**2. Empirical support for internet-delivered cognitive behaviour therapy**

Apart from some early research on computerised cognitive behaviour therapy [6, 7], efficacy trials began in earnest from the year 2000, and in recent years there has been a verifiable explosion in the number of published reports that support iCBT for a broad range of psychological disorders. Most notably, clinical trials have established a sound empirical base for the treatment of the major depressive disorder and a range of anxiety disorders (social anxiety, panic disorder, and generalised anxiety disorder) and emerging evidence for others (severe health anxiety, specific phobias).

Cognitive behaviour therapy (CBT) is the most widely researched and established evidencebased treatment for psychological disorders [1]. In recent years, internet-delivered cognitive behaviour therapy (iCBT) interventions have become a method for the dissemination of evidence-based treatments for a broad range of psychological disorders including depression and anxiety. More recently, iCBT is being used to address the psychological distress associated with the management of long-term conditions in individuals with, for example, diabetes,

The first complete cognitive behaviour therapy (CBT) treatment was delivered through the use of compact disc-read only memory (CD-ROM) that contained the full programme, such as Beating the Blues. As technology developed and the web evolved, such treatments were offered entirely online, thus heralding the dawn of internet-delivered interventions (e.g., MoodGym). The majority of internet-delivered interventions deliver cognitive behaviour therapy (CBT)-based treatments, as it is a structured and modular-based treatment that lends

Internet-delivered treatments are named variously as online interventions, web-based interventions, e-therapy, e-health, and computerised cognitive behaviour therapy (cCBT) [2]. Some of the developments in the field have used brand names such as Interapy for PTSD [3], Deprexis for depression [4], and SilverCloud for depression, anxiety, and long-term conditions management [5]. Technology-delivered psychological interventions have a rich history,

Results profit from many features and benefits of web development and design, where CBT protocols have been repurposed for use online. These features include the use of multimedia, open and unlimited access to the intervention, as well as delivering a secure platform, which protect the service users' confidentiality and data. Internet-delivered treatments place the pace and direction of the treatment in the hands of the service users and reduce the burden on therapists' time. The capacity to deliver evidence-based treatment protocols in this way could have enormous impact on healthcare provision into the future, some of which we have already seen today. This chapter focuses on internet-delivered cognitive behaviour therapy (iCBT) interventions for depression and anxiety as a way of illustrating the field of internet interventions. It will describe their development, adoption, and implementation in various settings, including, for example, healthcare and employee assistance programmes. We begin by summarising the empirical evidence that supports the use of iCBT interventions for depression and anxiety disorders. After that, we will describe iCBT interventions function in practical terms. This description will illustrate using a case study example. Service delivery examples follow, which help demonstrate the flexible use of iCBT in various settings. The chapter will end by addressing future directions for both academic study and the practical implementation of iCBT.

**2. Empirical support for internet-delivered cognitive behaviour therapy**

Apart from some early research on computerised cognitive behaviour therapy [6, 7], efficacy trials began in earnest from the year 2000, and in recent years there has been a verifiable explosion

coronary heart disease, and chronic pain.

224 Cognitive Behavioral Therapy and Clinical Applications

itself readily to being repurposed into an online format.

and it is still very much a developing field of study and clinical practice.

Given the high prevalence of depression and anxiety disorders and their global ubiquity, interest on iCBT has grown due to its potential to support the dissemination of evidencebased CBT. It is fair to say that internet-delivered cognitive behaviour therapy interventions find their historical roots in the treatment of depression and anxiety disorders. Several metaanalytic studies have now demonstrated the efficacy of iCBT for depression. The earliest of these studies included computerised and internet-delivered interventions, and consistently reported the same results that iCBT is effective as an intervention for the treatment of depression. Andersson and Cuijpers [8] examined a group of 12 studies and reported an overall post-treatment effect size of *d* = 0.41versus control groups. Their analysis showed that the effect size estimate was moderated significantly between supported (*d* = 0.61) and unsupported (*d* = 0.25) treatments. Another systematic review and meta-analysis conducted by Richards and Richardson [9], examined the efficacy of computer-based psychological interventions for depression and concluded that, while the outcomes of computer-assisted interventions for depression are generally positive, these results also vary depending on the type of support provided throughout the intervention. Specifically, therapist-supported studies demonstrated the highest effect size at post-treatment and follow-up (*d* = 0.78), followed by administrative-supported studies (*d* = 0.58); that is, the non-therapeutic support provided. Interventions that did not include a support component obtained the lowest estimated effect size (*d* = 0.36). The results support the inclusion of any form of support, either a professional therapist, or a trained para-professional, or indeed a trained peer volunteer, or technician, as beneficial for optimising the efficacy of iCBT interventions [5, 10, 11]. Also, a recent individual service user data meta-analysis has shown that adherence to treatment predicts better outcomes [12].

The ability of internet-delivered interventions to maintain clinical gains at follow-up can contribute significantly towards their acceptability, adoption, and implementation in clinical practice. Many trials incorporated follow-up to 6- or 12-months post-treatment [13–15], demonstrating that iCBT has the potential to achieve and maintain significant clinical gains for service users. A smaller number have shown lasting impacts up to 3-years post-treatment [16, 17]. In one non-inferiority controlled trial of iCBT for depression that included a face-to-face control group, 3-year follow-up data demonstrated sustained improvements for both groups, with no significant differences between them [16].

Achieving outcomes that are similar to what has been offered in face-to-face treatments for depression only strengthens the validity of iCBT interventions for depression. A small number of trials have attempted this comparison, and in a review of this work, the authors [18] concluded that any differences were non-significant. In fact, they report that the effect size (*g* = 0.12) favoured the supported iCBT over the face-to-face interventions. What is not clear and requires further attention is whether the mechanisms of change that facilitate the success of face-to-face interventions are equally relevant in iCBT interventions [19].

The science in this area is rapidly expanding with trials conducted in countries including Ireland [5], Switzerland [14], Germany [20], Australia [21], England [11], Canada [22], and the USA [23]. Besides, while most of the work has been with adults, there is some work with adolescents [24]. Recent avenues for research in iCBT for depression have included the cultural adaptation of interventions [25] and tailoring interventions to more appropriately meet the needs of individual users [26].

Service users can avail internet-delivered CBT in several ways, the two most common methods being through self-sign-up or via an invitation from a supporter. Self sign-up to iCBT occurs where the service user acquires access automatically through a website of a particular provider organisation (e.g., healthcare, employer, and educational) without the need for a formal triage or assessment. One example of this would be an employee having access to an internet-delivered stress management intervention as part of his/her employee assistance intranet. In contrast, an invitation from a supporter can be generated from the platform to a service user. In some cases, supporter sign-up involves an initial assessment of psychopathology and suitability for an iCBT intervention (e.g., in a mental health service setting or a university counselling clinic setting). For the purpose what follows, the treatment pathway within a mental health service organisation will be used to illustrate how iCBT functions.

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Post clinical assessment, a service user can be identified as suitable and be requiring an iCBT intervention. They provide their e-mail address to their supporter (clinician in this setting), who then invites them through their supporter account on the platform to use the intervention. An e-mail is posted to the service user that provides them with some preliminary information about the platform and a definite URL/web link that directs them to the sign-up process. The service user will then be prompted to create a unique username and password. As with all online utilities associated with potentially sensitive information, users should be required to create a password that is composed of upper and lowercase letters, numbers and special characters. Once the service user has completed the necessary sign-up steps, they will

In a supported mode of treatment, service users are expected to log-in to their account several times throughout the prescribed course. The supporter is supposed to review the service users' progress at regular, pre-determined intervals. These core expectations should be presented to the service user from the outset, along with other goals that may be of importance to the service providing the iCBT intervention. Support to iCBT is provided in one of two modalities:

As with all psychological treatments, service user reported outcomes are an important aspect of iCBT. Incorporating an assessment protocol for treatment can provide a supporter with further insight into the progress of the service user. For example, a series of measures on depression, anxiety, or other related constructs could be applied at baseline, at the intervals corresponding to the date of review set by the supporter and subsequent discharge. Administering the measures through an iCBT platform would allow supporters to gauge the improvement (or deterioration) of the service user over the course of their use of the intervention, where the information is presented in an easy-to-interpret manner. Assessments conducted in this way facilitate the assessment of risk during the intervention and automated

Synchronously: where both the service user and supporter are online at the same time, and the review is conducted

Asynchronously: where the service user and supporter are online at different times to engage with the programme content and providing a review, respectively. This type of contact takes the form of either e-mail or post-session

alerts can be established to inform supporters to take appropriate action.

gain access to their intervention.

over video conferencing or live chat.

review on the iCBT platform.

A similar picture of clinical efficacy for the anxiety disorders is established with trials for panic disorder, social anxiety disorder (SAD), generalised anxiety disorder, specific phobias, and severe health anxiety. The most recent review contributing to our understanding of the efficacy of iCBT for anxiety disorders is a Cochrane review on therapist-supported iCBT for anxiety disorders that included 30 studies [27].

The review [27] consisted of eight trials for panic disorder with or without agoraphobia and showed significant post-treatment and follow-up effects for iCBT for panic compared to waiting list controls. Some of these trials included a direct comparison with face-to-face treatment and demonstrated comparable outcomes. The evidence for panic disorder treatment delivered online is therefore good, although the diversity of trials and interventions is limited. Eleven trials of iCBT for social anxiety disorder (SAD) treatment were included in the review. Several different groups have researched treatment protocols for SAD and demonstrated large post-treatment and follow-up results, with effects being maintained up to 5-years [28]. What is also interesting is the comparison of iCBT for SAD with face-to-face treatment, and similar to panic disorder there is some good evidence to show similar outcomes [29].

Due to strict eligibility criteria, the Cochrane review included only a small proportion (four studies) of the available literature on generalised anxiety disorder (GAD). Another recent systematic review and meta-analysis of internet-delivered interventions for GAD considered a total of 17 studies and included 11 in a meta-analysis, where the treatment intervention delivered in 9 of the 11 studies was cognitive behaviour therapy [30]. Three of these studies are disorder specific, with interventions that directly addressed GAD [31–33]. The remaining six studies were transdiagnostic, treating either multiple anxiety disorders [34–36] or anxiety disorders and depression [21, 37]. The review concluded that across the studies there were significant improvements for internet-delivered interventions for GAD compared to waiting list controls.

Preliminary research has emerged that supports the use of iCBT in the treatment of severe health anxiety and specific phobias, but more studies are needed to establish this method in treating these disorders [38–41].
