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Background: Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression. Objective: This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3 -month assessments. Methods: We conducted a secondary data analysis of the E -COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment -as -usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory -Short Revised-Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire -9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale -Client [SUS -C]) at 3 months and baseline demographic information. Data from baseline and 3 -month assessments were analyzed using linear regression models that adjusted for a set of baseline variables. Result

Early access to evidence-based help is crucial for adolescents with anxiety disorders. Internet-delivered acceptance and commitment therapy (iACT) may offer adolescents increased access to care and more flexibility in engaging with treatment when and how they prefer. Process-based therapies, such as ACT, focus on the-oretically derived and empirically tested key mechanisms in treat-ment that enable change. This study aimed to investigate the effectiveness of iACT for adolescents with anxiety disorders. The study also assessed the relationship between psychological flexi-bility and treatment outcomes and the relationship between par-ticipating adolescents and therapists perceived alliance and treatment outcomes. This was a randomized controlled trial com-paring a 10-week intervention group with a wait-list control group. The 52 participants, aged 15 to 19, were recruited from all over Sweden. The treatment was effective in increasing quality of life and psychological flexibility, with moderate between-group effect sizes based on observed values. Changes in psychological flexibility was associated with changes in anxiety symptoms. The results further showed a statistically significant between-group difference in post-treatment diagnoses. No significant time per group interaction was found for anxiety symptoms, as both groups improved. Working alliance was rated as high by both participat-ing adolescents and therapists but showed no significant relation-ship with treatment outcomes. Participants found the treatment an acceptable intervention. This study shows promising results for iACT in treating adolescents with anxiety disorders. The results suggest the model of psychological flexibility as an important process of change in treatment outcomes. Future research should validate these findings in larger samples and clinical contexts., Funding Agencies|Ramp;D Primary Health Care, Vaestra Goetaland region

Early access to evidence-based help is crucial for adolescents with anxiety disorders. Internet-delivered acceptance and commitment therapy (iACT) may offer adolescents increased access to care and more flexibility in engaging with treatment when and how they prefer. Process-based therapies, such as ACT, focus on the-oretically derived and empirically tested key mechanisms in treat-ment that enable change. This study aimed to investigate the effectiveness of iACT for adolescents with anxiety disorders. The study also assessed the relationship between psychological flexi-bility and treatment outcomes and the relationship between par-ticipating adolescents and therapists perceived alliance and treatment outcomes. This was a randomized controlled trial com-paring a 10-week intervention group with a wait-list control group. The 52 participants, aged 15 to 19, were recruited from all over Sweden. The treatment was effective in increasing quality of life and psychological flexibility, with moderate between-group effect sizes based on observed values. Changes in psychological flexibility was associated with changes in anxiety symptoms. The results further showed a statistically significant between-group difference in post-treatment diagnoses. No significant time per group interaction was found for anxiety symptoms, as both groups improved. Working alliance was rated as high by both participat-ing adolescents and therapists but showed no significant relation-ship with treatment outcomes. Participants found the treatment an acceptable intervention. This study shows promising results for iACT in treating adolescents with anxiety disorders. The results suggest the model of psychological flexibility as an important process of change in treatment outcomes. Future research should validate these findings in larger samples and clinical contexts., Funding Agencies|Ramp;D Primary Health Care, Vaestra Goetaland region

Early access to evidence-based help is crucial for adolescents with anxiety disorders. Internet-delivered acceptance and commitment therapy (iACT) may offer adolescents increased access to care and more flexibility in engaging with treatment when and how they prefer. Process-based therapies, such as ACT, focus on the-oretically derived and empirically tested key mechanisms in treat-ment that enable change. This study aimed to investigate the effectiveness of iACT for adolescents with anxiety disorders. The study also assessed the relationship between psychological flexi-bility and treatment outcomes and the relationship between par-ticipating adolescents and therapists perceived alliance and treatment outcomes. This was a randomized controlled trial com-paring a 10-week intervention group with a wait-list control group. The 52 participants, aged 15 to 19, were recruited from all over Sweden. The treatment was effective in increasing quality of life and psychological flexibility, with moderate between-group effect sizes based on observed values. Changes in psychological flexibility was associated with changes in anxiety symptoms. The results further showed a statistically significant between-group difference in post-treatment diagnoses. No significant time per group interaction was found for anxiety symptoms, as both groups improved. Working alliance was rated as high by both participat-ing adolescents and therapists but showed no significant relation-ship with treatment outcomes. Participants found the treatment an acceptable intervention. This study shows promising results for iACT in treating adolescents with anxiety disorders. The results suggest the model of psychological flexibility as an important process of change in treatment outcomes. Future research should validate these findings in larger samples and clinical contexts., Funding Agencies|Ramp;D Primary Health Care, Vaestra Goetaland region

Even if much is known regarding the effects of internet-delivered cognitive behaviour therapy (ICBT) for depression there are several topics that have not been studied. In this factorial design trial with 197 participants we investigated if clients in ICBT could select treatment modules themselves based on a selection of 15 tailored treatment modules developed for use in ICBT for depression. We contrasted this against clinician-tailored module selection. We also investigated if support on demand (initiated by the client) could work as well as scheduled support. Finally, we tested if clients that were mentioned in supervision would improve more than clients not mentioned (with the exception of acute cases). The treatment period lasted for 10 weeks, and we measured effects at post-treatment and two-year follow-up. Measures of depression and secondary outcomes were collected at pre-treatment, post-treatment and two-year follow-up. Overall, within-group effects were large across con-ditions (e.g., d = 1.73 on the BDI-II). We also found a small but significant difference in favour of self-tailored treatment over clinician-tailored (d = 0.26). Within-group effects for the secondary measures were all moderate to large including a test of knowledge about CBT. The other two contrasts "support on demand" and "supervision" yielded mostly non-significant differences, with the exception of a larger dropout rate in the support on demand condition. There were few negative effects (2.2%). Effects were largely maintained at a two-year follow-up. We conclude that clients can choose treatment modules and that support on demand may work. The role of su-pervision is not yet clear as advice can be transferred across clients., Funding Agencies|Swedish Research Council [2018-02900]

Even if much is known regarding the effects of internet-delivered cognitive behaviour therapy (ICBT) for depression there are several topics that have not been studied. In this factorial design trial with 197 participants we investigated if clients in ICBT could select treatment modules themselves based on a selection of 15 tailored treatment modules developed for use in ICBT for depression. We contrasted this against clinician-tailored module selection. We also investigated if support on demand (initiated by the client) could work as well as scheduled support. Finally, we tested if clients that were mentioned in supervision would improve more than clients not mentioned (with the exception of acute cases). The treatment period lasted for 10 weeks, and we measured effects at post-treatment and two-year follow-up. Measures of depression and secondary outcomes were collected at pre-treatment, post-treatment and two-year follow-up. Overall, within-group effects were large across con-ditions (e.g., d = 1.73 on the BDI-II). We also found a small but significant difference in favour of self-tailored treatment over clinician-tailored (d = 0.26). Within-group effects for the secondary measures were all moderate to large including a test of knowledge about CBT. The other two contrasts "support on demand" and "supervision" yielded mostly non-significant differences, with the exception of a larger dropout rate in the support on demand condition. There were few negative effects (2.2%). Effects were largely maintained at a two-year follow-up. We conclude that clients can choose treatment modules and that support on demand may work. The role of su-pervision is not yet clear as advice can be transferred across clients., Funding Agencies|Swedish Research Council [2018-02900]

Even if much is known regarding the effects of internet-delivered cognitive behaviour therapy (ICBT) for depression there are several topics that have not been studied. In this factorial design trial with 197 participants we investigated if clients in ICBT could select treatment modules themselves based on a selection of 15 tailored treatment modules developed for use in ICBT for depression. We contrasted this against clinician-tailored module selection. We also investigated if support on demand (initiated by the client) could work as well as scheduled support. Finally, we tested if clients that were mentioned in supervision would improve more than clients not mentioned (with the exception of acute cases). The treatment period lasted for 10 weeks, and we measured effects at post-treatment and two-year follow-up. Measures of depression and secondary outcomes were collected at pre-treatment, post-treatment and two-year follow-up. Overall, within-group effects were large across con-ditions (e.g., d = 1.73 on the BDI-II). We also found a small but significant difference in favour of self-tailored treatment over clinician-tailored (d = 0.26). Within-group effects for the secondary measures were all moderate to large including a test of knowledge about CBT. The other two contrasts "support on demand" and "supervision" yielded mostly non-significant differences, with the exception of a larger dropout rate in the support on demand condition. There were few negative effects (2.2%). Effects were largely maintained at a two-year follow-up. We conclude that clients can choose treatment modules and that support on demand may work. The role of su-pervision is not yet clear as advice can be transferred across clients., Funding Agencies|Swedish Research Council [2018-02900]

Early access to evidence-based help is crucial for adolescents with anxiety disorders. Internet-delivered acceptance and commitment therapy (iACT) may offer adolescents increased access to care and more flexibility in engaging with treatment when and how they prefer. Process-based therapies, such as ACT, focus on the-oretically derived and empirically tested key mechanisms in treat-ment that enable change. This study aimed to investigate the effectiveness of iACT for adolescents with anxiety disorders. The study also assessed the relationship between psychological flexi-bility and treatment outcomes and the relationship between par-ticipating adolescents and therapists perceived alliance and treatment outcomes. This was a randomized controlled trial com-paring a 10-week intervention group with a wait-list control group. The 52 participants, aged 15 to 19, were recruited from all over Sweden. The treatment was effective in increasing quality of life and psychological flexibility, with moderate between-group effect sizes based on observed values. Changes in psychological flexibility was associated with changes in anxiety symptoms. The results further showed a statistically significant between-group difference in post-treatment diagnoses. No significant time per group interaction was found for anxiety symptoms, as both groups improved. Working alliance was rated as high by both participat-ing adolescents and therapists but showed no significant relation-ship with treatment outcomes. Participants found the treatment an acceptable intervention. This study shows promising results for iACT in treating adolescents with anxiety disorders. The results suggest the model of psychological flexibility as an important process of change in treatment outcomes. Future research should validate these findings in larger samples and clinical contexts., Funding Agencies|Ramp;D Primary Health Care, Vaestra Goetaland region

Even if much is known regarding the effects of internet-delivered cognitive behaviour therapy (ICBT) for depression there are several topics that have not been studied. In this factorial design trial with 197 participants we investigated if clients in ICBT could select treatment modules themselves based on a selection of 15 tailored treatment modules developed for use in ICBT for depression. We contrasted this against clinician-tailored module selection. We also investigated if support on demand (initiated by the client) could work as well as scheduled support. Finally, we tested if clients that were mentioned in supervision would improve more than clients not mentioned (with the exception of acute cases). The treatment period lasted for 10 weeks, and we measured effects at post-treatment and two-year follow-up. Measures of depression and secondary outcomes were collected at pre-treatment, post-treatment and two-year follow-up. Overall, within-group effects were large across con-ditions (e.g., d = 1.73 on the BDI-II). We also found a small but significant difference in favour of self-tailored treatment over clinician-tailored (d = 0.26). Within-group effects for the secondary measures were all moderate to large including a test of knowledge about CBT. The other two contrasts "support on demand" and "supervision" yielded mostly non-significant differences, with the exception of a larger dropout rate in the support on demand condition. There were few negative effects (2.2%). Effects were largely maintained at a two-year follow-up. We conclude that clients can choose treatment modules and that support on demand may work. The role of su-pervision is not yet clear as advice can be transferred across clients., Funding Agencies|Swedish Research Council [2018-02900]

Even if much is known regarding the effects of internet-delivered cognitive behaviour therapy (ICBT) for depression there are several topics that have not been studied. In this factorial design trial with 197 participants we investigated if clients in ICBT could select treatment modules themselves based on a selection of 15 tailored treatment modules developed for use in ICBT for depression. We contrasted this against clinician-tailored module selection. We also investigated if support on demand (initiated by the client) could work as well as scheduled support. Finally, we tested if clients that were mentioned in supervision would improve more than clients not mentioned (with the exception of acute cases). The treatment period lasted for 10 weeks, and we measured effects at post-treatment and two-year follow-up. Measures of depression and secondary outcomes were collected at pre-treatment, post-treatment and two-year follow-up. Overall, within-group effects were large across con-ditions (e.g., d = 1.73 on the BDI-II). We also found a small but significant difference in favour of self-tailored treatment over clinician-tailored (d = 0.26). Within-group effects for the secondary measures were all moderate to large including a test of knowledge about CBT. The other two contrasts "support on demand" and "supervision" yielded mostly non-significant differences, with the exception of a larger dropout rate in the support on demand condition. There were few negative effects (2.2%). Effects were largely maintained at a two-year follow-up. We conclude that clients can choose treatment modules and that support on demand may work. The role of su-pervision is not yet clear as advice can be transferred across clients., Funding Agencies|Swedish Research Council [2018-02900]

Early access to evidence-based help is crucial for adolescents with anxiety disorders. Internet-delivered acceptance and commitment therapy (iACT) may offer adolescents increased access to care and more flexibility in engaging with treatment when and how they prefer. Process-based therapies, such as ACT, focus on the-oretically derived and empirically tested key mechanisms in treat-ment that enable change. This study aimed to investigate the effectiveness of iACT for adolescents with anxiety disorders. The study also assessed the relationship between psychological flexi-bility and treatment outcomes and the relationship between par-ticipating adolescents and therapists perceived alliance and treatment outcomes. This was a randomized controlled trial com-paring a 10-week intervention group with a wait-list control group. The 52 participants, aged 15 to 19, were recruited from all over Sweden. The treatment was effective in increasing quality of life and psychological flexibility, with moderate between-group effect sizes based on observed values. Changes in psychological flexibility was associated with changes in anxiety symptoms. The results further showed a statistically significant between-group difference in post-treatment diagnoses. No significant time per group interaction was found for anxiety symptoms, as both groups improved. Working alliance was rated as high by both participat-ing adolescents and therapists but showed no significant relation-ship with treatment outcomes. Participants found the treatment an acceptable intervention. This study shows promising results for iACT in treating adolescents with anxiety disorders. The results suggest the model of psychological flexibility as an important process of change in treatment outcomes. Future research should validate these findings in larger samples and clinical contexts., Funding Agencies|Ramp;D Primary Health Care, Vaestra Goetaland region

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 reduc, Funding: Japan Society for the Promotion of ScienceMinistry of Education, Culture, Sports, Science and Technology, Japan (MEXT)Japan Society for the Promotion of Science [17K19808]; National Institute for Health Research (NIHR) Oxford Cognitive Health Clinical Research FacilityNational Institute for Health Research (NIHR); NIHR Oxford Health Biomedical Research Centre [BRC-1215-20005]; National Institute on Drug Abuse (NIDA)United States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Institute on Drug Abuse (NIDA) [K23 DA045766]; Canadian Institutes of Health ResearchCanadian Institutes of Health Research (CIHR) [152917]; National Institute of Mental HealthUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Institute of Mental Health (NIMH) [P50 MH119029, R01 MH111610]; NIHR Oxford Cognitive Health Clinical Research Facility; NIHR Research Professorship [RP-201708ST2-006]; NIHR Oxford and Thames Valley Applied Research Collaboration; Swiss National Science FoundationSwiss National Science Foundation (SNSF)European Commission [180083]; Netherlands Organisation for Health Research and DevelopmentNetherlands Organization for Health Research and Development [019.182SG.001]

IMPORTANCE Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them. OBJECTIVE To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information. DATA SOURCES We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019. STUDY SELECTION Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization. DATA EXTRACTION AND SYNTHESIS We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression. MAIN OUTCOMES AND MEASURES Patient Health Questionnaire-9 (PHQ-9) scores. RESULTS Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-0 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 score

Background: To address the increasing mental health problems among young people, health care needs to broaden the spectrum of interventions and increase access to care. One particularly promising first-line intervention is cognitive behavioral therapy (CBT) delivered via the Internet (iCBT). The outbreak of the Coronavirus disease -2019 (COVID -19) has made the need for solid digital mental health care systems clear. This is the first published study exploring the transition among therapists of working with face-to-face treatment to using iCBT for youths suffering from anxiety treated in primary care. Methods: Fourteen primary care therapists were included in the study. Semi-structured interviews (n = 26) were conducted on two occasions: before starting to use iCBT for youths, and at a subsequent follow-up after gaining treatment experience. Data was summarized into thematic categories. Results: The overarching themes that were identified were: Attitudes to iCBT before and after implementation; Experiences of treatment delivery; Characteristics of "the right patient;" and The role of the digital therapist. Conclusion: The participants generally had positive attitudes to iCBT for youths and saw it as a valuable alternative to face-to-face treatments. However, they identified challenges related to patient selection, and to motivating patients and maintaining a therapeutic relationship through mainly written communication. The participants appreciated the increase in variety that iCBT brought to their schedules, and also experienced iCBT as a relief from common challenges of therapeutic work, such as emotional stress and high cognitive demands. The participating therapists positive experiences support the introduction of iCBT for youths in routine primary care., Funding Agencies|R&D Primary Health Care, Region Vastra Gotaland

Background: To address the increasing mental health problems among young people, health care needs to broaden the spectrum of interventions and increase access to care. One particularly promising first-line intervention is cognitive behavioral therapy (CBT) delivered via the Internet (iCBT). The outbreak of the Coronavirus disease -2019 (COVID -19) has made the need for solid digital mental health care systems clear. This is the first published study exploring the transition among therapists of working with face-to-face treatment to using iCBT for youths suffering from anxiety treated in primary care. Methods: Fourteen primary care therapists were included in the study. Semi-structured interviews (n = 26) were conducted on two occasions: before starting to use iCBT for youths, and at a subsequent follow-up after gaining treatment experience. Data was summarized into thematic categories. Results: The overarching themes that were identified were: Attitudes to iCBT before and after implementation; Experiences of treatment delivery; Characteristics of "the right patient;" and The role of the digital therapist. Conclusion: The participants generally had positive attitudes to iCBT for youths and saw it as a valuable alternative to face-to-face treatments. However, they identified challenges related to patient selection, and to motivating patients and maintaining a therapeutic relationship through mainly written communication. The participants appreciated the increase in variety that iCBT brought to their schedules, and also experienced iCBT as a relief from common challenges of therapeutic work, such as emotional stress and high cognitive demands. The participating therapists positive experiences support the introduction of iCBT for youths in routine primary care., Funding Agencies|R&D Primary Health Care, Region Vastra Gotaland

Background: To address the increasing mental health problems among young people, health care needs to broaden the spectrum of interventions and increase access to care. One particularly promising first-line intervention is cognitive behavioral therapy (CBT) delivered via the Internet (iCBT). The outbreak of the Coronavirus disease -2019 (COVID -19) has made the need for solid digital mental health care systems clear. This is the first published study exploring the transition among therapists of working with face-to-face treatment to using iCBT for youths suffering from anxiety treated in primary care. Methods: Fourteen primary care therapists were included in the study. Semi-structured interviews (n = 26) were conducted on two occasions: before starting to use iCBT for youths, and at a subsequent follow-up after gaining treatment experience. Data was summarized into thematic categories. Results: The overarching themes that were identified were: Attitudes to iCBT before and after implementation; Experiences of treatment delivery; Characteristics of "the right patient;" and The role of the digital therapist. Conclusion: The participants generally had positive attitudes to iCBT for youths and saw it as a valuable alternative to face-to-face treatments. However, they identified challenges related to patient selection, and to motivating patients and maintaining a therapeutic relationship through mainly written communication. The participants appreciated the increase in variety that iCBT brought to their schedules, and also experienced iCBT as a relief from common challenges of therapeutic work, such as emotional stress and high cognitive demands. The participating therapists positive experiences support the introduction of iCBT for youths in routine primary care., Funding Agencies|R&D Primary Health Care, Region Vastra Gotaland

Background: To address the increasing mental health problems among young people, health care needs to broaden the spectrum of interventions and increase access to care. One particularly promising first-line intervention is cognitive behavioral therapy (CBT) delivered via the Internet (iCBT). The outbreak of the Coronavirus disease -2019 (COVID -19) has made the need for solid digital mental health care systems clear. This is the first published study exploring the transition among therapists of working with face-to-face treatment to using iCBT for youths suffering from anxiety treated in primary care. Methods: Fourteen primary care therapists were included in the study. Semi-structured interviews (n = 26) were conducted on two occasions: before starting to use iCBT for youths, and at a subsequent follow-up after gaining treatment experience. Data was summarized into thematic categories. Results: The overarching themes that were identified were: Attitudes to iCBT before and after implementation; Experiences of treatment delivery; Characteristics of "the right patient;" and The role of the digital therapist. Conclusion: The participants generally had positive attitudes to iCBT for youths and saw it as a valuable alternative to face-to-face treatments. However, they identified challenges related to patient selection, and to motivating patients and maintaining a therapeutic relationship through mainly written communication. The participants appreciated the increase in variety that iCBT brought to their schedules, and also experienced iCBT as a relief from common challenges of therapeutic work, such as emotional stress and high cognitive demands. The participating therapists positive experiences support the introduction of iCBT for youths in routine primary care., Funding Agencies|R&D Primary Health Care, Region Vastra Gotaland

Background: To address the increasing mental health problems among young people, health care needs to broaden the spectrum of interventions and increase access to care. One particularly promising first-line intervention is cognitive behavioral therapy (CBT) delivered via the Internet (iCBT). The outbreak of the Coronavirus disease -2019 (COVID -19) has made the need for solid digital mental health care systems clear. This is the first published study exploring the transition among therapists of working with face-to-face treatment to using iCBT for youths suffering from anxiety treated in primary care. Methods: Fourteen primary care therapists were included in the study. Semi-structured interviews (n = 26) were conducted on two occasions: before starting to use iCBT for youths, and at a subsequent follow-up after gaining treatment experience. Data was summarized into thematic categories. Results: The overarching themes that were identified were: Attitudes to iCBT before and after implementation; Experiences of treatment delivery; Characteristics of "the right patient;" and The role of the digital therapist. Conclusion: The participants generally had positive attitudes to iCBT for youths and saw it as a valuable alternative to face-to-face treatments. However, they identified challenges related to patient selection, and to motivating patients and maintaining a therapeutic relationship through mainly written communication. The participants appreciated the increase in variety that iCBT brought to their schedules, and also experienced iCBT as a relief from common challenges of therapeutic work, such as emotional stress and high cognitive demands. The participating therapists positive experiences support the introduction of iCBT for youths in routine primary care., Funding Agencies|R&D Primary Health Care, Region Vastra Gotaland

Background: To address the increasing mental health problems among young people, health care needs to broaden the spectrum of interventions and increase access to care. One particularly promising first-line intervention is cognitive behavioral therapy (CBT) delivered via the Internet (iCBT). The outbreak of the Coronavirus disease -2019 (COVID -19) has made the need for solid digital mental health care systems clear. This is the first published study exploring the transition among therapists of working with face-to-face treatment to using iCBT for youths suffering from anxiety treated in primary care. Methods: Fourteen primary care therapists were included in the study. Semi-structured interviews (n = 26) were conducted on two occasions: before starting to use iCBT for youths, and at a subsequent follow-up after gaining treatment experience. Data was summarized into thematic categories. Results: The overarching themes that were identified were: Attitudes to iCBT before and after implementation; Experiences of treatment delivery; Characteristics of "the right patient;" and The role of the digital therapist. Conclusion: The participants generally had positive attitudes to iCBT for youths and saw it as a valuable alternative to face-to-face treatments. However, they identified challenges related to patient selection, and to motivating patients and maintaining a therapeutic relationship through mainly written communication. The participants appreciated the increase in variety that iCBT brought to their schedules, and also experienced iCBT as a relief from common challenges of therapeutic work, such as emotional stress and high cognitive demands. The participating therapists positive experiences support the introduction of iCBT for youths in routine primary care., Funding Agencies|R&D Primary Health Care, Region Vastra Gotaland

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT., We thank the E-COMPARED consortium forfinancialsupport.

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT., We thank the E-COMPARED consortium forfinancialsupport.

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT., We thank the E-COMPARED consortium forfinancialsupport.

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT., We thank the E-COMPARED consortium forfinancialsupport.

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT., We thank the E-COMPARED consortium forfinancialsupport.

Little is known about clinically relevant changes in guided Internet-based interventions for depression. Moreover, methodological and power limitations preclude the identification of patients groups that may benefit more from these interventions. This study aimed to investigate response rates, remission rates, and their moderators in randomized controlled trials (RCTs) comparing the effect of guided Internet-based interventions for adult depression to control groups using an individual patient data meta-analysis approach. Literature searches in PubMed, Embase, PsycINFO and Cochrane Library resulted in 13,384 abstracts from database inception to January 1, 2016. Twenty-four RCTs (4889 participants) comparing a guided Internet-based intervention with a control group contributed data to the analysis. Missing data were multiply imputed. To examine treatment outcome on response and remission, mixed-effects models with participants nested within studies were used. Response and remission rates were calculated using the Reliable Change Index. The intervention group obtained significantly higher response rates (OR = 2.49, 95% CI 2.17-2.85) and remission rates compared to controls (OR = 2.41, 95% CI 2.07-2.79). The moderator analysis indicated that older participants (OR = 1.01) and native-born participants (1.66) were more likely to respond to treatment compared to younger participants and ethnic minorities respectively. Age (OR = 1.01) and ethnicity (1.73) also moderated the effects of treatment on remission.Moreover, adults with more severe depressive symptoms at baseline were more likely to remit after receiving intemet-based treatment (OR = 1.19). Guided Internet-based interventions lead to substantial positive treatment effects on treatment response and remission at post-treatment. Thus, such interventions may complement existing services for depression and potentially reduce the gap between the need and provision of evidence-based treatments.

Depression är en funktionsnedsättande problematik som påverkar en stor del av den vuxna populationen varje år. Trots ett omfattande behov av hjälp så råder det brist på tillgång till effektiv behandling. Kognitiv Beteendeterapi (KBT) är en evidensbaserad metod som har stöd vid behandling av depression och förmedlad via internet skulle metoden kunna tillgängliggöras för fler. Dock är det i dagsläget oklart vilka format och vilket innehåll som kan användas när behandlingen förmedlas via internet, samt vilken betydelse den terapeutiska alliansen har för en behandling som till största del sker på distans. Syftet med denna avhandling var att undersöka effekterna för olika format av internetbehandling (epostterapi, guidad självhjälp och blended treatment) vid depression, samt alliansens roll i dessa format. Studiernas resultat visar på att epostterapi och internetförmedlade självhjälpsprogram med behandlarstöd var effektiva metoder för att behandla depression. Alliansskattningar var höga, vilket visar att en positiv terapeutisk allians kan uppnås i internetbehandling. Patientskattningar av allians kunde inte predicera utfallet i någon av behandlingarna, men behandlarskattad allians predicerade förbättring på depressionsskattningar i blended treatment. Den här avhandlingen innehåller den första randomiserade kontrollerade studien på KBT-baserad epostterapi vid depression, samt det första internet-förmedlade självhjälpsprogrammet baserat på beteendeaktivering och ACT., Depression is a debilitating disorder that affects a large part of the adult population every year. Yet there is still a lack of access to effective care for people in need. Cognitive Behaviour therapy (CBT) is an evidence-based method for treating depression that together with the increased availability of Internet services provides an opportunity to increase access to effective treatment. Internet-based interventions can be effective in the treatment of depression, but there is a lack of knowledge concerning which formats of delivery that can be used and if therapeutic alliance is of equal importance when providing treatment over the Internet. The overall aim of this thesis was to examine the effects of different treatment formats (email therapy, guided self-help, and blended treatment) in internet-based CBT for depression and to further examine the role of alliance in these treatment modalities. Findings from this thesis show that email therapy and internetbased treatment programs were effective methods for treating depression. Alliance ratings were high, showing that a positive therapeutic alliance can be achieved in internet-based treatments. Patient-rated alliance could not predict outcome in any of the different treatment formats. However, therapist-rated alliance predicted change in depression during blended treatment. This thesis includes the first randomized controlled study on CBTbased email therapy, and the first internet-based behavioral activation program with ACT-components, for adult depression.

Depression är en funktionsnedsättande problematik som påverkar en stor del av den vuxna populationen varje år. Trots ett omfattande behov av hjälp så råder det brist på tillgång till effektiv behandling. Kognitiv Beteendeterapi (KBT) är en evidensbaserad metod som har stöd vid behandling av depression och förmedlad via internet skulle metoden kunna tillgängliggöras för fler. Dock är det i dagsläget oklart vilka format och vilket innehåll som kan användas när behandlingen förmedlas via internet, samt vilken betydelse den terapeutiska alliansen har för en behandling som till största del sker på distans. Syftet med denna avhandling var att undersöka effekterna för olika format av internetbehandling (epostterapi, guidad självhjälp och blended treatment) vid depression, samt alliansens roll i dessa format. Studiernas resultat visar på att epostterapi och internetförmedlade självhjälpsprogram med behandlarstöd var effektiva metoder för att behandla depression. Alliansskattningar var höga, vilket visar att en positiv terapeutisk allians kan uppnås i internetbehandling. Patientskattningar av allians kunde inte predicera utfallet i någon av behandlingarna, men behandlarskattad allians predicerade förbättring på depressionsskattningar i blended treatment. Den här avhandlingen innehåller den första randomiserade kontrollerade studien på KBT-baserad epostterapi vid depression, samt det första internet-förmedlade självhjälpsprogrammet baserat på beteendeaktivering och ACT., Depression is a debilitating disorder that affects a large part of the adult population every year. Yet there is still a lack of access to effective care for people in need. Cognitive Behaviour therapy (CBT) is an evidence-based method for treating depression that together with the increased availability of Internet services provides an opportunity to increase access to effective treatment. Internet-based interventions can be effective in the treatment of depression, but there is a lack of knowledge concerning which formats of delivery that can be used and if therapeutic alliance is of equal importance when providing treatment over the Internet. The overall aim of this thesis was to examine the effects of different treatment formats (email therapy, guided self-help, and blended treatment) in internet-based CBT for depression and to further examine the role of alliance in these treatment modalities. Findings from this thesis show that email therapy and internetbased treatment programs were effective methods for treating depression. Alliance ratings were high, showing that a positive therapeutic alliance can be achieved in internet-based treatments. Patient-rated alliance could not predict outcome in any of the different treatment formats. However, therapist-rated alliance predicted change in depression during blended treatment. This thesis includes the first randomized controlled study on CBTbased email therapy, and the first internet-based behavioral activation program with ACT-components, for adult depression.

Depression är en funktionsnedsättande problematik som påverkar en stor del av den vuxna populationen varje år. Trots ett omfattande behov av hjälp så råder det brist på tillgång till effektiv behandling. Kognitiv Beteendeterapi (KBT) är en evidensbaserad metod som har stöd vid behandling av depression och förmedlad via internet skulle metoden kunna tillgängliggöras för fler. Dock är det i dagsläget oklart vilka format och vilket innehåll som kan användas när behandlingen förmedlas via internet, samt vilken betydelse den terapeutiska alliansen har för en behandling som till största del sker på distans. Syftet med denna avhandling var att undersöka effekterna för olika format av internetbehandling (epostterapi, guidad självhjälp och blended treatment) vid depression, samt alliansens roll i dessa format. Studiernas resultat visar på att epostterapi och internetförmedlade självhjälpsprogram med behandlarstöd var effektiva metoder för att behandla depression. Alliansskattningar var höga, vilket visar att en positiv terapeutisk allians kan uppnås i internetbehandling. Patientskattningar av allians kunde inte predicera utfallet i någon av behandlingarna, men behandlarskattad allians predicerade förbättring på depressionsskattningar i blended treatment. Den här avhandlingen innehåller den första randomiserade kontrollerade studien på KBT-baserad epostterapi vid depression, samt det första internet-förmedlade självhjälpsprogrammet baserat på beteendeaktivering och ACT., Depression is a debilitating disorder that affects a large part of the adult population every year. Yet there is still a lack of access to effective care for people in need. Cognitive Behaviour therapy (CBT) is an evidence-based method for treating depression that together with the increased availability of Internet services provides an opportunity to increase access to effective treatment. Internet-based interventions can be effective in the treatment of depression, but there is a lack of knowledge concerning which formats of delivery that can be used and if therapeutic alliance is of equal importance when providing treatment over the Internet. The overall aim of this thesis was to examine the effects of different treatment formats (email therapy, guided self-help, and blended treatment) in internet-based CBT for depression and to further examine the role of alliance in these treatment modalities. Findings from this thesis show that email therapy and internetbased treatment programs were effective methods for treating depression. Alliance ratings were high, showing that a positive therapeutic alliance can be achieved in internet-based treatments. Patient-rated alliance could not predict outcome in any of the different treatment formats. However, therapist-rated alliance predicted change in depression during blended treatment. This thesis includes the first randomized controlled study on CBTbased email therapy, and the first internet-based behavioral activation program with ACT-components, for adult depression.

Depression är en funktionsnedsättande problematik som påverkar en stor del av den vuxna populationen varje år. Trots ett omfattande behov av hjälp så råder det brist på tillgång till effektiv behandling. Kognitiv Beteendeterapi (KBT) är en evidensbaserad metod som har stöd vid behandling av depression och förmedlad via internet skulle metoden kunna tillgängliggöras för fler. Dock är det i dagsläget oklart vilka format och vilket innehåll som kan användas när behandlingen förmedlas via internet, samt vilken betydelse den terapeutiska alliansen har för en behandling som till största del sker på distans. Syftet med denna avhandling var att undersöka effekterna för olika format av internetbehandling (epostterapi, guidad självhjälp och blended treatment) vid depression, samt alliansens roll i dessa format. Studiernas resultat visar på att epostterapi och internetförmedlade självhjälpsprogram med behandlarstöd var effektiva metoder för att behandla depression. Alliansskattningar var höga, vilket visar att en positiv terapeutisk allians kan uppnås i internetbehandling. Patientskattningar av allians kunde inte predicera utfallet i någon av behandlingarna, men behandlarskattad allians predicerade förbättring på depressionsskattningar i blended treatment. Den här avhandlingen innehåller den första randomiserade kontrollerade studien på KBT-baserad epostterapi vid depression, samt det första internet-förmedlade självhjälpsprogrammet baserat på beteendeaktivering och ACT., Depression is a debilitating disorder that affects a large part of the adult population every year. Yet there is still a lack of access to effective care for people in need. Cognitive Behaviour therapy (CBT) is an evidence-based method for treating depression that together with the increased availability of Internet services provides an opportunity to increase access to effective treatment. Internet-based interventions can be effective in the treatment of depression, but there is a lack of knowledge concerning which formats of delivery that can be used and if therapeutic alliance is of equal importance when providing treatment over the Internet. The overall aim of this thesis was to examine the effects of different treatment formats (email therapy, guided self-help, and blended treatment) in internet-based CBT for depression and to further examine the role of alliance in these treatment modalities. Findings from this thesis show that email therapy and internetbased treatment programs were effective methods for treating depression. Alliance ratings were high, showing that a positive therapeutic alliance can be achieved in internet-based treatments. Patient-rated alliance could not predict outcome in any of the different treatment formats. However, therapist-rated alliance predicted change in depression during blended treatment. This thesis includes the first randomized controlled study on CBTbased email therapy, and the first internet-based behavioral activation program with ACT-components, for adult depression.

Depression är en funktionsnedsättande problematik som påverkar en stor del av den vuxna populationen varje år. Trots ett omfattande behov av hjälp så råder det brist på tillgång till effektiv behandling. Kognitiv Beteendeterapi (KBT) är en evidensbaserad metod som har stöd vid behandling av depression och förmedlad via internet skulle metoden kunna tillgängliggöras för fler. Dock är det i dagsläget oklart vilka format och vilket innehåll som kan användas när behandlingen förmedlas via internet, samt vilken betydelse den terapeutiska alliansen har för en behandling som till största del sker på distans. Syftet med denna avhandling var att undersöka effekterna för olika format av internetbehandling (epostterapi, guidad självhjälp och blended treatment) vid depression, samt alliansens roll i dessa format. Studiernas resultat visar på att epostterapi och internetförmedlade självhjälpsprogram med behandlarstöd var effektiva metoder för att behandla depression. Alliansskattningar var höga, vilket visar att en positiv terapeutisk allians kan uppnås i internetbehandling. Patientskattningar av allians kunde inte predicera utfallet i någon av behandlingarna, men behandlarskattad allians predicerade förbättring på depressionsskattningar i blended treatment. Den här avhandlingen innehåller den första randomiserade kontrollerade studien på KBT-baserad epostterapi vid depression, samt det första internet-förmedlade självhjälpsprogrammet baserat på beteendeaktivering och ACT., Depression is a debilitating disorder that affects a large part of the adult population every year. Yet there is still a lack of access to effective care for people in need. Cognitive Behaviour therapy (CBT) is an evidence-based method for treating depression that together with the increased availability of Internet services provides an opportunity to increase access to effective treatment. Internet-based interventions can be effective in the treatment of depression, but there is a lack of knowledge concerning which formats of delivery that can be used and if therapeutic alliance is of equal importance when providing treatment over the Internet. The overall aim of this thesis was to examine the effects of different treatment formats (email therapy, guided self-help, and blended treatment) in internet-based CBT for depression and to further examine the role of alliance in these treatment modalities. Findings from this thesis show that email therapy and internetbased treatment programs were effective methods for treating depression. Alliance ratings were high, showing that a positive therapeutic alliance can be achieved in internet-based treatments. Patient-rated alliance could not predict outcome in any of the different treatment formats. However, therapist-rated alliance predicted change in depression during blended treatment. This thesis includes the first randomized controlled study on CBTbased email therapy, and the first internet-based behavioral activation program with ACT-components, for adult depression.

Objective Internet-delivered cognitive behavior therapy (ICBT) has been developed and tested for treating persons with generalized anxiety disorder (GAD). A new form of CBT focuses on acceptance (of internal experiences or difficult psychological content), mindfulness and valued actions. To date this form of CBT has not been delivered via the internet for persons with GAD. The aim of this study was to describe the functionality of a new internet-delivered acceptance-based behavior therapy for GAD, and to test the effect of the intervention in an open pilot trial. Methods Following exclusion of two patients we included 14 patients diagnosed with GAD from two primary care clinics. At 2–3 months follow-up after treatment 10 patients completed the outcome measures. The treatment lasted for an average of 15 weeks and consisted of acceptance-based techniques, behavior therapy components and homework assignments. Results A majority of participants completed all modules during the treatment. Findings on the Penn State Worry Questionnaire showed a within-group improvement of Cohen's d = 2.14 at posttreatment. At the follow-up results were maintained. Client satisfaction ratings were high. Conclusions We conclude that internet-delivered acceptance-based behavior therapy potentially can be a promising new treatment for GAD. A controlled trial of the program has already been completed.

Acceptance and Commitment Therapy (ACT) can be effective in treating anxiety disorders, yet there has been no study on Internet-delivered ACT for social anxiety disorder (SAD) and panic disorder (PD), nor any study investigating whether therapist guidance is superior to unguided self-help when supplemented with a smartphone application. In the current trial, n = 152 participants diagnosed with SAD and/or PD were randomized to therapist-guided or unguided treatment, or a waiting-list control group. Both treatment groups used an Internet-delivered ACT-based treatment program and a smartphone application. Outcome measures were self-rated general and social anxiety and panic symptoms. Treatment groups saw reduced general (d = 0.39) and social anxiety (d = 0.70), but not panic symptoms (d = 0.05) compared to the waiting-list group, yet no differences in outcomes were observed between guided and unguided interventions. We conclude that Internet-delivered ACT is appropriate for treating SAD and potentially PD. Smartphone applications may partially compensate for lack of therapist support. (C) 2016 Published by Elsevier Ltd., Funding Agencies|Swedish Research Council [2011-2913]; Forte [2013-1107]

Background: Almost nothing is known about the potential negative effects of Internet-based psychological treatments for depression. This study aims at investigating deterioration and its moderators within randomized trials on Internet-based guided self-help for adult depression, using an individual patient data meta-analyses (IPDMA) approach. Method: Studies were identified through systematic searches (PubMed, PsycINFO, EMBASE, Cochrane Library). Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e. 7.68 points in the CES-D; 7.63 points in the BDI). Two-step IPDMA procedures, with a random-effects model were used to pool data. Results: A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention v. control conditions (3.36 v. 7.60; relative risk 0.47, 95% confidence interval 0.29-0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education. Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit-risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration. Conclusions: Internet-based guided self-help is associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education., Funding Agencies|European Union [EU EFRE: ZW6-67280119999, CCI 2007DE161PR001, HEALTH.2013.3.1-1, 603098]

Predictive modeling of future health states can greatly contribute to more effective health care. Healthcare professionals can for example act in a more proactive way or predictions can drive more automated ways of therapy. However, the task is very challenging. Future developments likely depend on observations in the (recent) past, but how can we capture this history in features to generate accurate predictive models? And what length of history should we consider? We propose a framework that is able to generate patient tailored features from observations of the recent history that maximize predictive performance. For a case study in the domain of depression we find that using this method new data representations can be generated that increase the predictive performance significantly., Funding Agencies|EU FP7 project E-COMPARED [603098]

Background. It is well known that web-based interventions can be effective treatments for depression. However, dropout rates in web-based interventions are typically high, especially in self-guided web-based interventions. Rigorous empirical evidence regarding factors influencing dropout in self-guided web-based interventions is lacking due to small study sample sizes. In this paper we examined predictors of dropout in an individual patient data meta-analysis to gain a better understanding of who may benefit from these interventions. Method. A comprehensive literature search for all randomized controlled trials (RCTs) of psychotherapy for adults with depression from 2006 to January 2013 was conducted. Next, we approached authors to collect the primary data of the selected studies. Predictors of dropout, such as socio-demographic, clinical, and intervention characteristics were examined. Results. Data from 2705 participants across ten RCTs of self-guided web-based interventions for depression were analysed. The multivariate analysis indicated that male gender [relative risk (RR) 1.08], lower educational level (primary education, RR 1.26) and co-morbid anxiety symptoms (RR 1.18) significantly increased the risk of dropping out, while for every additional 4 years of age, the risk of dropping out significantly decreased (RR 0.94). Conclusions. Dropout can be predicted by several variables and is not randomly distributed. This knowledge may inform tailoring of online self-help interventions to prevent dropout in identified groups at risk.

Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3-4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.