Annual Review of Cybertherapy and Telemedicine 2012 3

B.K. Wiederhold and G. Riva (Eds.)

IOS Press, 2012
© 2012 Interactive Media Institute and IOS Press. All rights reserved.
doi:10.3233/978-1-61499-121-2-3

Guided Internet Treatment for Anxiety

Disorders. As Effective As Face-To-Face
Therapies?
Gerhard ANDERSSONa,1
a
Department of Behavioural Sciences and Learning, Linköping University and
Department of Clinical Neuroscience, Karolinska Institute, Sweden

Abstract. Introduction: Guided Internet-delivered treatments were developed in

the late 1990s and have since been tested in numerous controlled trials. While
promising, there are yet few direct comparisons between Internet treatments and
traditional face-to-face treatments. The aim of the present study is to present an
overview of the evidence in the field of anxiety disorders. Method: Studies were
located, including unpublished trials from our research group in Sweden. Results:
Results of direct comparative trials on panic disorder (n=3) and social anxiety
disorder (n=3) show equivalent outcomes. One study on specific phobia did not
show equivalent outcomes with an advantage for face-to-face treatment. However,
a systematic review by Cuijpers et al. (2010) found equivalent outcomes across
several self-help formats, suggesting that guided self-help overall can be as
affective as face-to-face treatments. Conclusion: Overall, there are still few large-
scale trials and statistical power is often limited. A preliminary conclusion is that
guided Internet treatment can be as effective as face-to-face treatments, but there is
a need to investigate moderators and mediators of the outcome.

Keywords.Guided internet-delivered cognitive behaviour therapy, panic disorder,

social anxiety disorder, specific phobia

Introduction

Using the internet to deliver evidence-based psychological treatments has a rather short
history butthere are now already numerous applications in which cognitive behavioural
therapy (CBT) has been transferred to the Internet [1]. There are various forms of
Internet-based CBT (ICBT) approaches, ranging from open access programs that are
unguided to guided ICBT programs that involve minimal therapist contact [2].
Evidence to date suggests that guided programs yield larger effects than unguided
treatments [3], but there are exceptions where unguided programs have been found to
be affective[4]. The aim of this paper is to review the literature in which guided ICBT
has been directly compared with traditional face-to-face delivered CBT within the same
studies in the field of anxiety disorders.

1
Corresponding Author: Gerhard Andersson, Department of Behavioural Sciences and Learning,
Linköping University, SE- 581 83 Linköping, Sweden. E-mail: Gerhard.Andersson@liu.se.
4 G. Andersson / Guided Internet Treatment for Anxiety Disorders

1. Method

1.1. Selection of studies and coding

Studies were located by means of literature searches on Medline and Psychological

Abstracts. Moreover, studies known to the author were included. Each study reviewed
is presented in terms of the within-group standardized mean difference (Cohen’s d),
where the difference between the average score at post treatment score was subtracted
from the pre-treatment score and divided by the pooled standard deviation. Between the
group effect sizes were calculated. Effect sizes of 0.8 are assumed to be large, while
effect sizes of 0.5 are moderate, and effect sizes of 0.2 are regarded as small [5].

2. Results

2.1. Panic disorder

To my knowledge there are three direct comparisons between live therapy and guided
ICBT for panic disorder. The first study was by Carlbring and co-workers in Sweden.
They conducted a randomized trial in which they compared 10 individual weekly
sessions of cognitive behaviour therapy for panic disorder with or without agoraphobia
with a 10-module guided self-help program on theInternet[6]. Composite within-group
effect sizes were high in both groups, while the between-group effect size was small
(Cohen’s d =0.16). A similar trial was conducted in Australia where the authors
compared their internet treatment with a standard face to face treatment and found
equivalent outcomes [7]. The authors found that 30.4% (14/46) of their Panic online
treatment participants reached the criteria of high end-state functioning, with the
corresponding figure in the face-to-face group being 27.5% (11/40). Between group
effect sizes were small across all measures. For example on the clinician rated panic
disorder rating the between group Cohen’s d effect size was d=0.15. The latest and
largest controlled trial on live versus guided ICBT for panic disorder was conducted by
a Swedish group [8]. A total of 113 consecutive patients were randomly assigned to 10
weeks of either guided ICBT (n = 53) or group CBT (n = 60).For the internet treatment
the within-group effect size (pre-post) on the panic disorder severity scale, PDSS[9]
was Cohen's d = 1.73, and for the group treatment it was d = 1.63. Between group
effect sizes were low (on the PDSS it was d = 0.00), and treatment effects were
maintained at 6-months follow-up.

2.2 Social anxiety disorder

For social anxiety disorder (SAD), also referred to as social phobia, there are at least
three randomized controlled trials directly comparing guided ICBT with face-to-face
treatment. The first study published was conducted by a research group in Spain[10].
While they focused on fear of public speaking all had a diagnosis of social phobia.
There were three groups in the trial with 62 participants being randomized to ICBT, 36
to live therapy and 29 to a waiting list group. Results showed improvements in both
treatment groups with effects being sustained in the 12-month follow-up. The between
group effect sizes were small between the two active treatments. In a small study a
 G. Andersson / Guided Internet Treatment for Anxiety Disorders 5

group of Australian researchers compared guided ICBT (n=23) with face-to-face CBT
(n=14) [11]. They found large within group effects and no difference between the two
conditions. For example, on the social interaction anxiety scale [12] the between group
difference was d=0.00. The most recent study on live versus ICBT for SAD was
conducted by a Swedish group and this is the largest study to date on SAD [13]. They
included and randomized participants to either guided ICBT (n = 64) orto
cognitivebehavioural group therapy (CBGT) (n = 62).Results showed that both groups
made large improvements, which were sustained at six months follow-up. At post-
treatment and follow-up respectively, Cohen’s d betweengroup effect sizes were 0.41
and 0.36 favouringICBT, which was not significant.

2.3. Specific phobia

There is to my knowledge only one small controlled small study on ICBT versus live
treatment of specific phobia [14], which was conducted in Sweden. The authors
compared guided ICBT with one session of live-exposure treatment in a sample of 30
spider-phobic patients. The Internet treatment consisted of five weekly text modules,
which were presented on a web page, a video in which exposure was modelled, and
support provided via Internet. The live-exposure treatment was delivered in a 3-hr
session following a brief orientation session. Results showed that the groups did not
differ at post treatment or follow-up, with the exception of the proportion showing
clinically significant change on abehavioural approach test. At post treatment 46.2% of
the Internet group and 85.7% in the live-exposure group achieved this change. At
follow-up the corresponding figures were 66.7% for the Internet group and 72.7% for
the live treatment. Within-group effect sizes for the spider phobia questionnaire were
large (d=1.84 and 2.58 for the internet and live-exposure groups, respectively, at post
treatment).

3. Discussion

There are now an increasing number of studies showing that guided self-help can be as
effective as face-to-face CBT [15]. In this review a selection of studies dealing with
specific anxiety disorders were described and the overall result suggests that guided
ICBT is as effective as face-to-face CBT. The possible exception is the small trial on
spider phobia.
Most of the trials reviewed here were small and have insufficient power to detect
small effect sizes. Indeed, testing for equivalence of treatment usually require very
large samples [16], which goes far beyond the resources for psychotherapy researchers.
Even if large studies on ICBT are starting to appear, for example on SAD [17] and
irritable bowel syndrome [18], there are no trials with more than 200 participants where
face-to-face and guided ICBT has been studied.
There are limitations with this review. First, there are unpublished trials which
could not be included on conditions like generalised anxiety disorder. Second, the face-
to-face comparisons have varied with some comparing guided ICBT with group
treatment and some with individual treatments. Third, I did not include a review on the
cost-effectiveness of ICBT versus face-to-face treatment. There is some evidence to
suggest that guided ICBT is more cost-effective [19], but more research is needed.
6 G. Andersson / Guided Internet Treatment for Anxiety Disorders

Finally, most of the studies have been conducted in specialist settings and in real life
most patients with anxiety disorders are treated in primary care settings.
In spite of these limitations, there is now emerging evidence that guided ICBT can
serve as a complement and sometimes replacement for face-to-face CBT. There are
several advantages to ICBT such as freedom to work from home outside of office hours
and also not needing to travel to clinics for treatment sessions. A major challenge is
dissemination of ICBT and also to develop reliable diagnostic procedures. Finally,
research should investigate moderators and mediators of outcome since there may be
differences between what makes ICBT and face-to-face treatments work [20].

References

[1] Andersson G. 2009. Using the internet to provide cognitive behaviour therapy. Behav Res Ther
47:175-180.
[2] Barak A, Klein B, Proudfoot JG. 2009. Defining Internet-supported therapeutic interventions. Ann
Behav Med 38:4–17.
[3] 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. Psychol Med 37:319-
328.
[4] Berger T, Caspar F, Richardson R, Kneubühler B, Sutter D, Andersson G. 2011. Internet-based
treatment of social phobia: A randomized controlled trial comparing unguided with two types of
guided self-help. Behav Res Ther 48:158-169.
[5] Cohen J. 1988. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence
Erlbaum Associates.
[6] Carlbring P, Nilsson-Ihrfelt E, Waara J, Kollenstam C, Buhrman M, Kaldo V, Söderberg M,
Ekselius L, Andersson G. 2005. Treatment of panic disorder: Live therapy vs. self-help via
Internet. Behav Res Ther 43:1321-1333.
[7] 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? J Anx
Disord 22:1273-1284.
[8] Bergström J, Andersson G, Ljótsson B, Rück C, Andréewitch 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.
[9] Shear MK, Brown TA, Barlow DH, Money R, Sholomskas DE, Woods SW, Gorman JM, Papp
LA. 1997. Multicenter collaborative panic disorder severity scale. Am J Psychiatry 154:1571-5.
[10] Botella C, Gallego MJ, Garcia-Palacios A, Guillen V, Banos RM, Quero S, Alcaniz M. 2010. An
Internet-based self-help treatment for fear of public speaking: a controlled trial. Cyberpsychol
Behav Soc Netw 13:407-21.
[11] Andrews G, Davies M, Titov N. 2011. Effectiveness randomized controlled trial of face to face
versus Internet cognitive behaviour therapy for social phobia. Aust N Z J Psychiatry 45:337-40.
[12] Mattick RP, Clarke JC. 1998. Development and validation of measures of social phobia scrutiny
fear and social interaction anxiety. Behav Res Ther 36:455-70.
[13] Hedman E, Andersson G, Ljótsson B, Andersson E, Rück C, Mörtberg 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(3):e18001.
[14] Andersson G, Waara J, Jonsson U, Malmaeus F, Carlbring P, Öst L-G. 2009. Internet-based self-
help vs. one-session exposure in the treatment of spider phobia: a randomized controlled trial.
Cogn Behav Ther 38:114-120.
[15] Cuijpers P, Donker T, van Straten A, Andersson G. 2010. Is guided self-help as effective as face-
to-face psychotherapy for depression and anxiety disorders? A meta-analysis of comparative
outcome studies. Psychol Med 40:1943-1957.
[16] Piaggio G, Elbourne DR, Altman DG, Pocock SJ, Evans SJ. 2006. Reporting of noninferiority and
equivalence randomized trials: an extension of the CONSORT statement. JAMA 295:1152-60.
[17] Andersson G, Carlbring P, Furmark T, on behalf of the SOFIE Research Group. 2012. Therapist
experience and knowledge acquisition in Internet-delivered CBT for social anxiety disorder: A
randomized controlled trial. PloS ONE 7(5):e37411.
 G. Andersson / Guided Internet Treatment for Anxiety Disorders 7

[18] Ljótsson B, Hedman E, Andersson E, Hesser H, Lindfors P, Hursti T, Rydh S, Rück C, Lindefors
N, Andersson G. 2011. Internet-delivered exposure based treatment vs. stress management for
irritable bowel syndrome: a randomized trial. Am J Gastroenterol 106:1481-1491.
[19] Hedman E, Andersson E, Ljótsson B, Andersson G, Rück 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. Behav Res Ther 49:729-736.
[20] Andersson G, Carlbring P, Berger T, Almlöv J, Cuijpers P. 2009. What makes Internet therapy
work? Cogn Behav Ther 38(S1):55-60.