Online therapy programs are usually promoted on more than their clinical results. They are said to be cheaper, available anywhere, available at any hour, quicker to start, less embarrassing, and lighter on therapist time. Those claims are made often enough that they can pass without examination.
Musiat and Tarrier, working at the Institute of Psychiatry in London, decided to examine them. Their 2014 systematic review searched Medline and Web of Science for controlled trials of computerised and internet-based CBT that reported on any of these supposed added benefits. They found 101 papers reporting 95 studies.
The results were uneven. Cost-effectiveness held up: computerised CBT was generally cost-effective and often cheaper than usual care. Treatment satisfaction was consistently high. Evidence for the other claims was thin. Geographic flexibility, time flexibility, shorter waiting times, reduced stigma and increased help-seeking had all been asserted more often than they had been measured.
One finding is directly useful for anyone choosing a program. Personal support made a difference to whether people finished, and it did not have to come from a therapist. Support in various forms was associated with better adherence and lower dropout.
The review makes a reasonable case that these programs are affordable and acceptable. The wider claims about access still need testing. A program you finish is worth more than one you abandon, and support is part of what determines which it will be.
The claims under examination
E-mental health had grown quickly by 2014, with computerised cognitive behaviour therapy, abbreviated cCBT, available for numerous conditions. Alongside claims of clinical effectiveness sat a second set of claims about advantages inherent to the delivery method. These are what the authors call collateral outcomes: benefits said to follow from delivering therapy by computer rather than in a room.
Eight were specified for review: cost-effectiveness, geographic flexibility, time flexibility, waiting time for treatment, stigma, therapist time, effects on help-seeking, and treatment satisfaction.
Method
The authors searched Medline and Web of Science for peer-reviewed controlled trials investigating collateral outcomes in computerised and internet-based CBT. The search identified 101 published papers, reporting 95 studies, which were included in the review.
What the evidence supported
Cost-effectiveness had the strongest support. The results suggest cCBT interventions are cost-effective and often cheaper than usual care. Treatment satisfaction with cCBT was found to be high.
What the evidence did not support
For geographic flexibility, time flexibility, waiting time for treatment, stigma and the effects on help-seeking, the review found limited evidence. This is not a finding that these advantages are absent. It is a finding that they have been asserted much more often than they have been demonstrated in controlled trials, which is a different problem and one that only further research can resolve.
Support and adherence
The most practically useful finding concerns personal support. The review found that support in cCBT took many forms and was not limited to therapists. Where it was present, it appeared to increase treatment adherence and reduce attrition.
This matters because attrition is the persistent weakness of self-guided digital treatment. A program with good outcomes among completers is of limited value if most users stop early. The review notes that more research on attrition is needed, which is a fair reading of the state of the field.
How to use this
For a person weighing up an online program alongside or instead of seeing a psychologist, the review supports two conclusions and cautions against several others. It is reasonable to expect a cCBT program to cost less than conventional care and to be satisfying to use. It is not yet established that it will reach people who could not otherwise get treatment, or that it removes the discomfort some people feel about seeking help.
The support finding is the one to act on. If a program offers some form of contact, whether from a clinician, a coach or a structured check-in, that is a feature to weigh heavily rather than an optional extra.
Limits
A systematic review inherits the limits of its sources. Where the underlying trials did not measure a collateral outcome, or measured it inconsistently, the review can only report the absence. The included studies span many conditions, programs and countries, so the finding that cCBT is cost-effective is a general statement rather than a guarantee about any particular program.
If you are using a digital program and finding it hard to keep going, that is a common experience rather than a personal failure, and adding some form of support is the change most likely to help.