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Does Internet-based guided-self-help for depression cause harm? An individual participant data meta-analysis on deterioration rates and its moderators in randomized controlled trials
Open accessAbstract
Background: Almost nothing is known about the potential negative effects of Internet-based psychological treatments for depression. This study aims at investigating deterioration and its moderators within randomized trials on Internet-based guided self-help for adult depression, using an individual patient data meta-analyses (IPDMA) approach. Method: Studies were identified through systematic searches (PubMed, PsycINFO, EMBASE, Cochrane Library). Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e. 7.68 points in the CES-D; 7.63 points in the BDI). Two-step IPDMA procedures, with a random-effects model were used to pool data. Results: A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention v . control conditions (3.36 v . 7.60; relative risk 0.47, 95% confidence interval 0.29–0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education. Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit–risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration. Conclusions: Internet-based guided self-help is associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education.
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“In a similar patientlevel analysis on guided ICBT 81 (18 stud ies, 2,079 participants), the deterioration rate was 3.36% in the treatment groups and 7.60% in the control groups (relative risk=0.47,95% CI: 0.29 to 0.75).”
From Internet-delivered psychological treatments: from innovation to implementation (2019) · cites this paper as [81]
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In the citing paper
“Patients with lower education presented a higher risk for deterioration than those with higher education.”
From Internet-delivered psychological treatments: from innovation to implementation (2019) · cites this paper as [81]
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“Although deterioration rates are infrequently reported in the literature, the proportion of individuals experiencing symptom deterioration during face-to-face psychological interventions is estimated to range between 3-14% (Ebert et al., 2016; Cujipers et al., 2018; Ronk et al., 2013), which is comparable to deterioration rates for online interventions (Ebert et al., 2016).”
From A randomised trial comparing a brief online delivery of mindfulness-plus-values versus values only for symptoms of depression: Does baseline severity matter? (2020) · cites this paper as Ebert et al., 2016
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In the citing paper
“However, the potential negative effect could be that self-help treatments could lead to a delayed help-seeking, which could result in further deterioration of symptoms, if the initial self-help treatment should be not sufficient.23”
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In the citing paper
“This is in line with previous research that suggests the use of synchronous support, such as weekly check-ins with a therapist or group support sessions as being beneficial for engaging individuals in self-guided in terventions (Baumeister, Reichler, Munzinger, & Lin 2014; Ebert et al., 2016).”
From An ACT self-help intervention for adults with a visible difference in appearance: A pilot feasibility and acceptability randomized controlled study. (2023) · cites this paper as Ebert et al., 2016
Experimental — accuracy not yet measured
In the citing paper
“The results of deterioration rates (3.2% in depression and 3.1% in anxiety studies) were slightly lower, but within the 95% CI of findings based on RCTs for internet-based guided self-help interventions (3.36%) for depression [164] and anxiety (5.8% [165]), and also comparable with deterioration rates in face-to-face psychotherapy for depression [166].”
From Effects of Internet-based cognitive behavioral therapy in routine care for adults in treatment for depression and anxiety: systematic review and meta-analysis (2020) · cites this paper as [164]
In the citing paper
“However, these studies also support the findings that deterioration rates are low and that psychological treatment reduces these rates.”
From Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates (2018) · cites this paper as Ebert et al., 2016
In the citing paper
“one recent IPD meta-analysis of trials on internet-based treatments of depression also found lower deterioration rates for patients receiving treatment compared to control groups”
From Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates (2018) · cites this paper as Ebert et al., 2016
In the citing paper
“The results of this study are in line with a growing number of metaanalytic studies showing that psychological treatments result in a significant reduction of deterioration in patients.”
From Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates (2018) · cites this paper as Ebert et al., 2016
In the citing paper
“and one type of intervention (internet-based CBT; (Ebert et al., 2016))”
From Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates (2018) · cites this paper as Ebert et al., 2016
In the citing paper
“but also found that patients with lower education had a higher risk for deterioration than patients with higher education (Ebert et al., 2016)”
From Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates (2018) · cites this paper as Ebert et al., 2016
In the citing paper
“A recent meta-analysis of individual participant data showed that guided iCBT for adults with depression is associated with a mean reduced risk for symptom deterioration compared to other control conditions [33].”
From Effectiveness and cost-effectiveness of guided Internet- and mobile-based CBT for adolescents and young adults with chronic somatic conditions and comorbid depression and anxiety symptoms (youthCOACHCD): study protocol for a multicentre randomized controlled trial (2020) · cites this paper as [33]
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Self-citationSextl-Plötz, T., Steinhoff, M., Baumeister, H., Cuijpers, P. J., Ebert, D. D., & Zarski, A. (2024) · Internet Interventions · doi:10.1016/j.invent.2024.100760 · Cited by 26
Self-citationSalomonsson, S., Santoft, F., Lindsäter, E., Ejeby, K., Ingvar, M., Öst, L.-G., Lekander, M., Ljótsson, B., & Hedman-Lagerlöf, E. (2020) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2019.1669701 · Cited by 20
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“This is in line with previous research that suggests the use of synchronous support, such as weekly check-ins with a therapist or group support sessions as being beneficial for engaging individuals in self-guided interventions (Baumeister, Reichler, Munzinger, & Lin 2014; Ebert et al., 2016).”
ResultMeyerhoff, J., Kruzan, K. P., Kim, K. A., Orden, K. A. V., & Mohr, D. C. (2022) · Archives of Suicide Research · doi:10.1080/13811118.2022.2096520 · Cited by 10
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Self-citation
Metadata
- Authors
- Ebert, D. D., Donkin, L., Andersson, G., Andrews, G., Berger, T., Carlbring, P., Rozenthal, A., Choi, I., Laferton, J. A. C., Johansson, R., Kleiboer, A., Lange, A., Lehr, D., Reins, J. A., Funk, B., Newby, J., Perini, S., Riper, H., Ruwaard, J., Sheeber, L., Snoek, F. J., Titov, N., Ünlü Ince, B., van Bastelaar, K., Vernmark, K., van Straten, A., Warmerdam, L., Salsman, N., & Cuijpers, P.
- Affiliations
- Friedrich-Alexander-Universität Erlangen-Nürnberg (DE)
- The University of Sydney (AU)
- Linköping University (SE)
- UNSW Sydney (AU)
- University of Bern (CH)
- Stockholm University (SE)
- Psychologische Hochschule Berlin (DE)
- Vrije Universiteit Amsterdam (NL)
- University of Amsterdam (NL)
- Leuphana University of Lüneburg (DE)
- Macquarie University (AU)
- Oregon Research Institute (US)
- Amsterdam UMC Location University of Amsterdam (NL)
- Xavier University (US)
- Corresponding author
- Ebert, D. D.
- ORCID
- Venue
- Psychological Medicine
- Publisher
- Cambridge University Press (CUP)
- Published
- 2016-09-20
- Volume
- 46
- Issue
- 13
- Pages
- 2679-2693
- ISSN
- 0033-2917 (ISSN-L)
- 1469-8978
- PMC
- PMC5560500
- OpenAlex
- W2522560600
- Cited by
- 154
- References
- 84
- Citations by year
- 2026: 6 · 2025: 6 · 2024: 9 · 2023: 23 · 2022: 14 · 2021: 17 · 2020: 21 · 2019: 23 · 2018: 21 · 2017: 12 · 2016: 2
- FWCI
- 3.11
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Psychological Medicine (publishedVersion)
- PubMed (publishedVersion)
- UvA-DARE (University of Amsterdam) (publishedVersion)
- Pure Amsterdam UMC (publishedVersion, other-oa)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
- PubMed Central (acceptedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Bern Open Repository and Information System (University of Bern) (submittedVersion, other-oa)
- Multilingual Matters (Channel View Publications) (submittedVersion, other-oa)
- VU Research Portal (submittedVersion)
- Funders
- European Commission (2007DE161PR001, 603098, CCI 2007DE161PR001)
- European Regional Development Fund (CCI 2007DE161PR001, 2007DE161PR001)
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD081362)
- H2020 European Research Council
- 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
- depression, symptom deterioration, educational attainment, treatment moderators, risk-benefit ratio, reliable change index, treatment response
- MeSH terms
- Major Depressive Disorder, Humans, Self Care, Randomized Controlled Trials as Topic, Outcome Assessment, Health Care, Internet
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