Internet‑Delivered Versus Face‑to‑Face Cognitive Behavior Therapy for Anxiety Disorders: Systematic Review and Meta‑Analysis

Narges Esfandiari, Mohammad A. Mazaheri, Saeed Akbari‑ Zardkhaneh, Vahid Sadeghi‑ Firoozabadi, Mona Cheraghi


Background: Over the last 20 years, internet‑delivered cognitive behavior therapy (ICBT) has been tested in a large number of randomized controlled trials, often with positive results. However, it is not widely known about the efficacy of ICBT as compared to face‑to‑face cognitive behavior therapy (CBT). Methods: In the present systematic review and meta‑analysis, ICBT for treatment of anxiety disorders was directly compared to face‑ to‑face CBT within the same trial. This study aimed to reinvestigate the effect of ICBT compared to face‑to‑face CBT for anxiety disorders. A total of 8 studies out of the 236 articles screened met all the inclusion criteria. The included studies targeting five different anxiety disorders, social anxiety disorder, adolescent anxiety, panic disorder, spider phobia, and fear of public speaking, had been carried out in Australia, Spain, and Sweden. The total number of participants was 348 in ICBT and 316 in face‑to‑face conditions. Results: The results of our meta‑analysis are interesting both from theoretical and practical standpoints, which showed a pooled effect size posttreatment with Hedges’ g = 0.01 (95% CI: −0.16 to 0.18), Conclusions: ICBT and face‑to‑face CBT created equivalent overall effects. in treatment of anxiety disorders. Since there have been similar systematic reviews about anxiety disorders so far, and in majority of them, ICBT has not been compared against face‑to‑face treatment. More research is needed to establish the general equivalence of the two treatment formats. Also, understanding what makes ICBT work is a challenge for future research.


Anxiety Disorders; cognitive behavior therapy; internet; meta‑analysis

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Andersson E, Ljótsson B, Hedman E, Kaldo V, Paxling B,

Andersson G, et al. Internet‑based cognitive behavior therapy for

obsessive compulsive disorder: A pilot study. BMC Psychiatry

;11. doi: 10.1186/1471‑244X‑11‑125.

Vigerland S, Lenhard F, Bonnert M, Lalouni M, Hedman E,

Ahlen J, et al. Internet‑delivered cognitive behavior therapy for

children and adolescents: A systematic review and meta‑analysis.

Clin Psychol Rev 2016;50:1‑10.

Guided internet-based treatments in psychiatry. Place of

publication not identified: Springer International PU; New York,

NY: Springer Berlin Heidelberg. 2016. ISBN 978‑3‑319‑06082‑8.

Lindefors N, Hedman E, Ljótsson B. Internet‑based cognitive

behavior therapy for anxiety and depression. In: Zohar J, editor.

Anxiety and Depression: The Möbius Strip. Neuilly‑sur‑Seine:

Laboratoires Servier; 2012.

Andersson G, Carlbring P, Lindefors N. History and current

status of ICBT. In: Lindefors N, Andersson G, editors. Guided

Internet‑Based Treatments in Psychiatry. New York, NY:

Springer; 2016. p. 1‑16.

Andersson G, Carlbring P, Hadjistavropoulos HD. Internet‑based

cognitive behavior therapy. In: Hofmann SG, Asmundson GJG,

editors. The Science of Cognitive Behavioral Therapy. San

Diego, CA: Academic Press. 2017. p. 531‑49.

Hedman E, Furmark T, Carlbring P, Ljótsson B, Ruck C,

Lindefors N, et al. A 5‑year follow‑up of Internet‑based cognitive

behavior therapy for social anxiety disorder. J Med Internet Res


Carlbring P, Andersson G, Cuijpers P, Riper H, Hedman‑Lagerlöf

E. Internet‑based vs. face‑to‑face cognitive behavior therapy for

psychiatric and somatic disorders: An updated systematic review

and meta‑analysis. Cogn Behav Ther 2017;47:1‑18.

Andersson G, Cuijpers P, Carlbring P, Riper H, Hedman E. Guided Internet‑based vs. face‑to‑face cognitive behavior therapy

for psychiatric and somatic disorders: A systematic review and

meta‑analysis. World Psychiatry 2014;13:288‑95.

Boettcher J, Carlbring P, Renneberg B, Berger T. Internet‑based

interventions for social anxiety disorder‑an overview.

Verhaltenstherapie 2013;23:160‑8.

Spence SH, Donovan CL, March S, Gamble A, Anderson RE,

Prosser S, et al. A randomized controlled trial of online versus

clinic‑based CBT for adolescent anxiety. J Consult Clin Psychol


Andersson G. Using the Internet to provide cognitive behaviour

therapy. Behav Res Ther 2009;47:175‑80.

Andersson G, Waara J, Jonsson U, Malmaeus F, Carlbring P,

Ost LG. Internet‑based self‑help versus one‑session exposure in

the treatment of spider phobia: A randomized controlled trial.

Cogn Behav Ther 2009;38:114‑20.

Bergström J, Andersson G, Ljótsson B, Ruck C, Andreewitch S,

Karlsson N, et al. Internet‑versus group‑administered

cognitive behaviour therapy for panic disorder in a psychiatric

setting: A randomised trial. BMC Psychiatry 2010;10. doi:


Botella C, Gallego M, Garcia‑Palacios A, Guillen V, Banos RM,

Quero S, et al. An Internet‑based self‑help treatment for fear

of public speaking: A controlled trial. Cyberpsychol Behav Soc

Netw 2010;13:407‑21.

Moncrieff J, Churchill R, Drummond DC, Mcguire H.

Development of a quality assessment instrument for trials of

treatments for depression and neurosis. Int J Methods Psychiatr

Res 2001;10:126‑33.

Higgins JPT, Green S. Cochrane Handbook for Systematic

Reviews of Interventions. Newark: John Wiley and Sons; 2011.

ISBN 978‑0470057964.

Hedman E, Alaoui SE, Lindefors N, Andersson E, Ruck C,

Ghaderi A, et al. Clinical effectiveness and cost‑effectiveness of

Internet‑ vs. group‑based cognitive behavior therapy for social

anxiety disorder: 4‑Year follow‑up of a randomized trial. Behav

Res Ther 2014;59:20‑9.

Hedman E, Andersson E, Ljótsson B, Andersson G, Rück C,

Lindefors N. Cost‑effectiveness of Internet‑based cognitive

behavior therapy vs. cognitive behavioral group therapy for

social anxiety disorder: Results from a randomized controlled

trial. Behav Res Ther 2011;49:729‑36.

Andrews G, Davies M, Titov N. Effectiveness randomized

controlled trial of face to face versus Internet cognitive behaviour

therapy for social phobia. Aust N Z J Psychiatry 2011;45:337‑40.

Carlbring P, Nilsson‑Ihrfelt E, Waara J, Kollenstam C, Buhrman M,

Kaldo, et al. Treatment of panic disorder: Live therapy vs.

self‑help via the Internet. Behav Res Ther 2005;43:1321‑33.

Rozental A, Magnusson K, Boettcher J, Andersson G,

Carlbring P. For better or worse: An individual patient data

meta‑analysis of deterioration among participants receiving

Internet‑based cognitive behavior therapy. J Consult Clin Psychol


Hansen NB, Lambert MJ, Forman EM. The psychotherapy

dose‑response effect and its implications for treatment

delivery services. Clinical Psychology: Science and Practice


Andersson G, Carlbring P, Rozental A. Response and remission

rates in Internet‑based cognitive behavior therapy: An individual

patient data meta‑analysis. Front Psychiatry 2019;10:749.

Johansson R, Ekbladh S, Hebert A, Lindström M,

Möller S, Petitt E, et al. Psychodynamic guided self‑help for

adult depression through the Internet: A randomised controlled

trial. PLoS One 2012;7:e38021.

Nyström MB, Stenling A, Sjöström E, Neely G, Lindner P,

hassmén P, et al. Behavioral activation versus physical activity

via the Internet: A randomized controlled trial. J Affect Disord


Carlbring P, Apelstrand M, Sehlin H, Amir N, Rousseau A,

Hofmann S, et al. Internet‑delivered attention bias modification

training in individuals with social anxiety disorder‑A double

blind randomized controlled trial. BMC Psychiatry 2012;12:1‑9.

doi: 10.1186/1471‑244X‑12‑66.

Warmerdam L, Straten AV, Twisk J, Riper H, Cuijpers P.

Internet‑based treatment for adults with depressive symptoms:

Randomized controlled trial. J Med Internet Res 2008;10. doi:


Ivanova E, Lindner P, Ly KH, Dahlin M, Vernmark k,

Andersson G, et al. Guided and unguided acceptance and

commitment therapy for social anxiety disorder and/or panic

disorder provided via the Internet and a smartphone application:

A randomized controlled trial. J Anxiety Disord 2016;44:27‑35.

Andersson G. The Internet and CBT: A Clinical Guide. Boca

Raton: CRC Press; 2015. ISBN 9781444170214.

Andersson G, Carlbring P, Furmark T. Therapist experience

and knowledge acquisition in Internet‑delivered CBT for social

anxiety disorder: A randomized controlled trial. PLoS One


Lindner P, Carlbring P, Flodman E, Hebert A, Poysti S,

Hagkvist, et al. Does cognitive flexibility predict treatment gains

in Internet‑delivered psychological treatment of social anxiety

disorder, depression, or tinnitus? Peer J 2016;4:e1934.

Ebert DD, Donkin L, Andersson G, Andrews G, Berger T,

Carlbring P, et al. Does Internet‑based guided‑self‑help

for depression cause harm? An individual participant data

meta‑analysis on deterioration rates and its moderators in

randomized controlled trials. Psychol Med 2016;46, 2679‑93.

Wampold BE. The Great Psychotherapy Debate: Models,

Methods, and Findings. Mahwah, NJ: Lawrence Erlbaum; 2001.

ISBN 10: 0805832017, ISBN 13: 9780805832013.

Andersson G, Paxling B, Wiwe M, Vernmark K, Felix CB,

Lundborg L, et al. Therapeutic alliance in guided

internet‑delivered cognitive behavioral treatment of depression,

generalized anxiety disorder and social anxiety disorder. Behav

Res Ther 2012;50:544‑50.

Hedman E, Andersson E, Andersson G, Lindefors N,

Lekander M, Rück, C, et al. Mediators in internet‑based

cognitive behavior therapy for severe health anxiety. PLoS One

;8. doi: 10.1371/journal.pone.0077752.

Hesser H, Westin VZ, Andersson G. Acceptance as a mediator

in internet‑delivered acceptance and commitment therapy

and cognitive behavior therapy for tinnitus. J Behav Med


Karyotaki E, Kleiboer A, Smit F, Turner DT, Pastor AM,

Andersson G, et al. Predictors of treatment dropout in self‑guided

web‑based interventions for depression: An ‘individual patient

data’ meta‑analysis. Psychol Med 2015;45, 2717‑26.