Up-scaling clinician assisted internet cognitive behavioural therapy (iCBT) for depression: A model for dissemination into primary care
Section snippets
Internet-delivered Cognitive Behavioural Therapy (iCBT)
Depression is typically identified and treated in primary care settings where the ability to deliver evidence based treatments is often constrained (Wolf & Hopko, 2008). A cost-effective and pragmatic means of increasing the quality of treatment available in primary care settings is through the use of internet-based cognitive behavioural therapy courses (iCBT). iCBT courses differ from asynchronous clinician delivered CBT or online counselling in that the content is automated, there is no
Efficacy trials: does iCBT work and how good is the research base?
Five meta-analyses of randomized controlled trials (RCTs) have shown that online/computerized CBT is associated with moderate to large effects on depression symptoms in people who putatively met criteria for major depressive disorder (MDD). Andersson and Cuijpers (2009) conducted a meta-analysis of internet based and other computerized psychological treatments for adult depression. They reported that the mean effect size superiority over the control group at post test in 15 studies was 0.41 and
What about patient adherence and satisfaction?
Adherence rates to iCBT vary between 55% and 96% (Andersson et al., 2005, Berger et al., 2011, Perini et al., 2009, Titov, Andrews, Davies, et al., 2010) which are superior to rates reported in other psychotherapy research and in regular clinical practice (Bados, Balaguer, & Saldaña, 2007). The majority of participants who have provided feedback ratings on the acceptability of iCBT are satisfied and participants note several advantages of computerized therapy including convenience, ability to
How well does iCBT compare to face-to-face CBT?
Overall findings suggest that iCBT produces equivalent effect sizes to time-limited face-to-face interventions (Andersson and Cuijpers, 2009, Andersson et al., 2005, Berger et al., 2011, Cuijpers et al., 2010, Johansson et al., 2012), but direct comparative trials are needed to substantiate equivalency. Andersson, Hesser, Veilord, et al. (2013) compared a seven module programme (as used in Andersson et al., 2005, Johansson et al., 2012, Vernmark et al., 2010) with an eight session group-based
How well are treatment effects sustained over longer periods of time?
Andersson, Hesser, Hummerdal, Bergman-Nordgren, and Carlbring (2013) followed-up participants from Vernmark et al.'s (2010) study of guided iCBT vs. tailored e-mail therapy and included patients who completed deferred guided iCBT (the original WLC). At 3.5 year follow-up within group effect sizes were large for both the guided CBT (d = 1.7) and e-mail therapy (d = 1.5) on the primary measure of depression (BDI). There was no indication of superior effects in the intensive tailored e-mail therapy
Can iCBT protect against relapse?
The risk of relapse in depression is regarded as high (Mueller et al., 1999). Meta-analysis indicates that depressed patients are significantly less likely to relapse following CBT compared to discontinuing pharmacotherapy (Cuijpers et al., 2013) and cognitive therapies produce better long-term outcomes when administered subsequent to other treatments (Bockting et al., 2009, Fava et al., 2004). Do the protective effects of CBT extend to iCBT? This possibility was addressed in a study by
Are certain patients unsuitable for iCBT?
Severely depressed patients are often excluded from efficacy trials of iCBT due to concerns about suicide risk and safety. Concerns about severity appear unfounded. Not only are adherence rates comparable to less severe patients, but also evidence suggests that severe patients benefit more (Donkin et al., submitted for publication, Williams and Andrews, 2013) and possess the requisite level of self-motivation to complete this form of intervention. Williams and Andrews (2013) reported that 25%
iCBT works, but how can clinicians and patients access the programmes?
In order for universal dissemination to occur, models of delivery must consider the need to establish long-term financial support to ensure sustainability and scalability. Tomlinson et al. (2013) provide a schematic account of the steps required to scale-up a new intervention (see Table 3). They promulgated criteria for establishing the efficacy, effectiveness and appropriate dissemination of new products: “country-wide implementation would be dependent on the completion (for each intervention)
Effectiveness and dissemination: does iCBT work in routine practice?
There is only a small literature on effectiveness and none that we can find on the logistics of dissemination. We will begin by reviewing the effectiveness literature and then outline our experience with disseminating the ThisWayUp courses in primary care and specialist care.
iCBT as standard of care?
The introduction of iCBT into clinical practice is not a hypothetical issue, nor one of standards, as the introduction of manualised therapy was. There are serious pressures mounting to ensure that iCBT becomes widely used.
- 1.
The first pressure is client choice. The authors are associated with an anxiety and depression clinic that provides face to face CBT at no charge. It sees 400 new patients a year. In the first year, when we offered participants the choice between iCBT that could be done at
Conclusions
iCBT can function both as a therapy enhancer for psychologists and as a physician extender for primary care clinicians. This form of treatment delivery is effective, acceptable to both patients and clinicians, and consistent with a stepped-care framework identified in the NICE guidelines as the method by which treatments for depression should be delivered (National Institute for Health and Clinical Excellence, 2009). In order to assist with the dissemination of this therapeutic modality into
Acknowledgement
Alishia D. Williams is supported by a National Health and Medical Research Council (NHMRC) of Australia Fellowship (630746).
References (52)
- et al.
Randomised controlled non-inferiority trial with 3-year follow-up of internet-delivered versus face-to-face group cognitive behavioural therapy for depression
Journal of Affective Disorders
(2013) - et al.
Computer-assisted therapies: Examination of therapist-level barriers to their use
Behavior Therapy
(2013) - et al.
Culturally attuned Internet treatment for depression amongst Chinese Australians: A randomised controlled trial
Journal of Affective Disorders
(2012) - et al.
Effectiveness of Internet-based cognitive behaviour therapy for depression in routine psychiatric care
Journal of Affective Disorders
(2014, Feb.) - et al.
Randomized controlled trial of internet-based therapy in depression
Behaviour Research and Therapy
(2012) - et al.
The effectiveness of transdiagnostic internet cognitive behavioural (iCBT) treatment for anxiety and depression in primary care
Journal of Affective Disorders
(2014) - et al.
Computer-based psychological treatments for depression: A systematic review and meta-analysis
Clinical Psychology Review
(2012) - et al.
Transdiagnostic Internet treatment for anxiety disorders: A randomized controlled trial
Behaviour Research and Therapy
(2010) - et al.
Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression
Behaviour Research and Therapy
(2010) - et al.
Internet-based versus face-to-face cognitive–behavioral intervention for depression: A randomized controlled non-inferiority trial
Journal of Affective Disorders
(2014)
Psychosocial and pharmacological interventions for depressed adults in primary care: A critical review
Clinical Psychology Review
A national survey of practicing psychologists' attitudes toward psychotherapy treatment manuals
Journal of Consulting and Clinical Psychology
Internet-based self-help for depression: Randomised controlled trial
British Journal of Psychiatry
Internet-based and other computerized psychological treatments for adult depression: A meta-analysis
Cognitive Behaviour Therapy
A 3.5-year follow-up of Internet-delivered cognitive behavior therapy for major depression
Journal of Mental Health
The treatment of anxiety disorders
Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis
PLoS One
Exploring the feasibility of a meta-structure for DSM-V and ICD-11: Could it improve utility and validity?
Psychological Medicine
Guidelines for providing psychological services and products using the internet and telecommunications technologies
Internet supported psychological interventions: A guide to navigating the online world of psychological programs
The efficacy of cognitive–behavioral therapy and the problem of drop-out
Journal of Clinical Psychology
Internet-based treatment of depression: A randomized controlled trial comparing guided with unguided self-help
Cognitive Behaviour Therapy
Long-term effects of preventive cognitive therapy in recurrent depression: A 5.5-year follow-up study
The Journal of Clinical Psychiatry
Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies
Psychological Medicine
Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis
BMJ Open
Internet-based treatment of depression: An “individual patient data” meta-analysis
Plos Medicine
Cited by (57)
Development and testing of iAware model for ubiquitous care of patients with symptoms of stress, anxiety and depression
2020, Computer Methods and Programs in BiomedicineCitation Excerpt :This approach to computing is covered by ubiquitous computing [9], being applied in different areas such as commerce [10], education [11] and health [12], the latter also known as u-Health. In this way, studies have shown that the use of fully automated self-help programs are commonly associated with low levels of adherence [13]. Therefore, programs designed as tools for use in psychotherapeutic treatment should consider user adherence as a form of reinforce bonding and remote support.
The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care: A systematic review and meta-analysis
2019, Journal of Affective DisordersCitation Excerpt :The primary search identified 4556 citations, of which 3617 were unique. Reference checking of relevant systematic reviews (Eells et al., 2014; Eysenbach et al., 2004; Olthuis et al., 2016; Andrews and Williams, 2015; Aboujaoude et al., 2015; Spek et al., 2007) and of the included studies identified an additional 28 citations. We then excluded 3522 studies based on review of the titles and abstracts, and another 104 after full text review (Fig. 1).
Evaluation of the implementation of an internet intervention in well-baby clinics: A pilot study
2018, Internet InterventionsMaladaptive behaviours associated with generalized anxiety disorder: An item response theory analysis
2018, Behavioural and Cognitive PsychotherapySokoon: A Gamification-Based Cognitive Behavioral Therapy Application - An Application for Depression, Stress, and Anxiety
2023, International Journal of Gaming and Computer-Mediated Simulations