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Am Fam Physician. 2016;93(1):19-20

Author disclosure: No relevant financial affiliations.

Clinical Question

Does therapist-supported online cognitive behavior therapy (CBT) improve anxiety and reduce symptoms in adults with anxiety disorders?

Evidence-Based Answer

Therapist-supported online CBT is more effective than no treatment and as effective as face-to-face CBT for reducing overall anxiety as well as symptoms, and improving quality of life in adults with anxiety disorders. (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)

Practice Pointers

Anxiety disorders include panic disorder, agoraphobia, social phobia, posttraumatic stress disorder, acute stress disorder, generalized anxiety disorder, obsessive-compulsive disorder, and specific phobia. As many as 18% of adults in the United States experience an anxiety disorder each year, with an estimated economic impact of $40 billion per year. CBT improves symptoms of anxiety disorders by treating maladaptive thoughts and behaviors, yet less than one-third of patients who have psychiatric diagnoses receive appropriate treatment. CBT delivered over the Internet with a therapist providing support by telephone or e-mail could overcome some access-related barriers to care, as well as increase patient privacy and confidentiality.

This Cochrane review included 30 randomized controlled trials with nearly 2,200 patients. Studies were excluded if participants had not been diagnosed with an anxiety disorder. Online CBT included support that was not face-to-face and was compared with control interventions (i.e., waiting list [no treatment], attention information, online discussion group); unguided CBT; or face-to-face CBT. Two-thirds of patients were women. The mean age of participants was 37 years, and most of the studies included patients who were taking psychiatric medications. The primary outcomes of interest were improvements in anxiety and anxiety symptoms, as measured by one of several validated tools.

Meta-analysis favored the therapist-supported online CBT over the control interventions for improving anxiety (relative risk = 4.18; 95% confidence interval, 2.42 to 7.22), reducing disorder-specific symptoms (standardized mean difference = −1.12; 95% confidence interval, −1.39 to −0.85), and improving general anxiety symptoms (standardized mean difference = −0.79; 95% confidence interval, −1.10 to −0.48). Online CBT also resulted in a significant improvement in quality of life (standardized mean difference = 0.51; 95% confidence interval, 0.40 to 0.61). These results remained significant when analyses were delineated by anxiety disorder.

Meta-analysis also showed no significant differences between unguided CBT (self-help) and therapist-supported online CBT in improving disorder-specific anxiety symptoms and reducing general anxiety symptoms. When online CBT was compared with face-to-face CBT, there were no significant differences in improvement of anxiety, severity of disorder-specific anxiety, or general anxiety symptoms. Outcomes favored therapist-supported online CBT for improvement in quality of life (standardized mean difference = 0.26; 95% confidence interval, 0.06 to 0.45).

The overall quality of the evidence was classified as low to moderate. Considering risk of bias, the included evidence is of moderate quality, because outcome assessors were inadequately blinded and several studies provided incomplete data. The interventions were quite heterogeneous. Adverse events were rarely reported.

Three other meta-analyses have demonstrated that therapist-supported online CBT is more effective than no treatment for the management of anxiety, and that therapist-supported care, as opposed to self-directed care, seems to improve outcomes.13 As described in this review, online CBT is consistent with current National Institute for Health and Care Excellence recommendations that CBT, during which patients are provided written materials and supported by therapist feedback, be delivered as part of a stepwise approach to treating generalized anxiety disorder and panic disorder.4

The practice recommendations in this activity are available at

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at

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