Published on 29.09.06 in Vol 8, No 3 (2006)
Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/576, first published Jul 18, 2006.
Directions for the International Society for Research on Internet Interventions (ISRII)
Comment in: Potts HWW. Is E-health Progressing Faster Than E-health Researchers? J Med Internet Res. 2006;8(3) p. e24 http://www.jmir.org/2006/3/e24/
: In 2004, the International Society for Research on Internet Interventions (ISRII) was formed to encourage eHealth researchers to collaborate in their efforts to further the science behind developing, testing, and disseminating Web-based treatment programs. The group held its second meeting (April 2006) to clarify the Society’s direction and identify key issues that need addressing in the field. These issues are identified and examined in the current paper. Given the success of using the Internet to treat a range of medical and mental health problems, and the growing need for better dissemination of health care, Internet interventions will almost certainly play a prominent role in global health. ISRII plans to provide the necessary venue to ensure the science driving this field is strong, enabling researchers to conduct the highest quality research and permitting meaningful conclusions from completed studies.
J Med Internet Res 2006;8(3):e23
The growth in Internet interventions for mental health and behavioral health programs has increased rapidly in the past decade (see ). Internet interventions are treatments, typically behaviorally based, that are operationalized and transformed for delivery via the Internet. Usually, they are highly structured; self-guided or partly self-guided; based on effective face-to-face interventions; personalized to the user; interactive; enhanced by graphics, animations, audio, and video; and tailored to provide follow-up and feedback [ ]. As of early 2006, there were over 25 randomized controlled trials of Internet-based mental health interventions (see reviews [ - ]), and, based on the 2006 meeting of the International Society for Research on Internet Interventions (ISRII) at the Karolinska Institute in Stockholm, Sweden, at least 10 additional Internet intervention trials are nearing completion or are being analyzed for publication (see www.isrii.org for a listing of presentations at the 2006 meeting).
While the feasibility (can the intervention be delivered) of Internet health interventions in general has been well validated, efficacy (is the intervention successful when delivered under controlled conditions ) of Internet applications has now also been established for a number of health problems, including anxiety (eg, panic [ - ], post-traumatic stress disorder [ - ], social anxiety disorder [ , ]), depression [ - ], eating disorders (eg, weight loss [ , ], binge eating and bulimia [ ]), body image [ , ], insomnia [ ], and more general medical areas such as headache [ , ], back pain [ ], diabetes management [ ], encopresis [ ], tinnitus [ - ], and smoking cessation [ ]. True effectiveness (is the intervention successful in actual clinical practice [ ]) and cost-effectiveness trials are underway.
Clearly, there is an appreciation for this new form of treatment and its unique ability to be widely disseminated as millions of dollars have already been allocated by the National Institutes of Health in the United States and other government agencies and various industries around the world. The recommendation of computer-based interventions such as Fear Fighter [, ] (for anxiety) and Beating the Blues [ , ] (for depression) by the United Kingdom’s National Institute for Health and Clinical Excellence (NICE) introduces a new level of acceptance by government and medical insurers of the feasibility and value of such interventions [ ]. This acceptance is an essential step in establishing this mode of treatment delivery (via computers and the Internet). This, along with investigating how Internet interventions compare with more traditional forms of treatment delivery (eg, bibliotherapy, individual and group face-to-face, telephone), will be important in clearly establishing Internet interventions as a viable and effective form of treatment, as well as demonstrating their ability to change behaviors and improve symptoms, cost-effectiveness, scalability, and acceptance in the community.
ISRII is an organization of researchers from around the world whose focus is on the development and testing of various Web-based health treatment programs. The primary aim of the Society is to promote the exchange of ideas and experiences among researchers involved in intervention research using the Internet. Among the many interests shared by the members are cognitive behavioral interventions using the Internet, technical solutions in Web applications, Web-based questionnaire assessments, and computer applications in clinical psychology and in psychiatry more broadly. At the April 2006 meeting, the organization confirmed its aims and identified a number of key issues for the future.
Key Aims and Directions
To continue to conduct the highest quality research and further establish the science of Internet interventions
The primary goal of ISRII is to continue high-quality research to determine the efficacy and effectiveness of health applications on the Internet, which is vital to the future of this mode of treatment. In particular, the Society aims to establish an evidence base for the usefulness of Internet applications across a range of disorders and diseases. This objective represented a major drive for the first ISRII conference in 2004. At these meetings, experts convene to critically review and improve the quality of intervention research undertaken by Society members. By ensuring that programs are empirically validated, reliable, and appropriately generalizable, ISRII distinguishes them from other industry, commercial, or otherwise nonempirically based Web programs.
To facilitate collaboration among Internet intervention researchers
Internet applications are potentially global, and collaboration in research and dissemination is likely to improve the quality and scope of the research, reduce disease burden, and improve outcomes. In particular, there is recognition among the Society researchers of the importance of working strategically to develop and evaluate Internet applications. Scalable, interactive applications are costly and time-consuming to produce, especially if they are to be empirically validated. There is significant potential in strategically developing new websites to reduce duplication and to avoid “dead ends.”
To better understand how behavior change and symptom improvement are produced through the use of Internet interventions
The chief goal of any Internet intervention is to produce cognitive and behavior change that leads to symptom improvement. Examining and testing this process using theories and models of behavior change is critical to furthering the understanding of how Internet interventions, and even treatments in general, work. Models specific to Internet interventions are needed as there are obvious differences in treatment delivery from traditional interventions. Evaluating the Internet as the platform for delivering treatments has some significant advantages over testing more traditional approaches. An advantage of conducting randomized controlled trials through the Internet is the ease of obtaining large sample sizes (no geographical limitations), making it possible to better examine mediators and moderators of treatment. In addition, deconstructing treatments is perfectly suited to Internet intervention research in that the programs are already operationalized and can be readily compartmentalized and studied separately. This may allow for a much better examination of the nonspecific variables of treatment than has been done in the past.
To implement and disseminate Internet applications to anyone, anywhere
A strength of the Society lies in the expertise of its members in delivering Internet applications at a community or population level. Models for the dissemination and implementation of scalable interventions are needed. A special function of the Society will be to organize translation of applications into languages other than the original development language in order to permit broader dissemination.
To develop an understanding of who will use Internet interventions and how to encourage adherence
Determining who wants to use and who is likely to use Internet interventions are important issues to consider for purposes of dissemination. Examining characteristics of Internet intervention users will help not only improve the tailored nature of these programs, but also help better predict outcomes. Poor adherence is a significant issue for most health interventions, including Internet interventions. The World Health Report of 2002 declared that adherence was the primary determinant of the effectiveness of treatment . This issue of adherence is a critical one for Internet intervention researchers and a key area of focus for the Society. Developing ways to reduce attrition, improve adherence, and maintain compliance is a major objective for members of the Society.
To use Internet research applications to collect minimum data sets
The inclusion of standard measures, such as the EuroQol (EQ-5D)  or the SF-12 [ ], will allow comparisons across health care systems (eg, Internet communities, clinical groups, and formal health care services), across health problem samples (eg, applications for depression in comparison to diabetes), and within Internet applications (eg, pre- to post-symptom change due to a program for panic).
To examine and validate current tests and measures for Internet delivery
Before well-validated, paper-and-pencil measures should be delivered online, a process of validating these tests in this new mode should be made. While not a major area of focus for this Society, it is an important related issue which most Internet intervention researchers manage.
To examine and test the validity of a range of new online tests and assessments
Validating new online tests and assessments will lead to a library of useful and valid Internet assessments. For example, creating and testing shortened versions of various psychological scales would be relatively easily achieved by using online surveys to validate the items compared to longer versions. There are multiple reasons to develop and validate briefer tests, including the recognition that the Internet is used in short bursts. Data collection can be rapid on the Internet, especially on open-access sites. The Internet also offers the possibility to considerably reduce the length of questionnaires while maintaining reliability. These “adaptive testing techniques” have been shown to reduce the number of necessary items to almost a quarter of that needed in paper versions of questionnaires  without any loss of accuracy. This area extends to other psychological tests, such as measures of information processing and neuropsychological testing via the Internet.
To provide a forum to examine models of commercialization
Given the time and resources invested in developing and testing Internet interventions, making these programs available to the public is often an important goal. Examining models of commercialization and dissemination to determine how best to make these programs available is critical. Given the research focus of the Society, these models might typically incorporate commercialization that allows continued research and evaluation. A range of business models are available to develop research prototypes into fully scaled applications. There may be joint business opportunities for groups of researchers. Discussions should lead to an understanding of how health structures and health system remuneration within countries influence methods of commercialization. Many researchers are interested in learning how their applications might be sustained when research funding ends. While commercializing is a potentially important area of focus, dissemination, however it may occur, is the goal.
To establish guidelines and parameters for the use of current and future interventions
Given the growth and consumer interest in Internet interventions, it is essential to establish and implement guidelines to identify and tag empirically validated, reliable, and effective applications. At a minimum, statements about minimal guidelines for quality and effectiveness are necessary. The Society also seeks to develop a classification scheme to differentiate intervention types (eg, information-only, interactive with information and decision support, interactive with additional human support) in order to enhance comparisons across applications, as well as improve consumer accessibility and understanding. This would likely also enrich future meta-analyses.
These 10 key issues constitute the main aims and directions of the ISRII. Given the wealth of experience, research, and dedication to the science of this discipline, ISRII expects to make significant and substantive contributions to the field of Internet interventions. The possibility of impacting countless lives with the ability to disseminate interventions anywhere in the world makes the mission of this Society a critical and rewarding endeavour.
The authors thank Frances Thorndike, PhD, at the University of Virginia Health System in Charlottesville, Virginia; Judy Proudfoot, PhD, at the Prince of Wales Hospital in Randwick, Australia; and Isaac Marks, MD, at King’s College in London, UK, for their editorial assistance in the preparation of this manuscript.
Conflicts of Interest
- Wantland DJ, Portillo CJ, Holzemer WL, Slaughter R, Mcghee EM. The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes. J Med Internet Res 2004 Nov 10;6(4):e40 [FREE Full text] [Medline] [CrossRef]
- Ritterband LM, Gonder-Frederick LA, Cox DJ, Clifton AD, West RW, Borowitz SM. Internet interventions: in review, in use, and into the future. Professional Psychology: Research & Practice 2003 Oct;34(5):527-534. [CrossRef]
- Griffiths KM, Christensen H. Review of randomised controlled trials of internet interventions for mental health disorders and related conditions. Clinical Psychologist 2006;10(1):16-29. [CrossRef]
- Griffiths F, Lindenmeyer A, Powell J, Lowe P, Thorogood M. Why are health care interventions delivered over the internet? A systematic review of the published literature. J Med Internet Res 2006;8(2):e10 [FREE Full text] [Medline] [CrossRef]
- Carlbring P, Andersson G. Internet and psychological treatment. How well can they be combined? Comput Hum Behav 2006;22(3):545-553. [CrossRef]
- Murray E, Burns J, See TS, Lai R, Nazareth I. Interactive Health Communication Applications for people with chronic disease. Cochrane Database Syst Rev 2005 Oct 19(4):CD004274. [Medline] [CrossRef]
- Howard KI, Moras K, Brill PL, Martinovich Z, Lutz W. Evaluation of psychotherapy. Efficacy, effectiveness, and patient progress. Am Psychol 1996 Oct;51(10):1059-1064. [Medline] [CrossRef]
- Carlbring P, Brunt S, et al. Remote treatment of panic disorder: A randomized trial of internet-based cognitive behavioral therapy supplemented with telephone calls. Am J Psychiatry . In press.
- Carlbring P, Nilsson-Ihrfelt E, Waara J, Kollenstam C, Buhrman M, Kaldo V, et al. Treatment of panic disorder: live therapy vs. self-help via the Internet. Behav Res Ther 2005 Oct;43(10):1321-1333. [Medline] [CrossRef]
- Klein B, Richards JC. A brief internet-based treatment for panic disorder. Behavioural & Cognitive Psychotherapy 2001;29(1):113-117. [CrossRef]
- Litz BT, Williams L, Wang J, Bryant R; Engel CCJ. A therapist-assisted internet self-help program for traumatic stress. Professional Psychology - Research & Practice 2004 Dec;35(6):628-634. [CrossRef]
- Lange A, Van De Ven JP, Schrieken B. Interapy: treatment of post-traumatic stress via the internet. Cogn Behav Ther 2003;32(3):110-124. [Medline] [CrossRef]
- Lange A, Rietdijk D, Hudcovicova M, Van De Ven JP, Schrieken B, Emmelkamp PMG. Interapy: a controlled randomized trial of the standardized treatment of posttraumatic stress through the internet. J Consult Clin Psychol 2003 Oct;71(5):901-909. [CrossRef] [Medline]
- Carlbring P, Furmark T, Steczko J, Ekselius L, Andersson G. An open study of internet-based bibliotherapy with minimal therapist contact via email for social phobia. Clinical Psychologist 2006 Mar;10(1):30-38. [CrossRef]
- Botella C, Hofmann SG, Moscovitch DA. A self-applied, Internet-based intervention for fear of public speaking. J Clin Psychol 2004 Aug;60(8):821-830. [Medline] [CrossRef]
- Clarke G, Eubanks D, Reid E, Kelleher C, O'connor E, Debar LL, et al. Overcoming Depression on the Internet (ODIN) (2): a randomized trial of a self-help depression skills program with reminders. J Med Internet Res 2005;7(2):e16 [FREE Full text] [Medline] [CrossRef]
- Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ 2004 Jan 31;328(7434):265 [FREE Full text] [Medline] [CrossRef]
- Andersson G, Bergström J, Holländare F, Carlbring P, Kaldo V, Ekselius L. Internet-based self-help for depression: randomised controlled trial. Br J Psychiatry 2005 Nov;187(5):456-461. [Medline] [CrossRef]
- Tate DF, Wing RR, Winett RA. Using Internet technology to deliver a behavioral weight loss program. JAMA 2001 Mar 7;285(9):1172-1177 [FREE Full text] [Medline] [CrossRef]
- Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. JAMA 2003 Apr 9;289(14):1833-1836 [FREE Full text] [CrossRef] [Medline]
- Ljótsson B, Mitsell K, Lundin C, Carlbring P, Ghaderi A. Remote treatment of bulimia nervosa and binge eating disorder: a randomized trial of Internet-based cognitive behavioral therapy. Behav Res Ther . In press.
- Celio AA, Winzelberg AJ, Dev P, Taylor CB. Improving compliance in on-line, structured self-help programs: evaluation of an eating disorder prevention program. J Psychiatr Pract 2002 Jan;8(1):14-20. [Medline] [CrossRef]
- Winzelberg AJ, Eppstein D, Eldredge KL, Wilfley D, Dasmahapatra R, Dev P, et al. Effectiveness of an Internet-based program for reducing risk factors for eating disorders. J Consult Clin Psychol 2000 Apr;68(2):346-350. [Medline] [CrossRef]
- Ström L, Pettersson R, Andersson G. Internet-based treatment for insomnia: a controlled evaluation. J Consult Clin Psychol 2004 Feb;72(1):113-120. [Medline] [CrossRef]
- Ström L, Pettersson R, Andersson G. A controlled trial of self-help treatment of recurrent headache conducted via the Internet. J Consult Clin Psychol 2000 Aug;68(4):722-727. [Medline] [CrossRef]
- Andersson G, Lundström P, Ström L. Internet-based treatment of headache: does telephone contact add anything? Headache 2003 Apr;43(4):353-361. [Medline] [CrossRef]
- Buhrman M, Fältenhag S, Ström L, Andersson G. Controlled trial of Internet-based treatment with telephone support for chronic back pain. Pain 2004 Oct;111(3):368-377. [Medline] [CrossRef]
- Mckay HG, Glasgow RE, Feil EG, Boles SM, Barrera MJ. Internet-based diabetes self-management and support: initial outcomes from the diabetes network project. Rehabilitation Psychology 2002 Feb;47(1):31-48. [CrossRef]
- Ritterband LM, Cox DJ, Walker LS, Kovatchev B, Mcknight L, Patel K, et al. An Internet intervention as adjunctive therapy for pediatric encopresis. J Consult Clin Psychol 2003 Oct;71(5):910-917. [CrossRef] [Medline]
- Andersson G, Strömgren T, Ström L, Lyttkens L. Randomized controlled trial of internet-based cognitive behavior therapy for distress associated with tinnitus. Psychosom Med 2002 Sep;64(5):810-816 [FREE Full text] [Medline] [CrossRef]
- Andersson G, Kaldo V. Internet-based cognitive behavioral therapy for tinnitus. J Clin Psychol 2004 Feb;60(2):171-178. [Medline] [CrossRef]
- Kaldo-Sandström V, Larsen HC, Andersson G. Internet-based cognitive-behavioral self-help treatment of tinnitus: clinical effectiveness and predictors of outcome. Am J Audiol 2004 Dec;13(2):185-192. [Medline] [CrossRef]
- Lenert L, Muñoz RF, Perez JE, Bansod A. Automated e-mail messaging as a tool for improving quit rates in an internet smoking cessation intervention. J Am Med Inform Assoc 2004 Jul;11(4):235-240 [FREE Full text] [Medline] [CrossRef]
- Kenwright M, Liness S, Marks I. Reducing demands on clinicians by offering computer-aided self-help for phobia/panic. Feasibility study. Br J Psychiatry 2001 Nov;179(5):456-459 [FREE Full text] [Medline] [CrossRef]
- Marks IM, Kenwright M, Mcdonough M, Whittaker M, Mataix-Cols D. Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomized controlled trial in phobia/panic disorder. Psychol Med 2004 Jan;34(1):9-17. [Medline] [CrossRef]
- Mccrone P, Knapp M, Proudfoot J, Ryden C, Cavanagh K, Shapiro DA, et al. Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. Br J Psychiatry 2004 Jul;185(1):55-62 [FREE Full text] [Medline] [CrossRef]
- Proudfoot J, Ryden C, Everitt B, Shapiro DA, Goldberg D, Mann A, et al. Clinical efficacy of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. Br J Psychiatry 2004 Jul;185(1):46-54 [FREE Full text] [Medline] [CrossRef]
- ; National Institute for Health and Clinical Excellence. Depression and anxiety - computerised cognitive behavioural therapy (CCBT). London, UK: National Institute for Health and Clinical Excellence; 2006. URL: http://www.nice.org.uk/page.aspx?o=TA97 [accessed 2006 Sep 23] [WebCite Cache]
- ; World Health Organization. The world health report 2002: reducing risks, promoting healthy lifestyle. Geneva, Switzerland: World Health Organization; 2002.
- Brooks R. EuroQol: the current state of play. Health Policy 1996 Jul;37(1):53-72. [Medline] [CrossRef]
- Ware J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996 Mar;34(3):220-233. [Medline] [CrossRef]
- Gardner W, Shear K, Kelleher KJ, Pajer KA, Mammen O, Buysse D, et al. Computerized adaptive measurement of depression: a simulation study. BMC Psychiatry 2004 May 6;4(1):13 [FREE Full text] [Medline] [CrossRef]
|ISRII: International Society for Research on Internet Interventions|
|NICE: National Institute for Health and Clinical Excellence|
Edited by G. Eysenbach; submitted 18.07.06; peer-reviewed by H Potts, JWH van der Slikke; comments to author 31.08.06; accepted 31.08.06; published 29.09.06
© Lee M Ritterband, Gerhard Andersson, Helen M Christensen, Per Carlbring, Pim Cuijpers. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 29.09.2006. Except where otherwise noted, articles published in the Journal of Medical Internet Research are distributed under the terms of the Creative Commons Attribution License (http://www.creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited, including full bibliographic details and the URL (see "please cite as" above), and this statement is included.