Romijn Geke, Batelaan Neeltje, Kok Robin, Koning Jeroen, van Balkom Anton, Titov Nickolai, Riper Heleen
Department of Clinical, Neuro and Developmental Psychology, VU University, Amsterdam Public Health Research Institute, Amsterdam, Netherlands.
Altrecht Academic Anxiety Centre, Utrecht, Netherlands.
J Med Internet Res. 2019 Apr 17;21(4):e11706. doi: 10.2196/11706.
Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects.
This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome.
We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials.
We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls.
iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients' greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings.
大量研究表明，互联网认知行为疗法（iCBT）对焦虑症有效。这些研究的参与者主要从社区招募，在较小程度上也从常规护理服务机构招募。对于不同的招募策略是否会导致不同的治疗效果，人们知之甚少。
本荟萃分析比较了从社区招募参与者的试验与从临床服务机构招募参与者的试验所获得的临床结果，并探讨了可能介导治疗结果差异的因素。
我们纳入了将iCBT治疗焦虑症的临床效果与对照条件（等待名单对照或面对面认知行为疗法）进行比较的随机对照试验。我们将试验分为开放招募试验（从社区招募）或临床服务招募试验（通过门诊诊所招募）。针对每种类型的试验，计算基于检查焦虑症状、抑郁症状和生活质量的测量指标的合并效应量。亚组分析检验了开放招募试验的临床结果与临床服务招募试验的结果是否不同。额外的分析探讨了哪些人口统计学、临床和治疗相关因素导致了开放招募试验与临床服务招募试验效应量的差异。
我们纳入了42项研究，共53项比较（43项开放招募比较和10项临床招募比较）。对焦虑测量指标的分析表明，首先，与临床招募研究相比，采用等待名单对照的iCBT开放招募研究在降低焦虑症状方面的效应量显著更高（Q = 10.09；P = 0.001）。在将治疗依从性和排除抑郁症状患者作为效应量的额外预测因素纳入的多变量元回归分析中，这种招募方法与效应量之间的关联不再显著。其次，在以面对面认知行为疗法作为对照的临床招募研究和开放招募研究中，降低焦虑症状的效应量没有显著差异。与面对面认知行为疗法和等待名单对照相比，开放招募试验和临床招募试验在次要结局方面的效果没有显著差异。
iCBT在临床实践中招募的样本中是有效的，但对于采用等待名单对照的研究，其效应量小于开放招募方法的试验。因此，对于常规护理中的焦虑症患者，iCBT的影响可能不如从社区招募的研究参与者那样积极。开放招募试验和临床服务招募试验之间的差异可能部分归因于开放招募试验中患者更高的治疗依从性以及这些研究中对严重抑郁症状患者更严格的排除。由于本荟萃分析中的大多数试验采用了开放招募方法，因此需要更多针对常规护理人群的研究来进一步验证这些发现。
