%0 Journal Article
%@ 2368-7959
%I JMIR Publications
%V 12
%N 
%P e64251
%T The Effect of Predicted Compliance With a Web-Based Intervention for Anxiety and Depression Among Latin American University Students: Randomized Controlled Trial
%A Benjet,Corina
%A Zainal,Nur Hani
%A Albor,Yesica
%A Alvis-Barranco,Libia
%A Carrasco Tapia,Nayib
%A Contreras-Ibáñez,Carlos C
%A Cortés-Morelos,Jacqueline
%A Cudris-Torres,Lorena
%A de la Peña,Francisco R
%A González,Noé
%A Gutierrez-Garcia,Raúl A
%A Vargas-Contreras,Eunice
%A Medina-Mora,Maria Elena
%A Patiño,Pamela
%A Gildea,Sarah M
%A Kennedy,Chris J
%A Luedtke,Alex
%A Sampson,Nancy A
%A Petukhova,Maria V
%A Zubizarreta,Jose R
%A Cuijpers,Pim
%A Kazdin,Alan E
%A Kessler,Ronald C
%+ Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA, 02115, United States, 1 617 432 3587, kessler@hcp.med.harvard.edu
%K anxiety
%K depression
%K web-based cognitive behavioral therapy
%K compliance
%K randomized controlled trial
%D 2025
%7 28.2.2025
%9 Original Paper
%J JMIR Ment Health
%G English
%X 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; χ21=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; χ21=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  
%R 10.2196/64251
%U https://mental.jmir.org/2025/1/e64251
%U https://doi.org/10.2196/64251