Don’t throw the baby out with the bathwater – asking the right questions when evaluating computerised CBT for depression in primary care

Posted by jchoules

7 May 2019

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Over a third of all patient visits with a general practitioner are estimated to involve a mental health component, and 90% of these patients are primarily managed in primary

care [1]. Due to this high demand, National Institute of Health and Care Excellence (NICE) guidelines recommend the provision of computerised CBT as an initial lower intensity treatment for depression in primary care [2]. Computerised CBT is more accessible, scalable and cheaper than face-to-face CBT and has the potential to reduce the burden of depression in primary care significantly.

Systematic reviews have confirmed the effectiveness of computerised CBT [3]. However, a randomised controlled trial published in the British Medical Journal in 2015 reported that supported computerised CBT did not improve depression outcomes compared with usual GP care alone [4]. On the back of this, the authors suggested that the routine promotion and commissioning of computerised CBT be reconsidered. I would caution against this for the following reasons:

• First, it is unlikely that computerised CBT will reduce depression if patients do not adequately use the platform or actively engage with the cognitive and behavioural techniques offline in their day-to-day lives. The median number of online sessions completed by patients in the study by Gilbody et al. ranged from 1–2, and no data were reported concerning offline engagement. Were the negative findings due to an ineffective intervention or the lack of engagement?
• Second, a large proportion of participants across all arms of the trial were using antidepressants (81%). It is therefore unsurprising that the trial failed to find a positive effect. The argument for computerised CBT is not that is will be more effective than usual care, but that it offers a viable alternative that takes the pressure off general practice and offers patients another treatment option that is less resource intensive.

The issues in the study by Gilbody et al. are by no means unique and are indeed prevalent across the field of computerised interventions for mental health. However, resolving these issues are fundamental to ensure we don’t prematurely reject interventions with the capacity to transform healthcare. As highlighted by the NHS -term plan, harnessing the power of technology and empowering people to take responsibility for managing their own health is vital to meet the increasing demand on healthcare services. This is well within our grasp, but we need to be asking the right questions!

Dr Jeff Lambert, Postdoctoral Research Associate in Primary Care, UEMS

References

1. Ferenchick EK, Ramanuj P, Pincus HA. Depression in primary care : part 1 — screening and diagnosis. Br Med J. 2019;
2. National Institute for Health and Clinical Excellence. Depression in adults: recognition and management. 2018.
3. Karyotaki E, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, et al. Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry. 2017;74(4):351–9.
4. Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, et al. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015; 1–13.

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