Improving Adherence and Clinical Outcomes in Self-Guided Internet Treatment for Anxiety and Depression: A 12-Month Follow-Up of a Randomised Controlled Trial
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BACKGROUND: A recent paper reported the outcomes of a study examining a new self-guided internet-delivered treatment, the Wellbeing Course, for symptoms of anxiety or depression. This study found the intervention resulted in significant symptom reductions. It also found that automated emails increased treatment completion and clinical improvements in a subsample with elevated anxiety and depression. AIMS: To examine the clinical outcomes and the effect of automated emails at 12 months post-treatment. METHOD: Participants, who were randomly allocated to a Treatment Plus Automated Emails Group (TEG; n = 100), a standard Treatment Group (TG; n = 106) or delayed-treatment Waitlist Control Group (Control; n = 51), were followed up at 12 months post-treatment. Eighty-one percent, 78% and 87% of participants in the TEG, TG and treated Waitlist Control Group provided symptom data at 12-month follow-up, respectively. The primary outcome measures were the Patient Health Questionnaire-9 Item Scale (PHQ-9) and the Generalized Anxiety Disorder-7 Item Scale (GAD-7). RESULTS: Significant improvements in symptoms of anxiety and depression were observed over time in both the TEG and TG (Fs >69, ps <.001) these were sustained from post-treatment to 12-month follow-up (ps >.05), and were associated with large effect sizes. No statistically significant differences in symptoms were found between the TEG and TG at post-treatment, 3-month or 12-month follow-up. Previously reported symptom differences between TEG and TG participants with comorbid symptoms were no longer present at 12-month follow-up (ps >.70). CONCLUSIONS: The overall benefits of the Wellbeing Course were sustained at 12-month follow-up. Although automated emails facilitated Course completion and reductions in symptoms for participants with comorbid anxiety and depression from pre-post treatment, these differences were no longer observed at 12-month follow-up. The results indicate that automated emails promote more rapid treatment response for people with elevated and comorbid symptoms, but may not improve longer term outcomes. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610001058066.
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Self-help interventions have a small but significant effect size compared to a control condition.
“the results so far indicate a small but significant effect size of these self-help interventions compared to a control condition [43–47].”
From An Internet-based treatment for flying phobia (NO-FEAR Airlines): Study protocol for a randomized controlled trial (2016) · cites this paper as [43]
The Results > Effect Sizes section reports large or moderate-to-large improvements within the treatment groups, but describes the small between-group effect sizes as non-significant. The Methods > Design and Sample Size section clarifies that this follow-up presents data for the waitlist control group after it received treatment, rather than a significant small effect against an untreated control condition. No page numbers are available in our copy. (LLM, conf=0.86)
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Experimental — accuracy not yet measuredUnguided self-help interventions are useful alternatives with similar outcomes that might work using automated reinforcement.
“other authors have shown that unguided self-help interventions are useful alternatives with similar outcomes that might work using automated reinforcement [40, 42, 43].”
From An Internet-based treatment for flying phobia (NO-FEAR Airlines): Study protocol for a randomized controlled trial (2016) · cites this paper as [43]
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Self-citationTechnology-based mental health assessment and intervention
Gould, C. E., Ma, F., Loup, J. R., Juang, C., Sakai, E. Y., & Pepin, R. L. (2020) · Elsevier eBooks · doi:10.1016/b978-0-12-800136-3.00024-7 · Cited by 9 · see citing works
Hill, J. J., Kuyken, W., & Richards, D. A. (2014) · Trials · doi:10.1186/1745-6215-15-452 · Cited by 8 · see citing works
ICBT in Psychiatry: Generalised Anxiety Disorder
Titov, N., Andersson, G., & Paxling, B. (2016) · Springer eBooks · doi:10.1007/978-3-319-06083-5_5 · Cited by 7 · see citing works
Self-citationSharma, R., Devi, K., Modi, M. K., & Sen, P. (2021) · 3 Biotech · doi:10.1007/s13205-021-02723-w · Cited by 6 · see citing works
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 · see citing works
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Morthland, M., Shah, A., Meadows, J. T., & Scogin, F. R. (2019) · Aging & Mental Health · doi:10.1080/13607863.2019.1609901 · Cited by 5 · see citing works
Ahmadi, F. B., Dehghan, M. J., Baharvand, V., & Azizi, A. (2023) · Frontiers in Health Informatics · doi:10.30699/fhi.v12i0.410 · Cited by 6 · see citing works
Elvira, A. C., Santacreu, M., Giráldez, C. A. M., & Shih, P. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2571 · Cited by 4 · see citing works
LeBlanc, J., Talbot, F., Fournier, V., Titov, N., & Dear, B. F. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100529 · Cited by 4 · see citing works
Self-citationMartel, M.-E., Dionne, F., Pagé, M. G., & Choinière, M. (2024) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2024.100760 · Cited by 3 · see citing works
Fournier, V., Talbot, F., Hadjistavropoulos, H. D., Titov, N., Dear, B. F., Lang, R., Saulnier, V., Hébert, H., & Cloutier, G. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100813 · Cited by 3 · see citing works
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Lister, H. (2016) · Cited by 3 · see citing works
Debrot, A., Kheyar, M., Efinger, L., Berthoud, L., & Pomini, V. (2022) · JMIR Research Protocols · doi:10.2196/39026 · Cited by 3 · see citing works
Debrot, A., Efinger, L., Kheyar, M., Pomini, V., & Berthoud, L. (2024) · JMIR Formative Research · doi:10.2196/57294 · Cited by 2 · see citing works
The Use of Technology to Augment Clinical Care in Depression and Anxiety Disorders: An Evidence Map
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Stepped Care for Depression: A Systematic Review and Feasibility Study
Hill, J. J. (2016) · Open Research Exeter (University of Exeter) · Cited by 2 · see citing works
Mindfulness in the Metaverse: Examinations into Women’s Well-being
Ranade, T., & Menon, P. P. (2022) · IEEE International Conference for Women in Innovation, Technology & Entrepreneurship (ICWITE) · doi:10.1109/icwite57052.2022.10176261 · Cited by 2 · see citing works
Internet-Delivered Cognitive Behaviour Therapy (ICBT) for Older Adults with Anxiety and Depression
Dear, B. F., Silfvernagel, K., & Fogliati, V. J. (2016) · Springer eBooks · doi:10.1007/978-3-319-06083-5_12 · Cited by 1 · see citing works
Self-citationPsychosocial Treatment of Anxiety in Later Life
Ramos, K., & Stanley, M. A. (2021) · Cambridge University Press eBooks · doi:10.1017/9781139087469.011
The application of Internet-based intervention in the treatment of depression
Xie, M., Gao, R., & Deng, K. (2022) · International Symposium on Artificial Intelligence for Medicine Sciences (ISAIMS) · doi:10.1145/3570773.3570846
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Less Might Not Be More, but May Be Enough for Some
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Bolarinwa, O. A., Mohammed, A., & Olawade, D. B. (2026) · Springer eBooks · doi:10.1007/978-3-031-97088-7_5
- Authors
- Titov, N., Dear, B. F., Johnston, L., McEvoy, P. M., Wootton, B., Terides, M. D., Gandy, M., Fogliati, V., Kayrouz, R., & Rapee, R. M.
- Affiliations
- Macquarie University (AU)
- The University of Western Australia (AU)
- Corresponding author
- Titov, Nickolai
- ORCID
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2014-02-25
- Volume
- 9
- Issue
- 2
- Pages
- e89591
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC3934918
- OpenAlex
- W1982865464
- Cited by
- 81
- References
- 34
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 5 · 2023: 4 · 2022: 6 · 2021: 11 · 2020: 1 · 2019: 7 · 2018: 4 · 2017: 5 · 2016: 18 · 2015: 12 · 2014: 6
- FWCI
- 21.18
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- EPubDev Repository (submittedVersion)
- eCite Digital Repository (University of Tasmania) (submittedVersion, cc-by)
- UWA Profiles and Research Repository (University of Western Australia) (submittedVersion, other-oa)
- UWA Profiles and Research Repository (UWA) (submittedVersion, other-oa)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- eSpace (Curtin University) (submittedVersion, cc-by)
- Figshare (submittedVersion, cc-by)
- UTS ePRESS (University of Technology Sydney) (submittedVersion)
- RUNE (Research UNE) (submittedVersion)
- Funders
- Medical Research Council
- National Health and Medical Research Council (630560)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- anxiety, depression, medication adherence, treatment completion, comorbid depression and anxiety, PHQ-9, GAD-7, digital mental health interventions
- MeSH terms
- Anxiety Disorders, Depressive Disorder, Follow-Up Studies, Humans, New Zealand, Prognosis, Psychotherapy, Therapy, Computer-Assisted, Time Factors, Comorbidity, Case-Control Studies, Patient Satisfaction, Internet, Medication Adherence
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