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Cited by 255Digital Mental Health InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychological Treatments and Assessments

Dismantling, optimising and personalising internet cognitive-behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data

Open access
Furukawa, Toshi A, Suganuma, Aya, Ostinelli, Edoardo G, Andersson, Gerhard, Beevers, Christopher G, Shumake, Jason, Berger, Thomas, Boele, Florien Willemijn +72 more·2021·The Lancet Psychiatry
DOI 10.1016/s2215-0366(21)00077-8PMC PMC8838916
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Abstract

Background Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom.Methods We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683.Findings We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components.Interpretation The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package.Funding Japan Society for the Promotion of Science.

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Crossref · 10.1016/s2215-0366(21)00077-8

Cites

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Statistics

Nothing to recompute.

Claims the paper makes

0 of 22 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Behavioural activation produced a beneficial additive effect on depression, with an iMD of -1.83 (95% CrI -2.90 to -0.80) and a standardised effect size of -0.31 (95% CrI -0.48 to -0.13).

    “There was evidence that the non-specific treatment effects and behavioural activation components might have beneficial effects”
    • Also stated in: § Discussion · plain
      “the iMD of −1·83 (95% CrI −2·90 to −0·80) for behavioural activation in our cNMA corresponds to a standardised effect size of −0·31 (95% CrI −0·48 to −0·13)”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Component effects are additive: for any component c, the relative effect of c plus X versus X alone is the same for any combination X not containing c, and there are no interactions between components.
  • Findingown data

    Human encouragement combined with automated encouragement reduces dropout from iCBT treatment, with a combined iOR of 0.32 (95% CrI 0.13 to 0.93).

    “We found that human encouragement in conjunction with automated encouragement decreases dropout from treatment (combined iOR 0·32 [95% CrI 0·13 to 0·93]; appendix p 73)”
    Quote in the paperSubstantial claim
  • Findingown data

    Behaviour therapy for insomnia was also helpful, with large point estimates but wider confidence intervals.

    “There was weaker evidence that behaviour therapy for insomnia was also helpful, showing large point estimates but with wider confidence intervals.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: Common heterogeneity was assumed across all treatment comparisons.
    • The authors state this as an assumption: Component effects were assumed to be additive.
  • Findingown data

    The design-by-treatment test showed strong evidence of global inconsistency (Q=37.8, 17 df, p=0.0026).

    “The design-by-treatment test for global inconsistency showed strong evidence of global inconsistency (Q=37·8, 17 df, p=0·0026);”
    Quote in the paperNot a substantial claim
  • Findingown data

    Cognitive restructuring did not show a beneficial additive effect in the current cNMA, with an iMD of 0.30 (95% CrI -0.87 to 1.41) and a standardised effect size of 0.05 (95% CrI -0.15 to 0.24).

    “which estimated the iMD for cognitive restructuring to be 0·30 (95% CrI −0·87 to 1·41), corresponding to a standardised effect size of 0·05 (95% CrI −0·15 to 0·24).”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Component effects are additive: for any component c, the relative effect of c plus X versus X alone is the same for any combination X not containing c, and there are no interactions between components.
  • May combine two claims. 21
  • Classified as probably not a substantial claim. 17

  • May combine two claims.

    Findingown data

    The review identified 76 randomised controlled trials of iCBT for depression, with 48 trials providing individual participant data (11,704 participants) and 28 trials providing aggregate data (6,474 participants).

    “We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants).”
    • Also stated in: § Results · plain
      “We finally included 76 trials and sought individual participant data from the original authors. Authors of 48 (63%) studies agreed to provide individual participant data representing 11 704 randomly assigned participants; the remaining 28 studies were included as aggregate data, representing 6474 randomly assigned participants (appendix p 17).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Behaviour therapy for insomnia might be beneficial, but the evidence is suggestive and imprecise and comes from only four studies.

    “weaker evidence that the behaviour therapy for insomnia component might be helpful”
    • Also stated in: § Discussion · hedged
      “There was suggestive evidence that behaviour therapy for insomnia could be beneficial. However, this therapy was included as a component in only four studies and the estimates for its efficacy were imprecise.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: Component effects are additive: for any component c, the relative effect of c plus X versus X alone is the same for any combination X not containing c, and there are no interactions between components.

  • May combine two claims.

    Findingown data

    Compared with waiting list, cognitive therapy, behavioural activation, third-wave CBT, CBT, psychoeducation, and problem-solving therapy all showed greater efficacy.

    “Cognitive therapy, behavioural activation, third-wave cognitive behavioural therapy, CBT, psychoeducation, and problem-solving therapy were all shown to be more efficacious than waiting list.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In the current network, unguided iCBT programmes often included relaxation: 14 of 29 (48%) when neither human encouragement nor therapeutic guidance was used, 13 of 29 (45%) when only human encouragement was used, and nine of 44 (20%) when both were used.

    “These programmes often included relaxation as a component: 14 (48%) of 29 programmes used relaxation when neither human encouragement nor therapeutic guidance was used, 13 (45%) of 29 programmes used relaxation when only human encouragement was used, but only nine (20%) of 44 programmes used relaxation when human encouragement plus therapeutic guidance were used”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    In the network, relaxation exercises were included in 36 arms, but the reports generally did not specify what patients actually did in each programme.

    “In our network, relaxation exercises were included in 36 arms but the reports generally did not specify what patients actually did in each programme.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The negative findings of López-López and colleagues might be explained by their inclusion of mostly face-to-face CBT, where therapists could modify or omit contents unless fidelity was rigorously monitored.

    “These negative findings might be due to the fact that the authors included mostly face-to-face CBT interventions, which generally allowed broad discretion to therapists who might have reduced, modified, or even left out some contents and introduced new contents outside the therapy manual, unless the trials were rigorously monitored for fidelity.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    One comparison (cognitive therapy vs attention or psychological placebo) had much higher baseline severity than other comparisons, but other effect modifiers appeared evenly distributed.

    “One comparison (cognitive therapy vs attention or psychological placebo) had much higher baseline severity than all other comparisons but otherwise these effect modifiers appeared to be evenly distributed across comparisons (appendix pp 64–65).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The funding body did not participate in designing the study, collecting or analysing data, interpreting results, or writing the report.

    “The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study was registered in PROSPERO (CRD42018104683).

    “This study is registered in PROSPERO (CRD42018104683)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Traditional dismantling studies have generally been underpowered and of poor methodological quality.

    “However, such studies have been typically underpowered and of poor methodological quality.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [4] Ahn, 2001, Where oh where are the specific ingredients? A meta-analysis of component studies in counseling and psychotherapy, J Couns Psychol source

      Not checked in the free run.

    • cites [5] Bell, 2013, Are the parts as good as the whole? A meta-analysis of component treatment studies, J Consult Clin Psychol source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Two independent reviewers assessed study validity using the Cochrane revised risk of bias tool.

    “Pairs of two independent reviewers (TAF, AS, EGO) independently assessed the validity of the included studies using the revised risk of bias tool by Cochrane.17”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] Sterne, 2019, RoB 2: a revised tool for assessing risk of bias in randomised trials, BMJ

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The study protocol had already been published.

    “This protocol for this study has already been published.18”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Furukawa, 2019, Dismantling, personalising and optimising internet cognitive-behavioural therapy for depression: a study protocol for individual participant data component network meta-analysis, BMJ Open

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Inter-rater reliability for risk of bias assessment was satisfactory, with mean agreement 93.9% and mean weighted kappa 0.52.

    “The inter-rater reliability of risk of bias assessment was satisfactory, with a mean percentage agreement of 93·9% (range 87·5–97·8%) and a mean weighted κ of 0·52 (range 0·17–0·84) for the five domains (appendix pp 58–59).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    CBT is the most widely studied psychotherapy for depression.

    “Cognitive behavioural therapy (CBT) is the most widely studied type of psychotherapy for depression.1,2”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [1] Barth, 2013, Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis, PLoS Med source

      Not checked in the free run.

    • cites [2] Cuijpers, 2019, The effects of fifteen evidence-supported therapies for adult depression: a meta-analytic review, Psychother Res

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Most included studies had low risk of bias for randomisation, missing outcome data, and selection of reported results; risk was uncertain for deviations from intended interventions and high for outcome measurement.

    “The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes.”
    • Also stated in: § Results · plain
      “The risk of bias according to the Cochrane’s revised risk of bias tool17 was low in 66 studies (86%) for randomisation process, in six studies (8%) for the deviation from intended interventions, in 64 studies (83%) for missing outcome data, in two studies (3%) for measurement of the outcome, and 53 studies (69%) for selection of the reported results.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The report follows PRISMA extension statements for network meta-analysis and individual participant data meta-analysis.

    “This report follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statements for network meta-analysis19 and for individual participant data meta-analysis.20”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] Hutton, 2015, The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations, Ann Intern Med source

      Not checked in the free run.

    • cites [20] Stewart, 2015, Preferred reporting items for systematic review and meta-analyses of individual participant data: the PRISMA-IPD statement, JAMA source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The contrast between behavioural activation and cognitive restructuring in the current analyses is due to how easily each skill is learned within iCBT, not to their intrinsic efficacy.

    “behavioural activation emerged as beneficial but cognitive restructuring did not in the current analyses, not because of these skills’ intrinsic efficacy but simply because of their ease of learning within iCBT.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Extrapolating component combinations beyond those examined in the current dataset increases uncertainty, and possible deviations from assumptions such as additivity may have a larger impact on validity.

    “We must be careful when extrapolating the combinations beyond those examined in the current dataset: as more and more components are combined to build packages not explored in the trials included in this study, the uncertainty around the estimates increases, and possible deviations from our assumptions (eg, additivity of component effects) might have a bigger impact on the validity of our results”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Component effects are additive: for any component c, the relative effect of c plus X versus X alone is the same for any combination X not containing c, and there are no interactions between components.

  • May combine two claims.

    Study design and conductown data

    There was indication of intransitivity for the comparison between cognitive therapy and attention or psychological placebo, and of global inconsistency in the network.

    “Fourth, there was indication of intransitivity for a comparison between cognitive therapy and attention or psychological placebo and of global inconsistency in the network.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A component network meta-analysis of CBT for panic disorder identified muscle relaxation as detrimental.

    “the cNMA of CBT for panic disorder has identified muscle relaxation as detrimental.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Pompoli, 2018, Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis, Psychol Med source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    A post-hoc sensitivity analysis examining potential interactions among components gave results similar to the additive model, but the study was possibly underpowered to detect interactions.

    “Although a post-hoc sensitivity analysis examining potential interactions among components provided similar results to the additive model, the study was possibly underpowered to detect interactions among components.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Component effects are additive: for any component c, the relative effect of c plus X versus X alone is the same for any combination X not containing c, and there are no interactions between components.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    The additive effect of guidance could be due to human encouragement alone or to the combination of human encouragement plus therapeutic guidance when baseline severity is high, with the incremental effect decreasing at lower baseline severity.

    “the additive effect of guidance could then be due to human encouragement or due to the combination of human encouragement plus therapeutic guidance when the baseline severity was high at 25 points; the incremental effect decreased when the baseline severity was lower.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    With detailed definitions and inquiries to authors, the study achieved satisfactory to excellent inter-rater agreement.

    “with detailed definitions as described in the table and inquiries of the authors when necessary (see appendix pp 18–41 for results of our communications), we were able to achieve satisfactory to excellent inter-rater agreement.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The component network meta-analysis increased precision by including more studies than narrowly defined dismantling studies and by combining direct and indirect estimates.

    “The cNMA increased precision by including more studies than narrowly defined dismantling studies and by combining direct and indirect estimates.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    López-López and colleagues' decomposition of CBT contents raised concerns because some arms contained only homework and many lacked psychoeducation.

    “López-López and colleagues’ decomposition of the CBT contents also raised some concerns because some arms had only homework as their content while many arms did not have psychoeducation”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] López-López, 2019, The process and delivery of CBT for depression in adults: a systematic review and network meta-analysis, Psychol Med source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Guided iCBT has been shown to be superior to unguided iCBT, especially among patients with higher baseline depression severity.

    “guided iCBT has been shown to be superior to unguided iCBT,10 especially among patients with higher baseline severity of depression.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [10] Cuijpers, 2019, Effectiveness and acceptability of cognitive behavior therapy delivery formats in adults with depression: a network meta-analysis, JAMA Psychiatry source

      Not checked in the free run.

    • cites [35] Karyotaki, 2021, Internet-based cognitive behavioral therapy for depression: a systematic review and individual patient data network meta-analysis, JAMA Psychiatry source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Conclusions about the specific efficacy of CBT skills apply to iCBT and might not readily generalise to face-to-face CBT.

    “Any conclusions about specific efficacy of CBT skills therefore pertain to iCBT and will inform which components to include in the efficacious and efficient iCBT package, but such findings might not readily generalise to face-to-face CBT.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    iCBT packages built from the identified components have the potential to be more efficacious, less burdensome for users, and less demanding on provider resources, making iCBT more scalable.

    “Such packages have the potential to be more efficacious, less burdensome for users, and less demanding on provider resources, with the net effect of rendering iCBT even more scalable.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Component effects are additive: for any component c, the relative effect of c plus X versus X alone is the same for any combination X not containing c, and there are no interactions between components.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Relaxation tended to be included in CBT arms with more skills, which might have reduced the time available to learn and practise those skills and lowered their efficacy.

    “Relaxation tended to be included in CBT arms that included a greater number of skills, which might have allowed less time to learn and practise those particular skills and have reduced their efficacy.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The non-specific treatment effects component includes both placebo effects and common or non-specific psychotherapy factors.

    “the non-specific treatment effects component includes both the placebo effect and the common or non-specific psychotherapy factor”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [33] Wampold, 2015, How important are the common factors in psychotherapy? An update, World Psychiatry source

      Not checked in the free run.

    • cites [34] Cuijpers, 2019, The role of common factors in psychotherapy outcomes, Annu Rev Clin Psychol source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given

    In the current network, there was no evidence of data availability bias for individual participant data or of publication bias of active treatments over the waiting list.

    “In the current network, there was no evidence of data availability bias for individual participant data or of publication bias of active treatments over the waiting list, the most frequent control condition.”
    Quote in the paperNot a substantial claim
31 of 31

  • The authors state this as an assumption.

    Skills not covered by the classification were assumed to have only non-specific treatment effects.

    “When skills not covered in this classification (eg, expressive writing, dreamwork) were included, we assumed such interventions to have some non-specific treatment effects only.”

  • The authors state this as an assumption.

    Common heterogeneity was assumed across all treatment comparisons.

    “assuming common heterogeneity for all treatment comparisons.25”

  • The authors state this as an assumption.

    Component effects were assumed to be additive.

    “The models disentangled the effects of components assuming additivity,9”

  • The authors state this as an assumption.

    Component-covariate interactions were assumed to be linear.

    “The component-covariate interactions were modelled assuming linearity.”

  • The paper relies on this without support.

    iCBT delivers each cognitive and behavioural skill uniformly and as intended by programme developers.

    “iCBT provides a unique platform whereby each cognitive and behavioural skill is offered uniformly and as intended by the programme developers.”

  • The authors state this as an assumption.

    Component effects are additive: for any component c, the relative effect of c plus X versus X alone is the same for any combination X not containing c, and there are no interactions between components.

    “we assumed additivity of the component effects—ie, that for any given component (c), the relative effect of c plus X versus X only is the same for any X, where X represents any combination of”
    “Thus, our results assumed no interactions between components.”

  • The authors state this as an assumption.

    Most participants completed a majority of the included components.

    “we can assume that most participants had actually completed a majority of the included components”

  • The paper relies on this without support.

    Human encouragement that does not refer to therapeutic contents can be provided by trained lay people.

    “Because human encouragement without reference to the therapeutic contents can be provided by trained lay people”
8 of 8

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • In the Strategic Use of New generation antidepressants study, switching or augmenting medications as early as 3 weeks was associated with an NNT of 10 in achieving remission by 9 weeks in comparison with standard length acute phase treatment.

    “For example, in the Strategic Use of New generation antidepressants study, switching or augmenting mediations as early as 3 weeks was associated with an NNT of 10 in achieving remission by 9 weeks in comparison with standard length acute phase treatment. 598”

    From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [598]

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Authors
Furukawa, T. A., Suganuma, A., Ostinelli, E. G., Andersson, G., Beevers, C. G., Shumake, J., Berger, T., Boele, F. W., Buntrock, C., Carlbring, P., Choi, I., Christensen, H., Mackinnon, A., Dahne, J., Huibers, M. J. H., Ebert, D. D., Farrer, L., Forand, N. R., Strunk, D. R., Ezawa, I. D., Forsell, E., Kaldo, V., Geraedts, A., Gilbody, S., Littlewood, E., Brabyn, S., Hadjistavropoulos, H. D., Schneider, L. H., Johansson, R., Kenter, R., Kivi, M., Björkelund, C., Kleiboer, A., Riper, H., Klein, J. P., Schröder, J., Meyer, B., Moritz, S., Bücker, L., Lintvedt, O., Johansson, P., Lundgren, J., Milgrom, J., Gemmill, A. W., Mohr, D. C., Montero-Marin, J., Garcia-Campayo, J., Nobis, S., Zarski, A.-C., O'Moore, K., Williams, A. D., Newby, J. M., Perini, S., Phillips, R., Schneider, J., Pots, W., Pugh, N. E., Richards, D., Rosso, I. M., Rauch, S. L., Sheeber, L. B., Smith, J., Spek, V., Pop, V. J., Ünlü, B., van Bastelaar, K. M. P., van Luenen, S., Garnefski, N., Kraaij, V., Vernmark, K., Warmerdam, L., van Straten, A., Zagorscak, P., Knaevelsrud, C., Heinrich, M., Miguel, C., Cipriani, A., Efthimiou, O., Karyotaki, E., & Cuijpers, P.
Affiliations
  • Kyoto University (JP)
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Corresponding author
Furukawa, Toshi A
ORCID
Venue
The Lancet Psychiatry
Publisher
Elsevier BV
Published
2021-06
Volume
8
Issue
6
Pages
500-511
ISSN
2215-0366 (ISSN-L)
DOI
10.1016/s2215-0366(21)00077-8
PMC
PMC8838916
OpenAlex
W3159498050
Cited by
255
References
49
Citations by year
2026: 34 · 2025: 39 · 2024: 71 · 2023: 49 · 2022: 49 · 2021: 12 · 2012: 1
FWCI
7.06
Type
journal article
Language
en
Open access
Licence
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  • Minerva Access (University of Melbourne) (submittedVersion)
  • mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (submittedVersion, other-oa)
  • Queen Mary Research Online (Queen Mary University of London) (submittedVersion)
  • VU Research Portal (submittedVersion)
  • Spiral (Imperial College London) (submittedVersion, cc-by-nc-nd)
  • Trinity's Access to Research Output (TARA) (Trinity College Dublin) (submittedVersion, cc-by-nc-sa)
  • Open Access CRIS of the University of Bern
Funders
Japan Society for the Promotion of Science
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 › Clinical Psychology › Psychological Treatments and Assessments
Keywords
depression, treatment components, behavioral activation, relaxation, treatment discontinuation, baseline depression severity, prognostic factors, personalized treatment, individual patient data, treatment optimization, digital mental health interventions
MeSH terms
Network Meta-Analysis, Depressive Disorder, Humans, Systems Analysis, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic, Outcome Assessment, Health Care, Internet

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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