Reaching Out with cCBT

So my wife found this article about computer-assisted Cognitive Behavioral Therapy (cCBT) for depression. It cited a study which found that it was no more effective than in-person “traditional” CBT  in primary care for helping depressed patients recover [1].

I wondered why anyone would believe that the challenges for engaging patients in face-to-face psychotherapy would be absent or less problematic in computer-assisted CBT (cCBT).

I wonder if anyone considered the usual drop-out rate for traditional psychotherapy, usually after only 4 or so sessions?

I see many patients hospitalized after medically and psychologically serious suicide attempts. After we work through a safety plan:

and decide together that psychiatric hospitalization might not be called for or even helpful, then working on the outpatient referral (preferably within days to a couple of weeks) raises the next question:

What’s the best way to help people starting building enough coping skills, resilience, and hope which will sustain them while waiting for the appointment in the clinic–which could take up to 3 months?

I have a couple of links to cCBT (The MindSpot Clinic and The MoodGym, the latter mentioned in the article) and I often suggest to patients that they check them out because they’re accessible and mostly free–two features often uncharacteristic of traditional CBT.

In addition to those, I often recommend getting a copy of “CBT for Dummies,” which also allows me to use a sense of humor (I’m not calling you a dummy; I’m just sayin’…obviously only after we’ve achieved rapport).

It’s also worth reminding readers that, in the study, cCBT was used as an adjunct to usual primary care. As the article author points out, “…many other studies on cCBT that show some benefit have been conducted in psychological settings, where patients might be more motivated to engage with these kinds of online programs.”

There’s more than one way to reach out.

Reference:

  1. Gilbody, S., et al. (2015). “Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial.” BMJ 351.
    Study question How effective is supported computerised cognitive behaviour therapy (cCBT) as an adjunct to usual primary care for adults with depression?Methods This was a pragmatic, multicentre, three arm, parallel randomised controlled trial with simple randomisation. Treatment allocation was not blinded. Participants were adults with symptoms of depression (score ≥10 on nine item patient health questionnaire, PHQ-9) who were randomised to receive a commercially produced cCBT programme (“Beating the Blues”) or a free to use cCBT programme (MoodGYM) in addition to usual GP care. Participants were supported and encouraged to complete the programme via weekly telephone calls. Control participants were offered usual GP care, with no constraints on the range of treatments that could be accessed. The primary outcome was severity of depression assessed with the PHQ-9 at four months. Secondary outcomes included health related quality of life (measured by SF-36) and psychological wellbeing (measured by CORE-OM) at four, 12, and 24 months and depression at 12 and 24 months.Study answer and limitations Participants offered commercial or free to use cCBT experienced no additional improvement in depression compared with usual GP care at four months (odds ratio 1.19 (95% confidence interval 0.75 to 1.88) for Beating the Blues v usual GP care; 0.98 (0.62 to 1.56) for MoodGYM v usual GP care). There was no evidence of an overall difference between either programme compared with usual GP care (0.99 (0.57 to 1.70) and 0.68 (0.42 to 1.10), respectively) at any time point. Commercially provided cCBT conferred no additional benefit over free to use cCBT or usual GP care at any follow-up point. Uptake and use of cCBT was low, despite regular telephone support. Nearly a quarter of participants (24%) had dropped out by four months. The study did not have enough power to detect small differences so these cannot be ruled out. Findings cannot be generalised to cCBT offered with a much higher level of guidance and support. What this study adds Supported cCBT does not substantially improve depression outcomes compared with usual GP care alone. In this study, neither a commercially available nor free to use computerised CBT intervention was superior to usual GP care.Funding, competing interests, data sharing Commissioned and funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project No 06/43/05). The authors have no competing interests. Requests for patient level data will be considered by the REEACT trial management groupTrial registration Current Controlled Trials ISRCTN91947481. Open Access: http://www.bmj.com/content/351/bmj.h5627
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Comments

  1. Well said, George 🙂

    Like

  2. Jim,

    Excellent points. The cCBT literature points out that this is a valuable resource. In our rationed systems of care, I don’t understand why every managed care system is not mandated to provide cCBT.

    I recall reading a paper that it was used in remote areas of Australia. The way mental health resources are managed in this country – most people here are in the mental health outback.

    At least give them cCBT.

    Liked by 1 person

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