E-health interventions for mental disorders: A systematic literature review on the effectiveness of Internet-based cognitive behavior therapy

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E-health interventions for mental disorders: A

systematic literature review on the effectiveness

of Internet-based cognitive behavior therapy

Liesanne Veenstra (S3539865)

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Abstract

Purpose: Internet-based cognitive behavior therapy (ICBT) has emerged as a promising

means for treating mental disorders. Although there have been many studies regarding ICBT, there is no clear overview of the current landscape concerning ICBT yet. This paper contains a systematic review of the outcomes of ICBT for mental disorders in terms of effectiveness.

Methods: This study used a systematic approach to review literature regarding ICBT

published from 2005 to 2018. In total, 43 relevant articles have been analyzed.

Findings: Most literature emphasized that ICBT could be equally effective as face-to-face

CBT in terms of reducing the symptoms. Moreover, ICBT has proven to be more cost-effective than face-to-face CBT and has other benefits such as reduced therapist time and increased access to treatments.

Conclusion: Now that ICBT is proven to be effective, future research is needed to determine

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Introduction

Nearly 25% of people worldwide are estimated to be affected by a mental disorder at some point in their lives, whereas about 450 million people are currently suffering from such disorders (WHO, 2001). Mental disorders include a broad range of problems, but they are generally characterized by abnormal thoughts, emotions, behavior and relationships with others. A study from the National Empowerment Center (2017) has suggested that people can fully recover from even the most severe forms of mental disorders, which is why it is

important that effective treatments are available for people suffering from mental disorders.

A widely used and effective form of therapy for a wide range of mental disorder is cognitive behavior therapy (CBT) (Hollon, Steward & Strunk, 2006). CBT treats problems and boosts happiness by modifying dysfunctional emotions, behavior, and thoughts. It focuses on

solutions, encourages patients to challenge distorted cognitions and tries to change destructive patterns of behavior. However, only one third of the people suffering from a mental disorder seek help from a health professional. This barrier to treatment service access is caused by long waiting periods, geographical constraints, stigma associated with psychological treatment use, and high treatment costs (Sunderland & Findlay, 2013). The increasing availability of internet and communication technology might play an important role in overcoming these treatment barriers. In the past decade, internet-based cognitive behavior therapy (ICBT) has emerged as a promising means of increasing the availability of CBT (Andersson, 2009).

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current landscape concerning the effectiveness of ICBT yet. Through such a review, it would become clear if ICBT could be an effective treatment next to, or instead of, conventional face-to-face CBT. Also, this would be a solution to overcome the great treatment barriers of mental disorders. In this review, effectiveness is defined as the extent to which stated objectives are met (Productivity Commission, 2013). Concerning ICBT, this means the extent to which the treatment has reduced the symptoms of the mental disorder. Furthermore, an important performance measure of effectiveness is cost-effectiveness. This can be defined as the extent to which the cost of resources has been minimized (Productivity Commission, 2013).

In order to address this gap in the literature, this study contributes to the current landscape of research on the effectiveness of Internet-based cognitive behavior therapy used for mental disorders. Therefore, the research question in this literature review is: “What is the current

landscape concerning the outcomes of Internet-based cognitive behavior therapy used for mental disorders in terms of effectiveness?” The aim of this paper is to review and analyze

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Methods

Search process

To get a clear overview of the current landscape concerning the effectiveness of internet-based cognitive behavior therapy (ICBT), I conducted a systematic review to create a complete, transparent literature review. Through this systematic review, it would become clear what studies have already been done in the area of ICBT. In short, the search consisted of several phases. First, I started with defining search terms and inclusion and exclusion criteria. After that, I started the search and selected relevant articles. The third phase was focused on analyzing the articles, which resulted in the final phase of discussing the results.

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The search was conducted on the database called PubMed. I used the search terms “cognitive behavior therapy” (Title) OR “cognitive behaviour therapy” (Title) OR “CBT” (Title) AND “internet” (Title) OR “internet-based” (Title) AND “effective” (Title/Abstract) OR

“effectiveness” (Title/Abstract). This search resulted in 86 potentially relevant articles, dated from 2005 until April 2018. I tried to include the most recent articles concerning this topic, since the research question is about creating an overview of the current landscape.

As a final check on completeness, I combined this systematic approach with the snowball approach. I scanned the reference lists of the relevant articles I found for any further relevant studies. In this search, I only included articles that met the same inclusion and exclusion criteria as mentioned before, the time frame of this search and which were relevant for this topic. This search resulted in another 5 included articles. My search stopped when I reached the number of 43 relevant articles. At this point, I could only find duplicates of the studies I had already included, dated articles or articles that were irrelevant for this research paper.

Analysis

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this literature review. Based on the reference lists of the relevant articles, another 5 articles were included. These papers were included based on the same inclusion and exclusion criteria as used in the previous search strategy. During this final search, I selected articles based on their titles and the year of the study, which had to be more recent than 2005. To determine whether to include an article or not, I read the findings and discussion. Altogether, 43 articles turned out to be relevant for the topic of this literature review.

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Through this search, I have worked inductively. From the beginning, I started collecting data that was relevant to the topic in this literature review, without basing it on some kind of hypothesis or theory. After searching for articles, it became clear that ICBT had been studied for multiple disorders, of which some disorders more often than others. So, I have grouped the articles per disorder to get a clear overview of the effectiveness of ICBT for particular

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Findings

Categorization of findings

Through the reading of the relevant articles, I have identified some common mental disorders that were mostly mentioned in combination with ICBT. Therefore, I have grouped the results of the search based on the mental disorder that was discussed in the article to get an overview of the studies per disorder (appendix 1). Based on this table, I can determine the effectiveness of ICBT per group of mental disorders instead of discussing the findings regarding many different disorders all together.

The mental disorders that have been identified during the search process are: anxiety disorder (including social anxiety, health anxiety and social phobia), depression, panic disorder, obsessive-compulsive disorder, alcohol use, irritable bowel syndrome and insomnia disorder. One category is a combination of anxiety and depression because these mental disorders have been discussed together frequently. All articles are categorized based on the sort of mental disorder, except for four articles. These articles studied or reviewed multiple disorders and are therefore mentioned under the subject of “multiple disorders”.

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Anxiety disorder

Most literature in this review is focused on a kind of anxiety disorder, including social anxiety disorder (also known as: social phobia) and health anxiety disorder. The most common

outcome of ICBT treatments in these articles is that ICBT is cost-effective compared to conventional face-to-face CBT (Alaoui et al., 2017; Bergman Nordgren et al., 2014; Hedman et al., 2013a). Andrews et al. (2011) suggest that ICBT is cost-effective due to the fact that this treatment reduces therapist time. This can be confirmed by the study of Hedman et al. (2011b), who found that ICBT reduced therapist time per treated patient by 90% compared to face-to-face CBT. But ICBT seems not only to be cost-effective from therapist’s perspective, it could also be cost-effective for patients. The reason for this is that patients can make their own schedule for the treatment, and consequently, don’t need time off work to go to therapy (Hedman et al., 2014a). Moreover, other studies identify the fact that ICBT leads to increased access to the treatment of anxiety disorder (Andrews et al., 2015; Dear et al., 2015; Hedman et al., 2016).

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found in their study that face-to-face CBT and medication might be preferred to ICBT, due to the fact that there is a large gap in patient familiarity with ICBT relative to face-to-face CBT and medication.

Depression

Next to anxiety disorder, depression is also one of the most common mental disorders identified in the articles. Similar to the articles regarding anxiety disorder, many studies suggest that ICBT for depression could be a cost-effective treatment compared to

conventional face-to-face CBT (Hollinghurst et al., 2010; Romero-Sanchiz et al., 2017; Rosso et al., 2017). Besides the fact that ICBT could be a cost-effective treatment, some studies have shown that ICBT reduces the symptoms of depression (Andersson et al., 2005; Rosso et al., 2017). Furthermore, it seems that there are some particular situations in which ICBT could be highly effective. For example, ICBT has proven to be highly effective in treating late life depression (Hobbs et al., 2018) or in routine care with qualified staff (Hedman et al., 2014b). However, the research of Hollinghurst et al. (2010) suggests that ICBT might not be a suitable treatment for all. Familiarity with computers is necessary, and this study found that the

absence of visual clues may expand the negative thoughts associated with depression in some patients. Moreover, this study suggests that ICBT appeals in particular to those who value the opportunity to review and reflect on therapy sessions and those who prefer anonymity.

Combination of depression and anxiety disorder

Many articles discuss the effectiveness of an ICBT treatment for depression in combination with anxiety disorder. According to Burhman et al. (2015), ICBT is a cost-effective treatment compared to face-to-face CBT, and can reach many more clients. From the patient’s

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depression and anxiety disorder. Regarding the effectiveness of the treatment, it is proven that ICBT could be equally effective as face-to-face CBT for treating older adults (Silfvernagel et al., 2017). Also, another study found that ICBT will be equally effective as face-to-face CBT, especially with therapist-support (Spek et al., 2007). Furthermore, a recent study of Edmonds et al. (2018) studied the predictors of symptom change and dropout with ICBT. They found that ICBT could be more effective for older adults than for younger adults, because patients of younger age were more likely to quit the treatment. Finally, Newby et al. (2017) made a distinction between transdiagnostic ICBT and disorder-specific ICBT. They found that both forms of ICBT could be effective, but that it depends on the preferences of the patient.

Other disorders

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Besides panic disorder and obsessive-compulsive disorder, a couple of studies focused on ICBT for excessive alcohol use, irritable bowel syndrome and insomnia disorder. For treating excessive alcohol use, Sundström et al. (2017) argue that ICBT could be feasible, safe and acceptable. Although, the researchers have not found evidence yet to prove that ICBT could be an alternative treatment to face-to-face CBT. For irritable bowel syndrome, Andersson et al. (2011b) discuss the fact that ICBT can both be an effective treatment to reduce symptoms and generate cost saving for the society. This is confirmed by a more recent study of Bonnert et al. (2017), who observed reductions of symptoms and a stable overall positive effect. But as for the treatment of excessive alcohol use, further research is needed due to the fact that there are only a few studies on ICBT for irritable bowel syndrome. Lastly, Slomski (2017) states that ICBT is an effective treatment for insomnia, that could reach unimaginable numbers of people. However, she suggests that further research is needed to determine for who ICBT can be most effective.

Overall findings

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Discussion

Key concepts

The aim of this literature review is to get an overview of the current landscape concerning the outcomes of ICBT in terms of effectiveness. As defined in the introduction, the effectiveness will be discussed in terms of cost-effectiveness and reduction of symptoms. Furthermore, other outcomes or benefits of ICBT will also be considered, to create a complete view of the current landscape concerning the effectiveness of ICBT. As described in Appendix 1 and Findings, many studies have researched the effectiveness of ICBT for several mental disorders. The mental disorders included in this literature review were anxiety, depression, mixed anxiety and depression, panic disorder, obsessive-compulsive disorder, excessive alcohol use and insomnia.

The findings, as discussed in the previous chapter, indicate that ICBT could be an equally effective treatment compared to face-to-face CBT in terms of cost-effectiveness and the reduction of symptoms. Other benefits that have been mentioned are the increased availability of the treatment and the reduced therapist time, with as consequence that more patients can be reached (Burhman et al., 2015). To refer back to the research question, many studies have researched the effectiveness of ICBT for different mental disorders, of which all contribute to creating a view of the current landscape. Regarding this current landscape, it can be

concluded that most studies agree on the fact that ICBT is equally effective as face-to-face CBT and therefore can be an alternative treatment (Andrews et al., 2011; Bergman Nordgren et al., 2014). In addition, ICBT is able to break through the existing treatment barriers such as long waiting periods, geographical constraints, stigma associated with psychological

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Conflicting results

The topics that were mostly debated in the literature were the cost-effectiveness of ICBT due to the reduced therapist time needed for treatment (Romero-Sanzich et al., 2017; Rosso et al., 2017). Next to the fact that ICBT reduces therapist time, it also increases the access to

treatments (Hedman et al., 2016). Consequently, many more patients can be reached and treated. It is also beneficial from the patient’s perspective, because ICBT is not restricted in time or to a specific geographical location. This will also reduce e.g. traveling costs, or costs for taking time off from their work (Hedman et al., 2014a).

But in some instances, I found conflicting or limited results. Whereas many studies argue that ICBT could be an effective alternative treatment for mental disorders, Soucy &

Hadjistavropoulus (2017) found that face-to-face CBT and medication were preferred above ICBT. The main reason for this outcome is that ICBT is a recent trend, and patients are not familiar with this treatment yet. This study also emphasized the fact that even if ICBT would be proven to be effective, the question remains for which groups of people it would be most applicable. This issue has also been discussed in other studies. Hollinghurst et al. (2010) suggested that ICBT will not be suitable for all, because familiarity with computers is necessary. Finally, according to Slomski (2017), ICBT could be an effective treatment for insomnia disorder, but that further research is needed to find out for who the treatment is most effective.

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of Edmonds et al. (2018) has identified patient characteristics that were significantly related to dropout of ICBT. They found that younger people were more likely to drop out of therapy, but the reason for that result remains unknown. So, further research is not only needed to identify for who ICBT is most effective, but also to discover the reasons why it could be more effective for one than for another.

Recommendations for future research

As mentioned above, there is already much literature available concerning the effectiveness of ICBT, but there is also a lot of research still needed. The first recommendation for future research is regarding the target groups of ICBT. Now that studies have proven that ICBT is a promising, cost-effective alternative to face-to-face CBT, further research is needed to discover for who ICBT could be most effective. The recent study of Edmonds et al. (2018) has already conducted such a research, but also suggests that future research needs to find out why ICBT is more effective for some groups than others.

Second, future research should pay more attention to the outcomes of ICBT for less common mental disorders. Most of the literature discussed in this review is focused on ICBT for either depression or anxiety disorder. Only a few articles have studied the effects of ICBT for less common mental disorders, like panic disorder or obsessive-compulsive disorder. If the outcomes of ICBT would also be researched for those mental disorders, there would be more knowledge about the scope of the treatment.

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important issue for the future. Now that many studies confirm the fact that ICBT can be equally effective as face-to-face CBT, further research is needed to exploit the outcomes of different forms of ICBT, such as transdiagnostic or disorder-specific.

Limitations of this study

There are a few limitations in this literature review. To start with conclusions regarding therapist-guided or unguided ICBT. The focus of this literature review was not on comparing therapist-guided and unguided ICBT. Thus, the findings of this review do not indicate

whether ICBT is more effective with or without therapist-support. However, through reading the articles, I have indicated that many studies have a different view of therapist-guided ICBT versus unguided ICBT. So, for a future study, it could be interesting to review the studies regarding the differences in outcomes between therapist-guided and unguided ICBT to determine which form could be most effective in certain circumstances.

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Appendix 1

Overview of findings

Type of disorder Outcomes of ICBT References

Anxiety and

depression • Equally effective for older adults

• Equally effective with therapist-support

• Cost-effective, reaches more clients (for chronic pain patients)

• More effective for older adults

• Increases access

• Both transdiagnostic and disorder-specific ICBT are effective

Silfernagel, K., Westlinder, A., Andersson, S., Bergman, K.,

Hernandez, R. D., Fallhagen, L. et al. (2017)

Spek, V., Cuijpers, P., Nyklicek, I., Riper, H., Keyzer, J. & Pop, V. (2007) Burhman, M., Syk, M., Burval, O., Hartig, T., Gordh, T. & Andersson, G. (2015)

Edmonds, M., Hadjistavropoulos, H. D., Schneider, L. H., Dear, B. F. & Titov, N. (2018)

Glasziou, P., Bennet, J.,

Greenberg, P., Green, S., Gunn, J., Hoffmann, T. et al. (2013)

Newby, J. M., Mewton, L. & Andrews, G. (2017)

Depression • Cost-effective

• Reduction of symptoms

• Large effects in late-life depression • Highly effective in routine care with

qualified staff

• Might not be suitable for all

Hollinghurst, S., Peters, T. J., Kaur, S., Wiles, N., Lewis, G. & Kessler, D. (2010); Romero-Sanchiz, P., Nogueira-Arjona, R., García-Ruiz, A., Luciano, J. V., Garcia Campavo, J., Gili M., et al. (2017); Rosso, I. M., Killgore, W. D., Olsen, E. A., Webb, C. A., Fukunaga, R., Auerbach, R. P., Gogel, H., et al. (2017)

Andersson, G., Bergström, J.,

Holländare, F., Carlbring, P., Kaldo, V. & Ekselius, L. (2005); Rosso, et al. (2017)

Hobbs, M. J., Joubert, A. E., Mahoney, A. E. J. & Andrews, G. (2018) Hedman, E., Ljótsson, B., Kaldo, V., Hesser, H., Alaoui, el S., Kraepelien M., et al. (2014b).

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Anxiety (including social, health and social phobia)

• Cost-effective

• Reduction of therapist time

• Effective with therapist-support

• Effective in a regular setting • Complementary to regular CBT • Geographical benefits

• Equally effective as regular CBT • Equally effective on the long-term • (Cost-)effective in follow-ups

• Alternative to standard care

• CBT and medication are preferred

Alaoui, el S., Hedman-Lagerlöf, E., Ljótsson, B. & Lindefors, N. (2017); Bergman Nordgren, L., Hedman, E., Etienne, J., Bodin, J., Kadowaki, A., Eriksson, S., et al. (2014); Hedman, E., Andersson, E., Lindefors, N.,

Andersson, G., Rück, C. & Ljótsson, B. (2013a); Hedman, E., Andersson, E., Ljótsson, B., Andersson, G., Rück, C. & Lindefors, N. (2011).

Andrews, G., Newby, J. M. & Williams, A. D. (2015); Dear, B. F., Zou, J. B., Ali, S., Lorian, C. N., Johnston, L. Sheehan, J., et al. (2015); Hedman, E., Andersson, E., Ljótsson, B., Axelsson, E. & Lekander, M. (2016); Hedman, E., Alaoui, el S., Lindefors, N., Andersson, E., Rück, C., Ghaderi, A., et al. (2014a).

Andrews, G., Davies, M. & Titov, N. (2011); Hedman, E., Andersson, G., Ljótsson, B., Andersson, E., Rück, C., Mörtberg, E. et al. (2011b);

Alaoui, el S., Hedman, E., Kaldo, V., Hesser, H., Kraepelien, M., et al. (2015).

Hedman, et al. (2011b) Hedman, et al. (2011b)

Andrews, et al. (2015); Hedman, et al. (2014)

Andrews, et al. (2011)

Carlbring, P., Bergman Nordgren, L., Furmark, T. & Andersson, G. (2009) Hedman, E., Andersson, E., Lindefors, N., Andersson, G., Rück, C. & Ljótsson, B. (2013); Hedman, E., Furmark, T., Carlbring, P., Ljótsson, B., Rück, C., Lindefors, N. et al. (2011c).

Bergman Nordgren, L., Hedman, E., Etienne, J., Bodin, J., Kadowaki, A., Eriksson, S., et al. (2014).

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Panic disorder • Effective with therapist-support

• Cost-effective

Hedman, E., Ljótsson, B., Rück, C., Bergström, J., Andersson, G., Kaldo, V., et al. (2013b); Nordgreen, T., Gjestad, R., Andersson, G., Carlbring, P. & Havink, O.E. (2018)

Bergström, J., Andersson, G., Ljótsson, B., Rück, C., Andréewitch, S.,

Karlsson, A. et al. (2010); Kiropoulus, L. A., Klein, B., Austin, D. W., Gilson, K., Pier, C., Mitchell, J. et al. (2008) Allen, A. R., Newby, J. M.,

Mackenzie, A., Smith, J., Boulton, M., Loughnan, S. A. et al. (2016).

Kiropoulus, et al. (2008)

Obsessive-compulsive disorder • Cost-effective

• Reduction of symptoms with therapist-support

Lenhard, F., Ssegonja, R., Andersson, E., Feldman, I., Rück, C., Mataix-Cols, D., et al. (2017)

Andersson, E., Enander, J., Andrén, P., Hedman, E., Ljótsson, B., Hursti, T. et al. (2012).

Andersson, E., Ljótsson, B., Hedman, E., Kaldo, V., Paxling, B., Andersson, G., et al. (2011a).

Andersson, et al. (2012); Lenhard, F., Vigerland S., Andersson, E., Rück, C., Mataix-Cols, D., Thulin, U., et al. (2014)

Alcohol use • Feasible, safe, acceptable Sundström, C., Kraepelien, M., Eék,

N., Fahlke, C., Kaldo, V. & Berman, A. H. (2017).

Irritable bowel

syndrome • More effective than waitlist

• (Cost-)Effective

Bonnert, M., Olén, O., Lalouni, M., Benninga, M. A., Bottai, M., Engelbrektsson, J., et al. (2017) Andersson, E., Ljótsson, B., Smit, F., Paxling, B., Hedman, E., Lindefors, N. et al. (2011b)

Insomnia • Effective treatment, but for who? Slomski, A. (2017)

Multiple disorders Andersson, G., Cuijpers, P., Carlbring,

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E-health interventions for mental disorders: A systematic literature review on the effectiveness of Internet-based cognitive behavior therapy