Acceptability of internet-based cognitive behavioural therapy (i-CBT) for post-traumatic stress disorder (PTSD): A systematic review
Open accessAbstract
Background: Internet-delivered Cognitive Behavioural Therapy (i-CBT) offers potential as an alternative, accessible, clinically and cost-effective treatment for post-traumatic stress disorder (PTSD), but little is known about its acceptability.Objective: To review the available evidence to understand the acceptability of i-CBT for PTSD.Method: We undertook a mixed-methods systematic review according to Cochrane Collaboration Guidelines, of randomised controlled trials (RCTs) of i-CBT for adults with PTSD. We examined included studies for measures of acceptability, and possible proxy indicators of acceptability, including dropout rates, which were meta-analysed as risk ratios (RRs).Results: Ten studies with 720 participants were included. We found i-CBT to be acceptable according to specific acceptability measures, and suggestions for acceptability according to some proxy measures of i-CBT programme usage. There was, however, evidence of greater dropout from i-CBT than waitlist (RR 1.39, CI 1.03–1.88; 8 studies; participants = 585) and no evidence of a difference in dropout between i-CBT and i-non-CBT (RR 2.14, CI 0.97–4.73; participants = 132; 2 studies).Conclusion: i-CBT appears a potentially acceptable intervention for adults with PTSD. We identified clinical and research questions, including the status of proxy indicators, and call for standardised, consistent treatment acceptability measurement.
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Internet-delivered CBT and i-CBT are effective interventions for adults with PTSD.
“Additionally, Internet-delivered CBT and i-CBT are effective interventions for adults with PTSD, according to studies [63].”
From Clinical Efficacy of Psychotherapeutic Interventions for Post-Traumatic Stress Disorder in Children and Adolescents: A Systematic Review and Analysis. (2024) · cites this paper as [63]
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Wild, J., Warnock‐Parkes, E., Murray, H., Kerr, A., Thew, G. R., Grey, N., Clark, D. M., & Ehlers, A. (2020) · European Journal of Psychotraumatology · doi:10.1080/20008198.2020.1785818 · Cited by 41 · see citing works
Gawlytta, R., Kesselmeier, M., Scherag, A., Niemeyer, H., Böttche, M., Knaevelsrud, C., & Rosendahl, J. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-050305 · Cited by 45 · see citing works
Six, S. G., Byrne, K., Aly, H., & Harris, M. W. (2022) · JMIR Mental Health · doi:10.2196/39516 · Cited by 31 · see citing works
“In addition to depression, CBT has been successful in treating symptoms of anxiety and stress [10-15].”
BackgroundGkintoni, E., Kourkoutas, E., Yotsidi, V., Stavrou, P. D., & Prinianaki, D. (2024) · Children · doi:10.3390/children11050579 · Cited by 37 · see citing works
“Additionally, Internet-delivered CBT and i-CBT are effective interventions for adults with PTSD, according to studies [63].”
BackgroundAdvances in PTSD Treatment Delivery: the Role of Digital Technology in PTSD Treatment
Kuhn, E., & Owen, J. E. (2020) · Current Treatment Options in Psychiatry · doi:10.1007/s40501-020-00207-x · Cited by 34 · see citing works
Campos, D., Mira, A., Bretón-López, J., Castilla, D., Botella, C., Baños, R. M., & Quero, S. (2018) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s153041 · Cited by 30 · see citing works
Böttche, M., Wagner, B., Vöhringer, M., Heinrich, M., Stein, J., Selmo, P., Stammel, N., & Knaevelsrud, C. (2021) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.1943870 · Cited by 32 · see citing works
“The study also has a high dropout rate, which, although comparable to other studies, could influence the results and thus generalized conclusions (Lewis et al., 2019; Simon et al., 2019).”
BackgroundMethodResultInfluentialLiu, X., Yang, Y., Ye, Z., Wang, F., Zeng, K., Sun, Y., Huang, Y., & Dai, L. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.08.156 · Cited by 29 · see citing works
Okeke, F. C., Onyishi, C. N., Nwankwor, P. P., & Ekwueme, S. C. (2021) · Internet Interventions · doi:10.1016/j.invent.2021.100482 · Cited by 29 · see citing works
Choi, Y., Choi, E.-J., & Ko, E. (2023) · Applied Psychophysiology and Biofeedback · doi:10.1007/s10484-023-09593-3 · Cited by 29 · see citing works
Belleville, G., Ouellet, M., Békés, V., Lebel, J., Morin, C. M., Bouchard, S., Guay, S., Bergeron, N., Ghosh, S., Campbell, T. S., et al. (2022) · Behavior Therapy · doi:10.1016/j.beth.2022.08.004 · Cited by 25 · see citing works
Richardson, J. D., Cyr, K. S., Forchuk, C. A., Liu, J. J. W., Plouffe, R. A., Le, T., Gargala, D., Deda, E., Soares, V., Hosseiny, F., et al. (2022) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.2012374 · Cited by 23 · see citing works
“Although internet-delivered CBT is widely available, its e cacy for treating military-related PTSD is still in its infancy[32] and, prior to the COVID-19 pandemic, had yet to be widely implemented in Veteran populations.”
BackgroundZhao, C., Zhao, Z., Levin, M. E., Lai, L., Shi, C., Hu, J., Chen, W., & Ren, Z. (2023) · Behaviour Research and Therapy · doi:10.1016/j.brat.2023.104440 · Cited by 22 · see citing works
Hirai, M., Dolma, S., Vernon, L. L., & Clum, G. A. (2020) · Psychology and Health · doi:10.1080/08870446.2020.1758324 · Cited by 21 · see citing works
Vöhringer, M., Knaevelsrud, C., Wagner, B., Slotta, M., Schmidt, A., Stammel, N., & Böttche, M. (2020) · European Journal of Psychotraumatology · doi:10.1080/20008198.2019.1706297 · Cited by 21 · see citing works
Norman, K. P., Govindjee, A., Norman, S. R., Godoy, M., Cerrone, K. L., Kieschnick, D. W., & Kassler, W. J. (2020) · JMIR Formative Research · doi:10.2196/17424 · Cited by 23 · see citing works
“Internet delivery of CBT via therapist-mediated video chat and mixtures of online therapy sessions with email homework assignments are as effective as in-person therapies [14-18].”
BackgroundObiweluozo, P. E., Dike, I. C., Ogba, F. N., Elom, C. O., Orabueze, F. O., Okoye-Ugwu, S., Ani, C., Onu, A. O., Ukaogo, V. O., Obayi, L. N., et al. (2021) · Science Progress · doi:10.1177/00368504211050278 · Cited by 19 · see citing works
“In blended therapy, online sessions offer participants unrestricted access to treatment materials and exercises at the comfort of their own home thereby reducing the cost and frequency of meetings.(63,64) Additionally, blended therapy reduces therapist time compared to only face-to-face sessions, yet offers the benefi…”
BackgroundSimon, N. A., Ploszajski, M., Lewis, C., Smallman, K., Roberts, N. P., Kitchiner, N., Brookes‐Howell, L., & Bisson, J. I. (2021) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12341 · Cited by 19 · see citing works
“The type and extent of guidance can vary widely between interventions (Simon et al., 2019).”
BackgroundSimmonds‐Buckley, M., Bennion, M. R., Kellett, S., Millings, A., Hardy, G. E., & Moore, R. K. (2020) · Journal of Medical Internet Research · doi:10.2196/17049 · Cited by 16 · see citing works
“It is acknowledged that dropout is a limited proxy for acceptability [82] and that wider indices of acceptability also include understanding barriers to e-therapy engagement.”
A Systematic Review of Evidence-Based Treatments for Adolescent and Adult Sexual Assault Victims
Miles, L. W., Valentine, J. L., Mabey, L., Hopkins, E., Stodtmeister, P. J., Rockwood, R. B., & Moxley, A. N. H. (2023) · Journal of the American Psychiatric Nurses Association · doi:10.1177/10783903231216138 · Cited by 21 · see citing works
“A systematic review of I-CBT RCTs found this PTSD therapy modality was acceptable for anyone over age 16 (Simon et al., 2019).”
PTSD and complex PTSD, current treatments and debates: a review of reviews
Billings, J., & Nicholls, H. (2025) · British Medical Bulletin · doi:10.1093/bmb/ldaf015 · Cited by 15 · see citing works
Changes in perceived social support and PTSD symptomatology among Danish army military personnel
Pollmann, J. B., Nielsen, A. B. S., Andersen, S. B., & Karstoft, K. (2021) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-021-02150-5 · Cited by 14 · see citing works
Condensed Internet-delivered prolonged exposure provided soon after trauma: a randomised trial
Bragesjö, M., Arnberg, F. K., Lauri, K. O., Aspvall, K., Särnholm, J., & Andersson, E. (2021) · Psychological Medicine · doi:10.1017/s0033291721003706 · Cited by 14 · see citing works
“A recent review found indications of elevated drop-out rates in patients undergoing Internet-based CBT for PTSD (Simon et al., 2019) and a trial that evaluated an automated digital early intervention that shares components with CIPE such as psychoeducation and in vivo exposure reported a low usage…”
Simon, N., Lewis, C. E., Smallman, K., Brookes-Howell, L., Roberts, N., Kitchiner, N., Ariti, C., Nollett, C., McNamara, R., & Bisson, J. (2023) · European Journal of Psychotraumatology · doi:10.1080/20008066.2023.2212554 · Cited by 11 · see citing works
“Non-uptake of ‘ Spring ’ therapy sessions was 5.2%, and non-uptake of ‘ Spring ’ programme steps was 10.3%, which contrasts with higher non-uptake rates in some other studies as reported in a systematic review of i-CBT for PTSD (Simon et al., 2019).”
BackgroundResultInfluentialLow-Intensity Interventions and EMDR Therapy
Maxfield, L. (2021) · Journal of EMDR Practice and Research · doi:10.1891/emdr-d-21-00009 · Cited by 12 · see citing works
“The dropout rates in computerized TF-CBT programs for PTSD were found to vary greatly, from 8.7% to 62.5% (Simon et al., 2019).”
BackgroundMethodInfluentialMcLean, C. P., Malek, N., & Straud, C. L. (2024) · Journal of Traumatic Stress · doi:10.1002/jts.23020 · Cited by 11 · see citing works
Australian Digital Mental Health Services: Consumer Perceptions of Their Usability and Acceptability
Ftanou, M., Machlin, A., Mangelsdorf, S. N., Morgan, A., & Bassilios, B. (2024) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-024-00431-9 · Cited by 11 · see citing works
“Lastly, studies that examined health professionals’ satisfaction with guided digital mental health services also found it to be high (Simon et al., 2019).”
Blackie, M., de Boer, K., Seabrook, E., Bates, G. W., & Nedeljkovic, M. (2024) · Trauma Violence & Abuse · doi:10.1177/15248380241238760 · Cited by 10 · see citing works
“These include financial limitations, scheduling conflicts, stigma, fear, and limited availability of qualified therapists (due to long treatment waitlists, remote location, or COVID-19 lockdowns) (Lewis et al., 2019; Simon et al., 2019).”
BackgroundMacKean, M., Lecchi, T., Mortimer, R., & Midgley, N. (2023) · Journal of Child Psychotherapy · doi:10.1080/0075417x.2023.2173271 · Cited by 10 · see citing works
“However, uptake of internet-based therapies generally remains low (Waller & Gilbody, 2009), and attrition rates high (Simon et al., 2019); this could be due to services not providing appropriate support for adolescents’ distinct socio-emotional and developmental needs (McGorry et al., 2013; Waller…”
BackgroundHadjistavropoulos, H. D., Hill, T. G., Philipp-Muller, A. E., Dear, B. F., & Titov, N. (2023) · Internet Interventions · doi:10.1016/j.invent.2023.100692 · Cited by 9 · see citing works
“…a valuable approach for improving client access to effective mental health care (e.g., Andersson et al., 2019; Carlbring et al., 2018; Etzelmueller et al., 2020; Karyotaki et al., 2021; Romijn et al., 2019; Simon et al., 2019), questions remain about what represents the optimal way to deliver ICBT.”
BackgroundStein, J., Vöhringer, M., Wagner, B., Stammel, N., Nesterko, Y., Böttche, M., & Knaevelsrud, C. (2023) · JMIR Mental Health · doi:10.2196/48689 · Cited by 9 · see citing works
“Overall, 16.7% (40/240) of participants did not start treatment, which is similar to previous studies conducted in internet-based and face-to-face settings in different populations [11,62,63].”
ResultInfluentialBenjet, C. L., Kessler, R. C., Kazdin, A. E., Cuijpers, P. J., Albor, Y., Tapias, N. E. C., Contreras‐Ibáñez, C. C., González, M. S. D., Gildea, S. M., González, N., et al. (2022) · Trials · doi:10.1186/s13063-022-06255-3 · Cited by 9 · see citing works
“While less is known about relative acceptability of Internet interventions and more traditional treatment delivery methods, the COVID-19 pandemic has been a game changer and made Internet interventions not only more acceptable, but necessary and is likely to remain a cost-effective option once the pandemic is over [10…”
BackgroundSystematic Review of Clinical Practice Guidelines for Insomnia Disorder
Seow, S. Y., Kwok, K. F. V., Tay, K. H., Chee, W. S. A., Rawtaer, I., Cheng, Y., Tan, Q. X., & Tan, S. M. (2022) · Journal of Psychiatric Practice · doi:10.1097/pra.0000000000000670 · Cited by 9 · see citing works
“17 The instrument comprises the following domains: (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, (6) editorial independence, and (7) an overall assessment.”
BackgroundWu, J., Tsai, Y.-Y., Chen, Y.-J., Hsiao, F., Hsu, C., Lin, K., & Liao, L. (2024) · Medical & Biological Engineering & Computing · doi:10.1007/s11517-024-03209-6 · Cited by 9 · see citing works
“These tools allow users to follow their personal growth and mental health status and treat several clinical situations, especially those associated with trauma-related stress [8, 9, 101, 102].”
Standard cognitive behavioral therapy for insomnia (CBT-I)
Muench, A., Vargas, I., Posner, D. A., & Perlis, M. L. (2021) · Elsevier eBooks · doi:10.1016/b978-0-12-822872-2.00012-8 · Cited by 7 · see citing works
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Chung, K., & Chung, E. (2020) · The Korean Journal of Clinical Psychology · doi:10.15842/kjcp.2020.39.4.006 · Cited by 6 · see citing works
Eze, A., Anyebe, M. O., Nnamani, R. G., Nwaogaidu, J. C., Mmegwa, P. U., Akubo, E. A., Bako, V. N., ISHAYA, S. N., Eze, M. I., Ekwueme, F. O., et al. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1140300 · Cited by 6 · see citing works
“Though the scale is relatively old, it has also proven valid in more recent studies (92) and is continually valuable in measuring the acceptability of internet therapy (93) and other recent clinical studies (94).”
BackgroundMethodInfluentialPaiva, J. M., Melani, M., Marques, E. S. N., von Arcosy, C., Coutinho, E. S. F., Ventura, P. R., & Berger, W. (2023) · Psychology Health & Medicine · doi:10.1080/13548506.2023.2292478 · Cited by 7 · see citing works
“Internet-delivered cognitive-behavioral therapy is an intervention that employs traditional or trauma-focused CBT techniques (Simon et al., 2019).”
BackgroundPsychological intervention with adult victims of sexual abuse: A comprehensive review
Fávero, M., Moreira, D. S., Abreu, B. M. V., Sánchez, A. D. C., Moreira, D. S., & Sousa‐Gomes, V. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2598 · Cited by 5 · see citing works
ter Heide, F. J. J., de Goede, M. L., van Dam, S., & Ekkers, S. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.890858 · Cited by 5 · see citing works
Fernández-Buendía, S., Miguel, C., Dumarkaitė, A., Kazlauskas, E., Cuijpers, P. J., & Quero, S. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.11.059 · Cited by 5 · see citing works
Ross, D., McCallum, N., Truuvert, A. K., Butt, A., Behdinan, T., Rojas, D., Soklaridis, S., & Vigod, S. N. (2024) · Journal of Mental Health · doi:10.1080/09638237.2024.2332797 · Cited by 4 · see citing works
“Currently, exposure-based interventions are the first-line treatment for the sequelae of PTSD, however, dropout rates in evidence-based PTSD interventions can be a concern (Alpert et al., 2020; Schrader & Ross, 2021; Simon et al., 2019).”
Pozza, A., Giangrasso, B., Baldo, D., Fort, A., Millozzi, G., Iocca, F., Angelo, N. L., Pugi, D., Gualtieri, G., Lorenzi, L., et al. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.917574 · Cited by 4 · see citing works
“The app will contain written and audio-visual materials inspired by evidence-based psychoeducation and cognitive behavioral exercises and techniques, which have already been demonstrated to be effective in promoting well-being and preventing stress by randomized controlled trials and metaanalyses (Spek et al., 2007; C…”
MethodÖzer, Ö., & Köksal, B. (2023) · OSMANGAZİ JOURNAL OF MEDICINE · doi:10.20515/otd.1309551 · Cited by 5 · see citing works
Lebel, J., Flores-Tremblay, T., Binet, É., Ouellet, M., & Belleville, G. (2021) · Santé mentale au Québec · doi:10.7202/1081516ar · Cited by 4 · see citing works
Ghiasi, H., Askarirostami, F., Bakhtiari, M., & Hasanvandi, S. (2022) · Medical Science · doi:10.54905/disssi/v26i122/ms119e2012 · Cited by 3 · see citing works
Zhang, G., Wang, S., Ma, P., & Pan, J. (2024) · Journal of Integrative Neuroscience · doi:10.31083/j.jin2311200 · Cited by 3 · see citing works
Hirai, M., Vernon, L. L., & Clum, G. A. (2025) · Journal of Trauma & Dissociation · doi:10.1080/15299732.2025.2503721 · Cited by 2 · see citing works
“…group and 27.3% in the adult-trauma group, which are acceptable compared to attrition rates reported for online EW studies (e.g., 55% attrition in Stockton et al., 2014; 28% in Hirai et al., 2020) and cognitive behavioral treatment outcome studies (up to 62.5% in a review by Simon et al., 2019).”
InfluentialThomson, N., Gilarova, M., Lawrence, J., Cullen, B., & Gardani, M. (2026) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2026.102279 · Cited by 2 · see citing works
Effect of smartphone app on post-traumatic stress disorder in COVID-19 convalescent patients
Wang, Y., Yang, X., Chen, H., & Xu, Y. (2021) · Medicine · doi:10.1097/md.0000000000025479 · Cited by 2 · see citing works
“The latest PTSD treatment guidelines recommend that patients should receive psychotherapy in the outpatient first.([15,16]) However, many factors limit patients’ access to treatment, including the limited number of qualified therapists and the high cost of psychotherapy.”
BackgroundЛІКУВАННЯ ПОСТТРАВМАТИЧНОГО СТРЕСОВОГО РОЗЛАДУ: ОГЛЯД КПТ ВТРУЧАНЬ НА ОСНОВІ ДОКАЗОВОЇ МЕДИЦИНИ
Mazur, O. V., Лемещук, М., Коваленко, І., Ордатій, Н. М., & Мацько, Н. (2023) · Наукові перспективи (Naukovì perspektivi) · doi:10.52058/2708-7530-2023-9(39)-600-612 · Cited by 2 · see citing works
The Well-being and Well-becoming of Adolescents and Young Adults
Torbuck, A., Winrow, E., Lloyd‐Williams, H., Lawrence, C. L., & Edwards, R. T. (2024) · doi:10.1093/9780191919336.003.0004 · Cited by 1 · see citing works
Li, W., & Wang, J. (2025) · SLEEP · doi:10.1093/sleep/zsaf417 · Cited by 1 · see citing works
The diary of an operational stress injury clinic psychiatrist during the COVID-19 pandemic
Richardson, J. D. (2020) · Journal of Military Veteran and Family Health · doi:10.3138/jmvfh-co19-0002 · Cited by 1 · see citing works
Gómez, R. M., Martínez-Vélez, N. A., Tiburcio, M., & Fernández-Torres, M. (2024) · Salud Mental · doi:10.17711/sm.0185-3325.2024.015 · Cited by 1 · see citing works
“…strategies offered in mental health have focused on evaluating their efficiency and effectiveness, an additional area of interest is the identification of factors that enhance their adoption by patients, such as acceptability (Musiat et al., 2014; Simon et al., 2019; Sobowale et al., 2016).”
Roth, M. L. (2020) · Journal of Military Veteran and Family Health · doi:10.3138/jmvfh-co19-0014 · Cited by 1 · see citing works
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Blackie, M., de Boer, K., Seabrook, E., Bates, G. W., & Nedeljkovic, M. (2020) · doi:10.31234/osf.io/f5dgm · Cited by 1 · see citing works
The diary of an Operational Stress Injury clinic psychiatrist during the COVID-19 pandemic
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Suggestions for the Development of Internet-based Cognitive-Behavioral Therapy with a Trauma Focus
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Advances in Psychotherapy for Posttraumatic Stress Disorder
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Temporal subtypes and characteristics of insomnia treatment responses
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“Notably, the therapeutic benefits of CBT-I extend beyond sleep improvement, demonstrating significant synergistic effects in comorbid psychiatric disorders such as depression 13 , bipolar disorder 14 , post-traumatic stress disorder (PTSD) 15 , and generalized anxiety disorder (GAD) 16 .”
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- Authors
- Simon, N., McGillivray, L., Roberts, N. P., Barawi, K., Lewis, C. E., & Bisson, J. I.
- Affiliations
- Cardiff University (GB)
- Cardiff and Vale University Health Board (GB)
- Corresponding author
- Simon, Natalie
- Venue
- European Journal of Psychotraumatology
- Publisher
- Informa UK Limited
- Published
- 2019-08-27
- Volume
- 10
- Issue
- 1
- Pages
- 1646092-1646092
- ISSN
- 2000-8066 (ISSN-L)
- PMC
- PMC6719262
- OpenAlex
- W2970971274
- Cited by
- 84
- References
- 58
- Citations by year
- 2026: 6 · 2025: 7 · 2024: 12 · 2023: 14 · 2022: 10 · 2021: 15 · 2020: 17 · 2019: 2 · 2018: 1
- FWCI
- 1.56
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- European Journal of Psychotraumatology (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- ORCA Online Research @Cardiff (Cardiff University) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Keywords
- internet-based cognitive behavioral therapy, post-traumatic stress disorder, acceptability, treatment discontinuation, online intervention
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