Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis

Abstract

Background Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects. Objective This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome. Methods We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials. Results We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P =.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls. Conclusions iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recr...

Effects of Internet-Based Cognitive Behavioral Therapy in Routine Care for Adults in Treatment for Depression and Anxiety: Systematic Review and Meta-Analysis

“…The finding that treatment outcomes of depression interventions were greater when recruitment was carried out using an open recruitment strategy in a community setting compared with when recruited in a clinical setting is in line with the findings of Romijn et al [ 13 ] with regard to randomized pragmatic studies on anxiety disorder treatments. However, in our study, this interaction was only found for depression and could not be confirmed for anxiety disorders.…”

“…The same study identified eight papers investigating the effectiveness of iCBT, reporting an average effect size of g =1.07 across the treatment of depression, panic disorder, generalized anxiety disorder, and social phobia [ 15 ]. The between-group effects were moderate to large ( g =0.72; 95% CI 0.60-0.83; P <.001; of I² =53, 95% CI 31-66) in the most recent meta-analysis of iCBT treatments for anxiety compared with control conditions in reducing symptoms of anxiety in an adult population [ 13 ]. Additionally, the results of this study are in line with meta-analytic findings on face-to-face CBT treatments implemented in routine care with pre-post effect size found in randomized trials ranging from d =0.69 to 2.28 for depression [ 28 ] and g =0.73 to 2.59 for anxiety treatments [ 163 ].…”

“…Systematic reviews on studies were also able to show comparable effects to face-to-face treatments in adults [ 16 , 17 ]. In a recent meta-analysis, Romijn et al [ 13 ] showed that iCBT interventions for anxiety disorders can also have significant effects obtained in trials implemented in clinical care. They also found that effects were smaller in samples recruited in clinical practice than in samples recruited with an open recruitment method compared with waitlist-control groups [ 13 ], which raises the question of the effects of iCBT when implemented in routine practice.…”

A pragmatic factorial randomized controlled trial of transdiagnostic internet-delivered cognitive behavioural therapy: Exploring benefits of homework reflection questionnaires and twice-weekly therapist support

“…In routine care, these lessons are most often offered with some degree of therapist support, such as weekly phone calls or emails ( Titov et al, 2019 ). There is now a large body of research demonstrating that iCBT, especially when offered with therapist support, results in moderate to large effects for various mental health symptoms, such as depression, generalized anxiety disorder, panic, social anxiety, and posttraumatic stress (e.g., Andersson et al, 2019 ; Etzelmueller et al, 2020 ; Romijn et al, 2019 ).…”

Internet-based self-help using automatic messages and support on demand for generalized anxiety disorder: an open pilot study

“…Third, and this is also relevant for the initial controlled trial, our sample were highly educated, and a large majority were female. While there are effectiveness trials on internet interventions [46], there is a need for further trials investigating whether automated and supporton-demand interventions work, as there might be differences in uptake, adherence, and effects when treatment is part of a regular service. In conclusion, this study supports the use of automated messages with support on demand as an alternative to weekly contact with a therapist during internet-based treatment for GAD.…”