Two decades of digital interventions for anxiety disorders: a systematic review and meta-analysis of treatment effectiveness

Pauley, Darin; Cuijpers, Pim; Papola, Davide; Miguel, Clara; Karyotaki, Eirini

doi:10.1017/s0033291721001999

Cited by 170Digital Mental Health InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMental Health Treatment and Access

Two decades of digital interventions for anxiety disorders: a systematic review and meta-analysis of treatment effectiveness

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Pauley, Darin, Cuijpers, Pim, Papola, Davide, Miguel, Clara, Karyotaki, Eirini·2021·Psychological Medicine

DOI 10.1017/s0033291721001999PMC PMC9899576

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Abstract

Abstract Background Digital interventions for anxiety disorders are a promising solution to address barriers to evidence-based treatment access. Precise and powerful estimates of digital intervention effectiveness for anxiety disorders are necessary for further adoption in practice. The present systematic review and meta-analysis examined the effectiveness of digital interventions across all anxiety disorders and specific to each disorder v. wait-list and care-as-usual controls. Methods A systematic search of bibliographic databases identified 15 030 abstracts from inception to 1 January 2020. Forty-seven randomized controlled trials (53 comparisons; 4958 participants) contributed to the meta-analysis. Subgroup analyses were conducted by an anxiety disorder, risk of bias, treatment support, recruitment, location and treatment adherence. Results A large, pooled effect size of g = 0.80 [95% Confidence Interval: 0.68–0.93] was found in favor of digital interventions. Moderate to large pooled effect sizes favoring digital interventions were found for generalized anxiety disorder ( g = 0.62), mixed anxiety samples ( g = 0.68), panic disorder with or without agoraphobia ( g = 1.08) and social anxiety disorder ( g = 0.76) subgroups. No subgroups were significantly different or related to the pooled effect size. Notably, the effects of guided interventions ( g = 0.84) and unguided interventions ( g = 0.64) were not significantly different. Supplemental analysis comparing digital and face-to-face interventions (9 comparisons; 683 participants) found no significant difference in effect [ g = 0.14 favoring digital interventions; Confidence Interval: −0.01 to 0.30]. Conclusion The precise and powerful estimates found further justify the application of digital interventions for anxiety disorders in place of wait-list or usual care.

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Internet-based treatments are effective for the treatment of anxiety disorders and depression.
“Evidence suggests that internet-based treatments are effective for the treatment of anxiety disorders and depression [35,36].”
From Evaluation and Future Challenges in a Self-Guided Web-Based Intervention With and Without Chat Support for Depression and Anxiety Symptoms During the COVID-19 Pandemic: Randomized Controlled Trial (2024) · cites this paper as [36]
The Discussion (page not provided) reports a large, significant effect of digital interventions for anxiety disorders compared with inactive controls. It says this meta-analysis was specific to anxiety disorders; although it mentions a prior review that included depression studies, it does not establish effectiveness for depression itself. (LLM, conf=0.88)
Experimental — accuracy not yet measured
Several meta-analyses show that self-guided and guided DMHIs, particularly internet CBT-based programs, significantly improve symptoms of depression (83 studies; Hedge g=0.52, 95% CI 0.43‐0.60) and anxiety (47 studies, Hedge g=0.80, 95% CI 0.68‐0.93).
“Several meta-analyses [16] show that self-guided and guided DMHIs, particularly internet CBT-based programs, significantly improve symptoms of depression (83 studies; Hedge g=0.52, 95% CI 0.43‐0.60 [15]) and anxiety (47 studies, Hedge g=0.80, 95% CI 0.68‐0.93) [18].”
From Needs and Expectations for the myNewWay Blended Digital and Face-to-Face Psychotherapy Model of Care for Depression and Anxiety (Part 2): Participatory Design Study including Mental Health Professionals (2025) · cites this paper as [18]
For anxiety, a recent meta-analysis reported that compared to inactive controls, guided and self-guided DMHIs significantly reduced anxiety symptoms across 47 studies, with a large pooled effect size (Hedges g=0.80; 95% CI 0.68-0.93).
“For anxiety, a recent meta-analysis [16] reported that compared to inactive controls, guided and self-guided DMHIs significantly reduced anxiety symptoms across 47 studies, with a large pooled effect size (Hedges g=0.80; 95% CI 0.68-0.93).”
From Needs and expectations for the myNewWay blended digital and face-to-face psychotherapy model of care for depression and anxiety (part 1): participatory design study including people with lived and living experience (2025) · cites this paper as [16]
Digital mental health interventions (DMHIs) are effective in reducing symptoms of depression and anxiety.
“Digital mental health interventions (DMHIs) are effective in reducing symptoms of depression and anxiety.”
From Needs and expectations for the myNewWay blended digital and face-to-face psychotherapy model of care for depression and anxiety (part 1): participatory design study including people with lived and living experience (2025) · cites this paper as [16]

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A randomized controlled trial of guided internet-delivered cognitive behaviour therapy for older adults with generalized anxiety
Jones, S. L., Hadjistavropoulos, H. D., & Soucy, J. N. (2016) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2015.10.006 · Cited by 110 · see citing works
A mobile app for social anxiety disorder: A three-arm randomized controlled trial comparing mobile and PC-based guided self-help interventions.
Stolz, T., Schulz, A., Krieger, T., Vincent, A., Urech, A., Moser, C., Westermann, S., & Berger, T. (2018) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000301 · Cited by 102 · see citing works
Effects of a transdiagnostic unguided Internet intervention (‘velibra’) for anxiety disorders in primary care: results of a randomized controlled trial
Berger, T., Urech, A., Krieger, T., Stolz, T., Schulz, A., Vincent, A., Moser, C. T., Moritz, S., & Meyer, B. (2017) · Psychological Medicine · doi:10.1017/s0033291716002270 · Cited by 98 · see citing works
Efficacy of an unguided internet‐based self‐help intervention for social anxiety disorder in university students: A randomized controlled trial
Kählke, F., Berger, T., Schulz, A., Baumeister, H., Berking, M., Auerbach, R. P., Bruffaerts, R., Cuijpers, P. J., Kessler, R. C., & Ebert, D. D. (2019) · International Journal of Methods in Psychiatric Research · doi:10.1002/mpr.1766 · Cited by 90 · see citing works
Self-citation
Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Randomized Controlled Switching Trial.
Gloster, A. T., Sonntag, R., Hoyer, J., Meyer, A. H., Heinze, S., Ströhle, A., Eifert, G., & Wittchen, H.-U. (2015) · Psychotherapy and Psychosomatics · doi:10.1159/000370162 · Cited by 88 · see citing works
Internet-delivered acceptance-based behaviour therapy for generalized anxiety disorder: A randomized controlled trial
Dahlin, M., Andersson, G., Magnusson, K., Johansson, T., Sjögren, J., Håkansson, A., Pettersson, M., Kadowaki, Å., Cuijpers, P., & Carlbring, P. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.12.007 · Cited by 86 · cited 1× · see citing works
“…review, all of which found no evidence of a difference between guided and unguided interventions (Berger et al., 2011; Ciuca et al., 2018; Dear et al., 2015, 2016; Fogliati et al., 2016; Gershkovich, Herbert, Forman, Schumacher, & Fischer, 2017; Ivanova et al., 2016; Olthuis, Watt,…”
Self-citation
Disorder-specific versus transdiagnostic and clinician-guided versus self-guided internet-delivered treatment for panic disorder and comorbid disorders: a randomized controlled trial
Fogliati, V. J., Dear, B. F., Staples, L. G., Terides, M. D., Sheehan, J., Johnston, L., Kayrouz, R., Dear, R., McEvoy, P. M., & Titov, N. (2016) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2016.03.005 · Cited by 86 · see citing works
HETEROGI: Stata module to quantify heterogeneity in a meta-analysis
Orsini, N., Bottai, M., Higgins, J. P. T., & Buchan, I. E. (2005) · RePEc: Research Papers in Economics · Cited by 85 · see citing works
Generalized anxiety disorder in primary care: Mental health services use and treatment adequacy
Roberge, P., Normand-Lauzière, F., Raymond, I., Luc, M., Tanguay-Bernard, M.-M., Duhoux, A., Bocti, C., & Fournier, L. (2015) · BMC Family Practice · doi:10.1186/s12875-015-0358-y · Cited by 85 · see citing works
Web-based therapist-assisted cognitive behavioral treatment of panic symptoms: A randomized controlled trial with a three-year follow-up
Ruwaard, J., Broeksteeg, J., Schrieken, B., Emmelkamp, P. M. G., & Lange, A. (2010) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2010.01.010 · Cited by 83 · see citing works
Internet-Delivered Cognitive-Behavioral Therapy for Social Anxiety Disorder in Romania: A Randomized Controlled Trial
Tulbure, B. T., Szentagotai, A., David, O., Ștefan, S., Månsson, K. N. T., David, D., & Andersson, G. (2015) · PLOS ONE · doi:10.1371/journal.pone.0123997 · Cited by 81 · see citing works
Internet cognitive behavioural therapy for panic disorder: Does the inclusion of stress management information improve end-state functioning?
Richards, J. C., Klein, B., & Austin, D. (2005) · Clinical Psychologist · doi:10.1080/13284200500378795 · Cited by 81 · see citing works
Advantages and disadvantages of online and blended therapy: replication and extension of findings on psychotherapists' appraisals
Schuster, R., Topooco, N., Keller, A., Radvogin, E., & Laireiter, A.-R. (2020) · Internet Interventions · doi:10.1016/j.invent.2020.100326 · Cited by 77 · cited 1× · see citing works
“Nonetheless, the results position digital interventions as a promising alternative to face-to-face treatment and underscore the potential to tailor care delivery models that suit the needs of patients and providers (Schuster, Topooco, Keller, Radvogin, & Laireiter, 2020).”
Prevention of Generalized Anxiety Disorder Using a Web Intervention, iChill: Randomized Controlled Trial
Christensen, H. M., Batterham, P. J., Mackinnon, A. J., Griffiths, K. M., Hehir, K. K., Kenardy, J. A., Gosling, J., & Bennett, K. (2014) · Journal of Medical Internet Research · doi:10.2196/jmir.3507 · Cited by 70 · see citing works
Individually Tailored Internet-Based Treatment for Young Adults and Adults With Panic Attacks: Randomized Controlled Trial
Silfvernagel, K., Carlbring, P., Kabo, J., Edström, S., Eriksson, J., Månson, L., & Andersson, G. (2012) · Journal of Medical Internet Research · doi:10.2196/jmir.1853 · Cited by 69 · see citing works
Stepped Care Versus Direct Face-to-Face Cognitive Behavior Therapy for Social Anxiety Disorder and Panic Disorder: A Randomized Effectiveness Trial
Nordgreen, T., Haug, T., Öst, L.-G., Andersson, G., Carlbring, P., Kvale, G., Tangen, T., Heiervang, E., & Havik, O. E. (2016) · Behavior Therapy · doi:10.1016/j.beth.2015.10.004 · Cited by 64 · see citing works
Digital psychotherapy as an effective and timely treatment option for depression and anxiety disorders: Implications for rural and remote practice
Weightman, M. (2020) · Journal of International Medical Research · doi:10.1177/0300060520928686 · Cited by 62 · see citing works
A sorrow shared is a sorrow halved? A three-arm randomized controlled trial comparing internet-based clinician-guided individual versus group treatment for social anxiety disorder
Schulz, A., Stolz, T., Vincent, A., Krieger, T., Andersson, G., & Berger, T. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.07.001 · Cited by 59 · see citing works
Internet-based treatment for panic disorder: A three-arm randomized controlled trial comparing guided (via real-time video sessions) with unguided self-help treatment and a waitlist control. PAXPD study results
Ciuca, A. M., Berger, T., Crişan, L. G., & Miclea, M. (2018) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2018.03.009 · Cited by 58 · see citing works
An internet-based guided self-help intervention for panic symptoms: randomized controlled trial
van Ballegooijen, W., Riper, H., Klein, B., Ebert, D. D., Kramer, J., Meulenbeek, P., & Cuijpers, P. (2013) · Journal of Medical Internet Research · doi:10.2196/jmir.2362 · Cited by 56 · see citing works
Self-citation
Internet-Based Affect-Focused Psychodynamic Therapy for Social Anxiety Disorder: A Randomized Controlled Trial With 2-Year Follow-Up
Johansson, R., Hesslow, T., Ljótsson, B., Jansson, A., Jonsson, L., Färdig, S., Karlsson, J., Hesser, H., Frederick, R. J., Lilliengren, P., et al. (2017) · Psychotherapy · doi:10.1037/pst0000147 · Cited by 55 · see citing works
Internet-based self-help treatment for panic disorder: a randomized controlled trial comparing mandatory versus optional complementary psychological support
Oromendia, P., Orrego, J., Bonillo, A., & Molinuevo, B. (2016) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2016.1163615 · Cited by 52 · cited 1× · see citing works
“…included studies, seven studies had multiple trial arms which were merged for analysis (Berger, Boettcher, & Caspar, 2014; Christensen et al., 2014; Oromendia, Orrego, Bonillo, & Molinuevo, 2016; Richards, Klein, & Austin, 2006; Robinson et al., 2010; Schulz et al., 2016; Stolz et al., 2018),…”
Short-term effectiveness of web-based guided self-help for phobic outpatients: randomized controlled trial.
Kok, R. N., van Straten, A., Beekman, A. T. F., & Cuijpers, P. (2014) · Journal of Medical Internet Research · doi:10.2196/jmir.3429 · Cited by 50 · see citing works
Self-citation
Effectiveness of computerised cognitive behaviour therapy for anxiety disorders in secondary care
Bell, C. J., Colhoun, H. C., Carter, F. A., & Frampton, C. M. (2012) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867412437345 · Cited by 50 · see citing works
Internet-Delivered Acceptance-Based Cognitive-Behavioral Intervention for Social Anxiety Disorder With and Without Therapist Support: A Randomized Trial.
Gershkovich, M., Herbert, J. D., Forman, E. M., Schumacher, L. M., & Fischer, L. E. (2017) · Behavior Modification · doi:10.1177/0145445517694457 · Cited by 46 · see citing works
Effectiveness of an internet-delivered intervention for generalized anxiety disorder in routine care: A randomised controlled trial in a student population
Richards, D., Timulák, L., Rashleigh, C., McLoughlin, O., Colla, A., Joyce, C., Doherty, G. J., Sharry, J., Duffy, D. J., & Anderson-Gibbons, M. (2016) · Internet Interventions · doi:10.1016/j.invent.2016.10.003 · Cited by 45 · see citing works
Internet cognitive–behavioural treatment for panic disorder: randomised controlled trial and evidence of effectiveness in primary care
Allen, A. R., Newby, J. M., Mackenzie, A., Smith, J., Boulton, M., Loughnan, S. A., & Andrews, G. (2016) · BJPsych Open · doi:10.1192/bjpo.bp.115.001826 · Cited by 43 · see citing works
Internet-delivered cognitive behavioral therapy for panic disorder with or without agoraphobia: a systematic review and meta-analysis
Stech, E. P., Lim, J., Upton, E. L., & Newby, J. M. (2020) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2019.1628808 · Cited by 43 · see citing works
A randomized controlled trial of a transdiagnostic Internet intervention for individuals with panic and phobias – one size fits all
Schröder, J., Jelinek, L., & Moritz, S. (2017) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2016.05.002 · Cited by 32 · see citing works
Internet-based CBT for social phobia and panic disorder in a specialised anxiety clinic in routine care: Results of a pilot randomised controlled trial
Mathiasen, K., Riper, H. M., Ehlers, L. H., Valentin, J. B., & Rosenberg, N. (2016) · Internet Interventions · doi:10.1016/j.invent.2016.03.001 · Cited by 28 · see citing works
Digitally Delivered Psychological Interventions for Anxiety Disorders: a Comprehensive Review
Stefanopoulou, E., Lewis, D., Taylor, M., Broscombe, J., & Larkin, J. (2018) · Psychiatric Quarterly · doi:10.1007/s11126-018-9620-5 · Cited by 28 · see citing works
Meta-analyses in mental health research. A practical guide
Cuijpers, P. (2016) · VU Research Portal · Cited by 25 · see citing works
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The cost-effectiveness of stepped care for the treatment of anxiety disorders in adults: A model-based economic analysis for the Australian setting
Stiles, J. A., Chatterton, M. L., Le, L. K., Lee, Y. Y., Whiteford, H., & Mihalopoulos, C. (2019) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2019.109812 · Cited by 17 · see citing works
Treatment adequacy of anxiety disorders among young adults in Finland
Kasteenpohja, T., Marttunen, M., Aalto-Setälä, T., Perälä, J., Saarni, S. I., & Suvisaari, J. (2016) · BMC Psychiatry · doi:10.1186/s12888-016-0766-0 · Cited by 14 · see citing works

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Impact of guidance on intervention adherence in computerised interventions for mental health problems: a meta-analysis
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Efficacy of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Meta-Analysis of Recent Literature
Bhattacharya, S., Goicoechea, C., Heshmati, S., Carpenter, J. K., & Hofmann, S. G. (2023) · Current Psychiatry Reports · doi:10.1007/s11920-022-01402-8 · Cited by 82 · see citing works
CBT treatment delivery formats for panic disorder: a systematic review and network meta-analysis of randomised controlled trials
Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Giovane, C. D., Pompoli, A., Pauley, D., Karyotaki, E., Sijbrandij, M., et al. (2022) · Psychological Medicine · doi:10.1017/s0033291722003683 · Cited by 83 · see citing works
Self-citation
Evaluation of the Use of Digital Mental Health Platforms and Interventions: Scoping Review
Balcombe, L., & Leo, D. D. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20010362 · Cited by 83 · see citing works
Digital Mental Health Interventions for University Students With Mental Health Difficulties: A Systematic Review and Meta‐Analysis
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State of the Science: Using Digital Mental Health Interventions to Extend the Impact of Psychological Services
Ramos, G., Hernandez-Ramos, R., Taylor, M. E., & Schueller, S. M. (2024) · Behavior Therapy · doi:10.1016/j.beth.2024.04.004 · Cited by 64 · see citing works
Guided internet-based transdiagnostic individually tailored Cognitive Behavioral Therapy for symptoms of depression and/or anxiety in college students: A randomized controlled trial
Karyotaki, E., Klein, A. M., Ciharova, M., Bolinski, F., Krijnen, L., de Koning, L., de Wit, L., van der Heijde, C. M., Ebert, D. D., Riper, H., et al. (2022) · Behaviour Research and Therapy · doi:10.1016/j.brat.2021.104028 · Cited by 60 · see citing works
“Previous research has shown that iCBT has moderate effects in reducing symptoms of adult depression and anxiety when delivered with some form of therapeutic support (Karyotaki et al., 2018; Karyotaki et al., 2021; Pauley, Cuijpers, Papola, Miguel, & Karyotaki, 2021).”
Self-citation
Digital Interventions for Common Mental Disorders in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis
Karyotaki, E., Miguel, C., Panagiotopoulou, O. M., Harrer, M., Seward, N., Sijbrandij, M., Araya, R., Patel, V., & Cuijpers, P. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.50 · Cited by 56 · see citing works
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The Effects of Artificial Intelligence Chatbots on Women’s Health: A Systematic Review and Meta-Analysis
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A tale of two countries: Increased uptake of digital mental health services during the COVID-19 pandemic in Australia and New Zealand
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Equity in Digital Mental Health Interventions in the United States: Where to Next?
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The Effects of Internet-Based Cognitive Behavioral Therapy for Suicidal Ideation or Behaviors on Depression, Anxiety, and Hopelessness in Individuals With Suicidal Ideation: Systematic Review and Meta-Analysis of Individual Participant Data
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COVID-19 related differences in the uptake and effects of internet-based cognitive behavioural therapy for symptoms of obsessive-compulsive disorder
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Effectiveness of telemedicine on common mental disorders: An umbrella review and meta-meta-analysis
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Feasibility, Perceived Impact, and Acceptability of a Socially Assistive Robot to Support Emotion Regulation With Highly Anxious University Students: Mixed Methods Open Trial
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Anxiety and depression in emerging adults: The STAND program as a model of scalable screening and intervention
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Efficacy of technology-based mental health interventions in minimizing mental health symptoms among in immigrants, asylum seekers or refugees; systematic review
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Authors: Pauley, D., Cuijpers, P., Papola, D., Miguel, C., & Karyotaki, E.
Affiliations: Amsterdam Public Health (NL)
University of Verona (IT)
Harvard University (US)
Corresponding author: Pauley, Darin
ORCID: Pauley, Darin
Cuijpers, Pim
Papola, Davide
Miguel, Clara
Karyotaki, Eirini
Venue: Psychological Medicine
Publisher: Cambridge University Press (CUP)
Published: 2021-05-28
Volume: 53
Issue: 2
Pages: 1-13
ISSN: 0033-2917 (ISSN-L)
1469-8978
DOI: 10.1017/s0033291721001999
PMC: PMC9899576
OpenAlex: W3165857807
Cited by: 170
References: 101
Citations by year: 2026: 29 · 2025: 46 · 2024: 45 · 2023: 33 · 2022: 9 · 2021: 8
FWCI: 3.82
Type: journal article
Language: en
Open access: hybrid
doi.org
Licence: cc-by
creativecommons.org/licenses/by/4.0/ (unspecified)
Locations: Psychological Medicine (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
VU Research Portal (publishedVersion, other-oa)
Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
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: digital interventions, anxiety disorders, treatment effectiveness, generalized anxiety disorder, panic disorder, social anxiety disorder, agoraphobia, medication adherence, access to mental health care
MeSH terms: Phobia, Social, Anxiety, Anxiety Disorders, Humans, Panic Disorder, Treatment Outcome

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Two decades of digital interventions for anxiety disorders: a systematic review and meta-analysis of treatment effectiveness

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