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Collateral outcomes in e-mental health: a systematic review of the evidence for added benefits of computerized cognitive behavior therapy interventions for mental health

  • P. Musiat (a1) and N. Tarrier (a1)

E-mental health is a growing research field and an increasing number of computerized cognitive behavior therapy (cCBT) interventions are available for numerous mental health issues. Such interventions are often claimed to have added benefits, or collateral outcomes, when compared with traditional delivery platforms. Our aim was to systematically review the evidence of the cost-effectiveness, geographic flexibility, time flexibility, waiting time for treatment, stigma, therapist time, effects on help-seeking and treatment satisfaction of cCBT interventions for mental health.


The electronic databases Medline and Web of Science were searched for peer-reviewed controlled trials investigating collateral outcomes in computerized and internet-based CBT.


The literature search identified 101 published papers (95 studies), which were included in this review. The results suggest that cCBT interventions are cost-effective and often cheaper than usual care. Limited evidence was found with regard to geographic flexibility, time flexibility, waiting time for treatment, stigma and the effects on help-seeking. Personal support in cCBT was found to take many forms, was not limited only to therapists, and seemed to increase treatment adherence and reduce attrition. Treatment satisfaction with cCBT was found to be high, but more research on attrition due to dissatisfaction is required.


Although the results of this systematic review on the collateral outcomes provide support for the potential of cCBT, these outcomes need to be better assessed within individual e-mental health studies.

Corresponding author
* Address for correspondence: P. Musiat, Ph.D., Institute of Psychiatry, PO Box 077, De Crespigny Park, London SE5 8AF, UK. (Email:
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AIHW (2004). Rural, Regional and Remote Health: A Guide to Remoteness Classifications. Australian Institute of Health and Welfare: Canberra, ACT.
Aisbett, D, Boyd, C, Francis, KJ, Newnham, K, Newnham, K (2007). Understanding barriers to mental health service utilization for adolescents in rural Australia. Rural and Remote Health 7, 624.
Anderson, P, Jacobs, C (2004). Computer-supported cognitive behavioral treatment of anxiety disorders. Journal of Clinical Psychology 60, 253267.
Andersson, E, Ljótsson, B, Smit, F, Paxling, B, Hedman, E, Lindefors, N, Andersson, G, Rück, C (2011). Cost-effectiveness of internet-based cognitive behavior therapy for irritable bowel syndrome: results from a randomized controlled trial. BMC Public Health 11, 215.
Andersson, G, Carlbring, P, Furmark, T; SOFIE Research Group (2012). Therapist experience and knowledge acquisition in internet-delivered CBT for social anxiety disorder: a randomized controlled trial. PLoS One 7, e37411.
Andersson, G, Cuijpers, P (2009). Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cognitive Behaviour Therapy 38, 196205.
Andrewes, H, Kenicer, D, McClay, C-A, Williams, C (2013). A national survey of the infrastructure and IT policies required to deliver computerised cognitive behavioural therapy in the English NHS. BMJ Open 3, e002277.
Andrews, G, Cuijpers, P, Craske, MG, McEvoy, P, Titov, N (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS One 5, e13196.
Andrews, G, Davies, M, Titov, N (2011). Effectiveness randomized controlled trial of face to face versus Internet cognitive behaviour therapy for social phobia. Australian and New Zealand Journal of Psychiatry 45, 337340.
APA (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. DSM-IV-TR. American Psychiatric Association: Washington, DC.
Beintner, I, Jacobi, C, Taylor, CB (2012). Effects of an internet-based prevention programme for eating disorders in the USA and Germany: a meta-analytic review. European Eating Disorders Review 20, 18.
Bergstrom, J, Andersson, G, Ljotsson, B, Ruck, C, Andreewitch, S, Karlsson, A, Carlbring, P, Andersson, E, Lindefors, N (2010). Internet-versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial. BMC Psychiatry 10, 54.
Bickel, WK, Marsch, LA, Buchhalter, AR, Badger, GJ (2008). Computerized behavior therapy for opioid-dependent outpatients: a randomized controlled trial. Experimental and Clinical Psychopharmacology 16, 132143.
Botella, C, Gallego, MJ, Garcia-Palacios, A, Banos, RM, Quero, S, Alcaniz, M (2009). The acceptability of an Internet-based self-help treatment for fear of public speaking. British Journal of Guidance and Counselling 37, 297311.
Butler, AC, Chapman, JE, Forman, EM, Beck, AT (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical Psychology Review 26, 1731.
Calear, AL, Christensen, H, Mackinnon, A, Griffiths, KM, O'Kearney, R (2009). The YouthMood Project: a cluster randomized controlled trial of an online cognitive behavioral program with adolescents. Journal of Consulting and Clinical Psychology 77, 10211032.
Carlbring, P, Ekselius, L, Andersson, G (2003). Treatment of panic disorder via the Internet: a randomized trial of CBT vs. applied relaxation. Journal of Behavior Therapy and Experimental Psychiatry 34, 129140.
Carlbring, P, Gunnarsdottir, M, Hedensjo, L, Andersson, G, Ekselius, L, Furmark, T (2007). Treatment of social phobia: randomised trial of internet-delivered cognitive-behavioural therapy with telephone support. British Journal of Psychiatry 190, 123128.
Carlbring, P, Maurin, L, Torngren, C, Linna, E, Eriksson, T, Sparthan, E, Straat, M, von Hage, CM, Bergman-Nordgren, L, Andersson, G (2011). Individually-tailored, Internet-based treatment for anxiety disorders: a randomized controlled trial. Behaviour Research and Therapy 49, 1824.
Carlbring, P, Nilsson-Ihrfelt, E, Waara, J, Kollenstam, C, Buhrman, M, Kaldo, V, Soderberg, M, Ekselius, L, Andersson, G (2005). Treatment of panic disorder: live therapy vs. self-help via the Internet. Behaviour Research and Therapy 43, 13211333.
Carrard, I, Crepin, C, Rouget, P, Lam, T, Golay, A, Van der Linden, M (2011). Randomised controlled trial of a guided self-help treatment on the Internet for binge eating disorder. Behaviour Research and Therapy 49, 482491.
Carroll, KM, Rounsaville, BJ (2010). Computer-assisted therapy in psychiatry: be brave – it's a new world. Current Psychiatry Reports 12, 426432.
Chiauzzi, E, Pujol, LA, Wood, M, Bond, K, Black, R, Yiu, E, Zacharoff, K (2010). painACTION-Back Pain: a self-management website for people with chronic back pain. Pain Medicine 11, 10441058.
Christensen, H, Griffiths, KM, Farrer, L (2009). Adherence in internet interventions for anxiety and depression: systematic review. Journal of Medical Internet Research 11, e13.
Christensen, H, Griffiths, KM, Mackinnon, AJ, Brittliffe, K (2006 a). Online randomized controlled trial of brief and full cognitive behaviour therapy for depression. Psychological Medicine 36, 17371746.
Christensen, H, Hickie, IB (2010). E-mental health: a new era in delivery of mental health services. Medical Journal of Australia 192, S2S3.
Christensen, H, Leach, LS, Barney, L, Mackinnon, AJ, Griffiths, KM (2006 b). The effect of web based depression interventions on self reported help seeking: randomised controlled trial [ISRCTN77824516]. BMC Psychiatry 6, 13.
Cuijpers, P, van Straten, A, Andersson, G (2008). Internet-administered cognitive behavior therapy for health problems: a systematic review. Journal of Behavioral Medicine 31, 169177.
Dölemeyer, R, Tietjen, A, Kersting, A, Wagner, B (2013). Internet-based interventions for eating disorders in adults: a systematic review. BMC Psychiatry 13, 116.
Donkin, L, Christensen, H, Naismith, SL, Neal, B, Hickie, IB, Glozier, N (2011). A systematic review of the impact of adherence on the effectiveness of e-therapies. Journal of Medical Internet Research 13, e52.
Eysenbach, G; CONSORT-EHEALTH group (2011). CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions. Journal of Medical Internet Research 13, e126.
Farrer, L, Christensen, H, Griffiths, KM, Mackinnon, A (2012). Web-based cognitive behavior therapy for depression with and without telephone tracking in a national helpline: secondary outcomes from a randomized controlled trial. Journal of Medical Internet Research 14, e68.
Fichter, MM, Quadflieg, N, Nisslmuller, K, Lindner, S, Osen, B, Huber, T, Wunsch-Leiteritz, W (2012). Does internet-based prevention reduce the risk of relapse for anorexia nervosa? Behaviour Research and Therapy 50, 180190.
Foroushani, PS, Schneider, J, Assareh, N (2011). Meta-review of the effectiveness of computerised CBT in treating depression. BMC Psychiatry 11, 131.
Furmark, T, Carlbring, P, Hedman, E, Sonnenstein, A, Clevberger, P, Bohman, B, Eriksson, A, Hallen, A, Frykman, M, Holmstrom, A, Sparthan, E, Tillfors, M, Ihrfelt, EN, Spak, M, Ekselius, L, Andersson, G (2009). Guided and unguided self-help for social anxiety disorder: randomised controlled trial. British Journal of Psychiatry 195, 440447.
Gerhards, SA, de Graaf, LE, Jacobs, LE, Severens, JL, Huibers, MJ, Arntz, A, Riper, H, Widdershoven, G, Metsemakers, JF, Evers, SM (2010). Economic evaluation of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial. British Journal of Psychiatry 196, 310318.
Griffiths, KM, Christensen, H, Jorm, AF, Evans, K, Groves, C (2004). Effect of web-based depression literacy and cognitive-behavioural therapy interventions on stigmatising attitudes to depression: randomised controlled trial. British Journal of Psychiatry 185, 342349.
Griffiths, KM, Farrer, L, Christensen, H (2010). The efficacy of internet interventions for depression and anxiety disorders: a review of randomised controlled trials. Medical Journal of Australia 192, S4S11.
Handley, TE, Kay-Lambkin, FJ, Inder, KJ, Attia, JR, Lewin, TJ, Kelly, BJ (2013). Feasibility of internet-delivered mental health treatments for rural populations. Social Psychiatry and Psychiatric Epidemiology. Published online: 21 May 2013 . doi:10.1007/s00127-013-0708-9.
Hedman, E, Andersson, E, Lindefors, N, Andersson, G, Ruck, C, Ljotsson, B (2013). Cost-effectiveness and long-term effectiveness of Internet-based cognitive behaviour therapy for severe health anxiety. Psychological Medicine 43, 363374.
Hedman, E, Andersson, E, Ljotsson, B, Andersson, G, Ruck, C, Lindefors, N (2011). Cost-effectiveness of Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: results from a randomized controlled trial. Behaviour Research and Therapy 49, 729736.
Hollandare, F, Johnsson, S, Randestad, M, Tillfors, M, Carlbring, P, Andersson, G, Engstrom, I (2011). Randomized trial of Internet-based relapse prevention for partially remitted depression. Acta Psychiatrica Scandinavica 124, 285294.
Hollinghurst, S, Peters, TJ, Kaur, S, Wiles, N, Lewis, G, Kessler, D (2010). Cost-effectiveness of therapist-delivered online cognitive-behavioural therapy for depression: randomised controlled trial. British Journal of Psychiatry 197, 297304.
Hunkeler, EM, Hung, YY, Rice, DP, Weisner, C, Hu, T (2001). Alcohol consumption patterns and health care costs in an HMO. Drug and Alcohol Dependence 64, 181190.
Illman, J (2004). Mental health. On the cyber couch. Health Service Journal 114, Suppl. 14–5.
Johansson, R, Sjoberg, E, Sjogren, M, Johnsson, E, Carlbring, P, Andersson, T, Rousseau, A, Andersson, G (2012). Tailored vs. standardized internet-based cognitive behavior therapy for depression and comorbid symptoms: a randomized controlled trial. PLoS One 7, e36905.
Johnston, L, Titov, N, Andrews, G, Spence, J, Dear, BF (2011). A RCT of a transdiagnostic internet-delivered treatment for three anxiety disorders: examination of support roles and disorder-specific outcomes. PLoS One 6, e28079.
Kaldo, V, Levin, S, Widarsson, J, Buhrman, M, Larsen, HC, Andersson, G (2008). Internet versus group cognitive-behavioral treatment of distress associated with tinnitus: a randomized controlled trial. Behavior Therapy 39, 348359.
Kay-Lambkin, FJ, Baker, AL, Kelly, B, Lewin, TJ (2011). Clinician-assisted computerised versus therapist-delivered treatment for depressive and addictive disorders: a randomised controlled trial. Medical Journal of Australia 195, S44S50.
Kenwright, M, Marks, I, Graham, C, Franses, A, Mataix-Cols, D (2005). Brief scheduled phone support from a clinician to enhance computer-aided self-help for obsessive-compulsive disorder: randomized controlled trial. Journal of Clinical Psychology 61, 14991508.
Khanna, MS, Kendall, PC (2010). Computer-assisted cognitive behavioral therapy for child anxiety: results of a randomized clinical trial. Journal of Consulting and Clinical Psychology 78, 737745.
Kiropoulos, LA, Klein, B, Austin, DW, Gilson, K, Pier, C, Mitchell, J, Ciechomski, L (2008). Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT? Journal of Anxiety Disorders 22, 12731284.
Klein, B, Austin, D, Pier, C, Kiropoulos, L, Shandley, K, Mitchell, J, Gilson, K, Ciechomski, L (2009). Internet-based treatment for panic disorder: does frequency of therapist contact make a difference? Cognitive Behaviour Therapy 38, 100113.
Klein, B, Richards, JC, Austin, DW (2006). Efficacy of internet therapy for panic disorder. Journal of Behavior Therapy and Experimental Psychiatry 37, 213238.
Ljotsson, B, Hedman, E, Andersson, E, Hesser, H, Lindfors, P, Hursti, T, Rydh, S, Ruck, C, Lindefors, N, Andersson, G (2011). Internet-delivered exposure-based treatment vs. stress management for irritable bowel syndrome: a randomized trial. American Journal of Gastroenterology 106, 14811491.
McClay, CA, Waters, L, McHale, C, Schmidt, U, Williams, C (2013). Online cognitive behavioral therapy for bulimic type disorders, delivered in the community by a nonclinician: qualitative study. Journal of Medical Internet Research 15, e46.
McCrone, P, Knapp, M, Proudfoot, J, Ryden, C, Cavanagh, K, Shapiro, DA, Ilson, S, Gray, JA, Goldberg, D, Mann, A, Marks, I, Everitt, B, Tylee, A (2004). Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. British Journal of Psychiatry 185, 5562.
McCrone, P, Marks, IM, Mataix-Cols, D, Kenwright, M, McDonough, M (2009). Computer-aided self-exposure therapy for phobia/panic disorder: a pilot economic evaluation. Cognitive Behaviour Therapy 38, 9199.
Melville, KM, Casey, LM, Kavanagh, DJ (2010). Dropout from Internet-based treatment for psychological disorders. British Journal of Clinical Psychology 49, 455471.
Moher, D, Liberati, A, Tetzlaff, J, Altman, DG; the PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. British Medical Journal 339, b2535.
Moss-Morris, R, McCrone, P, Yardley, L, van Kessel, K, Wills, G, Dennison, L (2012). A pilot randomised controlled trial of an Internet-based cognitive behavioural therapy self-management programme (MS Invigor8) for multiple sclerosis fatigue. Behaviour Research and Therapy 50, 415421.
Musiat, P, Schmidt, U (2010). Self-help and stepped care in eating disorders. In The Oxford Handbook of Eating Disorders (ed. Agras, W. S.), pp. 386401. Oxford University Press: Oxford.
NICE (2008). Depression and Anxiety – Computerised Cognitive Behaviour Therapy (CCBT). Technology appraisal TA97. National Institute for Health and Clinical Excellence: London.
NICE (2009 a). Depression in Adults with a Chronic Physical Health Problem: Treatment and Management. Clinical Guideline CG91. National Institute for Health and Clinical Excellence: London.
NICE (2009 b). Depression in Adults: The Treatment and Management of Depression in Adults. Clinical Guideline CG90. National Institute for Health and Clinical Excellence: London.
Nyenhuis, N, Zastrutzki, S, Weise, C, Jager, B, Kroner-Herwig, B (2013). The efficacy of minimal contact interventions for acute tinnitus: a randomised controlled study. Cognitive Behaviour Therapy 42, 127138.
Olmstead, TA, Ostrow, CD, Carroll, KM (2010). Cost-effectiveness of computer-assisted training in cognitive-behavioral therapy as an adjunct to standard care for addiction. Drug and Alcohol Dependence 110, 200207.
ONS (2011). Rural and Urban Areas: Comparing Lives using Rural/Urban Classifications. Office for National Statistics: Newport, South Wales.
Pollini, RA, McCall, L, Mehta, SH, Vlahov, D, Strathdee, SA (2006). Non-fatal overdose and subsequent drug treatment among injection drug users. Drug and Alcohol Dependence 83, 104110.
Posternak, MA, Miller, I (2001). Untreated short-term course of major depression: a meta-analysis of outcomes from studies using wait-list control groups. Journal of Affective Disorders 66, 139146.
Proudfoot, J (2004). Computer-based treatment for anxiety and depression: is it feasible? Is it effective? Neuroscience and Biobehavioral Reviews 28, 353363.
Redko, C, Rapp, RC, Carlson, RG (2006). Waiting time as a barrier to treatment entry: perceptions of substance users. Journal of Drug Issues 36, 831852.
Riper, H, Andersson, G, Christensen, H, Cuijpers, P, Lange, A, Eysenbach, G (2010). Theme issue on e-mental health: a growing field in internet research. Journal of Medical Internet Research 12, e74.
Robinson, E, Titov, N, Andrews, G, McIntyre, K, Schwencke, G, Solley, K (2010). Internet treatment for generalized anxiety disorder: a randomized controlled trial comparing clinician vs. technician assistance. PLoS One 5, e10942.
Robinson, P, Serfaty, M (2003). Computers, e-mail and therapy in eating disorders. European Eating Disorders Review 11, 210221.
Ruggeri, M (1994). Patients’ and relatives’ satisfaction with psychiatric services: the state of the art of its measurement. Social Psychiatry and Psychiatric Epidemiology 29, 212227.
Ruwaard, J, Lange, A, Bouwman, M, Broeksteeg, J, Schrieken, B (2007). E-mailed standardized cognitive behavioural treatment of work-related stress: a randomized controlled trial. Cognitive Behaviour Therapy 36, 179192.
Ruwaard, J, Lange, A, Broeksteeg, J, Renteria-Agirre, A, Schrieken, B, Dolan, CV, Emmelkamp, P (2013). Online cognitive-behavioural treatment of bulimic symptoms: a randomized controlled trial. Clinical Psychology and Psychotherapy 20, 308318.
Ruwaard, J, Schrieken, B, Schrijver, M, Broeksteeg, J, Dekker, J, Vermeulen, H, Lange, A (2009). Standardized web-based cognitive behavioural therapy of mild to moderate depression: a randomized controlled trial with a long-term follow-up. Cognitive Behaviour Therapy 38, 206221.
Schmidt, U, Wykes, T (2012). E-mental health – a land of unlimited possibilities. Journal of Mental Health 21, 327331.
Spence, SH, Donovan, CL, March, S, Gamble, A, Anderson, RE, Prosser, S, Kenardy, J (2011). A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety. Journal of Consulting and Clinical Psychology 79, 629642.
Spence, SH, Holmes, JM, March, S, Lipp, OV (2006). The feasibility and outcome of clinic plus internet delivery of cognitive-behavior therapy for childhood anxiety. Journal of Consulting and Clinical Psychology 74, 614621.
Spurgeon, JA, Wright, JH (2010). Computer-assisted cognitive-behavioral therapy. Current Psychiatry Reports 12, 547552.
Tait, RJ, Christensen, H (2010). Internet-based interventions for young people with problematic substance use: a systematic review. Medical Journal of Australia 192, S15.
Titov, N (2007). Status of computerized cognitive behavioural therapy for adults. Australian and New Zealand Journal of Psychiatry 41, 95114.
Titov, N, Andrews, G, Choi, I, Schwencke, G, Mahoney, A (2008). Shyness 3: randomized controlled trial of guided versus unguided Internet-based CBT for social phobia. Australian and New Zealand Journal of Psychiatry 42, 10301040.
Titov, N, Andrews, G, Davies, M, McIntyre, K, Robinson, E, Solley, K (2010). Internet treatment for depression: a randomized controlled trial comparing clinician vs. technician assistance. PLoS One 5, e10939.
Titov, N, Andrews, G, Schwencke, G, Solley, K, Johnston, L, Robinson, E (2009). An RCT comparing effect of two types of support on severity of symptoms for people completing Internet-based cognitive behaviour therapy for social phobia. Australian and New Zealand Journal of Psychiatry 43, 920926.
United Nations (2012). World Urbanization Prospects, the 2011 Revision. United Nations Department of Economic and Social Affairs, Population Division: New York.
U.S. Census Bureau (2010). 2010 Census Urban and Rural Classification and Urban Area Criteria. United States Census Bureau: Washington, DC.
Wagner, B, Knaevelsrud, C, Maercker, A (2006). Internet-based cognitive-behavioral therapy for complicated grief: a randomized controlled trial. Death Studies 30, 429453.
Whitfield, G, Williams, C (2004). If the evidence is so good – why doesn't anyone use them? A national survey of the use of computerized cognitive behaviour therapy. Behavioural and Cognitive Psychotherapy 32, 5765.
Wrigley, S, Jackson, H, Judd, F, Komiti, A (2005). Role of stigma and attitudes toward help-seeking from a general practitioner for mental health problems in a rural town. Australian and New Zealand Journal of Psychiatry 39, 514521.
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