Response and Remission Rates in Internet-Based Cognitive Behavior Therapy: An Individual Patient Data Meta-Analysis

Abstract

Background: Internet-delivered cognitive behavior therapy (ICBT) was developed over 20 years ago and has since undergone a number of controlled trials, as well as several systematic reviews and meta-analyses. However, the crucial question of response rates remains to be systematically investigated. The aim of this individual patient meta-analysis (IPDMA) was to use a large dataset of trials conducted in Sweden to determine reliable change and recovery rates across trials for a range of conditions. Methods: We used previously collected and aggregated data from 2,866 patients in 29 Swedish clinical trials of ICBT for three categories of conditions: anxiety disorders, depression, and others. Raw scores at pre-treatment and post-treatment were used in an IPDMA to determine the rate of reliable change and recovery. Jacobson and Truax’s, (1991) reliable change index (RCI) was calculated for each primary outcome measure in the trials as well as the recovery rates for each patient, with the additional requirement of having improved substantially. We subsequently explored potential predictors using binomial logistic regression. Results: In applying an RCI of z = 1.96, 1,162 (65.6%) of the patients receiving treatment were classified as achieving recovery, and 620 (35.0%) were classified as reaching remission. In terms of predictors, patients with higher symptom severity on the primary outcome measure at baseline [odds ratio (OR) = 1.36] and being female (OR = 2.22) increased the odds of responding to treatment. Having an anxiety disorder was found to decrease the response to treatment (OR = 0.51). Remission was predicted by diagnosis in the same direction (OR = 0.28), whereas symptom severity was inversely predictive of worse outcome (OR = 0.81). Conclusions: Response seems to occur among approximately half of all clients administered ICBT, whereas about a third reach remission. This indicates that the efficacy of ICBT is in line with that of CBT based in prior trials, with a possible caveat being the lower remission rates. Having more symptoms and being female might increase the chances of improvement, and a small negative effect of having anxiety disorder versus depression and other conditions may also exist. A limitation of the IPDMA was that only studies conducted in Sweden were included.

Predicting remission after internet-delivered psychotherapy in patients with depression using machine learning and multi-modal data

“…Our findings corroborate previous findings of symptom severity, education, age, medication use, and PRSs as predictors for ICBT outcomes. 3 8 10 12 13 16 19 Regarding remission of MDD in particular, our result is in line with Andersson and colleagues 11 in that depression symptom severity and higher anxiety predicted the outcome. Interestingly, the number of predictors that our final model settled with was fairly high (n = 45), also consistent with the logic of a multi-modal approach for predicting complex traits and behaviours.…”

“…6 7 However, a substantial portion of individualsestimates range from 10 to 60%do not respond sufficiently to ICBT. 8 9 As there is room for improvement, researchers have begun to investigate what variables predict symptom reduction, 3 8 10 remission status, 11 and other outcomes proximal to ICBT response such as adherence, 12 and dropout. 13 Identifying replicable predictors could inform clinical decision making allowing for better tailored intervention and care for these patients.…”

Development and evaluation of an internet-based treatment for generalized anxiety disorder : An acceptance-based approach

“…Different criteria for defining responders are used in different studies making comparisons to other studies difficult (Loerinc et al, 2015). However, the effects reported in this thesis are similar to those reported in a large study on clinical effects of ICBT treatments concluding that about one third reach remission post-treatment (Andersson, Carlbring, & Rozental, 2019). In a meta-analysis examining response rates in face-to-face treatment the response rate of CBT for GAD was 47% on average (Loerinc et al, 2015).…”

Digital technological interventions in mental health care

“…A meta-analysis of 29 Swedish studies including 2866 patients treated with ICBT for anxiety disorders, depression, and other disorders revealed that 65.6% of all patients improved, with one-third achieving remission. [ 3 ] As digital approaches to mental health increase, there is also space for artificial intelligence (AI) to be used to predict or detect or treat mental health issues. This can be incorporated into digital modalities via cell phone apps which can personalize mental health care and natural language, and access to data use can lead to formulation of conversation assistants online as well to be used for therapeutic intervention.…”