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

The DOI matches its Crossref record; 43 of the 49 references it cites were found in a registry or an index; none of the 22 sources its claims cite is checked for support yet.

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

Open access

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.

Overview

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

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  • It may state two separate claims as one. 21
  • Probably not a substantial claim. 17
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”
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Metadata

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)
  • Warneford Hospital (GB)
  • Linköping University (SE)
  • The University of Texas at Austin (US)
  • University of Bern (CH)
  • University of Leeds (GB)
  • Friedrich-Alexander-Universität Erlangen-Nürnberg (DE)
  • Stockholm University (SE)
  • The University of Sydney (AU)
  • Black Dog Institute (AU)
  • Medical University of South Carolina (US)
  • Vrije Universiteit Amsterdam (NL)
  • Technical University of Munich (DE)
  • Australian National University (AU)
  • Donald & Barbara Zucker School of Medicine at Hofstra/Northwell (US)
  • The Ohio State University (US)
  • Region Stockholm (SE)
  • Linnaeus University (SE)
  • University of York (GB)
  • University of Regina (CA)
  • St. Joseph’s Healthcare Hamilton (CA)
  • University of Bergen (NO)
  • University of Gothenburg (SE)
  • University of Lübeck (DE)
  • University Medical Center Hamburg-Eppendorf (DE)
  • GAIA (Germany) (DE)
  • The University of Melbourne (AU)
  • Northwestern University (US)
  • Klinikum Osnabrück (DE)
  • UNSW Sydney (AU)
  • St Vincent's Hospital Sydney (AU)
  • Imperial College London (GB)
  • University of Nottingham (GB)
  • University of Twente (NL)
  • Trinity College Dublin (IE)
  • McLean Hospital (US)
  • Oregon Research Institute (US)
  • Fontys University of Applied Sciences (NL)
  • Tilburg University (NL)
  • PsyQ (NL)
  • Leiden University (NL)
  • Zorginstituut Nederland (NL)
  • Freie Universität Berlin (DE)
  • Oxford Health NHS Foundation Trust (GB)
  • Harvard University (US)
Corresponding author
Furukawa, Toshi A
Venue
The Lancet Psychiatry
Publisher
Elsevier BV
Published
2021-06
Volume
8
Issue
6
Pages
500-511
ISSN
2215-0366 (ISSN-L)
OpenAlex
W3159498050
Cited by
255
References
49
Citations by year
2026: 34 · 2025: 39 · 2024: 71 · 2023: 49 · 2022: 49 · 2021: 12
FWCI
7.06
Type
journal article
Language
en
Open access
Locations
  • The Lancet Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • Pure Amsterdam UMC (publishedVersion, cc-by)
  • VU Research Portal (publishedVersion, other-oa)
  • PubMed Central (acceptedVersion)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
  • ANU Open Research (Australian National University) (submittedVersion)
  • Leiden Repository (Leiden University) (submittedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • BORIS (University Library Bern) (submittedVersion, cc-by-nc-nd)
  • Utrecht University Repository (Utrecht University) (submittedVersion)
  • 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

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