Computerised Cognitive Behavioural Therapy Research Articles

Computerised Cognitive Behavioural Therapy in an Adult Mental Health Service: A Pilot Study of Outcomes and Alliance

This pilot study aimed to explore the clinical outcomes and therapeutic relationship for clients of an adult mental health service using Beating the Blues, a computerised cognitive behaviour therapy (CCBT) package. Sixteen participants completed the programme and reported a significant reduction in Beck Depression Inventory scores posttreatment. Participants' mean item ratings on the relationship measure were above the neutral midpoint, but no association was found between the therapeutic relationship and outcome. The results are discussed in terms of the utility of CCBT as part of a stepped-care model and how further research might usefully explore the nature of the relationship formed between clients and CCBT programmes.

One-year follow-up results of unsupported online computerized cognitive behavioural therapy for depression in primary care: A randomized trial

Objective To report the one-year follow-up results of computerized cognitive behavioural therapy (CCBT), offered online without professional support, for depression compared with usual GP care and a combination of both treatments. To explore potential relapse prevention effects of CCBT. Methods 303 depressed patients were randomly allocated to (a) unsupported online CCBT (b) treatment as usual (TAU), or (c) CCBT and TAU combined. We had a 12-month follow-up period. Primary outcome measure was the Beck Depression Inventory II. Self-reported health care use was also measured. Key findings At 12 months, no statistically significant differences between the three interventions are found in the intention-to-treat population for depressive severity, reliable improvement, remission, and relapse. In the first quarter, differences in health care consumption between the three interventions are significant (i.e. less GP contacts, less antidepressant medication, and less specialist mental health care in the CCBT group), but these differences disappear over time. Conclusions Unsupported online CCBT is not superior to TAU by a GP for depression. With equal effects, CCBT alone leads to less health care consumption than TAU and CCBT&TAU. Overall effects are modest in all interventions, which can be explained by the finding that the use of health care services decreases despite the lack of substantial improvements.

The acceptability of computerised cognitive behavioural therapy for the treatment of depression in people with chronic physical disease: A qualitative study of people with multiple sclerosis

Background: People with chronic physical conditions are at elevated risk of depression. Due to a shortage of Cognitive Behavioural Therapy (CBT) practitioners, computerised CBT (CCBT) is recommended for people with mild to moderate depression. We assessed the applicability of CCBT for the treatment of depression in people with multiple sclerosis (MS). Methods: Depth interviews with 17 people with MS and mild to moderate depression who used one of the two CCBT packages for either eight (Beating the Blues; n = 8) or five (MoodGym; n = 9) weekly sessions were analysed using ‘Framework’. Results: Participants found CCBT-use burdensome due to their physical symptoms. In addition to perpetuating social isolation, the lack of human input meant some participants were unable to define problems, set goals or distinguish between events, thoughts and beliefs as required. CCBT did not legitimise their grief over losses concomitant with their MS. They characterised depression symptom inventories as contaminated by somatic symptoms of their MS. One CCBT package (MoodGym) was perceived as using inappropriate case material for people with the symptoms of MS. Conclusions: It is likely that generic CCBT packages for the treatment of depression will need to be adapted for people with chronic physical conditions to maximise their potential for health benefit.

Economic evaluation of online computerised cognitive–behavioural therapy without support for depression in primary care: randomised trial

Evidence about the cost-effectiveness and cost utility of computerised cognitive-behavioural therapy (CCBT) is still limited. Recently, we compared the clinical effectiveness of unsupported, online CCBT with treatment as usual (TAU) and a combination of CCBT and TAU (CCBT plus TAU) for depression. The study is registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236). To assess the cost-effectiveness of CCBT compared with TAU and CCBT plus TAU. Costs, depression severity and quality of life were measured for 12 months. Cost-effectiveness and cost-utility analyses were performed from a societal perspective. Uncertainty was dealt with by bootstrap replications and sensitivity analyses. Costs were lowest for the CCBT group. There are no significant group differences in effectiveness or quality of life. Cost-utility and cost-effectiveness analyses tend to be in favour of CCBT. On balance, CCBT constitutes the most efficient treatment strategy, although all treatments showed low adherence rates and modest improvements in depression and quality of life.

Utility of computerised cognitive–behavioural therapy for depression

A recent study found that people with depression identified in the community recovered equally well given unsupported computerised cognitive-behavioural therapy (CBT), general practitioner treatment or a combination of the two, even if they did not comply. The results are different from those reported elsewhere. Could natural remission explain the finding?

Predicting outcome in computerized cognitive behavioral therapy for depression in primary care: A randomized trial.

To explore pretreatment and short-term improvement variables as potential moderators and predictors of 12-month follow-up outcome of unsupported online computerized cognitive behavioral therapy (CCBT), usual care, and CCBT combined with usual care for depression. Three hundred and three depressed patients were randomly allocated to (a) unsupported online CCBT, (b) treatment as usual (TAU), or (c) CCBT and TAU combined (CCBT&TAU). Potential predictors and moderators were demographic, clinical, cognitive, and short-term improvement variables. Outcomes were the Beck Depression Inventory-II score at 12 months of follow-up and reliable change. Those with higher levels of extreme (positive) responding had a better outcome in CCBT compared with TAU, whereas those having a parental psychiatric history or a major depressive disorder diagnosis had a better outcome in CCBT&TAU compared with TAU. Predictors regardless of treatment type included current employment, low pretreatment illness severity, and short-term improvement on clinical variables. Optimistic patients, holding approach-oriented coping strategies, might benefit most from CCBT, whereas CCBT&TAU might be the most suitable option for those with more severe vulnerability characteristics. Those with the least impairment improve the most, regardless of treatment type.

Online CBT I: Bridging the Gap Between Eliza and Modern Online CBT Treatment Packages

AbstractReviews have demonstrated large effect sizes when using computerised cognitive behaviour therapy (CBT) protocols for treating anxiety, depression and health related concerns. However, the amount of therapist contact per user seems to be the most significant prognostic indicator. Thus, in some ways current online interventions can be viewed primarily as an extension of one-on-one therapy. The present article provides guidelines for targeting this limitation of online psychological interventions. The goal is to mimic the therapeutic relationship using a computer, without having any therapist involved. Consequently, thousands of users would be able to receive treatment simultaneously, reaching a wider audience, which was the initial goal of the online model. The development of a treatment program using file audit data is suggested as an alternative to having an individual therapist for each user. This is done by allowing the ‘computer psychologist’ to tailor individualised treatments for each user based on their psychological profile. The user is provided with individualised corrective feedback based on a set of prewritten responses to common faulty thoughts. A new paradigm is proposed for online treatment delivery.

Computerised Cognitive Behaviour Therapy for Phobias and Panic Disorder: A Systematic Review

Phobias and panic disorder are commonly treated within primary care settings. Cognitive behavioural therapy (CBT) is a recommended treatment for these disorders but access is limited due to too few therapists, expense and patients' reluctance to enter therapy. Computerised CBT (CCBT) is a self‐help option designed to offer patients the potential benefits of CBT with less therapist involvement. The review described here sought to identify studies evaluating the effectiveness of CCBT for phobias and panic disorders.

The role of computer‐aided psychotherapy within an NHS CBT specialist service

AbstractTo date, the feasibility of computer‐aided psychotherapy as an intervention has only been recognised in primary care practice. The present study sought to evaluate the impact of ‘Beating the Blues’ (BtB), an established computerised cognitive behaviour therapy (CCBT) self‐help programme for the management of anxiety and depression, within an NHS CBT specialist healthcare centre. Of the 555 service users who used BtB as part of routine care, with follow‐up assessment at six to eight weeks, 71% completed all eight sessions. Statistically significant differences on the Beck Depression Inventory‐II (BDI‐II) and Beck Anxiety Inventory (BAI) were found in completer and intention‐to‐treat analyses; 50% of completers achieved reliable change on the BDI‐II and approximately 25% of completers achieved reliable and clinically significant change on both measures. Outcomes were benchmarked against outcomes in studies of routine face‐to‐face CBT. These findings provide evidence that BtB may be of value to service users in secondary mental healthcare centres, alleviating current burdens on public health and therapeutic resources. Future research directions should include examining which factors influence individuals’ decisions to try computer‐aided psychotherapy, which individuals are best suited to using these interventions, and why some users drop out prior to programme completion.

Pragmatic evaluation of the viability of CCBT self‐help for depression in higher education

AbstractThis study explores the potential of a computerised cognitive behavioural therapy (CCBT) self‐help programme for depression within the context of a Higher Education Counselling Service. It seems timely to consider the place of evidence‐based alternatives to the face‐to‐face counselling traditionally provided in higher education with user choice in mind. There is also a need to cater for increasing numbers of students experiencing a wide range and severity of emotional difficulties, sometimes resulting in long waiting periods for help. In the study twelve depressed students used the CCBT programme ‘Beating the Blues’™. Ten (83.3%) participants completed the programme. Initial credibility of and expectancy‐for‐improvement from the intervention was high. Significant reductions in depression scores were found following completion, whilst anxiety scores changes were not significant. Feedback on the programme was largely positive. CCBT was clearly preferred to face‐to‐face counselling by some participants, supporting the need for a choice of interventions for students. These results suggest that CCBT may be an acceptable and effective intervention for a number of depressed students. It is argued that CCBT may be a viable addition to current provision in Higher Education Counselling Services and that further studies are required to investigate this further.

Attitudes Towards Computerized CBT for Depression Amongst a Student Population

Some studies of computerized cognitive behaviour therapy (CCBT) have found evidence of its effectiveness, yet a number have reported low uptake and/or completion rates. This study investigated attitudes towards CCBT for depression amongst 122 university students. The credibility of CCBT, expectancy-for-improvement and perceived likelihood of using it were all poor, although a minority (9.8%) stated a preference for CCBT over other interventions. When 20 of the original sample received a demonstration of a CCBT programme for depression, significant increases in credibility, expectancy-for-improvement and in perceived likelihood of using CCBT were found. Numbers stating a preference for CCBT increased to 30%. At both stages, most students stated a preference for CCBT to be accompanied by counselling. Qualitative analysis provided information about factors that might influence these attitudes. Implications for service delivery are discussed.

Status of Computerized Cognitive Behavioural Therapy for Adults

A growing body of evidence supports the efficacy of computerized cognitive behavioural therapy (CCBT). This technology has the potential to increase the capacity of mental health services, and to overcome some of the barriers to accessing mental health services, including stigma, traveling time for rural patients, treatment delays, and the low availability of skilled clinicians. This review discusses key issues around the implementation of CCBT in current mental health services, and summarizes recent evidence for the efficacy of CCBT in anxiety and depression. Many CCBT systems exist, and the evidence for each varies in quality and quantity. It is concluded that CCBT, particularly guided by a therapist, represents a promising resource. However, considerable work needs to be done to develop CCBT techniques that are appropriate to Australasian populations, acceptable to patients and clinicians, easy to use, and are clinically and cost effective. Suggestions are made for further research and useful website addresses are provided to assist clinicians in familiarizing themselves with CCBT.

Establishing the effectiveness of computerised cognitive behavioural therapy for secondary/tertiary mental health care service users with and without physical co-morbidities

Given the intricate link between the soma and the psyche, this study sought to identify whether the presence of physical co-morbidities among sufferers of depression altered the impact of computerised cognitive behavioural therapy (CCBT). Five-hundred-and-ninety service users used Beating the Blues (BtB) - an established CCBT programme - in an NHS specialist CBT unit. A control group, a standard intervention group, and a physical co-morbidity intervention group were compared on pre- and post-Beck Depression Inventory II (BDI-II) scores. Statistically significant differences on the BDI-II were found between the control group and each of the intervention groups, but not between the intervention groups themselves. A quarter of BtB completers in each intervention group achieved reliable and clinically significant change and were said to be ‘recovered.’ A further 23.8 per cent of the standard intervention group and 26.8 per cent of the physical co-morbidity group showed reliable improvement. These findings provide compelling evidence that CCBT may be of value to service users presenting with a variety of physical co-morbidities and depression at all levels of mental health care.

The effectiveness of computerized cognitive behavioural therapy in routine care

The efficacy of a Computerized Cognitive Behavioural Therapy (CCBT) package, Beating the Blues, has been demonstrated in a large randomized controlled trial. The current study tests the generalizability of this finding in a naturalistic non-randomized trial. 219 patients with anxiety and/or depression were recruited to receive CCBT in routine care. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) and Work and Social Adjustment scale (WSA) were administered pre-treatment, immediately on completing treatment and at 6 months post-treatment. Single-item self-report measures of anxiety and depression were also collected during each treatment session. Completer and intention-to-treat analysis demonstrated statistically and clinically significant improvements on the CORE-OM, WSA and in self-reported anxiety and depression. Intention-to-treat analysis indicated an average 0.29-point drop on the CORE-OM, equating to an uncontrolled pre-post effect size of 0.50. Research completers achieved an average 0.61-point drop equating to an uncontrolled pre-post size of 1.00 on the same measure. Where data was available (18%), these benefits were maintained at week 32 (6 months follow-up). CCBT can be an effective first line tool within a stepped care framework for the management of common mental health problems.

Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation

To evaluate computerised cognitive behaviour therapy (CCBT) for the treatment of anxiety, depression, phobias, panic and obsessive-compulsive behaviour (OCD). The software packages to be considered include Beating the Blues (BtB), Overcoming Depression: a five areas approach, FearFighter (FF), Cope and BT Steps. Other packages or programmes incorporating CCBT were also considered. Electronic databases from 1966 to March 2004. Evidence submitted by sponsors for CCBT products. A systematic review was a review of the literature and the evidence submitted by sponsors for each of the products. A series of cost-effectiveness models was developed and run by the project team for the five CCBT products across the three mental health conditions. Twenty studies were identified in the clinical effectiveness review. The analysis of these results showed some evidence that CCBT is as effective as therapist-led cognitive behaviour therapy (TCBT) for the treatment of depression/anxiety and phobia/panic and is more effective than treatment as usual (TAU) in the treatment of depression/anxiety. CCBT also appears to reduce therapist time compared with TCBT. When reviewing cost-effectiveness studies, only one published economic evaluation of CCBT was found. This was an economic evaluation of the depression software BtB alongside a randomised controlled trial (RCT), which found that BtB was cost-effective against TAU in terms of cost per quality-adjusted life-year (QALY) (less than 2000 pounds), however it contained weaknesses that were then addressed in the cost-effectiveness model developed for the study. The results of the model for the depression software packages in terms of incremental cost per QALY compared with TAU and the chance of being cost-effective at 30,000 pounds per QALY were for BtB 1801 pounds and 86.8%, for Cope 7139 pounds and 62.6% and for Overcoming Depression 5391 pounds and 54.4%. The strength of the BtB software being that it has been evaluated in the context of an RCT with a control group. The subgroup analysis found no differences across the severity groupings. For phobia/panic software, the model showed an incremental cost per QALY of FF over relaxation was 2380 pounds. Its position compared with TCBT is less clear. When modelling OCD packages, using the practice-level licence cost meant that BT Steps was dominated by TCBT, which had significantly better outcomes and was cheaper. However, the cheaper PCT licence resulted in the incremental cost-effectiveness of BT Steps over relaxation being 15,581 pounds and TCBT over BT Steps being 22,484 pounds. The study findings are subject to substantial uncertainties around the organisational level for purchasing these products and the likely throughput. This is in addition to concerns with the quality of evidence on response to therapy, longer term outcomes and quality of life. The position of CCBT within a stepped care programme needs to be identified, as well as its relationship to other efforts to increase access to CBT and psychological therapies. Research is needed to compare CCBT with other therapies that reduce therapist time, in particular bibliotherapy and to explore the use of CCBT via the Internet. Independent research is needed, particularly RCTs, that examine areas such as patient preference and therapist involvement within primary care.

The Impact of a Novel Computerized CBT CD Rom (Overcoming Depression) Offered to Patients Referred to Clinical Psychology

A new CBT based CD Rom (Williams, Taylor, Aubin, Harkin and Cottrell, 2002) was introduced as a way of offering a clinical psychology waiting-list initiative for patients with depression and depression with anxiety. This study evaluated the impact of this computerized cognitive behavioural therapy (CCBT) on consecutive referrals. Six hourly sessions of the interactive computer programme were offered to clients on the waiting list, to be completed by them with some support from a self-help support nurse. Seventy-eight consecutive referrals were offered an appointment for CCBT; 20 (26%) attended at least one session of CCBT and 14 (70% of starters) completed all six hour-long sessions. Beck Depression Inventory scores (BDI-II) fell from a mean of 28.15 (SD 11.41) to 20.00 (SD 10.41) (p = .000) over the 6-week intervention period using an intention to treat analysis. The discussion asks why only a quarter of patients on this psychology waiting list chose to use a CBT CD-Rom, but also notes that those who did use it had clinically and statistically significant reductions in their reported symptoms of depression.

COMPUTERIZED COGNITIVE BEHAVIOUR THERAPY: A SYSTEMATIC REVIEW

Depression, anxiety disorders and phobias are common mental health problems associated with considerable occupational and interpersonal impairment. Although there is substantial evidence to support the use of cognitive behaviour therapy (CBT) in the treatment of these disorders, access is limited. Computerized cognitive behaviour therapy (CCBT) is one of a variety of aids to self-management that offer patients the potential benefits of CBT with less therapist involvement than therapist led CBT (TCBT). In this systematic review of the efficacy of CCBT, 16 studies were identified. Of these 11 were RCTS and the remaining 5 were pilot or cohort studies. The quality of studies ranged from poor to moderate (although the criteria used precluded the highest rating). In the studies comparing CCBT with TCBT, five studies showed CCBT have equivalent outcomes to TCBT. One study of depressed inpatients found TCBT to be significantly more effective than CCBT. Four studies found CCBT to be more effective than treatment as usual (TAU). Two studies found CCBT to be no more effective than TAU. Two studies compared CCBT with bibliotherapy. Of these, one study found CCBT to be as effective as bibliotherapy and one found bibliotherapy to be significantly more effective than CCBT on some outcome measures. Although the results of this review are not conclusive, CCBT is potentially useful in the treatment of anxiety disorders, depression and phobias. From the results of this review, we make three recommendations to improve the quality of research in this field, and suggest four areas requiring further research.