Elsevier

The Lancet

Volume 374, Issue 9690, 22–28 August 2009, Pages 628-634
The Lancet

Articles
Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial

https://doi.org/10.1016/S0140-6736(09)61257-5Get rights and content

Summary

Background

Despite strong evidence for its effectiveness, cognitive-behavioural therapy (CBT) remains difficult to access. Computerised programs have been developed to improve accessibility, but whether these interventions are responsive to individual needs is unknown. We investigated the effectiveness of CBT delivered online in real time by a therapist for patients with depression in primary care.

Methods

In this multicentre, randomised controlled trial, 297 individuals with a score of 14 or more on the Beck depression inventory (BDI) and a confirmed diagnosis of depression were recruited from 55 general practices in Bristol, London, and Warwickshire, UK. Participants were randomly assigned, by a computer-generated code, to online CBT in addition to usual care (intervention; n=149) or to usual care from their general practitioner while on an 8-month waiting list for online CBT (control; n=148). Participants, researchers involved in recruitment, and therapists were masked in advance to allocation. The primary outcome was recovery from depression (BDI score <10) at 4 months. Analysis was by intention to treat. This trial is registered, number ISRCTN 45444578.

Findings

113 participants in the intervention group and 97 in the control group completed 4-month follow-up. 43 (38%) patients recovered from depression (BDI score <10) in the intervention group versus 23 (24%) in the control group at 4 months (odds ratio 2·39, 95% CI 1·23–4·67; p=0·011), and 46 (42%) versus 26 (26%) at 8 months (2·07, 1·11–3·87; p=0·023).

Interpretation

CBT seems to be effective when delivered online in real time by a therapist, with benefits maintained over 8 months. This method of delivery could broaden access to CBT.

Funding

BUPA Foundation.

Introduction

Psychological therapies should be more widely accessible for depression in primary care than they are at present. There is an increased awareness of the health-care burden of depression1 and a growing unease about the amounts of antidepressant prescribing compared with the resources made available for psychological therapies.2 Questions are being asked about the efficacy of antidepressant drugs,3 and some are concerned about the risk–benefit balance of selective serotonin re-uptake inhibitor antidepressants in specific groups of patients.4

The UK Government is committed to improving access to psychological therapies for people with depression. The plans include training a new workforce of 3600 therapists to deliver such therapies.5 Cognitive-behavioural therapy (CBT) is a large part of these plans. Despite a strong evidence base,6 CBT remains difficult to access, especially in primary care. CBT is adaptable to self-help materials, including interactive computerised programs.7, 8 Telephone-administered CBT is more effective than is usual care for patients with depression.9 Information technology has the potential to increase access to psychological therapy, and CBT does not have to be delivered face-to-face.

Computerised CBT programs, although effective, are inflexible, can be difficult to tailor to individual patient needs, and are associated with low rates of adherence.10 However, individual CBT can be offered by a therapist online, with instant messaging in which client and therapist communicate in real time with typewritten responses. Possible benefits from this approach include flexibility and optimum use of patient and therapist time, reaching client groups for whom travel to treatment centres is difficult for reasons of geography or disability, and access to foreign language therapists. Some evidence suggests that writing about traumatic events can lead to improvements in health.11 This approach is acceptable to patients with depression, and therapy without face-to-face contact could encourage greater disclosure.12 We investigated the effectiveness of online CBT for patients with depression in primary care.

Section snippets

Study design and participants

We undertook a randomised controlled trial, with recruitment taking place between Oct 1, 2005, and Feb 29, 2008. The sample comprised patients aged 18–75 years from primary care with a new episode of depression, which was defined as being diagnosed within the 4 weeks preceding referral. We excluded patients treated for depression in the 3 months before the present episode. Depression was defined as a score of 14 or more with the Beck depression inventory (BDI)13 and a diagnosis of depression

Results

Of the 512 people invited to participate, 119 were ineligible, 95 declined or were not contactable, and one was excluded in error (figure). The proportion of those eligible who were randomly assigned was 297 of 393 (76%). We recorded no differences between people randomly assigned and the remainder in terms of age and deprivation score, although randomised participants were slightly more likely to be women and less likely to be from a practice that had its own counsellor (data not shown).

Of the

Discussion

CBT for depression seems to be effective when delivered online by a therapist in real time. The participants' BDI scores suggest that more than two-thirds were severely depressed. All were confirmed ICD-10 cases of depression. Participants in the intervention group were more likely to recover than were those on the waiting list receiving usual GP care. The gains recorded at the 4-month follow-up were maintained at 8 months. Quality of life and measures of functional health status showed

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