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The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care: A systematic review and meta-analysis
Open accessAbstract
Purpose Psychological interventions are labor-intensive and expensive, but e-health interventions may support them in primary care. In this study, we systematically reviewed the effectiveness and cost-effectiveness of e-health interventions for depressive and anxiety symptoms and disorders in primary care.Methods We searched MEDLINE, Cochrane library, Embase, and PsychINFO until January 2018, for randomized controlled trials of e-health interventions for depression or anxiety in primary care. Two reviewers independently screened the identified publications, extracted data, and assessed risk of bias using the Cochrane Collaboration's tool.Results Out of 3617 publications, we included 14 that compared 33 treatments in 4183 participants. Overall, the methodological quality was poor to fair. The pooled effect size of e-health interventions was small (standardized mean difference = -0.19, 95%CI -0.31 to -0.06) for depression compared to control groups in the short-term, but this was maintained in the long-term (standardized mean difference = -0.22, 95%CI -0.35 to -0.09). Further analysis showed that e-health for depression had a small effect compared to care as usual and a moderate effect compared to waiting lists. One trial on anxiety showed no significant results. Four trials reported on cost-effectiveness.Limitations The trials studied different types of e-health interventions and had several risks of bias. Moreover, only one study was included for anxiety.Conclusions E-health interventions for depression have a small effect in primary care, with a moderate effect compared to waiting lists. The approach also appeared to be cost-effective for depression. However, we found no evidence for its effectiveness for anxiety.
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“However, offering these interventions in an online format may have unique benefits of increased accessibility and scalability, thereby lowering the threshold for participation [136] and potential cost-effectiveness [137].”
From New evidence in the booming field of online mindfulness: An updated meta-analysis of randomized controlled trials (2021) · cites this paper as [137]
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“Nevertheless, despite internet interventions’ attested efficacy [21] in treating various mental health conditions and its potential cost-effectiveness [22,23], internet interventions targeting cancer survivors are scant [24].”
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“This contributes to extensive heterogeneity between trials. 595”
From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [595]
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“Web-based platforms and smartphone apps represent an increasingly common way of supporting self-management or providing treatment for various conditions [14-16].”
Digital interventions in mental health: Evidence syntheses and economic modelling
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“Similarly, metaanalyses of eHealth interventions for general mental health indicate small to moderate effects for depression (Massoudi et al., 2019).”
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“In primary care clinical samples these results were supported, with a systematic review of digital interventions for depression and anxiety including over 4000 patients finding small positive, statistically significant effects of digital interventions compared to control groups, and, promisingly, this was maintained a…”
ResultImpact of digital services on healthcare and social welfare: An umbrella review
Härkönen, H., Lakoma, S., Verho, A., Torkki, P. M., Leskelä, R., Pennanen, P., Laukka, E., & Jansson, M. M. (2024) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2024.104692 · Cited by 39
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Gili, M., Castro, A., García‐Palacios, A., García‐Campayo, J., Mayoral, F., Botella, C., Roca, M., Barceló‐Soler, A., Hurtado, M. M., Navarro, M., et al. (2020) · Journal of Medical Internet Research · doi:10.2196/15845 · Cited by 36
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“Besides within-intervention guidance, guidance-related aspects of the study design such as the conduct of clinical interviews [14], use of automated reminders [15], or treatment setting in which the intervention is used [16] seem to be associated with greater effects.”
BackgroundoVRcome – Self-guided virtual reality for specific phobias: A randomised controlled trial
Lacey, C. J., Frampton, C. M., & Beaglehole, B. (2022) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/00048674221110779 · Cited by 29
“Selfguided mobile or digital health interventions have been shown to be effective for depression in primary care, although there is less evidence for their place in the treatment of anxiety (Massoudi et al., 2019).”
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“…have been few sustained efforts for developing eHealth programs specifically oriented to men with depression (Fogarty et al., 2017; Murphy et al., 2018), despite reviews concluding that eHealth interventions for depression show promise (Deady et al., 2017; Luo et al., 2020; Massoudi et al., 2019).”
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“Nevertheless, despite internet interventions’ attested efficacy [21] in treating various mental health conditions and its potential cost-effectiveness [22,23], internet interventions targeting cancer survivors are scant [24].”
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“E-health E-health interventions have been verified to be effective in a variety of health behavior promotion, including weight loss (Podina and Fodor 2018), depression and anxiety reduction (Massoudi et al. 2019), and PA promotion (Yu et al. 2023).”
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Digital interventions in adult mental healthcare settings: recent evidence and future directions
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“The authors of a meta-analysis focusing on IMI used to treat PTSD patients found medium effect sizes CI & the effectiveness of IMI for in healthcare samples was examined [34 && ].”
BackgroundE-mental health applications for depression: an evidence-based ethical analysis
Rubeis, G. (2021) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-019-01093-y · Cited by 17
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“There is evidence that mobile health technologies [13], electronic-health [36], faith-based [37], and community-based therapies [38] can improve patient outcomes.”
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“Criticisms of web-based interventions include poor methodological quality of effectiveness studies such as by comparing interventions with wait-list control groups or by showing evidence only through analysis of short-term effects [23,39].”
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“However, it is unclear if and under what circumstances they would be feasible or acceptable to participants [17].”
Castilla, D., Haro, M. V. N., Suso‐Ribera, C., Díaz‐García, A., Zaragozá, I., & García‐Palacios, A. (2022) · BMC Psychiatry · doi:10.1186/s12888-022-03800-x · Cited by 20
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Zheng, Q., Shi, L., Zhu, L., Jiao, N., Chong, Y. S., Chan, S. W., Chan, Y. H., Luo, N., Wang, W., & He, H. G. (2022) · Journal of Medical Internet Research · doi:10.2196/25821 · Cited by 14
“Another systematic review and meta-analysis reporting the effectiveness and cost-effectiveness of eHealth interventions for depression and anxiety in primary care demonstrated that eHealth was only cost-effective for depression, but there was no evidence for its effectiveness for anxiety [35].”
BackgroundBarceló‐Soler, A., García‐Campayo, J., Araya, R., Doukani, A., Gili, M., García‐Palacios, A., Mayoral, F., & Montero‐Marín, J. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1024966 · Cited by 14
Sten-Gahmberg, S., Pedersen, K., Harsheim, I. G., Løyland, H. I., & Abelsen, B. (2024) · BMC Health Services Research · doi:10.1186/s12913-024-10732-7 · Cited by 13
“The latter is a relatively common finding in the literature [12–14 , 33 Our analysis sheds light on the importance of using dedicated resources to develop and implement a new telemedicine-based service, and to involve other health-care services.”
Backgroundvan Gelder, N. E., Ligthart, S. A., van Rosmalen-Nooijens, K. A. W. L., Prins, J. B., & Oertelt‐Prigione, S. (2023) · Journal of Medical Internet Research · doi:10.2196/42641 · Cited by 16
“Nevertheless, they can be helpful and meaningful for health outcomes in the general population [77,78].”
Zhang, L., Chen, K., Li, S., Liu, S. K., & Wang, Z. (2025) · Current Issues in Molecular Biology · doi:10.3390/cimb47121061 · Cited by 12
“…for multi-omics data acquisition, model development, and validation must be justified by demonstrating long-term cost-effectiveness, potentially through reducing ineffective treatment trials and enabling preventative care, as evidenced in health-economic analyses of digital interventions [161].”
Kaiser, T., Boschloo, L., Berger, T., Meyer, B., Späth, C., Schröder, J., Hohagen, F., Moritz, S., & Klein, J. P. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.598317 · Cited by 12
Use of Telemedicine in Depression Care by Physicians: Scoping Review
Echelard, J.-F. (2021) · JMIR Formative Research · doi:10.2196/29159 · Cited by 12
“The study selection process is detailed in Figure 1 [10-37].”
BackgroundAli, S., Alemu, F. W., Owen, J. J., Eells, T. D., Antle, B. F., Lee, J. T., & Wright, J. H. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.44599 · Cited by 9
Westas, M., Mourad, G., Andersson, G., Neher, M., Lundgren, J., & Johansson, P. (2022) · BMC Psychiatry · doi:10.1186/s12888-022-03939-7 · Cited by 10
“A possible solution could be internet-based CBT (iCBT) which, compared to face-to-face CBT, has been found to be equally effective and also a cost-efficient treatment option for depression in other populations [11, 12].”
BackgroundMental Health of People Under Isolation During the covid-19 Outbreak: An Exploratory Study
Díaz, C. M. C., García, N. B., Alba‐Marrugo, M. A., Escudero, J. P. S., Marín-Cortés, A., & Tungjitcharoen, W. (2022) · Revista Colombiana de Psicología · doi:10.15446/rcp.v31n2.89960 · Cited by 10
“To achieve this, we suggest the use of teletherapy, the clinical efficacy of which has been proven to treat depression (Deady et al., 2017; Kim et al., 2019; Massoudi et al., 2019; McCall et al., 2019) and stress (Glassman et al., 2019; McLean et al., 2020; Morland et al., 2020).”
Methodter Harmsel, J. F., Smulders, L. M., Noordzij, M. L., Swinkels, L. T. A., Goudriaan, A. E., Popma, A., & van der Pol, T. M. (2022) · JMIR Formative Research · doi:10.2196/40237 · Cited by 10
“Positive influences on health care outcomes and cost-effectiveness have been reported for specific populations [8].”
BackgroundGual-Montolio, P., Suso‐Ribera, C., García‐Palacios, A., Castilla, D., Zaragozá, I., & Bretón-López, J. M. (2023) · Internet Interventions · doi:10.1016/j.invent.2023.100601 · Cited by 11
Castro, A., García‐Palacios, A., del Hoyo, Y. L., Mayoral, F., Pérez-Ara, M. Á., Baños, R. M., García‐Campayo, J., Hurtado, M. M., Botella, C., Barceló‐Soler, A., et al. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18041774 · Cited by 9
Feasibility of mHealth interventions for depressive symptoms in Latin America: a systematic review
Escobar-Viera, C. G., Cernuzzi, L., Miller, R. S., Rodríguez-Marín, H. J., Vieta, E., Toñánez, M. G., Marsch, L. A., & Hidalgo‐Mazzei, D. (2021) · International Review of Psychiatry · doi:10.1080/09540261.2021.1887822 · Cited by 12
“Hence, there is a major need of pragmatic, real-world studies evaluating not only efficacy and retention of stand-alone and independent mHealth platforms, but also effectiveness and retention when implemented in community health care systems (Massoudi et al., 2019).”
BackgroundGoff-Pronost, M. L., & Bongiovanni-Delarozière, I. (2023) · International Journal of Technology Assessment in Health Care · doi:10.1017/s0266462323002581 · Cited by 9
“The study by Massoudi (83) concerned the use of e-health interventions for patients with depressive symptoms or depressive disorders treated in primary care.”
BackgroundKöhnen, M., Kriston, L., Härter, M. C., Baumeister, H., & Liebherz, S. (2020) · Journal of Medical Internet Research · doi:10.2196/24584 · Cited by 11
“Our results are in line with 2 previous meta-analyses that found a small effect favoring TBIs in comparison with TAU [101,102].”
ResultTechnology innovation to improve SMEs sustainability
Gimin, G., Caska, C., Indrawati, H., & Yasin, M. (2024) · Journal of Science and Technology Policy Management · doi:10.1108/jstpm-12-2023-0237 · Cited by 7
Sabin, L., Mešić, A., Le, B. N., Halim, N., Hue, C. C. T., Bonawitz, R. E., Nguyen, H. V., Williams, A. L., Nguyen, T. T. T., Le, A. N., et al. (2022) · Global Health Science and Practice · doi:10.9745/ghsp-d-22-00008 · Cited by 7
Philipp, J., Franta, C., Zeiler, M. D., Truttmann, S., Wittek, T., Schöfbeck, G., Mairhofer, D., Mitterer, M., Laczkovics, C., Treasure, J. L., et al. (2024) · European Eating Disorders Review · doi:10.1002/erv.3080 · Cited by 7
Tribe, R. H., Alcock, K., Scior, K., & Huddy, V. C. (2021) · Journal of Mental Health · doi:10.1080/09638237.2021.1922641 · Cited by 7
“…over the last decade and reviews have suggested that online interventions are effective in treating anxiety and depression and that those who use the interventions are satisfied with them (Andersson et al., 2019; Lal & Adair, 2014, Massoudi et al., 2019; Meurk et al., 2016; Zhou et al., 2016).”
BackgroundCost Effectiveness of Digital Interventions for Generalised Anxiety Disorder: A Model-Based Analysis
Janković, D., Saramago, P., Gega, L., Marshall, D. C., Wright, K. E., Hafidh, M., Churchill, R. C., & Bojke, L. (2021) · PharmacoEconomics - Open · doi:10.1007/s41669-021-00318-y · Cited by 9
“Reviews of cost effectiveness of DIs were for mixed mood and anxiety disorders, so they were dominated by DIs for depression and did not report outcomes for GAD populations separately [7, 8].”
BackgroundPeeters, S. B., Hilgersom, M., van Krugten, F. C. W., Olaya, B., Haro, J. M., Feltz-Cornelis, C. M. V. D., & Roijen, L. H. (2024) · Journal of Mental Health · doi:10.1080/09638237.2024.2390371 · Cited by 5
“The results of this study about the potential of eHealth interventions being cost-effectiveness was in line with the literature conducted out of a broader perspective (Deady et al., 2017; Gentili et al., 2022; Massoudi et al., 2019).”
ResultLange, A. M. C., Humayun, S., & Jefford, T. (2022) · Child & Youth Care Forum · doi:10.1007/s10566-022-09692-y · Cited by 5
“Yet, teletherapy has the potential to increase access to therapy and reduce costs (Bennett et al., 2020; Massoudi et al., 2019).”
Reshaping youth mental health care for optimal system-level outcomes: A dynamic modelling analysis
Skinner, A., Perez-Bennetts, E., Iorfino, F., Varidel, M., Richards, M. J., Occhipinti, J., Song, Y. J. C., Rosenberg, S. P., Scott, E. M., & Hickie, I. B. (2025) · PLOS mental health. · doi:10.1371/journal.pmen.0000232 · Cited by 4
“Additionally, we assess the degree to which embedding readily scalable e-health interventions (self-directed online care) [18] in routine clinical practice can help to reduce total rates of illness progression and disengagement from treatment and increase the total rate of recovery (our primary…”
InfluentialGuertler, D., Krause, K., Möhring, A., Bischof, G., Batra, A., Freyer‐Adam, J., Ulbricht, S., Rumpf, H., Wurm, S., Cuijpers, P. J., et al. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.06.059 · Cited by 5
Quality of the digital gp visits and characteristics of the users: retrospective observational study
Lakoma, S., Pasanen, H., Lahdensuo, K., Pehkonen, J., Viinikainen, J., & Torkki, P. M. (2024) · Scandinavian Journal of Primary Health Care · doi:10.1080/02813432.2024.2380921 · Cited by 4
“…use, and cost at a global level [10]. some studies suggest that Dhs reduce the use of face-to-face health services, thereby improving access [11], while others indicate that Dhs increase resource utilization and act as a duplication of services alongside physical services [12]. however,…”
BackgroundRomy, R. W., & Nan, X. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100802 · Cited by 3
“Pre-pandemic research has shown that e-mental health interventions primarily addressed anxiety, depression, and stress as the most prevalent mental health concerns (Massoudi et al., 2019).”
Mendes-Santos, C. (2021) · Linköping studies in arts and science · doi:10.3384/9789179291143 · Cited by 3
Beintner, I., Kerber, A., Dominke, C., & Voderholzer, U. (2023) · JMIR Research Protocols · doi:10.2196/46651 · Cited by 3
“…contributing to the variability in the results of self-guided interventions include study design characteristics including the use of clinical interviews [42], automated reminders [43], and the clinical setting [41], as well as participant characteristics like the severity of the disorder [34].”
BackgroundSanftenberg, L., Bentrop, M., Jung‐Sievers, C., Dreischulte, T., & Gensichen, J. S. (2024) · Journal of Mental Health · doi:10.1080/09638237.2024.2426985 · Cited by 4
“Therefore, a wide range of telemental health interventions have now been developed, which can range from guided self-help instructions to audio-visual therapy concepts (Cuijpers et al., 2019; Massoudi et al., 2019).”
Telemedicine for Psychiatry and Mental Health
Garofalo, M., Vaithilingam, S. L., & Ferrando, S. J. (2020) · Springer eBooks · doi:10.1007/978-3-030-56917-4_23 · Cited by 3
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Medical policy for suicide prevention
Lee, S., & Park, J. (2019) · Journal of Korean Medical Association · doi:10.5124/jkma.2019.62.2.102 · Cited by 2
Krijnen, L., van Eldik, W. M., Mooren, T. T. M., van Rooijen, B., Boelen, P. A., van Baar, A. L., Spuij, M., Verhoeven, M., & Egberts, M. R. (2023) · Child and Adolescent Psychiatry and Mental Health · doi:10.1186/s13034-023-00686-9 · Cited by 2
“In the context of a crisis in which social restrictions apply, e-health interventions may be most feasible and have shown to be effective in targeting mental health problems in adults [61].”
BackgroundeHealth interventions for psychiatry in Switzerland and Russia: a comparative study
Chivilgina, O., Elger, B. S., Fedotov, I. A., & Jotterand, F. (2024) · Frontiers in Digital Health · doi:10.3389/fdgth.2023.1278176 · Cited by 1
“…computer-or mobile phone-mediated cognitive-behavioral therapy (11), monitoring medication adherence (12), preventing disease exacerbation, symptom management (13), symptom reduction (14), interventions for the treatment of alcohol and substance abuse (15) and many other aspects (16).”
BackgroundRaya‐Tena, A., Fernández-San-Martín, M. I., Martin, M., Casajuana‐Closas, M., Jiménez-Herrera, M. F., Fernández-San-Martin, M. I., Martin, M., Valmaña, G. S., Raya-Tena, A., Casañas, R., et al. (2024) · Enfermería Clínica · doi:10.1016/j.enfcli.2023.12.001 · Cited by 1
Raya‐Tena, A., Martin, M., Martín‐Royo, J., Casajuana‐Closas, M., Herrera, M., Martin, M., Martín‐Royo, J., Valmaña, G. S., Raya-Tena, A., Casañas, R., et al. (2024) · Enfermería Clínica (English Edition) · doi:10.1016/j.enfcle.2024.03.005 · Cited by 1
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Čihařová, M., Cuijpers, P. J., Harrer, M., Hirshler, Y., Panagiotopoulou, O.-M., Tong, L., Miguel, C., Frankova, I., Gemmill, A. W., Buntrock, C., et al. (2026) · Internet Interventions · doi:10.1016/j.invent.2026.100993 · Cited by 1
“All these formats may contribute to the accessibility of psycho-therapy thanks to the reduced stigma associated with their anonymity, as well as reduced time demands on both therapist and client (Massoudi et al., 2019; Paganini et al., 2018).”
Jørgensen, S. W., Petersen, E. N., Klausen, S. H., Lee, K., & Nørgaard, B. (2023) · International Journal of Mental Health Nursing · doi:10.1111/inm.13221 · Cited by 1
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“There is also the problem of handling suicidal patients that does not want to disclose about their current situation to their family members or friends [5].”
BackgroundoVRcome - Self Guided Virtual Reality for Specific Phobias. A Randomised Controlled TrialPreprint
Lacey, C. J., Beaglehole, B., & Frampton, C. M. (2022) · SSRN Electronic Journal · doi:10.2139/ssrn.4005916 · Cited by 1
Ethische Aspekte internet- und mobilgestützter Interventionen bei depressiven Störungen
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Depressive Erkrankungen in der Hausarztpraxis
Schulz, S., & Wolf, F. (2022) · Allgemeinmedizin up2date · doi:10.1055/a-1398-4588
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Acceptability of gynecologic e-health modalities by Hispanic/Latina women of reproductive age
Alvarado, A., Echevarria, P. M. R., Cotto-Vázquez, A. C., Núñez-González, S., Nieves-Vázquez, C. I., Sierra, C., Más-Vayas, L., Soto-Soto, D. M., Llorens, A., Bell, C., et al. (2024) · Health Policy and Technology · doi:10.1016/j.hlpt.2024.100841
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Haun, M. W., Tönnies, J., Brinster, R., Kronsteiner, D., Wensing, M., Szecsenyi, J., Vomhof, M., Icks, A., Wild, B., Hartmann, M., et al. (2021) · Figshare · doi:10.6084/m9.figshare.14545233
Haun, M. W., Tönnies, J., Brinster, R., Kronsteiner, D., Wensing, M., Szecsenyi, J., Vomhof, M., Icks, A., Wild, B., Hartmann, M., et al. (2021) · Figshare · doi:10.6084/m9.figshare.14545230
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Krijnen, L., van Eldik, W. M., Mooren, T. T. M., van Rooijen, B., Boelen, P. A., van Baar, A. L., Spuij, M., Verhoeven, M., & Egberts, M. R. (2024) · Figshare · doi:10.6084/m9.figshare.26653507
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Mental health promotion through soccer in high-risk communities: a narrative review
Нарзикулова, Д. Х., Kozokboeva, D., Gayupova, S., TOSHBOYEVA, B., Jonibek, K., Ostonov, O., qizi, H. B. H., & Egamberganova, D. (2026) · Discover Social Science and Health · doi:10.1007/s44155-026-00358-x
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Jagtenberg, E. M., Ligthart, S. A., Muilwijk, O. G., Akkermans, R., Spoelder, M., Burger, H., Maarsingh, O. R., Assendelft, W. J., & Hartman, T. O. (2026) · Trials · doi:10.1186/s13063-026-09786-1
“Previous published reviews highlight the potential of eHealth lifestyle interventions as valuable adjuncts to traditional depression treatment [18– 20].”
Self-citation
Metadata
- Authors
- Massoudi, B., Holvast, F., Bockting, C. L. H., Burger, H., & Blanker, M. H.
- Affiliations
- University Medical Center Groningen (NL)
- University of Groningen (NL)
- Corresponding author
- Massoudi, Btissame
- Venue
- Journal of Affective Disorders
- Publisher
- Elsevier BV
- Published
- 2019-02
- Volume
- 245
- Pages
- 728-743
- ISSN
- 0165-0327 (ISSN-L)
- OpenAlex
- W2900267347
- Cited by
- 101
- References
- 73
- Citations by year
- 2026: 6 · 2025: 9 · 2024: 19 · 2023: 13 · 2022: 19 · 2021: 21 · 2020: 10 · 2019: 4
- FWCI
- 1.18
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Affective Disorders (publishedVersion)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Keywords
- digital health interventions, depression, anxiety, primary care, cost-effectiveness, digital mental health, waiting list comparison, usual care, psychological intervention
- MeSH terms
- Anxiety, Cost-Benefit Analysis, Depression, Humans, Primary Health Care, Waiting Lists, Randomized Controlled Trials as Topic, Telemedicine
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