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Dropout from Internet‐based treatment for psychological disorders
Open accessAbstract
Purpose. The purpose of this review was to present an in‐depth analysis of literature identifying the extent of dropout from Internet‐based treatment programmes for psychological disorders, and literature exploring the variables associated with dropout from such programmes. Methods. A comprehensive literature search was conducted on PSYCHINFO and PUBMED with the keywords: dropouts, drop out, dropout, dropping out, attrition, premature termination, termination, non‐compliance, treatment, intervention, and program, each in combination with the key words Internet and web. A total of 19 studies published between 1990 and April 2009 and focusing on dropout from Internet‐based treatment programmes involving minimal therapist contact were identified and included in the review. Results. Dropout ranged from 2 to 83% and a weighted average of 31% of the participants dropped out of treatment. A range of variables have been examined for their association with dropout from Internet‐based treatment programmes for psychological disorders. Despite the numerous variables explored, evidence on any specific variables that may make an individual more likely to drop out of Internet‐based treatment is currently limited. Conclusions. This review highlights the need for more rigorous and theoretically guided research exploring the variables associated with dropping out of Internet‐based treatment for psychological disorders.
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“We observed a study dropout rate of 20%. In comparison to reported treatment dropout rates from efficacy studies among children and adolescents in an outpatient mental health care setting [63] as well as to these reported from internet-based interventions for mental disorders in AYA [64, 65], this rate is above average.”
From Feasibility and potential efficacy of a guided internet- and mobile-based CBT for adolescents and young adults with chronic medical conditions and comorbid depression or anxiety symptoms (youthCOACHCD): a randomized controlled pilot trial (2022) · cites this paper as [64]
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“This was a higher rate than the previous study using NO-FEAR Airlines (Campos et al., 2019), but closer to dropout rates traditionally proposed in the literature, where an average dropout rate of 31% has been reported (Melville et al., 2010), and similar to previous studies carried out with phobic patients, which report a 40.8% dropout rate (Kok et al., 2014).”
From An internet-based treatment for flying phobia using 360° images: A feasibility pilot study (2022) · cites this paper as Melville et al., 2010
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“This was comparable to another self-guided study using a 9-module, 2-week online program (75%; [27]) with similar financial incentives for the participants to take part, and on the higher end of other guided internet-based treatment programs (average adherence rates of 31%, range of 2%-83%) [37].”
From Development and feasibility of a digital acceptance and commitment therapy⇓based intervention for generalized anxiety disorder: Pilot acceptability study (2021) · cites this paper as [37]
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“For instance, Melville and colleagues reported an average drop-out rate of 31% in a systematic review.50”
From Clinical and cost-effectiveness of a guided internet-based Acceptance and Commitment Therapy to improve chronic pain-related disability in green professions (PACT-A): Study protocol of a pragmatic randomised controlled trial (2020) · cites this paper as [50]
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“To avoid a loss of power, the sample size was increased for this study, taking into account an average drop-out rate of 31%.50”
From Clinical and cost-effectiveness of a guided internet-based Acceptance and Commitment Therapy to improve chronic pain-related disability in green professions (PACT-A): Study protocol of a pragmatic randomised controlled trial (2020) · cites this paper as [50]
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“Similarly, concerns related to sustained engagement with web-based psychiatric interventions have been reported in routine-care implementation studies [4-6,17].”
From Digital Mental Health Interventions for Depression: Scoping Review of User Engagement (2022) · cites this paper as [17]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“early studies of unguided ICBT suffered from high drop out rates (a weighted average of 31% of the participants dropped out of treatment in 19 studies of Internetbased treatment pro grams for psychological disorders) 75”
From Internet-delivered psychological treatments: from innovation to implementation (2019) · cites this paper as [75]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“Nevertheless, the drop-out rates we observed are in line with those reported previously for online studies.”
From Reducing Test Anxiety During the COVID-19 Pandemic: A Comparison of the Effectiveness of Cognitive Behavioral Therapy and Acceptance and Commitment Therapy (2024) · cites this paper as Melville et al., 2010
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In the citing paper
“Melville et al. (2010), for example, reported that drop-out rates in an assesment of 56 online intervention studies were as much as 83% but had an average of 35%.”
From Reducing Test Anxiety During the COVID-19 Pandemic: A Comparison of the Effectiveness of Cognitive Behavioral Therapy and Acceptance and Commitment Therapy (2024) · cites this paper as Melville et al., 2010
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“This study found that approximately 41% of participants completed the study and that, on average, the final sample completed 70% of the intervention, which is higher than seen in most of the literature [48-50].”
From A Cognitive Behavioral Therapy Chatbot (Otis) for Health Anxiety Management: Mixed Methods Pilot Study (2022) · cites this paper as [49]
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“An a priori power analysis [41] estimated the targeted sample size to be N = 286 based on an expected treatment effect of d = 0.42 [83] at an alpha level of 5% of a one-tailed t-test, a power of 90% and an expected dropout rate of 31% [84].”
From Lessons Learned from an Attempted Pragmatic Randomized Controlled Trial for Improvement of Chronic Pain-Associated Disability in Green Professions: Long-Term Effectiveness of a Guided Online-Based Acceptance and Commitment Therapy (PACT-A) (2022) · cites this paper as [84]
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In the citing paper
“Also when it comes to interventions of longer periods, there is the risk of losing motivation to continue (Melville et al., 2010)”
From A Self-Applied Multi-Component Psychological Online Intervention Based on UX, for the Prevention of Complicated Grief Disorder in the Mexican Population During the COVID-19 Outbreak: Protocol of a Randomized Clinical Trial (2021) · cites this paper as Melville et al., 2010
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“and also when they are receiving online treatment, there is a bigger dropout of men than women, however the results are still inconclusive and further research needs to be conducted (Melville et al., 2010).”
From A Self-Applied Multi-Component Psychological Online Intervention Based on UX, for the Prevention of Complicated Grief Disorder in the Mexican Population During the COVID-19 Outbreak: Protocol of a Randomized Clinical Trial (2021) · cites this paper as Melville et al., 2010
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“a systematic review from 2010 reported a wide range of adherence rates (2%-83% [37]) in 16 studies using internet-based interventions and specifically called for analysis of variables associated with dropout.”
From Development and feasibility of a digital acceptance and commitment therapy⇓based intervention for generalized anxiety disorder: Pilot acceptability study (2021) · cites this paper as [37]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Since the present study aims for long-term follow-up and drop-out is assumed, the estimated sample size of 196 will be increased to be able to compensate a drop-out rate of 31%. Thus, the targeted total sample size of this study is going to be 286.”
From Clinical and cost-effectiveness of a guided internet-based Acceptance and Commitment Therapy to improve chronic pain-related disability in green professions (PACT-A): Study protocol of a pragmatic randomised controlled trial (2020) · cites this paper as [50]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“In addition, prior studies have shown that IMIs are frequently accompanied by high drop-out rates,36 50 51 which can lead to a significant loss of power.”
From Clinical and cost-effectiveness of a guided internet-based Acceptance and Commitment Therapy to improve chronic pain-related disability in green professions (PACT-A): Study protocol of a pragmatic randomised controlled trial (2020) · cites this paper as [50]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“This is in line with similar eHealth studies where one meta-analysis reported a 23% dropout overall for eHealth interventions57 and another which reported a weighted average attrition of 35% for online interventions.71”
From Novel ACT-based eHealth psychoeducational intervention for students with mental distress: A study protocol for a mixed-methodology pilot trial (2019) · cites this paper as [71]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Such non-adherence may arise from the requirement of active, self-motivated participation, which may act as a barrier to engagement [29].”
From Mindfulness for pain, depression, anxiety, and quality of life in people with spinal cord injury: A systematic review (2020) · cites this paper as [29]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The literature on side-effects of online psychological treatments is in its infancy, and although studies are beginning to emerge documenting participants' difficulties during online CBT (Boettcher et al., 2014; Melville et al., 2010), it is not yet known whether online mindfulness interventions are associated with any adverse events or side effects, particularly when participants undergo”
From Online mindfulness-enhanced cognitive behavioural therapy for anxiety and depression: Outcomes of a pilot trial (2018) · cites this paper as Melville et al., 2010
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Although some clinicians argue that some patients discontinue treatment due to major improvements already made during the current path of treatment, this is rather unlikely [51].”
From Efficacy and Acceptance of Cognitive Behavioral Therapy in Adults with Chronic Fatigue Syndrome: A Meta-analysis. (2024) · cites this paper as [51]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The mean rate of adherence to protocol (82.6%) was higher than published means for CBT based interventions where dropout rates range from 2% to 83% [60] and was comparable to the rates of adherence for the control groups (83.4%).”
From Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis. (2016) · cites this paper as [60]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“For each group, drop-out occurred leaving 30 participants in the ACT group and 47 in the CBT group (these rates are consistent with previous research, e.g., Melville et al., 2010).”
From Reducing Test Anxiety During the COVID-19 Pandemic: A Comparison of the Effectiveness of Cognitive Behavioral Therapy and Acceptance and Commitment Therapy (2024) · cites this paper as Melville et al., 2010
The cited source says what the claim attributes to it.
In the citing paper
“Adherence and dropouts are among the most discussed issues related to self-guided interventions (Cavanagh, 2010; Melville et al., 2010).”
From Internet-based self-administered intervention to reduce anxiety and depression symptomatology and improve well-being in 7 countries: protocol of a randomized control trial (2024) · cites this paper as Melville et al., 2010
The cited source says what the claim attributes to it.
In the citing paper
“First, previous research findings have shown high dropout rates in studies of internet psychological interventions [94].”
From Effectiveness and mediators of change of an online CBT intervention for students with adjustment disorder—study protocol for a randomized controlled trial (2023) · cites this paper as [94]
The cited source says what the claim attributes to it.
In the citing paper
“However, drop-out rates vary greatly across studies.36 50 51 Consequently, this study could also be underpowered or overpowered.”
The cited source says what the claim attributes to it.
In the citing paper
“Second, drop-out in internet-based interventions can be moderately to high (Melville et al., 2010), which can lead to reduced power of analyses.”
From The efficacy of automated feedback after internet-based depression screening: Study protocol of the German, three-armed, randomised controlled trial DISCOVER (2021) · cites this paper as Melville et al., 2010
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In the citing paper
“The attrition rates predicted are in line with reported rates in similar eHealth studies57 71”
From Novel ACT-based eHealth psychoeducational intervention for students with mental distress: A study protocol for a mixed-methodology pilot trial (2019) · cites this paper as [71]
The cited source says what the claim attributes to it.
In the citing paper
“Taking into account the significant dropout rate from IBIs (73, 81–83), this result shows the relevance of working to improve the participants’ expectations as a way to promote program adherence.”
The cited source says what the claim attributes to it.
In the citing paper
“While adherence to the program (59%) was consistent with some previously reported adherence rates (Melville et al., 2010), it was lower than adherence to the original 6-lesson iCBT delivered over 10 weeks (89%) reported by Newby et al. (2013), despite comparable clinician time spent per participant.”
From Online mindfulness-enhanced cognitive behavioural therapy for anxiety and depression: Outcomes of a pilot trial (2018) · cites this paper as Melville et al., 2010
The cited source says what the claim attributes to it.
In the citing paper
“The literature on side-effects of online psychological treatments is in its infancy, and although studies are beginning to emerge documenting participants' difficulties during online CBT (Boettcher et al., 2014; Melville et al., 2010), it is not yet known whether online mindfulness interventions are associated with any adverse events or side effects, particularly when participants undergo”
From Online mindfulness-enhanced cognitive behavioural therapy for anxiety and depression: Outcomes of a pilot trial (2018) · cites this paper as Melville et al., 2010
The cited source says what the claim attributes to it.
In the citing paper
“A systematic review of attrition rates from Internet-based treatment programs where therapist contact was minimal found an average dropout rate of 35%, with a range of 2% to 83% [46].”
From Feasibility and effectiveness of a web-based positive psychology program for youth mental health: Randomized controlled trial (2014) · cites this paper as [46]
The cited source says what the claim attributes to it.
In the citing paper
“Attrition rates were commensurate to other website interventions based on other therapy models [32], and treatment satisfaction was rated above average to high among participants who completed their respective iACT program.”
From Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review. (2019) · cites this paper as [32]
The cited source says what the claim attributes to it.
In the citing paper
“The mean attrition rate across all included studies (19.19%) was lower than the median dropout rate of 24% identified across other Web-based interventions, and lower than the weighted average of 35% [32].”
From Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review. (2019) · cites this paper as [32]
The cited source says what the claim attributes to it.
In the citing paper
“The mean attrition rate across all included studies (19.19%) was lower than the median dropout rate of 24% identified across other Web-based interventions, and lower than the weighted average of 35% [32].”
From Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review. (2019) · cites this paper as [32]
The check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“A further 13 participants in the intervention condition were deemed to be noncompliant because they reported using the incorrect website (see Figure 4) as per protocol [46,47].”
From Feasibility and effectiveness of a web-based positive psychology program for youth mental health: Randomized controlled trial (2014) · cites this paper as [46]
Experimental — accuracy not yet measuredIn the citing paper
“For example, study dropout or study attrition has been evaluated as a proxy for treatment dropout, with findings suggesting significant dropout [16-18].”
From Digital Mental Health Interventions for Depression: Scoping Review of User Engagement (2022) · cites this paper as [17]
In the citing paper
“Given these criteria, it is not surprising that many studies report variable adherence and completion rates [14,15] raising questions about satisfaction with e-mental health approaches [16].”
From Acceptability of Mental Health Apps for Aboriginal and Torres Strait Islander Australians: A Qualitative Study (2016) · cites this paper as [15]
In the citing paper
“We were confronted with a high attrition rate which is seen more often in Web-based interventions [71,72].”
From Long-Term Results of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Randomized Controlled Trial (2014) · cites this paper as [72]
In the citing paper
“others have found no association between adherence and age, gender, or education level [80,81].”
From Web-Based Interventions for Behavior Change and Self-Management: Potential, Pitfalls, and Progress (2012) · cites this paper as [81]
In the citing paper
“In our feasibility RCT, we found a dropout rate of 70%, which is consistent with other e-mental health studies [29,30].”
From Evaluating the Effectiveness of an E-Mental Health Intervention for People Living in Lebanon: Protocol for Two Randomized Controlled Trials (2021) · cites this paper as [30]
In the citing paper
“which is seen more often in Web-based interventions [73,74]”
From Short-Term Effects of a Web-Based Guided Self-Help Intervention for Employees With Depressive Symptoms: Randomized Controlled Trial (2014) · cites this paper as [74]
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Metadata
- Authors
- Melville, K. M., Casey, L. M., & Kavanagh, D. J.
- Affiliations
- Griffith University (AU)
- Queensland University of Technology (AU)
- Corresponding author
- Melville, Katherine M.
- ORCID
- Kavanagh, David J.
- Venue
- British Journal of Clinical Psychology
- Publisher
- Wiley
- Published
- 2010-11
- Volume
- 49
- Issue
- 4
- Pages
- 455-471
- ISSN
- 0144-6657 (ISSN-L)
- 2044-8260
- OpenAlex
- W1601069999
- Semantic Scholar
- c891fa1e16e494939665a91bf737cdb05e919d80
- Cited by
- 597
- References
- 60
- Citations by year
- 2026: 29 · 2025: 32 · 2024: 36 · 2023: 54 · 2022: 58 · 2021: 64 · 2020: 52 · 2019: 42 · 2018: 42 · 2017: 42 · 2016: 39 · 2015: 23 · 2014: 35 · 2013: 23 · 2012: 17
- FWCI
- 1.05
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- British Journal of Clinical Psychology (publishedVersion, other-oa)
- PubMed (publishedVersion)
- QUT ePrints (Queensland University of Technology) (submittedVersion, other-oa)
- Griffith Research Online (submittedVersion)
- Faculty of Health; Institute of Health and Biomedical Innovation
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- treatment discontinuation, attrition, online therapy, mental illness, predictors of dropout, medication adherence
- MeSH terms
- Anxiety Disorders, Mental Disorders, Cross-Sectional Studies, Depressive Disorder, Female, Humans, Male, Motivation, Patient Compliance, Patient Dropouts, Risk Factors, Stress Disorders, Post-Traumatic, Therapy, Computer-Assisted, Comorbidity, Cognitive Behavioral Therapy, Internet
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