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-9 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.

Do guided internet-based interventions result in clinically relevant changes for patients with depression? An individual participant data meta-analysis.

Little is known about clinically relevant changes in guided Internet-based interventions for depression. Moreover, methodological and power limitations preclude the identification of patients' groups that may benefit more from these interventions. This study aimed to investigate response rates, remission rates, and their moderators in randomized controlled trials (RCTs) comparing the effect of guided Internet-based interventions for adult depression to control groups using an individual patient data meta-analysis approach. Literature searches in PubMed, Embase, PsycINFO and Cochrane Library resulted in 13,384 abstracts from database inception to January 1, 2016. Twenty-four RCTs (4889 participants) comparing a guided Internet-based intervention with a control group contributed data to the analysis. Missing data were multiply imputed. To examine treatment outcome on response and remission, mixed-effects models with participants nested within studies were used. Response and remission rates were calculated using the Reliable Change Index. The intervention group obtained significantly higher response rates (OR = 2.49, 95% CI 2.17-2.85) and remission rates compared to controls (OR = 2.41, 95% CI 2.07-2.79). The moderator analysis indicated that older participants (OR = 1.01) and native-born participants (1.66) were more likely to respond to treatment compared to younger participants and ethnic minorities respectively. Age (OR = 1.01) and ethnicity (1.73) also moderated the effects of treatment on remission.Moreover, adults with more severe depressive symptoms at baseline were more likely to remit after receiving internet-based treatment (OR = 1.19). Guided Internet-based interventions lead to substantial positive treatment effects on treatment response and remission at post-treatment. Thus, such interventions may complement existing services for depression and potentially reduce the gap between the need and provision of evidence-based treatments.

Web-based psychotherapy for posttraumatic stress disorder in war-traumatized Arab patients: randomized controlled trial.

BACKGROUND: In recent years, armed conflicts in the Middle East have resulted in high rates of exposure to traumatic events. Despite the increasing demand of mental health care provision, ongoing violence limits conventional approaches of mental health care provision. Internet-based interventions for posttraumatic stress disorder (PTSD) have proved feasible and effective in Western countries, but their applicability and efficacy in war and conflict regions remains unknown. OBJECTIVE: This study investigated the efficacy of a cognitive behavioral Internet-based intervention for war-traumatized Arab patients, with focus on Iraq. METHODS: A total of 159 individuals with PTSD participated in a parallel group randomized trial. Participants were randomly allocated by a computer-generated sequence to a treatment group (n=79) or a waiting list control group (n=80). The treatment group received 2 weekly 45-minute cognitive behavioral interventions via Internet over a 5-week period (10 sessions in total). The primary outcome was recovery from posttraumatic stress symptoms. RESULTS: Posttraumatic stress symptoms were significantly reduced from baseline to posttreatment (intention-to-treat analysis) in the treatment group relative to the control group (F1,157=44.29, P<.001, d=0.92). Treatment effects were sustained at 3-month follow-up. Completer analysis indicated that 29 of 47 patients (62%) in the treatment group had recovered from posttraumatic stress symptoms at posttreatment (reliable change and Posttraumatic Stress Diagnostic Scale score <20) versus 1 patient (2%) in the control group (OR 74.19, 95% CI 9.93-585.8, P<.001) indicating that the chance of recovering was 74.19 times higher in the treatment than in the control group. CONCLUSIONS: The results indicate, even in unstable and insecure settings with ongoing exposure to human rights violations through war and dictatorships, people with posttraumatic stress symptoms benefit from a cognitive behavioral treatment provided entirely through the Internet. This method of delivery could improve patients' access to humanitarian aid in the form of e-mental health services. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry, ACTRN12611001019998; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=347505 (Archived by WebCite at http://www.webcitation.org/6Wto4HCdH).

Using a digital game for training desirable behavior in cognitive-behavioral therapy of burnout syndrome: a controlled study.

Burnout is a globally increasing illness, and as a result, many forms of burnout therapy have arisen. The use of digital games can be psychotherapeutically effective because they can transform exercises that are by themselves unattractive into intrinsically motivated action. This pilot study aims to test whether a specially designed game contributes to patients learning desired behavior and achieving other specific therapeutic goals in an online cognitive-behavioral therapy (CBT)-based burnout treatment context. In total, 101 participants took part in the experiment, under four conditions: (a) Game+Therapy, (b) Therapy Only, (c) Game Only, and (d) No Game+No Therapy. Pre- and postmeasures were taken online. Results showed that the two therapy conditions (Game+Therapy and Therapy Only) showed a greater decrease in complaints and disengagement, and a stronger increase in coping skills than the nontherapy conditions (Game Only and No Game+No Therapy). As expected, the Game+Therapy condition outperformed the Therapy Only condition on combined improvement measures of burnout symptoms. However, analyses of individual measures showed no effects. It can be cautiously concluded that the therapeutic digital game may be a useful tool when embedded in a therapeutic burnout treatment program and is probably more efficient than CBT, as it is used in current practice.

Online cognitive-behavioural treatment of bulimic symptoms: a randomized controlled trial.

BACKGROUND: Manualized cognitive-behavioural treatment (CBT) is underutilized in the treatment of bulimic symptoms. Internet-delivered treatment may reduce current barriers. OBJECTIVE: This study aimed to assess the efficacy of a new online CBT of bulimic symptoms. METHOD: Participants with bulimic symptoms (n = 105) were randomly allocated to online CBT, bibliotherapy or waiting list/delayed treatment condition. Data were gathered at pre-treatment, post-treatment and 1-year follow-up. OUTCOME MEASURES: The primary outcome measures were the Eating Disorder Examination Questionnaire (EDE-Q) and the frequency of binge eating and purging episodes. The secondary outcome measure was the Body Attitude Test. RESULTS: Dropout from Internet treatment was 26%. Intention-to-treat ANCOVAs of post-test data revealed that the EDE-Q scores and the frequency of binging and purging reduced more in the online CBT group compared with the bibliotherapy and waiting list groups (pooled between-group effect size: d = 0.9). At 1-year follow-up, improvements in the online CBT group had sustained. CONCLUSION: This study identifies online CBT as a viable alternative in the treatment of bulimic symptoms.

The effectiveness of online cognitive behavioral treatment in routine clinical practice.

CONTEXT: Randomized controlled trails have identified online cognitive behavioral therapy as an efficacious intervention in the management of common mental health disorders. OBJECTIVE: To assess the effectiveness of online CBT for different mental disorders in routine clinical practice. DESIGN: An uncontrolled before-after study, with measurements at baseline, posttest, 6-week follow-up, and 1-year follow-up. PARTICIPANTS & SETTING: 1500 adult patients (female: 67%; mean age: 40 years) with a GP referral for psychotherapy were treated at a Dutch online mental health clinic for symptoms of depression (n = 413), panic disorder (n = 139), posttraumatic stress (n = 478), or burnout (n = 470). INTERVENTIONS: Manualized, web-based, therapist-assisted CBT, of which the efficacy was previously demonstrated in a series of controlled trials. Standardized duration of treatment varied from 5 weeks (online CBT for Posttraumatic stress) to 16 weeks (online CBT for Depression). MAIN OUTCOME MEASURES: Validated self-report questionnaires of specific and general psychopathology, including the Beck Depression Inventory, the Impact of Event Scale, the Panic Disorder Severity Scale-Self Report, the Oldenburg Burnout Inventory, and the Depression Anxiety Stress Scales. RESULTS: Treatment adherence was 71% (n = 1071). Study attrition was 21% at posttest, 33% at 6-week FU and 65% at 1-year FU. Mixed-model repeated measures regression identified large short-term reductions in all measures of primary symptoms (d = 1.9±0.2 to d = 1.2±0.2; P<.001), which sustained up to one year after treatment. At posttest, rates of reliable improvement and recovery were 71% and 52% in the completer sample (full sample: 55%/40%). Patient satisfaction was high. CONCLUSIONS: Results suggest that online therapist-assisted CBT may be as effective in routine practice as it is in clinical trials. Although pre-treatment withdrawal and long-term outcomes require further study, results warrant continued implementation of online CBT.

Efficacy and effectiveness of online cognitive behavioral treatment: a decade of interapy research.

Since 1996, researchers of the Interapy research group of the University of Amsterdam have been examining the effects of online cognitive behavioral treatment (online CBT). Over the years, the group conducted nine controlled trials of online CBT for a variety of mental health disorders, among a total of 840 participants. These studies suggest that online CBT is a viable and effective alternative to face-to-face treatment. Treatment adherence was 82%, and reductions in psychopathology represented a large between-group effect size of SMD = 0.9 (95% CI: .7 to 1.1), which was maintained over long periods. The research culminated in the foundation of the Interapy clinic, which received Dutch health regulatory body approval in 2005. Since then, costs of online CBT are reimbursed through public health insurance. A large study of the treatment outcome of 1,500 patients of the Interapy clinic showed that effects in clinical practice are similar to those observed in the controlled trials, and comparable to selected benchmarks of naturalistic studies of face-to-face CBT. The accumulated evidence provides compelling support for the efficacy and effectiveness of online CBT.

Intraclass correlation associated with therapists: estimates and applications in planning psychotherapy research.

It is essential that outcome research permit clear conclusions to be drawn about the efficacy of interventions. The common practice of nesting therapists within conditions can pose important methodological challenges that affect interpretation, particularly if the study is not powered to account for the nested design. An obstacle to the optimal design of these studies is the lack of data about the intraclass correlation coefficient (ICC), which measures the statistical dependencies introduced by nesting. To begin the development of a public database of ICC estimates, the authors investigated ICCs for a variety outcomes reported in 20 psychotherapy outcome studies. The magnitude of the 495 ICC estimates varied widely across measures and studies. The authors provide recommendations regarding how to select and aggregate ICC estimates for power calculations and show how researchers can use ICC estimates to choose the number of patients and therapists that will optimize power. Attention to these recommendations will strengthen the validity of inferences drawn from psychotherapy studies that nest therapists within conditions.

Establishing guidelines for executing and reporting Internet intervention research.

The field of Internet interventions is growing rapidly. New programs are continually being developed to facilitate health and mental health promotion, disease and emotional distress prevention, risk factor management, treatment, and relapse prevention. However, a clear definition of Internet interventions, guidelines for research, and evidence of effectiveness have been slower to follow. This article focuses on the quality standardization of research on Internet-delivered psychological and behavioural interventions. Although the science underpinning Internet interventions is just starting to be established, across research studies there are often conceptual and methodological difficulties. The authors argue that this situation is due to the lack of universally accepted operational guidelines and evaluation methods. Following a critical appraisal of existing codes of conduct and guidelines for Internet-assisted psychological and health interventions, the authors developed a framework of guidelines for Internet intervention research utilizing aspects of facet theory (Guttman & Greenbaum, 1998). The framework of facets, elements, and guidelines of best practice in reporting Internet intervention research was then sent to several leading researchers in the field for their comment and input, so that a consensus framework could be agreed on. The authors outline 12 key facets to be considered when evaluating and reporting Internet intervention studies. Each facet consists of a range of recommended elements, designed as the minimum features for reporting Internet intervention studies. The authors propose that this framework be utilized when designing and reporting Internet intervention research, so results across studies can be replicated, extended, compared, and contrasted with greater ease and clarity.

Ethical dilemmas in online research and treatment of sexually abused adolescents.

BACKGROUND: In a recent uncontrolled trial of a new therapist-assisted Web-based treatment of adolescent victims of sexual abuse, the treatment effects were found to be promising. However, the study suffered a large pretreatment withdrawal rate that appeared to emanate from reluctance among the participants to disclose their identity and obtain their parents' consent. OBJECTIVE: Our objectives were to confirm the effects of the online treatment in a controlled trial and to evaluate measures to reduce pretreatment withdrawal in vulnerable populations including young victims of sexual abuse. METHODS: The study was designed as a within-subject baseline-controlled trial. Effects of an 8-week attention-placebo intervention were contrasted with the effects of an 8-week treatment episode. Several measures were taken to reduce pretreatment dropout. RESULTS: Pretreatment withdrawal was reduced but remained high (82/106, 77%). On the other hand, treatment dropout was low (4 out of 24 participants), and improvement during treatment showed significantly higher effects than during the attention placebo control period (net effect sizes between 0.5 and 1.6). CONCLUSIONS: In treatment of vulnerable young populations, caregivers and researchers will have to come to terms with high pretreatment withdrawal rates. Possible measures may reduce pretreatment withdrawal to some degree. Providing full anonymity is not a viable option since it is incompatible with the professional responsibility of the caregiver and restricts research possibilities.

Theme issue on e-mental health: a growing field in internet research.

This theme issue on e-mental health presents 16 articles from leading researchers working on systems and theories related to supporting and improving mental health conditions and mental health care using information and communication technologies. In this editorial, we present the background of this theme issue, and highlight the content of this issue.

Web-based therapist-assisted cognitive behavioral treatment of panic symptoms: a randomized controlled trial with a three-year follow-up.

BACKGROUND: Internet-delivered treatment may reduce barriers to care in those unwilling or unable to access traditional forms of treatment. OBJECTIVE: To assesses the efficacy of web-based therapist-assisted cognitive behavioral treatment (web-CBT) of panic symptoms. DESIGN: A randomized waiting-list controlled trial with an uncontrolled three-year follow-up. PARTICIPANTS: A community sample of 58 participants with chronic panic symptoms of varying severity (immediate treatment: n=27, waiting-list control: n=31). OUTCOME MEASURES: The primary outcome measures were a one-week Panic Diary and the Panic Disorder Severity Scale - Self-Report (PDSS-SR); secondary measures were the Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ), the Mobility Inventory - Alone subscale (MI-AAL), and the Depression Anxiety Stress Scales (DASS-42). RESULTS: In the RCT, 54 participants (93%) completed posttest measurements. With regard to the primary outcome measures, intention-to-treat ANCOVAs revealed that participants in the treatment condition improved more than the participants in the waiting-list control condition (p<.03), with a pooled between-group effect size of d=.7. After three years (n=47; 81% study compliance), effects were more pronounced. CONCLUSION: The results demonstrate the efficacy of therapist-assisted web-CBT in the treatment of panic symptoms.

Standardized web-based cognitive behavioural therapy of mild to moderate depression: a randomized controlled trial with a long-term follow-up.

Depression is common but undertreated. Web-based self-help provides a widely accessible treatment alternative for mild to moderate depression. However, the lack of therapist guidance may limit its efficacy. The authors assess the efficacy of therapist-guided web-based cognitive behavioural treatment (web-CBT) of mild to moderate depression. Fifty-four individuals with chronic, moderate depression participated in a randomized wait-list controlled trial, with an 18-month follow-up (immediate treatment: n = 36, wait-list control: n = 18). Primary outcome measures were the Beck Depression Inventory (BDI-IA) and the Depression scale of the Symptom Checklist-90-Revised (SCL-90-R. DEP). Secondary outcome measures were the Depression Anxiety Stress Scales and the Well-Being Questionnaire. Five participants (9%) dropped out. Intention-to-treat analyses of covariance revealed that participants in the treatment condition improved significantly more than those in the wait-list control condition (.011 < p < .015). With regard to the primary measures, between-group effects (d) were 0.7 for the BDI-IA and 1.1 for the SCL-90-R DEP. Posttest SCL-90- R DEP scores indicated recovery of 49% of the participants in the treatment group compared with 6% in the control group (odds ratio = 14.5; p < .004). On average, the effects were stable up to 18 months (n = 39), although medication was a strong predictor of relapse. The results demonstrate the efficacy of web-CBT for mild to moderate depression and the importance of therapist guidance in psychological interventions.

E-mailed standardized cognitive behavioural treatment of work-related stress: a randomized controlled trial.

The aim of this study was to assess the effects of a 7-week standardized cognitive behavioural treatment of work-related stress conducted via e-mail. A total of 342 people applied for treatment in reaction to a newspaper article. Initial screening reduced the sample to a heterogeneous (sub)clinical group of 239 participants. Participants were assigned randomly to a waiting list condition (n = 62), or to immediate treatment (n = 177). A follow-up was conducted 3 years after inception of the treatment. The outcome measures used were the Depression Anxiety Stress Scales (DASS-42) and the Emotional Exhaustion scale of the Maslach Burnout Inventory - General Survey (MBI-GS). Fifty participants (21%) dropped out. Both groups showed statistically significant improvements. Intention-to-treat analysis of covariance (ANCOVAs) revealed that participants in the treatment condition improved significantly more than those in the waiting control condition (0.001

or = d > or = 0.5 (anxiety)). The between-group effects ranged from d = 0.6 (stress) to d = 0.1 (anxiety). At follow-up, the effects were more pronounced, but this result requires replication in view of high attrition at follow-up. The results warrant further research on Internet-driven standardized cognitive behavioural therapy for work-related stress. Such research should include the direct comparison of this treatment with face-to-face treatment, and should address the optimal level of therapist contact in Internet-driven treatment.

The influence of current stress on dissociative experiences: an exploratory study in a non-clinical population.

In this study, the relationship between current stress, as perceived by an individual, and dissociative phenomena is explored. All subjects were in an acute and naturally caused stress-situation-sudden threat of dismissal from their jobs in a large multinational corporation. Dissociation and stress were measured at two different times over three months. Since information campaigns and psychological support programs were offered to all participants, levels of stress were expected to decrease significantly. The data show that dissociative experiences are elevated when subjects experience high levels of current stress, though scores fall within the normal non-pathological range. Furthermore, it appears that a decrease in stress level is associated with a significant decrease of dissociative symptoms. The results support a one-directional causal relationship: a decrease in perceived stress leads to a decrease in dissociative phenomena.

Interapy: a controlled randomized trial of the standardized treatment of posttraumatic stress through the internet.

Online therapy offers many advantages over face-to-face therapy. Interapy includes psychoeducation, screening, effect measures, and a protocol-driven treatment via the Internet for people suffering from posttraumatic stress. The present article reports the results of a controlled trial on the Internet-driven treatment of posttraumatic stress and grief in a group of people who manifested mild to relatively severe trauma symptoms. Participants in the treatment condition (n=69) improved significantly more than participants in the waiting-list control condition (n=32) on trauma-related symptoms and general psychopathology. The effect sizes were large. On most subscales, more than 50% of the treated participants showed reliable change and clinically significant improvement, with the highest percentages being found for depression and avoidance.

Interapy: treatment of post-traumatic stress via the internet.

This paper describes the theoretical background and procedures (including psycho-education, screening, treatment protocol and outcome measurement) involved in a protocol-driven internet treatment of post-traumatic stress and grief in a group of people who have suffered from mild to relatively severe trauma. The paper examines the results of 3 outcome and process studies, which were carried out initially in a student population and subsequently in the general population of highly traumatized people. In the latter study, participants in the experimental condition (n = 69) improved significantly more than participants in the waiting list control condition (n = 32), with respect to trauma-related symptoms and general psychopathology. The effect sizes were large. More than 50% of the participants treated showed reliable change and clinically significant improvement after treatment for avoidance and depression. Treatment proved most beneficial for participants who had suffered from intentional trauma and those who had not previously discussed the traumatic events with significant others. Content analysis of the publications indicates a remarkable increase in cognitive coping during treatment. The possibilities for future research into internet-driven treatment of post-traumatic stress symptomatology are discussed, including the proposal to study the effects of sending a final written letter to a significant other person.

Structured writing and processing major stressful events: a controlled trial.

BACKGROUND: Traumatic events may result in a variety of physical and psychological health problems. Self-confrontation with traumatic memories, by putting painful emotions and thoughts into (verbal) words, is associated with psychophysiological benefits. Self-confrontation may be invoked during sessions and enhanced by structural assignments, which the client carries out between the sessions. In this context, writing assignments could be a useful tool in reprocessing traumatic events. The effects of writing assignments have been demonstrated in several case studies and in a number of experimental studies. However, the experimental studies have several limitations, for example the effects of writing on the impact of trauma are not examined. Furthermore, the psychological mechanisms that mediate the effects of trauma on health are less clear. These two issues are the main issues of the current study. METHODS: A group of 26 participants were instructed to write about their negative events during five 45-min sessions over a period of 2 weeks. They were compared at pre-treatment, post-treatment and at 6-week follow-up to a waiting-list control group (n = 22). RESULTS: The trauma-writing groups experienced fewer intrusions and showed less avoidance behavior from pre-treatment to follow-up, whereas the waiting-list control group did not change significantly. Similar results were found on depressive symptoms. No effects on mood measures were found. CONCLUSIONS: Implications for future research and clinical practice are discussed.

PACHIQ-R: the Parent-Child Interaction Questionnaire--revised.

The PACHIQ (Parent-Child Interaction Questionnaire) is designed to help clinicians and researchers assess how parents view relationship with their children (PACHIQ-Parent version), and how children evaluate their relationship with their parents (PACHIQ-Child version). The items in this questionnaire refer to both interpersonal behavior and feelings. Conceptually, the PACHIQ is based on learning theory and structural systems theory. The development of the PACHIQ was described by Lange, Blonk and Wiers (1998). The present article reports additional psychometric data obtained in the development and validation of a revised, shorter version of the questionnaire (PACHIQ-R). We present norm tables for families with children who are referred for psychological treatment, and norm tables for families in the normal Dutch population. The PACHIQ-R displays a two-factor structure with factors interpreted as Conflict Resolution and Acceptance. The parent version of the PACHIQ-R contains 21 items, the child version 25 items.