CBT Plus Online Chat May Equal Help in 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