Can computer-guided cognitive behavioral therapy improve depression treatment?

In the United States, depression is the top cause of disability, but only 21% of patients diagnosed with major depression get treatment that meets the guidelines of the American Psychiatric Association. Of people seeking depression treatment, those who'd like to be treated with live psychotherapy outnumber those who'd like to be treated with medication three to one, but those who want live therapy often don't receive it. Access to psychotherapy is limited by the number of professionals in one's region, cost, and logistics — not to mention stigma. And when people do get therapy, therapists may not provide care that is evidence-based.

One way to get high-quality psychotherapy to people who need it is to automate and computerize the treatment process and deliver it through websites and apps. This could potentially offer guidelines-based treatment to anyone, anywhere, anytime, at a modest cost. Stand-alone computerized cognitive behavioral therapy (CCBT) has been found to be effective for the treatment of depression, and is already available from a few entities. But it's still not known how much, if at all, CCBT would improve treatment of depression in primary care, so a group of researchers in the United Kingdom recently tested the advantages of adding CCBT to standard treatment. They randomly assigned 691 people with depression into three different groups. One group received standard care, and the others received standard care plus one of two online CCBT programs.

Comparing CCBT with standard care for depression

As it turns out, standard depression treatment in UK primary care centers is quite good. Citizens are routinely offered antidepressant medications, psychotherapy, and access to community mental health teams, psychologists, psychiatrists, and counselors — a range of resources seldom available in US primary care practices.

There was a lot of crossover between the study groups. In the "standard care" group, 19% ended up using CCBT even though they weren't specifically assigned to that treatment. Between 77% and 84% of all three groups used medication to treat their depression, and "live" mental health specialists were seen by 17% of one and 24% of the other CCBT group.

Against this backdrop — with many participants in the CCBT groups also receiving mental health specialty treatment and 19% of the standard-practice group receiving CCBT — no significant difference in depression treatment results was found. However, in the US, the findings may have been very different, considering the limited array of mental health resources in most primary care clinics.

It would be most interesting, and more important, to know the benefit of using CCBT for patients who receive nothing else — no medication and no access to mental health specialists. It's for these patients that CCBT might be the most beneficial.

Challenges in getting people to use CCBT for depression treatment

Both of the CCBT websites had been tested in previous clinical trials and both had been found to be effective treatments — but they're only helpful if people use them. Even though the two stand-alone CCBT websites were designed to be used over either 6 or 8 "sessions," most people only used them once or twice, even though the study provided reminder calls to the participants. People with depression can experience fatigue, impaired concentration, and feelings of hopelessness. Getting them to consistently use CCBT websites on their own schedule is a challenge — even if these programs might be helpful in the end. More structure may be needed to keep people using CCBT.

What's the take-home? The biggest challenge isn't building a CCBT program that works; it's building one that people will use. Just as you need to entertain before you can educate, any CCBT program needs to be extremely engaging to users — and to provide immediate value from the first session. And, although the treatment-anywhere-anytime concept is alluring, relying on people to schedule CCBT themselves on their own time, in their own homes, may lead to high levels of drop-off; after all, you can always get around to it later.