Guided Online CBT Benefits Patients With Depression, Anxiety

Deploying a trained care manager along with a computerized therapy program may be the key to bringing cognitive-behavioral therapy to patients with depression and anxiety on a large scale, suggested a study published November 8, 2017, in JAMA Psychiatry.

The study tested the effectiveness of a computerized cognitive-behavioral therapy (CCBT) and an internet support group in a collaborative care setting, and the benefits of CCBT were clear: patients had improved quality of life and better mood and were less anxious than those given usual care by primary care physicians (PCPs), according to Bruce L. Rollman, M.D., a professor of medicine at the University of Pittsburgh School of Medicine, and colleagues.

Rollman’s study found that the more online sessions patients completed, the greater their mental health gains. Moreover, their recovery was long lasting, with improvements maintained six months after the care manager intervention ended.

The study included 704 patients diagnosed with anxiety, generalized anxiety, panic, or depression from 26 PCP offices in Pittsburgh. The participants were randomly assigned to receive guided CCBT, guided CCBT plus an internet support group, or usual care from their primary care physician.

All patients participating in CCBT were assigned to a care manager, a college graduate who received special training. The care managers conducted introductory phone calls with patients, monitored their activity on the CCBT site, and sent personalized feedback. Behind the scenes, care managers also monitored patients’ symptoms and gave recommendations to the patients’ PCPs.

“They contacted patients via phone whose symptoms had not improved or those who failed to log in regularly,” Rollman said.

The patients used the Beating the Blues CCBT program, which offered eight 50-minute interactive sessions that included online “homework” aimed at imparting basic cognitive-behavioral techniques. The computer program provided “supportive accountability” by guiding patients in working on their personal problems and prompting them to view assignments and enter test scores, so case managers could handle double the caseloads—90 to 100 patients each—compared with those in Rollmans’ previous studies, he said.

“These programs have the advantages of convenient 24/7 access, avoidance of stigma incurred by seeing a therapist, and greater consistence and scalability compared with traditional therapy,” Rollman and colleagues wrote.

Rollman said that before recommending CCBT, clinicians should first screen patients for substance abuse, suicidality, or particularly severe depression, for which such programs are not intended.

Online Support Groups: No Benefit Found

Researchers hoped they would also find a benefit from giving patients access to a moderated internet support group that offered patients a place to share treatment information and provide peer support, Rollman said. About one-third of participants were assigned to use the CCBT plus an online support group, which they could access via computer or smartphone.

The support group offered a variety of discussion boards, and links to external mental health resources. To enhance patient engagement, participants could give “stars” or “likes” to posts, guest moderators were invited, and various contests were held to encourage log-ins and comments.

However, the researchers found that the internet support group provided no additional benefit to patients over that seen by patients who used only the guided CCBT. Rollman said he was surprised that involvement in the internet support group did not appear to have a greater effect. “People who used the site more frequently may have had some benefit. We’re looking at this now.”

Other researchers were also surprised at the finding. “I think everybody would agree it’s good to have some social support in life, in general,” and especially among patients dealing with depression, for whom loneliness and isolation are common complaints, Michael E. Thase, M.D., a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania, told Psychiatric News. “I don’t think the jury is in that internet support groups don’t work.”

To be effective, such online support groups should be properly monitored to ensure cyber-bullying and other “destructive processes” are not introduced by the boards, Thase added.

Researchers noted that one challenge with online interventions is sustaining patient engagement sufficiently to improve clinical outcomes. About 228 patients in the study by Rollman and colleagues logged in to the internet support group at least once (75 percent) and 141 patients (62 percent) made at least one online comment or post.

In the future, clinicians can expect more robust and engaging computerized cognitive-behavioral therapy programs that are better tailored to patients’ needs, the University of Pittsburgh researchers said.

Future online support groups may be co-branded with a well-regarded patient information site, such as those by the Mayo Clinic or University of Pittsburgh Medical Center, to boost patient engagement, Rollman said. Each patient’s sign-in could be linked to his or her electronic record, so patients with a particular condition or using a certain medication could be automatically prompted to visit a board for that ailment.

Rollman said he hopes his research findings “will stimulate the field of e-mental health in the United States.”

“We anticipate more engaging and powerful CCBT programs better tailored to patients’ specific needs, sociodemographic characteristics, medical conditions, and cultural and linguistic preferences … will become widely deployed over the next decade,” researchers concluded. ■