Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data

Furukawa TA, Suganuma A, Ostinelli EG, Andersson G, Beevers CG, Shumake J, Berger T, Boele FW, Buntrock C, Carlbring P, Choi I, Christensen H, Mackinnon A, Dahne J, Huibers MJ, Ebert DD, Farrer L, Forand NR, Strunk DR, Ezawa ID, Forsell E, Kaldo V, Geraedts A, Gilbody S, Littlewood E, Brabyn S, Hadjistavropoulos HD, Schneider LH, Johansson R, Kenter R, Kivi M, Björkelund C, Kleiboer A, Riper H, Klein JP, Schröder J, Meyer B, Moritz S, Bücker L, Lintvedt O, Johansson P, Lundgren J, Milgrom J, Gemmill AW, Mohr DC, Montero-Marin J, Garcia-Campayo J, Nobis S, Zarski AC, O'Moore K, Williams AD, Newby JM, Perini S, Phillips R, Schneider J, Pots W, Pugh NE, Richards D, Rosso IM, Rauch SL, Sheeber LB, Smith J, Spek V, Pop VJ, Ünlü B, van Bastelaar KM, van Luenen S, Garnefski N, Kraaij V, Vernmark K, Warmerdam L, van Straten A, Zagorscak P, Knaevelsrud C, Heinrich M, Miguel C, Cipriani A, Efthimiou O, Karyotaki E, Cuijpers P (2021)

Publication Type: Journal article

Publication year: 2021

Journal

Book Volume: 8

Pages Range: 500-511

Journal Issue: 6

DOI: 10.1016/S2215-0366(21)00077-8

Abstract

BACKGROUND: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom. METHODS: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683. FINDINGS: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. INTERPRETATION: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package. FUNDING: Japan Society for the Promotion of Science.

Authors with CRIS profile

Involved external institutions

Stockholm University / Stockholms universitet Sweden (SE) University of New South Wales (UNSW) Australia (AU) Vrije Universiteit Amsterdam (VU) / University Amsterdam Netherlands (NL) Technische Universität München (TUM) Germany (DE) Australian National University (ANU) Australia (AU) Hofstra University United States (USA) (US) Ohio State University United States (USA) (US) Karolinska Institute Sweden (SE) University of York United Kingdom (GB) University of Regina Canada (CA) Kyoto University / 京都大学 Kyōto daigaku Japan (JP) St. Joseph's Healthcare Hamilton Canada (CA) University of Bergen / Universitetet i Bergen Norway (NO) University of Gothenburg / Göteborgs universitet Sweden (SE) University of Oxford United Kingdom (GB) University of Texas at Austin United States (USA) (US) Universität zu Lübeck Germany (DE) Universitätsklinikum Hamburg-Eppendorf (UKE) Germany (DE) Universität Bern Switzerland (CH) Gaia AG Germany (DE) University of Leeds United Kingdom (GB) Freie Universität Berlin Germany (DE) Norwegian Centre for E-health Research Norway (NO) Linköpings universitet / Linköping University Sweden (SE) The University of Melbourne Australia (AU) Northwestern University United States (USA) (US) Harvard University United States (USA) (US) Hospital Universitario Miguel Servet Spain (ES) Klinikum Osnabrück Germany (DE) St Vincent's Hospital Sydney Australia (AU) Imperial College London / The Imperial College of Science, Technology and Medicine United Kingdom (GB) University of Nottingham United Kingdom (GB) Leiden University Netherlands (NL) University of Twente Netherlands (NL) Trinity College Dublin Ireland (IE) McLean Hospital United States (USA) (US) Oregon Research Institute United States (USA) (US) Fontys University of Applied Sciences Netherlands (NL) Tilburg University Netherlands (NL) PsyQ Netherlands (NL) Amsterdam University Medical Centers (Amsterdam UMC) / Amsterdam Universitair Medische Centra Netherlands (NL)

How to cite

APA:

Furukawa, T.A., Suganuma, A., Ostinelli, E.G., Andersson, G., Beevers, C.G., Shumake, J.,... Cuijpers, P. (2021). Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data. The Lancet Psychiatry, 8(6), 500-511. https://doi.org/10.1016/S2215-0366(21)00077-8

MLA:

Furukawa, Toshi A., et al. "Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data." The Lancet Psychiatry 8.6 (2021): 500-511.

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