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Cited by 105COVID-19 and Mental HealthDigital Mental Health InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Brief Online Cognitive Behavioural Intervention for Dysfunctional Worry Related to the COVID-19 Pandemic: A Randomised Controlled Trial

Open access
Wahlund, Tove, Mataix-Cols, David, Olofsdotter Lauri, Klara, de Schipper, Elles, Ljótsson, Brjánn, Aspvall, Kristina, Andersson, Erik·2021·Psychotherapy and Psychosomatics
DOI 10.1159/000512843PMC PMC7801992
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Abstract

Introduction: Worries about the immediate and long-term consequences of the COVID-19 pandemic may for some individuals develop into pervasive worry that is disproportionate in its intensity or duration and significantly interferes with everyday life. Objective: The aim of this study was to investigate if a brief self-guided, online psychological intervention can reduce the degree of dysfunctional worry related to the COVID-19 pandemic and associated symptoms. Methods: 670 adults from the Swedish general population reporting daily uncontrollable worry about CO-VID-19 and its possible consequences (e.g., illness, death, the economy, one's family) were randomised (1:1 ratio) to a 3-week self-guided, online cognitive behavioural intervention targeting dysfunctional COVID-19 worry and associated symptoms, or a waiting list of equal duration. The primary outcome measure was a COVID-19 adapted version of the Generalised Anxiety Disorder 7-item scale administered at baseline and weeks 1-3 (primary endpoint). Follow-up assessments were conducted 1 month after treatment completion. The trial was registered on ClinicalTrials.gov (NCT04341922) before inclusion of the first participant. Results: The main pre-specified intention-to-treat analysis indicated significant reductions in COVID-19-related worry for the intervention group compared to the waiting list (β = 1.14, Z = 9.27, p < 0.001), corresponding to a medium effect size (bootstrapped d = 0.74 [95% CI: 0.58-0.90]). Improvements were also seen on all secondary measures, including mood, daily functioning, insomnia, and intolerance of uncertainty. Participant satisfaction was high. No serious adverse events were recorded. Conclusions: A brief digital and easily scalable self-guided psychological intervention can significantly reduce dysfunctional worry and associated behavioural symptoms related to the COVID-19 pandemic. © 2020 S. Karger AG, Basel. Copyright: All rights reserved.

Integrity signals

Registry

Crossref · 10.1159/000512843

Cites

27 of 27 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

6 of 16 cited sources checked · 4 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Excessive worry about one's health can lead to inappropriate healthcare seeking behaviour that may, in turn, add further pressure to the already burdened healthcare system.

    “For example, excessive worry about one's health can lead to inappropriate healthcare seeking behaviour that may, in turn, add further pressure to the already burdened healthcare system [4,5].”
    Quote in the paperSubstantial claim2 of 2 sources checked
  • Study design and conductcitation

    Statistical significance thresholds were adjusted to p < 0.0295 on all outcome measures to account for repeated testing in the final analyses, according to Pocock's boundary.

    “As we did an interim analysis after 300 included participants [8], the statistical significance thresholds were adjusted to p < 0.0295 on all outcome measures in order to account for repeated testing in the final analyses, according to Pocock's boundary [21].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [21] source

      The Meta-analysis method (section 5.2; page unavailable) describes effect-size calculations and 95% confidence intervals, while Table 2 reports outcome p-values. Searches for Pocock’s boundary, p < 0.0295, and an interim analysis after 300 participants found no passage in our copy addressing the claimed adjustment. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
  • Premisecitation

    Previous research has indicated that excessive checking is a central mechanism in worry-related problems.

    “Previous research has indicated that excessive checking is a central mechanism in worry-related problems [17,18].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [17] source
    • cites [18] source

      The Introduction discusses treatment for anxiety disorders, and Method > Description of the Intervention describes a diary for tracking panic symptoms. Neither passage addresses excessive checking as a mechanism in worry-related problems; searches for the claim’s wording and for checking or reassurance in panic disorder found no supporting passage in our copy. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
  • Premisecitation

    Internet-based interventions can be efficacious for excessive worry about everyday problems.

    “The results were in line with our previous work showing that internet-based interventions can be efficacious for excessive worry about everyday problems [6,7].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [6] source
    • cites [7] source
  • Findingown data

    Improvements were seen on all secondary measures, including mood, daily functioning, insomnia, and intolerance of uncertainty.

    “Improvements were also seen on all secondary measures, including mood, daily functioning, insomnia, and intolerance of uncertainty.”
    Quote in the paperSubstantial claim
  • May combine two claims. 20
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 15

  • May combine two claims.

    Premisecitation

    Unlike previous internet-based worry treatments, the current intervention was short (3 vs. 10 weeks) and entirely self-guided.

    “Unlike our previous internet-based worry treatments [6,7], the current intervention was short (3 vs. 10 weeks) and entirely self-guided.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [6] source
    • cites [7] source

  • May combine two claims. The quote only partly states this claim.

    Findingcitation

    The results from the pre-specified interim analysis of the first 300 participants were positive and did not indicate that the trial needed to be terminated prematurely.

    “The results from the interim analysis were positive and did not indicate that the trial needed to be terminated prematurely [8].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] source

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

    Findingnone given

    Participant satisfaction was high.

    “Participant satisfaction was high.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The intervention was associated with significant improvements on all secondary outcome measures, including daily functioning, depressive symptoms, insomnia, and intolerance of uncertainty.

    “As shown in Table 3, the intervention was associated with significant improvements on all secondary outcome measures, including daily functioning, depressive symptoms, insomnia, and intolerance of uncertainty.”
    • Also stated in: § Discussion · plain
      “The intervention also resulted in significant improvements in secondary outcomes (mood, daily functioning, insomnia, and intolerance of uncertainty) compared to the waiting list.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The intervention group had on average a 40% reduction in COVID-19-related worry, whereas the control group had a 17% reduction.

    “The intervention group had on average a 40% reduction in COVID-19-related worry whereas the corresponding reduction of worry in the control group was 17%.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    The randomisation list was created by an independent party (Karolinska Trial Alliance) and randomisation blocks came in different sizes unknown to the research team, eliminating allocation bias.

    “In order to eliminate allocation bias, the randomisation list was created by the independent party Karolinska Trial Alliance (KTA; www.karolinskatrialalliance.se) and randomisation blocks came in different sizes, unknown to the research team.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Data loss at the primary endpoint (week 3) was 11%, substantially lower than the worst-case scenario in the power analysis (30%).

    “Data loss at the primary endpoint (week 3) was 11%, which was substantially lower than the worst-case scenario in our power analysis (30%).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Primary analyses were conducted according to the intention-to-treat principle.

    “Primary analyses were conducted according to the intentionto-treat principle.”
    Quote in the paperSubstantial claim

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

    Study design and conductown data

    The trial was registered on ClinicalTrials.gov (NCT04341922) before inclusion of the first participant.

    “The trial was registered on ClinicalTrials.gov(NCT04341922) before inclusion of the first participant.”
    • Also stated in: § Trial Design · plain
      “the trial was registered on ClinicalTrials.govon April 10, 2020, before participant enrolment (registration ID: NCT04341922).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The study was designed with 90% power to detect a between-group effect size of Cohen's d = 0.3, using a two-tailed test with alpha 0.05 and allowing for 30% drop-out, and a sample size of 670 participants was estimated sufficient to detect a statistically significant difference.

    “With 90% power to detect such a difference, using a two-tailed test with an alpha level of 0.05 and allowing for a 30% drop-out rate, we estimated that a sample size of 670 participants would be sufficient to detect a statistically significant difference between the two groups.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The waiting list controls for the passage of time and spontaneous worry fluctuations, which is crucial given the rapidly changing landscape of COVID-19.

    “The waiting list controls for the passage of time and spontaneous worry fluctuations, which is crucial given the rapidly changing landscape of COVID-19.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Participants were randomised to the online intervention or to a waiting list in a 1:1 ratio.

    “Participants were randomised to the online intervention or to a waiting list (1: 1 ratio).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The self-reported adverse events were mild and typical of those reported in psychological treatment trials.

    “A small number of participants reported mild ad-verse events that are typical of psychological treatment trials.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Due to an administrative error, one participant who was randomised to the intervention was included in the trial despite not endorsing any of the additional inclusion criteria.

    “Due to an administrative error, one participant who was randomised to the intervention was included in the trial despite not endorsing any of the additional inclusion criteria.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The intervention is highly flexible and potentially very cost-effective.

    “This means that there is no need for a supporting clinician, scheduled appointments, or travel to a clinic, making the intervention highly flexible and potentially very cost-effective.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data.

    “All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The study used repeated measures.

    “The main strengths of the study were the randomised controlled design, the use of repeated measures, the wellpowered sample size and the relatively limited data loss (only 11% of the participants did not provide post-treatment measures, a substantially lower proportion than we expected and that is typically observed in other entirely self-guided psychological interventions) [22][23][24][25].”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Study design and conductnone given

    All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

    “The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The current intervention requires no supporting clinician, scheduled appointments, or travel to a clinic.

    “This means that there is no need for a supporting clinician, scheduled appointments, or travel to a clinic, making the intervention highly flexible and potentially very cost-effective.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    201 of 335 (60%) participants in the treatment group completed at least three modules, and 123 (37%) completed all five modules.

    “Briefly, 201 of 335 (60%) participants completed at least three modules and 123 (37%) completed all five modules.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Premisecitation

    The COVID-19 pandemic seems to be far from over and will likely continue to have a profound impact on the health and economy of citizens around the world.

    “The COVID-19 pandemic seems to be far from over [27] and will likely continue to have a profound impact on the health and economy of citizens around the world.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationreasoning

    The intervention is easily scalable and can be made available to the general population via secure digital platforms widely used in most advanced healthcare systems.

    “The intervention is therefore easily scalable and can be made available to the general population via secure digital platforms widely used in most advanced healthcare systems.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    A myriad of digital tools (e.g., health 'apps') have been made available for this purpose, but these have rarely been rigorously evaluated and often come at high cost for public healthcare providers.

    “A myriad of digital tools (e.g., health”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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

    Study design and conductreasoning

    The research team crosschecked the weekly randomisation report to ensure that there were no errors in the randomisation procedures.

    “This report was crosschecked weekly to ensure that there were no errors in the randomisation procedures.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    262 of 335 (79%) participants completed at least one worksheet, and 109 (33%) completed at least six worksheets.

    “Similarly, 262 of 335 (79%) participants completed at least one worksheet, and 109 (33%) completed at least six worksheets.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    In the rapidly evolving landscape of the COVID-19 pandemic, controlling for the passage of time is particularly important as worry is likely to fluctuate alongside changes in the spread of the virus, societal restrictions, and news coverage of the pandemic.

    “However, in the rapidly evolving landscape of the COVID-19 pandemic, controlling for the passage of time is particularly important as worry is likely to fluctuate alongside changes in the spread of the virus, societal restrictions, and news coverage of the pandemic.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationreasoning

    The fixed structure of the online, self-guided format eliminates the risk of therapist drift and ensures consistent delivery of the treatment content.

    “The fixed structure of the online, self-guided format eliminates the risk of therapist drift, and ensures consistent delivery of the treatment content.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The proportion of participants who did not provide post-treatment measures (11%) was substantially lower than expected and than typically observed in other entirely self-guided psychological interventions.

    “The main strengths of the study were the randomised controlled design, the use of repeated measures, the wellpowered sample size and the relatively limited data loss (only 11% of the participants did not provide post-treatment measures, a substantially lower proportion than we expected and that is typically observed in other entirely self-guided psychological interventions) [22][23][24][25].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22][23][24][25]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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

    Study design and conductnone given

    The funding organisation (VINNOVA) had no role in the conception of the study design, or in the collection, analysis or interpretation of the data, in the writing of the report, or in the decision to submit the paper.

    “The funding organisation (VINNOVA) had no role in the conception of the study design, or in the collection, analysis or interpretation of the data, in the writing of the report, or in the decision to submit the paper.”
    Quote in the paperNot a substantial claim
29 of 29

  • The paper relies on this without support.

    Many digital mental health programs and applications are not evaluated before being implemented or procured by public health services.

    “Unfortunately, many digital mental health programs and applications are not evaluated before being implemented or procured by public health services.”

  • The paper relies on this without support.

    The COVID-19-adapted GAD-7 validly measures dysfunctional COVID-19 worry.

    “The primary outcome was the Generalised Anxiety Disorder 7-items scale (GAD-7) [11] adapted to assess worry related to the COVID-19 pandemic (available at https://osf.io/exh47/).”
    “The internal consistency of the modified scale in the current sample was high (Cronbach's alpha = 0.83).”

  • The paper relies on this without support.

    Self-reported adverse events at week 3 capture all serious adverse events.

    “Adverse events were self-reported at week 3 in both groups.”

  • The paper relies on this without support.

    The current trial is the first to systematically evaluate a psychological intervention for dysfunctional worry related specifically to the COVID-19 pandemic.

    “However, the current trial is the first to systematically evaluate a psychological intervention for dysfunctional worry related specifically to the COVID-19 pandemic.”

  • The paper relies on this without support.

    The study was conducted in Sweden, a country with high internet access and usage.

    “Finally, the study was conducted in Sweden, a country with high internet access and usage.”

  • The paper relies on this without support.

    The intervention is already available free of charge to all citizens in Region Stockholm via the region's secure portal.

    “The intervention is already available free of charge to all citizens in Region Stockholm via the region's secure portal (https://www.1177.se/Stockholm/).”
6 of 6

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?

  • The study included a follow-up at 3 and 6 months, in contrast to some studies that did not include a follow-up period.

    “Regarding the strengths of this study, it was considered a follow-up at 3 and 6 months, in contrast to some studies that did not include a follow-up period [81-85].”

    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 [85]

    The 3- and 6-month follow-ups describe the citing authors’ own study, not Wahlund et al.’s trial. As an example of a study without follow-up, however, this source is contrary to the claim: its Trial Design and Outcomes and Assessment Points sections state that the intervention group was assessed 1 month after treatment. (LLM, conf=0.90)

    Checked by a reasoning model — may be wrong.

    Experimental — accuracy not yet measured

  • The study by Wahlund et al, an intervention without therapeutic guidance, showed favorable results in fear regarding COVID-19.

    “Concerning fear regarding COVID-19, the study by Wahlund et al [85], which is also an intervention without therapeutic guidance, showed favorable results in this variable, in contrast to the SGWI group, in which a positive effect was not achieved.”

    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 [85]

    The Discussion describes the intervention as entirely self-guided, and the Results report a larger reduction in COVID-19-related worry than in the waiting-list group. The paper does not report an improvement in fear regarding COVID-19 as a distinct outcome, so the claim is supported for worry but not specifically for fear. The supplied passages do not specify page numbers. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • A Swedish randomized study of 670 subjects found that a 3-week digital CBT intervention significantly reduced dysfunctional worry and improved insomnia, mood, daily functioning, and uncertainty compared with a waiting list.

    “The 3-week digital intervention significantly reduced dysfunctional worry while improving symptoms of insomnia, mood, daily functioning, and uncertainty [13].”

    From Overview of sleep management during COVID-19. (2022) · cites this paper as [13]

  • For specific management of COVID-19 sleep dysfunction, five CBT studies were available: two controlled insomnia trials, one worry/secondary insomnia study, one case study, and one small online child study.

    “As to specific management of sleep dysfunction during COVID-19, five studies of cognitive behavioral therapy (CBT) were available – two controlled trials of insomnia [11,12], one focused on worry and secondary insomnia [13], one case study [14] and a small online study in children [15].”

    From Overview of sleep management during COVID-19. (2022) · cites this paper as [13]

  • The study by Wahlund et al did not have an active control group.

    “However, it should be noted that the study by Wahlund et al [85] did not have an active control group.”

    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 [85]

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Consistentz = 9.27reported p < .001 · recomputed p < .001

    “Z = 9.27, p < .001”

  • Consistentz = 8.06reported p < .001 · recomputed p < .001

    “,Z = 8.06, p < .001”

  • Consistentz = 0.08reported p = .94 · recomputed p = .936

    “Z = 0.08, p = .94”

3 of 3

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Waiting-list women's percentage is misstated

    Minor

    The waiting-list group had 335 participants, so 270 women represent about 81%, not 77%.

    Reported 77 · recomputed 80.597015

1 of 1

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Related

Authors
Wahlund, T., Mataix-Cols, D., Olofsdotter Lauri, K., de Schipper, E., Ljótsson, B., Aspvall, K., & Andersson, E.
Affiliations
  • Karolinska Institutet (SE)
  • Region Stockholm (SE)
ORCID
Venue
Psychotherapy and Psychosomatics
Publisher
S. Karger AG
Published
2020-11-19
Volume
90
Issue
3
Pages
191-199
ISSN
  • 0033-3190 (ISSN-L)
  • 1423-0348
DOI
10.1159/000512843
PMC
PMC7801992
OpenAlex
W3101942540
Cited by
105
References
27
Citations by year
2026: 3 · 2025: 8 · 2024: 12 · 2023: 25 · 2022: 30 · 2021: 27
FWCI
8.18
Type
journal article
Language
en
Open access
Licence
Locations
  • Psychotherapy and Psychosomatics (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • VINNOVA (2020-02196)
  • Karolinska Institutet
Topics
  • Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
COVID-19 pandemic, generalized anxiety disorder, self-guided intervention, digital psychological interventions, intolerance of uncertainty, insomnia, mood, daily functioning, waitlist control
MeSH terms
Patient Health Questionnaire, Internet-Based Intervention, COVID-19, SARS-CoV-2, Adult, Aged, Aged, 80 and over, Anxiety, Female, Humans, Male, Middle Aged, Sweden, Cognitive Behavioral Therapy, Treatment Outcome, Young Adult

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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 2026-10-11.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-11.

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