Cost-effectiveness of internet-based cognitive-behavioural therapy and physical exercise for depression

Economic evaluation of Be a Mom, a web-based intervention to prevent postpartum depression in high-risk women alongside a randomized controlled trial

BACKGROUND

Postpartum depression (PPD) poses significant challenges, affecting both mothers and children, with substantial societal and economic implications. Internet-based cognitive behavioral therapy interventions (iCBT) offer promise in addressing PPD, but their economic impact remains unexplored. This study aimed to evaluate the cost-utility of Be a Mom, a self-guided iCBT intervention, compared with a waiting-list control among postpartum women at high risk of PPD.

METHODS

This economic evaluation was conducted alongside a 14-month randomized controlled trial adopting a societal perspective. Participants were randomized to Be a Mom (n = 542) or a waitlisted control group (n = 511). Self-report data on healthcare utilization, productivity losses, and quality-adjusted life years (QALYs) were collected at baseline, post-intervention, and 4 and 12 months post-intervention. Incremental cost-effectiveness ratios (ICERs) were calculated, and cost-effectiveness acceptability curves were generated using nonparametric bootstrapping. Sensitivity analyses were conducted to assess result robustness.

RESULTS

Over 14 months, Be a Mom generated a QALY gain of 0.0184 (0.0022, 0.0346), and cost savings of EUR 34.06 (-176.16, 108.04) compared to the control group. At a willingness to pay of EUR 20,000, Be a Mom had a 97.6 % probability of cost-effectiveness.

LIMITATIONS

Results have limitations due to self-selected sample, potential recall bias in self-reporting, missing data, limited follow-up, and the use of a waiting-list control group.

CONCLUSIONS

This study addresses a critical gap by providing evidence on the cost-utility of an iCBT intervention tailored for PPD prevention. Further research is essential to identify scalable and cost-effective interventions for reducing the burden of PPD.

Evaluating the effect of psychoeducational interventions on prenatal attachment and anxiety/depression in pregnant women and partners: A systematic review and meta-analysis

BACKGROUND

Evidence about effective psychoeducational interventions to improve prenatal attachment, anxiety and depression has been increasing, but it lacks a complete synthesis of the results. The aim of this study is to evaluate the effect of psychoeducational intervention on prenatal attachment and anxiety/depression in pregnant women and their partners.

METHODS

Ten databases were systematically searched to identify randomized controlled trials (RCTs) on the effectiveness of psychoeducational interventions on prenatal attachment from inception to March 2023, then manually screened to include studies of anxiety or depression. Two researchers assessed the methodological quality of the included studies using the Cochrane risk-of-bias tool and meta-analysis was performed using RevMan 5.4 software.

RESULTS

Ten RCTs with a total of 700 pregnant women and 399 partners were included. Prenatal attachment scores after the intervention (standardized mean difference = 1.10, 95 % CI 0.65 to 1.55, P <.00001) was significantly increased and anxiety scores (standardized mean difference = -0.99, 95 % CI -1.18 to -0.80, P <.00001) was significantly lower. The subgroup analysis showed that the different prenatal attachment assessment tools were the source of heterogeneity in the combined results. The sensitivity analysis results showed reliable pooled results except for the studies using the self-made anxiety scale.

CONCLUSION

This review suggests that psychoeducational interventions can effectively enhance prenatal attachment, reduce anxiety and depression, providing reference for the promotion of evidence-based practice of psychoeducational interventions in perinatal pregnant women and their partners.

Internet-delivered psychological treatment as an add-on to treatment as usual for common mental disorders: A systematic review with meta-analysis of randomized trials

BACKGROUND

Psychological treatments for common mental disorders are increasingly being delivered remotely via the internet. Evidence suggests that internet-delivered cognitive behavioural therapy (iCBT) is superior to waitlist. However, the benefits are unclear of using this treatment modality as an add-on to treatment as usual (TAU) in regular healthcare.

METHODS

The literature was systematically searched up to August 2021 for randomized trials of internet-delivered psychological treatments using TAU as the comparator. Eligible participants were diagnosed with depressive, anxiety, obsessive-compulsive, or trauma- and stress-related disorders. Outcomes of interest were symptoms, functioning, quality of life, healthcare utilization, and negative effects. Results were synthesized using random-effects meta-analyses. Quality of evidence was assessed using GRADE.

RESULTS

The included studies evaluated iCBT for adults with depression (k = 9), depressive or anxiety disorders (k = 4), and post-traumatic stress disorder (k = 2) and were conducted in primary care or similar settings. For depression, low-certainty evidence suggested beneficial short-term effects on symptoms (g = -0.23; 95 % CI: = -0.37, -0.09), response rate (OR = 2.46; 1.31, 4.64), and remission (OR = 1.70; 1.19, 2.42;). The certainty of evidence was very low for long-term effects, other outcomes, and other disorders.

LIMITATIONS

TAU varied across studies and was often insufficiently described.

CONCLUSIONS

iCBT as a complement to usual care for adult with depression may result in a small incremental effect, which potentially could be clinically important. Studies are lacking for several common disorders and for children, adolescents, and the elderly. More robust studies of long-term effects are also needed, to better inform clinical decision-making.

Internet-delivered cognitive behavioral therapy (iCBT) for common mental disorders and subsequent sickness absence: a systematic review and meta-analysis

AIM

The study aimed to critically review and synthesize the best available evidence about the effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (iCBT) in terms of reducing sickness absence (SA).

METHODS

We searched Medline (PubMed), Embase, PsycInfo, CINAHL, and Cochrane Central (up to November 2020) for English language peer-reviewed papers that described randomized controlled trials of therapist-guided iCBT compared with usual treatment for SA in adults with common mental disorders. Eligible studies were assessed with the Cochrane Risk of Bias 1 tool, meta-analysis was conducted using a random-effects model, and standardized mean differences (SMD) with 95% confidence intervals (CI) were reported. A subgroup analysis investigated potential moderating variables (diagnosis, SA at baseline, and estimated accuracy of self-report).

RESULTS

We identified 2788 references, of which 68 remained after the completion of the systematic screening process. A hand search of reference lists yielded no additional studies. The full texts of these 68 studies were appraised critically, and 11 were deemed to be suitable for a meta-analysis. SA was similar for iCBT and usual treatment groups (SMD: 0.02, 95% CI, -0.08 to 0.11), and remained similar even after the removal of two studies in which the recall time was over 3 months (SMD: 0.00, -0.11 to 0.12). Similar SA levels in intervention and control groups at 6-month and 12-month follow-up were observed in studies of participants with depression symptoms.

CONCLUSIONS

iCBT did not appear to be effective in terms of reducing (largely self-assessed) SA in adults with common mental disorders. There is a need to improve the method and consistency of assessing SA.

Cost-effectiveness of Internet Interventions Compared With Treatment as Usual for People With Mental Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

The economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternatives to usual care, but the evidence is mixed.

OBJECTIVE

The aim was to review the literature on the cost-effectiveness of internet interventions for mental disorders compared with usual care and to provide an estimate of the monetary benefits of such interventions compared with usual care.

METHODS

A systematic review and meta-analysis of randomized controlled trials was conducted, which included participants with symptoms of mental disorders; investigated a telephone- or internet-based intervention; included a control condition in the form of treatment as usual, psychological placebo, waiting list control, or bibliotherapy; reported outcomes on both quality of life and costs; and included articles published in English. Electronic databases such as PubMed (including MEDLINE), Embase, Emcare, PsycINFO, Web of Science, and the Cochrane Library were used. Data on risk of bias, quality of the economic evaluation, quality-adjusted life years, and costs were extracted from the included studies, and the incremental net benefit was calculated and pooled.

RESULTS

The search yielded 6226 abstracts, and 37 studies with 14,946 participants were included. The quality of economic evaluations of the included studies was rated as moderate, and the risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions were slightly more effective than usual care in terms of quality-adjusted life years gain (Hedges g=0.052, 95% CI 0.010-0.094; P=.02) and equally expensive (Hedges g=0.002, 95% CI -0.080 to 0.84; P=.96). The pooled incremental net benefit was US $255 (95% CI US $91 to US $419; P=.002), favoring internet interventions over usual care. The perspective of the economic evaluation and targeted mental disorder moderated the results.

CONCLUSIONS

The findings indicate that the cost-effectiveness of internet interventions for mental disorders compared with a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the field of mental health to pool cost-effectiveness outcomes in an aggregate data meta-analysis.

TRIAL REGISTRATION

PROSPERO CRD42019141659; https://tinyurl.com/3cu99b34.

Internet-delivered psychological interventions for reducing depressive, anxiety symptoms and fear of childbirth in pregnant women: A meta-analysis and meta-regression

OBJECTIVE

The current review aims to (1) investigate the effectiveness of Internet-based psychological intervention in reducing depressive, anxiety, and stress symptoms and fear of childbirth among pregnant women at post-intervention and follow-up; (2) compare the effects of the intervention using different psychological principles; and (3) explore potential covariates on the intervention effect.

METHODS

A literature search of seven databases was carried out to identify published and unpublished randomized controlled trials (RCTs) in English without any time limitation up to February 2021. Meta-analysis and meta-regression were conducted using Comprehensive Meta-analysis software. This review protocol was registered on PROSPERO (CRD42021235565).

RESULTS

Sixteen RCTs involving 3894 pregnant women were included from more than 23 countries. Internet-delivered psychological interventions were found to significantly (p < 0.05) reduce depressive (g = -0.16 to -0.32) and anxiety (g = -0.22 to -0.33) symptoms with small effect sizes at post-intervention and follow-up during 6 to 8 weeks postpartum compared with those in the comparator group. However, there was insufficient evidence for fear of childbirth and stress symptoms. Our subgroup analyses found that psychological interventions adopting component of cognitive behavioral therapy (g = -0.29) or mindfulness therapy (g = -0.62) showed beneficial effects to improve depressive symptoms among pregnant women. Univariate random-effect regression analyses showed that the attrition rate was a significant covariate (Z = -2.33, p = 0.02) on depressive symptoms. The certainty of main outcomes was graded from low to very low in accordance with the GRADE criteria.

CONCLUSIONS

Our reviews suggested that Internet-delivered psychological intervention may complement usual antenatal care in the improvement of depressive and anxiety symptoms. Future trials involving a large-scale sample are needed to improve the methodological quality.

Economic Evaluation of Cognitive Behavioral Therapy for Depression: A Systematic Review

OBJECTIVES

This study aimed to conduct a systematic review of cost-utility studies of internet-based and face-to-face cognitive behavioral therapy (CBT) for depression from childhood to adulthood and to examine their reporting and methodological quality.

METHODS

A structured search for cost-utility studies concerning CBT for depression was performed in 7 comprehensive databases from their inception to July 2020. Two reviewers independently screened the literature, abstracted data, and assessed quality using the Consolidated Health Economic Evaluation Reporting Standards and Quality of Health Economic Studies checklists. The primary outcome was the incremental cost-effectiveness ratio (ICER) across all studies. To make a relevant comparison of the ICERs across the identified studies, cost data were inflated to the year 2020 and converted into US dollars.

RESULTS

Thirty-eight studies were included in this review, of which 26 studies (68%) were deemed of high methodological quality and 12 studies (32%) of fair quality. Despite differences in study designs and settings, the conclusions of most included studies for adult depression were general agreement; they showed that face-to-face CBT monotherapy or combination therapy compared with antidepressants and usual care for adult depression were cost-effective from the societal, health system, or payer perspective (ICER -$241 212.4/quality-adjusted life-year [QALY] to $33 032.47/QALY, time horizon 12-60 months). Internet-based CBT regardless of guided or unguided also has a significant cost-effectiveness advantage (ICER -$37 717.52/QALY to $73 841.34/QALY, time horizon 3-36 months). In addition, CBT was cost-effective in preventing depression (ICER -$23 932.07/QALY to $26 092.02/QALY, time horizon 9-60 months). Nevertheless, the evidence for the cost-effectiveness of CBT for children and adolescents was still ambiguous.

CONCLUSIONS

Fair or high-quality evidence showed that CBT monotherapy or combination therapy for adult depression was cost-effective; whether CBT-related therapy was cost-effective for children and adolescents depression remains inconclusive.

Utilization of healthcare and prescription medicines after non-pharmacological interventions for depression - A 3-year register follow-up of an RCT in primary care

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A 3-year register follow-up of an RCT for depression interventions was conducted.

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Healthcare utilization and dispensed medicines were used as register outcomes.

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The interventions had no effect on consultations for mental illness during follow-up.

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Both interventions are appropriate additions to mild-moderate depression care.

Depression is a common, recurrent disorder. There is a need for readily available treatments with few negative side effects, that demands little resources and that are effective both in the short- and long term.

Our aim was to investigate the long-term effectiveness of two different interventions; physical exercise and internet-based cognitive behavioural therapy (internet-CBT), compared to usual care in patients with mild to moderate depression in a Swedish primary care setting.

We performed a register-based 3-year follow-up study of participants in the randomized controlled trial REGASSA (n = 940) using healthcare utilization and dispensed medicines as outcomes.

We found no difference between the three groups regarding proportion of participants consulting healthcare due to mental illness or pain during follow-up. Regarding number of consultations, there was no difference between the groups, except for consultations related to pain. For this outcome both treatment arms had significantly fewer consultations compared to usual care, during year 2–3, the risk ratio (RR) for physical exercise and internet-CBT was 0.64 (95% CI = 0.43–0.95) and 0.61 (95% CI = 0.41–0.90), respectively.

A significantly lower proportion of patients in both treatment arms were dispensed hypnotics and sedatives year 2–3 compared to the usual care arm, RR for both physical exercise and internet-CBT was 0.72 (95% CI = 0.53–0.98). No other differences between the groups were found.

In conclusion, considering long-term effects, both physical exercise and internet-CBT, being resource-efficient treatments, could be considered as appropriate additions for patients with mild to moderate depression in primary care settings.

Trial registration: The original RCT was registered with the German Clinical Trial Register (DRKS study ID: DRKS00008745).

Digital interventions in mental health: evidence syntheses and economic modelling

BACKGROUND

Economic evaluations provide evidence on whether or not digital interventions offer value for money, based on their costs and outcomes relative to the costs and outcomes of alternatives.

OBJECTIVES

(1) Evaluate and summarise published economic studies about digital interventions across different technologies, therapies, comparators and mental health conditions; (2) synthesise clinical evidence about digital interventions for an exemplar mental health condition; (3) construct an economic model for the same exemplar mental health condition using the previously synthesised clinical evidence; and (4) consult with stakeholders about how they understand and assess the value of digital interventions.

METHODS

We completed four work packages: (1) a systematic review and quality assessment of economic studies about digital interventions; (2) a systematic review and network meta-analysis of randomised controlled trials on digital interventions for generalised anxiety disorder; (3) an economic model and value-of-information analysis on digital interventions for generalised anxiety disorder; and (4) a series of knowledge exchange face-to-face and digital seminars with stakeholders.

RESULTS

In work package 1, we reviewed 76 economic evaluations: 11 economic models and 65 within-trial analyses. Although the results of the studies are not directly comparable because they used different methods, the overall picture suggests that digital interventions are likely to be cost-effective, compared with no intervention and non-therapeutic controls, whereas the value of digital interventions compared with face-to-face therapy or printed manuals is unclear. In work package 2, we carried out two network meta-analyses of 20 randomised controlled trials of digital interventions for generalised anxiety disorder with a total of 2350 participants. The results were used to inform our economic model, but when considered on their own they were inconclusive because of the very wide confidence intervals. In work package 3, our decision-analytic model found that digital interventions for generalised anxiety disorder were associated with lower net monetary benefit than medication and face-to-face therapy, but greater net monetary benefit than non-therapeutic controls and no intervention. Value for money was driven by clinical outcomes rather than by intervention costs, and a value-of-information analysis suggested that uncertainty in the treatment effect had the greatest value (£12.9B). In work package 4, stakeholders identified several areas of benefits and costs of digital interventions that are important to them, including safety, sustainability and reducing waiting times. Four factors may influence their decisions to use digital interventions, other than costs and outcomes: increasing patient choice, reaching underserved populations, enabling continuous care and accepting the 'inevitability of going digital'.

LIMITATIONS

There was substantial uncertainty around effect estimates of digital interventions compared with alternatives. This uncertainty was driven by the small number of studies informing most comparisons, the small samples in some of these studies and the studies' high risk of bias.

CONCLUSIONS

Digital interventions may offer good value for money as an alternative to 'doing nothing' or 'doing something non-therapeutic' (e.g. monitoring or having a general discussion), but their added value compared with medication, face-to-face therapy and printed manuals is uncertain. Clinical outcomes rather than intervention costs drive 'value for money'.

FUTURE WORK

There is a need to develop digital interventions that are more effective, rather than just cheaper, than their alternatives.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018105837.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 1. See the NIHR Journals Library website for further project information.

What is the short-term remission rate for people with untreated depression? A systematic review and meta-analysis

BACKGROUND

Depression is one of the prevalent mental illnesses and leading cause of global disease burden. However, most people with depression do not access treatment. Remission without treatment may occur in some cases of depression. This study aimed to estimate the short-term remission (natural recovery) from untreated depression.

METHODS

A systematic review and meta-analysis was registered on PROSPERO and conducted following PRISMA guidelines. EMBASE, PsycINFO, and PubMed were searched, supplemented with an additional hand search to identify studies reporting natural recovery from untreated depression. Study selection and screening were carried out by three independent reviewers. Methodological quality assessment of the included studies was conducted. Remission was defined as no longer meeting the diagnostic criteria or scoring below the cut off points of the validated tools as reported by the included studies. The data were synthesized using narrative summary and random-effects meta-analysis.

RESULTS

Sixteen waitlist-controlled trial studies were included in the systematic review and meta-analysis. The duration of follow-up ranged from 4 to 12 weeks with a median duration of 8 weeks. The overall pooled remission from untreated depression was 12.5%, 95% confidence interval (7.8, 18.0%). Due to lack of published data, we were unable to determine if the severity of depression symptoms was associated with remission rates.

CONCLUSIONS

Short-term remission from depression without treatment is uncommon. Across studies, 8 - 18% of people remitted without treatment within 12 weeks. Waitlist control groups may not represent all persons with depression.

Effectiveness of digital psychotherapeutic intervention among perinatal women: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The perinatal period is a challenging time of substantial emotional, physiological, social, and relational changes. Depression, anxiety, and stress symptoms are common, and co-exist in the perinatal period. Digital technology continues to grow at an unprecedented pace with wide application, including psychotherapeutic intervention. A growing number of meta-analyses supported the application of digital psychotherapeutic intervention across different populations, but relatively few meta- and meta-regression analyses have concentrated on perinatal women.

AIM

To evaluate the effectiveness of digital psychotherapeutic intervention on improving psychological outcomes among perinatal women and identify its essential features.

METHODS

Randomized controlled trials (RCTs) were obtained from eight databases, including Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, Scopus, PsycINFO, PubMed, Web of Science, and ProQuest Dissertation and Theses from inception up until November 24, 2020. Comprehensive Meta-analysis 3.0 software was used to conduct meta- and meta-regression analyses. The Cochrane risk-of-bias tool and the Grading of the Recommendation, Assessment, Development, and Evaluation system were adopted to assess the individual and overall qualities of the evidence, respectively.

RESULTS

A total of 25 RCTs that included 3239 women were identified. Meta-analyses revealed that intervention significantly improved depression (Hedges's g = 0.49), anxiety (g = 0.25), and stress (g = 0.47) symptoms compared to the control. Subgroup analyses demonstrated that a website platform with ≥ eight therapist-guided sessions using the theoretical principle of cognitive behavioral therapy was more effective than other treatments in improving depression symptoms in postnatal women. Meta-regression analyses observed that the age of perinatal women and the type of psychotherapy also had statistically significant effects on depression symptoms. Egger's regression asymmetry tests suggested that no publication biases occurred, but the overall quality of the evidence was very low.

CONCLUSION

This review suggests that digital psychotherapeutic intervention may be a potential solution to reduce psychological problems in perinatal women. Further high-quality RCTs with large sample sizes are needed.

Changes in alcohol consumption after treatment for depression: a secondary analysis of the Swedish randomised controlled study REGASSA

OBJECTIVES

Mental health problems and hazardous alcohol consumption often co-exist. Hazardous drinking could have a negative impact on different aspects of health and also negatively influence the effect of mental health treatment. The aims of this study were to examine if alcohol consumption patterns changed after treatment for depression and if the changes differed by treatment arm and patient sex.

METHODS

This study of 540 participants was conducted in a large randomised controlled trial (RCT) that aimed to compare the effect of internet-based cognitive behavioural therapy, physical exercise and treatment as usual on 945 participants with mild-to-moderate depression. Treatment lasted for 12 weeks; alcohol consumption (Alcohol Use Disorder Identification Test (AUDIT)) and depression (Montgomery Åsberg Depression Rating Scale (MADRS)) were assessed at baseline and 12-month follow-up. Changes in alcohol consumption were examined in relation to depression severity, treatment arm and patient sex.

RESULTS

The AUDIT distribution for the entire group remained unchanged after treatment for depression. Hazardous drinkers exhibit decreases in AUDIT scores, although they remained hazardous drinkers according to the cut-off scores. Hazardous drinkers experienced similar improvements in symptoms of depression compared with non-hazardous drinkers, and there was no significant relation between changes in AUDIT score and changes in depression. No differences between treatment arm and patient sex were found.

CONCLUSION

The alcohol consumption did not change, despite treatment effects on depression. Patients with depression should be screened for hazardous drinking habits and offered evidence-based treatment for hazardous alcohol use where this is indicated.

TRIAL REGISTRATION NUMBER

DRKS00008745.

Individually tailored internet treatment in routine care: A feasibility study

INTRODUCTION

Disorder-specific internet treatment, based on cognitive-behavioral therapy, has been a part of routine psychiatric care in Sweden since 2007, provided at the Internet Psychiatry Clinic in Stockholm. Individually tailored treatments, with the opportunity to target more than one condition within the same treatment, has since then been evaluated in randomized trials with promising results. To introduce an individually tailored treatment into a clinical setting originally designed for disorder-specific processes creates challenges, such as how to choose the optimal treatment type for each patient.

METHODS

The feasibility of a proposed new routine for assessment and initiation of either a disorder-specific or an individually tailored treatment was tested on patients self-referring to the Internet Psychiatry Clinic during three weeks (N = 66), by exploring the match between comorbid problem areas and patients' preferred treatments with available disorder-specific treatment options, as well as presenting these patients' preferred problem areas to work with in individually tailored treatment, and evaluating any problems with the proposed routine. The feasibility (i.e. satisfaction, credibility, treatment activity, adherence, and preliminary symptom reductions) in the individually tailored treatment were also explored on a smaller subgroup of eight patients.

RESULTS

A majority (65%) of patients screened had at least 2 comorbid problem areas, although 25% of these comorbid patients that where allocated with the help of the proposed routine still initiated disorder-specific treatment. The proposed assessment routine functioned satisfactorily within the up and running internet clinic. The individually tailored treatment was promising regarding satisfaction, credibility, adherence, and preliminary reductions in symptoms. A notable challenge encountered was that the platform was not set up to assist with assessment process or outcome monitoring for individually tailored treatment.

CONCLUSIONS

It seems feasible to combine individually tailored internet treatment and disorder-specific internet treatment within the same internet clinic. The addition of tailored treatment may prove to increase the number of patients included in treatment.

The effects of component-specific treatment compliance in individually tailored internet-based treatment

The objective of this study was to explore the effects of treatment compliance in a guided individually tailored internet‐based treatment (TAIL) in relation to depression and co‐morbid symptoms. Compliance with the homework in the different treatment components in TAIL, each aimed at a specific condition, was rated for 207 participants by independent assessors. Six subgroups (n = 34–131) were constructed consisting of participants with co‐occurring symptoms of worry, panic, social anxiety, stress, insomnia, or pain. For each group, hierarchical regression was used to investigate whether the total sum of compliance points, Overall Compliance, predicted reductions in depression and in condition‐specific symptoms. Also, in each subgroup, it was tested whether working with specific treatment components, Specific Compliance, predicted reduction of the targeted symptoms. Overall Compliance predicted 15% of the reduction in depression symptoms. For participants with worry, panic, social anxiety, stress, or insomnia, Overall Compliance also predicted symptom reductions in that specific condition. Specific Compliance predicted reduction in the targeted symptoms for participants with social anxiety, stress, and insomnia. Specific Compliance with stress and insomnia components also predicted reductions in depression. Our results strengthen the importance of compliance in internet‐based treatments. Because compliance with stress and insomnia components was particularly important for broad symptom reductions, these conditions should not be ignored when treating patients with co‐morbid symptoms.