Cognitive behavioural therapy effective when delivered in online by a therapist

Cognitive behavioural therapy (CBT) seems to be effective when delivered online in real time by a therapist, with benefits maintained over 8 months. This method of delivery could broaden access to CBT in primary care. These are the conclusions of an article in this week's Global Mental Health special edition of The Lancet, written by Dr David Kessler, NIHR National School for Primary Care Research, University of Bristol and colleagues.

Despite strong evidence for its effectiveness, CBT remains difficult to access.  Computerised programmes have been developed to improve accessibility, but whether these interventions are responsive to individual needs is unknown.  The authors investigated the effectiveness of online CBT for patients with depression in primary care.

In this randomised controlled trial, 297 patients with a confirmed diagnosis of depression were recruited from 55 general practices in Bristol, London, and Warwickshire.  Patients received online CBT in addition to usual care (intervention, 149 patients); or to usual care from their general practitioner while on an 8-month waiting list for online CBT (control, 148). The primary outcome was recovery from depression at 4 months.

The researchers found that 113 patients in the intervention group and 97 in the control group completed 4-month follow-up.  Thirty-eight per cent of patients recovered from depression in the intervention group versus 24 per cent in the control group at 4 months.  After 8 months, the proportions of patients that had recovered were 42 per cent (intervention) and 26 per cent (control).

The authors conclude: "The number of patients for whom online CBT is feasible and attractive will grow.  It could be useful in areas where access to psychological treatment is scare, and for patients whose first language is not English.  It could make access to psychotherapies more equitable by providing a service to patients in areas or even countries where psychological treatment is not readily available.  Real-time online CBT offers the flexibility and responsiveness of face-to-face CBT and is appropriate for people with severe symptoms.  It affords an opportunity for reflexion and review as part of the therapeutic process, which could enhance its effectiveness."

In an accompanying comment, Dr Gregory E Simon and Dr Evette J Ludman, Group Health Research Institute, Seattle, WA, USA, say that new communications techonologies will challenge some traditional notions about the essentials of psychotherapy-as it would allow, for example, more frequent contacts instead of one hour consultations every 1-2 weeks.  They conclude: "Traditional therapists might be horrified by the prospect of an overseas cognitive-behavioural call centre or live-chat centre, available whenever patients choose.  But the expectations of health-care providers are not the same as evidence.  And the evidence that matters concerns clinical benefit and economic value to patients, rather than appeal or value to providers."

Paper: Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial by David Kessler, Glyn Lewis, Surinder Kaur, Nicola Wiles, Michael King, Scott Weich, Debbie J Sharp, Ricardo Araya, Sandra Hollinghurst, Tim J Peters The Lancet Vol 374 August 22, 2009