Online CBT for Depression, GAD Is Effective for Most

By: BRIAN HOYLE, Clinical Psychiatry News Digital Network
May 17, 2012

Internet-based cognitive-behavioral therapy is a treatment approach that can benefit patients with anxiety and depression, researchers report.

The study, conducted by Matthew Sunderland, Ph.D., and colleagues, bolsters the case for the web-based approach as a way of overcoming treatment obstacles such as the lack of rural-based services and wait time (Behavior Res. and Therapy 2012;50:374-80).

Dr. Sunderland and his colleagues have been engaged in creating a web-based option for general practitioners and other front-line workers to treat patients, freeing therapy time for those patients in need of more intensive treatment. Hindering this goal has been a lack of information on the "trajectory of change" of patients during the treatment course, reported Dr. Sunderland of the University of New South Wales, Sydney.

The investigators studied 663 patients who completed an online cognitive-behavioral therapy (CBT) course for depression (n=302; 58% female) and generalized anxiety disorder (GAD) (n=361; 74% female). The patients’ average age was 43. The primary outcome measure was the Kessler-10 psychological distress scale. The time course of depression and GAD was respectively determined using the Patient Health Questionnaire-9 and GAD-7 instruments. Levels of functional impairment over the previous 30 days were measured using the World Health Organization Disability Assessment Schedule 2.0.

Most (75%-80%) patients with either psychological disorder displayed progressive and clinically significant improvements over the period of the six online course lessons, corroborating previous studies.

But the rest were "low responders," whose initial improvement leveled off and even slightly regressed in the later sessions, indicating to the researchers that Internet CBT for anxiety and depression "may be better suited as an initial step within a stepped care model for treatment."

When asked about the results, Erik Andersson, M.Sc., of the department of clinical neuroscience, Karolinska Institutet, Stockholm, said his overall impression is that they are impressive. "The rate of responders is high and much better than, for example, pharmacological treatments. Of course, one could wish they had more predictor variables, such as genetic data," he said. "That is an important issue for future research."

He also said the results should be compared to traditional live therapy.

What factors determine the good and low responses remain to be clarified.

"That is indeed the billion dollar question," Mr. Andersson said. "The authors have found some predictive variables, but it is always hard to tell on an individual level. Some patients really surprise you as a clinician. In my view, the ability to predict treatment success beforehand is still impossible to decide on an individual level. But this article gives some guidance in the clinical decision process.

Gerhard Andersson, Ph.D., said in an interview that it is unclear whether the low responders would indeed benefit from another form of therapy. "My impression is that there is a group (albeit small) who is less likely to benefit from therapy regardless what form of psychotherapy, said Dr. Andersson, of the department of behavioural sciences and learning at Linköping University, Sweden. "For depression, it is possible that combined treatment may lead to more responders, such as if Internet CBT and medication are combined."

Dr. Sunderland reported several study limitations, including the absence of a control group and the inability to look into the kinds of barriers that might have prevented people from benefiting from online CBT courses. "Further research with more robust experimental designs is required to address some of the questions regarding the defining features of the sub-classes raised in the current study," they wrote.

Dr. Sunderland reported no relevant financial conflicts of interest.