Personalized Transdiagnostic Cognitive Behavior Therapy With Midtreatment Stepped Care to Improve Mental Health Among University Students in Sweden: Feasibility Study for a Randomized Controlled Trial.
Topooco N, Lindner P, et al. • JMIR formative research • 2026
This pioneering study of personalized ICBT with adaptive change among university students demonstrated the overall feasibility of the treatment, though modifications are necessary to mitigate assessment attrition and reduce treatment-related stress.
Key Findings
Results
Recruitment and uptake rates were low, with only 7% of invited students completing screening and 4% being included in the study.
Of 749 invited students, 55 (7%) completed the study screening and 28 (4%) were included
Participants were recruited from students who had completed the WHO World Mental Health International College Student (WMH-ICS) mental health survey
Eligibility required a PHQ-9 score of 5-19, or GAD-7 score ≥5, or both
The study was conducted online in Sweden in autumn 2021
Results
Participants showed moderate-to-severe baseline levels of anxiety and depression symptoms at study entry.
The GAD-7 baseline score was 9.5 (SD 4.4)
The PHQ-9 baseline score was 11.2 (SD 5.2)
Eligibility criteria spanned mild to moderately severe depression (PHQ-9 scores 5-19) and at least mild anxiety (GAD-7 ≥5)
Results
The user-directed personalization feature produced a high degree of individualized treatment configurations across participants.
27 unique treatment configurations were yielded across 28 participants
Participants personalized their program by selecting a primary problem orientation (anxiety or depression) and choosing additional elective modules
Participants could also consult their therapist regarding module choices
Participants opened an average of 6.2 (SD 2.2) out of 8 treatment modules
Results
The midtreatment stepped care randomization procedure was successfully piloted, with the majority of remaining participants being randomized.
At week 4, 16 out of 27 (59%) participants remaining in treatment were randomized in the stepped care procedure
Participants without symptom improvement were randomized to adaptive enhancement of therapist support or to continue treatment as before
The stepped care procedure was part of the within-treatment adaptive modification based on early symptom trajectory
Results
Therapeutic alliance and treatment satisfaction were rated as acceptable to good by participants.
Ratings on self-report measures showed acceptable to good therapeutic alliance
Treatment satisfaction was also rated as acceptable to good
Eleven participants reported increased stress associated with the treatment, indicating a notable adverse experience
Results
Reductions in depression and anxiety symptoms were observed at post-measurement and at 6-month follow-up, but attrition was substantial.
Reductions in both GAD-7 and PHQ-9 scores were observed at post-measurement and 6-month follow-up
Changes in scores were calculated using mixed effects models
Attrition at post-measurement and 6-month follow-up was 43%
The high attrition rate was identified as a key issue requiring modification in a future definitive trial
Discussion
The study identified key modifications needed before conducting a full randomized controlled trial.
Modifications are necessary to mitigate assessment attrition, which reached 43% at post-measurement and follow-up
Reducing treatment-related stress was identified as a priority, given that 11 participants reported increased stress associated with treatment
The authors described the study as a 'pioneering study of personalized ICBT with adaptive change among university students'
The study was registered on ClinicalTrials.gov (NCT05509660)
What This Means
This research suggests that it is feasible to deliver a personalized, internet-based cognitive behavioral therapy (CBT) program to university students struggling with anxiety and depression. The program allowed students to tailor their treatment by choosing a primary focus (either anxiety or depression) and selecting additional therapy modules, resulting in nearly every participant having a uniquely configured treatment plan. Halfway through the 8-week program, students who were not improving had their level of therapist support adjusted — a process called 'stepped care.' Both anxiety and depression symptoms decreased over the course of treatment and remained lower at a 6-month follow-up, and students generally reported acceptable levels of satisfaction with the therapy and their relationship with their therapist.
However, the study also revealed important challenges. Very few of the students who were invited actually enrolled — only about 4% of those initially contacted participated — and 43% of participants did not complete the follow-up assessments. Additionally, 11 out of 28 participants reported that the treatment itself caused them extra stress, which is a concern that needs to be addressed. These findings highlight that while the core approach appears promising, the recruitment strategy, assessment burden, and potential for treatment-related stress all need to be improved before a larger, more rigorous trial can be conducted.
This research matters because university students experience mental health problems at high rates, and there is a need for flexible, scalable interventions that can address multiple issues like anxiety and depression simultaneously. Internet-delivered therapy that can be personalized and adapted mid-treatment could be a practical way to reach more students, but this study shows that careful design work is still needed to make such programs truly effective and accessible at scale.
Topooco N, Lindner P, Andersson C, Lindfors P, Molander O, Kraepelien M, et al.. (2026). Personalized Transdiagnostic Cognitive Behavior Therapy With Midtreatment Stepped Care to Improve Mental Health Among University Students in Sweden: Feasibility Study for a Randomized Controlled Trial.. JMIR formative research. https://doi.org/10.2196/68698