Many people with an anxiety disorder find it hard to reach treatment. Cost, distance and waiting times all get in the way. One response has been to deliver cognitive behavioural therapy (CBT) over the internet, with a therapist providing support along the way. Olthuis and colleagues reviewed the trials of this approach in adults.
The review screened 1736 citations and included 38 studies (3214 participants), covering social phobia, panic disorder, generalised anxiety disorder, post-traumatic stress disorder, obsessive compulsive disorder and specific phobia. Fourteen of the trials were conducted in Australia.
Compared with a waiting list, attention, information or online discussion group only, therapist-supported internet CBT was more likely to produce clinically important improvement in anxiety, and symptom measures favoured it too. Compared with face-to-face CBT, there were no significant differences in clinically important improvement. The evidence comparing it with unguided CBT, which is self-help without a therapist, was of very low quality and showed no clear difference.
The authors rated most of the evidence as low quality, and they note that further research is needed on possible harms, which were rarely reported.
For people who cannot easily attend sessions in person, this supports therapist-supported online CBT as a treatment that appears to be efficacious. If anxiety is affecting your life, please speak with your GP or a psychologist about the options available to you.
What the study did
This is a Cochrane systematic review, which is a structured search for every relevant trial followed by a combined analysis. Olthuis and colleagues wanted to know whether therapist-supported internet cognitive behavioural therapy (ICBT) helps adults with anxiety disorders. They looked at remission of an anxiety disorder diagnosis and reduction in anxiety symptoms, and they also assessed quality of life and satisfaction with the treatment.
The trials had to be randomised and had to compare therapist-supported ICBT with a waiting list, attention, information or online discussion group; with unguided CBT (self-help); or with face-to-face CBT. Participants were adults with a diagnosed anxiety disorder, including panic disorder, agoraphobia, social phobia, post-traumatic stress disorder, acute stress disorder, generalised anxiety disorder, obsessive compulsive disorder and specific phobia. Two authors independently assessed each study for inclusion and for risk of bias.
What it found
The authors screened 1736 citations and selected 38 studies (3214 participants). Social phobia was examined in 11 trials, panic disorder in 8, generalised anxiety disorder in 5, and post-traumatic stress disorder, obsessive compulsive disorder and specific phobia in 2 trials each. The studies were conducted in Sweden (18 trials), Australia (14 trials), Switzerland (3 trials), the Netherlands (2 trials) and the USA (1 trial).
Against the waiting list and similar comparison groups, low quality evidence from 11 studies (866 participants) gave a pooled risk ratio of 3.75 for clinically important improvement in anxiety after treatment, favouring therapist-supported ICBT. Symptom scores favoured it as well, for disorder-specific symptoms and for general anxiety symptoms, although the quality of that evidence was also low.
Against unguided CBT, one study showed no difference in clinically important improvement (54 participants, very low quality evidence), and the symptom comparisons showed no clear differences either.
Against face-to-face CBT, 4 studies (365 participants) found no significant difference in clinically important improvement (risk ratio 1.09, low quality evidence). Disorder-specific and general anxiety symptoms also showed no clear differences.
The limits
The authors are direct about the quality of the evidence. Risk of bias was low or unclear for most areas, but blinding of participants and personnel, and of outcome assessment, tended to carry a high risk of bias, which is common in trials of psychological treatment. Heterogeneity was substantial. This means the results differed between studies in a number of the analyses. Some of this was explained by the type of anxiety disorder, and some may come from combining many different assessment measures.
The comparison with unguided CBT rests on very low quality evidence, and the authors say that finding must be interpreted with caution because of imprecision. Adverse events were rarely reported, so the authors call for research to better define and measure any potential harms. They also suggest future studies should look at the role of the therapist in ICBT and test the approach in real-world settings.
Why it matters
The authors conclude that therapist-supported ICBT appears to be an efficacious treatment for anxiety in adults, and that it may not differ significantly from face-to-face CBT in reducing anxiety. For people who face obstacles to treatment, such as distance or limited local services, that is encouraging. It does not mean online therapy suits everyone, and the evidence is stronger for some comparisons than others.
If anxiety is getting in the way of your life, speak with your GP or a psychologist about which format of treatment might suit you. Effective help exists, and reaching out is a sound first step.