The Effectiveness and Acceptability of Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety in Routine Clinical Care

Evidence-based psychological interventions delivered via the internet and mobile technologies (Digital Mental Health) hold the promise of reducing barriers to care, including difficulties accessing treatment because of distance, cost, work and family commitments, and limited provider capacity. Such barriers represent a particular challenge for individuals with depression and anxiety, that tend to co-occur and to recur following treatment cessation, and which are among the most common and burdensome illnesses worldwide. Numerous randomized controlled trials have shown that internet-delivered cognitive behavioral therapy (ICBT) for depression and anxiety is highly effective in reducing the severity and impact of symptoms and improving overall functioning when compared to no-treatment in individuals recruited online. However, important knowledge gaps remain about the acceptability and effectiveness of ICBT when delivered in routine psychiatric care settings. Bridging these knowledge gaps is especially important now as ICBT is being disseminated at a rapid pace in Sweden. The current program of research was carried out with the purpose of investigating the usefulness, acceptability, and effectiveness of ICBT when delivered in a routine psychiatric care setting to adults. Study I was a naturalistic evaluation of the sustained effectiveness of treatment for depression in a psychiatric out-patient setting and examination of psychosocial and clinical predictors of symptom recurrence and relapse to a depression diagnosis. Study II was a randomized waitlist controlled trial evaluating the acceptability and effectiveness of an 8-week ICBT program for depression delivered in a routine psychiatric setting. Study III was a qualitative study that sought to identify why patients with mixed symptoms of generalized anxiety disorder (GAD) and depression had non-adhered to an ICBT program for GAD. Overall, the findings indicate that ICBT for depression delivered in a routine outpatient psychiatric care setting is acceptable and effective in reducing depressive symptoms as well as mitigating anxiety. However, the study also highlights challenges related to treatment adherence and the need for more effective interventions to prevent relapse and recurrence in psychiatric depression treatment. Further research and improvements in ICBT delivery are warranted to address these issues and enhance mental health care outcomes in such settings.

Digitizing psychological treatment can potentially enhance access to care, a critical consideration, particularly in the context of mental health. Individuals grappling with mental health issues often face circumstances that deter them from seeking professional help, even when it could be beneficial. At times, healthcare systems may be constrained by limited resources, making it challenging to provide care to all those in need. Given the high prevalence of conditions like depression and anxiety, which are among the most common and burdensome illnesses worldwide , ensuring access to care becomes a paramount concern for these populations. Internet-delivered cognitive-behavioral therapy has demonstrated its effectiveness in numerous research studies. However, knowledge gaps persist. As this form of treatment gains rapid adoption in Sweden, it is imperative to investigate its effectiveness not only in controlled research settings but also when integrated into routine healthcare services. The findings of this thesis suggest that internet-delivered therapy is indeed effective for treating depression and anxiety within regular healthcare settings. Nevertheless, the thesis also sheds light on challenges, such as issues related to treatment dropout rates, which can lead to compromised outcomes. Furthermore, addressing the needs of individuals with severe and recurrent symptoms presents an additional challenge. For these individuals, it is crucial to view psychiatric care not merely as a one-time intervention but as a potential requirement for long-term care and support.