Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms

Karyotaki, Eirini; Riper, Heleen; Twisk, Jos; Hoogendoorn, Adriaan; Kleiboer, Annet; Mira, Adriana; Mackinnon, Andrew; Meyer, Björn; Botella, Cristina; Littlewood, Elizabeth; Andersson, Gerhard; Christensen, Helen; Klein, Jan P.; Schröder, Johanna; Bretón-López, Juana; Scheider, Justine; Griffiths, Kathy; Farrer, Louise; Huibers, Marcus J. H.; Phillips, Rachel; ... (2017). Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms. JAMA psychiatry, 74(4), p. 351. American Medical Association 10.1001/jamapsychiatry.2017.0044

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Importance: Self-guided internet-based cognitive behavioral therapy (iCBT) has the potential to increase access and availability of evidence-based therapy and reduce the cost of depression treatment.
Objectives: To estimate the effect of self-guided iCBT in treating adults with depressive symptoms compared with controls and evaluate the moderating effects of treatment outcome and response.
Data Sources: A total of 13 384 abstracts were retrieved through a systematic literature search in PubMed, Embase, PsycINFO, and Cochrane Library from database inception to January 1, 2016.
Study Selection: Randomized clinical trials in which self-guided iCBT was compared with a control (usual care, waiting list, or attention control) in individuals with symptoms of depression.
Data Extraction and Synthesis: Primary authors provided individual participant data from 3876 participants from 13 of 16 eligible studies. Missing data were handled using multiple imputations. Mixed-effects models with participants nested within studies were used to examine treatment outcomes and moderators.
Main Outcomes and Measures: Outcomes included the Beck Depression Inventory, Center for Epidemiological Studies–Depression Scale, and 9-item Patient Health Questionnaire scores. Scales were standardized across the pool of the included studies.
Results: Of the 3876 study participants, the mean (SD) age was 42.0 (11.7) years, 2531 (66.0%) of 3832 were female, 1368 (53.1%) of 2574 completed secondary education, and 2262 (71.9%) of 3146 were employed. Self-guided iCBT was significantly more effective than controls on depressive symptoms severity (β = −0.21; Hedges g  = 0.27) and treatment response (β = 0.53; odds ratio, 1.95; 95% CI, 1.52-2.50; number needed to treat, 8). Adherence to treatment was associated with lower depressive symptoms (β = −0.19; P = .001) and greater response to treatment (β = 0.90; P < .001). None of the examined participant and study-level variables moderated treatment outcomes.
Conclusions and Relevance: Self-guided iCBT is effective in treating depressive symptoms. The use of meta-analyses of individual participant data provides substantial evidence for clinical and policy decision making because self-guided iCBT can be considered as an evidence-based first-step approach in treating symptoms of depression. Several limitations of the iCBT should be addressed before it can be disseminated into routine care.

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