The Internet and CBT: A New Clinical Application of an Effective Therapy

1. Introduction

2. Literature review

iCBT continues to be a hot area of research in psychiatry. A PubMed search of “Internet cognitive behavioral therapy” yielded over 1600 articles, about 300 more than a search conducted just 2 years ago [9]. The literature has been reviewed extensively by ourselves and others [9, 10, 11, 12, 13, 14, 15, 16, 17, 18]. Among the best-studied interventions are those for depression, anxiety, and physical illness. Presented here are some of the most recent systematic reviews, meta-analyses, and randomized controlled trials about treatment effectiveness and address some of the most pressing concerns and promising developments in the new field of iCBT.

3. Practical applications

As noted above, implementing iCBT in a primary-care setting would be important. To successfully do this, we must first understand how programs perform in the real world rather than the tightly controlled setting of a clinical trial. The REEACT trial was conducted in the UK, and considered how patients in a primary care setting could access iCBT (a pragmatic randomized controlled trial). The study included three groups of patients: those using a commercial program (Beating the Blues) in addition to general practitioner (GP) care, those using a free program (MoodGYM) in addition to GP care, and usual GP care (that is, access to antidepressants, counseling, psychological services, and secondary mental health services). Those patients who used iCBT also received weekly phone calls from trained technicians. In this trial, no differences in depressive symptoms or health state utility were observed between commercially available iCBT, free-to-use iCBT, and usual care. iCBT had a statistically significant benefit over usual care in the mental component of health-related quality of life and general psychological wellbeing at 12 months but not at 24 months. Even with telephone support, adherence was poor in both iCBT groups with only one completed session (as the median number of sessions completed). There was no observed advantage to using a commercially available program versus a free-to-use one [33]. Neither program was more cost effective than usual GP care [34]. When interviewed, participants liked the autonomy and flexibility of the program, but disliked the lack of interpersonal communication and customizability [35].

Because the patients in the REEACT trial expressed desire for more support, investigators conducted a second trial comparing the effectiveness of MoodGYM alone versus MoodGYM with telephone support (the REEACT-2 trial). The telephone support worker introduced patients to CBT, helped identify issues and set goals, motivated the patient, and discussed future steps. The study showed that telephone support made a difference, with significantly improved depression symptoms. The largest between-group difference was observed at 4 months (Cohen’s d = 0.32), but the difference was no longer significant after 12 months. The odds ratio of not being depressed at 4 months was 2.05 (95% CI 1.23, 3.42; P = 0.0030) when telephone support was added to MoodGYM. There were also significant between-group differences in depression and anxiety scores. However, the adherence to the program did not increase substantially with 45% of patients completing the first session in the MoodGYM alone group and 65% completing the first session in the telephone-support group. An economic analysis indicated that telephone support could increase quality of life (in quality-adjusted life year [QALY]) and reduce healthcare costs with a likelihood of being cost effective at ₤6933 per QALY [36, 37].

While the literature is vast, a pattern is clear: iCBT can be effective. Even unguided iCBT, with its number needed to treat of eight, is beneficial to some patients [23]. But it should be noted that the number needed to treat jumps up to 2.56 for children and adolescents with anxiety using therapist-guided iCBT [30]. The emerging data on iCBT effectiveness and cost seem to support a stepped-care model, where patients with less severe illness and more motivation can be treated with unguided iCBT. As illness severity and desire for interaction increases, there is a role for iCBT programs with progressively more support. This model would balance the cost of treatment while providing the most benefit to individual patients and the population as a whole.

4. iCBT and the real world

Beyond the research, there are more and more iCBT programs available to the public. While most iCBT programs contain eight to 12 self-guided goal-oriented modules [22, 38], they can vary in quality and type of care. Speaking to the latter point: iCBT has a broad spectrum of therapist involvement, ranging from none to high-level involvement. Some programs are free, while others are available for a fee. Depending on the country in which the patient lives, iCBT may be endorsed and even funded by government. Table 1 shows a sample of the various options offered to patients by existing iCBT programs. Below, we explore a few of the currently available iCBT options.

5. The Scarborough Hospital experience

The authors have been actively involved in the development and implementation of an iCBT program at The Scarborough Hospital (TSH, now part of the Scarborough and Rouge Hospital). This hospital serves Toronto, Canada’s diverse east end, and receives roughly 500 outpatient referrals a month. Here we review a case, and then consider the program and outcome data.

A.K. is a 27-year-old woman who suffers from severe anxiety. In the 2 years before her first outpatient appointment with the TSH clinic, she had left her apartment just a half dozen times – all to attend doctor’s appointments. She was originally referred by her neurologist (who she had been seeing for non-specific dizziness). In her early 20s, A.K. had a major depressive episode, and a past trial of an SSRI antidepressant. At TSH, she was seen by the first author of this paper, then referred for therapy with diagnoses of Generalized Anxiety Disorder and Panic Disorder. A.K. was bright and motivated – and ready for therapy. But when first offered a referral for CBT she hesitated: it was almost impossible for her to take the bus to the clinic, how could she come on a weekly basis? Like A.K., there are many patients that need CBT but have difficulty accessing the help they need – think of the single mother with childcare obligations and the small businessman who needs to attend meetings during the day.

In 2014, the TSH Mental Health Outpatient Program was completely revamped to increase access to evidence-based interventions. Staff were provided training in CBT, and patients were provided a combination of group and individual CBT sessions. After building staff capacity to provide CBT, we shifted our focus to increasing access to our interventions. We started by offering evening hours for more convenience but better access to in-person CBT did not address access barriers for people like A.K.

Every industry has turned to digital solutions for faster, easier, and more efficient services – could these types of solutions work in mental health service delivery as well? We developed a mental health app library in which apps vetted by our staff were included in our treatment regimen. Therapists used these apps to augment the in-person CBT, allowing patients to keep up with the material even if they had missed several sessions. But it was not enough to just offer CBT, we wanted to ensure that those in need had every chance of receiving it. It was this line of thinking that led to the development of our iCBT.

After a literature review looking at various international models of iCBT, and in collaboration with Queen’s University (where they were piloting a small iCBT program for adolescents), we developed our own modules closely mirroring our in-person CBT. The iCBT model consists of a therapist-guided Internet version, where patients complete the program on their own schedule and from a convenient location of their choice (where they have access to the Internet). Originally, patients were provided a total of eight modules that outline the main principles of CBT. This includes the importance of noticing the connections between our thoughts, feelings, and behaviors, scheduling mastery and pleasurable activities, utilizing breathing and relaxation exercises, and reviewing thought logs and restructuring inaccurate thoughts to more accurate ones. Each patient referred is assigned a therapist who communicates largely through email. The patient is emailed a module on a weekly basis for 8 weeks, and is asked to read the module and fill out the attached worksheets to be completed within a week.

Before launching the program, staff were provided 4 hours of training in providing e-therapy from a psychiatry resident at Queen’s University. We launched our program with the hope that we could replicate the results achieved in Sweden or Australia. However, a review of the results at 6 months showed that we had completely missed the mark. We had an alarming 90% dropout rate; many patients reported that they did not find the program helpful.

To understand the high dropout rate, we reached out to the patients in the program and asked how the program had failed to meet their needs. We gathered their feedback by asking questions such as, “Why did you drop out?” and “What three things would help you complete the program?” The responses were eye opening and a common theme emerged – the program was too rigid. Some patients felt that the deadlines for homework completion were too anxiety provoking; they could not possibly read through the modules and begin working on their thoughts within a week. The pace was overwhelming, so they did what made them feel better – they avoided the program altogether. Others who were higher functioning found the pace too slow and were eager to get through the concepts faster. Some found the concepts too confusing and wanted more examples and videos to better highlight the material. And some ran into technical issues – they could not download the document and type directly onto them. We had designed the program with what we thought the patients needed without asking them what would work best for them. The result was an inflexible program that did not take individual needs into account. We went back to the drawing board to incorporate the useful feedback provided by our patients and 3 months later relaunched our second version, iCBT 2.0.

With iCBT 2.0, we streamlined the modules to a total of six modules (from eight). We included more examples and visuals to better highlight the material. We addressed the technical concerns by creating the homework sheets as Microsoft Word documents, with which patients expressed more familiarity. However, the most important change we made was making the program more flexible and increasing interactions with the therapist. We worked collaboratively with our patients to determine timeframes that best worked with their schedules and presenting symptoms. For those whose symptoms were less distressing, we provided one or two modules per week, and for those who were struggling more with their symptoms, we gave them as much time as they needed to complete the modules. However, our therapists did check in weekly to let the patients know that they were available for support and to answer any questions regarding the modules. They also provided phone sessions when needed, to better explain the concepts and to troubleshoot. Table 2 shows key differences between iCBT 1.0 and 2.0.

A.K. was enrolled in iCBT 2.0 and did well. It took her about 4 months to complete the program, meaning she needed a few weeks per module, and she requested five telephone sessions. However, working collaboratively with A.K. and allowing her the time she needed, resulted in the best outcome for her. When she completed the program, her symptoms of depression, anxiety, and stress had decreased; she had added a number of a number of pleasurable activities to her weekly schedule; she was socializing outside of the house.

iCBT allowed A.K. to receive a gold standard treatment for her symptoms – a patient who otherwise would have fallen through the cracks. Many patients like A.K. never receive the services they need or others who can decline to the point of needing a hospitalization while waiting to gain access to services. We had a program that, if scaled up, could serve more patients without sacrificing quality. But was our iCBT as effective as our in-person CBT? We allowed patients to choose between traditional (group) CBT and iCBT. We collected outcome measures using the short version of Depression, Anxiety, Stress Scale (DASS 21) and the Quality of Life Enjoyment and Satisfaction Questionnaire for all patients receiving CBT whether it was in person or Internet-delivered. This allowed us to make a direct comparison between the two. To date we have had 80 patients complete this program. Preliminary data shows that those who have completed iCBT show a significant reduction in their symptoms of depression, anxiety, and stress with comparable results to our in-person CBT. The dropout rate is even lower for iCBT at 33% than our drop-out rate of 40% for the in person (group) CBT.

iCBT allowed TSH patients to receive CBT with easier and quicker access, at a lower cost. We found a way to serve more patients with no additional resources and without sacrificing quality. For the record, A.K. has welcomed her first child to the world this year, and hopes to return to the workforce in the coming months.

6. Limitations and strengths

Despite substantial research on iCBT in recent years, the limitations and strengths of this treatment modality remain relatively unchanged.

There are several notable limitations of iCBT. The first is the poor adherence. Several studies have looked at potential barriers to adherence. These barriers include lack of motivation, skepticism about iCBT, time constraints, and symptom improvement (reviewed in [59]). Several studies of primary-care-managed iCBT indicated that the lack of engagement may contribute to decreased adherence [26, 60, 61]. Further, depressive symptoms have been reported to interfere with patient engagement even among patients who felt favorably about the program [35], indicating that baseline disease severity can contribute to poor adherence. This hypothesis is supported by several studies showing an inverse association between adherence and baseline symptom severity or baseline psychological distress in patients with anxiety (reviewed in [62]). Oversight by a therapist, primary-care physician, or a trained staff member may be needed for some patients to adhere to iCBT. When patients regularly meet or speak with an individual or if their progress is being monitored regularly, they are more likely to continue to put effort into the program because someone is holding them accountable (reviewed in [60]). However, given the high heterogeneity of the results, it seems likely that the level of support required varies depending on the individual patient’s needs and preferences.

The second limitation of iCBT is misdiagnosis or inappropriate treatments. In an ideal world, trained individuals would diagnose patients and refer them to the appropriate iCBT program. The reality is that patients often rely on self-assessment of their mental status and select a program they think might help them. Many programs mitigate this issue by including the same validated diagnostic surveys researchers used to measure symptoms. Inclusion of these surveys has proven highly effective (reviewed in [60]). Further, advances in tailored and transdiagnostic iCBT have created an a la carte treatment plan that can be used to address comorbidities and patient-specific issues that might not be included in disease-specific iCBT [24]. It seems likely that this limitation will prove overblown as more trials are conducted, but it cannot yet be ruled out as a concern.

The third limitation is accessibility. A 2015 Pew Research Center survey showed that Internet and smartphone use is on the rise; however, there are some significant disparities in access. In countries with advanced economies, such as Canada, 90% of adults report they use the Internet or own a smartphone. In countries with developing economies, such as those in sub-Saharan Africa, the percent of adults who use the Internet or own a smartphone falls into the teens. There are large age, education, and income gaps for Internet usage and smartphone ownership. Further, in many countries, men have more access to Internet than women [63]. All of these disadvantaged groups, many of whom are the target audience for iCBT, could potentially be underserved. There is also the issue of comfort using a computer. ICBT is less likely to be used by patients who are not comfortable with technology [64], which is why user-friendliness is critical for achieving effective, sustained responses [65].

The fourth limitation is the variable quality of iCBT programs available. There is almost no barrier to creating a website or an app, and the number of iCBT programs available make it difficult to identify those that might be helpful. For example, a recent study attempted to characterize mobile phone apps for depression that were available on any app marketplace as of March 5, 2013. Apps were included if they used “depression” in the title or app description, targeted health consumers (i.e., patients, caregivers), and had an English language interface. Their search yielded 1054 apps; however, only 243 met the inclusion criteria. Of the 190 app developers, only 9.5% were medical centers, universities, or institutions; 29.5% were clearly labeled as coming from a commercial developer; and the rest did not provide any affiliation. Regarding content, only 29.6% of the 243 included apps reported an external or expert source as the basis of their app [17]. To the best of our knowledge, there has been no research on the potential harms of using a poor-quality iCBT program.

Despite the limitations, there are numerous strengths of iCBT programs. The first is the flexibility and privacy of iCBT, which can increase patient empowerment. The only thing a patient needs to get treatment is an Internet connection [14, 19]. Treatment is not confined to office hours, which means it can accommodate work schedules and personal responsibilities. It also lets patients have access to treatment as symptoms arise. Geography is not an issue with iCBT. In countries with iCBT, studies have shown that it can be remarkably successful in rural areas where access to mental healthcare is limited [55, 61, 66, 67]. For countries that lack programs specific to their population and culture, well-researched programs can be adapted for a fraction of the cost of making a new program and still yield substantial gains [68]. iCBT provides treatment options for patients who cannot access treatment due to physical, psychological, or mobility issues [10]. Regarding privacy, iCBT lets patients address their symptoms anonymously. This anonymity might help circumvent the social stigma associated with treatment and encourage patients who might not otherwise have sought treatment to get the help they need [19, 69].

The second benefit of iCBT is its increased efficiency. Even for cases of therapist-supported or tailored iCBT, which require clinician input, fewer resources are needed to treat an individual, and responses to patient concerns can be addressed whenever the therapist has time available [19]. One study comparing in-person CBT and iCBT showed that iCBT patients required only 7.5% of the time that in-person patients needed to achieve similar gains [70]. Further, much of the iCBT support can be performed by trained staff rather than a clinician [37, 71]. Many of the behaviors that therapists teach patients, such as task reinforcement, psychoeducation, and deadline flexibility [72], can be performed by trained staff rather than a clinician. Overall, iCBT has been shown to be more resource efficient even with clinician input, which would give more patients access overall.

The third strength of iCBT is its cost efficiency. Numerous studies have evaluated the costs of iCBT [16, 73]. It has been shown to be cost effective and reduce societal cost compared with waitlisted controls and in-person CBT [16, 36, 73]. As discussed above, it is relatively inexpensive to adapt an existing iCBT program [68], indicating that iCBT could potentially be implemented cost effectively.

7. Conclusions and future directions

Increasingly, payers – governments, employers, private insurance companies – are considering new ways of offering CBT. At the same time, people are looking to the Internet for solutions for their mental health problems. Australia has invested in iCBT, as have private companies; iCBT websites and apps are more and more popular; MoodGym has more than 850,000 registered users.

While we applaud the interest in evidence-based care, we offer a word of caution: not all iCBT programs are created equal. Yes, the literature is now rich in research studies on iCBT for common illness – for mental health illnesses, and also for physical health problems. And while the growing if young literature does support the use of iCBT, effectiveness is clearly tied to patient engagement. Clearly, therapist-guided iCBT has better results than non-therapist-guided iCBT.

As the experimentation grows, we suggest two forces will transform iCBT – and therapy itself. First, with declining stigma and increased demand for care, iCBT will be considered more of an option, given its effectiveness, and its advantages over traditional CBT – that is, the convenience and accessibility of iCBT, coupled with its lower costs and privacy. Second, as technology advances, iCBT could well be improved, moving beyond visually-pleasing graphics and – empowered with AI – entering into a world where programs learn from and adapt to the patients that they serve, offering CBT concepts, perhaps delivered with machine-learned empathy.

With regard to the latter point, we note that several products have already been developed with AI. An Indian group developed a therapy chatbot called Wysa. This interactive program claims to learn signs of anger and distress from its patients, and then employs evidenced-based therapy techniques when appropriate. Wysa is simple – but it is available 24 hours a day, 7 days a week – already offering more flexibility than its human therapist rivals.

We are in the early days of AI and mental health. Over time, iCBT programs will grow more sophisticated. How therapy changes exactly, of course, is impossible to predict. This much is clear: the 1970s, Beck-style approach to CBT, with one therapist and one patient, is being replaced as therapy gets modernized.