Internet-Delivered Psychological Treatments for Mood and Anxiety Disorders: A Systematic Review of Their Efficacy, Safety, and Cost-Effectiveness

Background Greater access to evidence-based psychological treatments is needed. This review aimed to evaluate whether internet-delivered psychological treatments for mood and anxiety disorders are efficacious, noninferior to established treatments, safe, and cost-effective for children, adolescents and adults. Methods We searched the literature for studies published until March 2013. Randomized controlled trials (RCTs) were considered for the assessment of short-term efficacy and safety and were pooled in meta-analyses. Other designs were also considered for long-term effect and cost-effectiveness. Comparisons against established treatments were evaluated for noninferiority. Two reviewers independently assessed the relevant studies for risk of bias. The quality of the evidence was graded using an international grading system. Results A total of 52 relevant RCTs were identified whereof 12 were excluded due to high risk of bias. Five cost-effectiveness studies were identified and three were excluded due to high risk of bias. The included trials mainly evaluated internet-delivered cognitive behavioral therapy (I-CBT) against a waiting list in adult volunteers and 88% were conducted in Sweden or Australia. One trial involved children. For adults, the quality of evidence was graded as moderate for the short-term efficacy of I-CBT vs. waiting list for mild/moderate depression (d = 0.83; 95% CI 0.59, 1.07) and social phobia (d = 0.85; 95% CI 0.66, 1.05), and moderate for no efficacy of internet-delivered attention bias modification vs. sham treatment for social phobia (d = −0.04; 95% CI −0.24, 0.35). The quality of evidence was graded as low/very low for other disorders, interventions, children/adolescents, noninferiority, adverse events, and cost-effectiveness. Conclusions I-CBT is a viable treatment option for adults with depression and some anxiety disorders who request this treatment modality. Important questions remain before broad implementation can be supported. Future research would benefit from prioritizing adapting treatments to children/adolescents and using noninferiority designs with established forms of treatment.

[1]  Guochen Song,et al.  Bayesian methods for the design and analysis of noninferiority trials , 2016, Journal of biopharmaceutical statistics.

[2]  A. James,et al.  Cognitive behavioural therapy for anxiety disorders in children and adolescents. , 2005, The Cochrane database of systematic reviews.

[3]  I. Alaie,et al.  Reporting of harms in randomized controlled trials of psychological interventions for mental and behavioral disorders: a review of current practice. , 2014, Contemporary clinical trials.

[4]  Katherine E Henson,et al.  Risk of Suicide After Cancer Diagnosis in England , 2018, JAMA psychiatry.

[5]  M. Mishkind,et al.  SYNCHRONOUS TELEHEALTH TECHNOLOGIES IN PSYCHOTHERAPY FOR DEPRESSION: A META‐ANALYSIS , 2013, Depression and anxiety.

[6]  I. Alaie,et al.  Recent randomized controlled trials of psychological interventions in healthcare: a review of their quantity, scope, and characteristics. , 2013, Journal of psychosomatic research.

[7]  J. Boettcher,et al.  Internet-Based Attention Bias Modification for Social Anxiety: A Randomised Controlled Comparison of Training towards Negative and Training Towards Positive Cues , 2013, PloS one.

[8]  M. Otto,et al.  Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. , 2013, The Journal of clinical psychiatry.

[9]  Janet B W Williams,et al.  Diagnostic and Statistical Manual of Mental Disorders , 2013 .

[10]  C. Weijer,et al.  Assay Sensitivity and the Epistemic Contexts of Clinical Trials , 2013, Perspectives in biology and medicine.

[11]  Per Carlbring,et al.  Internet-based behavioral activation and acceptance-based treatment for depression: a randomized controlled trial. , 2013, Journal of affective disorders.

[12]  G. Andersson,et al.  A 3.5-year follow-up of Internet-delivered cognitive behavior therapy for major depression , 2013, Journal of mental health.

[13]  Alishia D. Williams,et al.  Internet cognitive behavioural therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care , 2013, Psychological Medicine.

[14]  A. Gerlach,et al.  Internet-delivered attention modification training as a treatment for social phobia: a randomized controlled trial. , 2013, Behaviour research and therapy.

[15]  A. Peterson,et al.  The need for expanded monitoring of adverse events in behavioral health clinical trials. , 2013, Contemporary clinical trials.

[16]  N. Lindefors,et al.  Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost–effectiveness , 2012, Expert review of pharmacoeconomics & outcomes research.

[17]  G. Andersson,et al.  Internet-Based Psychodynamic versus Cognitive Behavioral Guided Self-Help for Generalized Anxiety Disorder: A Randomized Controlled Trial , 2012, Psychotherapy and Psychosomatics.

[18]  Gerhard Andersson,et al.  Internet-based psychological treatments for depression , 2012, Expert review of neurotherapeutics.

[19]  G. Andersson,et al.  Internet-delivered attention bias modification training in individuals with social anxiety disorder - a double blind randomized controlled trial , 2012, BMC Psychiatry.

[20]  G. Andersson,et al.  Psychodynamic Guided Self-Help for Adult Depression through the Internet: A Randomised Controlled Trial , 2012, PloS one.

[21]  G. Andersson,et al.  Therapist Experience and Knowledge Acquisition in Internet-Delivered CBT for Social Anxiety Disorder: A Randomized Controlled Trial , 2012, PloS one.

[22]  Per Carlbring,et al.  Tailored vs. Standardized Internet-Based Cognitive Behavior Therapy for Depression and Comorbid Symptoms: A Randomized Controlled Trial , 2012, PloS one.

[23]  G. Andersson,et al.  Internet-based cognitive behaviour therapy for obsessive–compulsive disorder: a randomized controlled trial , 2012, Psychological Medicine.

[24]  C. Bell,et al.  Effectiveness of computerised cognitive behaviour therapy for anxiety disorders in secondary care , 2012, The Australian and New Zealand journal of psychiatry.

[25]  Gavin Andrews,et al.  Culturally attuned Internet treatment for depression amongst Chinese Australians: a randomised controlled trial. , 2012, Journal of affective disorders.

[26]  J. Boettcher,et al.  Internet-Based Attention Training for Social Anxiety: A Randomized Controlled Trial , 2012, Cognitive Therapy and Research.

[27]  N. Titov,et al.  A RCT of a Transdiagnostic Internet-Delivered Treatment for Three Anxiety Disorders: Examination of Support Roles and Disorder-Specific Outcomes , 2011, PloS one.

[28]  Gerhard Andersson,et al.  Internet-Based Treatment of Depression: A Randomized Controlled Trial Comparing Guided with Unguided Self-Help , 2011, Cognitive behaviour therapy.

[29]  G. Andersson,et al.  Cost-effectiveness of Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: results from a randomized controlled trial. , 2011, Behaviour research and therapy.

[30]  J. Os,et al.  The size and burden of mental disorders and other disorders of the brain in Europe 2010 , 2011, European Neuropsychopharmacology.

[31]  G. Andersson,et al.  Guided Internet-Delivered Cognitive Behavior Therapy for Generalized Anxiety Disorder: A Randomized Controlled Trial , 2011, Cognitive behaviour therapy.

[32]  E. Walker,et al.  Diagnostic and Statistical Manual of Mental Disorders , 2013 .

[33]  N. Titov,et al.  Transdiagnostic internet treatment for anxiety and depression: a randomised controlled trial. , 2011, Behaviour research and therapy.

[34]  Bethany M. Wootton,et al.  Randomized controlled trial of Internet‐delivered cognitive behavioral therapy for posttraumatic stress disorder , 2011, Depression and anxiety.

[35]  G. Andersson,et al.  A 5-Year Follow-up of Internet-Based Cognitive Behavior Therapy for Social Anxiety Disorder , 2011, Journal of medical Internet research.

[36]  G. Andersson,et al.  Interpersonal psychotherapy for depression: a meta-analysis. , 2011, The American journal of psychiatry.

[37]  J. Lépine,et al.  The increasing burden of depression , 2011, Neuropsychiatric disease and treatment.

[38]  M. Gallagher,et al.  Efficacy of Telehealth Treatments for Posttraumatic Stress-Related Symptoms: A Meta-Analysis , 2011, Cognitive behaviour therapy.

[39]  J. Schumi,et al.  TRIALS REVIEW Open Access , 2022 .

[40]  Howard Balshem,et al.  GRADE guidelines: 3. Rating the quality of evidence. , 2011, Journal of clinical epidemiology.

[41]  G. Guyatt,et al.  GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias). , 2011, Journal of clinical epidemiology.

[42]  G. Andersson,et al.  Internet-Based Cognitive Behavior Therapy vs. Cognitive Behavioral Group Therapy for Social Anxiety Disorder: A Randomized Controlled Non-inferiority Trial , 2011, PloS one.

[43]  A. Kazdin,et al.  Rebooting Psychotherapy Research and Practice to Reduce the Burden of Mental Illness , 2011, Perspectives on psychological science : a journal of the Association for Psychological Science.

[44]  G. Andersson,et al.  Individually-tailored, Internet-based treatment for anxiety disorders: A randomized controlled trial. , 2011, Behaviour research and therapy.

[45]  Ayelet Meron Ruscio,et al.  Epidemiology of anxiety disorders. , 2020, Current topics in behavioral neurosciences.

[46]  Monique Ernst,et al.  Attention Bias Modification Treatment: A Meta-Analysis Toward the Establishment of Novel Treatment for Anxiety , 2010, Biological Psychiatry.

[47]  Michelle G. Craske,et al.  Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-Analysis , 2010, PloS one.

[48]  Sandra Hollinghurst,et al.  Cost-effectiveness of therapist-delivered online cognitive–behavioural therapy for depression: randomised controlled trial , 2010, British Journal of Psychiatry.

[49]  N. Titov,et al.  Transdiagnostic Internet treatment for anxiety disorders: A randomized controlled trial. , 2010, Behaviour research and therapy.

[50]  D. Tolin,et al.  Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. , 2010, Clinical psychology review.

[51]  Michele Tarsilla.  Cochrane Handbook for Systematic Reviews of Interventions , 2010, Journal of MultiDisciplinary Evaluation.

[52]  Per Carlbring,et al.  Internet-versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial , 2010, BMC psychiatry.

[53]  Gavin Andrews,et al.  Internet Treatment for Depression: A Randomized Controlled Trial Comparing Clinician vs. Technician Assistance , 2010, PloS one.

[54]  Gavin Andrews,et al.  Internet Treatment for Generalized Anxiety Disorder: A Randomized Controlled Trial Comparing Clinician vs. Technician Assistance , 2010, PloS one.

[55]  H. Christensen,et al.  The efficacy of internet interventions for depression and anxiety disorders: a review of randomised controlled trials , 2010, The Medical journal of Australia.

[56]  Per Carlbring,et al.  Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression. , 2010, Behaviour research and therapy.

[57]  J. Shedler.  The efficacy of psychodynamic psychotherapy. , 2010, The American psychologist.

[58]  N. Titov,et al.  Clinician-Assisted Internet-Based Treatment is Effective for Panic: A Randomized Controlled Trial , 2009, The Australian and New Zealand journal of psychiatry.

[59]  James Thomas,et al.  A web-based tool for adjusting costs to a specific target currency and price year , 2010 .

[60]  M. Stein,et al.  Behavioral neurobiology of anxiety and its treatment , 2010 .

[61]  G. Andersson,et al.  Internet-Based and Other Computerized Psychological Treatments for Adult Depression: A Meta-Analysis , 2009, Cognitive behaviour therapy.

[62]  G. Andersson,et al.  Guided and unguided self-help for social anxiety disorder: randomised controlled trial. , 2009, The British journal of psychiatry : the journal of mental science.

[63]  F. Caspar,et al.  Internet-based treatment for social phobia: a randomized controlled trial. , 2009, Journal of clinical psychology.

[64]  G. Andersson,et al.  Long-term outcome of Internet-delivered cognitive-behavioural therapy for social phobia: a 30-month follow-up. , 2009, Behaviour research and therapy.

[65]  N. Titov,et al.  Clinician-Assisted Internet-Based Treatment is Effective for Generalized Anxiety Disorder: Randomized Controlled Trial , 2009 .

[66]  Ricardo Araya,et al.  Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial , 2009, The Lancet.

[67]  G. Andersson,et al.  Internet‐Based Self‐Help Versus One‐Session Exposure in the Treatment of Spider Phobia: A Randomized Controlled Trial , 2009, Cognitive behaviour therapy.

[68]  S. Spence,et al.  The efficacy of an internet-based cognitive-behavioral therapy intervention for child anxiety disorders. , 2009, Journal of pediatric psychology.

[69]  G. Andersson.  Using the Internet to provide cognitive behaviour therapy. , 2009, Behaviour research and therapy.

[70]  C. Weijer,et al.  Helsinki discords: FDA, ethics, and international drug trials , 2009, The Lancet.

[71]  G. Andersson,et al.  What Makes Internet Therapy Work? , 2009, Cognitive behaviour therapy.

[72]  J. Abraham.  The international conference on harmonisation of technical requirements for registration of pharmaceuticals for human use , 2009 .

[73]  N. Titov,et al.  Shyness 3: Randomized Controlled Trial of Guided Versus Unguided Internet-Based CBT for Social Phobia , 2008, The Australian and New Zealand journal of psychiatry.

[74]  D. Altman,et al.  Assessing Risk of Bias in Included Studies , 2008 .

[75]  D. Altman,et al.  Chapter 8: Assessing risk of bias in included studies , 2008 .

[76]  A. Barak,et al.  A Comprehensive Review and a Meta-Analysis of the Effectiveness of Internet-Based Psychotherapeutic Interventions , 2008 .

[77]  N. Titov,et al.  Shyness 2: Treating Social Phobia Online: Replication and Extension , 2008, The Australian and New Zealand journal of psychiatry.

[78]  N. Titov,et al.  Shyness 1: Distance Treatment of Social Phobia Over the Internet , 2008, The Australian and New Zealand journal of psychiatry.

[79]  Jasper A. J. Smits,et al.  DISORDERS : A META-ANALYSIS OF RANDOMIZED PLACEBO-CONTROLLED TRIALS , 2008 .

[80]  G. Andersson,et al.  Internet-delivered treatments with or without therapist input: does the therapist factor have implications for efficacy and cost? , 2007, Expert review of pharmacoeconomics & outcomes research.

[81]  G. Andersson,et al.  Treatment of social phobia: randomised trial of internet-delivered cognitive-behavioural therapy with telephone support , 2007, British Journal of Psychiatry.

[82]  Per Carlbring,et al.  Remote treatment of panic disorder: a randomized trial of internet-based cognitive behavior therapy supplemented with telephone calls. , 2006, The American journal of psychiatry.

[83]  Heleen Riper,et al.  Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis , 2006, Psychological Medicine.

[84]  Britt Klein,et al.  Efficacy of internet therapy for panic disorder. , 2006, Journal of behavior therapy and experimental psychiatry.

[85]  G. Andersson,et al.  Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: a randomized controlled trial. , 2006, Journal of consulting and clinical psychology.

[86]  B. Lebowitz,et al.  Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. , 2006, The American journal of psychiatry.

[87]  A. Beck,et al.  The empirical status of cognitive-behavioral therapy: a review of meta-analyses. , 2006, Clinical psychology review.

[88]  G. Andersson,et al.  Treatment of panic disorder: live therapy vs. self-help via the Internet. , 2005, Behaviour research and therapy.

[89]  Olga V. Demler,et al.  Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. , 2005, Archives of general psychiatry.

[90]  C. Sherbourne,et al.  Quality of care for primary care patients with anxiety disorders. , 2004, The American journal of psychiatry.

[91]  R. Kessler,et al.  Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. , 2004, JAMA.

[92]  R. D'Agostino,et al.  Non‐inferiority trials: design concepts and issues – the encounters of academic consultants in statistics , 2002, Statistics in medicine.

[93]  S Greenland,et al.  On the bias produced by quality scores in meta-analysis, and a hierarchical view of proposed solutions. , 2001, Biostatistics.

[94]  Per Carlbring,et al.  Treatment of panic disorder via the internet: A randomized trial of a self-help program * , 2001 .

[95]  S Duval,et al.  Trim and Fill: A Simple Funnel‐Plot–Based Method of Testing and Adjusting for Publication Bias in Meta‐Analysis , 2000, Biometrics.

[96]  D. Cook,et al.  Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? , 1998, The Lancet.

[97]  R. DeRubeis,et al.  Update on Empirically Validated Therapies, II , 1998 .

[98]  Streichenwein Sm,et al.  Am J Psychiatry , 1996 .

[99]  D. Lawlor,et al.  Exercise for Depression. , 1978, The Physician and sportsmedicine.