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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
Open accessAbstract
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
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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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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Citations
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“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…”
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Cited by
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An overview of and recommendations for more accessible digital mental health services
Lattie, E. G., Stiles-Shields, C., & Graham, A. K. (2022) · Nature Reviews Psychology · doi:10.1038/s44159-021-00003-1 · Cited by 446
ICBT in routine care: A descriptive analysis of successful clinics in five countries
Titov, N., Dear, B., Nielssen, O., Staples, L., Hadjistavropoulos, H., Nugent, M., Adlam, K., Nordgreen, T., Bruvik, K. H., Hovland, A., et al. (2018) · Internet Interventions · doi:10.1016/j.invent.2018.07.006 · Cited by 353
“, costs, web application, retaining personnel) or future directions (Folker et al., 2018).”
BackgroundMethodInfluentialSelf-citationInternet interventions: Past, present and future
Andersson, G. (2018) · Internet Interventions · doi:10.1016/j.invent.2018.03.008 · Cited by 315
“Moreover, our trials on psychodynamic internet treatment are now included in systematic reviews on the effects of psychodynamic treatment (Fonagy, 2015).”
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Berardi, C., Antonini, M., Jordan, Z., Wechtler, H., Paolucci, F., & Hinwood, M. (2024) · BMC Health Services Research · doi:10.1186/s12913-023-10536-1 · Cited by 175
“…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].”
BackgroundInfluential
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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