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With the growing demand for internet-delivered cognitive behavioural therapy (iCBT), this pragmatic factorial (2 × 2 × 2) randomized controlled trial evaluated strategies for facilitating iCBT engagement and outcomes in routine care. Specifically, the benefits to patients and therapists of using homework reflection questionnaires and offering patients twice-weekly therapist support were examined. Patients ( n  = 632) accepted into iCBT for depression and/or anxiety were randomly assigned to complete homework reflection questionnaires or not (factor 1), receive once- or twice-weekly support (factor 2), and to receive care from therapists employed in one of two settings (iCBT clinic or a community mental health clinic; factor 3). Outcomes were measured at pre-treatment, and 8, 12, and 24-weeks post-enrollment. Therapist time was tracked and a focus group was conducted to examine therapist experiences. No differences in patient outcomes were found between therapists employed in the two settings; as such, these two groups were combined for further analyses. In terms of engagement, homework reflection questionnaires were associated with fewer website log-ins and days accessing iCBT; twice-weekly support was associated with more patient emails sent to therapists. Despite engagement differences, homework reflection questionnaires and twice-weekly support did not significantly impact primary outcomes; all groups showed large improvements in depression and anxiety that were maintained at 24-week follow-up. Therapists perceived a number of benefits and challenges associated with responding to homework reflection questionnaires and offering twice-weekly support; most notably the strategies did not benefit all patients. Twice-weekly support was associated with increased therapist time and organizational challenges. It is concluded that neither completion of homework questionnaires nor offering twice-weekly support significantly improve iCBT in routine care., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that appear to have influenced the work reported in this paper., (© 2020 The Author(s).)

With the growing use of ICBT in routine care clinics there is a need for literature on how to monitor and improve the quality of therapist behaviours in clinical practice. In this paper, we first provide background literature on Audit and Feedback (A&F), a common quality improvement technique, and then present a case study regarding the use of A&F to improve quality of therapist behaviours in emails sent to patients provided with ICBT in routine care. The A&F measure used was derived from previous research on therapist's email behaviours in ICBT. Fifteen undesirable therapist behaviours (e.g., Did Not Message, Unresponsive to Symptom Increase, Does Not Address Patient Concern ) were audited in 1840 emails sent from eight therapists to 198 randomly selected patients, representing 18% of 1114 patients who started between one and five lessons of ICBT in the previous year and did not formally withdraw from treatment ( n  = 31 patients). The therapists who were audited were provided feedback four times over a one-year period from October 2018 to September 2019. Overall, in all audit periods, we found a low percentage of undesirable therapist behaviours (i.e., therapists displayed the behaviour in 12% or less of the total emails sent). For most therapist behaviours, we saw a trend towards improvement across the four audit cycles. Three therapist behaviours (i.e., Failure to Ask One Question to the Patient , Poor Instructions , Not Linking Email to Course Content ) did not follow this pattern and were flagged for clinical discussion to determine why behaviours were elevated and whether these behaviours represented unrealistic expectations. The process was valuable for monitoring and improving therapist behaviours and highlights the need for future research on standards for therapist behaviours (e.g., which behaviours to focus on, setting acceptable levels of undesirable behaviour)., Competing Interests: All authors declare that they have no conflict of interest., (© 2020 The Authors.)