Anxiety and depression are two of the most common mental health disorders experienced during adolescence. The current gold standard treatment for these disorders is cognitive behavioural therapy (CBT), but many young people struggle to access treatment due to several barriers, including long waiting times and perceived stigma. However, a digital version of CBT, known as computerised cognitive behavioural therapy (cCBT), could help to address these barriers as it is more convenient, flexible, and is associated with less stigma than face-to-face therapy (Hollis et al., 2017).
Given that young people are typically avid users of technology and the internet (Ofcom, 2019) and the prevalence of anxiety and depressive disorders increases during adolescence (Costello et al., 2003), cCBT has the potential to reach and treat many young people with anxiety and depression. However, the effectiveness of cCBT had yet to be investigated in adolescents exclusively.
Wickersham and colleagues (2022) therefore conducted a systematic review and meta-analysis to investigate the efficacy of cCBT for treating anxiety and depression in adolescents.
Many young people with anxiety or depression struggle to access the help they need – could computerised CBT provide a solution?
Methods
To identify potentially relevant studies, one author systematically searched three databases, alongside hand-searching the reference lists of any included studies and existing systematic reviews. Two authors then independently screened titles, abstracts, and full texts to identify studies that:
- Included participants aged 11-19 years old
- Examined cCBT programmes
- Had anxiety or depression as the primary outcome measure
- Were completed randomised controlled trials (RCTs)
- Were written in English and peer-reviewed.
Both treatment and/or preventative focused cCBT programs could be included.
The authors then extracted study data using outcomes from the longest available follow-up period. The quality of each study was assessed using the Cochrane Collaboration Risk of Bias tool, with an overall rating of either good, fair, or poor.
Meta-analyses were conducted to examine the effects of cCBT on anxiety and depression symptom scores between the treatment and control groups at follow-up. Analyses were also carried out to investigate heterogeneity.
Results
16 studies were included in the final review. Across the studies, 13 different cCBT programmes were examined, including ‘MoodGYM’, ‘SPARX’, and ‘Stressbusters’. The studies involved a total of 4,012 participants aged 11-19 years, and were conducted in Australia, New Zealand, Canada, China, Netherlands, Japan, UK, Denmark, and Sweden. Across most of the intervention programs, little or no clinician or parental input was required.
Study quality was mixed across the 16 studies:
- 9 were rated as ‘poor quality’
- 2 were rated as ‘fair quality’
- 5 were rated as ‘good quality’
The results of the study showed a small but statistically significant effect of cCBT, with participants in intervention groups scoring lower follow-up scores than participants in control groups for both anxiety (standardized mean difference [SMD] = −0.21, 95% CI [−0.33 to −0.09]) and depression (SMD = −0.23, 95% CI [−0.39 to −0.07]).
The effect size varied based on the level of bias risk ratings. For the anxiety meta-analysis, studies rated ‘fair’ found the weakest evidence for the effectiveness of cCBT (SMD = −0.08, 95% CI [−0.31 to 0.15]). For the depression meta-analysis, studies rated ‘poor’ found the strongest evidence for an effect of cCBT (SMD = −0.32, 95% CI [−0.55 to −0.08]).
Additionally, there was evidence of heterogeneity for both the anxiety and depression meta-analyses, which was statistically significant for the depression meta-analysis only.
This review found a small but statistically significant positive effect of cCBT for the treatment of anxiety and depression in adolescents.
Conclusions
The meta-analysis indicates that cCBT has promise as an intervention for anxiety and depression in adolescents, finding statistically significant but small effects. This adds to the growing evidence-base on cCBT for youth mental health. However, the study also highlights the need for more high-quality and rigorous RCTs in this area, as the majority of studies included in the analysis were of poor quality and highly heterogenous.
The authors conclude that:
The clinical potential of cCBT in treating adolescent anxiety and depression is clear and has the scope to address current unmet needs within child and adolescent mental health service.
cCBT has the potential to address unmet needs within mental health services, but additional high-quality trials (and better ways to deliver cCBT!) are needed before this can happen.
Strengths and limitations
This is the first systematic review and meta-analysis to examine the efficacy of cCBT for anxiety and depression in adolescents, which is a key age group given the unique social and biological transitions experienced during this period, alongside the high prevalence of mental health disorders. The authors adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and pre-registered the review, demonstrating good practice and transparency in their research process. Additionally, the authors used robust methods and clearly reported their search strategy, data extraction, and assessments of study quality, providing a detailed overview of how the review was conducted.
The review identified studies conducted across various countries, suggesting that cCBT may be effective across several cultural settings. However, only studies conducted in high-income countries were identified, and the systematic search was limited to studies published in English and in peer-reviewed journals. This limits the conclusions that can be made about the effectiveness of cCBT in other populations, and indicates a risk of publication bias.
As the authors note, the majority of the included studies (56%) were rated as poor quality, which limits the strength of the findings. Notably, the evidence for the effectiveness of cCBT for depression was strongest in poor quality studies. This makes the evidence less compelling, and studies rated poor quality tend to exaggerate the overall size of the treatment effect (Khan et al., 1996) which calls into question the accuracy of the conclusions made about the efficacy of cCBT for anxiety and depression in adolescents.
Across the included studies, there was high heterogeneity, indicating that not all studies should not have been combined in a meta-analysis due to their differences. The authors suggest heterogeneity may have been a result of combining treatment and prevention studies, and combining superiority studies (used to show that one treatment is better than another) and noninferiority studies (used to show that a new treatment isn’t worse than another treatment). The review also did not analyse the input from therapists and/or parents across the studies, which has been shown to potentially contribute to treatment outcomes (Cardy et al., 2020). Again, this may have increased heterogeneity.
Finally, there were key methodological differences between the cCBT programs which were not accounted for. For example, some programmes had a strong focus on particular CBT techniques (e.g., cognitive restructuring) whereas others had other engaging elements, such as games and videos. This further demonstrates the heterogeneity of the studies included in the review, which limits the ability to identify what the active components of cCBT interventions are.
Most studies in the review were rated as poor quality and highly heterogenous, and it remains unclear as to what the active components of cCBT interventions are.
Implications for practice
The provision of cCBT through the NHS could help some young people who need support for anxiety and depression to access the treatment they need more easily. This could be of particular benefit to young people who would not otherwise be able to access traditional face-to-face therapies or who would prefer something remote. However, this review makes it clear that the evidence base for cCBT is currently weak and that high-quality future research is needed, so caution needs to be taken by practitioners before recommending cCBT programs.
Recently, NICE (2023) published early value assessment guidance on guided self-help digital CBT for children and young people with mild to moderate anxiety and/or low mood, and will make a recommendation as to whether these technologies should be routinely adopted across the NHS. Computerised or digital interventions are the future of mental health services, but researchers first need to ensure there is a solid evidence base of high-quality and rigorous RCTs to support the implementation of these interventions.
The current evidence base for cCBT is weak; so although computerised interventions may be the future of mental health, practitioners must take caution before recommending cCBT programmes.
Statement of interests
None.
Links
Primary paper
Wickersham, A., Barack, T., Cross, L., & Downs, J. (2022). Computerized cognitive behavioral therapy for treatment of depression and anxiety in adolescents: Systematic review and meta-analysis. Journal of Medical Internet Research, 24(4), e29842.
Other references
Cardy, J. L., Waite, P., Cocks, F., & Creswell, C. (2020). A Systematic Review of Parental Involvement in Cognitive Behavioural Therapy for Adolescent Anxiety Disorders. Clinical Child and Family Psychology Review, 23(4), 483–509.
Children and parents: media use and attitudes report 2018. (2019, February 1). Ofcom.
Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60(8), 837–844.
Hollis, C., Falconer, C. J., Martin, J. L., Whittington, C., Stockton, S., Glazebrook, C., & Davies, E. B. (2017). Annual Research Review: Digital health interventions for children and young people with mental health problems – a systematic and meta-review. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 58(4), 474–503.
Khan, K. S., Daya, S., & Jadad, A. (1996). The importance of quality of primary studies in producing unbiased systematic reviews. Archives of Internal Medicine, 156(6), 661–666.
National Institute for Health and Care Excellence. (2023, February 8). Guided self-help digital cognitive behavioural therapy for children and young people with mild to moderate symptoms of anxiety or low mood: early value assessment.
Photo credits
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Thank you for this contribution! It’s interesting to note that the effect size varied depending on the risk of bias ratings, with the strongest evidence found in studies rated as ‘poor’ for depression. Which studies, according to their quality ratings, demonstrated the most robust effect sizes in treating anxiety with cCBT?
Thank you Ivana! For the anxiety meta-analysis, the effect sizes were comparable for studies rated ‘good’ (SMD = -0.25, 95% CI [-0.47, -0.03]) and ‘poor’ (SMD = -0.22, 95% CI [-0.43, -0.02]), but studies rated ‘fair’ had the weakest effect sizes (SMD = −0.08, 95% CI [−0.31 to 0.15]).