@Article{info:doi/10.2196/64251,
author="Benjet, Corina
and Zainal, Nur Hani
and Albor, Yesica
and Alvis-Barranco, Libia
and Carrasco Tapia, Nayib
and Contreras-Ib{\'a}{\~{n}}ez, Carlos C
and Cort{\'e}s-Morelos, Jacqueline
and Cudris-Torres, Lorena
and de la Pe{\~{n}}a, Francisco R
and Gonz{\'a}lez, No{\'e}
and Gutierrez-Garcia, Ra{\'u}l A
and Vargas-Contreras, Eunice
and Medina-Mora, Maria Elena
and Pati{\~{n}}o, Pamela
and Gildea, Sarah M
and Kennedy, Chris J
and Luedtke, Alex
and Sampson, Nancy A
and Petukhova, Maria V
and Zubizarreta, Jose R
and Cuijpers, Pim
and Kazdin, Alan E
and Kessler, Ronald C",
title="The Effect of Predicted Compliance With a Web-Based Intervention for Anxiety and Depression Among Latin American University Students: Randomized Controlled Trial",
journal="JMIR Ment Health",
year="2025",
month="Feb",
day="28",
volume="12",
pages="e64251",
keywords="anxiety; depression; web-based cognitive behavioral therapy; compliance; randomized controlled trial",
abstract="Background: Web-based cognitive behavioral therapy (wb-CBT) is a scalable way to reach distressed university students. Guided wb-CBT is typically superior to self-guided wb-CBT over short follow-up periods, but evidence is less clear over longer periods. Objective: This study aimed to compare short-term (3 months) and longer-term (12 months) aggregate effects of guided and self-guided wb-CBT versus treatment as usual (TAU) in a randomized controlled trial of Colombian and Mexican university students and carry out an initially unplanned secondary analysis of the role of differential predicted compliance in explaining these differences. Methods: The 1319 participants, recruited either through email and social media outreach invitations or from waiting lists of campus mental health clinics, were undergraduates (1038/1319, 78.7{\%} female) with clinically significant baseline anxiety (Generalized Anxiety Disorder--7 score≥10) or depression (Patient Health Questionnaire--9 score≥10). The intervention arms comprised guided wb-CBT with weekly asynchronous written human feedback, self-guided wb-CBT with the same content as the guided modality, and TAU as provided at each university. The prespecified primary outcome was joint remission (Generalized Anxiety Disorder--7 score=0-4 and Patient Health Questionnaire--9 score=0-4). The secondary outcome was joint symptom reduction (mean scores on the Patient Health Questionnaire Anxiety and Depression Scale) at 3 and 12 months after randomization. Results: As reported previously, 3-month outcomes were significantly better with guided wb-CBT than self-guided wb-CBT (P=.02) or TAU (P=.02). However, subsequent follow-up showed that 12-month joint remission (adjusted risk differences=6.0-6.5, SE 0.4-0.5, and P<.001 to P=.007; adjusted mean differences=2.70-2.69, SE 0.7-0.8, and P<.001 to P=.001) was significantly better with self-guided wb-CBT than with the other interventions. Participants randomly assigned to the guided wb-CBT arm spent twice as many minutes logged on as those in the self-guided wb-CBT arm in the first 12 weeks (mean 12.5, SD 36.9 vs 5.9, SD 27.7; $\chi$21=107.1, P<.001), whereas participants in the self-guided wb-CBT arm spent twice as many minutes logged on as those in the guided wb-CBT arm in weeks 13 to 52 (mean 0.4, SD 7.5 vs 0.2, SD 4.4; $\chi$21=10.5, P=.001). Subgroup analysis showed that this longer-term superiority of self-guided wb-CBT was confined to the 40{\%} (528/1319) of participants with high predicted self-guided wb-CBT compliance beyond 3 months based on a counterfactual nested cross-validated machine learning model. The 12-month outcome differences were nonsignificant across arms among other participants (all P>.05). Conclusions: The results have important practical implications for precision intervention targeting to maximize longer-term wb-CBT benefits. Future research needs to investigate strategies to increase sustained guided wb-CBT use once guidance ends. Trial Registration: ClinicalTrials.gov NCT04780542; https://www.clinicaltrials.gov/study/NCT04780542 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-022-06255-3  ",
issn="2368-7959",
doi="10.2196/64251",
url="https://mental.jmir.org/2025/1/e64251",
url="https://doi.org/10.2196/64251"
}