University of Wuppertal, Germany;Kyoto University Graduate School of Medicine/School of Public Health, Japan.
Vrije Universiteit Amsterdam, Netherlands;Amsterdam Public Health Research Institute, Netherlands.
Vrije Universiteit Amsterdam, Netherlands;Amsterdam Public Health Research Institute, Netherlands;GGZ inGeest, Netherlands.
Harvard Medical School, Sweden.
MINECO, Spain;Valencia University, Spain.
Heidelberg Repatriation Hospital, Australia.
Harvard University, USA.
University of Amsterdam, Netherlands.
University of New South Wales, Australia.
University of New South Wales, Australia;University of Melbourne, Australia.
HumanTotalCare, Netherlands.
Vrije Universiteit Amsterdam, Netherlands;Amsterdam Public Health Research Institute, Netherlands.
Gaia AG, Germany;University of London, UK.
University of Gothenburg, Sweden.
Freie Universität Berlin, Germany.
The University of Texas at Austin, USA.
Jaume I University, Spain;Instituto Salud Carlos III, Spain.
The Ohio State University, USA.
Northwestern University, USA.
Friedrich-Alexander-University Erlangen-Nürnberg, Germany.
University of Bristol, UK;National Institute for Health Research Bristol Biomedical Research Centre, UK.
Trinity College Dublin School of Psychology, Ireland;SilverCloud Health, Ireland.
University of York, UK.
Karolinska Institutet, Sweden;Region Stockholm, Sweden.
Massachusetts General Hospital, USA.
China Academy of Chinese Medical Sciences, China.
Karolinska Institutet, Sweden;Region Stockholm, Sweden;Linköping University, Sweden.
University of Regina, Canada.
University of New South Wales, Australia.
The Ohio State University, USA.
University of Sydney, Australia.
McLean Hospital, USA;Harvard Medical School, USA.
Lübeck University, Germany.
The University of Texas at Austin, USA.
Miguel Servet University Hospital, Spain;RedIAPP, Spain.
Heidelberg Repatriation Hospital, Australia.
Imperial College London, UK.
University of Oxford, UK.
University of New South Wales, Australia.
Jaume I University, Spain;Instituto Salud Carlos III, Spain.
University of Nottingham, UK.
Linköping University, Sweden;Psykologpartners, Sweden.
University Medical Center Hamburg-Eppendorf, Germany.
Oregon Research Institute, USA.
National Health Care Institute, Netherlands.
The Australian National University, Australia.
Freie Universität Berlin, Germany.
Vrije Universiteit Amsterdam, Netherlands;Amsterdam Public Health Research Institute, Netherlands.
University of Gothenburg, Sweden.
Karolinska Institutet, Sweden;Region Stockholm, Sweden.
The Ohio State University Wexner Medical Center, USA;The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, USA.
University of Regina, Canada.
Karolinska Institutet, Sweden;Region Stockholm, Sweden.
Norwegian Center for E-health research, Norway.
Freie Universität Berlin, Germany.
Stockholm University, Sweden.
Imperial College London School of Public Health, UK.
Stockholm University, Sweden.
Harvard Medical School, USA.
SilverCloud Health, Ireland.
The Clinical Psychology Centre, Australia.
McLean Hospital, USA.
University of York, UK;Hull York Medical School, UK.
University Medical Center Hamburg-Eppendorf, Germany.
University of Bern, Switzerland.
Tilburg University, Netherlands.
Tilburg University, Netherlands.
Karolinska Institutet, Sweden;Region Stockholm, Sweden.
IMPORTANCE: Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them.
OBJECTIVE: To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information.
DATA SOURCES: We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019.
STUDY SELECTION: Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization.
DATA EXTRACTION AND SYNTHESIS: We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression.
MAIN OUTCOMES AND MEASURES: Patient Health Questionnaire-9 (PHQ-9) scores.
RESULTS: Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9.
CONCLUSIONS AND RELEVANCE: In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.
American Medical Association , 2021. Vol. 78, no 4, p. 361-371
Cognitive Behavioral Therapy, Depression Therapy, Depressive Disorder Therapy, Humans, Internet-Based Intervention, Network Meta-Analysis