Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis.

Importance Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them. Objective To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information. Data Sources We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019. Study Selection Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization. Data Extraction and Synthesis We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression. Main Outcomes and Measures Patient Health Questionnaire-9 (PHQ-9) scores. Results Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-0 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9. Conclusions and Relevance In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.

[1]  Andrew K. Przybylski,et al.  Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science , 2020, The Lancet Psychiatry.

[2]  Gerhard Andersson,et al.  The COVID-19 pandemic: The ‘black swan’ for mental health care and a turning point for e-health , 2020, Internet Interventions.

[3]  P. Cuijpers,et al.  A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression , 2020, World psychiatry : official journal of the World Psychiatric Association.

[4]  P. Cuijpers,et al.  Effectiveness and Acceptability of Cognitive Behavior Therapy Delivery Formats in Adults With Depression: A Network Meta-analysis. , 2019, JAMA psychiatry.

[5]  S. Khaled.  Prevalence and potential determinants of subthreshold and major depression in the general population of Qatar. , 2019, Journal of affective disorders.

[6]  P. Cuijpers,et al.  Guided or self-guided internet-based cognitive–behavioural therapy (iCBT) for depression? Study protocol of an individual participant data network meta-analysis , 2019, BMJ Open.

[7]  G. Andersson,et al.  Proof of Concept for an Adaptive Treatment Strategy to Prevent Failures in Internet-Delivered CBT: A Single-Blind Randomized Clinical Trial With Insomnia Patients. , 2019, The American journal of psychiatry.

[8]  G. Andersson,et al.  Internet‐delivered psychological treatments: from innovation to implementation , 2019, World psychiatry : official journal of the World Psychiatric Association.

[9]  A. Kersting,et al.  Computerized cognitive behavior therapy for patients with mild to moderately severe depression in primary care: A pragmatic cluster randomized controlled trial (@ktiv). , 2018, Journal of affective disorders.

[10]  Dan J Stein,et al.  The Lancet Commission on global mental health and sustainable development , 2018, The Lancet.

[11]  Alishia D. Williams,et al.  Do guided internet-based interventions result in clinically relevant changes for patients with depression? An individual participant data meta-analysis. , 2018, Clinical psychology review.

[12]  Johannes B Reitsma,et al.  An overview of methods for network meta-analysis using individual participant data: when do benefits arise? , 2018, Statistical methods in medical research.

[13]  C. Knaevelsrud,et al.  Benefits of Individualized Feedback in Internet-Based Interventions for Depression: A Randomized Controlled Trial , 2018, Psychotherapy and Psychosomatics.

[14]  K. Griffiths,et al.  Outcomes of an online computerized cognitive behavioral treatment program for treating chinese patients with depression: A pilot study. , 2017, Asian journal of psychiatry.

[15]  F. Holländare,et al.  Internet delivered cognitive behavior therapy for antenatal depression: A randomised controlled trial. , 2017, Journal of affective disorders.

[16]  Alishia D. Williams,et al.  Help from home for depression: A randomised controlled trial comparing internet-delivered cognitive behaviour therapy with bibliotherapy for depression , 2017, Internet interventions.

[17]  D. Strunk,et al.  Efficacy of Guided iCBT for Depression and Mediation of Change by Cognitive Skill Acquisition. , 2017, Behavior therapy.

[18]  R. Araya,et al.  Telephone-supported computerised cognitive–behavioural therapy: REEACT-2 large-scale pragmatic randomised controlled trial , 2017, British Journal of Psychiatry.

[19]  C. Beevers,et al.  Effectiveness of an Internet Intervention (Deprexis) for Depression in a United States Adult Sample: A Parallel-Group Pragmatic Randomized Controlled Trial , 2017, Journal of consulting and clinical psychology.

[20]  Elizabeth A. Olson,et al.  Internet‐based cognitive behavior therapy for major depressive disorder: A randomized controlled trial , 2017, Depression and anxiety.

[21]  Gerhard Andersson,et al.  Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data , 2017, JAMA psychiatry.

[22]  V. Patel,et al.  The Impact of Digital Technology on Psychological Treatments and Their Dissemination. , 2018, Focus.

[23]  N. Lindefors,et al.  Exercise and internet-based cognitive–behavioural therapy for depression: multicentre randomised controlled trial with 12-month follow-up , 2016, British Journal of Psychiatry.

[24]  Johannes B Reitsma,et al.  GetReal in network meta‐analysis: a review of the methodology , 2016, Research synthesis methods.

[25]  Gerhard Andersson,et al.  European COMPARative Effectiveness research on blended Depression treatment versus treatment-as-usual (E-COMPARED): study protocol for a randomized controlled, non-inferiority trial in eight European countries , 2016, Trials.

[26]  Cristina Botella,et al.  CONSORT-EHEALTH (V 1.6.1) - Submission/Publication , 2016 .

[27]  G. Andersson,et al.  Effects of a Psychological Internet Intervention in the Treatment of Mild to Moderate Depressive Symptoms: Results of the EVIDENT Study, a Randomized Controlled Trial , 2016, Psychotherapy and Psychosomatics.

[28]  P. Cuijpers,et al.  Scaling-up treatment of depression and anxiety: a global return on investment analysis. , 2016, The lancet. Psychiatry.

[29]  Milagra S. Tyler,et al.  Internet Cognitive Behavioral Therapy for Women With Postnatal Depression: A Randomized Controlled Trial of MumMoodBooster , 2016, Journal of Medical Internet Research.

[30]  H. Hadjistavropoulos,et al.  A Randomised Controlled Trial of Therapist-Assisted, Internet-Delivered Cognitive Behavior Therapy for Women with Maternal Depression , 2016, PloS one.

[31]  R. Kessler,et al.  Using patient self-reports to study heterogeneity of treatment effects in major depressive disorder , 2016, Epidemiology and Psychiatric Sciences.

[32]  J. Sharry,et al.  A randomized controlled trial of an internet-delivered treatment: Its potential as a low-intensity community intervention for adults with symptoms of depression , 2015, European Psychiatry.

[33]  Ricardo Araya,et al.  Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial , 2015, BMJ : British Medical Journal.

[34]  S. Hollon,et al.  A lifetime approach to major depressive disorder: The contributions of psychological interventions in preventing relapse and recurrence. , 2015, Clinical psychology review.

[35]  Alishia D. Williams,et al.  Positive imagery cognitive bias modification (CBM) and internet-based cognitive behavioral therapy (iCBT): A randomized controlled trial , 2015, Journal of affective disorders.

[36]  C. Beevers,et al.  Effects of an Internet intervention (Deprexis) on severe depression symptoms: Randomized controlled trial , 2015 .

[37]  Rebecca M. Turner,et al.  Predictive distributions were developed for the extent of heterogeneity in meta-analyses of continuous outcome data , 2015, Journal of clinical epidemiology.

[38]  C. Björkelund,et al.  Internet-Based Therapy for Mild to Moderate Depression in Swedish Primary Care: Short Term Results from the PRIM-NET Randomized Controlled Trial , 2014, Cognitive behaviour therapy.

[39]  P. Cuijpers,et al.  Short-Term Effects of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Randomized Controlled Trial , 2014, Journal of medical Internet research.

[40]  Harald Binder,et al.  Visualizing the flow of evidence in network meta‐analysis and characterizing mixed treatment comparisons , 2013, Statistics in medicine.

[41]  Xuan Cai,et al.  A Randomized Controlled Trial Evaluating a Manualized TeleCoaching Protocol for Improving Adherence to a Web-Based Intervention for the Treatment of Depression , 2013, PloS one.

[42]  J. Schneider,et al.  Randomized controlled trial of computerized cognitive behavioural therapy for depressive symptoms: effectiveness and costs of a workplace intervention , 2013, Psychological Medicine.

[43]  Steffen Moritz,et al.  A randomized controlled trial of internet-based therapy in depression. , 2012, Behaviour research and therapy.

[44]  Derek B. Kosty,et al.  Development and pilot evaluation of an Internet-facilitated cognitive-behavioral intervention for maternal depression. , 2012, Journal of consulting and clinical psychology.

[45]  Dan Jackson,et al.  Consistency and inconsistency in network meta-analysis: model estimation using multivariate meta-regression‡ , 2012, Research synthesis methods.

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

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

[48]  Helen Christensen,et al.  Internet-Based CBT for Depression with and without Telephone Tracking in a National Helpline: Randomised Controlled Trial , 2011, PloS one.

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

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

[51]  Katie A. McLaughlin,et al.  The Public Health Impact of Major Depression: A Call for Interdisciplinary Prevention Efforts , 2011, Prevention Science.

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

[53]  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.

[54]  R. Riley,et al.  Meta-analysis of individual participant data: rationale, conduct, and reporting , 2010, BMJ : British Medical Journal.

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

[56]  H. Riper,et al.  Clinical effectiveness of online computerised cognitive–behavioural therapy without support for depression in primary care: randomised trial , 2009, British Journal of Psychiatry.

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

[58]  C. Beevers,et al.  Effectiveness of a Novel Integrative Online Treatment for Depression (Deprexis): Randomized Controlled Trial , 2009, Journal of medical Internet research.

[59]  T. Strine,et al.  The PHQ-8 as a measure of current depression in the general population. , 2009, Journal of affective disorders.

[60]  J. Ruwaard,et al.  Standardized Web-Based Cognitive Behavioural Therapy of Mild to Moderate Depression: A Randomized Controlled Trial with a Long-Term Follow-Up , 2009, Cognitive behaviour therapy.

[61]  Heleen Riper,et al.  Internet-Based Treatment for Adults with Depressive Symptoms: Randomized Controlled Trial , 2008, Journal of medical Internet research.

[62]  P. Cuijpers,et al.  Self-help interventions for anxiety disorders: An overview , 2007, Current psychiatry reports.

[63]  Heleen Riper,et al.  Internet-based cognitive behavioural therapy for subthreshold depression in people over 50 years old: a randomized controlled clinical trial , 2007, Psychological Medicine.

[64]  G. Andersson,et al.  Internet-based self-help for depression: randomised controlled trial , 2005, British Journal of Psychiatry.

[65]  T. B. Üstün,et al.  Global burden of depressive disorders in the year 2000 , 2004, British Journal of Psychiatry.

[66]  H. Christensen,et al.  Delivering interventions for depression by using the internet: randomised controlled trial , 2004, BMJ : British Medical Journal.

[67]  R. Spitzer,et al.  The PHQ-9 , 2001, Journal of General Internal Medicine.

[68]  G. Smith,et al.  Bias in meta-analysis detected by a simple, graphical test , 1997, BMJ.

[69]  Simon Grund,et al.  jomo: A Flexible Package for Two-level Joint Modelling Multiple Imputation , 2019, R J..

[70]  N. Titov,et al.  Clinical and cost-effectiveness of therapist-guided internet-delivered cognitive behavior therapy for older adults with symptoms of depression: a randomized controlled trial. , 2015, Behavior therapy.

[71]  J. Bjorner,et al.  Standardization of depression measurement: a common metric was developed for 11 self-report depression measures. , 2014, Journal of clinical epidemiology.

[72]  Kathleen M Griffiths,et al.  Evaluating the effectiveness and efficacy of unguided internet-based self-help intervention for the prevention of depression: a randomized controlled trial. , 2013, Clinical psychology & psychotherapy.

[73]  N. Iwata,et al.  Neuropsychiatric Disease and Treatment , 2022 .