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Internet-Based and Other Computerized Psychological Treatments for Adult Depression: A Meta-Analysis


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Computerized and, more recently, Internet-based treatments for depression have been developed and tested in controlled trials. The aim of this meta-analysis was to summarize the effects of these treatments and investigate characteristics of studies that may be related to the effects. In particular, the authors were interested in the role of personal support when completing a computerized treatment. Following a literature search and coding, the authors included 12 studies, with a total of 2446 participants. Ten of the 12 studies were delivered via the Internet. The mean effect size of the 15 comparisons between Internet-based and other computerized psychological treatments vs. control groups at posttest was d = 0.41 (95% confidence interval [CI]: 0.29-0.54). However, this estimate was moderated by a significant difference between supported (d = 0.61; 95% CI: 0.45-0.77) and unsupported (d = 0.25; 95% CI: 0.14-0.35) treatments. The authors conclude that although more studies are needed, Internet and other computerized treatments hold promise as potentially evidence-based treatments of depression.
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Internet-Based and Other Computerized Psychological Treatments for
Adult Depression: A Meta-Analysis
Gerhard Anderssona; Pim Cuijpersb
a Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research,
Linköping University, Linköping, and Department of Clinical Neuroscience, Psychiatry Section,
Karolinska Institutet, Stockholm, Sweden b Department of Clinical Psychology and EMGO+ Institute,
VU University, Amsterdam, the Netherlands
Online publication date: 15 December 2009
To cite this Article Andersson, Gerhard and Cuijpers, Pim(2009) 'Internet-Based and Other Computerized Psychological
Treatments for Adult Depression: A Meta-Analysis', Cognitive Behaviour Therapy, 38: 4, 196 — 205
To link to this Article: DOI: 10.1080/16506070903318960
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Internet-Based and Other Computerized Psychological
Treatments for Adult Depression: A Meta-Analysis
Gerhard Andersson
and Pim Cuijpers
Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research,
¨ping University, Linko
¨ping, and Department of Clinical Neuroscience, Psychiatry
Section, Karolinska Institutet, Stockholm, Sweden;
Department of Clinical Psychology and
EMGOþInstitute, VU University, Amsterdam, the Netherlands
Abstract. Computerized and, more recently, Internet-based treatments for depression have been
developed and tested in controlled trials. The aim of this meta-analysis was to summarize the effects
of these treatments and investigate characteristics of studies that may be related to the effects. In
particular, the authors were interested in the role of personal support when completing a
computerized treatment. Following a literature search and coding, the authors included 12 studies,
with a total of 2446 participants. Ten of the 12 studies were delivered via the Internet. The mean effect
size of the 15 comparisons between Internet-based and other computerized psychological treatments
vs. control groups at posttest was d¼0.41 (95% confidence interval [CI]: 0.290.54). However, this
estimate was moderated by a significant difference between supported (d¼0.61; 95% CI: 0.45 0.77)
and unsupported (d¼0.25; 95% CI: 0.140.35) treatments. The authors conclude that although
more studies are needed, Internet and other computerized treatments hold promise as potentially
evidence-based treatments of depression. Key words: computerized treatment; depression; Internet-
based; role of support
Received 15 August, 2009; Accepted 8 September, 2009
*Correspondence address: Gerhard Andersson, PhD, Department of Behavioural Sciences,
¨ping University, SE-581 83 Linko
¨ping, Sweden. Tel: þ46 13 28 58 40; Fax: þ46 13 28 21
45. E-mail:
Adult depression is a costly condition for
which numerous different treatments have
been developed (Ebmeier, Donaghey, &
Steele, 2006). Among the psychological treat-
ment options, several have been found to be
effective (Cuijpers, van Straten, Andersson, &
van Oppen, 2008), with no or minor differ-
ences between the main treatment alternatives.
Cognitive behaviour therapy (CBT), however,
has been investigated in by far the most trials
and in different administration formats such
as group (McDermut, Miller, & Brown, 2001)
and telephone-assisted (e.g. Simon, Ludman,
Tutty, Operskalski, & Von Korff, 2004)
treatments. Computer and, more recently,
Internet delivery have become increasingly
common administration formats for
depression treatment in research and slowly
but gradually in clinical settings as well.
Computerized psychological treatments can
be delivered on devices such as stand-alone or
Internet-linked computers, PCs, palmtops,
phone-interactive voice response systems,
CD-ROMS, DVDs, cell phones, and VR
equipment (Marks, Cavanagh, & Gega,
2007). However, during the last 5 years, it is
mostly Internet-delivered treatments that have
been tested in research.
Internet-delivered treatments of depression
can take on different forms. One approach is
largely based on bibliotherapy, with mainly
text-based materials and guidance by a
therapist via e-mail or phone. On the other
end of the continuum, we find treatments that
are briefer and usually do not target persons
with clinical depression. Moreover, these
q2009 Taylor & Francis ISSN 1650-6073
DOI: 10.1080/16506070903318960
Cognitive Behaviour Therapy Vol 38, No 4, pp. 196–205, 2009
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treatments are commonly not delivered with
guidance and can hence be reached by more
people at a lower cost. They are, however,
probably less effective (Spek, Cuijpers, et al.,
2007). Regardless of the role of support,
treatment protocols also differ with regard to
how often and how many online activities are
included and how much feedback is
There are now several reviews and meta-
analyses on computerized (e.g. Cuijpers,
Marks, et al., 2009; Reger & Gahm, 2009)
and Internet-delivered (Barak, Hen, Boniel-
Nissim, & Shapira, 2008; Griffiths & Chris-
tensen, 2006; Spek, Cuijpers, et al., 2007)
treatments. In one previous review, Internet
treatments for depression were covered
(Andersson, 2006), but this was not a meta-
analysis. The other meta-analyses were not
specifically aimed at depression and have
included only a limited portion of currently
available trials. Given the very strong increase
in the number of controlled trials on
computerized and Internet-delivered treat-
ments of depression in the past few years, we
decided to conduct a new meta-analysis in
which we focused on depression only. We were
interested in investigating the role of support
and the overall effects compared with other
treatments. This meta-analysis adds to the
literature by providing an overview of the field
and by contrasting different approaches to
computerized treatment.
Identification and selection of studies
We used several methods to identify studies
for inclusion. First, we used a database of 1036
studies on the psychological treatment of
depression, which includes reports on com-
bined treatments and comparisons with
pharmacotherapy. This database has been
described in detail elsewhere (Cuijpers, van
Straten, Warmerdam, & Andersson, 2008)
and has been used in a series of earlier meta-
analyses (http://www.evidencebasedpsychoth The database was developed
through a comprehensive literature search
(from 1966 to January 2009), in which we
examined a total of 9011 abstracts: 1629 from
PubMed, 2439 from PsycINFO, 2606 from
Embase, and 2337 from the Cochrane Central
Register of Controlled Trials. These abstracts
were identified by combining terms indicative
of psychological treatment and depression
(both MeSH terms and text words). For this
database, we also collected the primary studies
from 42 meta-analyses of psychological treat-
ment for depression (http://www. For the
current study, we examined the full texts of
these 1036 studies, then examined the refer-
ence lists of earlier reviews and meta-analyses
(e.g. Spek, Cuijpers, et al., 2007), and checked
the references of the included primary studies.
We included (a) randomized trials (b) in
which the effects of an Internet-based or
computerized psychological treatment (c)
were compared with a (noncomputerized)
control or comparison group or a face-to-
face psychological treatment (d) in adults (e)
with depression (established by diagnostic
interview or elevated levels of depressive
symptoms based on self-report measures).
We also included studies that were aimed at
adults with depression and anxiety. We
excluded studies on inpatients and those on
adolescents or children (,18 years). We did
not include component studies (e.g. Christen-
sen, Griffiths, Mackinnon, & Brittliffe, 2006).
Comorbid general medical or psychiatric
disorders were not used as an exclusion
criterion. No language restrictions were
For each comparison between Internet-based
or computerized psychological treatment and
control conditions, we calculated the effect
size indicating the difference between the two
conditions at posttest (Cohen’s dor standar-
dized mean difference). We calculated the
effect sizes by subtracting (at posttest)
the average score of the treatment group
from the average score of the control group
and dividing the result by the pooled standard
deviations of the two groups. Effect sizes of
0.8 can be assumed to be large, 0.5 moderate
and 0.2 small (Cohen, 1988).
In the calculations of effect sizes, we only
used those instruments that explicitly
measured symptoms of depression. If more
than one depression measure was used, the
mean of the effect sizes was calculated, so that
each study only provided one effect size.
We only used the effect sizes indicating the
differences between the two types of treatment
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at posttest. We decided not to examine the
differential effects at follow-up because the
addition, the follow-up period differed con-
siderably among these studies.
To calculate pooled mean effect sizes, we
used Biostat’s computer program Comprehen-
sive Meta-Analysis (version 2.2.021). Because
we expected considerable heterogeneity
among the studies, we decided to calculate
mean effect sizes using a random-effects
model. In the random-effects model, it is
assumed that the included studies are drawn
from “populations” of studies that differ from
each other systematically (heterogeneity). In
this model, the effect sizes resulting from
included studies differ not only because of the
random error within studies (as in the fixed-
effects model) but also because of true
variation in effect size from one study to the
As a test of homogeneity of effect sizes, we
calculated the I
statistic, which is an
indicator of heterogeneity in percentages. A
value of 0% indicates no observed heterogen-
eity, and larger values show increasing
heterogeneity, with 25% as low, 50% as
moderate, and 75% as high heterogeneity
(Higgins, Thompson, & Deeks, 2003). We also
calculated the Qstatistic but only report
whether this was significant or not.
Subgroup analyses were conducted accord-
ing to the mixed-effect model. In this model,
studies within subgroups are pooled with the
random-effects model, whereas tests for
significant differences between subgroups are
conducted with the fixed-effects model.
Publication bias was tested by inspecting the
funnel plot on primary outcome measures and
by Duval and Tweedie’s (2000) trim and fill
procedure, which yields an estimate of the
effect size after the publication bias has been
taken into account (as implemented in
Comprehensive Meta-Analysis, version
Characteristics of included studies
A total of 12 studies, with 2446 participants
(1324 in the Internet-based and computerized
psychological treatment conditions, 996 in the
control conditions, and 126 in the face-to-face
comparison conditions) met all inclusion
criteria. Selected characteristics of these
studies are presented in Table 1.
Ten studies were aimed at adults in general,
and one was aimed at older adults and one at
young adults. All but one study recruited
participants from the community. Only two
studies included participants with depressive
disorder diagnosed in a formal diagnostic
interview. Six studies used a wait list control
group, four a care-as-usual control group, and
the remaining two studies another type of
control group. The 12 studies included 15
comparisons between an Internet-based or
computerized psychological treatment and a
control group (three studies included two
comparisons). In three studies, Internet-based
or computerized psychological treatment was
compared with face-to-face psychological
treatment. Eleven of the 15 comparisons
examined CBT, two problem-solving therapy,
and one psychoeducation. Two studies exam-
ined computerized psychological treatment
and the remaining 10 Internet-based psycho-
logical treatment. Five studies were conducted
in the United States, four in the Netherlands,
and one each in Sweden, United Kingdom,
and Australia. In one study only 50% of the
face-to-face treatment was replaced by a
computerized treatment (Wright et al., 2005).
We decided to include this study and examine
whether removal of this resulted in changes of
the mean effect size (which was not the case;
see later discussion).
Internet-based and computerized
psychological treatment versus control
groups: overall effect size
The mean effect size of the 15 comparisons
between Internet-based and computerized
psychological treatment vs. control groups at
posttest was 0.41 (95% confidence interval
[CI]: 0.290.54; Table 2). Heterogeneity was
moderate to high (I
¼57.49). The effect sizes
and 95% CIs of the individual contrast groups
are plotted in Figure 1.
Inspection of the forest plot suggested that
two studies were possible outliers (Selmi et al.,
1990; Wright et al., 2005). However, after
removal of these studies, the effect size
remained almost the same (d¼0.37; 95%
CI: 0.260.49) and heterogeneity remained at
a moderate level (I
198 Andersson and Cuijpers COGNITIVE BEHAVIOUR THERAPY
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Table 1.Selected characteristics of randomized controlled studies examining the effects of computerized and Internet-based psychotherapies for adult depression
population Recruitment Inclusion Condition NIntervention
computer Measure
et al. (2005)
($18 yrs)
Community p..55 for MDD
þMADRS-S 15-30
1. iCBT 36 5 modules CBT
and BA
E-mail I, 10 wks BDI;
2. WL/online
et al. (2004)
(18– 52 yrs)
K-10 $22 1. iCBT 182 1. 5 CBT
Telephone calls by
lay interviewers
(all conditions)
I, 6 wks CES-D Australia
2. iPE 165 2. 5 PE modules
3. Attention
178 –
et al. (2002)
Adults Via HMO Depressed,
1. iCBT 144 7 chapters CBT None I, NSD CES-D United States
2. CAU 155
et al. (2005)
Adults Via HMO Depressed,
1. iCBT-a 75 7 chapters CBT None: iCBT-a:
postcard reminders;
iCBT-b: telephone
I, NSD CES-D United States
2. iCBT-b 80
3. CAU 100
et al. (2009)
Young adults
(18– 24 yrs)
Via HMO Depressed,
1. iCBT 83 4 sections CBT None I, NSD PHQ-9 United States
2. CAU 77
et al. (2004)
(18– 75 yrs)
Primary care GHQ-12 .4
þCIS-R .12
(depression or
1. cCBT 112 8 sessions cCBT 5 min help at
beginning, end of
each session
I, 8 weeks BDI United Kingdom
2. CAU 109
et al. (2009)
($18 yrs)
Community BDI 10-29 1. iCBT 36 8 phases CBT,
I; 11 wks BDI,
SCL-90-R– D
The Netherlands
2. WL 18
et al. (1990)
Adults Community SCL-90-R .
65th percentile
þBDI $16
1. cCBT 12 6 sessions CBT Help at beginning,
end of each session
C; 6 wks BDI; HAM-D;
SCL-90-R– D
United States
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Table 1. Continued
population Recruitment Inclusion Condition NIntervention
computer Measure
2. ftf-CBT 12
3. WL 12
et al. (2007)
Older adults
Community Subthreshold
(EDS $12, no
1. iCBT 102 8 weekly
None I; 8 wks BDI The Netherlands
2. gCBT 99
3. WL 100
Van Straten
et al. (2008)
Adults Community Self-defined
depression or
1. iPST 107 5 weekly
E-mail I; 5 wks CES-D;
The Netherlands
2. WL 106
et al. (2008)
Adults Community CES-D $16 1. iCBT 88 1. 8 weekly
CBT; 2.5 weekly
modules PST
E-mail I: group
1, 8 wks;
2, 5 wks
CES-D The Netherlands
2. iPST 87
3. WL 87
et al. (2005)
(18– 65 yrs)
Community MDD (SCID)
þBDI $14
1. cCBT þftf 15 9 sessions CBT 25-min ftf
C; 8 wks BDI;
United States
2. ftf-only
3. WL 15
Note. BA, behavioural activation; BDI, Beck Depression Inventory; C, computerized treatment delivery; CAU, care-as-usual; CBT, cognitive behaviour therapy;
cCBT, computerized CBT; gCBT, group CBT; CES-D, Center for Epidemiological Studies– Depression scale; CIDI-SF, Composite International Diagnostic
Interview Short-Form; EDS, Edinburgh Depression Scale; ftf, face-to-face; GHQ, General Health Questionnaire; HAM-D, Hamilton Depression Rating Scale;
HMO, health maintenance organization; I, Internet treatment delivery; iCBT, Internet-based CBT; iPE, Internet-based psychoeducation; iPST, Internet-based
problem-solving therapy; K-10, Kessler 10; MADRS-S, Montgomery– Asberg Depression Rating Scale; MDD, major depressive disorder; MDI, Major Depression
Inventory; PE, psychoeducation; PHQ-9, Patient Health Questionnaire; PST, problem-solving therapy; RDC, Research Diagnostic Criteria; SADS, Schedule for
Affective Disorders; NSD, no standard duration; SCID, Structured Clinical Interview for DSM-IV; SCL-90-R, Symptom Checklist-90-R; SCL-90-R-D, SCL-90-R
Depression subscale; WL, wait-list.
Only the instruments that were used to calculate effect sizes are included.
200 Andersson and Cuijpers COGNITIVE BEHAVIOUR THERAPY
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In our analyses, we included three studies in
which two psychological treatments were
compared with the same control group. This
means that multiple comparisons from these
three studies were included in the same
analysis. These multiple comparisons, how-
ever, are not independent of each other, which
may have resulted in an artificial reduction of
heterogeneity. Therefore, we conducted
another meta-analysis, in which we included
only one comparison per study (Table 2).
From the three studies with multiple compari-
sons, we first included only the comparison
with the largest effect size. As can be seen in
Table 2, these analyses did indicate that
heterogeneity increased somewhat in some
analyses (I
¼65.35), although the effect size
did not differ very much from the overall
analyses. Then we repeated these analyses and
included only the smallest effect size of the
three studies with multiple comparisons.
These analyses also resulted in increased
heterogeneity (I
¼64.86) and a comparable
effect size.
Neither the funnel plots nor Duval and
Tweedie’s trim and fill procedure indicated a
significant publication bias.
Subgroup analyses
We conducted several subgroup analyses
(Table 2). These included type of psychologi-
cal treatment (Internet-based vs. computer-
ized), type of control group (care-as-usual,
wait-list, other), content of psychological
treatment (CBT vs. other), whether the study
only included participants with depression or
also persons with anxiety, and whether there
was professional support during the therapy
(yes or no).
Table 2. Meta-analyses of studies examining the effects of computerized and Internet-based psychological
treatments for adult depression
Study N
d95% CI ZI
Overall effects
All studies 15 0.41 0.29– 0.54 6.47**** 57.49***
One ES per study (highest) 12 0.45 0.29– 0.61 5.39**** 65.35***
One ES per study (lowest) 12 0.43 0.27– 0.59 5.21**** 64.86***
Two possible outliers removed
13 0.37 0.26– 0.49 6.41**** 51.36**
Subgroup analyses
Type .107
Internet-based 12 0.37 0.24– 0.49 5.84**** 53.83**
Computerized 3 0.85 0.27– 1.43 2.89*** 61.18*
Control group .038
Care-as-usual 5 0.23 0.06– 0.40 2.68*** 46.34
Wait-list 7 0.56 0.37 0.76 5.60**** 43.51
Other 3 0.45 0.21– 0.69 3.64**** 59.38*
Psychological treatment .923
CBT 12 0.42 0.26 0.59 5.09**** 64.82***
Other 3 0.41 0.27– 0.56 5.51**** 0
Anxiety allowed .234
Only depression 13 0.38 0.25– 0.51 5.75**** 57.26***
Depression or anxiety 2 0.64 0.24– 1.04 3.13*** 42.73
Professional support .000
Support 8 0.61 0.45– 0.77 7.67**** 23.74
No professional support 7 0.25 0.14– 0.35 4.75**** 10.41
C or I psychotherapy vs. ftf
psychotherapy (all studies)
320.05 20.29–0.20 20.36 0
Note. CBT, cognitive behaviour therapy; C, computerized treatment delivery; CI, confidence interval; ES, effect
size; ftf, face to face; I, Internet treatment delivery; N
, number of comparisons.
The pvalues indicate
whether the Qstatistic is significant (the I
statistics does not include a test of significance).
The pvalues
indicate whether the difference between the effect sizes in the subgroups is significant.
Selmi et al., 1990; Wright
et al., 2005.
All subgroup analyses were conducted with mixed-effects analyses. *p,.10. **p,.05.
***p,.01. ****p,.001.
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As can be seen in Table 2, the type of
control group was significantly associated
with the effect sizes ( p,.05). Studies with a
wait-list control had higher effect sizes than
care-as-usual and other control groups.
However, heterogeneity remained high in
these subgroups. We also found that studies
in which no professional support was given
had lower effect sizes than those in which
support was given ( p,.000). The heterogen-
eity in these two groups was low (I
Because the study by Christensen, Griffiths,
and Jorm (2004) was complex to interpret
(there was some support by telephone but
no clear help in working through the treat-
ment), we repeated this subgroup analysis
without this study. The results were, however,
comparable (unguided: d¼0.18; 95%
CI ¼0.05–0.30, I
¼0; guided: d¼0.61,
95% CI ¼0.45 0.77, I
¼23.74; p
difference ¼.000).
The aim of this meta-analysis was to
summarize the literature on Internet-based
and other computerized psychological treat-
ments for adult depression. We found an
overall effect size of d¼0.41, but that
estimate is probably not meaningful because
it hides the finding that interventions in which
support is provided to the participant are
more effective. Indeed, the computerized
interventions with support showed an average
between-group effect size of d¼0.61, whereas
the unsupported treatments had a much
smaller effect of d¼0.25. This is similar to
the findings by Spek, Cuijpers, et al. (2007),
who found that interventions without support
had an average effect size of d¼0.24, whereas
Internet interventions with support had a
large mean effect size of d¼1.0. Although the
meta-analyses overlap in terms of studies
included, we included more recent studies and
also other computerized treatments not
covered in the Spek et al. study (e.g. not
Internet-delivered). Overall, it appears that
computerized treatments with therapist sup-
port are much more effective than unsup-
ported treatments, and this has been
confirmed in open studies as well (e.g.
Christensen, Griffiths, Groves, & Korten,
2006). However, the concept of support is
not fully investigated in the literature, and we
cannot exclude the possibility that some forms
of support can be automated or that other
factors, such as having a clear deadline for
completion of a treatment with a scheduled
follow-up (e.g. a telephone interview), would
make less-supported treatments more effective
(Nordin, Carlbring, Cuijpers, & Andersson, in
press). Clearly, there is a need to investigate
Figure 1. Internet-based and other computerized treatments of depression compared to control groups:
standardized effect sizes.The letters A and B in the above figure refer to different subsamples within each study.
202 Andersson and Cuijpers COGNITIVE BEHAVIOUR THERAPY
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the concept of support further and the role of
therapist factors in computerized treatments
(e.g. Almlo
¨v, Carlbring, Berger, Cuijpers, &
Andersson, 2009).
There were few studies available for the
contrast between Internet-based or other
computerized treatments and face-to-face
treatments. Here we found no difference,
which is in line with other studies in the field of
anxiety disorders (e.g. Carlbring et al., 2005;
Kiropoulos et al., 2008). There is a need to
further test whether computerized treatment,
and Internet-delivered treatment in particular,
can be as effective as face-to-face treatments in
depression. These studies need to be designed
as equivalence studies, and indeed in our
meta-analysis the finding of no difference
could be regarded as a promising sign of
equivalence between the treatment formats.
Although the effects of supported computer-
ized treatments in this meta-analysis are in line
with those of previous meta-analyses for
psychological treatments (e.g. Cuijpers, van
Straten, Andersson, et al., 2008), they are
somewhat lower. However, the effects are not
low when compared with the effects of
psychological treatments in primary care
(Cuijpers, van Straten, van Schaik, & Anders-
son, 2009). Several other findings are worth
commenting on. We did not find a significant
difference between computerized and Inter-
net-delivered treatments, but this could be due
to power problems. In line with findings of
other studies, the type of control group
influenced the effect size estimate, with lower
effects when treatment as usual was the
comparison group. This was expected because
no treatment is worse than some treatment.
We did not find any differences between CBT-
oriented and other forms of computerized
treatments. This comparison was unbalanced,
with most of the studies being done from a
CBT perspective, but we welcome more
studies on computerized treatments from a
non-CBT perspective, because it is not settled
whether other evidence-based psychological
treatments such as interpersonal psychother-
apy are possible to transfer to the computer
medium or the Internet. We also did not find
any effects of comorbid anxiety on the effect
size estimate, but this needs to be further
explored in future studies, because there are
very few studies on computer interventions for
depression in which other conditions than
depression have been assessed.
In this meta-analysis, we did not present
data on quality assessment. However, all
studies were checked using the four basic
criteria, as suggested in the Cochrane Hand-
book for Systematic Reviews of Interventions
(Higgins & Green, 2005): allocation to
conditions conducted by an independent
(third) party, blinding of assessors of out-
comes, completeness of follow-up data, and
adequacy of random allocation concealment
to respondents. Overall, the study quality was
not satisfactory, but studies are increasingly
following the CONSORT guidelines (e.g.
Boutron, Moher, Altman, Schulz, & Ravaud,
There are several possible challenges for
future research. First, Internet-delivered and
other computerized psychological interven-
tions are still not supported by a solid
database, and many studies have failed to
perform a proper diagnostic assessment
(Andersson & Cuijpers, 2008). There is a
need for accurate diagnostic procedures in
future trials. Second, most studies have been
done either in an academic setting with
participants recruited via advertisement or
by an epidemiological screening approach.
Only one of the studies in our meta-analysis
included patients recruited from primary care.
There is a need for effectiveness studies of
Internet and other computerized treatments
involving patients from psychiatric settings.
Third, studies on long-term effects of treat-
ment are largely lacking. There is a 1-year
follow-up of the trial by Christensen et al.
(2004), which showed some remaining benefits
(Mackinnon, Griffiths, & Christensen, 2008),
but more research is needed, in particular,
because help-seeking and health care use
might be affected as an effect of treatment
(Christensen, Leach, Barney, Mackinnon, &
Griffiths, 2006). Fourth, our meta-analysis did
not cover the issue of whom Internet and other
computerized treatments are suitable for. For
example, one study found an indication that
number of previous depression episodes was
related to worse treatment outcome (Anders-
son, Bergstro
¨m, Holla
¨ndare, Ekselius, &
Carlbring, 2004). It is also important to
investigate differential predictors of outcome
for different treatment formats (Spek, Nyklı
cek, Cuijpers, & Pop, 2008).
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This meta-analytic review has some limi-
tations. First, we included very heterogeneous
treatments and samples. This can be seen as an
advantage for a meta-analysis because we then
could investigate differences between studies.
However, because relatively few studies could
be located, we were underpowered to detect
effects for some contrasts. A second limitation
has to do with the selection of adult samples
only. Our impression is that the available
studies on adolescents do not alter our main
finding that support may be needed to achieve
good outcomes (e.g. O’Kearney, Gibson,
Christensen, & Griffiths, 2006). A third
limitation concerns the methodological qual-
ity of the studies that we did not fully report.
For example, we did not include analyses on
the drop-out rate for different treatments,
which is a known problem in Internet
Despite the limitations of this meta-anal-
ysis, we believe there is emerging evidence that
Internet and other computerized intervention
can be helpful in reducing symptoms of
The preparation of this study was supported in
part by a grant from the Swedish Research
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... Online psychological interventions or OPIs (Peñate et al., 2014;Perle et al., 2011;Sierra et al., 2018), on the other hand, refer specifically to asynchronic selfhelp programs or services often inspired by existing evidence-based interventions, which represent a promising and flexible alternative to not only traditional psychotherapy but also synchronic tele-psychology approaches. Most OPIs feature psychoeducation regarding the target diagnosis, some sort of evaluation process, and explicit intervention components (Andersson & Cuijpers, 2009;Nelson et al., 2011;Peñate et al., 2014;Titov, 2007). ...
... General reviews on the efficacy of OPIs typically feature randomized controlled trials (RCTs) based on cognitive behavioral therapy (CBT). Results suggest that these interventions are effective for the treatment of depressive and anxiety disorders with effect sizes being moderated by variables such as duration, support, and baseline symptom levels (Andersson & Cuijpers, 2009;Andrews et al., 2010;Newman et al., 2011;Richards & Richardson, 2012;Spek et al., 2007;Wangelin et al., 2016). On the other hand, the existing meta-analyses assessing the effect of thirdwave OPIs are symptom based (i. ...
... The latter supports some of the findings on the general OPI reviews such as the effect moderations by duration (Andersson & Cuijpers, 2009;Andrews et al., 2010;Newman et al., 2011;Richards & Richardson, 2012;Spek et al., 2007;Wangelin et al., 2016). The current results are also coherent with the findings of existing literature that reported small to medium effect sizes for the treatment of depression and anxiety using third-wave OPIs (Kelson et al., 2019;O'Connor et al., 2018;Sierra et al., 2018). ...
... Based on previously conducted meta-analyses on the effect of psychosocial interventions [72], behavioural activation treatment [73] and supported internet-based treatment [74] on the social functioning of patients with depression, a medium effect size is expected. The sample size estimation for the RCT was based on a Cohen's d of 0.5, a p-value cut-off (alpha) of 0.05 (Z alpha 1.96) and a power (1beta) of 80% (Z beta 0.84). ...
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Background Despite the availability of a wide variety of evidence-based treatments for major depressive disorder (MDD), many patients still experience impairments in their lives after remission. Programs are needed that effectively support patients in coping with these impairments. The program Storytelling and Training to Advance Individual Recovery Skills (STAIRS) was developed to address this need and combines the use of peer contact, expert-by-experience guidance, family support and professional blended care. The aim of the planned study is (1) to assess the efficacy of the STAIRS program in patients with remitted MDD, (2) to investigate patients’ subjective experiences with STAIRS, and (3) to evaluate the program’s cost-effectiveness. Methods A concurrent mixed-methods randomized controlled trial design will be used. Patients aged between 18 and 65 years with remitted MDD (N = 140) will be randomized to either a group receiving care as usual (CAU) + the STAIRS-program or a control group receiving CAU + some basic psychoeducation. Quantitative efficacy data on functional and personal recovery and associated aspects will be collected using self-report questionnaires at the start of the intervention, immediately following the intervention, and at the six-month follow-up. Insights into patients’ experiences on perceived effects and the way in which different program elements contribute to this effect, as well as the usability and acceptability of the program, will be gained by conducting qualitative interviews with patients from the experimental group, who are selected using maximum variation sampling. Finally, data on healthcare resource use, productivity loss and quality of life will be collected and analysed to assess the cost-effectiveness and cost-utility of the STAIRS-program. Discussion Well-designed recovery-oriented programs for patients suffering from MDD are scarce. If efficacy and cost-effectiveness are demonstrated with this study and patients experience the STAIRS program as usable and acceptable, this program can be a valuable addition to CAU. The qualitative interviews may give insights into what works for whom, which can be used to promote implementation. Trial registration: This trial was registered at on 1 July 2021, registration number NCT05440812.
... Self-directed programs have far greater dissemination potential as they do not require a trained professional and can typically be administered at a lower cost. However, research on telehealth CBT interventions for mood and anxiety have found therapistassisted programs lead to better client outcomes than selfdirected programs (Andersson & Cuijpers, 2009;Spek et al., 2007). There has been limited research comparing selfdirected and therapist-assisted telehealth PMI for autism; however, research suggests that parent coaching with a trained professional may be necessary for some, but not all parents, to successfully implement evidence-based intervention techniques with fidelity (Wainer & Ingersoll, 2015). ...
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Purpose Although there is growing interest in telehealth to deliver parent-mediated intervention for autistic children, empirical evaluations are limited, and little is known regarding the relative benefits of self-directed and therapist-assisted telehealth interventions. This study examined the effect of self-directed and therapist-assisted ImPACT Online on parent learning and well-being, moderators of treatment, and predictors of program engagement. Method Sixty-four young autistic children and their primary caregiver participated. Children were matched on age and developmental quotient and randomly assigned to a therapist-assisted, self-directed, or resource support control group. Participants were assessed at intake, after 6 months (post), and at a 3-month follow-up. Results There was a significant treatment effect for parent learning for the therapist-assisted but not self-directed program; when analysis was limited to parents who completed the program, treatment effects were observed for both groups. There were no treatment effects for parent self-efficacy or parenting stress; however, there was an effect on parents’ perception of their child’s positive impact. Parenting stress did not moderate the effect of group on parent outcomes. Parent age, program satisfaction, and therapist assistance were all significant predictors of parent program engagement. Conclusion This study supports the efficacy of therapist-assisted telehealth parent-mediated intervention for teaching parents intervention strategies to support their child’s social communication and improving their perceptions of their child’s positive impact, and suggests that self-directed programs may be beneficial for parents who fully engage with the program.
... and Siddique[44]and Andersson and Cuijpers[45] conducted meta-analyses of online psychotherapy interventions and found that they can be as effective as traditional face-to-face therapy for treating loneliness.Proudfoot et al. [46] provided guidelines for executing and reporting internet intervention research, highlighting the potential of technology-based interventions to provide effective and affordable mental health support. In addition to the effectiveness of technology-based interventions, Wang et al.[47] demonstrated the potential of technology to increase access to mental health services during the COVID-19 outbreak in China. ...
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The increasing use of digital technologies in daily life has led to a growing number of studies in the field of digital psychology. While research in this area has provided valuable insights into the potential benefits and drawbacks of digital technologies for mental health and well-being, there is still much to be learned about the complex relationship between technology and psychology. This study aimed to investigate the effects of mindfulness-based mobile apps on university students' anxiety, loneliness, and well-being. It also explored the participants’ perceptions of the addictiveness of mindfulness-based mobile apps. The study used a multi-phase research design consisting of a correlational research method, a pretest-posttest randomized controlled trial, and a qualitative case study. Three subsets of participants were selected for each phase: correlations (n = 300), treatment (n = 60), and qualitative (n = 20). Data were collected from various sources, including the social anxiety scale, well-being scale, social media use integration scale, and interview checklist. Pearson correlation, multiple regression, and t-tests were used to analyze the quantitative data, while thematic analysis was used for the qualitative data. The results confirmed a significant correlation between social media use and the study variables. The treatment also decreased students' anxiety and increased their well-being. The participants also had different positive perceptions of the use of mindfulness-based mobile apps. These findings have theoretical and practical implications for digital psychologists.
... One limitation of mental health apps has been poor adherence (e.g., [23]), which can be remedied by including human support [24]. Adding regular phone contact can increase adherence and reduce dropouts [25][26][27][28]; however, the type of support that is the most efficacious has yet to be examined. Positive and corrective feedback is a versatile psychological tool for imparting cognitive behavioral skills, which consists of reinforcing the correct performance of a certain behavior and providing instructions to change those behaviors that have been performed incorrectly, and could improve adherence as well as efficacy [29] by allowing the strengthening of the therapeutic alliance, providing support and encouragement, and monitoring the assignment of homework [30]. ...
Full-text available
Due to the limited availability of in-person interventions for caregivers, the development of effective programs that use new technologies to prevent depression is needed. The goal of this research was to assess the efficacy of a cognitive behavioral intervention for the prevention of depression , administered to nonprofessional caregivers through a smartphone application (app). One hundred and seventy-five caregivers were randomly assigned to either an app-based cognitive be-havioral intervention (CBIA), the CBIA intervention plus a telephone conference call (CBIA + CC), or an a ention control group (ACG). At post-intervention, the incidence of depression was lower in the CBIA and CBIA + CC compared to the ACG (1.7% and 0.0% vs. 7.9%, respectively). The absolute risk, relative risk, and number needed to treat compared to the ACG were 6.2%, 21.6%, and 16 for the CBIA, whilst they were 8%, 0.0%, and 13 for the CBIA + CC. Depressive symptomatology was significantly lower in the CBIA and CBIA + CC compared to the ACG (d = 0.84, Cliff's δ = 0.49; d = 1.56, Cliff's δ = 0.72), as well as in the CBIA + CC compared to the CBIA (d = 0.72, Cliff's δ = 0.44). The prevention of depression was more likely in participants who received the CBIA, and adding the conference call in the CBIA + CC group improved the likelihood of this.
... Assigning 60 participants to each condition (LGBTQ-affirmative ICBT vs. assessment-only) and accounting for 20% attrition based on previous internet-based RCTs (Leluțiu-Weinberger et al., 2018;Pachankis & Goldfried, 2010) was estimated to be sufficient to provide 80% power (1ß) to detect a between-condition difference (p < 0.05) of d = 0.40, which is significantly lower than the effect found in comparisons of in-person LGBTQ-affirmative CBT against waitlist (d = 0.59 for HIV-transmission-risk behavior, d = 0.55 for depression; Pachankis et al., 2015) and lower than the smallest average meta-analytic effect (d = 0.66) of ICBT compared to weak control conditions for depression (Andersson & Cuijpers, 2009;Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014;Spek et al., 2007;Sztein, Koransky, Fegan, & Himelhoch, 2018). ...
... But the impact on engagement, and specifically engagement in real-world implementations of DMHIs, is less clear. Various studies suggest that human support increases engagement [57][58][59], but the finding is not universal. For example, Levin et al. [60] found that weekly coaching calls did not increase engagement relative to automated email prompts. ...
Full-text available
Digital mental health interventions (DMHIs) are an effective and accessible means of addressing the unprecedented levels of mental illness worldwide. Currently, however, patient engagement with DMHIs in real-world settings is often insufficient to see a clinical benefit. In order to realize the potential of DMHIs, there is a need to better understand what drives patient engagement. We discuss takeaways from the existing literature related to patient engagement with DMHIs and highlight gaps to be addressed through further research. Findings suggest that engagement is influenced by patient-, intervention-, and system-level factors. At the patient level, variables such as sex, education, personality traits, race, ethnicity, age, and symptom severity appear to be associated with engagement. At the intervention level, integrating human support, gamification, financial incentives, and persuasive technology features may improve engagement. Finally, although system-level factors have not been widely explored, the existing evidence suggests that achieving engagement will require addressing organizational and social barriers and drawing on the field of implementation science. Future research clarifying the patient-, intervention-, and system-level factors that drive engagement will be essential. Additionally, to facilitate an improved understanding of DMHI engagement, we propose the following: (a) widespread adoption of a minimum necessary 5-element engagement reporting framework, (b) broader application of alternative clinical trial designs, and (c) directed efforts to build upon an initial parsimonious conceptual model of DMHI engagement.
... IPIs address these issues and offer anonymity, flexibility, and cost-effectiveness [2]. Several meta-analyses have found IPIs to be efficacious for treating depression [3][4][5][6] and specifically for postpartum depression [7]. ...
Background: Internet-delivered psychological interventions (IPIs) have been shown to be effective for a variety of psychological concerns, including postpartum depression. Human-supported programs produce better adherence and larger effect sizes than unsupported programs; however, what it is about support that affects outcomes is not well understood. Therapeutic alliance is one possibility that has been found to contribute to outcomes; however, the specific mechanism is not well understood. Participant perspectives and qualitative methodology are nearly absent from the IPI alliance research and may help provide new directions. Objective: In this study, we aimed to provide participant perspectives on engagement with an IPI for postpartum depression to help inform alliance research, development of new IPIs, and inform resource allocation. Methods: A qualitative methodology was used to explore participant perspectives of veteran women's engagement with the MomMoodBooster program, a human-supported internet-delivered intervention for postpartum depression. Participants were asked 4 open-ended questions with the 3-month postintervention survey, "In what ways did you find the MomMoodBooster most helpful?" "How do you think the MomMoodBooster could have been improved?" "In what ways did you find the personal coach calls to be helpful?" and "How do you think the personal coach calls could have been improved?" Results: Data were collected from 184 participants who responded to at least 1 of the open-ended questions. These were analyzed using thematic analysis and a process of reaching a consensus among coders. The results suggest that not only the engagement with the support person is perceived as a significant contributor to participant experiences while using the MomMoodBooster content but also the relationship factors are particularly meaningful. The results provide insights into the specific qualities of the support person that were perceived as most impactful, such as warmth, empathy and genuineness, and feeling normalized and supported. In addition, the results provide insight into the specific change processes that can be targeted through support interactions, such as encouraging self-reflection and self-care and challenging negative thinking. Conclusions: These data emphasize the importance of relationship factors between support persons and an IPI program for postpartum depression. The findings suggest that focusing on specific aspects of the alliance and the therapeutic relationship could yield fruitful directions for the training of support personnel and for future alliance-based research of internet-delivered treatments.
Depression and marital satisfaction have a reciprocal cause-and-effect relationship. Thus, couple relationships should be considered to maximize the effectiveness of couple-oriented interventions for depression. Moreover, developing culturally tailored couple-oriented interventions is critical for improving cultural acceptability and enhancing the perceived effectiveness of the interventions. A new culturally tailored MindGuide Couple intervention was developed to prevent Korean middle adulthood depression and enhance couple relationships using intervention mapping. This feasibility study used a single-arm, pre- and post-test, and 2-month follow-up design to explore the reach, acceptability, and preliminary effectiveness of this preventive intervention. Reach was assessed by recruitment, retention, and completion rates; acceptability was measured based on helpfulness, suitability, and satisfaction; and preliminary effectiveness was measured by depression (CES-D), positive and negative affect (PANAS), satisfaction with life (SWLS), couple satisfaction (CSI), and healthy relationship between spouses (FRAS). Fifteen middle-aged couples participated in four psychoeducational and asynchronous online modules and four synchronous coaching sessions via videoconferencing for 5-7 weeks. Data were analyzed using descriptive statistics and repeated measures with analysis of variance. With a 94.1% completion rate, the participants demonstrated high satisfaction with the online coaching blended intervention and reported that it was helpful and easy to use. Both husbands and wives showed significant differences over time in depression, couple satisfaction, and healthy relationships between spouses. This feasibility study demonstrated the successful reach, acceptability, and potential effectiveness of this preventive intervention. Additionally, we suggest the importance of culturally tailored and online coaching blended couple-oriented intervention for preventing depression and promoting healthy couple relationships.
Üniversite öğrencilerinde ruh sağlığı problemleri yaygındır. Ancak damgalama, ulaşım, yüksek maliyet, uzmana ulaşamama, uzun bekleme listeleri gibi nedenlerden dolayı üniversite öğrencilerinin psikolojik yardım alma eğilimleri düşüktür. Üniversite öğrencilerinin psikolojik yardım alma engellerini ortadan kaldırabilecek alternatif psikolojik destek müdahaleleri geliştirilmektedir. Teknolojik gelişmelerin psikoloji alanına yansımasının bir sonucu olan internet tabanlı müdahaleler farklı gruplar ve farklı problem alanlarında etkililiği kanıtlanmış müdahalelerdir. Çeşitli kuramsal yaklaşımlara dayalı olarak geliştirilebilen internet tabanlı müdahaleler bilgisayar ya da mobil cihazlar yolu ile sunulmaktadır. İnternet tabanlı müdahaleler yüz yüze sunulan psikolojik yardım sürecine yardımcı bir araç olarak ya da tek başına bir müdahale olarak kullanılabilmektedir. Müdahaleler bir uzman desteği eşliğinde ya da kullanıcının yalnız başına kullanacağı şekilde dizayn edilebilmektedir. Bu derleme çalışmasının ilk bölümünde internet tabanlı müdahalelerin tanımı, kapsamı, türleri, etkililiği, avantajları ile birlikte internet tabanlı müdahalelerde katılım ve erken bırakma, olumsuz/yan etkiler ele alınmıştır. İkinci bölümde internet tabanlı müdahalelerin farklı problem alanları üzerindeki etkililiği üniversite öğrencileri üzerindeki çalışmalar bağlamında değerlendirilmiştir. Son bölümde Türkiye’deki mevcut durum ele alınmış ve bu alanda çalışacak araştırmacılara önerilerde bulunulmuştur.
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Internet-based psychotherapeutic interventions have been used for more than a decade, but no comprehensive review and no extensive meta-analysis of their effectiveness have been conducted. We have collected all of the empirical articles published up to March 2006 (n = 64) that examine the effectiveness of online therapy of different forms and performed a meta-analysis of all the studies reported in them (n = 92). These studies involved a total of 9,764 clients who were treated through various Internet-based psychological interventions for a variety of problems, whose effectiveness was assessed by different types of measures. The overall mean weighted effect size was found to be 0.53 (medium effect), which is quite similar to the average effect size of traditional, face-to-face therapy. Next, we examined interacting effects of various possible relevant moderators of the effects of online therapy, including type of therapy (self-help web-based therapy versus online communication-based etherapy), type of outcome measure, time of measurement of outcome (post-therapy or follow-up), type of problem treated, therapeutic approach, and communication modality, among others. A comparison between face-to-face and Internet intervention as reported on in 14 of the studies revealed no differences in effectiveness. The findings of this meta-analysis, and review of additional Internet therapy studies not included in the meta-analysis, provide strong support for the adoption of online psychological interventions as a legitimate therapeutic activity and suggest several insights in regard to its application. Limitations of the findings and recommendations concerning Internet-based therapy and future research are discussed.
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Introduction: Mild to moderate depression has been successfully treated with cognitive-behavioural (CBT) bibliotherapy, including minimal therapist contact. More recently, the Internet has been used to deliver the treatment, with obvious gains in terms of cost reduction and increased accessibility. In the present study we analysed pre-treatment predictors of improvement following Internet-based self-help treatment of mild to moderate depression. Patients and Methods: Included were 71 participants from a randomised trial who completed a 6-month follow-up. Change indexes were calculated from the Beck Depression Inventory (BDI) and the Montgomery Åsberg Depression Rating Scale (MADRS). Results: In line with the literature on depression, the number of previous episodes of depression was negatively associated with improvement after treatment. Follow-up scores on the BDI and MADRS were associated with pre-treatment levels of depression, anxiety and low levels of quality of life. Discussion: As indicated by traditional psychotherapy studies, finding predictors of outcome is a difficult task. Patients with repeated episodes of depression might benefit less from self-help over the Internet, but as the correlation is weak, no firm conclusions can be drawn.
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Internet-delivered cognitive behavioural therapy (CBT) can be an effective method for treating major depression, but it often works best when therapist support is provided in the form of e-mail support or telephone calls. The authors investigated whether there were any intraclass correlations within therapists when delivering CBT for major depression via the Internet. They included data from two trials involving 10 therapists treating a total of 103 patients. The results of a nested one-way model in which participants were treated as raters for different therapists indicated that measures pertaining to symptom reductions (Beck Depression Inventory, Montgomery-Asberg Depression Rating Scale-Self Report, and Beck Anxiety Inventory) did not support a clustering of data within therapists. However, the outcome on a secondary measure of life satisfaction (Quality of Life Inventory) yielded a significant intraclass correlation coefficient for therapists (r = .24, p = .001). The authors propose that text-based treatments are less sensitive to therapist effects when it comes to the primary symptom measures, but that treatment effects not directly targeted by the specific treatment program may be more dependent on the way the support is given and by whom (therapist effect). Limitations of the study are discussed.
Adequate reporting of randomized, controlled trials (RCTs) is necessary to allow accurate critical appraisal of the validity and applicability of the results. The CONSORT (Consolidated Standards of Reporting Trials) Statement, a 22-item checklist and flow diagram, is intended to address this problem by improving the reporting of RCTs. However, some specific issues that apply to trials of nonpharmacologic treatments (for example, surgery, technical interventions, devices, rehabilitation, psychotherapy, and behavioral intervention) are not specifically addressed in the CONSORT Statement. Furthermore, considerable evidence suggests that the reporting of nonpharmacologic trials still needs improvement. Therefore, the CONSORT group developed an extension of the CONSORT Statement for trials assessing nonpharmacologic treatments. A consensus meeting of 33 experts was organized in Paris, France, in February 2006, to develop an extension of the CONSORT Statement for trials of nonpharmacologic treatments. The participants extended 11 items from the CONSORT Statement, added 1 item, and developed a modified flow diagram. To allow adequate understanding and implementation of the CONSORT extension, the CONSORT group developed this elaboration and explanation document from a review of the literature to provide examples of adequate reporting. This extension, in conjunction with the main CONSORT Statement and other CONSORT extensions, should help to improve the reporting of RCTs performed in this field.
Self-help Internet interventions have the potential to enable consumers to play a central role in managing their own health. This paper contains a systematic review of 15 randomised controlled trials of the effectiveness of self-help Internet interventions for mental disorders and related conditions. Conditions addressed by the interventions included: depression, anxiety, stress, insomnia, headache, eating disorder and encopresis. Most interventions were reported to be effective in reducing risk factors or improving symptoms, although many of the studies had methodological limitations. Three of the interventions that reported positive outcomes are available without charge to the public.
The Cochrane Handbook for Systematic Reviews of Interventions (the Handbook) has undergone a substantial update, and Version 5 of the Handbook is now available online at and in RevMan 5. In addition, for the first time, the Handbook will soon be available as a printed volume, published by Wiley-Blackwell. We are anticipating release of this at the Colloquium in Freiburg. Version 5 of the Handbook describes the new methods available in RevMan 5, as well as containing extensive guidance on all aspects of Cochrane review methodology. It has a new structure, with 22 chapters divided into three parts. Part 1, relevant to all reviews, introduces Cochrane reviews, covering their planning and preparation, and their maintenance and updating, and ends with a guide to the contents of a Cochrane protocol and review. Part 2, relevant to all reviews, provides general methodological guidance on preparing reviews, covering question development, eligibility criteria, searching, collecting data, within-study bias (including completion of the Risk of Bias table), analysing data, reporting bias, presenting and interpreting results (including Summary of Findings tables). Part 3 addresses special topics that will be relevant to some, but not all, reviews, including particular considerations in addressing adverse effects, meta-analysis with non-standard study designs and using individual participant data. This part has new chapters on incorporating economic evaluations, non-randomized studies, qualitative research, patient-reported outcomes in reviews, prospective meta-analysis, reviews in health promotion and public health, and the new review type of overviews of reviews.
We conducted a meta-analysis of 48 research reports on the efficacy of group therapy for depression. In 15 studies in which treated participants were compared to untreated controls, the average effect size was 1.03, suggesting that the average treated participant was better off than about 85% of the untreated participants. Analyses of clinically significant change suggested that treated participants improved substantially. However, even after treatment, participants still had pronounced depressive symptomatology relative to normative levels of depressive symptoms seen in non-depressed individuals. We conclude that group therapy is an efficacious treatment for depressed patients. However, numerous questions remain unanswered. For example, little empirical work has investigated what advantages group therapy might have over individual therapy. We conclude by making recommendations for future research in this area.