Michael E. Thase, MD works with the Perelman School of Medicine of the University of Pennsylvania and the Cpl Michael J Crescenz Veterans Affairs Medical Center.
Cognitive-behavior therapy (CBT) is the most extensively studied form of psychotherapy for Major Depressive Disorder (MDD).(1,2) Meta-analyses of controlled trials have established that, across 12-16 weeks, the efficacy of CBT is comparable to antidepressant medication,(3-5) with a lower risk of relapse after treatment is stopped.(6,7) CBT also may significantly improve treatment outcomes when used in combination with pharmacotherapy,(8,9) especially for patients with more severe or treatment resistant depressive disorders.(10,11) Despite these compelling justifications, there are significant barriers that limit the use of CBT in contemporary practice. One barrier is that there are not enough trained therapists, particularly in rural and public mental health settings.(12) Another pertains to the cost of therapy, which can range from $1000 to $6000 for a 20 course of treatment. A third barrier is the result of the inconvenience and time involved with scheduling and attending a large number of sessions during a three to four month period. Thus, even though surveys suggest that many depressed people would rather be treated with psychotherapy than medication, antidepressant pharmacotherapy – not CBT – is by far the most widely used treatment for depression.(13)
If effective, computer-assisted cognitive behavior therapy (CCBT) could help to address all of these limitations.(14) Although the first form of CCBT was introduced more than 20 years ago,(15,16) research and development has skyrocketed over the past decade, especially since more sophisticated multimedia programs can now be accessed via the internet, such as Beating the Blues(17), Mood Gym(18) and Good Days Ahead(19) Meta-analyses of a burgeoning research literature have documented the efficacy of these various models of CCBT.(20-24) However, evidence indicates CCBT approaches that include therapist support for teaching, coaching and troubleshooting (i.e., 2-5 hours) are significantly more effective than programs that “stand alone” (i.e., make no use of clinician time).(23) In one recent primary care study, (25) for example, two different forms of CCBT without clinical support were no more effective than treatment as usual.
To help to establish the comparative value of therapist-assisted CCBT, my colleagues (Greg Brown and Marna Barrett) and I at the University of Pennsylvania joined forces with Jesse Wright and his colleague Tracy Eells at the University of Louisville. Jesse took the lead in developing Good Days Ahead [GDA],(19) a nine-module, multimedia program that was specifically intended to augment and streamline the efforts of a therapist. The promise of GDA was suggested by the results of two earlier case series (26,27) and a small (n=45) randomized, controlled trial.(28) In the latter study, patients in the CCBT arm received about 4 hours of therapist support, which was one half that of the group who received an 8 week course of individual CBT. Both groups improved significantly more than a wait list control condition.
We designed our study to provide a rigorous test of the value of this approach to CCBT. Specifically, we tested efficacy against a full 16 week, 20 session course of CBT conducted by experienced (“true believer”) therapists; this was more than three times the amount of therapist contact in the CCBT group. The study also included a six month follow-up and a systematic cost effectiveness analysis. The primary hypotheses were that CCBT were would be statistically noninferior to CBT and the CCBT would be significantly more cost-effective than conventional therapy.
Our findings were presented at the National Network of Depression Centers Annual Meeting and a paper summarizing our main findings is currently under editorial review. To briefly summarize, we enrolled 154 unmedicated patients meeting criteria for Major Depressive Disorder and approximately 80% of patients completed the 16-week protocol (CBT: 79%; CCBT: 82%). The CCBT group completed an average of 8.1 (sd=2.1) computer modules and received an average of 5.0 hours of clinical contact. Patients in the CBT group attended an average of 16.0 (sd=5.0) therapy sessions (13.3 hours total).
Patients in the CCBT group had a final HAMD score of 8.9 (sd=5.6; 95% confidence intervals of 7.5-10.3. Patients in the CBT group had a HAMD score of 9.2 (sd=6.3), with 95% confidence intervals of 7.6-10.8. CCBT thus met the criteria for noninferiority on the primary dependent measure. Intent to treat remission rates were similar in the two groups: 42.9 (CCBT) and 41.6 (CBT). The groups also did not differ significantly on any other measure of psychopathology or functioning at week 16. By contrast, the CCBT group scored significantly higher than the CBT group on a measure of knowledge about CBT. Patients in both groups maintained improvements throughout the follow-up and there were few relapses. Across the treatment and follow-up intervals, the cost of care in the CCBT group was $928 lower than in the CBT group. As the two interventions were equivalently effective despite a large difference in the cost of treatment, this approach to CCBT was highly cost-effective.
Discussion. Our findings indicate that a method of CCBT that blends internet-delivered therapy modules with about 5 hours of therapist contact across 16 weeks was effective as a full course of conventional CBT conducted by experienced therapists. Moreover, we found that the reduction in therapist contact was large enough to permit up to three times as many patients to be treated with the same resources. Although our study does not answer questions about the optimal amount of therapist contact to maximize results, our findings do suggest that number may well be below 5 hours of clinical contact. We also believe that the dissemination of CCBT could be facilitated by other modes of delivery of therapist support, including blending telephone, e-mail, and text messaging contacts with in person sessions. Future studies should focus on dissemination and optimizing therapist support methods to maximize public health significance.
1. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder, Third edition, Arlington, VA. [Available at http://www.guideline.gov/content.aspx?id=24158. Accessed November 27, 2016.]
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17. Beating the Blues™ US – Helping you to manage your emotional well-being. http://beatingthebluesus.com/ Accessed November 27, 2016.
18. MoodGYM training program. https://moodgym.anu.edu.au/welcome Accessed November 27, 2016.
19. Empower interactive. Good Days Ahead. http://www.empower-interactive.com/solutions/good-days-ahead/ Accessed November 27, 2016.
20. Andersson G, Topooco N, Havik O, Nordgreen T. Internet-supported versus face-to-face cognitive behavior therapy for depression. Expert Rev Neurother. 2016; 16(1):55-60.
21. Richards D, Richardson T. Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clin Psychol Rev. 2012;32(4):329-342.
22. Arnberg FK, Linton SJ, Hultcrantz M, Heintz E, Jonsson U. Internet-delivered psychological treatments for mood and anxiety disorders: a systematic review of their efficacy, safety, and cost-effectiveness. PLoS One. 2014;9(5):e98118.
23. So M, Yamaguchi S, Hashimoto S, et al. Is computerized CBT really helpful for adult depression? A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity. BMC Psychiatry. 2013;13:113.
24. Rozental A, Magnusson K, Boettcher J, Andersson G, Carlbring P. For better or worse: an individual patient data meta-analysis of deterioration among participants receiving internet-based cognitive behavior therapy. J Consult Clin Psychol. 2016. [Epub ahead of print 10.1037/ccp0000158].
25. Gilbody S, Littlewood E, Hewitt C, et al. Computerised cognitive behavior therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomized controlled trial. BMJ. 2015;351:h5627.
26. Wright JH, Wright AS, Salmon P, et al. Development and initial testing of a multimedia program for computer-assisted cognitive therapy. Am J Psychother. 2002;56(1):76-86.
27. Kim DR, Hantsoo L, Thase ME, Sammel M, Epperson CN. Computer-assisted cognitive behavioral therapy for pregnant women with major depressive disorder. J Womens Health (Larchmt). 2014;23(10):842-848.
28. Wright JH, Wright AS, Albano AM, et al. Computer-assisted cognitive therapy for depression: maintaining efficacy while reducing therapist time. Am J Psychiatry. 2005;162(6):1158-1164