Current NICE guidance recommends a ‘stepped’ approach to depression care, with patients first being offered lower intensity treatments before progressing to higher intensity, face to face treatments and/or medication, if their symptoms do not improve. Computerised or online CBT is offered by a number of providers, and involves completing a series of modules usually from a home computer with varying degrees of support but usually minimal or no direct contact with a therapist.
As demand for CBT currently outstrips availability, computerised CBT offers a promising alternative that could make this therapy more easily accessible. To date, evidence suggests that computerised CBT may be effective in depression, but findings vary and many studies have been carried out by the companies that produce CBT packages.
A new NIHR study, called REEACT, evaluated the effectiveness of two commonly used computerised CBT packages for people with depression, compared to usual GP care.
After four months, participants receiving computerised CBT showed no additional improvement in depression compared to those receiving usual care from their GP. Outcomes were no better for a pay-to-use commercial service (Beating the Blues) than for a free one (MoodGYM). With either package, participants had access to telephone support from a non-specialist, mainly to deal with technical issues.
The REEACT study was the first large, randomised trial to look at the effectiveness of computerised CBT in a primary care setting – which is the way it would normally be delivered in usual NHS practice. It involved almost 700 participants from 100 GP practices.
Although the findings in the REEACT study were less encouraging than previous research, it’s important to note that the majority of participants did not complete the course of CBT, with fewer than one in five finishing all the sessions. The most common number of sessions completed was just one or two (out of either six or eight, depending on the package used). This means that it is not possible to tell whether people might have benefited from the CBT, had they completed the course. In addition, the study looked at two CBT packages, but other packages are available which could offer different results.
Interviews with participants found that people had differing views about the course, with some appreciating the flexibility of a home-based programme, whilst others found it difficult to maintain motivation without support. There was no obvious pattern to determine which types of patient (for example, male or female) would favour computerised CBT or do well with it.
This study does not overturn previous findings that showed computerised CBT to be effective, but it does indicate that many people with depression may be unlikely to complete a course of computerised CBT if it is provided with only technical support and no input from a therapist.
The NIHR has funded a second, related study, REEACT2, to explore the effect of adding telephone facilitation to computerised CBT, in the form of a weekly call from a trained practitioner to discuss progress and undertake exercises. This study hasn’t published yet, but it will provide useful evidence about whether adding this type of support improves adherence to and outcomes from computerised CBT. See About this research for a link to the project