Studies have demonstrated that CBT works at least as well as antidepressants at reducing depression, perhaps even better (DeRubeis et al., 1999). However, it’s difficult for people with depression to access CBT due to lengthy waiting lists.
The Improving Access to Psychological Therapies (IAPT) scheme has had a major influence on waiting times for people with depression and anxiety in the UK. Despite this, one in five individuals are still waiting over a year to receive treatment (We Need to Talk Coalition, 2012). Sometimes individuals are never offered the therapy and even when it is available most people aren’t able to access the treatment at a suitable time and place.
Computerised cognitive behavioural therapy (CCBT) therefore appears to be an attractive option as it’s an accessible and cost-effective self-help treatment, suitable for many people who prefer to avoid the stigma and disclosure of sensitive information commonly incurred by seeing a therapist (Gega et al., 2004). The number of papers published on CCBT have markedly increased and to date, at least five meta-analyses have been conducted investigating the effectiveness of CCBT on adult depression. All of these showed that CCBT was beneficial with moderate effect sizes. So it seems so far, so good…
Recently, a meta-analysis was conducted by So and colleagues (2013) which re-evaluated the short-term effectiveness of CCBT and also investigated its long-term effects, functional improvement and dropout in adults with depression. Their findings were published in BMC Psychiatry. It shows that CCBT improves depressive symptoms in adults with depression in the short term. However, CCBT did not improve dropout rates, functioning or depressive symptoms in the long term.
The authors of the meta-analysis searched five databases: MEDLINE, PsycINFO, EMBASE, CENTRAL and CiNii. To be eligible for inclusion, all RCTs:
- Were published before 1st August 2011
- Investigated the effects of guided and unguided CCBT specific to depression
- Involved comparison with one or more control conditions
- Individuals had to be aged 18 or over and have depression
- Used reliable and standardised rating-scales equally at baseline and follow-up
- Had proper allocation, concealment, single or greater binding of outcome assessment
- Studies had to have a primary end point including a measure of depression at the outcome assessment immediately after intervention and long-term follow up (more than six months)
Studies were excluded if:
- Participants were inpatients
- Patients had severe symptoms from self-help intervention
- Participants had comorbidities including psychotic disorders, manic status, dementia and severe physical conditions
Out of 4,888 studies initially screened, fourteen studies and 2,807 participants met the inclusion criteria. Sixteen comparisons from these were used. There were more female than male subjects and their mean age ranged from 22.6 to 55 years. The majority of CCBT programmes were based on standard CBT, whilst combined CBT with other therapies was used in two trials. All studies used depression as the primary outcome and eight trials used the Beck Depression Inventory. Secondary outcome measures including functioning post-treatment and number of dropouts.
Cohen’s method was used and the standard mean difference for the overall pooled effects across the included studies was estimated with a random effects model.
Here is what the authors found:
- There was a significant difference in depressive symptoms between CCBT and controls immediately following treatment (pooled SMD: -0.48 [95% CI -0.63 to -0.33] indicating a significant moderate effect
- There was no significant difference in long-term follow up at six months between CCBT and controls (pooled SMD: -0.05 [95% CI -0.19 to 0.09]
- There was no significant difference in improved functioning between CCBT and controls as the pooled SMD was -0.05 [95% CI -0.32 to 0.22]
- A significantly higher drop out rate was found for the CCBT group compared to controls.
The authors concluded:
Despite a short-term reduction in depression at post-treatment, the effect at long-term follow-up and the function improvement were not significant, with significantly high dropout. Considering the risk of bias, our meta-analysis implied that the clinical usefulness of current CCBT for adult depression may need to be re-considered downwards in terms of practical implementation and methodological study.
Limitations and summary
There were some methodological weaknesses in this research which may have impacted on its validity and reliability. Firstly, not all studies used the Beck Depression Inventory (BDI) as the primary outcome measure. There were also issues with publication bias, control conditions and imputation. These issues could have influenced the findings and possibly overestimated the effects of CCBT. Moreover, there were more female subjects included so this sample was not truly representative of the population.
This meta-analysis suggests that CCBT improves depressive symptoms in adults in the short-term. However, long-term effects and functional improvement were not significant and a substantial dropout rate was revealed for the CCBT group. These results do cast doubt on the practical application of the effects of current CCBT for adults with depression. Mental health professionals may not trust the evidence for CCBT and thus not feel as confident in offering this therapy to individuals due to the non-improvement in long-term effects and functioning, as well as the high dropout rate. In addition, healthcare providers may be reluctant to pay for CCBT due to these findings.
Nevertheless, CCBT may be useful as part of a Stepped Care Programme for individuals who are on long waiting lists for other effective evidence-based psychotherapies, such as cognitive behavioural therapy. This would enable them to still take an active role in their recovery as well as be “held” by mental health services. CCBT could then act as an extension of a clinician and mental health services as opposed to a replacement of these.
One other concern is that not everybody is computer literate – this is especially problematic for some of our older elves! As is always the case, more careful research is required in this area in order to understand the true effects and potential of CCBT. This could investigate the effects of CCBT on a less biased sample and involve utilising one measure to assess depression severity e.g. the BDI.
So, M., Yamaguchi, S., Hashimoto, S., Sado, M., Furukawa, T.A. & McCrone, P. (2013). Is computerised CBT really helpful for adult depression? A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity (PDF). BMC Psychiatry, 13¸ 1-14.
We need to talk: getting the right therapy at the right time (PDF). MIND We Need to Talk Coalition, 2012.
DeRubeis, R. J., Gelfand, L. A., Tang, T. Z., et al. (1999) Medication versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. American Journal of Psychiatry, 156(7), 1007 -1013.
Services for Patients with Depression. Department of Health, Clinical Standards Advisory Group, 1999.
Gega, L., Marks, I. & Mataix-Cols, D. (2004). Computer-Aided CBT Self-Help for Anxiety and Depressive Disorders: Experience of a London Clinic and Future Directions (PDF). JCLP/In Session, 60(2), 147-157.
@Mental_Elf @KayFSheldon This is a crucial study as much govt policy based on CBT as THE talking therapy
Computerised CBT is effective for depression in the short-term, but new meta-analysis suggests no long-term fu… http://t.co/8Xeq6y2Dyw
Disappointing result, really.
@Mental_Elf @KayFSheldon CBT helped me stop gambling but it could never keep me stopped. I believe that CBT is a useful short term device.
@ProbGambler @Mental_Elf Do you that means there’s no point using CBT if it has no lasting effect? Or does it need modifying in some way?
@KayFSheldon @Mental_Elf CBT is useful for initial breaking of cycles / habits but does nothing for underlying symptoms which will return
@ProbGambler @KayFSheldon @Mental_Elf Relative told CBT works and then felt even guiltier afterwards because he was still depressed
@jaxrafferty @KayFSheldon @Mental_Elf CBT like ibuprofen targets pain but if pain caused by underlying issue then pain comes back
@ProbGambler @KayFSheldon @Mental_Elf Like the analogy
@KayFSheldon @Mental_Elf bit like the stop smoking CBT books can make you stop – but only stay stopped if you really wanted to stop anyway
Did this study report whether computer based CBT is as effective as face-to-face CBT? Sometimes talking to someone can be part of the therapy… And most studies agree that doing something is better than nothing! However, important to consider whether the treatments are equally efficacious.
Computerised CBT is effective for depression in the short-term, but new meta-analysis suggests… http://t.co/SiOKt2btnL
…And some can cause more harm than good…
Sounds like it might be useful to use as an interim therapy if waiting lists are inevitable? My main concern about this study was the amount of detail on the control groups though. No discussion about whether medication levels were the same between intervention and control groups. And looking at one study in detail, there did seem to be imbalances – and no test for heterogeneity between study groups.
Not all CCBT programmes are the same! Some are designed to be delivered with low intensity support over an extended period for these reasons … Many people’s experience of common mental health problems is that they are relapsing and remitting over time – I think this ‘assess, treat, close and discharge’ model does not fit well with many people’s lived experience of mental health problems, which can resurface at times of stress or vulnerability – maybe we need to rethink our approach – low intensity CCBT is ideal for supporting enduring but infrequent contact.
Computerised CBT is effective for depression in the short-term, but new meta-analysis suggests no long-term functiona http://t.co/u8f52v7kKc
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Computerised CBT effective for depression short-term, new analysis suggests no long-term improvement http://t.co/D3qEsus9zI via @sharethis
Computerised CBT is effective for depression in the short-term, but http://t.co/JMmwrjCCHX of interest to @kateanthony
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