Internet-Delivered Cognitive Behavioural Therapy for Post-traumatic Stress Disorder or Acute Stress Disorder: A Health Technology Assessment.

Background: Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) are mental health conditions that may emerge following a frightening or traumatic event in a person's life. We conducted a health technology assessment of internet-delivered cognitive behavioural therapy (iCBT) for adults with PTSD or ASD, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding iCBT for PTSD or ADS, and patient preferences and values.

Methods: We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of systematic reviews using ROBIS and of randomized controlled trials (RCTs) using the Cochrane Risk of Bias Tool, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria.We performed a systematic economic literature search to summarize the economic evidence on the cost-effectiveness of iCBT for adults with PTSD or ASD. We did not conduct a primary economic evaluation on iCBT for adults with PTSD, as an existing cost-utility analysis is directly applicable to this research question. We did not conduct a primary economic evaluation on iCBT for adults with ASD, as there is limited clinical evidence on this topic and because evidence on iCBT for PTSD may be generalizable to iCBT for ASD at risk of progressing to PTSD. We analyzed the budget impact of publicly funding iCBT for adults with PTSD or ASD in Ontario over the next 5 years.To contextualize the potential value of iCBT for PTSD, we reviewed relevant literature on patients' preferences and values and spoke with people who have lived experience with PTSD to explore their values, needs, and priorities.

Results: We identified no studies on the use of iCBT for prevention of PTSD or studies on the use of iCBT to treat ASD, nor studies that directly compared iCBT with face-to-face CBT for the treatment of PTSD. We included one systematic review of the use of iCBT to treat PTSD (10 RCTs, N = 720). Overall, iCBT is more effective than wait-list (waiting for iCBT) or usual care alone for reducing the severity of PTSD symptoms (standardized mean difference [SMD] = -0.60 [95% CI -0.97 to -0.24]; N = 560, 8 RCTs) (GRADE: Very low). Internet-delivered CBT is not more effective than non-CBT internet-delivered interventions for reducing the severity of PTSD symptoms (SMD = -0.08 [-0.52 to 0.35]; N = 82, 2 RCTs) (GRADE: Very low).We identified one economic evaluation on the cost-effectiveness of iCBT for adults with PTSD. For adults with PTSD, iCBT was found to be dominant (i.e., less costly and more effective) compared with usual care. The model used a Canadian public health care payer perspective, and there were no major limitations to the model structure, time horizon, or source of model inputs. The annual budget impact of publicly funding iCBT in Ontario over the next 5 years ranges from an additional $2.43 million in year 1 to $2.37 million in year 5, for a total additional cost of $16.53 million over the next 5 years. If treatment costs alone are considered, the annual budget impact ranges from an additional $3.37 million in year 1 to $17.84 million in year 5, for a total additional cost of $52.61 million over the next 5 years.Our review of the quantitative literature on patient preferences found that adults with PTSD may experience iCBT as a generally acceptable form of treatment, but there is uncertainty in the evidence due to incomplete follow-up in studies and variability in the nature and extent of the therapist-patient relationship. The 10 people we spoke with had all been diagnosed with PTSD. They reported on its negative impact on their quality of life, including difficulty in managing everyday activities, relationships, and employment. Participants viewed iCBT as beneficial to managing their PTSD symptoms but stressed the importance of combining it with face-to-face CBT. However, wait times for PTSD services are long, and out-of-pocket expenses could be a barrier for people without private insurance.

Conclusions: Internet-delivered CBT may reduce the severity of PTSD symptoms compared with wait-list or usual care, but the evidence is very uncertain, and iCBT may have little to no effect on improving PTSD symptoms compared with non-CBT interventions delivered online, but here as well the evidence is very uncertain.For adults with PTSD, iCBT may be cost-effective compared with usual care. We estimate that publicly funding iCBT in Ontario would result in additional costs of between $2.37 million and $2.43 million per year over the next 5 years.People with PTSD seem to generally find iCBT as an acceptable treatment option. People with PTSD with whom we spoke viewed iCBT to be effective and recommended it be combined with in-person psychotherapy.