Guided and Unguided Internet-Based Cognitive Behavioral Therapy Decreased Symptoms of Depression

This articles looks at the short-term and long-term efficacy of guided and unguided iCBT for depression using patient-level information.

Guided and unguided internet-based cognitive behavioral therapy (iCBT) was effective for the treatment of patients with depression, according to results of a meta-analysis, published in JAMA Psychiatry.

Researchers from Harvard Medical School searched publication databases through January 2019 for randomized clinical trials (RCTs) of guided or unguided iCBT for adults with depression.

A total of 42 studies comprising 9751 study participants conducted in 12 countries across Europe, North America, and China were included. The studies compared guided iCBT (n=13) or unguided iCBT (n=15) with control conditions of usual care (n=15) or waiting list (n=22). Guided and unguided iCBT were directly compared with each other in 5 studies.

iCBT comprised 5-18 (mean, 8.0; standard deviation [SD], 2.8) online sessions for 5-14 (mean, 9; SD, 2.5) weeks. Among the studies of guided therapy, the guidance was provided by students in clinical psychology (n=14), paraprofessionals or lay therapists (n=6), or licensed psychologists or psychotherapists (n=5).

The Patient Health Questionnaire-9 (PHQ-9) scores indicated guided iCBT more effectively improved symptoms of depression than unguided iCBT (mean difference [MD], -0.8; 95% CI, -1.4 to -0.2) as well as the control conditions of usual care (MD, -1.7; 95% CI, -2.3 to -1.1) or waiting list (MD, -3.3; 95% CI, -3.9 to -2.6). Unguided iCBT reduced symptoms of depression compared with the control conditions of usual care (MD, -0.9; 95% CI, -1.5 to -0.3) or waiting list (MD, -2.5; 95% CI, -3.2 to -1.8).

Among the studies with sufficient long-term follow-up, no significant differences were observed between guided or unguided iCBT at 6 (MD, -0.2; 95% CI, -0.8 to 0.3) or 12 (MD, 0.1; 95% CI, -0.4 to 0.6) months.

Treatment response was reported by nearly half (48%) of guided iCBT recipients and over a third (37%) of unguided iCBT recipients. Stratified by baseline severity of depressive symptoms, 46% of moderate and 55% of severe patients responded to guided iCBT compared with 39% and 40% to unguided iCBT, respectively.

This study was limited by not including data on comorbidities, duration of depressive symptoms, or number of previous episodes, all of which may have influenced patients’ response to therapy.

These data indicated that both guided and unguided iCBT was able to reduce symptoms of depression for up to 12 months among many patients. This low-cost therapy may be a viable treatment option for patients with moderate symptoms of depression, increasing access to care.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Karyotaki E, Efthimiou O, Miguel C, et al. Internet-based cognitive behavioral therapy for depression. A systematic review and individual patient data network meta-analysis. JAMA Psychiatry. Published online January 20, 2021. doi:10.1001/jamapsychiatry.2020.4364.