Computerized Cognitive Behavioral Therapy for Clinical Depression?

CBT for Depression

Clinical depression is a significant mental health issue effecting millions of people every year. In 2015 approximately 16.1 million American adults experienced at least one major depressive episode representing 6.7% of the adult population. Providing accessible and satisfactory treatment for Clinical Depression is clearly a priority. While medication is clearly a key component of the treatment of clinical depression, the role of therapy and specifically Cognitive Behavioral Therapy (CBT) is well-established. Cognitive Behavioral Therapy is recognized as a leading evidence-based treatment for  clinical depression with research suggesting that in order to maintain recovery, patient treatment that includes a combination of medication and CBT (Cognitive Behavioral Therapy) is recommended (Sudak, 2012).

Increasingly mental health professionals have been considering the use of online CBT in the treatment of Clinical Depression. Online and computer–based programs are viewed as a means of widening access to and reducing delays in receiving therapeutic treatment (Sidique, 2015). Online CBT comes in a variety of forms including computerized CBT programs (CCBT), chat -based CBT and CBT therapy delivered face-to-face online by a therapist. CCBT programs consist of those that are freely available and those that have been developed for commercial purposes. CCBT programs comprise a key element of therapeutic services in primary care setting in the UK and elsewhere (Gilbody et al, 2015). The use of computerized CBT in the treatment of Clinical Depression has been endorsed by NICE (the U.K. based National Institute for Health and Care Excellence) as an evidence based practice that should be incorporated into treatment of clinical depression.

Research evidence for CCBT programs has on the whole been quite promising with claims that it is comparable in efficacy to CBT with a therapist (Andrews et al, 2010). A meta-analysis of computerized treatments for clinical depression indicated that the effect is much greater where the CCBT is provided in conjunction with professional therapeutic support (Andersson G, Cuijpers P., 2009). Some concerns raised include the client’s ease with receiving CBT from a computer as opposed to a trained therapist,  clients failing to access or underutilizing these computerized programs and high  drop-out rates(Gilbody, 2015). Many of these studies have been led or supported by the developers of CCBTS and were not conducted in primary care settings.

A recent independent study by Gilbody et al (2015) highlights many of these concerns. 691 patients diagnosed with clinical depression and sourced from multiple primary care centers were randomly allocated to a group receiving just primary care from a General Practitioner or to one of two groups combining the primary care with two different CCBT programs – either 8 one hour sessions of the commercial Beating the Blues program or six one hour sessions of the free download MoodGYM. Participants in the study received weekly calls from a technician encouraging them to follow through on the programs. Participants were assessed in terms of their ratings on quality of life (health-related) and depression after 4, 12 and 24 months respectively. No additional improvement was noted in the CCBT group in comparison to the group provided only with GP care at 4 months. Neither the commercial or free CCBT program showed any difference in comparison with regular primary care across all time points. About a quarter of participants were no longer participating in the CCBT programs 4 months into the study. Around 80% of participants accessed the CCBT programs but around 17% of the participants allocated to the CCBT programs actually completed them. (Gilbody et al, 2015 and Sidique, 2015)

Gilbody et al (2015) found that clients generally did not adhere to or engage very actively with the CCBT programs. In exploring this lack of engagement participants in the study expressed an unwillingness to take part in CCBT and found it very challenging to actually log on and motivate themselves to utilize the program when they were suffering from clinical depression. So the problem did not lie with the efficacy of the CCBT itself but rather with the client’s incapacity to engage with it. Participants expressed a need for greater therapeutic support in conjunction with the CCBT program. While further research is clearly needed, the results of this kind of study suggest that CCBT programs need to be viewed with caution. While CCBT may have a function in a primary-care setting, it does not replace professional therapeutic support either delivered in person or online through chat, e-mail or webcam. It is likely to be of some benefit when used in conjunction with therapeutic support of some kind. As discussed in an earlier article exploring the efficacy of online therapy online services are generally viewed as more suitable for moderate to higher functioning individuals (Stofle, 2001). This observation is all the more relevant for computerized services especially with people with severe clinical depression. As Clariana (who posted a response to Haroon Sidique’s article) puts it: “Providing depressives with this kind of “help” is like expecting a blind person to traverse a city on their only (sic:own) and unassisted to be cured of blindness, it ain’t gonna happen…

References:

Andersson G, Cuijpers P. Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cog Behav Ther2009;38:196-205. CrossRef

Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PloS ONE2010;5:e13196. CrossRefMedline