Since the late 1990s, Internet-delivered cognitive behavior therapy (ICBT) has been developed and suggested as a solution to increase the access to evidence-based treatments for mental health problems in children and adults. ICBT tries to tackle a well-known problem: mental health problems are common and the demand for effective psychological treatments is high. However, traditional face-to-face therapy is only accessible to a fraction of patients. Common treatment barriers that hinder many patients from receiving the right therapy are for example the shortage of trained therapists and ethnic inequalities.
In 2020, the Covid-19 pandemic added another, unprecedented threat to the accessibility of evidence-based mental health care. Covid-19 and the necessary responses put in place have made it clear that digital solutions are essential to maintain a reasonable level of health care.
Thus, the Covid-19 crisis has been a major catalyst for the development and implementation of innovative digital mental health treatments. We regard this as a positive step but there is a risk that interventions are implemented in regular healthcare before they have been rigorously evaluated. Here, we wish to highlight that the process of development and scientific testing takes time, and that robust standards of efficacy, safety and cost-effectiveness should be applied before making novel digital interventions widely available to patients.
In the current publication1, our research team from the Karolinska Institutet in Stockholm, Sweden examined the long-term effects of an internet-delivered psychological intervention for youth with obsessive-compulsive disorder (OCD). OCD occurs in about one to two out of 100 children, is typically characterized by excessive handwashing, ordering, checking or other rituals, and has a significant impact on the everyday life of the affected.
We found that the treatment effects of the internet intervention were not only maintained up to one year after treatment, but that the participants’ symptoms continued to improve. This was unexpected, as treatment effects usually remain stable over time when patients are treated with traditional face-to-face CBT. It seems therefore that the benefits of ICBT unfold gradually over time, a finding that also has been observed in another study of ICBT for children with anxiety disorders2. More research is needed to explain this delayed treatment effect and the mechanisms behind it.
The demonstration of long-term maintenance of the therapeutic gains after ICBT is the latest in a series of publications that aimed to establish robust evidence for ICBT for OCD in youth. In 2014, we published the first results regarding the development and feasibility of this novel intervention3. Next, we conducted a randomized controlled trial, comparing ICBT with a no-treatment condition4, showing that ICBT indeed was effective in reducing OCD symptoms in a clinically meaningful way. We could also demonstrate cost-effectiveness of the intervention5 and identified patient characteristics associated with better outcomes6.
The next logical step was to evaluate the intervention against the gold-standard face-to-face CBT, with a large, on-going study nearing completion7. Ultimately, the level of evidence of all new health care interventions should be assessed by independent evaluators or national health agencies, using established tools for the grading of evidence e.g.8.
In conclusion, the development and evaluation of new digital interventions for mental health is a long and resource-intensive process and does not happen overnight. In the current example, it has taken approximately 7 years from the initial prototype to the current version of the treatment, which soon could be implemented at a first regular health care unit in Sweden. In comparison, the development of a new vaccine usually takes between 3 and 7 years9, although market introduction may well take up to 10 years10.
Hopefully, the discovery and production of a safe and effective Covid-19 vaccine can be sped up. More rapid development should also be possible for digital psychological interventions, given adequate funding. However, in the best interest of those in need of safe and effective help, we should be cautious to not cut any corners, but to take the time to develop good quality evidence prior to implementation.
1 Lenhard F, Andersson E, Mataix-Cols D, Rück C, Aspvall K, Serlachius E. Long-term outcomes of therapist-guided Internet-delivered cognitive behavior therapy for pediatric obsessive-compulsive disorder. npj Digit Med 2020; 3: 1–5.
2 Vigerland S, Serlachius E, Thulin U, Andersson G, Larsson J-O, Ljótsson B. Long-term outcomes and predictors of internet-delivered cognitive behavioral therapy for childhood anxiety disorders. Behav Res Ther 2017; 90: 67–75.
3 Lenhard F, Vigerland S, Andersson E, Rück C, Mataix-Cols D, Thulin U et al. Internet-delivered cognitive behavior therapy for adolescents with obsessive-compulsive disorder: An open trial. PLoS One 2014; 9: e100773.
4 Lenhard F, Andersson E, Mataix-Cols D, Rück C, Vigerland S, Högström J et al. Therapist-Guided, Internet-Delivered Cognitive-Behavioral Therapy for Adolescents With Obsessive-Compulsive Disorder: A Randomized Controlled Trial. J Am Acad Child Adolesc Psychiatry 2017; 56: 10--19.e2.
5 Lenhard F, Ssegonja R, Andersson E, Feldman I, Rück C, Mataix-Cols D et al. Cost-effectiveness of therapist-guided Internet-delivered Cognitive Behavior Therapy for pediatric Obsessive-Compulsive Disorder : Results from a Randomized Controlled Trial. BMJ Open 2017.
6 Lenhard F, Sauer S, Andersson E, Månsson KNT, Mataix-Cols D, Rück C et al. Prediction of outcome in internet-delivered cognitive behaviour therapy for paediatric obsessive-compulsive disorder: A machine learning approach. Int J Methods Psychiatr Res 2017; 27: e1576.
7 Aspvall K, Andersson E, Lenhard F, Melin K, Norlin L, Wallin L et al. Stepped Care Internet-Delivered vs Face-to-Face Cognitive-Behavior Therapy for Pediatric Obsessive-Compulsive Disorder. JAMA Netw Open 2019; 2: e1913810.
8 What is GRADE? | BMJ Best Practice. https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-is-grade/ (accessed 29 Sep2020).
9 Plotkin S, Robinson JM, Cunningham G, Iqbal R, Larsen S. The complexity and cost of vaccine manufacturing – An overview. Vaccine. 2017; 35: 4064–4071.
10 How long does it take to develop a vaccine? | World Economic Forum. https://www.weforum.org/agenda/2020/06/vaccine-development-barriers-coronavirus/ (accessed 29 Sep2020).