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Therapist-supportedInternetcognitive
behaviouraltherapyforanxietydisordersin
adults
ARTICLEinCOCHRANEDATABASEOFSYSTEMATICREVIEWS(ONLINE)·MARCH2015
ImpactFactor:6.03·DOI:10.1002/14651858.CD011565·Source:PubMed
CITATIONS
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129
5AUTHORS,INCLUDING:
MargoC.Watt
St.FrancisXavierUniversity
52PUBLICATIONS649CITATIONS
SEEPROFILE
SherryHStewart
DalhousieUniversity
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Retrievedon:07October2015
Therapist-supported Internet cognitive behavioural therapy
for anxiety disorders in adults (Review)
Olthuis JV, Watt MC, Bailey K, Hayden JA, Stewart SH
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2015, Issue 3
http://www.thecochranelibrary.com
Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
7BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
26ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . .
33DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
49CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
138DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Therapist-supported ICBT versus waiting list control, Outcome 1 Clinically Important
Improvement in Anxiety at Post-Treatment. . . . . . . . . . . . . . . . . . . . . . . . 140
Analysis 1.2. Comparison 1 Therapist-supported ICBT versus waiting list control, Outcome 2 Anxiety Symptom Severity
at Post-Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Analysis 1.3. Comparison 1 Therapist-supported ICBT versus waiting list control, Outcome 3 General Anxiety Symptom
Severity at Post-Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Analysis 1.4. Comparison 1 Therapist-supported ICBT versus waiting list control, Outcome 4 Quality of Life at Post-
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Analysis 2.1. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 1 Clinically Important
Improvement in Anxiety at Post-Treatment. . . . . . . . . . . . . . . . . . . . . . . . 145
Analysis 2.2. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 2 Anxiety Symptom Severity at
Post-Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Analysis 2.3. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 3 Anxiety Symptom Severity at
Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Analysis 2.4. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 4 General Anxiety Symptom
Severity at Post-Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Analysis 2.5. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 5 General Anxiety Symptom
Severity at Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Analysis 2.6. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 6 Quality of Life at Post-
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Analysis 2.7. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 7 Quality of Life at Follow-up. 149
Analysis 3.1. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 1 Clinically Important
Improvement in Anxiety at Post-Treatment. . . . . . . . . . . . . . . . . . . . . . . . 150
Analysis 3.2. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 2 Clinically Important
Improvement in Anxiety at Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . 151
Analysis 3.3. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 3 Anxiety Symptom Severity at
Post-Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Analysis 3.4. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 4 Anxiety Symptom Severity at
Follow-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Analysis 3.5. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 5 General Anxiety Symptom
Severity at Post-Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
iTherapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.6. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 6 General Anxiety Symptom
Severity at Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Analysis 3.7. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 7 Quality of Life at Post-
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Analysis 3.8. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 8 Quality of Life at Follow-
up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
157ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
179APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
180CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
180DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
180SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
181DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
182NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iiTherapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Therapist-supported Internet cognitive behavioural therapy
for anxiety disorders in adults
Janine V Olthuis1, Margo C Watt2, Kristen Bailey3, Jill A Hayden4, Sherry H Stewart5
1Department of Psychology and Neuroscience, Dalhousie University, Halifax, Canada. 2Psychology, Saint Francis Xavier University,
Antigonish, Canada. 3Department of Psychology and Neuroscience, Dalhousie University & IWK Health Centre, Halifax, Canada.
4Department of Community Health & Epidemiology, Dalhousie University, Halifax, Canada. 5Departments of Psychiatry, Psychology
and Neuroscience, and Community Health and Epidemiology, Dalhousie University, Halifax, Canada
Contact address: Janine V Olthuis, Department of Psychology and Neuroscience, Dalhousie University, 1355 Oxford Street, Halifax,
NS, B3H 4J1, Canada. janine.olthuis@dal.ca.
Editorial group: Cochrane Depression, Anxiety and Neurosis Group.
Publication status and date: New, published in Issue 3, 2015.
Review content assessed as up-to-date: 12 April 2013.
Citation: Olthuis JV, Watt MC, Bailey K, Hayden JA, Stewart SH. Therapist-supported Internet cognitive behavioural ther-
apy for anxiety disorders in adults. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD011565. DOI:
10.1002/14651858.CD011565.
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Cognitive behavioural therapy (CBT) is an evidence-based treatment for anxiety disorders. Many people have difficulty accessing
treatment, due to a variety of obstacles. Researchers have therefore explored the possibility of using the Internet to deliver CBT; it is
important to ensure the decision to promote such treatment is grounded in high quality evidence.
Objectives
To assess the effects of therapist-supported Internet CBT on remission of anxiety disorder diagnosis and reduction of anxiety symptoms
in adults as compared to waiting list control, unguided CBT, or face-to-face CBT. Effects of treatment on quality of life and patient
satisfaction with the intervention were also assessed.
Search methods
We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialized Register (CCDANCTR) to 12 April 2013.
The CCDANCTR includes relevantrandomised controlled trials from EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967
-). We also searched online clinical trial registries and reference lists of included studies. We contacted authors to locate further trials.
An update of an initial search (April 2013), conducted in September 2014, identified seven new completed studies, seven previously
ongoing studies now completed, and four new ongoing studies. This is a fast-moving area; we plan to update this review shortly,
incorporating these new studies.
Selection criteria
Each identified study was independently assessed for inclusion by two authors. To be included, studies had to be randomised controlled
trials of therapist-supported ICBT compared to a waiting list, attention, information, or online discussion group; unguided CBT (that
is, self-help); or face-to-face CBT. We included studies that treated adults with an anxiety disorder (panic disorder, agoraphobia, social
phobia, post-traumatic stress disorder, acute stress disorder, generalized anxiety disorder, obsessive compulsive disorder, and specific
phobia) defined according to the Diagnostic and Statistical Manual of Mental Disorders III, III-R, IV, IV-TR or the International
Classification of Disesases 9 or 10.
1Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Data collection and analysis
Two authors independently assessed the risk of bias of included studies and judged overall study quality. We used data from intention-
to-treat analyses wherever possible. We assessed treatment effect for the dichotomous outcome of clinically important improvement in
anxiety using a risk ratio (RR) with 95% confidence interval (CI). For disorder-specific and general anxiety symptom measures and
quality of life we assessed continuous scores using standardized mean differences (SMD). We examined statistical heterogeneity using
the I2statistic.
Main results
We screened 1000 citations and selected 30 studies (2181 participants) for inclusion. The studies examined social phobia (11 trials),
panic disorder with or without agoraphobia (8 trials), generalized anxiety disorder (4 trials), post-traumatic stress disorder (1 trial), and
specific phobia (1 trial). Five remaining studies included a range of anxiety disorder diagnoses. Studies were conducted in Sweden (15
trials), Australia (12 trials), Switzerland (2 trials), and the Netherlands (1 trial) and investigated a variety of ICBT protocols. Three
primary comparisons were identified, experimental versus waiting list control, experimental versus unguided ICBT, and experimental
versus face-to-face CBT.
Moderate quality evidence from 9 studies (644 participants) contributed to a pooled RR of 4.18 (95% CI 2.42 to 7.22) for clinically
important improvement in anxiety at post-treatment, favouring therapist-supported ICBT over a waiting list, attention, information,
or online discussion group only. Similarly, the SMD for disorder-specific symptoms at post-treatment (22 studies, 1573 participants;
SMD -1.12, 95% CI -1.39 to -0.85) and general anxiety symptoms at post-treatment (14 studies, 1004 participants; SMD -0.79, 95%
CI -1.10 to -0.48) favoured therapist-supported ICBT. The quality of the evidence for both outcomes was low.
One study compared unguided CBT to therapist-supported ICBT for clinically important improvement in anxiety at post-treatment,
showing no difference in outcome between treatments (54 participants; ver y low quality evidence). At post-treatment there were no clear
differences between unguided CBT and therapist-supported ICBT for disorder-specific anxiety symptoms (4 studies, 253 participants;
SMD -0.24, 95% CI -0.69 to 0.21; low quality evidence) or general anxiety symptoms (two studies, 138 participants; SMD 0.28, 95%
CI -2.21 to 2.78; low quality evidence).
Compared to face-to-face CBT, therapist-supported ICBT showed no significant differences in clinically important improvement in
anxiety at post-treatment (4 studies, 365 participants; RR 1.09, 95% CI 0.89 to 1.34; moderate quality evidence). There were also
no clear differences between face-to-face and therapist supported ICBT for disorder-specific anxiety symptoms at post-treatment (6
studies, 424 participants; SMD 0.09, 95% CI -0.26 to 0.43; low quality evidence) or general anxiety symptoms at post-treatment (5
studies, 317 participants; SMD 0.17, 95% CI -0.35 to 0.69; low quality evidence).
Overall, risk of bias in included studies was low or unclear for most domains. However, due to the nature of psychosocial intervention
trials, blinding of participants and personnel, and outcome assessment tendedto have a high risk of bias. Heterogeneity across anumber
of the meta-analyses was substantial, some was explained by type of anxiety disorder or may be meta-analytic measurement artefact due
to combining many assessment measures. Adverse events were rarely reported.
Authors’ conclusions
Therapist-supported ICBT appears to be an efficacious treatment for anxiety in adults. The evidence comparing therapist-supported
ICBT to waiting list, attention, information, or online discussion group only control was low to moderate quality, the evidence
comparing therapist-supported ICBT to unguided ICBT was low to very low quality, and comparisons of therapist-supported ICBT
to face-to-face CBT was low to moderate quality. Further research is needed to better define and measure any potential harms resulting
from treatment. These findings suggest that therapist-supported ICBT is more efficacious than a waiting list, attention, information,
or online discussion group only control, and that there may not be a significant difference in outcome between unguided CBT and
therapist-supported ICBT; however, this latter finding must be interpreted with caution due to imprecision. The evidence suggests that
therapist-supported ICBT may not be significantly different from face-to-face CBT in reducing anxiety. Future research should involve
equivalence trials comparing ICBT and face-to-face CBT, examine the importance of the role of the therapist in ICBT, and include
effectiveness trials of ICBT in real-world settings. A timely update to this review is needed given the fast pace of this area of research.
P L A I N L A N G U A G E S U M M A R Y
Internet-based cognitive behavioural therapy with therapist support for anxiety in adults: a review of the evidence
2Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Who may be interested in this review?
People who suffer from anxiety and their families.
General Practitioners.
Professionals working in psychological therapy services.
Developers of Internet-based therapies for mental health problems.
Why is this review important?
Many adults suffer from anxiety disorders, which have a significant impact on their everyday lives. Anxiety disorders often result in
high healthcare costs and high costs to society due to absence from work and reduced quality of life. Research has shown that cognitive
behavioural therapy (CBT) is an effective treatment which helps to reduce anxiety. However, many people are not able to access face-to-
face CBT due to long waiting lists, lack of available time for appointments, transportation problems, and limited numbers of qualified
therapists.
Internet-based CBT (ICBT) provides a possible solution to overcome many of the barriers to accessing face-to-face therapy. Therapists
can provide support to patients who are accessing Internet-based therapy by telephone or e-mail. It is hoped that this will provide a way
of increasing access to CBT, particularly for people who live in rural areas. It is not yet known whether ICBT with therapist support is
effective in reducing symptoms of anxiety.
What questions does this review aim to answer?
This review aims to summarise current research to find out whether ICBT with therapist support is an effective treatment for anxiety.
The review aims to answer the following questions:
- is ICBT with therapist support more effective than no treatment (waiting list)?
- how effective is ICBT with therapist support compared with face-to-face CBT?
- how effective is ICBT with therapist support compared with unguided CBT (self-help with no therapist input)?
- what is the quality of current research on ICBT with therapist support for anxiety?
Which studies were included in the review?
Databases were searched to find all high quality studies of ICBT with therapist support for anxiety published until May 2013. To be
included in the review, studies had to be randomised controlled trials involving adults over 18 years with a main diagnosis of an anxiety
disorder; 30 studies with a total of 2181 participants were included in the review.
What does the evidence from the review tell us?
ICBT with therapist support was significantly more effective than no treatment (waiting list) at improving anxiety and reducing
symptoms. The quality of the evidence was low to moderate.
There was no significant difference in the effectiveness of ICBT with therapist support and unguided CBT, though the quality of the
evidence was low to very low. Patient satisfaction was generally reported to be higher with therapist-supported ICBT, however patient
satisfaction was not formally assessed.
ICBT with therapist support may not differ in effectiveness as compared to face-to-face CBT. The quality of the evidence was low to
moderate.
There was a low risk of bias in the included studies, except for blinding of participants, personnel, and outcome assessment. Adverse
events were rarely reported in the studies.
3Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
Therapist-Supported ICBT compared to waiting list, attention, information, or online discussion group only control for anxiety disorders in adults
Patient or population: patients with anxiety disorders
Settings: outpatient care via Internet with e-mail or telephone support, or both
Intervention: therapist-supported ICBT
Comparison: waiting list, attention, information, or online discussion group only control
Outcomes Illustrative comparative risks* (95% CI) Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments
Assumed risk Corresponding risk
Waiting list, attention,
information, or online
discussion group only
controll
Therapist-supported
ICBT
Clinically important im-
provement in anxiety at
post-treatment
Indexed by a standard-
ized interview or clinically
accepted measure cut-off
score1
Study population RR 4.18
(2.42 to 7.22)
644
(9 studies)
⊕⊕⊕
moderate2
13 per 100 54 per 100
(31 to 93)
Moderate
8 per 100 33 per 100
(19 to 57)
Anxiety symptom sever-
ity at post-treatment
Indexed by a range of dis-
order-specific self-report
measures
The mean anxiety symp-
tom severity at post-treat-
ment in the intervention
groups was
1.12 standard deviations
lower
(1.39 to 0.85 lower)
1573
(24 studies)
⊕⊕
low3,4,5
A standard deviation of 0.
80 or greater represents a
large difference between
groups6
4Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
General anxiety symp-
tom severity at post-
treatment
Indexed by a range
of measures of anxiety
symptoms in general
The mean general anxi-
ety symptom severity at
post-treatment in the in-
tervention groups was
0.79 standard deviations
lower
(1.1 to 0.48 lower)
1004
(14 studies)
⊕⊕
low4,5,7
A standard deviation of 0.
80 or greater represents a
large difference between
groups6
Quality of life at post-
treatment
Indexed by self-report
measures of quality of life
or functional disability
The mean quality of life
at post-treatment in the
intervention groups was
0.51 standard deviations
higher
(0.4 to 0.61 higher)
1395
(20 studies)
⊕⊕⊕
moderate4,7
A standard deviation of
0.50 represents a mod-
erate difference between
groups6
Adverse events at post-
treatment
not reported
Study population Not estimable 0
(0)
See comment Because adverse events
were so rarely reported,
they could not be mean-
ingfully reported by com-
parison and are instead
described in the review
text
See comment See comment
Moderate
Participant satisfaction
Indexed by a mix of
qualitative and quantita-
tive self-report measures
Study population Not estimable 0
(13)
See comment Studies reported high
overall treatment satis-
faction for therapist-sup-
ported ICBT
See comment See comment
Moderate
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio
5Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1For clinically important improvement in anxiety, an event is indicative of a participant achieving clinically important improvement.
2Downgraded for risk of bias (-1) primarily because three of the included studies did not blind their outcome assessors to participants’
group assignment. Not downgraded for inconsistency (0) because heterogeneity was reduced following subgroup analysis by anxiety
disorder.
3Downgraded for risk of bias (-1) primarily due to concerns with selective outcome reporting in a few studies.
4Risk of bias (0). While participants in the included studies were not blind to their treatment condition when completing self-report
measures and therapists were not blind to the treatment they were delivering, these study characteristics cannot be avoided in this type
of clinical treatment.
5Downgraded for inconsistency (-1) because the heterogeneity amongst the included studies was quite high. This may be explained
by the variety of anxiety disorders investigated and differences in the treatment details; however, the number of studies that could be
included in subgroup analyses was not sufficient to provide useful reasons for this heterogeneity.
6According to Cohen’s (1969) interpretation of effect sizes.
7Downgraded for risk of bias (-1) primarily because two studies included baseline imbalances in participant severity across study
groups.
6Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
B A C K G R O U N D
Description of the condition
Individuals with anxiety disorders experience excessive anxiety
(fear or worry) which is disproportionate to actual threat or dan-
ger and significantly interferes with normal daily functioning.
Anxiety disorders can include a range of physical (for example,
trembling, tense muscles, rapid breathing), cognitive (for exam-
ple, worries, difficulty concentrating), emotional (for example,
distress, negative affect, irritability), and behavioural (for exam-
ple, difficulty sleeping, hyperarousal) symptoms. Often those with
anxiety disorders develop maladaptive strategies to lessen anxi-
ety, such as avoidance (Health Canada 2002;Wilson 2006) or
substance use (Stewart 2008). Studies from Canada (Statistics
Canada 2004), the USA (Kessler 2005a), Australia (Slade 2007),
Nigeria (Gureje 2006), and Europe (ESEMeD/MHEDEA 2000
Investigators 2004) suggest that 6% to 18% of adults experience
an anxiety disorder every year. Moreover, rates of remission within
one year are low, that is, from 33% to 42% across specific anxiety
disorders (Robins 1991).
There are many types of anxiety disorders,including panic disorder
(PD), agoraphobia, social phobia, post-traumatic stress disorder
(PTSD), acute stress disorder, generalized anxiety disorder (GAD),
obsessive compulsive disorder (OCD), and specific phobia. These
are diagnosed according to criteria outlined in the Diagnostic and
Statistical Manual of Mental Disorders (DSM IV-R) (APA 2000)
or the International Classification of Diseases (ICD 10) (WHO
1999). Anxiety disorders often co-occur with each other (Kessler
2005a) as well as with mood disorders (Fava 2000) and substance
abuse or dependence (Stewart 2008). They tend to have an early
onset (Kessler 2005b) and chronic course (Bruce 2005). Anxiety
disorders also have a major economic impact; for instance, costs
of direct treatment, unnecessary medical treatment, and work ab-
sences or lost productivity amount to more than USD 40 billion
per year in the United States (DuPont 1996;Greenberg 1999).
Studies have shown significantly higher annual per capita medical
costs for primary care patients with social phobia than for those
with no mental health diagnosis (GBP 11,952 and EUR 2957 re-
spectively) (Acarturk 2009); primary care patients with PD versus
those with a chronic somatic condition (EUR 10,269 versus EUR
3019) (Batelaan 2007); and primary care patients with GAD as
compared to those without GAD (USD 2375 versus USD 1448)
(Revicki 2012).
Description of the intervention
Accumulating research supports the efficacy of CBT in the treat-
ment of anxiety disorders (Bisson 2007;Hunot 2007;Norton
2007;Stewart 2009) and anxiety symptoms (Deacon 2004). As its
name suggests, CBT includes both cognitive as well as behavioural
interventions or techniques. It has no one ’founder’ and now exists
in many different forms. Its roots, however, lie largely in the work
of Aaron Beck (Beck 1979). While pharmacotherapy (most com-
monly, benzodiazepines or selective serotonin reuptake inhibitors)
has been shown to be effective in the treatment of anxiety disor-
ders, meta-analyses and review articles suggest that CBT is as e ffec-
tive in the acute phase of anxiety and may be more effective than
pharmacotherapy or a combination of both treatments in the long
term (Westra 1998;Otto 2000;Otto 2005;Pull 2007). More-
over, some anxiety medications pose significant risk for addiction
(McNaughton 2008) or serious side effects, or both (Buffett-Jerrot
2002;Choy 2007).
Unfortunately, certain barriers (for example, time constraints,
transportation problems, stigma, long waiting lists, a lack of suf-
ficiently qualified clinicians) continue to limit access to CBT
(Alvidrez 1999;Young 2001;Mohr 2006). Many of these bar-
riers are particularly relevant for those living in rural communi-
ties (Yuen 1996;Rost 2002;Hauenstein 2006). National surveys
in Canada (Statistics Canada 2004) and the US (Kessler 2004)
suggested that less than one third (only 32% and 20%, respec-
tively) of those with a current psychiatric disorder received some
form of treatment in the past year. In a Canadian sample, only
11% of individuals with an anxiety disorder had received treat-
ment (Ohayon 2000). Increasingly, efforts are being made to im-
prove access to CBT on a large scale, particularly for those groups
who are most at risk due to lack of services (for example, the UK-
based National Health Service ’Improving Access to Psychological
Therapies’ (IAPT) programme launched in 2006) (Department
of Health 2008). A distance delivery approach wherein CBT is
delivered over the Internet with a therapist providing support by
telephone or e-mail is one way to minimize treatment barriers and
increase access to care while still delivering empirically-supported
treatment. Such an approach could increase access to mental health
professionals for those in rural areas, facilitate treatment for those
of limited mobility, and increase patient confidentiality (that is,
by engaging in treatment from home clients do not ’risk’ being
seen at mental health clinics) and privacy (for example, a degree
of visual anonymity). The widespread availability of the Internet
makes this type of intervention feasible and worth consideration.
Recent systematic reviews of computer- and Internet-based treat-
ment for mental health problems suggest largely that these types of
treatment are more effective than a waiting list control and equally
effective as face-to-face psychotherapy in treating anxiety and de-
pression symptoms (Spek 2007;Bee 2008;Cuijpers 2009;Reger
2009;Cuijpers 2010).
How the intervention might work
Therapist-supported ICBT should work to treat anxiety in the
same manner as conventional face-to-face CBT. The underlying
principles of CBT posit that psychopathology, or emotional dis-
turbances, are the result of cognitive distortions and maladaptive
7Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
behaviour. Whereas there are hypotheses about the relative impor-
tance of cognitive and behavioural techniques, as well as sugges-
tions that the strong collaborative working relationship between
the therapist and client are key to the success of CBT, the ex-
act mechanisms of action in CBT are not yet well understood
(Olatunji 2010). It is thought that disorder-specific symptoms de-
velop as a result of a particular pattern of dysfunctional cogni-
tions in combination with a specific set of behaviours that serve
to exacerbate these dysfunctional cognitions further (Beck 2005).
As such, CBT works to improve symptoms by treating these mal-
adaptive cognitions and behaviours.
In essence, cognitive techniques and behaviour modification
strategies are used to identify, evaluate, and challenge underlying
maladaptive thoughts and beliefs. As an example , it is thought that
catastrophic thoughts about the outcomes of experiencing arousal-
related physiological sensations, as well as inaccurate predictions
about the probability of these dangerous outcomes, and avoid-
ance of situations that may induce these sensations contribute to
the development and maintenance of PD (Clark 1986;Barlow
1988). Accordingly, CBT for panic uses cognitive restructuring
techniques to teach individuals to identify and challenge their mal-
adaptive cognitions and beliefs. This is combined with the use of
gradual, repeated exposure to feared sensations to help individu-
als revise their perceptions of threat and reduce their fear of these
arousal-related physiological sensations (Landon 2004). A similar
description of the CBT model could be provided for the other
anxiety disorders (for example, social phobia) (Heimberg 2002).
Whereas the underlying cognitive and behavioural principles are
evident in the CBT interventions for each of the anxiety disorders,
current forms of CBT also target core components of a particular
disorder and, as such, specific models of CBT now exist for each
disorder, which modify and adapt CBT principles to fit disorder-
specific symptoms (for example, specific phobia (Ost 1997); OCD
(Salkovskis 1985;Foa 2010); PD (Clark 1986;Casey 2004); so-
cial phobia (Heimberg 2002); GAD (Dugas 2007); PTSD (Ehlers
2000).
ICBT therapists would be expected to draw on these models in
the same manner as face-to-face CBT therapists. Typically, ICBT
involves the client following a written treatment program avail-
able on the Internet in conjunction with receiving therapist sup-
port, either via telephone calls, texts, or e-mail (Andersson 2006).
The intervention involves content that mimics that of face-to-
face CBT, therapist-client contact (albeit through non-traditional
means), and the client engaging in further ’homework’ outside of
the session. As such, we anticipated that ICBT will work in the
same way and as well as traditional face-to-face CBT.
Why it is important to do this review
Recently, research into ICBT has elicited considerable inter-
est from within the scientific and clinical communities. With
advances in modern communication technologies and their
widespread availability, this type of treatment is quickly becom-
ing a more realistic option. These advances have come at a time
when long waiting lists and a lack of treatment availability stand
in stark contrast to the growing emphasis on the importance of
mental health and provision of evidence-based treatments. A de-
sire to pursue Internet treatment as a viable option to increase
access to treatment is growing. The importance of ensuring that
the decision to promote such treatment is grounded firmly in high
quality evidence is therefore paramount.
The present review asked whether therapist-supported ICBT is ef-
ficacious in treating anxiety, and if it is as efficacious as face-to-face
CBT. Past meta-analyses have reviewed the efficacy of ICBT for
anxiety symptoms (Spek 2007). A number of reviews that have in-
cluded ICBT have looked more broadly, however, at health prob-
lems in general (Barak 2008;Bee 2008) or all computer-based in-
terventions (Cuijpers 2009;Reger 2009;Andrews 2010). More-
over,many of the se reviewshave not focused on the role of therapist
involvement (for example, Cuijpers 2009;Reger 2009;Andrews
2010). Ultimately,as the field of ICBT is growing quickly, an up-
dated review on therapist-supported ICBT is needed. The findings
of this review will be helpful in guiding the path of future research
in this field away from continued replication of established find-
ings and toward addressing gaps in the literature and considering
the next steps in ICBT implementation.
There is a Cochrane Review on media-delivered CBT and be-
havioural therapy (BT) (self-help) for anxiety disorders (Mayo-
Wilson 2013). Mayo-Wilson’s review answers questions about the
efficacy of delivering CBT to clients in non-traditional formats,
including via the Internet. In the protocol of their review, Mayo-
Wilson specified that they would not include studies with therapist
contact. With a post-protocol change, they revised their review to
include studies that involved therapist contact with the qualifier
that the interventions must be able to be delivered stand-alone
without therapist contact. With this in mind, the focus of their
review remains largely on self-help therapies in which therapist in-
volvement is not necessary and treatment is largely client-driven.
Mayo-Wilson did not conduct analyses separating out those in-
terventions with and without therapist contact. As such, a meta-
analysis with a particular emphasis on the efficacy of the rapist-sup-
ported ICBT is needed, particularly as at this point there remains
conflicting evidence of the comparable efficacy of self-help and
therapist-supported interventions (for example, Spek 2007;Titov
2008c;Berger 2011). The present review considered the specific
efficacy of therapist-supported ICBT in comparison to each of a
waiting list control (that is, no treatment), traditional face-to-face
CBT, and self-help interventions and as such will fill a gap in the
literature and answer current calls for research in this area (Reger
2009). The protocol for the present review can be found in the
Cochrane Library (Olthuis 2011).
8Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
O B J E C T I V E S
To assess the effects of therapist-supported ICBT on remission of
anxiety disorder diagnosis and reduction of anxiety symptoms in
adults as compared to waiting list control, unguided CBT, or face-
to-face CBT. Effects of treatment on quality of life and patient
satisfaction with the intervention were also assessed.
M E T H O D S
Criteria for considering studies for this review
Types of studies
We included parallel group randomised controlled trials (RCTs),
cross-over, and cluster randomised trials.
Types of participants
Participant characteristics
We includedstudies of adults (over 18 years of age; no upper limit).
Diagnosis
Participants with a primary diagnosis of an anxiety disorder ac-
cording to the DSM-III (APA 1980), DSM-III-R (APA 1987),
DSM-IV (APA 1994), DSM-IV-TR (APA 2000), ICD-9 (WHO
1979) or ICD-10 (WHO 1999) diagnostic criteria.
We included studies that focused on or adequately reported sub-
group information for any of the following anxiety disorders: panic
disorder (PD) with or without agoraphobia, agoraphobia without
a history of panic, social phobia (social anxiety disorder), post-
traumatic stress disorder (PTSD), acute stress disorder, obsessive
compulsive disorder (OCD), specific phobia, generalized anxiety
disorder (GAD), and anxiety disorder not otherwise specified. In-
cluded studies used diagnoses determined using a validated diag-
nostic instrument, for example, the Structured Clinical Interview
for DSM-IV-TR Axis I Disorders (SCID-I) (First 2002).
Setting
We included studies in which treatment entailed participants en-
gaging in the treatment from their homes and therapists located
at primary care settings, university laboratories, community men-
tal health clinics, or private practice clinics. Participants could be
treatment-seeking community members responding to media ad-
vertisements for study participation or they could be referred to
the study by a health professional.
Co-morbidities
We included studies of participants with co-morbid diagnoses (for
example, major depressive disorder, substance abuse) only if they
had been diagnosed with a primary anxiety disorder. We did not
include studies of participants reporting anxiety symptoms that
did not meet criteria for an anxiety disorder (for example, partici-
pants with a clinical presentation of major depressive disorder who
reported subthreshold anxiety symptoms or participants scoring
high on measures of anxiety symptoms but who were not assessed
for a DSM diagnosis).
Types of interventions
Experimental interventions
Cognitive behavioural therapies
We included studies that investigated the efficacy of a thera-
pist-supported Internet cognitive behavioural therapy (CBT), be-
havioural therapy (BT), or cognitive therapy (CT) intervention
for anxiety, defined as the following.
•BT interventions must have been designed to change the
behaviours that result from maladaptive anxiety-related
cognitions (we included interventions including, but not limited
to, exposure, desensitization, and behavioural experiments).
•CT must have been focused on elements of cognitive
restructuring of irrational or maladaptive anxiety-related
cognitions.
•CBT interventions consisted of some combination of the
elements of CT and BT.
Whereas psychoeducation often is an important part of CBT, we
did not consider psychoeducation alone to be a sufficient CBT
intervention unless it included some of the other treatment com-
ponents described here.
Internet interventions
To be considered an Internet intervention, CBT must have been
delivered over the Internet through the use of web pages or e-
mail, or both. Crucially, Internet interventions must have included
therapist support but this interaction could not be face-to-face.
However, we included interventions that involved an initial face-
to-face intake or interview session or an initial session to orient
clients to the Internet delivery method or to engage in treatment
planning, or a combination of these. Thus, therapist support must
have occurred via e-mail or the telephone, or both. Including only
interventions that could be delivered entirely by distance methods
reflected a primary motive for conducting this review, to find ways
to increase access to treatment for those who may not be able to
visit provider centres. While it was possible that Internet-based
interventions that provided some support in a face-to-face setting
9Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
could be just as effectively restructured to be delivered completely
by distance, it was more rigorous to include only studies that pro-
vided evidence specifically on the efficacy of Internet CBT deliv-
ered completely via distance methods. We did not select interven-
tions based on their length, or the number or duration of sessions.
Comparator interventions
1. Waiting list, attention, information, or online discussion
group only control condition (no intervention for participants
beyond weekly status monitoring by research personnel or
accessing online non-treatment related disease information or
discussion groups)
2. Unguided CBT (i.e., self-help CBT with no therapist
support)
3. Conventional face-to-face CBT interventions (including
individual or group CBT delivered in a traditional face-to-face
format)
Types of outcome measures
Primary outcomes
1. Efficacy of therapist-supported ICBT in leading to
clinically important improvement in anxiety as determined by a
diagnostic interview, for example, the SCID-I (First 2002) or the
Anxiety Disorders Interview Schedule (ADIS-IV) (DiNardo
1994) or a defined cut-off on a validated scale, for example, the
Yale Brown Obsessive Compulsive Scale (YBOCS) (Goodman
1989). In case the Clinical Global Impression scale change or
improvement items (CGI) (Guy 1976) were used, we employed
a score of 1 = ’very much’ or 2 = ’much improved’ to indicate
clinically important improvement.
2. Efficacy of therapist-supported ICBT in leading to
reduction in anxiety symptom severity measured by scores on a
validated, observer-rated instrument, for example, the Hamilton
Anxiety Rating Scale (Hamilton 1959), or a validated self-report
measure of: (a) disorder-specific symptoms, for example, the
Social Phobia Scale (SPS) (Mattick 1998), and (b) anxiety
symptoms in general, for example, the Beck Anxiety Inventory
(BAI) (Beck 1991).
Secondary outcomes
1. Quality of life as assessed by either measures of quality of
life, for example, the Quality of Life Inventory (QOLI) (Frisch
1992), or measures of disability, for example the Sheehan
Disability Scales (SDS) (Leon 1997) as increasing disability
entails decreased quality of life. While research suggests that
quality of life and disability are distinct but somewhat
overlapping constructs (Hambrick 2003), quality of life
measures have not often been conceptually or operationally
distinguished from measures of disability, resulting in
considerable overlap amongst indices of quality of life and
disability (Mogotsi 2000). With this in mind, we anticipated an
overlapping conceptualization of these two constructs in the
included studies and included both types of measures within the
meta-analysis in order to capture all possible information about
treatment outcome related to quality of life.
2. Participant satisfaction with the intervention. Participant
satisfaction tends to be measured uniquely across different
studies using a mix of qualitative and quantitative indices. In
anticipation of this, we evaluated participants’ satisfaction with
the intervention of interest as compared to the comparator
interventions in a qualitative manner.
3. Adverse events, in whatever manner reported by study
authors.
Timing of outcome assessment
We performed separate analyses based on different periods of as-
sessment: immediately post-treatment and at one follow-up pe-
riod at least six months post-treatment but not more than one
year. When studies reported more than one follow-up assessment
point, we used the longest follow-up period so as to provide the
best estimate of the long-term outcomes of the intervention.
Hierarchy of outcome measures
For primary outcomes, separate meta-analyses were conducted for
the two outcomes. The clinically important improvement in anx-
iety outcome measures were selected according to the following
hierarchy, based on availability in a particular study: (1) diagnostic
interview, (2) cut-off on a validated scale, (3) CGI scores. For re-
duction in anxiety symptom severity, the outcomes of available ob-
server-rated and self-report measures were statistically combined
and a mean score was created across the measures within a partic-
ular study. Measures of variance for this mean score were created
by combining standard deviations across studies according to the
method described by Borenstein 2009. This method requires that
the correlation between two measures be known; as such, in the
case that this correlation was not known, the measures with better
psychometric properties were included in the analysis.
For secondary outcomes, quality of life outcome measures were
treated in the same way as anxiety symptom severity measures.
Due to the qualitative nature of the other secondary outcome, par-
ticipant satisfaction with the intervention, a hierarchy of outcome
measures was not required.
Search methods for identification of studies
We used several methods to identify both published and unpub-
lished studies for possible inclusion in this review (see below). We
did not restrict studies to those reported in any particular language;
however, we conducted searches in English and initiated contact
with authors in English.
10Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Electronic searches
The Cochrane, Depression, Anxiety and Neurosis Review
Group’s Specialised Register (CCDANCTR)
The Cochrane Depression, Anxiety and Neurosis Group (CC-
DAN) maintains two clinical trials registers at their editorial base
in Bristol, UK, a references register and a studies-based register.
The CCDANCTR-References Register contains over 37,000 re-
ports of RCTs in depression, anxiety, and neurosis. Approximately
60% of these references have been tagged to individual, coded tri-
als. The coded trials are held in the CCDANCTR-Studies Regis-
ter and records are linked between the two registers through the
use of unique Study ID tags. Coding of trials is based on the
EU-Psi coding manual. Please contact the CCDAN Trials Search
Co-ordinator for further details. Reports of trials for inclusion in
the Group’s registers are collated from routine (weekly), generic
searches of MEDLINE (1950 to date), EMBASE (1974 to date)
and PsycINFO (1967 to date); quarterly searches of the Cochrane
Central Register of Controlled Trials (CENTRAL), and review-
specific searches of additional databases. Reports of trials are also
sourced from international trial registers via the World Health
Organisation (WHO International Clinical Trials Registry Plat-
form (ICTRP), ClinicalTrials.gov, dr ug companies, and the hand-
searching of key journals, conference proceedings, and other (non-
Cochrane) systematic reviews and meta-analyses.
Details of CCDAN’s generic search strategies can be found on the
Group‘s website.
We searched the CCDAN Specialised Registers to 12 April 2013
and the results from this search were fully incorporated in the
present review. Additionally, prior to publication, CCDAN’s Tri-
als Search Co-ordinator performed a precise update search of the
CCDANCTR Registers in September 2014 (Appendix 1). The
results were screened at the CCDAN’s editorial base and by the
first author and relevant studies were placed in awaiting classifica-
tion or ongoing (as appropriate). These studies will be fully incor-
porated in a timely, future update of this review.
CCDANCTR-Studies
We searched the CCDANCTR-Studies Register using the follow-
ing search strategy:
1. Condition = (anxiety or *phobi* or PTSD or post-trauma* or
“post trauma*” or posttrauma* or “stress disorder” or panic or
OCD or obsess* or compulsi* or GAD)
2. Intervention = (CBT or cognitive or behavio* or *therap* or
treatment or intervention or training or counsel*)
3. Age Group = (adult or aged or unclear or “not stated”)
4. Free-Text = (computer* or distance* or remote or tele* or Inter-
net* or web* or WWW or phone or mobile or e-mail* or email*
or online* or on-line or videoconferenc* or video-conferenc* or
“chat room*” or “instant messaging” or iCBT)
5. (1 and 2 and 3 and 4)
CCDANCTR-References
We searched the CCDANCTR-References Register to identify
additional untagged or uncoded references using the following
strategy:
1. (anxiety or *phobi* or PTSD or post-trauma* or “posttrauma*”
or posttrauma* or (stress and disorder*) or panic or OCD or ob-
sess* or compulsi* or GAD):ti,ab,kw
2. (therap* or train*):ti,ab
3. (psychotherap* or cognitive or behavio* or CBT):ti,ab,kw
4. (acceptance* or assertive* or brief* or commitment* or exposure
or group or implosive or “problem solving” or problem-solving or
“solution focused” or solution-focused or schema):ti,ab,kw
5. (CBT or cognitive or behavio* or “contingency management”
or “functional analys*” or mindfulness* or “mind training” or psy-
choeducat* or relaxation or “role play*”):ti,ab,kw
6. ((2 or 3) and 4) or 5
7. (computer* or distance* or remote or tele* or Internet* or web*
or WWW or phone or mobile or e-mail* or email* or online* or
on-line or videoconferenc* or video-conferenc* or “chat room*”
or “instant messaging” or iCBT):ti,ab,kw
8. 1 and 6 and 7
Searching other resources
Reference lists
We examined the reference lists of previous related meta-analyses
(Spek 2007;Bee 2008;Cuijpers 2009;Reger 2009;Andrews 2010;
Cuijpers 2010) and of articles selected for inclusion in the present
review.
Personal contacts and correspondence
We contacted experts in the field, including principal authors of
RCTs in the field of ICBT for anxiety, via e-mail and asked them
if they were aware of any further studies which meet the present
review’s inclusion criteria.
Unpublished studies
In order to search for unpublished studies, we searched
international trial registries including via the WHO IC-
TRP (http://apps.who.int/trialsearch/) and ClinicalTrials.gov (
www.clinicaltrials.gov) in June 2013.
Data collection and analysis
Selection of studies
In collaboration with the CCDAN Trials Search Co-ordinator,one
review author (JVO) conducted searches of electronic databases
11Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
and reference lists and contacted authors in order to locate poten-
tial trials to be included in the review. Two review authors (JVO
and KMB) independently assessed the titles and abstracts of the
resulting lists of studies for relevance. We then obtained full ar-
ticles for potentially relevant abstracts. Both review authors inde-
pendently assessed the identified trials to determine eligibility as
outlined in Criteria for considering studies for this review. We col-
lated and compared assessments. In the case of disagreement with
respect to trial eligibility, we made the final decision by discus-
sion and consensus, if necessary with the involvement of another
member of the review group (MCW or SHS, or both).
Data extraction and management
We independently extracted data from the included studies re-
garding methodology and treatment outcomes, and recorded the
data using a data extraction spreadsheet designed by one of the
review authors (JVO). If the included trials did not provide com-
plete information (for example, details of dropout, group means
and standard deviations), we contacted the primary investigator
by e-mail to attempt to obtain unreported data to permit an in-
tention-to-treat (ITT) analysis. We contacted other investigators
as needed.
Two review authors (JVO and KMB) independently extracted the
following data from each trial report:
1. description of trial, including primary researcher and year
of publication;
2. characteristics of trial methodology, including the
diagnostic criteria employed, participant inclusion and exclusion
criteria, the screening instrument(s) used, the inclusion or
exclusion of co-morbidity, the receipt of other interventions
simultaneously, and the number of centres involved;
3. characteristics of participants, including age, gender,
primary diagnosis, any co-morbid diagnoses, and duration of
primary symptoms;
4. characteristics of the intervention (for both the
experimental and comparator interventions), including
intervention classification (i.e., CBT, BT, CT), content and
components (e.g., psychoeducation, relaxation training,
exposure, cognitive restructuring), method of delivery of
therapist support (e.g., telephone, e-mail), duration, amount of
therapist and experimenter contact, and number of participants
randomised to each intervention; and
5. outcome measures employed, as listed in Types of outcome
measures, as well as the dropout rates for participants in each
treatment condition and whether the data reflected intention-to-
treat (ITT) analyses with last observation carried forward
(LOCF) or another method.
We subsequently recorded data in RevMan 5.3 data tables
(RevMan 2014).
Main planned comparisons
We planned to compare each of the outcomes of interest, at post-
treatment and 6 to 12 month follow-up, for each of the following
comparisons:
1. therapist-supported ICBT versus waiting list, attention,
information, or online discussion group only control,
2. therapist-supported ICBT versus unguided CBT, and
3. therapist-supported ICBT versus face-to-face CBT.
Assessment of risk of bias in included studies
We assessed the risk of bias in each included study using the
Cochrane Collaboration’s ’risk of bias’ tool (Higgins 2011a). We
assessed the following six areas for risk of bias.
1. Sequence generation: was the allocation sequence of
participants adequately randomised?
2. Allocation concealment: was the allocation sequence
adequately concealed from participants as well as those involved
in the enrolment and assignment of participants?
3. Blinding: were participants, study personnel, and those
assessing outcomes kept unaware of participants’ allocation to a
study condition throughout the course of the investigation?
4. Incomplete outcome data: were there incomplete data for
the main or secondary outcomes (e.g., due to attrition)? Were
incomplete data adequately addressed?
5. Selective reporting: was the study free of suggestions of
selective reporting of outcomes (e.g., reporting of a subset of
outcomes on the basis of the results)?
6. Other potential threats to bias: was the study free of any
other problems (e.g., early stopping, baseline imbalance, cross-
over trials) that could have introduced bias?
We did not assess risk of bias related to therapist experience and
qualifications. Evidence in the field as to the impact of therapist
experience on treatment outcomes remains mixed (for example,
Hahlweg 2001;Andersson 2012;Norton 2014), as such, it would
be inappropriate to impose bias on a study based on a characteristic
we are unsure would actually introduce bias. In addition, we did
not assess risk of bias related to therapist allegiance. This was
because: (a) all studies investigated CBT, and (b) it was impossible
to know if researchers were allied with a particular type of delivery
method.
Two review authors (JVO and KMB) independently assessed risk
of bias for each included study. We resolved disagreements by
consensus and discussion with a third review author (MCW or
SHS) where necessary. If further information about a particular
trial was required to assess its risk of bias, we contacted the pr imary
investigator of the relevant study. We created ’risk of bias’ tables
describing the information outlined above, as reported in each
study. These tables also include a judgement on the risk of bias,
made by the review authors for each of the six areas, based on the
following three categories: (1) low risk of bias, (2) high risk of bias,
and (3) unclear or unknown risk of bias.
12Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Measures of treatment effect
Dichotomous outcomes
We analysed our only dichotomous outcome, clinically important
improvement in anxiety (yes or no) (as measured by no longer
meeting diagnostic criteria on a diagnostic interview, no longer
meeting a designated cut-off on a validated scale, or meeting the
criteria for very much or much improved on the CGI) using risk
ratios (RRs) and 95% confidence intervals (CIs) within studies.
Continuous outcomes
As most studies that were selecte d for inclusion used different mea-
sures to assess sufficiently similar constructs, we compared con-
tinuous outcomes (that is, general and disorder-specific anxiety
symptoms, quality of life) by calculating the standardized mean
difference (SMD) and its 95% CI. However, when all of the stud-
ies within a meta-analysis used the same measure to assess an out-
come (for example, if all studies within a meta-analysis used the
BAI to assess general anxiety symptoms), we compared continuous
outcomes by calculating the mean difference (MD) to facilitate
the interpretation of the clinical relevance of the findings.
Most included studies used more than one measure to assess each
of the continuous outcomes. Thus, a mean score was created across
the measures included within each study. Measures of variance for
this mean score were created by combining standard deviations
across studies according to the method described by Borenstein
2009. This method requires that the correlation between two mea-
sures be known; as such, on the rare occasion when this correlation
was not known and could not be identified in prior literature the
measure in question was excluded from analyses. This occurred in
four instances (Klein 2006,Richards 2006, and Kiropoulos 2008
for the Body Vigilance Scale; Andersson 2009 for the Fear Survey
Schedule III).
To combine measures of quality of life and disability into one
outcome, we reversed the scores of the disability measures (that is,
by subtracting mean scores from the measure total scores) to align
them with the quality of life measures.
Endpoint versus change data
Weanticipated that we might encounter some studies that reported
analyses based on changes from baseline and other studies that
reported analyses based on final values. We planned to present
the two types of analysis results in separate subgroups to avoid
confusion for readers and, where appropriate, to combine both
types of scores in the final results. Despite these plans, none of the
included studies reported change data so we used endpoint data
in all meta-analyses.
Skewed data
We dealt with skewed data according to the guidelines in the
Cochrane Handbook for Systematic Reviews of Interventions (Higgins
2011a) and Higgins 2008. In order to conduct the final analy-
sis, transformed or untransformed data had to be obtained for all
studies because log-transformed and untransformed data cannot
be combined in meta-analyses (Higgins 2011a). In the case that
a limited number of studies included in one meta-analysis pre-
sented log-transformed data, we back-transformed these data and
included untransformed data in the meta-analysis. We then con-
ducted a sensitivity analysis excluding any studies that presented
transformed data.
Unit of analysis issues
Parallel group randomised controlled trials (RCTs)
In some parallel group RCTs, participants randomly assigned to
a waiting list, attention, information, or online discussion group
only control were permitted to pursue the active treatment after
their period on the waiting list was complete. To analyse dichoto-
mous and continuous data for these trials, we only included data
from participants before they crossed over to their second treat-
ment condition; in other words, only data from the original com-
parison (waiting list, attention, information, or online discussion
group only control versus therapist-supported ICBT) was used in
the meta-analyses.
Cross-over trials
When included studies were cross-over trials, we planned to in-
clude only data from the first phase of the trial.
Cluster randomised trials
When cluster randomised trials had accounted for clustering
within their analyses (through the use of multilevel modelling or
general estimating equations, for example) we planned to include
data directly in the meta-analyses. For studies that failed to ap-
propriately account for clustering, we planned to impute the data
based on the number of clusters reported in each intervention
group, the size of each cluster, summary statistics, and an estimate
of intracluster correlation. We also planned to exclude cluster trials
with a high risk of bias (that is, where clustering was not accounted
for in analyses) from sensitivity analyses.
Multiple intervention arms
When multiple intervention arms met our inclusion criteria, we
planned to combine eligible groups to create a pair-wise compari-
son following the procedure outlined in the Cochrane Handbookf or
Systematic Reviews of Interventions (Higgins 2011a). We planned
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to conduct sensitivity analyses excluding any studies with multi-
ple intervention arms that did not report all intervention compar-
isons.
Dealing with missing data
We used data from ITT analyses whenever they were reported by
study authors. In 21 studies, authors employed a LOCF method
to address missing data with the assumption that participants who
were missing data following randomisation (that is, dropouts) did
not respond to treatment. Of the remaining studies, one study used
multiple imputation methods to create ITT data (van Ballegooijen
2013). Seven studies used a mixed effects models approach in an
ITT approach to deal with missing data (Bergstrom 2010;Berger
2011;Hedman 2011;Paxling 2011;Andersson 2012a;Andersson
2012b;Silfvernagel 2012). One study did not include ITT data
(Andersson 2009).
Because included studies did not report individual participant
data, if authors did not provide ITT analyses in their manuscript
we contacted the primary investigator by e-mail to attempt to ob-
tain unreported data to permit an ITT analysis. When we did not
receive responses from study authors we simply included their re-
ported, non-ITT, continuous outcome data in the analysis. This
was the case for one study (Andersson 2009). For dichotomous
outcomes, we were able to impute ITT data by assuming that par-
ticipants who had dropped out did not meet the target event (that
is, clinically important improvement in anxiety). We conducted
sensitivity analyses excluding studies for which ITT data were not
available (either from the published manuscript or from study au-
thors) to determine the extent to which missing data influenced
effect sizes.
If included trials did not provide complete information (that is,
group means, standard deviations, and sample size), we contacted
the primary investigator by e-mail to attempt to obtain unreported
data. We contacted other study investigators as needed. The only
sources for outcome data were the original published report or
author correspondence. If standard deviations were not available
from the authors, we planned to calculate these using other data
reported in the article, including t-values, CIs, and standard errors.
If that was not possible, we planned to impute standard deviations
from other investigations using similar measures and populations.
Assessment of heterogeneity
We tested the extent of statistical heterogeneity in meta-analyses
using the I2statistic (Higgins 2002), which calculates the per-
centage of variability due to heterogeneity rather than chance. Ac-
cording to the guidelines outlined in the Cochrane Handbook for
Systematic Reviews of Interventions, I2values may be interpreted as
follows:
•0% to 40% might not be important;
•30% to 60% may represent moderate heterogeneity;
•50% to 90% may represent substantial heterogeneity; and
•75% to 100% represents considerable heterogeneity
(Higgins 2011a).
We interpreted the importance of these I2values in consideration
of the magnitude and direction of effects and the strength of evi-
dence for heterogeneity (as indexed by the P value from the Chi2
test). If there was evidence of heterogeneity, we first re-checked the
data for accuracy. We considered sources of heterogeneity accord-
ing to the pre-specified subgroup and sensitivity analyses listed in
Subgroup analysis and investigation of heterogeneity.
Assessment of reporting biases
Where there were sufficient numbers of trials to make such a plot
meaningful (that is, at least 10 included studies (Higgins 2011a))
we constructed funnel plots to determine the possible influence of
publication bias. We planned to enhance fu nnel plots with contour
lines delineating areas of statistical significance (as suggested by
Peters 2008) to assist in the differentiation of asymmetry due to
publication bias or other causes.
Data synthesis
We combined data using an inverse-variance random-effects
model due to expected variation in the characteristics of the in-
terventions investigated and participant populations. We com-
bined dichotomous outcome measures by computing a pooled
risk ratio (RR) and 95% CI. We combined continuous outcomes
when means and standard deviations were available. When suf-
ficiently similar continuous outcomes were measured differently
across studies we calculated an overall standardized mean differ-
ence (SMD) and 95% CI. However, as indicated previously, when
outcomes were measured similarly across studies we used a mean
difference method. We used the RevMan 5.3 software for data
synthesis.
Subgroup analysis and investigation of heterogeneity
We conducted subgroup analyses but interpreted these with cau-
tion due to the risk of false positive conclusions. We planned to
perform the following subgroup analyses:
1. gender of participants;
2. type of anxiety disorder (i.e., PD with or without
agoraphobia, agoraphobia without a history of panic, social
phobia (social anxiety disorder), PTSD, acute stress disorder,
OCD, specific phobia, GAD, and anxiety disorder not otherwise
specified);
3. amount of therapist contact, designated as low (90 min or
less), medium (91 to 299 min), or high (300 min or more);
4. type of CBT (i.e., BT, CT, or CBT); and
5. research group (i.e., the laboratory from which the study
was generated).
14Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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We were not able to conduct a subgroup analysis based on gender
of participants as none of the included studies distinguished out-
comes based on this participant variable. We also were not able
to conduct a subgroup analysis based on type of CBT. Only one
study (Andersson 2009) had a stronger focus on BT, as compared
to CT or CBT, and no studies examined a CT only intervention.
For the final subgroup analysis by research group, three research
groups were identified: a group in Sweden, and two distinct groups
in Australia.
Sensitivity analysis
Weconducted sensitivity analyses to determine the extent to which
observed pooled effect sizes depend on the quality of the design
characteristics of studies. We planned to conduct the following
sensitivity analyses:
1. exclusion of studies with a designation of high risk of bias
for one or more of the categories as outlined in Assessment of
risk of bias in included studies;
2. exclusion of cluster randomised trials where clustering was
not appropriately accounted for in analysis;
3. exclusion of studies with multiple intervention arms with
selective reporting of intervention comparisons;
4. exclusion of studies with a somewhat more active waiting
list control condition (i.e., attention, information, or online
discussion group only control)
5. exclusion of studies with imputed standard deviations for
continuous outcomes;
6. exclusion of studies with back transformed data for
continuous outcomes;
7. exclusion of studies not reporting: (a) dichotomous, and (b)
continuous outcomes according to the ITT principle;
8. exclusion of studies with continuous outcomes analysed
using LOCF; and
9. assuming treatment dropouts were responders for
dichotomous outcomes.
Summary of findings
Summary of findings tables were created to present the main find-
ings of the review. We imported meta-analytic data from RevMan
into GRADEprofiler version 3.6 to create summary of findings
tables for each of the three most clinically relevant comparisons:
ICBT with therapist support versus waiting list control, ICBTwith
therapist support versus unguided ICBT, and ICBT with thera-
pist support versus face-to-face CBT. The summary of findings
tables present meta-analytic outcomes for each of the continuous
and dichotomous outcomes at post-treatment and summarize the
number of studies and participants included in each analysis. In
addition, GRADEprofiler allowed us to rate the quality of the evi-
dence for each outcome for each comparison considering: (a) risk
of bias, (b) inconsistency, (c) indirectness, (d) imprecision, and(e)
publication bias.
R E S U L T S
Description of studies
See Characteristics of included studies;Characteristics of excluded
studies
Results of the search
The electronic search of databases (conducted April 2013), yielded
826 citations for consideration for inclusion in the review, includ-
ing manuscripts in peer-reviewed journals, conference abstracts,
and clinical trial registrations. Employing secondary search meth-
ods, including searching clinical trial registries, contacting experts
in the field, and searching the reference lists of eligible studies,
resulted in another 471 citations for consideration. After de-du-
plication and following a brief screening of thetitles and abstracts,
212 were retrieved for a more detailed evaluation of eligibility.
One hundred and fifty-one studies were subsequently excluded for
failing to meet our inclusion criteria. The PRISMA flow diagram
shown in Figure 1 outlines the study selection process and broad
reasons for exclusion. Studies were excluded if: (a) participants did
not meet diagnostic criteria for an anxiety disorder, as assessed by
study authors (population), (b) the intervention of interest was not
ICBT, did not involve a therapist, or included too much face-to-
face therapist contact (intervention), (c) the comparator was not
appropriate given our selection criteria (comparator), (d) the trial
was not randomised or did not use adequate diagnostic measures
(methods), or (e) the trial was ongoing (ongoing).
15Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 1. PRISMA diagram of the search process.
16Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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After accounting for duplicate reports of the same trial, 30 studies
were eligible for inclusion in the meta-analyses. Seven studies iden-
tified from an updated search in September 2014 have been added
to studies awaiting classification (Andersson 2013;Berger 2014;
Ivarsson 2014;Newby 2013), as have seven studies which were
completed during the process of completing this review (Andrews
2011b;Andrews 2011c;Andrews 2012a;Berger 2012;Carlbring
2012;Greist 2012;Nordgren 2012). These studies will be fully
incorporated into the review in a timely, future update.
E-mail correspondence to collect information to supplement data
provided in the published reports was exchanged with Dr Tomas
Furmark (Furmark 2009a;Furmark 2009b), Dr Per Carlbring
(Carlbring 2001;Carlbring 2006;Carlbring 2007;Carlbring
2011), Dr Nickolai Titov (Titov 2008a;Titov 2008b;Titov 2008c ;
Titov 2009;Titov 2010;Titov 2011), Dr Britt Klein (Klein 2006;
Richards 2006;Kiropoulos 2008), and Dr Wouter van Ballegooi-
jen (van Ballegooijen 2013).
Included studies
See Characteristics of included studies for details of individual
studies and Table 1 for a summary table of the characteristics of
the included studies.
Design
All of the 30 included studies were parallel group RCTs. For studies
in which participants in the waiting list, attention, information, or
online discussion group only control were given the opportunity
to complete the treatment after their time on the waiting list, only
data from the original comparison were used in the meta-analyses.
There were no cross-over or cluster randomised trials.
Seven studies included multiple intervention arms: two (Titov
2008c;Furmark 2009a) compared the intervention of interest to
two eligible comparators (a waiting list, and unguided CBT) so
were included in multiple meta-analyses (ICBT versus waiting
list control, and ICBT versus unguided CBT), and five (Richards
2006,Furmark 2009b;Robinson 2010;Berger 2011,Johnston
2011) included a third treatment arm not relevant to the present
review.
Sample sizes
Sample sizes of included studies ranged from 21 (12 in the inter-
vention arm, 9 in the comparator arm (Richards 2006)) to 204
participants (102 in both the intervention and comparator arms
(Andersson 2012a)). The average study sample size was 74 partic-
ipants. In most studies there was an equal distribution of partici-
pants between the treatment and control arms. Only 2 studies had
< 30 participants, 14 studies had 30 to 60 participants, 7 studies
had 60 to 90 participants, and 6 studies had 90 to 130 partici-
pants, with 1 outlier at 204 participants (Andersson 2012a).
Setting
Included studies came primarily from one research group in Swe-
den (15 trials), two groups in Australia (Klein: 2 trials; Titov: 10
trials), a research group in Switzerland (2 trials), and one in the
Netherlands (1 trial).
Whereas researchers and treating clinicians were located at univer-
sity-affiliated hospitals or mental health centres, participants re-
ceived the intervention of interest in their home. Treatment took
place over the Internet and by telephone. Face-to-face CBT, when
included in a trial, was conducted in a psychiatric setting (for ex-
ample, hospital, mental health clinic).
Participants
Participants were men and women over 18 years of age. The av-
erage mean age of study participants was 37.3 years. Women rep-
resented an average of 67.1% of participants in each study. The
ethnicity of participants was not reliably reported. For most stud-
ies, participants were recruited via media advertisements or a re-
cruitment website (28 studies); in a minority of studies partici-
pants were recruited via clinic referrals (Bergstrom 2010;Hedman
2011).
All included participants qualified for one of the following anxiety
disorder diagnoses: social phobia (11 trials), PD with or without
agoraphobia (8 trials), GAD (4 trials), PTSD (1 trial), and spe-
cific phobia (1 trial). The five remaining studies included partici-
pants with a range of anxiety disorder diagnoses. Twenty-six trials
included participants with co-morbid diagnoses and four studies
did not report on their inclusion and exclusion criteria. Among
all studies, regardless of their inclusion or exclusion of co-mor-
bidities, 25 studies excluded participants who scored above a cer-
tain threshold on a measure of depressive symptoms, for example,
above 30 on the Montgomery-Asberg Depression Rating Scale
(MADRS) (Svanborg 1994), and 26 studies excluded participants
who endorsed suicidal ideation, for example, on the MADRS sui-
cide item, with the rationale that they were unclear about how
to handle this high risk participant via a distance treatment. Six-
teen studies excluded participants with substance misuse or depen-
dence problems and 16 studies excluded participants with active
psychosis with the rationale that these problems would interfere
with anxiety treatment.
Twenty-eight trials included participants who were using psychi-
atric medication (including selective serotonin reuptake inhibitors,
serotonin norepinephrine reuptake inhibitors, benzodiazepines,
benzodiazepine derivatives, neuroleptics, tricyclic antidepressants,
17Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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beta-blockers) concurrent with study participation (Berger 2009
excluded those using medication, and Andersson 2009 did not re-
port on co-use of medication). Participants were typically included
only if they had been at a stable dose for a certain time period
(one to three months) preceding the study. Four studies (Carlbring
2001;Carlbring 2005;Carlbring 2006;van Ballegooijen 2013)
included participants engaged in another type of psychological
therapy concurrent with study participation, one of which had no
participants that met this characteristic (Carlbring 2006).
Interventions
Experimental interventions
Twenty-nine studies included in the present review tested ICBT
while one study investigated Internet-based BT with a focus on
exposure (Andersson 2009). ICBT interventions involved partici-
pants following 5 (Andersson 2009;Berger 2009;Berger 2011) to
15 (Hedman 2011) online treatment modules (mean = 8; median
= 7; mode = 6) with e-mail support from therapists. Six studies also
provided therapist support by telephone (Titov 2009;Robinson
2010;Titov 2010 ;Johnston 2011;Spence 2011;Titov 2011) while
another seven of these studies also included participation in an
online discussion forum (Tillfors 2008;Furmark 2009a;Furmark
2009b;Bergstrom 2010;Spence 2011,Titov 2011;Andersson
2012a).
Interventions ranged in length from 4 (Andersson 2009) to 15
weeks (Hedman 2011) (mean = 9; median = 9; mode = 10). The
degree of therapist involvement in the included interventions was
widely variable; the average total time spent by a therapist with
a participant ranged from a minimum of 25 minutes (Carlbring
2001) to a maximum of 376 minutes (Richards 2006) with the
overall mean = 132 minutes and median = 120 minutes (2 stud-
ies (Berger 2009;Berger 2011) did not report therapist contact
time). Similarly, among studies that reported this information, the
average number of e-mails sent by study therapists ranged from a
minimum of 5 (Spence 2011;Titov 2011) to a maximum of 24
(Titov 2009;Titov 2010) with the overall mean = 14 e-mails and
median = 12 e-mails.
Of the 30 included studies, 28 specified that treatment was pro-
vided by a licensed clinical psychologist (22 studies) or clinical
psychology graduate students in training, or both (15 studies).
Clinical psychology graduate students providing therapy were en-
rolled in master’s or doctoral psychology programs as required for
them to practice in their country. Of those studies in which li-
censed clinical psychologists delivered the treatment, six specified
that clinicians were provided with supervision from an expert in
the field. Similarly, of those studies in which clinical psychology
students provided treatment, 12 specified that supervision from an
expert in the field was provided. The two remaining studies spec-
ified that therapy was delivered by therapists trained by the treat-
ment founder (Andersson 2009) and a psychiatry registrar (Wims
2010). Details on the experience and training of study therapists,
if provided, can be found in the Characteristics of included studies
section.
Comparator Interventions
Twenty-two studies compared the experimental intervention to
a waiting list, attention, information, or online discussion group
only control. All but five of these studies included strict wait-
ing list control conditions with no treatment provided to par-
ticipants and assessments occurring after the designated waiting
list period. Of the remaining five studies, the control condition
in one study included a weekly self-report assessment but no in-
tervention (Furmark 2009a). The control condition in two stud-
ies (Richards 2006;van Ballegooijen 2013) provided basic non-
treatment disease-related information to participants and one of
these studies (Richards 2006) included weekly status check-ins
by phone. Finally, the control condition in two studies permitted
participants to engage in an online discussion group (Carlbring
2011;Andersson 2012a).
Four studies compared therapist-supported ICBT to unguided
CBT (that is, self-help). Finally, six studies compared the experi-
mental intervention to traditional, face-to-face group or individ-
ual CBT. This number of studies adds up to more than the total
number of studies because two studies included more than one
comparator.
Outcomes
Primary outcomes
Each of the included studies reported on the efficacy of thera-
pist-supported ICBT. Fourteen studies assessed participants post-
treatment for clinically important improvement in anxiety (a di-
chotomous outcome) and three studies reassessed this outcome at
a follow-up of 6 to 12 months later. Each of the included stud-
ies reported on participants’ disorder-specific anxiety symptom
severity using a validated self-report or observer-rated instrument
(a continuous outcome) at post-treatment. Eight studies assessed
anxiety symptom severity at a follow-up of 6 to 12 months later.
Twenty of the included studies also measured participants’ symp-
toms of general anxiety using validated self-report instruments at
post-treatment. Six studies assessed general anxiety at a follow-up
of 6 to 12 months later. Please see Table 1 and Characteristics of
included studies for more details of outcome assessment.
It was rare for studies to report adverse events. In fact, adverse
events could only be assumed from measures of participants’symp-
tom deterioration during the study or reasons for participant
dropout related to the treatment.
18Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Secondary outcomes
Twenty-six studies measured quality of life at post-treatment, while
six studies included quality of life as an outcome at 6 to 12 month
follow-up.
Participant satisfaction with treatment was indexed by 15 stud-
ies at post-treatment. A variety of different measures of treatment
satisfaction were used ranging in degrees of comprehensiveness
and complexity. Across different measurement approaches, partic-
ipants were most commonly asked to indicate their overall satisfac-
tion with the treatment program, their satisfaction with particular
portions of the treatment program (for example, therapist corre-
spondence, Internet modules), and their satisfaction with the pace
of the treatment program. Of the 15 studies, only four reported
treatment satisfaction for both the experimental and comparator
interventions; the remaining trials compared the experimental in-
tervention to a waiting list control, which did not lend itself to an
evaluation of satisfaction.
Excluded studies
Studies were excluded for a variety of reasons (see Characteristics of
excluded studies and Figure 1, the former of which lists a number
of studies that were most like the included studies but differed in
important ways that prevented inclusion). Studies were frequently
excluded because the intervention was: (a) not distance-based, (b)
distance-based but included more than two sessions of face-to-
face contact between therapist and participant, (c) not delivered
by a therapist (that is, was a self-help program), or (d) not CBT.
Similarly, studies were excluded if participants did not meet our
criteria because they had subclinical anxiety symptoms or an anx-
iety disorder was not their primary diagnosis. We also excluded
a number of studies because a closer look showed that they were
not RCTs or did not compare the intervention of interest to a
comparison group that met the eligibility criteria.
Ongoing studies
We originally identified 14 ongoing studies (16 references; see
Ongoing studies). The updated search in September 2014 showed
that seven of these studies (Andrews 2011b;Andrews 2011c;
Andrews 2012a;Berger 2012;Carlbring 2012;Greist 2012;
Nordgren 2012) had been completed and so we classified these as
studies awaiting classification (see below).We will fully incorporate
these studies in the upcoming update of the review. The updated
search also identified four additional ongoing studies (Rollman
2012;Titov 2012;Lindner 2013;Miclea 2014). We found details
in the full report of one study (Carlbring 2010) which revealed
it no longer qualified for inclusion, and so we moved this study
from ongoing studies to excluded studies. This left a total of nine
ongoing studies; for more details see Characteristics of ongoing
studies.
Studies awaiting classification
The updated search in September 2014 showed that seven pre-
viously ongoing studies had been completed; we classified these
studies as awaiting classification, with the plan to fully incorporate
them in an immediate update of the review. The updated search
also identified seven additional studies which we have classified as
awaiting classification; these will also be fully incorporated in the
updated version of the review. For more details on these studies
see Characteristics of studies awaiting classification.
Risk of bias in included studies
Results of the risk of bias assessments of included studies are sum-
marized succinctly in Figure 2 and Figure 3. Overall, the risk of
bias in the included studies was low, with some notable exceptions
related to the nature of clinical trials of psychological treatments.
Figure 2. Risk of bias graph: review authors’ judgements about each risk of bias item presented as
percentages across all included studies.
19Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each included
study.
20Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Allocation
The majority of included studies (n = 27) used an adequate method
of randomisation, primarily an online random number generator,
to avoid selection bias. The three remaining studies reported that
participants were randomised but did not describe the randomi-
sation procedure.
Most study authors (n = 25) did not adequately report alloca-
tion concealment. The remaining five studies reported allocation
concealment procedures that would have minimized the risk of
selection bias (for example, random assignment was maintained
by an independent research team member not involved in other
study aspects who gave randomisations to participants just prior
to treatment commencement).
Blinding
The blinding of participants and study personnel is difficult when
investigating the efficacy of psychological treatments. Unlike phar-
macological trials in which medication type can be concealed, it
is very difficult to blind participants to the characteristics of the
treatment they are receiving as they are active participants. Sim-
ilarly, it is impossible to blind study therapists to the treatment
they are delivering as they take an active role in its execution. As
such, each of the included studies could be rated as having a high
risk of bias because participants and personnel were not blind to
treatment assignment. Though this study characteristic was a lim-
itation across studies, because it is standard practice with this type
of clinical trial we did not find it necessary to conduct sensitivity
analyses based on the characteristic.
We indexed blinding of outcome assessment separately for self-
report versus observer or interview-rated outcome measures. As
participants were not blind to their treatment condition in the
included studies, self-report outcomes measured in all of the in-
cluded studies were not blinded. Fifteen studies measured out-
comes using observer-rated instruments. In 10 of these studies in-
terviewers who were blind to the treatment condition conducted
the outcome assessments ensuring a low risk of bias. Of the re-
maining five studies, one was compromised by participants who
too frequently revealed their treatment condition to interviewers
(Berger 2011) and four used at least one interviewer who was aware
of participants’ random assignment (Richards 2006;Wims 2010;
Spence 2011;Titov 2011).
Incomplete outcome data
Attrition bias was not a significant issue in 28 of the included
studies. These 28 studies used an ITT analysis by either carrying
forward the last observations or using mixed models analyses to
control for outcomes lost to attrition. Moreover, rates of attrition
were often quite similar between treatment conditions. One study
did not use an ITT approach and as such may have been biased due
to attrition (Andersson 2009). A second study did use ITT analyses
but had large attrition that may have biased the findings despite
the use of ITT analyses (van Ballegooijen 2013). We investigated
the effect of these studies using sensitivity analyses.
Selective reporting
Nineteen of the included studies had been registered as clinical
trials allowing for a more accurate analysis of selective reporting.
Of these 19 studies, 12 reported on all outcomes outlined in the
trial registration. For six of the studies, one outcome outlined
in the trial registration was not reported in the final manuscript
(Titov 2008a;Titov 2008b;Titov 2008c;Berger 2009;Johnston
2011;van Ballegooijen 2013) and they were rated as having an
unclear risk of bias. One study (Titov 2010) had many outcomes
indicated in the trial registration that were not reported in the
final manuscript and was rated as having a high risk of bias. Those
studies that were not registered reported results for each of the
outcomes they measured, as described in their method; however,
given the lack of trial registration or protocol publication, these
studies were rated as having an unclear risk of bias.
Other potential sources of bias
Two of the included studies had a high risk of bias due to dif-
ferences in baseline severity between treatment groups (Richards
2006;Titov 2011). Four studies did not report any evaluations of
differences in baseline severity at baseline and so were rated as hav-
ing unclear risk of bias in this domain (Tillfors 2008;Andersson
2009;Bergstrom 2010;Paxling 2011). One study reported differ-
ences in age and marital status between study groups (Robinson
2010); as it was unclear if this would have an effect on study re-
sults, this study was rated as having unclear risk of bias in this
domain.
Effects of interventions
See: Summary of findings for the main comparison Therapist-
supported ICBT compared to waiting list, attention, information,
or online discussion group only control for anxiety disorders
in adults;Summary of findings 2 Therapist-supported ICBT
compared to unguided CBT for anxiety disorders in adults;
Summary of findings 3 Therapist-supported ICBT compared to
face-to-face CBT for anxiety disorders in adults
Primary and secondary outcomes are reported by comparison be-
low. Because adverse events were so rarely reported, they are not
21Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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reported by comparison but are instead reported here. Only four
studies included a measure that allowed for the assessment of par-
ticipant deterioration over the course of treatment, for example,
the CGI (Guy 1976). Andersson 2012a and Titov 2011 each iden-
tified one participant in the treatment condition who had deteri-
orated over the course of the study, but in neither case could their
deterioration be linked to the treatment itself. Carlbring 2011 re-
ported that no participants in their treatment condition had de-
teriorated. Hedman 2011 found one to two participants had de-
teriorated in each of the ICBT and face-to-face CBT conditions,
but there was no difference between conditions.
1. Therapist-supported ICBT versus waiting list,
attention, information, or online discussion group
only control
Twenty-two studies compared therapist-delivered distance CBT
with a waiting list, attention, information, or online discussion
group only control: Carlbring 2001;Carlbring 2006;Richards
2006;Carlbring 2007;Titov 2008a;Titov 2008b;Titov 2008c;
Berger 2009;Furmark 2009a;Titov 2009;Robinson 2010;Titov
2010;Wims 2010;Carlbring 2011;Johnston 2011;Paxling 2011;
Spence 2011;Titov 2011;Andersson 2012a;Andersson 2012b;
Silfvernagel 2012;van Ballegooijen 2013. See Table 2 for subgroup
analysis details.
Primary outcomes
1.1 Clinically important improvement in anxiety
Nine studies assessed clinically important improvement in anxiety
at post-treatment after therapist-supported ICBT versus a wait-
ing list, attention, information, or online discussion group only
control. A meta-analysis with 325 treatment participants and 319
controls yielded a RR of 4.18 (95% CI 2.42 to 7.22; Analysis 1.1)
in favour of the experimental intervention, with substantial het-
erogeneity (I2= 59%). These results did not change significantly
following sensitivity analyses according to active waiting list con-
trol conditions, high risk of bias (ROB), or assuming dropouts
were treatment responders. There was no difference in treatment
effect when analyzed by anxiety disorder (PD, social phobia, GAD,
and studies of mixed anxiety disorders; only one study examined
PTSD), amount of therapist contact (medium or low; only one
study examined high), or research group (Sweden, Australia 1;
only one study was done by Australia 2).
1.2 Reduction in disorder-specific anxiety symptom severity
All 22 studies that compared therapist-supported ICBT to a wait-
ing list, attention, information, or online discussion group only
control assessed disorder-specific anxiety symptoms at post-treat-
ment. Taken together, these 22 studies included 801 treatment
participants and 772 control participants. Meta-analytic findings
showed a significant SMD of -1.12 (95% CI -1.39 to -0.85;
Analysis 1.2; see Figure 4) in favour of the experimental condi-
tion, with considerable heterogeneity (I2= 83%). These results
did not change significantly following sensitivity analyses accord-
ing to active waiting list control conditions or high ROB. One
study, Titov 2010, included three separate anxiety disorder sub-
groups that completed disorder-specific measures so this study was
entered as three studies in this meta-analysis: Titov 2010 GAD;
Titov 2010 Panic; and Titov 2010 Social Phobia. There was no
difference in treatment effect when analyzed by anxiety disorder,
amount of therapist contact, or research group.
22Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 4. Forest plot: therapist-supported ICBT versus waiting list control for anxiety symptom severity at
post-treatment.
1.3 Reduction in general anxiety symptom severity
Fourteen studies assessed participants’ general anxiety after thera-
pist-supported ICBT (508 treatment participants) versus a waiting
list, attention, information, or online discussion group only con-
trol (496 controls). Data analysis resulted in a SMD of -0.79 (95%
CI -1.10 to -0.48; Analysis 1.3) showing a significantly greater
decrease in general anxiety following the experimental interven-
tion, with considerable heterogeneity (I2= 80%). Results were
consistent following sensitivity analyses according to active wait-
ing list control conditions and high ROB. There was no difference
in treatment effect when analyzed by anxiety disorder, amount of
therapist contact, or research group.
Secondary outcomes
1.4 Quality of life
Twenty studies reported on participants’ quality of life following
therapist-supported ICBT (707 treatment participants) versus a
waiting list, attention, information, or online discussion group
only control (688 controls). Analysis resulted in a SMD of 0.51
(95% CI 0.40 to 0.61; Analysis 1.4) in favour of the experimental
intervention, with minimal heterogeneity (I2= 0%) that may not
be important. Results did not change significantly following sen-
sitivity analyses according to active waiting list control conditions
or high ROB.
1.5 Participant satisfaction with the intervention
A comparison of treatment satisfaction was not warranted as au-
thors expectedly did not report on the satisfaction of participants
in the waiting list, attention, information, or online discussion
group only controls. Thirteen studies reported on participants’
satisfaction with treatment. Overall, participants reported a high
level of satisfaction with the intervention, with roughly 90% of
participants across these studies reporting being very or mostly sat-
isfied with the treatment. Several studies reported that over 90%
of participants found the quality of the online treatment mod-
ules and their correspondence with a therapist to be excellent or
good. Only a few studies mentioned any problems or dissatisfac-
tion with the intervention. Most notably, three studies reported
that a majority of participants (70%) found the treatment moved
too quickly (Carlbring 2006;Titov 2008a;Titov 2008b). Several
studies reported small numbers of participants who had been dis-
satisfied with treatment: 3% dissatisfied with treatment (Carlbring
2006); 6% rated quality of therapist correspondence as neutral
or somewhat dissatisfied, 1% rated quality of therapist contact as
very dissatisfied (Titov 2008b); 11% dissatisfied with treatment
(Berger 2009); 13% neutral or somewhat dissatisfied with treat-
ment, 2% rated quality of therapist correspondence as unsatisfac-
23Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
tory (Robinson 2010); 5% rated quality of therapist correspon-
dence as unsatisfactory (Titov 2010); 16% neutral or somewhat
dissatisfied with treatment, (Johnston 2011). Titov 2008c also re-
ported that 7% of participants found that their confidence in their
ability to manage their symptoms and their motivationto continue
practicing their skills had not changed. Berger 2009 reported that
one participant rated the self-help modules as too difficult and one
participant indicated that they did not understand the purpose of
the self-help modules.
2. Therapist-supported ICBT versus unguided CBT
Four studies compared therapist-supported ICBT with unguided
CBT: Titov 2008c;Furmark 2009a;Furmark 2009b;Berger 2011.
See Table 3 for subgroup analysis details for this comparison.
Primary outcomes
2.1 Clinically important improvement in anxiety
Only Berger 2011 assessed clinically important improvement in
anxiety after therapist-supported ICBT versus unguided CBT.
They reported that 16/27 participants receiving therapist-sup-
ported ICBT and 15/27 participants completing unguided CBT
no longer met the diagnostic criteria post-treatment (Analysis 2.1).
2.2 Reduction in disorder-specific anxiety symptom severity
The four studies that compared therapist-supported ICBT to un-
guided CBT (that is, self-help) assessed disorder-specific anxiety
symptoms at post-treatment. Combined, these studies included
127 treatment and 126 control participants and resulted in a non-
significant SMD of -0.24 (95% CI -0.69 to 0.21; Analysis 2.2),
with substantial heterogeneity (I2= 68%). At 6 to 12 month fol-
low-up, 3 studies reported on this outcome; a meta-analysis of
96 treatment and 96 comparator participants resulted in a SMD
of -0.30 (95% CI -0.58 to -0.01; Analysis 2.3) in favour of the
experimental intervention with minimal but difficult to estimate
heterogeneity (I2= 0%). No sensitivity analyses were required.
Subgroup analyses based on anxiety disorder were not warranted
as all studies investigated the efficacy of ICBT for social phobia.
Subgroup analyses based on therapist contact did result in one
change in treatment effect: For the primary outcome disorder-
specific anxiety symptoms at follow-up, a meta-analysis of two
studies with medium therapist contact (Furmark 2009a;Furmark
2009b) resulted in a non-significant difference with minimal but
difficult to estimate heterogeneity (SMD -0.31, 95% CI -0.65 to
0.03; I2= 3%). There was no difference in treatment effect when
analyzed by research group.
2.3 Reduction in general anxiety symptom severity
Only two studies assessed participants’ general anxiety after thera-
pist-supported ICBT (69 treatment participants) versus self-help
interventions (69 comparator participants). Data analysis resulted
in a non-significant mean difference of 0.28 (95% CI -2.21 to
2.78; Analysis 2.4), with minimal but difficult to estimate hetero-
geneity (I2= 0%). A similar result was found at 12 month follow-
up with the same studies; the mean difference was 0.72 (95% CI -
2.12 to 3.57; Analysis 2.5), with minimal but difficult to estimate
heterogeneity (I2= 0%). No sensitivity analyses were required.
Subgroup analyses based on anxiety disorder were not warranted
as both studies investigated the efficacy of ICBT for social phobia.
Subgroup analyses based on therapist contact and research group
did not change the treatment effect.
Secondary outcomes
2.4 Quality of life
Three studies indexed quality of life of participants following
therapist-supported ICBT (100 treatment participants) versus un-
guided CBT (99 control participants). Data analysis resulted in
a non-significant SMD of 0.07 (95% CI -0.37 to 0.50; Analysis
2.6), with moderate to substantial heterogeneity (I2= 58%). At
six to 12 month follow-up, only two of these studies indexed qual-
ity of life of participants following treatment (69 treatment and
69 comparator participants), with meta-analysis showing a similar
non-significant SMD of -0.19 (95% CI -0.53 to 0.14; Analysis
2.7), with minimal but difficult to estimate heterogeneity (I2=
0%). No sensitivity analyses were required.
2.5 Participant satisfaction with the intervention
Two studies indexed participant satisfaction with th e intervention.
Berger 2011 found that treatment satisfaction was significantly
higher in the therapist-supported ICBT condition as compared to
the self-help condition according to the Client Satisfacton Ques-
tionnaire (Attkisson 1982). Similarly, Titov 2008c found that a
significantly greater number of participants in the therapist-sup-
ported ICBT condition as compared to the self-help condition
were very or mostly satisfied with their treatment (no participants
reported being dissatisfied with treatment). However, Titov 2008c
reported no differences between conditions in perceptions of how
logical the treatment was, participants’ confidence in recommend-
ing the treatment to a friend, and the extent to which treatment
had increased participants’ confidence in managing their symp-
toms. Seven per cent of participants in the ICBT condition re-
ported that the treatment had not changed their confidence in
managing their symptoms or their motivation to keep practicing
techniques they had learned.
24Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
3. Therapist-supported ICBT versus face-to-face CBT
Six studies compared therapist-supported ICBT with face-to-face
CBT: Carlbring 2005;Kiropoulos 2008;Tillfors 2008;Andersson
2009;Bergstrom 2010;Hedman 2011. See Table 4 for subgroup
analysis details for this comparison.
Primary outcomes
3.1 Clinically important improvement in anxiety
Four studies assessed clinically important improvement in anxiety
at post-treatment after therapist-supported ICBT (185 treatment
participants) versus face-to-face CBT (180 comparator partici-
pants). Meta-analysis yielded a non-significant RR of 1.09 (95%
CI 0.89 to 1.34; Analysis 3.1), with minimal heterogeneity that
may not be important (I2= 0%). At 6 to 12 month follow-up,
the results of 3 studies that reported on clinically important im-
provement in anxiety, with 139 treatment and 140 comparator
participants, resulted in a non-significant RR of 1.10 (95% CI
0.94 to 1.27; Analysis 3.2), again with minimal heterogeneity (I2
= 0%). Results did not change significantly following a sensitivity
analysis assuming dropouts were treatment responders. Results for
this outcome remained non-significant following subgroup anal-
yses by anxiety disorder (PD and social phobia; only one study
examined specific phobia), therapist contact (low and high; only
one study involved medium therapist contact), and research group
(Sweden; only one study was done by Australia 2 and no studies
by Australia 1).
3.2 Reduction in disorder-specific anxiety symptom severity
The six studies that compared therapist-supported ICBT to face-
to-face CBT assessed changes in symptom specific anxiety. Us-
ing these 6 studies, including 215 treatment participants and 209
control participants, meta-analysis resulted in a non-significant
SMD of 0.09 (95% CI -0.26 to 0.43; Analysis 3.3; see Figure
5), with substantial heterogeneity (I2= 66%). At 6 to 12 month
follow-up, data from 5 studies, including 171 treatment partic-
ipants and 170 comparator participants, could be used to assess
changes in symptom specific anxiety. Meta-analysis resulted in a
non-significant SMD of -0.21 (-0.42 to 0.0; Analysis 3.4) with
minimal heterogeneity that may not be important (I2= 0%). Re-
sults remained non-significant following a sensitivity analysis ex-
cluding one study that did not use ITT analysis and had high ROB
(Andersson 2009).
Figure 5. Forest plot: therapist-supported ICBT versus face-to-face CBT for anxiety symptom severity at
post-treatment.
For disorder-specific anxiety symptoms, at post-treatment a
meta-analysis of the studies investigating PD (Carlbring 2005;
Kiropoulos 2008;Bergstrom 2010) found a significant SMD of
0.29 (95% CI 0.03 to 0.54) with minimal but difficult to estimate
heterogeneity (I2= 0%) in favour of face-to-face CBT. In contrast,
at post-treatment a meta-analysis of two studies investigating so-
cial phobia (Tillfors 2008;Hedman 2011) remained non-signif-
icant (in line with the overall meta-analysis) with substantial to
considerable heterogeneity (SMD -0.18, 95% CI -0.92 to 0.5; I
2= 76%). Unexpectedly, at 6 to 12 month follow-up it was only
the meta-analysis of social phobia studies (Tillfors 2008;Hedman
2011) that showed a significant difference between groups, with an
SMD of -0.39 (95% CI -0.71 to -0.08) with minimal but difficult
to estimate heterogeneity (I2= 0%) in favour of the experimen-
tal intervention, while the meta-analysis of PD studies (Carlbring
2005;Bergstrom 2010) was non-significant, also with minimal
but difficult to estimate heterogeneity (SMD -0.04, 95% CI 0.36
to 0.28; I2= 0%).
A subgroup analysis of studies with high therapist contact for the
disorder-specific anxiety symptoms outcome (Kiropoulos 2008;
Tillfors 2008) resulted in a significant SMD of 0.42 (95% CI 0.05
25Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
to 0.78), with minimal but difficult to estimate heterogeneity (I2=
0%), in favour of face-to-face CBT at post-treatment. The meta-
analysis of studies with low therapist contact remained non-signif-
icant (SMD -0.08, 95% CI -0.63 to 0.46) with substantial to con-
siderable heterogeneity (I2= 76%) (Andersson 2009;Bergstrom
2010;Hedman 2011).
3.3 Reduction in general anxiety symptom severity
Five studies reported participants’ levels of general anxiety post-
treatment. The five studies combined in the meta-analysis in-
cluded 163 treatment participants and 154 comparator partici-
pants and resulted in a non-significant SMD of 0.17 (95% CI -
0.35 to 0.69; Analysis 3.5), with substantial to considerable het-
erogeneity (I2= 79%). When the Kiropoulos 2008 study was re-
moved from the analysis (because it presented transformed data,
which we back-transformed to include in the analysis), the result-
ing SMD remained non-significant at -0.13 (95% CI -0.38 to
0.13) and heterogeneity was reduced (I2= 0%). At 6 to 12 month
follow-up 4 studies reported participants’ level of general anxiety.
The 4 studies included 121 treatment participants and 116 com-
parator participants and yielded a non-significant SMD of -0.16
(95% CI -0.42 to 0.09; Analysis 3.6) with minimal heterogeneity
that may not be important (I2= 0%). Results remained non-sig-
nificant following a sensitivity analysis excluding one study that
did not use ITT analyses and had high ROB (Andersson 2009).
Results for this outcome remained non-significant following sub-
group analyses by anxiety disorder (PD and social phobia; only
one study examined specific phobia), therapist contact (low and
high; only one study involved medium therapist contact), and re-
search group (Sweden; only one study was done by Australia 2 and
no studies by Australia 1).
Secondary outcomes
3.4 Quality of life
Five studies reported on participants’ quality of life following ther-
apist-supported ICBT (198 treatment participants) versus face-
to-face CBT (194 comparator participants). Analysis resulted in
a SMD of 0.26 (95% CI 0.06 to 0.45; Analysis 3.7) in favour of
the experimental intervention, with minimal heterogeneity that
may not be important (I2= 0%). This trend continued at 6 to
12 month follow-up. Four studies comprising 158 treatment and
158 comparator participants resulted in a SMD of 0.33 (95% CI
0.11 to 0.55; Analysis 3.8) in favour of the experimental interven-
tion, again with minimal heterogeneity (I2= 0%). No sensitivity
analyses were required.
3.5 Participant satisfaction with the intervention
Two studies indexed participant satisfaction with th e intervention.
Overall, treatment satisfaction was high across both therapist-sup-
ported ICBT and face-to-face CBT. In one study (Tillfors 2008),
only one participant in the ICBT condition and two participants
in the face-to-face condition reported being “neutral/somewhat
dissatisfied with treatment” and no participants reported being
“very dissatisfied” with treatment. Both studies found no signif-
icant difference between conditions in participants’ overall satis-
faction with the intervention or their perceptions of improvement
as a result of treatment.
A notable significant difference between treatment conditions ap-
peared in one instance: Kiropoulos 2008 found that participants
receiving therapist-supported ICBT reported significantly less en-
joyment in communicating with their therapist as compared to
participants receiving face-to-face CBT.
Sensitivity analysis
Sensitivity analyses are detailed in the results section above. Given
the available studies for this review, some of the planned sensitivity
analyses were not warranted. First, sensitivity analyses based on
the blinding of participants or personnel, or both, in the included
studies were not conducted because blinding of participants and
personnel is not standard practice with this type of clinical trial.
Second, as none of the included studies were cluster randomised
trials and none of the included studies with multiple intervention
arms had selective reporting of intervention comparisons, sensi-
tivity analyses based on these characteristics were not conducted.
Third, as we were not required to impute any standard devia-
tions, we also eliminated that planned sensitivity analysis. Only
one study included transformed data (Kiropoulos 2008) and it was
discussed in section 3.3 above, and only one study did not use ITT
data (Andersson 2009) and is discussed in sections 3.2 and 3.3
above. Finally, as LOCF was the primary method of ITT analysis
reported by authors, we did not exclude studies using LOCF.
26Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]
Therapist-supported ICBT compared to unguided CBT for anxiety disorders in adults
Patient or population: patients with anxiety disorders
Settings: outpatient care via Internet with e-mail or telephone support, or both
Intervention: therapist-supported ICBT
Comparison: unguided ICBT
Outcomes Illustrative comparative risks* (95% CI) Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments
Assumed risk Corresponding risk
Unguided ICBT Therapist-supported
ICBT
Clinically important im-
provement in anxiety at
post-treatment
Indexed by a standard-
ized interview or clinically
accepted measure cut-off
score1
See comment See comment Not estimable 54
(1 study)
⊕
very low2,3
Not pooled because only
one study in this compar-
ison for this outcome
Disorder-specific anxi-
ety symptom severity at
post-treatment
Indexed by a range of dis-
order-specific self-report
measures
The mean disorder-spe-
cific anxiety symptom
severity at post-treatment
in the intervention groups
was
0.24 standard deviations
lower
(0.69 lower to 0.21
higher)
253
(4 studies)
⊕⊕
low4,5,6
A standard deviation of 0.
20 represents a small dif-
ference between groups7
27Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
General anxiety symp-
tom severity at post-
treatment
Indexed by a range
of measures of anxiety
symptoms in general
The mean general anxi-
ety symptom severity at
post-treatment in the in-
tervention groups was
0.28 higher
(2.21 lower to 2.78
higher)
138
(2 studies)
⊕⊕
low3,4
Quality of life at post-
treatment
Indexed by self-report
measures of quality of life
or functional disability
The mean quality of life
at post-treatment in the
intervention groups was
0.07 standard deviations
higher
(0.37 lower to 0.5 higher)
199
(3 studies)
⊕⊕
low4,5,6
A standard deviation of 0.
10 represents a small dif-
ference between groups7
Adverse events at post-
treatment
not reported
Study population Not estimable 0
(0)
See comment Because adverse events
were so rarely reported,
they could not be mean-
ingfully reported by com-
parison and are instead
described in the review
text
See comment See comment
Moderate
Participant satisfaction
Indexed by a mix of
qualitative and quantita-
tive self-report measures
See comment See comment Not estimable 0
(2 studies)
See comment Studies generally re-
ported higher satisfaction
with therapist-supported
ICBT
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
28Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1For clinically important improvement in anxiety, an event is indicative of a participant achieving clinically important improvement.
2Downgraded for risk of bias (-1) primarily because of lack of blinding of outcome assessors.
3Downgraded for imprecision (-2) as there is only one or two studies within the comparison for this outcome.
4Risk of bias (0). While participants in the included studies were not blind to their treatment condition when completing self-report
measures and therapists were not blind to the treatment they were delivering, these study characteristics cannot be avoided in this type
of clinical treatment.
5Downgraded for inconsistency (-1) as the heterogeneity amongst the included studies was quite high.
6Downgraded for imprecision (-1) as there is a limited number of studies included in the comparison for this outcome.
7According to Cohen’s (1969) interpretation of effect sizes.
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29Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Therapist-supported ICBT compared to face-to-face CBT for anxiety disorders in adults
Patient or population: adults with anxiety disorders
Settings: outpatient care via Internet with e-mail or telephone support, or both
Intervention: therapist-supported ICBT
Comparison: face-to-face CBT
Outcomes Illustrative comparative risks* (95% CI) Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments
Assumed risk Corresponding risk
Face-to-face CBT Therapist-supported
ICBT
Clinically important im-
provement in anxiety at
post-treatment
Indexed by a standard-
ized interview or clinically
accepted measure cut-off
score1
Study population RR 1.09
(0.89 to 1.34)
365
(4 studies)
⊕⊕⊕
moderate2
41 per 100 44 per 100
(36 to 54)
Moderate
45 per 100 49 per 100
(40 to 61)
Anxiety symptom sever-
ity at post-treatment
Indexed by a range of dis-
order-specific self-report
measures
The mean anxiety symp-
tom severity at post-treat-
ment in the intervention
groups was
0.09 standard deviations
higher
(0.26 lower to 0.43
higher)
424
(6 studies)
⊕⊕
low3,4,5
There was no signifi-
cant difference between
groups
30Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
General anxiety symp-
tom severity at post-
treatment
Indexed by a range
of measures of anxiety
symptoms in general
The mean general anxi-
ety symptom severity at
post-treatment in the in-
tervention groups was
0.17 standard deviations
higher
(0.35 lower to 0.69
higher)
317
(5 studies)
⊕⊕
low3,4,5
There was no signifi-
cant difference between
groups
Quality of life at post-
treatment
Indexed by self-report
measures of quality of life
or functional disability
The mean quality of life
at post-treatment in the
intervention groups was
0.26 standard deviations
higher
(0.06 to 0.45 higher)
392
(5 studies)
⊕⊕⊕
moderate2,4
A standard deviation of 0.
20 represents a small dif-
ference between groups6
Adverse events at post-
treatment - not reported
See comment See comment Not estimable - See comment Because adverse events
were so rarely reported,
they could not be mean-
ingfully reported by com-
parison and are instead
described in the review
text
Participant satisfaction
Indexed by a mix of
qualitative and quantita-
tive self-report measures
Study population Not estimable 0
(2)
See comment Studies reported high
overall treatment satis-
faction across both con-
ditions
See comment See comment
Moderate
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio
31Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1For clinically important improvement in anxiety, an event is indicative of a participant achieving clinically important improvement at
post-treatment.
2Downgraded for imprecision (-1) primarily due to small sample size.
3Downgraded for risk of bias (-1) primarily because one included study provided incomplete outcome data (though sensitivity analyses
suggest no difference in findings when this study is excluded).
4Risk of bias (0). While participants in the included studies were not blind to their treatment condition when completing self-report
measures and therapists were not blind to the treatment they were delivering, these study characteristics cannot be avoided in this type
of clinical treatment.
5Downgraded for inconsistency (-1) primarily due to unexplained heterogeneity.
6According to Cohen’s (1969) interpretation of effect sizes.
32Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
D I S C U S S I O N
Summary of main results
Please refer to the Summary of findings for the main comparison,
Summary of findings 2, and Summary of findings 3 for a summary
of the main results.
The present review investigated the efficacy of therapist-supported
ICBT in treating anxiety disorders in adults. We identified 30
studies to be included in the review, comparing the intervention of
interest to a waiting list, attention, information, or online discus-
sion group only control, unguided CBT, and face-to-face group
or individual CBT.
The present findings suggest that therapist-supported ICBT is
more efficacious than a waiting list, attention, information, or on-
line discussion group only control in leading to clinically impor-
tant improvement in anxiety, reducing anxiety symptoms (both
disorder-specific and general), and improving quality of life. Re-
sults also generally showed no difference in outcomes following
therapist-supported ICBT versus unguided CBT at post-treat-
ment, though results are limited by low quality evidence due to a
limited number of studies (that is, imprecision). Moreover, results
suggest that therapist-supported ICBT may not be significantly
different from face-to-face group and individual CBT in treat-
ing anxiety disorders. Meta-analyses revealed no significant differ-
ences in clinically important improvement in anxiety or reduction
in anxiety symptoms (both disorder-specific and general) at post-
treatment or follow-up for these two interventions.
At 6 to 12 month follow-up, results generally mirror the post-
treatment findings but are limited by the small number of studies
and the degree of variability in the interventions under investi-
gation across studies. Thus, these findings should be interpreted
with caution.
All findings largely remained robust following sensitivity analyses
conducted to explore the impact of potential sources of bias or
heterogeneity. Subgroup analyses suggest that there may be some
differences in outcome based on the type of anxiety disorder being
treated or the amount of therapist contact in the intervention;
however, the small number of studies within each subgroup limits
our ability to draw firm conclusions based on these analyses. More
research is needed in these areas.
Overall completeness and applicability of
evidence
Taken together, the studies included in the present review go a
long way toward answering the question, is therapist-supported
ICBT an efficacious treatment for anxiety disorders in adults? In
particular, the included studies are of sufficient number to com-
prehensively compare the efficacy of therapist-supported ICBT to
a waiting list, attention, information, or online discussion group
only control. There are fewer, but still sufficient, studies to com-
pare the efficacy of therapist-supported ICBT to traditional face-
to-face CBT. In comparison, the number of studies comparing
therapist-supported ICBT to unguided CBT (that is, self-help)
is limited and therefore findings with respect to this comparison
must be interpreted with some caution.
In terms of the applicability of the evidence to ICBT interven-
tions and particular patient populations, several factors warrant
consideration when interpreting the present findings. First, the
included interventions are quite heterogeneous. While all studies
investigated therapist-supported ICBT, the nuances of each inter-
vention (for example, length, number of online modules, nature
of therapist support) varied widely. It seems prudent to note that
while these interventions seem efficacious as a whole, the optimal
characteristics of these interventions have yet to be identified.
Second, the included studies investigated a number of different
anxiety disorders with a particular focus on PD, social phobia,
and GAD, either separately or as part of a transdiagnostic treat-
ment package. As such, we can be most confident that the present
findings apply to the treatment of these disorders. More research
is needed into ICBT for other anxiety disorders, such as OCD,
PTSD, and specific phobia.
Third, researchers have previously raised some concerns about the
participants included in investigations of ICBT, as many of these
studies recruit participants from the community via media adver-
tisements (for example, Cuijpers 2009). There is some question
as to whether these participants are similar enough to participants
recruited for face-to-face CBT RCTs, who tend to be recruited via
clinic referrals. Despite this concern, research by Titov and col-
leagues (Titov 2010b) found that ICBT participants are as severe
in terms of symptom severity, distress, and disability as individu-
als attending a face-to-face clinic and more severe than individu-
als identified via an epidemiological survey. We also attempted to
account for this possible difference in participant characteristics
by including only individuals with an anxiety disorder diagnosed
using a standardized instrument.
Despite the heterogeneity of the interventions and populations
across studies, the robustness of findings following sensitivity anal-
yses lends credence to the efficacy of therapist-supported ICBT
as an alternative method of delivering CBT to those with anxiety
disorders who are in need of intervention. It is important to note,
however, that the search for studies for this review was conducted
over one year ago. An updated search conducted in September
2014 identified four new completed studies, seven previously on-
going studies that have now been completed, and three new on-
going studies that should be included in the present review. This
is a fast-moving area of research and as such we plan to conduct
an update of this review after its publication, in which these new
studies will be fully incorporated.
Quality of the evidence
33Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
We considered the quality of the evidence of the included studies
using the GRADE tool (Higgins 2011b). With respect to risk of
bias, the included evidence is of moderate quality as there were
only a few concerns with the internal validity of the included stud-
ies. The nature of clinical psychotherapy trials is such that keep-
ing the treatment condition concealed from the participant or the
therapist delivering the treatment is difficult, if not impossible,
thus introducing some potential for bias but nothing that could be
improved upon by higher quality study design. Conversely, there
were some difficulties with (a) blinding of outcome assessors, and
(b) incomplete outcome data in several of the included studies.
Sensitivity analyses excluding these studies suggest that any po-
tential bias introduced by these studies did not affect the meta-
analytic outcomes. It should be noted that theremay be some con-
cerns with selective outcome reporting, but these remain unclear.
Selective outcome reporting has been found to be an important
concern in non-pharmaceutical trials (Milette 2011), such as those
included here. Approximately one third of the studies included in
this review were not prospectively registered on a trial database.
As such, it is impossible to discern if these studies are biased by
selective reporting. It may be that with the advent of trial regis-
tration becoming more common, and expected, updates to this
review will be able to provide a more clear estimate of the risk of
selective outcome reporting.
There is a large degree of heterogeneity in a number of the meta-
analyses in this review, reducing the quality of some of the evi-
dence. Subgroup and sensitivity analyses provide some indication
of what may account for the heterogeneity, but there is by no means
a clear answer. Some degree of heterogeneity may have emerged
because we included studies of a range of anxiety disorders, includ-
ing PD, social phobia, GAD, specific phobia, and PTSD, in the
meta-analyses. It seems possible there are nuances unique to each
of these disorders and their treatment that might facilitate or ham-
per the efficacy of their treatment via therapist-supported ICBT.
Some subgroup analyses by anxiety disorder resulted in an impor-
tant decrease in heterogeneity, however in other cases heterogene-
ity did not decrease at all. This may have been in part because even
within studies of the same disorder, researchers employed different
outcome measures to assess treatment outcomes. The variability
in outcome measures within and across studies that were amalga-
mated in the meta-analyses may account for some important het-
erogeneity. Support for this hypothesis may be found in the fact
that the quality of life outcome tends to show the least heterogene-
ity across comparisons as well as the least variability in measures
used to assess quality of life. Also of importance, the nature of
the ICBT interventions included in this review is quite diverse in
terms of length, number of online modules, and nature of ther-
apist contact. It may be that the nuances of these treatments led
to nuanced differences in treatment outcome. However, subgroup
analyses based on amount of therapist contact, for example, did
not sufficiently and consistently reduce heterogeneity. Similarly,
subgroup analyses by research group did not consistently lead to
decreases in heterogeneity. This is surprising given the assumption
that studies conducted within the same research laboratory would
have some degree of consistency in methods, outcome measures,
participants, etc. Nevertheless, these studies did var y over the years
in terms of the anxiety disorder investigated and amount and na-
ture of therapist contact with participants.
All subgroup analyses are complicated by the fact that only a small
number of trials tended to be included in each analysis, making
it difficult to estimate heterogeneity. Thus, heterogeneity does re-
main somewhat of a concern in the present review. While this was
unexpected, it may be that there is simply too much variability in
study methods, populations, outcome measures, etc. across studies
and not enough studies to support meaningful subgroup analyses
at this time. Importantly, our speculation is that this heterogene-
ity might be explained by the expected factors discussed here as
opposed to any bias in the included studies. An increase in the
number of studies in this area in the future may allow us to explore
heterogeneity more robustly and meaningfully.
In considering the quality of the evidence, we also examined in-
directness of the included studies (that is, the degree to which the
included studies address the review objective) and the imprecision
of each study’s findings. Across included studies, we had no con-
cerns with indirectness. As far as imprecision, some of th e included
studies are limited by small sample size. The meta-analyses at-
tempt to address such small samples by combining studies, where
appropriate. Precision of findings may also be affected by rates
of dropout across interventions, particularly if there is the chance
that one of the two interventions being compared is likely to lead
to greater dropout. Givensome of the characteristics of ICBT (for
example, engaging from a distance, no requirement to commit
to appointment times or be accountable), one might expect there
to be greater dropout rates with this type of treatment. However,
the present findings suggest this may not be the case. There were
generally quite similar rates of dropout across the interventions
investigated (experimental and comparator). Almost all studies
used a rigorous and somewhat conservative method to account for
missing data. Sensitivity analyses on dichotomous outcomes, as-
suming dropouts were treatment responders, did not significantly
change the meta-analytic outcomes. These details suggest that the
precision of findings are not significantly threatened by treatment
dropout rates.
Finally, we considered whether publication bias might have af-
fected the evidence. The number of studies within each compar-
ison in the present review only permitted the analysis of funnel
plots for several outcomes for the comparison of the intervention
and a waiting list control. A visual inspection of these funnel plots
suggested that there may have been a small study effect (that is, the
potential for some publication bias). Because there were less than
10 studies in the other meta-analyses in this review (in accordance
with the guidelines for the use of funnel plots in the Cochrane
Handbook for Systematic Reviews of Interventions (Higgins 2011a)),
we did not analyze publication bias using funnel plots for the re-
34Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
maining comparisons. To complement the use of funnel plots, we
looked to match trials recorded in clinical trial registries with pub-
lished manuscripts. Accounting for the fact that many of the most
recent registered trials are still ongoing or may be in the process
of being published, we only observed a handful of registries that
could not be matched with a published trial. This would suggest
that, at least recently (since trial registration has been strongly en-
couraged), publication bias may not be a significant concern for
this review. However, our findings with respect to the consistency
between trial registries and published studies do not rule out ear-
lier publication bias or the possibility of bias due to smaller-scale,
unfunded studies that may not have been registered. In a further
effort to assess for publication bias, we contacted authors in the
field to inquire about any unpublished findings and were only in-
formed of one study that was unfinished and unpublished due to
difficulties with funding. With these factors in mind, we cannot
make a conclusive statement about publication bias. Publication
bias may not limit the quality of the included evidence but readers
should keep the possibility of this bias in mind when interpreting
the review findings.
Overall, the included evidence, across studies and comparisons, is
of low to moderate quality. In many cases reductions in quality
tend to be due to heterogeneity, which may be explained by meta-
analytic methods rather than the evidence itself. This finding lends
confidence to the present meta-analytic results and conclusions
about the efficacy of therapist-supported ICBT for anxiety disor-
ders.
Potential biases in the review process
Given the variability within ICBT interventions, it is possible that
there are several biases inherent in the present review. First, we
elected to include only those interventions that did not include
face-to-face therapist contact during active treatment. This may
have excluded studies that were simply conducted within thera-
pists’ offices for practical purposes, and only included brief thera-
pist interaction but could in fact have been followed online by a
client at home as well. In this way, the included studies may not
comprehensively include all possible ICBT treatments. Second,
we included only interventions with active therapist involvement.
This decision was made because (a) there seems to be an impor-
tant distinction between guided and unguided treatment, and (b)
some prior research has suggested that therapist involvement may
be an important part of distance treatment (Spek 2007;Andersson
2009b). Nevertheless, this decision impacted the types of trials
included in the present review and led to the exclusion of some
Internet-based studies that did not directly involve therapists but
included interactive voice response software (Greist 2002). While
preliminary work has been done, further research will need to
investigate the importance of active versus automated versus no
therapist involvement in ICBT.
Another potential bias in the review process may have been intro-
duced as we elected to include only those studies in which par-
ticipants were identified as meeting diagnostic criteria for an anx-
iety disorder, as determined by a validated measure. While this
is good practice for the empirical validity of the present review,
it may not accurately reflect clinical practice. It is likely that as a
part of regular clinical practice, clients with subclinical diagnoses
might be assigned to pursue ICBT. We might assume that these
treatments would be as effective for individuals with subclinical
symptom patterns as they are for those with diagnosed disorders
(for example, Spek 2007); however, our exclusion of these popu-
lations prevents any firm statements in this regard.
The present review is also potentially biased in the way that we have
measured one of our primary outcomes, clinically important im-
provement in anxiety. This outcome would possibly be more clin-
ically useful had it been narrowed to assess diagnostic remission,
in particular, or divided into two outcomes assessing remission
and recovery separately. This issue is larger than the field of ICBT
and is a result of the lack of consensus in clinical psychology re-
search in general regarding the most robust way to assess clinically
significant improvement resulting from treatment. Consequently,
there are a variety of ways to assess treatment outcome, includ-
ing measures of remission, recovery, clinically significant improve-
ment, and high end state functioning. Because this issue is quite
prevalent in ICBT for anxiety studies as well, we elected to com-
bine each of these unique ways of determining notable changes in
symptomatology and functioning post-treatment by creating the
clinically important improvement outcome. While relevant and
useful, the nuances of remission and recovery may be lost by being
subsumed within this category. As the field expands, and consis-
tency in reporting treatment outcomes increases, it may be useful
to subdivide this outcome to more clearly capture remission and
recovery.
It is also worth mentioning that given the conceptual and oper-
ational overlap between quality of life and disability measures in
the anxiety disorder literature (Mogotsi 2000), we included both
outcomes within the same meta-analysis. However, given research
suggesting that these concepts are overlapping but also distinct
(Hambrick 2003), it may be that some variability in the impact
of treatment on these measures was missed through their amalga-
mation. Future studies on ICBT should consider assessing both
quality of life and disability as separate treatment outcomes.
Finally, it is necessary to note that our method of statistical analy-
sis may have introduced some bias into the results. In combining
multiple measures within one study that assessed the same out-
come (for example, combining several measures of panic symp-
toms into one mean and standard deviation) we made use of a
method described by Borenstein 2009 that requires the availability
of bivariate correlations between the study measures in order for
them to be combined. In four studies in the present review, these
correlations were not available. In these situations we simply ex-
cluded the measure in question from the overall mean and measure
35Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
of variance. The general concordance between each of the symp-
tom measures within each study (that is, a series of symptom mea-
sures tended to show similar direction and degree of change from
pre- to post-treatment) means that the exclusion of one measure
should not significantly impact the results. However, this process
may have introduced some small degree of bias into the findings.
Agreements and disagreements with other
studies or reviews
A number of prior meta-analyses have investigated the efficacy of
ICBT. These meta-analyses have ranged from a quite broad scope
investigating the efficacy of Internet interventions for any health
problems (d = 0.53; Barak 2008) to a more focused scope inves-
tigating the efficacy of ICBT for clinical and subclinical anxiety
and mood symptoms (d = 0.96; Spek 2007) or anxiety and mood
disorders in Sweden (d = 0.91; Andersson 2007). Taken together,
these reviews support the present findings that ICBT is efficacious
in reducing anxiety symptoms as compared to control interven-
tions (for example, waiting list control). Within their broad meta-
analysis, Barak 2008 found that interventions designed to treat
PTSD and those targeting PD showed the largest effect sizes (g =
0.88 and 0.80, respectively). Spek 2007 found that those interven-
tions that included therapist contact, as opposed to those that did
not, showed a particularly large effect size (d = 1.00). It should be
noted that some concerns were raised about the methodological
quality of the studies included in these types of reviews given their
small sample sizes, the absence of details about randomisation and
treatment allocation methods, and lack of adequate information
about treatment compliance and credibility (Postel 2008).
Recently, Mayo-Wilson 2013 completed a review of media-deliv-
ered self-help BT and CBT for anxiety disorders. Within their
review they included ICBT studies delivered both with and with-
out therapist contact. In line with the present findings, their re-
view suggested that media-delivered self-help BT and CBT were
more efficacious than no treatment (that is, a waiting list con-
trol). In contrast to the present findings, their review resulted in
some suggestion that media-delivered self-help BT and CBT were
somewhat inferior to face-to-face CBT with the conclusion that
for those who can access it, face-to-face CBT is probably superior.
The differences between these findings and those in the present
review may be due in part to the differences in therapist involve-
ment between included studies across the two reviews. Therapist
involvement in media-delivered treatments, such as ICBT, may
lead the treatments to be more similar in efficacy to face-to-face
CBT than those interventions without therapist support.
In addition, several meta-analyses have investigated the effects of
computer-based psychotherapy for mental health problems more
broadly, th e re sults of which are also in accordance with the present
findings. In a meta-analysis of computer-aided psychotherapy (in-
cluding treatment delivered via stand-alone or Internet-linked
computers, smartphones, palm pilots, interactive voice response,
and CDs or DVDs) for anxiety disorders, Cuijpers 2009 found
that computer-aided psychotherapy was more effective than con-
trol conditions (d = 1.08) in reducing anxiety symptoms, and
computer-aided psychotherapy outcomes did not differ signifi-
cantly from those outcomes achieved through face-to-face treat-
ment. Similarly, Reger 2009 found medium to large effects sizes
when comparing computer-based CBT and ICBT to waiting list,
placebo, or treatment as usual comparators in treating anxiety.
When they investigated the effects of therapist involvement on
their findings, no significant differences were identified based on
amount of therapist contact. Most recently, Andrews 2010 inves-
tigated the effects of computer therapy for anxiety and depres-
sion (including both computer- and Internet-aided treatments) as
compared to control conditions and face-to-face treatment. They
found computer-based therapy to be superior to control for the
treatment of social phobia (g = 0.92), PD (g = 0.83), and GAD (g
= 1.12). They also found a non-significant difference in outcome
between computer-based and face-to-face CBT.
It is important to note that theselatter meta-analyses looked more
broadly at methods of administering treatment via computer tech-
nology, including but not limited to the Internet. Moreover, they
included research into non-therapist supported interventions, in-
terventions administered using interactive voice response, as well
as those that included substantial face-to-face contact. Neverthe-
less, despite the differences between these meta-analyses and our
own, the overall body of research serves to add further evidence
for the efficacy of therapist-supported ICBT in treating anxiety
disorders.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
The present findings, in consideration of the quality and quantity
of the included studies, suggest that therapist-supported ICBT is
more efficacious in treating anxiety disorders among adults than
a waiting list, attention, information, or online discussion group
only control. The evidence also suggests that therapist-supported
ICBT may not differ from unguided ICBT in efficacy; however,
this evidence is significantly limited by a lack of studies in this
comparison and must be interpreted with caution. In addition,
findings suggest that therapist-supported ICBT may not result in
significantly different anxiety outcomes as compared to face-to-
face CBT. Face-to-face CBT is currently the intervention of choice
for the treatment of anxiety disorders (Bisson 2007;Hunot 2007;
Norton 2007;Stewart 2009).
Our results, in conjunction with the findings of prior meta-anal-
yses (for example, Cuijpers 2009;Andrews 2010), clearly support
further research and development of this technology and type of
treatment delivery. The benefit of Internet delivery is in its ability
36Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
to extend treatment to individuals who may not be able to access
treatment through traditional means. It is evidently a promising
method to overcome obstacles to treatment delivery.
One important next step for this field is to extend research be-
yond the two laboratories that are responsible for almost all of the
studies in this area. Replication of results across research sites and
groups will go far toward increasing practitioners’ confidence in
the intervention as well as interest in exploring greater incorpora-
tion of this type of treatment into general practice. Another im-
portant step will be to uncover the most effective way to make this
type of service delivery available to potential clients. For example,
it may be possible to administer it as an extended service through
regular mental health clinics, offering clients the choice to engage
in Internet-based or face-to-face treatment. Alternatively, ICBT
may be more easily administered through clinics or divisions of
clinics devoted entirely to this type of treatment.
Given the findings of the present review, it seems timely to start to
think about the best ways to incorporate ICBT into clinical prac-
tice and exploring the effectiveness of these methods. Widespread
rollout of ICBT may not yet be warranted, but continued steps
toward this goal should be pursued. Internet-based programs ap-
pear to be efficacious in reducing anxiety symptoms and there are
many individuals in need of treatment who could benefit from
this type of delivery.
Implications for research
The present review suggests some important directions for future
research. First, further research is needed into the efficacy of ICBT
for the anxiety disorders that have not yet been extensively exam-
ined, including OCD, PTSD, and specific phobia. The fact that
these disorders tend to be thought of as more complex, and rely
heavily on exposure-based elements, may have deterred researchers
from translating them into an ICBT intervention. However, given
the similarities in CBT for these disorders and CBT for the already
investigated disorders (PD, social phobia, and GAD), including
other disorders with a heavy emphasis on exposure (that is, PD),
it seems possible that ICBT would also be efficacious in treating
these disorders and thus warrants investigation. The ongoing stud-
ies outlined in this review suggest that research into these disorders
is indeed increasing. With respect to specific phobia, it is possible
that this category of disorder has received substantial attention as
it is less commonly treated in clinics because it tends to be less
functionally impairing relative to other anxiety disorders and often
requires only short interventions. An extensive collection of self-
help manuals to treat specific phobias exist; suggesting that this
type of treatment would be very amenable to an ICBT delivery
and would likely lead to efficacious interventions. Further research
into these disorders would be an important area of investigation.
Second, while research comparing therapist-supported ICBT to
a waiting list, attention, information, or online discussion group
only control is substantial, studies comparing therapist-supported
ICBT to face-to-face therapy are somewhat fewer. Subgroup anal-
yses in the present review suggest some ambiguity with respect to
the comparable efficacy of treatment between ICBT and face-to-
face CBT for social phobia and PD. Further studies would help
clarify this question. Moreover, the nature of the included studies
is only sufficient for us to conclude that there may not be signifi-
cant differences in treatment outcome between face-to-face CBT
and ICBT with therapist support. Future equivalence trials are
warranted to further clarify the direct comparability of ICBT with
therapist support and face-to-face CBT for anxiety.
Third, the importance of the therapist in ICBT remains somewhat
unclear. On the one hand prior work has suggested an important
association between therapist involvement and ICBT treatment
outcome (Spek 2007;Andersson 2009b). On the other hand the
studies included in our comparison of therapist-supported ICBT
versus unguided CBT (each of which focused on social phobia)
suggest no difference in treatment outcome between the two in-
terventions. More studies comparing therapist-supported ICBT
versus unguided CBT are needed to clarify the role of the ther-
apist. Moreover, if therapist contact is important, the amount of
contact that would optimize treatment outcome as well as the use
of resources has yet to be determined. Each of the included studies
in this review employed various amounts of therapist contact in
delivering ICBT. Subgroup analyses based on the amount of ther-
apist contact did not suggest many differences from the overall
pooled analysis; however, the subgroups were rather small and set
somewhat arbitrarily. Future research into the optimal amount of
therapist contact would help maximize the efficacy and efficiency
with which ICBT could be delivered.
Fourth, with respect to the assessment of study outcomes, the in-
clusion of diagnostic assessment post-treatment is encouraged in
future trials in this field. While all studies measured anxiety symp-
toms via self-report, more objective measures of participants’ di-
agnostic profile will help in determining the clinical significance
of treatment outcomes. Fifth, this review highlighted the limited
number of studies conducting follow-up assessments of partici-
pants’ symptoms. While the present results do not suggest a sig-
nificant relapse in symptoms after a six month follow-up period,
further studies are needed.
Sixth, it is important to note that any adverse effects of ICBT
have not been well-examined. Evidently, this type of treatment did
not result in significant symptom reduction for each participant.
There were also a small number of participants across studies who
reported being dissatisfied with this type of treatment. More re-
search is needed to better define and measure ’harms’ that might
result from this type of treatment.
Finally, as suggested above, future effectiveness studies examining
the best way to incorporate ICBT into regular clinical practice
seem to be an important next step in the field.
37Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A C K N O W L E D G E M E N T S
The authors would like to thank Karen Neves, Reference and Re-
search Librarian at Dalhousie University, and Sarah Dawson, Trial
Search Co-ordinator for the Cochrane Collaboration Depression,
Anxiety, and Neurosis Group (CCDAN), for their help in devel-
oping and conducting the search strategy for the present review.
We would also like to thank Leah Jones for her administrative and
research assistance with the review process. Finally, we would like
to thank the CCDAN editorial team, particularly Chris Cham-
pion and Jessica Sharp, for their advice and assistance.
R E F E R E N C E S
References to studies included in this review
Andersson 2009 {published data only (unpublished sought but not
used)}
Andersson G, Jonsson U, Malmaeus F, Carlbring P, Waara
J, Ost LG. Treatment of specific phobia delivered via the
internet vs. one-session exposure treatment. 32nd Congress
of the British Association for Behavioural and Cognitive
Psychotherapist (jointly with the European Association of
Behavioural and Cognitive Therapies). Manchester, UK,
September 2004:166.
∗Andersson G, Waara J, Jonsson U, Malmaeus F, Carlbring
P, Ost, L. Internet-based self-help versus one-session
exposure in the treatment of spider phobia: A randomized
controlled trial. Cognitive Behaviour Therapy 2009;38(2):
114–20. [DOI: 10.1080/16506070902931326]
Andersson 2012a {published data only}
∗Andersson G, Carlbring P, Furmark T, on behalf of
the SOFIE Research Group. Therapist experience and
knowledge acquisition in Internet-delivered CBT for social
anxiety disorder: A randomized controlled trial. PLoS ONE
2012;7:e37411. [DOI: 10.1371/journal.pone.0037411]
Andersson G, Paxling B, Wiwe M, Vernmark K, Felix CB,
Lundborg L, et al. Therapeutic alliance in guided internet-
delivered cognitive behavioural treatment of depression,
generalized anxiety disorder and social anxiety disorder.
Behaviour Research and Therapy 2012;50:544–50. [DOI:
10.1016/j.brat.2012.05.003]
Furmark T. Treating social phobia via the Internet: Genetic
influences on the response to Internet-delivered cognitive-
behavior therapy [UMIN000001383]. WHO International
Clinical Trials Registry Platform [www.who.int/ictrp] 2008.
Andersson 2012b {published data only}
Andersson G. Psychodynamic internet treatment versus
cognitive behavioral therapy (CBT) for generalized
anxiety disorder [NCT01312116]. ClinicalTrials.gov
[www.clinicaltrials.gov] 2011.
∗Andersson G, Paxling B, Roch-Norlund P, Ostman G,
Norgren A, Almlov J, et al. Internet-based psychodynamic
versus cognitive behavioral guided self-help for generalized
anxiety disorder: A randomized controlled trial.
Psychotherapy and Psychosomatics 2012;81:344–55. [DOI:
10.1159/000339371]
Berger 2009 {published data only}
∗Berger T, Hohl E, Caspar F. Internet-based treatment for
social phobia: A randomized controlled trial. Journal of
Clinical Psychology 2009;65(10):1021–35. [DOI: 10.1002/
jclp.20603]
Berger T, Hohl E, Casper F. Internet-based treatment
for social phobia: A 6-month follow-up [Internetbasierte
therapie der sozialen phobie: Ergebnisse einer 6–monate–
katamnese]. Zeitschrift fur Klinische Psychologie und
Psychotherapie: Forschung und Praxis 2010;39:217–21.
[DOI: 10.1026/1616-3443/a000050]
Caspar F. A randomized controlled trial of a web-
based treatment for social phobia [ISRCTN62304985].
ControlledTrials.com [www.controlled-trials.com] 2007.
Berger 2011 {published data only}
Berger T, Caspar F, Richardson R, Kneubuhler B, Sutter D,
Andersson G. Internet-based treatment of social phobia: A
randomized controlled trial comparing unguided with two
types of guided self-help. Behaviour Research and Therapy
2011;49(3):158–69. [DOI: 10.1016/j.brat.2010.12.007]
Bergstrom 2010 {published data only (unpublished sought but not
used)}
∗Bergstrom J, Andersson G, Ljotsson B, Ruck C,
Andreewitch S, Karlsson A, et al. Internet-versus group-
administered cognitive behaviour therapy for panic disorder
in a psychiatric setting: A randomised trial. BMC Psychiatry
2010;10:54. [DOI: 10.1186/1471-244X-10-54]
El Alaoui S, Hedman E, Ljotsson B, Bergstrom J, Andersson
E, Ruck C, et al. Predictors and moderators of internet-
and group-based cognitive beahviour therapy for panic
disorder. PLoS One 2013;8:e79024. [DOI: 10.1371/
journal.pone.0079024]
Lindefors N. Internet- versus group-administered cognitive
behavior therapy for panic disorder [NCT00845260].
ClinicalTrials.gov [www.clinicaltrials.gov] 2009.
Lonsdorf TB, Ruck C, Bergstrom J, Andersson G, Ohman
A, Lindefors N, et al. The COMTval158met polymorphism
is associated with symptoms relief during exposure-based
38Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
cognitive-behavioral treatment in panic disorder. BMC
Psychiatry 2010;10:99. [DOI: 10.1186/1471-244X-10-99]
Carlbring 2001 {published and unpublished data}
Carlbring P, Westling BE, Ljungstrand P, Ekselius L,
Andersson G. Treatment of panic disorder via the internet:
A randomized trial of a self-help program. Behavior
Therapy 2001;32(4):751–64. [DOI: 10.1016/S0005-7894
(01)80019-8]
Carlbring 2005 {published data only}
Andersson G, Carlbring P, Grimlund A. Predicting
treatment outcome in internet versus face to face treatment
of panic disorder. Computers in Human Behavior 2008;24:
1790–801. [DOI: 10.1016/j.chb.2008.02.003]
∗Carlbring P, Nilsson-Ihrfelt E, Waara J, Kollenstam C,
Buhrman M, Kaldo V, et al. Treatment of panic disorder:
Live therapy vs. self-help via the internet. Behaviour
Research and Therapy 2005;43(10):1321–33. [DOI:
10.1016/j.brat.2004.10.002]
Carlbring P, Nilsson-Ihrfelt E, Waara J, Kollenstam C,
Burman M, Kaldo V, et al. Treatment of panic disorder:
Live therapy vs. self-help via the Internet. Congress of
the British Association for Behavioural and Cognitive
Psychotherapies (jointly with the European Association of
Behavioural and Cognitive and Therapies). Manchester,
UK, September 2004:166.
Carlbring 2006 {published data only (unpublished sought but not
used)}
Almlov J, Carlbring P, Kallqvist K, Paxling B, Cuijpers
P, Andersson G. Therapist effects in guided internet-
delivered CBT for anxiety disorders. Behavioural and
Cognitive Psychotherapy 2011;39:311–22. [DOI: 10.1017/
S135246581000069X]
∗Carlbring P, Bohman S, Brunt S, Buhrman M, Westling
BE, Ekselius L, et al. Remote treatment of panic disorder:
A randomized trial of internet-based cognitive behavior
therapy supplemented with telephone calls. American
Journal of Psychiatry 2006;163(12):2119–25. [DOI:
10.1176/appi.ajp.163.12.2119]
Nordgreen T, Havik OE, Ost LG, Furmark T, Carlbring
P, Andersson G. Outcome predictors in guided and
unguided self-help for social anxiety disorder. Behaviour
Research and Therapy 2012;50:13–21. [DOI: 10.1016/
j.brat.2011.10.009]
Carlbring 2007 {published data only (unpublished sought but not
used)}
Carlbring P, Bergman Nordgren L, Furmark T, Andersson
G. Long-term outcome of Internet-delivered cognitive-
behavioural therapy for social phobia: A 30-month follow-
up. Behaviour Research and Therapy 2009;47:848–50.
[DOI: 10.1016/j.brat.2009.06.012]
Carlbring P, Bohman S, Brunt S, Buhrman M, Westling
BE, Ekselius L, et al. Remote treatment of panic disorder:
A randomized trial of internet-based cognitive behavior
therapy supplemented with telephone calls. American
Journal of Psychiatry 2006;163:2119–25. [DOI: 10.1176/
appi.ajp.163.12.2119]
∗Carlbring P, Gunnarsdottir M, Hedensjo L, Andersson
G, Ekselius L, Furmark T. Treatment of social phobia:
Randomised trial of internet-delivered cognitive-behavioural
therapy with telephone support. British Journal of Psychiatry
2007;190(2):123–8. [DOI: 10.1192/bjp.bp.105.020107]
Nordgreen T, Havik OE, Ost LG, Furmark T, Carlbring
P, Andersson G. Outcome predictors in guided and
unguided self-help for social anxiety disorder. Behaviour
Research and Therapy 2012;50:13–21. [DOI: 10.1016/
j.brat.2011.10.009]
Carlbring 2011 {published data only}
Carlbring P, Maurin L, Torngren C, Linna E, Eriksson
T, Sparthan E, et al. Individually-tailored, internet-based
treatment for anxiety disorders: A randomized controlled
trial. Behaviour Research and Therapy 2011;49(1):18–24.
[DOI: 10.1016/j.brat.2010.10.002]
Furmark 2009a {published data only}
∗Furmark T, Carlbring P, Hedman E, Sonnenstein A,
Clevberger P, Bohman B, et al. Guided and unguided self-
help for social anxiety disorder: Randomised controlled
trial. British Journal of Psychiatry 2009;195(5):440–7.
[DOI: 10.1192/bjp.bp.108.060996]
Hedman E, Furmark T, Carlbring P, Ljótsson B, Rück
C, Lindefors N, et al. A 5-year follow-up of internet-
based cognitive behavior therapy for social anxiety disorder.
Journal of Medical Internet Research 2011;13:e39. [DOI:
10.2196/jmir.1776]
Lindefors N. Five year follow-up of internet-based cognitive
behaviour therapy (CBT) for social anxiety disorder (SAD)
(SOFIE-5YFU). ClinicalTrials.gov [www.clinicaltrials.gov]
2010.
Nordgreen T, Havik OE, Ost LG, Furmark T, Carlbring
P, Andersson G. Outcome predictors in guided and
unguided self-help for social anxiety disorder. Behaviour
Research and Therapy 2012;50:13–21. [DOI: 10.1016/
j.brat.2011.10.009]
Furmark 2009b {published data only}
∗Furmark T, Carlbring P, Hedman E, Sonnenstein A,
Clevberger P, Bohman B, et al. Guided and unguided self-
help for social anxiety disorder: Randomised controlled
trial. British Journal of Psychiatry 2009;195(5):440–7.
[DOI: 10.1192/bjp.bp.108.060996]
Hedman E, Furmark T, Carlbring P, Ljótsson B, Rück
C, Lindefors N, et al. A 5-year follow-up of internet-
based cognitive behavior therapy for social anxiety disorder.
Journal of Medical Internet Research 2011;13:e39. [DOI:
10.2196/jmir.1776]
Lindefors N. Five year follow-up of internet-based cognitive
behaviour therapy (CBT) for social anxiety disorder (SAD)
(SOFIE-5YFU) [NCT01145690]. ClinicalTrials.gov
[www.clinicaltrials.gov] 2010.
Nordgreen T, Havik OE, Ost LG, Furmark T, Carlbring
P, Andersson G. Outcome predictors in guided and
unguided self-help for social anxiety disorder. Behaviour
39Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Research and Therapy 2012;50:13–21. [DOI: 10.1016/
j.brat.2011.10.009]
Hedman 2011 {published data only}
Hedman E, Andersson E, Ljotsson B, Andersson G, Ruck C,
Lindefors N. Cost-effectiveness of Internet-based cognitive
behavior therapy vs. cognitive behavioral group therapy
for social anxiety disorder: Results from a randomised
controlled trial. Behaviour Research and Therapy 2011;49:
729–36. [DOI: 10.1016/j.brat.2011.07.009]
∗Hedman E, Andersson G, Ljotsson B, Andersson E, Ruck
C, Mortberg E, et al. Internet-based cognitive behavior
therapy vs. cognitive behavioral group therapy for social
anxiety disorder: A randomized controlled non-inferiority
trial. PLoS ONE 2011;6(3):e18001. [DOI: 10.1371/
journal.pone.0018001]
Hedman E, Ljotsson B, Andersson G, Andersson E,
Schalling M, Lindefors N, et al. Clinical and genetic
outcome determinants of Internet- and group-based
cognitive behavior therapy for social anxiety disorder.
Acta Psychiatrica Scandinavia 2012;126:126–36. [DOI:
10.1111/j.1600-0447.2012.01834.x]
Lindefors N. A comparison between internet therapy and
group therapy for social phobia - A trial using cognitive
behavioural therapy [NCT00564967]. ClinicalTrials.gov
[www.clinicaltrials.gov] 2007.
Johnston 2011 {published data only}
∗Johnston L, Titov N, Andrews G, Spence J, Dear BF. A
RCT of a transdiagnostic internet-delivered treatment for
three anxiety disorders: Examination of support roles and
disorder-specific outcomes. PLoS ONE 2011;6:e28079.
[DOI: 10.1371/journal.pone.0028079]
Titov N. Internet-based treatment of generalized anxiety
disorder, and/or social phobia, and/or panic disorder (the
Anxiety program): A randomized controlled study exploring
the role of a clinician [ACTRN12610000242022].
Australian New Zealand Clinical Trials Registry [
www.anzctr.org.au] 2010, March.
Kiropoulos 2008 {published data only (unpublished sought but not
used)}
∗Kiropoulos LA, Klein B, Austin DW, Gilson K, Pier C,
Mitchell J, et al. Is internet-based CBT for panic disorder
and agoraphobia as effective as face-to-face CBT?. Journal
of Anxiety Disorders 2008;22(8):1273–84. [DOI: 10.1016/
j.janxdis.2008.01.008]
Kiropoulos LA, Klein B, Austin DW, Pier C, Mitchell J. Is
internet-based CBT for panic disorder and agoraphobia
as effective as face-to-face CBT?. Australian Association
for Cognitive and Behaviour Therapy Annual Conference.
Manly, Australia, 2006.
Paxling 2011 {published data only}
Andersson G, Paxling B, Wiwe M, Vernmark K, Felix CB,
Lundborg L, et al. Therapeutic alliance in guided internet-
delivered cognitive behavioural treatment of depression,
generalized anxiety disorder and social anxiety disorder.
Behaviour Research and Therapy 2012;50:544–50. [DOI:
10.1016/j.brat.2012.05.003]
Paxling B. A randomized clinical trial of internet-delivered
cognitive behaviour therapy for generalized anxiety disorder
[UMIN000001353]. WHO International Clinical Trials
Registry Platform [www.who.int/ictrp] 2008.
∗Paxling B, Almlov J, Dahlin M, Carlbring P, Breitholtz
E, Eriksson T, et al. Guided internet-delivered
cognitive behavior therapy for generalized anxiety
disorder: A randomized controlled trial. Cognitive
Behaviour Therapy 2011;40:159–73. [DOI: 10.1080/
16506073.2011.576699]
Paxling B, Lundgren S, Norman A, Almlov J, & Carlbring
P. Therapist behaviours in internet-delivered cognitive
behaviour therapy: Analyses of e-mail correspondence in the
treatment of generalized anxiety disorder. Behavioural and
Cognitive Psychotherapy 2013;41:280–9. [DOI: 10.1017/
S1352465812000240]
Richards 2006 {publis hed data only (unpublished sought but not used)}
Richards JC, Klein B, Austin DW. Internet cognitive
behavioural therapy for panic disorder: Does the inclusion
of stress management information improve end-state
functioning?. Clinical Psychologist 2006;10(1):2–15. [DOI:
10.1080/13284200500378795]
Robinson 2010 {published data only (unpublished sought but not
used)}
∗Robinson E, Titov N, Andrews G, McIntryre K,
Schwencke G, Solley K. Internet treatment for generalized
anxiety disorder: A randomized controlled trial comparing
clinician vs. technician assistance. PLoS ONE 2010;5(6):
e10942. [DOI: 10.1371/journal.pone.0010942]
Titov N. Internet-based treatment of generalized
anxiety disorder (the Worry program): A randomized
controlled study exploring the role of a clinician
[ACTRN12609000563268]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2009.
Silfvernagel 2012 {published data only}
Silfvernagel K, Carlbring P, Kabo J, Edström S, Eriksson
J, Månson L, et al. Individually tailored Internet-based
treatment for young adults and adults with panic attacks:
Randomized controlled trial. Journal of Medical Internet
Research 2012;14:e65. [DOI: 10.2196/jmir.1853]
Spence 2011 {published data only}
Spence J, Titov N, Dear BF, Johnston L, Solley K, Lorian
C, et al. Randomized controlled trial of internet-delivered
cognitive behavioral therapy for posttraumatic stress
disorder. Depression and Anxiety 2011;28:541–50. [DOI:
10.1002/da.20835]
Tillfors 2008 {published data only (unpublished sought but not used)}
Tillfors M, Carlbring P, Furmark T, Lewenhaupt S, Spak
M, Eriksson A, et al. Treating university students with
social phobia and public speaking fears: Internet delivered
self-help with or without live group exposure sessions.
Depression and Anxiety 2008;25(8):708–17. [DOI:
10.1002/da.20416]
40Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Titov 2008a {published data only (unpublished sought but not used)}
Titov N. A randomized controlled study on the
effect of Internet based education for treating social
phobia using cognitive behavioural techniques
[ACTRN12607000235404]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] May 2007.
Titov N, Andrews G, Johnston L, Schwencke G, Choi
I. Shyness programme: Longer term benefits, cost-
effectiveness, and acceptability. Australian and New Zealand
Journal of Psychiatry 2009;43:36–44. [DOI: 10.1080/
00048670802534424]
∗Titov N, Andrews G, Schwencke G, Drobny J, Einstein
D. Shyness 1: Distance treatment of social phobia
over the internet. Australian and New Zealand Journal
of Psychiatry 2008;42(7):585–94. [DOI: 10.1080/
00048670802119762]
Titov N, Gibson M, Andrews G, McEvoy P. Internet
treatment for social phobia reduces comorbidity. Australian
and New Zealand Journal of Psychiatry 2009;43:754–9.
[DOI: 10.1080/00048670903001992]
Titov 2008b {published data only (unpublished sought but not used)}
Titov N. A randomized controlled study on the
effect of internet based education for treating social
phobia using cognitive behavioural techniques
[ACTRN12607000235404]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2007.
Titov N, Andrews G, Johnston L, Schwenke G, Choi
I. Shyness programme: Longer term benefits, cost-
effectiveness, and acceptability. Australian and New Zealand
Journal of Psychiatry 2009;43:36–44. [DOI: 10.1080/
00048670802534424]
∗Titov N, Andrews G, Schwencke G. Shyness 2: Treating
social phobia online: Replication and extension. Australian
and New Zealand Journal of Psychiatry 2008;42(7):595–605.
[DOI: 10.1080/00048670802119820]
Titov N, Gibson M, Andrews G, McEvoy P. Internet
treatment for social phobia reduces comorbidity. Australian
and New Zealand Journal of Psychiatry 2009;43:754–9.
[DOI: 10.1080/00048670903001992]
Titov 2008c {published and unpublished data}
Titov N. A randomized controlled study on the role of
therapist in an Internet-based treatment program for
social phobia using cognitive behavioural techniques
[ACTRN12608000192381]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2008.
∗Titov N, Andrews G, Choi I, Schwencke G, Mahoney
A. Shyness 3: Randomized controlled trial of guided
versus unguided internet-based CBT for social phobia.
Australia and New Zealand Journal of Psychiatry 2008;42
(12):1030–40. [DOI: 10.1080/00048670802512107]
Titov N, Andrews G, Johnston L, Schwenke G, Choi
I. Shyness programme: Longer term benefits, cost-
effectiveness, and acceptability. Australian and New Zealand
Journal of Psychiatry 2009;43:36–44. [DOI: 10.1080/
00048670802534424]
Titov N, Gibson M, Andrews G, McEvoy P. Internet
treatment for social phobia reduces comorbidity. Australian
and New Zealand Journal of Psychiatry 2009;43:754–9.
[DOI: 10.1080/00048670903001992]
Titov 2009 {published data only (unpublished sought but not used)}
Lorian CN, Titov N, Grisham JR. Changes in risk-taking
over the course of an Internet-delivered cognitive behavioral
treatment for generalized anxiety disorder. Journal of
Anxiety Disorders 2012;26:140–9. [DOI: 10.1016/
j.janxdis.2011.10.003]
Titov N. Internet-based education for generalized anxiety
disorder (the Worry Program): A randomized controlled
trial [ACTRN12609000136202]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2009.
∗Titov N, Andrews G, Robinson E, Schwencke G,
Johnston L, Solley K, et al. Clinician-assisted internet-
based treatment is effective for generalized anxiety disorder:
Randomized controlled trial. Australian and New Zealand
Journal of Psychiatry 2009;43(10):905–12. [DOI: 10.1080/
00048670903179269]
Titov 2010 {published data only}
∗Titov N, Andrews G, Johnston L, Robinson E, Spence J.
Transdiagnostic internet treatment for anxiety disorders: A
randomized controlled trial. Behaviour Research and Therapy
2010;48(9):890–9. [DOI: 10.1016/j.brat.2010.05.014]
Titov 2010 GAD {published data only}
Titov N, Andrews G, Johnston L, Robinson E, Spence J.
Transdiagnostic internet treatment for anxiety disorders: A
randomized controlled trial. Behaviour Research and Therapy
2010;48:890–9. [DOI: 10.1016/j.brat.2010.05.014]
Titov 2010 Panic {published data only}
∗Titov N, Andrews G, Johnston L, Robinson E, Spence J.
Transdiagnostic internet treatment for anxiety disorders: A
randomized controlled trial. Behaviour Research and Therapy
2010;48:890–9. [DOI: 10.1016/j.brat.2010.05.014]
Titov 2010 Social Phobia {published data only}
Titov N, Andrews G, Johnston L, Robinson E, Spence J.
Transdiagnostic internet treatment for anxiety disorders: A
randomized controlled trial. Behaviour Research and Therapy
2010;48:890–9. [DOI: 10.1016/j.brat.2010.05.014]
Titov 2011 {published data only}
Dear BF, Titov N, Schwencke G, Andrews G, Johnston
L, Craske MG, et al. An open trial of a brief
transdiagnostic internet treatment for anxiety and
depression [ACTRN12610000555055]. Behaviour Research
and Therapy 2011;49(12):830–7.
Titov N. The Wellbeing Program: A randomized controlled
trial of internet-based treatment of anxiety and depression
[ACTRN12610000247077]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2010.
∗Titov N, Dear BF, Schwencke G, Andrews G, Johnston
L, Craske MG, et al. Transdiagnostic internet treatment
for anxiety and depression: A randomised controlled trial.
Behaviour Research and Therapy 2011;49:441–52. [DOI:
10.1016/j.brat.2011.03.007]
van Ballegooijen 2013 {published data only}
∗van Ballegooijen W, Riper H, Klein B, Ebert DD, Kramer
J, Meulenbeek P, Cuijpers P. An Internet-based guided
41Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
self-help intervention for panic symptoms: Randomized
controlled trial. Journal of Medical Internet Research 2013;
15:e154. [: NTR1639]
van Ballegooijen W, Riper H, van Straten A, Kramer J,
Conijn B, Cuijpers P. The effects of an Internet based self-
help course for reducing panic symptoms - Don’t Panic
Online: Study protocol for a randomised controlled trial.
Trials 2011;12:75. [DOI: 10.1186/1745-6215-12-75]
Wims 2010 {published data only (unpublished sought but not used)}
Wims E. The effectiveness of clinician assisted internet
based cognitive behaviour therapy for panic disorder
[ACTRN12608000548336]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2008, October.
∗Wims E, Titov N, Andrews G, Choi I. Clinician-
assisted internet-based treatment is effective for panic: A
randomized controlled trial. Australian and New Zealand
Journal of Psychiatry 2010;44(7):599–607. [DOI: 10.3109/
00048671003614171]
References to studies excluded from this review
Andersson 2006 {published data only}
Andersson G, Carlbring P, Holmström A, Sparthan E,
Furmark T, Nilsson-Ihrfelt E, et al. Internet-based self-
help with therapist feedback and in vivo group exposure for
social phobia: A randomized controlled trial. Journal of
Consulting and Clinical Psychology 2006;74:677–86. [DOI:
10.1037/0022-006X.74.4.677]
Andersson 2012c {published data only}
∗Andersson E, Enander J, Andren P, Hedman E, Ljotsson
B, Hursti T, et al. Internet-based cognitive behaviour
therapy for obsessive-compulsive disorder: A randomized
controlled trial. Psychological Medicine 2012;42:2193–203.
[DOI: 10.1017/S0033291712000244]
Ruck C. Internet-based cognitive behavior therapy (CBT)
for obsessive compulsive disorder (OCD) [NCT01347099].
ClinicalTrials.gov [www.clinicaltrials.gov] 2011.
Andrews 2011 {published data only}
Andrews G. In patients seeking treatment for social phobia
internet cognitive behaviour therapy will be compared with
face to face cognitive behaviour therapy on the reduction
in social phobia scores [ACTRN12611000626965].
Australian New Zealand Clinical Trials Registry
[www.anzctr.org.au] June 2011.
∗Andrews G, Davies M, Titov N. Effectiveness randomized
controlled trial of face to face versus Internet cognitive
behaviour therapy for social phobia. Australian and New
Zealand Journal of Psychiatry 2011;45:337–40. [DOI:
10.3109/00048674.2010.538840]
Bell 2012 {published data only}
Bell CJ, Colhoun HC, Carter FA, Frampton CM.
Effectiveness of computerised cognitive behaviour therapy
for anxiety disorders in secondary care. Australian and New
Zealand Journal of Psychiatry 2012;46:630–40. [DOI:
10.1177/0004867412437345]
Carlbring 2003 {published data only}
Carlbring P, Ekselius L, Andersson G. Treatment of panic
disorder via the internet: A randomized trial of CBT vs.
applied relaxation. Journal of Behavior Therapy 2003;34(2):
129–40. [DOI: 10.1016/S0005-7916(03)00026-0]
Carlbring 2010 {published data only}
Carlbring P. Treatment of social phobia over the
internet (SOFIE-8) [NCT01312571]. ClinicalTrials.gov
[www.clinicaltrials.gov] 2010, August.
Carlbring 2011b {published data only}
Carlbring P, Maurin T, Sjomark J, Maurin L, Westling BE,
Ekselius L, et al. All at once or one at a time? A randomized
controlled trial comparing two ways to deliver bibliotherapy
for panic disorder. Cognitive Behaviour Therapy 2011;40:
228–35. [DOI: 10.1080/16506073.2011.553629]
Cunningham 2006 {published data only}
Cunningham V, Lefkoe M, Sechrest L. Eliminating fears:
An intervention that permanently eliminates the fear of
public speaking. Clinical Psychology & Psychotherapy 2006;
13:183–93. [DOI: 10.1002/cpp.487]
Ellis 2011 {published data only}
Ellis LA, Campbell AJ, Sethi S, O’Dea BM. Comparative
randomized trial of an online cognitive-behavioral therapy
program and an online support group for depression and
anxiety. Journal of CyberTherapy and Rehabilitation 2011;4:
461–7.
Febbraro 2005 {published data only}
Febbraro GAR. An investigation into the effectiveness of
bibliotherapy and minimal contact interventions in the
treatment of panic attacks. Journal of Clinical Psychology
2005;61:763–79. [DOI: 10.1002/jclp.20097]
Gilson 2006 {published data only}
Gilson K, Pier C, Austin DW, Mitchell J, Schattner P, Pierce
D, et al. Evaluation of internet-based cognitive behavioural
therapy for panic disorder in general medical practice. 29th
Australian Association for Cognitive and Behaviour Therapy
Annual Conference. Manly, Australia, October 2006.
Greist 2002 {published data only}
Greist JH, Marks IM, Baer L, Kobak KA, Wenzel KW,
Hirsch MJ, et al. Behavior therapy for obsessive-compulsive
disorder guided by a computer or by a clinician compared
with relaxation as a control. Journal of Clinical Psychiatry
2002;63:138–45. [DOI: 10.4088/JCP.v63n0209]
Kenardy 2003 {published data only}
Kenardy JA, Dow MGT, Johnston DW, Newman MG,
Thomson A, Taylor CB. A comparison of delivery methods
of cognitive-behavioral therapy for panic disorder: An
international multicenter trial. Journal of Consulting and
Clinical Psychology 2003;71:1068–75. [DOI: 10.1037/
0022-006X.71.6.1068]
Kenwright 2005 {published data only}
Kenwright M, Marks I, Graham C, Franses A, Mataix-
Cols D. Brief scheduled phone support from a clinician to
enhance computer-aided self-help for obsessive-compulsive
disorder: Randomized controlled trial. Journal of Clinical
Psychology 2005;61:499–508. [DOI: 10.1002/jclp.20204]
42Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Klein 2001 {published data only}
Klein B, Richards JC. A brief internet-based treatment for
panic disorder. Behavioural and Cognitive Psychotherapy
2001;29:113–7. [DOI: 10.1017/S1352465801001138]
Klein 2006 {published data only}
Klein B, Richards JC, Austin DW. Efficacy of internet
therapy for panic disorder. Journal of Behavior Therapy and
Experimental Psychiatry 2006;37:213–38. [DOI: 10.1016/
j.jbtep.2005.07.001]
Klein 2009 {published data only}
Klein B, Austin D, Pier C, Kiropoulos L, Shandley K,
Mitchell J, et al. Internet-based treatment for panic
disorder: Does frequency of therapist contact make a
difference?. Cognitive Behaviour Therapy 2009;38:100–13.
[DOI: 10.1080/16506070802561132]
Knaevelsrud 2007 {published data only}
Knaevelsrud C, Maercker A. Internet-based treatment for
PTSD reduces distress and facilitates the development of
a strong therapeutic alliance: A randomized controlled
clinical trial. BMC Psychiatry 2007;7:13. [DOI: 10.1186/
1471-244X-7-13]
Lange 2001 {published data only}
Lange A, van de Ven JP, Schrieken B, Emmelkamp PM.
Interapy. Treatment of posttraumatic stress through the
Internet: A controlled trial. Journal of Behavior Therapy and
Experimental Psychiatry 2001;32:73–90. [DOI: 10.1016/
S0005-7916(01)00023-4]
Lange 2003 {published data only}
Lange A, Rietdijk D, Hudcovicova M, van de Ven JP,
Schrieken B, Emmelkamp PM. Interapy: A controlled
randomized trial of the standardized treatment of
posttraumatic stress through the Internet. Journal of
Consulting and Clinical Psychology 2003;71:901–9. [DOI:
10.1037/0022-006X.71.5.901]
Litz 2007 {published data only}
Bruner V, Gore K, DeDeyn J, Jaffer A, Litz B, Bryant R. A
therapist-guided internet-based self-management approach
to post-traumatic stress after military events. International
Society for Traumatic Stress Studies. New Orleans, LA,
November 2004.
Litz BT, Engel CC, Bryant RA, Papa A. A randomized,
controlled proof-of-concept trial of an internet-
based, therapist-assisted self-management treatment
for posttraumatic stress disorder. American Journal of
Psychiatry 2007;164(11):1676–83. [DOI: 10.1176/
appi.ajp.2007.06122057]
Marks 2004 {published data only}
Marks IM, Kenwright M, McDonough M, Whittaker M,
Mataix-Cols D. Saving clinicians’ time by delegating routine
aspects of therapy to a computer: A randomized controlled
trial in phobia/panic disorder. Psychological Medicine 2004;
34:9–17. [DOI: 10.1017/S003329170300878X]
Newman 1997 {published data only}
Newman MG, Kenardy J, Herman S, Taylor CB.
Comparison of palmtop-computer-assisted brief cognitive-
behavioral treatment to cognitive-behavioral treatment for
panic disorder. Journal of Consulting and Clinical Psychology
1997;65:178–83. [DOI: 10.1037/0022-006X.65.1.178]
Pittaway 2009 {published data only}
Pittaway S, Cupitt C, Palmer D, Arowobusoye N, Milne
R, Holttum S, et al. Comparative, clinical feasibility study
of three tools for delivery of cognitive behavioural therapy
for mild to moderate depression and anxiety provided on a
self-help basis. Mental Health in Family Medicine 2009;6:
145–54.
Ruwaard 2010 {published data only}
Ruwaard J, Broeksteeg J, Schrieken B, Emmelkamp P,
Lange A. Web-based therapist-assisted cognitive behavioral
treatment of panic symptoms: A randomized controlled
trial with a three-year follow-up. Journal of Anxiety Disorders
2010;24:387–96. [DOI: 10.1016/j.janxdis.2010.01.010]
Saul 2007 {published data only}
Saul JE. A comparison of Internet-based versus face-to-face
cognitive behavioral therapy for snake phobia. Dissertation
Abstracts International 2007;67:6077.
Schneider 2005 {published data only}
Schneider AJ, Mataix-Cols D, Marks IM, Bachofen
M. Internet-guided self-help with or without exposure
therapy for phobic and panic disorders. Psychotherapy
and Psychosomatics 2005;74:154–64. [DOI: 10.1159/
000084000]
Shandley 2008 {published data only}
Shandley K, Austin DW, Klein B, Pier C, Schattner P,
Pierce D, et al. Therapist-assisted, Internet-based treatment
for panic disorder: Can general practitioners achieve
comparable patient outcomes to psychologists?. Journal of
Medical Internet Research 2008;10:65–79. [DOI: 10.2196/
jmir.1033]
Titov 2009b {published data only}
Titov N, Andrews G, Schwencke G, Solley K, Johnston
L, Robinson E. An RCT comparing effect of two types of
support on severity of symptoms for people completing
Internet-based cognitive behaviour therapy for social
phobia. Australian and New Zealand Journal of Psychiatry
2009;43:920–6. [DOI: 10.1080/00048670903179228]
van Straten 2008 {published data only}
van Straten A, Cuijpers P, Smits N. Effectiveness of a web-
based self-help intervention for symptoms of depression,
anxiety, and stress: Randomized controlled trial. Journal
of Medical Internet Research 2008;10:e7. [DOI: 10.2196/
jmir.954]
Wagner 2012 {published data only}
Wagner B, Brand J, Schulz W, Knaevelsrud C. Online
working alliance predicts treatment outcome for
posttraumatic stress symptoms in Arab war-traumatized
patients. Depression and Anxiety 2012;29:646–51. [DOI:
10.1002/da.21962]
References to studies awaiting assessment
Andersson 2013 {published data only}
∗Andersson G, Warra J, Jonsson U, Malmaeus F, Carlbring
P, Ost L-G. Internet-based exposure treatment versus one-
43Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
session exposure treatment of snake phobia: A randomized
controlled trial. Cognitive Behaviour Therapy 2013;42:
284–91. [DOI: 10.1080/1656073.2013.844202]
Andrews 2011b {published data only}
Andrews G. A randomised controlled trial comparing
clinician-assisted Internet based treatment for panic disorder
with or without agoraphobia vs. a waitlist control on
severity of symptoms of panic [ACTRN12611001120965].
Australian New Zealand Clinical Trials Registry
[www.anzctr.org.au] 2011.
Andrews 2011c {published data only}
Andrews G. The Wellbeing6 Program for Anxiety
and Depression - A Randomised Controlled Trial
[ACTRN12611001055998]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] October 2011.
Andrews 2011d {published data only}
Andrews G. A randomized controlled trial of Internet
based education for social phobia, panic disorder
(with or without agoraphobia), and generalised anxiety
disorder, comparing immediate education versus delayed
education groups on severity of symptoms of anxiety
[ACTRN12611000625976]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2011.
Andrews 2012a {published data only}
Andrews G. A randomised controlled trial comparing
clinician-assisted Internet based treatment for
Obsessive Compulsive Disorder (OCD) vs. a waitlist
control condition on severity of symptoms of OCD
[ACTRN12612001073897]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2012.
Berger 2012 {published data only}
Berger M. Internet-based treatment for obsessive-compulsive
disorder - acceptance and effectiveness [DRKS00004612].
German Clinical Trials Register [www.germanctr.de] 2012.
Berger 2014 {published data only}
∗Berger T, Boettcher J, Caspar F. Internet-based guided self-
help for several anxiety disorders: A randomized controlled
trial comparing a tailored with a standardized disorder-
specific approach. Psychotherapy 2014;51:207–19. [DOI:
10.1037/a0032527]
Carlbring 2012 {published data only}
Carlbring P. Internet-based treatment of generalized
anxiety disorder [NCT01570374]. ClinicalTrials.gov
[www.clinicaltrials.gov] 2012.
Greist 2012 {published data only}
Greist R, Kobak K. Computer assisted cognitive behavior
therapy for obsessive-compulsive disorder: A comprehensive
stepped-care approach [NCT01522287]. ClinicalTrials.gov
[www.clinicaltrials.gov] 2012.
Ivarsson 2014 {published data only}
∗Ivarsson D, Blom M, Hesser H, Carlbring P, Enderby
P, Nordberg R, Andersson G. Guided internet-delivered
cognitive behavior therapy for post-traumatic stress disorder:
A randomized controlled trial. Internet Interventions 2014;
1:33–40. [DOI: 10.1016/j.invent.2014.03.002]
Newby 2013 {published data only}
Newby JM. The Wellbeing6 program for anxiety
and depression: A randomised controlled trial
[ACTRN12611001055998]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2011.
∗Newby JM, Mackenzie A, Williams AD, McIntyre
K, Watts S, Wong N, Andrews G. Internet cognitive
behavioural therapy for mixed anxiety and depression: A
randomized controlled trial and evidence of effectiveness in
primary care. Psychological Medicine 2013;43:2635–48.
[DOI: 10.1017/S0033291713000111]
Newby JM, Williams AD, Andrews G. Reductions in
negative repetitive thinking and metacognitive beliefs during
transdiagnostic internet cognitive behavioural therapy
(iCBT) for mixed anxiety and depression. Behaviour
Research and Therapy 2014;59:52–60. [DOI: 10.1016/
j.brat.2014.05.009]
Nordgren 2012 {published data only}
Carlbring P. Internet-administrated treatment of anxiety
disorders (NOVA II) [NCT01390168]. ClinicalTrials.gov
[www.clinicaltrials.gov] 2011.
Nordgren LB, Andersson G, Kadowaki A, Carlbring
P. Tailored internet-administered treatment of anxiety
disorders for primary care patients: Study protocol for a
randomised controlled trial. Trials 2012;13:16. [DOI:
10.1186/1745-6215-13-16]
∗Nordgren LB, Hedman E, Etienne J, Bodin J, Kadowaki
A, Eriksson S, et al. Effectiveness and cost-effectiveness of
individually tailored Internet-delivered cognitive behavior
therapy for anxiety disorders in a primary care population: A
randomized controlled trial. Behaviour Research and Therapy
2014;59:1–11. [DOI: 10.1016/j.brat.2014.05.007]
Richards 2014 {published data only}
Richards D. Internet delivered treatment for generalized
anxiety symptoms in students [ISRCTN16303842].
ISRCTN Registry [www.isrctn.com] 2013.
Richards D, Timulak L, Doherty G, Sharry J, McLoughlin
O, Rashleigh C, et al. Low-intensity internet-delivered
treatment for generalized anxiety symptoms in routine care:
protocol for a randomized controlled trial. Trials 2014;15:
145.
Schreuders 2008 {published data only}
Schreuders B. Phobias under control. Internet-based guided
self-help for treatment of social, agora-, or specific phobia
(s): a pilot trial [NTR1260]. Nederlands Trial Register
[www.trialregister.nl/trialreg/] 2008.
References to ongoing studies
Andrews 2012b {published data only}
Andrews G. The Obsessive Compulsive Disorder
(OCD) Program: A randomised controlled trial of online
versus face-to-face cognitive behavioural therapy (CBT)
[ACTRN12612001306808]. Australian New Zealand
Clinical Trials Registry [www.anzctr.org.au] 2012.
44Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Bishop 2012 {published data only}
Bishop TM, Possemato K, Acosta M, Lantinga LJ, Maisto
S, Marsch L, et al. Moving forward: Update on the
development of a web-based cognitive behavioral treatment
for OEF/OIF veterans with PTSD symptoms and substance
misuse [abstract]. Alcoholism: Experimental and Clinical
Research 2012;36:347A.
Clark 2012 {published data only}
Clark DM. Internet-based cognitive therapy for social
anxiety disorder [ISRCTN95458747]. Controlled
Trials.com [www.controlled-trials.com] 2012.
Kok 2012 {published data only}
Kok RN, van Straten A, Beekman A, Bosmans J, de Neef
M, Cuijpers P. Effectiveness and cost-effectiveness of web-
based treatment for phobic outpatients on a waiting list
for psychotherapy: protocol of a randomised controlled
trial. BMC Psychiatry 2012;12:131. [DOI: 10.1186/
1471-244X-12-131]
Lindner 2013 {published data only}
Carlbring P. ACT-smart: Smartphone-supplemented iCBT
for social phobia and/or panic disorder [NCT01963806].
ClinicalTrials.gov 2013.
Lindner P, Ivanova E, Ly KH, Andersson G, & Carlbring
P. Guided and unguided CBT for social aniety disorder
and/or panic disorder via the Internet and a smartphone
application: Study protocol for a randomised controlled
trial. Trials 2013;14:437. [: 10.1186/1745–6215–14–437]
Miclea 2014 {published data only}
Miclea M. PAXonline: A randomized controlled
trial assessing the efficacy of an Internet-based
cognitive behavior intervention for Panic Disorder
[ACTRN12614000547640]. Australian New Zealand
Clinical Trials Registry 2014.
Rollman 2012 {published data only}
Rollman B. Online treatments for mood and
anxiety disorders in primary care [NCT01482806].
ClinicalTrials.gov [http://clinicaltrials.gov] 2011.
Titov 2012 {published data only}
Titov N. A randomized controlled trial of the effects
of disorder-specific vs. trans-diagnostic and self-
guided vs. guided Internet-administered treatment
on symptoms of social phobia in Australian adult
[ACTRN12612000430831]. Australia New Zealand
Clinical Trial Registry 2012.
Tulbure 2012 {published data only}
Tudor TB. Internet treatment for social phobia
(iSOFIE-Ro) [NCT01557894]. ClinicalTrials.gov
[www.clinicaltrials.gov] 2012.
Tulbure BT, Mansson KNT, Andersson G. Internet
treatment for social anxiety disorder in Romania: Study
protocol for a randomized controlled trial. Trials 2012;13:
202. [DOI: 10.1186/1745-6215-13-202]
von Essen 2008 {published data only}
von Essen L. Treatment of posttraumatic stress disorder
among parents of children with cancer with cognitive
behavioural therapy over the Internet. Pediatric Blood
Cancer 2008;50:9.
Additional references
Acarturk 2009
Acarturk C, Smit F, de Graaf R, van Straten A, Ten Have M,
Cuijpers P. Economic costs of social phobia: A population-
based study. Journal of Affective Disorders 2009;115:421–9.
[DOI: 10.1016/j.jad.2008.10.008]
Alvidrez 1999
Alvidrez J, Azocar F. Distressed women’s clinic patients:
preferences for mental health treatments and perceived
obstacles. General Hospital Psychiatry 1999;21(5):340–7.
Andersson 2007
Andersson G, Cuijpers P, Carlbring P, Lindefors N. Effects
of internet-delivered cognitive behaviour therapy for anxiety
and mood disorders. Review Series: Psychiatry 2007;9:9–14.
Andersson 2009b
Andersson G. Using the internet to provide cognitive
behaviour therapy. Behaviour Research and Therapy 2009;
47:175–80. [DOI: 10.1016/j.brat.2009.01.010]
Andersson 2012
Andersson G, Carlbring P, Furmark T. Therapist experience
and knowledge acquisition in internet-delivered CBT
for social anxiety disorder: a randomized controlled
trial. PLoS ONE 2012;7:e37411. [DOI: 10.1371/
journal.pone.0037411]
Andrews 2010
Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N.
Computer therapy for the anxiety and depressive disorders
is effective, acceptable, and practical health care: A meta-
analysis. PLoS ONE 2010;5:e13196. [DOI: 10.1371/
journal.pone.0013196]
APA 1980
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 3rd Edition. Washington, DC:
American Psychiatric Association, 1980.
APA 1987
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 3rd Edition. Washington, DC:
American Psychiatric Association, 1987.
APA 1994
American Psychiatric Association. Diagnostic and Statistical
Manual. 4th Edition. Washington, DC: American
Psychiatric Association, 1994.
APA 2000
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 4th Edition. Washington, DC:
American Psychiatric Association, 2000.
Attkisson 1982
Attkisson CC, Zwick R. The client satisfaction
questionnaire: Psychometric properties and correlations
with service utilization and psychotherapy outcome.
Evaluation and Program Planning 1982;5(3):233–7.
45Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Barak 2008
Barak A, Hen L, Boniel-Nissim M, Shapira N. A
comprehensive review and a meta-analysis of the
effectiveness of internet-based psychotherapeutic
interventions. Journal of Technology in Human Services
2008;26:109–60. [DOI: 10.1080/15228830802094429]
Barlow 1988
Barlow DH. Anxiety and its disorders: the nature and
treatment of anxiety and panic. New York: Guilford Press,
1988.
Batelaan 2007
Batelaan N, Smit F, de Graaf R, van Balkom A, Vollebergh
W, Beekman A. Economic costs of full-blown and
subthreshold panic disorder. Journal of Affective Disorders
2007;104:127–36. [DOI: 10.1016/j.jad.2007.03.013]
Beck 1979
Beck AT, Rush AJ, Shaw BF, Emergy G. Cognitive therapy of
depression. New York: The Guilford Press, 1979.
Beck 1991
Beck A, Steer R. Beck Anxiety Inventory manual. San
Antonio, TX: The Psychological Corporation, 1991.
Beck 2005
Beck AT, Emery G. Anxiety disorders and phobias: A cognitive
perspective. New York: Basic Books, 2005.
Bee 2008
Bee PE, Bower P, Lovell K, Gilbody S, Richards D, Gask L,
et al. Psychotherapy mediated by remote communication
technologies: a meta-analytic review. BMC Psychiatry 2008;
8:60.
Bisson 2007
Bisson J, Andrew M. Psychological treatment of post-
traumatic stress disorder (PTSD). Cochrane Database
of Systematic Reviews 2007, Issue 3. [DOI: 10.1002/
14651858.CD003388.pub3]
Borenstein 2009
Borenstein M, Hedges LV, Higgins JPT, Rothstein HR.
Introduction to meta-analysis. Hoboken, NJ: John Wiley &
Sons, Ltd, 2009.
Bruce 2005
Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB,
Pagano M, et al. Influence of psychiatric comorbidity on
recovery and recurrence in generalized anxiety disorder,
social phobia, and panic disorder: a 12-year prospective
study. American Journal of Psychiatry 2005;162(6):1179–87.
Buffett-Jerrot 2002
Buffett-Jerrott SE, Stewart SH. Cognitive and sedative
effects of benzodiazepine use. Current Pharmaceutical
Design 2002;8(1):45–58.
Casey 2004
Casey LM, Oei TPS, Newcombe PA. An integrated
cognitive model of panic disorder: The role of positive and
negative cognitions. Clinical Psychology Review 2004;24:
529–55. [DOI: 10.1016/j.cpr.2004.01.005]
Choy 2007
Choy Y. Managing side effects of anxiolytics. Primary
Psychiatry 2007;14(7):68–76.
Clark 1986
Clark DM. A cognitive approach to panic. Behaviour
Research and Therapy 1986;24(4):461–70.
Cuijpers 2009
Cuijpers P, Marks IM, van Straten A, Cavanagh K,
Gega L, Andersson G. Computer-aided psychotherapy
for anxiety disorders: A meta-analytic review. Cognitive
Behaviour Therapy 2009;38:66–82. [DOI: 10.1080/
16506070802694776]
Cuijpers 2010
Cuijpers P, Donker T, van Straten A, Li J, Andersson G. Is
guided self-help as effective as face-to-face psychotherapy
for depression and anxiety disorders? A systematic
review and meta-analysis of comparative outcome studies.
Psychological Medicine 2010;40:1942–57. [DOI: 10.1017/
S0033291710000772]
Deacon 2004
Deacon BJ, Abramowitz JS. Cognitive and behavioral
treatments for anxiety disorders: a review of meta-analytic
findings. Journal of Clinical Psychology 2004;60(4):429–41.
Department of Health 2008
Department of Health. Improving Access to Psychological
Therapies Implementation Plan: National Guidelines for
Regional Delivery. London: DoH, 2008.
DiNardo 1994
DiNardo P, Brown TA, Barlow DH. Anxiety Disorders
Interview Schedule for DSM-IV. Anxiety Disorders Interview
Schedule for DSM-IV. San Antonio, TX: The Psychological
Corporation, 1994.
Dugas 2007
Dugas MJ, Robichaud M. Cognitive-behavioral treatment for
generalized anxiety disorder: From science to practice. New
York: Routledge, 2007.
DuPont 1996
DuPont RL, Rice DP, Miller LS, Shiraki SS, Rowland CR,
Harwood HJ. Economic costs of anxiety disorders. Anxiety
1996;2:167–72.
Ehlers 2000
Ehlers A, Clark DM. A cognitive model of posttraumatic
stress disorder. Behaviour Research and Therapy 2000;38:
319–45.
ESEMeD/MHEDEA 2000 Investigators 2004
The ESEMeD/MHEDEA 2000 Investigators. Prevalence
of mental disorders in Europe: results from the European
Study of the Epidemiology of Mental Disorders (ESEMeD)
project. Acta Psychiatrica Scandinavica 2004;109 Suppl
420:21–7.
First 2002
First MB, Spitzer RL, Gibbon M, Williams JBW. Structured
Clinical Interview for DSM-IV-TR Axis I Disorders, Research
Version, Patient Edition (SCID-I/P). New York: Biometrics
Research, New York State Psychiatric Institute, 2002.
46Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Foa 2010
Foa EB. Cognitive behavioral therapy of obsessive-
compulsive disorder. Dialogues in Clinical Neuroscience
2010;12(2):199–207.
Frisch 1992
Frisch MB, Cornell J, Villanueva M, Retzlaff PJ. Clinical
validation of the quality of life inventory: A measure of
life satisfaction for use in treatment planning and outcome
assessment. Psychological Assessment 1992;4:92–101.
Goodman 1989
Goodman WK, Price LH, Rasmussen SA, Mazure C,
Fleischmann RL, Hill CL, et al. The Yale-Brown Obsessive
Compulsive Scale, I: Development, use, and reliability.
Archives of General Psychiatry 1989;46(11):1006–11.
Greenberg 1999
Greenberg PE, Sisitsky T, Kessler RC, Finkelstein SN,
Berndt ER, Davidson JRT, et al. The economic burden of
anxiety disorders in the 1990s. Journal of Clinical Psychiatry
1999;60:427–35. [DOI: 10.4088/JCP.v60n0702]
Gureje 2006
Gureje O, Lasebikan VO, Kola L, Makanjuola VA. Lifetime
and 12-month prevalence of mental disorders in the
Nigerian Survey of Mental Health and Well-Being. British
Journal of Psychiatry 2006;188(5):465–71.
Guy 1976
Guy W. ECDEU assessment manual for psychopharmacology.
Rockville, MD: US Department of Health Education and
Welfare, 1976.
Hahlweg 2001
Hahlweg K, Fiegenbaum W, Frank M, Schroeder B, von
Witzleben I. Short- and long-term effectiveness of an
empirically supported treatment for agoraphobia. Journal of
Consulting and Clinical Psychology 2001;69:375–82. [DOI:
10.1037/0022-006X.69.3.375]
Hambrick 2003
Hambrick JP, Turk CL, Heimberg RG, Schneier FR,
Liebowitz MR. The experience of disability and quality of
life in social anxiety disorder. Depression and Anxiety 2003;
18:46–50. [DOI: 10.1002/da.10110]
Hamilton 1959
Hamilton M. The assessment of anxiety states by rating.
British Journal of Medical Psychology 1959;32:50–5.
Hauenstein 2006
Hauenstein EJ, Petterson S, Merwin E, RovnyakV, Heise B,
Wagner D. Rurality, gender, and mental health treatment.
Family and Community Health 2006;29(3):169–85.
Health Canada 2002
Health Canada. A report on mental illness in Canada.
www.phac-aspc.gc.ca/publicat/miic-mmac/index.html.
Ottawa, ON: Health Canada Editorial Board, (accessed 25
March 2008).
Heimberg 2002
Heimberg RG. Cognitive-behavioral therapy for social
anxiety disorder: current status and future directions.
Biological Psychiatry 2002;51(1):101–8.
Higgins 2002
Higgins J, Thompson S. Quantifying heterogeneity in a
meta-analysis. Statistical Medicine 2002;21(11):1539–58.
Higgins 2008
Higgins JPT, White IR, Anzures-Cabrera J. Meta-analysis
of skewed data: Combining results reported on log-
transformed or raw scales. Statistics in Medicine 2008;27:
6072–92. [DOI: 10.1002/sim.3427]
Higgins 2011a
Higgins JPT, Green S (editors). Cochrane Handbook for
Systematic Review of Interventions Version 5.1.0 [updated
March 2011]. The Cochrane Collaboration, 2011.
Available from www.cochranehandbook.org. The Cochrane
Collaboration.
Higgins 2011b
Higgins JPT, Altman DG, Gotzsche PC, Juni P, Moher D,
Oxman AD, et al. The Cochrane Collaboration’s tool for
assessing risk of bias in randomised trials. BMJ 2011;343:
d5928. [DOI: 10.1136/bmj.d5928]
Hunot 2007
Hunot V, Churchill R, Teixeira V, Silva de Lima M.
Psychological therapies for generalised anxiety disorder.
Cochrane Database of Systematic Reviews 2007, Issue 1.
[DOI: 10.1002/14651858.CD001848.pub4]
Kessler 2004
Kessler RC, McGonagle KA, Zhoa S, Nelson CB, Hughes
M, Eshleman S, et al. Lifetime and 12-month prevalence
of DSM-III-R psychiatric disorders in the United States:
Results from the National Comorbidity Survey. Archives
of General Psychiatry 1994;51:8–19. [DOI: 10.1001/
archpsyc.1994.03950010008002]
Kessler 2005a
Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence,
severity, and comorbidity of 12-month DSM-IV disorders
in the national comorbidity survey replication. Archives of
General Psychiatry 2005;62(6):617–27.
Kessler 2005b
Kessler RC, Berglund P, Demler O, Jin R, Merikangas
KR, Walters EE. Lifetime prevalence and age-of-onset
distributions of DSM-IV disorders in the national
comorbidity survey replication. Archives of General
Psychiatry 2005;62(6):593–602.
Landon 2004
Landon TA, Barlow DH. Cognitive-behavioural treatment
for panic disorder: current status. Journal of Psychiatric
Practice 2004;10(4):211–26.
Leon 1997
Leon AC, Olfson M, Portera L, Farber L, Sheehan DV.
Assessing psychiatric impairment in primary care with the
Sheehan Disability Scale. International Journal of Psychiatric
Medicine 1997;27:93–105.
Mattick 1998
Mattick RP, Clarke JC. Development and validation of
measures of social phobia scrutiny fear and social interaction
anxiety. Behaviour Research and Therapy 1998;36(4):
455–70.
47Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Mayo-Wilson 2013
Mayo-Wilson E, Montgomery P. Media-delivered cognitive
behavioural therapy and behavioural therapy (self-help)
for anxiety disorders in adults. Cochrane Database of
Systematic Reviews 2013, Issue 9. [DOI: 10.1002/
14651858.CD005330.pub4]
McNaughton 2008
McNaughton N. The neurobiology of anxiety: potential for
co-morbidity of anxiety and substance use disorders. In:
Stewart SH, Conrod PJ editor(s). Anxiety and substance use
disorders. New York, NY: Springer, 2008:19–33.
Milette 2011
Milette K, Roseman M, Thombs BD. Transparency of
outcome reporting and trial registration of randomized
controlled trials in top psychosomatic and behavioral
health journals: A systematic review. Journal of
Psychosomatic Research 2011;70:205–17. [DOI: 10.1016/
j.jpsychores.2010.09.015]
Mogotsi 2000
Mogotsi M, Kaminer D, Stein DJ. Quality of life in the
anxiety disorders. Harvard Review of Psychiatry 2000;8:
273–82. [DOI: 10.1093/hrp/8.6.273]
Mohr 2006
Mohr DC, Hart SL, Howard I, Julian L, Vella L, Catledge
C, et al. Barriers to psychotherapy among depressed and
nondepressed primary care patients. Annals of Behavior
Medicine 2006;32(3):254–8.
Norton 2007
Norton PJ, Price EC. A meta-analytic review of adult
cognitive-behavioral treatment outcomes across anxiety
disorders. Journal of Nervous and Mental Diseases 2007;195
(6):521–31.
Norton 2014
Norton PJ, Little TE, Wetterneck CT. Does experience
matter? Trainee experience and outcomes during
transdiagnostic cognitive-behavioral group therapy for
anxiety. Cognitive Behaviour Therapy 2014;43:230–8.
[DOI: 10.1080/16506073.2014.919014]
Ohayon 2000
Ohayon MM, Shapiro CM, Kennedy SH. Differentiating
DSM-IV anxiety and depressive disorders in the general
population: Comorbidity and treatment consequences.
Canadian Journal of Psychiatry 2000;45:166–72.
Olatunji 2010
Olatunji BO, Hollon SD. Preface: the current status of
cognitive behavioral therapy for psychiatric disorders.
Psychiatric Clinics of North America 2010;33(3):xiii–ix.
Olthuis 2011
Olthuis JV, Watt MC, Stewart SH. Therapist-delivered
distance cognitive behavioural therapy for anxiety disorders
in adults. Cochrane Database of Systematic Reviews 2011,
Issue 3. [DOI: 10.1002/14651858.CD009028]
Ost 1997
Ost LG. Rapid treatments of specific phobias. In: GCL
Davey editor(s). Phobias: A handbook of theory, research, and
treatment. Chichester, UK: Wiley, 1997:227–46.
Otto 2000
Otto MW, Pollack MH, Maki KM. Empirically supported
treatments for panic disorder: costs, benefits, and stepped
care. Journal of Consulting and Clinical Psychology 2000;68
(4):556–63.
Otto 2005
Otto MW, Smits JAJ, Reese HE. Combined psychotherapy
and pharmacotherapy for mood and anxiety disorders in
adults: Review and analysis. Clinical Psychology: Science and
Practice 2005;12(1):72–86.
Peters 2008
Peters J, Sutton AJ, Jones DR, Abrams KR, Rushton
L. Contour-enhanced meta-analysis funnel plots help
distinguish publication bias from other causes of asymmetry.
Journal of Clinical Epidemiology 2008;61(10):991–6.
Postel 2008
Postel MG, de Haan HA, De Jong CAJ. E-therapy for
mental health problems: A systematic review. Telemedicine
and e-Health 2008;14:707–14. [DOI: 10.1089/
tmj.2007.0111]
Pull 2007
Pull CB. Combined pharmacotherapy and cognitive-
behavioral therapy for anxiety disorders. Current Opinion in
Psychiatry 2007;20(1):30–5.
Reger 2009
Reger MA, Gahm GA. A meta-analysis of the effects
of internet- and computer-based cognitive-behavioral
treatments for anxiety. Journal of Clinical Psychology 2009;
65(1):53–75.
Revicki 2012
Revicki DA, Travers K, Wyrwich KW, Svedsater H, Locklear
J, Stoeckl Mattera M, et al. Humanistic and economic
burden of generalized anxiety disorder in North America
and Europe. Journal of Affective Disorders 2012;140:
103–12. [DOI: 10.1016/j.jad.2011.11.014]
RevMan 2014
The Nordic Cochrane Centre, The Cochrane Collaboration.
Review Manager (RevMan). 5.3. Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2014.
Robins 1991
Robins LN, Locke BZ, Regier DA. An overview of
psychiatric disorders in America. In: LN Robins, DA Regier
editor(s). Psychiatric disorders in America: The Epidemiologic
Catchment Area Study. New York: Free Press, 1991:328–66.
Rost 2002
Rost K, Fortney J, Fischer E, Smith J. Use, quality, and
outcomes of care for mental health: the rural perspective.
Medical Care Research and Review 2002;59(3):231–65.
48Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Salkovskis 1985
Salkovskis P. Obsessional-compulsive problems: a cognitive
behavioural analysis. Behaviour Research and Therapy 1985;
23:571–83.
Slade 2007
Slade T, Johnston A, Oakley Brown MA, Andrews G,
Whiteford H. 2007 National Survey of Mental Health and
Wellbeing: Methods and key findings. Australian and New
Zealand Journal of Psychiatry 2009;43(7):594–605.
Spek 2007
Spek V, Cuijpers P, Nyklicek I, Riper H, Keyzer
J, Pop V. Internet-based cognitive behaviour for
symptoms of depression and anxiety: A meta-analysis.
Psychological Medicine 2007;37:319–28. [DOI: 10.1017/
S0033291706008944]
Statistics Canada 2004
Statistics Canada. Canadian Community Health Survey:
Mental health and well-being. http://www.statcan.ca/
english/freepub/82-617-XIE/index.htm (accessed 25 March
2008).
Stewart 2008
Stewart SH, Conrod PJ, editors. Anxiety and substance use
disorders: the vicious cycle of comorbidity. New York, NY:
Springer, 2008.
Stewart 2009
Stewart RE, Chambless DL. Cognitive-behavioral therapy
for adult anxiety disorders in clinical practice: a meta-
analysis of effectiveness studies. Journal of Consulting and
Clinical Psychology 2009;77(4):595–606.
Svanborg 1994
Svanborg P, Asberg M. A new self-rating scale for
depression and anxiety states based on the comprehensive
psychopathological rating scale. ACTA Psychiatrica
Scandinavica 1994;89:21–8. [DOI: 10.1111/j.1600-
0447.1994.tb01480.x]
Titov 2010b
Titov N, Andrews G, Kemp A, Robinson E. Characteristics
of adults with anxiety or depression treated at an internet
clinic: Comparison with a national survey and an outpatient
clinic. PLoS ONE 2010;5:e10885. [DOI: 10.1371/
journal.pone.0010885]
Westra 1998
Westra HA, Stewart SH. Cognitive behavioural therapy
and pharmacotherapy: complementary or contradictory
approaches to the treatment of anxiety?. Clinical Psychology
Review 1998;18(3):307–40.
WHO 1979
International Classification of Diseases (9th revision).
World Health Organization 1979.
WHO 1999
International Statistical Classification of Diseases and
Related Health Problems (10th revision). World Health
Organization 1999.
Wilson 2006
Wilson KA, Hayward C. Unique contributions of anxiety
sensitivity to avoidance: a prospective study in adolescents.
Behaviour Research and Therapy 2006;44(4):601–9.
Young 2001
Young AS, Klap R, Sherbourne CD, Wells KB. The quality
of care for depressive and anxiety disorders in the United
States. Archives of General Psychiatry 2001;58(1):55–61.
Yuen 1996
Yuen EJ, Gerdes JL, Gonzales JJ. Patterns of rural mental
health care: an exploratory study. General Hospital Psychiatry
1996;18(1):14–21.
∗Indicates the major publication for the study
49Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Andersson 2009
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Specific Phobia, Spider Type
Method of diagnosis: SCID-IV
N: 27
Age: M = 25.6 (SD = 4.1); range = 18 to 65 years
Sex: 84.8% women
Country of residence: Sweden
Method of enrollment: responded to media advertisements in community
Baseline depression severity: (BDI-II) ICBT M = 7.9 (SD = 5.9); Live exposure M =
6.9 (SD = 6.2)
Interventions Participants were randomly assigned to either:
(1) Internet-based BT with e-mail support (n = 13)
Duration: 5 online modules completed over 4 weeks
Treatment protocol*: participants completed online modules on psychoeducation and
exposure, with e-mail support from a therapist for module exercises
Therapists: trained and supervised in this treatment protocol by treatment founder (
st)
Therapist contact: 25 min per participant
Face-to-face contact: none
Dropout: n = 0; 0%
(2) Live exposure (n = 14)
Duration: 2 face-to-face sessions over 1 week
Treatment protocol*: participants attended an orientation session and one graded ex-
posure session with a therapist
Therapists: trained and supervised in this treatment protocol by treatment founder (
st)
Therapist, face-to-face contact: one orientation session and one 3 hr exposure session
Dropout: n = 0; 0%
Outcomes Timepoints for assessment: pre- and post-treatment and 1 year follow-up
Primary outcomes:
(1) specific phobia symptoms: Behavioural Avoidance Test; Spider Phobia Questionnaire;
Fear Survey Schedule-III
(2) general anxiety: Beck Anxiety Inventory
Notes *treatment based on: st, L.-G. (1997). Rapid treatments of specific phobias. In G.C.
L. Davey (Ed.), Phobias: A handbook of theory, research and treatment (pp. 227-246).
Chichester, UK: Wiley.
Risk of bias
Bias Authors’ judgement Support for judgement
50Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Andersson 2009 (Continued)
Random sequence generation (selection
bias)
Unclear risk Quote: “Thirty participants...were randomised by an in-
dependent person to either...”
Comment: insufficient detail about method of randomi-
sation provided to determine risk
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus face-to-face CBT)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
High risk Quote: “Three participants were dropped because of
computer problems (n=1) or lack of time (n=2).”
Comment: unclear which treatment condition the drop-
outs were from; ITT analyses were not used
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Unclear risk Group comparisons at baseline not reported
Andersson 2012a
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: SCID-IV
N: 204
Age: for ICBT, M = 38.1 (SD = 11.3); for discussion group, M = 38.4 (SD = 10.9);
range = 19 to 71 years
Sex: 61% women
Country of residence: Sweden
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: 13.7%
Method of enrollment: responded to online study advertisement
Baseline depression severity: (MADRS-S) ICBT M = 13.45 (SD = 7.14); Discussion
group M = 14.29 (SD = 6.63)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support (n = 102)
Duration: 9 online modules completed over 9 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, social skills, and relapse prevention, with email support
from a therapist for module exercises
51Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Andersson 2012a (Continued)
Therapists: 7 licensed clinical psychologists (avg. 3 years experience; previous experience
with Internet treatment) and 6 clinical psychology students in their last year of the
master’s program; all had basic CBT training; students had clinical supervision during
study
Therapist contact: 15 min per participant each week
Face-to-face contact: none
Dropout: n = 8; 7.8%
(2) Online discussion group (n = 102)
Duration: 9 weeks
Treatment protocol: participants made weekly posts in an online topic-relevant discus-
sion group
Therapist, face-to-face contact: none
Dropout: n = 2; 2%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) social phobia symptoms: Liebowitz Social Anxiety Scale, Social Phobia Scale, Social
Interaction Anxiety Scale, Social Phobia Screening Questionnaire
(2) general anxiety: Beck Anxiety Inventory
(3) clinically important improvement: Clinical Global Impression Improvement Scale
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on: Furmark, T., Holmstrom, A., Sparthan, E., Carlbring, P., & Ander-
sson, G. (2006). Social fobi - Effectiv hjalp med kognitiv beteendeterapi [Social phobia
- effective help via CBT]. Stockholm: Liber
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Randomization was performed by an indepen-
dent third-party using an online true random-number
service (www.random.org).”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus online discussion group)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “Outcome assessors were not aware of treatment
status before the interview.”
Comment: interviewers were blind to treatment condi-
52Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Andersson 2012a (Continued)
tion
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Eight participants in the treatment group and 2
in the control group did not complete posttreatment data
yielding a 5% dropout. In accordance with the ITT prin-
ciple, all participants were asked to complete posttreat-
ment and follow-up assessments, regardless of how many
treatment modules they had completed and all were in-
cluded in the analyses.”
Comment: a small number of dropouts from both con-
ditions was reported; ITT analyses were used
Selective reporting (reporting bias) Low risk Results were reported for all outcome measures outlined
in the trial registration
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Andersson 2012b
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Generalized Anxiety Disorder
Method of diagnosis: SCID-IV
N: 81
Age: for ICBT, M = 44.4 (SD = 12.8); for internet psychodynamic therapy, M = 36.4
(SD = 9.7); for WLC, M = 39.6 (13.7); range = 19 to 66 years
Sex: 76.5% women
Country of residence: Sweden
Psychiatric co-morbidity: 22.2% Social Phobia, 19.8% Panic Disorder, 3.7% OCD,
23.5% Major Depression
Co-use of adjunct therapy: excluded
Co-use of medication: 32.1%
Method of enrollment: responded to study advertisements in community and online
Baseline depression severity: (MADRS-S) ICBT M = 22.30 (SD = 6.52); WLC M =
21.41 (SD = 5.99)
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail support (n = 27)
Duration: 8 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on psychoeducation, ap-
plied relaxation, worry time, cognitive restructuring, problem solving, exposure, sleep
management, and relapse prevention, with e-mail support from a therapist for module
exercises
Therapists: 2 licensed psychologists (previous experience with Internet treatment) and
3 psychology students in their final year; all had CBT training; supervised by a senior
researcher and licensed CBT therapist
Therapist contact: M total time spent by therapist per participant = 92 min (SD = 61)
Face-to-face contact: none
53Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Andersson 2012b (Continued)
Dropout: n = 7; 25.9%
(2) Internet-based psychodynamic therapy with email support (n = 27)
Duration: 8 online modules completed over 8 weeks
Treatment Protocolˆ: participants completed online modules on seeing, understanding,
and breaking unconscious patterns that contribute to emotional difficulties and guarding
against future relapses, with email support and encouragement from a therapist
Therapists: a licensed psychologist and 3 students in their final year of a clinical psy-
chology program; all trained in psychodynamic therapy
Therapist contact: M total time spent by therapist per participant = 113 min (SD = 41)
Face-to-face contact: none
Dropout: n = 5; 18.5%
(3) Waiting list control (n = 27)
Duration: 8 weeks
Therapist, face-to-face contact: none
Dropout: n = 2; 7.4%
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month follow-up
Primary outcomes:
(1) generalized anxiety disorder symptoms: Penn State Worry Questionnaire, Generalized
Anxiety Disorder Questionnaire IV
(2) general anxiety: State Trait Anxiety Inventory, Beck Anxiety Inventory
(3) clinically important improvement: SCID-IV
Secondary outcome:
(1) quality of life: Quality of Life Inventory (at post-treatment): participants reported if
they were completely, moderately, or not satisfied with treatment
Notes *treatment based on: Paxling, B., Almlov, J., Dahlin, M., Carlbring, P., Breitholtz, E.,
Eriksson, T., & Andersson, G. (2011). Internet-delivered cognitive behaviour therapy for
generalized anxiety disorder: A randomized controlled trial. Cognitive Behaviour Therapy,
40, 159-173.
ˆtreatment based on: Silverberg, F. (2005). Make the leap: A practical guide to breaking
the patterns that hold you back. New York: Marlow and Company.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The randomization procedure was managed by
an external administrator who was not otherwise involved
in the study. A true random number service (www.ran-
dom.org) was used to ensure complete randomness. Ran-
domization was done after inclusion wherein participants
were randomized to the three groups with no stratifica-
tion.”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
54Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Andersson 2012b (Continued)
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus online discussion group)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “After the treatment period, the interviewers
were blinded concerning participant status and allocation
(given that the posttreatment interviewers did not have
access to information about the participants). In addi-
tion, participants were asked not to reveal whether they
had received treatment.”
Comment: interviewers were blinded
Incomplete outcome data (attrition bias)
All outcomes
Low risk A small number of dropouts from each condition (de-
pending on outcome measure, 4 to 7 for Internet CBT,
1 to 5 dropouts for Internet psychodynamic therapy and
1 to 2 dropouts for waiting list control) and intention-
to-treat analyses were used
Selective reporting (reporting bias) Low risk All results were reported for all outcome measures out-
lined in the trial registration
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Berger 2009
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: SCID-IV
N: 52
Age: M = 28.9 (SD = 5.3); range = 19 to 43 years
Sex: 44.2% women
Country of residence: 88% Switzerland, 10% France, 2% Belgium
Psychiatric co-morbidity: 26.9% had a co-morbid Axis I diagnosis
Co-use of adjunct therapy or medication: excluded
Method of enrollment: responded to study advertisements in community and online
Baseline depression severity: (BDI-II) ICBT M = 16.6 (SD = 6.2); WLC M = 17.9
(SD = 10.4)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with email support (n = 31)
Duration: 5 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on psychoeducation, self-
55Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Berger 2009 (Continued)
focused attention, safety behaviours, in vivo exposure, and cognitive restructuring, with
email support from a therapist for module exercises
Therapists: 6 master’s level clinical psychologists; 4 in their first year of a CBT training
program, 2 in a postgraduate clinical psychology and psychotherapy course
Therapist contact: M e-mails from participant = 5.5 (range = 0 to 16); in addition to
responding to these, therapists sent weekly motivating e-mails
Face-to-face contact: none
Dropout: n = 3; 9.7%
(2) Waiting list control (n = 21)
Duration: 10 weeks
Therapist, face-to-face contact: none
Dropout: n = 2; 9.5%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcome:
(1) social phobia symptoms: Liebowitz Social Anxiety Scale - Self-Report; Social Phobia
Scale; Social Interaction Anxiety Scale
Secondary outcome:
(1) treatment satisfaction (at post-treatment): participants reported if they were com-
pletely, moderately, or not satisfied with treatment
Notes *treatment based on: Stangier, U., Heidenreich, T., & Peitz, M. (2003). Soziale Phobien.
Ein kognitiv-verhaltenstherapeutisches Behandlungsmanual [Social phobia. A cognitive-
behavioral treatment manual]. Weinheim: Beltz
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “We used a weighted randomizations procedure
(Altman, 1991), such that 60% were assigned to the
treatment condition and 40% to the waiting-list control
group. According to a computer-generated randomiza-
tions scheme...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “After randomizations, 5 participants (3 in the
treatment group and 2 in the control group) dropped out
during the course of the study and did not complete post
56Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Berger 2009 (Continued)
assessment (9.6%). According to an ITT paradigm...”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) Unclear risk Trial registration suggests that the State Trait Anxiety In-
ventory was completed by participants, however, results
are not reported for this outcome; all other outcomes ut-
lined in the protocol are reported in the manuscript
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Berger 2011
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: SCID-IV
N: 81
Age: M = 37.2 (SD = 11.2); range = 19 to 62 years
Sex: 53.1% women
Country of residence: Switzerland
Psychiatric co-morbidity: 38% had at least one other Axis I diagnosis; 12% PD, 10%
Specific Phobia, 2% GAD, 22% MDD or Dysthymia, 2% Eating Disorder
Co-use of adjunct therapy: excluded
Co-use of medication: 7.4%
Method of enrollment: responded to study advertisements in community and online
Baseline depression severity: (BDI-II) Guided ICBT M = 18.2 (SD = 11.5); Unguided
ICBT M = 17.7 (SD = 9.8)
Interventions Participants were randomly assigned to one of:
(1) Guided internet-based CBT (with e-mail support) (n = 27)
Duration: 5 online modules completed over 10 weeks (M hrs spent online = 10)
Treatment protocol*: participants completed online modules on motivational inter-
viewing, psychoeducation, cognitive restructuring, self-focused attention, and exposure,
with weekly e-mail support from a therapist
Therapists: 2 clinical psychology master’s level graduate students, 2 master’s level clinical
psychologists in post-graduate CBT training, 2 licensed psychologists with more than 5
years research and clinical experience
Therapist contact: M e-mails from participant = 6.16 (SD = 4.56; range = 1 to 17); M
e-mails from therapist = 12.44 (SD = 2.85; range = 6 to 17)
Face-to-face contact: none
Dropout: n = 3; 11.1%
(2) Unguided internet-based CBT (n = 27)
Duration: 5 online modules completed over 10 weeks (M hrs spent online = 9.5)
Treatment protocol*: participants completed online modules on motivational inter-
viewing, psychoeducation, cognitive restructuring, self-focused attention, and exposure
57Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Berger 2011 (Continued)
independently
Therapist, face-to-face contact: none
Dropout: n = 1; 3.7%
(3) Step-up on demand Internet-based CBT (with e-mail or phone support) (n = 27)
Duration: 5 online modules completed over 10 weeks (M hrs spent online = 10.5)
Treatment protocol*: participants completed online modules on motivational inter-
viewing, psychoeducation, cognitive restructuring, self-focused attention, and exposure,
with e-mail or phone support, or both, from a therapist as requested
Therapists: 2 clinical psychology master’s level graduate students, 2 master’s level clinical
psychologists in post-graduate CBT training, 2 licensed psychologists with more than 5
years research and clinical experience
Therapist contact: 52% of participants did not request contact, 33% requested weekly
e-mail contact, 7% requested weekly e-mail and phone contact
Face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 6 month follow-up
Primary outcomes:
(1) social phobia symptoms: Liebowitz Social Anxiety Scale - Self-Report; Social Phobia
Scale; Social Interaction Anxiety Scale
(2) clinically important improvement: SCID-IV
Secondary outcome:
(1) treatment satisfaction (at post-treatment): Client Satisfaction Questionnaire
Notes *treatment based on: Stangier, U., Heidenreich, T., & Peitz, M. (2003). Soziale Phobien.
Ein kognitiv-verhaltenstherapeutisches Behandlungsmanual [Social phobia. A cognitive-
behavioral treatment manual]. Weinheim: Beltz
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Participants were randomised into one of the
three conditions using a computerized random number
generator (www.random.org).”
Comment: adequate randomisation method
Allocation concealment (selection bias) Low risk Quote: “The allocation schedule was generated by an in-
dependent researcher and was unknown to the investiga-
tors.”
Comment: allocation likely concealed sufficiently to pre-
vent deviations from protocol
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment
condition nor therapists to the treatment they delivered
(guided versus unguided versus step-up on demand In-
ternet-based CBT)
58Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Berger 2011 (Continued)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
High risk Quote: “The interviewers could not be kept blind regard-
ing group assignment at post-assessment because some
participants disclosed aspects of the group assignment
during the interview.”
Comment: attempts were made to ensure interviewers
were blind to treatment condition, however, participants
revealed their treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Six participants (7.4%) dropped out before post-
treatment assessment (one in the self-help group, three in
the guided self-help group, and two in the step-up of sup-
port on demand condition).”; “There was no significant
difference in terms of demographics, pre-treatment, or
post-treatment scores between those who provided post-
treatment and follow-up data and those who did not...”;
“All analyses were based on the ITT sample.”
Comment: a small and similar number of dropouts from
the three treatment conditions was reported; reasons
were provided for dropouts (self-help: disappointed with
group assignment; guided self-help: wanted face-to-face
contact or had internet trouble; step-up on demand: va-
cation or no reason); ITT analyses were used
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Bergstrom 2010
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder (n=16) or Panic Disorder with Agoraphobia (n =
88)
Method of diagnosis: MINI
N: 104
Age: for ICBT, M = 33.8 (SD = 9.7); for face-to-face CBT, M = 34.6 (SD = 9.2)
Sex: 61.5% women
Country of residence: Sweden
Co-use of adjunct therapy: excluded
Co-use of medication: 45% (34% SSRI or SNRI, 13% benzodiazepines, 24% benzo-
diazepine derivatives or neuroleptics, 5% tricyclic antidepressants)
Method of enrollment: referred to study by health professionals or self-referred to study
clinic
59Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Bergstrom 2010 (Continued)
Baseline depression severity: (MADRS-S) ICBT M = 8.9 (SD = 5.2); face-to-face CBT
M = 9.5 (SD = 4.9)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support (n = 50)
Duration: 10 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, and relapse prevention, with e-mail support from a ther-
apist for module exercises, and posted on an online discussion forum
Therapists: psychologists
Therapist contact: M e-mails from therapist = 11.3 (SD = 4.3); M total time spent by
therapist per participant = 35.4 min (SD = 19)
Face-to-face contact: none
Dropout: n = 9; 17%
(2) Face-to-face group CBT (n = 54)
Duration: 10 face-to-face group therapy sessions over 10 weeks
Treatment protocol*: group sessions focused on psychoeducation, cognitive restructur-
ing, exposure, and relapse prevention
Therapists: 2 regular clinical psychologists, not specially trained for this study
Therapist, face-to-face contact: 10 x 2 hr group sessions
Dropout: n = 11; 18.3%
Outcomes Timepoints for assessment: pre- and post-treatment and 6 month follow-up
Primary outcomes:
(1) panic symptoms: Panic Disorder Severity Scale; Anxiety Sensitivity Index
(2) clinically important improvement: MINI
Secondary outcome:
(1) quality of life: Sheehan Disability Scale
Notes *treatment based on: Barlow D.H., & Craske M.G. (2000). Mastery of your anxiety and
panic (MAP-3). San
Antonio: The Psychological Corporation.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The participants were divided into two groups.
..by an independent random number procedure...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Low risk Quote: “...where each patient was assigned to either treat-
ment by the opening of sealed numbered envelopes.”
Comment: adequate allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment
condition nor therapists to the treatment they delivered
(Internet-based applied relaxation versus Internet-based
CBT)
60Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Bergstrom 2010 (Continued)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
Low risk Quote: “All outcome measures...were administered dur-
ing the clinical interview...”
Comment: self-report outcomes were not completed
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “The psychiatrists performing the clinical inter-
views at post-treatment and follow-up were blind to treat-
ment condition.”; “All outcome measures...were admin-
istered during the clinical interview...”
Comment: interviewers were blind to treatment condi-
tion
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Nine participants dropped out after randomisa-
tion but before commencing treatment. Various reasons
were given for not starting treatment, but all pertained to
different life circumstances of the individual participants
and not to randomisation status. These initial dropouts
were excluded from the statistical analyses.”; “A num-
ber of patients did not return for the clinical interview
at post-treatment... a mixed effects models approach was
used in the statistical analysis to adjust for these missing
values.”
Comment: a similar number of dropouts from both treat-
ment conditions was reported (during treatment:six from
treatment, five from comparator); mixed effects models
were used to account for missing data
Selective reporting (reporting bias) Low risk Results for all outcome measures outlined in the trial
registration were reported
Other bias Unclear risk Group comparisons at baseline not reported
Carlbring 2001
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder
Method of diagnosis: CIDI and ADIS-IV
N: 41
Age: M = 34 (SD = 7.5); range = 21 to 51 years
Sex: 71% women
Country of residence: Sweden
Psychiatric co-morbidity: included
Co-use of adjunct therapy: ongoing for > 6 months and not CBT (n = 1)
Co-use of medication: 64% (44% SSRIs, 10% benzodiazepines, 5% beta-blockers, 5%
tricyclic antidepressants)
Method of enrollment: responded to media advertisements in community
Baseline depression severity: (BDI-II) ICBT M = 11.4 (SD = 3.7); WLC M = 13.1
(SD = 6.2)
61Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2001 (Continued)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with email support (n = 21)
Duration: 6 online modules completed over 7 to 12 weeks
Treatment protocol*: participants completed online modules on psychoeducation,
breathing retraining, cognitive restructuring, exposure, and relapse prevention, with
email support from a therapist for module exercises
Therapists: a clinical psychology graduate student
Therapist contact: M reciprocal e-mail contacts = 7.5 (SD = 1.2; range = 6 to 15); M
total time spent by therapist per participant = 90 min
Face-to-face contact: none
Dropout: n = 4; 19%
(2) Waiting list control (n = 20)
Duration: 7 to 12 weeks
Therapist, face-to-face contact: none
Dropout: n = 1; 5%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) panic and agoraphobia symptoms: Body Sensations Questionnaire; Agoraphobic
Cognitions Questionnaire; Mobility Inventory
(2) general anxiety: Beck Anxiety Inventory
Secondary outcomes:
(1) quality of life: Quality of Life Inventory
(2) treatment satisfaction (at post-treatment): Evaluation of Self-Help Program and Ad-
visory Service
Notes *treatment based on: Barlow, D.H., & Craske, M.G. (1994). Mastery of your anxiety
and panic. San Antonio, TX: The Psychological Corporation. AND Zuercher-White, E.
(1998). An end to panic: Breakthrough techniques for overcoming panic disorder (2nd ed.).
Oakland, CA: New Harbinger Publications.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Participants were divided into two groups by the
drawing of lots. These were drawn for the two treatment
groupings pairwise for participants who had completed
their baseline measurements. In other words, as soon as
two participants had completed their baseline measure-
ments, one was allocated to the treatment group and the
other to the waiting-list group.”
Comment: adequate randomiation method
Allocation concealment (selection bias) Low risk Appears that lots were drawn immediately before assign-
ment so allocation was likely concealed adequately
62Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2001 (Continued)
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment
condition nor therapists to the treatment they delivered
(waiting list versus Internet-based CBT)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-reported and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “After randomizations, five people dropped out
during the course of the study. There were four dropouts
from the treatment group and one from the waiting-list
group, χ2(1) = 2.9, P < 0.05. In the treatment group, lack
of time was given as the main reason for discontinuing
(n = 3). One patient dropped out because of a newly
discovered cancer. The person who left the waiting-list
group gave no reason.”; “...intention-to-treat evaluation
of the results.”
Comment: though there was a difference in the number
of dropouts between the two treatment conditions, the
number of dropouts was small and reasons did not re-
late directly to treatment components; ITT analyses were
used
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Carlbring 2005
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder (49%) or Panic Disorder with Agoraphobia (51%)
Method of diagnosis: SCID-IV
N: 49
Age: M = 35 (SD = 7.7); range = 18 to 60 years
Sex: 71% women
Country of residence: Sweden
Psychiatric co-morbidity: 49% another Anxiety Disorder, 6% Major Depression
Co-use of adjunct therapy: ongoing for > 6 months and not CBT (4%)
Co-use of medication: 30.6% SSRIs, 8.2% benzodiazepines, 6.1% beta-blockers, 6.1%
tricyclic antidepressants
Method of enrollment: responded to media advertisements in community
Baseline depression severity: (BDI-II) ICBT M = 11.8 (SD = 7.8); face-to-face CBT
M = 15.9 (SD = 9.0); (MADRS-S) ICBT M = 13.4 (SD = 5.3); face-to-face CBT M =
16.0 (SD = 4.3)
63Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2005 (Continued)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with email support (n = 25)
Duration: 10 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on psychoeducation,
breathing retraining, cognitive restructuring, exposure, and relapse prevention, with e-
mail support from a therapist for module exercises
Therapists: 4 licensed clinical psychologists (research or clinical experience, or both,
with anxiety disorders), 3 advanced graduate students with a master’s degree in clinical
psychology, 1 student in final semester of master’s degree program; all supervised by a
licensed CBT psychologist and supervisor
Therapist contact: M reciprocal e-mail contacts = 15.4 (SD = 5.5; range = 4-31); M
total time spent by therapist per participant = 150 min
Face-to-face contact: none
Dropout: n = 3; 12%
(2) Face-to-face individual CBT (n = 24)
Duration: 10 individual face-to-face sessions over 10 weeks
Treatment protocol*: sessions focused on psychoeducation, breathing retraining, cog-
nitive restructuring, exposure, and relapse prevention
Therapists: 4 licensed clinical psychologists (research and/or clinical experience with
anxiety disorders), 3 advanced graduate students with a master’s degree in clinical psy-
chology, 1 student in the final semester of their master’s degree program; all supervised
by a licensed CBT psychologist and supervisor
Therapist, face-to-face contact: 10 x 45 to 60 min sessions
Dropout: n = 3; 12.5%
Outcomes Timepoints for assessment: pre- and post-treatment and 1 year follow-up
(1) panic and agoraphobia symptoms: Body Sensations Questionnaire; Agoraphobic
Cognitions Questionnaire; Mobility Inventory
(2) general anxiety: Beck Anxiety Inventory
(3) clinically important improvement: SCID-IV
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on: Barlow, D.H., & Craske, M.G. (1994). Mastery of your anxiety
and panic. San Antonio, TX: The Psychological Corporation. AND Zuercher-White, E.
(1998). An end to panic: Breakthrough techniques for overcoming panic disorder (2nd ed.).
Oakland, CA: New Harbinger Publications.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Participants were divided into two groups...by a
true random-number-service (http://www.random.org).
”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
64Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2005 (Continued)
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (face-
to-face CBT or Internet-based CBT)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “...a clinical re-interview (SCID) was adminis-
tered by an independent psychologist blind for treatment
condition.”
Comment: interviewers were blind to treatment condi-
tion
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “After randomizations, six people dropped out
during the course of the study. There were three drop-
outs from the LIVE therapy group and three from the
IT group. Lack of time was given as the main reason
for discontinuing. However, in accordance with the in-
tention to treat paradigm...post-treatment data were col-
lected from all dropouts.”
Comment: a small and similar number of dropouts re-
ported in the two treatment conditions; used ITT anal-
ysis
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Carlbring 2006
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder
Method of Diagnosis: SCID-IV
N: 60
Age: M = 36.7 (SD = 10); range = 18 to 60 years
Sex: 60% women
Country of residence: Sweden
Psychiatric co-morbidity: included
Co-use of adjunct therapy: none
Co-use of medication: 54%
Method of enrollment: responded to media advertisements in community
Baseline depression severity: (BDI-II) ICBT M = 17.7 (SD = 8.8); WLC CBT M =
15.4 (SD = 7.4); (MADR-S) ICBT M = 16.4 (SD = 7.2); WLC CBT M = 15.1 (SD =
6.0)
65Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2006 (Continued)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail and phone support (n = 30)
Duration: 10 online modules completed over 10 weeks
Treatment protocol: participants completed online modules on psychoeducation,
breathing retraining, cognitive restructuring, exposure, and relapse prevention, with
email support from a therapist for module exercises
Therapists: 1 licensed psychologist, 2 students in their final year of a clinical psychology
master’s program; all had regular supervision from an experienced CBT psychologist
Therapist contact: M reciprocal contacts = 13.5 (SD = 4.4; range = 7-29); M time spent
by therapist per participant per week = 12 min; M length of weekly phone conversations
= 11.8 min (range = 9.6 to 15.6)
Face-to-face contact: none
Dropout: n = 2; 6.7%
(2) Waiting list control (n = 30)
Duration: 10 weeks
Therapist, face-to-face contact: none
Dropout: n = 1; 3.3%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) panic and agoraphobia symptoms: Body Sensations Questionnaire; Agoraphobic
Cognitions Questionnaire; Mobility Inventory
(2) general anxiety: Beck Anxiety Inventory
(3) clinically important improvement: SCID-IV
Secondary outcomes:
(1) quality of life: Quality of Life Inventory
(2) treatment satisfaction (at post-treatment): participants reported if they were satisfied,
very satisfied, or dissatisfied with treatment and gave their opinion on the pace of the
program
Notes
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The participants were divided into two groups,
treatment or a waiting list, by a true random-number
service.”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list)
66Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2006 (Continued)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “...a reinterview administered by an independent
psychologist who was blind to treatment condition.”
Comment: interviewers were blind to treatment condi-
tion
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “One participant dropped out during the study;
shortage of time was said to be the main reason. How-
ever, in accordance with the intention-to-treat paradigm.
.. posttreatment data were also collected from the partici-
pant who dropped out. Two par ticipants in the treatment
condition and one on the waiting list did not return their
posttreatment questionnaires. Therefore, their pretreat-
ment scores were carried forward to the posttreatment
assessment point.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Carlbring 2007
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of Diagnosis: SCID-IV
N: 60
Age: for ICBT, M = 32.4 (SD = 9.1); for WLC, M = 32.9 (SD = 9.2); range = 18 to 60
years
Sex: 64.9% women
Country of residence: Sweden
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: included
Method of enrollment: responded to media advertisements in community
Baseline depression severity: (MADRS-S) ICBT M = 13.4 (SD = 8.4); WLC CBT M
= 13.5 (SD = 6.0)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail and phone support (n=30)
Duration: 9 online modules completed over 9 weeks
67Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2007 (Continued)
Treatment protocol*: participants completed online modules, with e-mail support from
a therapist for module exercises
Therapists: 2 students completing their last semester of a clinical psychology master’s
degree
Therapist contact: M time spent by therapist per participant per week = 22 min; M
length of weekly phone conversations = 10.5 min (SD = 3.6)
Face-to-face contact: none
Dropout: n = 2; 6.7%
(2) Waiting list control (n = 30)
Duration: 9 weeks
Therapist, face-to-face contact: none
Dropout: n = 2; 6.7%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) social phobia symptoms: Liebowitz Social Anxiety Scale - Self-Report; Social Phobia
Scale; Social Interaction Anxiety Scale; Social Phobia Screening Questionnaire
(2) general anxiety: Beck Anxiety Inventory
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on: Furmark, T., Holmstrom, A., Sparthan, E., et al. (2006). Social
Phobia - effective treatment with
cognitive-behavioural therapy (in Swedish). Liber.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “...were divided into two groups (treatment or
waiting-list control) by an online true random-number
service independent of the investigators and therapists.
This service is run by the Department of Computer Sci-
ence at the University of Dublin and the numbers are
generated using a purely random process (atmospheric
disturbances in space).”
Comment: adequate randomisation process
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
68Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2007 (Continued)
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Two participants, one in each condition, were
excluded from the analysis since they started other treat-
ment during the period. A total of 27 of the 29 people in
the treatment group completed all nine modules within
the intended 9-week time frame. Lack of time was pro-
vided as the explanation for terminating treatment pre-
maturely. One of them did not send in post-treatment
measures, which explains why intention-to-treat analysis
was used. Finally, after randomisation but before answer-
ing the pre-treatment questionnaires, one person in the
waiting-list chose to refrain from participating because of
lack of computer access. Thus, data for 29 participants
in the treatment group and 28 in the control group were
eligible for analysis.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Carlbring 2011
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder (9%), Panic Disorder with Agoraphobia (22%),
Social Phobia (39%), Generalized Anxiety Disorder (20%), Anxiety Disorder not oth-
erwise specified (13%)
Method of diagnosis: SCID-IV
N: 54
Age: M = 38.8 (SD = 10.7); range = 22 to 63 years
Sex: 76% women
Country of residence: Sweden
Psychiatric co-morbidity: 2% OCD, 2% PTSD, 20% MDD, 7% mild Depression,
15% Dysthymia
Co-use of adjunct therapy: excluded
Co-use of medication: 26% using an antidepressant or anxiolytic
Method of enrollment: responded to study advertisements in community and online
Baseline depression severity: (MADRS-S) ICBT M = 20.41 (SD = 7.31); attention
control M = 19.59 (SD = 7.43)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support (n = 27)
Duration: 6 to 10 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules as prescribed by a therapist
on topics related to their diagnosis, with e-mail support from a therapist for module
69Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2011 (Continued)
exercises
Therapists: 8 clinical psychology master’s students in last semester of training
Therapist contact: M time spent by therapist per participant per week = 15 min
Face-to-face contact: none
Dropout: n = 2; 7.4%
(2) Attention control (n = 27)
Duration: 10 weeks
Treatment protocol: participants made weekly posts in a confidential online support
group based on a theme posted by a therapist
Therapists: 8 clinical psychology master’s students in last semester of training
Therapist contact: therapist spent 1 hr per week monitoring forum
Face-to-face contact: none
Dropout: n = 0; 0%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) anxiety symptoms: Clinical Outcomes in Routine Evaluation - Outcome Measure
(2) general anxiety: Beck Anxiety Inventory
(3) clinically important improvement: Clinical Global Impression Scale
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on Internet-based programs described in: Andersson, G., Carlbring, P.
, Holmström, A., Sparthan, E., Furmark, T., Nilsson-Ihrfelt, E., et al. (2006). Internet-
based self-help with therapist feedback and in vivo group exposure for social phobia: a
randomised controlled trial. Journal of Consulting and Clinical Psychology, 74, 677-686.
; Carlbring, P., Westling, B. E., Ljungstrand, P., Ekselius, L, & Andersson, G. (2001).
Treatment of panic disorder via the Internet: A randomised trial of a self-help program.
Behavior Therapy, 32, 751-764.; AND Vernmark, K., Lenndin, J., Bjärehed, J., Carlsson,
M., Karlsson, J., Öberg, J., et al. (2010). Internet administered guided self-help versus
individualized e-mail therapy: a randomised trial of two versions of CBT for major
depression. Behaviour Research and Therapy, 48, 368-376.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The participants were divided into two groups..
. by an online true random-number service independent
of the investigators and therapists.”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment
condition nor therapists to the treatment they delivered
(Internet-based applied relaxation versus Internet-based
CBT)
70Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Carlbring 2011 (Continued)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “...a clinical global impression of improvement
(CGI-I) was mapped on a 7-point scale (CGI; Guy, 1976)
after a telephone interview by a blind assessor who had no
earlier contact with the participants and no knowledge
of to which group they had been randomly allocated.”
Comment: interviewers were blind to treatment condi-
tion
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “The response rate was... 96.3% (52/54) at post-
treatment.”; “Since the missing data at post-treatment
was only in the treatment group, repeated ANOVAs with
conservative imputation according to the last observa-
tion-carried-forward method in case of missing data was
used in the analysis of the immediate results.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported (two from treat-
ment, zero from comparator); used ITT analysis
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Furmark 2009a
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: SCID-IV
N: 120
Age: for Internet CBT, M = 35 (SD = 10.2); for bibliotherapy, M = 37.7 (SD = 10.3);
for waiting list, M = 35.7 (SD = 10.9)
Sex: 67.5% women
Country of residence: Sweden
Co-use of adjunct therapy: excluded
Co-use of medication: 13.9%
Method of enrollment: responded to study advertisements in community and online
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail support (n = 40)
Duration: 9 online modules completed over 9 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, social skills, and relapse prevention, with e-mail support
from a therapist for module exercises, and posted on an online discussion forum
71Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Furmark 2009a (Continued)
Therapists: 6 licensed clinical psychologists, 7 clinical psychology students in final year
of master’s program; students had clinical supervision during the study
Therapist contact: 15 min per week
Face-to-face contact: none
Dropout: n = 1; 2.5%
(2) Bibliotherapy (n = 40)
Duration: 9 sections of the manual completed over 9 weeks
Treatment protocol*: participants received a sel f-help manual in the mail and completed
it independently
Therapist, face-to-face contact: none
Dropout: n = 1; 2.5%
(3) Waiting list control (n = 40)
Duration: 9 weeks, completed weekly assessment measure
Therapist, face-to-face contact: none
Dropout: n = 1; 2.5%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) social phobia symptoms: Liebowitz Social Anxiety Scale - Self-Report; Social Phobia
Scale; Social Interaction Anxiety Scale; Social Phobia Screening Questionnaire
(2) general anxiety: Beck Anxiety Inventory
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on: Carlbring, P., Furmark, T., Steczkó, J., Ekselius, L., & Andersson,
G. (2006). An open study of internet-based bibliotherapy with minimal therapist contact
via email for social phobia. Clinical Psychology, 10, 30-38.; Andersson, G., Carlbring, P.
, Holmström, A., Sparthan, E., Furmark, T., Nilsson-Ihrfelt, E., et al. (2006). Internet-
based self-help with therapist feedback and in-vivo group exposure for social phobia: A
randomised controlled trial. Journal of Consulting and Clinical Psychology, 74, 677-686.;
Carlbring, P., Gunnarsdóttir, M., Hedensjö, L., Andersson, G., Ekselius, L., & Furmark,
T. (2007). Treatment of social phobia: randomised trial of internet-delivered cognitive-
behavioural therapy with telephone support. British Journal of Psychiatry, 190, 123-128.
; AND Tillfors, M., Carlbring, P., Furmark, T., Lewenhaupt, S., Spak, M., Eriksson, A.,
et al. (2008). Treating university students with social phobia and public speaking fears:
internet delivered self-help with or without live group exposure sessions. Depression and
Anxiety, 25, 708-717.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Randomisation was performed by an indepen-
dent third party using an online true random-number
service.”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
72Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Furmark 2009a (Continued)
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus pure bibliotherapy versus wait-
ing list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk Quote: “...assessors were not masked with regard to the
treatment assignment. However, all assessments were
conducted online with standardised written instructions
and automatic scoring, reducing the risk of reactivity or
experimenter effects.”
Comment: all outcome measures were self-report and
participants were not blind to their own treatment con-
dition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Two participants, one each from the pure bib-
liotherapy and waiting-list groups, withdrew immedi-
ately after randomisation because of personal reasons and
one additional participant (ICBT group) did not provide
post-treatment data.”; “For all randomised participants,
missing data were replaced by the last obtained score (pre-
or post-treatment), i.e., last observation carried forward.
”; “Ten participants (4.3%) withdrew from the study af-
ter the first (n=6) or second (n=4) treatment week, the
main reasons being lack of time or motivation and per-
sonal problems unrelated to the treatment. In accordance
with the intention-to-treat principle, all participants were
asked to complete post-treatment and follow-up assess-
ments, regardless of how many treatment modules they
had completed.”
Comment: one participant from each of ICBT, waiting
list, and bibliotherapy did not complete post-treatment
measures; reasons for dropout from treatment seem un-
related to treatment condition although are not provided
based on treatment condition; ITT analyses were used
Selective reporting (reporting bias) Low risk Results for all outcome measures outlined in the trial
registration were reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
73Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Furmark 2009b
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: SCID-IV
N: 115
Age: for internet CBT, M = 34.9 (SD = 8.4); for bibliotherapy, M = 32.5 (SD = 8.5); for
bibliotherapy and discussion group, M = 35 (SD = 10.4); for internet applied relaxation,
M = 36.4 (SD = 9.8)
Sex: 67.8% women
Country of residence: Sweden
Co-use of adjunct therapy: excluded
Co-use of medication: 6.7%
Method of enrollment: responded to study advertisements in community and online
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail support (n 2 9)
Duration: 9 online modules completed over 9 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, social skills, and relapse prevention, with e-mail support
from a therapist for module exercises, and posted on an online discussion forum
Therapists: 6 licensed clinical psychologists, 7 clinical psychology students in final year
of master’s program; students had clinical supervision during the study
Therapist contact: 15 min per week
Face-to-face contact: none
Dropout: n = 0; 0%
(2) Bibliotherapy (n = 29)
Duration: 9 sections of the manual completed over 9 weeks
Treatment protocol*: participants received a sel f-help manual in the mail and completed
it independently
Therapist, face-to-face contact: none
Dropout: n = 0; 0%
(3) Bibliotherapy and discussion group (n=28)
Duration: 9 sections of the manual completed over 9 weeks
Treatment protocol*: participants received a sel f-help manual in the mail and completed
it independently as well as posting weekly on an online discussion forum
Therapist, face-to-face contact: none
Dropout: n = 0; 0%
(4) Internet-based applied relaxation (n = 29)
Duration: 9 online modules completed over 9 weeks
Treatment protocolˆ: participants completed online modules on psychoeducation, re-
laxation, and relapse prevention, with e-mail support from a therapist for module exer-
cises, and posted weekly on an online discussion forum
Therapists: a licensed clinical psychologist, clinical psychology graduate students
Therapist contact: 15 min per week
Face-to-face contact: none
Dropout: n = 0; 0%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) social phobia symptoms: Liebowitz Social Anxiety Scale - Self-Report; Social Phobia
74Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Furmark 2009b (Continued)
Scale; Social Interaction Anxiety Scale; Social Phobia Screening Questionnaire
(2) general anxiety: Beck Anxiety Inventory
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on: Carlbring, P., Furmark, T., Steczkó, J., Ekselius, L., & Andersson,
G. (2006). An open study of internet-based bibliotherapy with minimal therapist contact
via email for social phobia. Clinical Psychology, 10, 30-38.; Andersson, G., Carlbring, P.
, Holmström, A., Sparthan, E., Furmark, T., Nilsson-Ihrfelt, E., et al. (2006). Internet-
based self-help with therapist feedback and in-vivo group exposure for social phobia: A
randomised controlled trial. Journal of Consulting and Clinical Psychology, 74, 677-686.;
Carlbring, P., Gunnarsdóttir, M., Hedensjö, L., Andersson, G., Ekselius, L., & Furmark,
T. (2007). Treatment of social phobia: randomised trial of internet-delivered cognitive-
behavioural therapy with telephone support. British Journal of Psychiatry, 190, 123-128.
; AND Tillfors, M., Carlbring, P., Furmark, T., Lewenhaupt, S., Spak, M., Eriksson, A.,
et al. (2008). Treating university students with social phobia and public speaking fears:
internet delivered self-help with or without live group exposure sessions. Depression and
Anxiety, 25, 708-717.
ˆtreatment based on: st, L.G. (1997). Till mpad avslappning [applied relaxation]. Stock-
holm, Sweden: Repro HSC.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Randomisation was performed by an indepen-
dent third party using an online true random-number
service.”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment
condition nor therapists to the treatment they delivered
(ICBT versus pure bibliotherapy versus waiting list ver-
sus applied relaxation)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk Quote: “...assessors were not masked with regard to the
treatment assignment. However, all assessments were
conducted online with standardised written instructions
and automatic scoring, reducing the risk of reactivity or
experimenter effects.”
Comment: all outcome measures were self-report and
participants were not blind to their own treatment con-
dition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Two participants, one each from the pure bib-
liotherapy and waiting-list groups, withdrew immedi-
ately after randomisation because of personal reasons and
75Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Furmark 2009b (Continued)
one additional participant (ICBT group) did not provide
post-treatment data.”; “For all randomised participants,
missing data were replaced by the last obtained score (pre-
or post-treatment), i.e., last observation carried forward.
”; “In accordance with the intention-to-treat principle,
all participants were asked to complete post-treatment
and follow-up assessments, regardless of how many treat-
ment modules they had completed.”
Comment: there was a very small and similar number of
participants from each treatment condition who did not
complete post-treatment measures; ITT analyses were
used
Selective reporting (reporting bias) Low risk Results for all outcome measures outlined in the trial
registration were reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Hedman 2011
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of d: SCID-IV and MINI
N: 126
Age: for ICBT, M = 35.2 (SD = 11.1); for face-to-face CBT, M = 35.5 (SD = 11.6);
range = 18 to 64 years
Sex: 38% women
Country of residence: Sweden
Psychiatric co-morbidity: 18% another Anxiety Disorder, 15% MDD
Co-use of adjunct therapy: excluded
Co-use of medication: 19.8% SSRIs, 4.8% SNRIs
Method of enrollment: referred to study by health professionals or self-referred to study
clinic
Baseline depression severity: (MADRS-S) ICBT M = 12.7 (SD = 6.5); face-to-face
CBT M = 14.0 (SD = 8.0)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support (n = 64)
Duration: 15 online modules completed over 15 weeks
Treatment protocol*: participants completed online modules on social phobia treatment
themes such as exposure and cognitive restructuring, with email support from a therapist
for module activities
Therapists: 8 clinical psychologists (1 to 4 years experience with Internet CBT)
Therapist contact: M emails by therapists = 17.4; M time spent by therapist per partic-
ipant per week = 5.5 min (SD = 3.6)
Face-to-face contact: none
Dropout: n = 1; 1.6%
76Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Hedman 2011 (Continued)
(2) Face-to-face group CBT (n = 62)
Duration: 15 face-to-face group sessions over 15 weeks
Treatment protocolˆ: participants attended face-to-face group therapy sessions on social
phobia treatment themes including cognitive restructuring and exposure
Therapists: 6 clinical psychologists (2-15 years experience with CBT for social phobia)
; supervised by a licensed psychotherapist experienced in CBT for social phobia
Therapist, face-to-face contact: 15 x 2.5 hr group therapy sessions
Dropout: n = 0; 0%
Outcomes Timepoints for assessment: pre- and post-treatment and 6 month follow-up
Primary outcomes:
(1) social phobia symptoms: Liebowitz Social Anxiety Scale - Clinician; Social Phobia
Scale; Social Interaction Anxiety Scale; Anxiety Sensitivity Index
(2) general anxiety: Beck Anxiety Inventory
(3) clinically important improvement: SCID-IV
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on: Andersson, G., Carlbring, P., Holmström, A., Sparthan, E., Fur-
mark, T., Nilsson-Ihrfelt, E., et al. (2006). Internet-based self-help with therapist feed-
back and in-vivo group exposure for social phobia: A randomised controlled trial. Journal
of Consulting and Clinical Psychology, 74, 677-686.; Carlbring, P., Gunnarsdóttir, M.,
Hedensjö, L., Andersson, G., Ekselius, L., & Furmark, T. (2007). Treatment of social
phobia: randomised trial of internet-delivered cognitive-behavioural therapy with tele-
phone support. British Journal of Psychiatry, 190, 123-128.; AND Tillfors, M., Carl-
bring, P., Furmark, T., Lewenhaupt, S., Spak, M., Eriksson, A., et al. (2008). Treating
university students with social phobia and public speaking fears: internet delivered self-
help with or without live group exposure sessions. Depression and Anxiety, 25, 708-717.
ˆtreatment based on: Heimberg, R.G., & Becke r, R.E. (2002). Cognitive-behavioral group
therapy for social phobia. Basic mechanisms and clinical strategies. New York: Guilford
Press.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “A true random number service (http://www.ran-
dom.org) was used to ensure randomizations... Partici-
pants were allocated to CBGT or ICBT in a 1:1 ratio us-
ing simple randomizations with no restrictions or match-
ing.”
Comment: adequate randomisation method
Allocation concealment (selection bias) Low risk Quote: “The randomizations procedure involved two ex-
ternal persons not involved in the study; one provided
randomizations data and the other monitored that no
manipulation of treatment allocation was performed by
the research group.”; “The random sequence was gener-
ated after inclusion of participants to ensure that assign-
77Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Hedman 2011 (Continued)
ment of intervention was concealed from assessing psy-
chiatrists and researchers of the study.”
Comment: adequate allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (in-
ternet-based CBT versus face-to-face CBT)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “To ensure the integrity of the blinding proce-
dure, participants were instructed not to mention which
treatment they had received during the post-treatment
and follow-up interviews. After completing the inter-
views, the assessing psychiatrists guessed allocation status
for each participant.”; “In four instances blinding was
broken. On two occasions participants accidentally men-
tioned their treatment allocation status to the assessor,
and in another two occasions it was deemed necessary to
break the blinding because of the need to assess increased
depressive symptoms during treatment... There was no
significant association between assessors’ guess and actual
treatment allocation (χ2= 0.27, df = 1, p= .61), indicat-
ing successful blinding.”
Comment: interviewers were blind to treatment condi-
tion
Incomplete outcome data (attrition bias)
All outcomes
Low risk A similar number of dropouts from both treatment con-
ditions was reported (13 for ICBT; 12 for CBGT); ITT
analyses were used
Selective reporting (reporting bias) Unclear risk It is unclear if several outcomes in the trial registration
(described as WQ, TIC-P, SSP) were reported in the
manuscript; all other outcome measures outlined in the
trial registration were reported in the mansucript
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Johnston 2011
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder with or without agoraphobia (20.6%), Social Pho-
bia (34.4%), generalized anxiety disorder (45%)
Method of diagnosis: MINI
78Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Johnston 2011 (Continued)
N: 139
Age: M = 41.62 (SD = 12.83); range = 19 to 79 years
Sex: 58.8% women
Country of residence: Australia
Psychiatric co-morbidity: 29% another Anxiety Disorder only, 9.2% another Affective
Disorder only, 32.1% another Anxiety and Affective disorder
Co-use of adjunct therapy: excluded
Co-use of medication: 29%
Method of enrollment: responded to online study advertisements
Baseline depression severity: (PHQ-9) ICBT with clinician M = 11.63 (SD = 5.96);
WLC M = 11.71 (SD = 6.31)
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail and phone support from a clinician (n = 47)
Duration: 8 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on disorder-specific psy-
choeducation, cognitive restructuring, core beliefs, exposure, assertiveness communica-
tion and interpersonal boundaries, and relapse prevention, with email and phone sup-
port from a therapist for module activities
Therapists: 1 clinical psychologist with specialist post-graduate training in clinical psy-
chology and 2.5 years postgraduate experience
Therapist contact: M emails by therapist = 8.83 (SD = 3.19); M phone calls by therapist
= 7.54 (SD = 2.43); M time spent by therapist per participant overall = 69.09 min (SD
= 32.29)
Face-to-face contact: none
Dropout: n = 5; 10.6%
(2) Internet-based CBT with e-mail and phone support from a coach (n = 46)
Duration: 8 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on disorder-specific psy-
choeducation, cognitive restructuring, core beliefs, exposure, assertiveness communica-
tion and interpersonal boundaries, and relapse prevention, with email and phone sup-
port from a coach for module activities (no clinical support)
Therapists: 1 clinical psychologist with specialist post-graduate training in clinical psy-
chology and 2.5 years postgraduate experience
Therapist contact: M e-mails by coach = 8.88 (SD = 4.38); M phone calls by coach =
7.56 (SD = 1.19); M time spent by coach per participant overall = 69.09 min (SD = 30.
75)
Face-to-face contact: none
Dropout: n = 4; 8.7%
(2) Waiting list control (n = 46)
Duration: 10 weeks
Therapist, face-to-face contact: none
Dropout: n = 5; 10.9%
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month follow-up
Primary outcomes:
(1) disorder-specific symptoms: Penn State Worry Questionnaire; Social Phobia Scale/
Social Interaction Anxiety Scale - Short Form; Panic Disorder Severity Scale - Self-Rating
(2) general anxiety symptoms: GAD-7, Depression Anxiety Stress Scales - 21
79Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Johnston 2011 (Continued)
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction: A 7-item questionnaire based on the Credibility/Expectancy
Questionnaire
Notes *treatment based on: Titov , N., Andrews, G., Johnston, L., Robinson, E., Spence, J.
(2010). Transdiagnostic Internet treatment for anxiety disorders: A randomised con-
trolled trial. Behaviour Research and Therapy, 48, 890-9.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “...were randomised via a true randomizations
process (www.random.org), generated by an independent
person, to either...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Low risk Quote: “The allocation sequence preceded pre-treatment
diagnostic interviews and was concealed from LJ and JS
[pre-treatment interviewers].”
Comment: unclear how allocation concealment occurred
but it seems to have taken place
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list control)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcomes were self-report outcome measures, partic-
ipants were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “All post-treatment and 3-month follow-up anal-
yses involved an intention-to-treat (ITT) design and
missing data was addressed by carrying forward the
first available data (baseline-observation-carried-forward;
BOCF).”
Comment: ITT analyses were used
Selective reporting (reporting bias) Unclear risk One measure that appears in the trial protocol (Agora-
phobic Cognitions Questionnaire) is not reported; all
other outcomes in the trial registration are reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
80Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Kiropoulos 2008
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder (41.9%) or Panic Disorder with Agoraphobia (58.
1%)
Method of diagnosis: ADIS-IV
N: 86
Age: M = 38.96 (SD = 11.13); range = 20 to 64 years
Sex: 72.1% women
Country of residence: Australia
Psychiatric co-morbidity: 16% Social Phobia, 17% GAD, 10% Specific Phobia, 3%
PTSD, 10% MDD, 5% Dysthymia, 1% Alcohol Abuse, 8% Hypochondriasis
Co-use of adjunct therapy: excluded
Co-use of medication: 47.7%
Method of enrollment: responded to media advertisements in community and online
Baseline depression severity: (DASS depression, log transformed) ICBT M = 2.72 (SD
= 1.80); face-to-face CBT M = 2.98 (SD = 1.61)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support (n = 46)
Duration: 6 online modules (+ 2 optional modules) completed over 6 weeks
Treatment protocol*: participants completed online modules on deep breathing, cog-
nitive restructuring, and exposure, with e-mail support from a therapist for module ac-
tivities (optional modules on stress and benzodiazepines)
Therapists: 9 registered and 1 probationary psychologist; all trained in CBT
Therapist contact: M e-mails by therapist = 18.24 (SD = 9.82); M e-mails by participant
= 10.64 (SD = 8.21); M time spent by therapist per participant = 352 min (SD = 240)
Face-to-face contact: none
Dropout: n = 5; 10.9%
(2) Face-to-face individual CBT (n = 40)
Duration: 12 face-to-face group sessions over 12 weeks
Treatment protocolˆ: participants attended face-to-face group therapy sessions on social
phobia treatment themes including cognitive restructuring and exposure
Therapists: registered psychologists
Therapist, face-to-face contact: 12 x 60 to 90 min sessions; M = 568 min (SD = 255.
12)
Dropout: n = 2; 5%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) panic and agoraphobia symptoms: Panic Disorder Severity Scale; Body Vigilance
Scale; Agoraphobic Cognitions Questionnaire; Anxiety Sensitivity Profile
(2) general anxiety: DASS Stress and Anxiety subscales
(3) clinically important improvement: ADIS-IV
Secondary outcomes:
(1) quality of life: WHO Quality of Life - BREF subscales
(2) treatment satisfaction (at post-treatment): Treatment Satisfaction Questionnaire -
Modified
81Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Kiropoulos 2008 (Continued)
Notes *on-line treatment program: Panic Online
ˆtreatment based on: Barlow, D.H., & Craske, M.G. (2000). Mastery of your anxiety and
panic: MAP-3. New York: Graywind Publications.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “...they were randomly allocated using a random
numbers table...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus face-to-face CBT)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “All assessors were blind to treatment allocation
of eligible participants into the study.”
Comment: interviewers were blind to treatment condi-
tion
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “The attrition rates were 10.9% (5/46) and 5%
(2/40) for the PO and face-to-face treatment conditions,
respectively. A Fisher’s exact test revealed no difference in
attrition rates between the two treatment conditions, χ2
(1, N = 86) = .44, P> .05. Reasons for non-completion
of either treatment included participants not being con-
tactable, changing their mind about taking part in the
study, because they could no longer commit to the 12-
week treatment program or because they no longer had
access to the Internet.”; “Data analysis involved inten-
tion-to-treat analyses.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
82Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Paxling 2011
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Generalized Anxiety Disorder
Method of diagnosis: SCID-IV
N: 89
Age: M = 39.3 (SD = 10.8); range = 18 to 66
Sex: 79.8% women
Country of residence: Sweden
Psychiatric co-morbidity: included; 22.5% MDD
Co-use of adjunct therapy: excluded
Co-use of medication: 37.1%
Method of enrollment: responded to media advertisements in the community and
online
Baseline depression severity: (BDI-II) ICBT M = 17.66 (SD = 9.81); WLC M = 16.
93 (SD = 7.91)
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail support (n = 44)
Duration: 8 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on psychoeducation, ap-
plied relaxation, worry time, cognitive restructuring, problem solving, sleep manage-
ment, exposure, and relapse prevention with email support from a therapist for module
activities
Therapists: psychologists in their final year of training; all trained for 1 week in CBT
protocol; supervision provided by experienced clinician
Therapist contact: M time spent by therapist per participant = 97 min (SD = 52)
Face-to-face contact: none
Dropout: n = 6; 13.6%
(2) Waiting list control (n = 45)
Duration: 8 weeks
Therapist, face-to-face contact: none
Dropout: n = 1; 2.2%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) generalized anxiety symptoms: Penn State Worry Questionnaire, Generalized Anxiety
Disorder Questionnaire - IV
(2) general anxiety symptoms: State Trait Anxiety Inventory, Beck Anxiety Inventory
Secondary outcomes:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on parts of: Ost, L.G. (1987) Applied relaxation: Description of a
coping technique and review of controlled studies. Behaviour Research and Therapy, 25,
379-409.; Borkovec, T.D., & Costello, E. (1993). Efficacy of applied relaxation and
cognitive-behavioral therapy in the treatment of generalized anxiety disorder. Journal of
Consulting and Clinical Psychology, 61, 611-9.; Borkovec,T.D., Wilkinson, L., Folensbee,
R., & Lerman, C. (1983). Stimulus control applications to treatment of worry. Behaviour
Research and Therapy, 21, 247-51.; Borkovec, T.D., & Sharpless, B. (2004). Generalized
anxiety disorder: Bringing cognitive-behavioral therapy into the valued present. In S. C.
83Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Paxling 2011 (Continued)
Hayes, V.M. Follette, & M.M. Linehan (Eds.), Mindfulness and acceptance (pp. 209-42)
. New York, NY: Guilford Press.; Zetterqvist, K., Maanmies, J., Strom, L., & Andersson,
G. (2003). Randomized controlled trial of Internet-based stress management. Cognitive
Behaviour Therapy, 3, 151-60.; Sanderson, W. C., & Rygh, J.L. (2004). Treating general-
ized anxiety disorder: Evidence-based strategies, tools, and techniques. New York, NY: Guil-
ford Press.; Strom, L., Pettersson, R., & Andersson, G. (2004). Internet-based treatment
for insomnia: A controlled evaluation. Journal of Consulting and Clinical Psychology, 72,
113-20..
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The 89 participants were randomised...by an in-
dependent person not involved in the study. A computer-
generated random list was obtained via www.random.
org, which utilizes atmospheric noise to create random
sequences of numbers.”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list control)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “The interviewers were blinded concerning par-
ticipant status (e.g. treatment or control) since the post-
treatment interviewers did not have access to informa-
tion about the participants and started each interview by
asking the participants not to say whether they were in
the treatment or control condition.”
Comment: interviewers were blind to treatment condi-
tion
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Posttreatment measures were obtained from 38
or 44 randomised participants in the treatment group
(86%) and 44 of 45 in the control group (98%).”; “In
order to account for dropouts without assuming that the
first measurement was stable (i.e., the last observation car-
ried forward assumption), we used a mixed-effects mod-
els approach...Mixed-effect models are able to accommo-
date missing data and integrate time-varying factors.”
Comment: very little data was incomplete; an ITT ap-
proach was used
84Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Paxling 2011 (Continued)
Selective reporting (reporting bias) Low risk Results were reported for all outcome measures outlined
in the trial registration
Other bias Unclear risk Group comparisons at baseline not reported
Richards 2006
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder (21.9%) or Panic Disorder with Agoraphobia (78.
1%)
Method of diagnosis: ADIS-IV
N: 23
Age: M = 36.59 (SD = 9.9); range = 18 to 70
Sex: 68.8% women
Country of residence: Australia
Psychiatric co-morbidity: 22% Social Phobia, 13% GAD, 9% Specific Phobia, 6%
PTSD, 9% MDD, 6% Hypochondriasis, 3% Somatization Disorder
Co-use of adjunct therapy: excluded
Co-use of medication: 15.6% antidepressants, 12.5% benzodiazepines, 9.4% both an-
tidepressants and benzodiazepines
Method of enrollment: responded to online study advertisements
Baseline depression severity: (DASS depression) ICBT M = 21.25 (SD = 12.3); control
M = 6.79 (SD = 6.4)
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail support (n = 12)
Duration: 6 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on relaxation strategies,
cognitive restructuring, and exposure, with e-mail support from a therapist for module
activities
Therapists: 1 clinical psychologist, 3 doctoral clinical psychology students; all experi-
enced in CBT
Therapist contact: M emails by therapist = 18 (SD = 6.5); M e-mails by participant =
15.3 (SD = 12.8); M time spent by therapist per participant = 376.30 min (SD = 156.8)
Face-to-face contact: none
Dropout: n = 2; 16.7%
(2) Internet-based CBT and stress management with email support (n = 11)
Duration: 12 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on relaxation strategies,
cognitive restructuring, and exposure, as well as several stress management modules, with
email support from a therapist for module activities
Therapists: 1 clinical psychologist, 3 doctoral clinical psychology students; all experi-
enced in CBT
Therapist contact: M e-mails by therapist = 12.9 (SD = 3.8); M e-mails by participant
= 11.6 (SD = 13.3); M time spent by therapist per participant = 309.30 min (SD = 111.
3)
Face-to-face contact: none
85Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Richards 2006 (Continued)
Dropout: n = 1; 9%
(3) Internet-based information control (n = 9)
Duration: 8 weeks
Treatment protocol: participants read online non-CBT panic resources and provided
weekly status reports to a therapist via e-mail
Therapists: 1 doctoral clinical psychology student
Therapist contact: limited to weekly status update e-mails
Face-to-face contact: none
Dropout: n = 2; 22.2%
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month follow-up
Primary outcomes:
(1) panic and agoraphobia symptoms: Panic Disorder Severity Scale; Body Vigilance
Scale; Agoraphobic Cognitions Questionnaire; Anxiety Sensitivity Profile
(2) general anxiety: DASS Stress and Anxiety subscales
(3) clinically important improvement: ADIS-IV
Secondary outcome:
(1) quality of life: WHO Quality of Life subscales
Notes *on-line treatment program: Panic Online
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Unclear risk ABC block randomisation was used (information pro-
vided by authors via personal correspondence); unclear
if sequential design or a more rigorous randomisation
method was used
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based without stress management versus Internet-
based with stress management versus Internet-based in-
formation control)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
High risk Quote: “The two assessors were the second author of
the present study and a probationary registered psychol-
ogist/PhD candidate. The second author was not blind
to treatment allocation, although the other assessor was.
.. To evaluate reliability of assessment, a third assessor
(the 3rd author), who was blind to the treatment allo-
cation, reviewed 15% of the clinical interviews...”; “The
86Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Richards 2006 (Continued)
two clinicians who conducted the assessments did not
provide any treatment.”
Comment: not all interviewers were blind to treatment
condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “The attrition rate for PO1 was 16.7% (2/12),
9% (1/11) in PO2 and 22% (2/9) in IC. Reasons given
for discontinuing treatment in the PO1 condition were a
lack of motivation or an episode of major depression. The
PO2 person discontinued because of a wish to commence
selective serotonin reuptake inhibitor medication halfway
through the study. Of the two IC participants, no reason
for discontinuing was given.”; “Data analysis involved
intention-to-treat analyses.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias High risk At baseline, treatment groups scored significantly higher
on the DASS depression subscale than control partici-
pants
Robinson 2010
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Generalized Anxiety Disorder
Method of diagnosis: MINI
N: 101
Age: M = 46.96 (SD = 12.70); range = 18 to 80
Sex: 68.3% women
Country of residence: Australia
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: included
Method of enrollment: responded to online study advertisements
Baseline depression severity: (PHQ-9) ICBT with clinician M = 11.40 (SD = 4.63);
WLC M = 12.5 (SD = 4.73)
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail and phone support from a clinician (n = 51)
Duration: 6 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on cognitive restructuring,
challenging core beliefs, and exposure, with e-mail and phone support from a therapist
for module activities
Therapists: 1 registered clinical psychologist
Therapist contact: M e-mails or calls by therapist = 33.2 (SD = 4); M time spent by
87Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Robinson 2010 (Continued)
therapist per participant = 80.8 min (SD = 22.6)
Face-to-face contact: none
Dropout: n = 5; 9.8%
(2) Internet-based CBT with e-mail and phone support from a technician (n = 50)
Duration: 6 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on cognitive restructur-
ing, challenging core beliefs, and exposure, with e-mail and phone encouragement and
instructions from a technician
Therapists: no therapist; clinic manager acted as technician
Therapist contact: none; M e-mails or calls by technician = 31.1 (SD =3.1); M time
spent by clinician per participant = 74.5 min (SD = 7.8)
Dropout: n = 5; 10%
Face-to-Face Contact: none
(3) Waiting list control (n = 49)
Duration: 11 weeks
Therapist, face-to-face contact: none
Dropout: n = 2; 4.1%
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month follow-up
Primary outcomes:
(1) generalized anxiety symptoms: Penn State Worry Questionnaire
(2) clinically important improvement: GAD-7
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction (at post-treatment): A 7-item questionnaire based on the Cred-
ibility/Expectancy Questionnaire
Notes *on-line treatment program: Worry Program - Titov N, Andrews G, Robinson E,
Schwencke G, Johnston L, et al. (2009). Clinician-assisted Internet-based treatment is
effective for generalized anxiety disorder: a randomised controlled trial. Australian and
New Zealand Journal of Psychiatry, 43, 905-912.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The 150 people accepted into the program were
randomised by NT [2nd author] via a true randomisation
process (www.random.org)...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk Quote: “Allocation preceded the diagnostic telephone
call.”
Comment: insufficient detail about method of allocation
concealment provided to determine risk
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT clinician versus Internet-based CBT
88Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Robinson 2010 (Continued)
technician versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Post-treatment data was collected from 45
(90%) TA, 46 (98%) CA group members, and from 47/
48 (98%) of control group participants.”; “In accordance
with the ITT and LOCF paradigm...”
Comment: a small and similar number of participants
from both treatment conditions did not complete post-
treatment measures; ITT analyses were used
Selective reporting (reporting bias) Low risk Results for all outcome measures outlined in the trial
registration were reported
Other bias Unclear risk There were significant differences in marital status and
age between the control and treatment groups at baseline
Silfvernagel 2012
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Anxiety Disorder
Method of diagnosis: SCID-IV
N: 57
Age: M = 32.4 (SD = 6.9); range = 20 to 45
Sex: 65% women
Country of residence: Sweden
Psychiatric co-morbidity: 32%
Co-use of adjunct therapy: excluded
Co-use of medication: included if stable dose for past 3 months
Method of enrollment: responded to media advertisements in community and online
Baseline depression severity: (MADRS-S) ICBT M = 15.81 (SD = 7.35); WLC M =
17.93 (SD = 8.38)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support from a clinician (n = 29)
Duration: 6 to 8 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, and exposure, with e-mail support from a therapist for module ac-
tivities
Therapists: 3 clinical psychology master’s students; completed clinical training; super-
vised by experienced clinical psychologists
Therapist contact: 15 min/week; approximately 19 e-mail exchanges between therapist
and participant during treatment
Face-to-face contact: none
89Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Silfvernagel 2012 (Continued)
Dropout: n = 10; 34.5%
(2) Waiting list control (n = 28)
Duration: 10 weeks
Therapist, face-to-face contact: none
Dropout: n = 2; 7.1%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) panic symptoms: Panic Disorder Severity Scale
(2) general anxiety: Beck Anxiety Inventory; Clinical Outcomes in Routine Evaluation
- Outcome Measure
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on Internet-based programs described in: Andersson, G., Carlbring, P.
, Holmström, A., Sparthan, E., Furmark, T., Nilsson-Ihrfelt, E., et al. (2006). Internet-
based self-help with therapist feedback and invivo group exposure for social phobia: a
randomised controlled trial. Journal of Consulting and Clinical Psychology, 74, 677-686.
; Carlbring, P., Westling, B.E., Ljungstrand, P., Ekselius, L, & Andersson, G. (2001).
Treatment of panic disorder via the Internet: A randomised trial of a self-help program.
Behavior Therapy, 32, 751-764.; AND Vernmark, K., Lenndin, J., Bjärehed, J., Carlsson,
M., Karlsson, J., Öberg, J., et al. (2010). Internet administered guided self-help versus
individualized e-mail therapy: a randomised trial of two versions of CBT for major
depression. Behaviour Research and Therapy, 48, 368-376.; Carlbring, P., Maurin, L.,
Törngren, C., Linna, E., Eriksson, T., Sparthan, E., et al. (2011). Individually-tailored,
Internet-based treatment for anxiety disorders: A randomised controlled trial. Behaviour
Research and Therapy, 49, 18-24.; Andersson, G., Estling, F., Jakobsson, E., Cuijpers, P.
, & Carlbring, P. (2011). Can the patient decide which modules to endorse? An open
trial of tailored internet treatment of anxiety disorders. Cognitive Behavior Therapy, 40,
57-64.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The participants were divided into two groups
so that the two predetermined age groups 18-30 years
(young adults) and 31-45 years(adults) were equally rep-
resented in each condition. The blocked randomizations
process was conducted through an online true random
number-generation service (random.org) independent of
the investigators and therapists.”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk Quote: “The blocked randomizations process was con-
ducted...independent of the investigators and therapists.
”
Comment: no more specific mention of allocation con-
cealment present
90Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Silfvernagel 2012 (Continued)
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT clinician versus Internet-based CBT
technician versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
Low risk Quote: “At posttreatment participants were instructed
via email to complete the follow-up questionnaires and to
participate in a semistructured telephone interview car-
ried out by a blinded assessor who had no earlier contact
with the participants.”
Comment: assessors were blind to treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “A mixed-models approach with an unstructured
covariance structure was endorsed as a way to handle
missing data at posttreatment.”
Comment: ITT analysis was used
Selective reporting (reporting bias) Low risk Results for all outcome measures outlined in the trial
registration were reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Spence 2011
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Post-traumatic Stress Disorder
Method of Diagnosis: MINI
N: 44
Age: M = 42.6 (SD = 13.1); range = 21 to 68
Sex: 81% women
Country of residence: Australia
Psychiatric co-morbidity: 62% MDD, 33% Social Phobia, 31% PD with or without
Agoraphobia, 26% GAD, 17% OCD
Co-use of adjunct therapy: excluded
Co-use of medication: 60%
Method of enrollment: responded to media advertisements in community and online
Baseline depression severity: (PHQ-9) ICBT M = 15.61 (SD = 7.35); WLC CBT M
= 15.05 (SD = 4.9)
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail and phone support from a clinician (n = 23)
Duration: 7 online modules completed over 8 weeks
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Spence 2011 (Continued)
Treatment protocol*: participants completed online modules on psychoeducation, de-
arousal strategies, cognitive restructuring, graded exposure, and relapse prevention with
e-mail and phone support from a therapist for module activities
Therapists: 1 clinical psychologist
Therapist contact: M e-mails by therapist = 5.39 (SD = 3.54); M phone calls by therapist
= 7.87 (SD = 2.56); M time spent by therapist per participant = 103.91 min (SD = 96.
53)
Face-to-face contact: none
Dropout: n = 2; 8.7%
(2) Waiting list control (n = 21)
Duration: 8 weeks
Therapist, face-to-face contact: none
Dropout: n = 3; 14.3%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) post-traumatic stress symptoms: Post-traumatic Stress Disorder Checklist - Civilian
(2) general anxiety symptoms: GAD-7
(3) clinically important improvement: Post-traumatic Stress Disorder Checklist - Civilian
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction (at post-treatment): a 7-item questionnaire based on the Cred-
ibility/Expectancy Questionnaire
Notes *treatment is based on: Andrews, G. (2003). The treatment of anxiety disorders: Clinician
guides and patient manuals. Cambridge: Cambridge University Press.; Perini, S., Titov,
N., & Andrews, G. (2008). The climate sadness program of Internet-based treatment
for depression: A pilot study. Journal of Applied Psychology, 4, 18-24.; Robinson, E.,
Titov, N., Andrews, G., McIntyre, K., Schwencke, G., & Solley, K. (2010). Internet
treatment for generalized anxiety disorder: A randomised controlled trial comparing
clinician vs. technician assistance. PLoS ONE, 5, e10942.; Wims, E., Titov, N., Andrews,
G., & Choi, I. (2010). Clinician-assisted Internet-based treatment is effective for panic:
A randomised controlled trial. Australian and New Zealand Journal of Psychiatry, 44,
599-607.; Titov, N., Andrews, G., Johnston, L., Robinson, E., & Spence, J. (2010).
Transdiagnostic Internet treatment for anxiety disorders: A randomised controlled trial.
Behaviour Research and Therapy, 48, 890-9.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “...randomised via a true randomizations process
(www.random.org), generated by an independent per-
son...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
92Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Spence 2011 (Continued)
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus online discussion group)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
High risk Quote: “The assessments were conducted by JS and KS,
who were not blind to the participants’ condition.”
Comment: interviewers were not blind to treatment con-
dition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “All post-treatment analyses involved a conserva-
tive intention-to-treat (ITT) design where missing data
was addressed by carrying forward the first available
data (i.e. Baseline-observation-carried-forward model).”;
“Five participants did not complete the program: one
for unknown reasons; three because of competing time
commitments; and one because of a relapse of depres-
sive symptoms. There were no formal withdrawals dur-
ing the treatment program.”; “Post-treatment data were
collected from 21/23 (91%) Tre atment and 18/21 (86%)
Control group participants.”
Comment: very little data were missing; ITT analyses
were used
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Tillfors 2008
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of Diagnosis: SCID-IV
N: 38
Age: for ICBT, M = 32.3 (SD = 9.7); for ICBT + exposure, M = 30.4 (SD = 6.3); range
= 19 to 53
Sex: 78.9% women
Country of residence: Sweden
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: included
Method of enrollment: responded to media advertisements in community and online
Baseline depression severity: (MADRS-S) ICBT M = 11.3 (SD = 7.3); ICBT + exposure
93Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Tillfors 2008 (Continued)
M = 12.4 (SD = 6.4)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support (n = 19)
Duration: 9 online modules completed in 9 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, social skills, and relapse prevention, with e-mail support
from a therapist for module activities, and participated in an online discussion forum
Therapists: 2 licensed clinical psychologists (research or clinical experience, or both, in
social phobia), 2 clinical psychology students in final year of master’s program; supervised
by licensed CBT psychotherapist
Therapist contact: 35 min per week
Face-to-face contact: none
Dropout: n = 1; 5.3%
(2) Internet-based CBT with e-mail support and face-to-face exposure (n = 19)
Duration: 9 online modules and 5 face-to-face group exposure sessions over 9 weeks
Treatment protocol*ˆ: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, social skills, and relapse prevention, with e-mail support
from a therapist for module activities, and participated in an online discussion forum as
well as attending 5 face-to-face group therapy sessions
Therapists: 2 licensed clinical psychologists, 2 psychologist candidates
Therapist contact: 35 min per week by e-mail and 5 x 2.25 hr exposure sessions
Face-to-face contact: 5 x 2.25 hr exposure sessions
Dropout: n = 1; 5.3%
Outcomes Timepoints for assessment: pre- and post-treatment and 1 year follow-up
Primary outcomes:
(1) social phobia symptoms: Liebowitz Social Anxiety Scale - Self-Report; Social Phobia
Scale; Social Interaction Anxiety Scale; Social Phobia Screening Questionnaire
(2) general anxiety: Beck Anxiety Inventory
Secondary outcomes:
(1) quality of life: Quality of Life Inventory
(2) treatment satisfaction (at post-treatment): participants reported on the quality of
the overall treatment, its components, and its tempo as well as perceptions of their own
improvement
Notes *treatment based on: Rodebaugh, T.L., Holaway, R.M., & Heimberg, R.G. (2004). The
treatment of social anxiety disorder. Clinical Psychology Review, 24, 883-908. AND Clark,
D.M., & Wells, A. (1995). A cognitive model of social phobia. In R.G. Heimberg, M.R.
Liebowitz, D.A. Hope, & F.R. Schneier (Eds.), Social phobia: Diagnosis, assessment and
treatment (pp. 69-93). New York, NY: Guilford Press.
êxposure sessions based on Heimberg, R.G., & Becker, R.E. (2002). Cognitive-behavioral
group therapy for social phobia: basic mechanisms and clinical strategies. New York, NY:
Guilford Press.
Risk of bias
Bias Authors’ judgement Support for judgement
94Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Tillfors 2008 (Continued)
Random sequence generation (selection
bias)
Unclear risk Quote: “...38 were eventually randomised into either...”
Comment: no information on method of randomisation
provided
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus Internet-based CBT plus live
exposure)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “At post-test, all participants except one answered
their computerized questionnaires. The pre-test score of
that participant was carried forward to the post-test as-
sessment point (e.g., last observation carried forward).”
Comment: though there were a number of participants
who did not complete all treatment modules (n = 10
ICBT + Exp; n = 9 ICBT) the numbers were relatively
equal across conditions and participants still provided
post-treatment data; ITT analyses used
Selective reporting (reporting bias) Unclear risk No study protocol or trial registration available
Other bias Unclear risk Group comparisons at baseline not reported
Titov 2008a
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: CIDI
N: 105
Age: M = 38.13 (SD = 12.24); range = 18 to 72
Sex: 59% women
Country of residence: Australia
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: 29%
Method of enrollment: responded to media advertisements in community
Baseline depression severity: (PHQ-9) ICBT M = 8.0 (SD = 4.95); WLC M = 8.02
(SD = 5.32)
95Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Titov 2008a (Continued)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support (n = 50)
Duration: 6 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, and relapse prevention, with email support from a thera-
pist for module activities
Therapists: 1 clinical psychologist
Therapist contact: M time spent by therapist per participant = 125 min (SD = 25)
Face-to-face contact: none
Dropout: n = 6; 12%
(2) Waiting list control (n = 55)
Duration: 10 weeks
Therapist, face-to-face contact: none
Dropout: n = 6; 10.9%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcome:
(1) social phobia symptoms: Social Interaction Anxiety Scale; Social Phobia Scale
Secondary outcomes:
(1) quality of life: WHO Disability Assessment Schedule
(2) treatment satisfaction (at post-treatment): a 7-item questionnaire based on the Cred-
ibility/Expectancy Questionnaire
Notes *online treatment program: Shyness Programme (based on CLIMATEGP program writ-
ten by Drobny and Einstein)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “...were randomised via a true randomizations
process (www.random.org) to either...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Eleven members of the treatment group (22%)
failed to complete all six lessons within the required time
frame. Of these non-completers, two formally withdrew
citing lack of time and motivation after experiencing a
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Titov 2008a (Continued)
death or illness in the family; one reported that the expo-
sure exercises were too anxiety provoking; one reported
he did not find the programme helpful; one reported tak-
ing an overseas holiday; three cited a change in work or
study commitments affecting their ability to complete
the programme requirements; one reported complica-
tions due to her pregnancy and two did not give a rea-
son.”; “Post-treatment data were collected from 93 par-
ticipants (44/50 treatment group participants and 49/49
waitlist control group participants). In accordance with
the intention-to-treat paradigm, the pre-treatment scores
of these six participants who did not complete the post-
treatment questionnaires were replicated as their post-
treatment scores.”
Comment: there were a number of dropouts from the
treatment group, however some of these dropouts still
provided post-treatment data; ITT analyses were used
Selective reporting (reporting bias) Unclear risk Results for one outcome measure outlined in the trial
registry (GAD-7) are not reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Titov 2008b
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: CIDI
N: 88
Age: M = 36.79 (SD = 10.93); range = 20 to 61
Sex: 62.96% women
Country of residence: Australia
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: 25.9%
Method of enrollment: responded to media advertisements in community
Baseline depression severity: (PHQ-9) ICBT M = 8.44 (SD = 5.7); WLC M = 7.35
(SD = 4.19)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with email support (n = 43)
Duration: 6 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, and relapse prevention, with email support from a thera-
pist for module activities
Therapists: 1 clinical psychologist
Therapist contact: M time spent by therapist per participant = 126.76 min (SD = 30.
97Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Titov 2008b (Continued)
89)
Face-to-face contact: none
Dropout: n = 5; 11.6%
(2) Waiting list control (n = 45)
Duration: 10 weeks
Therapist, face-to-face contact: none
Dropout: n = 5; 11.1%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcome:
(1) social phobia symptoms: Social Interaction Anxiety Scale; Social Phobia Scale
Secondary outcomes:
(1) quality of life: WHO Disability Assessment Schedule
(2) treatment satisfaction (at post-treatment): a 7-item questionnaire based on the Cred-
ibility/Expectancy Questionnaire
Notes *online treatment program: Shyness Programme (based on CLIMATEGP program writ-
ten by Drobny and Einstein)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The 88 people accepted into the programme
were randomised via a true randomizations process
(www.random.org) to either...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Eight members of the treatment group (20%)
failed to complete all six lessons within the require time
frame. Of these eight non-completers, one said the pro-
gramme was not helpful, and one reported they had im-
proved sufficiently.”; “...post-treatment data were col-
lected from 78 participants (38/41 treatment group par-
ticipants and 40/40 waitlist control group participants).
In accordance with the intention-to-treat paradigm, the
pre-treatment scores...were replicated as their post-treat-
ment scores.”
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Titov 2008b (Continued)
Comment: a small and similar number of participants
from both treatment conditions did not complete post-
treatment measures; ITT analyses were used
Selective reporting (reporting bias) Unclear risk Results for one outcome measure outlined in the trial
registry (GAD-7) are not reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Titov 2008c
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of Diagnosis: MINI
N: 98
Age: M = 37.97 (SD = 11.29); range = 18 to 64
Sex: 61.05% women
Country of residence: Australia
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: 25.9%
Method of enrollment: responded to media advertisements in community
Baseline depression severity: (PHQ-9) ICBT M = 7.65 (SD = 4.72); Unguided ICBT
M = 7.0 (SD = 5.27); WLC M = 7.03 (SD = 5.28)
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail support (n = 32)
Duration: 6 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, and relapse prevention, with email support from a thera-
pist for module activities
Therapists: 2 clinical psychologists
Therapist contact: M time spent by therapist per participant = 168 minutes (SD = 40)
Face-to-face contact: none
Dropout: n = 2; 6.3%
(2) Internet-based CBT (n = 31)
Duration: 6 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, and relapse prevention independently
Therapist, face-to-face contact: none
Dropout: n = 4; 12.9%
(3) Waiting list control (n = 35)
Duration: 10 weeks
Therapist, face-to-face contact: none
Dropout: n = 1; 2.9%
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Titov 2008c (Continued)
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcome:
(1) social phobia symptoms: Social Interaction Anxiety Scale; Social Phobia Scale
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction: a 7-item questionnaire based on the Credibility/Expectancy
Questionnaire
Notes *online treatment program: Shyness Programme (based on CLIMATEGP program writ-
ten by Drobny and Einstein)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The 98 people accepted into the programme
were randomised via a true randomizations process
(www.random.org) to either...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (clin-
ician-assisted computerized CBT versus non-clinician-
assisted computerized CBT versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Post-treatment data were collected from 91 par-
ticipants (30/31 CaCCBT group participants, 27/30
CCBT group participants, and from 34/34 control group
participants). In accordance with the ITT paradigm, the
pre-treatment scores of the four participants who did not
complete their post-treatment questionnaires were repli-
cated as their post-treatment scores.”
Comment: a small and similar number of participants
from both treatment conditions did not complete post-
treatment measures; ITT analyses were used
Selective reporting (reporting bias) Unclear risk Results for one outcome measures (GAD-7) outlined in
the trial registration were not reported; all other outcome
measures outlined in the trial registration were reported
100Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Titov 2008c (Continued)
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Titov 2009
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Generalized Anxiety Disorder
Method of Diagnosis: MINI
N: 48
Age: M = 44 (SD = 12.98)
Sex: 76% women
Country of residence: Australia
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: 29%
Method of enrollment: responded to online study advertisements
Baseline depression severity: (PHQ-9) ICBT M = 11.58 (SD = 5.24); WLC M = 13.
0 (SD = 6.19)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail and phone support (n = 25)
Duration: 6 online modules completed over 9 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, core beliefs, and relapse prevention, with e-mail and phone
support from a therapist for module activities
Therapists: 1 clinical psychologist
Therapist contact: M e-mails by therapist = 23.7; M telephone calls by therapist = 4.1;
M instant messages by therapist = 5.5; M time spent by therapist per participant = 130
min
Face-to-face contact: none
Dropout: n = 5; 20%
(2) Waiting list control (n = 23)
Duration: 9 weeks
Therapist, face-to-face contact: none
Dropout: n = 4; 17.4%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) general anxiety symptoms: Penn State Worry Questionnaire
(2) clinically important improvement: GAD-7
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction: A 7-item questionnaire based on the Credibility/ Expectancy
Questionnaire
Notes *online treatment program: Worry Programme, developed for this study
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Titov 2009 (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The 48 people accepted into the programme
were randomised by NT [Nickolai Titov] via a true ran-
domizations process (www.random.org) to either...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk Quote: “Allocation preceded the screening phone call.”
Comment: unclear if allocation was kept concealed from
screener
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Post-treatment data were collected from 21/24
(88%) treatment group participants and 19/21 (90%) of
control group participants. In accordance with the ITT
paradigm, the pre-treatment scores ofthe five par ticipants
who did not complete the post-treatment questionnaires
were replicated as their post-treatment scores.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) Low risk Results for all outcome measures outlined in the trial
registration were reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Titov 2010
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder with Agoraphobia (26.9%), Social Phobia (29.5%)
, Generalized Anxiety Disorder (43.6%)
Method of Diagnosis: MINI
N: 86
Age: M = 39.5 (SD = 13)
Sex: 67.9% women
Country of residence: Australia
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Titov 2010 (Continued)
Psychiatric co-morbidity: 28.2% another Anxiety Disorder only, 20.5% another Af-
fective Disorder only, 26.9% another Anxiety and Affective Disorder
Co-use of adjunct therapy: excluded
Co-use of medication: 47.4%
Method of enrollment: responded to online study advertisements
Baseline depression severity: (PHQ-9) ICBT M = 10.77 (SD = 5.20); WLC M = 10.
84 (SD = 6.26)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with email and phone support (n = 42)
Duration: 6 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on disorder-specific psy-
choeducation, cognitive restructuring, exposure, assertiveness training, and relapse pre-
vention, with email and phone support from a therapist for module activities
Therapists: 2 clinical psychologists
Therapist contact: M e-mails by therapist = 23.6; M time spent by therapist per partic-
ipant = 46 min (SD = 16)
Face-to-face contact: none
Dropout: n = 6; 14.3%
(2) Waiting list control (n=44)
Duration: 8 weeks
Therapist, face-to-face contact: none
Dropout: n = 8; 18.2%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) disorder-specific symptoms: Penn State Worry Questionnaire; Social Phobia Screen-
ing Questionnaire; Panic Disorder Severity Scale - Self-Rating
(2) clinically important improvement: GAD-7
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction: a 7-item questionnaire based on the Credibility/Expectancy
Questionnaire
Notes *online treatment program: Anxiety Programme, developed for this study
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Eighty six applicants met all inclusion criteria
and were randomised by NT [Nickolai Titov] via a true
randomizations process (www.random.org)...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk Quote: “Allocation preceded the screening phone call.”
Comment: unclear if screener was aware of group alloca-
tion
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Titov 2010 (Continued)
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT vs. waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Post-treatment data (Time 2) was collected from
38/40 (95%) treatment group participants and 40/40
(100%) control group participants... In accordance with
the ITT and BOCF principles, the pre-treatment scores
of participants who did not complete the post-treatment.
.. questionnaires were replicated as their post-treatment.
.. scores.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) High risk Results for several outcome measures (Beck Anxiety In-
ventory, Social Phobia Scale, Social Interaction Anxi-
ety Scale, Agoraphobic Cognitions Questionnaire, Body
Vigilance Scale, WHO Disability Assessment Schedule
II) outlined in the trial registration were not reported and
other scales not in the trial registration (Penn State Worry
Questionnaire, Social Phobia Screening Questionnaire,
Panic Disorder Severity Scale) were reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Titov 2010 GAD
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Generalized Anxiety Disorder
Method of Diagnosis: MINI
N: 34
Ageˆ: M = 39.5 (SD = 13)
Sexˆ: 67.9% women
Country of residence: Australia
Psychiatric co-morbidityˆ: 28.2% another Anxiety Disorder only, 20.5% another Af-
fective Disorder only, 26.9% another Anxiety and Affective Disorder
Co-use of adjunct therapy: excluded
Co-use of medicationˆ: 47.4%
Method of enrollment: responded to online study advertisements
Baseline depression severityˆ: (PHQ-9) ICBT M = 10.77 (SD = 5.20); WLC M = 10.
84 (SD = 6.26)
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Titov 2010 GAD (Continued)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with email and phone support (n = 18)
Duration: 6 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, assertiveness training, and relapse prevention, with email
and phone support from a therapist for module activities
Therapists: 2 clinical psychologists
Therapist contactˆ: M emails by therapist = 23.6; M time spent by therapist per par-
ticipant = 46 min (SD = 16)
Face-to-face contact: none
Dropoutˆ: n = 6; 14.3%
(2) Waiting list control (n = 16)
Duration: 8 weeks
Therapist, face-to-face contact: none
Dropoutˆ: n = 8; 18.2%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) generalized anxiety disorder symptoms: Penn State Worry Questionnaire
(2) clinically important improvement: GAD-7
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction: a 7-item questionnaire based on the Credibility/Expectancy
Questionnaire
Notes *online treatment program: Anxiety Programme, developed for this study
ˆstatistics for entire Titov 2010 sample
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Eighty six applicants met all inclusion criteria
and were randomised by NT [Nickolai Titov] via a true
randomizations process (www.random.org)...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk Quote: “Allocation preceded the screening phone call.”
Comment: unclear if screener was aware of group alloca-
tion
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
105Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Titov 2010 GAD (Continued)
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Post-treatment data (Time 2) was collected from
38/40 (95%) treatment group participants and 40/40
(100%) control group participants... In accordance with
the ITT and BOCF principles, the pre-treatment scores
of participants who did not complete the post-treatment.
.. questionnaires were replicated as their post-treatment.
.. scores.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) High risk Results forseveral outcome measures outlined in thetrial
registration were not reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Titov 2010 Panic
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder with Agoraphobia
Method of Diagnosis: MINI
N: 21
Ageˆ: M = 39.5 (SD = 13)
Sexˆ: 67.9% women
Country of residence: Australia
Psychiatric co-morbidityˆ: 28.2% another Anxiety Disorder only, 20.5% another Af-
fective Disorder only, 26.9% another Anxiety and Affective Disorder
Co-use of adjunct therapy: excluded
Co-use of medicationˆ: 47.4%
Method of enrollment: responded to online study advertisements
Baseline depression severityˆ: (PHQ-9) ICBT M = 10.77 (SD = 5.20); WLC M = 10.
84 (SD = 6.26)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail and phone support (n = 10)
Duration: 6 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, assertiveness training, and relapse prevention, with e-mail
and phone support from a therapist for module activities
Therapists: 2 clinical psychologists
Therapist contactˆ: M e-mails by therapist = 23.6; M time spent by therapist per
participant = 46 min (SD = 16)
Face-to-face contact: none
Dropoutˆ: n = 6; 14.3%
(2) Waiting list control (n = 11)
Duration: 8 weeks
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Titov 2010 Panic (Continued)
Therapist, face-to-face contact: none
Dropoutˆ: n = 8; 18.2%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) panic symptoms: Panic Disorder Severity Scale - Self-Rating
(2) clinically important improvement: GAD-7
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction: a 7-item questionnaire based on the Credibility/Expectancy
Questionnaire
Notes *online treatment program: Anxiety Programme, developed for this study
ˆstatistics for entire Titov 2010 sample
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Eighty six applicants met all inclusion criteria
and were randomised by NT [Nickolai Titov] via a true
randomizations process (www.random.org)...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk Quote: “Allocation preceded the screening phone call.”
Comment: unclear if screener was aware of group alloca-
tion
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Post-treatment data (Time 2) was collected from
38/40 (95%) treatment group participants and 40/40
(100%) control group participants... In accordance with
the ITT and BOCF principles, the pre-treatment scores
of participants who did not complete the post-treatment.
.. questionnaires were replicated as their post-treatment.
.. scores.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) High risk Results forseveral outcome measures outlined in thetrial
registration were not reported
107Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Titov 2010 Panic (Continued)
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Titov 2010 Social Phobia
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: MINI
N: 23
Ageˆ: M = 39.5 (SD = 13)
Sexˆ: 67.9% women
Country of residence: Australia
Psychiatric co-morbidityˆ: 28.2% another Anxiety Disorder only, 20.5% another Af-
fective Disorder only, 26.9% another Anxiety and Affective Disorder
Co-use of adjunct therapy: excluded
Co-use of medicationˆ: 47.4%
Method of enrollment: responded to online study advertisements
Baseline depression severityˆ: (PHQ-9) ICBT M = 10.77 (SD = 5.20); WLC M = 10.
84 (SD = 6.26)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail and phone support (n = 12)
Duration: 6 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, exposure, assertiveness training, and relapse prevention, with e-mail
and phone support from a therapist for module activities
Therapists: 2 clinical psychologists
Therapist contactˆ: M e-mails by therapist = 23.6; M time spent by therapist per
participant = 46 min (SD = 16)
Face-to-face contact: none
Dropoutˆ: n = 6; 14.3%
(2) Waiting list control (n = 11)
Duration: 8 weeks
Therapist, face-to-face contact: none
Dropoutˆ: n = 8; 18.2%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) social phobia symptoms: Social Phobia Screening Questionnaire
(2) clinically important improvement: GAD-7
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction: a 7-item questionnaire based on the Credibility/ Expectancy
Questionnaire
Notes *online treatment program: Anxiety Programme, developed for this study
ˆstatistics for entire Titov 2010 sample
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Titov 2010 Social Phobia (Continued)
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “Eighty six applicants met all inclusion criteria
and were randomised by NT [Nickolai Titov] via a true
randomizations process (www.random.org)...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk Quote: “Allocation preceded the screening phone call.”
Comment: unclear if screener was aware of group alloca-
tion
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT versus waiting list)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk All outcome measures were self-report and participants
were not blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Post-treatment data (Time 2) was collected from
38/40 (95%) treatment group participants and 40/40
(100%) control group participants... In accordance with
the ITT and BOCF principles, the pre-treatment scores
of participants who did not complete the post-treatment.
.. questionnaires were replicated as their post-treatment.
.. scores.”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) High risk Results forseveral outcome measures outlined in thetrial
registration were not reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Titov 2011
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder with or without Agoraphobia (10%), Social Phobia
(11%), Generalized Anxiety Disorder (28%), MDD (51%; not included in review)
Method of diagnosis: MINI
N: 74
Age: M = 43.9 (SD = 14.6); range = 18 to 79
Sex: 73% women
109Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Titov 2011 (Continued)
Country of residence: Australia
Psychiatric co-morbidity: 81% had another co-morbid Anxiety or Depressive Disorder
Co-use of adjunct therapy: excluded
Co-use of medication: 54%
Method of enrollment: responded to online study advertisements
Baseline depression severity: (PHQ-9) ICBT M = 13.48 (SD = 5.36); WLC M = 12.
56 (SD = 5.81)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail and phone support (n = 37)
Duration: 8 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
nitive restructuring, de-arousal strategies, behavioural activation, exposure, challenging
core beliefs, and relapse prevention, with e-mail and phone support from a therapist for
module activities
Therapists: 1 clinical psychologist
Therapist contact: M e-mails by therapist = 5.45 (SD = 3.57); M phone calls by therapist
= 9.35 (SD = 2.96); M time spent by therapist per participant = 84.76 min (SD = 50.
37)
Face-to-face contact: none
Dropout: n = 3; 8.1%
(2) Waiting list control (n = 37)
Duration: 10 weeks
Therapist, face-to-face contact: none
Dropout: n = 2; 5.4%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) disorder-specific symptoms: Penn State Worry Questionnaire; Social Phobia - 12;
Panic Disorder Severity Scale
(2) general anxiety: GAD-7, Depression Anxiety Stress Scales - 21
Secondary outcomes:
(1) quality of life: Sheehan Disability Scale
(2) treatment satisfaction: a 7-item questionnaire based on the Credibility/Expectancy
Questionnaire
Notes *treatment based on: Andrews, G., Creamer, M., Crino, R., Hunt, C., Lampe, L., &
Page, A. (2003). The treatment of anxiety disorders: Clinician guides and patient manuals
(2nd ed.). UK: University Press, Cambridge.; Perini, S., Titov, N., & Andrews, G. (2009)
. Clinician-assisted Internet-based treatment is effective for depression: A randomised
controlled trial. Australian and New Zealand Journal of Psychiatry, 43, 571-8.; Titov, N.
, Andrews, G., Davies, M., McIntyre, K., Robinson, E., & Solley, K. (2010). Internet
treatment for depression: A randomised controlled trial comparing clinician vs. techni-
cian assistance. PLoS ONE, 5, e10939.; Robinson, E., Titov, N., Andrews, G., McIn-
tyre, K., Schwencke, G., & Solley, K. (2010). Internet treatment for generalized anxiety
disorder: A randomised controlled trial comparing clinician vs. technician assistance.
PLoS ONE, 5, e10942.; Titov, N., Andrews, G., Schwencke, G., Drobny, J., & Einstein,
D. (2008). Shyness 1: Distance treatment of social phobia over the internet. Australian
and New Zealand Journal of Psychiatry, 42, 585-94.; Wims, E., Titov, N., Andrews, G.
110Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Titov 2011 (Continued)
, & Choi, I. (2010). Clinician-assisted internet-based treatment is effective for panic: A
randomised controlled trial. Australian and New Zealand Journal of Psychiatry, 44, 599-
607.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: ”...randomised via a true randomisation process
(www.random.org), generated by an independent per-
son...“
Comment: adequate randomisation method”
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment con-
dition nor therapists to the treatment they delivered (In-
ternet-based CBT vs. waiting list control)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
High risk Quote: “These [diagnostic] assessments were conducted
by BFD and GS, who were not blind to participant’s
condition.”
Comment: interviewers were not blind to treatment con-
dition
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “All post-treatment analyses involved a conserva-
tive intention-to-treat (ITT) design where missing data
was addressed by carrying forward the first available
data (i.e., baseline-observation-carried-forward model;
BOCF).”
Comment: there were only four formal withdrawals from
the study; ITT analyses were used
Selective reporting (reporting bias) Low risk Results for all outcome measures outlined in the trial
registration were reported
Other bias High risk Treatment group endorsed significantly higher PDSS-SR
scores than controls at baseline
111Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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van Ballegooijen 2013
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder with or without Agoraphobia (78%), Agoraphobia
without Panic (14%)
Method of diagnosis: CIDI
N: 126
Age: M = 36.6 (SD = 11.4); range = 18 to 67
Sex: 67.5% women
Country of residence: Netherlands
Psychiatric co-morbidity: included
Co-use of adjunct therapy: included
Co-use of medication: included
Method of enrollment: responded to media advertisements in community and online
Baseline depression severity: (CES-D) ICBT M = 20.0 (SD = 9.1); WLC M = 21.6
(SD = 9.0)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support (n = 63)
Duration: 6 online modules completed over 12 weeks
Treatment protocol*: participants completed online modules on various cognitive and
behavioural techniques and skills, with e-mail support from a therapist for module
activities
Therapists: master’s level clinical psychology students; supervised by clinical psychologist
Therapist contact: M time spent by therapist per participant = 1 to 2 hours
Face-to-face contact: none
Dropout: n = 29; 46%
(2) Waiting list control (n = 63)
Duration: 12 weeks
Treatment protocol: participants had access to online non-CBT panic resources
Therapist, face-to-face contact: none
Dropout: n = 24; 38.1%
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) disorder-specific symptoms: Panic Disorder Severity Scale
(2) general anxiety: Beck Anxiety Inventory
Notes *treatment called Don’t Panic Online, described in: van Ballegooijen, W., Riper, H., van
Straten, A., Kramer, J., Conijn, B., & Cuijpers, P. (2011). The effects of an Internet
based self-help course for reducing panic symptoms--Don’t Panic Online: Study protocol
for a randomised controlled trial. Trials, 12, 75.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “After the interview, all participants were ran-
domized to 1 of the 2 groups. Randomization was strat-
ified for the presence or absence of agoraphobic symp-
112Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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van Ballegooijen 2013 (Continued)
toms (PDSS-SR item 4 score ≥2) and the use of antide-
pressants or sedatives. Randomization lists were gener-
ated automatically using a computer program.”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to the treatment con-
dition they were in (Internet-based CBT or waiting list
control)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Incomplete outcome data (attrition bias)
All outcomes
High risk Significant drop out in both conditions; ITT analyses
were employed via multiple imputation
Selective reporting (reporting bias) Unclear risk One outcome - quality of life, as measured by the Eu-
roQol Questionnaire - outlined in the published study
protocol was not reported; results for all other outcome
measures outlined in the study protocol were reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Wims 2010
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder with or without Agoraphobia
Method of Diagnosis: MINI
N: 2759
Age: M = 42.08 (SD = 12.29)
Sex: 76% women
Country of residence: Australia
Psychiatric co-morbidity: 21% Social Phobia, 31% GAD, 10% OCD, 7% PTSD,
21% Major Depressive episode
Co-use of adjunct therapy: excluded
Co-use of medication: 31%
Method of enrollment: responded to online study advertisements
Baseline depression aeverity: (PHQ-9) ICBT M = 10.34 (SD = 4.09); WLC M = 10.
24 (SD = 5.93)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support (n = 32)
Duration: 6 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cog-
113Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Wims 2010 (Continued)
nitive restructuring, exposure, physiological de-arousal, and relapse prevention, with
email support from a therapist for module activities
Therapists: 1 psychiatry registrar
Therapist contact: M e-mails by therapist = 7.5; M time spent by therapist per partici-
pant = 75 min
Face-to-face contact: none
Dropout: n = 10; 31.3%
(2) Waiting list control (n = 27)
Duration: 8 weeks
Therapist, face-to-face contact: none
Dropout: n = 5; 18.5%
Outcomes Timepoints for assessment: pre- and post-treatment and 1 month follow-up
Primary outcome:
(1) panic and agoraphobia symptoms: Panic Disorder Severity Scale; Body Sensations
Questionnaire; Agoraphobic Cognitions Questionnaire; Mobility Inventory
Secondary outcome:
(1) quality of life: Sheehan Disability Scale
Notes *online treatment program: Panic Program - Wims E, Titov N, Andrews G. (2008). The
Panic program: An open trial
of Internet-based treatment for panic disorder. Electronic Journal of Applied Psychology,
4, 2.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection
bias)
Low risk Quote: “The 59 people accepted into the program were
randomised via a true randomizations process (www.ran-
dom.org) to either...”
Comment: adequate randomisation method
Allocation concealment (selection bias) Unclear risk No mention of allocation concealment
Blinding of participants and personnel
(performance bias)
All outcomes
High risk Not possible to blind participants to their treatment
condition nor therapists to the treatment they delivered
(Internet-based applied relaxation versus Internet-based
CBT)
Blinding of outcome assessment (detection
bias)
Self-Report Outcomes
High risk For self-report outcome measures, participants were not
blind to their own treatment condition
Blinding of outcome assessment (detection
bias)
Observer/Interview-Rated Outcomes
High risk Quote: “...the lack of blinding in the administration of
the PDSS is a source of bias, which may account for the
larger effect sizes in this domain.”
Comment: interviewers were not blind to treatment con-
dition
114Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Wims 2010 (Continued)
Incomplete outcome data (attrition bias)
All outcomes
Low risk Quote: “Two participants found the program required
more time than they were able to set aside, one person
dropped out due to increased severity of their anxiety
which required inpatient admission, another became ill,
another found the course too difficult and the final par-
ticipant moved house during the program and no longer
had internet access.”; “Post-treatment data was collected
from 44 participants (22/29 treatment group and 22/25
waitlist control group). In accordance with the intention-
to-treat paradigm, the pre-treatment scores of the partic-
ipants who did not complete the post-treatment ques-
tionnaires were replicated as their post-treatment scores.
”
Comment: a small and similar number of dropouts from
both treatment conditions was reported; ITT analyses
were used
Selective reporting (reporting bias) Low risk Results for all outcome measures outlined in the trial
registration were reported
Other bias Low risk Groups did not differ significantly on any measures at
pre-treatment
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Andersson 2006 The intervention involved too much face-to-face contact between therapist and participant (i.e., two live
exposure sessions)
Andersson 2012c The comparison conditionwas non-directive suppor tive therapy and thus too active for the present comparisons
of interest
Andrews 2011 A standardized diagnostic instrument was not used to assess participants for an anxiety disorder
Bell 2012 The intervention did not involve therapist support
Carlbring 2003 The comparison was active applied relaxation and did not fit into one of the present comparisons
Carlbring 2010 The comparator condition included attention bias modification and so did not fit in any of our comparator
categories and was not appropriate for inclusion
Carlbring 2011b Both of the treatment conditions in this study qualified as our intervention of interest, so no appropriate
comparator
115Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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(Continued)
Cunningham 2006 Participants did not meet DSM or ICD criteria for an anxiety disorder diagnosis
Ellis 2011 Participants were not diagnosed with a DSM or ICD anxiety disorder by study investigators
Febbraro 2005 Only a portion of the sample was diagnosed with PD and it could not be separated from the rest of the sample
Gilson 2006 The comparator condition involved internet-based CBT delivered by a physician (vs. a psychologist) and so
was not sufficiently different from the intervention of interest to be appropriate for inclusion
Greist 2002 The intervention was not delivered directly by a therapist but instead used voice response technology
Kenardy 2003 The intervention was computer-augmented; there were six face-to-face sessions between therapist and partici-
pant
Kenwright 2005 The comparator condition was also therapist-delivered distance CBT and so was not sufficiently different from
the intervention of interest to be appropriate for inclusion
Klein 2001 The intervention was not therapist-delivered (i.e., was entirely self-help)
Klein 2006 Participants were randomised with ’sequential randomisation’, which is more accurately described as sequential
allocation with no randomisation
Klein 2009 The comparator condition was also therapist-delivered distance CBT and so was not sufficiently different from
the intervention of interest to be appropriate for inclusion
Knaevelsrud 2007 Participants were not diagnosed with a DSM or ICD anxiety disorder by study investigators
Lange 2001 Participants were not diagnosed with a DSM or ICD anxiety disorder by study investigators
Lange 2003 Participants were not diagnosed with a DSM or ICD anxiety disorder by study investigators
Litz 2007 The comparison was active online supportive counselling and thus too active for the present comparisons
Marks 2004 The intervention involved too much face-to-face contact between therapist and participant (i.e., in addition
to the computer-based session, each session involved 15 minutes of face-to-face contact)
Newman 1997 The intervention was computer-augmented; there were four face-to-face sessions between therapist and partic-
ipant
Pittaway 2009 Participants were not diagnosed with a DSM or ICD anxiety disorder by study investigators
Ruwaard 2010 Participants had panic attacks but were not diagnosed with PD
Saul 2007 Participants were not diagnosed with a DSM or ICD anxiety disorder by study investigators
Schneider 2005 The comparator condition was also distance CBT delivered by a physician, just without exposure, and so was
not significantly different from the intervention of interest to be appropriate for inclusion
116Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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(Continued)
Shandley 2008 The comparator condition was also distance CBT delivered by a physician and so was not sufficiently different
from the intervention of interest to be appropriate for inclusion
Titov 2009b The comparator condition was also therapist-delivered distance CBT and so was not sufficiently different from
the intervention of interest to be appropriate for inclusion
van Straten 2008 Participants were not diagnosed with a DSM or ICD anxiety disorder by study investigators
Wagner 2012 Participants did not have to have a DSM or ICD anxiety disorder diagnosis to participate in this investigation
Characteristics of studies awaiting assessment [ordered by study ID]
Andersson 2013
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Specific Phobia, Snake Type
Method of Diagnosis: SCID-IV
N: 30
Age: M = 27.2 (SD = 8.1); range = 19 to 54 years
Sex: 84.6% women
Country of residence: Sweden
Method of enrollment: responded to media advertisements in community
Baseline depression severity: (BDI-II) ICBT M = 3.6 (SD = 3.4); Live exposure M = 6.8 (SD = 3.3)
Interventions Participants were randomly assigned to either:
(1) Internet-based BT with e-mail support (n = 15)
Duration: 4 online modules completed over 4 weeks
Treatment protocol: participants completed online modules on psychoeducation and exposure, with e-mail support
from a therapist for module exercises
Therapists: two clinical psychology students in their last year, one PhD student in clinical psychology, and one
licensed psychologist
Therapist contact: 25 min per participant
Face-to-face contact: none
Dropout: n = 2; 13%
(2) Live exposure (n = 15)
Duration: 1 face-to-face session
Treatment protocol*: participants attended an orientation session and 3 hr graded exposure session with a therapist
Therapists: two clinical psychology students in their last year, one PhD student in clinical psychology, and one
licensed psychologist
Therapist, face-to-face contact: 1 x 3 hr exposure session
Dropout: n = 2; 13%
Outcomes Timepoints for assessment: pre- and post-treatment and 1 year follow-up
Primary outcomes:
(1) specific phobia symptoms: Behavioural Avoidance Test; Snake Phobia Questionnaire; Fear Survey Schedule-III
(2) general anxiety: Beck Anxiety Inventory
117Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Andersson 2013 (Continued)
Notes
Andrews 2011b
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder with or without Agoraphobia
Method of diagnosis: MINI
Age: 18 years and older
Country of residence: Australia
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: permitted if stable dose for past month
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail support
Duration: 5 online modules completed over 8 weeks
Treatment protocol: participants complete online CBT modules about the management of panic symptoms with e-
mail support from a therapist
Therapists: psychiatrists
Therapist contact: as and when required
Face-to-face contact: none
(2) Waiting list control
Duration: 8 weeks
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month follow-up
Primary outcome:
(1) panic symptoms: Panic Disorder Severity Scale
Secondary outcome:
(1) quality of life: World Health Organization Disability Assessment Scale
Notes ACTRN12611001120965
Andrews 2011c
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Generalized Anxiety Disorder
Method of diagnosis: MINI
Age: 18 years and older
Country of residence: Australia
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: permitted (except benzodiazepines) if stable dose for past month
118Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Andrews 2011c (Continued)
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail and telephone support
Duration: 6 online modules completed over 8 to 10 weeks
Treatment protocol: participants complete online CBT modules about the management of generalized anxiety
symptoms with e-mail or telephone support, or both, from a therapist
Therapists: clinical psychologist
Therapist contact: as and when required
Face-to-face contact: none
(2) Waiting list control
Duration: 10 weeks
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month follow-up
Primary outcome:
(1) generalized anxiety symptoms: GAD-7, Penn State Worry Questionnaire
Secondary outcomes:
(1) quality of life: WHO Disability Assessment Scale
(2) treatment satisfaction (at post-treatment): patient satisfaction questionnaire
Notes ACTRN12611001055998
Andrews 2011d
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia, Panic Disorder (with or without agoraphobia), or Generalized Anxiety Disorder,
or both
Method of diagnosis: MINI
Age: 18 years and older
Country of residence: Australia
Psychiatric co-morbidity: included, except Substance Abuse and Dependence, Psychotic Disorder
Co-use of adjunct therapy: excluded
Co-use of medication: permitted (except benzodiazepines) if stable dose for past month
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail and telephone support
Duration: 6 online modules completed over 9 weeks
Treatment protocol: participants complete online CBT modules about the management of their anxiety disorder
with weekly telephone calls and access to a moderated online discussion forum
Therapists: unknown
Therapist contact: 2 to 7 min/week
Face-to-face contact: none
(2) Waiting list control
Duration: 10 weeks
Therapist, face-to-face contact: none
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Andrews 2011d (Continued)
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month follow-up
Primary outcomes:
(1) clinically significant improvement: MINI
(2) general anxiety symptoms: Beck Anxiety Inventory
(3) panic symptoms: Body Vigilance Scale, Agoraphobic Questionnaire
(4) generalized anxiety disorder symptoms: GAD-7
(5) social phobia symptoms: Social Interaction Anxiety Scale
Secondary outcome:
(1) quality of life: Sheehan Disability Scale, World Health Organisation Disability Assessment Schedule II
Notes ACTRN12611000625976
Andrews 2012a
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Obsessive Compulsive Disorder
Method of diagnosis: MINI
Age: 18 years and older
Country of residence: Australia
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: permitted (except benzodiazepines) if stable dose for past month
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail and telephone support
Duration: 6 online modules completed over 8 to 10 weeks
Treatment protocol: participants complete online CBT modules about the management of obsessive compulsive
disorder with e-mail or telephone support, or both, from a therapist
Therapists: clinical psychologist
Therapist contact: as and when required
Face-to-face contact: none
(2) Waiting list control
Duration: 10 weeks
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month follow-up
Primary outcomes:
(1) obsessive compulsive disorder symptoms: Obsessive Beliefs Questionnaire, Dimensional Obsessive Compulsive
Scale
(2) general anxiety symptoms: GAD-7
Secondary outcome:
(1) quality of life: Sheehan Disability Scale
Notes ACTRN12612001073897
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Berger 2012
Methods Randomized controlled trial
Participants Diagnosis: DSM-IV Obsessive Compulsive Disorder
Method of Diagnosis: YBOCS
Age: 18-65 years
Country of Residence: Germany
Psychiatric Comorbidity: included (except severe Major Depression)
Co-use of Adjunct Therapy: excluded
Co-use of Medication: permitted (except benzodiazepines) if stable dose for past month
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with email and telephone support
Duration: 14 online modules
Treatment Protocol: participants complete online modules on exposure and response prevention including psychoe-
duction, processing of functionalities, and strategies for relapse prevention with therapist support via email
Therapists: unknown
Therapist Contact: unknown
Face-to-Face Contact: none
(2) Waiting list control
Duration: length of treatment (exact duration unknown)
Therapist/Face-to-Face Contact: none
Outcomes Timepoints for Assessment: pre- and post-treatment and 2 and 6 month follow-up
Primary outcome:
(1) obsessive compulsive disorder symptoms: YBOCS, Obsessive Compulsive Inventory Revised
Notes DRKS00004612
Berger 2014
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia (n = 113), Panic Disorder with or without Agoraphobia (n = 44), and Generalized
Anxiety Disorder (n = 33)
Method of Diagnosis: SCID-IV
N: 132
Age: M = 35.1 (SD = 11.4); range = 18 to 65 years
Sex: 56.1% women
Country of residence: Switzerland, Germany, Austria
Psychiatric co-morbidity: 37.1% Anxiety Disorder, 13.6% Mood Disorder, 15.9% Specific Phobia, 5.3% OCD,
12.1% other Axis I disorder
Co-use of adjunct therapy: no
Co-use of medication: yes if stable dose for one month pre-treatment
Method of enrollment: responded to online and media study advertisements
Baseline depression severity: (BDI-II) ICBT M = 19.1 (SD = 10.4); WLC M = 20.3 (SD = 10.1)
Interventions Participants were randomly assigned to one of:
(1) Internet-based CBT with e-mail support (n = 44)
Duration: 8 online modules completed over 8 weeks
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Berger 2014 (Continued)
Treatment protocol*: participants completed online modules on motivational enhancement, psychoeducation, cog-
nitive restructuring, mindfulness, exposure, lifestyle modification, and relapse prevention, with email support from
a therapist for module exercises
Therapists: 5 Master of Science students in their last term of clinical psychology and psychotherapy, a psychologist
with a master’s degree in clinical psychology and in their fourth year of a 5 yr post-graduate CBT psychotherapy
program, and a CBT therapist
Therapist contact: M e-mails written by clients = 6.53 (SD = 7.2), M e-mails written by therapists = 12.6 (SD = 4.
6)
Face-to-face contact: none
Dropout: n = 5; 11%
(2) Internet-based CBT with e-mail support tailored to diagnoses (n = 44)
Duration: 8 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on motivational enhancement, psychoeducation, cog-
nitive restructuring, mindfulness, exposure, lifestyle modification, and relapse prevention, with email support from
a therapist for module exercises; prescribed modules depended on participants’ primary and comorbid diagnoses
Therapists: 5 Master of Science students in their last term of clinical psychology and psychotherapy, a psychologist
with a master’s degree in clinical psychology and in their fourth year of a 5 yr post-graduate CBT psychotherapy
program, and a CBT therapist
Therapist contact: M e-mails written by clients = 6.53 (SD = 7.2), M e-mails written by therapists = 12.6 (SD = 4.
6)
Face-to-face contact: none
Dropout: n = 4; 10%
(3) Waiting list control (n = 44)
Duration: 8 weeks
Therapist, face-to-face contact: none
Dropout: n = 4; 10%
Outcomes Timepoints for assessment: pre- and post-treatment and 1 year follow-up
Primary outcomes:
(1) social phobia symptoms: Social Phobia Scale, Social Interaction Anxiety Scale
(2) generalized anxiety symptoms: Penn State Worry Questionnaire
(3) panic and agoraphobia symptoms: Agoraphobic Cognitions Questionnaire, Bodily Sensations Questionnaire,
Mobility Inventory for Agoraphobia
(4) general anxiety: Beck Anxiety Inventory, Brief Symptom Inventory
(5) clinically significant improvement: SCID-IV
Notes *treatment based on: Clark, D.M., & Wells, A. (1995). A cognitive model of social phobia. New York: Guilford
Press.; Stangier, U., Heidenreich, T., & Peitz, M. (2003). Soziale Phobien. Ein kognitiv-verhaltenstherapeutisches
Behandlungsmanual. Weinheim: Beltz.; Margraft, J., & Schneider, S. (1989). Panik: Angstanfalle und ihre Behandlung.
Berlin: Springer.; Schneider, S., & Margraf, J. (1998). Fortschritte der psychotherapie: Agoraphobie und panikstorung.
Gottingen: Hogrefe.; Becker,E., & Margraf, J. (2002). Generalisierte Angststorung. Ein Therapieprogramm. Weinheim:
Beltz Verlag.
122Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Carlbring 2012
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Generalized Anxiety Disorder
Method of diagnosis: unknown
Age: 18 years and older
Country of residence: Sweden
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: permitted if stable
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail support
Duration: 9 weeks
Treatment protocol: participants complete online CBT modules with email support from a therapist for module
exercises
Therapists: unknown
Therapist contact: unknown
Face-to-face contact: none
(2) Waiting list control
Duration: 9 weeks
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 6 month, 1 year, and 2 year follow-ups
Primary outcomes:
(1) generalized anxiety symptoms: Penn State Worry Questionnaire; GAD-7
(2) general anxiety symptoms: Beck Anxiety Inventory
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes NCT01570374
Greist 2012
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Obsessive Compulsive Disorder
Method of diagnosis: YBOCS
Age: 18 years or older
Country of residence: USA
Psychiatric co-morbidity: included (except significant co-morbid Depression)
Co-use of adjunct therapy or medication: unknown
Interventions Participants randomly assigned to one of:
(1) Internet-based CBT with telephone support from a therapist
Duration: 12 weeks
Treatment protocol: participants complete online CBT for OCD modules with weekly telephone coaching from a
therapist
Therapists: ’CBT therapist’
Therapist contact: weekly coaching via telephone
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Greist 2012 (Continued)
Face-to-face contact: none
(2) Internet-based CBT with telephone support from a non-therapist
Duration: 12 weeks
Treatment protocol: participants complete online CBT for OCD modules with weekly telephone coaching from a
non-therapist
Therapists: unknown (non-therapist)
Therapist contact: weekly coaching via telephone
Face-to-face contact: none
(3) Internet-based unguided CBT
Duration: 12 weeks
Treatment protocol: participants complete online CBT for OCD self-help modules
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcome:
(1) obsessive-compulsive symptoms: YBOCS
Notes NCT01522287
Ivarsson 2014
Methods Randomized controlled trial
Participants Diagnosis: DSM-IV PTSD
Method of diagnosis: CAPS
N: 62
Age:M= 46 (SD = 11.7); range = 21-67 years
Sex: 82.3% women
Country of residence: Sweden
Co-use of adjunct therapy: no
Co-use of medication: yes if stable dose for 3 months pre-treatment
Method of Eenrollment: responded to media study advertisements
Baseline depression severity: (BDI-II) ICBT M= 26.6 (SD = 11.4); WLC M= 26.4 (SD = 10.9)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with email support (n=44)
Duration: 8 online modules completed over 8 weeks
Treatment protocol*: participants completed online modules on psychoeducation, anxiety coping skill training,
exposure, and cognitive restructuring, with email support from a therapist for module exercises
Therapists: students in a 5 year clinical psychology program
Therapist contact:M28 mins/week; range = 11-52 mins/week
Face-to-face contact: none
Dropout: n=3; 10%
(2) Waiting List Control (n=44)
Duration: 8 weeks
Therapist/face-to-face contact: none
Dropout: n=5; 16%
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Ivarsson 2014 (Continued)
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcomes:
(1) posttraumatic stress symptoms: Impact of Events Scale Revised, Posttraumatic stress Diagnostic Scale
(2) general anxiety: Beck Anxiety Inventory
(3) clinically significant improvement: CAPS, Clinical Global Impression - Improvement Scale
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes *treatment based on Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007). Psychological
treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis. British Journal of Psychiatry,
190, 97-104.; Harvey, A. G., Bryant, R. A., & Tarrier, N. (2003). Cognitive behaviour therapy for posttraumatic
stress disorder. Clinical Psychology Review, 23, 501-522.
Newby 2013
Methods Randomized controlled trial
Participants Diagnosis: DSM-IV GAD and/or MDD (only participants with GAD included in this review)
Method of diagnosis: MINI
N: 109
Age:M= 44.3 (SD = 12.2); range = 21-80 years
Sex: 77.8% women
Country of residence: Australia
Psychiatric comorbidity: MDD
Co-use of adjunct therapy: yes if stable for 2 months pre-treatment
Co-use of medication: yes if stable dose for 2 months pre-treatment
Method of enrollment: responded to online study advertisements
Baseline depression severity: (BDI-II) ICBT M= 21.2 (SD = 7.0); WLC M= 22.4 (SD = 9.2)
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with email and phone support (n=49)
Duration: 6 online modules completed over 10 weeks
Treatment protocol*: participants completed online modules on psychoeducation, cognitive restructuring, mind-
fulness, exposure, and relapse prevention, with email and phone support from a therapist for module exercises
Therapists: practice manager, supervised by a clinical psychologist
Face-to-face contact: none
Dropout: n=3; 6%
(2) Waiting List Control (n=60)
Duration: 10 weeks
Therapist/face-to-face contact: none
Dropout: n=6; 10%
Outcomes Timepoints for assessment: pre- and post-treatment and 1 year follow-up
Primary outcome:
(1) generalized anxiety symptoms: GAD-7, Penn State Worry Questionnaire
Secondary outcome:
(1) quality of life: WHO Disability Assessment Schedule - II
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Newby 2013 (Continued)
Notes *treatment based on Worry and Sadness Program (www.virtualclinic.org.au)
Nordgren 2012
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder with or without Agoraphobia (n = 31), Agoraphobia (n = 8), Social Phobia (n
= 32), Generalized Anxiety Disorder (n = 10), Anxiety Disorder Not Otherwise Specified (n = 19)
Method of Diagnosis: SCID-IV
N: 100
Age: for ICBT M = 35 (SD = 13); for WLC M = 36 (SD = 12); range = 19 to 68 years
Sex: 63% women
Country of residence: Sweden
Psychiatric co-morbidity: Anxiety Disorders (n = 31), Mood Disorders (n = 43), Hypochondriasis (n = 1)
Co-use of adjunct therapy: excluded
Co-use of medication: 26%
Method of enrollment: participants were recruited from a clinical population through referral from their general
practitioner or a nurse, when seeking help at their primary care centre
Baseline depression severity: (MADRS-S) for ICBT, M 19.6 (SD = 1.0); for WLC, M = 17.8 (SD = 1.0)
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail support from a therapist
Duration: 7 to 10 online modules completed over 10 weeks
Treatment protocol: participants complete online modules on cognitive restructuring, disorder-specific anxiety
symptom management, relaxation, behavioural activation, mindfulness, assertiveness, problem solving, stress man-
agement, sleep, and relapse prevention with e-mail support from a therapist for module exercises
Therapists: seven Master’s of Science students
Therapist contact: 15 min/week
Face-to-face contact: none
Dropout: n = 4; 8%
(2) Waiting list control
Duration: 10 weeks
Therapist, face-to-face contact: none
Dropout: n = 5; 10%
Outcomes Timepoints for assessment: pre- and post-treatment and 12 month follow-up
Primary outcome:
(1) general anxiety symptoms: Clinical Outcomes in Routine Evaluation - Outcome Measure; Beck Anxiety Inventory
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Notes NCT01390168
126Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Richards 2014
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Generalized Anxiety Disorder
Method of Diagnosis: GAD-7
Age: 18 years or older
Country of residence: Ireland
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: excluded
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail support
Duration: 6 online modules completed weekly
Treatment protocol: participants complete online CBT modules about the management of GAD with e-mail support
from a therapist
Therapists: clinical psychology graduate students at the master’s level
Therapist contact: 10-15 min/week
Face-to-face contact: none
(2) Waiting list control
Duration: 6 weeks
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month follow-up
Primary outcome:
(1) general anxiety symptoms: GAD-7, Penn State Worry Questionnaire
Secondary outcome:
(1) quality of life: EuroQol 5D, Work and Social Adjustment questionnaire
(2) treatment satisfaction: Helpful Aspects of Therapy Form, Satisfaction with Treatment questionnaire
Notes ISRCTN16303842
Schreuders 2008
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia, Specific Phobia, or Agoraphobia
Method of diagnosis: unknown
Age: unknown
Country of residence: Netherlands
Psychiatric co-morbidity: unknown
Co-use of adjunct therapy: unknown
Co-use of medication: unknown
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail support
Duration: 6 online modules completed over 12 weeks
Treatment protocol: participants complete online CBT modules with a focus on exposure with e-mail support from
a therapist
Therapists: unknown
127Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Schreuders 2008 (Continued)
Therapist contact: unknown
Face-to-face contact: none
(2) Unclear
Outcomes Timepoints for assessment: pre- and and post-treatment and 3 month follow-up
Primary outcome:
(1) anxiety symptoms: measurement method unknown
Secondary outcome:
(1) treatment satisfaction
Notes NTR 1260
Characteristics of ongoing studies [ordered by study ID]
Andrews 2012b
Trial name or title The Obsessive Compulsive Disorder (OCD) Program - A randomised controlled trial of online versus face-
to-face cognitive behavioural therapy (CBT)
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Obsessive Compulsive Disorder
Method of diagnosis: MINI
Age: 18 years and older
Country of residence: Australia
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: permitted (except benzodiazepines) if stable dose for past month
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail and telephone support
Duration: 6 online modules completed over 12 weeks
Treatment protocol: participants complete online CBT modules about the management of obsessive com-
pulsive disorder with e-mail or telephone support, or both, from a therapist
Therapists: clinical psychologist
Therapist contact: weekly for first two weeks and then when required
Face-to-face contact: none
(2) Face-to-face individual CBT
Duration: 12 face-to-face individual therapy sessions over 12 weeks
Treatment protocol: individual sessions focused on helping individuals gradually confront feared situations
Therapists: clinical psychologists
Therapist, face-to-face contact: 12 x 1 hr sessions
Outcomes Timepoints for assessment: pre-, mid-, and post-treatment and 3 month follow-up
Primary outcomes:
(1) obsessive compulsive disorder symptoms: Obsessive Beliefs Questionnaire, Dimensional Obsessive Com-
pulsive Scale
(2) general anxiety symptoms: GAD-7
128Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Andrews 2012b (Continued)
Secondary outcome:
(1) quality of life: Sheehan Disability Scale
Starting date December, 2012
Contact information Professor Gavin Andrews, St Vincent’s Hospital, Sydney, 390 Victoria St, Darlinghurst NSW 2010, Australia;
Tel: +612 8382 1400; Fax: +612 8382 1401; gavina@unsw.edu.au
Notes
Bishop 2012
Trial name or title Development of a web-based cognitive behavioral treatment for OEF/OIF veterans with PTSD symptoms
and substance misuse
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Post-traumatic Stress Disorder
Method of diagnosis: unknown
Age: 21 years and older
Country of residence: USA
Psychiatric co-morbidity: included
Co-use of adjunct therapy or medication: unknown
Interventions Participants were randomly assigned to either:
(1) Internet-based CBT with e-mail support
Duration: 24 brief online intervention modules
Treatment protocol: participants complete online modules on CBT for PTSD with e-mail support from a
therapist
Therapists: unknown
Therapist contact: unknown
Face-to-face contact: none
(2) Waiting list control
Duration: unknown
Face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcome:
(1) post-traumatic stress symptoms: unknown how these symptoms were measured
Starting date Spring 2012
Contact information Kyle Possemato, Ph.D.; Syracuse VA Medical Center, Syracuse, NY 13210; kyle.possemato@va.gov
Notes
129Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Clark 2012
Trial name or title A randomised controlled trial of internet-based cognitive therapy (iCT) and standard cognitive therapy (CT)
for social anxiety disorder
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: unknown
Age: 18 to 65 years
Country of residence: United Kingdom
Psychiatric co-morbidity: included
Co-use of adjunct therapy: excluded
Co-use of medication: permitted if stable for past two months
Interventions Participants randomly assigned to one of:
(1) Internet-based CT with e-mail and telephone support
Duration: 14 weeks
Treatment protocol: participants complete online CT modules, including video demonstrations of procedures
and virtual audiences to practice real-life tasks, with e-mail and telephone support from a therapist
Therapists: unknown
Therapist contact: 10 to 15 min phone conversations weekly in addition to e-mail contact
Face-to-face contact: none
(2) Face-to-face CT
Duration: 14 weeks
Treatment protocol: participants complete 14 weekly individual CT sessions with a therapist
Therapists: unknown
Therapist contact: 14 x 90 min individual sessions
Face-to-face contact: 14 x 90 min individual sessions
(3) Waiting list control
Duration: 14 weeks
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 3 month and 1 year follow-ups
Primary outcome:
(1) social phobia symptoms: Anxiety Disorders Interview Schedule (Fear and Avoidance Scale) for DSM-
IV; Social Phobia Weekly Summary Scale; Liebowitz Social Anxiety Scale; Fear of Negative Evaluation Scale;
Social Phobia Scale; Social Interaction and Anxiety Scale
Secondary outcome:
(1) quality of life: Sheehan Disability Scale
Starting date January, 2013
Contact information Professor David M Clark; Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental
Psychology, Tinbergen Building, 9 South Parks Road; david.clark@psy.ox.ac.uk
Notes
130Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Kok 2012
Trial name or title Effectiveness and cost-effectiveness of web-based treatment for phobic outpatients on a waiting list for psy-
chotherapy: Protocol of a randomised controlled trial
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia, Agoraphobia, Specific Phobia
Method of diagnosis: CIDI
Age: 18 years or older
Country of residence: the Netherlands
Psychiatric co-morbidity: included, expect Bipolar Disorder or Psychosis
Co-use of adjunct therapy: unknown
Co-use of medication: included if stable during treatment
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail support from a therapist
Duration: 5 weeks
Treatment protocol: participants complete online modules on psychoeducation, exposure, and relapse pre-
vention with e-mail support from a therapist for module exercises
Therapists: master’s level clinical psychology students
Therapist contact: amount unknown; coaching through a secure online message system
Face-to-face contact: none
(2) Self-help bibliotherapy
Duration: 5 weeks
Treatment protocol: participants receive a self-help book for phobias free in the mail, however, they are given
no instructions or expectations
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 3, 6, 9, and 12 month follow-up
Primary outcome:
(1) phobia symptoms: Fear Questionnaire
(2) general anxiety symptoms: Beck Anxiety Inventory
Secondary outcome:
(1) quality of life: EuroQol 5-D
(2) treatment satisfaction: Client Satisfaction Questionnaire
Starting date October, 2010
Contact information Robin N Kok, Department of Clinical Psychology and the EMGO institute for Health and Care Research,
Faculty of Psychology and Education, VU University Amsterdam, Van der Boechorststraat 1, 1081, BT
Amsterdam, The Netherlands; r.n.kok@vu.nl
Notes
131Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lindner 2013
Trial name or title ACT-smart: Smartphone-supplemented iCBT for social phobia and/or panic disorder
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder
Method of diagnosis: SCID-IV
Age: 18 years or older
Country of residence: Sweden
Psychiatric co-morbidity: excluded if another condition requiring specialized treatment
Co-use of adjunct therapy: excluded
Co-use of medication: included if stable for past 3 months
Interventions Participants randomly assigned to one of:
(1) Internet-based CBT plus smartphone with e-mail support
Duration: 10 online modules over 10 weeks
Treatment protocol: participants complete online modules on psychoeducation, relaxation, cognitive re-
structuring, and exposure, with e-mail and Skype support from a therapist for module exercises
Therapists: unknown
Therapist contact: 15 min/week; feedback and support provided in response to participants’ homework
completion
Face-to-face contact: none
(2) Unguided Internet-based CBT plus smartphone
Duration: 10 online modules over 10 weeks
Treatment protocol: participants complete online modules on psychoeducation, relaxation, cognitive re-
structuring, and exposure, with e-mail and Skype support from a therapist for module exercises
Therapists: unknown
Therapist, face-to-face contact: none
(3) Waiting list control
Duration: 10 weeks
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 1, 3, 6, and 12 month follow-ups
Primary outcome:
(1) panic disorder symptoms: Panic Disorder Severity Rating Scale
(2) social phobia symptoms: Liebowitz Social Anxiety Scale
(3) general anxiety: GAD-7
Secondary outcome:
(1) quality of life: Quality of Life Inventory
Starting date 2013, October
Contact information Per Carlbring, Professor, Stockholm University
Notes
132Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Miclea 2014
Trial name or title PAXonline: A randomized controlled trial assessing the efficacy of an Internet-based cognitive behavior
intervention for panic disorder
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Panic Disorder
Method of diagnosis: SCID-IV
Age: 18 to 65 years
Country of residence: Romania
Psychiatric co-morbidity: included, except severe Depression, Substance Abuse, Personality Disorders, psy-
chotic disorders, mental retardation
Co-use of adjunct therapy: excluded
Co-use of medication: excluded if using benzodiazepines
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail support
Duration: 16 online modules over 12 weeks
Treatment protocol: participants complete online modules on psychoeducation, relaxation, cognitive re-
structuring, and exposure, with e-mail and Skype support from a therapist for module exercises
Therapists: unknown
Therapist contact: feedback and support provided in response to participants’ homework completion
Face-to-face contact: none
(2) Unguided Internet-based CBT
Duration: 16 online modules over 12 weeks
Treatment protocol: participants complete online modules on psychoeducation, relaxation, cognitive re-
structuring, and exposure
Therapists: unknown
Therapist, face-to-face contact: none
(3) Waiting list control
Duration: 12 weeks
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 1, 3, 6, and 12 month follow-ups
Primary outcome:
(1) panic disorder symptoms: Panic Disorder Severity Rating Scale, Agoraphobic Cognitions Questionnaire,
Body Sensations Questionnaire
Starting date May, 2014
Contact information Mircea Miclea, Babes-Bolyai University, School of Psychology and Educational Sciences, Department of
Psychology 37, Republicii Street, Cluj - Napoca, Cluj, Romania, 400015; Tel: +40 753 529 753; liviugcrisan.
neuro@gmail.com
Notes
133Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Rollman 2012
Trial name or title Online treatments for mood and anxiety disorders in primary care
Methods Randomised controlled trial
Participants 18 to 75 years of age
Current major depression, panic and/or generalized anxiety disorder on PRIME-MD
Diagnosis: DSM-IV Panic Disorder, Generalized Anxiety Disorder, or MDD (not included in review)
Method of diagnosis: PRIME-MD
Age: 18 to 75 years
Country of residence: USA
Psychiatric co-morbidity: included, except Substance Abuse, Psychosis, Bipolar Disorder
Co-use of adjunct therapy: excluded
Co-use of medication: unknown
Interventions Participants randomly assigned to one of:
(1) Internet-based CBT with e-mail support
Duration: unknown
Treatment protocol: participants complete online treatment modules for anxiety with weekly e-mail support
from a therapist
Therapist, face-to-face contact: unknown
(2) Internet-based CBT with e-mail support and online support group
Duration: unknown
Treatment protocol: participants complete online treatment modules for anxiety with weekly e-mail support
from a therapist
Therapist, face-to-face contact: unknown
(3) Usual care
Duration: unknown
Therapist, face-to-face contact: variable by type of intervention provided as part of usual care
Outcomes Timepoints for assessment: pre-treatment and 6 or 12 month follow-ups
Primary outcome:
(1) general anxiety symptoms: Hamilton Rating Scale for Anxiety
(2) general anxiety: GAD-7
Secondary outcome:
(1) quality of life: WHO Health and Work Performance Questionnaire, SF-12
Starting date 2011, November
Contact information Bruce Rollman, University of Pittsburgh
Notes NCT01482806
134Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Titov 2012
Trial name or title A randomized controlled trial of the effects of disorder-specific vs. trans-diagnostic and self-guided vs. guided
Internet-administered treatment on symptoms of social phobia in Australian adults
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: MINI
Age: 18 to 64 years
Country of residence: Australia
Psychiatric co-morbidity: included, except Psychosis
Co-use of adjunct therapy: excluded
Co-use of medication: included if stable dose for past month
Interventions Participants randomly assigned to one of:
(1) Unguided disorder-specific Internet-based CBT
Duration: 5 online modules over 8 week
Treatment protocol: participants complete online treatment modules for social phobia
Therapist, face-to-face contact: none
(2) Unguided Trans-diagnostic Internet-based CBT
Duration: 5 online modules over 8 week
Treatment protocol: participants complete online treatment modules for anxiety and depression
Therapist, face-to-face contact: none
(3) Disorder-specific Internet-based CBT with e-mail or phone support, or both
Duration: 5 online modules over 8 week
Treatment protocol: participants complete online treatment modules for social phobia with weekly phone
or e-mail support, or both, from a therapist
Therapist contact: weekly
Face-to-face contact: none
(4) Trans-diagnostic Internet-based CBT with e-mail or phone support, or both
Duration: 5 online modules over 8 week
Treatment protocol: participants complete online treatment modules for anxiety and depression with weekly
phone or e-mail support, or both, from a therapist
Therapist contact: weekly
Face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 6, 12, and 24 month follow-ups
Primary outcome:
(1) social phobia symptoms: MINI - Social Phobia Inventory
(2) general anxiety: GAD-7
Secondary outcome:
(1) quality of life: Sheehan Disability Scale
Starting date 2012, April
Contact information Nickolai Titov, Centre for Emotional Health, Department of Psychology, Building/Room C3A 724 Macquarie
University, North Ryde, NSW 2109
Notes ACTRN12612000430831
135Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Tulbure 2012
Trial name or title Internet treatment for social anxiety disorder in Romania
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Social Phobia
Method of diagnosis: SCID-IV
Age: 18 years or older
Country of residence: Romania
Psychiatric co-morbidity: included, except Borderline Personality Disorder or Psychosis
Co-use of adjunct therapy: excluded
Co-use of medication: included if stable dose for past month
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail support
Duration: 9 online modules over 9 weeks
Treatment protocol: participants complete online modules on psychoeducation, cognitive restructuring, and
exposure, with e-mail support from a therapist for module exercises
Therapist contact: feedback and support provided in response to participants’ homework completion
Face-to-face contact: none
(2) Waiting list control
Duration: 9 weeks
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment and 6 month follow-up
Primary outcome:
(1) social phobia symptoms: Liebowitz Social Anxiety Scale; Social Phobia Inventory; Social Interaction
Anxiety Scale; Social Phobia Screening Questionnaire
Starting date April, 2012
Contact information Bogdan Tudor Tulbure, Babes-Bolyai University, Cluj - Napoca, Cluj, Romania, 400084; Tel: 0040 745
753061; bogdan.tulbure@ubbcluj.ro
Notes
von Essen 2008
Trial name or title Treatment of post-traumatic stress disorder among parentsof children with cancer with cognitive behavioural
therapy over the Internet
Methods Randomised controlled trial
Participants Diagnosis: DSM-IV Post-traumatic Stress Disorder
Method of diagnosis: unknown
Age: 18 years or older
Country of residence: Sweden
Psychiatric co-morbidity: unknown
Co-use of adjunct therapy or medication: unknown
136Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
von Essen 2008 (Continued)
Interventions Participants randomly assigned to either:
(1) Internet-based CBT with e-mail support
Duration: unknown
Treatment protocol: participants complete online modules of CBT for PTSD with e-mail support from a
therapist
Therapists: unknown
Therapist contact: unknown
Face-to-face contact: none
(2) Waiting list control
Duration: unknown
Therapist, face-to-face contact: none
Outcomes Timepoints for assessment: pre- and post-treatment
Primary outcome:
(1) post-traumatic stress symptoms: unknown how these symptoms will be measured
Starting date Unknown
Contact information Louise von Essen, Uppsala universitet
Notes
137Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
D A T A A N D A N A L Y S E S
Comparison 1. Therapist-supported ICBT versus waiting list control
Outcome or subgroup title No. of
studies
No. of
participants Statistical method Effect size
1 Clinically Important
Improvement in Anxiety at
Post-Treatment
9 644 Risk Ratio (M-H, Random, 95% CI) 4.18 [2.42, 7.22]
2 Anxiety Symptom Severity at
Post-Treatment
24 1573 Std. Mean Difference (IV, Random, 95% CI) -1.12 [-1.39, -0.85]
3 General Anxiety Symptom
Severity at Post-Treatment
14 1004 Std. Mean Difference (IV, Random, 95% CI) -0.79 [-1.10, -0.48]
4 Quality of Life at Post-Treatment 20 1395 Std. Mean Difference (IV, Random, 95% CI) 0.51 [0.40, 0.61]
Comparison 2. Therapist-supported ICBT versus unguided CBT
Outcome or subgroup title No. of
studies
No. of
participants Statistical method Effect size
1 Clinically Important
Improvement in Anxiety at
Post-Treatment
1 Risk Ratio (M-H, Random, 95% CI) Totals not selected
2 Anxiety Symptom Severity at
Post-Treatment
4 253 Std. Mean Difference (IV, Random, 95% CI) -0.24 [-0.69, 0.21]
3 Anxiety Symptom Severity at
Follow-up
3 192 Std. Mean Difference (IV, Random, 95% CI) -0.30 [-0.58, -0.01]
4 General Anxiety Symptom
Severity at Post-Treatment
2 138 Mean Difference (IV, Random, 95% CI) 0.28 [-2.21, 2.78]
5 General Anxiety Symptom
Severity at Follow-up
2 138 Mean Difference (IV, Random, 95% CI) 0.72 [-2.12, 3.57]
6 Quality of Life at Post-Treatment 3 199 Std. Mean Difference (IV, Random, 95% CI) 0.07 [-0.37, 0.50]
7 Quality of Life at Follow-up 2 138 Std. Mean Difference (IV, Random, 95% CI) -0.19 [-0.53, 0.14]
138Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 3. Therapist-supported ICBT versus face-to-face CBT
Outcome or subgroup title No. of
studies
No. of
participants Statistical method Effect size
1 Clinically Important
Improvement in Anxiety at
Post-Treatment
4 365 Risk Ratio (M-H, Random, 95% CI) 1.09 [0.89, 1.34]
2 Clinically Important
Improvement in Anxiety at
Follow-up
3 279 Risk Ratio (M-H, Random, 95% CI) 1.10 [0.94, 1.27]
3 Anxiety Symptom Severity at
Post-Treatment
6 424 Std. Mean Difference (IV, Random, 95% CI) 0.09 [-0.26, 0.43]
4 Anxiety Symptom Severity at
Follow-Up
5 341 Std. Mean Difference (IV, Random, 95% CI) -0.21 [-0.42, 0.00]
5 General Anxiety Symptom
Severity at Post-Treatment
5 317 Std. Mean Difference (IV, Random, 95% CI) 0.17 [-0.35, 0.69]
6 General Anxiety Symptom
Severity at Follow-up
4 237 Std. Mean Difference (IV, Random, 95% CI) -0.16 [-0.42, 0.09]
7 Quality of Life at Post-Treatment 5 392 Std. Mean Difference (IV, Random, 95% CI) 0.26 [0.06, 0.45]
8 Quality of Life at Follow-up 4 316 Std. Mean Difference (IV, Random, 95% CI) 0.33 [0.11, 0.55]
139Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.1. Comparison 1 Therapist-supported ICBT versus waiting list control, Outcome 1 Clinically
Important Improvement in Anxiety at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 1 Therapist-supported ICBT versus waiting list control
Outcome: 1 Clinically Impor tant Improvement in Anxiety at Post-Treatment
Study or subgroup ICBT Waiting List Risk Ratio Weight Risk Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
Andersson 2012a 36/102 6/102 14.9 % 6.00 [ 2.64, 13.62 ]
Andersson 2012b 7/20 4/25 12.0 % 2.19 [ 0.74, 6.43 ]
Carlbring 2006 23/30 0/30 3.3 % 47.00 [ 2.99, 740.03 ]
Carlbring 2011 16/27 2/27 9.3 % 8.00 [ 2.03, 31.48 ]
Richards 2006 4/12 0/9 3.2 % 6.92 [ 0.42, 114.19 ]
Robinson 2010 39/47 19/48 20.3 % 2.10 [ 1.44, 3.04 ]
Spence 2011 14/23 4/19 13.6 % 2.89 [ 1.14, 7.33 ]
Titov 2009 19/24 3/21 12.1 % 5.54 [ 1.91, 16.12 ]
Titov 2010 16/40 3/38 11.2 % 5.07 [ 1.60, 16.01 ]
Total (95% CI) 325 319 100.0 % 4.18 [ 2.42, 7.22 ]
Total events: 174 (ICBT), 41 (Waiting List)
Heterogeneity: Tau2= 0.35; Chi2= 19.62, df = 8 (P = 0.01); I2=59%
Test for overall effect: Z = 5.13 (P < 0.00001)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours Waiting List Favours ICBT
140Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.2. Comparison 1 Therapist-supported ICBT versus waiting list control, Outcome 2 Anxiety
Symptom Severity at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 1 Therapist-supported ICBT versus waiting list control
Outcome: 2 Anxiety Symptom Severity at Post-Treatment
Study or subgroup ICBT Waiting List
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Andersson 2012a 102 29.94 (8.27) 102 42.38 (8.05) 4.9 % -1.52 [ -1.83, -1.21 ]
Andersson 2012b 23 34.66 (4.86) 26 35.7 (5.48) 4.3 % -0.20 [ -0.76, 0.37 ]
Berger 2009 31 36.77 (8.9) 21 48.33 (7.08) 4.1 % -1.39 [ -2.00, -0.77 ]
Carlbring 2001 21 33.86 (4.63) 20 45.43 (5.96) 3.7 % -2.13 [ -2.91, -1.35 ]
Carlbring 2006 30 13.83 (1.65) 30 21.98 (2.05) 3.2 % -4.32 [ -5.27, -3.38 ]
Carlbring 2007 29 22.58 (6.03) 28 37.08 (6.52) 4.0 % -2.28 [ -2.96, -1.60 ]
Carlbring 2011 27 0.99 (0.58) 27 1.48 (0.4) 4.3 % -0.97 [ -1.54, -0.40 ]
Furmark 2009a 40 34.43 (7.15) 40 45.54 (9.46) 4.5 % -1.31 [ -1.80, -0.83 ]
Johnston 2011 46 7.54 (5.7) 42 11.79 (4.6) 4.6 % -0.81 [ -1.25, -0.37 ]
Paxling 2011 44 32.14 (6.41) 45 39.6 (3.92) 4.6 % -1.40 [ -1.86, -0.93 ]
Richards 2006 12 13.53 (5.48) 9 17.5 (3.59) 3.3 % -0.80 [ -1.70, 0.11 ]
Robinson 2010 47 51.45 (12.28) 48 64.22 (11.81) 4.6 % -1.05 [ -1.48, -0.62 ]
Silfvernagel 2012 29 6.54 (4.97) 28 13.81 (5.49) 4.2 % -1.37 [ -1.95, -0.79 ]
Spence 2011 23 44.78 (17.29) 19 51.79 (12.51) 4.1 % -0.45 [ -1.06, 0.17 ]
Titov 2008a 50 29.94 (9.05) 49 42.46 (11.54) 4.7 % -1.20 [ -1.63, -0.77 ]
Titov 2008b 41 29.01 (11.54) 40 44.79 (10.17) 4.5 % -1.44 [ -1.93, -0.94 ]
Titov 2008c 31 29.76 (8.02) 34 44.25 (13.56) 4.4 % -1.27 [ -1.81, -0.73 ]
Titov 2009 24 56.75 (10.78) 21 66.14 (8.7) 4.1 % -0.93 [ -1.55, -0.32 ]
Titov 2010 GAD 18 60.94 (9.4) 16 61.94 (11.16) 4.0 % -0.10 [ -0.77, 0.58 ]
Titov 2010 Panic 10 7.7 (3.97) 11 15 (6.72) 3.2 % -1.25 [ -2.21, -0.30 ]
Titov 2010 Social Phobia 12 13.25 (10.69) 11 18.36 (11.91) 3.5 % -0.44 [ -1.27, 0.39 ]
Titov 2011 19 7.63 (5.3) 17 8.88 (4.11) 4.0 % -0.26 [ -0.91, 0.40 ]
van Ballegooijen 2013 63 5.8 (4.9) 63 7.3 (4.9) 4.8 % -0.30 [ -0.66, 0.05 ]
Wims 2010 29 41.6 (6.3) 25 45.1 (6.15) 4.3 % -0.55 [ -1.10, -0.01 ]
-4 -2 0 2 4
Favours ICBT Favours Waiting List
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141Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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(... Continued)
Study or subgroup ICBT Waiting List
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Total (95% CI) 801 772 100.0 % -1.12 [ -1.39, -0.85 ]
Heterogeneity: Tau2= 0.36; Chi2= 133.74, df = 23 (P<0.00001); I2=83%
Test for overall effect: Z = 8.14 (P < 0.00001)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
Favours ICBT Favours Waiting List
Analysis 1.3. Comparison 1 Therapist-supported ICBT versus waiting list control, Outcome 3 General
Anxiety Symptom Severity at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 1 Therapist-supported ICBT versus waiting list control
Outcome: 3 General Anxiety Symptom Severity at Post-Treatment
Study or subgroup ICBT Waiting List
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Andersson 2012a 102 9.46 (6.42) 102 14 (8.35) 8.6 % -0.61 [ -0.89, -0.33 ]
Andersson 2012b 23 38.46 (3.52) 26 43.49 (5.41) 6.8 % -1.07 [ -1.67, -0.47 ]
Carlbring 2001 21 9.8 (8.4) 20 21.2 (10.4) 6.4 % -1.19 [ -1.86, -0.52 ]
Carlbring 2006 30 8.5 (5.5) 30 19.6 (9.9) 7.1 % -1.37 [ -1.93, -0.80 ]
Carlbring 2007 29 8.2 (7.9) 28 14.5 (9) 7.2 % -0.73 [ -1.27, -0.20 ]
Carlbring 2011 27 13.85 (9.21) 27 17.15 (8.04) 7.2 % -0.38 [ -0.91, 0.16 ]
Furmark 2009a 40 10.18 (6.28) 40 15.32 (9.27) 7.7 % -0.64 [ -1.09, -0.19 ]
Johnston 2011 46 34.87 (23.95) 42 48.48 (20.41) 7.9 % -0.60 [ -1.03, -0.18 ]
Paxling 2011 44 35.47 (4.67) 45 45.81 (2.46) 6.9 % -2.76 [ -3.34, -2.17 ]
Richards 2006 12 18.38 (11.92) 9 17.61 (8.03) 5.3 % 0.07 [ -0.79, 0.94 ]
Silfvernagel 2012 29 17.86 (8.5) 28 23.04 (9.38) 7.3 % -0.57 [ -1.10, -0.04 ]
-4 - 2 0 2 4
Favours ICBT Favours Waiting List
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142Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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(... Continued)
Study or subgroup ICBT Waiting List
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Spence 2011 23 7.91 (5.98) 19 10.63 (3.53) 6.7 % -0.53 [ -1.15, 0.09 ]
Titov 2011 19 37.05 (23.18) 17 43.06 (20.65) 6.5 % -0.27 [ -0.92, 0.39 ]
van Ballegooijen 2013 63 17 (12.7) 63 22 (12.7) 8.3 % -0.39 [ -0.74, -0.04 ]
Total (95% CI) 508 496 100.0 % -0.79 [ -1.10, -0.48 ]
Heterogeneity: Tau2= 0.26; Chi2= 66.04, df = 13 (P<0.00001); I2=80%
Test for overall effect: Z = 5.06 (P < 0.00001)
Test for subgroup differences: Not applicable
-4 - 2 0 2 4
Favours ICBT Favours Waiting List
Analysis 1.4. Comparison 1 Therapist-supported ICBT versus waiting list control, Outcome 4 Quality of
Life at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 1 Therapist-supported ICBT versus waiting list control
Outcome: 4 Quality of Life at Post-Treatment
Study or subgroup ICBT Waiting List
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Andersson 2012a 102 1.29 (2.04) 102 0.76 (1.69) 15.1 % 0.28 [ 0.01, 0.56 ]
Andersson 2012b 23 1.64 (1.5) 26 1 (1.56) 3.6 % 0.41 [ -0.16, 0.98 ]
Carlbring 2001 21 2.2 (1.2) 20 1.3 (1.2) 2.8 % 0.74 [ 0.10, 1.37 ]
Carlbring 2006 30 1.8 (1.6) 30 1.1 (1.6) 4.4 % 0.43 [ -0.08, 0.94 ]
Carlbring 2007 29 1.4 (1.8) 28 0.7 (1.8) 4.2 % 0.38 [ -0.14, 0.91 ]
Carlbring 2011 27 1.99 (1.73) 27 0.83 (1.61) 3.8 % 0.68 [ 0.13, 1.23 ]
Furmark 2009a 40 1.3 (1.98) 40 0.44 (1.64) 5.8 % 0.47 [ 0.02, 0.91 ]
Johnston 2011 46 18.17 (7.93) 42 14.12 (7.75) 6.3 % 0.51 [ 0.09, 0.94 ]
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Favours Waiting List Favours ICBT
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143Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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(... Continued)
Study or subgroup ICBT Waiting List
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Paxling 2011 44 1.34 (1.72) 45 0.44 (1.79) 6.4 % 0.51 [ 0.09, 0.93 ]
Richards 2006 12 59.09 (9.12) 9 51.73 (9.8) 1.4 % 0.75 [ -0.15, 1.65 ]
Robinson 2010 47 20.6 (9.37) 48 14.25 (7.71) 6.6 % 0.73 [ 0.32, 1.15 ]
Silfvernagel 2012 29 1.67 (1.47) 28 0.7 (1.7) 4.1 % 0.60 [ 0.07, 1.13 ]
Spence 2011 23 16.78 (9.42) 19 11.89 (6.67) 3.0 % 0.58 [ -0.04, 1.20 ]
Titov 2008a 50 33.22 (12.93) 49 23.91 (14.95) 7.0 % 0.66 [ 0.26, 1.07 ]
Titov 2008b 41 33.77 (12.94) 40 25.08 (13.04) 5.7 % 0.66 [ 0.21, 1.11 ]
Titov 2008c 31 21.16 (6.63) 34 18.5 (7.48) 4.7 % 0.37 [ -0.12, 0.86 ]
Titov 2009 24 22.17 (7.86) 21 15 (10.34) 3.1 % 0.77 [ 0.17, 1.38 ]
Titov 2010 40 19.52 (7.69) 38 13.58 (9.14) 5.5 % 0.70 [ 0.24, 1.16 ]
Titov 2011 19 16 (10.31) 17 14.53 (8.01) 2.7 % 0.15 [ -0.50, 0.81 ]
Wims 2010 29 15.63 (8.39) 25 14.47 (5.35) 4.0 % 0.16 [ -0.38, 0.70 ]
Total (95% CI) 707 688 100.0 % 0.51 [ 0.40, 0.61 ]
Heterogeneity: Tau2= 0.0; Chi2= 10.94, df = 19 (P = 0.93); I2=0.0%
Test for overall effect: Z = 9.26 (P < 0.00001)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
Favours Waiting List Favours ICBT
144Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.1. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 1 Clinically
Important Improvement in Anxiety at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 2 Therapist-supported ICBT versus unguided CBT
Outcome: 1 Clinically Impor tant Improvement in Anxiety at Post-Treatment
Study or subgroup ICBT Unguided CBT Risk Ratio Risk Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
Berger 2011 16/27 15/27 1.07 [ 0.67, 1.69 ]
0.01 0.1 1 10 100
Favours Unguided CBT Favours ICBT
Analysis 2.2. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 2 Anxiety Symptom
Severity at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 2 Therapist-supported ICBT versus unguided CBT
Outcome: 2 Anxiety Symptom Severity at Post-Treatment
Study or subgroup Guided ICBT Unguided CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Berger 2011 27 31.08 (8.88) 27 34.7 (7.83) 23.9 % -0.43 [ -0.97, 0.11 ]
Furmark 2009a 40 34.43 (7.15) 40 33.65 (9.09) 27.1 % 0.09 [ -0.34, 0.53 ]
Furmark 2009b 29 30.19 (7.93) 29 28.9 (9.06) 24.6 % 0.15 [ -0.37, 0.66 ]
Titov 2008c 31 29.76 (8.02) 30 38.15 (11.93) 24.4 % -0.82 [ -1.34, -0.29 ]
Total (95% CI) 127 126 100.0 % -0.24 [ -0.69, 0.21 ]
Heterogeneity: Tau2= 0.14; Chi2= 9.50, df = 3 (P = 0.02); I2=68%
Test for overall effect: Z = 1.05 (P = 0.30)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
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145Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Analysis 2.3. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 3 Anxiety Symptom
Severity at Follow-up.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 2 Therapist-supported ICBT versus unguided CBT
Outcome: 3 Anxiety Symptom Severity at Follow-up
Study or subgroup ICBT Unguided CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Berger 2011 27 30.8 (9.21) 27 33.1 (7.89) 28.3 % -0.26 [ -0.80, 0.27 ]
Furmark 2009a 40 28.29 (7.45) 40 31.99 (8.34) 41.1 % -0.46 [ -0.91, -0.02 ]
Furmark 2009b 29 28.38 (8.68) 29 29.36 (8.82) 30.6 % -0.11 [ -0.63, 0.40 ]
Total (95% CI) 96 96 100.0 % -0.30 [ -0.58, -0.01 ]
Heterogeneity: Tau2= 0.0; Chi2= 1.06, df = 2 (P = 0.59); I2=0.0%
Test for overall effect: Z = 2.06 (P = 0.040)
Test for subgroup differences: Not applicable
-4 - 2 0 2 4
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146Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Analysis 2.4. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 4 General Anxiety
Symptom Severity at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 2 Therapist-supported ICBT versus unguided CBT
Outcome: 4 General Anxiety Symptom Severity at Post-Treatment
Study or subgroup ICBT Unguided CBT
Mean
Difference Weight
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Furmark 2009a 40 10.18 (6.82) 40 10.5 (7.51) 62.9 % -0.32 [ -3.46, 2.82 ]
Furmark 2009b 29 10.9 (7.86) 29 9.59 (8.06) 37.1 % 1.31 [ -2.79, 5.41 ]
Total (95% CI) 69 69 100.0 % 0.28 [ -2.21, 2.78 ]
Heterogeneity: Tau2= 0.0; Chi2= 0.38, df = 1 (P = 0.54); I2=0.0%
Test for overall effect: Z = 0.22 (P = 0.82)
Test for subgroup differences: Not applicable
-10 -5 0 5 10
Favours ICBT Favours U nguided CBT
Analysis 2.5. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 5 General Anxiety
Symptom Severity at Follow-up.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 2 Therapist-supported ICBT versus unguided CBT
Outcome: 5 General Anxiety Symptom Severity at Follow-up
Study or subgroup ICBT Unguided CBT
Mean
Difference Weight
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Furmark 2009a 40 9.1 (9.64) 40 9.08 (7.97) 53.9 % 0.02 [ -3.86, 3.90 ]
Furmark 2009b 29 11.14 (9.78) 29 9.59 (6.09) 46.1 % 1.55 [ -2.64, 5.74 ]
Total (95% CI) 69 69 100.0 % 0.72 [ -2.12, 3.57 ]
Heterogeneity: Tau2= 0.0; Chi2= 0.28, df = 1 (P = 0.60); I2=0.0%
Test for overall effect: Z = 0.50 (P = 0.62)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
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147Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.6. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 6 Quality of Life at
Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 2 Therapist-supported ICBT versus unguided CBT
Outcome: 6 Quality of Life at Post-Treatment
Study or subgroup ICBT Unguided CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Furmark 2009a 40 1.3 (1.98) 40 1.44 (1.66) 36.3 % -0.08 [ -0.51, 0.36 ]
Furmark 2009b 29 1.12 (1.9) 29 1.56 (1.81) 31.7 % -0.23 [ -0.75, 0.28 ]
Titov 2008c 31 21.16 (6.63) 30 17.13 (8.54) 32.0 % 0.52 [ 0.01, 1.03 ]
Total (95% CI) 100 99 100.0 % 0.07 [ -0.37, 0.50 ]
Heterogeneity: Tau2= 0.08; Chi2= 4.75, df = 2 (P = 0.09); I2=58%
Test for overall effect: Z = 0.30 (P = 0.77)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
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148Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.7. Comparison 2 Therapist-supported ICBT versus unguided CBT, Outcome 7 Quality of Life at
Follow-up.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 2 Therapist-supported ICBT versus unguided CBT
Outcome: 7 Quality of Life at Follow-up
Study or subgroup ICBT Unguided CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Furmark 2009a 40 1.63 (1.64) 40 1.72 (1.4) 58.4 % -0.06 [ -0.50, 0.38 ]
Furmark 2009b 29 0.97 (1.83) 29 1.7 (1.96) 41.6 % -0.38 [ -0.90, 0.14 ]
Total (95% CI) 69 69 100.0 % -0.19 [ -0.53, 0.14 ]
Heterogeneity: Tau2= 0.0; Chi2= 0.86, df = 1 (P = 0.35); I2=0.0%
Test for overall effect: Z = 1.12 (P = 0.26)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
Favours Unguided CBT Favours ICBT
149Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.1. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 1 Clinically
Important Improvement in Anxiety at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 3 Therapist-supported ICBT versus face-to-face CBT
Outcome: 1 Clinically Impor tant Improvement in Anxiety at Post-Treatment
Study or subgroup ICBT Face-to-Face CBT Risk Ratio Weight Risk Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
Bergstrom 2010 30/50 34/54 45.0 % 0.95 [ 0.70, 1.29 ]
Carlbring 2005 20/25 16/24 35.4 % 1.20 [ 0.85, 1.69 ]
Hedman 2011 18/64 12/62 10.2 % 1.45 [ 0.77, 2.76 ]
Kiropoulos 2008 14/46 11/40 9.4 % 1.11 [ 0.57, 2.15 ]
Total (95% CI) 185 180 100.0 % 1.09 [ 0.89, 1.34 ]
Total events: 82 (ICBT), 73 (Face-to-Face CBT)
Heterogeneity: Tau2= 0.0; Chi2= 1.85, df = 3 (P = 0.60); I2=0.0%
Test for overall effect: Z = 0.87 (P = 0.39)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours ICBT Favours Face-to-Face CBT
150Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.2. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 2 Clinically
Important Improvement in Anxiety at Follow-up.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 3 Therapist-supported ICBT versus face-to-face CBT
Outcome: 2 Clinically Impor tant Improvement in Anxiety at Follow-up
Study or subgroup ICBT Face-to-Face CBT Risk Ratio Weight Risk Ratio
n/N n/N
M-
H,Random,95%
CI
M-
H,Random,95%
CI
Bergstrom 2010 35/50 32/54 27.5 % 1.18 [ 0.89, 1.57 ]
Carlbring 2005 23/25 21/24 62.1 % 1.05 [ 0.87, 1.27 ]
Hedman 2011 25/64 21/62 10.5 % 1.15 [ 0.73, 1.83 ]
Total (95% CI) 139 140 100.0 % 1.10 [ 0.94, 1.27 ]
Total events: 83 (ICBT), 74 (Face-to-Face CBT)
Heterogeneity: Tau2= 0.0; Chi2= 0.70, df = 2 (P = 0.70); I2=0.0%
Test for overall effect: Z = 1.20 (P = 0.23)
Test for subgroup differences: Not applicable
0.01 0.1 1 10 100
Favours ICBT Favours Face-to-Face CBT
151Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Analysis 3.3. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 3 Anxiety
Symptom Severity at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 3 Therapist-supported ICBT versus face-to-face CBT
Outcome: 3 Anxiety Symptom Severity at Post-Treatment
Study or subgroup ICBT Face-to-Face CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Andersson 2009 13 10.7 (6.8) 14 10.1 (5.6) 11.7 % 0.09 [ -0.66, 0.85 ]
Bergstrom 2010 50 12.2 (5.48) 54 10.9 (5.17) 19.9 % 0.24 [ -0.14, 0.63 ]
Carlbring 2005 25 14.68 (1.99) 24 14.58 (1.67) 15.6 % 0.05 [ -0.51, 0.61 ]
Hedman 2011 64 27.93 (6.66) 62 31.68 (7.94) 20.7 % -0.51 [ -0.86, -0.15 ]
Kiropoulos 2008 44 11.46 (4.07) 37 9.4 (4.27) 18.4 % 0.49 [ 0.05, 0.93 ]
Tillfors 2008 19 25.7 (6.27) 18 24 (6.69) 13.7 % 0.26 [ -0.39, 0.90 ]
Total (95% CI) 215 209 100.0 % 0.09 [ -0.26, 0.43 ]
Heterogeneity: Tau2= 0.12; Chi2= 14.65, df = 5 (P = 0.01); I2=66%
Test for overall effect: Z = 0.50 (P = 0.62)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
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152Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Analysis 3.4. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 4 Anxiety
Symptom Severity at Follow-Up.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 3 Therapist-supported ICBT versus face-to-face CBT
Outcome: 4 Anxiety Symptom Severity at Follow-Up
Study or subgroup ICBT Face-to-Face CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Andersson 2009 13 10.8 (5.3) 12 11.3 (5.4) 7.4 % -0.09 [ -0.88, 0.69 ]
Bergstrom 2010 50 10.35 (5.23) 54 10.55 (5.41) 30.8 % -0.04 [ -0.42, 0.35 ]
Carlbring 2005 25 14.55 (2.06) 24 14.63 (1.95) 14.5 % -0.04 [ -0.60, 0.52 ]
Hedman 2011 64 23.5 (7.76) 62 27.15 (7.36) 36.3 % -0.48 [ -0.83, -0.13 ]
Tillfors 2008 19 23 (5.78) 18 23.78 (7.49) 11.0 % -0.11 [ -0.76, 0.53 ]
Total (95% CI) 171 170 100.0 % -0.21 [ -0.42, 0.00 ]
Heterogeneity: Tau2= 0.0; Chi2= 3.53, df = 4 (P = 0.47); I2=0.0%
Test for overall effect: Z = 1.93 (P = 0.053)
Test for subgroup differences: Not applicable
-4 - 2 0 2 4
Favours ICBT Favours Face-to-Face CBT
153Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Analysis 3.5. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 5 General
Anxiety Symptom Severity at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 3 Therapist-supported ICBT versus face-to-face CBT
Outcome: 5 General Anxiety Symptom Severity at Post-Treatment
Study or subgroup ICBT Face-to-Face CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Andersson 2009 13 9.7 (8.2) 12 7.2 (6.1) 16.3 % 0.33 [ -0.46, 1.12 ]
Carlbring 2005 25 10.9 (7.1) 24 12.3 (7.7) 20.1 % -0.19 [ -0.75, 0.38 ]
Hedman 2011 64 12.1 (8.6) 62 14.2 (11.3) 23.4 % -0.21 [ -0.56, 0.14 ]
Kiropoulos 2008 42 9.93 (1.91) 38 8 (1.87) 21.6 % 1.01 [ 0.54, 1.48 ]
Tillfors 2008 19 5.8 (5.3) 18 6.2 (4.8) 18.7 % -0.08 [ -0.72, 0.57 ]
Total (95% CI) 163 154 100.0 % 0.17 [ -0.35, 0.69 ]
Heterogeneity: Tau2= 0.27; Chi2= 19.10, df = 4 (P = 0.00075); I2=79%
Test for overall effect: Z = 0.65 (P = 0.52)
Test for subgroup differences: Not applicable
-4 -2 0 2 4
Favours ICBT Favours Face-to-Face CBT
154Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
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Analysis 3.6. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 6 General
Anxiety Symptom Severity at Follow-up.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 3 Therapist-supported ICBT versus face-to-face CBT
Outcome: 6 General Anxiety Symptom Severity at Follow-up
Study or subgroup ICBT Face-to-Face CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Andersson 2009 13 6.8 (3.8) 12 8.5 (6.6) 10.4 % -0.31 [ -1.10, 0.48 ]
Carlbring 2005 25 10.7 (7.9) 24 12.3 (10.1) 20.7 % -0.17 [ -0.74, 0.39 ]
Hedman 2011 64 10.6 (10) 62 11.8 (9.2) 53.3 % -0.12 [ -0.47, 0.23 ]
Tillfors 2008 19 6.1 (3.7) 18 6.8 (3.6) 15.6 % -0.19 [ -0.83, 0.46 ]
Total (95% CI) 121 116 100.0 % -0.16 [ -0.42, 0.09 ]
Heterogeneity: Tau2= 0.0; Chi2= 0.19, df = 3 (P = 0.98); I2=0.0%
Test for overall effect: Z = 1.26 (P = 0.21)
Test for subgroup differences: Not applicable
-4 - 2 0 2 4
Favours ICBT Favours Face-to-Face CBT
155Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.7. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 7 Quality of Life
at Post-Treatment.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 3 Therapist-supported ICBT versus face-to-face CBT
Outcome: 7 Quality of Life at Post-Treatment
Study or subgroup ICBT Face-to-Face CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Bergstrom 2010 50 7.93 (1.4) 54 7.17 (1.75) 26.1 % 0.47 [ 0.08, 0.86 ]
Carlbring 2005 25 2 (1.4) 24 1.7 (1.5) 12.6 % 0.20 [ -0.36, 0.77 ]
Hedman 2011 64 1.6 (1.6) 62 1.1 (1.7) 32.2 % 0.30 [ -0.05, 0.65 ]
Kiropoulos 2008 40 66.55 (7.1) 36 65.98 (7.51) 19.6 % 0.08 [ -0.37, 0.53 ]
Tillfors 2008 19 2 (1.2) 18 2.1 (1.9) 9.6 % -0.06 [ -0.71, 0.58 ]
Total (95% CI) 198 194 100.0 % 0.26 [ 0.06, 0.45 ]
Heterogeneity: Tau2= 0.0; Chi2= 2.83, df = 4 (P = 0.59); I2=0.0%
Test for overall effect: Z = 2.51 (P = 0.012)
Test for subgroup differences: Not applicable
-4 - 2 0 2 4
Favours Face-to-Face CBT Favours ICBT
156Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.8. Comparison 3 Therapist-supported ICBT versus face-to-face CBT, Outcome 8 Quality of Life
at Follow-up.
Review: Therapist-suppor ted Internet cognitive behavioural therapy for anxiety disorders in adults
Comparison: 3 Therapist-supported ICBT versus face-to-face CBT
Outcome: 8 Quality of Life at Follow-up
Study or subgroup ICBT Face-to-Face CBT
Std.
Mean
Difference Weight
Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Bergstrom 2010 50 8.33 (1.42) 54 7.77 (1.73) 32.9 % 0.35 [ -0.04, 0.74 ]
Carlbring 2005 25 1.9 (1.4) 24 1.7 (1.3) 15.7 % 0.15 [ -0.42, 0.71 ]
Hedman 2011 64 1.8 (1.5) 62 1.1 (1.5) 39.5 % 0.46 [ 0.11, 0.82 ]
Tillfors 2008 19 2.1 (1.3) 18 2 (1.8) 11.9 % 0.06 [ -0.58, 0.71 ]
Total (95% CI) 158 158 100.0 % 0.33 [ 0.11, 0.55 ]
Heterogeneity: Tau2= 0.0; Chi2= 1.63, df = 3 (P = 0.65); I2=0.0%
Test for overall effect: Z = 2.90 (P = 0.0038)
Test for subgroup differences: Not applicable
-4 - 2 0 2 4
Favours Face-to-Face CBT Favours ICBT
A D D I T I O N A L T A B L E S
Table 1. Summary of included studies table
Study Diagnosis
and Co-
morbidity
Partici-
pant
Charac-
teristics
(M age,
age range,
sex, coun-
try of resi-
dence)
Co-Use of
Medica-
tion
N Intervention
Type & Therapist
Duration Contact
Compari-
son
Assessment
Points
Outcomes
An-
dersson et
al (2009)
Spe-
cific Pho-
bia, Spider
Type
co-mor-
bidity not
reported
Mage=25.
6 (4.1)
18-65
years
84.8%
women
Sweden
Not
reported
27 IBT
with email:
4 wks; 5
online mod-
ules
Mtotal time
spent
per partici-
pant = 25
min
Orienta-
tion and 1 3-
hour live ex-
posure ses-
sion
post-
treatment
12-month
follow-up
specific pho-
bia sx; gen-
eral anxiety
sx
157Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Summary of included studies table (Continued)
An-
dersson et
al (2012a)
Social
Phobia
co-mor-
bidity in-
cluded
but not re-
ported
ICBT
Mage=38.
1 (11.3)
WLC
Mage=38.
4 (10.9)
19-71
years
61%
women
Sweden
13.7% us-
ing medi-
cation
204 ICBT
with email:
9 wks; 9
online mod-
ules
Mtime
spent per
participant
per week =
15 min
Online Dis-
cussion
Group
post-
treatment
diagnostic
status; social
phobia sx;
QOL; gen-
eral anxiety
sx;
An-
dersson et
al (2012b)
GAD
22.2% So-
cial Pho-
bia, 19.8%
PD, 3.7%
OCD, 23.
5% MDD
ICBT
Mage=44.
4 (12.8)
IPDTM
age=36.4
(9.7)
WLC
Mage=39.
6 (13.7)
19-66
years
76.5%
women
Sweden
32.1% us-
ing medi-
cation
81 ICBT
with email:
8 wks; 8
online mod-
ules
Mtotal time
spent
per partici-
pant = 92
min (SD=
61)
(1) Waiting
List Control
(2) IPDT: 8
wks; 8
online mod-
ules
post-
treatment
diagnostic
status, GAD
sx; gen-
eral anxiety
sx; QOL
Berger et
al (2009)
Social
Phobia
26.9% co-
morbid
Axis I dis-
order
Mage=28.
9 (5.3)
19-43
years
44.2%
women
Switzer-
land,
France,
Belgium
Excluded 52 ICBT
with email:
10 wks; 5
online mod-
ules
M=5.5
emails from
participant
weekly
emails from
therapist
Waiting List
Control
post-
treatment
social pho-
bia sx; treat-
ment satis-
faction
Berger et
al (2011)
Social
Phobia
38% co-
morbid
Axis I dis-
order;
12% PD,
10% Spe-
cific Pho-
bia,
2% GAD,
Mage=37.
2 (11.2)
19-62
years
53.1%
women
Switzer-
land
7.4%
using med-
ication
81 ICBT
with email:
10 wks; 5
online mod-
ules
M=
6.16 (SD=4.
56; range=
1-17) emails
from partic-
ipant
M=
12.44 (SD=
2.85; range=
6-17) emails
(1)
Unguided
ICBT
10 weeks; 5
online mod-
ules
(2) Step-up
on demand
ICBT
post-
treatment
6-month
follow-up
diagnostic
status; social
pho-
bia sx; treat-
ment satis-
faction
158Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Summary of included studies table (Continued)
22%
MDD/
Dys-
thymia,
2% ED
from thera-
pist
Bergstrom
et al
(2010)
15.4% PD
84.6% PD
with Ago-
raphobia
co-mor-
bidity not
reported
ICBT
Mage=33.
8 (9.
7) GCBT
Mage=34.
6 (9.2)
18 years or
older
61.5%
women
Sweden
45% using
medica-
tion; 34%
SSRI/
SNRIs,
13% BZ,
24% BZ
derivatives
or neu-
roleptics;
5% TCAs
104 ICBT
with email:
10 wks; 10
online mod-
ules
M=11.
3 (SD=4.3)
emails from
therapist
Mtotal time
spent
per partici-
pant = 35.
4 min (SD=
19)
10 weekly 2-
hour
sessions of
GCBT
post-
treatment
6 month fol-
low-up
di-
agnostic sta-
tus; PD sx;
QOL
Carl-
bring et al
(2001)
PD
co-mor-
bidity in-
cluded
but not re-
ported
Mage=34
(7.5)
21-51
years
71%
women
Sweden
64% using
medica-
tion; 44%
SSRIs,
10% BZ,
5% TCAs,
5% beta-
blockers
41 ICBT
with email:
7-12 wks; 6
online mod-
ules
Mreciprocal
emails = 7.
5 (SD=1.2;
range=6-15)
Mtotal time
spent
per partici-
pant = 90
min
Waiting List
Control
post-
treatment
di-
agnostic sta-
tus; PD sx;
QOL;
general anx-
iety sx; treat-
ment satis-
faction
Carl-
bring et al
(2005)
49% PD
51% PD
with Ago-
raphobia
49% Anx-
iety Disor-
der; 6%
MDD
Mage=35.
0 (7.7)
18-60
years old
71%
women
Sweden
30.6% SS-
RIs, 8.
2% BZ, 6.
1% TCAs,
6.1% beta
blockers
49 ICBT
with email:
10 wks; 10
online mod-
ules
Mreciprocal
emails =15.
4 (SD=5.5;
range=4-31)
Mtotal time
spent per
participant
=150 min
10
weekly 45-
60 min ses-
sions of in-
dividual
CBT
post-
treatment
12-month
follow-up
di-
agnostic sta-
tus; PD and
agorapho-
bia sx; gen-
eral anxiety
sx; QOL
Carl-
bring et al
(2006)
PD
co-mor-
bidity in-
cluded
but not re-
ported
Mage=36.
7 (10)
18-60
years
60%
women
Sweden
54%
using med-
ication
60 ICBT with
email &
phone:
10 wks; 10
online mod-
ules
Mrecipro-
cal contacts
= 13.5 (SD
=4.4; range=
7-29)
Mtime
spent per
participant
per week =
12 min
Mlength
phone call =
Waiting List
Control
post-
treatment
diagnostic
status;
PD and ago-
raphobia sx;
general anx-
iety sx;
QOL; treat-
ment satis-
faction
159Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Summary of included studies table (Continued)
11.8 min
(range= 9.6-
15.6)
Carl-
bring et al
(2007)
Social
Phobia
co-mor-
bidity in-
cluded
but not re-
ported
ICBT
Mage=32.
4 (9.1)
WLC
Mage=32.
9 (9.2)
18-60
years
64.9%
women
Sweden
Included
but not re-
ported
60 ICBT with
email
& phone: 9
wks; 9
online mod-
ules
Mtime
spent per
participant
per week =
22 min
Mlength
phone call =
10.5 min
(SD= 3.6)
Waiting List
Control
post-
treatment
social pho-
bia sx; gen-
eral anxiety
sx; QOL
Carl-
bring et al
(2011)
9% PD
22% PD
with Ago-
raphobia
39% Social
Phobia
20% GAD
13% AD-
NOS
2% OCD,
2% PTSD,
20%
MDD, 7%
mild de-
pression;
15% Dys-
thymia
Mage=38.
8 (10.7)
22-63
years
76%
women
Sweden
26% using
an antide-
pressant or
anxiolytic
54 ICBT
with email:
10 wks;
6-10 online
modules
Mtime
spent per
participant
per week =
15 min
Attention
Control
10 wks of
posts in an
online sup-
port forum
post-
treatment
di-
agnostic sta-
tus; anxiety
sx (broadly)
; QOL; gen-
eral anxiety
sx
Fur-
mark et al
(2009a)
Social
Phobia
co-mor-
bidity not
reported
ICBT
Mage=35
(10.2)
WLC
Mage=35.
7 (10.9)
Bib Mage=
37.7 (10.
3)
18 years or
older
67.5%
women
Sweden
13.9% us-
ing medi-
cation
120 ICBT
with email:
9 wks; 9
online mod-
ules
Mtime
spent per
participant
per week =
15 min
(1) Biblio-
ther-
apy: 9 wks; 9
lessons
(2) Waiting
List Control
post-
treatment
social pho-
bia sx; gen-
eral anxiety
sx; QOL
160Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Summary of included studies table (Continued)
Fur-
mark et al
(2009b)
Social
Phobia
co-mor-
bidity not
reported
ICBT
Mage=34.
9 (8.4)
Bib Mage=
32.5 (8.5)
Applied
Relaxation
Mage=36.
4 (9.8)
18 years or
older
67.8%
women
Sweden
6.7%
using med-
ication
115 ICBT
with email:
9 wks; 9
online mod-
ules
Mtime
spent per
participant
per week =
15 min
(1) Biblio-
ther-
apy: 9 wks; 9
lessons
(2) Biblio-
therapy and
discus-
sion group:
9 wks; 9
lessons
(2) Internet-
based ap-
plied relax-
ation: 9 wks;
9 online
modules
post-
treatment
social pho-
bia sx; gen-
eral anxiety
sx; QOL
Hed-
man et al
(2011)
Social
Phobia
47.
5% Anxi-
ety Disor-
der, 15.1%
MDD
ICBT
Mage=35.
2 (11.
1) GCBT
Mage=35.
5 (11.6)
18-64
years
35.7%
women
Sweden
19.8% SS-
RIs, 4.8%
SNRIs
126 ICBT
with email:
15 wks; 15
online mod-
ules
M=17.
4 emails per
participant
Mtime
spent per
par-
ticipant per
week = 5.5
min (SD=3.
6)
15 weekly 2.
5-hour ses-
sions of
GCBT
post-
treatment
6 month fol-
low-up
diagnostic
status; social
phobia sx;
QOL; gen-
eral anxiety
sx
John-
ston et al
(2011)
20.6%
PD with or
with-
out Agora-
phobia
34.4% So-
cial Phobia
45% GAD
29% Anx-
iety Disor-
der, 9.
2% Affec-
tive Disor-
der, 32.1%
both disor-
ders
Mage=41.
62 (12.83)
19-79
years
58.8%
women
Australia
29%
using med-
ication
139 ICBT with
email &
phone:
10 wks; 8
online mod-
ules
M=
8.83 (SD=3.
29) emails
per partici-
pant
M=7.54
(SD=
2.43) phone
calls per par-
ticipant
Mtotal time
spent per
participant
= 69.09 min
(SD=32.29)
Waiting List
Control
post-
treatment
disorder-
specific sx;
general anx-
iety sx;
QOL; treat-
ment satis-
faction
Kiropou-
los et al
(2008)
41.9% PD
58.1% PD
with Ago-
Mage=38.
96 (11.13)
20-64
47.7% us-
ing medi-
cation
86 ICBT
with email:
6 wks, 6 re-
M=
18.24 (SD=
9.82) emails
12 weekly 1-
hour ses-
sions of in-
post-
treatment
diagnostic
status;
PD and ago-
161Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Summary of included studies table (Continued)
raphobia
72.1% co-
mor-
bid Mood,
Anxiety,
Somato-
form, or
Substance
Disorder
years
72.1%
women
Australia
quired & 2
optional
online mod-
ules
from thera-
pist
M=
10.64 (SD=
8.21) emails
from partic-
ipant
Mtotal time
spent per
participant
= 352 min
(SD=240)
dividual
CBT
raphobia sx;
general anx-
iety sx;
QOL; treat-
ment satis-
faction
Paxling et
al (2012)
GAD
co-mor-
bidity in-
cluded but
not fully
re-
ported; 22.
5% MDD
Mage=39.
3 (10.8)
18-66
years
79.8%
women
Sweden
37.1% us-
ing medi-
cation
89 ICBT
with email:
8 wks; 8
online mod-
ules
Mtotal time
spent
per partici-
pant = 97
min (SD=
52)
Waiting List
Control
post-
treatment
GAD sx;
general anx-
iety sx;
QOL
Richards
et al
(2006)
21.9% PD
78.1% PD
with Ago-
raphobia
22% So-
cial Pho-
bia, 13%
GAD, 9%
Specific
Pho-
bia, 6%
PTSD, 9%
MDD, 6%
Hypochon-
driasis, 3%
Somatiza-
tion
Mage=36.
59 (9.9)
18-70
years
68.8%
women
Australia
15.6%
anti-
depres-
sants, 12.
5% BZ, 9.
4% antide-
pressants
and BZ
23 ICBT
with email:
8 wks, 6
online mod-
ules
M=18 (SD=
6.5) emails
from thera-
pist
M=15.
3 (SD=12.8)
emails from
participant
Mtotal time
spent
per partici-
pant =376.
3 min (SD=
156.8)
Information
Only Con-
trol
Weekly sta-
tus updates
to clinician
and access to
online non-
CBT info
post-
treatment
di-
agnostic sta-
tus; PD and
agorapho-
bia sx; gen-
eral anxiety
sx; QOL
Robin-
son et al
(2010)
GAD
co-mor-
bidity in-
cluded
but not re-
ported
Mage=46.
96 (12.7)
18-80
years
68.3%
women
Australia
Included
but not re-
ported
101 ICBT with
email
and phone:
10 wks; 6
online mod-
ules
M=
33.2 (SD=4)
emails/
calls per par-
ticipant
Mtotal time
spent
per partici-
pant = 80.
Waiting List
Control
post-
treatment
diagnostic
status; GAD
sx;
QOL; treat-
ment satis-
faction
162Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Summary of included studies table (Continued)
8 min (SD=
22.6)
Silfver-
nagel et al
(2012)
7% PD
83% PD
with Ago-
raphobia
16% Social
Phobia
19% GAD
2%
ADNOS
32% co-
morbid
disorder
Mage=32.
4 (6.9)
20-45
years
65%
women
Sweden
47%
using med-
ication
57 ICBT
with email:
8 wks; 6-8
online mod-
ules
Mtime
spent
per partici-
pant = 15
min/week
Waiting List
Control
post-
treatment
di-
agnostic sta-
tus; PD sx;
general anx-
iety sx;
QOL
Spence et
al (2011)
PTSD
62%
MDD,
33% Social
Phobia,
31%
PD with or
without
Agorapho-
bia, 26%
GAD;
17% OCD
Mage=42.
6 (13.1)
21-68
years
81%
women
Australia
60%
using med-
ication
44 ICBT with
email
& phone: 8
wks; 7
online mod-
ules
M=
5.39 (SD=3.
54) emails
per partici-
pant
M=7.87
(SD=
2.56) phone
calls per par-
ticipant
Mtotal time
spent
per partici-
pant = 103.
91 min
(SD=96.53)
Waiting List
Control
post-
treatment
diagnostic
remis-
sion; PTSD
sx; QOL;
general anx-
iety sx; treat-
ment satis-
faction
Tillfors et
al (2008)
Social
Phobia
co-mor-
bidity in-
cluded
but not re-
ported
ICBT
Mage=32.
3 (9.7)
ICBT+exposure
Mage=
30.4 (6.3)
19-53
years
78.9%
women
Sweden
Included
but not re-
ported
38 ICBT
with email:
9 wks; 9
online mod-
ules
M=35
min per par-
ticipant per
week
ICBT with
email (9 on-
line
modules) +
5 live 2.25-
hour expo-
sure ses-
sions; 9 wks
post-
treatment
12-month
follow-up
social pho-
bia sx; gen-
eral anxiety
sx;
QOL; treat-
ment satis-
faction
Titov et al
(2008a)
Social
Phobia
co-mor-
bidity in-
Mage=38.
13 (12.24)
18-72
years
29%
using med-
ication
105 ICBT
with email:
10 wks; 6
Mtotal time
spent per
participant
Waiting List
Control
post-
treatment
social pho-
bia sx;
QOL; treat-
163Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Summary of included studies table (Continued)
cluded
but not re-
ported
59%
women
Australia
online mod-
ules
= 125 min
(SD=25)
ment satis-
faction
Titov et al
(2008b)
Social
Phobia
co-mor-
bidity in-
cluded
but not re-
ported
Mage=36.
79 (10.93)
20-61
years
62.96%
women
Australia
25.9% us-
ing medi-
cation
88 ICBT
with email:
10 wks; 6
online mod-
ules
Mtotal time
spent
per partici-
pant = 126.
76 min
(SD=30.89)
Waiting List
Control
post-
treatment
social pho-
bia sx;
QOL; treat-
ment satis-
faction
Titov et al
(2008c)
Social
Phobia
co-mor-
bidity in-
cluded
but not re-
ported
Mage=37.
97 (11.29)
18-64
years
61.05%
women
Australia
25.9% us-
ing medi-
cation
98 ICBT
with email:
10 wks; 6
online mod-
ules
Mtotal time
spent per
participant
= 168 min
(SD=40)
(1)
Unguided
ICBT
10 wks; 6
online mod-
ules
(2) Waiting
List Control
post-
treatment
social pho-
bia sx;
QOL; treat-
ment satis-
faction
Titov et al
(2009)
GAD
co-mor-
bidity in-
cluded
but not re-
ported
Mage=44
(12.98)
18 years or
older
76%
women
Australia
29%
using med-
ication
48 ICBT with
email
& phone: 9
wks, 6
online mod-
ules
M=23.
7 emails, 5.5
instant mes-
sages, and 4.
1 calls per
participant
Mtotal time
spent
per partici-
pant = 130
min
Waiting List
Control
post-
treatment
diagnostic
status; GAD
sx;
QOL; treat-
ment satis-
faction
Titov et al
(2010)
26.9% PD
with Ago-
raphobia
29.5% So-
cial Phobia
43.6%
GAD
28.
2% Anxi-
ety Disor-
der, 20.5%
Affec-
tive Disor-
der, 26.9%
both disor-
ders
Mage=39.
5 (13)
18 years or
older
67.9%
women
Australia
47.4% us-
ing medi-
cation
86 ICBT with
email
& phone: 8
wks; 6
online mod-
ules
M=23.
6emails
from thera-
pist
Mtotal time
spent
per partici-
pant = 46
min (SD=
16)
Waiting List
Control
post-
treatment
diagnostic
status; dis-
order-
specific anx-
iety sx;
QOL; treat-
ment satis-
faction
164Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Summary of included studies table (Continued)
Titov et al
(2011)
10%
PD with or
with-
out Agora-
phobia
11% Social
Phobia
28% GAD
51%
MDD
81% had a
co-
morbidity
Mage=43.
9 (14.6)
18-79
years
73%
women
Australia
54%
using med-
ication
74 ICBT with
email &
phone:
10 wks; 8
online mod-
ules
M=
5.45 (SD=3.
57) emails
per partici-
pant
M=9.35
(SD=
2.96) phone
calls per par-
ticipant
Mtotal time
spent per
participant
= 84.76 min
(SD=50.37)
Waiting List
Control
post-
treatment
disorder-
specific sx;
general anx-
iety sx;
QOL; treat-
ment satis-
faction
Van Balle-
gooijen et
al (2013)
78%
PD with or
with-
out Agora-
phobia
14% Ago-
raphobia
co-mor-
bidity in-
cluded
but not re-
ported
Mage=36.
6 (11.4)
18-67
years
67.5%
women
Nether-
lands
Included
but not re-
ported
126 ICBT
with email:
12 wks; 6
online mod-
ules
Mtotal time
spent
per partici-
pant = 1 to 2
hours
Waiting List
Control
post-
treatment
PD sx; gen-
eral anxiety
sx
Wims et al
(2010)
PD with or
with-
out Agora-
phobia
21% Social
Phobia,
31%
GAD,
10%
OCD,
7% PTSD,
21%
MDD
Mage=42.
08 (12.29)
18 years or
older
76%
women
Australia
31%
using med-
ication
59 ICBT
with email:
8 wks; 6
online mod-
ules
M=7.5
emails from
therapist
Mtotal time
spent
per partici-
pant = 75
min
Waiting List
Control
post-
treatment
diagnostic
status;
PD & ago-
raphobia sx;
QOL
Notes: All data in the above table represent only that included in/relevant to the present review.
ADNOS = anxiety disorder, not otherwise specified; Bib = Bibliotherapy; BZ = benzodiazepine; ED = eating disorder; GAD = generalized
anxiety disorder; GCBT = group cognitive behavioural therapy; IBT = internet-based behavioural therapy; ICBT = internet-based
cognitive behavioural therapy; IPDT = internet-based psychodynamic therapy; MDD = major depressive disorder; PD = panicdisorder;
QOL = quality of life; SNRI = serotonin-norepinephrine re-uptake inhibitor; SSRI = selective serotonin re-uptake inhibitor; sx =
symptoms; TCA = tricyclic antidepressant; VCBT = videoconferencing cognitive-behavioural therapy; WLC = waiting list control.
165Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Subgroup analyses. Comparison 1: therapist-supported ICBT versus waiting list control
Outcome and Subgroup No. of Stud-
ies
No. of
Participants
ICBT
Comparator
Statistical
Method
Effect Size I2
Clinically Important Improvement in Anxiety at Post-Treatment
a. By Disorder
i) Panic 2 42 39 RR, M-H,
Random
18.32 [2.50,
134.18]
3
ii) Social
Phobia
1 102 102 RR, M-H,
Random
6.00 [2.64, 13.
62]
--
iii) GAD 3 91 94 RR, M-H,
Random
2.58 [1.48, 4.
51]
36
iv) PTSD 1 23 19 RR, M-H,
Random
2.89 [1.14, 7.
33]
--
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
2 67 65 RR, M-H,
Random
6.12 [2.54, 14.
77]
0
b. By Therapist Contact
i) High 1 12 9 RR, M-H,
Random
6.92 [0.42,
114.19]
--
ii) Medium 6 226 224 RR, M-H,
Random
4.74 [2.66, 8.
46]
35
iii) Low 2 87 86 RR, M-H,
Random
2.80 [1.17, 6.
66]
57
c. By Research Group
i) Sweden 4 179 184 RR, M-H,
Random
5.76 [2.26, 14.
70]
53
ii) Australia
1
4 134 126 RR, M-H,
Random
3.06 [1.79, 5.
23]
43
iii) Australia
2
1 47 48 RR, M-H,
Random
2.10 [1.44, 3.
04]
--
166Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Subgroup analyses. Comparison 1: therapist-supported ICBT versus waiting list control (Continued)
Anxiety Symptom Severity at Post-Treatment
a. By Disorder
i) Panic 5 155 147 SMD,
Random
-1.58 [-2.79, -
0.37]
94
ii) Social
Phobia
7 324 314 SMD,
Random
-1.44 [-1.65, -
1.23]
25
iii) GAD 4 138 140 SMD,
Random
-0.91 [-1.40, -
0.43]
72
iv) PTSD 1 23 19 SMD,
Random
-0.45 [-1.06, 0.
17]
--
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
5 161 152 SMD,
Random
-0.75 [-1.10, -
0.40]
52
b. By Therapist Contact
i) High 1 12 9 SMD,
Random
-0.80 [-1.70, 0.
11]
--
ii) Medium 14 556 552 SMD,
Random
-1.30 [-1.68, -
0.92]
87
iii) Low 7 233 211 SMD,
Random
-0.87 [-1.23, -
0.50]
68
c. By Research Group
i) Sweden 10 408 409 SMD,
Random
-1.51 [-2.05, -
0.97]
91
ii) Australia
1
10 350 333 SMD,
Random
-0.85 [-1.09, -
0.61]
53
iii) Australia
2
1 12 9 SMD,
Random
-0.80 [-1.70, 0.
11]
--
167Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 2. Subgroup analyses. Comparison 1: therapist-supported ICBT versus waiting list control (Continued)
General Anxiety Symptom Severity at Post-Treatment
a. By Disorder
i) Panic 4 126 122 SMD,
Random
-0.74 [-1.35, -
0.13]
78
ii) Social
Phobia
3 171 170 SMD,
Random
-0.64 [-0.85, -
0.42]
0
iii) GAD 2 67 71 SMD,
Random
-1.91 [-3.57, -
0.26]
94
iv) PTSD 1 23 19 SMD,
Random
-0.53 [-1.15, 0.
09]
--
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
4 121 114 SMD,
Random
-0.49 [-0.75, -
0.23]
0
b. By Therapist Contact
i) High 1 12 9 SMD,
Random
0.07 [-0.79, 0.
94]
--
ii) Medium 10 410 408 SMD,
Random
-0.89 [-1.27, -
0.50]
85
iii) Low 3 86 79 SMD,
Random
-0.67 [-1.13, -
0.21]
48
c. By Research Group
i) Sweden 10 408 409 SMD,
Random
-0.95 [-1.33, -
0.56]
85
ii) Australia
1
3 88 78 SMD,
Random
-0.51 [-0.82, -
0.20]
0
iii) Australia
2
1 12 9 SMD,
Random
0.07 [-0.79, 0.
94]
--
168Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 3. Subgroup analyses. Comparison 2: therapist-supported ICBT versus unguided CBT
Outcome and Subgroup No. of Stud-
ies
No. of
Participants
ICBT
Comparator
Statistical
Method
Effect Size I2
Clinically Important Improvement in Anxiety at Post-Treatment
a. By Disorder
i) Panic 0 -- -- -- -- --
ii) Social
Phobia
1 27 27 RR, M-H,
Random
1.07 [0.67, 1.
69]
--
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 0 -- -- -- -- --
ii) Medium 0 -- -- -- -- --
iii) Low 1 27 27 RR, M-H,
Random
1.07 [0.67, 1.
69]
--
c. By Research Group
i) Sweden 1 27 27 RR, M-H,
Random
1.07 [0.67, 1.
69]
--
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
0 -- -- -- -- --
Anxiety Symptom Severity at Post-Treatment
169Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 3. Subgroup analyses. Comparison 2: therapist-supported ICBT versus unguided CBT (Continued)
a. By Disorder
i) Panic 0 -- -- -- -- --
ii) Social
Phobia
4 127 126 SMD,
Random
-0.24 [-0.69, 0.
21]
68
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 0 -- -- -- -- --
ii) Medium 3 100 99 SMD,
Random
-0.18 [-0.78, 0.
41]
77
iii) Low 1 27 27 SMD,
Random
-0.43 [-0.97, 0.
11]
--
c. By Research Group
i) Sweden 3 96 96 SMD,
Random
-0.04 [-0.38, 0.
30]
30
ii) Australia
1
1 31 30 SMD,
Random
-0.82 [-1.34, -
0.29]
--
iii) Australia
2
0 -- -- -- -- --
General Anxiety Symptom Severity at Post-Treatment
a. By Disorder
i) Panic 0 -- -- -- -- --
ii) Social
Phobia
2 69 69 MD, Random 0.28 [-2.21, 2.
78]
0
170Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 3. Subgroup analyses. Comparison 2: therapist-supported ICBT versus unguided CBT (Continued)
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 0 -- -- -- -- --
ii) Medium 2 69 69 MD, Random 0.28 [-2.21, 2.
78]
0
iii) Low 0 -- -- -- -- --
c. By Research Group
i) Sweden 2 69 69 MD, Random 0.28 [-2.21, 2.
78]
0
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
0 -- -- -- -- --
Clinically Important Improvement in Anxiety at Follow-up
a. By Disorder
i) Panic 0 -- -- -- -- --
ii) Social
Phobia
0 -- -- -- -- --
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
0 -- -- -- -- --
171Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 3. Subgroup analyses. Comparison 2: therapist-supported ICBT versus unguided CBT (Continued)
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 0 -- -- -- -- --
ii) Medium 0 -- -- -- -- --
iii) Low 0 -- -- -- -- --
c. By Research Group
i) Sweden 0 -- -- -- -- --
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
0 -- -- -- -- --
Anxiety Symptom Severity at Follow-up
a. By Disorder
i) Panic 0 -- -- -- -- --
ii) Social
Phobia
3 96 96 SMD,
Random
-0.30 [-0.58, -
0.01]
0
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact at Follow-up
i) High 0 -- -- -- -- --
ii) Medium 2 69 69 SMD,
Random
-0.31 [-0.65, 0.
03]
3
172Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 3. Subgroup analyses. Comparison 2: therapist-supported ICBT versus unguided CBT (Continued)
iii) Low 1 27 27 SMD,
Random
-0.26 [-0.80, 0.
27]
--
c. By Research Group
i) Sweden 3 96 96 SMD,
Random
-0.30 [-0.58, -
0.01]
0
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
0 -- -- -- -- --
General Anxiety Symptom Severity at Follow-up
a. By Disorder
i) Panic 0 -- -- -- -- --
ii) Social
Phobia
2 69 69 MD, Random 0.72 [-2.12, 3.
57]
0
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 0 -- -- -- -- --
ii) Medium 2 69 69 MD, Random 0.72 [-2.12, 3.
57]
0
iii) Low 0 -- -- -- -- --
c. By Research Group
i) Sweden 2 69 69 MD, Random 0.72 [-2.12, 3.
57]
0
173Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 3. Subgroup analyses. Comparison 2: therapist-supported ICBT versus unguided CBT (Continued)
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
0 -- -- -- -- --
Table 4. Subgroup analyses. Comparison 3: therapist-supported ICBT versus face-to-face CBT
Outcome and Subgroup No. of Stud-
ies
No. of
Participants
ICBT
Comparator
Statistical
Method
Effect Size I2
Clinically Important Improvement in Anxiety at Post-Treatment
a. By Disorder
i) Panic 3 121 118 RR, M-H,
Random
1.06 [0.85, 1.
32]
0
ii) Social
Phobia
1 64 62 RR, M-H,
Random
1.45 [0.77, 2.
76]
--
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 1 46 40 RR, M-H,
Random
1.11 [0.57, 2.
15]
--
ii) Medium 1 25 24 RR, M-H,
Random
1.20 [0.85, 1.
69]
--
iii) Low 2 114 116 RR, M-H,
Random
1.08 [0.72, 1.
60]
34
c. By Research Group
174Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 4. Subgroup analyses. Comparison 3: therapist-supported ICBT versus face-to-face CBT (Continued)
i) Sweden 3 139 140 RR, M-H,
Random
1.09 [0.88, 1.
36]
0
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
1 46 40 RR, M-H,
Random
1.11 [0.57, 2.
15]
--
Anxiety Symptom Severity at Post-Treatment
a. By Disorder
i) Panic 3 119 115 SMD,
Random
0.29 [0.03, 0.
54]
0
ii) Social
Phobia
2 83 80 SMD,
Random
-0.18 [-0.92, 0.
57]
76
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
1 13 14 SMD,
Random
0.09 [-0.66, 0.
85]
--
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 2 63 55 SMD,
Random
0.42 [0.05, 0.
78]
0
ii) Medium 1 25 24 SMD,
Random
0.05 [-0.51, 0.
61]
--
iii) Low 3 127 130 SMD,
Random
-0.08 [-0.63, 0.
46]
76
c. By Research Group
i) Sweden 5 171 172 SMD,
Random
-0.01 [-0.36, 0.
35]
59
175Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 4. Subgroup analyses. Comparison 3: therapist-supported ICBT versus face-to-face CBT (Continued)
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
1 44 37 SMD,
Random
0.49 [0.05, 0.
93]
--
General Anxiety Symptom Severity at Post-Treatment
a. By Disorder
i) Panic 2 67 62 SMD,
Random
0.42 [-0.75, 1.
60]
90
ii) Social
Phobia
2 83 80 SMD,
Random
-0.18 [-0.49, 0.
13]
0
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
1 13 12 SMD,
Random
0.33 [-0.46, 1,
12]
--
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 2 61 56 SMD,
Random
0.49 [-0.57, 1.
56]
86
ii) Medium 1 25 24 SMD,
Random
-0.19 [-0.75, 0.
38]
--
iii) Low 2 77 74 SMD,
Random
-0.06 [-0.53, 0.
41]
33
c. By Research Group
i) Sweden 4 121 116 SMD,
Random
-0.13 [-0.38, 0.
13]
0
ii) Australia
1
0 -- -- -- -- --
176Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 4. Subgroup analyses. Comparison 3: therapist-supported ICBT versus face-to-face CBT (Continued)
iii) Australia
2
1 42 38 SMD,
Random
1.01 [0.54, 1.
48]
--
Clinically Important Improvement in Anxiety at Follow-up
a. By Disorder
i) Panic 2 75 78 RR, M-H,
Random
1.09 [0.93, 1.
28]
0
ii) Social
Phobia
1 64 62 RR, M-H,
Random
1.15 [0.73, 1.
83]
--
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
0 -- -- -- -- --
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 0 -- -- -- -- --
ii) Medium 1 25 24 RR, M-H,
Random
1.05 [0.87, 1.
27]
--
iii) Low 2 114 116 RR, M-H,
Random
1.17 [0.92, 1.
50]
0
c. By Research Group
i) Sweden 3 139 140 RR, M-H,
Random
1.10 [0.94, 1.
27]
0
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
0 -- -- -- -- --
177Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 4. Subgroup analyses. Comparison 3: therapist-supported ICBT versus face-to-face CBT (Continued)
Anxiety Symptom Severity at Follow-up
a. By Disorder
i) Panic 2 75 78 SMD,
Random
-0.04 [-0.36, 0.
28]
0
ii) Social
Phobia
2 83 80 SMD,
Random
-0.39 [-0.71, -
0.08]
0
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
1 13 12 SMD,
Random
-0.09 [-0.88, 0.
69]
--
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 1 19 18 SMD,
Random
-0.11 [-0.76, 0.
53]
--
ii) Medium 1 25 24 SMD,
Random
-0.04 [-0.60, 0.
52]
--
iii) Low 3 127 128 SMD,
Random
-0.24 [-0.56, 0.
07]
32
c. By Research Group
i) Sweden 5 171 170 SMD,
Random
-0.21 [-0.42, 0.
00]
0
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
0 -- -- -- -- --
General Anxiety Symptom Severity at Follow-up
a. By Disorder
178Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 4. Subgroup analyses. Comparison 3: therapist-supported ICBT versus face-to-face CBT (Continued)
i) Panic 1 25 24 SMD,
Random
-0.17 [-0.74, 0.
39]
--
ii) Social
Phobia
2 83 80 SMD,
Random
-0.14 [-0.45, 0.
17]
0
iii) GAD 0 -- -- -- -- --
iv) PTSD 0 -- -- -- -- --
v) Specific
Phobia
1 13 12 SMD,
Random
-0.31 [-1.10, 0.
48]
--
vi) Trans-di-
agnostic
0 -- -- -- -- --
b. By Therapist Contact
i) High 1 19 18 SMD,
Random
-0.19 [-0.83, 0.
46]
--
ii) Medium 1 25 24 SMD,
Random
-0.17 [-0.74, 0.
39]
--
iii) Low 2 77 74 SMD,
Random
-0.15 [-0.47, 0.
17]
0
c. By Research Group
i) Sweden 4 121 116 SMD,
Random
-0.16 [-0.42, 0.
09]
0
ii) Australia
1
0 -- -- -- -- --
iii) Australia
2
0 -- -- -- -- --
179Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A P P E N D I C E S
Appendix 1. CCDANCTR update search (25 September 2014)
#1 (internet* or online or web*):ti
#2 (*phobi* or panic or “anxiety disorder*” or (anxiety and depression) or GAD or “general* anxiety” or OCD or obsess* or PTSD or
*trauma* or “stress disorder*”):ti
#3 (assisted or administer* or coach* or guided or guidance or *therapist* or ((telephone or email) next (support or assist*))):ti,ab
#4 (#1 and #2 and #3)
#5 (2012* or 2013* or 2014*):yr,xdd
[ti:title; ab:abstract; yr:year; xdd:record entry date]
C O N T R I B U T I O N S O F A U T H O R S
This review was prepared primarily by Dr Olthuis in close collaboration with respect to its content (search criteria, search methods,
data analysis and interpretation) with Dr Watt and Dr Stewart. Data extraction and ROB assessment were completed by Dr Olthuis
and Ms Bailey. Dr Hayden provided an extensive contribution with respect to Cochrane protocol and methods throughout the review
process and the preparation of the review manuscript.
D E C L A R A T I O N S O F I N T E R E S T
None of the authors have known competing interests.
S O U R C E S O F S U P P O R T
Internal sources
•Dalhousie University Department of Psychology and Neuroscience and Department of Psychiatry, Canada.
Dr Stewart is supported by the Department of Psychology and Neuroscience and the Department of Psychiatry at Dalhousie
University.
•Saint Francis Xavier University Department of Psychology, Canada.
Dr Watt is supported by the Department of Psychology at Saint Francis Xavier University.
•Killam Graduate Student Scholarship (Dalhousie University), Canada.
Dr Olthuis’s graduate studies at the time of completion of this review were supported by a Killam Graduate Student Scholarship.
•Dalhousie University Department of Community Health and Epidemiology, Canada.
Dr Hayden is supported by the Department of Community Health and Epidemiology at Dalhousie University for administrative
support and office space.
•Dalhousie University Department of Psychology, Canada.
Ms Bailey is supported by the Department of Psychology at Dalhousie University.
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External sources
•Nova Scotia Health Research Foundation, Canada.
This project was supported by a Knowledge Transfer/Exchange Systematic Review Grant to Dr Watt, Dr Olthuis, and Dr Stewart
from the Nova Scotia Health Research Foundation.
•Canadian Institutes of Health Research, Vanier Canada Graduate Scholarship, Canada.
Dr Olthuis’s graduate studies at the time of completion of this review were supported by a Vanier Canada Graduate Scholarship from
the Canadian Institutes of Health Research.
•Canadian Institutes of Health Research, Pain in Child Health Initiative, Canada.
Ms Bailey is supported by Pain in Child Health, a strategic training initiative by the Canadian Institutes of Health Research.
•Nova Scotia Health Research Foundation, Canada.
The Nova Scotia Health Research Foundation provides infrastructure funding to Dr Hayden to support to the Nova Scotia Cochrane
Resource Centre.
•Canadian Chiropractic Research Foundation/Dalhousie University, Canada.
Dr Hayden is supported by a Research Professorship Award from the Canadian Chiropractic Research Foundation.
D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W
Several changes were made to our protocol (Olthuis 2011) during the transition from protocol to full review. They are listed here.
1. In the protocol, we planned to assess the efficacy of a broader range of distance delivery treatments including Internet-supported
CBT and also CBT delivered by phone or videoconferencing. A reviewer commented that these different types of distance delivery
were too broad and dissimilar to be included in the same review. As such, we have now focused the review only on Internet-supported
CBT interventions to increase homogeneity across included studies and to improve interpretation of findings. With the exception of
the characteristics of the experimental intervention, the protocol remains largely unchanged.
2. In the protocol we stated that ’relaxation’ could qualify as a CBT intervention. This was an oversight; on further consideration the
review team decided there were significant differences between relaxation alone and the key components of CT, BT, and CBT. Thus,
while relaxation could qualify as part of an intervention of interest if it was presented as a component of a more comprehensive CBT
package, we did not include therapist-supported Internet-based relaxation as an intervention of interest.
3. We originally planned to include quasi-RCTs, as stated in our protocol. However, the field was more developed than we anticipated.
Thus, in order to increase the strength of the evidence within the review, we elected to exclude quasi-RCTs and include only RCTs.
4. In the original protocol we had designated the first primary outcome as the efficacy of therapist-supported ICBT in reducing anxiety,
as measured by either remission of anxiety disorder diagnosis or reduction in anxiety symptom severity. With respect to the latter,
we specified that a reduction in anxiety symptom severity could be indexed by measures of either disorder-specific anxiety symptoms
or anxiety symptoms in general. On further consideration, we decided amalgamating these two types of measures resulted in lost
information about the efficacy of the intervention. Thus, in the review we indexed the efficacy of therapist-supported ICBT in reducing
anxiety as measured by (a) remission of anxiety disorder diagnosis, (b) a reduction in disorder-specific anxiety symptoms, and (c) a
reduction in anxiety symptoms in general.
5. The protocol listed our time periods for outcome assessment as short-term (less than 12 months) and long-term (12 months or
greater). Later, we decided that we wanted to select one time period that would maximize the number of studies that could be included
and would be clinically meaningful. Thus, we consolidated our follow-up assessment to one time point, 6 to 12 months.
6. In the original protocol, we planned to assess dropout and treatment adherence as a secondary outcome. After reviewing the included
studies, we observed that so many different methods of indexing dropout were used (e.g., number of participants not completing entire
treatment protocol, number of participants not completing 75% of treatment protocol, number of participants not completing follow-
up questionnaires) that combining these measures across studies did not lend itself to any type of meaningful interpretation. As such,
rather than examine dropout and treatment adherence as a separate outcome, we elected to assess this outcome via risk of bias and
sensitivity analyses. More specifically, in the risk of bias evaluation, we identified studies that did not use an adequate ITT paradigm in
their data analytic procedure; then we excluded these studies using sensitivity analyses.
7. We removed the originally planned sensitivity analysis which would have excluded cross-over trials with carry-over effects. The
inclusion of this sensitivity analysis in our protocol was an oversight as we had elected to only include data from participants before
they crossed over to their second treatment condition.
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8. In response to suggestions by review editors, we added in a subgroup analysis (by research group) and two sensitivity analyses
(exclusion of studies with an active waiting list control; assuming that treatment dropouts were responders on dichotomous outcomes)
that were not proposed in the original published protocol.
N O T E S
An updated search conducted in September 2014 identified four new completed studies, seven previously ongoing studies that have
now been completed, and three new ongoing studies that should be included in the present review. This is a fast-moving area of research
and as such we plan to conduct an update of this review after its publication, in which these new studies will be fully incorporated.
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