Treating treatment non-responders: A meta-analysis of randomized controlled psychotherapy trials

A transdiagnostic group exercise intervention for mental health outpatients in Germany (ImPuls): results of a pragmatic, multisite, block-randomised, phase 3 controlled trial

BACKGROUND

Globally, mental health conditions pose a substantial burden of disease. Despite the availability of evidence-based pharmacological and psychological treatments, the symptoms of a substantial subgroup of patients do not respond to these interventions, and only a minority of patients have access to them. This study aimed to assess the efficacy of ImPuls, a 6-month transdiagnostic group exercise intervention, plus treatment-as-usual, compared with treatment-as-usual alone in outpatients with various mental disorders.

METHODS

In this pragmatic, two-arm, multisite, randomised controlled trial in Germany, ten outpatient rehabilitative and medical care facilities were involved as study sites. Participants were outpatients diagnosed according to ICD-10 with one or more of the following disorders based on structured clinical interviews: moderate or severe depression, primary insomnia, post-traumatic stress disorder (PTSD), panic disorder, or agoraphobia. Participants were required to be aged between 18 years and 65 years, insured by the health insurers Allgemeine Ortskrankenkasse Baden-Württemberg or Techniker Krankenkasse, fluent in German, and without medical contraindications for exercise. Blocks of six participants were randomly allocated to ImPuls plus treatment-as-usual or treatment-as-usual alone (allocation ratio: 1:1), stratified by study site. The randomisation sequence was generated by an external data manager. The team responsible for data collection and management was masked to the randomisation sequence. The ImPuls intervention comprised evidence-based outdoor exercises lasting 30 min, and aimed at achieving at least moderate intensity. It also incorporated behavioural change techniques targeting motivational and volitional determinants of exercise behaviour. Treatment-as-usual was representative of typical outpatient health care in Germany, allowing patients access to any standard treatments. The primary outcome was global symptom severity at 6 months after randomisation, measured using self-report on the Brief Symptom Inventory (BSI-18) and analysed in the intention-to-treat sample. No individuals with lived experience of mental illness were involved in conducting the study or writing the final publication. Safety was assessed in all participants. The trial was registered with the German Clinical Trials Register (DRKS00024152) with a completion date of June 30, 2024.

FINDINGS

600 patients provided informed consent, were recruited to the study, and underwent a diagnostic interview between Jan 1, 2021, and May 31, 2022. Following this, 199 were excluded on the basis of inclusion and exclusion criteria and one withdrew consent during the baseline assessment. Of the 400 eligible participants, 284 (71%) self-identified as female, 106 (27%) self-identified as male, and nine (2%) self-identified as other. The mean age was 42·20 years (SD 13·23; range 19-65). Ethnicity data were not assessed. 287 (72%) participants met the criteria for moderate or severe depression, 81 (20%) for primary insomnia, 37 (9%) for agoraphobia, 46 (12%) for panic disorder, and 72 (18%) for PTSD. 199 participants were allocated to the intervention group of ImPuls plus treatment-as-usual and 201 to the control group of treatment-as-usual alone. 38 (19%) participants did not receive the minimum ImPuls intervention dose. ImPuls plus treatment-as-usual demonstrated superior efficacy to treatment-as-usual alone in reducing global symptom severity, with an adjusted difference on BSI-18 of 4·11 (95% CI 1·74-6·48; d=0·35 [95% CI 0·14-0·56]; p=0·0007) at 6 months. There were no significant differences in the total number of adverse events or serious adverse events between the two groups. There was one serious adverse event (male, torn ligament) related to the intervention.

INTERPRETATION

ImPuls is an efficacious transdiagnostic adjunctive treatment in outpatient mental health care. Our findings suggest that exercise therapy should be implemented in outpatient mental health care as an adjunctive transdiagnostic treatment for mental disorders such as depression, insomnia, panic disorder, agoraphobia, and PTSD. Transdiagnostic group exercise interventions might ameliorate the existing disparity in care provision between the many individuals in need of evidence-based treatment and the few who are receiving it.

FUNDING

The German Innovation Fund of the Federal Joint Committee of Germany.

[Treatment resistance in anxiety disorders-Definition and treatment options]

Treatment resistance in anxiety disorders represents a clinical challenge, contributes to the chronicity of the diseases as well as sequential comorbidities, and is associated with a significant individual and socioeconomic burden. This narrative review presents the operational definition of treatment resistance in anxiety disorders according to international consensus criteria (< 50% reduction in the Hamilton Anxiety Scale, HAM‑A, score or < 50% reduction in the Beck Anxiety Inventory, BAI, score or a clinical global impression-improvement, CGI‑I, score > 2). At least two unsuccessful guideline-based treatment attempts with pharmacological monotherapy or at least one unsuccessful treatment attempt with adequately delivered cognitive behavioral therapy are required. Pharmacotherapeutically, after excluding pseudo-resistance, switching the medication within one class or to another class and augmentation strategies with other antidepressants (mirtazapine, agomelatine), antipsychotics (quetiapine) or anticonvulsants (valproate) are recommended. Psychotherapeutically, third-wave therapies, psychodynamic therapy, systemic therapy and physical exercise can be considered for therapy resistance. In cases of no response to psychotherapy or pharmacotherapy, the respective other form of therapy or a combination of both should be offered. Compounds targeting the glutamatergic and endocannabinoid systems as well as neuropeptides are being tested as potential innovative pharmaceuticals for treatment-resistant anxiety disorders. There is an urgent need for further research to identify predictive markers and mechanisms as well as to develop innovative pharmacological and psychotherapeutic interventions for treatment-resistant anxiety disorders.

[Non-response to psychotherapy: concepts, problems and referral options]

AIM

In this paper we review the current literature on the clinical problem that some patients do not achieve response after adequately conducted psychotherapy. We explicate our understanding of nonresponse and treatment resistance including the operational definitions, summarize the theoretical explanations and empirical studies and put forward possible study designs and treatment options.

METHODS

Literature search using PubMed and Web of Science.

RESULTS

For the domain of psychotherapy, the term treatment resistance does not seem appropriate; instead, we use the more descriptive terms nonresponse and recurrent nonresponse. Generally, this topic is far less represented in psychotherapy than in pharmacotherapy. Controlled switching studies with a switch from pharmacotherapy to psychotherapy are rare and those switching from one psychotherapeutic approach to another are nearly nonexistent. Building on clinical considerations, we propose a flow-chart for clinical decision making after nonresponse in psychotherapy.

DISCUSSION

Learning from errors is highly beneficial. This principle should be more consistently followed up in psychotherapy research as well as in supervision and training. Guidelines should include consensual and evidence-based advice on how to deal with nonresponse and recurring nonresponse.

Internet- and mobile-based anxiety and depression interventions for children and adolescents: efficacy and negative effects - a systematic review and meta-analysis

Mental disorders, most commonly anxiety disorders and fourth most common depression, are prevalent in children and adolescents. Internet- and mobile-based interventions might represent a scalable approach to improve mental health care, however, evidence so far is inconclusive and systematic reports on negative effects are missing. Four data-bases were searched for randomized controlled trials evaluating internet- and mobile-based interventions (IMIs) targeting anxiety disorders or depression in children and adolescents up to 18 years exhibiting clinically relevant symptoms. Meta-analytic evaluations were conducted in comparison to active and passive control groups, furthermore, pre-defined sub-groups were explored and reported negative effects examined. Pooled estimates showed a moderate positive effect for IMIs targeting anxiety disorders compared to passive control groups (g = -0.69; CI -0.94 to -0.45; k = 8; n = 559; p ≤ 0,001), but not for depression. Pooled estimates compared to active control groups remained non-significant. Subgroup analyses were largely omitted due to an insufficient number of trials or were non-significant. Negative effects were mainly reported as drop-out rates and (non)-response rates, while additional negative effects, such as deterioration rates or the development of additional symptoms, were reported by only one third of included studies. The focus on children and adolescents with clinically relevant symptoms allowed the present findings to complement previous work, however, the limited amount of trials hindered many planned comparisons. The overview of reported negative effects highlighted that negative effects are being neglected in the majority of RCTs. Hence, in the future RCTs should include more information about potential negative effects, at best a combination of quantitative and qualitative information. Open Science Framework (osf.io/ch5nj).

Additive effects of adjunctive app-based interventions for mental disorders - A systematic review and meta-analysis of randomised controlled trials

Background

It is uncertain whether app-based interventions add value to existing mental health care.

Objective

To examine the incremental effects of app-based interventions when used as adjunct to mental health interventions.

Methods

We searched PubMed, PsycINFO, Scopus, Web of Science, and Cochrane Library databases on September 15th, 2023, for randomised controlled trials (RCTs) on mental health interventions with an adjunct app-based intervention compared to the same intervention-only arm for adults with mental disorders or respective clinically relevant symptomatology. We conducted meta-analyses on symptoms of different mental disorders at postintervention. PROSPERO, CRD42018098545.

Results

We identified 46 RCTs (4869 participants). Thirty-two adjunctive app-based interventions passively or actively monitored symptoms and behaviour, and in 13 interventions, the monitored data were sent to a therapist. We found additive effects on symptoms of depression (g = 0.17; 95 % CI 0.02 to 0.33; k = 7 comparisons), anxiety (g = 0.80; 95 % CI 0.06 to 1.54; k = 3), mania (g = 0.2; 95 % CI 0.02 to 0.38; k = 4), smoking cessation (g = 0.43; 95 % CI 0.29 to 0.58; k = 10), and alcohol use (g = 0.23; 95 % CI 0.08 to 0.39; k = 7). No significant effects were found on symptoms of depression within a bipolar disorder (g = -0.07; 95 % CI -0.37 to 0.23, k = 4) and eating disorders (g = -0.02; 95 % CI -0.44 to 0.4, k = 3). Studies on depression, mania, smoking, and alcohol use had a low heterogeneity between the trials. For other mental disorders, only single studies were identified. Only ten studies had a low risk of bias, and 25 studies reported insufficient statistical power.

Discussion

App-based interventions may be used to enhance mental health interventions to further reduce symptoms of depression, anxiety, mania, smoking, and alcohol use. However, the effects were small, except for anxiety, and limited due to study quality. Further high-quality research with larger sample sizes is warranted to better understand how app-based interventions can be most effectively combined with established interventions to improve outcomes.

Effectiveness of behavioral activation and mindfulness in increasing reward sensitivity and reducing depressive symptoms - A randomized controlled trial

Reward insensitivity is a potential key mechanism regarding the maintenance of depression. However, there is a lack of research examining and comparing the effectiveness of different psychological interventions in modifying reward insensitivity. This four-arm randomized controlled trial (RCT) investigated a two-week online intervention. After screening for eligibility, a total of 336 participants were randomized, and 224 participated per-protocol. Participants were assigned to either a) behavioral activation, b) mindfulness and gratitude, c) a combination of both, or d) a waitlist control condition. They received videos and implemented daily exercises. Reward sensitivity and depressive symptoms served as primary outcomes. Behavioral activation and mindfulness significantly improved depressive symptoms and reward sensitivity. However, the effects of behavioral activation were not superior. The combination treatment versus the waiting group was insignificant regarding reward insensitivity. Explorative analyses revealed that all intervention groups reduced anhedonia substantially. Our findings imply that brief online interventions with behavioral activation and mindfulness-based approaches can impact reward insensitivity, while effects for a combination were less clear. Nonetheless, our results do not allow us to infer the differential effectiveness of the interventions. There is a clear need for treatments better targeting maintaining factors of depression, such as reward insensitivity. Clinical trial registration number: NCT05402150.

The definition of treatment resistance in anxiety disorders: a Delphi method-based consensus guideline

Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment-resistant anxiety disorders (TR-AD) informing such trials is currently lacking. We used a Delphi method-based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR-AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free-text responses to a 29-item questionnaire on relevant aspects of TR-AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR-AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR-AD vs. "difficult-to-treat" anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method-based consensus on operational criteria for TR-AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence-based stepped-care treatment algorithms for patients with anxiety disorders.

What if we wait? Using synthetic waiting lists to estimate treatment effects in routine outcome data

Objective: Due to the lack of randomization, pre-post routine outcome data precludes causal conclusions. We propose the "synthetic waiting list" (SWL) control group to overcome this limitation.

Method: First, a step-by-step introduction illustrates this novel approach. Then, this approach is demonstrated using an empirical example with data from an outpatient cognitive-behavioral therapy (CBT) clinic (N = 139). We trained an ensemble machine learning model ("Super Learner") on a data set of patients waiting for treatment (N = 311) to make counterfactual predictions of symptom change during this hypothetical period.

Results: The between-group treatment effect was estimated to be d = 0.42. Of the patients who received CBT, 43.88% achieved reliable and clinically significant change, while this probability was estimated to be 14.54% in the SWL group. Counterfactual estimates suggest a clear net benefit of psychotherapy for 41% of patients. In 32%, the benefit was unclear, and 27% would have improved similarly without receiving CBT.

Conclusions: The SWL is a viable new approach that provides between-group outcome estimates similar to those reported in the literature comparing psychotherapy with high-intensity control interventions. It holds the potential to mitigate common limitations of routine outcome data analysis.

The Role of Psychotherapy in the Management of Treatment-Resistant Depression

This article reviews the role of psychotherapy in management of treatment-resistant depression (TRD). Meta-analyses of randomized trials show that psychotherapy has a positive therapeutic benefit in TRD. There is less evidence that one type of psychotherapy approach is superior to another. However, more trials have examined cognitive-based therapies than other forms of psychotherapy. Also reviewed is the potential combination of psychotherapy modalities and medication/somatic therapies as an approach to TRD. There is significant interest in ways that psychotherapy modalities could be combined with medication/somatic therapies to harness a state of enhanced neural plasticity and improve longer-term outcomes in mood disorders.

Early trajectories of symptom change and working alliance as predictors of treatment outcome

OBJECTIVE

We aim to examine how different trajectories of symptom change and working alliance in early psychotherapy predict treatment outcomes.

METHOD

We performed a growth mixture model (GMM) to examine trajectories of symptom change and working alliance in the first five therapy sessions in a sample of 272 outpatients and tested the association of early symptom trajectories and alliance patterns with treatment outcome.

RESULTS

We identified two symptom trajectories: high symptom/steady change (63.2%) and early improving (36.8%), and four alliance development patterns: undeveloped alliance (40.1%), strengthening moderate alliance (31.6%), optimal alliance (17.3%), and improved alliance (11%) in early psychotherapy. The symptom trajectories and alliance patterns both independently and interactively predicted treatment outcomes. The optimal alliance was generally associated with the best outcome. The effect of improved alliance on treatment outcome was moderated by symptom trajectories: for high symptom/steady change subgroup, the improved alliance was related to better treatment outcome, whereas for early improving subgroup, the improved alliance was associated with poorer outcome.

CONCLUSIONS

Patients fell into different trajectories regarding symptom reduction and alliance development in early psychotherapy that affected final treatment outcome. Combining early symptom trajectories and alliance trajectories simultaneously can facilitate routine outcome monitoring and contribute to the prediction of treatment outcome.

Toward Precision Characterization and Treatment of Psychopathology: A Path Forward and Integrative Framework of the Hierarchical Taxonomy of Psychopathology and the Research Domain Criteria

A critical mission of psychological science is to conduct research that ultimately improves the lives of individuals who experience psychopathology. One important aspect of accomplishing this mission is increasing the likelihood that treatments will work for each person. I contend that treatment prognosis can be improved by moving toward a precision-medicine model. I advance a principle-driven framework for working toward these objectives. First, I synthesize the Hierarchical Taxonomy of Psychopathology and the Research Domain Criteria and demonstrate how integrating these models facilitates precision characterization of psychopathology. Second, I outline and demonstrate a systematic process for approaching treatment selection by leveraging precisely characterized representations of psychopathology. Finally, I advocate the research and clinical applications of this framework. Although clinical and psychological scientists are conducting exciting, multidisciplinary, and methodologically rigorous research in their respective domains, the impact of these pursuits will be maximized in the context of a unifying theoretical framework that supports a clear guiding mission.

Is it worth it to personalize the treatment of PTSD? - A variance-ratio meta-analysis and estimation of treatment effect heterogeneity in RCTs of PTSD

Several evidence-based treatments for posttraumatic stress disorder (PTSD) are recommended by international guidelines (e.g., APA, NICE). While their average effects are in general high, non-response rates indicate differential treatment effects. Here, we used a large database of RCTs on psychotherapy for PTSD to determine a reliable estimate of this heterogeneity in treatment effects (HTE) by applying Bayesian variance ratio meta-analysis. In total, 66 studies with a total of 8803 patients were included in our study. HTE was found for all psychological treatments, with varying degrees of certainty, only slight differences between psychological treatments, and active control groups yielding a smaller variance ratio compared to waiting list control groups. Across all psychological treatment and control group types, the estimate for the intercept was 0.12, indicating a 12% higher variance of posttreatment values in the intervention groups after controlling for differences in treatment outcomes. This study is the first to determine the maximum increase in treatment effects of psychological treatments for PTSD by personalization. The results indicate that there is comparatively high heterogeneity in treatment effects across all psychological treatment and control groups, which in turn allow personalizing psychological treatments by using treatment selection approaches.

Boosting psychological change: Combining non-invasive brain stimulation with psychotherapy

Mental health disorders and substance use disorders are a leading cause of morbidity and mortality worldwide, and one of the most important challenges for public health systems. While evidence-based psychotherapy is generally pursued to address mental health challenges, psychological change is often hampered by non-adherence to treatments, relapses, and practical barriers (e.g., time, cost). In recent decades, Non-invasive brain stimulation (NIBS) techniques have emerged as promising tools to directly target dysfunctional neural circuitry and promote long-lasting plastic changes. While the therapeutic efficacy of NIBS protocols for mental illnesses has been established, neuromodulatory interventions might also be employed to support the processes activated by psychotherapy. Indeed, combining psychotherapy with NIBS might help tailor the treatment to the patient's unique characteristics and therapeutic goal, and would allow more direct control of the neuronal changes induced by therapy. Herein, we overview emerging evidence on the use of NIBS to enhance the psychotherapeutic effect, while highlighting the next steps in advancing clinical and research methods toward personalized intervention approaches.

Testing the Differential Impact of an Internet-Based Mental Health Intervention on Outcomes of Well-being and Psychological Distress During COVID-19: Uncontrolled Intervention Study

BACKGROUND

During COVID-19, the psychological distress and well-being of the general population has been precarious, increasing the need to determine the impact of complementary internet-based psychological interventions on both positive mental health as well as distress states. Psychological distress and mental well-being represent distinct dimensions of our mental health, and congruent changes in outcomes of distress and well-being do not necessarily co-occur within individuals. When testing intervention impact, it is therefore important to assess change in both outcomes at the individual level, rather than solely testing group differences in average scores at the group level.

OBJECTIVE

This study set out to investigate the differential impact of an internet-based group mental health intervention on outcomes of positive mental health (ie, well-being, life satisfaction, resilience) and indicators of psychological distress (ie, depression, anxiety, stress).

METHODS

A 5-week mental health intervention was delivered to 89 participants using the Zoom platform during 2020. Impact on outcomes of distress, well-being, and resilience was assessed at the start and end of the program with multiple analysis of variance (MANOVA) and reliable change indices (RCIs) being used to determine program impact at the group and individual levels, respectively.

RESULTS

The intervention significantly improved all mental health outcomes measured, (F6,83=5.60, P<.001; Wilks Λ=.71; partial η2=.29) showing small to moderate effect sizes on individual outcomes. The largest effect sizes were observed for life satisfaction and overall well-being (η2=.22 and η2=.2, respectively). Larger effect sizes were noted for those with problematic mental health scores at baseline. A total of 92% (82/89) of participants demonstrated reliable change in at least one mental health outcome. Differential response patterns using RCI revealed that more than one-half of the participants showed improvement in both mental well-being and psychological distress, over one-quarter in outcomes of well-being only, and almost one-fifth in distress only.

CONCLUSIONS

The results provide evidence for the significant impact of an internet-based mental health intervention during COVID-19 and indicate the importance of assessing dimensions of both well-being and distress when determining mental health intervention effectiveness.

Non-Responder: Psychotherapie als Behandlungsoption?

Etwa jede/r 3. Patient/in mit psychischen Störungen spricht nicht auf die zunächst gewählte Therapieform an. Ob die Betroffenen dann von einer psychotherapeutischen Alternativbehandlung profitieren könnten, ist bis heute weitestgehend unklar. Gloster und Team haben deshalb hier angesetzt und legen nun die Ergebnisse einer Metaanalyse von 18 Studien zum Thema vor.

Mechanisms of change in acceptance and commitment therapy for primary headaches

BACKGROUND

Despite the demonstrated effectiveness of behavioural headache interventions, it is not yet known which intervention processes account for treatment responses. Acceptance and commitment therapy (ACT), an emerging behavioural intervention for headaches, proposes psychological flexibility (PF) processes as the mechanisms via which intervention change occurs. This is the first study examining these processes of change variables on headache-related disability and quality of life (treatment outcome).

METHODS

Data originated from a Randomized Clinical Trial evaluating the efficacy of ACT for primary headaches. Ninety-four individuals with primary headaches (M = 43 y; 84% females; M headache frequency/month = 9.30) were randomized to either an ACT-based or a Wait-list control group (N = 47 in each). Participants completed questionnaires related to their headache experiences and PF processes at pre- (T1), post-treatment (T2), and 3-month follow-up (T3).

RESULTS

Following a bootstrapped cross product of coefficients approach, results demonstrated mediating effects of headache acceptance, cognitive defusion, avoidance of headache, and mindfulness in the ACT group compared to control on parameters of headache-related disability and quality of life at post and 3-month follow-ups.

CONCLUSIONS

These findings demonstrate that changes in certain PF processes lower disability and improve quality of life in headache sufferers, supporting that ACT works via its proposed mechanisms of change. Interventions for headache management may be optimized if they target increases in headache acceptance, defusion from thoughts, and mindfulness.

SIGNIFICANCE

Psychological flexibility (PF) guides the ACT approach, an emerging behavioral headache intervention that focuses on optimizing head pain adjustment via flexible responses to pain. It targets at increasing daily functioning rather than preventing or controlling headache episodes. Pain acceptance, cognitive defusion, and mindfulness act as processes of functional change in ACT, lowering disability and increasing daily functioning and quality of life. These components can upgrade the established effectiveness of behavioral headache interventions with personalized, modularized therapeutic targets that can help headache sufferers re-establish optimal daily functioning even in fluctuating and persistent headache episodes.

TRIAL REGISTRATION

clinical trials.gov registry (NCT02734992).

A comparison of electronically-delivered and face to face cognitive behavioural therapies in depressive disorders: A systematic review and meta-analysis

BACKGROUND

Cognitive behavioural therapy (CBT) is a widely used treatment for depression. However, limited resource availability poses several barriers to patients seeking access to care, including lengthy wait times and geographical limitations. This has prompted health care services to introduce electronically delivered CBT (eCBT) to facilitate access. Although previous reviews have compared the effects of eCBT to face-to-face CBT, there is an overall lack of adequately powered and up-to-date evidence in the literature to provide a reliable comparison between the two modes of administration. The purpose of this study is to evaluate the effects of eCBT compared to face-to-face CBT through a systematic review of the literature.

METHODS

To be eligible for this review, studies needed to be randomized controlled trials evaluating the clinical effectiveness of any form of eCBT compared to face-to-face CBT. These encompassed studies evaluating a wide range of outcomes including severity of symptoms, adverse outcomes, clinically relevant outcomes, global functionality, participant satisfaction, quality of life, and affordability. There were no restrictions on participant age or sex.We searched MEDLINE, EMBASE, Psych Info, Cochrane CENTRAL and CINAHL databases from inception to February 20th, 2020 using a comprehensive search strategy. All stages of literature screening and data extraction were completed independently in duplicate. Data extraction and risk of bias analyses, including GRADE ratings, were conducted on studies meeting inclusion criteria. Qualitative measures are reported in a narrative summary. We pooled quantitative data in meta-analyses to provide an estimated summary effect. This review adheres to PRISMA reporting guidelines.

FINDINGS

In total, we included 17 studies in our analyses. Our results demonstrated that eCBT was more effective than face-to-face CBT at reducing depression symptom severity (Standardized mean difference [SMD]: -1.73; 95% confidence interval [CI]: -2.72, -0.74; GRADE: moderate quality of evidence). There were no significant differences between the two interventions on participant satisfaction (SMD 0.13 95%; CI -0.32, 0.59; GRADE: low quality of evidence). One RCT reported eCBT to be less costly than face-to-face CBT (GRADE: low quality of evidence). Results did not differ when stratified by subgroups such as participant age and study location.

INTERPRETATION

Although we found eCBT to have moderate evidence of effectiveness in reducing symptoms of depression, high heterogeneity among studies precludes definitive conclusions for all outcomes. With the current reliance and accessibility of technology to increasing number of people worldwide, serious consideration in utilizing technology should be given to maximize accessibility for depression treatments. Our results found eCBT is at least as effective as face to face CBT, thus eCBT should be offered if preferred by patients and therapists.

FUNDING

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.