Use and acceptability of unsupported online computerized cognitive behavioral therapy for depression and associations with clinical outcome
Abstract
Background In a recent randomized trial, we were unable to confirm the previously reported high effectiveness of CCBT. Therefore, the aim of the current study was to have a closer look at usage and acceptability (i.e. expectancy, credibility, and satisfaction) of the intervention. Methods Depressed participants (N=200) were given login codes for unsupported online CCBT. A track-and-trace system tracked which components were used. We used a 9-month follow-up period. Results Uptake was sufficient, but dropout was high. Many usage indices were positively associated with short-term depressive improvement, whereas only homework was related to long-term improvement. Acceptability was good and expectancy could predict long-term, but not short-term outcome. Limitations Associations between use of CCBT and improvement are merely correlational. Our sample was too depressed in relation to the scope of the intervention. We relied on online self-report measures. Analyses were exploratory in nature. Conclusions Although CCBT might be a feasible and acceptable treatment for depression, means to improve treatment adherence are needed for moderately to severely depressed individuals.
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The homework compliance of this study was higher compared to previous studies that implemented CBT interventions digitally, face-to-face, or via telephone.
“The homework compliance of this study was higher compared to previous studies that implemented CBT interventions digitally, face-to-face, or via telephone (49–52).”
From A virtual reality-based self-guided training on identification of negative automatic thoughts in healthy adults: a mixed-methods feasibility study (2024) · cites this paper as [51]
Satisfaction provides information about the feasibility of the intervention, helping to optimize its effectiveness.
“Moreover, “satisfaction” provides information about the feasibility of the intervention, helping to optimize its effectiveness (45).”
Few studies have focused on the assessment of treatment acceptability in terms of IBIs and its relationship with effectiveness.
“the importance of treatment acceptability is known, and few studies have focused on its assessment in terms of IBIs and its relationship with effectiveness (29, 35, 42, 43, 45, 52).”
Some variables related to treatment acceptability are expectations and satisfaction.
“Some variables related to treatment acceptability are expectations and satisfaction (42–45).”
Satisfaction has been found to help optimize intervention efficacy.
“This is an important result because satisfaction has been found to help to optimize intervention efficacy (10, 45), and the results in the present study show that the same thing might occur with an IBI program for depression in primary care settings.”
Website exposure and program usage was positively correlated with outcomes in interventions targeting smokeless tobacco, depression, and physical activity.
“Website exposure and program usage was positively correlated with outcomes in interventions targeting smokeless tobacco [64], depression [65], and physical activity [66].”
From A Systematic Review of the Impact of Adherence on the Effectiveness of e-Therapies (2011) · cites this paper as [65]
Patients with more severe symptoms of depression may need different programs or more intensive guidance in online therapy to reach recovery.
“While standalone eHealth interventions could also be beneficial in secondary health care, patients with more severe symptoms of depression may need different programs or a more intensive guidance in their online therapy in order to reach recovery [4,11,16].”
A higher number of logins, greater total time spent using the treatment and greater use of an online mood diary were predictive of better outcome at 3 months postintervention.
“One study reported that a higher number of logins, greater total time spent using the treatment and greater use of an online mood diary were predictive of better outcome at 3 months postintervention (de Graaf et al., 2009).”
From Predictors of adherence and outcome in internet-based cognitive behavior therapy delivered in a telephone counseling setting (2014) · cites this paper as de Graaf et al., 2009
Treatment expectations were positively related to outcome in one study, but no association was found in another.
“However only one of the studies found that treatment expectations were positively related to outcome (de Graaf et al., 2009), with the second reporting no association (Cavanagh et al., 2009).”
From Predictors of adherence and outcome in internet-based cognitive behavior therapy delivered in a telephone counseling setting (2014) · cites this paper as de Graaf et al., 2009
Perceived treatment credibility was unrelated to outcome.
“Of the two studies which have examined this question, both reported that perceived treatment credibility was unrelated to outcome (Cavanagh et al., 2009;de Graaf, Huibers, Riper, Gerhards, & Arntz, 2009).”
From Predictors of adherence and outcome in internet-based cognitive behavior therapy delivered in a telephone counseling setting (2014) · cites this paper as de Graaf, Huibers, Riper, Gerhards, & Arntz, 2009
Compliance with homework exercises was significantly associated with better treatment outcome at 9 months.
“Compliance with homework exercises was also significantly associated with better treatment outcome at 9 months (de Graaf et al., 2009).”
From Predictors of adherence and outcome in internet-based cognitive behavior therapy delivered in a telephone counseling setting (2014) · cites this paper as de Graaf et al., 2009
de Graaf and colleagues (2009) reported that better treatment outcome was associated with greater number of logins, greater total time spent using the intervention, and greater compliance with homework exercises.
“de Graaf and colleagues (2009) who reported that better treatment outcome was associated with greater number of logins, greater total time spent using the intervention, and greater compliance with homework exercises.”
From Predictors of adherence and outcome in internet-based cognitive behavior therapy delivered in a telephone counseling setting (2014) · cites this paper as de Graaf et al., 2009
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“…and communication technologies (ICT, such as the Internet), may be a promising way of alleviating the treatment gap in this population as they are highly accessible, cheap, acceptable, and less stigmatizing, thanks to their higher anonymity (Cuijpers et al., 2017; de Graaf et al., 2009).”
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Muntingh, A., Hoogendoorn, A. W., van Schaik, A., van Straten, A., Stolk, E. A., van Balkom, A. J. L. M., & Batelaan, N. M. (2019) · PLoS ONE · doi:10.1371/journal.pone.0219588 · Cited by 17 · see citing works
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Forand, N. R., Huibers, M., & DeRubeis, R. (2017) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000182 · Cited by 13 · see citing works
“In the current sample, the average intake depression score was in the moderate to severe range, suggesting that the sample was relatively impaired (de Graaf et al., 2009).”
BackgroundMethodResultInfluentialSelf-citationOnline self-help for suicidal thoughts: 3-month follow-up results and participant evaluation
van Spijker, B. A. J., van Straten, A., & Kerkhof, A. J. F. M. (2015) · Internet Interventions · doi:10.1016/j.invent.2015.07.001 · Cited by 10 · see citing works
Schwartz, H., McCusker, J., da Costa, D., Singh, S., Baskaran, S., Belzile, É., & Roost, K. V. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100597 · Cited by 9 · see citing works
“Perinatal mood and anxiety disorders affect at least 1 in 5 women during the perinatal period from pregnancy until 1 year postpartum (Dennis et al., 2017).”
BackgroundThielecke, J., Kuper, P. R., Ebert, D. D., Cuijpers, P. J., Smit, F., Riper, H. M., Lehr, D., & Buntrock, C. (2023) · Health Expectations · doi:10.1111/hex.13951 · Cited by 6 · see citing works
Self-citationCludius, B., Schröder, J., & Moritz, S. (2017) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465817000571 · Cited by 13 · see citing works
“However, they are in line with online treatments in patients with anxiety or depression (range: 66–97%; Spek et al., 2007) and psychological internet interventions in MDD without therapist contact (de Graaf et al., 2009).”
BackgroundMilgrom, J., & Gemmill, A. W. (2014) · Evidence-Based Nursing · doi:10.1136/eb-2013-101636 · Cited by 7 · see citing works
Wenger, F., Allenhof, C., Schreynemackers, S., Hegerl, U., & Reich, H. (2023) · JMIR Formative Research · doi:10.2196/53768 · Cited by 5 · see citing works
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Whelen, M. L., Ezawa, I. D., & Strunk, D. R. (2022) · Psychotherapy Research · doi:10.1080/10503307.2022.2156304 · Cited by 4 · see citing works
“The average BDI score at intake was 30.95 ( SD = 8.82) which is comparable to other depression studies (e.g., Bruijniks et al., 2020; de Graaf et al., 2009).”
InfluentialBruin, E. K.-D., Muntingh, A., Bourguignon, E., Hoogendoorn, A., Maarsingh, O., van Balkom, A. V., Batelaan, N., van Straten, A., & van Meijel, B. (2022) · JMIR Mental Health · doi:10.2196/25441 · Cited by 4 · see citing works
„iFightDepression“ im stationären Setting
Schwarz, J., Mauche, N., Oehler, C., Rummel-Kluge, C., Hegerl, U., & Strauss, M. (2021) · Der Nervenarzt · doi:10.1007/s00115-021-01214-w · Cited by 4 · see citing works
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Computerized Cognitive Training Based upon Neuroplasticity
Shinaver, C. S., & Entwistle, P. C. (2015) · Health informatics · doi:10.1007/978-3-319-14109-1_5 · Cited by 4 · see citing works
“Their conclusion was similar to that of Newman Szkodny, Llera, Preworski in 2011, they found that although this computerized approach for depression was feasible there was a need to increase adherence for moderately to severely depressed subjects [28].”
BackgroundResultInfluentialBockting, C., Kok, G. D., van der Kamp, L., Smit, F., van Valen, E., Schoevers, R., van Marwijk, H. V., Cuijpers, P., Riper, H., Dekker, J., et al. (2011) · BMC Psychiatry · doi:10.1186/1471-244x-11-12 · Cited by 3 · see citing works
“Participants in the M-CT group will also answer questions of the Dutch version of the Credibility and expectancy questionnaire [37,38] before and after finishing M-CT.”
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Wang, S., Zhang, C., Huang, J. W., Liu, T., & Xu, W. (2025) · Behavioral Sciences · doi:10.3390/bs15111554 · Cited by 1 · see citing works
“…trials of online interventions examining dose–response effects have found that the number of sessions users complete and the duration of usage correlate with improved outcomes, with these benefits persisting into follow-up period (de Graaf et al., 2009; Li et al., 2022; Z. Yang et al., 2024).”
Gupta, N., Gardin, F., Berger, T., & Kawohl, W. (2025) · JMIR Human Factors · doi:10.2196/85816 · Cited by 1 · see citing works
“These findings are consistent with the broader literature on digital interventions, which has repeatedly documented high rates of nonuse and early disengagement [5,6].”
Evia, Á. F. V. D. L. G., Eberle, J. W., Baee, S., Wolfe, E. C., Boukhechba, M., Funk, D. H., Teachman, B. A., & Barnes, L. E. (2025) · PLOS Digital Health · doi:10.1371/journal.pdig.0000945
Enrique-Roig, Á., Palacios, J. E., Ryan, H., & Richards, D. (2018) · doi:10.2196/preprints.12775 · Cited by 1
Tien jaar monitor GGZ-preventie: inzichten en vraagstukken
Schotanus-dijkstra, M., Ruiter, M., van der Poel, A., Hosman, C., & Boon, B. (2013) · Tijdschrift voor gezondheidswetenschappen · doi:10.1007/s12508-013-0078-4 · Cited by 1 · see citing works
Guzman, C., & Ernesto, Á. (2015) · heiDOK (Heidelberg University) · doi:10.11588/heidok.00019010 · Cited by 1 · see citing works
Opinion of the Patients About an Internet-Based Psychological Treatment Protocol
González-Robles, A., Mira, A., Díaz, A., García-Palacios, A., Riera, A., Baños, R., & Botella, C. (2015) · International Conference on Ubiquitous Computing and Ambient Intelligence · doi:10.1007/978-3-319-26401-1_43
- Authors
- de Graaf, L. E., Huibers, M. J. H., Riper, H., Gerhards, S. A. H., & Arntz, A.
- Affiliations
- Maastricht University (NL)
- Trimbos Institute (NL)
- Venue
- Journal of Affective Disorders
- Publisher
- Elsevier BV
- Published
- 2009-08
- Volume
- 116
- Issue
- 3
- Pages
- 227-231
- ISSN
- 0165-0327 (ISSN-L)
- OpenAlex
- W2164956998
- Cited by
- 86
- References
- 0
- Citations by year
- 2026: 2 · 2025: 3 · 2024: 4 · 2023: 2 · 2022: 6 · 2021: 1 · 2020: 3 · 2019: 3 · 2018: 5 · 2017: 10 · 2016: 7 · 2015: 5 · 2014: 5 · 2013: 10 · 2012: 8
- FWCI
- 7.77
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Affective Disorders (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion)
- Digital Academic REpository of VU University Amsterdam (Vrije Universiteit Amsterdam) (submittedVersion)
- VU Research Portal (submittedVersion)
- Research Publications (Maastricht University) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- internet-based cognitive behavioral therapy, depression, treatment acceptability, treatment uptake, dropout, homework adherence, treatment expectancy, credibility, user satisfaction, track and trace systems, medication adherence, long-term outcomes
- MeSH terms
- Adolescent, Adult, Aged, Major Depressive Disorder, Female, Humans, Male, Mental Health Services, Middle Aged, Patient Acceptance of Health Care, Prospective Studies, Cognitive Behavioral Therapy, Treatment Outcome, Internet, Young Adult
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