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Computerized cognitive behavioral therapy (cCBT) has been proven to be effective in depression care. Moreover, cCBT packages are becoming increasingly popular. A central aspect concerning the take-up and success of any treatment is its user acceptance.
The aim of this study was to update and expand on earlier work on user acceptance of cCBT for depression.
This paper systematically reviewed quantitative and qualitative studies regarding the user acceptance of cCBT for depression. The initial search was conducted in January 2016 and involved the following databases: Web of Science, PubMed, the Cochrane Library, and PsycINFO. Studies were retained if they described the explicit examination of the user acceptance, experiences, or satisfaction related to a cCBT intervention, if they reported depression as a primary outcome, and if they were published in German or English from July 2007 onward.
A total of 1736 studies were identified, of which 29 studies were eligible for review. User acceptance was operationalized and analyzed very heterogeneously. Eight studies reported a very high level of acceptance, 17 indicated a high level of acceptance, and one study showed a moderate level of acceptance. Two qualitative studies considered the positive and negative aspects concerning the user acceptance of cCBT. However, a substantial proportion of reviewed studies revealed several methodical shortcomings.
In general, people experience cCBT for depression as predominantly positive, which supports the potential role of these innovative treatments. However, methodological challenges do exist in terms of defining user acceptance, clear operationalization of concepts, and measurement.
Depressive disorders are among the most common and serious mental illnesses [
The concept of user acceptance arose as a key term in the scientific discourse. Definitions of the term differ widely depending on the intended use [
Since the emergence of the first cCBT programs, there have been a number of reviews addressing the user acceptance of cCBT; however, they have utilized different approaches. In their reviews, Titov [
On this basis, we provide a systematic overview on user acceptance of cCBT for depression over the last 10 years and widen the perspective to include the notion that the process of user acceptance spans a number of phases, including accepting, experiencing, and being satisfied with cCBT. We intend to answer the following research questions: (1) which measures were used to examine the user acceptance of cCBT for depression? and (2) to what degree do users accept cCBT for depression?
This systematic review was conducted according to guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [
Since cCBT programs may be also designed for people not undergoing medical treatment, we decided to widen the focus on people with or without medical attention. Thus, studies with participants of all ages with a diagnosis of depression of all degrees of severity were regarded as eligible for inclusion in this review.
All cCBT interventions and their subtypes (eg, mindfulness-based cognitive therapy and behavioral activation) delivered alone or as part of a package of care via the Internet were taken into consideration.
Randomized controlled trials (RCTs), nonrandomized comparative trials, noncomparative trials, and qualitative studies published from July 2007 to January 2016 were included.
Studies were included if they reported on the following: data on user acceptance in terms of acceptability, satisfaction, or experiences concerning cCBT; studies with depression as a primary outcome; and studies providing information on study design and measures, including a description of the delivered treatment and the sample including the number, age, and sex of participants. Studies were excluded if they were not reported in English or German or if they were single case reports.
The search for relevant literature was conducted in four bibliographic databases from July 1, 2007 to January 31, 2016, which are as follows: Web of Science, PubMed, the Cochrane Library, and PsycINFO. Furthermore, the bibliographies of identified papers were searched to identify other potentially eligible papers. Since studies about user acceptance emanate from a young research area, it is conceivable that many studies measure or report about it via proxy indices, which was considered in the search strategy of this study. Considering British and American spelling, a search strategy combining the following search terms was used to ensure complete coverage of studies: Concept 1 (“internet” OR “web” OR “DVD” OR “CD-ROM” OR “online” OR “computer*” OR “e-health” OR “electronic” OR “program” OR “programme”) AND Concept 2 (“CCBT” OR “CBT” OR “cognitive therapy” OR “behavior therapy” OR “behavioral therapy” OR “behavioural therapy” OR “behaviour therapy”) AND Concept 3 (“accept*” OR “satisfaction” OR “adherence” OR “compliance” OR “take up rates” OR “patient dropout rates” OR “reasons for dropout” OR “patient drop-out rates” OR “reasons for drop-out”) AND Concept 4 (“depress*” OR “dysthym*” OR “mood disorder” OR “affective disorder” OR “melancholia”).
After removing duplicates identified in databases and reference lists, titles and abstracts of the texts were scanned to examine indications for meeting the inclusion criteria. For all remaining papers that deemed relevant, the full text was reviewed. All information from the included studies was gathered by one reviewer and checked by a second.
We extracted information on the characteristics of the program, as well as information on the study design, the setting, the ways of recruitment, the sample, dropout and completion rates, and, if available, reasons for dropout.
To allow a better comparability, we transferred the results into levels of acceptance that range from low (−−) to moderate (−) to high (+) to very high (++). The levels follow the results reported in percentage and scale values that were assigned to quartiles. Therefore, results ranging between 0% and 25% were assigned to
If there were considerations of positive and negatives aspects concerning the user acceptance of cCBT, they were characterized (~).
As shown in
Objects of investigation were several cCBT programs, including “MoodGYM” and “Beating the Blues” that were examined most commonly.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of the study selection and eligibility process.
Characteristics of the computerized cognitive behavioral therapy (cCBT) programs.
Author, year, country | Description of the program | Support (nontherapeutic support; therapist support) |
Ahmedani et al, 2015, United States [ |
iCBTa program (no name), brief tailored mobile health intervention, based on a combination of motivational interviewing and CBTb models | yes; no |
Berger et al, 2011, Switzerland [ |
Deprexis, a self-help program comprising 10 content modules and a summary module covering a variety of therapeutic content that is broadly consistent with a cognitive behavioral model | no; yes (participants randomized in guided self-help condition received email contact with a therapist) |
IGc I: unguided self-help condition | ||
IG II: guided self-help condition | ||
Berman et al, 2014, United States [ |
ePST, a 6-session, stand-alone multimedia, interactive, computer-based problem-solving treatment | yes; no |
Boeschoten et al, 2012, The Netherlands [ |
cCBTd program (no name), based on the original “problem-solving therapy,” adjusted for multiple sclerosis patients with comorbid depression and comprising 5 modules containing text, exercise, and examples | yes; no |
Burns et al, 2011, United States [ |
Mobilyze!, an 8-week mobile phone– and Internet-based intervention for depression | yes; yes |
Cartreine et al, 2012, United States [ |
ePST, a 6-session, stand-alone multimedia, interactive, computer-based problem-solving treatment | not reported |
Choi et al, 2012, Australia [ |
The Brighten Your Mood Program, a cultural adapted version of the Sadness Program comprising 6 lessons | yes; no |
Danaher et al, 2013, United States [ |
MomMoodBooster |
yes |
de Graaf et al, 2009, The Netherlands [ |
Colour Your Life, a Web-based multimedia, interactive, self-help cCBT program for depression based on the Dutch version “Coping With Depression course” and comprises 8 weekly sessions | no; only participants who got the intervention + TAU |
Colour Your Life + TAUe | ||
Dear et al, 2013, Australia [ |
Managing Your Mood, a structured 5-lesson Web-based intervention that encourages participants to learn and practice core CBT psychological skills | yes |
Dimidjian et al, 2014, United States [ |
Mindful Mood Balance, a Web-based, 8-session self-administered platform | not reported |
Geraedts et al, 2015, The Netherlands [ |
Happy@Work, a brief 6-lesson Internet intervention based on problem-solving treatment, cognitive therapy, and a guideline for employees to help them prevent work-related stress | yes |
Gerhards et al, 2011, The Netherlands [ |
Colour Your Life |
no; no |
Hind et al, 2010, United Kingdom [ |
Beating the Blues, an interactive computer program with 8 modules for the treatment of depressive and anxiety disorders | yes |
MoodGYM, a freeware cCBT program comprising 5 modules | ||
IG I: Beating the Blues | ||
IG II: MoodGYM | ||
Høifødt et al, 2013, Norway [ |
MoodGYM, a Web-based program containing 5 modules comprising written information, animations, interactive exercises, and quizzes | no; yes |
Kay-Lambkin et al, 2011, Australia [ |
SHADE, a clinician-assisted computer-based psychological treatment comprising 10 sessions and delivered on DVD | yes |
Knowles et al, 2015, United Kingdom [ |
MoodGYM, a Web-based program containing 5 modules comprising written information, animations, interactive exercises, and quizzes | no |
Beating the Blues, an interactive computer program with 8 modules for the treatment of depressive and anxiety disorders | ||
Kok et al, 2014, The Netherlands [ |
Depressionfree, comprising Internet-based preventive cognitive therapy with 8 modules, telephone-delivered psychotherapy and mood monitoring | yes; yes |
Depressionfree + TAU | ||
Lintvedt et al, 2013, Norway [ |
MoodGYM, a self-help program based on principles of CBT, interpersonal therapy, and relaxation techniques comprising 5 modules | no; no |
BluePages provides evidence-based information about depression | ||
Lucassen et al, 2014, New Zealand [ |
Rainbow SPARX, an interactive fantasy game comprising 7 modules designed to deliver CBT for the treatment of clinically significant depression; customized for sexual minority youth | yes |
McMurchie et al, 2013, United Kingdom [ |
Beating the Blues, an interactive computer program with 8 modules for the treatment of depressive and anxiety disorders | yes; no |
Beating the Blues + TAU | ||
Merry et al, 2012, New Zealand [ |
SPARX, an interactive fantasy game comprising 7 modules designed to deliver CBT for the treatment of clinically significant depression | no; no |
O'Mahen et al, 2013, United Kingdom [ |
Postnatal Internet-based behavioral activation (iBAf), adapted for postnatal Web-based delivery from the manual developed for behavioral activation, comprising 11 weekly sessions | Access to Netmums’ general depression chat room monitored by parent supporters and specialist health visitors |
Postnatal iBA + TAU | ||
Perini et al, 2009, Australia [ |
The Sadness Program, a cCBT comprising 6 Web-based lessons, homework assignments, participation in an online discussion forum, and regular email contact with a mental health clinician | yes; yes |
Richards and Timulak, 2013, Ireland [ |
Beating the Blues, an interactive computer program with 8 modules for the treatment of depressive and anxiety disorders | no; only participants who were treated with intervention II got additional support from a therapist |
IG I: Self-administered Beating the Blues | ||
IG II: Therapist-delivered Beating the Blues | ||
Schneider et al, 2014, United Kingdom [ |
MoodGYM, a Web-based program containing 5 modules comprising written information, animations, interactive exercises, and quizzes | yes; no |
Sheeber et al, 2012, United States [ |
Mom-Net program, an 8-session, Internet-facilitated CBT treatment for subthreshold and full syndrome depression, tailored to mothers of young children; the content foundation for the program was the Coping With Depression course | yes |
IG I: Internet-facilitated intervention | ||
IG II: Delayed intervention or facilitated TAU | ||
Stasiak et al, 2014, New Zealand [ |
The journey, a cCBT with 7 modules of well-established core cognitive behavioral therapy techniques. | yes; no |
Titov et al, 2010, Australia [ |
The Sadness Program, a cCBT program comprising 6 Web-based lessons, printable summary and homework assignments, automatic emails, and additional resource documents | yes; yes |
IG I: Technician-assisted group | ||
IG II: Clinician-assisted group |
aiCBT: Internet-based cognitive behavioral therapy.
bCBT: cognitive behavioral therapy.
cIG: intervention group.
dcCBT: computerized cognitive behavioral therapy.
eTAU: treatment-as-usual.
fiBA: Internet-based behavioral activation.
As illustrated in
There were four studies that ascertained take-up, dropout, or completion rates as a means of assessing the user acceptance of cCBT. As
For the studies reporting on dropout rates, the mean percentage of dropout rates was 31.5% (SD 19.49), with a range of 0% to 63%. Twelve trials listed reasons for dropout. The most commonly stated reasons were a lack of time (n=6), technical difficulties, or computer-related problems (n=4), or participants experiencing the treatment as inconvenient (n=4). Since the trials differed in terms of study design, the extent of disclosure, and definitions of dropout and completion, it was difficult to draw comparisons between them regarding completion and dropout rates. Moreover, four studies documented take-up rates as follows: 83.3% [
Two qualitative studies (7%) referred to considerations of positive and negative aspects concerning the user acceptance of cCBT. Specifically, Gerhards et al [
One special feature of three of the studies is the comparison of guided and unguided programs [
Although results give evidence of cCBT for depression being highly accepted, it should be noted that several studies do not give an exact definition of their object of investigation. As a consequence, the studies’ stated objective is not in accordance with the measures that were used to examine the user acceptance of cCBT. These questionnaires did not refer explicitly to acceptability, satisfaction, or experiences but target related constructs such as ease of use [
We intended to conduct a comprehensive review of studies regarding the user acceptance of cCBT for depression, updating the findings of Kaltenthaler et al [
Corresponding with the findings of Kaltenthaler et al [
When examining the user acceptance of cCBT for depression, most studies employed direct measures. Only a few studies made use of only indirect measures and consulted take-up, dropout, or completion rates for examining the user acceptance of cCBT [
In general, the reported take-up rates for cCBT programs were wide ranging, making it difficult to draw comparisons with take-up rates for face-to-face CBT. However, the majority of studies reported dropout rates that are comparable with those reported for face-to-face CBT. In the RCT by Ekeblad et al [
Upon closer examination of the reviewed studies, a number of methodological inaccuracies become apparent. Often no precise distinctions were made regarding the definition of acceptance, operationalization, and presentation of results. As a consequence, terms such as acceptance or acceptability, satisfaction, and usability were used interchangeably, although they can have different meanings [
These theoretical considerations are central to Kollmann [
The studies that made a comparison between guided and unguided cCBT programs regarding user acceptance revealed highly diverse results [
Differentiated user perceptions of cCBT were central in the presentation of qualitative results by Gerhards et al [
To our knowledge, this is the first review updating the state of the art regarding the user acceptance of cCBT for depression since Kaltenthaler et al [
There are a number of limitations to this review. The results of the studies provide a good overview of the user acceptance of cCBT for depression; however, they differ considerably in design, including sample characteristics, program features, and the condition under which treatment was offered. For example, four studies gave information on the user acceptance of cCBT reporting only on those participants who completed the treatment [
There had been considerations to assess the quality of the studies formally. Since we included various study types ranging from RCTs to comparative trials to qualitative studies (see
Furthermore, research on user acceptance is vulnerable to a selection bias because the process of accepting may already begin “before” using an innovative treatment, which means that people who have reservations regarding cCBT for depression may do not get involved in the first place. Moreover, it remains unknown if the refusal to participate in a study originates from reservations regarding cCBT or research itself. At the same time, research aspects may have an opposite unintended consequence; the program may encourage participation and adherence simply because it is being researched. Furthermore, user acceptance of cCBT for depression may be influenced by aspects associated with the user’s medical condition. Thus, depressive mood, a loss of energy and drive as characteristics of depressive disorders may affect the motivation to start or adhere to cCBT. In addition to these aspects, the severity of symptoms and possible comorbidities are difficult to examine in terms of user acceptance.
In conclusion, users of cCBT for depression experience the treatment as predominantly positive, which supports the potential benefit of innovative treatments such as cCBT. The preferred measures for examining the user acceptance in terms of acceptability, satisfaction, and experiences with cCBT were well-established questionnaires but principally study-specific developed questionnaires. Indirect measures such as completion, take-up, and dropout rates, as well as reasons for take-up and dropout were less common. However, there is considerable discrepancy regarding the objective’s definition and operationalization.
As can be seen in
The consideration of qualitative data is important since the accumulated material contains more details about the perspectives of trial participants than quantitative data does. Hence, in addition to take-up, completion, and dropout rates, it is important to learn about the reasons for take-up and dropout because one cannot be sure if discontinuing a treatment results from a negative attitude toward the treatment or other reasons such as those associated with research, technical, or personal circumstances.
A combination of quantitative and qualitative investigation examining expectations and experiences may prove beneficial. With the help of the juxtaposition of expectations and experiences, research on acceptance may fulfill its interpretation as a process in keeping with Kollmann’s [
In accordance with Kaltenthaler et al [
Recommended examination of user acceptance.
Agnes-Davies Relationship Measure
Acceptability of Self-Guided Treatment Questionnaire
Beck depression inventory
baseline
cognitive behavioral therapy
computerized cognitive behavioral therapy
Credibility or Expectancy Questionnaire
Client Satisfaction Questionnaire
follow-up
Internet-based behavioral activation
Internet-based cognitive behavioral therapy
intervention group
multiple sclerosis
Patient, problem, or population; Intervention; Comparison, control, or comparator; Outcome
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
randomized controlled trial
standard deviation
therapy attitude inventory
technology acceptance model
treatment-as-usual
visual analogue scale
Fragebogen zur Patientenzufriedenheit (German version of CSQ-8)
This study was funded in affiliation with the German Research Foundation (DFG, grant number: LO 2171 / 1-1) and is published in affiliation with the German Federal Ministry of Education and Research (grant number: 01GY1613).
None declared.
Characteristics of the studies reviewed.
Measures and results of the studies reviewed.
Dropout and reasons for dropout of the studies reviewed.