Elsevier

Clinical Psychology Review

Volume 41, November 2015, Pages 40-48
Clinical Psychology Review

Up-scaling clinician assisted internet cognitive behavioural therapy (iCBT) for depression: A model for dissemination into primary care

https://doi.org/10.1016/j.cpr.2014.05.006Get rights and content

Highlights

  • iCBT for depression meets criteria for a well-established treatment.

  • iCBT can function as a therapy enhancer and physician extender.

  • Upscaling of iCBT into primary care is feasible.

Abstract

Depression is a global health problem but only a minority of people with depression receive even minimally adequate treatment. Internet delivered automated cognitive behaviour therapy (iCBT) which is easily distributed and in which fidelity is guaranteed could be one solution to the problem of increasing coverage. In this review of iCBT for Major Depressive Disorder in adults, we address the concerns of clinicians in utilizing this technology by reviewing the research evidence with reference to efficacy and effectiveness and presenting a model for dissemination and uptake of iCBT into practice. This review includes studies of participants who would meet criteria for major depressive disorder who were supported as they learnt and implemented changes in thoughts, emotions and behaviours by using cognitive behaviour principles. We conclude that this form of treatment is effective and acceptable to both patients and clinicians.

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).

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