Computerised cognitive behavioural therapy and its uses

Eva Kaltenthaler BSc, MSc, PhD, Kate Cavanagh DPhil DClinPsych Computerised cognitive behavioural therapy and its uses The use of computer software programmes to deliver cognitive behavioural therapy to people with mental health disorders is becoming increasingly popular. Here the authors describe what conditions computerised cognitive behavioural therapy may be useful for, discuss its advantages and disadvantages and outline the current NICE guidance on its use. 22 There is substantial evidence to support the use of psychological therapies, particularly cognitive behavioural therapy (CBT) in the treatment of depression and anxiety. 1-4 However, there is also evidence that patients are not consistently receiving evidence-based psychological therapies in routine clinical care. 5 Problems with the dissemination of CBT therapies have been identified and include the expense associated with service costs, long waiting times for therapy, problems with accessing services, and a scarcity and inequitable geographic distribution of accredited CBT therapists. 6 In response to these challenges, alternative modes of delivering CBT for mild and moderate anxiety and depression have been developed including: group therapy, bibliotherapy and computerised CBT (CCBT). Computer software programs are increasingly used to provide psychological therapies to people with mental health disorders. This article sets out to describe CCBT, what conditions it may be useful for, advantages and disadvantages of the use of CCBT as well as current National Institute for Health and Clinical Excellence (NICE) guidance on its usage. What is CCBT? CCBT is a generic term that is used to refer to a number of methods of delivering CBT via an interactive computer interface that uses patient input to make at least some psychotherapy decisions. 7 It can be delivered on a personal computer at home, over the internet, on a mobile device, eg palmtop, Blackberry, iphone, via a standalone computer in a health care setting or via the telephone using interactive voice response (IVR) systems. It can be used as the primary treatment intervention, with minimal therapist involvement, or as augmentation to a therapist-delivered programme where the use of CCBT supplements the work of the therapist. Computerised programs for common mental health problems have been developed primarily to improve the availability, access and choice of evidencebased interventions. The perceived advantage of reduction in the costs associated with therapist treatment has also been noted. The dominant therapeutic paradigm adopted in computer-assisted psychotherapies is cognitive and behavioural, as the manualised, structured and collaborative approach and techniques of this model are well matched to adaptation into computer methods of delivery. The CCBT evidence base Cognitive and behavioural approaches are recognised to be among the most effective psychological interventions for depression and anxiety 2-4 and selfhelp interventions based on cognitive and behavioural principles may also be helpful, particularly for problems of mild to moderate severity. There is increasingly good quality evidence that CCBT is effective. In a systematic review of CCBT for the treatment of mild-to-moderate depression, four randomised controlled trials (RCTs) were identified, three of which showed evidence of effectiveness. 8 A meta-analysis of CCBT programs for anxiety has indicated a benefit of CCBT over non-treatment comparison groups and equivalent outcomes to face-toface CBT therapies. 9 Further studies looking at specific programs, such as Beating the Blues, in primary and secondary care have shown encouraging preliminary results for the role of CCBT as a first step, supported self-help treatment for anxiety and depression. 10,11 Meta-analyses focusing specifically on internetbased programs have echoed these findings, for example Spek et al. 12 identified 28 RCTs comparing internet-based CBT programs for anxiety and depression with control groups such as waiting lists, treatment as usual and placebos but not other active treatments. Prevention studies were included. The authors found a moderate overall effect size and sig- www.progressnp.com

nificant heterogeneity between the studies. They found that those studies with therapist support were more effective than those without, and interventions with anxiety were more effective than interventions for depression. 12 The body of evidence suggests that self-help programmes including CCBT can be of benefit to people with anxiety and depression when offered in a service context that offers brief support from trained workers. 12-14 A review of internet-based CBT programs has identified a significant relationship between therapist support time and program outcomes, 15 which might be mediated by increased program engagement. Titov et al. 16 report an RCT of CCBT for social phobia. In this study, those assigned to clinician-assisted CCBT did better than self-guided CBT and waiting list control groups whose group outcomes were equivalent; however, those people in the self-guided CCBT group who completed the six-lesson program made good progress. In primary care, studies of online unsupported CCBT for depression have demonstrated less positive outcomes, for example in a large trial de Graaf et al. 17 found no benefit in offering an unsupported CCBT program as an alternative or in addition to usual care. What conditions it CCBT useful for? To date the major client groups for computerised psychological therapies have been those with anxiety disorders including panic, phobia, post-traumatic stress disorder and obsessive compulsive disorder, and subthreshold and mild to moderate depression, but computerised psychotherapies have also been used for treatment of eating disorders, sexual problems, psychosis, alcohol and substance misuse, smoking cessation and the treatment of childhood problems, among others. 18 Internet-administered CBT has also been used for many other health problems including headache, pain, tinnitus, chronic physical health conditions, breast cancer, insomnia and paediatric brain injury. 19 Many new CCBT programs are in development, a primary area of development being into programs for children and adolescents. One such program, Stressbusters has been developed for young people with depression. In a small preliminary study, this program was found to significantly improve symptoms of depression in adolescents. 20 Advantages and disadvantages compared with face-to-face therapy Several advantages for using CCBT have been identified. These include the potential for considerable cost savings due to the decrease in therapist time 24

CCBT program Description of program Outcomes reviewed by NICE (2009) Notes (as used in RCT study) Internet-based self- Five text-based modules: introduction; Evidence of benefit over online discussion group Swedish language only help for depression behavioural activation; cognitive restructuring; only (RCT; Andersson et al, 2005) 28 sleep and physical health; and relapse prevention and future goals. Each module ends with a quiz. Responses are automatically sent to therapist who provides a feedback email and code for next module within 24 hours. Accessed online. Approximately two hours therapist support time per user Moodgym Online assessments plus five interactive modules, Evidence of benefit over weekly attention placebo http://moodgym.anu.edu.au made available sequentially weekly, revision of all phone calls only (RCT, N=525,Christensen et al, modules in week 6. Topics include cognitive 2004) 29 restructuring, pleasant activities and assertiveness training. Online exercises, quizzes and downloads are available. Accessed online. Supported by weekly phone calls, to a total of approximately one hour per user Overcoming Interactive, text-based, seven-chapter program of self- No evidence of benefit for unsupported program Program is no longer available. Depression on the paced, skills training focusing on the acquisition and over waiting list control (RCT, N=299, Clarke et http://www.kpchr.org/feelbetter/ Internet use of cognitive restructuring techniques. Accessed al, 2002). 30 Evidence of benefit over treatment as online. No therapist support to the program was given usual control when telephone or postcard program reminders are used (RCT, N=255, Clarke et al, 2005) 31 Beating the Blues Introductory video plus eight interactive, multimedia Evidence of benefit over primary care treatment This program is now available weekly sessions covering a range of cognitive and as usual (RCT, N=274, Proudfoot et al, 2004) 32 online. www.beatingtheblues.co.uk behavioural techniques (thought recording, challenging unhelpful thinking, attributional style, goal setting, sleep management, task breakdown, problem solving, etc). Homework between sessions, weekly monitoring of progress and review. Accessed via appointments in healthcare or other community setting, supported by a trained worker at weekly appointments, total of approximately one hour support time per user Cognitive Therapy: Eight interactive, multimedia sessions designed to Computer-assisted cognitive therapy and standard The self-help content of this A Multimedia engage patients, teach core methods of standard cognitive therapy were superior to the wait list program is available on DVD, Learning Program cognitive therapy and reinforce learning. Computer- control group for treatment of depression and repackaged as Good days ahead: a assisted therapy offered as a package with nine weekly did not differ from each other on the primary multimedia cognitive therapy face-to-face therapy sessions (1 x 50 minutes, 8 x 25 outcome variables (RCT, N=45, Wright et al, program minutes) followed immediately by weekly computer 2005) 33 http://www.mindstreet.com/ based sessions (8 x 20-30 minutes). Accessed via appointments in outpatient clinic. Total of approximately four hours therapist contact per user Table 1. Computerised cognitive behavioural therapy (CCBT) programs for depression reviewed by NICE, 2009 4 www.progressnp.com 25

CCBT program Description of program Outcomes reviewed by NICE (2009) Notes (as used in RCT study) Computer- Six-session, text-based, interactive computer cognitive Evidence of benefit over a waiting list control This program has never been administered behavioural treatment program. Accessed in healthcare group (with monitoring phone calls), and brought to market cognitive-behavioral setting. Therapist available, but contact kept to a equivalence to face-to-face CBT of similar duration therapy for minimum (RCT, N=36, Selmi et al, 1990) 34 depression Internet-based Eight weekly modules with text, exercises, videos and Evidence of benefit over a waiting list control Dutch language program. Only cognitive figures, based on coping with depression group group, and equivalence to group CBT based on participants over 50 years old behavioural therapy treatment manual (Lewinsohn et al, 1992). 35 Accessed same treatment manual (RCT, N=301, Spek et al, recruited for subthreshold online. No professional support was given 2007) 36 depression Table 1 (cont.). Computerised cognitive behavioural therapy (CCBT) programs for depression reviewed by NICE, 2009 4 26 required per patient. CCBT allows access to psychological therapies more quickly and to more people as it can be delivered in a variety of settings including at home. Other advantages of CCBT have been proposed including access to a consistent source of therapeutic expertise that can be readily updated, and that incorporates regular problem and symptom monitoring and feedback. Being a client-led treatment, CCBT can also promote agency, mastery, control and learned resourcefulness. 18,21 There are also potential disadvantages to CCBT such as the lack of face-to-face contact and potential issues relating to safety. A review of the acceptability of CCBT 22 found 16 studies of CCBT for depression that provided information on recruitment rates, patient drop-outs and patient-completed questionnaires. The authors found limited information on patient take-up rates and recruitment methods. Drop-out rates appeared to be comparable with other forms of treatment although take-up rates were much lower. Only six of the 16 studies included specific questions on patient acceptability and this was only provided for those who had completed treatment. Several of the included studies reported positive expectancies and high satisfaction in routine care CCBT services for those completing treatment. Waller and Gilbody 23 in their review of barriers to the uptake of CCBT found that substantial numbers of potential participants were lost before trials began and only a median of 56 per cent completed a full course of CCBT. Mitchell and Gordon 24 explored attitudes towards CCBT among 122 university students and found that only 9.8 per cent of the sample stated a preference for CCBT over other interventions for depression, although preference rates rose following a demonstration of a CCBT program. A study of 200 participants, using unsupported online CCBT found that uptake was sufficient but participant drop-out was high. The authors concluded that means to improve treatment adherence were needed. 16 Developments in the field of CCBT have promoted an emerging science of uptake, engagement and completion increasing our understanding of the factors associated with optimal, short-term and sustainable user and population benefits from CCBT. 25 Current NICE guidance on CCBT usage In 2006, NICE recommended two software packages for the treatment of depression and anxiety through their technology appraisal process (TA07). 26 These packages were: Beating the Blues for people with mild and moderate depression and FearFighter for people with panic and phobia. For depression, this guidance has now been superseded by the updated NICE Depression in Adults guideline (CG90), 4 which incorporates recommendations on the use of CCBT for depression and interprets the evidence for CCBT in terms of a class effect. The guideline states that for people with persistent subthreshold depressive symptoms or mild-to-moderate depression, one or more of following interventions could be offered, guided by the person s preference: Individual guided self-help based on the principles of CBT CCBT A structured group physical activity programme. www.progressnp.com

CCBT for people with persistent subthreshold depressive symptoms or mild-to-moderate depression should: Be provided via a stand-alone computer-based or web-based program Include an explanation of the CBT model, encourage tasks between sessions, and use thought-challenging and active monitoring of behaviour, thought patterns and outcomes Be supported by a trained practitioner, who typically provides limited facilitation of the program and reviews progress and outcome Typically take place over 9 to 12 weeks, including follow-up. The guidelines state that a range of low-intensity interventions (guided self-help, group-based physical activity programmes and CCBT) have been identified as being effective for subthreshold depressive symptoms and mild-to-moderate depression. As there are few trials that allow for direct clinical or cost-effectiveness comparisons of any of the interventions, the guidelines recommend that the decision as to which intervention to offer should, in significant part, be guided by the preference of people with depression and this is reflected in the recommendations. The data also did not support the view that any particular mode of delivery (internet versus desktop-based CCBT) for any low-intensity intervention had any specific advantage over another, apart from the fact that both guided selfhelp and CCBT should be based on cognitive behavioural principles. All interventions seem to require some form of support to be fully effective. The Guidelines Development Group were also concerned that the effective delivery of the interventions may be compromised by differences in the style and content of delivery of the intervention and so have drawn on existing trial data to offer specific recommendations on the content of the inter - ventions. The NICE guidelines on Depression with a Chronic Physical Health Problem (CG91) 27 make similar recommendations on the use of CCBT for patients with persistent subthreshold depressive symptoms or mild-to-moderate depression and a chronic physical health problem, and for patients with subthreshold depressive symptoms that complicate the care of the chronic physical health problem. Conclusions There is growing interest and an expanding evidence base for CCBT in the management of common mental health problems. Recent NICE guidelines recom- 28

mend CCBT as a first-line treatment choice for persistent subthreshold, mild-to-moderate depression, phobia and panic. Supported CCBT interventions have higher rates of adherence and better outcomes than unsupported programs, and services can provide support for CCBT to improve the benefits of these programs. This support might include information and taster sessions of CCBT programs to promote uptake along with regular support offered face-to-face, by phone or email and log-on reminders to promote program engagement, adherence and completion. 25 Declaration of interest Kate Cavanagh is a consultant to Ultrasis plc, which licences Beating the Blues. Dr Kaltenthaler is a Senior Research Fellow, ScHARR, University of Sheffield, and Dr Cavanagh is a Senior Lecturer in Psychology, University of Sussex, Falmer, East Sussex References 1. Treatment Choice in Psychological Therapies and Counselling. Evidence Based Clinical Practice Guideline. Department of Health, 2001. 2. 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