July 2010 Articles

Introduction and context

Anxiety and depression are common mental disorders that affect 20% of the adult population annually [1] and result in a significant health burden. These conditions can be effectively treated with cognitive behavioural therapy (CBT) [2]. However, in a typical 12-month period, fewer than 50% of sufferers report seeking treatment from a health professional, and of these, only 50% receive evidence-based treatment [3]. Barriers to evidence-based treatment include direct and indirect costs, a shortfall in trained mental health clinicians (particularly in rural areas), difficulty attending treatment during usual office hours, and stigma. Strategies for reducing these barriers have considerable appeal.

Computer-delivered CBT (CCBT) is emerging as a technique that may help overcome barriers to access while increasing the capacity of existing mental health services to meet demand [4]. CCBT programs teach patients the same principles and techniques taught in face-to-face CBT. CCBT programs may be accessed at a medical centre or at home via an internet connection (internet-based CBT, or iCBT). The term CCBT will be used to describe both in this report.

CCBT presents CBT in a highly structured format comprising a number of educational lessons, homework assignments, and supplementary resources via an engaging user interface (Figure 1). Because the computer presents time-consuming components of treatment (such as education), the clinician time required is often considerably less than in face-to-face treatment [5]. Programs are often administered with regular communication with a clinician via email, telephone, or online forums, but such programs may be integrated with face-to-face consultations [6]. Self-guided programs are also increasingly available, but clinician-guided programs or guidance by ‘technicians’ (non-health professionals supervised by clinicians) is superior on current evidence [7].

Figure 1.

Lesson 1 from the VirtualClinic [29] Depression (Sadness) Program

The program comprises lessons (providing structured psycho-education), arrows for navigation, homework/summary (to download, print, and save), online forums (moderated by clinicians), supplementary resources, stories from previous participants, video/multimedia clips, and has a secure internet connection.

The majority of studies of CCBT have been published in the past 5 years, but the use of computers to assist in administering psychological therapies began in the 1960s. This report summarizes recent data from randomized controlled trials (RCTs) on the efficacy and effectiveness of clinician-assisted CCBT for depression and anxiety disorders.

Recent advances

Implications for clinical practice

A rapidly growing body of evidence supports the efficacy and effectiveness of CCBT for anxiety and depression. In the context of a worldwide shortage of therapists, large numbers of untreated people, difficulty attending treatment during usual business hours, and stigma, such programs have considerable potential. Federal governments in several countries, including Australia, Holland, and England, are now funding large-scale trials or have begun implementing CCBT programs for anxiety and depression. For example, in the UK, two CCBT programs are funded by the National Health Service for delivering CBT in the management of mild to moderate depression, panic, and phobia, within stepped-care management programs [24,25]. In Holland, therapist-guided CCBT is accepted as a valid alternative to face-to-face psychotherapy. However, an obvious question is how to integrate CCBT into existing mental health services.

Several models of service delivery are possible, ranging from entirely self-guided programs to entirely clinician-guided. To help address the massive waiting lists for mental health care, self-guided or technician- or clinician-assisted CCBT (completed either at a computer in the outpatient clinic or at home) programs are being employed within stepped-care models as a first-level treatment option, with technician- or clinician-assisted CCBT (completed either at a computer in the outpatient clinic or at home) as a second step and face-to-face treatment as a subsequent step. It is likely that participation in earlier steps will potentiate subsequent treatment, but the results of this research are still pending. Preliminary data from trials in primary care indicate that assisted CCBT [26] results in outcomes that are superior to those of self-guided programs [27].

Hurdles to successful implementation include the need for reliable software, hardware, and internet connections in addition to those hurdles already identified in the implementation of evidence-based practice [28]. Appropriate, safe, and ethical data management protocols need to be standardized, legislation about registration of clinicians working across federal or state and territory borders needs to be clarified, and sensible strategies for working with suicidal clients need to be tested.

In summary, the potential of CCBT programs to extend the capacity of existing mental health services is considerable. Careful attention must be paid to evaluating models of intervention to realise this potential.