Toshi A Furukawa1, Aya Suganuma2, Edoardo G Ostinelli3, Gerhard Andersson4, Christopher G Beevers5, Jason Shumake5, Thomas Berger6, Florien Willemijn Boele7, Claudia Buntrock8, Per Carlbring9, Isabella Choi10, Helen Christensen11, Andrew Mackinnon11, Jennifer Dahne12, Marcus J H Huibers13, David D Ebert14, Louise Farrer15, Nicholas R Forand16, Daniel R Strunk17, Iony D Ezawa17, Erik Forsell18, Viktor Kaldo19, Anna Geraedts20, Simon Gilbody21, Elizabeth Littlewood21, Sally Brabyn21, Heather D Hadjistavropoulos22, Luke H Schneider23, Robert Johansson9, Robin Kenter24, Marie Kivi25, Cecilia Björkelund26, Annet Kleiboer13, Heleen Riper13, Jan Philipp Klein27, Johanna Schröder28, Björn Meyer29, Steffen Moritz30, Lara Bücker30, Ove Lintvedt31, Peter Johansson32, Johan Lundgren32, Jeannette Milgrom33, Alan W Gemmill33, David C Mohr34, Jesus Montero-Marin3, Javier Garcia-Campayo35, Stephanie Nobis36, Anna-Carlotta Zarski8, Kathleen O'Moore11, Alishia D Williams37, Jill M Newby38, Sarah Perini39, Rachel Phillips40, Justine Schneider41, Wendy Pots42, Nicole E Pugh43, Derek Richards44, Isabelle M Rosso45, Scott L Rauch45, Lisa B Sheeber46, Jessica Smith47, Viola Spek48, Victor J Pop49, Burçin Ünlü50, Kim M P van Bastelaar51, Sanne van Luenen52, Nadia Garnefski52, Vivian Kraaij52, Kristofer Vernmark53, Lisanne Warmerdam54, Annemieke van Straten13, Pavle Zagorscak55, Christine Knaevelsrud55, Manuel Heinrich55, Clara Miguel13, Andrea Cipriani56, Orestis Efthimiou57, Eirini Karyotaki58, Pim Cuijpers13. 1. Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan. Electronic address: furukawa@kuhp.kyoto-u.ac.jp. 2. Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan. 3. Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK. 4. Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden; Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden. 5. Department of Psychology and Institute for Mental Health Research, University of Texas at Austin, Austin, TX, USA. 6. Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland. 7. Patient Centred Outcomes Research Group, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK. 8. Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany. 9. Department of Psychology, Stockholm University, Stockholm, Sweden. 10. Central Clinical School, Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia. 11. Black Dog Institute and University of New South Wales, Prince of Wales Hospital, Sydney, NSW, Australia. 12. Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA. 13. Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands. 14. Department for Sport and Health Sciences, Chair for Psychology & Digital Mental Health Care, Technical University Munich, Germany. 15. Centre for Mental Health Research, The Australian National University, Canberra, Australia. 16. Department of Psychiatry, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA. 17. Department of Psychology, The Ohio State University, Columbus, OH, USA. 18. Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden. 19. Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden; Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden. 20. Soulve Innovations, Utrecht, Netherlands. 21. Department of Health Sciences, University of York, York, UK. 22. Department of Psychology, University of Regina, Regina, SK, Canada. 23. Anxiety Treatment and Research Clinic, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada. 24. Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway. 25. Department of Psychology, University of Gothenburg, Gothenburg, Sweden. 26. Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden. 27. Department of Psychiatry and Psychotherapy, Luebeck University, Luebeck, Germany. 28. Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 29. Research Department, GAIA AG, Hamburg, Germany. 30. Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 31. Norwegian Center for E-health research, Tromsø, Norway. 32. Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden. 33. Parent-Infant Research Institute and Austin Health, Melbourne School of Psychological Sciences, University of Melbourne, VIC, Australia. 34. Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, Chicago, IL, USA. 35. Aragon Institute for Health Research, Miguel Servet University Hospital, Zaragoza, Spain; Primary Care Prevention and Health Promotion Research Network, RedIAPP, Madrid, Spain. 36. Klinikum Osnabrück, Osnabrück, Germany. 37. Department of Psychology, Faculty of Science, The University of New South Wales, Sydney, NSW, Australia. 38. School of Psychology, University of New South Wales at the Black Dog Institute, Sydney, NSW, Australia. 39. Clinical Research Unit for Anxiety and Depression, St Vincent's Hospital, Sydney, NSW, Australia. 40. Faculty of Medicine, School of Public Health, Imperial College London, London, UK. 41. School of Sociology & Social Policy and Institute of Mental Health, University of Nottingham, Nottingham, UK. 42. Department of Psychology, Health & Technology, University of Twente, Enschede, Netherlands. 43. Private practice, Vancouver, BC, Canada. 44. University of Dublin, Trinity College, School of Psychology, E-mental Health Research Group, Dublin, Ireland; SilverCloud Health, Clinical Research & Innovation, Dublin, Ireland. 45. McLean Hospital, Belmont, MA, USA. 46. Oregon Research Institute, Eugene, OR, USA. 47. Imperial Clinical Trials Unit, Imperial College London, London, UK. 48. School of Applied Psychology, Fontys University of Applied Science, Eindhoven, Netherlands. 49. Department of Medical & Clinical Psychology, Tilburg University, Tilburg, Netherlands. 50. PsyQ Online, Haarlem, Netherlands. 51. Amsterdam University Medical Centre, Amsterdam, Netherlands. 52. Department of Clinical Psychology, Leiden University, Leiden, Netherlands. 53. Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden. 54. National Health Care Institute, Diemen, Netherlands. 55. Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany. 56. Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK. 57. Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland. 58. Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
Abstract
BACKGROUND: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom. METHODS: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683. FINDINGS: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. INTERPRETATION: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package. FUNDING: Japan Society for the Promotion of Science.
BACKGROUND: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom. METHODS: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683. FINDINGS: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. INTERPRETATION: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package. FUNDING: Japan Society for the Promotion of Science.
Authors: Eirini Karyotaki; David Daniel Ebert; Liesje Donkin; Heleen Riper; Jos Twisk; Simone Burger; Alexander Rozental; Alfred Lange; Alishia D Williams; Anna Carlotta Zarski; Anna Geraedts; Annemieke van Straten; Annet Kleiboer; Björn Meyer; Burçin B Ünlü Ince; Claudia Buntrock; Dirk Lehr; Frank J Snoek; Gavin Andrews; Gerhard Andersson; Isabella Choi; Jeroen Ruwaard; Jan Philipp Klein; Jill M Newby; Johanna Schröder; Johannes A C Laferton; Kim Van Bastelaar; Kotaro Imamura; Kristofer Vernmark; Leif Boß; Lisa B Sheeber; Marie Kivi; Matthias Berking; Nickolai Titov; Per Carlbring; Robert Johansson; Robin Kenter; Sarah Perini; Steffen Moritz; Stephanie Nobis; Thomas Berger; Viktor Kaldo; Yvonne Forsell; Nils Lindefors; Martin Kraepelien; Cecilia Björkelund; Norito Kawakami; Pim Cuijpers Journal: Clin Psychol Rev Date: 2018-06-19
Authors: Charles B Nemeroff; Christine M Heim; Michael E Thase; Daniel N Klein; A John Rush; Alan F Schatzberg; Philip T Ninan; James P McCullough; Paul M Weiss; David L Dunner; Barbara O Rothbaum; Susan Kornstein; Gabor Keitner; Martin B Keller Journal: Proc Natl Acad Sci U S A Date: 2003-11-13 Impact factor: 11.205
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Authors: Edward Watkins; Alexandra Newbold; Michelle Tester-Jones; Mahmood Javaid; Jennifer Cadman; Linda M Collins; John Graham; Mohammod Mostazir Journal: BMC Psychiatry Date: 2016-10-06 Impact factor: 3.630
Authors: Kerstin Spanhel; Eva Hovestadt; Dirk Lehr; Kai Spiegelhalder; Harald Baumeister; Juergen Bengel; Lasse B Sander Journal: Front Psychiatry Date: 2022-02-23 Impact factor: 4.157
Authors: Ellen Driessen; Zachary D Cohen; Lorenzo Lorenzo-Luaces; Steven D Hollon; David A Richards; Keith S Dobson; Sona Dimidjian; Jaime Delgadillo; Fernando L Vázquez; Kathleen McNamara; John J Horan; Pauline Gardner; Tian P Oei; Anuj H P Mehta; Jos W R Twisk; Ioana A Cristea; Pim Cuijpers Journal: BJPsych Open Date: 2022-08-10