**2.2. Anxiety**

There is strong evidence in the literature supporting the use of iCBT for anxiety disorders. For example, there are three major meta-analyses that included between 12, 17, and 23 studies, and all showed the effectiveness of this intervention [14, 20, 28]. The Cochrane Collaboration recently updated their systematic review of therapist-supported iCBT for adults with anxiety disorders. They identified 38 randomized controlled trials (11 studying social phobia, eight studying panic disorders, eight studying multiple anxiety disorders, five studying generalized anxiety disorder, two studying PTSD, two studying OCD, and two studying phobias). Trial comparators included controls (i.e., waiting list, information, attention, online discussion groups), unguided iCBT, and face-to-face CBT. 11 trials compared therapist-supported iCBT with controls. For a clinically relevant improvement in anxiety symptoms, the pooled risk ratio (RR) was 3.75 (95% CI 2.51, 5.60; I<sup>2</sup> = 50%) favoring therapist-supported iCBT over controls. Reductions in disorder-specific symptoms and general anxiety symptoms were significantly greater for therapist-supported iCBT compared with controls. Only one very low-quality study compared therapist-supported and unguided iCBT; thus, no conclusions could be drawn. Four studies compared therapist-supported iCBT with face-to-face CBT. For a clinically relevant improvement in anxiety symptoms, the pooled RR was 1.09 (95% CI 0.89, 1.34; I<sup>2</sup> = 0%), indicating no significant difference between therapist-supported iCBT and faceto-face CBT. Further, no significant differences were observed in disorder-specific and general anxiety symptoms. While most of the evidence was low to moderate quality, the data suggest that therapist-supported iCBT is an effective treatment for anxiety disorders and could be as effective as face-to-face CBT. However, additional, better-designed studies are needed to draw stronger conclusions [29].

Given the technological nature of iCBT, do children and adolescents respond well to this intervention? Recently, Ebert *et al*. conducted a meta-analysis of iCBT for anxiety and depression in children and adolescents. They identified 13 RCTs: seven studying anxiety, four studying depression, and two studying both. The studies used non-intervention or placebo controls. 11 studies used therapist-guided iCBT. Compared with controls, iCBT had a mean effect size of 0.72 (95% CI 0.55, 0.90; P < 0.001) on symptoms of anxiety or depression. To get one positive outcome, the number needed to treat was 2.56. Interventions targeted at adolescents had larger effect sizes than those targeted at children (g = 0.95 and 0.51, respectively). While the studies had a variety of treatment strategies and no long-term follow-up, the data seem to indicate that iCBT may be an effective treatment for anxiety and depression symptoms in children and adolescents [30].

#### **2.3. Physical illness**

their analysis, the estimated number needed to treat to achieve a 50% reduction in depressive symptoms was eight patients [23]. What is particularly notable about this study is the number needed to treat. As first glance, this number seems too high to be clinically relevant. However, when considering the low expense associated with self-guided iCBT and when applying iCBT

Another question around implementation: can iCBT be adopted for more than one diagnosis? Depression is often comorbid with other psychiatric diagnoses, such as anxiety. To determine the effectiveness of a transdiagnostic and tailored approach for treating adult patients with depression and/or anxiety, Păsărelu *et al*. conducted a meta-analysis of randomized controlled trials. They included 19 trials with 2952 participants. Transdiagnostic and tailored iCBT yielded controlled Hedges' g values of 0.79 (95% CI: 0.59, 1.00) for depression, 0.82 (95% CI: 0.58, 1.05) for anxiety, and 0.56 (95% CI: 0.37, 0.73) for quality of life [24].

A final question around implementation: can iCBT be offered in the primary care setting? Depression, after all, is most often treated in a primary-care setting [25, 26]. One recent randomized controlled trial investigated the long-term effects of iCBT for depression administered through 16 primary-care centers (the PRIM-NET trial). Researchers compared a three-month therapist-supported iCBT program with treatment as usual for depression. Treatment as usual included in-person therapy, pharmacotherapy, sick leave, and any combination thereof. Patients were followed for 12 months. Within group effect sizes for iCBT and treatment as usual were high (Cohen's d = 1.42 and 1.29, respectively, at 12 months). No significant differences in depressive symptoms, quality of life, and psychological distress were observed between iCBT and treatment as usual at 3, 6, and 12 months. These data indicate that long-term iCBT with therapist support may be as effective as treatment as usual in a primary-

There is strong evidence in the literature supporting the use of iCBT for anxiety disorders. For example, there are three major meta-analyses that included between 12, 17, and 23 studies, and all showed the effectiveness of this intervention [14, 20, 28]. The Cochrane Collaboration recently updated their systematic review of therapist-supported iCBT for adults with anxiety disorders. They identified 38 randomized controlled trials (11 studying social phobia, eight studying panic disorders, eight studying multiple anxiety disorders, five studying generalized anxiety disorder, two studying PTSD, two studying OCD, and two studying phobias). Trial comparators included controls (i.e., waiting list, information, attention, online discussion groups), unguided iCBT, and face-to-face CBT. 11 trials compared therapist-supported iCBT with controls. For a clinically relevant improvement in anxiety symptoms, the pooled risk ratio (RR) was 3.75 (95% CI 2.51, 5.60; I<sup>2</sup> = 50%) favoring therapist-supported iCBT over controls. Reductions in disorder-specific symptoms and general anxiety symptoms were significantly greater for therapist-supported iCBT compared with controls. Only one very low-quality study compared therapist-supported and unguided iCBT; thus, no conclusions could be drawn. Four studies compared therapist-supported iCBT with face-to-face CBT. For

to an entire population, the investment could be worth the cost.

204 Cognitive Behavioral Therapy and Clinical Applications

care setting [27].

**2.2. Anxiety**

One very promising direction for iCBT is its use to treat distress caused by physical illness. In 2013, researchers conducted a systematic review investigating iCBT as an intervention for psychological distress in patients suffering from physical illnesses. Illnesses included irritable bowel syndrome (five trials), tinnitus (four trials), chronic pain (three trials), chronic back pain (three trials), infertility (two trials), as well as for a variety of other diseases (diabetes, HIV, multiple sclerosis, migraines, early breast cancer, with a trial each). At the time of this chapter's writing, the quality of evidence for iCBT was low and few conclusions could be drawn [31].

Since then numerous programs have emerged, especially for patients with cancer [9]. For example, a recent randomized controlled trial compared iCBT versus care as usual in breast cancer survivors with severe fatigue. The iCBT program started with two face-to-face sessions with a therapist followed by eight web-based modules. Therapists tailored modules and supported patients through the program. One final face-to-face session was conducted approximately 6 months after beginning treatment. At 6 months, participants in the iCBT group had significantly lower fatigue scores (mean difference, 11.5; 95% CI 7.7, 15.3) with a large effect size (Cohen d = 1.0) compared with care as usual. The iCBT group also had reduced functional impairment (mean difference, 297.8; 95% CI 145.5, 450.1) and psychological distress (mean difference, 5.7; 95% CI 3.4, 7.9) and increased quality of life (mean difference, 11.7; 95% CI 5.8, 17.7) compared with the care as usual group. Effect sizes of those measures ranged from 0.6 to 0.8 [32]. Some studies of iCBT for use in patients with brain injury, heart disease, and recurrent headaches is provided in **Box 1**.

#### *Brain Injury:*

Patients with acquired brain injury often have cognitive symptoms. These symptoms can potentially be addressed with iCBT. Recently, a systematic review of studies using iCBT to treat cognitive symptoms in adult patients with acquired brain injury was published. Among the 14 included high-quality randomized controlled trials, there was strong evidence that iCBT improved processing speed in patients with multiple sclerosis. There was moderate evidence that iCBT improved memory in patients with multiple sclerosis or brain tumors. However, more evidence from trials that use activities, participation, and body structure outcomes is needed to draw a strong conclusion [74].

number of sessions completed). There was no observed advantage to using a commercially available program versus a free-to-use one [33]. Neither program was more cost effective than usual GP care [34]. When interviewed, participants liked the autonomy and flexibility of the program, but disliked the lack of interpersonal communication and customizability [35].

The Internet and CBT: A New Clinical Application of an Effective Therapy

http://dx.doi.org/10.5772/intechopen.72146

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Because the patients in the REEACT trial expressed desire for more support, investigators conducted a second trial comparing the effectiveness of MoodGYM alone versus MoodGYM with telephone support (the REEACT-2 trial). The telephone support worker introduced patients to CBT, helped identify issues and set goals, motivated the patient, and discussed future steps. The study showed that telephone support made a difference, with significantly improved depression symptoms. The largest between-group difference was observed at 4 months (Cohen's d = 0.32), but the difference was no longer significant after 12 months. The odds ratio of not being depressed at 4 months was 2.05 (95% CI 1.23, 3.42; P = 0.0030) when telephone support was added to MoodGYM. There were also significant between-group differences in depression and anxiety scores. However, the adherence to the program did not increase substantially with 45% of patients completing the first session in the MoodGYM alone group and 65% completing the first session in the telephone-support group. An economic analysis indicated that telephone support could increase quality of life (in quality-adjusted life year [QALY]) and reduce

healthcare costs with a likelihood of being cost effective at ₤6933 per QALY [36, 37].

**4. iCBT and the real world**

**Features Options**

**Table 1.** Available features of iCBT.

While the literature is vast, a pattern is clear: iCBT can be effective. Even unguided iCBT, with its number needed to treat of eight, is beneficial to some patients [23]. But it should be noted that the number needed to treat jumps up to 2.56 for children and adolescents with anxiety using therapist-guided iCBT [30]. The emerging data on iCBT effectiveness and cost seem to support a stepped-care model, where patients with less severe illness and more motivation can be treated with unguided iCBT. As illness severity and desire for interaction increases, there is a role for iCBT programs with progressively more support. This model would balance the cost of treatment while providing the most benefit to individual patients and the population as a whole.

Beyond the research, there are more and more iCBT programs available to the public. While most iCBT programs contain eight to 12 self-guided goal-oriented modules [22, 38], they can vary in quality and type of care. Speaking to the latter point: iCBT has a broad spectrum of therapist involvement, ranging from none to high-level involvement. Some programs are free, while others

Level of support Self-guided, staff-supported, therapist-supported, chatbot-supported

Cost Free, app purchase price, subscription fee

Teaching style Tutorial, story-based, game-based

#### *Heart disease:*

Depressive and anxiety symptoms are common following myocardial infarction. CBT has been shown to be an effective treatment strategy for these symptoms, so researchers developed a therapist-supported, self-tailored iCBT program for patients following a myocardial infarction. In a randomized controlled trial comparing iCBT to standard care, patients in the iCBT group selected two to three modules from the ten available. Each module contained two to four steps, and patients were asked to complete a step per week. A pilot study showed that the study was acceptable (68% of eligible patients enrolled) and participants were sufficiently active (50% had completed at least one module assignment within 3 weeks). The full trial is currently ongoing [75].

#### Recurrent headaches

For children and adolescents with recurrent headaches, psychological interventions, including relaxation and CBT, have proved to be effective treatments. Researchers conducted a randomized controlled trial comparing the effects of iCBT, applied relaxation, and an educational control in children and adolescents with recurrent headaches. All patients received an educational module discussing headaches. The iCBT program had five additional modules that included stress management, cognitive-restructuring, and relaxation techniques. The applied relaxation program had more extensive relaxation training, which included the module provided to the iCBT group. All patients had email contact with a therapist. When comparing iCBT and applied relaxation with education, the numbers needed to treat were 2.0 and 5.2, respectively. Responder rate was significantly higher for iCBT (63%) at post-treatment compared with applied relaxation (32%) and education (19%) but not at the six-month follow-up. At post-treatment, iCBT had the largest within-effect sizes for headache duration and frequency as well as pain catastrophizing. Further studies are needed, but these results support the use of iCBT to treat recurrent headaches in children and adolescents [76].

**Box 1:** Evidence for using iCBT to treat psychological distress associated with physical illness.
