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Review Article · Übersichtsarbeit
Verhaltenstherapie 2013;23:140–148
DOI: 10.1159/000354779
Online publiziert: 22. August 2013
Effectiveness of Guided Internet-Based Cognitive
Behavior Therapy in Regular Clinical Settings
Gerhard Anderssona,b Erik Hedmanb,c
a
Department of Behavioral Science and Learning, Swedish Institute for Disability Research, Linköping University,
Department of Clinical Neuroscience, Division of Psychiatry,
c
Department of Clinical Neuroscience, Osher Center for Integrative Medicine and Division of Psychology,
Karolinska Institutet, Stockholm, Sweden
Keywords
Internet-based cognitive behavior therapy · ICBT ·
Dissemination · Effectiveness · Efficacy trial ·
Anxiety and mood disorders
Schlüsselwörter
Internetvermittelte Verhaltenstherapie · ICBT ·
Verbreitung · Wirkung · Wirksamkeitsstudie ·
Angst- und Befindlichkeitsstörungen
Summary
Therapist-guided internet-based cognitive behavior therapy
(ICBT) has been tested in numerous controlled trials conducted in research settings. It is now established that this
novel treatment format works for a range of clinical conditions. It is less well known if the promising results from efficacy studies can be transferred to routine clinical practice.
In this paper we review the evidence from effectiveness
studies and highlight challenges when implementing ICBT.
Following literature searches we identified 4 controlled trials and 8 open studies, involving a total of 3,888 patients.
There is now an increasing number of effectiveness studies
on ICBT with studies on panic disorder, social anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder, depression, tinnitus, and irritable bowel syndrome.
All indicate that it is possible to transfer ICBT to clinical
practice with sustained effects and moderate to large effect
sizes. However, it is not clear which model to use for service
delivery, and more work remains to be done on dissemination of ICBT. Moreover, the knowledge about outcome predictors from controlled efficacy trials is probably less relevant, and studies with large clinically representative samples are needed to investigate for which patients ICBT is
suitable. In this work existing data could be combined and
reanalyzed to study predictors of outcome.
Zusammenfassung
Therapeutengeleitete internetbasierte Verhaltenstherapie
(ICBT) wurde in zahlreichen kontrollierten Studien evaluiert,
die im Forschungssetting durchgeführt worden waren. Inzwischen ist anerkannt, dass dieses neuartige Behandlungsformat bei einer Vielzahl klinischer Fälle Wirkung zeigt. Weniger bekannt ist, ob die vielversprechenden Resultate, die
Wirksamkeitsstudien zeigten, in die routinemäßige klinische
Praxis übertragen werden können. In der vorliegenden Arbeit überprüfen wir Belege aus Wirksamkeitsstudien und
beleuchten Herausforderungen, die mit der Implementierung von ICBT verbunden sind. Im Rahmen einer Literaturrecherche konnten wir 4 kontrollierte und 8 offene Studien
identifizieren, die insgesamt 3888 Patienten umfassten. Derzeit wächst die Anzahl an Studien zur Wirkung von ICBT mit
Bezug auf Panikstörungen, soziale Angststörung, generalisierte Angststörung, posttraumatische Belastungsstörung,
Depression, Tinnitus und Reizdarmsyndrom. Sämtliche Studien weisen darauf hin, dass es möglich ist, ICBT mit nachhaltigen Auswirkungen und mittleren bis hohen Effektstärken in die klinische Praxis zu übertragen. Jedoch ist noch
nicht geklärt, welches Modell für die Leistungsanforderung
angewandt werden soll. Daher muss die Verbreitung von
ICBT in weiteren Studien erhoben werden. Darüber hinaus
sind die Erkenntnisse zu Prädiktoren von Ergebnissen aus
kontrollierten Wirksamkeitsstudien möglicherweise weniger
relevant, und Studien mit großen klinisch repräsentativen
Stichproben sind notwendig, um zu erheben, für welche Patienten sich ICBT eignet. In der vorliegenden Übersicht
wurde die bestehende Datenlage kombiniert und für eine
Erhebung von Ergebnisprädiktoren ausgewertet.
© 2013 S. Karger GmbH, Freiburg
1016-6262/13/0233-0140$38.00/0
Fax +49 761 4 52 07 14
[email protected]
www.karger.com
Accessible online at:
www.karger.com/ver
Gerhard Andersson, Ph.D.
Department of Behavioral Sciences and Learning
Linköping University
581 83 Linköping, Sweden
[email protected]
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b
Psychological treatment for mental and functional disorders has been around for a long time, and during the last 15
years there has been an expansion of technology-assisted psychological therapies [Marks et al., 2007]. The use of internet
to deliver evidence-based psychological treatments has a
short history, in spite of that there is now a large number of
controlled trials for a range of conditions [Hedman et al.,
2012a]. Indeed, since the first studies in the late 1990ies research on internet-based cognitive behavior therapy (ICBT)
has grown steadily [Hedman et al., 2012a]. One problem with
the existing literature is, however, that very different names
have been used to describe fairly similar interventions, and
sometimes the same term is used to describe very different
interventions [Barak et al., 2009]. In this paper we will cover
guided self-help interventions where the therapist interaction
is asynchronous and the treatment is mainly delivered via
websites in the form of text, pictures, and audio files [Andersson, 2009]. This treatment is being referred to as guided
ICBT [Andersson et al., 2013]. There are other forms of internet treatments, such as real-time chat [Kessler et al., 2009],
totally automated treatments with no clinician interaction before, during or after treatment [Klein et al., 2011], and other
blended treatments where the internet is used as an adjunct
or as aftercare following live treatment [Bauer et al., 2011].
These treatments are not covered in this review. One reason
is that totally automated open access treatments are much
easier to disseminate as they do not require any interaction
with a clinician [Christensen et al., 2006], and the main obstacle with such treatments is the risk of non-adherence [Christensen et al., 2009]. To date, most evidence also indicates that
guided internet treatments are more effective than totally automated treatments [Gellatly et al., 2007; Johansson and Andersson, 2012].
The topic of this paper is dissemination and how well guided ICBT works in routine clinical practice settings [Andersson et al., 2009a]. In the psychological literature, there are 2
types of research studies testing psychological treatments. The
first type is often referred to as ‘efficacy studies’ [Seligman,
1995]. In efficacy studies internal validity is prioritized, which
means that experimental control is important. In practice, this
means that research participants tend to be highly selected,
homogenous in clinical characteristics, self-referred, and therapists are well trained and monitored for adherence to treatment manuals [Shadish et al., 1997]. Moreover, efficacy studies tend to be conducted at research university clinics where
therapists usually have smaller caseloads sometimes supported by students in training. In effect, it is often unclear if the
results of such studies can be generalized to routine practice.
As a response to the critique raised against efficacy trials
[Westen et al., 2004], ‘effectiveness studies’ have been outlined and conducted [Hunsley and Lee, 2007]. These studies
examine whether a treatment works in real-world settings and
Effectiveness of Guided ICBT in Regular
Clinical Settings
in situations that clinicians encounter in their daily routine
practice [Lutz, 2003]. This type of study emphasizes the external validity of the research findings. However, there is no
sharp distinction here, and it can be argued that clinical intervention research, e.g., trials on psychotherapy, always have
elements of effectiveness as they include real patients with
disorders that are indeed both comorbid and severe [Stirman
et al., 2003]. Moreover, efficacy and effectiveness studies can
be regarded as extremes on a continuum [Streiner, 2002]. For
example, a study may be conducted in a specialist research
clinic, but with regular patients referred to the treatment, and
the therapists who provide the treatment may be both clinicians and researchers. When it comes to guided ICBT, things
become even more complicated. Some of the criteria suggested for effectiveness trials are less relevant for guided ICBT.
For example, when disseminating guided ICBT the actual
treatment program remains the same and does not change
with therapist. Another aspect of ICBT is that assessments
are often embedded in the treatment. This facilitates outcome
monitoring, and the difference seen between face-to-face efficacy versus effectiveness trials, where efficacy trials tend to
have much more assessments than in clinical practice, is less
present in ICBT effectiveness trials. Moreover, monitoring
may increase treatment adherence. For the present review we
defined effectiveness study as a study conducted in a setting
equivalent or similar to routine clinical care where patients
are not solely recruited through self-referral and treatments
are delivered by staff with permanent employment.
The aim of this paper is to provide an updated review on
how guided ICBT has been implemented and tested in regular
clinical settings. First, we will briefly review what is known
from efficacy studies with regard to therapist factors and patient characteristics predictive of treatment response. Then
we will provide a review of the effectiveness studies that have
been published on ICBT where some form of clinician contact
has been included. Finally, we will discuss some challenges
when implementing ICBT in routine clinical practice.
What Contributes to Good ICBT Outcomes? –
Knowledge from Efficacy Studies
The empirical support for guided ICBT has been covered
in many previous systematic reviews and meta-analyses [Andrews et al., 2010; Hedman et al., 2012a], not only for mood
and anxiety disorders [Spek et al., 2007], but also for somatic
problems [Cuijpers et al., 2008]. In general, these reviews
have demonstrated that guided ICBT can be highly efficacious for several common psychiatric disorders with effect
sizes similar to those of live CBT. When disseminating ICBT
to routine care it is not only the treatment effects that are important, but also what is known regarding moderators and
mediators of outcomes in efficacy trials. In contrast to the
number of controlled trials, much less has been published on
Verhaltenstherapie 2013;23:140–148
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Introduction
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Verhaltenstherapie 2013;23:140–148
to locate the predictors of negative outcome and dropout, as
this has implications for whom the treatment should be offered. Here the literature is scattered. For example, Hedman
et al. [2012b] did find that genetic factors did not predict outcome in a study on SAD, whereas working full time, having
children, less depressive symptoms, and higher expectancy of
treatment effectiveness did. Some studies have found that adherence to treatment predicts outcome, but this is rather a
moderator of outcome and ‘after the fact’; to be clinically useful pre-treatment predictors of subsequent adherence would
be needed. A recently published predictor study using adherence as dependent variable showed that higher baseline symptom levels led to better adherence [Calear et al., 2013]. Along
the same lines it seems quite clear that more severe symptoms
are not necessarily a negative predictor of outcome, which has
been shown in studies on SAD [Nordgreen et al., 2012] and
depression [Bower et al., 2013], although it might be the case
that symptoms of personality disorder are a negative predictor
[Andersson et al., 2008]. Another potential negative predictor
of relevance in the treatment of depression is number of previous depression episodes [Andersson et al., 2004]. To sum
up, there is yet no established knowledge about predictors of
outcome of guided ICBT, and indeed it is also the case that
outcome can be hard to predict for face-to-face therapies
[Driessen and Hollon, 2010]. Moreover, with more effectiveness data coming out knowledge about clinical outcome predictors in routine clinical practice settings will be obtained.
An important potential advantage from those studies when it
comes to prediction is that they will be less likely to have the
restriction of range in terms of phenotype often inherent in
randomized trials. This will in turn contribute a higher chance
of detecting stable predictors of outcome.
An Overview of Effectiveness Studies
In this review we included effectiveness studies on ICBT
where some form of therapist interaction had been involved.
Moreover, we did not include studies where the setting and
the contact with the clinicians were not directly related to the
treatment program [Farrer et al., 2011]. We also excluded a
study on problem solving therapy in which the treatment was
presented as an option when waiting for face-to-face treatment [Kenter et al., 2013]. In total we describe 4 controlled
trials and 8 open studies, involving a total of 3,888 patients.
These studies were explicitly described as effectiveness studies and we acknowledge the possibility that studies may exist
on guided ICBT which could be regarded as effectiveness
studies but are not described as such. Although all studies
were considered effectiveness studies trials using a randomized design and open studies are reported in separate tables as the open studies were judged to have been conducted
in purely clinical routine care settings whereas RCTs always
involve more rigorous procedures.
Andersson/Hedman
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what makes ICBT work, and most papers on the topic have
been based on ideas and impressions [Andersson et al., 2009b;
Ritterband et al., 2009], including practice guidelines [Abbot
et al., 2008]. We will comment briefly on 2 aspects of treatment delivery that could be important to consider when implementing in routine clinical practice. The first is the role of
the therapist who provides the guidance in ICBT, which is of
interest as treatments that provide therapist support tend to
produce better outcomes [Lewis et al., 2012]. As a starting
point, we can conclude that the therapeutic alliance in guided
ICBT is usually rated as high by patients [Knaevelsrud and
Maercker, 2006; Andersson et al., 2012b; Bergman-Nordgren
et al., 2013], but that it rarely predicts outcome. Second, we
may conclude that the therapist factor probably only plays a
minor role [Almlöv et al., 2009, 2011]. This is not the same as
saying that it is unimportant what the therapist does [Paxling
et al., 2013]. Even if most of the communication between the
therapist and the patient is in the form of general support
[Sanchez-Ortiz et al., 2011], there is room for therapist’s drift
and a lenient attitude towards homework completion. In one
of the few controlled trials on the role of the therapist in
ICBT, it was found that experienced therapists tended to devote less time to their clients, but there were no differences in
outcome when compared to the inexperienced therapists in a
trial on social anxiety disorder (SAD) [Andersson et al.,
2012a]. Moreover, there are studies suggesting that guidance
can be provided from a more technical point of view that does
not require a clinician [Titov et al., 2010a]. A preliminary conclusion is that the therapist is important in ICBT, but that the
firm structure of the treatment leaves less room for betweentherapist effects and that it is probably the case that less training is needed than in regular CBT. In addition, another advantage of asynchronous contact in ICBT is that less experienced therapists can have good results because they can spend
more time on their feedback (i.e. discuss with colleagues, reflect about the response, and ask for supervision). Overall
there is not much written on the role of supervision in ICBT
and how therapists should be trained [Hadjistavropoulos et
al., 2012].
A second point to consider before implementation is what
the literature says about predictors of outcome. Even if mediators of outcome are important to consider for treatment development [Kazdin, 2007], it is probably the case that predictors of outcome are more important when moving an intervention to routine clinical practice. For example, if studies on
ICBT mainly have included well-educated patients, and routine clinical practice is likely to involve patients who are less
well educated, it is crucial to know if level of education is a
predictor of outcome. Another example is comorbidity. If,
e.g., persons with suicidal ideation have been excluded from
efficacy trials (note that actual suicide risk is different from
slightly elevated levels of suicidal thoughts), this can have implications for dissemination in routine practice. When it
comes to predictors of outcome it is probably most important
Table 1. Effectiveness RCTs of ICBT
Reference
Country
Disorder
Treatment arms
Outcome
Effect sizesa (pre/post d)
Bergström et al. [2010]
Sweden
panic disorder
a) ICBT (n = 50)
b) Live CBT (n = 54)
PDSS
a) 1.73
b) 1.63
Andrews et al. [2011]
Australia
social anxiety
disorder
a) ICBT (n = 23)
b) Live BT (n = 14)
SIAS
a) 0.75
b) 0.89
Hedman et al. [2011]
Sweden
social anxiety
disorder
a) ICBT (n = 64)
b) Live CBT (n = 62)
LSAS
a) 1.42
b) 0.97
Ljotsson et al. [2011]
Sweden
IBS
a) ICBT (n = 30)
b) WLC (n = 31)
GSRS-IBS
a) 1.28
b) –0.08
ICBT = internet-based cognitive behavior therapy; CBT = cognitive behavior therapy; PDSS = Panic Disorder Severity
Scale; SIAS = Social Interaction Anxiety Scale; LSAS = Liebowitz Social Anxiety Scale; WLC = waiting list control;
IBS = irritable bowel syndrome; GI = gastrointestinal; GSRS = Gastrointestinal Symptom Rating Scale.
a
Effect sizes have been recalculated from summary statistics in the original papers.
Table 2. Effectiveness studies of ICBT delivered to patients in clinical routine practice
Reference
Country
Disorder
N
Outcome
Effect sizesa (pre/post d)
Bergström et al. [2009]
Hedman et al. [2013]
Ruwaard et al. [2012]
Sweden
Sweden
the Netherlands
panic disorder
panic disorder
a) panic disorder
b) posttraumatic stress
c) depression
d) burnout
20
570
a) 139
b) 478
c) 413
d) 470
PDSS
PDSS-SR
a) PDSS-SR
b) IES-intrusion and avoidance
c) BDI
d) DASS-stress
2.5
a) 1.07
a) 1.36
b) 1.36
c) 2.01
d) 1.49
Aydos et al. [2009]
Australia
social anxiety disorder
17
a) SIAS
b) SPS
a) 1.51
b) 0.60
Newby et al. [2013]
Australia
mixed anxiety and
depression
136
a) GAD-7
b) PHQ-9
a) 1.15
b) 0.89
Mewton et al. [2012]
Williams and Andrews
[2013]
Australia
Australia
general anxiety disorder
depression
588
359
GAD-7
PHQ-9
0.86
0.98
Kaldo et al. [2004]
Kaldo et al. [2013]
Sweden
Sweden
tinnitus
tinnitus
77
293
TRQ
TRQ
0.56
0.58
Panic Disorder
The first condition for which effectiveness data exist is
panic disorder. This condition has been the topic of several
controlled efficacy studies [Andersson and Carlbring, 2011].
In table 1 we describe a controlled effectiveness trial by Bergström and colleagues [Bergström et al., 2010], in which live
CBT was directly compared with ICBT. That study was preceded by a small effectiveness study on ICBT from the same
group [Bergström et al., 2009], which is described in table 2.
As shown in the tables within group effect sizes were large in
these studies and differences between ICBT and live CBT
were minimal. More recently, the Swedish research group at
Karolinska Institutet has recently published effectiveness data
from their ICBT unit [Hedman et al., 2013] with a total of 570
patients with panic disorder. The results showed that ICBT
could be highly effective also when delivered as routine clini-
cal care (table 2). Ruwaard and colleagues [Ruwaard et al.,
2012] published data on a large series of clinical patients out
of which 139 had been treated for panic disorder with their
program ‘Interapy’. As displayed in table 2 effect sizes were
large. Overall, the evidence from 1 controlled effectiveness
trial and 3 open effectiveness trials clearly indicates that the
results from the efficacy studies are sustained when delivered
in routine practice.
Effectiveness of Guided ICBT in Regular
Clinical Settings
Verhaltenstherapie 2013;23:140–148
SAD
For SAD there are even more controlled efficacy studies
that have been published since the first trial on the ‘SOFIE’
program [Andersson et al., 2006], and also a few effectiveness
studies. The first one was a small trial with 17 clinical patients
who received ICBT for SAD [Aydos et al., 2009] with the
‘Shyness’ program [Titov et al., 2008] (table 2). There are also
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ICBT = internet-based cognitive behavior therapy; PDSS = Panic Disorder Severity Scale; SIAS = Social Interaction Anxiety Scale;
GAD-7 = Generalized Anxiety Disorder Scale, 7-item version; PHQ-9 = Patient Health Questionnaire 9; PDSS-SR = Panic Disorder Severity Scale
Self-Report; IES = Impact of Event Scale; BDI = Beck Depression Inventory; DASS = Depression Anxiety Stress Scales; TRQ = Tinnitus Reaction
Questionnaire.
a
Effect sizes have been recalculated from summary statistics in the original papers.
Generalized Anxiety Disorder
To our knowledge there is only 1 effectiveness study on the
treatment of generalized anxiety disorder (GAD), which is a
test of the ‘Worry’ program from Australia [Titov et al., 2009].
As seen in table 2, a large series of patients have been treated
[Mewton et al., 2012], and it is clear that the large treatment
effects from the relatively few efficacy trials on GAD are replicated [Titov et al., 2009; Paxling et al., 2011; Andersson et
al., 2012c]. With regards to posttraumatic stress disorder there
are controlled efficacy trials [Andersson, 2010], but to our
knowledge effectiveness data have only been reported for the
Interapy program [Lange et al., 2003], as presented in table 2.
The results of that study however show that ICBT for posttraumatic stress can yield large effects when delivered in routine care. For other specific anxiety disorders, such as obsessive compulsive disorder, specific phobia, and severe health
anxiety, there are controlled efficacy trials, but no effectiveness trials on guided ICBT.
Mixed Anxiety and Depression
It is widely acknowledged that there is an overlap between
mood and anxiety disorders, and in a recent effectiveness trial
on mixed anxiety and depression [Newby et al., 2013] it was
found that the ICBT treatment worked in a general practice
setting. From the Swedish research group there is an ongoing
controlled effectiveness study [Bergman Nordgren et al.,
2012], in which tailored ICBT has been tested [Carlbring et
al., 2011] for patients with mixed anxiety and depression in
primary care. Unpublished data from that trial show clear
benefits of treatment. Overall, however there are still very
few studies on tailored and transdiagnostic ICBT when delivered in routine practice.
Depression
Mild to moderate depression is another field for which
there have been many controlled efficacy trials [Richards and
Richardson, 2012]. We have not located any controlled effectiveness trial on depression, but open studies have been pub-
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lished. In a large sample of 359 patients it was found that the
treatment ‘Sadness’ worked [Williams and Andrews, 2013],
and the authors also reported that health condition of more
severe and suicidal patients also improved. A separate report
has been published by the same group showing that suicidal
ideation should not be an exclusion criterion; these patients
make substantial reductions of depressive symptoms following ICBT [Watts et al., 2012]. The second data set on depression presented in table 2 comes from the Interapy group, who
have treated both depression and burnout with large within
group effects sizes [Ruwaard et al., 2012]. For both of these
conditions there have been previous controlled efficacy trials
[Ruwaard et al., 2007, 2009]. There is clearly a need for more
effectiveness studies on guided ICBT for depression, but the
ones available suggest that the treatment can be transferred to
clinical practice.
Somatic Conditions
In the field of somatic disorders there has been an active
research with a large number of controlled trials on therapistguided ICBT. One of the first conditions to be treated with
ICBT was tinnitus, which is ringing or buzzing in the ears with
no external origin [Baguley et al., 2013]. The first controlled
trial on ICBT for tinnitus was published more than 10 years
ago [Andersson et al., 2002], but even before that the treatment was implemented in regular clinical practice in Uppsala,
Sweden. An early effectiveness study showed that the treatment worked [Kaldo-Sandström et al., 2004], and table 2 also
presents the outcomes of a recently published effectiveness
study from the same clinic [Kaldo et al., 2013]. As with live
CBT for tinnitus effect sizes are slightly smaller in ICBT for
tinnitus compared to ICBT for anxiety disorders. Finally,
there is one controlled effectiveness trial on ICBT for irritable
bowel syndrome (IBS), which is a condition characterized by
abdominal pain or discomfort combined with diarrhea and/or
constipation [Blanchard, 2001]. The controlled trial [Ljótsson
et al., 2011] (table 1) largely replicated the findings from a
previous efficacy trial demonstrating large within group effect
sizes [Ljótsson et al., 2010]. As with the anxiety disorders,
there are several health conditions for which there are only
efficacy studies on guided ICBT and no investigations on effectiveness, including, e.g., chronic pain, headache, diabetes,
psychological distress in cancer patients, eating disorders, and
erectile dysfunction [Hedman et al., 2012a].
Discussion
Overall, this review suggests that the effects found in controlled efficacy trials on guided ICBT tend to be replicated in
clinical practice in ICBT for panic disorder, SAD, GAD, posttraumatic stress disorder, burn out, depression, mixed anxiety
and depression, tinnitus, and IBS. This is in line with what has
been observed when face-to-face therapies have been tested
Andersson/Hedman
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2 controlled effectiveness trials. In Australia, Andrews and
colleagues [Andrews et al., 2011] conducted a small controlled
effectiveness trial where they compared ICBT with face-toface group CBT. As seen in table 1 both treatments were
equally effective. In a larger trial, ICBT was compared with
group CBT and in this trial there was even a tendency for the
ICBT group to improve more [Hedman et al., 2011a]. For this
study there is also a separate report showing that ICBT is
cost-effective compared to live CBT [Hedman et al., 2011b].
Thus, data from effectiveness studies indicate that the promising effects from the efficacy studies clearly replicate when the
treatment is delivered in routine practice settings. Larger series of patients should however be examined, as the 2 controlled trials involved randomization which is not a characteristic
of regular practice.
adolescents [Stallard et al., 2010], attitudes appear to be positive. When it comes to patient attitudes data is not consistent
and potentially there are differences between countries and
settings, with some studies showing more positive attitudes
[Spence et al., 2011; Wootton et al., 2011] than others [Mohr
et al., 2010]. A sixth important point is the role of healthcare
regulation and reimbursement issues that are instrumental
when implementing ICBT in clinical practice. For example in
Norway, it has not been allowed to communicate with patients over internet [Nordgreen et al., 2010], and funding of
services differs widely between countries where some countries offer services free of charge and others are linked with
insurance companies who may have their own preferences
and regulations. A related factor is the role of professional organizations such as unions and how they influence services
and license to practice. A final point to discuss, which has
bearings on the distinction between efficacy and effectiveness
studies, is how much the clinic should mimic the research setting (e.g., if the number of outcome measures should be kept
the same or cut down). It is obviously much easier to retain
aspects of the efficacy study in the field of ICBT, such as routine administration of measures and the treatment staying intact, but there are also things that can differ. One thing is that
clinicians who have not been part of treatment development
may feel more detached from the treatment and hence it may
be a good idea to include clinician input in treatment planning
and the actual treatment content. Indeed, there is preliminary
evidence that tailored treatment, where the treatment modules are individually prescribed, might benefit patients with
more severe disorders [Johansson et al., 2012]. In any case the
tailoring procedures and pre-treatment case conceptualization
may be something that would make ICBT more attractive to
clinicians and indeed patients as well.
This review has limitations. First, the search for literature
was complicated by the fact that there is no real consensus on
how to describe and report ICBT studies. For example, there
are efficacy studies where the clinician handling the patients
has been a practitioner [Shandley et al., 2008], and in our review we rather focused on the setting in which ICBT was delivered (i.e., routine care), which is just one aspect of effectiveness. Second, many ICBT efficacy trials have recruited
participants from the general public and it may be that the research participants in those trials are more representative for
the public than clinic patients [Titov et al., 2010b]. This would
make the distinction between efficacy and effectiveness
blurred. As a third limitation we acknowledge that we did not
code our retrieved studies for clinical representativeness
[Stewart and Chambless, 2009]. As a fourth limitation we note
that most effectiveness studies covered in this review have
been delivered in specialist clinics, and in some cases ICBT
has been the only treatment delivered [Ruwaard et al., 2012],
whereas in others ICBT has been one of several treatment options [Kaldo et al., 2013].
Effectiveness of Guided ICBT in Regular
Clinical Settings
Verhaltenstherapie 2013;23:140–148
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[Stewart and Chambless, 2009]. There are however few studies on the effectiveness of guided ICBT, and for many conditions there are no effectiveness studies at all, which should be
seen in the light of more than 100 controlled efficacy trials
[Hedman et al., 2012a].
There are many topics to discuss when considering dissemination of ICBT into daily routine practice. One first crucial
issue, not touched upon in this review, is the role of data security [Bennett et al., 2010] and the need for a robust web solution in order to handle large number of participants. A second
issue has to do with assessment procedures, as ICBT inherently involves computerized online assessment procedures
alongside the treatment [Andersson et al., 2010]. Overall, evidence suggests that psychometric measurement characteristics
are maintained when measures are administered online [Carlbring et al., 2007; Hedman et al., 2010], but to our knowledge
there is not much written about how well online measures
work in routine clinical practice. A third related aspect of
ICBT in routine clinical settings is how diagnostic interviews
are conducted. For example, at the ICBT unit at Karolinska
Institutet, Psychiatry Southwest, ICBT is always preceded and
followed by a psychiatric diagnostic interview in vivo, but
whether this is needed apart from the obvious benefits in
terms of risk assessment and possibilities to directly refer patients to other treatment alternatives (e.g., medication) is not
clear. For example, in one study on SAD there were no differences in effects whether a diagnostic pre-treatment interview
was included or not [Boettcher et al., 2012]. In many efficacy
studies the diagnostic interviews have been administered over
telephone, which is one alternative [Crippa et al., 2008]. Overall, dissemination of ICBT is not only about treatment provision, but also concerns referral routes, assessments, management of patients less suitable for ICBT, and outcome monitoring including follow-ups. In addition, there is initial evidence suggesting that ICBT can prevent relapse in depression
[Holländare et al., 2011], and in the future it is possible that
longer ICBT treatments (extending over years) and booster
treatments will be developed for more chronic conditions and
where there is a risk of relapse. A fourth point to consider is
the training of therapists in ICBT and if there should be separate therapists who work with guidance (perhaps less in need
of training but under supervision), or if ICBT should be seen
as one of many tools in the therapist toolbox. We referred
earlier to the observation that therapist factors are probably
less important in ICBT, but this does not necessarily mean
that just anyone is a suitable internet therapist as there is always a risk for mistakes in text communication. Even if there
are preliminary guidelines on how to best guide patients in
ICBT [Titov, 2010; Hadjistavropoulos et al., 2011], more work
is needed when it comes to practice guidelines. A fifth related
issue is if therapists and patients are interested in and want
ICBT. There is an emerging literature on clinicians’ attitudes
towards ICBT [Wangberg et al., 2007; Gun et al., 2011], and
with the possible exception of clinicians treating children and
Conclusions
Acknowledgement
ICBT involving clinician contact has been tested in efficacy
trials with most studies indicating that the treatment works
when it is transported to routine care. Studies on panic disorder, SAD, GAD, posttraumatic stress disorder, depression,
mixed anxiety and depression, tinnitus, and IBS all indicate
that it is possible to transfer ICBT to clinical practice with sustained effects. There are however several knowledge gaps and
many conditions for which efficacy data has not been reported.
Moreover, clinical predictors of outcome should be reported
in large series of patients, and there is a need to study the implementation process when ICBT is spread to routine care.
The preparation of this paper was supported in part by grants from
the Swedish council for working and life research, the Swedish research
council, and Linköping University.
Discosure Statement
The authors declare that there is no conflict of interests concerning
this paper.
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