Zhou Et Al 2021 Are Online Mental Health Interventions For Youth Effective A Systematic Review

Research
Journal of Telemedicine and Telecare

2021, Vol. 27(10) 638–666
Are online mental health interventions © The Author(s) 2021
Article reuse guidelines:
for youth effective? A systematic review sagepub.com/journals-permissions
DOI: 10.1177/1357633X211047285
journals.sagepub.com/home/jtt
Xiaoyun Zhou1,2 , Sisira Edirippulige1,2 , Xuejun Bai3,

and Matthew Bambling1,4,5,6
Abstract
Objectives: This systematic review aims to examine the effectiveness of online mental health interventions for youth.
Methods: We searched seven electronic databases (PubMed, PsycINFO, Medline, Embase, CINAHL, Web of Science and
SCOPUS) for the past 10 years to identify randomized controlled trials which have evaluated the use of telehealth inter-
ventions for young people with mental health problems. The included studies were assessed for quality and risk of bias.
Results: Forty-five randomized controlled trials (n = 13,291 participants) were eligible for this review. Most studies (35
trials) evaluated the use of web-based self-help platforms to deliver cognitive behavioural therapy (14 trials), mindfulness
(four trials), acceptance commitment therapy (five trials) and positive psychology (two trials). Mobile/computer applica-
tions were used to deliver cognitive behavioural therapy (four trials) and coping strategies training (two trials). Web-based
synchronous chat (one trial) was used to assist communication between counsellors and participants. Three studies used
artificial intelligence-based conversational agents to deliver cognitive behavioural therapy (two trials) and problem-solving-
strategy training (one trial). Eighty-two percent (n = 37) identified the participants as student population (i.e. university
students, high school students). Sixty-four percent (n = 29) of the telehealth interventions were found to be effective
in managing depression, anxiety, stress, insomnia and improving quality of life when compared with control conditions.
Conclusions: Online mental health interventions were found to be effective in managing diverse mental health condi-
tions among youth. Online self-help platforms were the most frequently used modality and artificial intelligence-based
chatbots are merging as potential solutions. Future research is warranted to investigate the solutions to improve the
retention rate and satisfaction of telehealth interventions among this population.
Keywords
Telehealth, telemedicine, adolescent, youth, mental health, effectiveness, systematic review
Date received: 19 July 2021; Date accepted: 1 September 2021
Introduction Telehealth has been increasingly used to manage youth

mental health; for instance, E-CYMHS, a video-based
The age-of-onset for mood and anxiety disorders was mental health program, was developed to provide
reported as 15–24 years.1,2 The prevalence rate for signifi-
cant symptoms for depression or anxiety among youth was
up to 28% in 2018.3,4 The global prevalence of subthres- 1
Centre for Online Health, The University of Queensland, Australia
hold social anxiety disorders among youth was estimated 2
Centre for Health Services Research, The University of Queensland,
to be 36% in 2020.5 Youth-onset mental health problems Australia
3
are associated with chronic and severe mental disorders in Academy of Psychology and Behavior, Tianjin Normal University, China
4
Navitas ACAP School of Psychology, Australia
adulthood.6 Early interventions in youth are effective in 5
School of Psychology, Queensland University of Technology, Australia
preventing the progression to chronic mental health pro- 6
Brisbane Central Medical School, The University of Queensland,
blems, however, it is estimated that the cost for mental Australia
health services was estimated to be $6460 per youth in
2019.7 The perceived need for mental health service Corresponding author:
Xiaoyun Zhou, Centre for Online Health, The University of Queensland,
among youth is increasing, however, the accessibility, Ground Floor Building 33, Princess Alexandra Hospital, 199 Ipswich Road,
affordability and stigma associated with mental health ser- Woolloongabba QLD 4102, Australia.
vices prevented youth from seeking professional help. Email: [email protected]
Zhou et al. 639
Australian rural adolescents with mental health care.8,9 In Quality assessment

addition to videoconferencing, various technologies (e.g.
Two independent reviewers (XZ and SE) used JBI’s
email, text, e-consult) have been integrated into youth
Critical Appraisal Checklist for Randomised Controlled
mental health care shown to be accessible, effective and
Trials23 to assess the quality of the studies. Any discrepan-
cost-effective.10 Despite of efforts made by health care pro-
cies were revolved around the involvement of a third
viders, young people may also prefer to access mental
reviewer (MB). The total score ranged from 1 to 13
health services through websites and applications.11,12
points. For this review, studies meeting at least 10 out of
Increasing number of studies have evaluated the effect of
13 criteria were categorised into ‘good’ quality, seven to
online interventions to manage youth mental health con-
nine were categorised into ‘moderate’ quality, less than
cerns. However, some studies showed that online interven-
seven were deemed ‘poor’ quality. The studies that scored
tions were effective in reducing depression,13,14
less than seven were excluded from this review.
anxiety,15,16 conduct disorders17 and substance abuse18
among youth. Whilst others suggested that online interven-
tions were not effective in managing mental health Results
issues.19–21 To date there has not been a systematic evalu-
ation of the evidence for online mental health interventions The initial search identified 2184 articles from PubMed,
among youth. The purpose of this study is to systematically PsycINFO, Medline, Embase, CINAHL, Web of Science
review the literature to determine the effects of online and SCOPUS. After duplicates were removed, 1426 articles
mental health interventions for youth. were screened for title and abstract. Screening for titles and
abstracts excluded 971 articles. A total of 455 full texts
were screened against inclusion and exclusion criteria.
Methods Three hundred and eighty-two ineligible articles were
removed (see Figure 1). Seventy-three articles were
Search procedures assessed for methodological quality using the JBI tool
This review was conducted between November 2020 and July and 28 were deemed to be of poor quality and excluded.
2021. The preferred reporting items for systematic reviews Forty-five studies were included in this review.
and meta-analysis (PRISMA) guidelines were followed to iden-
tify and analyse relevant studies.22 Search terms were adoles-
cent, mental health, telehealth, and intervention and databases
Study characteristics
were PubMed, PsycINFO, Medline, Embase, CINAHL, web Forty-five randomized controlled trials (RCTs) (n = 13,291
of science and SCOPUS (see Appendix 1). The inclusion and participants) were included in this review (see Appendix 2
exclusion criteria were formulated following PICO. We included for characteristics of each study). The year of publication
studies that (i) included youth (15–24 years); (ii) were rando- ranged from 2012 to 2021. The majority of the studies
mised controlled trials (RCTs); (iii) were underpinned by were conducted in developed countries (e.g. the USA,
stand-alone or combined psychological therapies; (iv) were Australia, the UK etc.). Thirty-seven studies identified their
delivered via online format (e.g. mobile applications, web-based sample as the student population. The mean age of partici-
programs etc.); and (v) targeted mental health outcomes. We pants ranged from 14.8 to 26.7 years. Twenty-three studies
excluded studies that (i) only recruited parents or teachers of recruited a universal sample, the other 22 studies recruited
youth; (ii) were quasi-experimental studies, single-arm trials, selected samples with elevated symptoms. The sample sizes
cross-sectional studies or qualitative studies; (iv) used online ranged widely from 61 to 1767. The intervention duration
interventions which were not based on psychological therapies ranged from one session to 12 months. Thirty-five studies
(e.g. solely based on physical activities); (v) solely used tele- used web-based self-help platforms as formats to deliver psy-
phone consulting; email or face-to-face counselling as delivery chological interventions. Six studies used applications, one
format; (vi) did not include mental health outcomes or primarily study used web-based synchronous chat, and three studies
targeted conduct disorders (e.g. drug abuse). Two authors (XZ used artificial intelligence (AI)-based conversational agents.
and SE) independently performed the screening process, and dis-
agreement was resolved by the third author (MB).
Quality appraisal
An overview of the quality appraisal of the included studies
Data extraction is illustrated in Appendix 3. Due to the nature of online
In addition to basic demographic details of the included interventions, no studies concealed participants or research-
studies, we collected and tabulated the following informa- ers from the interventions. The risk of selection bias was
tion: study design, sample characteristics, modalities of reported in six studies15,20,24–27 and four studies16,28–30
online interventions, psychological interventions, mental did not report baseline differences. In addition, 10
health outcomes, effect sizes and retention rates. studies14,15,20,21,27,31–35 did not report concealing outcomes
640 Journal of Telemedicine and Telecare 27(10)
Figure 1. Preferred reporting items for systematic reviews and meta-analysis (PRISMA) flowchart.
assessors from the intervention allocations. Three stress level (n = 14, 40%). Several studies also investigated
studies25,36,37 reported that extra contacts were provided mental health outcomes relating to mental health well-
to intervention groups (e.g. extra email, text messages for being,13,20,25,32,44,45 quality of life,32,36,37,46 life satisfac-
encouraging engagement with the interventions). tion,21,44 psychological distress,16,25,37,45 insomnia47 and
Furthermore, there was insufficient description and analysis sleep quality.43
of lost participants.15,19,21,27,28,30,32,38–42 Five studies did
not perform intent-to-treat analysis.28,33,36,42,43
Modalities of online mental health interventions
Thirty-five studies (78%) used web-based self-help plat-
Efficacy outcomes forms as formats to deliver psychological interventions.
The most frequently assessed mental health outcomes were Six studies used applications (13%), one study (2%) used
depression or depressive symptoms (n = 38; 84%), web-based synchronous chat and three studies (7%) used
anxiety-related symptoms (n = 33; 73%), psychological AI-based conversational agents.
Zhou et al. 641
The efficacy of web-based self-help platforms. Web-based school students. Findings were that the intervention had
self-help platforms were the most frequently used online no impact on anxiety, depressive symptoms or mental
format (n = 35).14,20,25–27,29,30,33,34,36,37,39,40,42–44,46–55 A health wellbeing. One intervention was based on CBT
total of 24 studies were effective in managing and mindfulness,38 the intervention was effective in redu-
mental health issues whilst other 11 were found to be not cing depression, and anxiety but not effective in reducing
effective. psychological stress levels. Farrer et al.37 used a web-based
self-help platform to deliver psychoeducation and train stu-
Cognitive behavioural therapy. Fourteen self-help plat- dents with coping strategies. They found that the interven-
forms were underpinned by cognitive behavioural tion was not effective in reducing anxiety, depression,
therapy.15,16,27,33,35,39,42,48,50,52,53,55–57 Eleven studies psychological distress or improving quality of life.
found that the web-based platforms underpinned by cogni- Gladstone et al.29 delivered a combination of behavioural
tive behavioural therapies were effective in reducing out- activation strategies and interpersonal psychotherapy tech-
comes scores relating to depression,15,27,35,39,48,50,52,55,57 niques via a web-based self-help platform. They found
anxiety,15,33,39,50,55–57 psychological stress level15,39 as the intervention was not effective in reducing anxiety or
compared with the control condition. In contrast, the depressive symptoms. Schleider et al.54 delivered psychoe-
other three studies showed that their interventions were ducation on growth mindsets of personality, self-regulation
not effective in reducing anxiety,16,42 depression16,42,53 and intelligence via a web-based platform. They found that
and psychological stress level.16 the intervention was effective in reducing depressive symp-
Acceptance commitment therapy. Five trials were toms, but not effective in reducing social anxiety symp-
underpinned by acceptance commitment toms. Short et al.47 delivered web-based self-help
therapy.21,25,36,40,51 Three interventions were effective in intervention which combined motivational interviewing
reducing depression,36 psychological stress level,36,51 psy- (MI) and CBT. They found that the intervention was not
chological distress25 and improving quality of life36 and effective in reducing anxiety or insomnia.
mental health wellbeing.25 In contrast, two interventions
did not affect outcomes relating to depressive symp-
toms,40,51 life satisfaction,51 anxiety40 and psychological Efficacy of web-based applications. Six studies13,24,32,45,58,59
stress level.40 used web-based mobile applications as vehicle to deliver
psychological interventions. CBT,32,45,58,59 mindfulness,32
Mindfulness. Four studies14,31,43,46 tested the effective- attention bias modification training,32 coping strategies24,58
ness of web-based programs among young people. One and social learning theory45 were used as psychological
study did not report the efficacy due to the low retention interventions which underpinned these web-based applica-
rate.43 The other three mindfulness web-based interventions. Three studies13,58,59 demonstrated the effectiveness
tions14,31,46 showed efficacies in reducing perceived of app-based intervention in improving mental health well-
stress, anxiety, depression14,31,46 and improving quality of being13 and reducing anxiety, depression13,58,59 and per-
life.46 ceived stress.58 The effect sizes ranged from d = 0.30 to d
= 0.76. In contrast, two studies24,32 did not find significant
Positive psychology. Two self-help platforms were differences between intervention groups and control groups
based on positive psychology.30,44 Burckhardt et al.44 in the changes of mental health outcomes at post-
found that the intervention was not effective in managing intervention. Interestingly, O’Dea et al.45 found that the
anxiety, depression, stress, life satisfaction or mental intervention was not effective in reducing depression or
health wellbeing. In contrast, the other intervention30 was anxiety. However, it demonstrated effectiveness in improv-
effective. ing mental health wellbeing. The retention rates ranged
Other stand-alone interventions. Four online platforms from 28% to 92.7%.
were based on present control theory,49 psychodynamic
therapy,41 social cognitive theory26 and religious beliefs
spiritual practices.34 All of these interventions were found Efficacy of web-based synchronous chat between
to be effective in reducing psychological stress level, psychotherapists and participants. Kramer et al.60 tested the
anxiety and depression. effectiveness of web-based synchronous chat between
mental health professionals and participants. The interven-
Combined psychological interventions. Six studies used tion consisted of individual real-time chat sessions with a
web-based self-help interventions combined with several psychotherapist Solution-Focused Brief Therapy (SFBT)
psychological interventions.20,29,37,38,47,54 Calear et al.20 techniques were used by the psychotherapist The result
used a web-based self-help platform to deliver a combin- showed that compared with the waiting list condition, the
ation of psychoeducation, cognitive behavioural therapy intervention group showed significantly greater reductions
(CBT), relaxation skills and physical activity among in symptoms of depression. The retention rate was 51%.
Efficacy of AI-based conversational agents (chatbots). Three engagement varied widely for self-help programs. Some
studies19,28,61 tested the effectiveness of AI-based chatbot studies, therefore, sent participants reminders to increase
in reducing anxiety and depression among university stu- the engagement.25,37 This nevertheless may produce mod-
dents. Bird et al.19 used a computerised AI-based chatbot erators and contaminate the intervention.65 Therefore,
(MYLO) to train participants with problem-solving strate- future studies investigating the effect of self-help platforms
gies. They used another mental health chatbot (ELIZA) as should take into account co-design to increase the
a control condition. ELIZA is a text-based chatbot designed engagement.
to encourage users to discuss their problems. They found Our study suggested mixed evidence relating to the
that both intervention and control groups demonstrated sig- effectiveness of web-based applications in managing
nificant reductions in depression and anxiety. However, mental health issues among youth. Previous reviews inves-
MYLO was not found to be more effective than ELIZA. tigating the effectiveness of app-based mental health inter-
Fitzpatrick and Darcy61 and Fulmer et al.28 used chatbots ventions found a similar trend.70 This potentially reflects
(Weobot and Tess) to deliver CBT. Both studies provided the fact that app-based interventions are still in the
control groups with only online mental health-related infor- nascent stages. More rigorous designs of apps for youth
mation. Fitzpatrick et al. found that the intervention was mental health are needed. Unlike the previous study
effective in reducing depressive symptoms but not in redu- which indicate a mean effect size of d = 0.42 for anxiety
cing anxiety. Fulmer et al. found that the chatbot (Tess) was and d = 0.16 for depression for app-based interventions,
effective in reducing depression and anxiety. The retention our study found that the effect sizes of app-based interven-
rate of AI-based chatbot interventions ranged from 83% to tions ranged from d = 0.32 to 0.76 for anxiety and d = 0.30
100%, with one study reporting 83% and two studies to 0.63 for depression. This is likely because included
reporting 100%. studies in our review are all underpinned by standardized
psychotherapy approaches. Our study also found slightly
higher retention rates for mental health applications which
ranged from 58% to 92%. This may be because compared
Discussion to self-help platforms, applications could be accessed via
Telehealth is a clinically effective approach for managing various devices (e.g. tablets, smartphones and laptops),
diverse health conditions62,63 and it is well-accepted and and are therefore easy to use. A review conducted by
widely used in the management of mental health con- Chan and Honey71 suggested that consumers held positive
cerns.64 This systematic review summarised the modalities attitudes toward mental health apps and rated them ‘easy to
and effectiveness of online mental health interventions for use’.
youth in the recent literature. Four modalities were used In line with the previous review,72 our studies only
to manage youth mental health problems: web-based self- found a limited number of synchronous text-based chats,
help platforms, web-based applications, web-based syn- indicating that there is potentially a research gap in investi-
chronous chat and AI-based chatbots. Sixty-four percent gating the efficacy of this modality. The only study in this
(n = 29) of the online interventions were effective in mana- review suggested that web-based synchronous chat was
ging depression, anxiety, psychological stress level, insom- effective in reducing depression as compared with the
nia and psychological distress and improving mental health control condition. As this modality relied largely on the
well-being, life satisfaction, sleep quality, and quality of life characteristics of the psychotherapist, this modality served
among youth. mostly as a communication tool.
Web-based self-help platforms were the most frequent Three trials were identified that investigated the effect-
method used in the reviewed studies (n = 35). In line with iveness of AI-based chatbots. The evidence was mixed
previous studies,65,66 majority of self-help platforms (n = with two studies showing reduced anxiety28 and depres-
25) were effective in managing anxiety, depression and sion28,61 whilst one study did not.19 Abd-Alrazaq et al.73
psychological stress level when compared with the also found conflicting results relating to the effectiveness
control conditions, with those underpinned by cognitive of the chatbots in managing anxiety and depression.
behavioural therapies demonstrating most evidence. These These altogether suggested that confirmatory studies asses-
included self-help platforms comprised of different sing the effectiveness of chatbots are needed. Moreover, the
modules with each module achieving certain aims such as AI-based chatbots had the highest retention rates: 83% (n =
psychoeducation and skills training. Participants could 1) to 100% (n = 2). This finding is in line with previous
access the platform at their convenience. Previous studies studies74 which suggested that chatbots were rated as
have suggested that internet self-help platforms were con- acceptable, satisfying and enjoyable.
venient67 and helpful in reducing stigma.68 It is worth The majority (33/45) of the included studies were of
noting that the retention rate ranged widely from 1% to ‘good’ quality, however, the included studies are heteroge-
100%. This confirmed previous findings relating to online neous. For instance, some studies recruited a universal
self-help platforms,69 which indicated that the uptake and sample whilst some studies recruited a targeted sample
Zhou et al. 643
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health interventions have the potential as an effective treat- 11. Becker MPE, Christensen BK, Cunningham CE, et al.
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Declaration of conflicting interests 13. Bendtsen M, Mussener U, Linderoth C, et al. A mobile health
intervention for mental health promotion among university
The authors declared no potential conflicts of interest with respect students: randomized controlled trial. JMIR Mhealth
to the research, authorship, and/or publication of this article. Uhealth 2020; 8: e17208.
14. Cavanagh K, Churchard A, O’Hanlon P, et al. A randomised
Funding controlled trial of a brief online mindfulness-based interven-
tion in a non-clinical population: replication and extension.
The authors disclosed receipt of the following financial support for
Mindfulness 2018; 9: 1191–1205.
the research, authorship, and/or publication of this article: This
15. Day V, McGrath PJ and Wojtowicz M. Internet-based guided
work was supported by the Major Projects of the National
self-help for university students with anxiety, depression and
Social Science Foundation (grant no. 20ZDA079).
stress: a randomized controlled clinical trial. Behav Res Ther
2013; 51: 344–351.
ORCID iD 16. Dear BF, Fogliati VJ, Fogliati R, et al. Treating anxiety and
Xiaoyun Zhou https://orcid.org/0000-0002-3903-4166 depression in young adults: a randomised controlled trial
Sisira Edirippulige https://orcid.org/0000-0001-6196-5437 comparing clinician-guided versus self-guided internet-
delivered cognitive behavioural therapy. Aust N Z J
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Appendix 1
Table A1. Searching strategy for each database.
Database Number Searching strategy
PubMed 202 (((Adolescent[Ti/Ab] OR Adolescence[Ti/Ab] OR Teen[Ti/Ab] OR Teenager[Ti/Ab] OR Youth[Ti/Ab] OR

student[Ti/Ab] OR ‘young adult’ [Ti/Ab] OR ‘young people’ [Ti/Ab]) AND (‘mental health’ [Ti/Ab] OR
‘mental disorder’ [Ti/Ab] OR depressive[Ti/Ab] OR depression [Ti/Ab] OR anxiety [Ti/Ab] OR stress [Ti/
Ab] OR ‘psychological wellbeing’ [Ti/Ab])) AND (Web-based [Ti/Ab] OR computerized[Ti/Ab] OR
‘mobile health’ [Ti/Ab] OR mHealth[Ti/Ab] OR eHealth [Ti/Ab] OR telehealth [Ti/Ab] OR VR [Ti/Ab] OR
‘virtual reality’ [Ti/Ab] OR text-messaging [Ti/Ab] OR ‘text messaging’ [Ti/Ab] OR ‘text message’ [Ti/Ab]
OR ‘text based’ [Ti/Ab] OR texting [Ti/Ab] OR text-based [Ti/Ab] OR SMS [Ti/Ab] OR app [Ti/Ab] OR
application [Ti/Ab] OR digital [Ti/Ab] OR internet-based [Ti/Ab] OR online [Ti/Ab] OR chatbot[Ti/Ab]
OR ‘conversational agent’ [Ti/Ab] OR chatterbot[Ti/Ab] OR ‘conversational bot’ [Ti/Ab] OR ‘dialog agent’
[Ti/Ab] OR ‘virtual agent’ [Ti/Ab] OR ‘artificial intelligent’ [Ti/Ab] OR AI[Ti/Ab] OR ‘artificial intelligence’
[Ti/Ab] OR NLP[Ti/Ab] OR ‘natural language processing’ [Ti/Ab] OR cyber[Ti/Ab])) AND
(Intervention[Ti/Ab] OR program[Ti/Ab]).
Filters: Filters applied: Books and Documents, Clinical Trial, Randomized Controlled Trial, in the last 10 years,
Child: birth-18 years, Adolescent: 13–18 years, Young Adult: 19–24 years.
PsycINFO 678 Abstract: Adolescent OR Adolescence OR Teen OR Teenager OR Youth OR student OR ‘young adult’ OR
‘young people’ AND Abstract: ‘mental health’ OR ‘mental disorder’ OR depressive OR depression OR
anxiety OR stress OR ‘psychological wellbeing’ AND Abstract: Web-based OR computerized OR ‘mobile
health’ OR mHealth OR eHealth OR telehealth OR VR OR ‘virtual reality’ OR text-messaging OR ‘text
messaging’ OR ‘text message’ OR ‘text based’ OR texting OR text-based OR SMS OR app OR application
OR digital OR internet-based OR online OR chatbot OR ‘conversational agent’ OR chatterbot OR
‘conversational bot’ OR ‘dialog agent’ OR ‘virtual agent’ OR ‘artificial intelligent’ OR AI OR ‘artificial
intelligence’ OR NLP OR ‘natural language processing’ OR cyber AND Abstract: Intervention OR
Abstract: program AND NOT Methodology: Literature Review OR Systematic Review OR Meta-Analysis
AND Peer-Reviewed Journals only AND Year: 2010 To 9999.
Medline 296 TI (Adolescent OR Adolescence OR Teen OR Teenager OR Youth OR student OR ‘young adult’ OR ‘young
people’) AND AB (‘mental health’ OR ‘mental disorder’ OR depressive OR depression OR anxiety OR
stress OR ‘psychological wellbeing’) AND TI (Web-based OR computerized OR ‘mobile health’ OR
mHealth OR eHealth OR telehealth OR VR OR ‘virtual reality’ OR text-messaging OR ‘text messaging’ OR
‘text message’ OR ‘text based’ OR texting OR text-based OR SMS OR app OR application OR digital OR
internet-based OR online OR chatbot OR ‘conversational agent’ OR chatterbot OR ‘conversational bot’
OR ‘dialog agent’ OR ‘virtual agent’ OR ‘artificial intelligent’ OR AI OR ‘artificial intelligence’ OR NLP OR
‘natural language processing’ OR cyber) AND TI (Intervention OR program OR cost-effectiveness OR
perspective OR perception).
Limiters – Scholarly (Peer Reviewed) Journals; Date of Publication: 20100101 –; Language: English.
Expanders – Apply equivalent subjects.
Search modes – Find all my search terms.
Embase 354 (adolescent:ab,ti OR adolescence:ab,ti OR teen:ab,ti OR teenager:ab,ti OR youth:ab,ti OR student:ab,ti OR
’young adult’:ab,ti OR ’young people’:ab,ti) AND (’mental health’:ab,ti OR ’mental disorder’:ab,ti OR
depressive:ab,ti OR depression:ab,ti OR anxiety:ab,ti OR stress:ab,ti OR ’psychological wellbeing’:ab,ti)
AND (’web based’:ab,ti OR computerized:ab,ti OR ’mobile health’:ab,ti OR mhealth:ab,ti OR ehealth:ab,ti
OR telehealth:ab,ti OR vr:ab,ti OR ’virtual reality’:ab,ti OR ’text messaging’:ab,ti OR ’text message’:ab,ti
OR texting:ab,ti OR ’text based’:ab,ti OR sms:ab,ti OR app:ab,ti OR application:ab,ti OR digital:ab,ti OR
’internet based’:ab,ti OR online:ab,ti OR chatbot:ab,ti OR ’conversational agent’:ab,ti OR chatterbot:ab,ti
OR ’conversational bot’:ab,ti OR ’dialog agent’:ab,ti OR ’virtual agent’:ab,ti OR ’artificial intelligent’:ab,ti
OR ai:ab,ti OR ’artificial intelligence’:ab,ti OR nlp:ab,ti OR ’natural language processing’:ab,ti OR cyber:ab,
ti) AND (intervention:ab,ti OR program:ab,ti) AND ([controlled clinical trial]/lim OR [randomized
controlled trial]/lim) AND [2010–2021]/py.
CINAHL 184 TI (Adolescent OR Adolescence OR Teen OR Teenager OR Youth OR student OR ‘young adult’ OR ‘young
people’) AND AB (‘mental health’ OR ‘mental disorder’ OR depressive OR depression OR anxiety OR
stress OR ‘psychological wellbeing’) AND AB (Web-based OR computerized OR ‘mobile health’ OR
(continued)
Zhou et al. 647
Table A1. Continued
Database Number Searching strategy
mHealth OR eHealth OR telehealth OR VR OR ‘virtual reality’ OR text-messaging OR ‘text messaging’ OR

‘text message’ OR ‘text based’ OR texting OR text-based OR SMS OR app OR application OR digital OR
internet-based OR online OR chatbot OR ‘conversational agent’ OR chatterbot OR ‘conversational bot’
OR ‘dialog agent’ OR ‘virtual agent’ OR ‘artificial intelligent’ OR AI OR ‘artificial intelligence’ OR NLP OR
‘natural language processing’ OR cyber) AND TI (Intervention OR program) Limiters – Published Date:
20100101–; English Language; Peer Reviewed.
Expanders – Apply equivalent subjects.
Narrow by SubjectAge: – adult: 19–44 years.
Narrow by SubjectAge: – adolescent: 13–18 years.
Search modes – Boolean/Phrase.
Narrow by SubjectAge: – adolescent: 13–18 years.
Search modes – Boolean/Phrase.
Web of 208 TITLE: (Adolescent OR Adolescence OR Teen OR Teenager OR Youth OR student OR ‘young adult’ OR
Science ‘young people’) AND TITLE: (‘mental health’ OR ‘mental disorder’ OR depressive OR depression OR
anxiety OR stress OR ‘psychological wellbeing’) AND TITLE: (Web-based OR computerized OR ‘mobile
health’ OR mHealth OR eHealth OR telehealth OR VR OR ‘virtual reality’ OR text-messaging OR ‘text
messaging’ OR ‘text message’ OR ‘text based’ OR texting OR text-based OR SMS OR app OR application
OR digital OR internet-based OR online OR chatbot OR ‘conversational agent’ OR chatterbot OR
‘conversational bot’ OR ‘dialog agent’ OR ‘virtual agent’ OR ‘artificial intelligent’ OR AI OR ‘artificial
intelligence’ OR NLP OR ‘natural language processing’ OR cyber) AND TITLE: (Intervention OR
program).
Timespan: 2010–2021. Indexes: SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH,
ESCI, CCR-EXPANDED, IC.
SCOPUS 262 (TITLE (adolescent OR adolescence OR teen OR teenager OR youth OR student OR ‘young adult’ OR
‘young people’) AND TITLE-ABS-KEY (‘mental health’ OR ‘mental disorder’ OR depressive OR
depression OR anxiety OR stress OR ‘psychological wellbeing’) AND TITLE (web-based OR
computerized OR ‘mobile health’ OR mhealth OR ehealth OR telehealth OR vr OR ‘virtual reality’ OR
text-messaging OR ‘text messaging’ OR ‘text message’ OR ‘text based’ OR texting OR text-based OR sms
OR app OR application OR digital OR internet) AND TITLE (intervention OR program OR
cost-effectiveness OR perspective OR perception)) AND DOCTYPE (ar) AND PUBYEAR > 2009.
Appendix 2
648
Table A2. Characteristics of each study.
Retention rate (i.e.

Percentage of
Sample [sample participants who
description; finished
Study design condition (universal/ Assessed Results (statistical post-intervention/
Author, year, （intervention/control targeted); age; Online intervention Psychological mental health significance compared Effect size of follow-up
country group; duration） number] modalities intervention outcomes with control group) intervention assessment)
Ahmad 2020, Design: 4-arm RCT Sample description: Web-based platform: Mindfulness Depression, At 8-week time point, Did not report Post-intervention:
Canada Intervention groups: university students Video-based anxiety, stress compared with the 92%
web-based Condition: modules, symptoms control condition,
interventions universal peer-to-peer there was significant
Control group: WLC Age: M = 24.8 discussion forums, reductions in
Duration: 8 weeks Number:113 brief guided symptoms of
videoconferences depression (p <
0.001), anxiety (p =
0.01) and stress (p <
0.01).
Antonson Design: 3-arm RCT Sample description: Web-based self-help Mindfulness Sleep quality; Did not report the Did not report Post-intervention:
2018, Intervention group 1: upper secondary program: video and perceived effectiveness due to 1%
Sweden internet based school students audio material, stress low compliance
mindfulness Condition: Any device
Intervention group 2: universal Age: 15– No human
internet music 19 interference
therapy intervention Number:283
Control group: WLC
Duration: 8 weeks
Bendtsen Design: 2-arm RCT Sample description: Fully automated mobile Positive psychology Mental health Compared with Wellbeing: IRR = Post-intervention:
2020, Intervention group: university students phone application wellbeing; control group, there 1.052 58%
Sweden mHealth Condition: and daily text anxiety; was significant Depression: IRR =
intervention universal messages depression improvement in 0.878; anxiety: IRR
Control group: TAU Age: Mean = 25 mental health = 0.936
Duration: 10 weeks Number: 654 wellbeing (p = 0.02)
and significant
reduction in anxiety
(p = 0.02) and
depression (p =
0.05)
Bird 2018, UK Design: two-arm RCT Sample description: AI-based computerized Problem-solving skills Depression, Both programs N/A Post-intervention:
Intervention group: university students conversational agent building anxiety, stress (MYLO and ELIZA) 100%
AI-based Condition: were associated with
computerized universal improvements in
Journal of Telemedicine and Telecare 27(10)
(continued)
Table A2. Continued

Percentage of
Zhou et al.

intervention (MYLO) Age: M = 22.8 problem distress (p

Control group: Number:213 < 0.01, η2 = 0.23,)
ELIZA which anxiety and
emulates a Rogerian depression (η2=
psychotherapist 0.24), but MYLO
Duration: 2 weeks was not found to be
more effective than
ELIZA.
Burckhardt Design: two-arm RCT Sample description: Web-based self-help Positive psychology Depression, Both Bite Back and Did not report Post-intervention:
2015, Intervention group: high school program anxiety, stress, control conditions 33%
Australia web-based students life satisfaction, demonstrated
intervention (Bite Condition: mental health significant
Back) universal wellbeing improvements in life
Control group: Age: 12.6–15.6 satisfaction scores
non-psychology Number: 572 post-intervention,
entertainment however only
websites control condition
Duration:6 weeks demonstrated
significant increases
in flourishing scores
(mental health
wellbeing)
post-intervention.
Calear 2016, Design: three-arm Sample description: Web-based self-help Psychoeducation, Generalized There was no N/A Post-intervention:
Australia cluster RCT school students program CBT, relaxation anxiety, social significant 47.5%
Intervention group: Condition: and physical anxiety, anxiety improvement
online self-help universal activity. sensitivity, (compared with
program (e-GAD Age: M = 14.83 depressive control group) for
school method; Number: 1767 symptoms, generalized anxiety,
e-GAD service mental health social anxiety,
method) wellbeing anxiety sensitivity,
Control group: WLC depressive
Duration: 6 weeks symptoms, mental
health wellbeing.
Cavanagh Design: two-arm RCT Sample description: Web-based self-help Mindfulness Perceived There were significant Mindfulness skills: d Post-intervention:
2013, UK Intervention group: university students program stress, improvement in = 0.27; perceived 52.3%
online self-help Condition: perceived stress, stress: d = 0.37;
(continued)
649
Table A2. Continued
650

Percentage of
mindfulness program universal depression, anxiety/depression anxiety and

Control group: WLC Age: M = 24.7 anxiety symptoms depression: d =
Duration: two-week Number: 104 0.24
Cook 2019, Design: three-arm Sample description: Therapist-guided Rumination-focused Depression, No formal significance Did not report Post-intervention:
UK RCT university students web-based self-help CBT anxiety analyses were 77.7%
Intervention group1: Condition: platform undertaken relative
guided web-based targeted (those to an unguided
intervention with elevated web-based
Intervention group1: rumination) intervention.
unguided web-based Age: M = 20 For guided
intervention Number: 235 web-based
Control group: TAU intervention:
Duration: 6 modules compared with
(3 months) control condition,
depression (p <
0.05) score
significantly lower
for guided
web-based
intervention at
post-intervention.
Day 2013, Design: two-arm RCT Setting: university Web-based guided CBT Anxiety, There were significant Depression: ηp2 = 80% participants
Canada Intervention group: students self-help program depression, reductions in 0.07; Anxiety: ηp2 completed
Online CBT Condition: stress depression, anxiety = 0.08; stress: ηp2 post-intervention
intervention distressed and stress compared = 0.12 assessment
Control group: WLC Age: M = 23.55 with control
Dose: 6 weeks Number: 66 condition
Dear 2018, Design: two-arm RCT Setting: young adults Web-based (self-help CBT Depression, There was no At 3 month At post-intervention:
Australia Intervention group 1: Condition: those or clinician guided) Anxiety, significant difference follow-up, effect 88.5%
clinician guided with anxiety and platform general between the two size for difference
web-based depressive psychological groups at post-test was 0.31
intervention (CG) symptoms distress in outcomes relating
Intervention group 2: Age: M = 21.47 to anxiety,
self-guided Number: 192 depression and
web-based psychological stress.
intervention (SG) At 3-month
follow-up, SG group
(continued)
Table A2. Continued

Percentage of
Zhou et al.

Dose: 4 sessions (5 reported

weeks) significantly more
anxiety symptoms
than the CG group
(p = 0.002).
Edridge 2020, Design: two-arm RCT Setting: primary and Web-based CBT, mindfulness, mental health There were no N/A Did not report
UK Intervention group: secondary school smartphone or tablet and attention bias wellbeing, significant
mHealth students application modification health-related differences between
intervention Condition: training (ABMT) quality of life the ReZone
(ReZone) universal condition and
Control group: TAU Age: 10–15 management as usual
Dose: 12 classes Number: 409 in the self-reported
outcome measures.
ElMorr 2020, Design: two-arm RCT Sample description: Web-based platform CBT and mindfulness Depression, Compared with Depression: d = 92.5% of participants
Canada Intervention group: university students (online videos, anxiety, control group, 0.69; completed
web-based guided Condition: peer-to-peer perceived intervention group Anxiety: d = 0.74; post-intervention
mindfulness-CBT universal discussion forums, stress achieved significant assessment
condition Age: M = 22.6 live reductions in
Control group: WLC Number: 160 videoconferences) depression (P = .01),
Duration: 8 weeks anxiety (P = .006).
There were no
statistically
significant
differences in
perceived stress P =
.48).
Eustis 2018, Design: two-arm RCT Sample description: Web-based self-help ACT Depression, Compared with Stress: d = 0.44; 50% of participants
USA Intervention group: university students platform; anxiety, stress, control group, Depression: d = completed
web-based Condition: quality of life intervention group 0.80; post-intervention
intervention universal achieved significantly Quality of life: d = assessment. 41%
(SATDS) Age: M = 25.4 more reductions in 0.52 completed
Control group: WLC Number: 156 stress (p = 0.04) and 1-month follow-up
Duration: 3 sessions depression (p < assessment.
(4 weeks) 0.001) and achieved
a significant more
increase in quality of
life (p = 0.02), but
(continued)
651
652
Table A2. Continued

Percentage of
not in anxiety (p =
0.46)
Farrer 2019, Design: two-arm RCT Sample description: Web-based self-help Psychoeducation, Depression, There was no N/A 72% of participants
Australia Intervention group: university students platform coping strategies anxiety, quality significant difference completed
online intervention Condition: training of life, between post-intervention
(UVC) targeted (those psychological intervention and assessment. 47.5%
Control group: WLC with elevated distress control group in completed
Duration: 6 weeks psychological outcomes relating to 3-month follow-up
distress (K10 > anxiety (p = 0.32), assessment.
15)) depression (p =
Age: M = 22 0.45), psychological
Number:200 distress (p = 0.09) or
quality of life (p =
0.74).
Frazier 2015, Design: two-arm RCT Sample description: Web-based self-help Present control Perceived Compared with Between-group 56.8% of participants
USA Intervention group: university students platform theory stress, stress control condition, effect size range completed
web-based stress Condition: symptoms, intervention group from: d = 0.30 to d post-intervention
management universal depression, achieved significantly = 0.36 at assessment. 52.5%
program (PCI) Age: 18–21 anxiety bigger reductions in post-intervention completed a
Control group: Number: 257 perceived stress (p = but d = 0.12 at 3-week follow-up
stress-information 0.007), DASS stress follow-up. assessment.
only (p = 0.006), anxiety
Duration: two weeks (p = 0.05),
depression (p =
0.02).
Gladstone Design: two-arm RCT Sample description: Web-based self-help Behavioral activation Depression, There were no N/A Did not report
2020, USA Intervention group: adolescents platform strategies training, anxiety significant
web-based self-help Condition: interpersonal differences between
intervention targeted (those psychotherapy groups in change in
(CATCH-IT) with elevated techniques training depressive
Control group: depression) symptoms (p = 0.80)
online health Age: 15.4 or anxiety (p =
education (HE) Number: 369 0.79).
Duration: 14 Improvement in
modules (24 months) depressive
(continued)
Table A2. Continued

Percentage of
Zhou et al.

symptoms was
statistically
significant (p < 0.05)
for both groups.
Improvement in
anxiety was
significant for
CATCH-IT (p =
0.04) but not HE (p
= 0.07).
Harrer 2018, Design: two-arm RCT Sample description: Internet- and CBT, Perceived Compared to control Stress: d = 0.69; 92.7% of participants
Germany Intervention group: university students app-based program problem-focused stress, group, intervention Anxiety: d = 0.76; completed
internet- and Condition: coping and depression, group achieved a Depression: d = post-intervention
app-based targeted (those emotion-focused state anxiety bigger reduction in 0.63 assessment. 70% of
intervention with elevated coping perceived stress, participants
(CATCH-IT) levels of perceived depression, anxiety. completed
Control group: WLC stress (PSS-4 > = follow-up
Duration: 7 weeks 8)) assessment (3
Age: M = 24 months after
Number: 150 randomization).
Lappalainen Design: three-arm Sample description: Online self-help ACT Depressive The change in the two N/A 96.0% of the
2021, RCT secondary school platform and symptoms; life intervention groups participant finished
Finland Intervention group1: students WhatsApp messages satisfaction was not significantly post-assessment.
online intervention Condition: sent by coaches different compared
with two face-to-face universal with the control
sessions Age:15–16 (M = group in regard to
Intervention group2: 15.27) depressive
online intervention Number: 243 symptoms (p =
with no face-to-face 0.153); life
sessions satisfaction (p =
Control group: no 0.195).
treatment
Duration: 5 weeks
Ip 2016, China Design: two-arm RCT Sample description: Web-based self-help CBT Depression, At post-intervention, Post-intervention: post-intervention:
Intervention group: secondary school program anxiety, stress intervention group Depression: d = 97%
online intervention students achieved statistically −0.28;
Control group: Condition: significant Anxiety: d =
(continued)
653
654
Table A2. Continued

Percentage of
attention control targeted (those reductions in DASS −0.35;

Duration: 8 months with anxiety (p = 0.01), Stress: d = −0.27
mild-to-moderate depression (p = 4-month
depressive 0.03) and stress (p = follow-up: d =
symptoms) 0.03). −0.36
Age: M = 14.63 At 4-month
Number: 257 follow-up,
intervention group
improved
significantly in
depression (p =
0.01)
Kählke 2019, Design: two-arm RCT Sample description: Web-based self-help CBT for social Social anxiety Results indicated Social anxiety Post-intervention:
Germany, Intervention group: university students platform phobia disorder, moderate to large disorder: 92.5%
Australia, internet-based Condition: depression effect sizes in favor
Switzerland self-help intervention targeted (those of intervention
Control group: WLC with social anxiety group compared
Duration: 10 weeks disorder) with WLC for SAD
Age: M = 26.7 at posttest for the
Number: 200 primary outcomes
(SPS:d = 0.76; SIAS:d
= 0.55, p < 0.001).
Effects on all
secondary outcomes
were significant and
in favour of the
intervention group
Kenny 2020, Design: cluster Sample description: Smartphone app Emotional Depression, No significant changes N/A Post-intervention:
Ireland two-arm RCT school students self-monitoring and anxiety, stress, in the intervention 67.7%
Intervention group: Condition: the use of positive mental health group from pre-test
mental health mobile universal coping strategies well-being to post-test, when
app (CopeSmart) Age: 15–18 compared to the
Control group: Number:560 control group, in
Duration: 4 weeks terms of emotional
(continued)
Table A2. Continued
Zhou et al.

Percentage of
distress, mental
health well-being,
emotional
self-awareness or
coping strategies.
Kramer 2014, Design: two-arm RCT Sample description: Brief web-based Solution-Focused Depression Compared with D = 0.79 Post-intervention:
the Intervention group: young people (12– synchronous chat Brief Therapy control condition, 51%
Netherlands web-based chat 22 years) (PratenOnline/ (SFBT) intervention group
treatment Condition: Talking online) showed significantly
Control group: WLC targeted (those greater
Duration: 4.5 months with depressive improvement at
symptoms) post-intervention.
Age: M = 19.5
Number: 263
Lahtinen, Design: two-arm RCT Sample description: Web-based self-help mindfulness Anxiety, Completing the MBP Anxiety: d = 0.26; Post-intervention:
2020, Intervention group: upper secondary platform depression, resulted in a Depression: d = 70.3%;
Finland digital school students qualify of life small-to-moderate 0.15; At 3-month
mindfulness-based Condition: reduction in anxiety Quality of life: d = follow-up: 53.7%
intervention universal (p < 0.01), a small 0.16
Control group: WLC Age: M = 17 reduction in
Duration: 8 weeks Number: 1349 depression (p <
0.01), and a small
increase in quality of
life (p = 0.05).
Levin 2020, Design: four-arm RCT Sample description: Web-based self-help ACT Psychological All three ACT Psychological Post-intervention:
USA Intervention group: university students program distress, conditions distress: d = 0.71– 89%
online intervention Condition: mental health significantly 0.86 mental health At follow-up:
Control group: WLC targeted (those wellbeing improved over time wellbeing: d = 84.6%
Duration: 12 sessions were relative to the 0.14–0.69
psychologically waitlist condition on
distressed) the primary
Age: M = 22 outcome of mental
Number: 181 health symptoms
(psychological
(continued)
655
656
Table A2. Continued

Percentage of
distress: p < 0.001;

mental health
wellbeing: p < 0.05).
Levin 2014, Design: two-arm RCT Sample description: Web-based self-help ACT Depression, For distressed Anxiety: d = 0.81; Did not report
USA Intervention group: university students program anxiety, stress students, Depression: d =
web-based ACT Condition: intervention group 0.91.
program universal showed significant
Control group: WLC Age: 18 reductions in anxiety
Duration: 3 weeks Number: 76 (p = 0.03),
depression (p =
0.02). No significant
between-group
differences were
observed on
depression or
anxiety among
non-distressed
students.
Lindqvist Design: two-arm RCT Sample description: Web-based Affect-focused Depression, Compared with Depression: d = Post-intervention:
2020, Intervention group: adolescents therapist-supported psychodynamic anxiety control condition, 0.80–0.82; 92.0%
Sweden internet-based Condition: self-help platform therapy intervention group Anxiety: d = 0.78;
psychodynamic targeted (those significantly reduced emotion
therapy intervention with unipolar depression (p = regulation: d =
(IPDT) depressive 0.01) anxiety (p < 0.97;
Control group: disorder) 0.001). self-compassion: d
internet-based Age: 16.6 = 0.65
supportive group Number: 76
Duration: 8 weeks
McCall 2018, Design: two-arm RCT Sample description: Web-based self-help CBT Social anxiety Compared control d = 0.56 64.4%
Canada Intervention group: university students platform condition,
web-based social Condition: intervention group
anxiety intervention targeted (those showed significant
self-reported to improvement in
(continued)
Table A2. Continued

Zhou et al.
Percentage of
Control group: WLC experience social social anxiety

Duration: 4 months anxiety) symptoms (p =
Age: 22 0.001).
Number: 65
McCloud Design: two-arm RCT Sample description: Smartphone app CBT Depression, Compared with At week 6: anxiety: d Post-intervention:
2020, UK Intervention group: university students anxiety control condition, at = 0.32 58.3%
smartphone app Condition: week 6, intervention At week4:
intervention targeted (those group significantly Anxiety: d = 0.58;
Control group: ELC self-identified as reduced depression depression: d =
Duration: 6 weeks experiencing (p = 0.006); at week 0.30
anxiety or 4, intervention
depression) group significantly
Age: M = 24.3 reduced anxiety (p =
Number: 168 0.001) and
depression (p =
0.04).
Melnyk 2015, Design: cluster Sample description: Web-based self-help CBT Anxiety, There were no N/A 99% of participants
two-arm RCT university students platform depression significant finished all sessions
Intervention group: Condition: differences in anxiety
online universal and depressive
cognitive-behavioral Age: M = 18 symptoms between
skill-building Number: 121 the groups
intervention
Control group: TAU
Duration: 7 sessions
Merry 2012, Design: two-arm Sample description: Computerized CBT Depression, SPARX was not N/A Post-intervention:
New randomized adolescents gamified self-help anxiety inferior to treatment 90.9%
Zealand controlled (primary care program as usual. 3-month follow-up:
non-inferiority trial health sites) Post-intervention, 89.8%
Intervention group: Condition: there was a mean
computerized targeted (those reduction of 10.32 in
self-help intervention who seek help for SPARX and 7.59 in
(SPARX) depressive treatment as usual in
Control group: TAU symptoms) raw scores on the
(face-to-face children’s depression
(continued)
657
658
Table A2. Continued

Percentage of
counselling) Age: M = 15.6 rating scale-revised

Duration: 7 modules Number: 187 (P = 0.079).
(4–7 weeks)
Moeini 2019, Design: two-arm RCT Sample description: Web-based self-help Social cognitive Depression The intervention Did not report At post-intervention
Iran Intervention group: high school platform theory group achieved (24 weeks): 35.2%
web-based students significantly more
intervention Condition: reduction in
Control group: targeted (female, depressive
Duration: 6 months with symptoms,
mild-to-moderate compared with
depressive control group (p <
symptoms) 0.05).
Age: M = 16.7
Number: 128
O’Dea 2020, Design: two-arm RCT Sample description: Smartphone CBT and Social Depression, At post-intervention, Well-being: d = 0.37; At post-intervention:
Australia Intervention group: adolescents application Learning Theory anxiety, there was no help-seeking 83.9%;
mobile intervention Condition: (WeClick) psychological significant difference intention: d = 0.36 At 12-week
Control group: WLC universal distress, in depression or follow-up: 59.6%
Duration: 4 weeks Age: 14.82 mental health anxiety between
Number: 193 wellbeing intervention and
control groups.
However, there was
a significant
difference in health
wellbeing (p = 0.02)
and help-seeking
intention (p =
0.016–0.008)
Osborn 2020, Design: two-arm RCT Sample description: Web-based self-help Positive psychology Depression, Compared to the Depression: Post-intervention:
Kenya Intervention group: high school platform anxiety control, intervention Full sample: d = 100%
digital intervention students group produced a 0.50
Control group: study Condition: greater reduction in Subsample of
skill control universal depressive youths with
Duration: single Age: M = 15.54 symptoms in both moderate to
session, two weeks Number: 103 the full sample (p =
(continued)
Table A2. Continued
Zhou et al.

Percentage of
0.028) and a severe depression:

subsample of youths d = 0.83
with moderate to
severe depression
symptoms (p =
0.010). There were
no significant effects
on anxiety
symptoms.
Perry 2017, Design: cluster Sample description: Web-based gamified CBT Depression Compared to Post-intervention: d Post-intervention:
Australia two-arm RCT secondary school self-help platform controls, = 0.29 75.2%
Intervention group: students participants in the 6 months 6-month follow-up:
online intervention Condition: intervention group post-baseline: d = 63.1%
(SPARX-R) universal showed significantly 0.21
Control group: Age: M = 16.7 reduced depression
online active control Number: 540 symptoms relative to
program (lifeSTYLE) the control at
Duration: 7 modules; post-intervention (p
7 weeks < 0.001) and 6
months
post-baseline (p =
0.01) but not at 18
months
post-baseline.
Puolakanaho Design: 3-arm RCT Sample description: Web-based self-help ACT Stress The intervention Stress: d = 0.22 Post-intervention:
2019, Intervention groups: secondary school platform group showed a Academic 96.0%
Finland (i) iACTface group students small but significant buoyancy: d = 0.27
(web-based Condition: decrease in overall
interventions plus a universal stress (p = 0.037).
face-to-face meeting Age: M = 15
(ii) iACT group (only Number: 249
web-based
intervention)
(continued)
659
Table A2. Continued
660

Percentage of
Control group: TAU

Duration: 5 weeks
Ren 2016， Design: two-arm RCT Sample description: Web-based self-help CBT Depression Compared with Depression: d = Post-intervention:
China Intervention group: university students platform control condition, 0.79-0.93 72.5
Chinese version of Condition: intervention group
MoodGYM targeted (those achieved a
Control group: WLC with elevated significantly larger
Duration: 3 weeks depression reduction in
symptoms) depression (p <
Age: M = 20.82 0.05)
Number: 62
Richards Design: two-arm RCT Sample description: Web-based self-help CBT Depression There was a significant N/A Post-intervention:
2013, Irish Intervention group: university students platform overall improvement 45.5%
online self-help Condition: over time for both 16-week follow-up:
intervention (cCBT) targeted (those groups on 42.6%
Control group: with symptoms of depression (p < 32-week follow-up:
therapist-assist email depression) 0.001). 32.7%
therapy (eCBT) Age: 26.45 There were no
Duration: 8 weeks Number: 101 significant difference
between
intervention and
control groups.
Rickhi 2015, Design: two-arm RCT Sample description: Web-based self-help Spiritual practices Depression At week 8, N/A Post-intervention:
Canada Intervention group: adolescents and platform and religious beliefs intervention group 93.5%
web-based program young adults achieved a greater
Control group: WLC Condition: reduction in
Duration: 8 weeks targeted (those depression (p <
with major 0.05).
depressive
disorder)
Age: M = 17.74
Number: 62
Schleider Design: two-arm RCT Sample description: Web-based self-help Psychoeducation on Depression, Compared with Depression: d = 0.23 Post-intervention:
2019, USA Intervention group: high school platform growth mind-sets social anxiety control group, 99.5%
online self-help students of personality, intervention group 4-month follow-up:
intervention Condition: self-regulation, and achieved significant 95.0%
Control group: targeted (female) intelligence reductions in
(continued)
Table A2. Continued
Zhou et al.

Percentage of
Duration: one Age: M = 15.2 depressive

session Number: 222 symptoms (p =
0.04). There were
no significant
differences between
intervention and
control groups for
reduction in social
anxiety symptoms.
Short 2020, Design: two-arm RCT Sample description: Web-based self-help MI, CBT Anxiety, There was no N/A Post-intervention:
USA Intervention group: university students platform insomnia significant difference 73.8%
web-based Condition: between the two
intervention targeted (those groups in outcomes
Control group: with elevated relating to anxiety (p
web-based education subclinical anxiety = 0.40) or insomnia
about physical health and insomnia) (p = 0.09).
Duration: one Age: M = 19.43
session (1 month) Number: 61
Stjerneklar Design: two-arm RCT Sample description: Web-based CBT Anxiety Compared with those Clinician-rated Post-intervention:
2019， Intervention group: adolescents therapist-guided in control condition, severity of anxiety: 75.7%
Denmark web-based Condition: platform significantly more d = 0.83 3-month follow-up:
intervention targeted (those adolescents in the 61.4%
(ChilledOut) with anxiety intervention group
Control group: WLC disorders) were free of anxiety
Duration: 8 modules Age: M = 15 diagnosis (p = 0.027)
(14 weeks) Number: 70
Topooco Design: two-arm RCT Sample description: Web-based self-help CBT Depression Compared with D = 0.86 Post-intervention:
2019, Intervention group: adolescents platform and control condition, 94.3%
Sweden web-based Condition: real-time therapist intervention group 12-month
intervention targeted (those sessions via chat demonstrated a follow-up:
Control group: with depressive significant decrease
minimal attention symptoms) in depression
control
(continued)
661
662
Table A2. Continued

Percentage of
Duration: 8 weeks (8 Age: M = 17.5 symptoms (P <

modules) Number: 70 0.001)
Wong 2014, Design: three-arm Sample description: Web-based self-help CBT Anxiety, Compared to the Depression Post-intervention:
Australia cluster RCT school students platform plus depression control group, intervention: 27.15%
Intervention group 1: Condition: teachers stimulating students in the (anxiety: d = 0.29;
anxiety universal discussion depression depression: d =
internet-based Age: 14–16 intervention group 0.14).
intervention Number: 976 showed a significant Anxiety
Intervention group 2: improvement in intervention:
depression anxiety (p < 0.01) anxiety: d = 0.18
internet-based and depressive
intervention symptoms (p < 0.05)
Control group: TAU at the end of the
Duration: depression course, whilst
intervention (7 students in the
lessons); anxiety anxiety intervention
intervention (6 demonstrated a
lessons) reduction in
symptoms of anxiety
(p < 0.05).
Fitzpatrick Design: two-arm RCT Sample description: Fully automated CBT Anxiety, Compared to control Depression: d = 0.44 Post-intervention:
2017, USA Intervention group: university students text-based depression condition, 83%
chatbot intervention Condition: conversational agent intervention group
(Weobot) targeted (those (Weobot) significantly reduced
Control group: with symptoms of depression (p =
information-only anxiety and 0.017).
control group depression) There was no
Duration: two weeks Age: M = 22.2 significant difference
(up to 20 sessions) Number: 70 between
intervention group
and control group
on anxiety. However,
both groups
improved
significantly on
(continued)
Zhou et al.
Table A2. Continued

Percentage of
anxiety symptoms (p
= 0.004).
Fulmer 2018, Design: three-arm Sample description: AI-based chatbot (Tess) CBT Depression, Compare with control Did not report Post-intervention:
USA RCT university students anxiety group, intervention 100%
Intervention group 1: Condition: group 1
2-week chatbot universal demonstrated a
intervention Age: M = 22.9 significant reduction
Intervention group 2: Number: 75 in depression (p =
4-week chatbot 0.02); both
intervention intervention groups
Control group: 1 and 2
information only demonstrated a
control significant reduction
Duration: 2–4 weeks in anxiety (group 1: p
= 0.045; group 2: p =
0.02).
663
Appendix 3
664
Table A3. Assessment of methodological quality of the included studies.
8. Was 13. Was the trial

follow-up design
complete and appropriate, and
if not, were any deviations
7. Were differences from the standard
treatment between RCT design
1. Was true 5. Were groups groups in 9. Were 10. Were (individual
randomization 2. Was 3. Were those 6. Were treated terms of participants outcomes randomization,
used for allocation treatment 4. Were delivering outcomes identically their analysed in measured 11. Were 12. Was parallel groups)
assignment of to groups participants treatment assessors other than follow-up the groups to in the same outcomes appropriate accounted for in
participants to treatment similar at blind to blind to blind to the adequately which they way for measured statistical the conduct and
treatment groups the treatment treatment treatment intervention described were treatment in a reliable analysis analysis of the
groups? concealed? baseline? assignment? assignment? assignment? of interest? and analysed? randomized? groups? way? used? trial? Score
Ahmad et al., Yes Yes Yes No No NA Yes Yes Yes Yes Yes Yes Yes 11
2020
Antonson et al., Yes Yes Yes No No Yes Yes Yes No Yes Yes Yes Yes 10
2018
Bendtsen et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2020
Bird et al., 2018 Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes 10
Burckhardt Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
et al., 2015
Calear et al., Yes Yes No No No NA Yes Yes Yes Yes Yes Yes Yes 9
2016
Cavanagh et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2013
Cook et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2019
Day et al., 2013 Yes Yes No No No NA Yes No Yes Yes Yes Yes Yes 8
Dear et al., 2018 Yes Yes NA No No Yes Yes Yes Yes Yes Yes Yes Yes 10
Edridge et al., Yes Yes Yes No No NA Yes No Yes Yes Yes Yes Yes 8
2020
El Morr et al., Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes 10
2020
Eustis et al., 2018 Yes Yes Yes No No Yes No Yes No Yes Yes Yes Yes 8
Farrer et al., Yes Yes Yes No No Yes No Yes Yes Yes Yes Yes Yes 10
2019
Frazier et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2015
Gladstone et al., Yes Yes NA No No Yes Yes Yes Yes Yes Yes Yes Yes 10
2020
(continued)
Table A3. Continued

Zhou et al.
follow-up design
Harrer et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2018
Lappalainen Yes Yes Yes No No NA Yes No Yes Yes Yes Yes Yes 9
et al., 2021
Ip et al., 2016 Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes 10
Kählke et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2019
Kenny et al., Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes 10
2020
Kramer et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2014
Lahtinen & Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
Salmivalli,
2020
Levin et al., 2020 Yes Yes No No No Yes No Yes Yes Yes Yes Yes Yes 9
Levin et al., 2014 Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes 10
Lindqvist et al., Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes 10
2020
McCall et al., Yes Yes Yes No No NA Yes Yes No Yes Yes Yes Yes 9
2018
McCloud et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2020
Melnyk et al., Yes Yes Yes No No Yes Yes No NA Yes Yes Yes Yes 9
2015
Merry et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2012
Moeini et al., Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes 10
2019
O’Dea et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2020
(continued)
665
666
Table A3. Continued

follow-up design
Osborn et al., Yes Yes NA No No Yes Yes No Yes Yes Yes Yes Yes 9
2020
Perry et al., 2017 Yes Yes No No No NA Yes No Yes Yes Yes Yes Yes 8
Puolakanaho Yes Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes 10
et al., 2019
Ren et al., 2016 Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
Richards et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2013
Rickhi et al., Yes Yes Yes No No NA Yes Yes Yes Yes Yes Yes Yes 10
2015
Schleider et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2019
Short & Yes Yes Yes No No Yes Yes NA Yes Yes Yes Yes Yes 10
Schmidt, 2020
Stjerneklar et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2019
Topooco et al., Yes Yes Yes No No NA Yes Yes Yes Yes Yes Yes Yes 10
2019
Wong et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 11
2014
Fitzpatrick et al., Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes 12
2017
Fulmer et al., Yes Yes NA No No Yes Yes No No Yes Yes Yes Yes 9
2018
NA: not available.


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Research

Journal of Telemedicine and Telecare

Xiaoyun Zhou1,2 , Sisira Edirippulige1,2 , Xuejun Bai3,

Introduction Telehealth has been increasingly used to manage youth

Australian rural adolescents with mental health care.8,9 In Quality assessment

Table A1. Searching strategy for each database.

Database Number Searching strategy

PubMed 202 (((Adolescent[Ti/Ab] OR Adolescence[Ti/Ab] OR Teen[Ti/Ab] OR Teenager[Ti/Ab] OR Youth[Ti/Ab] OR

Table A1. Continued

Database Number Searching strategy

mHealth OR eHealth OR telehealth OR VR OR ‘virtual reality’ OR text-messaging OR ‘text messaging’ OR

Table A2. Characteristics of each study.

Retention rate (i.e.

Retention rate (i.e.

Sample [sample participants who

intervention (MYLO) Age: M = 22.8 problem distress (p

Retention rate (i.e.

mindfulness program universal depression, anxiety/depression anxiety and

Retention rate (i.e.

Sample [sample participants who

Dose: 4 sessions (5 reported

Retention rate (i.e.

Retention rate (i.e.

Sample [sample participants who

Table A2. Continued

Retention rate (i.e.

attention control targeted (those reductions in DASS −0.35;

Retention rate (i.e.

Table A2. Continued

Retention rate (i.e.

distress: p < 0.001;

Retention rate (i.e.

Control group: WLC experience social social anxiety

Retention rate (i.e.

counselling) Age: M = 15.6 rating scale-revised

Retention rate (i.e.

0.028) and a severe depression:

Retention rate (i.e.

Control group: TAU

Retention rate (i.e.

Duration: one Age: M = 15.2 depressive

Retention rate (i.e.

Duration: 8 weeks (8 Age: M = 17.5 symptoms (P <

Table A2. Continued

Retention rate (i.e.

Table A3. Assessment of methodological quality of the included studies.

8. Was 13. Was the trial

8. Was 13. Was the trial

Table A3. Continued

8. Was 13. Was the trial

NA: not available.

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