Advancing equity in routine-care internet-delivered cognitive behaviour therapy: Representativeness, outcomes, engagement, and satisfaction

Abstract

Background Internet-delivered cognitive behaviour therapy (ICBT) has potential to reduce access barriers, yet it remains unclear how well routine-care ICBT reaches underserved groups and whether symptom outcomes, engagement, and satisfaction are comparable across demographic subgroups. Methods Routine-care ICBT clinic data (N = 1640) collected in 2021 were compared with provincial census estimates from the 2021 Canadian census (N = 22,705) after harmonizing demographic categories. Longitudinal depressive and anxiety outcomes were analyzed using mixed-effects models with categorical time, testing subgroup main effects and subgroup-by-time interactions. Engagement (lesson completion) and satisfaction were analyzed using logistic regression models. Results Several groups had lower representation relative to census benchmarks, including men, clients with lower education, Indigenous and some racialized groups, newcomers, rural/small-town residents, whereas women, higher education, and White clients had higher representation. Depression and anxiety symptoms declined significantly over time across all demographic groups. Engagement was high (~82% completed ≥3 of 5 lessons). Older age predicted greater lesson completion. Satisfaction was high overall and with course materials, with relatively lower satisfaction among clients who were not partnered. Conclusions Although some groups were underrepresented, consistent with face-to-face treatment, routine-care ICBT was associated with substantial symptom improvement across all demographic subgroups, alongside high engagement and satisfaction. Areas of lower representation highlight the need for targeted outreach and engagement supports, particularly to men, people with lower educational attainment, Indigenous and some racialized communities, newcomers, and people living outside large urban centres.