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Implementing internet-delivered cognitive behavior therapy for common mental health disorders: A comparative case study of implementation challenges perceived by therapists and managers in five European internet services
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OBJECTIVE: Internet-delivered cognitive behavior therapy programs have been developed and evaluated in randomized controlled trials during the past two decades to alleviate the rising demand for effective treatment of common mental health disorders such as anxiety and depression. While most of the research on internet-based cognitive behavior therapy (iCBT) has focused on efficacy and effectiveness only little attention has been devoted to the implementation of iCBT. The aim of this study was to identify the main implementation challenges perceived by therapists and managers involved in the practical operation of iCBT services in routine care settings in five European countries. METHOD: The study was designed as a multiple comparative case study to explore differences and similarities between five different iCBT services in Sweden, Norway, Denmark, The Netherlands and Scotland. Field visits were carried out to each of the five services including interviews with the management of the service (n = 9), focus group interviews with key staff (n = 15) and demonstration of online programs. The data material was processed through thematic, comparative analysis. RESULTS: The analysis generated four transversal themes: 1) integration in the mental health care system; 2) recruitment of patients; 3) working practice of therapists; and 4) long-term sustainability of service. The main results concerned the need to address the informal integration in the health care systems related to the perceived skepticism towards iCBT from GPs and face-to-face therapists, the role of referral models and communication strategies for the stable recruitment of patients, the need for knowledge, standards and material for the training of therapists in the provision of online feedback, the need to improve the possibilities to tailor programs to individual patients, and the need for considerate long-term sustainability planning of the transitions from local projects to permanent regional or national services. CONCLUSION: The present study gives an overview of the main implementation challenges regarding the practical operation of iCBT services perceived by the therapists and managers of the iCBT services. Future studies into specific details of each challenge will be important to strengthen the evidence base of iCBT and to improve uptake and implementation of iCBT in routine care.
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“It has also been rolled out to NHS primary care across Scotland as one of its low intensity treatments and in self-guided format for patients with mild to moderate anxiety and depression (Du et al ., 2013; Folker et al ., 2018; NHS Lothian, 2019; The Scottish Government, 2017).”
From A qualitative study of patients’ experiences and acceptance of computerised cognitive behavioural therapy in primary care, Scotland (2021) · cites this paper as Folker et al., 2018
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“Computerised cognitive behavioural therapy (CCBT) has been made available within the National Health Service (NHS) across Scotland as an alternative treatment for mild to moderate anxiety and depression.”
From A qualitative study of patients’ experiences and acceptance of computerised cognitive behavioural therapy in primary care, Scotland (2021) · cites this paper as Folker et al., 2018
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“Moreover, insufficient information for patients can lead to inappropriate referrals (Bennett et al ., 2008) or an incorrect match between patients and programmes (Folker et al ., 2018).”
From A qualitative study of patients’ experiences and acceptance of computerised cognitive behavioural therapy in primary care, Scotland (2021) · cites this paper as Folker et al., 2018
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“Researchers also noted that a GP ' s referral of a patient for CCBT could take a month and suggested that selfreferral would be a much faster option. It would also help to improve accessibility of CCBT services (Folker et al ., 2018; Titov et al ., 2018).”
From A qualitative study of patients’ experiences and acceptance of computerised cognitive behavioural therapy in primary care, Scotland (2021) · cites this paper as Folker et al., 2018
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“In addition, this study complements research concerning the constraints on implementation of CCBT services (Folker et al ., 2018), and might shed light on potential reasons for poor engagement of patients (Apolinario-Hagen et al ., 2017) and high drop-out rates.”
From A qualitative study of patients’ experiences and acceptance of computerised cognitive behavioural therapy in primary care, Scotland (2021) · cites this paper as Folker et al., 2018
In the citing paper
“As research showed that one of the barriers for implementation is the low usability of internet-based interventions, it is important to assess the usability of iCBT [5, 6].”
From Dimensionality of the system usability scale among professionals using internet-based interventions for depression: a confirmatory factor analysis (2020) · cites this paper as [5]
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“during treatment and practice them after their mostly short-term, minimally supported active treatments have ended (Folker et al., 2018; Titov et al., 2018).”
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Internet-delivered self-help for adults with ADHD (MyADHD): usability study
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“For common mental health disorders like depression and anxiety, internet-delivered interventions are part of official treatment guidelines [2].”
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User journey method: a case study for improving digital intervention use measurement
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“This provided us with several insights: [1] The nature of the intervention influences its modelling and measurement.”
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“This might indicate that the mail function was viewed as a possibility for the therapist to have some influence on, and tailor the intervention for the patients, which is a frequently described challenge and potential barrier for internetdelivered treatment (Folker et al., 2018; Meisel et al., 2018; Titzler et al., 20…”
BackgroundResultInfluentialDuffy, D. J., Richards, D., Earley, C., & Timulák, L. (2023) · Frontiers in Digital Health · doi:10.3389/fdgth.2023.1139125 · Cited by 10
Nævdal, R., Vis, C., & Kenter, R. M. F. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100881 · Cited by 6
“Group B consisted of three clinics established through a dissemination project conducted from 2019 to 2021 within the Western Health Region of Norway.”
InfluentialBjarke, J., Gjestad, R., & Nordgreen, T. (2025) · JMIR Mental Health · doi:10.2196/68165 · Cited by 7
“However, the implementation of guided ICBT in specialist mental health care has been slow, partly due to lack of knowledge, prejudice, and negative attitudes among health care professionals and general practitioners (GPs) [26].”
Freund, J., Ebert, D. D., Thielecke, J., Braun, L., Baumeister, H., Berking, M., & Titzler, I. (2023) · Frontiers in Digital Health · doi:10.3389/fdgth.2022.1083143 · Cited by 6
Measuring and Fostering Engagement with Mental Health e-Coaches
Callejas, Z., Griol, D., Benghazi, K., Noguera, M., Chollet, G., Torres, M. I., & Esposito, A. A. (2020) · Companion Publication of the International Conference on Multimodal Interaction (ICMI Companion) · doi:10.1145/3395035.3425316 · Cited by 5
“Meeting the demands for prevention and treatment of common mental health disorders constitutes a major health challenge [12].”
BackgroundDu, E., Quayle, E., & Macleod, H. (2021) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x21000210 · Cited by 5
Bringing a Systems Approach to Living Donor Kidney Transplantation
Horton, A., Loban, K., Nugus, P., Fortin, M., Gunaratnam, L., Knoll, G. A., Mucsi, I., Chaudhury, P. K., Landsberg, D. N., Pâquet, M. R., et al. (2024) · Kidney International Reports · doi:10.1016/j.ekir.2024.07.014 · Cited by 5
Research status of internet-delivered cognitive behavioral therapy in cancer patients
Li, B., & Wang, J. (2023) · World Journal of Psychiatry · doi:10.5498/wjp.v13.i11.831 · Cited by 6
Shiner, C. T., Li, I., Millard, M., & Mahoney, A. (2024) · Disability and Rehabilitation Assistive Technology · doi:10.1080/17483107.2024.2389208 · Cited by 4
Bendelin, N., Gerdle, B. U. C., & Andersson, G. (2023) · Scandinavian Journal of Pain · doi:10.1515/sjpain-2022-0139 · Cited by 4
“These process evaluations have resulted in guidelines emphasizing appropriate governance to ensure maintenance of safe and high-quality interventions [20] and built-in routines for referrals and alignments with other health services [19].”
BackgroundShirotsuki, K., Uehara, S., Adachi, S., & Nakao, M. (2019) · Psych · doi:10.3390/psych1010025 · Cited by 4
“A previous study suggested that good writing skills are considered necessary to provide effective ICBT [33].”
BackgroundLorente-Català, R., Gili, M., del Hoyo, Y. L., Mayoral, F., Pérez‐Aranda, A., Castro, A., Moreno, E. V., Baños, R., Roca, M., Monreal‐Bartolomé, A., et al. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100581 · Cited by 5
“Although these characteristics act as facilitators, the lack of time, the negative beliefs about the intervention and ICT, and the lack of knowledge are some of the observed barriers (Folker et al., 2018; Vis et al., 2018; Wilhelmsen et al., 2014).”
BackgroundDopp, A. R., North, M. N., Gilbert, M., Ringel, J. S., Silovsky, J. F., Blythe, M., Edwards, D., Schmidt, S. R., & Funderburk, B. W. (2024) · Implementation Research and Practice · doi:10.1177/26334895241249394 · Cited by 3
“…across diverse sources of evidence despite the small sample available for this pilot study, similar to the rich fi ndings of prior comparative case studies from implementation research (Bullock & Lavis, 2019; Dickson et al., 2022; Folker et al., 2018; Thompson et al., 2022; Zeitlin et al., 2016).”
MethodResultSemonella, M., Marchesi, G., Castelnuovo, G., Andersson, G., & Pietrabissa, G. (2024) · Digital Health · doi:10.1177/20552076241258419 · Cited by 4
Petersen, E. M., Öfverström, H. A., Johansson, M., Sundström, C., & Berman, A. H. (2025) · Addiction Science & Clinical Practice · doi:10.1186/s13722-025-00570-1 · Cited by 5
“However, developing effective communication strategies and structured patient referrals is also vital for successful digital intervention adoption, as shown in previous studies [43, 44].”
Bäckström, M. K., Girdler, S. J., Jonsson, U., Håkansson, C., & Lexén, A. (2025) · PLoS ONE · doi:10.1371/journal.pone.0327617 · Cited by 3
“Conducting a case study is well-suited to study complex interplays concerning mental health and well-being needs and outcomes [93–95], this due to its methodological emphasis on building a case with multiple chains of evidence and situating the research within the phenomena studied [96].”
Mendes-Santos, C. (2021) · Linköping studies in arts and science · doi:10.3384/9789179291143 · Cited by 3
Ganapathy, A., Casey, L. M., Rowland, D. P., Grady, A. B., Sotheren, K. V., & Clough, B. A. (2023) · Advances in Mental Health · doi:10.1080/18387357.2023.2254864 · Cited by 4
Celleri, M., Klajner, F., Cremades, F. C., Garay, C. J., Etchevers, M. J., & Osma, J. (2025) · Journal of Clinical Psychology · doi:10.1002/jclp.70037 · Cited by 2
“…interventions are superficial, as a barrier to implementation, consistent with previous research about negative attitudes from therapists as a barrier (Folker et al. 2018), and therapists' willingness to use tele-therapy tools depends on their perceived usefulness (Monthuy ‐ Blanc et al. 2013).”
Vernmark, K., Geranmayeh, A., Topooco, N., Andersson, G., & Shahnavaz, S. (2026) · JMIR Human Factors · doi:10.2196/75263 · Cited by 3
“If digital interventions are to help close this gap, it is essential to understand how they should be provided in routine care settings [78], including through broad dissemination that extends beyond trauma-focused treatment in specialized settings [64].”
Brunner, I. C., Støme, L. N., & Kenter, R. M. F. (2026) · Internet Interventions · doi:10.1016/j.invent.2026.100983 · Cited by 2
“A study on the implementation of guided DMHIs in five countries by Folker et al. identified the referral process as a source of time waste because the programs were not suitable for a substantial fraction of the patients (Folker et al., 2018).”
Sampson, E. (2023) · Journal of Psychosocial Nursing and Mental Health Services · doi:10.3928/02793695-20230424-01 · Cited by 2
Beahm, J. D., McCall, H. C., Carleton, R. N., Jones, N. A., & Hadjistavropoulos, H. D. (2024) · Internet Interventions · doi:10.1016/j.invent.2024.100718 · Cited by 2
“Previous research has examined the perceptions of ICBT service providers, managers, and ICBT users (e.g., Duffy et al., 2023; Folker et al., 2018).”
BackgroundMathiasen, K., Andersen, T. E., Lichtenstein, M. B., Riper, H., Kleiboer, A., & Roessler, K. K. (2022) · doi:10.2196/preprints.36577 · Cited by 2
Self-citationMathiasen, K., Holmberg, T. T., Skaarnes, H., Jensen, E. S., Vis, C., & Tarp, K. (2023) · Frontiers in Digital Health · doi:10.3389/fdgth.2023.1128893 · Cited by 2
“One of the barriers which can obstruct the dissemination of iCBT is the implementation process itself (17, 18).”
BackgroundSelf-citationThuen, C., Hinderaker, H. K., Steinsvik, E. K., Vikøren, L. A. S., Lied, G. A., Berentsen, B., & Kenter, R. M. F. (2025) · BMC Health Services Research · doi:10.1186/s12913-025-13171-0 · Cited by 1
“Our findings align with previous research in which leadership engagement and organisational location within larger specialised organisations were identified as facilitators [14, 20].”
Lee, M., Hunter, S. B., Tumendemberel, B., Shiferaw, M., Godley, M. D., Purtle, J., Aarons, G. A., & Dopp, A. R. (2025) · Implementation Science · doi:10.1186/s13012-025-01470-3 · Cited by 1
“Other applications of these methods have evaluated EBP implementation and sustainment [17, 34, 35], as well as policy-and systems-level efforts to implement and sustain change [36–39].”
Bjarke, J., Gjestad, R., & Nordgreen, T. (2026) · Internet Interventions · doi:10.1016/j.invent.2026.100907 · Cited by 1
“Self-referral is an established pathway to ICBT-clinics in several countries (Titov et al., 2018; Folker et al., 2018), yet to our knowledge, no previous study has examined referral pathway as a potential moderating factor on treatment outcomes in routine clinical care.”
Family digital mental health interventions: aligning design and systemic practice principles
Welsh, E. T., Boyd, J., Cloud, Z. C. G., Cordukes, K., Charles, N., & McIntosh, J. (2026) · Mental Health and Digital Technologies · doi:10.1108/mhdt-03-2026-0021 · Cited by 1
Improve Job Satisfaction With Cognitive Behavioral Therapy
Jones, K. (2020) · Advances in higher education and professional development book series · doi:10.4018/978-1-7998-3519-6.ch002 · Cited by 1
Bertuzzi, V., Semonella, M., Castelnuovo, G., Andersson, G., & Pietrabissa, G. (2023) · doi:10.2196/preprints.46692 · Cited by 1
Comorbid mental and substance use disorders: A common and complex treatment consideration
Prior, K. (2021) · Bulletin of the Menninger Clinic · doi:10.1521/bumc.2021.85.2.89
Choate, S. A. (2022) · ThinkIR: The University of Louisville's Institutional Repository (University of Louisville) · doi:10.18297/etd/3980
Lundorff, M., Damholdt, M. F., Nissen, E. R., & Zachariae, B. (2021) · Psyke & Logos · doi:10.7146/pl.v42i1.128774
Bendelin, N. (2023) · Linköping University medical dissertations · doi:10.3384/9789180750288
Implementing internet-delivered cognitive behavioural therapy in integrated care systems
Duffy, D. J., & Rota, J. (2024) · British Journal of Healthcare Management · doi:10.12968/bjhc.2024.0037
Bjarke, J., Gjestad, R., & Nordgreen, T. (2024) · doi:10.2196/preprints.68165
Frumer, M., Rask, M. T., Frostholm, L., & Rosendal, M. (2024) · Research Square · doi:10.21203/rs.3.rs-5366931/v1
Internet-Based Cognitive Rehabilitation for Working Cancer Survivors
Klaver, K. M., Duijts, S. F. A., Geusgens, C. A. V., Aarts, M. J. B., Ponds, R., van der Beek, A. J., & Schagen, S. B. (2025) · Journal of Occupational and Environmental Medicine · doi:10.1097/jom.0000000000003312
“66,67 Therefore, in order to maintain the implementation scores as found within the current RCTalso in future clinical practice, additional implementation efforts (eg, generating awareness of the online cognitive rehabilitation program among the target population and professionals, advocating for…”
Metadata
- Authors
- Folker, A. P., Mathiasen, K., Lauridsen, S. M., Stenderup, E., Dozeman, E., & Folker, M. P.
- Affiliations
- University of Southern Denmark (DK)
- GGZ inGeest (NL)
- Corresponding author
- Folker, Anna Paldam
- Venue
- Internet Interventions
- Publisher
- Elsevier BV
- Published
- 2018-03
- Volume
- 11
- Pages
- 60-70
- ISSN
- 2214-7829 (ISSN-L)
- PMC
- PMC6084870
- OpenAlex
- W2789586768
- Cited by
- 116
- References
- 65
- Citations by year
- 2026: 10 · 2025: 20 · 2024: 13 · 2023: 15 · 2022: 12 · 2021: 9 · 2020: 17 · 2019: 13 · 2018: 7
- FWCI
- 14.50
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Internet Interventions (publishedVersion, cc-by-nc-nd)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion, cc-by)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion, cc-by-nc-nd)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Funders
- TrygFonden (113360)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Keywords
- internet-based cognitive behavioral therapy, implementation barriers, common mental disorders, anxiety, depression, usual care, therapist training, online feedback, referral model, patient recruitment
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