Online computerized cognitive-behavioral therapy (CCBT), both alone and in combination with an Internet support group (ISG), is more effective than usual primary care for the treatment of depression and anxiety, new research shows.
Investigators at the University of Pittsburgh, in Pennsylvania, found that CCBT, when managed by a care manager and when utilized either alone or in combination with ISG, significantly improved depression and anxiety symptoms compared to usual care. However, the addition of an ISG provided no further benefit.
The study is the first randomized trial to evaluate the effectiveness of providing these technologies through a collaborative care program. The model is now up and running in 26 practices in the Pittsburgh area.
“We were able to show this model can be used where there aren’t enough mental health professionals, such as inner cities or rural areas,” lead investigator Bruce Rollman, MD, MPH, University of Pittsburgh School of Medicine, told Medscape Medical News. “I hope this will be practice changing in the US.
“But I want to stress that it’s not just about technology; it’s also about the people,” he said. “What our study showed is that these programs work, but it’s really important to have a human involved.”
The study was published online November 8in JAMA Psychiatry.
Lack of Data
Numerous trials have proven the effectiveness of collaborative care strategies in the treatment of depression and anxiety, and this approach is known to be superior to usual care from primary care physicians for these conditions.
These programs usually involve nonphysician care managers who contact patients to promote evidence-based treatment protocols for chronic conditions and to monitor patients’ clinical response under the supervision of a primary care physician.
However, challenges have limited the provision of collaborative care in routine clinical practice, and until now, advances in technology that have the potential to overcome these barriers have not been tested. Use of ISGs have grown in popularity around the world, and though anecdotal evidence of their effectiveness has been widely circulated, their effectiveness has not been established in randomized trials.
Eligible patients were required to have Internet and email access. They were also required to have scored 10 or greater on either the seven-item Generalized Anxiety Disorder scale or the nine-item Patient Health Questionnaire and to be free of alcohol dependence, active suicidality, or other serious mental illness.
In response to an electronic medical record prompt, primary care physicians from 26 practices in Pittsburgh referred 2884 patients aged 18 to 75 years to the trial from August 2012 to September 2014.
The study utilized the Beating the Blues CCBT program, which consists of a 10-minute introductory video followed by eight 50-minute interactive sessions that care managers encourage patients to complete every 1 to 2 weeks.
The ISG was password protected, could be accessed by patients via computer or smartphone, and offered discussion boards and links to external resources. The duration of the program was 6 months, and care managers informed primary care physicians of their patients’ progress.
A total of 704 patients met eligibility criteria and were randomly assigned to CCBT alone (n = 301), CCBT+ISG (n = 302), or usual care (n = 101). The majority of patients were white; about 80% were women; and the mean age was 42.7 years.
At 6-month assessment, about 84% of patients who received CCBT alone had started the program, and 37% had completed all eight sessions. In the CCBT+ISG group, 75% had logged into the ISG at least once, of whom 62% provided one or more comments or posts.
At 6-month follow-up, mental health–related quality of life was measured with the 12-Item Short-Form Health Survey Mental Health Composite Scale. Depression and anxiety symptoms were measured with the Patient-Reported Outcomes Measurement Information System (PROMIS). Treatment durability was assessed 6 months later.
Improved Mood, Anxiety
The investigators observed similar 6-month improvements in mental health–related quality of life, mood, and anxiety symptoms in the CCBT+ISG and CCBT-alone cohorts.
However, when compared to patients who received usual care, patients in the CCBT-alone cohort were found to have significant 6-month effect size improvements in PROMIS mood symptoms (effect size, 0.31) and PROMIS anxiety symptoms (effect size, 0.26). The improvements persisted 6 months later.
The investigators also found a dose effect such that the more CCBT sessions a patient completed, the stronger the improvement in effect size (PROMIS mood symptoms in patients who completed ≥4 sessions: effect size, 0.41; patients who completed all eight sessions: effect size, 0.52).
This dose effect confirms the importance of patient engagement, said Dr Rollman. He cited a 2015 study by Prof Simon Gilbody and colleagues in which the investigators found no differences in mood symptoms among 691 primary care patients with depression. The patients were randomly assigned to receive either CCBT or usual care, and the study employed the same CCBT program that Dr Rollman’s team used.
In Dr Gilbody’s study, staff offered minimal support but did not monitor patients’ symptoms or send recommendations to primary care providers. As a result, patient adherence to CCBT was low (median sessions completed, <2).
“This was, predictably, a negative study,” said Dr Rollman. He noted the importance of utilizing a collaborative care model: “Gilbody had the program, but there wasn’t enough human support.”
Dr Rollman predicted that in the near future, CCBT programs will be used increasingly for other conditions, including heart disease, insomnia, tobacco addiction, and substance abuse. He said that an ideal time to use these programs is when patients are undergoing treatments such as dialysis. “These programs are scalable and allow us to mass-customize interventions to provide care to patients,” he said.
“Our report confirms the effectiveness of guided CCBT, highlights the critical importance of patient engagement with online interventions, and provides high-quality evidence about the limits and potential benefits of these emerging technologies,” the authors note.
Important Implications
Commenting on the findings for Medscape Medical News, Lori Raney, MD, who was not involved in the study, noted that there is a national shortage of individuals trained to deliver collaborative care, so technology that extends “the reach of our limited behavioral health workforce ― we call them practice extenders ― allows care managers to take on larger caseloads.
“This is exciting research, and we need more of it,” said Dr Raney, who is a leading authority on the collaborative care model and is chair of the American Psychiatric Association’s Workgroup on Integrated Care. “Now that integrated care is getting ready to take off, we don’t have a workforce to do it. Studies like this are extremely helpful in guiding us to where we need to go.”
However, adherence to online programs remains a barrier to care, she said. She noted that only 37% of patients in the study who received CCBT alone completed all eight sessions.
“That’s one of the drawbacks of the technology. For whatever reason, about half the patients don’t go all the way through the sessions,” she said. “So the question remains: What else is it going to take to get people to engage, or is the fact that they did half of the sessions sufficient?
“There are flaws in our thinking around this, because patients aren’t engaging like we want them to with the technology,” she added. “Maybe we need to have patients involved in the development of the technology. That’s one of the frontiers of research right now ― patients telling us what works for them.”
The study authors note that these findings “have important implications for transforming the way mental health care is delivered in primary care and focus further attention to the emerging field of e-mental health.”
This trial was funded by the National Institute of Mental Health. The computer program used in the study was donated by the University of Pittsburgh Medical Center. The authors, Dr Rollman, and Dr Raney have disclosed no relevant financial relationships.
JAMA Psychiatry. Published online November 8, 2017. Full text
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