**4.3. FearFighter**

are available for a fee. Depending on the country in which the patient lives, iCBT may be endorsed and even funded by government. **Table 1** shows a sample of the various options offered to patients by existing iCBT programs. Below, we explore a few of the currently available iCBT options.

One of the most popular and best-studied iCBT programs is MoodGYM. The program comprises an introduction module, five learning modules, and a review module. MoodGYM uses fictional stories built around a set of six cartoon characters to present the principles of CBT in an approachable manner. As the participant progresses through the modules, they learn: (1) how negative thoughts affect their feeling, (2) how to identify those thoughts, (3) how to remove themselves those thoughts to view them objectively, (4) how to reduce stress, and (5) how relationships can affect thoughts and feelings. There are online worksheets, workbooks, and downloadable materials as well as games and activities to complete with each module. Outcome measures are collected before starting and after completing the five modules to

MoodGYM was developed with the support of the Australian government and is available in five languages. MoodGYM was initially free, but currently this program charges patients \$39 (AUD) for a 12-month subscription to the materials. There are about 850,000 registered users. Recently, a meta-analysis of the effectiveness of MoodGYM for depression and anxiety was performed. For patients with anxiety, MoodGYM had a medium effect size (g = 0.57, 95% CI 0.20, 0.94; I<sup>2</sup> = 85%). For patients with depression or general psychological distress, MoodGYM trended toward effectiveness, but fell short of statistical significance (g = 0.17, 95% CI -0.01, 0.38 and g = 0.34, 95% CI -0.04, 0.68; respectively). Adherence in the included studies ranged widely, from 10–100% of patients completing all modules, though the authors noted that: "adherence rates can be problematic" [39]. The effect size was higher in studies with high adherence (>50% of modules completed) versus those with low adherence (g = 0.64, 95% CI

CBT-I Coach is a smart-device app that can be used for insomnia. The app is available for iOS and Android platforms, and as of February 2016, it has been downloaded over 80,000 times. CBT-I Coach was developed by the United States Department of Veterans Affairs to support their clinician-guided CBT-I program. One of the major components of CBT-I Coach is keeping a Sleep Diary. The app has a diary function built in to keep track of sleep behaviors. The diary function includes drop down menus and places to enter text to facilitate documentation of sleep quantity and quality. The app also includes the Insomnia Severity Index (ISI) scores so the patient can keep track of their progress without visiting their clinician. The app can plot the quantitative diary data and ISI scores graphically so the user can easily see change over time. Both the diary and ISI scores can be sent to the user's clinician to provide a more comprehensive picture of patient progress. Users can set up notifications to remind them to fill out their diary. CBT-I Coach also has extensive educational material, recommendations for sleep hygiene and stimulus control, dynamic checklists to encourage health habits and prevent relapse, audio-guided relaxation exercises, and tools for cognitive restructuring [40].

determine if MoodGYM improved the participants' symptoms [39].

0.15, 1.14, I<sup>2</sup> = 79% and g = 0.22, 95% CI 0.42, 0.41, I<sup>2</sup> = 72%; respectively).

**4.1. MoodGYM**

208 Cognitive Behavioral Therapy and Clinical Applications

**4.2. CBT-I Coach**

FearFighter is a web-based iCBT program offered by a for-profit company in the UK. The program offers nine sessions that offer patients basic information on CBT, and a focus on negative thinking and overgeneralizations. This program is somewhat unique is the inclusion of videos, helping patients better understand basic concepts. At the end of the program, participants are given access to worksheets and summaries for later reference.

The program was endorsed by the UK's National Institute of Clinical Excellence (NICE), and can be "prescribed" by a primary care doctor (allowing for public coverage in some parts of that country), but patients can also self-refer. FearFighter have been the subject of numerous studies [51–56]. FearFighter has been shown to be superior to computer-guided non-exposure controls and as good as clinician-guided CBT for at least 3 months, though adherence to FearFighter was lower than clinician-guided therapy [56]. Both patients and clinicians were satisfied with how easy FearFighter was to use and the results of the program [52, 54–58].

#### **4.4. SuperBetter**

SuperBetter is an online and app-based game designed to help build "social, mental, and emotional resilience" to overcome challenges in life. Players are encouraged to set a goal for themselves in real life. Based on the goal, the game will offer appropriate activities for the player. "Power-ups" are activities that you can do in real life to improve resilience. "Quests" are in-site activities the player can participate in to teach them coping skills. "Bad Guys" are physical or mental bad habits that the player must battle. The site recommends completing three Power-ups and three Quests as well as battling one Bad Guy per day. Players can earn points for improving their resilience. Once you have met your goal, you achieve an "Epic Win." If the player sets a new goal, then they start a new game. The site has custom daily and weekly questionnaires to track progress in terms of the amount of time a player is happy, expressed as a percentage, and their resilience. Players can also recruit "allies" (e.g., friends, family). Allies can view the player's progress and offer support in the form of likes or comments. The game is highly customizable and can be adapted to address any challenges, from general life changes to mental and physical illness.

There is one randomized controlled clinical trial where patients with significant depression symptoms used SuperBetter. Players were asked to play the game 10 min a day for 1 month. Patients playing SuperBetter had larger reductions in depression symptoms, based on CES-D scores, than waitlisted controls at 1-month (Cohen's d = 1.05). The game has also been evaluated in an NIH-funded clinical trial but the results are pending.

Every industry has turned to digital solutions for faster, easier, and more efficient services – could these types of solutions work in mental health service delivery as well? We developed a mental health app library in which apps vetted by our staff were included in our treatment regimen. Therapists used these apps to augment the in-person CBT, allowing patients to keep up with the material even if they had missed several sessions. But it was not enough to just offer CBT, we wanted to ensure that those in need had every chance of receiving it. It was this

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

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After a literature review looking at various international models of iCBT, and in collaboration with Queen's University (where they were piloting a small iCBT program for adolescents), we developed our own modules closely mirroring our in-person CBT. The iCBT model consists of a therapist-guided Internet version, where patients complete the program on their own schedule and from a convenient location of their choice (where they have access to the Internet). Originally, patients were provided a total of eight modules that outline the main principles of CBT. This includes the importance of noticing the connections between our thoughts, feelings, and behaviors, scheduling mastery and pleasurable activities, utilizing breathing and relaxation exercises, and reviewing thought logs and restructuring inaccurate thoughts to more accurate ones. Each patient referred is assigned a therapist who communicates largely through email. The patient is emailed a module on a weekly basis for 8 weeks, and is asked to

read the module and fill out the attached worksheets to be completed within a week.

90% dropout rate; many patients reported that they did not find the program helpful.

Before launching the program, staff were provided 4 hours of training in providing e-therapy from a psychiatry resident at Queen's University. We launched our program with the hope that we could replicate the results achieved in Sweden or Australia. However, a review of the results at 6 months showed that we had completely missed the mark. We had an alarming

To understand the high dropout rate, we reached out to the patients in the program and asked how the program had failed to meet their needs. We gathered their feedback by asking questions such as, "Why did you drop out?" and "What three things would help you complete the program?" The responses were eye opening and a common theme emerged – the program was too rigid. Some patients felt that the deadlines for homework completion were too anxiety provoking; they could not possibly read through the modules and begin working on their thoughts within a week. The pace was overwhelming, so they did what made them feel better – they avoided the program altogether. Others who were higher functioning found the pace too slow and were eager to get through the concepts faster. Some found the concepts too confusing and wanted more examples and videos to better highlight the material. And some ran into technical issues – they could not download the document and type directly onto them. We had designed the program with what we thought the patients needed without asking them what would work best for them. The result was an inflexible program that did not take individual needs into account. We went back to the drawing board to incorporate the useful feedback provided by our patients and 3 months later relaunched our second version,

With iCBT 2.0, we streamlined the modules to a total of six modules (from eight). We included more examples and visuals to better highlight the material. We addressed the technical concerns by creating the homework sheets as Microsoft Word documents, with which patients

line of thinking that led to the development of our iCBT.

iCBT 2.0.

These different programs are very different in their approach to iCBT. And, of course, there are many other programs available. And while we acknowledge that there is no one right approach to iCBT, we recognize that many of the products on the market today have little or no evidence to support their effectiveness. We offer this advice: potential iCBT users should be careful when deciding on a program (or programs) to use. Users should look for government endorsements, affiliations with academic and/or medical institutions, and published results in peer-reviewed journals. If the program includes therapist support or uses therapists as a content source, a list of their qualifications should be easily accessible on the program's website. However, users should still check the therapist's credentials [9]. Users also should be careful not to be deceived by certifications, as they are not necessarily an indicator of quality. While many of the high-quality programs available do charge a fee, users should be wary of programs that try to sell them products or "cures" [17]. A little due diligence should help users identify a program that can help them address their symptoms rather than simply separate them from their own money.
