Skip to main content Accessibility help

Effects of a transdiagnostic unguided Internet intervention (‘velibra’) for anxiety disorders in primary care: results of a randomized controlled trial

  • T. Berger (a1), A. Urech (a1), T. Krieger (a1), T. Stolz (a1), A. Schulz (a1), A. Vincent (a1), C. T. Moser (a1), S. Moritz (a2) and B. Meyer (a3) (a4)...



Internet-based cognitive–behavioural treatment (ICBT) for anxiety disorders has shown some promise, but no study has yet examined unguided ICBT in primary care. This randomized controlled trial (RCT) investigated whether a transdiagnostic, unguided ICBT programme for anxiety disorders is effective in primary care settings, after a face-to-face consultation with a physician (MD). We hypothesized that care as usual (CAU) plus unguided ICBT would be superior to CAU in reducing anxiety and related symptoms among patients with social anxiety disorder (SAD), panic disorder with or without agoraphobia (PDA) and/or generalized anxiety disorder (GAD).


Adults (n = 139) with at least one of these anxiety disorders, as reported by their MD and confirmed by a structured diagnostic interview, were randomized. Unguided ICBT was provided by a novel transdiagnostic ICBT programme (‘velibra’). Primary outcomes were generic measures, such as anxiety and depression symptom severity, and diagnostic status at post-treatment (9 weeks). Secondary outcomes included anxiety disorder-specific measures, quality of life, treatment adherence, satisfaction, and general psychiatric symptomatology at follow-up (6 months after randomization).


CAU plus unguided ICBT was more effective than CAU at post-treatment, with small to medium between-group effect sizes on primary (Cohen's d = 0.41–0.47) and secondary (Cohen's d = 0.16–0.61) outcomes. Treatment gains were maintained at follow-up. In the treatment group, 28.2% of those with a SAD diagnosis, 38.3% with a PDA diagnosis, and 44.8% with a GAD diagnosis at pretreatment no longer fulfilled diagnostic criteria at post-treatment.


The unguided ICBT intervention examined is effective for anxiety disorders when delivered in primary care.


Corresponding author

*Address for correspondence: T. Berger, Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland. (Email:


Hide All
Andersson, G (2016). Internet-delivered psychological treatments. Annual Review of Clinical Psychology 12, 157179.
Andrews, G, Davies, M, Titov, N (2011). Effectiveness randomised controlled trial of face to face versus Internet cognitive behaviour therapy for social phobia. Australian and New Zealand Journal of Psychiatry 45, 337340.
Attkisson, CC, Zwick, R (1982). The Client Satisfaction Questionnaire. Psychometric properties and correlations with service utilization and psychotherapy outcome. Evaluation and Program Planning 5, 233237.
Aydos, L, Titov, N, Andrews, G (2009). Shyness 5: the clinical effectiveness of Internet-based clinician-assisted treatment of social phobia. Australasian Psychiatry 17, 488492.
Baldwin, DS, Anderson, IM, Nutt, DJ, Bandelow, B, Bond, A, Davidson, JR, den Boer, JA, Fineberg, NA, Knapp, M, Scott, J, Wittchen, HU; British Association for Psychopharmacology (2005). Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 19, 567596.
Ball, MJ, Lillis, J (2001). E-health: transforming the physician/patient relationship. International Journal of Medical Informatics 61, 110.
Barlow, DH, Allen, LB, Choate, ML (2004). Toward a unified treatment for emotional disorders. Behavior Therapy 35, 205230.
Barlow, DH, Farchione, TJ, Fairholme, CP, Ellard, KK, Boisseau, CL, Allen, LB, May, JTE (2010). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide. Oxford University Press: New York.
Bateson, M, Brilot, B, Nettle, D (2011). Anxiety: an evolutionary approach. Canadian Journal of Psychiatry 56, 707715.
Beard, C, Amir, N (2008). A multi-session interpretation modification program: changes in interpretation and social anxiety symptoms. Behaviour Research and Therapy 46, 11351141.
Beck, AT, Epstein, N, Brown, G, Steer, RA (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology 56, 893897.
Beck, AT, Steer, RA, Brown, GK (1996). BDI-II, Beck Depression Inventory: Manual. Harcourt Brace: Boston, MA.
Berger, T, Boettcher, J, Caspar, F (2014). Internet-based guided self-help for several anxiety disorders: a randomized controlled trial comparing a tailored with a standardized disorder-specific approach. Psychotherapy (Chicago) 51, 207219.
Berger, T, Caspar, F, Richardson, R, Kneubuhler, B, Sutter, D, Andersson, G (2011 a). Internet-based treatment of social phobia: a randomised controlled trial comparing unguided with two types of guided self-help. Behaviour Research and Therapy 49, 158169.
Berger, T, Hammerli, K, Gubser, N, Andersson, G, Caspar, F (2011 b). Internet-based treatment of depression: a randomised controlled trial comparing guided with unguided self-help. Cognitive Behaviour Therapy 40, 251266.
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.
Bijl, RV, Ravelli, A (2000). Psychiatric morbidity, service use, and need for care in the general population: results of The Netherlands Mental Health Survey and Incidence Study. American Journal of Public Health 90, 602607.
Butler, AC, Chapman, JE, Forman, EM, Beck, AT (2006). The empirical status of cognitive–behavioural therapy: a review of meta-analyses. Clinical Psychology Review 26, 1731.
Carlbring, P, Maurin, L, Torngren, C, Linna, E, Eriksson, T, Sparthan, E, Straat, M, Marquez von Hage, C, Bergman-Nordgren, L, Andersson, G (2011). Individually-tailored, Internet-based treatment for anxiety disorders: a randomised controlled trial. Behaviour Research and Therapy 49, 1824.
Carver, CS (2006). Approach, avoidance, and the self-regulation of affect and action. Motivation and Emotion 30, 105110.
Chambless, DL, Caputo, GC, Bright, P, Gallagher, R (1984). Assessment of fear of fear in agoraphobics: the Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology 52, 10901097.
Chambless, DL, Caputo, GC, Jasin, S, Gracely, EJ, Williams, C (1985). The Mobility Inventory for Agoraphobia. Behaviour Research and Therapy 23, 3544.
Dear, BF, Staples, LG, Terides, MD, Karin, E, Zou, J, Johnston, L, Gandy, M, Fogliati, VJ, Wootton, BM, McEvoy, PM, Titov, N (2015). Transdiagnostic versus disorder-specific and clinician-guided versus self-guided Internet-delivered treatment for generalized anxiety disorder and comorbid disorders: a randomized controlled trial. Journal of Anxiety Disorders 36, 6377.
Derogatis, LR (1993). Brief Symptom Inventory (BSI): Administration, Scoring and Procedures Manual. National Computer Systems: Minneapolis,MN.
El Alaoui, S, Hedman, E, Kaldo, V, Hesser, H, Kraepelien, M, Andersson, E, Ruck, C, Andersson, G, Ljotsson, B, Lindefors, N (2015). Effectiveness of Internet-based cognitive–behavior therapy for social anxiety disorder in clinical psychiatry. Journal of Consulting and Clinical Psychology 83, 902914.
Emmelkamp, PMG, David, D, Beckers, T, Muris, P, Cuijpers, P, Lutz, W, Andersson, G, Araya, R, Banos Rivera, RM, Barkham, M, Berking, M, Berger, T, Botella, C, Carlbring, P, Colom, F, Essau, C, Hermans, D, Hofmann, SG, Knappe, S, Ollendick, TH, Raes, F, Rief, W, Riper, H, Van Der Oord, S, Vervliet, B (2014). Advancing psychotherapy and evidence-based psychological interventions. International Journal of Methods in Psychiatric Research 23, 5891.
First, MB, Spitzer, RL, Gibbon, M, Williams, JBW (1995). Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) . American Psychiatric Press: Washington, DC.
Fogliati, VJ, Dear, BF, Staples, LG, Terides, MD, Sheehan, J, Johnston, L, Kayrouz, R, Dear, R, McEvoy, PM, Titov, N (2016). Disorder-specific versus transdiagnostic and clinician-guided versus self-guided Internet-delivered treatment for panic disorder and comorbid disorders: a randomized controlled trial. Journal of Anxiety Disorders 39, 88102.
Grawe, K (2007). Neuropsychotherapy: How the Neurosciences Inform Effective Psychotherapy. Erlbaum: Mahwah, NJ.
Gueorguieva, R, Krystal, JH (2004). Move over ANOVA: progress in analyzing repeated-measures data and its reflection in papers published in the Archives of General Psychiatry. Archives of General Psychiatry 61, 310317.
Hedman, E, Andersson, G, Ljótsson, B, Andersson, E, Ruck, C, Mortberg, E, Lindefors, N (2011). Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: a randomized controlled non-inferiority trial. PLoS ONE 6, e18001.
Hedman, E, Ljotsson, B, Ruck, C, Bergstrom, J, Andersson, G, Kaldo, V, Jansson, L, Andersson, E, Andersson, E, Blom, K, El Alaoui, S, Falk, L, Ivarsson, J, Nasri, B, Rydh, S, Lindefors, N (2013). Effectiveness of Internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care. Acta Psychiatrica Scandinavica 128, 457467.
Issakidis, C, Sanderson, K, Corry, J, Andrews, G, Lapsley, H (2004). Modelling the population cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders. Psychological Medicine 34, 1935.
Katz, SJ, Kessler, RC, Lin, E, Wells, KB (1998). Medication management of depression in the United States and Ontario. Journal of General Internal Medicine 13, 7785.
Kessler, D, Lloyd, K, Lewis, G, Gray, DP (1999). Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care. BMJ 318, 436439.
Kessler, RC, McGonagle, KA, Zhao, S, Nelson, CB, Hughes, M, Eshleman, S, Wittchen, HU, Kendler, KS (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry 51, 819.
Klein, JP, Berger, T, Schröder, J, Späth, C, Meyer, B, Caspar, F, Lutz, W, Arndt, A, Greiner, W, Gräfe, V, Hautzinger, M, Fuhr, K, Rose, M, Nolte, S, Löwe, B, Andersson, G, Vettorazzi, E, Moritz, S, Hohagen, F (2016). Effects of a psychological Internet intervention in the treatment of mild to moderate depressive symptoms: results of the EVIDENT study, a randomized controlled trial. Psychotherapy and Psychosomatics 85, 218228.
Kroenke, K, Spitzer, RL, Williams, JB, Monahan, PO, Löwe, B (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine 146, 317325.
Lovibond, SH, Lovibond, PF (1995). Manual for the Depression Anxiety Stress Scales. Psychology Foundation: Sydney.
Löwe, B, Gräfe, K, Zipfel, S, Spitzer, RL, Herrmann-Lingen, C, Witte, S, Herzog, W (2003). Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians’ diagnosis. Journal of Psychosomatic Research 55, 515519.
Mattick, RP, Clarke, JC (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy 20, 323.
McManus, F, Shafran, R, Cooper, Z (2010). What does a transdiagnostic approach have to offer the treatment of anxiety disorders? British Journal of Clinical Psychology 49, 491505.
Mendlowicz, MV, Stein, MB (2000). Quality of life in individuals with anxiety disorders. American Journal of Psychiatry 157, 669682.
Meyer, B, Berger, T, Caspar, F, Beevers, CG, Andersson, G, Weiss, M (2009). Effectiveness of a novel integrative online treatment for depression (Deprexis): randomized controlled trial. Journal of Medical Internet Research 11, e15.
Meyer, TJ, Miller, ML, Metzger, RL, Borkovec, TD (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy 28, 487495.
Mogg, K, Bradley, BP (1998). A cognitive–motivational analysis of anxiety. Behaviour Research and Therapy 36, 809848.
Moritz, S, Schilling, L, Hauschildt, M, Schroder, J, Treszl, A (2012). A randomized controlled trial of Internet-based therapy in depression. Behaviour Research and Therapy 50, 513521.
Newby, JM, Mackenzie, A, Williams, AD, McIntyre, K, Watts, S, Wong, N, Andrews, G (2013). Internet cognitive behavioural therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care. Psychological Medicine 43, 26352648.
Newby, JM, Mewton, L, Williams, AD, Andrews, G (2014). Effectiveness of transdiagnostic Internet cognitive behavioural treatment for mixed anxiety and depression in primary care. Journal of Affective Disorders 165, 4552.
Nordgren, LB, Hedman, E, Etienne, J, Bodin, J, Kadowaki, A, Eriksson, S, Lindkvist, E, Andersson, G, Carlbring, P (2014). Effectiveness and cost-effectiveness of individually tailored Internet-delivered cognitive behavior therapy for anxiety disorders in a primary care population: a randomized controlled trial. Behaviour Research and Therapy 59, 111.
Regier, DA, Narrow, WE, Rae, DS, Manderscheid, RW, Locke, BZ, Goodwin, FK (1993). The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry 50, 8594.
Richards, D, Richardson, T (2012). Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clinical Psychology Review 32, 329342.
Ruwaard, J, Lange, A, Schrieken, B, Dolan, CV, Emmelkamp, P (2012). The effectiveness of online cognitive behavioural treatment in routine clinical practice. PLOS ONE 7, e40089.
Spek, V, Cuijpers, P, Nyklicek, I, Riper, H, Keyzer, J, Pop, V (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychological Medicine 37, 319328.
Stein, MB, Sherbourne, CD, Craske, MG, Means-Christensen, A, Bystritsky, A, Katon, W, Sullivan, G, Roy-Byrne, PP (2004). Quality of care for primary care patients with anxiety disorders. American Journal of Psychiatry 161, 22302237.
Titov, N, Andrews, G, Johnston, L, Robinson, E, Spence, J (2010). Transdiagnostic Internet treatment for anxiety disorders: a randomised controlled trial. Behaviour Research and Therapy 48, 890899.
Titov, N, Dear, BF, Staples, LG, Bennett-Levy, J, Klein, B, Rapee, RM, Shann, C, Richards, D, Andersson, G, Ritterband, L, Purtell, C, Bezuidenhout, G, Johnston, L, Nielssen, OB (2015). MindSpot clinic: an accessible, efficient, and effective online treatment service for anxiety and depression. Psychiatric Services 66, 10431050.
van Schaik, DJ, Klijn, AF, van Hout, HP, van Marwijk, HW, Beekman, AT, de Haan, M, van Dyck, R (2004). Patients’ preferences in the treatment of depressive disorder in primary care. General Hospital Psychiatry 26, 184189.
Waller, R, Gilbody, S (2009). Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence. Psychological Medicine 39, 705712.
Wang, PS, Aguilar-Gaxiola, S, Alonso, J, Angermeyer, MC, Borges, G, Bromet, EJ, Bruffaerts, R, de Girolamo, G, de Graaf, R, Gureje, O, Haro, JM, Karam, EG, Kessler, RC, Kovess, V, Lane, MC, Lee, S, Levinson, D, Ono, Y, Petukhova, M, Posada-Villa, J, Seedat, S, Wells, JE (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 370, 841850.
Wang, PS, Demler, O, Kessler, RC (2002). Adequacy of treatment for serious mental illness in the United States. American Journal of Public Health 92, 9298.
Ware, J Jr., Kosinski, M, Keller, SD (1996). A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care 34, 220233.
Weiller, E, Bisserbe, JC, Maier, W, Lecrubier, Y (1998). Prevalence and recognition of anxiety syndromes in five European primary care settings. A report from the WHO Study on Psychological Problems in General Health Care. British Journal of Psychiatry 173, 1823.
Williams, AD, Andrews, G (2013). The effectiveness of Internet cognitive behavioural therapy (iCBT) for depression in primary care: a quality assurance study. PLOS ONE 8, e57447.


Related content

Powered by UNSILO

Effects of a transdiagnostic unguided Internet intervention (‘velibra’) for anxiety disorders in primary care: results of a randomized controlled trial

  • T. Berger (a1), A. Urech (a1), T. Krieger (a1), T. Stolz (a1), A. Schulz (a1), A. Vincent (a1), C. T. Moser (a1), S. Moritz (a2) and B. Meyer (a3) (a4)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.