Internet-based psychological treatments for depression
Open accessAbstract
Major depression is highly prevalent, and is associated with high societal costs and individual suffering. Evidence-based psychological treatments obtain good results, but access to these treatments is limited. One way to solve this problem is to provide internet-based psychological treatments, for example, with therapist support via email. During the last decade, internet-delivered cognitive-behavioral therapy (ICBT) has been tested in a series of controlled trials. However, the ICBT interventions are delivered with different levels of contact with a clinician, ranging from nonexisting to a thorough pretreatment assessment in addition to continuous support during treatment. In this review, the authors have found an evidence for a strong correlation between the degree of support and outcome. The authors have also reviewed how treatment content in ICBT varies among treatments, and how various therapist factors may influence outcome. Future possible applications of ICBT for depression and future research needs are also discussed.
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Written from the paper’s full text.
TL;DR
This review summarizes controlled trials of internet-based cognitive-behavioral therapy (ICBT) for depression and finds guided ICBT effective, with more human support associated with larger effects. It also reviews treatment content and therapist factors, noting limited evidence on therapist variables and need for future research.
Key findings
- Across 25 controlled trials (33 comparisons with control), effect sizes ranged from 0.10 to 1.20; the mean effect size was not reported because the report was not a formal meta-analysis. A prior meta-analysis found overall d = 0.41 (95% CI: 0.29–0.54), with guided treatments d = 0.61 (95% CI: 0.45–0.77) versus unguided d = 0.25 (95% CI: 0.14–0.35).
- Degree of human support correlated with outcome: average effect sizes by support category were d = 0.21, 0.44, 0.58, and 0.76; Spearman ρ = 0.64 (p < 0.01). A prior meta-analysis comparing guided self-help with face-to-face treatment found d = -0.03, indicating no difference in general.
- Most included studies used CBT, but problem-solving therapy and psychoeducation appeared comparable in efficacy; an internet-based psychodynamic treatment for depression had a between-group effect size of d = 1.11 (95% CI: 0.67–1.56) versus an active control. In relapse prevention, significantly fewer ICBT participants relapsed compared with control (10.5 vs 37.8%).
- Therapist factors showed small or nonexisting effects on some measures; Australian studies found no outcome differences between psychologist and technician delivery, and therapeutic alliance did not predict outcome in ICBT or face-to-face therapy for depression.
Methods
- Narrative review of controlled trials of ICBT for depression located via Medline, reference lists, and a search for ongoing studies by active researchers; 25 controlled trials were included, eight of which compared more than one treatment with a control, yielding 33 comparisons.
- Studies were categorized by degree of support: 0 = no human contact before, during, or after treatment; 1 = contact before treatment only; 2 = contact mainly during treatment; 3 = contact before, during, and after treatment. Effect sizes (Cohen’s d) were summarized, and a Spearman correlation between degree of support and effect size was calculated.
- The review also examined treatment content variations, specific populations, and therapist factors; it was not a formal meta-analysis.
Limitations
- The authors state the aim was not to conduct a formal meta-analysis, so the mean effect size is not reported; support categorization and moderator findings are exploratory.
- The authors note that no trial directly manipulates pretreatment contact, the effect of a clear deadline has not been tested explicitly in ICBT for depression, and little is known about therapist factors in ICBT.
- Evident from the text: this is a narrative review of heterogeneous trials with varying definitions of support; conclusions about support and therapist factors rely on indirect comparisons and small studies (e.g., Australian therapist-versus-technician studies each had only one therapist and one technician).
Model-written summary. Check it against the paper before relying on it.
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Cites
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Claims the paper makes
0 of 30 cited sources checked · 0 supported · 0 flagged
- Findingown data§ Abstract
There is a strong correlation between the degree of support and outcome in ICBT for depression (ρ=0.64, p<0.01).
“In this review, the authors have found an evidence for a strong correlation between the degree of support and outcome.”
- Also stated in: § How important is guidance in guided ICBT? · hedged
“A Spearman correlation of ρ = 0.64 (p < 0.01) was obtained between degree of support and effect size, indicating that more support yields larger effects.”
Quote in the paperSubstantial claim- Rests on an assumption: The association between degree of support and effect size is causal (more support causes larger effects).
- Also stated in: § How important is guidance in guided ICBT? · hedged
- Findingnone given§ Does treatment content in ICBT matter?
With a few exceptions, all published studies considered in this review have been based on CBT.
“With a few exceptions, all published studies considered in this review have been based on CBT.”
Quote in the paperNot a substantial claim - Findingnone given§ Abstract
ICBT interventions are delivered with different levels of contact with a clinician, ranging from nonexisting to a thorough pretreatment assessment in addition to continuous support during treatment.
“However, the ICBT interventions are delivered with different levels of contact with a clinician, ranging from nonexisting to a thorough pretreatment assessment in addition to continuous support during treatment.”
Quote in the paperSubstantial claim - Findingown data§ How important is guidance in guided ICBT?
In the review's categorization, average between-group effect sizes for degree of support categories 0, 1, 2, and 3 were d=0.21, 0.44, 0.58, and 0.76 respectively.
“The average effect sizes for the respective categories were d = 0.21, 0.44, 0.58 and 0.76.”
Quote in the paperSubstantial claim - Findingown data§ The present review
Across the 25 controlled trials reviewed, effect sizes ranged between 0.10 and 1.20.
“As seen in the table, effect sizes range between 0.10 and 1.20.”
Quote in the paperNot a substantial claim
- Interpretationreasoning§ Does treatment content in ICBT matter?
Psychological treatments other than CBT may be possible to deliver via the internet.
“This also indicates that psychological treatments other than CBT may be possible to deliver via the internet.”
Quote in the paperSubstantial claim - Interpretationcitation§ Internet-based psychological treatments for depression
It is possible to deliver an ICBT intervention to patients with bipolar disorder.
“Despite few differences between treatment and control, this study represents a proof-of-concept that it is possible to deliver an ICBT intervention to patients with bipolar disorder.”
Quote in the paperSubstantial claim - Premisecitation§ Internet-based psychological treatments for depression
Tailored ICBT is superior to nontailored ICBT for patients with more severe forms of depression.
“The study by Johansson et al. included a comparison between tailored and nontailored treatment for depression and provided data that indicate that tailored treatment is superior to nontailored treatment for patients with more severe forms of depression [26].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [26] Johansson, 2012, PLoS ONE source
Not checked in the free run.
- Premisecitation§ Abstract
Access to evidence-based psychological treatments for depression is limited.
“Evidence-based psychological treatments obtain good results, but access to these treatments is limited.”
- Also stated in: § CME · plain
“In a 2003 survey, approximately half of the 12-month cases in the USA were receiving treatment for depression, and only 18-25% were adequately treated [3].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [3] Kessler, 2003, JAMA source
Not checked in the free run.
- Also stated in: § CME · plain
- Premisecitation§ Does treatment content in ICBT matter?
There are few indications of differences in efficacy between various face-to-face psychological treatments for depression.
“These results are mirrored by the fact that there are few indications of differences in efficacy between various face-to-face psychological treatments for depression [4].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [4] Cuijpers, 2008, J. Consult. Clin. Psychol. source
Not checked in the free run.
- Premisecitation§ The overall effect of ICBT for depression
A meta-analysis on self-guided psychological treatments found an overall effect size of d=0.28 (95% CI 0.14-0.42).
“This result was mirrored by a meta-analysis on self-guided psychological treatments (not necessarily internet based or computer based) [9], which found an overall effect size of d = 0.28 (95% CI: 0.14-0.42).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [9] Cuijpers, 2011, PLoS ONE source
Not checked in the free run.
- Interpretationown data§ The overall effect of ICBT for depression
There is no evidence for a difference between guided ICBT and face-to-face therapy.
“In summary, there is mounting support for a difference between guided and unguided ICBT, but no evidence for a difference between guided ICBT and face-to-face therapy.”
Quote in the paperSubstantial claim- Rests on an assumption: The effect sizes from different meta-analyses (e.g., Cohen's d and Hedges's g) are comparable across analyses.
- Rests on an assumption: The face-to-face treatments in the meta-analysis by [11] are comparable to guided ICBT in the other meta-analyses.
- Premisecitation§ Internet-based psychological treatments for depression
In another study, adding ICBT to CAU did not improve the outcome.
“In another study, adding ICBT to CAU did not improve the outcome [19].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [19] de Graaf, 2009, Br. J. Psychiatry source
Not checked in the free run.
- Premisecitation§ The overall effect of ICBT for depression
A meta-analysis focused on ICBT for depression and anxiety found an overall effect size (Hedges's g) of g=0.78 for the depression studies.
“Another metaanalysis, which focused on ICBT for both depression and anxiety disorders, found an overall effect size (Hedges's g) of g = 0.78 for the depression studies [10].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [10] Andrews, 2010, PLoS ONE source
Not checked in the free run.
- Interpretationown data§ The overall effect of ICBT for depression
There is mounting support for a difference between guided and unguided ICBT.
“In summary, there is mounting support for a difference between guided and unguided ICBT, but no evidence for a difference between guided ICBT and face-to-face therapy.”
Quote in the paperSubstantial claim - Interpretationreasoning§ The overall effect of ICBT for depression
Guided ICBT for depression may be on a par with face-to-face treatment.
“These average effect sizes indicate that guided ICBT for depression may be on a par with face-to-face treatment.”
Quote in the paperSubstantial claim- Rests on an assumption: The effect sizes from different meta-analyses (e.g., Cohen's d and Hedges's g) are comparable across analyses.
- Interpretationcitation§ Internet-based psychological treatments for depression
With the exception of the study by Johansson et al., no study exists where differences in efficacy between ICBT treatments are observed.
“With the exception of study by Johansson et al., no study exists where differences in efficacy between ICBT treatments are observed [26].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [26] Johansson, 2012, PLoS ONE source
Not checked in the free run.
- Interpretationown data§ How important is guidance in guided ICBT?
More support yields larger effects in ICBT for depression.
“A Spearman correlation of ρ = 0.64 (p < 0.01) was obtained between degree of support and effect size, indicating that more support yields larger effects.”
Quote in the paperSubstantial claim- Rests on an assumption: The association between degree of support and effect size is causal (more support causes larger effects).
- Interpretationcitation§ Internet-based psychological treatments for depression
ICBT can enhance regular treatment in terms of efficacy.
“This study is an example of how ICBT can enhance regular treatment in terms of efficacy.”
Quote in the paperSubstantial claim - Premisenone given§ Internet-based psychological treatments for depression
There are important differences between the therapist-supported intervention in the study by Kessler et al. [28] and the nonguided intervention in the study by de Graaf et al. [19].
“However, despite similar delivery context and study design, there are important differences between the therapist-supported intervention in the study by Kessler et al. [28] and the nonguided intervention in the study by de Graaf et al. [19].”
Quote in the paperSubstantial claim0 of 2 sources checked - Interpretationown data§ How important is guidance in guided ICBT?
Guided internet-based psychological treatments are more effective than unguided treatments.
“In conclusion, there is now a strong support for the claim that guided internet-based psychological treatments are more effective than unguided treatments.”
Quote in the paperSubstantial claim - Premisecitation§ Internet-based psychological treatments for depression
In a trial of partially remitted depression, significantly fewer participants receiving ICBT experienced relapse compared with control (10.5% vs 37.8%).
“Significantly, fewer participants receiving ICBT experienced relapse compared with those in the control group (10.5 compared with 37.8%), which is in line with previous face-to-face studies [30].”
Quote in the paperSubstantial claim0 of 2 sources checked - Interpretationreasoning§ Does treatment content in ICBT matter?
Psychological treatments other than CBT can be delivered through the internet.
“These studies suggest that psychological treatments other than CBT can be delivered through the internet and open up a mixture of various treatment approaches”
Quote in the paperSubstantial claim - Interpretationreasoning§ How important is guidance in guided ICBT?
The effect of guidance may be moderated by whether pretreatment contact is available.
“The categorization of studies after degree of support indicates that the effect of guidance may be moderated by whether pretreatment contact is available.”
Quote in the paperSubstantial claim - Premisecitation§ How important is guidance in guided ICBT?
Two recent studies on unguided treatments showed medium-to-large effects when including a contact by telephone before treatment.
“For example, two recent studies on unguided treatments showed medium-to-large effects when including a contact by telephone before treatment [16,17].”
Quote in the paperNot a substantial claim0 of 2 sources checked - Premisecitation§ The overall effect of ICBT for depression
In that meta-analysis, the effect size was significantly moderated by guided (d=0.61; 95% CI 0.45-0.77) versus unguided (d=0.25; 95% CI 0.14-0.35) treatments.
“Importantly, this effect size was significantly moderated by a difference between guided (d = 0.61; 95% CI: 0.45-0.77)and unguided (d = 0.25; 95% CI: 0.14-0.35)treatments.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [8] Andersson, 2009, Cogn. Behav. Ther. source
Not checked in the free run.
- Premisecitation§ Key issues
In three Australian studies, data give no support for differences in treatment outcome between psychologist and computer technician therapists in ICBT.
“While each study only had one therapist and one technician, the data give no support for differences in treatment outcome between therapists in ICBT.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [37][38][39]
Not checked in the free run.
- Premisecitation§ Key issues
In two Swedish studies, small intraclass correlations on some measures indicate nonexisting or small therapist effects in ICBT.
“Small intraclass correlations are found on some measures, indicating nonexisting or small therapist effects in ICBT [34,35].”
Quote in the paperNot a substantial claim0 of 2 sources checked - Interpretationreasoning§ Internet-based psychological treatments for depression
ICBT has proven to be a way to reach out to new populations.
“As depression continues to be a worldwide health problem, ICBT has proven to be a way to reach out to new populations.”
Quote in the paperSubstantial claim - Interpretationreasoning§ Key issues
There are some indications that nonclinicians may be able to provide ICBT.
“There are some indications that nonclinicians may be able to provide ICBT.”
Quote in the paperNot a substantial claim - Premisecitation§ Expert commentary & five-year view
A technician can deliver internet-delivered cognitive-behavioral therapy (ICBT) with preserved efficacy.
“• Indicates that a technician can deliver ICBT with preserved efficacy.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [37] Titov, 2010, PLoS ONE source
Not checked in the free run.
- Interpretationreasoning§ Key issues
It is possible to specify therapist behavior as certain 'roles', which even nonclinical staff can adhere to.
“The Australian studies indicate that it is possible to specify the therapist behavior as certain 'roles', which even nonclinical staff can adhere to.”
Quote in the paperNot a substantial claim
- May combine two claims. 9
- Classified as probably not a substantial claim. 12
May combine two claims.
Findingown data§ Key issuesIn the authors' research group's ICBT trials, high alliance ratings were found, but alliance ratings cannot predict treatment outcome.
“Although high alliance ratings have been found in the trials, we cannot predict treatment outcome using alliance ratings.”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationcitation§ How important is guidance in guided ICBT?Pretreatment contact is often in the form of a structured diagnostic interview and probably results in more reliable diagnostic categories for inclusion in a trial.
“This pretreatment contact is often in the form of a structured diagnostic interview [20,21], and probably results in more reliable diagnostic categories for inclusion in a trial.”
Quote in the paperNot a substantial claim0 of 2 sources checkedMay combine two claims.
Premisecitation§ Does treatment content in ICBT matter?Internet-based problem-solving therapy and psychoeducational intervention seem comparable in efficacy to CBT for depression.
“Both these treatments seem to be comparable in efficacy to CBT [13,14].”
Quote in the paperSubstantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).
Premisecitation§ Internet-based psychological treatments for depressionThere are few indications of differential efficacy between active ICBT treatments.
“This study is one of the few that provides some indications of differential efficacy between active treatments.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [26] Johansson, 2012, PLoS ONE source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Interpretationreasoning§ Internet-based psychological treatments for depressionThe primary benefit of transdiagnostic treatment is that it makes the procedure of treatment selection less demanding.
“The primary benefit of this kind of 'one size fits all' treatment is that it makes the procedure of treatment selection less demanding.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Interpretationreasoning§ How important is guidance in guided ICBT?Pretreatment contact could enhance guided treatments that do not have a telephone or face-to-face contact before treatment.
“Figure 1 indicates that a pretreatment contact could enhance guided treatments, which do not have a telephone or face-to-face contact before treatment.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Interpretationreasoning§ How important is guidance in guided ICBT?Reliable diagnostic procedures may enhance overall treatment effects by ensuring that the patients included in the treatment present with problems that the treatment is intended to treat.
“In addition, reliable diagnostic procedures may also enhance overall treatment effects, for example, by ensuring that the patients included in the treatment present with problems, that the treatment is intended to treat.”
Quote in the paperNot a substantial claimMay combine two claims.
Premisecitation§ Internet-based psychological treatments for depressionIndividually tailored ICBT has proven efficacy compared with control for mixed anxiety and for depression with high comorbid anxiety.
“Recent results exist proving the efficacy compared with control for mixed anxiety [25,27] and in the treatment of depression with a high amount of comorbid anxiety [26].”
Quote in the paperSubstantial claim0 of 3 sources checkedMay combine two claims.
Interpretationcitation§ Expert commentary & five-year viewInternet-based psychological treatments are important treatment alternatives that can be as effective as face-to-face CBT.
“Recent reviews conclude that internet-based psychological treatments are important treatment alternatives that can be as effective as face-to-face CBT.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Interpretationcitation§ Expert commentary & five-year viewTailored internet-delivered cognitive-behavioral therapy (ICBT) may work better than nontailored treatment for more severely depressed patients.
“Table: that tailored ICBT may work better than nontailored treatment for more severely depressed patients.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [26] Johansson, 2012, PLoS ONE source
Not checked in the free run.
Probably not a substantial claim: may not pass S4 (based). May combine two claims.
Interpretationnone given§ Key issuesUnified and tailored ICBT approaches provide a promising treatment development that may broaden the scope of ICBT.
“Unified and tailored ICBT approaches provide a promising treatment development that may broaden the scope of ICBT.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).
Interpretationnone given§ Key issuesModern technology, such as smartphones and artificial intelligence, may potentially enhance ICBT.
“Modern technology, such as smartphones and artificial intelligence, may potentially enhance ICBT.”
Quote in the paperNot a substantial claimMay combine two claims.
Premisecitation§ Key issuesIn a study of ICBT and face-to-face therapy for depression, therapeutic alliance was present and comparable but could not predict treatment outcome.
“While alliance was present and comparable in the two groups, it could not predict treatment outcome in any of the two treatment groups.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [40] Preschl, 2011, BMC Psychiatry source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ Expert commentary & five-year viewDeprexis, the treatment tested by Meyer et al. [23] and Berger et al. [16], is an example of a blend of cognitive-behavioral therapy (CBT) with non-CBT components, including positive psychology interventions, dreamwork, and emotion-focused interventions above more traditional cognitive and behavioral techniques.
“Deprexis, the treatment tested by Meyer et al. [23] and Berger et al. [16], is an example of such a blend as it includes positive psychology interventions, dreamwork and emotion-focused interventions above more traditional cognitive and behavioral techniques.”
Quote in the paperNot a substantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.
Interpretationreasoning§ Expert commentary & five-year viewPretreatment interviews involving diagnostic procedures could prevent prescribing ICBT to patients who drop out immediately or receive a treatment that does not suit their problem profile.
“As pretreatment interviews often involve diagnostic procedures, the time invested could also prevent prescribing ICBT to patients who drop out immediately or receive a treatment that does not suit their problem profile.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).
Interpretationreasoning§ Expert commentary & five-year viewAn unguided self-help program with a thorough assessment and clear deadline may be easier to implement in primary care than a treatment that requires continuous therapist support.
“For example, an unguided self-help program with a thorough assessment and clear deadline may be easier to implement in primary care than a treatment that requires continuous therapist support.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Interpretationcitation§ Key issuesMicroanalyses of therapist behavior in ICBT may enhance ICBT for depression and other conditions.
“This study opens the way for microanalyses of therapist behavior in ICBT, which may enhance ICBT for depression and other conditions.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
Interpretationnone given§ Key issuesContact before and/or after the treatment may potentially enhance both guided and unguided ICBT.
“Contact before and/or after the treatment may potentially enhance both guided and unguided ICBT.”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationnone given§ Key issuesInternet-based psychological treatments are effective and provide an important treatment alternative to face-to-face psychological treatments and medication.
“Internet-based psychological treatments are effective and provide an important treatment alternative to face-to-face psychological treatments and medication.”
Quote in the paperNot a substantial claim
The paper relies on this without support.
The association between degree of support and effect size is causal (more support causes larger effects).
“A Spearman correlation of ρ = 0.64 (p < 0.01) was obtained between degree of support and effect size, indicating that more support yields larger effects.”
The paper relies on this without support.
The effect sizes from different meta-analyses (e.g., Cohen's d and Hedges's g) are comparable across analyses.
“These average effect sizes indicate that guided ICBT for depression may be on a par with face-to-face treatment.”
The paper relies on this without support.
The face-to-face treatments in the meta-analysis by [11] are comparable to guided ICBT in the other meta-analyses.
“The overall betweengroup effect size was d = -0.03,indicating no difference between internet-based and face-to-face treatments in general.”
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?
Integration of human coaching and support in digital mental health interventions can help improve adherence and behavior change outcomes.
“The integration of human coaching and support in digital mental health interventions can help improve adherence and behavior change outcomes [17,18]”
From Engagement and effectiveness of a healthy-coping intervention via chatbot for university students during the COVID-19 pandemic: Mixed methods proof-of-concept study (2021) · cites this paper as [17]
In “How important is guidance in guided ICBT?” (page not provided), the review defines support as human contact and reports that greater support is associated with larger treatment effects. The “Key issues” section (page not provided) also reports an association between therapist behaviors and module completion, which bears on adherence. The paper does not establish improved behavior-change outcomes as distinct from treatment effects, and its evidence concerns internet-based psychological treatment rather than digital mental health interventions generally. (LLM, conf=0.84)
Experimental — accuracy not yet measuredLiterature shows that in online programs without support, preceding human contact increases effectiveness.
“The literature shows that, in online programs without support during the intervention, preceding human contact increases the effectiveness (20); therefore, it would be interesting during this contact to transmit the rationale and the usefulness of the program.”
From Exploring the relationship between the acceptability of an internet-based intervention for depression in primary care and clinical outcomes: Secondary analysis of a randomized controlled trial (2019) · cites this paper as [20]
In “How important is guidance in guided ICBT?” (page unavailable), the review reports larger average effects for programs with pretreatment contact than for those with no human contact, and medium-to-large effects in two unguided studies with prior telephone contact. But two unguided studies with prior face-to-face contact had low or nearly nonexistent effects; the authors say the effect of pretreatment contact remains uncertain and has not been directly tested. The claim states an increase in effectiveness more definitively than the source supports. (LLM, conf=0.87)
Experimental — accuracy not yet measuredThe Internet has been shown to be an effective tool for treating a broad range of psychological disorders and psychiatric conditions, particularly depression and anxiety disorders.
“The Internet has been shown to be an effective tool for treating a broad range of psychological disorders and psychiatric conditions, particularly depression and anxiety disorders [33–35]”
From An Internet-based treatment for flying phobia (NO-FEAR Airlines): Study protocol for a randomized controlled trial (2016) · cites this paper as [34]
The section “Internet-based psychological treatments for depression” reports that a transdiagnostic internet-based treatment appears effective for both depression and anxiety, and describes efficacy results for tailored treatments. The review does not establish effectiveness across the broader range of psychological disorders and psychiatric conditions claimed. (LLM, conf=0.84)
Experimental — accuracy not yet measuredGuidance is a beneficial feature that leads to better adherence and better outcomes in programs administered through the Internet.
“evidence shows that guidance is a beneficial feature that leads to better adherence and better outcomes in programs administered through the Internet [34, 39–41].”
From An Internet-based treatment for flying phobia (NO-FEAR Airlines): Study protocol for a randomized controlled trial (2016) · cites this paper as [34]
The section “How important is guidance in guided ICBT?” reports that guided Internet-based treatments are more effective than unguided treatments and that greater support is associated with larger effects. It does not establish the claimed improvement in adherence; a search for adherence found no supporting passage. The review also concerns Internet-based psychological treatments for depression, rather than Internet-administered programs generally. Page numbers were not available in our copy. (LLM, conf=0.86)
Experimental — accuracy not yet measuredOverall, people benefit from iCBT when paired with therapist assistance or used alone, although the magnitude of effect is likely higher for programs with therapist assistance.
“Overall, people benefit from iCBT when paired with therapist assistance or used alone, although the magnitude of effect is likely higher for programs with therapist assistance (9).”
From Improving Acceptability and Uptake Behavior for Internet-Based Cognitive-Behavioral Therapy (2021) · cites this paper as [9]
Internet-based interventions are effective in treating depression.
“The results obtained so far are consistent and promising, showing that Internet-based interventions are effective in treating depression.”
A growing body of research supports the efficacy of Internet-based interventions for the treatment of depression.
“A growing body of research supports the efficacy of Internet-based interventions (IBIs) for the treatment of depression (17, 20–24).”
There is a strong correlation between outcome and amount of therapeutic support in self-help interventions.
“Johansson and Andersson (2012) found a strong correlation between the outcome and the amount of therapeutic support.”
From Using a transdiagnostic, psychodynamic online self-help intervention to maintain inpatient psychosomatic treatment effects: Study protocol of a feasibility study (2016) · cites this paper as Johansson and Andersson, 2012
A growing number of studies report effectiveness of chatbots in reducing perceived stress.
“as well as their effectiveness in reducing perceived stress [16-25]”
From Engagement and effectiveness of a healthy-coping intervention via chatbot for university students during the COVID-19 pandemic: Mixed methods proof-of-concept study (2021) · cites this paper as [17]
The present review discusses controlled trials of internet-delivered treatments for depression, not chatbot studies. Searches for chatbots and perceived-stress reduction found no passage in our copy addressing the attributed claim. (LLM, conf=0.76)
Experimental — accuracy not yet measuredCBT is suitable for implementation in digital health interventions.
“Moreover, and with regard to its structure, it is suitable for implementation in digital health interventions [37-40].”
From Mobile Sensing and Support for People With Depression: A Pilot Trial in the Wild (2016) · cites this paper as [37]
eHealth interventions that include some form of guidance are associated with larger effect sizes than those that do not.
“It is consistently shown that eHealth interventions that include some form of guidance are associated with larger effect sizes than those that do not [60]”
From eHealth interventions for the prevention of depression and anxiety in the general population: a systematic review and meta-analysis (2017) · cites this paper as [60]
Internet-based interventions have shown to be effective in community and clinical settings, including the treatment of depression, anxiety and sleep disorders.
“Internet-based interventions have shown to be effective in community and clinical settings, including the treatment of depression [14–16], anxiety [17, 18] and sleep disorders [19].”
Internet-based mental health interventions without guidance are often much less effective than interventions including at least some guidance from a professional.
“Internet-based mental health interventions without guidance are often much less effective than interventions including at least some guidance from a professional [15, 16].”
Johannson and Andersson suggested a linear positive effect of therapist guidance on symptom outcome, with between-group Cohen's d effect sizes of 0.21 for no therapist contact, 0.44 for contact before treatment, 0.58 for contact during treatment, and 0.76 for contact before and during treatment.
“They suggest a linear positive effect, that is, no therapist contact showed a between-group Cohen’s d effect size of d = 0.21, whereas therapist contact before treatment resulted in d = 0.44 and during treatment in d = 0.58. Therapist contact before and during treatment produced an effect size of d = 0.76.”
From Low intensity technology-delivered cognitive behavioral therapy for obsessive-compulsive disorder: a meta-analysis (2021) · cites this paper as [72]
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.
“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 [42]
Effect sizes have been estimated at d=0.44-1.90 for clinician-supported, and d=0.21-0.70 for self-guided, interventions.
“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 [42]
The effect sizes on depression symptoms in this study (partial eta2 = .021 for the full population and partial eta2 = .093 for those with EAP access, converting to approximately Cohen's d=0.30 and 0.64, respectively) are comparable to those reported for previous meta-analyses of self-guided, Internet-based CBT programs (Cohen's d=0.21-0.31).
“The effect sizes on depression symptoms in this study (partial eta2 = .021 for the full population and partial eta2 = .093 for those with EAP access, which convert to approximately Cohen’s d=0.30 and 0.64, respectively) are comparable to those reported for previous meta-analyses of self-guided, Internet-based CBT programs (Cohen’s d=0.21-0.31) [42,44].”
From MoodHacker Mobile Web App With Email for Adults to Self-Manage Mild-to-Moderate Depression: Randomized Controlled Trial (2016) · cites this paper as [42]
Evidence from prior online CBT-based programs suggests that supporting the mobile intervention with counselors, such as those working in EAPs, is likely to increase both adherence to the app and efficacy in reducing depression symptoms.
“Evidence from prior online CBT-based programs suggests that supporting the mobile intervention with counselors, such as those working in EAPs, is likely to increase both adherence to the app and efficacy in reducing depression symptoms [42,43,47,89].”
From MoodHacker Mobile Web App With Email for Adults to Self-Manage Mild-to-Moderate Depression: Randomized Controlled Trial (2016) · cites this paper as [42]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Reported effect-size range excludes values in Table 1
MinorThe review says effect sizes start at 0.10, but Table 1 reports an effect size of 0.00 for Clarke et al. (2002).
“As seen in the table, effect sizes range between 0.10 and 1.20.”
“| Clarke et al. | USA | | None | None | 1. CBT | 144 | 1 = 2 | CES-D | 0.00 | [45] |”
Category 3 support has conflicting definitions
MinorThe text requires contact before, during and after treatment for category 3, while the Figure 1 description defines it using only contact before and during treatment.
“Finally, the degree of support was defined as 3 when there was a contact with the research staff or clinicians before, during and after the treatment period.”
“3, contact both before and during treatment.”
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“range, but somewhat below average, whereas the effects on SWLS and on depression and anxiety measured with HADS were commensurable to effects found previously for similar measures [12-14,27,99,100].”
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“The integration of human coaching and support in digital mental health interventions can help improve adherence and behavior change outcomes [17,18], although this may reduce the scalability of such solutions.”
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“Research on depression has shown that more severely affected patients respond better to tailored, rather than to nontailored treatment [128].”
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“Moreover, supported Internet-delivered interventions evidence both greater program adherence [12] and stronger effects than self-directed interventions [13], with more frequent support resulting in greater symptom change [14].”
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“Adherence rates and outcomes appear more favorable when active human support or guidance is integrated into the digital tool (12, 13), but this limits scalability.”
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- Authors
- Johansson, R., & Andersson, G.
- Affiliations
- Linköping University (SE)
- Venue
- Expert Review of Neurotherapeutics
- Publisher
- Informa UK Limited
- Published
- 2012-07
- Volume
- 12
- Issue
- 7
- Pages
- 861-870
- ISSN
- 1473-7175 (ISSN-L)
- 1744-8360
- OpenAlex
- W2086497737
- Cited by
- 509
- References
- 51
- Citations by year
- 2026: 12 · 2025: 17 · 2024: 22 · 2023: 36 · 2022: 35 · 2021: 43 · 2020: 37 · 2019: 35 · 2018: 48 · 2017: 51 · 2016: 55 · 2015: 44 · 2014: 38 · 2013: 35 · 2012: 1
- FWCI
- 52.89
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Expert Review of Neurotherapeutics (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Linköpings Universitet
- Vetenskapsrådet
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Keywords
- internet-based psychological treatment, major depressive disorder, internet-based cognitive behavioral therapy, therapist support, treatment outcomes, access to mental health care, treatment content, therapist factors
- MeSH terms
- Depression, Humans, Cognitive Behavioral Therapy, Internet
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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.
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