Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost–effectiveness

Abstract

Internet-based cognitive behavior therapy (ICBT) is a promising treatment that may increase availability of cognitive behavior therapy (CBT) for psychiatric disorders and other clinical problems. The main objective of this study was to determine the applications, clinical efficacy and cost-effectiveness of ICBT. The authors conducted a systematic review to identify randomized controlled trials investigating CBT delivered via the internet for adult patient populations. Searches to identify studies investigating cost-effectiveness of ICBT were also conducted. Evidence status for each clinical application was determined using the American Psychologist Association criteria for empirically supported treatments. Of 1104 studies reviewed, 108 met criteria for inclusion, of which 103 reported on clinical efficacy and eight on cost-effectiveness. Results showed that ICBT has been tested for 25 different clinical disorders, whereas most randomized controlled trials have been aimed at depression, anxiety disorders and chronic pain. Internet-based treatments for depression, social phobia and panic disorder were classified as well-established, that is, meeting the highest level of criteria for evidence. Effect sizes were large in the treatment of depression, anxiety disorders, severe health anxiety, irritable bowel syndrome, female sexual dysfunction, eating disorders, cannabis use and pathological gambling. For other clinical problems, effect sizes were small to moderate. Comparison to conventional CBT showed that ICBT produces equivalent effects. Cost-effectiveness data were relatively scarce but suggested that ICBT has more than 50% probability of being cost effective compared with no treatment or to conventional CBT when willingness to pay for an additional improvement is zero. Although ICBT is a promising treatment option for several disorders, it can only be regarded as a well-established treatment for depression, panic disorder and social phobia. It seems that ICBT is as effective as conventional CBT for respective clinical disorder, that is, if conventional CBT works then ICBT works. The large effects and the limited therapist time required suggest that the treatment is highly cost effective for well-established indications.

Cost effectiveness of guided Internet-based interventions for depression in comparison with control conditions: An individual-participant data meta-analysis

“…Our results are not in line with findings from earlier systematic reviews evaluating the cost effectiveness of Internet‐based treatments (Donker et al., 2015; Hedman et al., 2012). The authors of previous studies concluded that Internet‐based treatments have high probability of being cost effective compared to controls for various mental health problems including depression (Donker et al., 2015; Hedman et al., 2012).…”

“…The authors of previous studies concluded that Internet‐based treatments have high probability of being cost effective compared to controls for various mental health problems including depression (Donker et al., 2015; Hedman et al., 2012). Other authors, however, stated that the information they had was not sufficient to draw firm conclusions (Andersson, Wagner, & Cuijpers, 2016; Arnberg, Linton, Hultcrantz, Heintz, & Jonsson, 2014).…”

“…A possible explanation for the difference between our conclusions and those of some of the previous studies is the absence of guidelines on what probability of cost effectiveness is perceived acceptable by healthcare decision makers. As a result, sometimes relatively low probabilities (e.g., anything higher than .50) have led to the conclusion that the intervention under study was cost effective in comparison with its comparator (Hedman et al., 2012). In addition, systematic reviews typically do not pool data from cost‐effectiveness studies and researchers are limited to descriptive analysis of point estimates of the ICERs without assessing statistical uncertainty.…”

“…A small number of systematic reviews have evaluated the cost effectiveness of Internet‐based interventions (Donker et al., 2015; Hedman, Ljotsson, & Lindefors, 2012; Tate, Finkelstein, Khavjou, & Gustafson, 2009). Even though the authors concluded that Internet‐based interventions are a potentially useful clinical tool, they also concluded that there is a lack of evidence supporting their cost effectiveness.…”

“…However, the RCTs included in these systematic reviews had different methodological approaches: they differed in the perspective used to estimate costs (e.g., societal or national healthcare provider), the valuation of cost categories, the outcome measures, and the analyses performed. As a result, review authors were unable to statistically pool the cost‐effectiveness results in an aggregate data meta‐analysis (Donker et al., 2015; Hedman et al., 2012; Tate et al., 2009). …”