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Online CBT May Be Better Than Usual Care for Depression

Pauline Anderson

August 24, 2009 — Online cognitive behavioral therapy (CBT), delivered in real-time with a trained therapist, is more effective than usual primary care in successfully treating patients with depression, a new study has found.

The randomized controlled trial showed that patients with depression accessing this intervention were almost 2.5 times more likely to recover than were those receiving only usual care from their general practitioner, which typically consists of a prescription for antidepressants as well as support and counseling.

This type of intervention could go a long way toward solving the problem of access to therapy for patients who are disabled, agoraphobic, or living in a rural area, or whose first language is not English, said lead author David Kessler, MD, clinical lecturer, Department of Community Based Medicine, University of Bristol, United Kingdom, in an interview with Medscape Psychiatry.

However, not all patients are keen to receive online therapy, said Dr. Kessler.

The article appeared in the Global Mental Health special edition of The Lancet.

Between October 1, 2005, and February 29, 2008, researchers recruited patients aged 18 to 75 years with depression from 55 general practices in 3 centers in England. A diagnosis of depression was defined as a score of 14 or more on the Beck Depression Inventory and was confirmed using the International Statistical Classification of Diseases 10th revision.

After completing a baseline questionnaire, 149 patients were randomly assigned to the intervention group (online CBT in addition to usual care from their general practitioner) and 148 to the control group (usual care while on a waiting list for online CBT).

Severe Depression

More than two thirds of study participants were women, and their mean age was 34.9 years. Most study participants had severe depression; at baseline, 68% of the intervention group and 70% of the control group had a Beck Depression Inventory score of greater than 28.

"These are not people who were just off color for a few days," said Dr. Kessler.

In addition to a diagnosis of depression, all but 4 participants also had another psychiatric diagnosis such as generalized anxiety, phobia, or panic disorder.

The intervention consisted of 10 55-minute sessions during which participants and therapists communicated through online texting. Patients maintained the same therapist throughout the trial. "It's like having an instant messaging conversation with a friend, or a therapist in this case, where you type in something and the therapist types in a response, and it's backwards and forwards like that," explained Dr. Kessler.

Gains Maintained

In the intervention group, 113 patients completed 4-months of follow-up, as did 97 patients in the control group. At that time, those in the intervention group were more likely to have recovered (defined as a score of <10 on the Beck scale) than were those in the control group (38% vs 24%; odds ratio, 2.39; 95% confidence interval, 1.23 – 4.67). These gains were maintained at the second follow-up — at 8 months, the rates were 42% for the intervention group compared with 26% for the control group (odds ratio, 2.07; 95% confidence interval, 1.11 – 3.87).

The effect of the intervention was greater in participants with more severe depressive symptoms at baseline, said Dr. Kessler. "This is important because there are some people out there who say that psychotherapy is okay if you've got mild depression but may not be as effective for severe depression."

An online intervention has several advantages over face-to-face therapy. In addition to making therapy available to patients who cannot easily access a therapist, it offers a great deal of flexibility to both therapist and patient in terms of planning convenient times for sessions, said Dr. Kessler.

Although the online intervention in the study did not include Skype or other video chat elements, Dr. Kessler said this might be a topic for future research.

Moment of Reflection

However, he said, actually writing about their thoughts rather than talking about them is more helpful to some people. Some feel that it allows them to be more honest. "If you write something down, you have to think about it and edit it a little bit; in other words, there's a moment of reflection," said Dr. Kessler.

He talked about the concept of "meta-cognitive awareness," or of being made aware of one's thoughts. "The idea is that you stand back from your own thoughts and have a look at them," said Dr. Kessler. "When you're depressed, you sometimes have these awful negative thoughts — for example, 'nobody loves me' — but when you stand back and have a look at that, it may not be quite accurate."

Research shows that people who have experienced a traumatic event get relief when writing about that event, said Dr. Kessler. He noted that in the early years of psychoanalysis, therapists did not allow patients to make eye contact with them.

But online therapy is not for everyone. "Some people can't use computers, some people can't type, some people want to see the person they're talking to," said Dr. Kessler. "I don't think we should pretend for a second that it's great for everybody."

Online real-time therapy could work for psychiatric illnesses other than depression; for example, anxiety, said Dr. Kessler. In addition, the online approach could offer therapies other than CBT to patients, he said.

Psychotherapy Rates "Flat"

In an accompanying editorial, Gregory E Simon, MD, senior investigator and group health psychiatrist, and Evette J. Ludman, PhD, senior research associate, Group Health Research Institute, Seattle, Washington, pointed out that rates of drug treatment for depression have increased dramatically over the past 20 years, whereas rates of in-person psychotherapy "are flat to declining."

Internet-based treatment, they said, could serve patients who have no access to trained or certified cognitive behavioral therapists and offers flexibility, convenience, and briefer and more frequent contacts than 1 hour face-to-face consultations every 1 to 2 weeks.

Such new communication technologies could provoke much-needed innovation in psychotherapy, they wrote. "Traditional therapists might be horrified by the prospect of an overseas cognitive behavioural call centre or live-chat centre, available whenever patients choose. But the expectations of health-care providers are not the same as evidence. And the evidence that matters concerns clinical benefit and economic value to patients, rather than appeal or value to providers."

The authors have disclosed no relevant financial relationships.

Lancet. 2009;374:628–634, 594–595.


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