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How does iCBT positively and negatively affect patients who experience anxiety and depression?

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Accessibility issues to trained clinicians in CBT approaches

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Accessibility issues to trained clinicians in CBT approaches

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The studies showed that nonprofessionals can effectively deliver iCBT for depression, which is helpful in areas with a shortage of trained clinicians. However, supervision by trained professionals, especially for crisis situations, is important. Supervision of coaches improves treatment outcomes for depression but not for anxiety.

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Effectiveness Compared to Traditional Face-to Face Therapy

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Effectiveness Compared to Traditional Face-to Face Therapy

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Patient Preferences and Satisfaction of iCBT

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Patient Preferences and Satisfaction of iCBT

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Outcomes may vary between group online sessions and one-on-one therapy, highlighting the importance of tailored approaches to maximize efficacy in the patients part of this research used the online CBT from their own homes, which they seemed to appreciate, however not all patients developed meaningful online relationships some of them continued with therapy but most withdrew without experiencing the benefits.

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One of the main issues in online CBT was the lack of support to stick to the program/sessions which caused issues in establishing a strong relationship and poor adherence with the two individuals in sessions.

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Many participants expressed feeling disconnected or not having enough support around them during sessions, which diminished the therapeutic experience.

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The study addresses the mental health crisis exacerbated by the COVID-19 pandemic, emphasizing that technology-assisted CBT could help meet the rising demand for mental health services.

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“However, not all patients developed meaningful online relationships; some of these continued with therapy, but most withdrew without experiencing benefit” (Beattie, A. et al., 2009, p. 51).

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"Effects in the subgroup of depression studies involving nonprofessionals were large, indicating the potential to deliver iCBT services, for example, in contexts when there might be a shortage of trained clinicians. In cases where nonprofessionals deliver guidance in iCBT services, supervision by trained clinicians, including the availability of professionals for crisis intervention, seems warranted" (Etzelmueller et al., 2020, p. 17).

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"The main barriers included: experiencing a lack of identification with and applicability of CCBT, lack of support to adhere to the program or to gain deeper understanding, and inadequate computer/internet skills, equipment, or location" (Gerhads et al., 2011, p. 123).

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"Nearly all non-completers who followed at least one CCBT

session indicated a preference or need for support. But also

some of the completers preferred some kind of support or

argued that other CCBT users could need support" (Gerhads et al., 2011, p. 122).

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"Anxiety and depression are some of the most common mental health problems experienced by CYP, and these conditions have been significantly exacerbated by the COVID-19 pandemic" (Bevilacqua et al., 2024, p. 3).

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In this study, allowing patients to choose between online and in-person therapy significantly improved their engagement. By providng them with the option to select the format that best suits their individuals preferences and needs, they tend to commit more to their sessions; which leads to better adherence and outcomes in managing anxiety and depression.

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"Providing participants with a choice gave the opportunity to assess treatment effectiveness. This strategy reflected a real-world model where participants had autonomy over their treatment delivery method. Baseline differences between participants in the treatment groups highlights the importance of patient-centered therapy and the need for future studies to account for symptom severity when allocating patients to the most appropriate treatment type." (Alavi et al., 2023, p.1).

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According to the study's patient preferences, iCBT presented a number of challenges for the participants. These obstacles included difficulties identifying with or using the iCBT program, a lack of support to stay engaged or completely understand the content, and challenges caused by insufficient computer or bad internet, equipment, or even the location in which they accessed the sessions

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"The pooled reported percentage of sessions completed, that is, 62.6% in depression and 57.3% in anxiety studies, was lower than that described in meta-analyses on adherence in RCTs on iCBT interventions. Comparing the adherence to iCBT and face-to-face CBT, van Ballegooijen et al reported that on average, participants completed 80.8% of treatment sessions in the iCBT and 83.9% in the face-to-face intervention.

Similarly, the percentage of participants completing the

treatment as planned was lower (62.8% for depression and

61.7% for anxiety studies) than reported elsewhere. These differences might be due to the assumed adherence-fostering effect of randomized controlled settings versus routine care." (Etzelmueller et al., 2020, p. 16).

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Impact of Treatment Format on Patient Completion and Satisfaction

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Impact of Treatment Format on Patient Completion and Satisfaction

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In this study, the completion rates for iCBT sessions were 62.6% for depression and 57.3% for anxiety, which is lower than the completion rates reported in meta-analyses of randomized controlled trials (RCTs). In those RCTs, participants completed 80.8% of iCBT sessions and 83.9% of face-to-face CBT sessions. Additionally, the percentage of participants completing the treatment as planned in this study was 62.8% for depression and 61.7% for anxiety, which is also lower than what's typically reported in meta-analyses of RCTs. The difference may be due to the stronger adherence typically seen in controlled trials compared to real-world settings.

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"The patients' preferences in this study revealed that they faced several barriers during CCBT. These barriers included difficulty identifying with or applying the CCBT-CYL program, a lack of support to stay committed or fully understand the material, and challenges related to inadequate computer or internet skills, equipment, or even the location in which they accessed the sessions" (Gerhads et al., 2011, p.123).

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Online therapy programs (iCBT) for depression work better when trained professionals like therapists or psychiatrists are involved, compared to when less trained people (such as nurses, general doctors, or counselors) are guiding the treatment.

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"Further subgroup analyses indicated that iCBT services for the treatment of depression utilize trained professionals (psychotherapists and psychiatrists) to result in larger pre-post changes compared with iCBT services that used only nonprofessionals not trained in CBT (psychologists without specialized CBT training, nurses, GPs, counsellors, coaches, and lived experience coordinators) However, we did not find this effect in the anxiety studies." (Etzelmueller et al., 2020, p. 17).

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The treatment gap for common mental disorders in LMICs is significant, with an estimated 90% of people in these

settings unable to access appropriate mental health care (Vos et al., 2015 as cited in Madeeha Latif et al., 2021, p.2) compared with a mean treatment gap of 53.2% in North America, for example (Kohn et al., 2018 as cited in Madeeha Latif et al., 2021, p.2).

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Accessibility and convenience of online CBT have improved, allowing individuals in low and middle-income countries to engage in therapy from home, reducing geographical barriers.

Online CBT is often more affordable than traditional therapy, making mental health care more accessible to those of lower incomes, and geographically convenient.

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"CBT-based self-help and guided self-help (GSH) may represent low-cost and scalable interventions that can be delivered without additional strain on the already limited resources in LMICs" (Latif et al., 2021).

"Self-help and GSH can be delivered online, and have been found to be effective and feasible for individuals with depression and anxiety" (Andrews et al., 2018, as cited in Latif et al., 2021).

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Treatment gap for mental health services

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Treatment gap for mental health services

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According to this study, an estimated 90% of individuals in LMICs are unable to access appropriate mental health care. Whereas in North America the treatment gap is 52%.

Online CBT improves access, allowing patients in both regions to receive therapy from home.

Convenience: It offers flexibility, making it easier for busy individuals to engage in therapy.

Limitations: Some may prefer in-person therapy, and internet issues in LMICs can hinder access.

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This form of therapy has helped patients who were physically unable to commit to attending in person therapy sessions. Such as those with a physical disability, tight work or school schedules, taking care of family (small children, elderly people, etc.).

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“Computerized and online forms of therapy offer the potential to enhance patient access to CBT” (Beattie, A. et al., 2009, p. 46).

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Patients were hesitant in trying out the therapy, as they were unable to create a bond of trust with the therapists and counsellors due to being unable to see them face to face. The patients did feel more comfortable after compromising and being to use online platforms such as Zoom, Google Meet, and Microsoft Team.

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Leveraging the unprecedented increase in cell ’phone users and internet technologies, as well as the decline in prices of handheld mobile devices, may overcome barriers to care and address the huge mental health treatment gap in these settings ((Lambert & Littlefield, 2009; Lewis et al., 2012; UN Foundation-Vodafone Foundation Partnership, 2020; WHO, 2011, as cited in Beattie et al., 2009, p. 46)

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"When it comes to effectiveness, there are now at least four controlled trials and eight open studies showing that ICBT works in regular clinical settings. However, controlled trials such as the ones reviewed in this meta-analysis all require that participants consent to being randomized to either ICBT or face-to-face treatment, a requirement that limits the generalizability of the results." (Andersson et al., 2014)

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"60% of people with mental health concern in Canada don't go and seek help, and a big reason for that is stigma, and having internet-based tools available can help break the ice for a lot of people who are experiencing particularly mild or moderate forms of depression or anxiety" (CBC News: The National, 2015, 1:18–2:05).

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"The research over the last decade has shown that online models have been very effective in treating anxiety and depression. A review of this evidence aims to give us the confidence to scale up available internet-based models to improve access to mental health services for Canadians. This is particularly important for individuals living in rural communities and for our multicultural populations, where access to therapy in one’s own language can be a big issue. Additionally, many Canadians lack insurance to cover the costs of a psychologist or social worker providing this type of therapy" (CBC News: The National, 2015, 0:30–1:12).

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“Another important point is that this study was carried out as a psychoeducation programme rather than a group therapy session. While efforts were taken to provide an interactive environment for participants, in reality however, individual and group interaction and engagement was limited” (Uysal et al., 2022).

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“Another limitation of this study may be the use of videoconferencing. Since the participants attended the sessions from their homes, they might face distractions that interfere with the desired outcomes” (Uysal et al., 2022).

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Significant improvement for children and adolescence 

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Significant improvement for children and adolescence 

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Internet-delivered CBT with limited therapist involvement has demonstrated significant improvements in anxiety disorders among children and adolescent.

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"There are now several control trials showing that iCBT with minimal therapist support can produce significant improvements in anxiety for children and adolescence presenting with anxiety disorders" (Spence, 2020, 1:28).

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Breaking Barriers - The Effectiveness of Online Therapy in Reaching Those Who Avoid Face-to-Face Treatment

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Breaking Barriers - The Effectiveness of Online Therapy in Reaching Those Who Avoid Face-to-Face Treatment

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Online therapy offers a private, flexible option for people who may avoid face-to-face treatment. It helps those who feel uncomfortable or stigmatized by in-person therapy, making it a good alternative for managing mental health concerns such as anxiety and depression.

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The Role of Online Therapy in Enhancing Accessibility and Convenience for Canadians

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The Role of Online Therapy in Enhancing Accessibility and Convenience for Canadians

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Online therapy improves accessibility for Canadians by removing barriers like travel and scheduling, making mental health support more convenient and widely available, especially in remote areas.

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"In a systematic literature review, Olsson et al. (2021) reported that children and adolescents with symptoms of anxiety and depression who participated in individual / group CBT interventions reported medium to high treatment satisfaction" (Uysal et al., 2022).

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In their systematic literature review, Olsson et al. (2021) found that children and adolescents experiencing anxiety and depression who took part in individual or group cognitive-behavioral therapy (CBT) generally felt satisfied with their treatment, reporting medium to high levels of satisfaction.

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limited group interactions and engagement

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limited group interactions and engagement

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This study was conducted as a psychoeducation program rather than a group therapy session is another crucial issue. Although efforts were made to create an interactive setting for participants, there was actually little opportunity for both individual and group contact and involvement.

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The use of videoconferencing could be another limitation of this study. Participants can encounter distractions that interfere with the intended results because they conducted the sessions from the comfort of their own homes.

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According to this study iCBT is useful for treating depression and anxiety, and its results are comparable to those of conventional in-person therapy (Andersson et al., 2014). However, because trial participants may differ from the general population seeking care, the need that participants consent to randomization may restrict the generalizability of these findings. The research still shows that iCBT has the potential to be a flexible and easily accessible treatment approach.

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While online CBT offers therapy where a webcam is involved, another method used was telephone calls. The patient and therapist would call each other, without having to use their computers webcams or phone to directly speak to each other. The patients who were able to call instead of having to meet online found it easier and "comforting" using this method. Another method was messaging, where patients could message their therapists in real time. Therapists would also send "reminders", which was appreciated by the patients.

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"I found it much easier to have a telephone call with her. I think it did help that I’d met her once, so I knew what she looked like. But there was a complete and utter trust and we got on, and I really, really liked her. And I liked the fact that she understood me straightaway. And it didn’t bother me that it wasn't face-to-face. And there was something that was really quite comforting about still being in my own home, and with my own surroundings, and with things that comforted me. And if I’d finished the modules, or I’d finished a conversation, and I was feeling low, then I was instantly able to do something" (Maddox, 2020).

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Interest in computerized and non-computerized self-directed cognitive behavioral therapy for individuals with depression is increasing due to its accessibility and lower resource requirements compared to traditional psychotherapy.

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"Given the potential for more accessibility and less resource demands compared with other types of psychotherapy, there is interest in evaluating the clinical effectiveness of computerized and non-computerized self directed CBT for individuals with clinically diagnosed depression.” (Boudreau et al., 2010, p. 2)