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Is self-guided internet-based cognitive behavioural therapy (iCBT) harmful? An individual participant data meta-analysis.

  • Karyotaki, Eirini1
  • Kemmeren, Lise2
  • Riper, Heleen1
  • Twisk, Jos3
  • Hoogendoorn, Adriaan2
  • Kleiboer, Annet1
  • Mira, Adriana4
  • Mackinnon, Andrew5
  • Meyer, Björn6
  • Botella, Cristina4
  • Littlewood, Elizabeth7
  • Andersson, Gerhard8
  • Christensen, Helen5
  • Klein, Jan P9
  • Schröder, Johanna10
  • Bretón-López, Juana4
  • Scheider, Justine11
  • Griffiths, Kathy12
  • Farrer, Louise13
  • Huibers, Marcus J H1
  • And 7 more
  • 1 Department of Clinical Psychology,VU Amsterdam and Institute for Public Health Research,Amsterdam,the Netherlands. , (Netherlands)
  • 2 Department of Psychiatry,GGZ inGeest and VU University Medical Centre, Amsterdam Public Health research institute,Amsterdam,the Netherlands. , (Netherlands)
  • 3 Department of Epidemiology and Biostatistics and Amsterdam Institute for Public Health Research,VU University Amsterdam,Amsterdam,the Netherlands. , (Netherlands)
  • 4 Department of Psychology and Technology,Jaume University,Castellon,Spain. , (Spain)
  • 5 Black Dog Institute and University of New South Wales, Prince of Wales Hospital,Sydney,Australia. , (Australia)
  • 6 Research Department, Germany and Department of Psychology,City University,Gaia AG, Hamburg, London,UK. , (Germany)
  • 7 Department of Health Sciences,University of York,York,UK.
  • 8 Department of Behavioural Sciences and Learning,Sweden Institute for Disability Research, Linköping University,Linköping,Sweden. , (Sweden)
  • 9 Department of Psychiatry and Psychotherapy,Lübeck University,Lübeck,Germany. , (Germany)
  • 10 Department of Psychiatry and Psychotherapy,University Medical Center Hamburg-Eppendorf,Hamburg,Germany. , (Germany)
  • 11 Institute of Mental Health, University of Nottingham,Nottingham,UK.
  • 12 Research School of Psychology, College of Biology, Medicine & Environment, Australian National University,Canberra,Australia. , (Australia)
  • 13 Centre for Mental Health Research, The Australian National University,Canberra,Australia. , (Australia)
  • 14 Department of Primary Care and Public Health Sciences,King's College London,London,UK.
  • 15 Department of Clinical Psychology and Psychotherapy,University of Bern,Bern,Switzerland. , (Switzerland)
  • 16 CoRPS - Center of Research on Psychology in Somatic diseases, Tilburg University,Tilburg,the Netherlands. , (Netherlands)
Published Article
Psychological Medicine
Cambridge University Press
Publication Date
Nov 01, 2018
DOI: 10.1017/S0033291718000648
PMID: 29540243


Little is known about potential harmful effects as a consequence of self-guided internet-based cognitive behaviour therapy (iCBT), such as symptom deterioration rates. Thus, safety concerns remain and hamper the implementation of self-guided iCBT into clinical practice. We aimed to conduct an individual participant data (IPD) meta-analysis to determine the prevalence of clinically significant deterioration (symptom worsening) in adults with depressive symptoms who received self-guided iCBT compared with control conditions. Several socio-demographic, clinical and study-level variables were tested as potential moderators of deterioration. Randomised controlled trials that reported results of self-guided iCBT compared with control conditions in adults with symptoms of depression were selected. Mixed effects models with participants nested within studies were used to examine possible clinically significant deterioration rates. Thirteen out of 16 eligible trials were included in the present IPD meta-analysis. Of the 3805 participants analysed, 7.2% showed clinically significant deterioration (5.8% and 9.1% of participants in the intervention and control groups, respectively). Participants in self-guided iCBT were less likely to deteriorate (OR 0.62, p < 0.001) compared with control conditions. None of the examined participant- and study-level moderators were significantly associated with deterioration rates. Self-guided iCBT has a lower rate of negative outcomes on symptoms than control conditions and could be a first step treatment approach for adult depression as well as an alternative to watchful waiting in general practice.

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