NIHR Signal Online cognitive behavioural therapy is no more effective than usual GP care for people with depression

Published on 9 February 2016

Computerised cognitive behavioural therapy (CBT) in addition to usual GP care was no more effective than usual GP care alone at four months or at 24 months. It was also not a popular treatment for patients with mild to moderate depression who typically only used the programme once or twice. Indeed, more than four out of five patients did not complete the course.

Depression affects large numbers of people in the UK. Other research shows that CBT is effective in treating depression, but it is expensive to provide and people sometimes have to wait for treatment due to limited numbers of therapists. CBT delivered online or via a computer was thought to offer a potential low-cost alternative. This new NIHR evidence suggests support for patients using these programmes will be needed to improve adherence to treatment.

This finding came from a large UK-based trial of 691 patients in 100 practices. Two online programmes, one free to use and one commercially available, were tested.

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Why was this study needed?

Depression accounts for 7% of the disease burden in the UK, more than any other single health condition. CBT is often used to treat depression and is effective. However, large numbers of people requiring treatment places a substantial burden on local health budgets and limited number of therapists may make it difficult to meet demand. Computerised CBT delivered remotely has been heralded as a potential solution because it is lower in cost than face-to-face CBT and can be provided at home. It is endorsed in guidelines and forms a component of NHS funded 'Improving Access to Psychological Therapy' services, but research has generally been conducted in specialist centres and by researchers who have also developed the programmes.

The NIHR funded this large trial to assess whether CBT delivered remotely by computer was better at 24 months, than usual care and advice provided by GPs. The researchers also looked to see if there was any difference in effectiveness between a paid-for and free service.

What did this study do?

The REEACT trial randomly allocated 691 people from 100 GP practices to three groups. One received usual GP care (239 people), a second group received usual GP care plus a commercial computer CBT intervention (“Beating the Blues”, 210 people), the third group received usual care plus a free to use computer CBT intervention (MoodGYM, 242 people).

People receiving computerised CBT received weekly phone calls (not from a health professional) to encourage them to use the programme and to address any technical issues they may be experiencing. Beating the Blues consists of an introductory video, followed by eight 50 minute modules and includes “homework” exercises to be done between modules. MoodGYM comprises five interactive modules that are released weekly and a sixth revision session.

There was no interaction with clinicians or individualised feedback in either computer programme. GP care was not restricted during the trial, so participants could access antidepressant medication, other psychological therapies and secondary mental health services, if needed.

What did it find?

  • There was no significant difference between usual GP care, Beating the Blues plus usual care, or MoodGYM plus usual care at four, 12 or 24 months. For example, at four months those offered the commercial computerised CBT experienced no additional improvement in depression compared with usual GP care (odds ratio 1.19, 95% confidence interval 0.75 to 1.88).
  • At four months almost half of each group were still depressed (a score of 10 or more on the 27 point patient health questionnaire, PHQ-9): 50% of those receiving Beating the Blues, 49% of people receiving MoodGYM and 44% of those receiving usual GP care alone. The effectiveness of MoodGYM, at this point or later, was not significantly different than Beating the Blues.
  • Take-up of computerised CBT was low, despite regular calls to encourage participants to use the programmes. The median number of sessions completed was two out of eight for Beating the Blues and one out of six for MoodGYM. Only 18% of people who started Beating the Blues completed all modules and 16% for MoodGYM.

What does current guidance say on this issue?

NICE’s 2009 guidance on managing depression in adults recommends computerised CBT as a “low intensity” psychological intervention for managing mild to moderate depression. For people with depression alongside a chronic physical health problem NICE recommends that it is offered to those with mild to moderate depression, and to people with sub-threshold depression (fewer than five symptoms of depression) or where depression interferes with the treatment of their physical condition.

NICE recommends that any computerised CBT programme offered includes an explanation of how CBT works, enables users to challenge and monitor their behaviour and thought patterns, and encourages users to try out their CBT skills through tasks between sessions.

What are the implications?

This trial showed that two types of computerised CBT (plus usual GP care) were no more effective than usual GP care in treating clinical depression. Although remote CBT is a lower cost option than face-to-face CBT it offered little to no additional benefit and most patients did not complete the course. A free to use programme was found to be equally as effective as a paid-for product. NICE recommended that computerised CBT is delivered with some support. This suggestion is reinforced by this trial, as it found that engagement was low with only weekly phone calls from a non-clinician of a general nature. Further NIHR research is now testing the effectiveness of computerised CBT with additional clinical support and findings should be available later this year. It is likely that more intensive support from a trained health professional will be required if computerised CBT is to find a place amongst the treatment options currently available.

Citation and Funding

Gilbody S, Littlewood E, Hewitt C, et al. Computerised cognitive behavioural therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015;351:h56271.

This project was funded by the National Institute for Health Research Health Technology Assessment (HTA) programme (project number 06/43/05).

Bibliography

RCPsych. No health without public mental health: the case for action. Position statement PS4/2010. London: Royal College of Psychiatrists; 2010.

NICE. Depression in adults with chronic physical health problem: recognition and management. CG91. London: National Institute for Health and Care Excellence; 2009.

NICE. Depression in adults: recognition and management. CG90. London: National Institute for Health and Care Excellence; 2009.

Why was this study needed?

Depression accounts for 7% of the disease burden in the UK, more than any other single health condition. CBT is often used to treat depression and is effective. However, large numbers of people requiring treatment places a substantial burden on local health budgets and limited number of therapists may make it difficult to meet demand. Computerised CBT delivered remotely has been heralded as a potential solution because it is lower in cost than face-to-face CBT and can be provided at home. It is endorsed in guidelines and forms a component of NHS funded 'Improving Access to Psychological Therapy' services, but research has generally been conducted in specialist centres and by researchers who have also developed the programmes.

The NIHR funded this large trial to assess whether CBT delivered remotely by computer was better at 24 months, than usual care and advice provided by GPs. The researchers also looked to see if there was any difference in effectiveness between a paid-for and free service.

What did this study do?

The REEACT trial randomly allocated 691 people from 100 GP practices to three groups. One received usual GP care (239 people), a second group received usual GP care plus a commercial computer CBT intervention (“Beating the Blues”, 210 people), the third group received usual care plus a free to use computer CBT intervention (MoodGYM, 242 people).

People receiving computerised CBT received weekly phone calls (not from a health professional) to encourage them to use the programme and to address any technical issues they may be experiencing. Beating the Blues consists of an introductory video, followed by eight 50 minute modules and includes “homework” exercises to be done between modules. MoodGYM comprises five interactive modules that are released weekly and a sixth revision session.

There was no interaction with clinicians or individualised feedback in either computer programme. GP care was not restricted during the trial, so participants could access antidepressant medication, other psychological therapies and secondary mental health services, if needed.

What did it find?

  • There was no significant difference between usual GP care, Beating the Blues plus usual care, or MoodGYM plus usual care at four, 12 or 24 months. For example, at four months those offered the commercial computerised CBT experienced no additional improvement in depression compared with usual GP care (odds ratio 1.19, 95% confidence interval 0.75 to 1.88).
  • At four months almost half of each group were still depressed (a score of 10 or more on the 27 point patient health questionnaire, PHQ-9): 50% of those receiving Beating the Blues, 49% of people receiving MoodGYM and 44% of those receiving usual GP care alone. The effectiveness of MoodGYM, at this point or later, was not significantly different than Beating the Blues.
  • Take-up of computerised CBT was low, despite regular calls to encourage participants to use the programmes. The median number of sessions completed was two out of eight for Beating the Blues and one out of six for MoodGYM. Only 18% of people who started Beating the Blues completed all modules and 16% for MoodGYM.

What does current guidance say on this issue?

NICE’s 2009 guidance on managing depression in adults recommends computerised CBT as a “low intensity” psychological intervention for managing mild to moderate depression. For people with depression alongside a chronic physical health problem NICE recommends that it is offered to those with mild to moderate depression, and to people with sub-threshold depression (fewer than five symptoms of depression) or where depression interferes with the treatment of their physical condition.

NICE recommends that any computerised CBT programme offered includes an explanation of how CBT works, enables users to challenge and monitor their behaviour and thought patterns, and encourages users to try out their CBT skills through tasks between sessions.

What are the implications?

This trial showed that two types of computerised CBT (plus usual GP care) were no more effective than usual GP care in treating clinical depression. Although remote CBT is a lower cost option than face-to-face CBT it offered little to no additional benefit and most patients did not complete the course. A free to use programme was found to be equally as effective as a paid-for product. NICE recommended that computerised CBT is delivered with some support. This suggestion is reinforced by this trial, as it found that engagement was low with only weekly phone calls from a non-clinician of a general nature. Further NIHR research is now testing the effectiveness of computerised CBT with additional clinical support and findings should be available later this year. It is likely that more intensive support from a trained health professional will be required if computerised CBT is to find a place amongst the treatment options currently available.

Citation and Funding

Gilbody S, Littlewood E, Hewitt C, et al. Computerised cognitive behavioural therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015;351:h56271.

This project was funded by the National Institute for Health Research Health Technology Assessment (HTA) programme (project number 06/43/05).

Bibliography

RCPsych. No health without public mental health: the case for action. Position statement PS4/2010. London: Royal College of Psychiatrists; 2010.

NICE. Depression in adults with chronic physical health problem: recognition and management. CG91. London: National Institute for Health and Care Excellence; 2009.

NICE. Depression in adults: recognition and management. CG90. London: National Institute for Health and Care Excellence; 2009.

Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial

Published on 11 November 2015

Simon Gilbody, Elizabeth Littlewood, Catherine Hewitt, Gwen Brierley, Puvan Tharmanathan, Ricardo Araya, Michael Barkham, Peter Bower, Cindy Cooper, Linda Gask, David Kessler,Helen Lester,Karina Lovell, Glenys Parry, David A Richards, Phil Andersen, Sally Brabyn, Sarah Knowles, Charles Shepherd, Debbie Tallon, David White

BMJ , 2015

Study question How effective is supported computerised cognitive behaviour therapy (cCBT) as an adjunct to usual primary care for adults with depression? Methods This was a pragmatic, multicentre, three arm, parallel randomised controlled trial with simple randomisation. Treatment allocation was not blinded. Participants were adults with symptoms of depression (score ≥10 on nine item patient health questionnaire, PHQ-9) who were randomised to receive a commercially produced cCBT programme (“Beating the Blues”) or a free to use cCBT programme (MoodGYM) in addition to usual GP care. Participants were supported and encouraged to complete the programme via weekly telephone calls. Control participants were offered usual GP care, with no constraints on the range of treatments that could be accessed. The primary outcome was severity of depression assessed with the PHQ-9 at four months. Secondary outcomes included health related quality of life (measured by SF-36) and psychological wellbeing (measured by CORE-OM) at four, 12, and 24 months and depression at 12 and 24 months. Study answer and limitations Participants offered commercial or free to use cCBT experienced no additional improvement in depression compared with usual GP care at four months (odds ratio 1.19 (95% confidence interval 0.75 to 1.88) for Beating the Blues v usual GP care; 0.98 (0.62 to 1.56) for MoodGYM v usual GP care). There was no evidence of an overall difference between either programme compared with usual GP care (0.99 (0.57 to 1.70) and 0.68 (0.42 to 1.10), respectively) at any time point. Commercially provided cCBT conferred no additional benefit over free to use cCBT or usual GP care at any follow-up point. Uptake and use of cCBT was low, despite regular telephone support. Nearly a quarter of participants (24%) had dropped out by four months. The study did not have enough power to detect small differences so these cannot be ruled out. Findings cannot be generalised to cCBT offered with a much higher level of guidance and support. What this study adds Supported cCBT does not substantially improve depression outcomes compared with usual GP care alone. In this study, neither a commercially available nor free to use computerised CBT intervention was superior to usual GP care. Funding, competing interests, data sharing Commissioned and funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project No 06/43/05). The authors have no competing interests. Requests for patient level data will be considered by the REEACT trial management group

Cognitive behavioural therapy (CBT) is a talking therapy that can help people change their engrained ways of thinking and behaving.

It is commonly used to treat anxiety or depression but can be useful for other mental and physical health problems.

CBT cannot remove problems, but it can help people deal with them in a more positive way. It is based on the concept that thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can become a vicious cycle.

CBT aims to help stop this cycle by breaking down overwhelming problems into smaller parts and showing people that change to negative patterns can improve the way they feel.

Unlike some other talking treatments, CBT deals with current problems, rather than focusing on issues from your past. It looks for practical ways to improve the current state of mind on a daily basis.

Expert commentary

This important study produced unexpected results. Depressed patients voted (very loudly) with their feet. Despite the rigour of the trial and the provenance of the chosen computer packages, most participants only ever accessed these once or twice. We don’t know whether these findings reflect secular improvements in GPs’ treatment of depression over time, the lack of ‘support’ for users of computerised CBT or contamination. But what this tells us is that computerised CBT without clinician support should not be offered routinely to people with mild to moderate depression in primary care.

Professor Scott Weich, Professor of Psychiatry, University of Warwick