Psychiatr News December 16, 2005
Volume 40, Number 24, page 20
© 2005 American Psychiatric Association
CBT Plus Online Chat May Equal Help in Depression
Jim Rosack
Internet-based therapy may be an alternative or complement to more
traditional therapy for mild to moderate depression.
Researchers in Sweden have found that an Internet-based form of
cognitive-behavioral therapy (CBT), along with participation in an Internet
discussion group, can significantly improve symptoms for those with mild to
moderate depression. The self-directed program also appeared to be beneficial
in reducing anxiety symptoms and improving patients' overall quality of
life.
Indeed, said Gerhard Andersson, Ph.D., a professor of behavioral sciences
at Linkoping University, "self-help treatment of depression is an
attractive treatment option" and may be just as effective as traditional
face-to-face forms of psychotherapy.
Andersson and his colleagues reported their findings in the November
British Journal of Psychiatry. The work was funded by the L.J.
Boethius Foundation and the Swedish Research Council.
Andersson and his team conducted a controlled trial comparing a group of
patients with mild to moderate depressive symptoms randomly assigned to either
the Internet-based therapy plus a "chat-room" type of discussion
group or participation in a discussion group alone without any psychotherapy.
All participants completed a computerized version of the Composite
International Diagnostic Interview-Short Form and the Montgomery-Asberg
Depression Rating Scale-Self Rated (MADRS-S), and answered a series of
questions regarding demographic data, medical history, and current contact
with health care professionals and current medications.
Patients were included in the study if their total MADRS-S score was
between 15 and 30, signifying mild to moderate depression. Patients with
bipolar disorder or psychosis were excluded, as were patients who had
previously engaged in any form of CBT for depression. No antidepressant
medications could be started or changed during the month preceding entry into
the study; however, patients who were taking medication and were stable were
allowed to continue on the medication throughout the study.
The primary outcome measure was the 21-item Beck Depression Inventory.
Secondary measures included the MADRS-S, the Beck Anxiety Inventory, and the
Quality of Life Inventory.
The self-guided CBT program consisted of a series of five modules, which
include an introduction and units on behavioral activation, cognitive
restructuring, sleep and physical health, and relapse prevention and future
goals.
Each module included a series of questions, formatted as a quiz. After a
patient completed the quiz for the first module, the answers were transmitted
to one of the doctoral-level therapists in the study. The therapist provided
individualized feedback via e-mail and then "unlocked" access to
the next online module in the series.
All patients were assessed weekly during the study. Six months after
treatment ended, patients were contacted through e-mail and asked to complete
the same battery of assessments used at baseline.
The series of modules was designed to be completed within a period of eight
weeks with each patient spending approximately two hours on each module,
including time for e-mails between the patient and therapist and time
monitoring comments posted to the online discussion group.
Participation in an online discussion group was segregated so that those
patients completing the online CBT modules accessed one chat room, while those
who were randomly assigned to only a discussion group had access to a separate
chat room. Therapists monitored both discussion groups and controlled
participants' online postings in the same manner as a moderated list
serve.
The study had 117 patients at its start, with 57 assigned to the CBT plus
discussion group, and a control group of 60 assigned to the discussion group
alone. Nearly twice as many patients dropped out of the CBT group as the
control group—21 versus 11. The primary reason for withdrawing was that
"the treatment was perceived as too demanding." At the six-month
follow-up, data were assessed for 36 patients in the CBT group and 35 patients
in the control group.
Compared with the controls, patients who completed the CBT modules and
participated in the online discussion group saw statistically significantly
greater improvements on all measures except the quality-of-life index. The
differences between the two groups were sustained at six months.
Andersson and his colleagues caution that no formal diagnosis was made when
patients entered the study and thus some variability in the study population
could have existed. "Independent ratings by clinicians," they
wrote, "would have strengthened the self-report findings."
In addition, the authors noted that "confounding with respect to
medication status cannot be ignored." They also said "the study
period was relatively short, and it would have been preferable to have had a
control group that had not received any self-help or psychotherapy at the
six-month follow-up."
Finally, Andersson and his team called for further research to evaluate the
true benefits, as well as cost-effectiveness, of Internet-based therapeutic
techniques. "Internet-delivered cognitive-behavioral therapy should be
pursued further," they wrote, "as a complement to, or treatment
alternative for, mild to moderate depression."
An abstract for "Internet-Based Self-Help for Depression: A
Randomized Controlled Trial" is posted at
<http://bjp.rcpsych.org/cgi/content/abstract/187/5/456>.
Br J Psychiatry 2005 187 456[Abstract/Free Full Text]
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