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Irish Journal of Psychological Medicine
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Computerised cognitive behavioural therapy: helping Ireland log on
C. Twomey, G. O'Reilly and M. Byrne
Irish Journal of Psychological Medicine / Volume 30 / Issue 01 / March 2013, pp 29 - 56
DOI: 10.1017/ipm.2012.5, Published online: 19 March 2013
Link to this article: http://journals.cambridge.org/abstract_S0790966712000055
How to cite this article:
C. Twomey, G. O'Reilly and M. Byrne (2013). Computerised cognitive behavioural therapy: helping Ireland log on. Irish
Journal of Psychological Medicine, 30, pp 29-56 doi:10.1017/ipm.2012.5
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Irish Journal of Psychological Medicine (2013), 30, 29– 56. &College of Psychiatrists of Ireland 2013
doi:10.1017/ipm.2012.5
ORIGINAL RESEARCH
Computerised cognitive behavioural therapy:
helping Ireland log on
C. Twomey
1,2
, G. O’Reilly
1
and M. Byrne
2
*
1
School of Psychology, University College Dublin, Ireland
2
Roscommon Service Area, Health Service Executive (HSE) West, Ireland
Objectives. The aim of this article is to review and highlight evidence-based computerised cognitive behavioural therapy
(cCBT) programmes that can potentially be used in Ireland for the treatment of mild-to-moderate mental health
difficulties.
Methods. The authors undertook a literature search using three databases, and consulted a recognised, university-
developed web portal. For a programme to be included in this review, it had to (a) have at least one randomised
controlled trial demonstrating its efficacy; (b) be available on the internet; and (c) be delivered in English.
Findings. Twenty-five cCBT programmes that met the inclusion criteria were profiled. Taken together, these programmes
target various anxiety difficulties (i.e. generalised anxiety, panic/phobia, social anxiety and post-traumatic stress),
depression (or low mood), eating problems, stress, insomnia, pain and alcohol misuse.
Conclusions. cCBT programmes, preferably administered as part of a stepped-care model, offer effective, low-cost and
low-intensity interventions for a wide range of psychological problems. Their use could be beneficial given how
underdeveloped primary care mental health services are in Ireland.
Received 15 May 2012; Accepted 22 August 2012
Key words: Computerised CBT, internet-delivered therapy, Ireland, stepped care.
Introduction
Despite extensive evidence for its effectiveness, cogni-
tive behavioural therapy (CBT) is difficult to access
because of insufficient numbers of trained clinicians,
both in primary and secondary care (Hoifort et al.
2011). CBT’s inaccessibility may be especially pertinent
in Ireland because of our underdeveloped services
(Department of Health and Children, 2006). For
example, a 2004 survey of 231 South Western Area
Health Board General Practitioners (GPs) found that
less than a third of GPs had postgraduate training in
psychological therapies and that 85% referred less than
5% of their service users with mental health difficulties
to mental health specialists (Copty, 2004). Moreover,
data extracted from a 2008 Economic and Social
Research Institute national survey found that just
20.4% of those who had consulted their GP about
mental health problems in the previous year (n5255)
had subsequently attended secondary care (Tedstone
Doherty et al. 2008). A recent survey of GP adult
attendees in a rural area (n5273) also found that
although one in three attendees registered as having
varying degrees of psychological distress, just 11%
were in receipt of mental health services (Hughes et al.
2010). It therefore appears that many in Ireland who
seek help with their mental health difficulties are not
receiving CBT in either primary or secondary care.
To increase access to psychological therapies, particu-
larly CBT, the United Kingdom’s National Health Service
(NHS)begantorollouttheImprovingAccessto
Psychological Therapies (IAPT) initiative in 2008. This
entailed creating extra psychological therapist posts using
a stepped-care model whereby low-intensity interventions
are provided as a first option, before referral to higher
intensity interventions (O’Shea & Byrne, in press). This
stepped-care model is in line with the United Kingdom’s
National Institute for Health and Clinical Excellence
(NICE) best-practice guidelines and represents optimum
usage of limited resources (NICE, 2009, 2011). In Ireland,
the Health Service Executive (HSE) has also increased
funding for psychological therapy provision recently.
Five million euro has been allocated to the National
Counselling Service to provide time-limited counselling to
adults with medical cards in primary care. However,
contrary to the IAPT initiative and NICE’s (NICE, 2009,
2011) best-practice guidelines, a stepped-care model of
service provision will only be trialled in one pilot site.
In the light of our underdeveloped services and
the push to decrease the number of public sector
* Address for correspondence: Dr M. Byrne, Principal Psychologist
Manager, Psychology Department, Health Service, Executive West,
Primary Care Centre, Golf Links Road, Roscommon, Dublin, Ireland.
(Email: michaelj.byrne@hse.ie)
employees, other ways to increase access to CBT must
be explored, at least in the short term. One such
avenue, and examined in this article, is CBT delivered
over the internet, or computerised CBT (cCBT). Whether
delivered in self-help or in a therapist-assisted format,
cCBThasmanyadvantagessuchasitsconvenience,low-
cost and confidential nature (Andrews et al. 2010). There
is substantial evidence for its efficacy for a range of
mental health difficulties including anxiety (Spek et al.
2007; Andrews et al. 2010) depression/low mood
(Andersson & Cuijpers, 2009; Andrews et al. 2010)
and alcoholism (Rooke et al. 2010). Moreover, it has
been shown to be effective in primary care (Hoifort
et al. 2011), and its growing evidence base means that it
has substantial potential to assist primary care staff in
delivering effective low-intensity but high-throughput
psychological interventions (Wade, 2010). NICE recom-
mends cCBT for the treatment of mild-to-moderate
anxiety and depression, delivered as part of a stepped-
care model (NICE, 2006).
Owing to the largely unregulated nature of the
internet, and the proliferation of internet therapy
websites in recent years, the quality of services provided
through such websites is likely to vary (Christensen et al.
2010). Clinicians therefore need to become familiar with
high-quality cCBT programmes so that they can refer
service users to these as part of a best-practice stepped-
care model. Accordingly, the aim of this review is
to highlight evidence-based cCBT programmes that
potentially can be availed of by clinicians and service
users in Ireland.
Methods
The authors conducted computer-based literature
searches of the Psych ARTICLES, PsychINFO and
Academic Search Premier databases. They used Boolean
operators (OR, AND) and various search terms related to
cCBT such as: ‘online CBT’/‘internet therapy’/‘compu-
terised CBT’/‘internet-delivered treatment’/‘self-help’/
‘computer’/‘self-guided’/‘web’/‘cyber’. They added
these to search terms for various psychological
problems (e.g. ‘anxiety’/‘depression’/‘stress’/‘insom-
nia’) and research designs (e.g. ‘random/’controlled’/
‘RCT’). In addition, they performed manual searches
of various academic journals to locate articles that
were included in reference lists of previously identified
articles. The authors also consulted the Australian
National University-developed web portal Beacon that
provides a comprehensive database of cCBT pro-
grammes, how to access them, as well as the published
evidence behind them (Beacon, homepage on the
internet; Christensen et al. 2010).
To ensure that programmes included in this review
were understandable, accessible and not prone to
experimental bias and/or error (Spring, 2007),
the authors used the following inclusion criteria:
(a) English-language-only programmes; (b) those that
are currently delivered via the internet; and (c) those
that had at least one published randomised controlled
trial (RCT) demonstrating their efficacy. Furthermore,
to enable valid comparison, the authors included only
those RCTs with waitlist controls and/or face-to-face
treatment groups that were not receiving a computerised
intervention (Andersson & Cuijpers, 2009).
Findings
Twenty-five cCBT programmes met the inclusion criteria
(Fig. 1). Taken together, these programmes target a range
of psychological difficulties in adolescents and children,
and adults: generalised anxiety (GA), panic/phobia,
social anxiety (SA), post-traumatic stress disorder
(PTSD), depression (or low mood), eating problems,
stress, insomnia, pain and alcohol misuse. Notably,
and usefully, some of the programmes (e.g. ‘Beating
the Blues’, ‘Mood Gym’) can treat more than one
difficulty at a time.
The next section of this article profiles the identified
cCBT programmes, categorised by the mental health
difficulty they target. First, those cCBT programmes
for GA are examined.
cCBT programmes for GA
Seven cCBT programmes for GA met this article’s
inclusion criteria (Table 1). Six of these programmes
were developed in Australia and one was developed in
the United Kingdom (‘Beating the Blues’). Currently, two
programmes are freely accessible online by residents of
Ireland – ‘MoodGym’ and ‘Online Anxiety Prevention’.
However, ‘Beating the Blues’ is provided via primary
care by the United Kingdom’s NHS and can be
purchased online. Four of the programmes are delivered
with therapist assistance but three (i.e. ‘MoodGym’,
‘Beating the Blues’ and ‘Online Anxiety Prevention’) can
be completed on a self-help basis. The total number of
sessions for the programmes ranges from 5 to 10.
Four of the programmes have two RCTs demon-
strating their efficacy, and three have one RCT. The
strongest evidence appears to be for the ‘eCentre
Clinic-Worry Programme’ and ‘BRAVE-ONLINE’ (for
children) as shown by large effect sizes and the use of
clinically screened samples across two RCTs each. The
former programme’s RCT participants were self-referred,
whereas the latter’s RCT participants (i.e. children) were
referred from many sources (e.g. parents, teachers and
clinicians). ‘MoodGym’ also has substantial evidence for
GA – it has two RCTs that yielded small-to-medium
effect sizes. One of these RCTs had a large, school-based
30 C. Twomey et al.
and non-clinical sample and the other had a small self-
referred clinically screened sample. It has the added
advantage of being suitable for both adults and
adolescents. The United Kingdom’s ‘Beating the Blues’
has two large-scale RCTs with GP-referred clinically
screened samples, demonstrating its efficacy. Effect sizes
here were with small to medium. However, the latter
RCT only found effectiveness in those with more severe
anxiety. The evidence for each of the three programmes
with one RCT is not referred to here because of word
constraints but is viewable in Table 1.
cCBT programmes for panic/phobia
Three cCBT programmes for panic/phobia met this
article’s inclusion criteria (Table 2). Two of these
programmes (eCentre Clinic’s-Panic & Anxiety Pro-
grammes) were developed in Australia and one was
developed in the United Kingdom (‘FearFighter’). None
of the three programmes are freely accessible online by
residents of Ireland. However, ‘FearFighter’ is pro-
vided via primary care by the United Kingdom’s NHS.
‘FearFighter’ can be completed on a self-help basis,
whereas the other two programmes are delivered with
therapist assistance. The total number of sessions for
the programmes ranges from 6 to 9.
All three programmes have one RCT, with clinically
screened samples, demonstrating their efficacy. The
strongest evidence appears to be for ‘FearFighter’ – its
RCT has the largest sample and effect sizes of the
three. Its sample was referred by health professionals
and also by self-referral. However, the ‘eCentre Clinic-
Panic Programme’ was shown to be effective across
a wider range of measures (three as opposed to two),
although with smaller effect sizes, in a self-referred
sample. The other programme, ‘eCentre Clinic-Anxiety
Programme’, is advantageous in that it has also
been shown to be effective for GA (Table 1), and SA
(Table 3). It yielded a medium effect size in a self-
referred sample.
Fig. 1. RCT-Supported cCBT Programmes delivered, in English, on the internet.
Computerised cognitive behavioural therapy 31
Table 1. cCBT programmes for GA
Year Sample Referred by Clinical screening Randomisation GA outcome measure(s) Outcomes
Name: eCentre Clinic – Worry Programme. Country: Australia. Authors: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/. Population: Adults. Format: TA with weekly phone calls. Schedule: 6 weekly sessions.
Availability: Via research participation in Australia only. RCTs: 2
Titov et al.
(2009)
48 adults (age range not
reported; M544 years;
76% female)
Self-applied via
website
Not experiencing psychosis or
severe depression (defined as a
total score ,23 or responding
.2 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); meet
DSM-IV (American Psychiatric
Association, 2000) criteria for
GA, criteria confirmed by
clinical interview
a. Worry Programme (n525)
b. Waitlist control (n523)
>Generalised Anxiety
Disorder-7 Item Scale
(GAD-7) (Spitzer et al. 2006)
>Penn State Worry
Questionnaire (PSWQ)
(Meyer et al. 1990)
>At PI, the Worry Programme
significantly reduced GA symptoms
as shown by the GAD-7 (d51.24)
and the PSWQ (d50.96), relative
to the waitlist control
>No FU data were recorded
Robinson et al.
(2010)
145 adults aged 18–80 years
(M546.96 years;
68.3% female)
Self-applied via
website
Not experiencing psychosis or
severe depression (defined as a
total score ,23 or responding
.2 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001) meet DSM-
IV (American Psychiatric
Association, 2000) criteria for
GA, criteria confirmed by
clinical interview
a. Worry Programme with
technical assistance
(WTECH; n550)
b. Worry Programme with
clinical assistance (WCLIN;
n547)
c. Waitlist control (n548)
>GAD-7 (Spitzer et al. 2006)
>PSWQ (Meyer et al. 1990)
>At PI, WTECH and WCLIN were
similarly effective. Both conditions
significantly reduced GA symptoms
as shown by the GAD-7 (d51.06,
d51.06) and the PSWQ (d51.25,
d51.05) compared with control
>At PI (2) also significantly reduced
GA symptoms (d51.06) compared
with control
>Treatment gains for both
conditions were maintained at
3-month FU (with no control group
comparison). Both were similarly
effective (GAD-7) but the WCLIN
group had made extra gains on the
PSWQ (d50.34)
32 C. Twomey et al.
Table 1. Continued
Year Sample Referred by Clinical screening Randomisation GA outcome measure(s) Outcomes
Name: BRAVE-ONLINE
a
.Country: Australia. Authors: S. Spence, C. Donovan, S. March & J. Holmes. Web: http://www.brave.psy.uq.edu.au/index.html?site5gp&page5meet. Population: Children and
adolescents. Format: TA – emails and phone calls. Schedule: 10 weekly sessions. Availability: Via research participation in Australia only. RCTs: 2.
March et al.
(2009)
73 children aged 7–12 years
(M59.45 years; 54.8%
female)
Parents, teachers,
guidance officers
and clinicians
Prior diagnosis of an anxiety
disorder (other than obsessive-
compulsive disorder, panic
disorder, or PTSD).
Experiencing at least moderate
anxiety (defined as a total score
of .4) on the Anxiety Disorder
Interview Schedule (ADIS)
(Silverman & Albano, 1996) that
was administered by a clinician
a. BRAVE-ONLINE (n540)
b. Waitlist control (n533)
>Anxiety Disorder
Interview Schedule (ADIS)
(Silverman & Albano,
1996)
>Spence Children’s Anxiety
Scale – Child version
(SCAS-C) (Spence, 1998)
>Spence Children’s Anxiety
Scale – Parent version
(SCAS-P) (Spence, 1999)
>For diagnostic severity reduction
(ADIS), BRAVE-ONLINE was
significantly more effective then
waitlist control (d50.56). Benefits
were maintained at 6-month FU
(there was no control group at FU)
>For anxiety symptoms (on SCAS-C),
BRAVE-ONLINE was not more
effective then waitlist control.
However for anxiety symptoms
(on SCAS-P), it was more effective
(d50.31). Benefits were
maintained at 6-month FU
Spence et al.
(2011)
115 adolescents aged
12–18 years (M513.98
years; 59.1% female)
Self-recruited by
adverts, parents,
teachers, guidance
officers and
clinicians also
referred children
Prior diagnosis of SA, separation
anxiety disorder, GA or a
specific phobia. Not
experiencing ‘moderately
disturbing’ anxiety or greater
(defined as a total score of .6)
on the Anxiety Disorder
Interview Schedule (ADIS)
(Silverman & Albano, 1996) that
was administered by a clinician
a. BRAVE-ONLINE (n544)
b. Face-to-face CBT (n544)
c. Waitlist control (n527)
>ADIS (Silverman &
Albano, 1996)
>SCAS-C (Spence, 1998)
>SCAS-P (Spence, 1999)
>For diagnostic severity reduction
(ADIS), BRAVE-ONLINE was
significantly more effective then
waitlist control (d51.45) and
similarly effective to face-to-face
CBT. Both intervention conditions
maintained benefits at a similar
level at 6-month and 12-month FU
(there was no waitlist control
group at FUs)
>For anxiety symptoms (on SCAS-C),
BRAVE-ONLINE was not more
effective than waitlist control.
However, for anxiety symptoms
(on SCAS-P), it was more effective
(d50.22). Benefits were
maintained at FUs
Computerised cognitive behavioural therapy 33
Table 1. Continued
Year Sample Referred by Clinical screening Randomisation GA outcome measure(s) Outcomes
Name: MoodGym
b
.Country: Australia. Authors: H. Christensen & K. Griffiths. Web: http://moodgym.anu.edu.au/welcome. Population: Adults and adolescents. Format: SH. Schedule: 5 sessions, completed at
own pace. Availability: Freely accessible. RCTs: 2.
Calear et al.
(2009)
1,477 children aged 12–17
years (M514.34 years;
55.9% female) from
32 schools
School as part of the
curriculum
None a. Classroom-delivered
MoodGym (n5563)
b. Control (n5914) (cluster
randomisation)
>Revised Children’s
Manifest Anxiety Scale
(RCMAS) (Reynolds &
Richmond, 1985)
>MoodGym group had significantly
lower levels of anxiety at PI
(d50.15), and at 6-month FU
(d50.25) than control group
Sethi et al.
(2010)
34 university students
aged 18–23 years
(M519.47 years;
78.1% female)
Self-recruited by
adverts
Mild-to-moderate depression or
anxiety shown by the
Depression Anxiety Stress Scale-
21 (cut-off scores not reported
DASS-21) (Lovibond &
Lovibond, 1995). Clinical
interview not conducted
a. MoodGym (n59)
b. Face-to-face CBT (n510)
c. Face-to-face CBT1Mood-
Gym (n59)
d. Control (n510)
>DASS-21 (Lovibond &
Lovibond, 1995)
>For anxiety reduction (DASS-21),
Face-to-face CBT1MoodGym was
significantly more effective than
MoodGym (d50.62) and face-to-
face CBT (d50.65). MoodGym
was significantly more effective
than control (d50.54) only
Name: Beating the Blues. Country: UK. Author: J. Proudfoot. Web: http://www.beatingtheblues.co.uk/. Population: Adults. Format: SH. Schedule: 8 weekly sessions. Availability: Via public health services in UK,
USA, Canada, New Zealand and Australia. Also can be purchased online for $230 (,h166.) RCTs: 2.
Proudfoot et al.
(2003)
167 primary care service
users aged 18–75 years
(M544.7 years; 73.7%
female)
GPs and primary
care staff
Prior diagnosis of depressive and/
or anxiety disorder; scores of >4
on the General Health
Questionnaire-12 (GHQ-12)
(Goldberg, 1972) and >12 on the
Clinical Interview Schedule-
Revised: PROQSY (Lewis, 1994)
that was administered by a
clinician
a. Beating the Blues (1non-
therapeutic GP support;
n589)
b. GP Treatment-as-usual
(n578)
>Beck Anxiety Inventory
(BAI) (Beck & Steer et al.
1990)
>At PI, Beating the Blues was
significantly more effective than
treatment-as-usual for anxiety
reduction (d50.45)
>At 3-month (d50.25) and
6-month (d50.29) FU, Beating the
Blues was significantly more
effective than treatment-as-usual
for anxiety reduction
Proudfoot et al.
(2004)
107 primary care service
users aged 18–75 years
were included to the
above study (total
n5274; M543.37
GPs and primary
care staff
Prior diagnosis of depressive and/
or anxiety disorder; scores of >4
on the General Health
Questionnaire-12 (GHQ-12)
(Goldberg, 1972) and >12 on the
a. Beating the Blues (1non-
therapeutic GP support;
n5146)
b. GP Treatment-as-usual
(n5128)
>Beck Anxiety Inventory
(BAI) (Beck & Steer,
1990)
>At PI and FUs, Beating the
Blues was not significantly
more effective than treatment-
as-usual for anxiety reduction.
However it came close to being
years; 74% female) Clinical Interview Schedule-
Revised: PROQSY (Lewis, 1994)
that was administered by a
clinician
more effective (p50.06)
>Moreover, in those with more
severe anxiety (i.e. participants
with scores .18 on the BAI at
the start of the study) it was
significantly more effective
34 C. Twomey et al.
Table 1. Continued
Year Sample Referred by Clinical screening Randomisation GA outcome measure(s) Outcomes
Name: eCentre Clinic – Anxiety Programme. Country: Australia. Authors: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/. Population: Adults. Format: TA with weekly phone calls. Schedule: 6 weekly
sessions. Availability: Via research participation in Australia only. RCTs: 1.
Titov et al.
(2010)
78 adults aged 18–74 years
(M539.53 years; 67.9%
female)
Self-applied via
website
Not experiencing psychosis or
severe depression (defined as a
total score ,23 or responding
.2 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); meet DSM-
IV (American Psychiatric
Association, 2000) criteria for
GA, SA and/or panic disorder.
a. Anxiety Programme
(n540)
b. Waitlist control (n538)
>GAD-7 (Spitzer et al. 2006)
>PSWQ (Meyer et al. 1990)
>At PI, the Anxiety Programme
significantly reduced GA
symptoms as shown by the GAD-7
(d50.81) relative to the waitlist
control. Treatment gains were
maintained at 3-month FU (with
no control group comparison)
>However, the Anxiety Programme
did not significantly reduce GA as
shown by the PSWQ, relative to
the waitlist control
Name: eCentre Clinic – Well-being Programme. Country: Australia. Authors: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/. Population: Adults. Format: TA with weekly phone calls. Schedule: 8 weekly
sessions. Availability: Via research participation in Australia only. RCTs: 1.
Titov et al.
(2011)
77 adults aged 18–79 years
(M543.9 years; 73%
female)
Self-applied via
website
Not experiencing psychosis or
severe depression (defined as a
total score ,23 or responding
.2 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); meet DSM-
IV (American Psychiatric
Association, 2000) criteria for
depression, GA, SA and/or
panic disorder. Criteria
confirmed by clinical interview
a. Well-Being Programme
(n537)
b. Waitlist control (n537)
>GAD-7 (Spitzer et al. 2006)
>PSWQ (Meyer et al. 1990)
>At PI, the Well-Being Programme
significantly reduced GA symp-
toms as shown by the GAD-7
(d50.52) and the PSWQ (d50.47),
relative to the waitlist control.
Treatment gains were maintained
at 3-month FU (with no control
group comparison)
Computerised cognitive behavioural therapy 35
Table 1. Continued
Year Sample Referred by Clinical screening Randomisation GA outcome measure(s) Outcomes
Name: Online Anxiety Prevention. Country: Australia. Authors: J. Kenardy & V. Rosa. Web: http://www2.psy.uq.edu.au/,jkweb/. Population: Adults and adolescents. Format: SH. Schedule: 6 weekly sessions.
Availability: Freely accessible. RCTs: 1.
Kenardy et al.
(2003);
Kenardy
et al. (2006)
83 university students aged
17–51 years (M520.73
years; 61.7% female)
University
administered initial
surveys to first year
students.
Score of >24 on the Anxiety
Sensitivity Index (ASI) (Peterson
& Reiss, 1992) used to represent
top third of scores. Clinical
interviews not conducted
a. Online Anxiety Prevention
(n543)
b. Waitlist control (n540)
>ASI (Peterson & Reiss,
1992)
>Catastrophic Cognitions
Questionnaire-Modified
(CCQ) (Khawaja et al. 1994)
>At PI (d50.24) and 3-month FU
(d50.31), Online Anxiety
Prevention significantly reduced
anxiety-related cognitions (CCQ)
relative to the control group
>At PI and 3-month FU, Online
Anxiety Prevention did not
significantly reduce anxiety
sensitivity (ASI), relative to
the control group
GA, Generalised anxiety; SA, social anxiety; PTSD, post-traumatic stress disorder; SH, self help; TA, therapist assisted; PI, post-intervention; FU, follow-up; d, Cohen’s d(between-group).
a
One other RCT for BRAVE-ONLINE has been published, but the cCBT intervention condition consisted of half of treatment-as-usual sessions delivered via BRAVE-ONLINE. Thus it was not possible to
determine whether BRAVE-ONLINE led to additional treatment benefits (Spence et al. 2006).
b
Four other RCTs were conducted on MoodGym. One was excluded from the table because the study’s outcome measures measured general psychological distress rather than a specific difficulty (e.g., GA)
(Hickie et al. 2010). Another was excluded because it examined stigmatising attitudes towards depression and had mixed results (Griffiths et al. 2004). The other two were excluded because they used
MoodGym in conjunction with a computerised psychoeducation intervention (Farrer et al. 2011; Lintvedt et al. 2013).
36 C. Twomey et al.
Table 2. cCBT programmes for panic/phobia
Year Sample Referred by Clinical screening Randomisation Panic outcome measure(s) Outcomes
Name: FearFighter
a
.Country: UK. Author: I. Marks. Web: http://www.fearfighter.com/. Population: Adults. Format: SH but access to helpline is provided. Schedule: 9 sessions, completed at own pace.
Availability: Via public health services in UK, USA, Australia, Denmark and Holland. RCTs: 1.
Marks et al.
(2004)
93 hospital outpatients
(age range not reported;
M538 years; 69%
female)
Health professionals
and self (replied to
notices in GP
practices or self-help
groups)
Meet DSM-IV (American
Psychiatric Association, 2000)
criteria for agoraphobia without
panic disorder, panic disorder
with agoraphobia, SA, or
specific phobia; score of >4on
the Global Phobia Scale of the
Fear Questionnaire (FQ) (Marks
& Mathews, 1979). Criteria
confirmed by clinical interview.
a. FearFighter (n535)
b. Face-to-face self-exposure
therapy (n538)
c. Computer-guided self-
relaxation (control; n517)
>Main Problem and Goals
instrument (Marks, 1986)
>Global Phobia Scale of the
FQ (Marks & Mathews,
1979)
>At PI, FearFighter and face-to-face
therapy were similarly effective.
FearFighter significantly reduced
panic symptoms as shown by the
Main Problems and Goals instru-
ment (d51.44) and the FQ (d50.9)
relative to control
>Gains were maintained at 1-month
FU (required descriptive data to
calculate between-groups dnot
provided at FU)
Name: eCentre Clinic – Panic Programme. Country: Australia. Author: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/. Population: Adults. Format: TA with weekly phone calls. Schedule: 6 weekly
sessions. Availability: Via research participation in Australia only. RCTs: 1.
Wims et al.
(2010)
59 adults aged 20–70 years
(M542.1 years; 76%
female)
Self-applied via
website
Not experiencing psychosis or
severe depression (defined as a
total score ,23 or responding
.2 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); meet
DSM-IV (American Psychiatric
Association, 2000) criteria for
depression, GA, SA and/or
panic disorder. Criteria
confirmed by clinical interview
a. Panic Programme (n532)
b. Waitlist control (n527)
>Panic Disorder Severity
Scale Self Rating (PDSS-SR)
(Houck et al. 2002)
>Mobility Inventory for
Agoraphobia (MI)
(Chambless et al. 1985)
>Agoraphobic Cognitions
Questionnaire (ACQ)
(Chambless et al. 1984)
>Body Sensations Question-
naire (BSQ) (Chambless
et al. 1984)
>At PI (d50.59) and 1-month FU
(d50.72), the Panic Programme
significantly reduced panic
symptoms as shown by the PDSS-SR,
relative to the waitlist control
>At PI (d50.59) the Panic
Programme significantly reduced
panic symptoms as shown by the
ACQ (d50.51) and the BSQ
(d50.33), relative to the waitlist
control. (Data for these instruments
not sufficient to calculate between-
groups dat FU)
>The Panic programme was not
significantly more effective than
the waitlist control as shown by
the MI
Computerised cognitive behavioural therapy 37
cCBT programmes for SA
Three cCBT programmes for SA met this article’s
inclusion criteria (Table 3). Two of these programmes
(eCentre Clinic’s-Shyness & Anxiety Programmes)
were developed in Australia and one was developed
in Spain (‘Talk to Me’). None of the three programmes
are freely accessible online by residents of Ireland.
However, ‘Talk to Me’ is available for an unspecified
fee. ‘Talk to Me’ can be completed on a self-help basis,
whereas the other two programmes are delivered with
therapist assistance. The total number of sessions for
the programmes ranges from 3 to 6.
The strongest evidence here is clearly for the
‘eCentre Clinic-Shyness Programme’. It has four RCTs
demonstrating its efficacy in clinically screened sam-
ples, compared with the other two programmes that
have one RCT behind them. Moreover, for the
treatment of SA, it yielded large effect sizes. Three of
its RCT’s participants were self-referred but, notably,
the other one had participants who were GP referred
(although with a small sample size). As mentioned
above, the ‘eCentre Clinic-Anxiety Programme’ is
advantageous in that it has also been shown to be
effective for three mental health difficulties – GA
(Table 1), panic/phobia (Table 2) and SA (Table 3). For
SA, it yielded a moderate effect size in a self-referred,
clinically screened sample. The other programme ‘Talk
to Me’ had moderate effect sizes for SA in a self-
referred, clinically screened sample. However, it is
geared towards public speaking difficulties to a larger
extent than SA.
cCBT programmes for PTSD
One cCBT programme for PTSD, the ‘eCentre Clinic-
PTSD Programme’, met this article’s inclusion criteria
(Table 4). This therapist-assisted programme has seven
sessions. It was developed in Australia and is not
currently accessible online by residents of Ireland. It
has one RCT showing its efficacy within a self-referred,
clinically screened sample. It yielded a moderate
effect size. The RCT is limited by its relatively small
sample size.
cCBT programmes for depression (or low mood)
Six cCBT programmes for depression met this article’s
inclusion criteria (Table 5). Three of these programmes
were developed in Australia. The other three were
developed in the United Kingdom, Germany and the
United States, respectively. Currently, two of these
programmes, ‘MoodGym’ and ‘MoodHelper’, are freely
accessible online by residents of Ireland. However,
‘Beating the Blues’ is provided via primary care by the
United Kingdom’s NHS and can be purchased online.
Table 2. Continued
Year Sample Referred by Clinical screening Randomisation Panic outcome measure(s) Outcomes
Name: eCentre Clinic – Anxiety Programme. Country: Australia. Author: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/ Population: Adults. Format: TA with weekly phone calls. Schedule: 6 weekly
sessions. Availability: Via research participation in Australia only. RCTs: 1.
Titov et al.
(2010)
78 adults aged 18–74 years
(M539.53 years; 67.9%
female)
Self-applied via
website
Not experiencing psychosis or severe
depression (defined as a total
score ,23 or responding .2to
Question 9 (suicidal ideation) on
the Patient Health Questionnaire-9
Item (PHQ-9) (Kroenke et al.
2001); meet DSM-IV (American
Psychiatric Association, 2000)
criteria for GA, SA and/or panic
disorder. Criteria confirmed by
clinical interview
a. Anxiety Programme
(n540)
b. Waitlist control (n538)
>PDSS-SR (Wims et al. 2010) >At PI, the Anxiety Programme
significantly reduced panic
symptoms as shown by the
PDSS-SR (d50.43.) relative to the
waitlist control. Treatment gains
were maintained at 3-month
FU (with no control group
comparison)
GA, Generalised anxiety; SA, social anxiety; PTSD, post-traumatic stress disorder; SH, self help; TA, therapist assisted; PI, post-intervention; FU, follow-up; d, Cohen’s d(between-group).
a
FearFighter has another RCT demonstrating its efficacy (Schneider et al. 2005). However, as the control used in the study was a computerised control, it did not enable valid comparison (Andersson &
Cuijpers, 2009), and was thus excluded.
38 C. Twomey et al.
Table 3. cCBT programmes for SA
Year Sample Referred by Clinical screening Randomisation SA outcome measure(s) Outcomes
Name: eCentre Clinic – Shyness Programme. Country: Australia. Authors: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/ Population: Adults. Format: TA with weekly phone calls. Schedule: 6 weekly
sessions. Availability: Via research participation in Australia only. RCTs: 4.
Titov et al.
(2008)
99 adults aged 18–72 years
(M538.13 years, 58.6%
female)
Self-recruited by
adverts
Not experiencing psychosis or severe
depression (defined as a total
score <20 or responding .0to
Question 9 (suicidal ideation) on
the Patient Health Questionnaire-9
Item (PHQ-9) (Kroenke et al.
2001); meet DSM-IV (American
Psychiatric Association, 2000)
criteria for SA, Criteria confirmed
by clinical interview.
a. Shyness Programme
(n550)
b. Waitlist control (n549)
>Social Interaction Anxiety
Scale (SIAS) (Mattick &
Clarke, 1998)
>Social Phobia Scale (SPS)
(Mattick & Clarke, 1998)
>At PI, significant reductions in
social anxiety as shown by the
SIAS (d50.86) and the SPS
(d51.04) relative to waitlist
control
Titov et al.
(2008)
81 adults aged 20–61 years
(M536.79 years,
62.96% female)
Self-recruited by
adverts
Not experiencing psychosis or
severe depression (defined as a
total score <20 or responding
.0 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); meet
DSM-IV (American Psychiatric
Association, 2000) criteria for
SA, Criteria confirmed by
clinical interview
a. Shyness Programme
(n541)
b. Waitlist control (n540)
>SIAS (Mattick & Clarke,
1998)
>SPS (Mattick & Clarke,
1998)
>At PI, significant reductions in
social anxiety as shown by the
SIAS (d51.29) and the SPS
(d51.1) relative to waitlist control
Titov et al.
(2008)
93 adults aged 18–64 years
(M537.97 years, 61.1%
female)
Self-applied via
website
Not experiencing psychosis or severe
depression (defined as a total
score <20 or responding .0to
Question 9 (suicidal ideation) on
the Patient Health Questionnaire-9
Item (PHQ-9) (Kroenke et al.
2001); meet DSM-IV (American
Psychiatric Association, 2000)
criteria for SA, Criteria confirmed
by clinical interview
a. TA Shyness Programme
(n531)
b. SH Shyness programme
(n530)
c. Waitlist control (n532)
>SIAS (Mattick & Clarke,
1998)
>SPS (Mattick & Clarke,
1998)
>At PI, TA Shyness group had a
significantly superior reductions in
social anxiety relative to the SH
Shyness group (d50.64, d50.67)
and waitlist control group
(d51.47, d51.17) as shown by the
SIAS and the SPS respectively
>SH Shyness group was not
significantly more effective than
waitlist control
Andrews et al.
(2011)
37 GP service users (age
range not reported;
M531.9 years, 40.5%
female)
GPs Prior diagnosis of SA confirmed by
clinical interview by
psychiatrist
a. Shyness Programme
(n523)
b. Face-to-face CBT (n514)
>SIAS (Mattick & Clarke,
1998)
>SPS (Mattick & Clarke,
1998)
At PI, both forms of treatment were
similarly effective, and significantly
reduced social anxiety as shown by
the SIAS and the SPS
Computerised cognitive behavioural therapy 39
Table 3. Continued
Year Sample Referred by Clinical screening Randomisation SA outcome measure(s) Outcomes
Name: eCentre Clinic – Anxiety Programme. Country: Australia. Authors: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/ Population: Adults. Format: TA with weekly phone calls. Schedule: 6 weekly
sessions. Availability: Via research participation in Australia only. RCTs: 1.
Titov et al.
(2010)
78 adults aged 18–74 years
(M539.53 years;
67.9% female)
Self-applied via
website
Not experiencing psychosis or
severe depression (defined as a
total score ,23 or responding
.2 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); meet DSM-
IV (American Psychiatric
Association, 2000) criteria for
GA, SA and/or panic disorder.
Criteria confirmed by clinical
interview
a. Anxiety Programme
(n540)
b. Waitlist control (n538)
>Social Phobia Screening
Questionnaire (SPSQ)
(Furmark et al. 1999)
>At PI, the Anxiety Programme
significantly reduced SA
symptoms as shown by the SPSQ
(d50.43) relative to the waitlist
control. Treatment gains were
maintained at 3-month FU (with
no control group comparison)
Name: Talk to Me. Country: Spain. Author: C. Botella. Web: http://www.internetmeayuda.com/mhpEnglish/saludo.htm Population: Adults. Format: SH Schedule: 3 sessions, completed at own pace.
Availability: Fee-based (unspecified amount). RCTs: 1.
Botella et al.
(2010)
127 university students
aged 18–48 years
(M524.4 years;
79.2% female)
Self-recruited by
adverts
Meet the DSM-IV (American
Psychiatric Association, 2000)
criteria for SA; not have
diagnosis of major depression,
substance abuse difficulties
psychosis or mental retardation.
Criteria confirmed by clinical
interview
a. SH Talk to Me (n562)
b. Therapist-delivered Talk to
Me (n536)
c. Waitlist control (n529)
>Brief version of the Fear of
Negative Evaluation Scale
(BFNE) (Leary, 1983)
>Social Avoidance and
Distress Scale (SAS)
(Watson & Friend, 1969)
>At PI, both treatment conditions
were similarly effective. SH Talk to
Me significantly reduced fear of
negative evaluation (d50.58)
relative to the waitlist control. It
also significantly reduced SA
symptoms as shown by the SAS
(d50.54), relative to the
waitlist control
>Treatment gains for both treatment
conditions were maintained at
12-month FU (no control
group at FU)
GA, Generalised anxiety; SA, social anxiety; SH, self help; TA, therapist assisted; PI, post-intervention; FU, follow-up; d, Cohen’s d(between-group).
40 C. Twomey et al.
Similarly, ‘Deprexis’ can be purchased online. Whereas
ECentre Clinic’s ‘Sadness’ and ‘Well-being’ programmes
are both delivered with therapist assistance, the other
three programmes can be completed on a self-help basis.
The total number of sessions for the programmes ranges
from 5 to 10, although ‘MoodHelper’ is a diary-style
intervention completed at one’s own pace.
One of the programmes, ‘MoodGym’, has three
RCTs showing its efficacy, two programmes have two
RCTs, and three programmes have one RCT. Although
‘MoodGym’ has the most RCTs, one of these had a
small, self-referred sample and one had a school-based
non-clinical sample. Furthermore, in the latter RCT,
‘MoodGym’ was found to be effective for males only.
However, it was found to be effective in an RCT with a
large, self-referred, clinically screened sample. Overall,
it seems that the strongest evidence is for ‘Beating the
Blues’ and ‘eCentre Clinic-Sadness’. The former has
two large-scale RCTs in GP-referred, clinically
screened samples that yielded medium effect sizes.
The latter has two RCTs in self-referred, clinically
screened samples that both yielded large effect sizes.
However, one of the RCTs for ‘eCentre Clinic-Sadness’
had a small sample size and both RCTs are limited
by little to no follow-up data. The three programmes
with one RCT are not elaborated on here because of
word constraints, but the evidence behind each is
detailed in Table 5.
cCBT programmes for eating problems
Three cCBT programmes for eating problems met this
article’s inclusion criteria (Table 6). These programmes
were developed in the United States, United Kingdom
and Switzerland, respectively. None of these are freely
accessible online by residents in Ireland. However,
‘Overcoming Bulimia Online’ (UK) can be purchased
online for ,h75 and ‘Student Bodies’ can be purchased
via private contract by institutions and individuals.
The other programme ‘Salut BN’ (Switzerland) is a
long-term fee-based intervention that requires sub-
stantial service integration. Overcoming ‘Bulimia
Online’ and ‘Student Bodies’ can be completed on a
self-help basis, but ‘Salut BN’ is delivered with
therapist assistance and integrated face-to-face sessions.
The former two programmes have eight sessions each,
but ‘Salut BN’ has seven multifaceted ‘modules’ that are
completed over 6 months.
One of the programmes, ‘Student Bodies’, has two
RCTs showing its efficacy, and the other two pro-
grammes have one RCT each. All four RCTs have
screened, self-referred, female-only samples. The two
RCTs on ‘Student Bodies’ have large sample sizes and
yielded medium effect sizes. However, screening
ensured that the sample was non-clinical in nature.
Table 4. cCBT programmes for PTSD
Year Sample Referred by Clinical screening Randomisation PTSD outcome measure(s) Outcomes
Name: eCentre Clinic – PTSD Programme. Country: Australia. Authors: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/ Population: Adults. Format: TA with weekly phone calls. Schedule: 7 weekly
sessions. Availability: Via research participation in Australia only. RCTs: 1.
Spence et al.
(2011)
42 adults aged 21–68 years
(M542.6 years, 80.9%
female)
Self-applied via
website and
adverts
Not experiencing psychosis or severe
depression (defined as a total score
,23 or responding .2toQuestion9
(suicidal ideation) on the Patient
Health Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); not experiencing
high dissociation (defined as score of
,40 on the Dissociative Experiences
Scale) (Carlson et al.1993);meet
DSM-IV (American Psychiatric
Association, 2000) criteria for PTSD.
Criteria confirmed by clinical
interview
a. PTSD Programme
(n523)
b. Waitlist control (n519)
>PTSD checklist
(Weathers et al. 1993)
>At PI, significant reductions in
PTSD symptoms (d50.47), relative
to waitlist control
>Benefits maintained at 3-month FU
(no control group at FU)
Computerised cognitive behavioural therapy 41
Table 5. cCBT programmes for depression
Year Sample Referred by Clinical screening Randomisation
Depression outcome
measure(s) Outcomes
Name: Beating the Blues. Country: UK. Author: J. Proudfoot. Web: http://www.beatingtheblues.co.uk/. Population: Adults. Format: SH. Schedule: 8 weekly sessions. Availability: Via public health services in UK,
USA, Canada, New Zealand, and Australia. Also can be purchased online for $230 (,h166.) RCTs: 2.
Proudfoot et al.
(2003)
167 primary care service
users aged 18–75 years
(M544.7 years; 73.7%
female)
GPs and primary care
staff
Prior diagnosis of depressive and/
or anxiety disorder; scores of >4
on the General Health
Questionnaire-12 (GHQ-12)
(Goldberg, 1972) and >12 on the
Clinical Interview Schedule-
Revised: PROQSY (Lewis, 1994)
that was administered by a
clinician
a. Beating the Blues (1non-
therapeutic GP support;
n589)
b. GP treatment-as-usual
(n578)
>Beck Depression Inventory
II (BDI) (Beck et al. 1996)
>At PI, Beating the Blues was
significantly more effective than
treatment-as-usual for depression
reduction (d50.54)
>At 3-month (d50.5) and 6-month
(d50.55) FUs, Beating the Blues
was significantly more effective
than treatment-as-usual for
depression reduction
Proudfoot et al.
(2004)
107 primary care service
users aged 18–75 years
were included to the
above study (total
n5274; M543.37
years; 74% female)
GPs and primary care
staff.
Prior diagnosis of depressive and/
or anxiety disorder; scores of >4
on the General Health
Questionnaire-12 (GHQ-12)
(Goldberg, 1972) and >12 on the
Clinical Interview Schedule-
Revised: PROQSY (Lewis, 1994)
that was administered by a
clinician.
a. Beating the Blues (1non-
therapeutic GP support;
n5146)
b. GP Treatment-as-usual
(n5128)
>BDI (Beck et al. 1996) >At PI, Beating the Blues was
significantly more effective than
treatment-as-usual for depression
reduction (d50.62)
>At 3-month (d50.5) and 8-month
(d50.56) FUs, Beating the Blues
was significantly more effective
than treatment-as-usual for
depression reduction
Name: eCentre Clinic – Sadness Programme. Country: Australia. Authors: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/ Population: Adults. Format: TA with weekly phone calls. Schedule: 8 weekly
sessions. Availability: Via research participation in Australia only. RCTs: 2.
Perini et al.
(2009)
45 adults aged 19–85 years
(M549.29 years,
77.85%)
Self-applied via
website
Not experiencing psychosis or
severe depression (defined as a
total score ,23 or responding
.2 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); meet DSM-
IV (American Psychiatric
Association, 2000) criteria for
GA. Criteria confirmed by
clinical interview
a. Sadness Programme
(n527)
b. Waitlist control (n518)
>PHQ-9 (Kroenke et al. 2001)
>BDI (Beck et al. 1996)
>At PI, the sadness programme
significantly reduced depression as
shown by the PHQ-9 (d50.89) and
the BDI (d50.63), relative to the
waitlist control
>No FU data was collected
42 C. Twomey et al.
Table 5. Continued
Year Sample Referred by Clinical screening Randomisation
Depression outcome
measure(s) Outcomes
Titov et al.
(2010)
126 adults aged 19–73
years (M543 years,
74% female)
Self-applied via
website
Not experiencing psychosis or
severe depression (defined as a
total score ,23 or responding
.2 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); meet DSM-
IV (American Psychiatric
Association, 2000) criteria for
GA. Criteria confirmed by
clinical interview
a. Sadness Programme with
technical assistance
(STECH; n541)
b. Sadness Programme with
clinical assistance (SCLIN;
n545)
c. Waitlist control (n540)
>PHQ-9 (Kroenke et al. 2001)
>BDI (Beck et al. 1996)
>At PI, the STECH and SCLIN groups
were similarly effective. Both signifi-
cantly reduced depression as shown
by the PHQ-9 (d51.27., d51.39)
and the BDI (d51.09., d51.09),
relative to the waitlist control
>At 4-month FU, treatment benefits
were maintained (with no control
group comparison) and the STECH
group had significantly lower
scores on the PHQ-9 than the
SCLIN group (d50.46)
Name: MoodGym
a
.Country: Australia. Authors: H. Christensen & K. Griffiths. Web: http://moodgym.anu.edu.au/welcome. Population: Adults and adolescents. Format: SH. Schedule: 5 sessions, completed at
own pace. Availability: Freely accessible. RCTs: 3.
Christensen
et al. (2004);
Mackinnon
et al. (2008)
525 adults aged 18–52
years (M536.43 years;
71.4% female)
Self-recruited by mail Score >22 on Kessler Psychological
Distress Scale (K10) (Kessler
et al. 2002). Clinical interview
not conducted
a. MoodGym (n5182)
b. Psychoeducation website
(n5165)
c. Control (n5178)
>Centre for Epidemiologic
Studies – Depression Scale
(CES-D) (Randolf, 1977)
>At PI, both MoodGym (d50.33)
and psychoeducation website
interventions (d50.31) groups
were similarly effective – both
significantly reduced depression
symptoms, relative to the control
>At 6-month FU, MoodGym
(d50.2) and psychoeducation
website intervention (d50.25)
groups maintained benefits
relative to the control group
>At 12-month FU, MoodGym
(d50.21) and psychoeducation
website intervention (d50.36)
groups maintained benefits
relative to the control group
Calear et al.
(2009)
1477 children aged 12–17
years (M514.34 years;
55.9% female) from 32
schools
School – as part of the
curriculum
None a. Classroom-delivered
MoodGym (n5563)
b. Control (n5914)
>CES-D Scale (Randolf,
1977)
>MoodGym group had significantly
lower levels of depression for males
but not females at PI (d50.43), and at
6-month FU (d50.27) relative to
waitlist control
Computerised cognitive behavioural therapy 43
Table 5. Continued
Year Sample Referred by Clinical screening Randomisation
Depression outcome
measure(s) Outcomes
Sethi et al.
(2010)
34 university students aged
18–23 years (M519.47
years; 78.1% female)
Self-recruited by
adverts
Mild-to-moderate depression or
anxiety shown by the
Depression Anxiety Stress Scale-
21 (cut-off scores not reported
DASS-21) (Lovibond &
Lovibond, 1995). Clinical
interview not conducted
a. MoodGym (n59)
b. Face-to-face CBT (n510)
c. Face-to-face CBT1Mood-
Gym (n59)
d. Control (n510)
>DASS-21 (Lovibond &
Lovibond, 1995)
>Automatic Thoughts
Questionnaire (ATQ)
(Hollon & Kendall, 1980)
>For depression (DASS-21)
MG1F2F was significantly more
effective than MoodGym (d50.87)
but not face-to-face CBT (d51.28)
MoodGym was not more effective
than control
>For automatic thoughts
frequency (ATQ), MG1F2F was
significantly more effective than
MoodGym (d50.43), and face-
to-face CBT (d50.59). MoodGym
was significantly more effective
than control (d50.63) only
Name: eCentre Clinic – Well-being Programme. Country: Australia. Authors: N. Titov & B. Dear. Web: http://www.ecentreclinic.org/. Population: Adults. Format: TA with weekly phone calls. Schedule: 8 weekly
sessions. Availability: Via research participation in Australia only. RCTs: 1.
Titov et al.
(2011)
77 adults aged 18–79 years
(M543.9 years; 73%
female)
Self-applied via
website
Not experiencing psychosis or
severe depression (defined as a
total score ,23 or responding
.2 to Question 9 (suicidal
ideation) on the Patient Health
Questionnaire-9 Item (PHQ-9)
(Kroenke et al. 2001); meet DSM-
IV (American Psychiatric
Association, 2000) criteria for
depression, GA, SA and/or
panic disorder. Criteria
confirmed by clinical interview
a. Well-Being Programme
(n537)
b. Waitlist control (n537)
>PHQ-9 (Kroenke et al. 2001) >At PI, the Well-Being Programme
significantly reduced depression
symptoms (d50.52) relative to the
waitlist control
>Treatment gains were maintained
at 3-month FU (with no control
group comparison)
44 C. Twomey et al.
Table 5. Continued
Year Sample Referred by Clinical screening Randomisation
Depression outcome
measure(s) Outcomes
Name: MoodHelper. Country: USA. Author: G. Clarke. Web: https://www.kpchr.org/moodhelper/ Population: Adults and adolescents. Format: SH. Schedule: Diary completed at own pace. Availability: Freely
accessible. RCTs: 1.
Clarke et al.
(2009)
160 adults aged 18–24
years (M522.65 years;
80% female)
Self-recruited by mail Classed as depressed by a health
maintenance organisation’s
electronic medical record.
Clinical interview not
conducted
a. MoodHelper (n583)
b. Treatment-as-usual
(various) consisting mainly
of psycho-pharmacology
and psychotherapy
(n577)
>Patient Health
Questionnaire-8 item
(PHQ-8) (Spitzer et al.
1999)
>For depression, across 32 weeks,
MoodHelper was significantly
more effective than treatment-as-
usual (d50.2, net effect size across
32 weeks)
>For females, there was a larger
effect (d50.42, net effect size
across 32 weeks)
Name: Deprexis. Country: Germany. Authors: B. Meyer, T .Berger, F. Caspar, C.G. Beevers, G. Andersson & M. Weiss. Population: Adults. Format: SH. Schedule: 10 weekly sessions. Availability: Fee-based – costs
h279 and can be purchased via the website. RCTs: 1.
Meyer et al.
(2009)
396 adults aged 18–27
years (M534.74 years,
76% female)
Self-recruited by
adverts
None a. Treatment-as-usual with
immediate access to
Deprexis (DNOW; n5320)
b. Treatment as-usual with
delayed access (9 week
delay) to Deprexis
(DLATER, n576)
>BDI (Beck et al. 1996) >At 9 week PI, DNOW significantly
reduced depression (d50.64),
relative to DLATER
>Treatment benefits were main-
tained at 18 week and 6-month
FUs. At 6-months both groups had
similarly beneficial treatment
scores (as the effect of the delay
was now minimal)
GA, Generalised anxiety, SA, social anxiety; SH, self help; TA, therapist assisted; PI, post-intervention; FU, follow-up; d, Cohen’s d(between-group).
a
Four other RCTs were conducted on MoodGym (see note in Table 1).
Computerised cognitive behavioural therapy 45
Table 6. cCBT programmes for eating problems
Year Sample Referred by Clinical screening Randomisation
Eating problems outcome
measure(s) Outcomes
Name: Student Bodies
a
.Country: USA. Authors: A.J. Winzelberg & A. Celio. Web: http://www.beyondblackboards.com/StudentBodies.aspx Population: Adolescents and young adults. Format: SH with online
forum access. Schedule: 8 weekly sessions. Availability: Fee-based, private contract. RCTs: 2.
Barr Taylor
et al. (2006)
480 female university
students aged 17–31
years (M520.8 years)
Self-recruited by
adverts
Body mass index (BMI) >18 and
<32. Must not meet DSM-IV
(American Psychiatric
Association, 2000) criteria for an
eating disorder. Absence of
diagnosis confirmed by clinical
interview. Must score >50 on
the Weight Concerns Scale
(WCS) (Killen et al. 1994),
indicating moderate to high fear
of gaining weight
a. Student Bodies (n5244)
b. Waitlist control (n5236)
>Eating Disorder Inventory
(EDI) (Garner & Olmsted,
1984)
>Eating Disorder Examination–
Questionnaire (EDE-Q)
(Fairburn & Beglin, 1994)
>WCS (Killen et al. 1994)
>At PI, Student Bodies significantly
improved body image as shown by
the EDI drive for thinness
(d50.61) and bulimia subscales
(d50.22), EDE-Q (d50.7), and the
WCS (d50.81), relative to waitlist
control
>At 1-year FU treatment gains were
maintained as shown by the EDI
drive for thinness subscale
(d50.61) EDE-Q (d50.7), and the
WCS (d50.81), relative to waitlist
control. However, the between-
group scores on the EDI bulimia
subscale were no longer significant
Jacobi et al.
(2007)
97 female university
students aged 18–29
years (M522.3 years)
Self-recruited by
adverts
BMI >18 and <30. Must not meet
(unspecified) criteria for an
eating disorder during the last
year, report frequent binge
eating/purging episodes,
engage in substance or drug
abuse, must not be using
psychotropic medication or
have had previous suicidal
ideation. Criteria confirmed by
clinical interview
a. Student Bodies (n547)
b. Waitlist control (n550)
>EDI (Killen et al. 1994)
>EDE-Q (Garner & Olmsted,
1984)
>WCS (Fairburn & Beglin,
1994)
>At PI, Student Bodies significantly
improved body image as shown by
the EDI drive for thinness subscale
(d50.42), EDE-Q restraint sub-
scale (d50.65), and the WCS
(d50.18), relative to waitlist
control. However, non-significant
was found on the measures’
other subscales
>At 3-month FU, treatment gains
were maintained as shown by the
EDI drive for thinness subscale
(d50.34) and the EDE-Q restraint
subscale (d50.54) but not the
WCS, relative to the waitlist
control
46 C. Twomey et al.
Table 6. Continued
Year Sample Referred by Clinical screening Randomisation
Eating problems outcome
measure(s) Outcomes
Name: Overcoming Bulimia Online (OBO). Country: UK. Authors: C. Williams & U.H. Schmidt. Web: http://www.overcomingbulimiaonline.com/ Population: For adults. Format: SH with online forum access.
Schedule: 8 weekly sessions. Availability: Fee-based, can be purchased via the website for £65 (h75 approximately). RCTs: 1.
Sanchez-Ortiz
et al. (2011)
76 female university
students (age range not
reported; M523.9
years)
Self-recruited by
adverts
Meet DSM-IV (American
Psychiatric Association, 2000)
criteria for bulimia nervosa (BN)
or eating disorder not otherwise
specified (EDNOS), must not
have a diagnosis of binge eating
disorder or a major disorder
requiring a ‘different
intervention’; BMI .18.5.
Criteria confirmed by clinical
interview
a. OBO (n538)
b. Waitlist control/delayed
treatment group (n538)
>EDE-Q (Garner & Olmsted,
1984)
>At PI, OBO significantly improved
body image as shown by the
EDE-Q (d51.23), relative to
waitlist control
>At 6-month FU, treatment gains
were maintained on the EDE-Q
(d50.95), relative to the waitlist
control
Name: Salut BN. Country: Switzerland. Authors: T. Lam & colleagues. Web: http://www2.salut-ed.org/demo/. Population: For adults. Format: TA with weekly emails and a minimum of three face-to-face
meetings. Schedule: 7 modules, within each is several lessons and exercises. Takes 6 months to complete. Availability: Fee-based, available in various European countries (but not Ireland or the UK). RCTs: 1.
Carrad et al.
(2011)
74 females aged 21–60
years (M536 years)
Self-recruited by
adverts
Meet DSM-IV (American
Psychiatric Association, 2000)
criteria for binge eating
disorder, no recent suicide
attempt, no past obesity
surgery. Criteria confirmed by
clinical interview
a. Salut BN (n537)
b. Waitlist control (n537)
>EDE-Q (Garner & Olmsted,
1984)
>EDI (Killen et al. 1994)
>Three-Factor Eating Ques-
tionnaire (TFEQ) (Stunkard
& Messick, 1985)
>At PI, Salut BN significantly
reduced bulimia nervosa
symptoms as shown by the EDE-Q
(d50.38), the EDI bulimia subscale
(d50.73) and the TFEQ hunger
subscale (d50.91), relative to
waitlist control
>At 1-year FU, treatment gains were
on these three measures
respectively (d50.3, d50.44,
d50.46), relative to the waitlist
control
TA, Therapist assisted; PI, post-intervention; FU, follow-up; d, Cohen’s d(between-group).
a
Student Bodies has another RCT which (partially) shows its efficacy (Celio et al. 2000). However, it was excluded because the intervention group completed Student Bodies alongside face-to-face and group
therapy sessions. Thus it was not possible to determine whether Student Bodies led to additional treatment benefits.
Computerised cognitive behavioural therapy 47
Table 7. cCBT programmes for stress
Year Sample Referred by Clinical screening Randomisation Stress outcome measure(s) Outcomes
Name: Stress and Mood Management. Country: USA. Authors: D. Billings, R.F. Cook, A. Hendrickson & C.D. Dove. Web: http://www.centerforworkforcehealth.com/gallery.htm Population: Adults. Format: SH.
Schedule: 4 sessions, completed at own pace. Availability: Fee-based, typically organisations purchase it for their employees, via the website. RCTs: 1.
Billings et al.
(2008)
309 adults aged 20–69
years (mean age not
reported; age range;
Self-recruited by email
and at employment
fair
None a. Stress and Mood
Management
b. Waitlist control
>Symptoms of Distress
Scale (Orioli et al. 1991)
>At PI, Stress and Mood
Management significantly reduced
distress symptoms, relative to
70.6% female) working
at a technology firm (nfor each group not stated) waitlist control. However, this
was at p,0.05 level of significance
and the effect size was low
(d50.11)
SH, Self help; PI, post-intervention; FU, follow-up; d, Cohen’s d(between-group).
Table 8. cCBT programmes for insomnia
Year Sample Referred by Clinical screening Randomisation Insomnia outcome measure(s) Outcomes
Name: SHUTi. Country: USA. Authors: L.M. Ritterband, L. Gonder-Frederick, C. Morin, F. Thorndike. Web: http://shuti.bht.virginia.edu/modules/8?page513 Population: Adults. Format: SH with automated
email reminders. Schedule: 6 weekly sessions. Availability: Freely accessible online by research participation only. RCTs: 1.
Ritterband et al.
(2009)
44 adults aged 18–65 years
(M544.86 years; 77.3%
female)
Self-recruited by
adverts
Meet DSM-IV (American
Psychiatric Association, 2000)
criteria for primary insomnia.
Criteria confirmed by clinical
interview
a. SHUTi (n522)
b. Waitlist Control (n522)
>Insomnia Severity Index
(Morin, 1993)
>At PI, Stress and Mood Management
significantly reduced insomnia
severity, relative to the waitlist
control (d51.68)
>Treatment gains were maintained
at FU (with no control group
comparison)
SH, Self help; PI, post-intervention; FU, follow-up; d, Cohen’s d(between-group).
48 C. Twomey et al.
Table 9. cCBT programmes for pain
Year Sample Referred by Clinical screening Randomisation Pain outcome measure(s) Outcomes
Name: Help Yourself Online. Country: Canada. Authors: C.L. Hicks, C.L. von Baeyer, P.J. McGrath. Web: http://www.usask.ca/childpain/research/hicks/hyo-available.htm Population: Children aged 9–16 years.
Format: TA – regular phone calls and emails. Schedule: 7-week programme. Availability: Freely accessible by contacting the authors. RCTs: 1.
Hicks et al.
(2006)
47 children aged 9–16
years (M511.7 years,
63.8% female)
Self-recruited by
adverts
Meet (unspecified) diagnostic
criteria of at least three
episodes of head or abdominal
pain within a 3-month period.
Criteria confirmed by clinical
interview
a. Help yourself online
(n525)
b. Waitlist control (n522)
>Daily pain diary (numeric
scale)
>Pediatric Quality of Life
Inventory Version 4.0
(PedsQL4.0) (Varni, 1998)
>At PI, Help yourself online
significantly reduced reported pain
frequency (d50.27) and pain
intensity (d50.56), relative to
waitlist control. More pain-free
days were also reported (d50.53)
>At 3-month FU, Help Yourself
Online maintained treatment gains
in terms of reported pain intensity
(d51.14) and pain-free days
(d50.38), but not pain frequency,
relative to waitlist control.
>No significant treatment benefits
were found on the PedsQl
Name: PainACTION. Country: USA. Authors: E. Chiauzzi, J. Bromberg & L. Menefee. Web: http://www.painaction.com/members/MyPage.aspx Population: Adults. Format: SH. Schedule: Unstructured,
completed at own pace. Availability: Freely accessible. RCTs: 1.
Chiauzzi et al.
(2010)
199 adults aged 18–79
years (M 546.14 years,
67.6% female)
Self-recruited by email
and staff recruiting
at a pain centre
Reported presence of recurrent
back pain. Clinical interview not
conducted
a. PainACTION (n5104)
b. Psychoeducation control
(n595)
>Brief Pain Inventory (BPI)
(Cleeland & Ryan, 1994)
>Oswestry Disability Ques-
tionnaire (ODQ) (Fairbank
et al. 1980)
>Chronic Pain Coping
Inventory-42 (CPIC)
(Jensen et al. 1995)
>Pain Catastrophising Scale
(PCS) (Sullivan et al. 1995)
>Pain Self-Efficacy
Questionnaire (PSEQ)
(Nicholas, 2007)
>At PI. PainACTION significantly
reduced pain catastrophizing (PCS;
d54.94)) and increased use of pain
coping strategies (CPIC – coping
subscale; d51.34), relative to the
control. These relative gains were
maintained at 6-month FU as
shown by the PCS (d54.94) and
the CPIC-coping subscale
(d51.74)
>No significant inter-group
differences were found on the BPI,
ODQ, PSEQ or other subscales
of the CPIC
Computerised cognitive behavioural therapy 49
The RCTs on ‘Overcoming Bulimia Online’ and ‘Salut
BN’ yielded medium to large effect sizes within compa-
ratively smaller samples. However, as both had clinically
screened samples, there is arguably stronger evidence
behind them than ‘Student Bodies’.
cCBT programmes for stress
One cCBT programme for stress, ‘Stress & Mood
Management’, met this article’s inclusion criteria
(Table 7). This self-help programme has four sessions.
It was developed in the United States and is currently
only available if purchased by organisations on behalf
of their employees. It has one RCT showing its efficacy,
but the significance level (p-value) was relatively weak
and the effect size was low. Furthermore, participants
were not clinically screened and it was a self-referred
(although large) sample.
cCBT programmes for insomnia
One cCBT programme for insomnia, ‘SHUTi’, met this
article’s inclusion criteria (Table 8). This self-help
programme has six sessions. Developed in the United
States, it is freely accessible by residents of Ireland
through research participation only (via the website). It
has one RCT with a clinically screened sample
showing its efficacy. The effect size here was large
but the study is limited by its small sample in which
participants were self-referred.
cCBT programmes for pain
Three cCBT programmes for pain met this article’s
inclusion criteria (Table 9). Two of these programmes
were developed in the United States, and the other was
developed in Canada. One of the programmes, ‘Pain-
ACTION’ (i.e. for chronic back pain management), is
freely accessible online by residents of Ireland. How-
ever, the other two programmes are freely available in
indirect ways – ‘Help Yourself Online’ can be accessed
by contacting its authors and ‘Web-MAP’ can be
availed of via research participation. ‘Help Yourself
Online’ is delivered with therapist assistance, but the
other two programmes can be completed on a self-help
basis. ‘Help Yourself Online’ and ‘Web-MAP’ have
seven and eight sessions, respectively, and ‘Pain
ACTION’ is an unstructured programme.
All three programmes have one RCT demonstrating
their efficacy. ‘Pain ACTION’s’ RCT has the largest
sample and effect sizes, and its sample was clinically
screened. However, significant improvements were
not made on several of its measures and its sample had
self-referred participants. Although each yielded med-
ium effect sizes, the other two programmes’ RCTs are
limited by the absence of clinical screening, the use of
Table 9. Continued
Year Sample Referred by Clinical screening Randomisation Pain outcome measure(s) Outcomes
Name: Web-MAP. Country: USA. Authors: T. Palermo, A. Wilson, M. Peters, A. Lewandowski & H. Somhegyi. Web: http://www.webmap2.com/welcome/ Population: Children & Adolescents. Format: SH.
Schedule: 8 weekly sessions. Availability: Freely accessible via research participation. RCTs: 1.
Palermo et al.
(2009)
48 children and
adolescents aged 11–17
years (M514.8 years;
72.9% female) attending
a speciality care clinic
Physicians from
speciality care clinic
Reported presence of recurrent
pain. Clinical interview not
conducted
a. Web-MAP (n526)
b. Waitlist control (n522)
>Daily online pain diary
(numeric scale)
>Child Activity Limitations
Interview (CALI) (Palermo
et al. 2004)
>At PI, significant reductions in pain
intensity (as shown by diary
d50.57) and activity limitations
(d50.77) relative to waitlist
control
>Benefits were maintained at
3-month FU (with no control group
comparison at FU)
SH, Self help; TA, therapist assisted; PI, post-intervention; FU, follow-up; d, Cohen’s d(between-group).
50 C. Twomey et al.
Table 10. cCBT programmes for alcohol misuse
Year Sample Referred by Clinical screening Randomisation Alcohol outcome measure(s) Outcomes
Name: Look at Your Drinking. Country: Netherlands. Authors: M.G. Postel and colleagues. Web: http://www.lookatyourdrinking.com/ Population: Adults. Format: TA with email communication. Schedule: 9
sessions, typically completed over 3 months. Availability: Fee-based; negotiable price. RCTs: 1.
Postel et al.
(2010)
156 adults aged 22–66
years (M545.3 years,
84% female)
Self-applied via
website and adverts
Drink .151,67units of alcohol
per week (for females); drink
.221,99 units of alcohol a
week (for males). Clinical
interview not conducted
a. Look at your drinking
(n578)
b. Waitlist control (n578)
>Retrospective (weekly)
drinking diary
>Maudsley Addiction Pro-
file, Health Symptom Scale
(MAP-HSS) (Marsden et al.
1998)
>At PI, Look at Your Drinking was
significantly effective for reducing
alcohol consumption as shown by
the diary (d51.21), relative to the
waitlist control
>It also improved health levels as
shown by the MAP-HSS (d50.96),
relative to the waitlist control
Name: Jellinek. Country: Netherlands. Authors: M. Blankers, M. Koeter, G. Schippers. Web: http://www.jellinek.nl/english. Population: Adults. Format: SH. Schedule: Online journal completed at own pace.
Availability: Freely accessible. RCTs: 1.
Blankers et al.
(2011)
205 adults (age range not
reported; M542.2
years, 50.1% female)
Self-applied via
website
Alcohol Use Disorders
Identification Test (AUDIT)
(Saunders et al. 1993); drink
.14 standard drinks per week.
Clinical interview not
conducted
a. SH Jellinek (n568)
b. TA Jellinek (n568)
c. Waitlist control (n569)
>Retrospective self-report
>AUDIT (Saunders et al.
1993)
>At PI, both SH (d50.36) and TA
Jellinek (d50.59) were similarly
and significantly effective for
reducing alcohol consumption (as
shown by self-report), relative to
the waitlist control. At 6-month
FU, treatment benefits were main-
tained (with no control group
comparison at FU)
>At PI, both SH (d50.27) and TA
Jellinek (d50.59) were similarly
and significantly effective for
reducing alcohol consumption (as
shown by the AUDIT), relative to
the waitlist control. At 6-month
FU, treatment benefits were main-
tained (with no control group
comparison at FU)
SH, Self help; TA, therapist assisted; PI, post-intervention; FU, follow-up; d, Cohen’s d(between-group).
Computerised cognitive behavioural therapy 51
non-standardised measures (e.g. pain diaries), and
small sample sizes. The RCT on ‘Web-MAP’ had a
physician-referred sample whereas the RCT on ‘Help
Yourself Online’ had a self-referred sample.
cCBT programmes for alcohol misuse
Two cCBT programmes for alcohol misuse met this
article’s inclusion criteria (Table 10). Both of these
programmes were developed in the Netherlands, and
are accessible online by residents of Ireland. However,
whereas ‘Jellinek’ is freely accessible, ‘Look at Your
Drinking’ must be purchased for a negotiated fee.
Moreover, the former can be completed on a self-help
basis, whereas the latter is delivered with therapist
assistance. ‘Jellinek’ is an unstructured, journal-style
programme, whereas ‘Look at Your Drinking’ has nine
sessions.
Both programmes have one RCT demonstrating
their efficacy, with large, self-referred samples. Parti-
cipants in each RCT were screened for alcohol use
levels. ‘Look at Your Drinking’ yielded large effect
sizes, whereas ‘Jellinek’ only yielded small-to-medium
effect sizes. Both RCTs are limited in that they rely
primarily on retrospective self-report for ascertaining
alcohol consumption levels.
Conclusions
This article identified 25 RCT-supported cCBT pro-
grammes that are delivered in English, via the internet.
The highest number of programmes were for GA
(n57) and depression (n56). Similarly, the highest
number of RCTs (across the programmes) were for GA
(n511) and depression (n510). These findings are in
line with research that shows that most of the evidence
for cCBT’s effectiveness is for anxiety and depression
(Spek et al. 2007; Andrews et al. 2010). These findings
also complement NICE’s best-practice guidelines that
recommend the use of cCBT for mild-to-moderate
anxiety and depression (NICE, 2006). Nevertheless,
this article demonstrated that a wide variety of cCBT
programmes for a range of mental health difficulties
can potentially be availed of in Ireland, although for a
set or negotiated fee for most programmes.
Various issues should be taken into account when
interpreting the positive findings concerning cCBT.
First, just 20% of the 35 indentified RCTs had
participants who were referred to cCBT programmes
by health professionals (mainly GPs), with the rest self-
referred. Some research has indicated that self-referees
to cCBT have better outcomes than those referred by
mental health professionals, but worse outcomes than
those referred by GPs (Mataix-Cols et al. 2006).
Therefore, it is likely that the referral source influenced
the findings, although in an unclear manner. Second,
little or no follow-up data were included in several of
the RCTs. If such data are not available for a particular
cCBT programme, clinicians should perhaps only refer
service users to it as a precursor or adjunct to
‘treatment as usual’. Third, 80% of the identified
programmes were for adults only, and some presenta-
tions (e.g. PTSD, stress and insomnia) had only one
programme each. Thus, although it has wide applic-
ability, cCBT may not be suitable for various client
groups. Finally, as the authors of the cCBT pro-
grammes were also authors on most of the RCTs, as
has been reported in studies concerning face-to-face
CBT (Cuijpers et al. 2010), it is possible that a
publication bias may have led to negative results for
particular cCBT programmes not being published.
Irish clinicians and service users may also find it
interesting to note that various cCBT programmes have
also been developed in Ireland in recent years. For
example, the online mental health promotion project,
‘Headsup’ that is run by the Rehab Group, provides a
cCBT skills programme (HeadsUp). The Technology
Enhanced Therapy project set up collaboratively by the
National Digital Research Centre (Trinity College Dublin)
and the charity Parents Plus also provides online
programmes (entitled ‘SilvercloudHealth’) for depression
and eating problems for adolescents and young adults
(SilverCloud). However, unlike the programmes detailed
in this review, these programmes have as yet no
published RCTs demonstrating their effectiveness, though
two RCTs are reportedly underway.
Looking to the future, the HSE is funding a 2-year
collaborative stepped-care and high-throughput ser-
vice in Roscommon for adults with mild-to-moderate
mental health difficulties. A key part of this pilot is the
planned development by the psychology services of
HSE-owned cCBT programmes for common mental
health difficulties. In-house ownership of such pro-
grammes will substantially reduce the cost of future
provision of such programmes to our service users,
and will facilitate adapting these over time to better
meet evolving or emerging clinical needs.
To conclude, NICE (2006) recommends that cCBT
programmessuchasthoseidentifiedinthisarticleare
best administered by clinicians as part of a stepped-care
model alongside low-intensity interventions such as
bibliotherapy and brief CBT (Twomey & Byrne, 2012).
Referring service users to these programmes could be
beneficial, especially in the light of our underdeveloped
mental health services and the limited availability of one-
to-one CBT. Before choosing a particular programme,
clinicians and service users are advised to examine its
effectiveness, particularly as profiled in this article’s
tables. It is time for us to log on to cCBT and to ‘step up’
or expand our mental health services.
52 C. Twomey et al.
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