In the absence of effects: an individual patient data meta-analysis of non-response and its predictors in internet-based cognitive behavior therapy
Open accessAbstract
Background: Negative effects of psychological treatments have recently received increased attention in both research and clinical practice. Most investigations have focused on determining the occurrence and characteristics of deterioration and other adverse and unwanted events, such as interpersonal issues, indicating that patients quite frequently experience such incidents in treatment. However, non-response is also negative if it might have prolonged an ongoing condition and caused unnecessary suffering. Yet few attempts have been made to directly explore non-response in psychological treatment or its plausible causes. Internet-based cognitive behavior therapy (ICBT) has been found effective for a number of diagnoses but has not yet been systematically explored with regard to those patients who do not respond. Methods: The current study collected and aggregated data from 2866 patients in 29 clinical randomized trials of ICBT for three categories of diagnoses: anxiety disorders, depression, and other (erectile dysfunction, relationship problems, and gambling disorder). Raw scores from each patient variable were used in an individual patient data meta-analysis to determine the rate of non-response on the primary outcome measure for each clinical trial, while its potential predictors were examined using binomial logistic regression. The reliable change index (RCI) was used to classify patients as non-responders. Results: Of the 2118 patients receiving treatment, and when applying a RCI of z ≥ 1.96, 567 (26.8%) were classified as non-responders. In terms of predictors, patients with higher symptom severity on the primary outcome measure at baseline, Odds Ratio (OR) = 2.04, having a primary anxiety disorder (OR = 5.75), and being of male gender (OR = 1.80), might have higher odds of not responding to treatment. Conclusion: Non-response seems to occur among approximately a quarter of all patients in ICBT, with predictors related to greater symptoms, anxiety disorders, and gender indicating increasing the odds of not responding. However, the results need to be replicated before establishing their clinical relevance, and the use of the RCI as a way of determining non-response needs to be validated by other means, such as by interviewing patients classified as non-responders.
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A recent meta-analysis including 2,118 patients receiving internet-based cognitive behavior therapy has shown that more severe anxiety symptoms represent a crucial factor for successful positive ED outcomes.
“A recent meta-analysis including 2,118 patients receiving internet-based cognitive behavior therapy has shown that more severe anxiety symptoms represent a crucial factor for successful positive ED outcomes.22”
From A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM) (2021) · cites this paper as [22]
The Results (Study Characteristics) confirm that 2,118 patients received ICBT and that one included trial concerned erectile dysfunction. But the Discussion says higher baseline symptom severity might increase the odds of non-response, not successful outcomes; it does not establish this predictor specifically for erectile dysfunction. (LLM, conf=0.90)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredGiven that iCBT has an estimated non-response rate of 25%, alternative interventions such as iACT may prove to be a useful alternative.
“Given that iCBT has an estimated non-response rate of 25 % according to a recent meta-analysis (Rozental et al., 2019), alternative interventions such as iACT may prove to be a useful alternative.”
From An open trial of the feasibility of brief internet-delivered acceptance and commitment therapy (iACT) for chronic anxiety and depression (2023) · cites this paper as Rozental et al., 2019
The observed nonresponse rates are in line with meta-analytic findings on response rates in internet-based settings.
“while in line with meta-analytic findings on response rates in internet-based settings (Rozental etal., 2019)”
From Transdiagnostic Processes as Mediators of Change in an Internet-Delivered Intervention Based on the Unified Protocol (2022) · cites this paper as Rozental et al., 2019
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“05) was used as a conservative criterion for both reliable improvement and deterioration [92].”
MethodInternet Interventions in Clinical Psychology
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- Authors
- Rozental, A., Andersson, G., & Carlbring, P.
- Affiliations
- Karolinska Institutet (SE)
- Linköping University (SE)
- Stockholm University (SE)
- Corresponding author
- Carlbring, Per
- Venue
- Frontiers in Psychology
- Publisher
- Frontiers Media SA
- Published
- 2019-03-29
- Volume
- 10
- Pages
- 589-589
- ISSN
- 1664-1078 (ISSN-L)
- PMC
- PMC6450428
- OpenAlex
- W2928191556
- Cited by
- 74
- References
- 102
- Citations by year
- 2026: 5 · 2025: 10 · 2024: 15 · 2023: 11 · 2022: 13 · 2021: 7 · 2020: 7 · 2019: 6
- FWCI
- 1.17
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Psychology (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- University of Southern Denmark Research Portal (University of Southern Denmark) (publishedVersion, cc-by)
- KTH Publication Database DiVA (KTH Royal Institute of Technology) (submittedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- 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
- internet-based cognitive behavioral therapy, predictors of non-response, anxiety disorders, depression, erectile dysfunction, relationship problems, gambling addiction, symptom severity, gender differences, reliable change index
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