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Am Fam Physician. 2018;98(7):459-460

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Clinical Question

Is therapist-guided, Internet-delivered cognitive behavior therapy (CBT) an effective treatment for anxiety in adults?

Evidence-Based Answer

Therapist-guided, Internet-delivered CBT can be used as an effective treatment for anxiety in adults and is similar in effectiveness to face-to-face CBT. (Strength of Recommendation: B, based on a randomized controlled trial [RCT] and a systematic review of RCTs.)

Evidence Summary

A 2015 meta-analysis of 30 RCTs (N = 2,181) compared CBT with waitlist controls for treatment of anxiety disorders in adults.1 Interventions included therapist-guided, Internet-delivered CBT; unguided Internet-delivered CBT (self-help); and face-to-face CBT. Participants were included if they were older than 18 years and met diagnostic criteria for a primary anxiety disorder. They were referred by their treating professional or responded to media advertisements. Patients received the intervention in their homes. Therapists were located in primary care settings, community mental health centers, private practices, or university laboratories. All interventions combined elements of cognitive restructuring and behavioral change; psychoeducation alone was not considered CBT. Internet interventions included websites and e-mail, and excluded face-to-face encounters with the therapist except for basic orientation. Study design varied in the frequency and length of intervention. Outcomes were analyzed immediately after treatment and again six to 12 months later. Therapist-guided, Internet-delivered CBT was superior to controls for improving anxiety (moderate-quality evidence; nine RCTs; N = 644; relative risk [RR] = 4.2; 95% confidence interval [CI], 2.4 to 7.2); symptoms of specific anxiety disorders (low-quality evidence; 22 RCTs; N = 1,573; standard mean deviation [SMD] = −1.1; 95% CI, −1.4 to −0.85); and general anxiety symptoms (low-quality evidence; 12 RCTs; N = 1,004; SMD = −0.79; 95% CI, −1.1 to −0.48). There was no difference between therapist-guided, Internet-delivered CBT and face-to-face CBT for overall improvement in anxiety (RR = 1.1; 95% CI, 0.89 to 1.3); disorder-specific symptoms (SMD = 0.09; 95% CI, −0.26 to 0.43); or general anxiety symptoms (SMD = 0.17; 95% CI, −0.35 to 0.69). There were no differences between therapist-guided, Internet-delivered CBT and unguided Internet-delivered CBT for overall improvement in anxiety (insufficient data); disorder-specific symptoms (SMD = −0.24; 95% CI, −0.69 to 0.21); or general anxiety symptoms (SMD = 0.28; 95% CI, −2.2 to 2.8). Limitations included imprecision of psychosocial interventions, blinding issues, and nonstandardized methodology.

A 2016 RCT (n = 46) compared therapist-guided, Internet-delivered CBT with a control intervention for generalized anxiety disorder in persons 60 years and older.2 Participants were 87% female with a mean age of 66 years; met diagnostic criteria for generalized anxiety disorder; and had a score greater than 10 on the Generalized Anxiety Disorder-7 (GAD-7) scale, no recent medication adjustments, and no severe medical illness or comorbid mental illness. The intervention consisted of seven Internet modules presented over seven to 10 weeks. Patients were assessed before treatment, immediately after treatment, and one month after treatment. Symptom improvement (as measured by the GAD-7 scale) was observed from baseline to immediately after treatment, and effect size was measured with Cohen's d (small effect = 0.2, moderate effect = 0.5, and large effect = 0.8). Both groups had improvement in GAD-7 scores after treatment (CBT mean = 6.5 ± 4.6; control = 10 ± 4.2), with the greatest effect in the CBT group (d = 0.91). There was a large difference in effect between CBT and controls (d = 0.85), and a small difference from baseline to posttreatment in the control group (d = 0.38). Participants who received CBT had faster improvement; 86% had a GAD-7 score less than 10 at the end of the intervention. Anxiety scores continued to improve in the month after the intervention. The generalizability and applicability of this trial may be limited by the small number and majority of female participants.

Help Desk Answers provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (

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This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN’s Help Desk Answers published in AFP is available at

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