Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis

Figures & data

Figure 1. Study inclusion process throughout the review.

Table 1. Characteristics of the included studies.

										Quality criteria
Country (Reference)	Disorder				Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Type of therapy (number of modules/sessions; weeks of therapy)	RSG (sel. bias)	AC (sel. bias)	Blinding (det. bias)	Incomp. data (att. bias)	Selectiv. report (report bias)	Drop-outs post	ITT	Sample (clinical or self-Ref.)
		N	N	Out-come	INT	INT	FTF	FTF
		INT	FTF		pre	post	pre	post
SAD
Sweden	Social anxiety disorder	64	62	LSAS	68.4 (21.0)	39.4 (19.9)	71.9 (22.9)	48.5 (25.0)	INT: CBT (15; 15 w)	Low risk	Low risk	Low risk	Low risk	Low risk	12%	Y	Mixed
Hedman, Andersson, et al. (2011)									FTF: group CBT (15; 15 w)
Australia	Social anxiety disorder	23	14	SIAS	54.5 (12.4)	44.0 (15.9)	57.8 (43.9)	43.9 (18.7)	INT: CBT (6; 8 w)	Low risk	Unclear	NA-SR	Low risk	Low risk	32%	Y	Clinical
Andrews et al. (2011)									FTF: group CBT (7; 7 w)
Spain	Social anxiety disorder	62	36	FPSQ	53.3 (14.3)	39.7 (15.5)	50.5 (11.9)	39.3 (13.0)	INT: CBT (- ;8 w)	Unclear	Unclear	NA-SR	High risk?	Low risk	55%	Y	Mixed
Botella et al. (2010)									FTF: CBT(16;8 w)
Panic disorder
Sweden	Panic disorder	25	24	BSQ	48.7 (11.7)	31.8 (11.6)	52.6 (10.8)	31.3 (9.1)	INT: CBT (10; 10 w)	Low risk	Low risk	NA-SR	Low risk	Low risk	12%	Y	Self-Ref.
Carlbring et al. (2005)									FTF: CBT(10;10 w)
Sweden	Panic disorder	53	60	PDSS	14.1 (4.3)	6.3 (4.7)	14.2 (4.0)	6.3 (5.6)	INT: CBT (10;10 w)	Low risk	Low risk	Low risk	Low risk	Low risk	18%	Y	Mixed
Bergström et al. (2010)									FTF: group CBT (10; 10 w)
Australia	Panic disorder	46	40	PDSS	14.9 (4.4)	9.9 (5.9)	14.8 (4.0)	9.2 (5.7)	INT: CBT (6; 12 w)	Low risk	Low risk	Low risk	Low risk	Low risk	0%	Y	Self-Ref.
Kiropoulos et al. (2008)									FTF: CBT (12;12 w)
Depression
The Netherlands	Depressive symptoms in elderly	102	99	BDI	19.2 (7.2)	12.0 (8.1)	17.9 (10.0)	11.4 (9.4)	INT: (CBT (8; 8 w)	Low risk	Low risk	NA-SR	High risk?	Low risk	39%	Y	Self-Ref.
Spek et al. (2007)									FTF: Group CBT (10; 10 w)
Switzerland	Depressive symptoms	32	30	BDI	23.0 (6.1)	12.4 (10.0)	23.4 (7.6)	12.3 (8.8)	INT: CBT (7;8 w)	Low risk	Unclear	NA-SR	Low risk	Low risk	15%	Y	Self-Ref.
Wagner et al. (2014)									FTF: CBT (8; 8 w)
Sweden	Depressive symptoms	33	36	MADRS-S	23.6 (4.8)	13.6 (9.8)	24.1 (5.0)	17.1 (5.0)	INT: CBT (7; 7 w?)	Low risk	Low risk	NA-SR	Low risk	Low risk	6%	Y	Self-Ref.
Andersson, Hesser, et al. (2013)									FTF: Group CBT (8; 8w)
Finland	Depressive symptoms	19	19	BDI-II	20.8 (9.3)	10.3 (8.2)	23.1 (6.4)	9.2 (5.2)	INT: ACT (?; 6 w)	Unclear	Unclear	NA-SR	Low risk	Low risk	3%	N	Self-Ref.
Lappalainen et al. (2014)									FTF: ACT (6; 6 w)
Body image
Australia	Body dissatisfaction	21	19	BSQ*	129.1 (27.3)	98.4 (35.6)	140.8 (37.2)	109.6 (47.7)	INT: CBT (8; 8 w)	Unclear	Low risk	NA-SR	Low risk	Low risk	17.5%	Y	Self-Ref.
Gollings and Paxton (2006)									FTF: group CBT (8; 8 w)
Australia	Body dissatisfaction, disordered eating	42	37	BSQ*	134.3 (22.5)	116.8 (35.9)	143.3 (28.9)	105.8 (34.0)	INT: CBT (8; 8 w)	Low risk	Low risk	NA-SR	Low risk	Low risk	26%	Y	Sel-Ref.
Paxton et al. (2007)									FTF: group CBT (8; 8 w)
Tinnitus
Sweden	Tinnitus	26	25	TRQ	26.4 (15.6)	18.0 (16.2)	30.0 (18.0)	18.6 (17.0)	INT: CBT (6; 6 w)	Low risk/unclear	Low risk/unclear	NA-SR	Low risk	Low risk	14%	Y	Mixed
Kaldo et al. (2008)									FTF: Group CBT (7;7 w)
Germany	Tinnitus	41	43	Mini-TQ	12.2 (4.6)	7.4 (5.3)	14.2 (4.5)	8.1 (4.9)	INT: (12–18; 10 w)	Low risk	Low risk	NA-SR	Low risk	Low risk	7%	Y	Mixed
Jasper et al. (2014)									FTF: (10, 10 w)
Sexual problems
USA	Male sexual dysfunction	41	40	IIEF	27.4 (17.3)	31.3 (20.4)	26.4 (18.2)	34.4 (22.2)	INT: CBT (-, 12w)	Unclear	Unclear	NA-SR	Low risk	Low risk	20%	Y	Mixed
Schover et al. (2012)									FTF: I-CBT (3;12w)
Chronic pain
Spain	Fibromyalgia	20	20	FIQ	56.6 (19.8)	57.0 (18.2)	68.4 (19.5)	58.2 (18.6)	INT:CBT (10; 10w)	Low risk	Unclear	NA-SR	Low risk	Unclear	0%	Y	Clinical
Vallejo et al. (2015)									FTF: Group CBT (10;10w)
Specific phobia
Sweden	Spider phobia	15	15	BAT		10.5 (1.5)		11.1 (1.2)	INT: CBT (5; 4 w)	Unclear	Unclear	NA-SR	Low risk	Low risk	10%	No	Self-Ref.
Andersson et al. (2009)									FTF: CBT (2;1 w)
Sweden	Snake phobia	15	15	BAT	4.1 (3.3)	3.0 (3.1)	9.6 (2.6)	11.2 (2.1)	INT: CBT (4; 4 w)	Low risk	Low risk	Unclear	Low risk	Low risk	13%	No	Self-Ref.
Andersson, Waara, et al. (2013)									FTF CBT (2; 1 w)
Insomnia
The Netherlands	Insomnia	30	30	ISI	18.2 (2.9)	12.4 (4.8)	17.3 (2.9)	7.1 (4.2)	INT: CBT (6; 8 w)	Unclear	Unclear	NA-SR	Low risk	Low risk	8%	Y	Self-Ref.
Lancee et al. (2016)									FTF: CBT (6; 12 w)
Sweden	Insomnia	24	24	ISI	18.7 (4.4)	9.7 (5.3)	17.9 (3.9)	8.4 (4.9)	INT: CBT (8; 8 w)	Low risk	Low risk	NA-SR	Low risk	Low risk	6%	Y	Self-Ref.
Blom et al. (2015)									FTF: Group CBT (8; 8 w)

Abbreviations: INT, internet-treatment; FTF, Face-to-face treatment; RSG, random sequence generation; AC, allocation concealment; Incomp., incomplete; Selectiv., selective; ITT, intention-to-treat; Self-ref, self-referred; Sel., Selection; CBT, Cognitive Behavior Therapy; W, weeks; NA-SR, Not applicable due to self-report; LSAS; Liebowitz Social Anxiety Scale; SIAS, Social Interaction Anxiety Scale; FPSQ, Fear of Public Speaking Questionnaire; BSQ, Body Sensation Questionnaire; BSQ*, Body Shape Questionnaire; PDSS, Panic Disorder Severity Scale; BDI, Beck Depression Inventory; MADRS-S, Montgomery Åsberg Depression Rating Scale—Self-rated; TRQ, Tinnitus Reaction Questionnaire; Mini-TQ, Mini Tinnitus Questionnaire; IIEF, International Index of Erectile Function; FIQ, Fibromyalgia Impact Questionnaire; BAT, Behavioral approach test.

Figure 2. Forest plot displaying effect sizes of studies comparing internet-based treatment with face-to-face treatment.

Figure 3. Estimated risk of bias across all included studies.

Note: Studies using self-report only were omitted from assessment of blinding of outcome assessment. Hence, the white space in the bar for detection bias.

Figure 4. Funnel plot to assess for publication bias by relating effect sizes of the studies to standard errors.

Abbreviation: SMD, standardized mean difference.

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