Guided iCBT outperforms unguided counterpart in treating depression, according to JAMA paper

The study also found that iCBT both guided and unguided reduced depression symptoms at a higher rate than treatment as usual or a waiting list.
By Laura Lovett
01:07 pm

Guided internet-based cognitive behavioral therapy (iCBT) outperformed both unguided iCBT and treatment as usual for treating depression, according to a new meta-analysis of 39 studies published in JAMA yesterday.

Additionally, researchers found that unguided iCBT also reduced depression symptom compared to treatment as usual and waiting list.

The difference between guided and unguided iCBT comes down to whether or not a patient has access to therapeutic support, either in a synchronous or asynchronous form.

"Although guided iCBT was associated with greater improvement compared with unguided iCBT on average, many people with depression may still benefit from the iCBT without therapeutic guidance, and optimizing treatment assignment would considerably expand treatment coverage worldwide," authors of the analysis wrote.


Researchers used the Patient Health Questionnaire-9 (PHQ-) score, an assessment used for depression, as the main outcome and measure in the study. The aggregated data network meta-analyses found guided CBT more effective than unguided, with a mean difference in post treatment PHQ-9 scores of −0.8; 95% CI, −1.4 to −0.2.

Guided iCBT was also more effective than treatment as usual, with a mean difference of −1.7; 95% CI, −2.3 to −1.1, and waiting list with a mean difference of, −3.3; 95% CI, −3.9 to −2.6, the research revealed.

Unguided iCBT also reduced symptoms compared with TAU (MD, −0.9; 95% CI, −1.5 to −0.3) and waiting list (MD, −2.5; 95% CI, −3.2 to −1.8), according to the paper.

Researchers discovered that the difference in results between unguided and guided iCBT was highest in individuals with moderate to severe depression, whereas the results were more similar in those with mild to moderate depression.


The analysis screened a total of 2,552 full texts and zeroed in on 42 eligible randomized control trials. Of those 39 included patient-level data on 9,751 individuals. Additionally, a further 10.9% of patient-level data was not usable due to missing information on primary outcome. Eventually 8,107 IPDs were synthesized.

In order to be included, the randomized clinical trials needed to be comparing either guided or unguided iCBT against each other or a different type of control, and had to be focused on individuals with depression. The treatments couldn't be blended with in-person treatment or deliver the treatment exclusively through smartphone.


Integrating CBT into digital tools is becoming very popular. The tech has caught the attention of some big health industry names. In 2019, UnitedHealth Group's Optum health purchased AbleTo, which provided guided iCBT, for roughly $470 million.

Additionally, health insurer Aetna International announced it was partnering Wysa, an AI-powered chatbot that provides CBT.


"In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, [and] benefits were more substantial in individuals with moderate to severe depression," the authors wrote.

"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."



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