Internet-based CBT not effective as stand-alone intervention for depression
At least one third of those suffering from depressive illness do not seek medical help. Men are less likely to seek treatment than women.1
Patients may choose not to present emotional problems to GPs because of fear of stigmatisation, embarrassment or a perception that we do not have enough time.2 It has been suggested that internet-based CBT is a way of reaching people who might otherwise not receive treatment.
A new study, in Psychological Medicine, has found that internet-based CBT is not effective as a stand-alone intervention for patients with depression.
The study, a meta-analysis of the effectiveness of internet-based CBT, identified 12 randomised controlled trials by a systematic search of the literature from 1990 onwards, supplemented by personal communication.
The trials were very heterogeneous, comprising a mixture of treatment and prevention studies, with or without therapist support, on patients with either anxiety disorders or depression.
To obtain compatible data, it was therefore necessary to analyse the depression studies separately, having excluded an outlying study that provided therapist support.
It remains doubtful, however, whether these studies are comparable: participants were not required to meet diagnostic criteria for depression, one study was a prevention study and control conditions differed widely.
The mean effect size for the four remaining depression studies was small (0.22). This compares poorly with the reported effect sizes for brief cognitive therapy (0.7-1.2) and computer-assisted CBT in general practice (1.2).3
The effect size for the outlying study, in which therapists monitored progress and gave feedback to participants, was 0.9.
One of the fundamental principles of cognitive therapy is that it requires a sound therapeutic alliance. It has even been suggested that the quality of the therapeutic relationship is more important than the specific type of psychotherapy used in determining the clinical outcome.4 The experience of feeling fully understood by an empathic clinician or therapist (but not a computer) may itself have curative power.5 Burns and Nolen-Hoeksema found that patients of the warmest and most empathic CBT therapists improved significantly more than the patients of the therapists with the lowest empathy ratings.4
Computers may complement the role of physicians and therapists, but they are no substitute.
Spek V, Cuijpers P, Nyklicek I et al. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychological Medicine 2007; 37: 319-28Reviewer
Dr Phillip Bland