Internet-based psychological treatment for anxiety and mood disorders

Summary and conclusions

A number of psychological treatments have received a high priority in national guidelines for the treatment of anxiety and mood disorders, and they represent an important part of the treatment services offered for these conditions. However, access to these treatments varies greatly across the country.

Traditionally, psychological treatment has been provided to patients individually or in groups by a therapist. The internet offers new opportunities for providing treatment at a distance, so as to increase accessibility and reach groups that for various reasons do not receive treatment at traditional health care services. Internet-based cognitive behavioural therapy (CBT) in particular has been evaluated in many international studies over the past decade.

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.

SBU has evaluated the short and long-term benefits and risks of internet-based psychological treatment for anxiety and mood disorders for children, adolescents, and adults. The evaluation also covered cost-effectiveness and aspects of ethics, transferability and implementation, and was based on the scientific literature.

Conclusions

• It is not evident whether psychological treatment via the internet is non-inferior to corresponding treatment by a therapist.
• 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. 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

Internet at least non-inferior to group

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 RCT	()
Social phobia (short-term effect)	Internet-based CBT, with therapist support	Group CBT	Internet at least non-inferior group	126/1 RCT	()
Social phobia (short-term effect)	Internet-based CBT, with therapist support	Waiting list	Internet better than waiting list	709/8 RCT	()
Social phobia (short-term effect)	Internet-based attention bias modification	Placebo	Internet not better than placebo	206/3 RCT	()
Panic disorder (short-term effect)	Internet-based CBT, with therapist support	Waiting list	Internet better than waiting list	148/3 RCT	()
Generalised anxiety disorder (short-term effect)	Internet-based CBT, with therapist support	Waiting list	Internet better than waiting list	271/4 RCT	()
Anxiety disorders (short-term effect)	Transdiagnostic internet-based CBT, with therapist support	Waiting list	Internet better than waiting list	414/5 RCT	()
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, generalised anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, specific phobia and transdiagnostic treatment of anxiety disorders.

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.

The quality of evidence has four levels

High quality of evidence ()
Based on studies with low or moderate risk of bias with no factors that weaken the overall assessment.

Moderate quality of evidence ()
Based on studies with low or moderate risk of bias with a single factor that weaken the overall assessment.

Low quality of evidence ()
Based on studies with low or moderate risk of bias with some factors that weaken the overall assessment.

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

The stronger the quality of evidence, the lower is the likelihood that new research findings would affect the documented results within the foreseeable future.

For more information please contact Monica Hultcrantz e-mail: registrator@sbu.se