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KCEHR4Y

Internet-delivered psychological treatments for mood and anxiety disorders

KCE has read for you

Kirsten Holdt Henningsen

Mental diseases, in particular depression, are the first cause of disability in Belgium. Results from a health interview survey from the Scientific Institute of Public Health (WIV-ISP) in 2008 indicated a self-reported prevalence of depression of 9%, while 6% of the responders reported they suffered from anxiety disorder1.
The Swedish Council on Health Technology Assessment (SBU) published in August, 2013 a systematic literature review to evaluate whether internet-delivered psychological treatments for mood and anxiety disorders in children, adolescents and adults are efficacious, noninferior to more established treatment forms, safe and cost-effective.2 The specific diagnoses included were major depressive disorder, dysthymia, bipolar disorder, social phobia, panic disorder, generalized anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder, specific phobia, and separation anxiety (in children and adolescents). The SBU review was quality appraised by KCE using the AMSTAR tool and received a quality score of 9/11.

1. Background

Psychotherapy ranks high in national clinical guidelines for mood and anxiety disorders. A recent KCE guideline3 on the long-term efficacy of psychotherapy for depression recommends that psychotherapy* combined with antidepressant medication is the preferred treatment option for patients with a major depression both in the acute phase and the continuation phase.
Traditionally, psychological treatments are delivered by a therapist face-to-face to an individual or to a group. The internet offers the opportunity to deliver the treatment from a distance, and consequently might improve accessibility for those individuals who, for various reasons, do not have direct access to treatment within the health care system.
Internet-based treatment is normally structured as a self-help programme over the course of 6-15 weeks, with support from a qualified therapist via e-mail, the treatment platform or telephone. Some programmes, on the other hand, are performed totally independently by the participant or with administrative support. Each week, participants log on to a website and access a text chapter, exercises, and homework. The programmes vary in terms of interactivity and the use of sound and video clips.
During the last decade a large number of studies, particularly on internet-delivered cognitive behavioural therapy, have tried to evaluate whether this type of treatment delivery is efficacious.
*the effect is only currently sufficiently studied for cognitive behavioural therapy (CBT)

2. Main results

The table below provides an overview of the evidence SBU found on the efficacy of treatment for mood and anxiety disorders, for adults and children respectively.

Adults

Disorder

Treatment

Comparator

Result

Number of participants
/studies

Quality of evidence

Major depression

(short-term effect)

Internet-based CBT, with therapist support

Waiting list

Internet better than waiting list

323/5 RCTs

Moderate

Social phobia

(short-term effect)

Internet-based CBT, with therapist support

Group CBT

Internet at least non-inferior to group CBT

126/1 RCT

Low

 

Social phobia

(short-term effect)

Internet-based CBT, with therapist support

Waiting list

Internet better than waiting list

709/8 RCTs

Moderate

Social phobia

(short-term effect)

 

Internet-based attention bias modification*

Placebo

Internet not better than placebo

206/3 RCTs

Moderate

Panic disorder

(short-term effect)

Internet-based CBT, with therapist support

Waiting list

Internet better than waiting list

148/3 RCTs

Low

Generalised anxiety disorder

(short-term effect)

Internet-based CBT, with therapist support

Waiting list

Internet better than waiting list

271/4 RCTs

Low

Anxiety disorders

(short-term effect)

Transdiagnostic internet-based CBT**, with therapist support

Waiting list

Internet better than waiting list

414/5 RCTs

Low

Very low quality of evidence

For other questions regarding the following diagnoses, there is very low quality of evidence: major depression, bipolar disorder, social phobia, panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, specific phobia and transdiagnostic treatment of anxiety disorders.

SBU considers that when the quality of the evidence is very low, it is practically insufficient. Very low quality evidence could be due to weaknesses on several areas, or that all studies have a high risk of bias.

* Attention bias modification is a computerized treatment form for social phobia based on the hypothesis that patients with this disorder have an increased tendency to focus their attention on threatening social stimuli. The treatment attempts to retrain automatic attentional processes towards neutral rather than threatening stimuli.
** A transdiagnostic treatment applies the same underlying treatment principles across various mental disorders, without tailoring the protocol to specific diagnoses.

Children

Very low quality of evidence

For all questions regarding the following diagnoses, there is very low quality of evidence:  major depression, bipolar disorder, social phobia, panic disorder, generalised anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, specific phobia, separation anxiety and transdiagnostic treatment* of anxiety disorders.

SBU considers that when the quality of the evidence is very low, it is practically insufficient. Very low quality evidence could be due to weaknesses on several areas, or that all studies have a high risk of bias.

A transdiagnostic treatment applies the same underlying treatment principles across various mental disorders, without tailoring the protocol to specific diagnoses.

3. Conclusions of the SBU review

  • Internet-based CBT, with the support of a therapist, reduces symptoms in adults with social phobia or mild to moderate major depression, and who have themselves sought this form of treatment. There is some evidence that this also applies to panic disorder and generalised anxiety disorder. Most trials have compared the treatment only with waiting lists and have short follow-up periods (< 6 months). Further trials are needed to assess the effect of treatment in the longer term.
  • Given our present level of knowledge, internet-based CBT with therapist support may be considered as part of a wider range of psychological methods for these conditions and mainly for patients who are motivated to seek this form of treatment.
  • Treatment costs for internet-based CBT in the short term are probably lower than for CBT in a group or individually. However, since the effects of these treatment alternatives have not been adequately compared, it is not possible to ascertain which alternative is cost-effective.
  • It is important to investigate whether this type of treatment can reach people who are in need of care but who are not currently being treated through ordinary health and medical care. In order to further clarify what role internet-based treatment might have in the care of anxiety and mood disorders, it is also important to clarify the extent to which internet-based treatment is requested by patients.
  • More and larger-scale studies are required in order to assess:

-- whether internet-based psychological treatment has an effect that is non-inferior to that of established psychological treatment methods

-- what risks might be involved in participating in internet-based treatment

-- what effect internet-based psychological treatment has on anxiety and mood disorders in children and adolescents

-- the effect of types of internet-based psychological treatment other than CBT with therapist support

-- whether there are groups of patients for whom treatment via the internet is more or less appropriate

References:

1. Scientific Institute of Public Health. Highlights of the Belgian Health Interview Survey 2008.  Available from: https://his.wiv-isp.be/Shared Documents/Summary_2008.pdf

2. SBU - Swedish Council on Health Technology Assessment. Internetförmedlad psykologisk behandling vid ångest- och förstämningssyndrom: SBU alert-rapport nr 2013-02: 2013-08-28.

3. Karyotaki E, Smit Y, Cuijpers P, Debauche M, De Keyser T, Habraken H, et al. The long-term efficacy of psychotherapy, alone or in combination with antidepressants, in the treatment of adult major depression Good Clinical Practice (GCP). Brussels: Belgian Health Care Knowledge Centre (KCE); 2014 02/10/2014. KCE Reports 230 Available from: http://kce.fgov.be/publication/report/the-long-term-efficacy-of-psychotherapy-alone-or-in-combination-with-antidepressa 

published on 07-10-2014