DMHIs [46][47][48][49]. It is possible that the therapist supports increase engagement and symptom improvements through a remote continuous care approach whereby therapists first establish rapport and trust with patients, then foster a digital therapeutic alliance over the duration of the intervention [50,51]. ...
Full-text available
PurposeMajor depression affects 10% of the US adult population annually, contributing to significant burden and impairment. Research indicates treatment response is a non-linear process characterized by combinations of gradual changes and abrupt shifts in depression symptoms, although less is known about differential trajectories of depression symptoms in therapist-supported digital mental health interventions (DMHI).Methods Repeated measures latent profile analysis was used to empirically identify differential trajectories based upon biweekly depression scores on the Patient Health Questionnaire-9 (PHQ-9) among patients engaging in a therapist-supported DMHI from January 2020 to July 2021. Multivariate associations between symptom trajectories with sociodemographics and clinical characteristics were examined with multinomial logistic regression. Minimal clinically important differences (MCID) were defined as a five-point change on the PHQ-9 from baseline to week 12.ResultsThe final sample included 2192 patients aged 18 to 82 (mean = 39.1). Four distinct trajectories emerged that differed by symptom severity and trajectory of depression symptoms over 12 weeks. All trajectories demonstrated reductions in symptoms. Despite meeting MCID criteria, evidence of treatment resistance was found among the trajectory with the highest symptom severity. Chronicity of major depressive episodes and lifetime trauma exposures were ubiquitous across the trajectories in a multinomial logistic regression model.Conclusions These data indicate that changes in depression symptoms during DMHI are heterogenous and non-linear, suggesting a need for precision care strategies to address treatment resistance and increase engagement. Future efforts should examine the effectiveness of trauma-informed treatment modules for DMHIs as well as protocols for continuation treatment and relapse prevention.
... Although therapist support has previously been shown to be both appreciated [20,21] and associated with better clinical outcomes [29], the benefits of self-guided ICBT are significant in terms of scalability. A recent meta-analysis also found that self-guided ICBT may be an adequate treatment for those with sub-threshold and milder problems [30] and consequently self-guided online BA might suffice for adolescents with milder depression. ...
Full-text available
Behavioural Activation (BA) is an established treatment for adults with depression, and research on BA for adolescents is promising. However, there is a knowledge gap in terms of the experiences of adolescents and their parents BA for depression delivered online. Furthermore, there have been no previous studies conducted on the experiences of respondents with regard to the role of the therapist in online treatment. Therefore, the primary aim of this study is to explore the experiences of online BA among adolescents with depression and how their parents experience supporting their adolescent through treatment. Second, the experiences of having online therapy with or without a therapist were explored. Semi-structured interviews were conducted with eight adolescents and nine parents (n = 17) who completed guided or self-guided online BA. Reflexive thematic analysis was used to identify aspects of the experience of treatment that were important to adolescents and their parents. Two main themes were generated: (1) opportunities or barriers to engaging in treatment and (2) parental involvement is valued and welcomed. This study contributes valuable information regarding user experiences of BA treatment, the importance of therapist support and parental involvement in treating adolescents with depression. Trial registration number: Identifier NCT04117789, Date of registration: 07 October 2019.
... On the other hand, guided internet-based interventions involve minimal but regular contact with therapists, typically over email, to support, guide, provide feedback to, and reinforce users working on self-help material. 7,8 Guided interventions have been observed to result in higher retention rates and better outcomes as compared to unguided self-help interventions. 6,8 Some challenges of internet-based interventions include a lack of therapeutic alliance, difficulty in adequately addressing crises or clarifying comprehension errors, and limited scope for individualization and translatability to real life. ...
Full-text available
Internet-based interventions for common mental health disorders have the potential to improve access to mental health care, particularly in resource-constrained settings. Blended interventions, which are a combination of internet-based intervention and face-to-face sessions can increase ease of access, as well as provide scope for therapeutic alliance and individualization while reducing clinician burden and improving adherence. This paper presents observations and insights based on our experience of using a blended intervention with clients with mild-to-moderate severity of depression. Clients worked on an internet-based structured self-help program and attended 4-6 face-to-face/video-based sessions during an 8-week period. Clients found the structured nature of the program, flexibility and privacy offered by the intervention to be appealing, reported improved self-reliance and confidence in handling future difficulties and were satisfied on the whole with the blended intervention. Preference for relying on face-to-face sessions or the internet-based program varied depending on clients’ motivation for therapy, symptom severity and previous experience and expectations of therapy. Challenges faced by the therapist included gauging clients’ suitability for the blended format, assessing concerns in a quick manner while developing a good working alliance and efficiently establishing the links between client concerns and the relevant modules of the internet-based program. Ensuring flexibility rather than a fixed protocol in the ratio of face-to-face and internet-based sessions was another important learning. The blended interventions when judiciously applied, hold good potential for use in busy outpatient settings and merit attention of researchers and practitioners. Keywords: Blended intervention, depression, India, internet-based interventions, digital mental health, technology and mental health
... In general for this type of treatment, when clinician support is additionally available it may result in improved outcomes [137][138][139]. Specifically for OCD, a meta-analysis found small effect sizes (g = 0.33) for self-administered self-help, moderate effect sizes (g = 0.68) for predominantly self-help, and large effect sizes (g = 0.91) for minimal contact self-help [140]. ...
Background Despite significant advances in the understanding and treatment of obsessive compulsive disorder (OCD), current treatment options are limited in terms of efficacy for symptom remission. Thus, assessing the potential role of iterative or alternate psychotherapies is important. Also, the potential role of digital technologies to enhance the accessibility of these therapies, should not be underestimated. We also need to embrace the idea of a more personalized treatment choice, being cognisant of clinical, genetic and neuroimaging predictors of treatment response. Procedures Non-systematic review of current literature on emerging psychological and digital therapies for OCD, as well as of potential biomarkers of treatment response. Findings A number of ‘third wave’ therapies (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy) have an emerging and encouraging evidence base in OCD. Other approaches entail employment of elements of other psychotherapies such as Dialectical Behaviour Therapy; or trauma-focussed therapies such as Eye Movement Desensitisation and Reprocessing, and Imagery Rescripting and Narrative Therapy. Further strategies include Danger Ideation Reduction Therapy and Habit Reversal. For these latter approaches, large-scale randomised controlled trials are largely lacking, and the precise role of these therapies in treating people with OCD, remains to be clarified. A concentrated 4-day program (the Bergen program) has shown promising short- and long-term results. Exercise, music, and art therapy have not been adequately tested in people with OCD, but may have an adjunctive role. Digital technologies are being actively investigated for enhancing reach and efficacy of psychological therapies for OCD. Biomarkers, including genetic and neuroimaging, are starting to point to a future with more ‘personalised medicine informed’ treatment strategizing for OCD. Conclusions There are a number of potential psychological options for the treatment of people with OCD who do not respond adequately to exposure/response prevention or cognitive behaviour therapy. Adjunctive exercise, music, and art therapy might be useful, albeit the evidence base for these is very small. Consideration should be given to different ways of delivering such interventions, including group-based, concentrated, inpatient, or with outreach, where appropriate. Digital technologies are an emerging field with a number of potential applications for aiding the treatment of OCD. Biomarkers for treatment response determination have much potential capacity and deserve further empirical testing.
... What constitutes good therapist support is still unclear. While one review found evidence for a strong correlation between the degree of support and outcome in the treatment of depression, where a higher degree of support included contact before and/or after treatment (Johansson and Andersson, 2012), few studies have examined the actual dose-response relationship (Baumeister et al., 2014). It has been debated how therapist experience relates to the effectiveness of the support. ...
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Internet-delivered interventions are generally effective for psychological problems. While the presence of a clinician guiding the client via text messages typically leads to better outcomes, the characteristics of what constitutes high-quality communication are less well investigated. This study aimed to identify how an internet therapist most effectively communicates with clients in internet-delivered cognitive behavioral therapy (ICBT). Using data from a treatment study of depressed adolescents with a focus on participants who had a positive outcome, messages from therapists were analyzed using thematic analysis. The study focused on the therapist's 1) encouragement and 2) affirmation, and how the therapists used 3) personal address. The analysis resulted in a total of twelve themes (Persistence Wins, You Are a Superhero, You Make Your Luck, You Understand, Hard Times, You Are Like Others, My View on the Matter, Time for a Change, Welcome In, Let Me Help You, You Affect Me, and I Am Human). Overall, the themes form patterns where treatment is described as hard work that requires a motivated client who is encouraged by the therapist. The findings are discussed based on the cognitive behavioral theoretical foundation of the treatment, prior research on therapist behaviors, and the fact that the treatment is provided over the internet.
... In recent years, internet-based and especially selfhelp interventions have become popular due to their availability and cost-effectiveness, on the one hand, and their promising outcomes in enhancing an individuals' wellbeing and mental health, on the other (e.g., Andersson & Cuijpers, 2009;Grist & Cavanagh, 2013). Superior results have been achieved through guided self-help interventions compared to self-help alone (Johansson & Andersson, 2012;Richards & Richardson, 2012). In a previous study, a guided online ACT intervention with university students indicated that ACT participants experienced greater improvements in well-being, life satisfaction, and mindfulness skills, and these effects were maintained over time (Räsänen et al., 2016). ...
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This study investigated whether an internet-based intervention aimed at enhancing the psychological well-being of female soccer players before the competitive season could be effective approach to meet the needs of the players. Players (n= 43; 17–26 years old)on the four separated teams in Finland’shighest league were assigned to either a guided six-week online Acceptance and Commitment Therapy intervention (ACTi) or to a control condition (CON). A between-groups pre–post (ACTi vs. CON) design was implemented before the competitive season. Players in the ACTi were offered three group sessions, performed internet-based tasks, and were individually supported by a guide. The results demonstrated that the ACTi players maintained their sports-related well-being (between-group, d = 0.72), while the sports-related well-being of the CON players, especially emotional and social well-being, had declined. In addition, ACTi players’perceived stress (d = 0.60) and depression (d = 0.88) declined, while their psychological flexibility in sports (d = 0.41) increased compared to the CON players. These results suggest that before the competitive season, players’ sports-related well-being decreases. The ACT intervention seemed to prevent this decrease and provide players with the skills to cope with emotional and social stressors related to the competitive season.
... interventions as compared to either face-to-face therapy 37,38 or self-guided Internet interventions, [39][40][41] it is notable that 58% of technology-based family interventions integrated human-based interactions, of which 37% provided families with an assigned coach, either through videoconferencing or phone calls. 36 However, studies also suggest that there is little benefit to therapist guidance for Internet interventions, [42][43][44] indicating that the effect of guidance is still unsettled. ...
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Aim: The current study aims to review the existing literature on internet-based health interventions directed to support parents of children aged 0 to 5 years. Methods: We systematically searched electronic databases between January 2000 and 2018. The search consisted of terms describing eHealth, intervention, and families and/or children. Results: Internet-based parent support interventions were most often directed at rehabilitation and selective prevention, and we identified more studies on mental health (57%) than somatic health (41%). Developmental disorders were the most frequently studied mental health condition (n = 33), while interventions for obesity (15%) were the most studied somatic health condition. Forty-four percent of mental health studies were RCTs and 65% of interventions were theory driven. Interventions most often used a behavioral approach, included guidance, and delivered content via text-based information. Conclusion: Several significant gaps were identified such as the need for more research outside of English-speaking countries, more systematic reviews, and effect studies. This review also elucidates the need for researchers to improve reporting on the theoretical approaches employed in interventions, and to focus on determining the importance of guidance. Finally, program developers should consider using more audio-visual technology to avoid reinforcing social inequalities in access to healthcare.
A service evaluation measured the effectiveness of adapting a psychoeducational group intervention, within a CMHT, online during the Covid-19 pandemic. Outcome measures imply online interventions are as effective as face-to-face groups and may influence service provision moving forward.
Aims and objective: To explore the experiences of patients with non-cardiac chest pain and cardiac anxiety regarding participation in an internet-delivered cognitive behavioural therapy program. Background: Non-cardiac chest pain is common and leads to cardiac anxiety. Internet-delivered cognitive behavioural therapy may be a possible option to decrease cardiac anxiety in these patients. We have recently evaluated the effect of an internet-delivered cognitive behavioural therapy program on cardiac anxiety. Design: An inductive qualitative study using content analysis and the COREQ checklist. Methods: Semi-structured interviews with 16 Swedish patients, who had participated in the internet-delivered cognitive behavioural therapy program. Results: Three categories were found. The first, 'Driving factors for participation in the internet-delivered cognitive behavioural therapy program' described the impact of pain on their lives and struggle that led them to participating in the program. The second, 'The program as a catalyst' described that the program was helpful, trustworthy and useful and the last category, 'Learning to live with chest pain' described the program as a tool for gaining the strength and skills to live a normal life despite chest pain. Conclusions: The program was experienced as an opportunity to return to a normal life. The program was perceived as helpful, trustworthy and useful, which helped the participants challenge their fear of chest pain and death, and gain strength and new insights into their ability to live a normal life. Relevance to clinical practice: A tailored internet-delivered cognitive behavioural therapy program delivered by a nurse therapist with clinical experience of the patient group is important to improve cardiac anxiety. Patient or public contribution: Patients or the general public were not involved in the design, analysis or interpretation of the data of this study, but two patients with experience of non-cardiac chest pain were involved in the development of the pilot study. Trial registration: NCT03336112; https://www. Clinicaltrials: gov/ct2/show/NCT03336112.
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The authors examined the amount and durability of change in the cognitive content of 156 adult outpatients with recurrent major depressive disorder after treatment with cognitive therapy. The pre– post magnitude of change was large for the Attributional Style Questionnaire Failure composite (d = 0.79), Dysfunctional Attitudes Scale (d = 1.05), and Self-Efficacy Scale (d = 0.83), and small for the Attributional Style Questionnaire Success composite (d = 0.30). Changes in cognitive content were clinically significant, as defined by their 64%–87% scores overlapping with score distributions from community dwellers. Improvement was durable over a 2-year follow-up. Changes in negative cognitive content could be detected early and distinguished responders from nonresponders. In responders, continuation-phase cognitive therapy was associated with further improvements on only 1 measure of cognitive content. Early changes in negative cognitive content did not predict later changes in depressive symptoms, which the authors discuss in the context of methodological challenges and the cognitive theory of depression.
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Depression is common but undertreated. Web-based self-help provides a widely accessible treatment alternative for mild to moderate depression. However, the lack of therapist guidance may limit its efficacy. The authors assess the efficacy of therapist-guided web-based cognitive behavioural treatment (web-CBT) of mild to moderate depression. Fifty-four individuals with chronic, moderate depression participated in a randomized wait-list controlled trial, with an 18-month follow-up (immediate treatment: n = 36, wait-list control: n = 18). Primary outcome measures were the Beck Depression Inventory (BDI-IA) and the Depression scale of the Symptom Checklist-90-Revised (SCL-90-R. DEP). Secondary outcome measures were the Depression Anxiety Stress Scales and the Well-Being Questionnaire. Five participants (9%) dropped out. Intention-to-treat analyses of covariance revealed that participants in the treatment condition improved significantly more than those in the wait-list control condition (.011 < p < .015). With regard to the primary measures, between-group effects (d) were 0.7 for the BDI-IA and 1.1 for the SCL-90-R DEP. Posttest SCL-90- R DEP scores indicated recovery of 49% of the participants in the treatment group compared with 6% in the control group (odds ratio = 14.5; p < .004). On average, the effects were stable up to 18 months (n = 39), although medication was a strong predictor of relapse. The results demonstrate the efficacy of web-CBT for mild to moderate depression and the importance of therapist guidance in psychological interventions.
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Background: Depression is associated with immense suffering and costs, and many patients receive inadequate care, often because of the limited availability of treatment. Web-based treatments may play an increasingly important role in closing this gap between demand and supply. We developed the integrative, Web-based program Deprexis, which covers therapeutic approaches such as behavioral activation, cognitive restructuring, mindfulness/acceptance exercises, and social skills training. Objective: To evaluate the effectiveness of the Web-based intervention in a randomized controlled trial. Methods: There were 396 adults recruited via Internet depression forums in Germany, and they were randomly assigned in an 80:20 weighted randomization sequence to either 9 weeks of immediate-program-access as an add-on to treatment-as-usual (N = 320), or to a 9-week delayed-access plus treatment-as-usual condition (N = 76). At pre- and post-treatment and 6-month follow-up, we measured depression (Beck Depression Inventory) as the primary outcome measure and social functioning (Work and Social Adjustment Scale) as the secondary outcome measure. Completer analyses and intention-to-treat analyses were performed. Results: Of 396 participants, 216 (55%) completed the post-measurement 9 weeks later. Available case analyses revealed a significant reduction in depression severity (BDI), Cohen’s d = .64 (CI 95% = 0.33 - 0.94), and significant improvement in social functioning (WSA), Cohen’s d = .64, 95% (CI 95% = 0.33 - 0.95). These improvements were maintained at 6-month follow-up. Intention-to-treat analyses confirmed significant effects on depression and social functioning improvements (BDI: Cohen’s d = .30, CI 95% = 0.05 - 0.55; WSA: Cohen’s d = .36, CI 95% = 0.10 - 0.61). Moreover, a much higher percentage of patients in the intervention group experienced a significant reduction of depression symptoms (BDI: odds ratio [OR] = 6.8, CI 95% = 2.90 - 18.19) and recovered more often (OR = 17.3, 95% CI 2.3 - 130). More than 80% of the users felt subjectively that the program had been helpful. Conclusions: This integrative, Web-based intervention was effective in reducing symptoms of depression and in improving social functioning. Findings suggest that the program could serve as an adjunctive or stand-alone treatment tool for patients suffering from symptoms of depression. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 64953693; (Archived by WebCite at
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Previous studies on Internet-based treatment with minimal therapist guidance have shown promising results for several specific diagnoses. To (1) investigate the effects of a tailored, therapist-guided, Internet-based treatment for individuals with reoccurring panic attacks, and (2) to examine whether people in different age groups (18-30 years and 31-45 years) would respond differently to the treatment. We recruited 149 participants from an online list of individuals having expressed an interest in Internet treatment. Screening consisted of online questionnaires followed by a telephone interview. A total of 57 participants were included after a semistructured diagnostic interview, and they were randomly assigned to an 8-week treatment program (n = 29) or to a control condition (n = 28). Treatment consisted of individually prescribed cognitive behavior therapy text modules in conjunction with online therapist guidance. The control group consisted of people on a waitlist who later received treatment. All dependent measures improved significantly immediately following treatment and at the 12-month follow-up. The between-group effect size on the primary outcome measure, the Panic Disorder Severity Scale, was d = 1.41 (95% confidence interval 0.81-1.95) at posttreatment. The within-group effect size from pretreatment to 12-month follow-up was d = 1.66 (95% confidence interval 1.14-2.35). Age group had no effect, suggesting that age did not influence the outcome. Tailoring an Internet-based treatment can be a feasible approach in the treatment of panic symptoms and comorbid anxiety and depressive symptoms. Younger adults benefit as much as adults over 30 years and up to 45 years of age. NCT01296321; (Archived by WebCite at
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Background: Internet-delivered cognitive behaviour therapy (iCBT) has been found to be an effective way to disseminate psychological treatment, and support given by a therapist seems to be important in order to achieve good outcomes. Little is known about what the therapists actually do when they provide support in iCBT and whether their behaviour influences treatment outcome. Aims: This study addressed the content of therapist e-mails in guided iCBT for generalized anxiety disorder. Method: We examined 490 e-mails from three therapists providing support to 44 patients who participated in a controlled trial on iCBT for generalized anxiety disorder. Results: Through content analysis of the written correspondence, eight distinguishable therapist behaviours were derived: deadline flexibility, task reinforcement, alliance bolstering, task prompting, psychoeducation, self-disclosure, self-efficacy shaping, and empathetic utterances. We found that task reinforcement, task prompting, self-efficacy shaping and empathetic utterances correlated with module completion. Deadline flexibility was negatively associated with outcome and task reinforcement positively correlated with changes on the Penn State Worry Questionnaire. Conclusions: Different types of therapist behaviours can be identified in iCBT, and though many of these behaviours are correlated to each other, different behaviours have an impact on change in symptoms and module completion.
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Background and aims: Major depression can be treated by means of cognitive behavior therapy, delivered via the Internet as guided self-help. Individually tailored guided self-help treatments have shown promising results in the treatment of anxiety disorders. This randomized controlled trial tested the efficacy of an Internet-based individually tailored guided self-help treatment which specifically targeted depression with comorbid symptoms. The treatment was compared both to standardized (non-tailored) Internet-based treatment and to an active control group in the form of a monitored online discussion group. Both guided self-help treatments were based on cognitive behavior therapy and lasted for 10 weeks. The discussion group consisted of weekly discussion themes related to depression and the treatment of depression. Methods: A total of 121 participants with diagnosed major depressive disorder and with a range of comorbid symptoms were randomized to three groups. The tailored treatment consisted of a prescribed set of modules targeting depression as well as comorbid problems. The standardized treatment was a previously tested guided self-help program for depression. Results: From pre-treatment to post-treatment, both treatment groups improved on measures of depression, anxiety and quality of life. The results were maintained at a 6-month follow-up. Subgroup analyses showed that the tailored treatment was more effective than the standardized treatment among participants with higher levels of depression at baseline and more comorbidity, both in terms of reduction of depressive symptoms and on recovery rates. In the subgroup with lower baseline scores of depression, few differences were seen between treatments and the discussion group. Conclusions: This study shows that tailored Internet-based treatment for depression is effective and that addressing comorbidity by tailoring may be one way of making guided self-help treatments more effective than standardized approaches in the treatment of more severe depression. Trial registration: NCT01181583.
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Internet-delivered cognitive behavioural therapy (CBT) can be an effective method for treating major depression, but it often works best when therapist support is provided in the form of e-mail support or telephone calls. The authors investigated whether there were any intraclass correlations within therapists when delivering CBT for major depression via the Internet. They included data from two trials involving 10 therapists treating a total of 103 patients. The results of a nested one-way model in which participants were treated as raters for different therapists indicated that measures pertaining to symptom reductions (Beck Depression Inventory, Montgomery-Asberg Depression Rating Scale-Self Report, and Beck Anxiety Inventory) did not support a clustering of data within therapists. However, the outcome on a secondary measure of life satisfaction (Quality of Life Inventory) yielded a significant intraclass correlation coefficient for therapists (r = .24, p = .001). The authors propose that text-based treatments are less sensitive to therapist effects when it comes to the primary symptom measures, but that treatment effects not directly targeted by the specific treatment program may be more dependent on the way the support is given and by whom (therapist effect). Limitations of the study are discussed.
Objective: The present study (Shyness 6) compares the benefits and acceptability of two types of guidance on severity of symptoms during Internet treatment for social phobia. Methods: Non-inferiority randomized controlled trial of Internet treatment, supplemented with weekly telephone calls from a technician (computerized cognitive-behavioural treatment (CCBT + Tel), or regular access to a clinician-moderated online discussion forum (CCBT + Forum), was carried out. An intention-to-treat model was used for data analyses. The participants consisted of 82 volunteers with social phobia. The intervention consisted of six lessons of CCBT for social phobia (the Shyness programme) with complex automated reminders. The main outcome measures were the Social Interaction Anxiety Scale and Social Phobia Scale. Results: A total of 79% of CCBT + Tel and 79% of CCBT + Forum group participants completed all six lessons. Large mean within-groups effect sizes (Cohen's d) for the two social phobia measures were found for the CCBT + Tel and CCBT + Forum groups (1.31 and 1.54, respectively). Each participant in the CCBT + Tel group received a mean total of 38 min of technician time over the 8 week programme, while participants in the CCBT + Forum group received a mean total of 37 min of clinician time. Quantitative and qualitative data indicate that both the CCBT + Tel and CCBT + Forum procedures were equally and highly acceptable to participants. Conclusions: The Shyness programme with either telephone support or access to a clinician-moderated online forum resulted in good clinical outcomes with equivalent patient acceptability. These results confirm that people with social phobia may significantly benefit from a highly structured education programme administered by clinical or non-clinical staff.