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Is computerised CBT really helpful for adult depression?-A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity
Open accessAbstract
BACKGROUND: Depression is a major cause of disability worldwide, and computerised cognitive behavioural therapy (CCBT) is expected to be a more augmentative and efficient treatment. According to previous meta-analyses of CCBT, there is a need for a meta-analytic revaluation of the short-term effectiveness of this therapy and for an evaluation of its long-term effects, functional improvement and dropout. METHODS: Five databases were used (MEDLINE, PsycINFO, EMBASE, CENTRAL and CiNii). We included all RCTs with proper concealment and blinding of outcome assessment for the clinical effectiveness of CCBT in adults (aged 18 and over) with depression. Using Cohen's method, the standard mean difference (SMD) for the overall pooled effects across the included studies was estimated with a random effect model. The main outcome measure and the relative risk of dropout were included in the meta-analysis. RESULTS: Fourteen trials met the inclusion criteria, and sixteen comparisons from these were used for the largest meta-analysis ever. All research used appropriate random sequence generation and Intention-to-Treat analyses (ITT), and employed self-reported measures as the primary outcome. For the sixteen comparisons (2807 participants) comparing CCBT and control conditions, the pooled SMD was -0.48 [95% IC -0.63 to -0.33], suggesting similar effect to the past reviews. Also, there was no significant clinical effect at long follow-up and no improvement of function found. Furthermore, a significantly higher drop-out rate was found for CCBT than for controls. When including studies without BDI as a rating scale and with only modern imputation as sensitivity analysis, the pooled SMD remained significant despite the reduction from a moderate to a small effect. Significant publication bias was found in a funnel plot and on two tests (Begg's p = 0.09; Egger's p = 0.01). Using a trim and fill analysis, the SMD was -0.32 [95% CI -0.49 to -0.16]. CONCLUSION: Despite a short-term reduction in depression at post-treatment, the effect at long follow-up and the function improvement were not significant, with significantly high drop-out. Considering the risk of bias, our meta-analysis implied that the clinical usefulness of current CCBT for adult depression may need to be re-considered downwards in terms of practical implementation and methodological validity.
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“the effects were observed to be transient and the participants’ drop-out rate was high [5].”
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“A number of studies in the broader CCBT literature have found evidence of a publication bias. Studies reporting negative findings are less likely to be published [26,49,50].”
From Computerized cognitive behavior therapy for anxiety and depression in rural areas:a systematic review (2015) · cites this paper as [50]
In the citing paper
“Effect sizes have been estimated at d=0.44-1.90 for clinician-supported, and d=0.21-0.70 for self-guided, interventions [42-45,47,48].”
From MoodHacker Mobile Web App With Email for Adults to Self-Manage Mild-to-Moderate Depression: Randomized Controlled Trial (2016) · cites this paper as [45]
In the citing paper
“Thus there is currently ample evidence for the short and long term benefits for eHealth delivered Cognitive Behavioural Therapy (CBT) for treating anxiety and depressive conditions in both general population and clinical settings [21–23], with greater improvement shown for those interventions that include guidance throughout the intervention period [21,24].”
From Effectiveness of eHealth interventions for reducing mental health conditions in employees: A systematic review and meta-analysis (2017) · cites this paper as [22]
In the citing paper
“Internet-delivered CBT-based programs for depression symptom management have been shown to be effective both for adults with major depressive disorder and those with elevated, but subthreshold, depression symptoms, although one recent review identified concerns with dropout and lack of long-term effects [42-45].”
From MoodHacker Mobile Web App With Email for Adults to Self-Manage Mild-to-Moderate Depression: Randomized Controlled Trial (2016) · cites this paper as [45]
In the citing paper
“Although our results are consistent with a recent meta-analysis of computerized CBT programs showing that results of computer-based CBT programs typically attenuate over time [45]”
From MoodHacker Mobile Web App With Email for Adults to Self-Manage Mild-to-Moderate Depression: Randomized Controlled Trial (2016) · cites this paper as [45]
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ResultAn evaluation of a peer support intervention for student mental health
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“The mid-point retention is comparable to computerised CBT, a NICE recommend psycho-social intervention for mild to moderate depression, which has a 50% attrition (So et al., 2013).”
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“Of note, there was one meta-analysis investigation in which follow-up rates of depressive symptoms were found to be not significantly different from the control group.(25) The present meta-analysis also examined whether clinician assistance was a necessary prerequisite for the success of an iCBT program.”
ResultImproving the Efficiency of Psychotherapy for Depression: Computer-Assisted Versus Standard CBT
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BackgroundWeb-Based Bereavement Care: A Systematic Review and Meta-Analysis
Wagner, B., Rosenberg, N., Hofmann, L., & Maaß, U. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.00525 · Cited by 129
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“For example, they tend to have short-term effects [13] and only when supported by a therapist, rather than as stand-alone interventions [14,15].”
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Systematic review of universal and targeted workplace interventions for depression
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“some question about the impact of this approach alone (79).”
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Internet‐Based Psychotherapy for Adult Depression: What About the Mechanisms of Change?
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“One caveat of this type of therapy is its low adherence rate [32,33].”
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“Several studies show that Web-based psychological treatments are effective for the treatment of depression, in both unguided and guided interventions, although the effects are more favorable in the latter case [33,36-38].”
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“, outside controlled research settings, has smaller effects and a higher attrition rate when compared to computerized CBT in adults who are recruited for participation in research [22].”
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“Moderate effect sizes in terms of reductions in depressive symptoms have been noted in CBT based online interventions, but a meta-analysis indicated low impact on functioning [10,54].”
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“First, a plethora of articles stated a lack of research that details the process of implementing iCBT in naturalistic settings; therefore, more research is needed to understand and improve iCBT uptake [38,44,52,56-58, 60, 64, 65 ].”
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“al [48] that found short-term effects of internet-based treatments for MDD but no effects beyond 6 months posttreatment.”
Telepsychiatry in an Era of Digital Mental Health Startups
Achtyes, E. D., Glenn, T., Monteith, S., Geddes, J. R., Whybrow, P. C., Martini, J., & Bauer, M. (2023) · Current Psychiatry Reports · doi:10.1007/s11920-023-01425-9 · Cited by 32
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“Although the potential effects of iCBT in reducing depressive symptoms have been shown in meta-analyses [3, 4], the effects were observed to be transient and the participants’ drop-out rate was high [5].”
BackgroundSelf-citationAkechi, T., Yamaguchi, T., Uchida, M., Imai, F., Momino, K., Katsuki, F., Sakurai, N., Miyaji, T., Horikoshi, M., Furukawa, T. A., et al. (2018) · BMJ Open · doi:10.1136/bmjopen-2018-024794 · Cited by 27
Self-citationAutomatic Identification of Depression Using Facial Images with Deep Convolutional Neural Network
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Computer-Assisted CBT and Mobile Apps for Depression: Assessment and Integration Into Clinical Care
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“Thus, current literature suggests supplementing pharmacological interventions with cognitive behavioral therapy (CBT) as the most effective combination treatment for the management of major depression in most patients [11,12].”
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“However, longterm remission rates from depression or anxiety symptoms after low-intensity treatment appear to be low (Ali et al., 2017) and dropout rates are high (So et al., 2013), which may result in further demoralization and reduced treatment seeking.”
BackgroundResultInfluentialGiosan, C., Cobeanu, O., Mogoaşe, C., Szentagotai, A., Mureşan, V., & Boian, R. (2017) · Trials · doi:10.1186/s13063-017-1960-1 · Cited by 23
“Moreover, the benefits of treatment have been reported to be rather short lived, the impact on functioning was found to be minimal, and high attrition rates seriously limited the potential clinical benefits [17].”
BackgroundYu, S., Liu, Y., Cao, M., Tian, Q., Xu, M., Yu, L., Yang, S., & Zhang, W. (2025) · Cancer Nursing · doi:10.1097/ncc.0000000000001274 · Cited by 22
Taylor, A., Tallon, D., Kessler, D. S., Peters, T. J., Shafran, R., Williams, C., & Wiles, N. (2019) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2019.1641146 · Cited by 25
“Whilst some investigators have found that computerised CBT is acceptable to both patients and therapists, trial outcomes have been mixed (Gilbody et al., 2015; So et al., 2013).”
BackgroundBrief Online Self-help Exercises for Postnatal Women to Improve Mood: A Pilot Study
Ayers, S., Fitzgerald, G., & Thompson, S. (2015) · Maternal and Child Health Journal · doi:10.1007/s10995-015-1755-5 · Cited by 22
Integrating the Digital and the Traditional to Deliver Therapy for Depression
Stawarz, K., Preist, C., Tallon, D., Thomas, L., Turner, K. M., Wiles, N., Kessler, D. S., Shafran, R., & Coyle, D. (2020) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3313831.3376510 · Cited by 27
“They can be an effective first-step approach in treating symptoms of depression [1, 29, 57], but cCBT has been predominantly used for low-intensity treatment [53] and improvements in depression tend to be short-term and drop-out rates high [34, 66].”
BackgroundPihlaja, S., Lahti, J. M. T., Lipsanen, J. O., Ritola, V., Gummerus, E.-M., Stenberg, J., & Joffe, G. (2020) · Journal of Medical Internet Research · doi:10.2196/15732 · Cited by 23
Are Trials of Computerized Therapy Generalizable? A Multidimensional Meta-analysis
Wilks, C. R., Zieve, G. G., & Lessing, H. K. (2016) · Telemedicine and e-Health · doi:10.1089/tmj.2015.0129 · Cited by 18
Rodriguez-Pulido, F., Castillo-Sánchez, G., Hamrioui, S., Martin, L. D., Vazquez-Beltrán, P., Díez, I. D. L. T., & Franco, M. (2020) · Journal of Medical Systems · doi:10.1007/s10916-020-1543-7 · Cited by 21
Klein, N. S., Kok, G. D., Burger, H., van Valen, E., Riper, H. M., Cuijpers, P. J., Dekker, J., Smit, F., van der Heiden, C., & Bockting, C. (2018) · Psychotherapy and Psychosomatics · doi:10.1159/000485039 · Cited by 20
Krejtz, I., Holas, P., Rusanowska, M., & Nezlek, J. B. (2018) · Journal of Clinical Psychology · doi:10.1002/jclp.22617 · Cited by 20
Yokomitsu, K., Irie, T., Sekiguchi, M., Shimizu, A., Matsuoka, H., Merry, S., & Stasiak, K. (2020) · JMIR Research Protocols · doi:10.2196/15164 · Cited by 16
“Considering these findings, we assumed a similar effect size (0.60) to that of internet-based and other computerized psychological treatments or game-based digital interventions against wait-list [22,35,36] for the reduction of primary outcomes assessed using Patient Health Questionnaire-9 (PHQ-9).”
InfluentialRodríguez-Fernández, J. M., Danies, E., Hoertel, N., Galanter, W., Saner, H. E., & Franco, O. H. (2021) · Journal of Applied Gerontology · doi:10.1177/07334648211056231 · Cited by 17
“Telemedicine alternatives in mental health care can facilitate therapy delivery, information resources, counseling, and networking (Cooper, 2013; Dölemeyer et al., 2013; So et al., 2013).”
BackgroundLobban, F. A., Appelbe, D. E., Appleton, V., Billsborough, J., Fisher, N. R., Foster, S., Gill, B., Glentworth, D., Harrop, C. E., Johnson, S., et al. (2020) · BMC Health Services Research · doi:10.1186/s12913-020-5002-4 · Cited by 18
“Despite substantial investment, many DHIs are either not adopted by their intended users, are abandoned, fail to scale up locally or spread to other settings, or are not sustained over time [9, 10].”
BackgroundMoving towards the benign: automatic interpretation bias modification in dysphoria
Cowden Hindash, A. H., & Rottenberg, J. A. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.09.005 · Cited by 15
Yoshizaki, A., Murata, E., Yamamoto, T., Fujisawa, T. X., Hanaie, R., Hirata, I., Matsumoto, S., Mohri, I., & Taniike, M. (2023) · JMIR mhealth and uhealth · doi:10.2196/40836 · Cited by 18
“One of the goals of remote interventions such as mHealth or computerized cognitive behavioral therapy is to minimize dropouts and maintain intervention adherence—high dropout rates, which can reach up to 80%, have been one of the main issues plaguing remote cognitive behavioral therapy [44-47].”
Kanapathy, J., & Bogle, V. (2019) · Journal of Health Psychology · doi:10.1177/1359105317713360 · Cited by 14
Patient experience of supported computerized CBT in an inner-city IAPT service: a qualitative study
Perera-Delcourt, R. P., & Sharkey, G. (2019) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x18000284 · Cited by 14
“…be less impressive and have shorter-term effect, and also be compromised by higher drop-out, than previously considered (de Graaf et al. , 2009); particularly when publication bias and detail of study findings are taken into account, according to the largest meta-analysis to date (So et al. , 2013).”
BackgroundGiosan, C., Cobeanu, O., Mogoaşe, C., Szentágotai Tătar, A., Mureşan, V., & Boian, R. (2016) · Trials · doi:10.1186/s13063-016-1740-3 · Cited by 13
Internetbasierte Therapie in der Versorgung von Patienten mit depressiven Störungen: Ein Überblick
Backenstrass, M., & Wolf, M. (2018) · Zeitschrift für Psychiatrie Psychologie und Psychotherapie · doi:10.1024/1661-4747/a000339 · Cited by 8
Psychology in the Age of Austerity
Ferraro, D. J. (2016) · Psychotherapy and Politics International · doi:10.1002/ppi.1369 · Cited by 12
Rajeshkumar, L., Mishkind, M. C., Coleman, J. J., Pahwa, M., LaPreze, D., Solenske, S., & Wright, J. H. (2024) · Journal of Psychiatric Practice · doi:10.1097/pra.0000000000000815 · Cited by 12
Szigethy, E., Solano, F., Wallace, M., Perry, D. L., Morrell, L., Scott, K., Bell, M. J., & Oser, M. (2018) · BMJ Open · doi:10.1136/bmjopen-2017-019108 · Cited by 10
In-Depth Co-Design of Mental Health Monitoring Technologies by People with Lived Experience
Patrickson, B., Musker, M., Thorpe, D., van Kasteren, Y., Bidargaddi, N. P., & The Consumer and Carer Advisory Group (CCAG) (2023) · Future Internet · doi:10.3390/fi15060191 · Cited by 11
Computerised cognitive behaviour therapy for major depression: a reply to the REEACT trial
Andrews, G., Hobbs, M., & Newby, J. (2016) · Evidence-Based Mental Health · doi:10.1136/eb-2015-102293 · Cited by 13
Dissemination of computer-assisted cognitive-behavior therapy for depression in primary care
Antle, B. F., Owen, J. J., Eells, T. D., Wells, M. J., Harris, L. M., Cappiccie, A., Wright, B., Williams, S. M., & Wright, J. H. (2018) · Contemporary Clinical Trials · doi:10.1016/j.cct.2018.11.001 · Cited by 10
Fulford, H., McSwiggan, L. C., Kroll, T., & MacGillivray, S. A. (2016) · JMIR Mental Health · doi:10.2196/mental.5966 · Cited by 9
“However, in a recent meta-analysis of computerized cognitive behavioral therapy (cCBT) by So et al [9] only short-term reductions in symptoms were noted, long-term follow-up and functional improvement were not significant and there was a recommendation that the clinical usefulness of cCBT should be reconsidered downwa…”
Psychological Wellbeing and Work
Stolk, C. V., Hofman, J., Hafner, M., & Janta, B. (2014) · Cited by 8
Amer, N. A., Shohieb, S. M., Eladrosy, W., Liu, S., Nam, Y., & Abdelrazek, S. M. (2024) · Digital Health · doi:10.1177/20552076241263317 · Cited by 8
Mental Health and the Self-Tracking Student
Weinberg, L. (2021) · Catalyst Feminism Theory Technoscience · doi:10.28968/cftt.v7i1.34039 · Cited by 7
“…online measures involving selfadministration and mindfulness techniques have been shown to have “high dropout rates” and “no long-term benefits” (So et al. 2013), and yet is increasingly advocated for in a range of institutional contexts, including schools, workplaces, | Catalyst: Feminism,…”
BackgroundΠαπαδάτου-Παστού, Μ., Goozée, R., Barley, E. A., Haddad, M., & Tzotzoli, P. (2015) · Pilot and Feasibility Studies · doi:10.1186/s40814-015-0029-8 · Cited by 8
Computerised self help for depression in primary care
Dowrick, C. F. (2015) · BMJ · doi:10.1136/bmj.h5942 · Cited by 7
Exploring the use of mobile information and communication technologies by people with mood disorders
Fulford, H., McSwiggan, L. C., Kroll, T., & MacGillivray, S. A. (2019) · International Journal of Mental Health Nursing · doi:10.1111/inm.12632 · Cited by 6
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Du, E., Quayle, E., & Macleod, H. (2021) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x21000210 · Cited by 5
“Furthermore, the use and uptake of CCBT to date is still low, which remains a challenge and a cause for concern (Clarke et al., 2015; Gilbody et al., 2015; Richards and Richardson, 2012; So et al., 2013; Wright et al., 2019).”
Internet-Delivered Psychotherapy for Anxiety Disorders and Depression
Titov, N., Dear, B. F., & Andersson, G. (2014) · Focus · doi:10.1176/appi.focus.12.3.299 · Cited by 5
Practical Development of a Robot to Assist Cognitive Reconstruction in Psychiatric Day Care
Akiyoshi, T., Sumioka, H., Kumazaki, H., Nakanishi, J., Kato, H., & Shiomi, M. (2023) · ACM/IEEE International Conference on Human-Robot Interaction (HRI) · doi:10.1145/3568294.3580150 · Cited by 5
“Although such support is necessary, the number of psychiatrists, nurses, and counselors who specialize in CBT is still limited [26].”
BackgroundMethodCan Cognitive Therapy Be Conducted by Computers?
Eells, T. D., Barrett, M. S., Wright, J. H., & Thase, M. E. (2015) · Current Behavioral Neuroscience Reports · doi:10.1007/s40473-015-0051-4 · Cited by 5
“A meta-analysis by So and colleagues [22] explicitly focused on two issues of concern raised in the Richards and”
MethodMacKinnon, D. F., & Chen, L. N. (2024) · Springer eBooks · doi:10.1007/978-3-030-51366-5_20 · Cited by 5
Luberto, C. M., Perez, G. K., Finkelstein‐Fox, L., Millstein, R. A., Fell, L. A., Chad‐Friedman, E., Park, E. R., & Kuhlthau, K. A. (2021) · Global Advances in Health and Medicine · doi:10.1177/21649561211047804 · Cited by 4
Barriers to Implementation of a Technology-Based Mental Health Intervention in a Rural Setting
Antle, B. F., Harris, L. M., Wright, J. H., Eells, T. D., Cappiccie, A., Williams, S. M., Katz, R., Logsdon, A. R., & Owen, J. J. (2021) · Contemporary Rural Social Work Journal · doi:10.61611/2165-4611.1220 · Cited by 3
“…compared to waitlist controls, information control, treatment as usual, or placebo (Andrews et al., 2018; Thase et al., 2018; Wright et al., 2018; So et al., 2013; Wilks et al., 2016; Richards & Richardson, 2012; Andrews et al., 2010), with changes sustained six weeks to six months post…”
Background
Metadata
- Authors
- So, M., Yamaguchi, S., Hashimoto, S., Sado, M., Furukawa, T. A., & McCrone, P.
- Affiliations
- King's College London (GB)
- National Center of Neurology and Psychiatry (JP)
- Edogawa University (JP)
- Keio University (JP)
- Kyoto University (JP)
- Corresponding author
- So, Mirai
- Venue
- BMC Psychiatry
- Published
- 2013-04-15
- Volume
- 13
- Issue
- 1
- Pages
- 113-113
- ISSN
- 1471-244X (ISSN-L)
- PMC
- PMC3638010
- OpenAlex
- W1998160684
- Cited by
- 129
- References
- 66
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 6 · 2023: 8 · 2022: 8 · 2021: 9 · 2020: 11 · 2019: 9 · 2018: 18 · 2017: 15 · 2016: 14 · 2015: 16 · 2014: 8 · 2013: 1
- FWCI
- 19.87
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Psychiatry (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- Funders
- Japan Society for the Promotion of Science (25293150)
- 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 › Psychotherapy Techniques and Applications
- Keywords
- computerized cognitive behavioral therapy, adult depression, treatment effectiveness, long-term follow-up, functional improvement, dropout, publication bias, risk of bias, methodological validity, clinical implementation
- MeSH terms
- Adult, Depressive Disorder, Humans, Therapy, Computer-Assisted, Cognitive Behavioral Therapy, Treatment Outcome
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