Journal of Psychotherapy Integration

© 2020 American Psychological Association 2020, Vol. 30, No. 2, 188 –207
ISSN: 1053-0479 http://dx.doi.org/10.1037/int0000217

eHealth to Redress Psychotherapy Access Barriers Both New and

Old: A Review of Reviews and Meta-Analyses

Charles B. Bennett Anna C. Sever

and Camilo J. Ruggero Texas Woman’s University
University of North Texas
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Lamia Yanouri
This document is copyrighted by the American Psychological Association or one of its allied publishers.

University of North Texas

COVID-19 public health proscriptions have created severe if temporary, barriers to

accessing face-to-face psychotherapy across the world. As disruptive as these are, they
come on top of more long-standing barriers to getting psychotherapy faced by millions
in need. eHealth interventions offer an avenue for redressing both types of barriers, but
evidence about their efficacy remains a concern. This review of reviews and meta-
analyses outlines the strength of evidence and effect sizes for guided and unguided
approaches to eHealth interventions targeting common problems in psychotherapy (i.e.,
depression, anxiety, substance abuse, and general well-being). After a comprehensive
search, a total of 65 reviews and meta-analyses were identified and evaluated for
treatment effects, moderators, acceptability, and attrition. Findings show eHealth is
acceptable and effective at improving depression, anxiety, alcohol-related problems,
and general mental health compared to waitlist, and can even offer benefit as an adjunct
to traditional psychotherapy. Mixed evidence was found when comparing guided
versus unguided interventions as well as the strength of benefit relative to active
controls and the degree to which these approaches are associated with attrition. eHealth
interventions have the potential to be an effective tool for redressing both new and old
psychotherapy access barriers.

Keywords: eHealth, Internet intervention, smartphone applications, telehealth, telebe-

havioral health

As of Spring 2020, more than half the
world’s population has been advised to shelter
at home and practice physical distancing due to
COVID-19, disrupting access to care across
health systems (e.g., Centers for Disease Con-
trol and Prevention, 2020). These proscriptions
threaten delivery of typical, face-to-face psy-
chotherapy (Travers, 2020), forcing psychother-
apists to find alternatives, including telehealth
(DeAngelis, 2020).
As serious and acute as the disruption from
COVID-19, it comes on top of another long-
simmering crisis: the enduring lack of access to
traditional psychotherapeutic care faced by mil-
lions. As just one example from a developed
country, a National Survey on Drug Use and

Editor’s Note. Associate Editor Ueli Kramer served as
the action editor for this article. This article received rapid
review due to the time-sensitive nature of the content, but
our standard high-quality peer review process was upheld.
Charles B. Bennett and Camilo J. Ruggero, Department of
Psychology, University of North Texas; Anna C. Sever, Depart-
ment of Psychology, Texas Woman’s University; Lamia
Yanouri, Department of Psychology, University of North Texas.
Charles B. Bennett and Camilo J. Ruggero share joint first
authorship. Support for this article was provided in part by an
award from the U.S. Health Resources and Services Admin-
istration (1D40HP33372-01-00) and an award from the Texas
Higher Education Coordinating Board (MHGP).
Correspondence concerning this article should be ad-
dressed to Camilo J. Ruggero, Department of Psychology,
University of North Texas, 1155 Union Circle Number
311280, Denton, TX 76203. E-mail: Camilo.Ruggero@unt
.edu

188
 EHEALTH TO REDRESS ACCESS BARRIERS
Health estimated that less than half of the 44.7
million people in the United States with a mental
illness received mental health services in the past
year (and most of it not in the form of psycho-
therapy; Park-Lee, Lipari, Hedden, Kroutil, &
Porter, 2017). Another estimate suggested the
United States would need close to 20,000 more
psychologists simply to meet the unmet mental
health needs of its population (Markit, 2018), with
rates of utilization and access even lower in many
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other countries around the world (Demyttenaere et
This document is copyrighted by the American Psychological Association or one of its allied publishers.
al., 2004). Moreover, the problem of restricted
access to care is not uniform across societies, most
often harming more marginalized or poorer
groups (e.g., Ojeda & McGuire, 2006; Cooper et
al., 2013).
In the face of this existing crisis, COVID-19
threatens to exacerbate long-standing dispar-
ities in health and access. For example, anec-
dotal accounts across the world are showing
more racial/ethnic minorities are bearing the
brunt of the initial impact (Baker & Snyder,
2020; Intensive Care National Audit and Re-
search Centre, 2020; Milwaukee County,
2020). COVID-19 represents a significant
stressor even beyond its physical toll and is
expected to lead to an increased risk for psy-
chological disorders (Jalloh et al., 2018;
Xiang et al., 2020). Taken together, the in-
creased physical and psychological toll from
COVID-19 will only accentuate and exacerbate
existing disparities in health and access to
health care, including access to psychotherapy.
eHealth Interventions to Redress New and
Old Access Barriers
COVID-19 has provoked a rethinking of tra-
ditional, face-to-face psychotherapeutic models
with the potential to powerfully redress new and
old barriers to access. The most immediate and
obvious response has been telepsychotherapy
(or telemental health or telebehavioral health) to
provide psychotherapy through videoconfer-
ence or phone (Luxton, Pruitt, & Osenbach,
2014). As important as this stopgap is, it re-
mains tied to one-on-one (or sometimes group)
interactions. They help redress some access bar-
riers (e.g., rural clients or those with transpor-
tation barriers), but shortages in the psychology
workforce mean these advances will fall short
of the scale required to address the tremendous
unmet needs around the world.
189
In contrast, eHealth intervention references a
broader suite of approaches that also rely heav-
ily on technology. Among them, a number of
psychotherapy approaches were developed to
be delivered in clinician assisted semiunguided
or entirely unguided modes, either through the
Internet on home computers or through smart-
phone-based applications (O’Connor, Mun-
nelly, Whelan, & McHugh, 2018; Sierra, Ruiz,
& Flórez, 2018). Widespread access to the Internet
and smartphones in many countries (e.g., ⬎90%
Internet and ⬎80% smartphone in the United
States; Pew Research Center, 2019a, 2019b)
make these approaches tenable for many who
have no other means of accessing care.
Typically, eHealth approaches to psychother-
apy come in a number of formats and ap-
proaches. For example, some have taken cogni-
tive– behavioral therapy (CBT) principles and
created self-directed approaches through the In-
ternet. Others have taken a similar approach
with acceptance and commitment therapy
(ACT), dialectical– behavioral therapy (DBT),
and mindfulness, to name a few of the most
frequently studied. Despite their promise, the
efficacy of these approaches needs to be estab-
lished and their integration with traditional psy-
chotherapy considered given that most mental
health applications on the market have sparse
efficacy evidence (Larsen et al., 2019).
Current Study
The present study reviewed the strength of
evidence for the efficacy of guided and un-
guided eHealth approaches to psychotherapy.
The review was limited to evidence related to
the most common conditions presenting for
treatment, namely depression, anxiety, sub-
stance use, and general well-being (cf. Kessler,
Chiu, Demler, Merikangas, & Walters, 2005).
Given extensive reviews in each of these areas,
we identified and synthesized findings from all
reviews and meta-analyses of eHealth interven-
tions for each of these four domains. The size of
effects was reviewed, as were potential moder-
ators, attrition rates, and acceptability. When
ambiguous, preference was given to the weight
of meta-analytic studies over qualitative re-
views. Finally, we discuss some clinical take-
aways based on our review.
 190 BENNETT, RUGGERO, SEVER, AND YANOURI
Method
Study Criteria and Selection
A search of reviews and meta-analyses eval-
uating the effectiveness of web-based and app-
based interventions for four target conditions
(i.e., depression, anxiety, substance abuse and
general well-being) was completed in March
and April 2020. Articles were excluded for (a)
not being a review or a meta-analysis, (b) not
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evaluating the effectiveness of web-based or
This document is copyrighted by the American Psychological Association or one of its allied publishers.
app-based interventions, (c) not analyzing
eHealth interventions for general mental health,
anxiety, depression, or substances, or (d) not
being a peer reviewed article (e.g., books).
Figure 1. Literature review and study selection PRISMA chart.
The search followed PRISMA recommenda-
tions (see Figure 1; Moher, Liberati, Tetzlaff, &
Altman, 2009), and search terms (see Figure 1)
yielded 7,831 studies. In addition, “ancestor”
and “descendent” searches of all included arti-
cles were conducted. After application of exclu-
sion criteria, 97 articles were identified, but
closer examination removed 32 of them for not
meeting criteria. Overall then, 65 reviews and
meta-analyses were reported below.
Review Plan
First, the most common types of interven-
tions and study designs were reviewed to better
 EHEALTH TO REDRESS ACCESS BARRIERS
characterize the nature of the interventions. Sec-
ond, all reviews and meta-analyses were re-
viewed to excise or understand clinical outcome
effect sizes. For some articles, this included a
single outcome, whereas others reported multi-
ple ones. Whenever possible, numeric effect
sizes were extracted as Hedge’s g or Cohen’s d.
This review followed common conventions for
determining the size of an effect (i.e., small
effects around d ⫽ 0.20, medium effects around
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d ⫽ 0.50, and large effects around d ⫽ 0.80).
This document is copyrighted by the American Psychological Association or one of its allied publishers.
When no effect size was available, effect size
was considered to be as reported by the authors
of the article. The lead author (Charles B. Ben-
nett) initially excised all effect sizes, but this
process was independently conducted and veri-
fied by two others (Camilo J. Ruggero and
Lamia Yanouri), with discrepancies resolved by
consensus. Third, moderators were also identi-
fied across studies, and those most commonly
studied reported. Fourth, articles were reviewed
for attrition rates, acceptability, and safety when
this was reported.
Results
Common Interventions in the Target
Reviews and Meta-Analyses
eHealth interventions varied with respect to de-
sign features, approaches and populations studied
(see Table 1). They included both web-based as
well as app for smartphone-based interventions,
although most of the studies reviewed were web-
based interventions. Many interventions reviewed
were designed to be self-guided, but they some-
times included some form of clinician contact,
such as messaging. These messages may have
been automated or manually sent (e.g., by a clini-
cian), and may have been for a variety of pur-
poses, such as encouraging the use of therapeutic
content or reminders to increase adherence. Al-
though not as intensive as traditional face-to-face
psychotherapy, this contact still resulted in the
intervention not being entirely unguided. Impor-
tantly, studies with even minor amount of profes-
sional support (e.g., single sessions or occasional
adherence reminders via e-mail) were considered
“guided” in this review given they increase clini-
cal workload. Across all randomized controlled
trials (RCTs) in the included meta-analyses, 241
featured a guided intervention and 274 were un-
guided. This relatively equal division was not con-
191
sistent across conditions. Specifically, those tar-
geting anxiety and depression were more often
guided in some way (139 guided vs. 69 unguided),
and those targeting substances were mostly un-
guided (21 guided vs. 123 unguided). RCTs fea-
turing interventions for general mental health
were evenly split (81 guided vs. 82 unguided).
Participants were recruited from a wide vari-
ety of populations. Samples were commonly
comprised of community, clinical, or under-
graduate participants. More specific populations
(e.g., caregivers, children and adolescents, and
employees) were also studied, though less fre-
quently. And, although it varied from study-to-
study, common comparison groups included in-
active controls (e.g., waitlist controls [WLCs])
and to a much lesser degree active controls
(e.g., attention).
RCTs within the included articles were reg-
ularly evaluated for quality. Generally, bias risk
was found to be low or unclear, with the excep-
tion of blinding. A majority of RCTs did not
feature a single or double blinded design. Given
comparison groups were commonly WLCs,
lack of blinding was to be expected.
Overall Effect Sizes for eHealth
Across the 65 meta-analyses and non-meta-
analytic reviews, there was evidence for small-
to-moderate effects of the eHealth interventions
relative to wait-list or other controls across dif-
ferent conditions. Table 1 summarizes the over-
all effects reported in the 37 meta-analyses, as
well as moderators reviewed. Findings indicate
eHealth can be viable approach to addressing
access barriers when traditional psychotherapy
or telepsychology is not available— either due
to COVID-19 restrictions or due to long-
standing barriers to access discussed earlier. We
review overall effects and moderators in more
detail according to condition.
Depression
One of the earliest depression-targeted
eHealth reviews found that web-based interven-
tions could produce improvements in symptoms
severity, comorbid conditions, and overall func-
tioning (Richardson, Stallard, & Velleman,
2010). Since this review, effects were more
thoroughly examined across 24 reviews and
meta-analyses. Interventions targeting depres-
sion have included ACT, behavioral activation,
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192
Table 1
Summary of eHealth Meta-Analyses Evaluating Clinical Outcome
Type of Psychological
Author intervention Description of samplesa approach(es) Guided vs. unguided Effect size [95% CI] Outcome Moderators

General mental health

Andersson et al. Web-based k ⫽ 7, Self-referred CBT N/A g ⫽ ⫺0.01 [⫺0.13, 0.12] Overall (⫺) Study quality
(2014) k ⫽ 1, Clinical
k ⫽ 5, Mixed
N ⫽ 1,053
Brown et al. (2016) Web-based k ⫽ 8, General ACT k ⫽ 7, Guided g ⫽ .18ⴱ [0.02, 0.34] Anxiety
k ⫽ 2, Clinical k ⫽ 3, Unguided g ⫽ .24ⴱ [0.04, 0.45] Depression
k ⫽ 2, Undergraduates g ⫽ .06 [⫺0.11, 0.23] Quality of life
N ⫽ Not reported; range: 38–236
(only three studies over 100
participants)
Carolan et al. (2017) Web-based k ⫽ 12, General CBT k ⫽ 10, Guided g ⫽ .37ⴱ [0.23, 0.50] Well-being (⫹) Increased engagement associated
with faster treatment gains
ⴱ
k ⫽ 10, Some psychological Other k ⫽ 11, Unguided g ⫽ .25 [0.09, 0.41] Work productivity (⫺) Psychological approach
distress
N ⫽ 5,260 (⫺) Guided vs. unguided
Harrer et al. (2019) Web-based k ⫽ 48, Undergraduates CBT k ⫽ 20, Guided g ⫽ .18ⴱ [0.08, 0.27] Depression (⫹) Inactive ⬎ active control
N ⫽ 10,583 Mindfulness k ⫽ 9, Reminders only g ⫽ .27ⴱ [0.13, 0.40] Anxiety (⫺) Psychological approach
Other k ⫽ 24, Unguided g ⫽ .20ⴱ [0.02, 0.38] Stress (⫺) Guided vs. unguided
g ⫽ .52ⴱ [0.22, 0.83] Eating Disorder (⫺) Treatment length
g ⫽ .41ⴱ [0.26, 0.56] Functioning (⫺) Compensation
g ⫽ .15 [⫺0.20, 0.50] Well-being
Sherifali et al. (2018) Web-based k ⫽ 13, Caregivers to adults with Not specified; Not reported d ⫽ .19 [⫺0.05, 0.43] Depression (⫹) Support increased effectiveness for
chronic conditions information or depression and overall health
N ⫽ Not reported education d ⫽ .01 [⫺0.19, 0.20] Coping
d ⫽ .29 [⫺0.11, 0.69] Overall mental health
d ⫽ ⫺0.01 [⫺0.51, 0.49] Quality of life
d ⫽ .35 [⫺2.00, 1.30] Overall health
d ⫽ .48ⴱ [0.22, 0.75] Stress/distress
BENNETT, RUGGERO, SEVER, AND YANOURI

d ⫽ .40ⴱ [0.22, 0.58] Anxiety

Spijkerman et al. Web-based k ⫽ 5, Somatic illness ACT k ⫽ 9, Guided g ⫽ .29ⴱ [0.13, 0.46] Depression (⫹) Guided ⬎ unguided
(2016) k ⫽ 3, Psychological illness Mindfulness k ⫽ 6, Unguided g ⫽ .22ⴱ [0.05, 0.39] Anxiety (⫺) ACT ⫽ mindfulness
k ⫽ 7, Nonclinical g ⫽ .23ⴱ [0.09, 0.38] Well-being (⫺) Study quality
N ⫽ 2,360 g ⫽ .32ⴱ [0.23, 0.42] Mindfulness
g ⫽ .51ⴱ [0.26, 0.75] Stress
Linardon (2019) App-based k ⫽ 17, General Mindfulness, acceptance, k ⫽ 12, Guided g ⫽ .29ⴱ [0.17, 0.41] Acceptance/Mindfulness (⫹) Inactive ⬎ active controls
k ⫽ 16, Varied and self-compassion k ⫽ 21, Unguided g ⫽ .32ⴱ [0.16, 0.48] Distress (⫺) Guided vs. unguided
N ⫽ Not specified g ⫽ .31ⴱ [0.07, 0.56] Self-compassion
Linardon et al., 2019 App-based k ⫽ 66, Clinical, at-risk, and CBT Unclear, but a g ⫽ .28ⴱ [0.21, 0.36] Depression (⫹) Guided ⬎ unguided
nonclinical majority were
N ⫽ Not reported ACT unguided g ⫽ .30ⴱ [0.20, 0.40] Anxiety (⫹) Use of reminders
Mindfulness g ⫽ .35ⴱ [0.21, 0.48] Stress (⫹) Longer duration ⬎ shorter
g ⫽ .35ⴱ [0.29, 0.42] Quality of life
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Table 1 (continued)
Type of Psychological
Author intervention Description of samplesa approach(es) Guided vs. unguided Effect size [95% CI] Outcome Moderators
ⴱ
O’Connor et al. Both k ⫽ 9, Somatic illness ACT k ⫽ 14, Guided g ⫽ .52 [0.26, 0.77] Depression (inactive control) (⫹) Inactive ⬎ active control
(2018) k ⫽ 7, Psychological illness MBCT k ⫽ 3, Unguided g ⫽ .29ⴱ [0.14, 0.44] Depression (active control) (⫺) Psychological approach
k ⫽ 5, Nonclinical CBASP k ⫽ 2, Unclear g ⫽ .32ⴱ [0.09, 0.56] Anxiety (inactive control)
N ⫽ 3,176 CBT g ⫽ .31ⴱ [0.07, 0.54] Anxiety (active control)
CMT g ⫽ .46ⴱ [0.00, 0.92] Quality of life (inactive control)
BA g ⫽ .31 [⫺0.31, 0.93] Quality of life (active control)
Stratton et al. (2017) Both k ⫽ 23, Paid employees CBT k ⫽ 9 Guided g ⫽ .24ⴱ [0.13, 0.35] Overall (⫹) Mindfulness ⬎ CBT
N ⫽ 6,442 Mindfulness k ⫽ 14 Unguided g ⫽ .25ⴱ Depression
Stress management g ⫽ .21 Anxiety
g ⫽ .30ⴱ Stress

Depression
Andersson et al. Web-based N ⫽ 2,446 CBT k ⫽ 7, Unguided d ⫽ .41ⴱ [0.29, 0.54] Depression (⫺) Comorbid anxiety
(2009) k ⫽ 12; 15 Comparisons, mostly k ⫽ 8, Guided (⫹) Guided ⬎ unguided
community adults
Andrews et al. Web-based k ⫽ 22, Clinical CBT k ⫽ 12, Guided g ⫽ .78ⴱ [0.59, 0.96] Depression
(2010) N ⫽ 1,746 k ⫽ 10, Unguided
Cowpertwait and Web-based k ⫽ 13, Community CBT k ⫽ 11, Guided g ⫽ .43ⴱ [0.29, 0.57] Depression (⫹) Used with reminders
Clarke (2013) k ⫽ 3, Primary care k ⫽ 7, Unguided g ⫽ .37ⴱ [0.13, 0.61] Well-being (⫹) Used with medication
k ⫽ 2, Secondary care (⫺) Control group
N ⫽ 2,946 (⫺) Guided vs. unguided
(⫺) Diagnosis vs. symptoms
Davies et al. (2014) Web-based k ⫽ 17, Undergraduates CBT k ⫽ 10 Guided d ⫽ .43ⴱ [0.22, 0.63] Depression (inactive control) (⫹) Inactive ⬎ active control
N ⫽ 1,795 k ⫽ 7 Unguided d ⫽ .73ⴱ [0.19, 1.27] Stress (inactive control)
d ⫽ .28 [0.20, 0.75] Depression (active control)
Ebert et al. (2015) Web-based k ⫽ 13, Children and adolescents CBT k ⫽ 11 Guided g ⫽ .56ⴱ [0.31, 0.82] Depression (⫺) Diagnosis vs. symptoms
N ⫽ 768 k ⫽ 2 Unguided (⫺) Children vs. adolescents
(⫺) Study Quality
Huguet et al. (2018) Web-based k ⫽ 9, Nonclinical BA (all) k ⫽ 9 Guided N/Ab N/Ab (⫺) Psychological approach
N ⫽ 2,157 PST
EHEALTH TO REDRESS ACCESS BARRIERS

ACT
Loughnan et al. Web-based k ⫽ 7, Perinatal women CBT k ⫽ 7 Guided g ⫽ .60ⴱ [0.43, 0.78] Depression
(2019) N ⫽ 595 BA
Newby et al. (2016) Web-based k ⫽ 17, Clinical Transdiagnostic CBT k ⫽ 16 Guided g ⫽ .84ⴱ [0.67, 1.02] Depression
N ⫽ 2,290 k ⫽ 1 Unguided
Pennant et al. (2015) Web-based k ⫽ 27, Children, adolescents, and CBT Unclear, but most d ⫽ .62ⴱ [0.11, 1.13] Depression (at risk)
young adults (includes both at- appear to include
risk and general population some professional
samples) guidance.
N ⫽ 3,389 ABM d ⫽ .15ⴱ [0.03, 0.26] Depression (general population)
CGM
PST
Self-monitoring
exposure
(table continues)
193
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194
Table 1 (continued)
Type of Psychological
Author intervention Description of samplesa approach(es) Guided vs. unguided Effect size [95% CI] Outcome Moderators

Richards and Web-based k ⫽ 16, General CBT k ⫽ 12 Guided d ⫽ .56ⴱ [0.41, 0.71] Depression (⫹) Guided ⬎ unguided
Richardson k ⫽ 3, Specific k ⫽ 9 Unguided (⫺) Control group
(2012) N ⫽ 10,583
Twomey and Web-based k ⫽ 12, University, community, CBT (MoodGYM) k ⫽ 12 Guided g ⫽ .36ⴱ [0.17, 0.56] Depression (⫹) Inactive ⬎ active control
O’Reilly (2017) and primary care
ⴱ
N ⫽ 5,745 g ⫽ .57 [0.20, 0.94] Anxiety (⫹) Adherence
g ⫽ .34 [⫺0.04, 0.68] Distress (⫺) Author vs. independent evaluation
Twomey et al. (2017) Web-based k ⫽ 8, Community CBT (Deprexis) k ⫽ 2 Guided g ⫽ .54ⴱ [0.39, 0.69] Depression (⫺) Guided vs. unguided
N ⫽ 2,402 k ⫽ 5 Unguided (⫺) Author vs. independent evaluation
Firth, Torous, App-based k ⫽ 16, Clinical CBT No specified g ⫽ .38ⴱ [0.24, 0.52] Depression (⫹) Inactive ⬎ active control
Nicholas, k ⫽ 1, General ACT (⫺) Feedback feature
Carney, k ⫽ 1, Veterans Mindfulness (⫺) Mood monitoring feature
Rosenbaum, et N ⫽ 3,414 Self-monitoring (⫺) CBT ⫽ mindfulness
al. (2017)
Cheng et al. (2019) Both k ⫽ 12, People with HIV/AIDS CBT k ⫽ 9 Guided d ⫽ .23ⴱ [0.06, 0.39] Depression (⫹) Recent publications ⬎ older
publications
N ⫽ 1,163 Interpersonal k ⫽ 3 Unguided d ⫽ .07 [⫺0.18, 0.31] Psychological symptoms (⫹) Fewer than 9 sessions
Coping d ⫽ .03 [⫺0.24, 0.17] Stress (⫹) Use of goal setting
MI d ⫽ .08 [0.17, 0.32] Coping (⫺) Guided vs. unguided
d ⫽ .68 [⫺0.28, 1.64] Interpersonal problems
d ⫽ .06 [⫺0.31, 0.19] Social relations
Deady et al. (2017) Both k ⫽ 6, General CBT k ⫽ 5 Guided d ⫽ .27ⴱ [0.15, 0.39] Overall (⫺) Psychological approach
k ⫽ 4, Undergraduates ACT k ⫽ 5 Unguided d ⫽ .25ⴱ [0.09, 0.41] Depression
N ⫽ 4,522
Josephine et al. Both k ⫽ 17, General CBT k ⫽ 14 Guided g ⫽ .90ⴱ [0.73, 1.07] Depression
(2017)
k ⫽ 2, Clinical Psychodynamic k ⫽ 5 Unguided g ⫽ .41ⴱ [0.12, 0.69] Anxiety
N ⫽ 1,650 BA
CBM
PST
ACT
BENNETT, RUGGERO, SEVER, AND YANOURI

Sierra et al. (2018) Both k ⫽ 6, Not specified ACT Not reported d ⫽ .61ⴱ [0.47, 0.75] Depression
N ⫽ 1,744 BA
CBT

Anxiety
Andrews et al. Web-based k ⫽ 22, Clinical CBT k ⫽ 12, Guided g ⫽ .92ⴱ [0.74, 1.09] Social Phobia
(2010) N ⫽ 1,746 k ⫽ 10, Unguided g ⫽ .83ⴱ [0.45, 1.21] Panic Disorder
g ⫽ 1.12ⴱ [0.76, 1.47] GAD
Davies et al. (2014) Web-based k ⫽ 17, Undergraduates CBT k ⫽ 10 Guided d ⫽ .56ⴱ [0.35, 0.77] Anxiety (inactive control) (⫹) Inactive ⬎ active control
N ⫽ 1,795 k ⫽ 7 Unguided d ⫽ .18 [⫺0.62, 0.98] Anxiety (active control)
Ebert et al. (2015) Web-based k ⫽ 13, Children and adolescents CBT k ⫽ 11 Guided g ⫽ .65ⴱ [0.40, 0.90] Anxiety (⫺) Diagnosis vs. symptoms
N ⫽ 768 k ⫽ 2 Unguided (⫺) Children vs. adolescents
ⴱ
Loughnan et al. Web-based k ⫽ 7, Perinatal women CBT k ⫽ 7 Guided g ⫽ .54 [0.24, 0.85] Anxiety
(2019) N ⫽ 595 BA
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Table 1 (continued)
Type of Psychological
Author intervention Description of samplesa approach(es) Guided vs. unguided Effect size [95% CI] Outcome Moderators
ⴱ
Newby et al. (2016) Web-based k ⫽ 17, Clinical Transdiagnostic CBT k ⫽ 16 Guided g ⫽ .78 [0.57, 0.99] Anxiety (⫺) Number of modules
N ⫽ 2,290 k ⫽ 1 Unguided (⫺) Control group
ⴱ
Pennant et al. (2015) Web-based k ⫽ 27, Children, adolescents, and CBT Unclear, but most d ⫽ .77 [0.09, 1.45] Anxiety (at risk)
young adults appear to include
N ⫽ 3,389 ABM some professional d ⫽ .15ⴱ [0.03, 0.26] Anxiety (general)
CGM guidance.
PST
Self-monitoring
exposure
Firth, Torous, App-based k ⫽ 3, Clinical CBT k ⫽ 1 Guided g ⫽ .33ⴱ [0.17, 0.48] Anxiety (⫺) Control group
Nicholas, k ⫽ 4, General ACT k ⫽ 8 Unguided (⫺) Comorbid physical illness
Carney, k ⫽ 1, Nurses BA (⫺) Trauma history
Rosenbaum, et N ⫽ 1,837 PST (⫺) Comorbid depression
al. (2017)
Positive psychology (⫺) General stress
Deady et al. (2017) Both k ⫽ 6, General CBT k ⫽ 5 Guided d ⫽ .27ⴱ [0.15, 0.39] Overall
k ⫽ 4, Undergraduates ACT k ⫽ 5 Unguided d ⫽ .31ⴱ [0.10, 0.52] Anxiety
N ⫽ 4,522
Domhardt et al. Both k ⫽ 34, mostly community CBT Unclear d ⫽ 1.67ⴱ [0.42, 2.93] Anxiety (active control) (⫹) Guided ⬎ unguided
(2019) N ⫽ 3,724 Psychodynamic d ⫽ .69ⴱ [0.40, 0.98] Anxiety (peer support) (⫺) Psychological approach
Interpersonal (⫺) Transdiagnostic vs. disorder
specific
(⫺) eHealth vs. eHealth as adjunct

Alcohol
Donoghue et al. Web-based k ⫽ 17, Undergraduates and CBT Not reported d ⫽ 2.67ⴱ Alcohol per week (⬍3 months) (⫹) Follow-up length
(2014) community
ⴱ
N ⫽ 10,021 MI d ⫽ 2.34 Alcohol per week (3–6 months)
Other/Unclear d ⫽ 2.74ⴱ Alcohol per week (6–12
EHEALTH TO REDRESS ACCESS BARRIERS

months)
d ⫽ .82 Alcohol per week (ⱖ12
months)
Dotson et al. (2015) Web-based k ⫽ 8, Undergraduates PNF k ⫽ 8 Unguided d ⫽ .29ⴱ [0.16, 0.42] Drinks per week (GNF) (⫺) Type of feedback
N ⫽ 2,050 d ⫽ .28ⴱ [0.12, 0.45] Drinks per week (GSP)
d ⫽ .16ⴱ [0.04, 0.28] Negative consequences
Riper et al. (2011) Web-based k ⫽ 9, Undergraduate PNF k ⫽ 9 Unguided g ⫽ .44ⴱ [0.29, 0.50] Alcohol use (⫺) Use of feedback
N ⫽ 1,553 CBT (⫺) Control group
MI
BSC
Rooke et al. (2010) Web-based k ⫽ 42, Nonclinical Not specified Unclear d ⫽ .22ⴱ [0.14, 0.29] Alcohol use
N ⫽ 10,632
(table continues)
195
 This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

196

Table 1 (continued)
Type of Psychological
Author intervention Description of samplesa approach(es) Guided vs. unguided Effect size [95% CI] Outcome Moderators

Black et al. (2016) Both k ⫽ 76, University and heavy drinkers MI k ⫽ 7 Guided g ⫽ .31ⴱ [0.18, 0.43] Total quantity (⫹) Guided ⬎ unguided
N ⫽ Not reported Other k ⫽ 69 Unguided g ⫽ .18ⴱ [0.09, 0.27] Average quantity (⫹) Inclusion of normative information
g ⫽ .19ⴱ [0.07, 0.31] Peak quantity (⫹) Use of feedback
g ⫽ .16ⴱ [0.04, 0.28] Heaving episodic drinking (⫹) Use of reminders
g ⫽ .06 [⫺0.22, 0.35] Frequency (⫹) Women ⬎ men
Prosser et al. (2018) Both k ⫽ 23, Undergraduates PF k ⫽ 23 Unguided d ⫽ .15ⴱ [0.09, 0.21] Drinks per week (⫹) Use of feedback
N ⫽ 7,614 (⫺) Risk status
(⫺) Publication year

Smoking cessation
Rooke et al. (2010) Web-based k ⫽ 42, Nonclinical Not specified Unclear d ⫽ .14ⴱ [0.06, 0.23] Smoking (⫺) Guided vs. unguided
N ⫽ 10,632

Illicit substances
Boumparis et al. Web-based k ⫽ 10, Clinical CRA k ⫽ 10 Guided g ⫽ .32ⴱ [0.15, 0.49] Any substance (⫹) Use of medication
(2017) k ⫽ 8, Community CBT k ⫽ 8 Unguided g ⫽ .36ⴱ [0.20, 0.53] Opioids (⫺) Control group
N ⫽ 2,836 MI g ⫽ .13 [⫺0.05, 0.31] Stimulants (⫺) Psychological approach
CM
CR
Tait et al. (2013) Web-based k ⫽ 10, University, community, clinic MI k ⫽ 4 Guided g ⫽ .16ⴱ [0.09, 0.22] Cannabis use (⫺) Control group
N ⫽ 4,125 CBT k ⫽ 6 Unguided (⫺) Age group
PCT (⫺) Gender
CM (⫺) Prevention vs. Treatment
(⫺) Guided vs. unguided
(⫺) Number of sessions
(⫺) Follow-up length
BENNETT, RUGGERO, SEVER, AND YANOURI

Note. Most interventions were compared to a control group consisting of wait-list control, active control, care as usual or a combination of these. Effects from the type of control is noted in the
moderator column when it was tested. CI ⫽ confidence interval; BA ⫽ behavioral activation; GAD ⫽ generalized anxiety disorder; GNF/GSP ⫽ gender neutral/specific feedback; PST ⫽
problem-solving therapy; CBM ⫽ cognitive bias modification; ABM ⫽ attention bias modification; MI ⫽ motivation interviewing; CBT ⫽ cognitive–behavioral therapy; ACT ⫽ acceptance and
commitment therapy; PNF/PF ⫽ personalized normative feedback/personalized feedback; BSC ⫽ behavioral self-control training; CRA ⫽ community reinforcement approach; CM ⫽ contingency
management; CR ⫽ cognitive rehabilitation; PCT ⫽ person–centered therapy; N/A ⫽ not applicable. Positive effect sizes indicate greater change in favor of the eHealth intervention. (⫹) indicates
an effect as a moderator; (⫺) indicates no effect as a moderator.
a
k references the number of studies. b Study compared BA interventions to other interventions. There was no overall reported effect size, but the conclusion was that BA is equivalent to other
approaches at decreasing depression.
ⴱ
p ⬍ .05.
 EHEALTH TO REDRESS ACCESS BARRIERS
mindfulness, metacognitive therapy, DBT, ru-
mination-focused CBT, and CBT. The most
common of these approaches was CBT, with
ACT and behavioral activation also frequently
seen.
Web- and app-based interventions consis-
tently observed small to medium (and occasion-
ally large) reductions in depression severity,
with some evidence that the benefits can last at
least up to 6 months (range: g ⫽ 0.15 to 0.90;
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Andersson & Cuijpers, 2009; Andrews, Cui-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
jpers, Craske, McEvoy, & Titov, 2010;
Charova, Dorstyn, Tully, & Mittag, 2015;
Cheng, Kumar, Wong, & Lau, 2019; Cowpert-
wait & Clarke, 2013; Davies, Morriss, & Gla-
zebrook, 2014; Deady et al., 2017; Donker et
al., 2013; Firth, Torous, Nicholas, Carney,
Pratap, et al., 2017; Foroushani, Schneider, &
Assareh, 2011; Josephine, Josefine, Philipp, Da-
vid, & Harald, 2017; Loughnan, Joubert, Grier-
son, Andrews, & Newby, 2019; Newby,
Twomey, Li, & Andrews, 2016; Richards &
Richardson, 2012; Sierra et al., 2018; Twomey
& O’Reilly, 2017; Twomey, O’Reilly, &
Meyer, 2017). This effect was consistent for
children, adolescents, and young adults (g ⫽
0.56; Ebert et al., 2015; Pennant et al., 2015).
Interventions targeting depression were also
found to have secondary benefits, including
small to medium improvements in quality of
life, problem-solving skills for negative prob-
lems, self-efficacy, anxiety, and well-being
(Charova et al., 2015; Twomey & O’Reilly,
2017; Foroushani et al., 2011). There were
mixed findings regarding stress (one meta-
analysis observed a reduction in stress, but one
other review and meta-analysis found no bene-
fits for stress, affect, or life satisfaction;
Charova et al., 2015; Davies et al., 2014;
Twomey & O’Reilly, 2017).
Some important moderators were identified.
Perhaps most consistently assessed, there were
mixed findings when comparing guided to un-
guided interventions. Two meta-analyses found
no difference (Cheng et al., 2019; Cowpertwait
& Clarke, 2013), with other meta-analytic evi-
dence suggesting that increased guidance from
professionals resulted in greater therapeutic ef-
fects (Andersson & Cuijpers, 2009; Johansson
& Andersson, 2012; Richards & Richardson,
2012).
Another mixed finding was regarding control
groups. Though most meta-analyses found no
197
difference between inactive and active controls
(Andersson & Cuijpers, 2009; Cowpertwait &
Clarke, 2013; Newby et al., 2016; Richards &
Richardson, 2012), one meta-analysis yielded
larger effects when treatment groups were com-
pared to inactive control groups (vs. active con-
trol groups; Davies et al., 2014).
Several other moderators were tested. Treat-
ments tended to have larger effects when they
were shorter (fewer than nine sessions) but were
also drawn out over longer periods of time
(i.e., ⬎6 weeks; Cheng et al., 2019). Effects
were also larger when reminders were used
(Cheng et al., 2019) and when treatments were
conducted in conjunction with medication
(Cowpertwait & Clarke, 2013). Interventions
that focused on changing lifestyle (i.e., decreas-
ing alcohol use, improving sleep, and/or in-
creasing physical activity) were found to lead to
lower depression (Young et al., 2018). Finally,
publication year was found to act as a modera-
tor, with newer trials yielding larger reductions
in depression (Cheng et al., 2019), perhaps in-
dicating the technology and the field has gotten
better about implementing web-based and app-
based interventions.
Other moderators did not seem to have an
effect. Specifically, no effects were found for
diagnosis (Cowpertwait & Clarke, 2013; Ebert
et al., 2015), psychological approach (Huguet et
al., 2018; Johansson & Andersson, 2012;
Newby et al., 2016) or urban/rural nature of the
sample (Vallury, Jones, & Oosterbroek, 2015).
Anxiety
A total of 13 reviews and meta-analyses were
focused on disorders related to anxiety, with
RCTs including samples for the following con-
ditions: social phobia, generalized anxiety dis-
order, posttraumatic stress disorder, panic dis-
order, obsessive– compulsive disorder,
agoraphobia, separation anxiety disorder, ill-
ness anxiety disorder, specific phobia, and non-
specific symptoms of anxiety (i.e., no diagno-
sis). Most interventions were based on CBT
(fewer with ACT or other orientations). Moder-
ate to large reductions in anxiety symptoms
were seen across reviews and meta-analyses
(range: g ⫽ 0.18 to 1.67; Davies et al., 2014;
Deady et al., 2017; Loughnan et al., 2019;
Domhardt, Geßlein, von Rezori, & Baumeister,
2019; Donker et al., 2013; Firth, Torous, Nich-
 198 BENNETT, RUGGERO, SEVER, AND YANOURI
olas, Carney, Rosenbaum, et al., 2017; Newby
et al., 2016). A similar effect was observed in
trials for children, adolescents, and young
adults (Ebert et al., 2015; Pennant et al., 2015),
as well as with individuals with comorbid phys-
ical illness, trauma history, depression, and gen-
eral stress (Firth, Torous, Nicholas, Carney,
Rosenbaum, et al., 2017).
Similar moderators as those in depression
were evaluated for anxiety-focused eHealth in-
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terventions. Mixed evidence was found regard-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ing the comparison of guided versus unguided
interventions (i.e., two reviews found no differ-
ences, whereas another review and a meta-
analysis found that guided outperformed un-
guided ones; Boettcher, Carlbring, Renneberg,
& Berger, 2013; Domhardt et al., 2019; Kelson,
Rollin, Ridout, & Campbell, 2019; Newby et
al., 2016). In regard to control groups, inactive
groups were found to be associated with larger
effect sizes than those of active controls (Davies
et al., 2014; Firth, Torous, Nicholas, Carney,
Rosenbaum, et al., 2017). In addition, and par-
ticularly relevant for this study, individuals liv-
ing in urban and rural areas were found to
achieve the same therapeutic benefits (Vallury
et al., 2015).
One interesting finding pertains to diagnosis.
Large reductions in targeted social anxiety (d ⫽
0.92), panic disorder (d ⫽ 0.83), and general-
ized anxiety disorder (d ⫽ 1.11) were observed
in web-based interventions, with evidence that
the effect may persist up to 5 years for social
anxiety (Andrews et al., 2010; Boettcher et al.,
2013). No observed differences were found be-
tween self-reported symptoms and diagnosis
(Ebert et al., 2015), nor were any differences
found for psychological orientation upon which
the intervention was based (Domhardt et al.,
2019). Together, these findings provide evi-
dence for developing eHealth interventions for
anxiety based on a transdiagnostic framework.
Substance Use
Among eHealth interventions targeting sub-
stance use, those for alcohol-related problems
were most studied. Across 14 reviews and meta-
analyses, a medium effect size was observed for
the reduction in the frequency and quantity of
alcohol consumption, peak alcohol blood con-
centration, number of risky and heavy drinking
days, and the negative consequences associated
with it (Bewick et al., 2008; Bhochhibhoya,
Hayes, Branscum, & Taylor, 2015; Black, Mul-
lan, & Sharpe, 2016; Chebli, Blaszczynski, &
Gainsbury, 2016; Donoghue, Patton, Phillips,
Deluca, & Drummond, 2014; Dotson, Dunn, &
Bowers, 2015; Fowler, Holt, & Joshi, 2016;
Kazemi et al., 2017; Khadjesari, Murray, He-
witt, Hartley, & Godfrey, 2011; Leeman, Perez,
Nogueira, & DeMartini, 2015; Oosterveen,
Tzelepis, Ashton, & Hutchesson, 2017; Prosser,
Gee, & Jones, 2018; Riper et al., 2011; Rooke,
Thorsteinsson, Karpin, Copeland, & Allsop,
2010; Sundström, Blankers, & Khadjesari,
2017; White et al., 2010). Compared to face-to-
face interventions, one review found that web-
based interventions performed similarly on al-
cohol related outcomes (e.g., abstinence, mean
drinks per day; Chebli et al., 2016). Importantly,
although eHealth intervention effects were ob-
served, they were inconsistently observed
across all reviews and meta-analyses. When
considering process-oriented information,
larger effects were observed when eHealth in-
terventions included some form of guidance,
normative information, feedback, and remind-
ers (Black et al., 2016; Prosser et al., 2018). In
addition, no reviews or meta-analyses reported
any related differences in psychological ap-
proach.
A total of three reviews and one meta-
analysis examined smoking cessation and found
that eHealth interventions helped to reduce cig-
arette smoking (Chebli et al., 2016; Rooke et al.,
2010; Shahab & McEwen, 2009). Higher absti-
nence rates were seen in the short-term, but this
effect disappeared by about 6 months (Oost-
erveen et al., 2017; Rooke et al., 2010). How-
ever, even though the abstinence rates declined
by 6 months, the decrease in the number of
cigarettes remained. Also worth noting is that
the findings of these reviews and meta-analysis
suggested that higher levels of engagement
were related to abstinence rates.
eHealth interventions to treat illicit sub-
stances were not as studied as other areas. A
meta-analysis explored this area and found
small-to-moderate decreases in the use of opi-
oids, but not stimulants (Boumparis, Karyotaki,
Schaub, Cuijpers, & Riper, 2017). Another
meta-analysis found a small decrease in canna-
bis use (g ⫽ 0.16; Tait, Spijkerman, & Riper,
2013), which was not moderated by any related
factors, such as type of control group, age,
 EHEALTH TO REDRESS ACCESS BARRIERS
gender, prevention versus treatment, guided
versus unguided, or number of sessions.
General Mental Health
Fifteen reviews and meta-analyses examined
the effect of eHealth interventions on general
mental health. These were of studies that had
lax inclusion/exclusion criteria (e.g., no specific
diagnosis or problem for inclusion or exclusion)
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and diverse samples, including employees, col-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
lege students, patient, and community partici-
pants. They tended to focus on diffuse outcomes
related to distress, most often depression, anxi-
ety or stress. The interventions featured in these
studies included CBT, ACT, DBT, metacogni-
tive therapy, mindfulness-based cognitive ther-
apy, schema therapy, cognitive– behavioral
analysis system of psychotherapy, compassion-
focused therapy, and compassionate mind train-
ing. Of these, ACT and mindfulness occurred
most frequently.
Results from meta-analyses suggested inter-
ventions were associated with a small effect for
reducing the severity of depression and anxiety
relative to all control groups, with effect sizes
ranging from g ⫽ 0.18 to 0.29 and g ⫽ 0.18 to
0.27, respectively (Brown, Glendenning, Hoon,
& John, 2016; Griffiths & Christensen, 2007;
Harrer et al., 2019; Heber et al., 2017; Linardon,
Cuijpers, Carlbring, Messer, & Fuller-Tyszkie-
wicz, 2019; O’Connor et al., 2018; Ploeg et al.,
2017; Spijkerman, Pots, & Bohlmeijer, 2016;
Stratton et al., 2017). Moderate effect sizes
were observed for reducing stress (g ⫽ 0.20 to
0.51; Harrer et al., 2019; Heber et al., 2017;
Linardon et al., 2019; Ploeg et al., 2017; Sheri-
fali et al., 2018; Spijkerman et al., 2016; Strat-
ton et al., 2017; Wang, Varma, & Prosperi,
2018). A variety of other effects were less com-
monly studied. Small improvements on well-
being (g ⫽ 0.23 to 0.37) and work productivity
were found (g ⫽ 0.25; Carolan, Harris, & Ca-
vanagh, 2017; Spijkerman et al., 2016). eHealth
interventions were also found to be moderately
effective at improving eating disorders (g ⫽
0.52) and general functioning (g ⫽ 0.41; Harrer
et al., 2019). One review also noted that such
interventions may help to decrease mental
health stigma (Griffiths & Christensen, 2007).
For interventions with children and adoles-
cence, some preliminary evidence indicates that
apps can be used to improve depression, anxi-
199
ety, stress, self-esteem, and OCD symptoms
(but not body dissatisfaction; Grist, Porter, &
Stallard, 2017). Importantly, when effect sizes
were computed, they tended to range from mod-
erate to large. However, they suffered due to
lack of independent replication (i.e., separate
research teams who evaluated the clinical utility
of an app), and some of these preliminary con-
clusions are based solely on pre–post designs
with no control group.
Results were not universally positive. In stud-
ies that featured samples of caregivers to adults
with chronic conditions, no improvements in
depression, coping, overall mental health, qual-
ity of life, and overall health were observed
after use of web-based interventions (Sherifali
et al., 2018). However, increased peer and pro-
fessional support led to decreased depression
and improved overall health in these caregiver
samples (Sherifali et al., 2018). Furthermore,
another meta-analysis comprised of general,
clinical, and undergraduate samples found no
effect for web-based ACT on quality of life
(Brown et al., 2016).
Important moderators were considered across
these reviews and meta-analyses. Evidence for
the effect of guidance was mixed. In two meta-
analyses, eHealth interventions for general
mental health were not found to not be moder-
ated by professional guidance (Carolan et al.,
2017; Harrer et al., 2019), whereas in two other
meta-analyses found evidence that guided inter-
ventions were superior to unguided ones, par-
ticularly for stress (Linardon et al., 2019; Spi-
jkerman et al., 2016). There was also no
difference in effect based on the psychological
approach of the intervention (Carolan et al.,
2017; Harrer et al., 2019; Spijkerman et al.,
2016), with the exception of one meta-analysis
that found mindfulness significantly outper-
formed CBT (g ⫽ 0.60 and g ⫽ 0.15, respec-
tively; Stratton et al., 2017). Although treatment
length was not found to impact outcomes (Har-
rer et al., 2019), efforts to increase engagement
were associated with faster treatment gains
(e.g., a reminder system or a self-monitoring
component; Bush, Armstrong, & Hoyt, 2019;
Carolan et al., 2017; Linardon, 2019). Finally,
comparisons with inactive controls tended to be
larger than those with active controls (Harrer et
al., 2019; Heber et al., 2017). Slightly beyond
the scope of the current study, guided web-
based interventions were found to perform sim-
 200 BENNETT, RUGGERO, SEVER, AND YANOURI
ilarly to face-to-face interventions (Andersson,
Cuijpers, Carlbring, Riper, & Hedman, 2014).
However, due to the limited number of studies,
this should be considered a preliminary finding.
Integration of eHealth as an Adjunct to
Traditional Psychotherapy
To this point, eHealth interventions were
mostly compared to some form of nontherapy
control (e.g., WLC or psychoeducation). Al-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
though this evidence suggests eHealth can offer
This document is copyrighted by the American Psychological Association or one of its allied publishers.
a plausible solution to overcoming barriers to
care, eHealth can also play another role: an
adjunct to traditional psychotherapy. Meta-
analytic findings support this notion. When
comparing “treatment” to “treatment with
eHealth,” a small effect size (d ⫽ 0.27) was
found in favor of the combined intervention
(Lindhiem, Bennett, Rosen, & Silk, 2015). This
is particularly important because this is an ad-
ditional benefit that goes beyond the typical
treatment effects. For example, this technology
can enable clinicians to administer momentary
behavioral diaries, help teach behavioral skills
with video demonstrations, and utilize remind-
ers to encourage the practice of skills (e.g.,
Pramana, Parmanto, Kendall, & Silk, 2014).
Attrition Rates
Although consistent effects were generally
observed, the attrition rates varied greatly in
range and were most often reported for inter-
ventions treating depression. In these, mean at-
trition rates ranged from 26.5% to 57% (Cow-
pertwait & Clarke, 2013; Josephine et al., 2017;
Richards & Richardson, 2012; Sierra et al.,
2018; Twomey et al., 2017), but ranges varied
by as much as 60% across trials (Cheng et al.,
2019; Josephine et al., 2017; Sierra et al., 2018,
respectively).
Two meta-analyses compared attrition for
guided versus unguided interventions in depres-
sion and found unguided ones had substantially
higher attrition rates (i.e., 26% vs. 44% in one
study [Cowpertwait & Clarke, 2013] and 28%
vs. 74% in the other [Richards & Richardson,
2012]; both times favoring lower attrition with
guided approach). Importantly, the second
meta-analysis found even the use of administra-
tive support for the eHealth intervention sub-
stantially reduced the attrition rate (38% vs.
74%; Richards & Richardson, 2012).
Attrition in the other conditions was not stud-
ied as frequently. In those examining general
mental health, a mean dropout rate of 23% was
observed (Carolan et al., 2017). In two meta-
analyses, ranges were similarly wide but dif-
fered greatly in magnitude (3–54% and 39.5–
92%; Carolan et al., 2017; Spijkerman et al.,
2016, respectively). Ranges for interventions
targeting alcohol were generally lower (4.2–
21%, 0 – 42%; Dotson et al., 2015; Riper et al.,
2011, respectively), and were generally lower
for guided interventions when compared to un-
guided ones (Domhardt et al., 2019).
Acceptability
eHealth interventions were generally found
to be acceptable to use by participants who
engaged them. Specifically, all types of eHealth
interventions were found to be moderately to-
highly satisfactory (Andrews et al., 2010;
Charova et al., 2015; Davies et al., 2014;
Donker et al., 2013; Grist et al., 2017; Kelson et
al., 2019; Richardson et al., 2010; Shahab &
McEwen, 2009). Increased satisfaction was
linked to therapist guidance, interventions that
were structured, inclusion of specific examples,
and the opportunity to make peer connections
(Charova et al., 2015). Interestingly, one review
found that satisfaction ratings were independent
of attrition rate (Kelson et al., 2019). Another
review that featured child and adolescent sam-
ples found similar trends of satisfaction as pre-
viously noted, but also noted that parents en-
joyed the anonymous nature of an eHealth
interventions (Richardson et al., 2010). This
same review also recognized two criticisms: the
difficulty level of some modules and the time
demand. None of the included reviews and
meta-analyses considered the satisfaction of
psychotherapists or safety when using the soft-
ware (e.g., breach of confidentiality). Overall,
clients report adequate levels of satisfaction
with the use of eHealth interventions.
Limitations of eHealth Interventions
eHealth interventions are not without limita-
tions. As highlighted above, a number of interven-
tions include some degree of clinical support.
However, this support is not always provided
through face-to-face interactions, which raises
questions regarding the quality of the therapeutic
 EHEALTH TO REDRESS ACCESS BARRIERS
relationship and care provided. Establishing trust
may be more difficult remotely than in person and
could ultimately perpetuate misdiagnoses and an
over reliance on psychotropic medication (Dorsey
& Topol, 2016). In addition, as new treatments
become available, or current ones augmented,
eHealth requires an additional step in the form of
software updates to ensure that outdated interven-
tions are not employed. The improper implemen-
tation of health services could raise the risk of
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adverse health outcomes, or at least decreased
This document is copyrighted by the American Psychological Association or one of its allied publishers.
effectiveness (Dorsey & Topol, 2016). Another
limitation has to do with Internet access, which,
though widespread, is not universal, especially
among those most in need (e.g., rural, older, lower
income, less education, and more chronic condi-
tions; Fox & Purcell, 2010; Rainie, 2015). In ad-
dition, this general modality increases privacy
risks and every software program may vary in
how private psychotherapeutic data is handled,
with some having more risk of privacy breach
than others. This modality when used adjunctively
also increases risks associated with potentially
practicing outside of one’s licensed jurisdiction.
Finally, there remains the possibility that eHealth
might offer some benefit, but not as much as
traditional psychotherapy and may delay a person
from seeking traditional treatment that could ben-
efit them more.
Discussion and Recommendations
Across 65 reviews and meta-analyses,
eHealth interventions— either guided or un-
guided— demonstrated at least a small effect for
treatment of depression, anxiety, nonspecific
mental health concerns, and alcohol-related dis-
orders relative to no treatment or waitlist. These
interventions did not only consistently improve
the target condition, but also provided second-
ary benefits (e.g., reduction in stress, improved
comorbid symptoms). Though not studied as
frequently, benefits appear similar for children
and adolescents. Smoking rates and illicit drug
use (e.g., cannabis and opioids) were also not
studied as often, but there was some evidence
for improvements. Given COVID-19 disrup-
tions to people’s ability to access face-to-face
psychotherapy and the longer-standing tradi-
tional barriers, these results are a promising
avenue for making benefits of psychotherapy
more widely available.
201
A number of moderators and caveats are worth
noting. Across reviews, there was clear evidence
of acceptability among those who engaged in the
eHealth intervention. However, there was also ev-
idence that the stand-alone interventions with no
clinical contacts had higher rates of attrition, sug-
gesting that perhaps the best approach is to inte-
grate eHealth with some form of clinical contact,
even administrative contact if nothing else. De-
spite acceptability, few reviews explicitly ad-
dressed issues relevant to safety. There was no
obvious evidence of harm noted across studies,
suggesting the greatest harm may be by omission
of treatment from attrition than by any obvious
iatrogenic effects.
Beyond attrition per se, the importance of
guided versus unguided treatment on the size of
the treatment effect was mixed. Some evidence
pointed to no difference, but other reviews
showed larger effects for treatments with clini-
cal guidance, as well as benefits for adherence
rates and other outcomes (e.g., Richards &
Richardson, 2012; Domhardt et al., 2019). This
suggests that even minimal support can increase
the benefits of an eHealth intervention.
Although not studied as frequently, a few
other moderators are also worth noting. Some
reviews and meta-analyses found that higher
engagement with an eHealth intervention led to
greater clinical outcomes, as did the use of
reminders and feedback. Despite these interven-
tions taking a variety of different psychological
orientations, a vast majority of reviews and
meta-analyses found no clear benefit for one
orientation over another. Also, eHealth inter-
ventions were determined to perform equally
well at both the symptom and diagnostic levels,
providing support for dimensional approaches
to treatment (cf., Ruggero et al., 2019).
Finally, the degree to which these interven-
tions work as well as traditional psychotherapy
remains unresolved. Most of the studies relied
on waitlist controls, and studies with active
comparisons found mixed evidence regarding
equivalence. Also more limited was the extent
of studies using eHealth as an adjunct to tradi-
tional psychotherapy. Those studies did tend to
find there was an added benefit.
Before considering clinical implications, lim-
itations need to be considered. Most of the
studies that went into the reviews were not
blinded. This is understandable given that many
of the comparisons were based on WLC. How-
 202 BENNETT, RUGGERO, SEVER, AND YANOURI
ever, this risks overestimating the size of the
benefit from eHealth per se. Also, our review
of reviews and meta-analyses did not consider
the effect of overlapping RCTs appearing
across the articles. In other words, we re-
ported multiple effect sizes from the different
reviews, but these cannot simply be averaged
to gather a total or overall effect because they
contain redundancies in terms of studies in-
cluded. Finally, the populations included in
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
this review varied greatly and we did not
This document is copyrighted by the American Psychological Association or one of its allied publishers.
systematically assess how eHealth interven-
tion efficacy may vary across them.
Despite limitations, findings suggest at least
five clinical takeaways. First and foremost, the
evidence supports using eHealth interventions for
psychotherapeutic benefit, so clinicians may be
advised to consider how to integrate them into
treatment. Many practices and areas have insuffi-
cient providers and/or long wait-list periods before
a patient can engage traditional psychotherapy,
making eHealth a viable alternative until services
become available. Or, it can be used as part of a
stepped-care approach (van Straten, Hill, Rich-
ards, & Cuijpers, 2015), with more intensive face-
to-face services reserved for more severe cases.
Alternatively, clinicians can refer eHealth services
to clients who, for whatever reason (e.g., stigma),
are unlikely to attend face-to-face psychotherapy.
Ideally, eHealth would be offered with some clin-
ical or administrative support given evidence this
reduces attrition, or even as an adjunct to psycho-
therapy.
Second, clinicians need to remain mindful of
empirical evidence for whatever eHealth interven-
tion they recommend. There are thousands of
freely available apps, but most have no evidence
for their efficacy. For example, only some of the
most popular mental health apps available have
any evidence to support them (see Wang, Fagan,
& Yu, 2020).
Third, when selecting an intervention, it is
worth considering common features from this re-
view shown to be important. Interventions that
involve some form of contact with an external
source reduce attrition, as do those used in an
adjunctive capacity. Interventions with reminders
and feedback increase treatment engagement and
adherence. Other moderators may be more spe-
cific to the treatment problem.
Fourth, clinicians should take time to become
familiar with the technology and approach of
whatever intervention they recommend. Not only
does this include understanding functionality, user
interface, and privacy limits, but also the psycho-
logical approach on which the intervention is
based and how this fits within the larger treatment
plan.
Fifth, clinicians should consider ethical impli-
cations (see Wang et al., 2020) of using an
eHealth intervention. Among them, mental health
professionals are obligated to maximize benefit
and minimize harm, as well as work to ensure that
people have access to psychological resources.
eHealth represents an increasingly acceptable and
effective way to potentially address this obliga-
tion.
Conclusion
Barriers to accessing psychotherapy long pre-
date the COVID-19 pandemic, but this crisis has
spotlighted the need to use technology to over-
come them. Most recent efforts focus on telepsy-
chotherapy, but these approaches cannot be scaled
up to redress the shortage of psychologists needed
to address mental health care needs around the
world. eHealth’s ability to be widely distributed at
lower cost makes it a promising solution for over-
coming many of the access barriers faced by peo-
ple. Both web-based and app-based interventions
appear to be effective at treating mental illness,
especially when compared to people who would
not otherwise receive services. Moreover, for in-
dividuals who have access and are actively partic-
ipating in psychotherapy, eHealth can enhance
those services as an adjunctive component.
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eHealth para remediar las barreras de acceso a la psicoterapia, tanto nuevas como antiguas: una
reseña de reseña y metaanálisis
Las proscripciones de salud pública de COVID-19 han creado barreras severas, aunque temporales para acceso a
psicoterapia cara a cara en todo el mundo. Tan disruptivos como estos son, se suman a las barreras más antiguas para obtener
psicoterapia a los que a millones en necesidad se enfrentan. Las intervenciones de eSalud ofrecen una vía para corregir
ambos tipos de barreras, pero la evidencia sobre su eficacia sigue siendo motivo de preocupación. Esta reseña de reseñas
y los metaanálisis describen la fuerza de la evidencia y los tamaños del efecto para guiados y enfoques no guiados para las
intervenciones de eSalud dirigidas a problemas comunes en psicoterapia (es decir, depresión, ansiedad, abuso de sustancias,
y bienestar general). Después de una búsqueda exhaustiva, se identificaron un total de 65 reseñas y metaanálisis y se
evaluaron los efectos del tratamiento, moderadores, aceptabilidad y desgaste. Hallazgos muestran que la eSalud es aceptable
y efectiva para mejorar la depresión, la ansiedad y el alcohol problemas y salud mental en general en comparación con la
lista de espera, e incluso puede ofrecer beneficio como complemento de la psicoterapia tradicional. Se encontró evidencia
mixta cuando comparar intervenciones guiadas versus no guiadas, así como la fuerza del beneficio en relación con los
controles activos y el grado en que estos enfoques están asociados con desgaste. Las intervenciones de eSalud tienen el
potencial de ser una herramienta efectiva para remediar las barreras de acceso a la psicoterapia nuevas y antiguas.

eSalud, intervención en internet, aplicaciones para teléfonos inteligentes, msalud, barreras

智慧醫療矯正使用心理治療的新舊障礙：回顧與後設分析之評論
在世界各地，COVID-19公共衛生禁令們創造了使用面對面心理治療的嚴重暫時性障礙。它們是如此的具有破壞
性, 以至於超越了數百萬有需求的人在取得心理治療時面對的更長期存在的障礙。智慧醫療提供了一條路徑矯正這
兩種類型的障礙, 但有關其功效的證據仍然值得關注。此針對文獻和後設分析之評論概述了智慧醫療針對心理治療
常見問題 (即抑鬱症，焦慮症，藥物濫用和總體健康狀況) 的有指導和無指導的干預策略之證據強度和效應值。經
過全面性的搜索, 共有65份回顧和後設分析被識別並評估治療效果, 調節因子, 可接受性和損耗。研究顯示智慧醫療
在改善抑鬱症, 焦慮症, 酗酒相關方面問題以及相較於候補名單的一般心理健康是可接受且有效的; 作為傳統心理治
療的附屬物, 其甚至可以提供效益。在比較有指導及無指導的干預、關於積極控制的受益強度, 以及這些方法與損
耗的關聯程度時, 我們發現了混合的證據。智慧醫療干預有可能成為矯正新舊的心理治療使用障礙有效的工具。

智慧醫療, 網路干預, 智能手機應用程式, 移動醫療, 障礙

Received April 7, 2020

Revision received April 24, 2020
Accepted April 27, 2020 䡲