Internet-Based Cognitive Behavioral Therapy for Patients With Chronic Somatic Conditions: A Meta-Analytic Review

Background Patients with chronic somatic conditions face unique challenges accessing mental health care outside of their homes due to symptoms and physical limitations. Internet-based cognitive behavioral therapy (ICBT) has shown to be effective for various psychological conditions. The increasing number of recent trials need to be systematically evaluated and quantitatively analyzed to determine whether ICBT is also effective for chronic somatic conditions and to gain insight into the types of problems that could be targeted. Objective Our goal was to describe and evaluate the effectiveness of guided ICBT interventions for chronic somatic conditions on general psychological outcomes, disease-related physical outcomes, and disease-related impact on daily life outcomes. The role of treatment length was also examined. Methods PubMed, PsycINFO, and Embase were searched from inception until February 2012, by combining search terms indicative of effect studies, Internet, and cognitive behavioral therapy. Studies were included if they fulfilled the following six criteria: (1) randomized controlled trial, (2) Internet-based interventions, (3) based on cognitive behavioral therapy, (4) therapist-guided, (5) adult (≥18 years old) patients with an existing chronic somatic condition, and (6) published in English. 23 randomized controlled trials of guided ICBT were selected by 2 independent raters after reviewing 4848 abstracts. Demographic, clinical, and methodological variables were extracted. Standardized mean differences were calculated between intervention and control conditions for each outcome and pooled using random effects models when appropriate. Results Guided ICBT was shown to improve all outcome categories with small effect sizes for generic psychological outcomes (effect size range 0.17-0.21) and occasionally larger effects for disease-specific physical outcomes (effect size range 0.07 to 1.19) and disease-related impact outcomes (effect size range 0.17-1.11). Interventions with a longer treatment duration (>6 weeks) led to more consistent effects on depression. Conclusions Guided ICBT appears to be a promising and effective treatment for chronic somatic conditions to improve psychological and physical functioning and disease-related impact. The most consistent improvements were found for disease-specific outcomes, which supports the possible relevance of tailoring interventions to specific patient groups. Explorative analyses revealed that longer treatment length holds the promise of larger treatment effects for the specific outcome of depression. While the current meta-analysis focused on several chronic somatic conditions, future meta-analyses for separate chronic somatic conditions can further consolidate these results, also in terms of cost-effectiveness.

[1]  H. van Os-Medendorp,et al.  A systematic review of the effects of e-health on chronically ill patients. , 2011, Journal of clinical nursing.

[2]  Jacob Cohen.  Statistical Power Analysis for the Behavioral Sciences , 1969, The SAGE Encyclopedia of Research Design.

[3]  S. Hollon,et al.  6 – Cognitive Therapy of Depression1 , 1979 .

[4]  Gerhard Andersson,et al.  A Cluster Randomised Trial of an Internet-Based Intervention Program for Tinnitus Distress in an Industrial Setting , 2009, Cognitive behaviour therapy.

[5]  A. Passmore,et al.  Effectiveness of an online fatigue self-management programme for people with chronic neurological conditions: a randomized controlled trial , 2010, Clinical rehabilitation.

[6]  Gerhard Andersson,et al.  Internet‐Based Treatment of Headache: Does Telephone Contact Add Anything? , 2003, Headache.

[7]  H. Stuckey,et al.  Chronic Health Conditions and Internet Behavioral Interventions: A Review of Factors to Enhance User Engagement , 2011, Computers, informatics, nursing : CIN.

[8]  K. Lorig,et al.  Internet-Based Chronic Disease Self-Management: A Randomized Trial , 2006, Medical care.

[9]  J. Overholser,et al.  Evaluating depression severity and remission with a modified Beck Depression Inventory , 2000 .

[10]  H. Christensen,et al.  Online randomized controlled trial of brief and full cognitive behaviour therapy for depression , 2006, Psychological Medicine.

[11]  Richard Beck,et al.  Cognitive-Behavioral Therapy in the Treatment of Anger: A Meta-Analysis , 2004, Cognitive Therapy and Research.

[12]  Mick P Couper,et al.  Engagement and Retention: Measuring Breadth and Depth of Participant Use of an Online Intervention , 2010, Journal of medical Internet research.

[13]  G. Andersson,et al.  Internet-based treatment of depression , 2015 .

[14]  Karl E. Peace,et al.  Intention to treat in clinical trials , 1989 .

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

[16]  Per Carlbring,et al.  A randomized controlled trial of Internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus. , 2012, Journal of consulting and clinical psychology.

[17]  P. Tugwell,et al.  Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses? , 2000, The Lancet.

[18]  J. Seeley,et al.  Methodological Issues in Research on Web-Based Behavioral Interventions , 2009, Annals of behavioral medicine : a publication of the Society of Behavioral Medicine.

[19]  Gerhard Andersson,et al.  Internet versus group cognitive-behavioral treatment of distress associated with tinnitus: a randomized controlled trial. , 2008, Behavior therapy.

[20]  K. Holroyd,et al.  A comparison of pharmacological (amitriptyline HCL) and nonpharmacological (cognitive-behavioral) therapies for chronic tension headaches. , 1991, Journal of consulting and clinical psychology.

[21]  C D Naylor,et al.  Incorporating variations in the quality of individual randomized trials into meta-analysis. , 1992, Journal of clinical epidemiology.

[22]  Azizeh K Sowan,et al.  Paradata: a new data source from web-administered measures. , 2010, Computers, informatics, nursing : CIN.

[23]  Felipe Fregni,et al.  The efficacy of Web-based cognitive behavioral interventions for chronic pain: a systematic review and meta-analysis. , 2010, The journal of pain : official journal of the American Pain Society.

[24]  Gerhard Andersson,et al.  Internet-delivered treatment to promote health , 2011, Current opinion in psychiatry.

[25]  F. Griffiths,et al.  Why Are Health Care Interventions Delivered Over the Internet? A Systematic Review of the Published Literature , 2006, Journal of medical Internet research.

[26]  S. Morris.  Estimating Effect Sizes From Pretest-Posttest-Control Group Designs , 2008 .

[27]  G. Andersson,et al.  A controlled trial of self-help treatment of recurrent headache conducted via the Internet. , 2000, Journal of consulting and clinical psychology.

[28]  C. Naylor.  Two cheers for meta-analysis: problems and opportunities in aggregating results of clinical trials. , 1988, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[29]  G. Eysenbach.  The Law of Attrition , 2005, Journal of medical Internet research.

[30]  L. Hedges,et al.  Fixed- and random-effects models in meta-analysis. , 1998 .

[31]  M. Milonova,et al.  Brief cognitive-behavioral internet therapy for irritable bowel syndrome. , 2009, Behaviour research and therapy.

[32]  G. Andersson,et al.  A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress. , 2011, Clinical psychology review.

[33]  E. Blanchard,et al.  A randomized controlled trial of an internet-based treatment for chronic headache. , 2005, Behaviour research and therapy.

[34]  J. Higgins.  Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration , 2011 .

[35]  C. White,et al.  Cognitive behavioral principles in managing chronic disease. , 2001, The Western journal of medicine.

[36]  Gerhard Andersson,et al.  Long-term follow-up of internet-delivered exposure and mindfulness based treatment for irritable bowel syndrome. , 2011, Behaviour research and therapy.

[37]  G. Andersson,et al.  Guided internet-based cognitive behavioural treatment for chronic back pain reduces pain catastrophizing: a randomized controlled trial. , 2011, Journal of rehabilitation medicine.

[38]  R. Deyo,et al.  Generic and Disease-Specific Measures in Assessing Health Status and Quality of Life , 1989, Medical care.

[39]  O Siddiqui,et al.  A comparison of the random-effects pattern mixture model with last-observation-carried-forward (LOCF) analysis in longitudinal clinical trials with dropouts. , 1998, Journal of biopharmaceutical statistics.

[40]  G. Andersson,et al.  Please Scroll down for Article Cognitive Behaviour Therapy Can the Patient Decide Which Modules to Endorse? an Open Trial of Tailored Internet Treatment of Anxiety Disorders , 2022 .

[41]  Gerhard Andersson,et al.  Controlled trial of Internet-based treatment with telephone support for chronic back pain , 2004, Pain.

[42]  Juliann Cortese,et al.  Computer-tailored health interventions delivered over the Web: review and analysis of key components. , 2009, Patient education and counseling.

[43]  F. Heuvel,et al.  Handboek psychologische interventies bij chronisch-somatische aandoeningen , 2004 .

[44]  T. Brown,et al.  Cognitive–behavioural therapy as an adjunctive treatment in chronic physical illness , 2009 .

[45]  G. Molenberghs,et al.  Linear Mixed Models for Longitudinal Data , 2001 .

[46]  Yun-Hsiang Lee,et al.  A systematic review of the effectiveness of problem-solving approaches towards symptom management in cancer care. , 2011, Journal of clinical nursing.

[47]  Heleen Riper,et al.  Web-Based Depression Treatment for Type 1 and Type 2 Diabetic Patients , 2011, Diabetes Care.

[48]  Gerhard Andersson,et al.  Randomized Controlled Trial of Internet-Based Cognitive Behavior Therapy for Distress Associated With Tinnitus , 2002, Psychosomatic medicine.

[49]  G. Andersson,et al.  Internet-administered cognitive behavior therapy for health problems: a systematic review , 2007, Journal of Behavioral Medicine.

[50]  W. Larbig,et al.  Online counseling via e-mail for breast cancer patients on the German internet: preliminary results of a psychoeducational intervention , 2011, Psycho-social medicine.

[51]  G. Andersson,et al.  Pros and cons of online cognitive–behavioural therapy , 2008, British Journal of Psychiatry.

[52]  S. Hollon,et al.  Cognitive Therapy for Depression , 1990 .

[53]  S. Rabe-Hesketh,et al.  Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes , 2004, The Lancet.

[54]  V. Hunot,et al.  Cognitive behaviour therapy for chronic fatigue syndrome in adults , 2022 .

[55]  D. Wantland,et al.  The Effectiveness of Web-Based vs. Non-Web-Based Interventions: A Meta-Analysis of Behavioral Change Outcomes , 2004, Journal of medical Internet research.

[56]  C. Muhr,et al.  Multimodal behavioral treatment of migraine: An Internet-administered, randomized, controlled trial , 2011, Upsala journal of medical sciences.

[57]  S. Michie,et al.  Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy , 2010, Journal of medical Internet research.

[58]  R. Kerns,et al.  Meta-analysis of psychological interventions for chronic low back pain. , 2007, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[59]  E. Mayo-Wilson.  Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. , 2007, Psychological medicine.

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

[61]  Alireza Ahmadvand.  CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions , 2011 .

[62]  N. Talley.  Internet-Delivered Exposure-Based Treatment vs. Stress Management for Irritable Bowel Syndrome: A Randomized Trial , 2012 .

[63]  Jessica Holt,et al.  A systematic review of internet-based self-management interventions for youth with health conditions. , 2009, Journal of pediatric psychology.

[64]  D. Altman,et al.  Measuring inconsistency in meta-analyses , 2003, BMJ : British Medical Journal.

[65]  G. Anderson,et al.  Chronic Care: Making the Case for Ongoing Care , 2010 .

[66]  A. Speckens,et al.  Cognitive–behavioural therapy for depression in people with a somatic disease: meta-analysis of randomised controlled trials , 2010, British Journal of Psychiatry.

[67]  G. Guyatt,et al.  Comparative responsiveness of generic and specific quality-of-life instruments. , 2003, Journal of clinical epidemiology.

[68]  S. Kelders,et al.  Persuasive System Design Does Matter: A Systematic Review of Adherence to Web-Based Interventions , 2012, Journal of medical Internet research.

[69]  M. D. de Bruin‐Weller,et al.  E‐health in caring for patients with atopic dermatitis: a randomized controlled cost‐effectiveness study of internet‐guided monitoring and online self‐management training , 2012, The British journal of dermatology.

[70]  S. Michie,et al.  What design features are used in effective e-health interventions? A review using techniques from Critical Interpretive Synthesis. , 2012, Telemedicine journal and e-health : the official journal of the American Telemedicine Association.

[71]  G. Andersson,et al.  Cost-effectiveness of internet-based cognitive behavior therapy for irritable bowel syndrome: results from a randomized controlled trial , 2011, BMC public health.

[72]  Valarie Blue Bird Jernigan,et al.  Online Diabetes Self-Management Program , 2010, Diabetes Care.

[73]  Devan V Mehrotra,et al.  Analysis of incomplete longitudinal binary data using multiple imputation , 2006, Statistics in medicine.

[74]  G. Andersson,et al.  Acceptability, effectiveness, and cost-effectiveness of internet-based exposure treatment for irritable bowel syndrome in a clinical sample: a randomized controlled trial , 2011, BMC gastroenterology.

[75]  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.

[76]  G. Brattberg.  Internet-based rehabilitation for individuals with chronic pain and burnout: a randomized trial , 2006, International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation.

[77]  K. Lorig,et al.  The internet-based arthritis self-management program: a one-year randomized trial for patients with arthritis or fibromyalgia. , 2008, Arthritis and rheumatism.

[78]  T. Packer.  An occupation-focused approach to self-management , 2010 .

[79]  Nancy J. Thompson,et al.  Distance delivery of mindfulness-based cognitive therapy for depression: Project UPLIFT , 2010, Epilepsy & Behavior.

[80]  Rita Bode,et al.  The effectiveness of an online mind-body intervention for older adults with chronic pain. , 2009, The journal of pain : official journal of the American Pain Society.

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

[82]  Isabelle Boutron,et al.  Blinding was judged more difficult to achieve and maintain in nonpharmacologic than pharmacologic trials. , 2004, Journal of clinical epidemiology.

[83]  Eric A. Finkelstein,et al.  Cost Effectiveness of Internet Interventions: Review and Recommendations , 2009, Annals of behavioral medicine : a publication of the Society of Behavioral Medicine.