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Original Investigation
April 2017

Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive SymptomsA Meta-analysis of Individual Participant Data

Author Affiliations
  • 1Department of Clinical Psychology and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
  • 2Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, Vrije Universiteit University Amsterdam, Amsterdam, the Netherlands
  • 3Department of Psychiatry, Geestelijke Gezondheidszorg inGeest inGeest and Vrije Universiteit University Medical Centre, Amsterdam, the Netherlands
  • 4EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
  • 5Department of Psychology and Technology, Jaume University, Castellon, Spain
  • 6Black Dog Institute and University of New South Wales, Prince of Wales Hospital, Sydney, Australia
  • 7Center for Mental Health, University of Melbourne, Melbourne, Australia
  • 8Research Department, Gaia AG, Hamburg, Germany
  • 9Department of Psychology, City University, London, England
  • 10IBER of Physiopathology of Obesity and Nutrition, Santiago de Compostela, Spain
  • 11Department of Health Sciences, University of York, York, England
  • 12Department of Behavioural Sciences and Learning, Sweden Institute for Disability Research, Linköping University, Linköping, Sweden
  • 13Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institute for Disability Research, Stockholm, Sweden
  • 14Department of Psychiatry and Psychotherapy, Luebeck University, Luebeck, Germany
  • 15Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  • 16Institute of Mental Health, University of Nottingham, Nottingham, England
  • 17Research School of Psychology, College of Biology, Medicine & Environment, Australian National University, Canberra, Australia
  • 18Centre for Mental Health Research, The Australian National University, Canberra, Australia
  • 19Department of Primary Care and Public Health Sciences, King's College London, London, England
  • 20Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
  • 21Department of Psychology and Health, Tilburg University and Diagnostic Centre Eindhoven, Eindhoven, the Netherlands
JAMA Psychiatry. 2017;74(4):351-359. doi:10.1001/jamapsychiatry.2017.0044
Key Points

Questions  Is self-guided internet-based cognitive behavioral therapy effective in treating depressive symptoms and which variables moderate treatment outcome?

Findings  In this meta-analysis of individual participant data from 3876 adults, internet-based cognitive behavioral therapy was more effective compared with controls. Adherence predicted better treatment outcomes within the experimental condition.

Meaning  Self-guided internet-based cognitive behavioral therapy may be a viable alternative to current first-step treatment approaches for symptoms of depression, particularly in those individuals who are not willing to have any therapeutic contact.


Importance  Self-guided internet-based cognitive behavioral therapy (iCBT) has the potential to increase access and availability of evidence-based therapy and reduce the cost of depression treatment.

Objectives  To estimate the effect of self-guided iCBT in treating adults with depressive symptoms compared with controls and evaluate the moderating effects of treatment outcome and response.

Data Sources  A total of 13 384 abstracts were retrieved through a systematic literature search in PubMed, Embase, PsycINFO, and Cochrane Library from database inception to January 1, 2016.

Study Selection  Randomized clinical trials in which self-guided iCBT was compared with a control (usual care, waiting list, or attention control) in individuals with symptoms of depression.

Data Extraction and Synthesis  Primary authors provided individual participant data from 3876 participants from 13 of 16 eligible studies. Missing data were handled using multiple imputations. Mixed-effects models with participants nested within studies were used to examine treatment outcomes and moderators.

Main Outcomes and Measures  Outcomes included the Beck Depression Inventory, Center for Epidemiological Studies–Depression Scale, and 9-item Patient Health Questionnaire scores. Scales were standardized across the pool of the included studies.

Results  Of the 3876 study participants, the mean (SD) age was 42.0 (11.7) years, 2531 (66.0%) of 3832 were female, 1368 (53.1%) of 2574 completed secondary education, and 2262 (71.9%) of 3146 were employed. Self-guided iCBT was significantly more effective than controls on depressive symptoms severity (β = −0.21; Hedges g  = 0.27) and treatment response (β = 0.53; odds ratio, 1.95; 95% CI, 1.52-2.50; number needed to treat, 8). Adherence to treatment was associated with lower depressive symptoms (β = −0.19; P = .001) and greater response to treatment (β = 0.90; P < .001). None of the examined participant and study-level variables moderated treatment outcomes.

Conclusions and Relevance  Self-guided iCBT is effective in treating depressive symptoms. The use of meta-analyses of individual participant data provides substantial evidence for clinical and policy decision making because self-guided iCBT can be considered as an evidence-based first-step approach in treating symptoms of depression. Several limitations of the iCBT should be addressed before it can be disseminated into routine care.