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The COVID-19 pandemic: The ‘black swan’ for mental health care and a turning point for e-health

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The COVID-19 pandemic: The ‘black swan’ for mental health
care and a turning point for e-health
Tim R. Wind, Marleen Rijkeboer, Gerhard Andersson, Heleen
Riper
PII: S2214-7829(20)30046-4
DOI: https://doi.org/10.1016/j.invent.2020.100317
Reference: INVENT 100317
To appear in: Internet Interventions
Received date: 17 March 2020
Revised date: 18 March 2020
Accepted date: 18 March 2020
Please cite this article as: T.R. Wind, M. Rijkeboer, G. Andersson, et al., The COVID-19
pandemic: The ‘black swan’ for mental health care and a turning point for e-health,
Internet Interventions (2020), https://doi.org/10.1016/j.invent.2020.100317
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The COVID-19 pandemic: The black swan for mental health care and a turning point for e-
health
Tim R. Wind, PhD1, Marleen Rijkeboer, PhD2 Gerhard Andersson, PhD3, & Heleen Riper,
PhD 4 5
1Foundation Centrum '45, Oegstgeest, The Netherlands | partner in Arq Psychotrauma Expert
Group, Nienoord 5, 1112 XE Diemen, The Netherlands
2Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience,
Maastricht University, The Netherlands
3Department of Behavioural Science and Learning, Linköping University, Linköping, Sweden
and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
4Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit,
Amsterdam, The Netherlands
5 Department of Research and Innovation, GGZ in Geest/Amsterdam University Medical
Center, VU University Medical Center, Amsterdam, Netherlands
In February 2020, Duan and Zhu (2020) stressed the need for a solid Chinese evidence-based
mental health care system in times of public health emergencies such as the outbreak of the
Coronavirus disease-2019 (COVID-19). That would enable treatment of people who suffer
from mental health problems in relation to the epidemic. The WHO has meanwhile labelled
the Coronavirus a pandemic, and it is now hitting Europe, the USA, and Australia hard as
well. In an attempt to reduce the risk of infections, many mental health care providers in
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afflicted countries are currently closing their doors for patients who need ambulatory face-to-
face therapy. They are simultaneously trying to replace some of these contacts with digital
therapies. Most probably, European mental health care institutions have yet to experience the
full impact of the coronavirus crisis. At the same time, the demand for mental health care
among infected patients and their relatives is expected to rise (Blumenstyk, 2020). Levels of
anxiety will increase, both through direct causes including fears of contamination, stress,
grief, and depression triggered by exposure to the virus, and through influences from the
consequences of the social and economic mayhem that is occurring on individual and societal
levels. We expect that this "black swan" moment (Blumenstyk, 2020) - an unforeseen event
that changes everything - will lead to a partly, though robust, shift in mental health care
provision towards online prevention, treatment, and care in the near future. We also need to
consider the role of psychological processes and fear that may cause further harm on top of
the pandemic (Asmundson, & Taylor, 2020).
The obvious solution to continue mental health care within a pandemic is to provide mental
health care at a „warm‟ distance by video-conferencing psychotherapy and internet
interventions. A systematic review showed that videoconferencing psychotherapy show
promising results for anxiety and mood disorders (Berryhill et al., 2019), and the evidence-
base for therapist-guided internet interventions is even stronger (Andersson, 2016; ). Yet,
despite two decades of evidence-based e-mental health services, numerous barriers have
stalled the overall implementation in routine care thus far (Vis et al., 2018; Tuerk et al.,
2019). One of the most important barriers highlighted, however, has been that e-mental health
has not been integrated as a normal part of routine care practice due to the lack of acceptance
by health professionals themselves (Topocoo et al., 2017). Myths on telehealth such as “the
therapeutic alliance can only be established face-to-face” have dominated the field, in spite of
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research showing the opposite (Berger, 2017). In that sense, learning curves in the adoption of
new e-mental health technologies by both patients and psychologists have progressed far
more slowly than initially expected, thus tallying with the estimate that it takes on average16
years for a health care innovation to be implemented (Rogers et al., 2017). There are however
exceptions in the world but progress is still slow.
In the Netherlands and elsewhere, we are now witnessing a phenomenon whereby the
outbreak of COVID-19 is hastening managers, ICT-staff, and clinicians to overcome all such
barriers overnight, from a pragmatic standpoint seldom seen before. The virus seems a
greater catalyst for the implementation of online therapy and e-health tools in routine practice
than two decades of many brilliant, but failed, attempts in this domain (Mohr et al., 2018).
After all, since predictions about COVID-19 are largely unclear as of yet, it is now time to
create a longer-term solution to the problem of heterogeneous patient populations, such as
those still active in the community and those that are house-bound or isolated in hospitals.
Videoconferencing and internet interventions could therefore be very helpful in mental health
care, as well as in physical care and can be easily upscaled to serve isolated regions and reach
across borders.
Thus, the “black swan virus” has already enabled wide-scale acceptance of videoconferencing
by health professionals and patients alike creating a win-win situation for both. We should
stress that e-mental health applications hold value far beyond the provision of
videoconferencing psychotherapy in the current situation of crisis. Countries hit by the
Corona virus may also consider adopting a wider public e-mental health approach, which
would focus additionally on prevention and on reaching people at risk for mental health
disorders. In this respect, not only guided but also fully self-guided interventions, such as self-
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help apps or online therapeutic modules, could also be applied in settings and countries with
scarce mental health resources (Christiani & Setiawan, 2018). We should also consider the
need for treatment development (for the psychological problems caused by corona virus
isolation), which is by far more rapid in the field of internet interventions than in traditional
psychotherapy (Andersson et al., 2019).
It is likely that the response to this emergency will be more than a temporary increase in
online work (Blumenstyk, 2020). Once mental health care institutions have developed the
capabilities of serving their patients via videoconferencing and other digital technologies,
there is little reason for them to give these up, in view of the many advantages (Blumenstyk,
2020; Tuerk et al., 2019).This black swan should be a call for action by encouraging providers
to move more rapidly towards blended care models (van der Vaart et al., 2014; Kooistra et al
2019). Agility, flexibility, and resilience are essential skills for 21-st-century institutions,
particularly when unforeseen disruptive viruses and devastating events driven by climate
change are likely to be increasingly common (Blumenstyk, 2020). We urge practitioners to
promptly start adopting e-mental health care applications, both as methods to continue their
care to current patients in need and as interventions to cope with the imminent upsurge in
mental health symptoms due to the coronavirus.
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... Thus, effective mental health services are essential and urgent under such a circumstance. In the post-pandemic era, online psychological interventions have been boosted and broadly accepted, as it is more accessible and efficient than traditional onsite or face-to-face psychotherapy (Wind et al., 2020). ...
... In the post-pandemic era, enormous needs for psychological interventions are yet to be fulfilled. Online psychological intervention can benefit a broad range of people with lower costs and higher accessibility without worrying about exposure to the infection (Wind et al., 2020). However, few studies reviewed online psychological interventions of COVID-19 related distress, and the effective settings are yet to be clarified. ...
Article
Full-text available
Objective A quantitative synthesis of online psychotherapies' effectiveness in managing COVID-19 related distress is lacking. This study aimed to estimate online psychological interventions' effectiveness and associated factors on COVID-19 related psychological distress. Methods Multi-databases including PubMed, EBSCO, ProQuest, and Cochrane were searched repeatedly till the end of June 2022. Hand-picking was also utilized for relevant papers. Depression, anxiety, stress, and quality of sleep were evaluated as outcomes. The risk of bias was evaluated using the Cochrane tool. Data analyses were conducted through Review Manager (version 5.4.1). Results A total of 13 studies involving 1,897 participants were included for meta-analysis. Results showed that online psychotherapy significantly reduced the levels of depression [standard mean difference, SMD = −0.45, 95% CI (−0.69, −0.20)], anxiety [SMD = −0.67, 95% CI (−0.99, −0.36)], and stress [SMD = −0.73, 95% CI (−1.11, −0.34)], but not quality of sleep [SMD = −0.53, 95% CI (−1.23, 0.17)]. In addition, guided therapies were more effective than self-help ones on reducing levels of anxiety (χ ² = 5.58, p = 0.02, and I ² = 82.1%), and ≤ 2 weeks' daily interventions were more effective on treating depression than 2-month weekly interventions (χ ² = 7.97, p = 0.005, I ² = 87.5%). Conclusion Online psychological interventions effectively reduced COVID-19 related depression, anxiety, and stress levels, and the effectiveness was influenced by settings like guidance and duration and frequency. Systematic review registration https://inplasy.com/inplasy-2022-7-0081/ , identifier: INPLASY202270081.
... psychotherapy using telecommunication technologies (Sampaio et al., 2021;Wind et al., 2020). The transition to virtual mental healthcare changed therapy itself. ...
... This dual experience of both positive J o u r n a l P r e -p r o o f and negative aspects corresponds to findings on tele-psychotherapy, tele-CAT and the online setting during COVID-19 reported elsewhere (Bianchi et al., 2022;Biancalani et al., 2021;Ellman, 2021;Feniger-Schaal et al., 2022). For example, this dual experience echoes studies on psychotherapy during the pandemic which show that many psychotherapists experienced significant interruptions to their practice due to lack of experience with tele-psychotherapy prior to the lockdown, patients' lack of privacy at home, and difficulties in communicationrelated to limited nonverbal communication in the online setting (Boldrini et al., 2020;Wind et al., 2020). At the same time they found their experiences with tele-psychotherapy to be better than expected with more opportunities to provide therapy during the lockdowns (Poletti et al., 2021). ...
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Since the outbreak of the COVID-19 pandemic in March 2020, mental health professionals have been called upon to cope with various challenges, including the shift to telehealth without prior training, overload in the workplace, increased risk of infection, and personal stressors relating to the pandemic. This article presents the qualitative findings of a larger international mixed-method study that explored the experiences of creative arts therapists around the globe during the first year of the pandemic (Feniger-Schaal et al., 2022). Twenty creative arts therapists were interviewed between July 2020 and March 2021. Transcriptions of the interviews were qualitatively analyzed through reflexive thematic analysis. Three main themes were identified: an experience of processing the losses caused by the pandemic, a restorative orientation that focused on adaptations the therapists made, and innovations that lead to personal and professional growth. Artistic engagement and creativity were found to be a resource when coping with losses and helped therapists adapt to the shift to tele-creative arts therapies (tele-CAT). Although this shift can lead to advances in the field of creative arts therapies, it requires further consideration, including the need for ethical guidelines, specific training, the development of digital methods that support the creative process, and dedicated supervision for therapists. The findings also point to the importance of psychological support to mitigate the burden therapists experience during stressful events.
... Early on in the pandemic, the importance of giving greater consideration to people with mental disorders in the context of contact restrictions and also enabling therapeutic services in a timely manner in accordance with applicable regulations was emphasised (e.g., [7,20]). In this context, the potential of e-mental health services was also repeatedly highlighted (e.g., [34]). ...
... There are many more opportunities here to adapt these offers to specific target groups (e.g., for people with mental disorders or young people). E-mental health services should play a key role in this, and the COVID-19 pandemic could thus represent a turning point for e-mental health (e.g., [34]). As another result of the study, physical activities can also be more focused on, according to applicable government pandemic measures. ...
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Background The COVID-19 pandemic was associated with far-reaching changes all over the world. Health care systems were and are also affected. Little is known about the impact of these changes and the duration of the pandemic on people with mental disorders. The aim of this longitudinal follow-up study was to investigate the mental health status, medical care provision, and attitudes towards the pandemic of these people at the end of the second pandemic lockdown in Germany in 2021, and to compare these findings with the results of 2020. Methods People with mental disorders currently receiving treatment in the psychiatric outpatient department of the University Hospital Leipzig, Germany, were asked about depressive symptoms (PHQ-9), self-reported medical care provision, attitudes and social and emotional aspects of the pandemic (social support [ESSI], perceived stress [PSS-4], loneliness [UCLA-3-LS], and resilience [BRS]) using structured telephone interviews. Results In total, N = 75 participants who had already participated in the first survey in 2020 took part in the follow-up telephone interviews. The most frequent clinician-rated diagnoses were attention deficit disorder/attention deficit hyperactivity disorder ( n = 21; 28.0%) and obsessive-compulsive disorder ( n = 16; 21.3%). In comparison to 2020, a significantly higher proportion of participants reported no problems in receiving medical care provision. Compared to the previous year, the resilience of the participants had significantly decreased. Depressive symptoms, social support, perceived stress, and loneliness remained stable. Significantly more participants felt restricted by the pandemic-related government measures in 2021 than in 2020. Conclusions This study highlights the importance for continued efforts to maintain stable medical care provision for people with mental disorders during the COVID-19 pandemic, as except for a decrease in resilience, mental health status remained stable. Nonetheless there is still a need for continued treatment to stabilise and improve this status.
... Dünyanın farklı yerlerindeki birinci basamak sağlık çalışanları, sanal danışma ve izleme ve mümkün uygulamalarının kullanımı yoluyla bakım sunumuna devam etmiştir. Bazı ülkelerde (örneğin ABD, Kanada) ve belirli hasta grupları için (örneğin ruh sağlığı ihtiyaçları olanlar) pandemiden önce uzaktan konsültasyon yapma fikri düşünülemezdi (Quartz,2020;The Conversation, 2020;Global News, 2020;Wind TR, Rijkeboer M, Andersson G, et al, 2020). Ne yazık ki, birçok kaynak yetersizliği çeken ülkelerde (Afrika, Latin Amerika) tele-tıp uygulamalarına geçme seçenekleri çok daha sınırlı olmuştur. ...
... A recent review of different video-conferencing and internet-based psychotherapies, however, showed that independent of communication modalities and the amount of contact, therapeutic alliance ratings were comparable to those found in face-to-face therapy (Berger, 2017). In view of multiple advantages such as flexibility in scheduling the appointments and the increased uptake of tele-and (guided) virtual mental health in later stages of the pandemic, mental health care institutions may continue to serve their patients via tele-or virtual mental health solutions or through a mixture of both by providing blended care even beyond pandemic times (Wind, Rijkeboer, Andersson, & Riper, 2020). ...
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Mitigating the COVID-19 related disruptions in mental health care services is crucial in a time of increased mental health disorders. Numerous reviews have been conducted on the process of implementing technology-based mental health care during the pandemic. The research question of this umbrella review was to examine what the impact of COVID-19 was on access and delivery of mental health services and how mental health services have changed during the pandemic. A systematic search for systematic reviews and meta-analyses was conducted up to August 12, 2022, and 38 systematic reviews were identified. Main disruptions during COVID-19 were reduced access to outpatient mental health care and reduced admissions and earlier discharge from inpatient care. In response, synchronous telemental health tools such as videoconferencing were used to provide remote care similar to pre-COVID care, and to a lesser extent asynchronous virtual mental health tools such as apps. Implementation of synchronous tools were facilitated by time-efficiency and flexibility during the pandemic but there was a lack of accessibility for specific vulnerable populations. Main barriers among practitioners and patients to use digital mental health tools were poor technological literacy, particularly when preexisting inequalities existed, and beliefs about reduced therapeutic alliance particularly in case of severe mental disorders. Absence of organizational support for technological implementation of digital mental health interventions due to inadequate IT infrastructure, lack of funding, as well as lack of privacy and safety, challenged implementation during COVID-19. Reviews were of low to moderate quality, covered heterogeneously designed primary studies and lacked findings of implementation in low- and middle-income countries. These gaps in the evidence were particularly prevalent in studies conducted early in the pandemic. This umbrella review shows that during the COVID-19 pandemic, practitioners and mental health care institutions mainly used synchronous telemental health tools, and to a lesser degree asynchronous tools to enable continued access to mental health care for patients. Numerous barriers to these tools were identified, and call for further improvements. In addition, more high quality research into comparative effectiveness and working mechanisms may improve scalability of mental health care in general and in future infectious disease outbreaks.
... In addition, the current pandemic-related restrictions (particularly social distancing) made face-to-face mental health care difficult to access. Therefore, there has been a growing interest and investment in e-mental health as an option to address barriers to seeking help from mental health professionals (Saladino et al., 2020;Wind et al., 2020). For instance, the Portuguese Psychological Association (OPP) recommended implementing psychological interventions for parents and infants using distance communication media during the pandemic context (OPP, 2020). ...
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... 41 It has been welldocumented that the internet provides a substitute way of reaching out to society and promoting access to health care. [42][43][44] Positive empirical evidence has accumulated in the field of health management, indicating that e-health services have successfully emerged as a useful complement to health care and a vital part of an inclusive health care system. 45 Building up a society of digital inclusion in the aging process helps people access early, timely, and long-term health management in their later lives. ...
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Introduction: Depression is the leading cause of disability in the world. Despite the prevalence of depression, a small proportion of individuals seek mental health services. A cost-effective method for increasing access to mental health services is the implementation of telemental-health programs. This review aims to summarize the state of the field on the efficacy and effectiveness of videoconferencing psychotherapy (VCP) for the treatment of depression. Materials and methods: Systematic literature searches were performed using PsychINFO, PubMed, and EMBASE. Specific inclusion criteria were used to identify controlled and uncontrolled studies evaluating VCP for the treatment of depression. Data extraction included study assessment quality, research design, sample size, intervention details, outcome results, intervention effect size, and statistical differences between VCP and in-person (IP) therapy. Results: Of the 1,424 abstracts screened, 92 articles were critically reviewed. Thirty-three articles were included in the review, with 14 randomized controlled studies, 4 controlled nonrandomized studies, and 15 uncontrolled studies. Sample size ranged from 1 to 243 participants. Twenty-one studies reported statistically significant reductions in depressive symptoms following VCP, and the median effect size for studies ranged from medium to the very large range. Most controlled studies reported no statistical differences between VCP and IP groups receiving the same intervention. Conclusions: VCP for the treatment of depression is a promising method for delivering mental health services. More rigorous research is needed to evaluate VCP on depression in various contexts and participants.
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Background: Electronic mental health interventions (eMental health or eMH) can be used to increase accessibility of mental health services for mood disorders, with indications of comparable clinical outcomes as face-to-face psychotherapy. However, the actual use of eMH in routine mental health care lags behind expectations. Identifying the factors that might promote or inhibit implementation of eMH in routine care may help to overcome this gap between effectiveness studies and routine care. Objective: This paper reports the results of a systematic review of the scientific literature identifying those determinants of practices relevant to implementing eMH for mood disorders in routine practice. Methods: A broad search strategy was developed with high sensitivity to four key terms: implementation, mental health care practice, mood disorder, and eMH. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was applied to guide the review and structure the results. Thematic analysis was applied to identify the most important determinants that facilitate or hinder implementation of eMH in routine practice. Results: A total of 13,147 articles were screened, of which 48 studies were included in the review. Most studies addressed aspects of the reach (n=33) of eMH, followed by intervention adoption (n=19), implementation of eMH (n=6), and maintenance (n=4) of eMH in routine care. More than half of the studies investigated the provision of mental health services through videoconferencing technologies (n=26), followed by Internet-based interventions (n=20). The majority (n=44) of the studies were of a descriptive nature. Across all RE-AIM domains, we identified 37 determinants clustered in six main themes: acceptance, appropriateness, engagement, resources, work processes, and leadership. The determinants of practices are expressed at different levels, including patients, mental health staff, organizations, and health care system level. Depending on the context, these determinants hinder or facilitate successful implementation of eMH. Conclusions: Of the 37 determinants, three were reported most frequently: (1) the acceptance of eMH concerning expectations and preferences of patients and professionals about receiving and providing eMH in routine care, (2) the appropriateness of eMH in addressing patients' mental health disorders, and (3) the availability, reliability, and interoperability with other existing technologies such as the electronic health records are important factors for mental health care professionals to remain engaged in providing eMH to their patients in routine care. On the basis of the taxonomy of determinants of practices developed in this review, implementation-enhancing interventions can be designed and applied to achieve better implementation outcomes. Suggestions for future research and implementation practice are provided.
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Digital mental health (DMH) interventions have promised to revolutionize mental health care by increasing its accessibility, availability, attractiveness, and cost-effectiveness. The first generation of web-based DMH interventions have consistently been found to be clinically effective for common mental disorders, such as depression and anxiety, in more than 100 randomized clinical trials (RCTs) and meta-analyses, particularly when accompanied by low-intensity coaching.¹ Inspired by this research, numerous health care systems have attempted to implement DMH interventions to address the large burden of mental health. However, these real-world implementation efforts have failed, often because they are not used by patients or therapists. This large research to practice gap suggests failures at many points, including DMH intervention design, research methods, and implementation approaches. The promised revolution in mental health will require a paradigm shift that addresses all 3 components to overcome the design, research, and routine care chasms.
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This review summarizes six decades of clinical outcome research relevant to evidence-based practices for depression and anxiety delivered via clinical videoconferencing. The authors conducted a literature search of previous systematic reviews and an updated search of publications specific to anxiety and depression. Overall, strong evidence supports the safety and clinical effectiveness of administering evidence-based psychotherapy for anxiety and depression via clinical videoconferencing among heterogeneous populations and age ranges, and in multiple care settings, with similar outcomes to in-person care. Despite the overall clinical effectiveness of the modality, the authors discuss common logistical and institutional barriers to long-term effective implementation. Future systems-level research is required to investigate replicable and sustainable models for implementing and expanding access to evidence-based psychotherapies via clinical videoconferencing.
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Background: Cognitive behavioral therapy (CBT) is an effective treatment, but access is often restricted due to costs and limited availability of trained therapists. Blending online and face-to-face CBT for depression might improve cost-effectiveness and treatment availability. Objective: This pilot study aimed to examine the costs and effectiveness of blended CBT compared with standard CBT for depressed patients in specialized mental health care to guide further research and development of blended CBT. Methods: Patients were randomly allocated to blended CBT (n=53) or standard CBT (n=49). Blended CBT consisted of 10 weekly face-to-face sessions and 9 Web-based sessions. Standard CBT consisted of 15 to 20 weekly face-to-face sessions. At baseline and 10, 20, and 30 weeks after start of treatment, self-assessed depression severity, quality-adjusted life-years (QALYs), and costs were measured. Clinicians, blinded to treatment allocation, assessed psychopathology at all time points. Data were analyzed using linear mixed models. Uncertainty intervals around cost and effect estimates were estimated with 5000 Monte Carlo simulations. Results: Blended CBT treatment duration was mean 19.0 (SD 12.6) weeks versus mean 33.2 (SD 23.0) weeks in standard CBT (P<.001). No significant differences were found between groups for depressive episodes (risk difference [RD] 0.06, 95% CI -0.05 to 0.19), response to treatment (RD 0.03, 95% CI -0.10 to 0.15), and QALYs (mean difference 0.01, 95% CI -0.03 to 0.04). Mean societal costs for blended CBT were €1183 higher than standard CBT. This difference was not significant (95% CI -399 to 2765). Blended CBT had a probability of being cost-effective compared with standard CBT of 0.02 per extra QALY and 0.37 for an additional treatment response, at a ceiling ratio of €25,000. For health care providers, mean costs for blended CBT were €176 lower than standard CBT. This difference was not significant (95% CI -659 to 343). At €0 per additional unit of effect, the probability of blended CBT being cost-effective compared with standard CBT was 0.75. The probability increased to 0.88 at a ceiling ratio of €5000 for an added treatment response, and to 0.85 at €10,000 per QALY gained. For avoiding new depressive episodes, blended CBT was deemed not cost-effective compared with standard CBT because the increase in costs was associated with negative effects. Conclusions: This pilot study shows that blended CBT might be a promising way to engage depressed patients in specialized mental health care. Compared with standard CBT, blended CBT was not considered cost-effective from a societal perspective but had an acceptable probability of being cost-effective from the health care provider perspective. Results should be carefully interpreted due to the small sample size. Further research in larger replication studies focused on optimizing the clinical effects of blended CBT and its budget impact is warranted. Trial registration: Netherlands Trial Register NTR4650; https://www.trialregister.nl/trial/4408. International registered report identifier (irrid): RR2-10.1186/s12888-014-0290-z.
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Internet interventions, and in particular Internet‐delivered cognitive behaviour therapy (ICBT), have existed for at least 20 years. Here we review the treatment approach and the evidence base, arguing that ICBT can be viewed as a vehicle for innovation. ICBT has been developed and tested for several psychiatric and somatic conditions, and direct comparative studies suggest that therapist‐guided ICBT is more effective than a waiting list for anxiety disorders and depression, and tends to be as effective as face‐to‐face CBT. Studies on the possible harmful effects of ICBT are also reviewed: a significant minority of people do experience negative effects, although rates of deterioration appear similar to those reported for face‐to‐face treatments and lower than for control conditions. We further review studies on change mechanisms and conclude that few, if any, consistent moderators and mediators of change have been identified. A recent trend to focus on knowledge acquisition is considered, and a discussion on the possibilities and hurdles of implementing ICBT is presented. The latter includes findings suggesting that attitudes toward ICBT may not be as positive as when using modern information technology as an adjunct to face‐to‐face therapy (i.e., blended treatment). Finally, we discuss future directions, including the role played by technology and machine learning, blended treatment, adaptation of treatment for minorities and non‐Western settings, other therapeutic approaches than ICBT (including Internet‐delivered psychodynamic and interpersonal psychotherapy as well as acceptance and commitment therapy), emerging regulations, and the importance of reporting failed trials.