Journal of Affective Disorders 199 (2016) 3041

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Review article

Transdiagnostic computerised cognitive behavioural therapy

for depression and anxiety: A systematic review and meta-analysis
Jill M. Newby a,n, Conal Twomey b, Susan Shi Yuan Li a, Gavin Andrews a
a
Clinical Research Unit for Anxiety and Depression (CRUfAD), School of Psychiatry, Faculty of Medicine, UNSW Australia at St Vincent's Hospital, Sydney,
Australia
b
Faculty of Social and Human Sciences, University of Southampton, Southampton, UK

art ic l e i nf o

a b s t r a c t

Article history:
Received 12 January 2016
Received in revised form
17 February 2016
Accepted 7 March 2016
Available online 24 March 2016

An increasing number of computerised transdiagnostic cognitive behavioural therapy programs (TDcCBT) have been developed in the past decade, but there are no meta-analyses to explore the efcacy of
these programs, nor moderators of the effects. The current meta-analysis focused on studies evaluating
TD-cCBT interventions to examine their effects on anxiety, depression and quality of life (QOL). Results
from 17 RCTs showed computerised TD-cCBT outperformed control conditions on all outcome measures
at post-treatment, with large effect sizes for depression (g's .84), and medium effect sizes for anxiety
(g .78) and QOL (g .48). RCT quality was generally good, although heterogeneity was moderate to high.
Further analyses revealed that studies comparing TD-cCBT to waitlist controls had the largest differences
(g .93) compared to active (g .59) and usual care control groups (g .37) on anxiety outcomes, but
there was no inuence of control group subtype on depression outcomes. Treatment length, symptom
target (mixed versus anxiety only), treatment design (standardised versus tailored), and therapist
experience (students versus qualied therapists) did not inuence the results. Preliminary evidence
from 4 comparisons with disorder-specic treatments suggests transdiagnostic treatments are as effective for reducing anxiety, and there may be small but superior outcomes for TD-cCBT programs for
reducing depression (g .21) and improving QOL (g .21) compared to disorder-specic cCBT. These
ndings show that TD-cCBT programs are efcacious, and have comparable effects to disorder-specic
cCBT programs.
& 2016 Elsevier B.V. All rights reserved.

Keywords:
Transdiagnostic, Cognitive Behaviour Therapy (CBT), depression, anxiety, computer,
internettreatment outcome
Meta-analysis
Systematic review
Depression
Anxiety
Transdiagnostic

Contents
1.
2.

3.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
1.1.
Aim/objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.1.
Protocol and registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.2.
Inclusion/Eligibility criteria (PICOS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.3.
Excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.4.
Identication and selection of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.5.
Study selection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.6.
Data extraction and management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.7.
Primary and secondary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.7.1.
Primary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.7.2.
Secondary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.7.3.
Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.8.
Risk of bias in individual studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Statistical analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.1.
Calculation of effect sizes: TD-cCBT versus controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.2.
Testing homogeneity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Corresponding author.
E-mail address: j.newby@unsw.edu.au (J.M. Newby).

http://dx.doi.org/10.1016/j.jad.2016.03.018
0165-0327/& 2016 Elsevier B.V. All rights reserved.

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

31

3.2.1.
Subgroup analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Risk of bias across studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.3.1.
Testing for publication bias and dealing with publication bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.1.
Study selection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.2.
Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.3.
Risk of bias in randomised controlled trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.4.
Synthesis of results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.4.1.
Between-group effects of TD-cCBT versus control groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.4.2.
Comparisons between TD-cCBT versus controls on secondary outcome measures (generalised anxiety, social anxiety and panic
disorder severity). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.4.3.
Comparisons between TD-cCBT versus disorder-specic treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.5.
Subgroup analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.5.1.
Tailored versus standardised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.5.2.
Treatment modules (less than 6 modules [short] versus 6 or more [long]) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.5.3.
Treatment target (anxiety only versus anxiety and depression) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.5.4.
Control type (waitlist control, usual care, active control) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.5.5.
Clinical prole (clinical versus non-clinical) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.5.6.
Therapist experience level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.6.
Publication bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5.1.
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
5.2.
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Appendix A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.3.

1. Introduction
Depression and anxiety disorders represent two of the top ve
leading causes of disability worldwide (Vos et al., 2015). These
disorders have high comorbidity rates, share many similar symptoms, features, latent structure, and vulnerability factors (Goldberg
et al., 2009; Watson, 2005). Cognitive Behavioural Therapy (CBT) is
currently recommended as the rst-line treatment for depressive
and anxiety disorders, as a stand-alone intervention for mild to
moderate cases, or in combination with pharmacological treatments for more complex cases and those with comorbidities
(Pilling et al., 2011). While the majority of CBT manuals and
treatment evaluations have been diagnosis-driven (i.e., designed
to target specic disorders), transdiagnostic CBT protocols have
also been shown to be effective (Norton and Philipp, 2008).
Transdiagnostic CBT interventions bring together the core components of CBT, such as psychoeducation, skills practice (e.g., cognitive
challenging, graded exposure, activity planning) and relapse prevention, with the aim of targeting shared cognitive, emotional and behavioural maintaining factors cutting across diagnostic categories
(McEvoy et al., 2009). Rather than delivering separate programs for
separate diagnoses, transdiagnostic CBT interventions focus on commonalities across disorders and address heterogeneous emotional
disorders and comorbidities within the one treatment protocol. There
are several practical advantages of the transdiagnostic approach including increased efciency, and ease of implementation. Although the
majority of studies of transdiagnostic interventions report the efcacy
of face-to-face treatments (e.g., Barlow et al., 2004 and see; Newby
et al. (2015) for a review), there is now a substantive literature reporting positive effects of transdiagnostic CBT programs delivered via
the computer or internet. There have been a wide variety of TD-cCBT
programs that have now been shown to be effective, including standardised programs for mixed anxiety disorders (Johnston et al., 2013),
and anxiety and depression (Newby et al., 2013; Titov et al., 2011), as
well as modularised and tailored treatment packages (Carlbring et al.,
2011; Nordgren et al., 2014).
Computerised CBT has several benets compared to face-to-face
treatment, including high treatment delity, increased convenience,
reduced cost, and scalability. Computerised interventions essentially

deliver CBT 101; the core components of CBT including psychoeducation, cognitive (e.g., thought monitoring, cognitive restructuring) and
behavioural therapy (e.g., behavioural activation and graded exposure)
components within a series of modules/lessons, supplemented by
additional homework assignments to consolidate the learning of key
concepts. Clinician guidance is typically provided in the form of email
or telephone contact throughout the intervention period.
To our knowledge there are no existing systematic reviews or
meta-analyses solely focused on transdiagnostic computerised CBT
interventions (TD-cCBT). In the only meta-analysis to include TD-cCBT
with face-to-face protocols, Newby et al. (2015) found that the
pooled within-group effect sizes pre-to-post treatment reductions in
depression and anxiety symptoms were large for TD-cCBT, and
similar to the effect sizes pooled across individual face-to-face transdiagnostic interventions. However, the study by Newby et al. (2015)
was focused on a broad array of transdiagnostic treatment approaches
including CBT and other psychotherapies (e.g., mindfulness-based interventions), and did not examine the overall efcacy of TD-cCBT
programs.
There have been no meta-analytic reviews to explore the overall
efcacy of computerised TD-cCBT interventions versus control
groups, including disorder-specic CBT control interventions. Individual RCTs have generally failed to nd a signicant difference
between computerised TD-cCBT versus disorder-specic CBT interventions (e.g., Berger et al., 2014; Dear et al., 2015). However, is
unclear whether these ndings are due to a lack of power, or lack of
difference between the two approaches. Combining the results
across individual RCTs using meta-analytic techniques will result in
greater power to explore this question. It is also unknown what
features, components and aspects of the program render these TDcCBT programs efcacious. The existing programs differ in their
targeted conditions (e.g., mixed anxiety disorders versus anxiety
and depression), the length, whether they are self-or clinicianguided, and the level of therapist expertise and training.
1.1. Aim/objectives
The overall aim of this study was to conduct a systematic review and meta-analysis of RCTs of computerised TD-cCBT. Our

32

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

specic aims were:

1. To investigate the efcacy of TD-cCBT compared to waiting list or
usual care or placebo control groups, as well as disorder-specic CBT.
2. To investigate the moderators of treatment effects including
therapeutic factors (dose, treatment target, and therapist experience level), and sample characteristics (e.g., clinical/nonclinical or mixed sample).
Because the most recent meta-analysis of face-to-face transdiagnostic CBT found moderate effect size superiority over control
conditions for anxiety severity at post-treatment (Reinholt and
Krogh, 2014), we hypothesised that computerised TD-cCBT would
outperform control conditions.

journal up to October 8, 2015. We included all randomised

controlled trials comparing transdiagnostic interventions to a
control condition. RCTs with multiple control conditions were
also included as long as all of the other inclusion criteria were
met. We included randomised trials in which the effects of
transdiagnostic treatment were compared with either: (a) a notreatment (WLC) condition; (b) a care-as-usual, or treatment-asusual control condition (TAU); (c) another control psychological
treatment (e.g., relaxation) or attention control condition; or
(d) a disorder-specic psychological treatment. This enabled us
to calculate between-groups effect sizes based on comparisons
between conditions at post-treatment. Diagnostic status was not
used as an outcome variable because there were too few studies
that reported this variable at post-treatment or follow-up.
2.3. Excluded studies

2. Methods
2.1. Protocol and registration
This systematic review was conducted in accordance with the
PRISMA guidelines (Moher et al., 2009), and the review protocol
was developed following the procedures outlined in the Cochrane
Handbook for systematic reviews (Higgins and Green, 2011). The
protocol was registered with PROSPERO1 [CRD42015023744].
2.2. Inclusion/Eligibility criteria (PICOS)

(1) Participants: studies were included in which participants were

adults (18 years and older), who had elevated symptoms of distress, anxiety and/or depression, or a diagnosis of either an anxiety
disorder, mixed anxiety disorder and depression, and/or a depressive disorder according to DSM or ICD. Studies of participants
seeking treatment for anxiety/depression were also included.
(2) Interventions: we included studies of transdiagnostic interventions delivered over the internet or via computer. Self-help and
clinician-guided interventions were included, along with interventions that were delivered solely via mobile phone application.
Transdiagnostic interventions were dened as those which are
treatments designed specically to target either: (i) depression
and anxiety, (ii) mixed anxiety disorders/symptoms, or (iii) the
diagnosis of mixed depression and anxiety. The comorbid disorders do not necessarily have to be within the same individual
for an intervention to be considered transdiagnostic. For example,
the treatment may be broad spectrum (e.g., CBT for anxiety, for a
sample of individuals with heterogeneous anxiety disorders such
as GAD, panic disorder or social anxiety disorder), or may specically be designed to target individuals who are experiencing
comorbidity (e.g., CBT for GAD and MDD comorbidity).
(3) Comparisons: studies were included that reported comparisons
between transdiagnostic computerised treatments and waiting
list (delayed treatment control groups), treatment-as-usual or
usual care control groups (TAU), disorder-specic interventions,
or psychological treatment placebo control groups.
(4) Outcomes: studies that reported at least one self-report and/or
clinician-rated measure of depression or anxiety symptoms at
post-treatment for both of the groups were included. This enabled
us to calculate between-groups effect sizes based on comparisons
between conditions at post-treatment. To explore the maintenance
of gains following treatment, data at short-term 36-months posttreatment) and long-term (12 months and beyond) were extracted.
(5) Studies: we included studies published in a peer-reviewed
1

http://www.crd.york.ac.uk/PROSPERO/index.asp

We excluded studies in which the psychological treatment was

not delivered via computer or the internet, studies in which there
was insufcient data reported to calculate effect sizes and where we
could not obtain those data, and studies that focused on samples
under age 18. Case series, case reports, non-randomised studies,
and open trials were excluded. Studies with mixed samples with
psychotic disorders, personality disorders, and substance use disorders were excluded. Interventions that involved combinations of
pharmacological and psychological interventions were excluded.
Studies that evaluate the impact of disorder-specic interventions
(designed to treat one depressive or anxiety disorder diagnosis)
which did not target relevant comorbidities were excluded.
2.4. Identication and selection of studies
To identify studies for possible inclusion, we conducted comprehensive systematic searches of the electronic databases PSYCInfo,
EMBASE, PUBMED, MEDLINE, the Cochrane Register of Controlled
Trials and Google Scholar up to 8 October 2015 (see Appendix A for
our electronic search strategy for PSYCInfo). To broaden the search
criteria and maximise the sensitivity of our search, we combined
terms indicative of anxiety, depression, mixed anxiety and depression, anxious depression, as well as various anxiety and depressive
disorders with the terms transdiagnostic and CBT and psychotherapy. We searched for randomised trials. We also searched the references lists of relevant manuscripts and previous reviews of this literature, to identify additional studies that met our inclusion criteria.
2.5. Study selection
Both the rst and second authors (JN and CT) screened all of the
titles and abstracts for all studies to determine their relevance to
this study. Studies that could be immediately excluded on the
basis of the title and abstract were discarded. For the remaining
references, both JN and CT independently reviewed full text
manuscripts to assess eligibility for inclusion, and disagreements
were resolved through discussion.
2.6. Data extraction and management
Data regarding methodology and outcome measures were extracted into a Microsoft Excel spread sheet by JN and SL, before
being transferred to Comprehensive Meta-Analysis (version 3.0;
Biostat, Inc.) for the meta-analysis. The following information from
each study was extracted: authors, year of publication, sample size,
country mean age, type of intervention (self-help or clinician-guided), type of control condition (i.e., WLC, TAU), length and dose of
treatment (number of modules/lessons and duration of intervention
period), treatment target (depression and anxiety or mixed

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

anxiety), qualication level of clinicians, tailored/standardised intervention, self-report symptom severity (depression, generalised
anxiety, social anxiety, panic disorder, quality of life), adherence,
adverse events. For multiple reports of the same study, we combined the outcome measures and considered them as one study.
2.7. Primary and secondary outcomes
2.7.1. Primary outcomes
Self-reported symptoms of depression, anxiety and functional impairment/quality of life according to continuous outcome measures.
2.7.2. Secondary outcomes
(i) Self-reported generalised anxiety, social anxiety and panic
disorder severity, according to continuous symptom measures.
(ii) Adherence (proportion of participants who complete the
treatment).
(iii) Adverse reactions (patients with worsening, or other negative effects during the intervention or control period).
2.7.3. Follow-up
We analysed data comparing TD-cCBT to control groups at posttreatment. We extracted and analysed outcome data on primary
and secondary outcomes at post-treatment. There was not enough
information reported in the studies to analyse diagnostic status
following treatment, nor follow-up comparisons. Because many of
the studies used more than one instrument to measure depression
or anxiety, we used the primary outcome as reported by the study
investigators, or if absent, we used the most frequently used measures across studies (e.g., BDI, PHQ-9, DASS-21 depression subscale).
All included studies reported means and standard deviations at
post-intervention, allowing us to calculate the effect size directly.
2.8. Risk of bias in individual studies
We assessed the quality and risk of bias of included trials using the
Risk of Bias tool, developed by the Cochrane Collaboration (Higgins
and Green, 2011). This tool allowed us to assess possible sources of risk
in RCTs, including: (1) allocation sequence, (2) allocation concealment,
(3) blinding of participants, personnel and outcome assessors, (4) incomplete outcome data, and (5) selective reporting. The assessment of
study quality was conducted by two independent reviewers (JN and an
independent research assistant) and disagreements were resolved via
discussion. See Table 1 for quality ratings of included controlled trials.

3. Statistical analyses
3.1. Calculation of effect sizes: TD-cCBT versus controls
For each comparison between TD-cCBT and a control condition, we
calculated the effect size (Hedges g) referring to the difference between the two groups at post-treatment (standardised mean difference) and the 95% condence intervals around the effect sizes. Effect
sizes were calculated by subtracting the average score of the transdiagnostic treatment at post-treatment from the average score for the
control group, and dividing the result by the pooled standard deviation of the two groups. Effect sizes of .2, .5 and .8 refer to small,
moderate and large effect sizes respectively (Cohen, 1988). Effect sizes
were also adjusted to address small sample sizes, according to the
procedures outlined in Hedges and Olin (1985, or Hedges g).
To calculate pooled mean effect sizes, we used the program
Comprehensive Meta-Analysis (version 3.0, Biostat Inc.). Given
there is variability across the interventions, we calculated the mean
effect sizes using a random effects model. The random effects model
assumes that the true effect size varies from one study to the next,

33

and that the studies in our analysis represent a random sample of

effect sizes that could have been observed. The summary effect is
our estimate of the mean of these effects (Borenstein et al., 2009).
3.2. Testing homogeneity
To test the homogeneity of effect sizes, we calculated the I2
statistic, which is an indicator of heterogeneity across effect sizes,
and is provided as a score in percentages. A value of 0% indicates
no heterogeneity, whereas scores of 25%, 50% and 75% indicate
low, moderate, and high heterogeneity, respectively.
3.2.1. Subgroup analyses
A number of subgroup analyses were planned, in which treatment
type (tailored versus standardised), treatment target (mixed symptoms of anxiety and depression versus anxiety only), control condition type (waitlist versus active versus usual care), treatment length
(short/less than 6 modules versus long/6 or more modules), clinical
patient prole (non-clinical versus clinical) was examined, using a
mixed-effects model. There was only one purely self-guided program,
so we did not compare self-guided to clinician-guided programs. In
this model, a random-effects model is used to pool studies within
subgroups (e.g., tailored program), and we test for signicant differences between subgroups using a random-effects model.
3.3. Risk of bias across studies
3.3.1. Testing for publication bias and dealing with publication bias
To test for publication bias, we inspected the funnel plot on the
primary outcome measures (for depression, anxiety and quality of
life measures respectively) (Egger et al., 1997). In addition, we also
conducted Duval and Tweedie's Trim and Fill procedure (Duval and
Tweedie, 2000a, 2000b) within Comprehensive Meta-Analysis,
which yields an adjusted effect size that takes into account the
publication bias observed within the funnel plot. This procedure
corrects for the variance of the effects and provides a best estimate
of the unbiased effect size.
4. Results
4.1. Study selection
Fig. 1 presents the owchart describing the inclusion of studies. A total of 7742
titles and abstracts were examined. 7706 were rejected at title and abstract, and a
further 17 were rejected after the entire article was reviewed. This left a total of 17
included RCTs; of these there were 20 comparisons. One study by Titov et al. (2013)
compared internet-delivered TD-cCBT with and without automated emails compared to a WLC group. Because there were no signicant differences between the
TD groups, the data were combined.
4.2. Study characteristics
Table 1 includes the characteristics of included studies. We included 17 RCTs
with 2290 patients. The majority of studies included adults 18 years or over, with
one evaluating TD-cCBT in adults over 60. Eight evaluated TD-cCBT programs for
mixed anxiety disorders, 9 evaluated mixed anxiety and depression (two of these
reported that they targeted individuals with MDD and comorbid anxiety). The
studies ranged in sample sizes from 54 to 338 individuals. For the control groups,
9 compared TD-cCBT to waiting list control group (WLC), 2 to usual care, 3 to an
active control group (2 online forum, one relaxation training), and 4 compared TDcCBT to disorder-specic computerised CBT control groups. In addition, there was
one study that compared cCBT (the Fear Fighter Program; FF) to a face-to-face
TD-CBT program, and another study comparing cCBT (FF) to an alternative cCBT
program for phobias that did not include exposure therapy elements.2 In terms of

2
These studies were not included in the calculation of effect sizes comparing
transdiagnostic treatments versus control groups, as they did not fall within the
control group categories that were the focus of this review.

34

Table 1
Study characteristics of randomised controlled trials evaluating computerised transdiagnostic cognitive behavioural therapy.
Study

Country

Sample

Clinical

Mean age N

Transdiagnostic
treatment target

Switzerland,
Germany,
Austria

DSM-IV GAD, SocPhob, Panic/Ag

Clinical

35

TD-iCBT: 44, DSiCBT: 44, WLC:

44

Anx

Carlbring
et al.,
2011
Day et al.,
2013

Sweden

DSM-IV anxiety
disorder (including
ADNOS)
University students
with elevated depression, anxiety or
stress
Older adults (60 )
with anxiety
symptoms
DSM-IV
GAD comorbid
disorders
MDD comorbid
symptoms

Clinical

39

iCBT: 27 Online
forum: 27

Anx

Nonclinical

23

TD-iCBT: 33,
WLC: 33

Dep/Anx

Nonclinical

65

TD-iCBT: 33,
WLC: 37

Anx

Clinical

44

TD-iCBT: 170, DS- Dep/Anx

CBT: 168

Clinical

45

RCTiCBT (tailored): 36, DSiCBT: 37 Online

discussion forum: 42
DS-iCBT-CO: 47
DS-iCBT-CL: 46
WLC: 46

Canada

Dear et al.,
2015 #1

Australia

Dear et al.,
2015 #2

Australia

Johansson
et al.,
2012

Sweden

Johnston
et al.,
2011

Australia

DSM-IV GAD, SocPhob, Panic/Ag

Clinical

42

Marks
et al.,
2004
Mullin
et al.,
2015

United
Kingdom

ICD-10 Phobia or
Panic/Ag

Clinical

38

Australia

University students
with anxiety and
depression
symptoms
GAD/MDD

Nonclinical

Newby
et al.,
2013
Nordgren
et al.,
2014

Australia

Delivery
format

Number
modules

Therapist

Outcome
measures

10

Clinical psychology students

MADRS-S,
BAI, QOLI

5 core 6
optional

Graduate or undergraduate
student

DASS-D,
DASS-A

Internet

Masters/doctoral
level psychologist

PHQ-9, GAD7, SDS

Internet

Masters/doctoral
level psychologist

PHQ-9, GAD7, SDS

BDI-II, BAI,
QOLI

WLC

DS-iCBT
(for GAD)

810

10

Masters level
psychologists

Internet

10

TD-CBT
(f2f), RT

Computer

10

GAD-7, PHQDS-iCBT-CO: registered psycholo- 9, SDS

gistDS-iCBT-CL:
doctoral level
psychologist
Nurse and
FQ, WSAS
psychologist

Dep/Anx

WLC

Internet

Dep/Anx

WLC

Internet

6
Phase 1:
3, Phase
2/3: 6,
Phase 4: 5
6
10

Anx

27

TD-iCBT: 30
WLC: 23

Clinical

44

TD-iCBT: 46,
WLC: 53

Sweden

DSM-IV principal
anxiety disorder

Clinical

35

TD-iCBT: 50, TAU: Anx

50

TAU

Internet

710

Proudfoot
et al.,
2004

United
Kingdom

Clinical

44

TD-CCBT: 146
TAU: 128

TAU

Computer

Schneider
et al.,
2005

United
Kingdom

ICD-10 depression,
mixed anxiety/depression or anxiety
disorder
ICD-10 agoraphobia
(with or without
panic disorder), social or specic
phobia

Clinical

39

Anx
TD-CCBT (with
exposure): 45,
TD-CCBT (without exposure): 12

CCBT without
exposure

Computer

Dep/Anx

Internet

TD-CCBT: 37 TDCBT: 39 RT: 17

WLC

WLC

610

Anx

BAI, BDI-II,

Internet

DS-iCBT
(for MDD),
Online
Forum

a
Master of Science
students and
psychologist

Dep/Anx

Quality ratings

Internet

DS-iCBT
(for the
primary
disorder),
WLC
Online
Forum

Number
weeks

10

10

Provisionally registered
psychologist

PHQ-9, GAD7, SDS

Doctoral level
psychologist

PHQ-9, GAD7, WHODAS

Masters students
supervised by licensed clinical
psychologists
Nurse

BAI, MADRSS, QOLI,

BDI-II, BAI,
WSAS

FQ-total
phobia, FQ
depression,
WSAS

Psychiatrists

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

Berger
et al.,
2014

Control

35

the sample characteristics, the majority of trials (n 14) included participants with
clinical levels of symptoms who met diagnostic criteria for either ICD or DSM diagnoses according to structured diagnostic interview.
A wide range of outcome measures were used to assess self-reported anxiety
and depressive symptoms and quality of life, with the most common the PHQ-9
and BDI-II for depression and the GAD-7 and BAI for anxiety. Of the 17 trials, three
did not include quality of life assessment measures. There were only two studies
that reported outcomes for both the TD-cCBT group and control group at follow-up
(one at 3-months, and the second at 6-month follow-up). The remaining studies
generally reported outcomes for the TD-cCBT groups at either short- or long-term
follow-up, but the control group went on to receive treatment during the follow-up
period.
Adherence rates ranged between 43% and 90%, although the denition used to
dene adherence or program completion varied across studies. Some used the
denition of having completed all modules, whereas others used the denition of
having completed more than 75% of the modules. No studies specically reported
on adverse events or unwanted negative side effects attributed to the program.
However, of the four studies which reported information about symptom deterioration, one study found no evidence of clinically reliable deterioration, two
studies found under ve percent of the TD-cCBT participants evidenced reliable
deterioration, and the nal study found that 7.5% of the TD-cCBT group experienced
increases in GAD-7 or PHQ-9 scores by more than 5 points at post-treatment
(compared to 13.7% of the WLC group).
4.3. Risk of bias in randomised controlled trials
The methodological quality of studies varied, but was generally of good quality
(see Table 1). All studies (100%) reported adequate generation of random sequencing,
16 (94%) reported adequately concealing group allocation, and 5 (24%) reported
appropriate blinding of outcome assessments (double blinding is very difcult and
with internet delivered treatment delivered to people in remote locations, single
blinding even more difcult). All studies (100%) appropriately managed incomplete
outcome data by including intention to treat analyses, and 16 studies (94%) were
found to have low risk of bias for selective reporting of outcomes. Overall, only four
studies were classied by reviewers as at low risk of bias on all ve measures of risk
of bias, although 12 were coded as low risk of bias on four measures.

Titov et al. (2013) was combined with Titov et al. (2014) which reported the 12-month follow-up data.

4.4. Synthesis of results

Note: Programs/Control Groups: TD-CCBT transdiagnostic computerised cognitive behavioural therapy; DS-iCBT disorder-specic internet-delivered cognitive behavioural therapy, TD-iCBT transdiagnostic internet-delivered
cognitive behavioural therapy, iCBT internet-delivered cognitive behavioural therapy, iCBT (CO) internet cognitive behavioural therapy with coach guidance, iCBT (CL) internet cognitive behavioural therapy with clinician
guidance, TAUtreatment as usual, WLC waiting list control. SG self-guided, AE automatic emails, RT relaxation training, WLC waiting list control. Diagnoses: ADNOS Anxiety Disorder not Otherwise Specied. anxiety
disorder, MADD mixed anxiety and depressive disorder, MDD major depressive disorder, OCD obsessive compulsive disorder, Panic/Ag panic disorder and/or agoraphobia, PTSD posttraumatic stress disorder, SocPhob social phobia or social anxiety disorder. Depression Outcome measures: BDI-II Beck Depression Inventory, DASS-D Depression Anxiety Stress Scale Depression subscale, PHQ-9 Patient Health Questionnaire-9,
MADRS-S: Montgomery-Asberg Depression Rating Scale self rated version. Anxiety outcome measures: BAI Beck Anxiety Inventory, FQ Fear Questionnaire; GAD-7 Generalised Anxiety Disorder 7, DASS-A Depression
Anxiety Stress Scale - Anxiety subscale. Quality of life/functional impairment outcome measures: SDS Sheehan Disability Scale; WSAS: Work and Social Adjustment Scale; QOLI: Quality of Life Inventory; WHODAS-II: World
Health Organisation Disability Assessment Schedule. Quality ratings a allocation sequence adequately generated, b allocation adequately concealed, c blinding of outcome assessment, d incompletely data adequately
addressed, eselective reporting.  low risk (included information protecting against bias); high risk (did not protect against source of bias), ? unclear risk.

Masters/doctoral
level psychologist
8
Internet
44
Clinical
Australia
Titov et al.,
2015

TD-iCBT: 149 DSCBT: 141

Dep/Anx

DS-iCBT
(for MDD)

8
Internet
41
NonClinical

Self-identied principal depression,

GAD, SocPhob or
Panic Disorder
DSM-IV MDD comorbid disorders
Australia
Titov et al.,
2013a

Anx/Dep
TD-ICBT(AE):
100, TD-ICBT (no
AE): 106, WLC, 51

WLC

10
Internet
Anx
TD-iCBT: 37
WLC: 38
Australia
Titov et al.,
2011

44

WLC

PHQ-9, GAD7, SDS

PHQ-9, GAD7,

Internet
Dep/Anx
TD-iCBT: 40
WLC: 38

DSM-IV GAD, Panic/ Clinical

Ag, SocPhob, or
MDD
DSM-IV GAD, SocClinical
Phob, Panic/Ag
Australia
Titov et al.,
2010

39

WLC

10

Masters or doctoral level clinical

psychologist
Masters or doctoral level clinical
psychologist
SG

PHQ-9, GAD7, WHODASII

PHQ-9, GAD7, SDS

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

4.4.1. Between-group effects of TD-cCBT versus control groups

We compared the effects of TD-cCBT with control groups (including WLC, TAU,
and active control groups) in 14 studies. Figs. 2, 3 and 4 show forest plots for anxiety, depression and quality of life outcomes respectively. These analyses excluded
studies that compared transdiagnostic treatments with alternative transdiagnostic
interventions, with disorder-specic interventions, and comparisons between
alternative versions of cCBT. The overall effect sizes was moderate for anxiety severity (n 14, g .78, 95%CI:.57398), with moderate heterogeneity (I2 68), large
for depression (n 13, g .84, 95%CI:.671.01), with moderate heterogeneity
(I2 54), and small to moderate for quality of life measures (n 10, g .48, 95%
CI:.35.61), with no heterogeneity (I2 0).Figs. 57.
4.4.2. Comparisons between TD-cCBT versus controls on secondary outcome measures
(generalised anxiety, social anxiety and panic disorder severity)
The pooled data across the RCTs yielded large between-groups effect sizes
compared to controls on measures of generalised anxiety (n 8, g .98, 95%CI:.72
1.23), moderate differences on measures of panic disorder severity (n 4, g .65,
95%CI:.44.87), and moderate between-groups differences on measures of social
anxiety severity (n4, g .58, 95%CI:.27.90).
4.4.3. Comparisons between TD-cCBT versus disorder-specic treatments
Only four studies compared TD-cCBT to disorder-specic treatment control conditions. The analysis showed that there were no signicant differences between transdiagnostic and disorder-specic treatments for anxiety (n3, g .05, 95%CI: .14 to .23)
but there were signicant differences for depression outcomes, with the results in favour of the transdiagnostic cCBT (n3, g.21, 95%CI:.004.41), with minimal heterogeneity (I2 0) amongst these effects. There were also signicant differences for quality
of life, with results in favour of the transdiagnostic treatments (n 3, g .23, 95%
CI:.007.39), with minimal heterogeneity (I2 0) amongst these effects.
4.5. Subgroup analyses
4.5.1. Tailored versus standardised
There were no differences between the effects sizes between studies that
evaluated tailored versus standardised TD-cCBT interventions for anxiety outcomes
(standardised: n 10, g .84, 95% CI:.581.09; tailored: n 3, g .57, 95% CI:.31.83)
(Q*bet 2.10, df 1, p .15) nor depression (standardised: n 10, g .85, 95% CI:.62
1.07; tailored: n 3, g .86, 95% CI:.601.13) (Q*bet .01, df 1, p .91).

36

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

Fig. 1. Study ow chart.

4.5.2. Treatment modules (less than 6 modules [short] versus 6 or more [long])
To explore whether the number of modules made a difference, we coded each
study into less than 6 modules or 6 or more modules. There were no signicant
differences in the effect sizes for anxiety (short: n 4, g1.08, 95% CI:.491.66; long:
n 10, g.67, 95% CI:..49.85) (Q*bet 1.71, df1, p .19) nor depression (short: n 4,
g1.17, 95% CI:.531.71; long: n9, g.74, 95% CI:.61.87) (Q*bet 1.49, df1, p .22).
4.5.3. Treatment target (anxiety only versus anxiety and depression)
In the next subgroup analysis, we compared the mean controlled effect size for
sub-groups based on treatment target. There were no statistically signicant differences in the controlled effect size obtained for anxiety outcomes between
TDcCBT interventions targeting anxiety only (n 7, g .94, 95% CI:.591.29) or depression and anxiety (n 7, g .63, 95% CI:.42.84) (Q*bet 2.21, df 1, p .14), or on
depression outcomes (anxiety only: n 6, g 1.02, 95% CI:.651.38; depression and
anxiety: n 7, g .72, 95% CI:.57.86) (Q*bet 2.24, df 1, p .14).

4.5.4. Control type (waitlist control, usual care, active control)

In the next subgroup analysis, we compared the mean controlled effect size for sub
groups based on control subtype. There were statistically signicant differences in the
controlled effect size obtained for anxiety outcomes (Q*bet 9.22, df 2, po.05), with
comparisons between TD-cCBT and WLC yielding the largest differences, (WLC: n 9,
g .93, 95% CI:.691.17), followed by comparisons with active control groups (active:
n 3, g .59, 95% CI:.29.90), and usual care the smallest difference (TAU: n 2, g.37,
95% CI:.09.65). However, there was no inuence of control subtype on the effect sizes
for depression outcome measures (Q*bet .55, df2, p .76). WLC: n 9, g .88, 95%
CI:.631.13; active: n2, g.74, 95% CI:.58-1.01; TAU: n 2, g .82, 95% CI:.46-1.17).

4.5.5. Clinical prole (clinical versus non-clinical)

In the next subgroup analysis, we compared the mean controlled effect size for sub
groups based on whether the sample was clinical (i.e., all participants had a diagnosis) or
non-clinical (participants had elevated symptoms, but were not required to meet diagnostic criteria for inclusion into the study). There were no statistically signicant

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

Study name

Comparison

Outcome

Statistics for each study

37

Hedges's g and 95% CI

Hedges's Lower Upper

g
limit
limit

Berger et al., 2014

Carlbring et al., 2011
Day et al. 2013
Dear et al. 2015 #1
Johannson et al., 2012
Johnston et al., 2011
Marks et al., 2004
Mullin et al. 2013
Newby et al., 2013
Nordgren et al. 2014
Proudfoot et al., 2004
Titov et al., 2010
Titov et al., 2011
Titov et al., 2013

TD-ICBT vs WLC
TD-ICBT vs DF
TD-ICBT vs WLC
TD-ICBT vs WLC
TD-ICBT vs DF
TD-ICBT vs WLC
TD-CCBT vs RT
TD-ICBT vs WLC
TD-ICBT vs WLC
TD-ICBT vs TAU
TD-CCBT vs TAU
TD-ICBT vs WLC
TD-ICBT vs WLC
TD-ICBT vs WLC

Anxiety
Anxiety
Anxiety
Anxiety
Anxiety
Anxiety
Anxiety
Anxiety
Anxiety
Anxiety
Anxiety
Anxiety
Anxiety
Anxiety

0.802
0.765
0.603
2.132
0.452
1.079
0.642
0.839
0.844
0.555
0.261
0.768
0.690
0.816
0.779

0.371
0.220
0.115
1.548
0.005
0.691
-0.018
0.280
0.434
0.158
0.001
0.312
0.226
0.503
0.573

1.233
1.310
1.090
2.715
0.898
1.466
1.301
1.397
1.253
0.951
0.520
1.224
1.155
1.130
0.985
-2.00

-1.00
Favours Control

0.00

1.00

2.00

Favours Transdiagnostic

Fig. 2. Forest plot of controlled between-group effect sizes for comparisons between transdiagnostic computerised cognitive behavioural therapy and control groups on selfreported anxiety.

Study name

Comparison

Outcome

Statistics for each study

Hedges's g and 95% CI

Hedges's Lower Upper

g
limit
limit

Berger et al., 2014

Carlbring et al., 2011
Day et al. 2013
Dear et al. 2015 #1
Johannson et al., 2012
Johnston et al., 2011
Mullin et al. 2013
Newby et al., 2013
Nordgren et al. 2014
Proudfoot et al., 2004
Titov et al., 2010
Titov et al., 2011
Titov et al., 2013

TD-ICBT vs WLC
TD-ICBT vs DF
TD-ICBT vs WLC
TD-ICBT vs WLC
TD-ICBT vs DF
TD-ICBT vs WLC
TD-ICBT vs WLC
TD-ICBT vs WLC
TD-ICBT vs TAU
TD-CCBT vs TAU
TD-ICBT vs WLC
TD-ICBT vs WLC
TD-ICBT vs WLC

Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression
Depression

0.873
0.774
0.957
2.174
0.847
0.790
0.602
0.739
0.929
0.642
0.479
0.732
0.820
0.841

0.439
0.228
0.453
1.587
0.387
0.413
0.055
0.333
0.519
0.384
0.033
0.266
0.506
0.668

1.306
1.319
1.461
2.762
1.308
1.168
1.149
1.144
1.339
0.901
0.925
1.198
1.134
1.015
-2.00

-1.00
Favours Control

0.00

1.00

2.00

Favours Transdiagnostic

Fig. 3. Forest plot of controlled between-group effect sizes for comparisons between transdiagnostic computerised cognitive behavioural therapy and control groups on selfreported depression.
differences in the controlled effect size obtained for anxiety outcomes (Q*bet 1.71, df 1,
p .19; clinical: n 10, g .67, 95% CI:.49.85, non-clinical/mixed: n 4, g .1.08, 95%
CI:.491.66), nor depression outcomes (Q*bet 1.49, df 1, p .22; clinical: n9, g .74,
95% CI:.61.87, non-clinical/mixed: n 4, g .1.17, 95% CI:.521.71).
4.5.6. Therapist experience level
We conducted a subgroup analysis to compare the effects of studies where the
participants were supervised by qualied psychologists versus students. Of those
that reported both students and other psychologists were coded in the student
category. There were no differences for anxiety (Q*bet .51, df 1, p .47; psychologists: n 7, g .91, 95% CI:.561.25, students: n4, g .75, 95% CI:.501.00), or
depression outcomes (Q*bet .27, df 1, p .61; psychologists: n7, g .92, 95%
CI:.60.1.25, students: n 4, g .82, 95% CI:.571.07).
4.6. Publication bias
There was no evidence of risk of bias observed within the funnel plot, or when

conducting Duval and Tweedie's trim and ll procedure for anxiety, depression.
However there was evidence of risk of bias for the measure of quality of life, with
2 studies trimmed, and the adjusted point estimate of n 2 studies trimmed,
g .42, 95%CI:.29.56.

5. Discussion
The current study is the rst systematic review and meta-analysis of
the effects of computerised transdiagnostic CBT (TD-cCBT) interventions
in adults. This study examined the relative efcacy of computerised and
internet-delivered TD-cCBT programs compared to control conditions,
including how TD-cCBT programs perform relative to disorder-specic
programs. We identied 17 RCTs with a total of 2290 participants
evaluating these programs. The majority were designed to target mixed

38

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

Study name

Comparison

Outcome

Statistics for each study

Hedges's g and 95% CI

Hedges's Lower Upper

g
limit
limit

Carlbring et al., 2011

Johannson et al., 2012
Johnston et al., 2011
Marks et al., 2004
Mullin et al. 2013
Newby et al., 2013
Nordgren et al. 2014
Proudfoot et al., 2004
Titov et al., 2010
Titov et al., 2011

TD-ICBT vs DF
TD-ICBT vs DF
TD-ICBT vs WLC
TD-CCBT vs RT
TD-ICBT vs WLC
TD-ICBT vs WLC
TD-ICBT vs TAU
TD-CCBT vs TAU
TD-ICBT vs WLC
TD-ICBT vs WLC

QOL
QOL
QOL
QOL
QOL
QOL
QOL
QOL
QOL
QOL

0.572
0.589
0.846
0.209
0.597
0.268
0.473
0.335
0.531
0.513
0.478

0.035
0.138
0.467
-0.436
0.050
-0.126
0.079
0.082
0.084
0.054
0.348

1.109
1.039
1.224
0.853
1.144
0.661
0.868
0.589
0.978
0.971
0.608
-2.00

-1.00

0.00

Favours Control

1.00

2.00

Favours Transdiagnostic

Fig. 4. Forest plot of controlled between-group effect sizes for comparisons between transdiagnostic computerised cognitive behavioural therapy and control groups on selfreported quality of life.

Fig. 5. Forest plot of controlled between-group effect sizes for comparisons between transdiagnostic computerised cognitive behavioural therapy and disorder-specic
cognitive behavioural therapy on self-reported anxiety.

Fig. 6. Forest plot of controlled between-group effect sizes for comparisons between transdiagnostic computerised cognitive behavioural therapy and disorder-specic
cognitive behavioural therapy on self-reported depression.

Study name

Dear et al. 2015 #2

Comparison

Outcome

Statistics for each study

Hedges's
g

Lower
limit

Upper
limit

0.420

TD-ICBT vs DS-ICBT QOL

0.206

-0.007

Johannson et al., 2012 TD-ICBT vs DS-ICBT QOL

0.214

-0.241

0.670

Titov et al., 2015

0.272

0.005

0.538

0.230

0.074

0.386

TD-ICBT vs DS-ICBT QOL

Hedges's g and 95% CI

-2.00

-1.00

0.00

Favours Disorder-Specific

1.00

2.00

Favours Transdiagnostic

Fig. 7. Forest plot of controlled between-group effect sizes for comparisons between transdiagnostic computerised cognitive behavioural therapy and disorder-specic
cognitive behavioural therapy on self-reported quality of life.

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

anxiety disorders, were clinician-guided and targeted patients with diagnosed disorders. There were no RCTs of mobile phone applications.
The majority of trials compared transdiagnostic treatments to
WLC groups, but transdiagnostic treatments were also compared
to usual care, and online discussion forums. There were no comparisons between TD-cCBT with pharmacotherapies. Pooling the
results across RCTs demonstrated that TD-cCBT outperformed
control groups on depression (g .84), anxiety (g .78,) and quality of life (g .48), as well as the secondary outcome measures of
generalised anxiety severity (g.98), panic severity (g .65), and
social anxiety severity (g .58) at post-treatment. There were too
few studies with results for the TD-cCBT intervention and control
groups to synthesise the data at follow-up. The controlled effect
sizes corresponding to the differences between computerised TDcCBT and controls were moderate for anxiety, which is consistent
with previous ndings from meta-analyses of face to face CBT
programs (Reinholt and Krogh, 2014), and a more broad range of
transdiagnostic psychological interventions (Newby et al., 2015).
Evidence of reliable deterioration was relatively rare, although
only 4 studies reported any information about whether participants experienced symptom deterioration, and none reported on
adverse events. Heterogeneity was also moderate to high for all
outcome measures, suggesting there was signicant variability
amongst these effects. We also found some evidence of publication
bias for quality of life outcomes, which suggests these effect estimates may be inated, but only to a small degree.
A major aim of this study was to examine whether there were
any components or features of the transdiagnostic programs that
inuenced the efcacy of the programs, as this question has never
been studied. This was to attempt to clarify the reasons for the
heterogeneity and to account for the mixed ndings in the literature regarding the size of the effects observed across studies. When
we examined potential sources of heterogeneity, we could nd no
differences between tailored and standardised protocols, protocols
that targeted depression and anxiety versus mixed anxiety symptoms/disorders, studies that were short (less than 6 modules) versus long (6 or more modules or lessons), or programs that were
supervised by students versus qualied psychologists. It is possible
that the failure to nd differences between these subgroups was
due to a lack of power. With growing numbers of RCTs being conducted in the eld, we will be able to conduct a follow-up metaanalysis in future to examine this question, and other important
questions such as the impact of adherence on outcomes. The only
signicant nding that may account for the source of heterogeneity
was the control group used: studies that compared TD-cCBT to WLC
had the largest between-groups effect sizes compared to those
which used a usual care or active psychological treatment control
group for anxiety outcomes (but not depression).
Another aim of this study was to compare the efcacy of
transdiagnostic versus disorder-specic CBT interventions. Recent
studies by Titov and colleagues (Dear et al., 2015) have enabled us
to pool the effects across large scale studies to begin to examine
this issue. We found overall that there was minimal difference
between TD-CCBT and disorder-specic computerised CBT for anxiety outcomes, but there was a small but superior gain in TD-cCBT
protocols for depression and quality of life outcomes. Studies using

39

relatively large samples (n 200300) have not detected these

differences, which is likely due to a lack of power. However, given
that the relative difference between transdiagnostic and disorderspecic computerised therapies appears to be very small, it remains to be determined whether these ndings are clinically relevant or signicant in real-world clinical practice. It would be
interesting to examine whether patient preferences inuence the
degree of benet experienced across TD-cCBT versus disorderspecic cCBT interventions, and the relative difference in efcacy
on composite or transdiagnostic measures of depression and anxiety symptoms.
5.1. Limitations
The results of this study need to be interpreted in the context of
some limitations. First, only included published studies; grey literature and unpublished studies were not included in the metaanalysis. Second, our search was restricted to examining CBT
protocols, because they have been most widely examined, and
enabled us to examine some of the issues that may inuence the
size of the treatment effects. Third, the impact of transdiagnostic
treatments was determined using self-report measures because
clinician-rated instruments were not consistently used across
studies. This may have resulted in inated estimates of effect sizes.
An important area for future research will be to examine the effects of TD-cCBT programs with clinician-ratings and self-report
measures, and examine whether the size of the effect differs according to the specic outcome measures used. Finally, we used a
range of subgroup analyses to explore the possible reasons for the
high heterogeneity found in the treatment effects. The study may
have lacked power to detect differences between subgroups due to
the small number of studies in the subgroups. In addition, because
the results from our subgroup analyses are purely observational
(Borenstein and Higgins, 2013), we cannot conclude that treatment type and format caused the differences in outcomes we
observed in outcomes. It is also possible that the subgroups differed in other important ways that inuenced outcomes (e.g.,
choice of assessment measure).
5.2. Summary
In summary, this is the rst meta-analysis to provide evidence
from randomised controlled trials for the efcacy of TD-cCBT in
reducing depression and anxiety severity, and improving quality of
life. The effects of TD-cCBT appear to be relatively similar to disorder-specic CCBT programs, and offer several advantages in
terms of practicality, increased efciency and the ability to address
multiple comorbidities. Future studies would benet from examining the sources of heterogeneity amongst treatment effects
observed across studies, comparing between TD-cCBT and control
groups with long-term follow-up, comparing TD-cCBT programs to
pharmacotherapies, and examining whether adopting a blended
approach that combines computerised and face-to-face CBT improves outcomes for individuals suffering from anxiety and
depression.

Appendix A
PsycINFO search terms
1 (Anxiety or Social Anxiety or Anxiety Disorder$ or Generali$ed Anxiety Disorder or Generali$ed Anxiety or Panic or Panic Attack$ or
Panic Disorder or Agoraphobia or Phobias or Acute Stress Disorder or Obsessive Compulsive Disorder or Phobia$ or Posttraumatic

40

J.M. Newby et al. / Journal of Affective Disorders 199 (2016) 3041

Stress Disorder or Separation Anxiety or $phobia or Social Phobia or Social Anxiety Disorder or Affective Disorders or Mood Disorder
$ or Depression or Major Depression or Major Depressive Disorder or Dysthymic Disorder or Dysthym$ or Endogenous Depression or
Postpartum Depression or Reactive Depression or Treatment Resistant Depression or Atypical Depression or Recurrent Depression or
Mental Health or (Mixed anxiety and depression) or Depressive or Depressed or Panic or Phobic* or phobia or Obsessive compulsive
or Mood disorder* or compulsive hoarding or post-traumatic stress or anxiety disorder* or dysthymia or transdiagnostic or illness
anxiety or illness anxiety disorder or health anxiety or health anxiety disorder or hypochondria$ or tailor*).mp. [mp title, abstract,
heading word, table of contents, key concepts, original title, tests & measures]
2 (Online Therapy or Internet or Internet-delivered or Web-based or Web or Computer or Computer$ or Computer Application$ or
Computer Assisted Therapy or Computer Therapy or Computerized or Computerised or Online or Websites or e-mail or email or
technology-assisted or computer-based or Internet-based or mobile or smartphone or tablet).mp. or *phone/[mp title, abstract,
heading word, table of contents, key concepts, original title, tests & measures]
3 (Online Therapy or Psychotherapy or Psychotherapy or Behavior Therapy or Behaviour Therapy or Brief Psychotherapy or Cognitive
4Behavior Therapy or Cognitive Behaviour Therapy or Cognitive Behavio$ Therapy or Cognitive Behavioural Therapy or Cognitive
Behavioral Therapy or Unied Protocol or Emotion Focused or Experiential Psychotherapy or Expressive Psychotherapy or Eye
Movement Desensitization Therapy or Geriatric Psychotherapy or Group Psychotherapy or Individual Psychotherapy or Narrative
Therapy or Solution Focused Therapy or Supportive Psychotherapy or Cognitive Therapy or Dialectical Behaviour Therapy or Dialectical Behaviour Therapy or Exposure Therapy or Implosive Therapy or (Exposure and Response Prevention) or Systematic Desensiti$ation Therapy or Behavior Modication or Behaviour Modication or Counseling or Self Help or Self Help Techniques or CCBT
or minimal therapist support or guided self-help or supervised self-help or minimal contact therap* or clinician-guided or relaxation
or therapy).mp. [mp title, abstract, heading word, table of contents, key concepts, original title, tests & measures]
4 (Randomized Controlled Trial or Randomised Controlled Trial or controlled trial or randomi$ed or Randomized or randomization or
randomisation or randomly assigned or Controlled or trial or RCT).mp. [mp title, abstract, heading word, table of contents, key
concepts, original title, tests & measures]
5 1 and 2 and 3 and 4

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