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

“We used qualitative content analysis to analyse the data in which coding categories are derived directly from the text data (Hsieh and Shannon, 2005).”

“Various frameworks and conceptual models of implementation exist within the field of implementation science e.g. the Consolidated Framework for Implementation Science (Damschroder et al., 2009; Hadjistavropoulos et al., 2017), Theory of Diffusion (Rogers, 2003), the RE-AIM model (Bennett and Glasgow, 2009), and Normal…”

“However, as pointed out by Greenhalgh et al. (2004), Fixsen et al. (2005) and Ross et al. (2016) sustainability or maintenance is rarely singled out as a separate implementation challenge and there have been little empirical work examining factors that either facilitate or limit sustainability of…”

“The study was designed as a multiple comparative case study to explore differences and similarities between cases (Yin, 2014; Crowe et al., 2011; Stake, 2006).”

“…mental and somatic disorders with outcomes that are comparable to face-to-face interventions when delivered with some form of professional guidance (Andersson et al., 2014; Andersson and Hedman, 2013; Arnberg et al., 2014; El Alaoui et al., 2015; Hedman et al., 2013; Hedman et al., 2014; Karyotaki…”

“Future research could aim to answer these questions through systematic experiments with service models and implementation strategies (Powell et al., 2014; Ross et al., 2016).”

“Several randomized controlled trials and meta-analyses have demonstrated that iCBT can be effective for various mental and somatic disorders with outcomes that are comparable to face-to-face interventions when delivered with some form of professional guidance (Andersson et al., 2014; Andersson and Hedman, 2013; Arnber…”

“Internet-based psychological treatment for common mental health disorders may be one way to minimise barriers to treatment delivery and increase access to evidence-based treatment (Andersson, 2016).”

“In our study, the perceived skepticism of CBT colleagues was mainly linked to worries about the quality of the therapeutic relationship and the overall quality of iCBT aligning with previous studies of CBT therapists and referring-providers' perceptions and attitudes towards iCBT (Topooco et al., 2017; Waller and Gilb…”

“Several randomized controlled trials and meta-analyses have demonstrated that iCBT can be effective for various mental and somatic disorders with outcomes that are comparable to face-to-face interventions when delivered with some form of professional guidance (Andersson et al., 2014; Andersson and Hedman, 2013; Arnber…”

“cognitive behavior therapy (CBT) or Interpersonal Psychotherapy (IPT)), and psychopharmacology, a substantial proportion of people suffering from mental disorders go untreated (Demyttenaere et al., 2004; Thornicroft et al., 2017; Alonso et al., 2007).”

“In a British study of attitudes towards iCBT in the general population it was found that web-based treatments were expected to be convenient but to have lower appeal and credibility than face-to-face therapy (Musiat et al., 2014).”

“Few studies have specifically targeted tailored treatment in iCBT, but it has been indicated that programs which can be adapted to individual patients' conditions may be superior to standardized iCBT programs for higher severity levels of mental health disorders (Carlbring et al., 2011; Andersson et al., 2011; Johanss…”

“Future research could aim to answer these questions through systematic experiments with service models and implementation strategies (Powell et al., 2014; Ross et al., 2016).”

“Regarding patients' attitudes it has been found that patients worry about the clinical effectiveness of iCBT (Topooco et al., 2017) which has been shown to correlate with poorer treatment outcome (El Alaoui et al.”

“…in iCBT, but it has been indicated that programs which can be adapted to individual patients' conditions may be superior to standardized iCBT programs for higher severity levels of mental health disorders (Carlbring et al., 2011; Andersson et al., 2011; Johansson et al., 2012; Andersson, 2016).”

“In a study of the use of the iCBT program FearFighter for anxiety on waiting list patients in a Danish secondary routine care clinic no treatment effect was found (Mathiasen et al., 2016) even though the program had been shown to be effective in earlier studies (Marks et al., 2004).”

“E.g. results from the MindSpot Clinic in Australia suggest that only 25% of self-referring patients take up free iCBT (Titov et al., 2017).”

“…and how to disseminate iCBT is an open question, since few implementation studies of internet-delivered treatments have been performed in routine care settings (Hadjistavropoulos et al., 2014; Ebert and Baumeister, 2017; Hadjistavropoulos et al., 2017; Titov et al., 2017; Nordgreen et al., 2018).”

“…there are other examples of iCBT services operating in routine care such as THIS WAY UP Clinic (Newby et al., 2016) and the MindSpot Clinic (Titov et al., 2017, 2015) in Australia sponsored by the Australian Government and the Online Therapy Unit (Hadjistavropoulos et al., 2016, 2017) in…”

“Although some authors have identified key components to consider for successful implementation (Andersson and Hedman, 2013; Andersson et al., 2008) very little research has been done on implementation challenges and facilitators relating to the practical operation of iCBT services…”

“Although some authors have identified key components to consider for successful implementation (Andersson and Hedman, 2013; Andersson et al., 2008) very little research has been done on implementation challenges and facilitators relating to the practical operation of iCBT services (Hadjistavropoulos et al.”

“…there are other examples of iCBT services operating in routine care such as THIS WAY UP Clinic (Newby et al., 2016) and the MindSpot Clinic (Titov et al., 2017, 2015) in Australia sponsored by the Australian Government and the Online Therapy Unit (Hadjistavropoulos et al., 2016, 2017) in Canada.”

“Few studies have specifically targeted tailored treatment in iCBT, but it has been indicated that programs which can be adapted to individual patients' conditions may be superior to standardized iCBT programs for higher severity levels of mental health disorders (Carlbring et al., 2011; Andersson et al., 2011; Johanss…”

“…about the quality of the therapeutic relationship and the overall quality of iCBT aligning with previous studies of CBT therapists and referring-providers' perceptions and attitudes towards iCBT (Topooco et al., 2017; Waller and Gilbody, 2009; Musiat et al., 2014; Hadjistavropoulos et al., 2017).”

“…treatment among providers and patients, lack of awareness of internetbased treatment options among patients and providers, high drop-out numbers from treatment, limited availability of adequately trained professionals and limited evidence for cost-effectiveness (Batterham et al., 2015).”

“Research concerning iCBT has so far primarily focused on efficacy and effectiveness trials, with little attention to the process of implementation (Drozd et al., 2016; Vis et al., 2015).”

“Research concerning iCBT has so far primarily focused on efficacy and effectiveness trials, with little attention to the process of implementation (Drozd et al., 2016; Vis et al., 2015).”

“…and how to disseminate iCBT is an open question, since few implementation studies of internet-delivered treatments have been performed in routine care settings (Hadjistavropoulos et al., 2014; Ebert and Baumeister, 2017; Hadjistavropoulos et al., 2017; Titov et al., 2017; Nordgreen et al., 2018).”

“Emphasis on the working practices of iCBT therapists as important factors in the implementation of iCBT is also stressed in the literature (Wilhelmsen et al., 2014; Bengtsson et al., 2015; Mol et al., 2016).”

“Regarding patients' attitudes it has been found that patients worry about the clinical effectiveness of iCBT (Topooco et al., 2017) which has been shown to correlate with poorer treatment outcome (El Alaoui et al., 2016).”

“Emphasis on the working practices of iCBT therapists as important factors in the implementation of iCBT is also stressed in the literature (Wilhelmsen et al., 2014; Bengtsson et al., 2015; Mol et al., 2016).”

“, 2008) very little research has been done on implementation challenges and facilitators relating to the practical operation of iCBT services (Hadjistavropoulos et al., 2017; Nordgreen et al., 2018).”

“Several randomized controlled trials and meta-analyses have demonstrated that iCBT can be effective for various mental and somatic disorders with outcomes that are comparable to face-to-face interventions when delivered with some form of professional guidance (Andersson et al., 2014; Andersson and Hedman, 2013; Arnber…”

“According to Andersson and Hedman (2013), it is possible to transfer iCBT into routine clinical practice with moderate to large effect sizes; however, which service model should be used for iCBT and how to disseminate iCBT is an open question, since few implementation studies of internet-delivered treatments have been…”

“In a study of the use of the iCBT program FearFighter for anxiety on waiting list patients in a Danish secondary routine care clinic no treatment effect was found (Mathiasen et al., 2016) even though the program had been shown to be effective in earlier studies (Marks et al., 2004).”

“(2015) described how determinants of implementation of clinical guidelines in health care should be described on three levels: i) the developers, ii) the professionals/coordinators in the organizations, and iii) the end users (Fleuren et al., 2015).”

“Emphasis on the working practices of iCBT therapists as important factors in the implementation of iCBT is also stressed in the literature (Wilhelmsen et al., 2014; Bengtsson et al., 2015; Mol et al., 2016).”

“, costs, web application, retaining personnel) or future directions (Folker et al., 2018).”

“Moreover, our trials on psychodynamic internet treatment are now included in systematic reviews on the effects of psychodynamic treatment (Fonagy, 2015).”

“…sectors such as health, justice, social support with public engagement in policy development [40, 94] may allow better coordination to facilitate implementation, while public awareness through marketing will drive engagement and create acceptance and facilitate demand [40, 55, 69, 72, 81, 94, 115].”