The Effectiveness of Internet CBT

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The Effectiveness of Internet CBT

The Effectiveness of Internet Cognitive Behaviour Therapy (iCBT) for depression in Primary Care : A Quality Assurance Study

Alisha Williams Gavin Andrews.
PLoS ONE 8(2): e57447. Doi:10.1371/journal.pone.0057447

There are at least 25 controlled trials that show the efficacy of internet CBT.
Meta analyses of RCTs of iCBT for depression have shown evidence that it is comparable to best practice face-to-face CBT.

The Williams and Andrews research, which was carried out at St Vincent’s Hospital Sydney, looked at whether iCBT was effective in clinical primary care practice, not just in the confines of randomised control trials.

Patients were referred by their GPS to enrol in the Sadness Program of the CRUfAD clinic. Approximately 75% of referrals comprised mild to moderate levels of depressed mood as the doctors were advised the program was less likely to benefit patients with very severe presentations (depression, persistant suicidal thoughts, drug and alcohol dependence, schizophrenia, bipolar disorder and those taking benzodiazepines or atypical antipsychotics).

The doctor was alerted if the patients’ Kessler-10 (K10) Psychological Distress Scale indicated elevated distress or the patient indicated suicidality on the Patient Health Questionnaire (PHQ).

The Sadness Program consists of 6 online lessons of best practice CBT and regular homework and access to other resources. Within the program the patient has to complete a lesson before moving onto further lessons, then wait 5 days to complete homework tasks and review the materials. All patients have 10 weeks to complete the program and are encouraged to complete the lessons at a pace of one lesson per fortnight.

Data was collected from 359 patients between October 2010 and November 2011. The mean age was 41.59 years and 59% were female. 54% were from a rural or remote community.

Outcome was measured using the Patient Health Questionnaire (PHQ-9), Kessler-10 (K10) Psychological Distress Sacle and the WHO Disability Assessment Schedule (WHODAS-II). Clinically significant change was defined in 3 ways.

1. Remission when a post treatment score was below the cut off for probable diagnosis of depression.
2. Recovery when there was reduction of at least 50% of pre-treatment PHQ-9 score.
3. Reliable improvement, which was defined as a decrease of at least 5 points and a change of severity category such from moderate to mild.


359 patients enrolled

26.5% were within the 0-9 sub-threshold range
26% were mild
23% were moderate
17% severe
7.5% very severe.

194 (54%) completed all the 6 lessons.
113 (32%) completed 4 lessons (Non completers)
52 (15%) completed 1-3 lessons , (Dropouts).

The risk of non completion was not related to gender of the patient, the profession of the referrer (e.g.GP, Psychologist, Nurse), or to the geographical location of the patient . Completion was however related to the age of the patient where the older the patient the more likely s/he was to complete the program.

There was a significant reduction in scores in all 3 measures for those who completed the course.

• 112 (31%) of patients admitted to suicidal thoughts during the program. The majority of these 53% completed the program. 68% completed at least 4 lessons. Suicidal thoughts were not found to be a barrier for improvement from treatment.
• 91 of 144 (63%) patients who met the criteria for depression (PHQ9 >9) who completed all six lessons reached remission .
• 71 of 144 (49%) patients showed evidence of recovery (at least 50% reduction in PHQ-9 baseline score)
• 77 of 144 ( 54%) showed evidence of clinically reliable change.

The greatest reduction on K10 scores occurred within the first 4 lessons.
Almost half of the patients (44%) who dropped out after lesson 4 managed to benefit from the program despite non-completion.

This study certainly clarifies the effectiveness of Internet-based CBT. These programs have comparable rates of engagement and outcome and are a very good treatment option in primary care.

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This article was written by Cloud Psychology