During the last two decades, Internet-delivered cognitive behavior therapy (ICBT) has been tested in hundreds of randomized controlled trials, often with promising results. However, the control ...groups were often waitlisted, care-as-usual or attention control. Hence, little is known about the relative efficacy of ICBT as compared to face-to-face cognitive behavior therapy (CBT). In the present systematic review and meta-analysis, which included 1418 participants, guided ICBT for psychiatric and somatic conditions were directly compared to face-to-face CBT within the same trial. Out of the 2078 articles screened, a total of 20 studies met all inclusion criteria. Results showed a pooled effect size at post-treatment of Hedges g = .05 (95% CI, −.09 to .20), indicating that ICBT and face-to-face treatment produced equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there have been few studies of the individual psychiatric and somatic conditions so far, and for the majority, guided ICBT has not been compared against face-to-face treatment. Thus, more research, preferably with larger sample sizes, is needed to establish the general equivalence of the two treatment formats.
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BFBNIB, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Providing therapist‐guided cognitive behaviour therapy via the Internet (ICBT) has advantages, but a central research question is to what extent similar clinical effects can be obtained as with ...gold‐standard face‐to‐face cognitive behaviour therapy (CBT). In a previous meta‐analysis published in this journal, which was updated in 2018, we found evidence that the pooled effects for the two formats were equivalent in the treatment of psychiatric and somatic disorders, but the number of published randomized trials was relatively low (n=20). As this is a field that moves rapidly, the aim of the current study was to conduct an update of our systematic review and meta‐analysis of the clinical effects of ICBT vs. face‐to‐face CBT for psychiatric and somatic disorders in adults. We searched the PubMed database for relevant studies published from 2016 to 2022. The main inclusion criteria were that studies had to compare ICBT to face‐to‐face CBT using a randomized controlled design and targeting adult populations. Quality assessment was made using the Cochrane risk of bias criteria (Version 1), and the main outcome estimate was the pooled standardized effect size (Hedges’ g) using a random effects model. We screened 5,601 records and included 11 new randomized trials, adding them to the 20 previously identified ones (total n=31). Sixteen different clinical conditions were targeted in the included studies. Half of the trials were in the fields of depression/depressive symptoms or some form of anxiety disorder. The pooled effect size across all disorders was g=0.02 (95% CI: –0.09 to 0.14) and the quality of the included studies was acceptable. This meta‐analysis further supports the notion that therapist‐supported ICBT yields similar effects as face‐to‐face CBT.
Background and Aims
Most alcohol‐dependent people have a moderate level of dependence. General practitioners (GPs) hesitate to engage in this area, and need to have access to treatment they find ...applicable and feasible to use. The aim of this present study was to test if an open‐ended internet‐based cognitive–behavioral therapy (iCBT) program added to treatment‐as‐usual (TAU) is more effective than TAU‐only for alcohol‐dependent patients in primary care.
Design, Setting and Participants
The present study was a two‐group, parallel, randomized controlled superiority trial comparing iCBT+TAU versus TAU‐only at 3‐ and 12‐month follow‐ups. TAU was delivered at 14 primary care centers in Stockholm, Sweden. A total of 264 patients (mean age 51 years, of whom 148 were female and 116 were male) with alcohol dependence and hazardous alcohol consumption were enrolled between September 2017 and November 2019.
Measurements
Participants were randomized at a ratio of 1:1 to iCBT, as a self‐help intervention added to TAU (n = 132) or to TAU‐only (n = 132). The GPs gave participants in both treatment arms feedback on the assessments and biomarkers and offered TAU at the primary care center. Primary outcome was weekly alcohol consumption in g/week at 12‐month follow‐up, analyzed according to intention‐to‐treat (n = 132 + 132). The per‐protocol analysis included participants who completed at least one module of iCBT (n = 102 + 132).
Findings
There was no significant difference in weekly alcohol consumption between iCBT+TAU and TAU in the intention‐to‐treat (ITT) analysis at 12‐month follow‐up iCBT+TAU = 133.56 (95% confidence interval, CI = 100.94–166.19) and TAU = 176.20 (95% CI = 144.04–208.35), P = 0.068, d = 0.23. In the per‐protocol analysis, including only those who initiated iCBT, the iCBT+TAU group showed lower mean weekly alcohol consumption compared with TAU iCBT+TAU = 107.46 (95% CI = 71.17–143.74), TAU = 176.00 (95% CI = 144.21–207.80), P = 0.010, d = 0.42.
Conclusions
In Sweden, an internet‐based cognitive–behavioral program added to treatment‐as‐usual to reduce alcohol consumption showed weak evidence of a benefit at 12 months in the intention‐to‐treat analysis and good evidence of a benefit in the per‐protocol analysis.
Internet-based cognitive behavior therapy (ICBT) is a promising treatment that may increase availability of cognitive behavior therapy (CBT) for psychiatric disorders and other clinical problems. The ...main objective of this study was to determine the applications, clinical efficacy and cost-effectiveness of ICBT. The authors conducted a systematic review to identify randomized controlled trials investigating CBT delivered via the internet for adult patient populations. Searches to identify studies investigating cost-effectiveness of ICBT were also conducted. Evidence status for each clinical application was determined using the American Psychologist Association criteria for empirically supported treatments. Of 1104 studies reviewed, 108 met criteria for inclusion, of which 103 reported on clinical efficacy and eight on cost-effectiveness. Results showed that ICBT has been tested for 25 different clinical disorders, whereas most randomized controlled trials have been aimed at depression, anxiety disorders and chronic pain. Internet-based treatments for depression, social phobia and panic disorder were classified as well-established, that is, meeting the highest level of criteria for evidence. Effect sizes were large in the treatment of depression, anxiety disorders, severe health anxiety, irritable bowel syndrome, female sexual dysfunction, eating disorders, cannabis use and pathological gambling. For other clinical problems, effect sizes were small to moderate. Comparison to conventional CBT showed that ICBT produces equivalent effects. Cost-effectiveness data were relatively scarce but suggested that ICBT has more than 50% probability of being cost effective compared with no treatment or to conventional CBT when willingness to pay for an additional improvement is zero. Although ICBT is a promising treatment option for several disorders, it can only be regarded as a well-established treatment for depression, panic disorder and social phobia. It seems that ICBT is as effective as conventional CBT for respective clinical disorder, that is, if conventional CBT works then ICBT works. The large effects and the limited therapist time required suggest that the treatment is highly cost effective for well-established indications.
Internet‐delivered cognitive behavior therapy (ICBT) has been tested in many research trials, but to a lesser extent directly compared to face‐to‐face delivered cognitive behavior therapy (CBT). We ...conducted a systematic review and meta‐analysis of trials in which guided ICBT was directly compared to face‐to‐face CBT. Studies on psychiatric and somatic conditions were included. Systematic searches resulted in 13 studies (total N=1053) that met all criteria and were included in the review. There were three studies on social anxiety disorder, three on panic disorder, two on depressive symptoms, two on body dissatisfaction, one on tinnitus, one on male sexual dysfunction, and one on spider phobia. Face‐to‐face CBT was either in the individual format (n=6) or in the group format (n=7). We also assessed quality and risk of bias. Results showed a pooled effect size (Hedges' g) at post‐treatment of −0.01 (95% CI: −0.13 to 0.12), indicating that guided ICBT and face‐to‐face treatment produce equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there are still few studies for each psychiatric and somatic condition and many conditions for which guided ICBT has not been compared to face‐to‐face treatment. Thus, more research is needed to establish equivalence of the two treatment formats.
Objective: Systematic exposure is potentially an effective treatment procedure for treating irritable bowel syndrome (IBS), but little is known about the processes by which it achieves its effect on ...outcome. The aim of this study was to identify mediators in a previously published randomized dismantling trial in which participants with IBS were randomized to Internet-delivered cognitive-behavioral treatment (ICBT) that incorporated systematic exposure or to the same treatment protocol without exposure (ICBT-WE). Method: Weekly measurements of gastrointestinal anxiety-specific process variables (behavioral avoidance, gastrointestinal-specific anxiety) based on the gastrointestinal symptom-specific anxiety model, generic process variables (self-efficacy and mindful nonreactivity), and treatment outcome (IBS symptoms) were obtained from 309 participants with IBS. Growth models and cross-lagged panel models, estimated within structural equation modeling, were employed to evaluate mediators of outcome. Results: Parallel process growth modeling showed that behavioral avoidance, gastrointestinal-specific anxiety, self-efficacy mediated the incremental effect of ICBT compared to ICBT-WE. The mediated effect of avoidance was stronger for individuals scoring high on the avoidance variable at 1st measurement point. Cross-lagged regression analyses with random effects revealed that behavioral avoidance and gastrointestinal-specific anxiety had a stronger effect on subsequent symptom change rather than vice versa, whereas mindful nonreactivity and self-efficacy displayed the opposite pattern. Conclusions: The evidence collectively provided support for the hypothesis that exposure for IBS achieves its positive results by virtue of changing gastrointestinal anxiety-specific processes rather than generic processes. IBS-specific behavioral avoidance emerged as the most clear-cut mediator of the specific effect of exposure on outcome.
What is the public health significance of this article?
This study highlights the importance of changing maladaptive avoidance and gastrointestinal anxiety when treating individuals with irritable bowel syndrome using exposure therapy. Exposure-based interventions may be especially well suited for individuals who display a pattern of excessive avoidance behavior.
Background
Self‐harm is common and there is a need for studies that investigate the relevance of this behavior in clinical samples to inform risk assessment and treatment. The objectives in the ...current studies were to compare clinical and psychosocial correlates and subsequent adverse outcomes in youth who present to child and adolescent mental health services (CAMHS) with self‐harm only (SH), self‐harm with suicidality (SH+SU), with those without any indication of SH or SH+SU.
Methods
We conducted a case–control study and a longitudinal cohort study using data from a regional clinical care register, and Swedish national registers. The case–control study included all patients (5–17 years) between 2011 and 2015 (N = 25,161). SH and SH+SU cases were compared with controls (patients without SH) regarding a range of correlates. The longitudinal study included former CAMHS patients (N = 6,120) who were followed for a median time of 2.8 years after termination of CAMHS contact regarding outcomes such as clinical care consumption, social welfare recipiency, and crime conviction.
Results
In the case–control study, both the SH and SH+SU groups received more clinical care, had lower global functioning, and higher odds of having mental disorders compared to controls. In most comparisons, the SH+SU group had more problems than the SH group. In the longitudinal study, the same pattern emerged for most outcomes; for example, the adjusted hazard ratio for recurrent care due to self‐harm was 23.1 (95% confidence interval CI, 17.0–31.4) in the SH+SU group compared to 3.9 (95% CI, 2.3–6.7) in the SH group.
Conclusions
Adolescent patients presenting with self‐harm have higher risks for adverse outcomes than patients without self‐harm. Suicidality in addition to self‐harm is associated with more severe outcomes, importantly recurrent episodes of care for self‐harm.
Background
A recent randomized controlled trial (N = 140) was indicative of large and sustained average improvements of Internet‐based exposure for fibromyalgia, as compared to a waitlist. However, ...little is known about who benefits the most from this treatment.
Objectives
To test for potential moderating effects of age, educational attainment, the duration of fibromyalgia, baseline overall fibromyalgia severity, pain intensity, fibromyalgia‐related avoidance behaviour and symptom preoccupation on the waitlist‐controlled effect of 10 weeks of Internet‐based exposure for fibromyalgia.
Methods
Secondary analysis of a randomized controlled trial (ClinicalTrials.gov NCT02638636). We used linear mixed effects models to determine whether the waitlist‐controlled effect of exposure therapy on overall fibromyalgia severity (Fibromyalgia Impact Questionnaire) differed as a function of the potential moderators.
Results
Only pain intensity (0–10) was found to be a significant moderator, where a higher baseline pain intensity predicted a more limited waitlist‐controlled effect of Internet‐based exposure (B = 3.48, 95% CI: 0.84–6.13). Standardized point estimates of effects were small for the sociodemographic variables, and in the moderate range for some clinical variables that did not reach statistical significance such as behavioural avoidance and time with the fibromyalgia diagnosis.
Conclusions
Results suggest that Internet‐based exposure treatment was more useful for participants with lower baseline levels of pain, and less so for participants with higher baseline levels of pain. The treatment had relatively similar effects across the other tested moderators.
Significance
This study evaluated potential effect moderators in exposure‐based treatment for fibromyalgia. Results indicated that a higher level of pain intensity at baseline was predictive of a less favourable outcome. It may be extra important to monitor progression for these patients and to provide additional therapeutic support when needed.
Past research has failed to identify consistent moderators of outcomes in psychological treatments for irritable bowel syndrome (IBS). The aim of this study was to test previously identified ...mediators as potential moderators of the effects of exposure therapy on IBS symptoms in a previously published randomized component trial. In total, 309 participants with IBS were randomized to internet-delivered cognitive behavioral treatment that included exposure (ICBT) or to the same treatment protocol without exposure (ICBT-WE) and were asked to report on gastrointestinal symptoms at pretreatment, posttreatment and weekly during the treatment. Pretreatment scores of The Visceral Sensitivity Index (VSI) and The Irritable Bowel Syndrome Behavioral Responses Questionnaire (IBS-BRQ) (i.e., gastrointestinal anxiety and avoidance behavior) were evaluated as predictors and moderators. Piecewise latent growth curve models were employed to evaluate moderators during distinct phases of the trial, prior to and following the onset of exposure in ICBT. Results revealed that pretreatment scores on IBS-BRQ (avoidance) moderated the effect of exposure therapy during the specific phase in which exposure was implemented in ICBT, with higher avoidance scores linked to stronger positive effects of exposure. VSI did not serve as predictor nor moderator. Adding exposure to CBT seems to be especially important for persons with moderate to high levels of avoidance behaviors in order to reduce gastrointestinal symptoms.
•Moderators of exposure therapy for Irritable Bowel Syndrome (IBS) were evaluated.•Baseline scores of mediators of exposure therapy served as candidate moderators.•IBS-specific avoidance moderated the add-on effect of exposure on IBS-symptoms.
Aim
To validate child‐adapted shortened versions of the Irritable Bowel Syndrome‐Behavioural Responses Questionnaire (IBS‐BRQ; short scale denoted BRQ‐C) and the Visceral Sensitivity Index (VSI; ...short scale denoted VSI‐C) for children with functional abdominal pain disorders (FAPDs).
Methods
A child psychologist supervised by a child gastroenterologist was responsible for shortening the scales (BRQ‐C, 11 items; and VSI‐C, 7 items). Then, a sample of 89 children aged 8–12 years with FAPDs was used in the validation. Construct validity was assessed with correlations. Measures included gastrointestinal symptoms, quality of life, pain intensity and anxiety. Also, internal consistency, test–retest reliability, administration time and factor structure were assessed.
Results
Internal consistency for the BRQ‐C and the VSI‐C was α = 0.84 and α = 0.80, respectively. Correlations with related scales were similar between child‐adapted scales and original scales, indicating construct validity equivalence. Correlations between short scales and original scales were high. Mean administration time was reduced by 47% (BRQ‐C) and 42% (VSI‐C), compared with original scales. Test–retest reliability was r = 0.72 for BRQ‐C and r = 0.83 for VSI‐C. BRQ‐C had two factors (Avoidance and Bowel control). VSI‐C had a unifactorial structure.
Conclusion
The BRQ‐C and the VSI‐C were found to be time‐saving, reliable and valid for children with FAPDs.
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