Deborah Brauser

May 22, 2017

SAN DIEGO, California – Internet-based cognitive-behavioral therapy (iCBT) can help reduce symptoms of depression – immediately and up to 6 months post treatment, a new review suggests.

In a meta-analysis of 14 published randomized controlled trials (RCTs) of adults with mild to moderate depression, iCBT had a significant "medium effect" on symptom severity at end of study and a "large sustained effect" during follow-up assessment compared with no treatment.

"I think the take-away message is that this is an option to provide patients who might not otherwise seek mental health services," lead author Charles Koransky, MD, a fourth-year resident at the University of Maryland/Sheppard Pratt Psychiatry Program in Baltimore, told Medscape Medical News.

He presented the findings during a press briefing here at the American Psychiatric Association (APA) 2017 Annual Meeting.

Dr Charles Koransky

Session moderator Ranna Parekh, MD, MPH, director of the Division of Diversity and Health Equity at the APA, agreed that this could be a helpful tool for patients.

"Access to vulnerable populations is a serious issue. So I think the Internet is a wonderful way to access people who would otherwise not get therapy," said Dr Parekh.

Barriers to Care

Dr Koransky noted that although in-person CBT has been shown to effectively reduce symptoms of depression, there are obstacles to this kind of treatment, including stigma, cost, and a lack of time and providers.

"To overcome these barriers, CBT is being delivered over the Internet through several different ways," he said.

As reported at the time by Medscape Medical News, findings from a large RCT of 945 Swedish adults were published in November in the British Journal of Psychiatry. Those findings showed that 12 weeks of prescribed exercise or iCBT significantly reduced depression severity compared with usual care.

For the current analysis, the researchers examined RCTs published between January 2005 and December 2015. Each of the studies had from 45 to 396 participants (about 76% women). All of the patients were older than 18 years and were randomly allocated either to receive iCBT or to be placed a wait list.

The studies assessed Internet-based programs with modules "that patients can work through in order to decrease their symptoms." All of the iCBT programs were time limited.

None of the included studies were conducted in the United States. Nine were conducted in Europe, and five in Australia, "locations which have socialized medicine," reported Dr Koransky. He added that he did not find any Canadian studies that included control groups on a wait list.

In 10 of the reviewed studies, clinicians assisted in the iCBT programs; two studies had no clinician assistance; and two had both clinician-assisted programs and non-clinician-assisted programs.

Effective Treatment Modality

At the end of the studies' treatment periods, the combined standardized mean difference (SMD) for reduction in depressive symptoms for the iCBT group vs the wait-list group was 0.74 (95% confidence interval [CI], 0.63 - 0.86; P < .001).

During 3- to 6-month follow-ups, the combined SMD was 0.85 (95% CI, 0.71 - 0.99; P < .001).

Interestingly, there was no significant difference between studies with and those without clinician assistance (SMDs, 0.73 and 0.77, respectively). But Dr Koransky noted that that could be because "clinician assistance" mostly referred to quick check-ins via telephone or email by clinicians concerning the patient's progress.

"So I think there is still value for a therapist to aid in this," he said.

Overall, iCBT might be "a good treatment modality" for patients who cannot come in for traditional face-to-face therapy – or who may be reluctant to do so for a variety of reasons, he said.

He noted that study limitations include the lack of US RCTs, the lack of uniformity among the iCBT programs, the higher than expected number of female participants, and the fact that recruitment was through advertisements ― "meaning that these were highly motivated participants who were probably seeking out some sort of alleviation of their depressive symptoms."

He added that future research would include US-based studies, as well as recruitment of patients from primary care.

Coinvestigator Leah Fegan, MD, also a psychiatry resident at the University of Maryland/Sheppard Pratt, noted that although their results were exciting, she would like to see more research conducted in other populations.

Dr Leah Fegan

"Another message would be to mental health policy leaders to see what we can do to come together as far as providing reimbursement for the clinician assistance part of these programs," said Dr Fegan.

The Start of a "Wonderful Conversation"

During the post-presentation question-and-answer session, Joy Osofsky, PhD, professor of pediatrics and psychiatry at Louisiana State University Health Sciences Center, New Orleans, noted that her center has integrated behavioral health and primary care.

And, at least anecdotally, "we found no difference between in-person mental health intervention and telemedicine, which supports these new data," said Dr Osofsky.

Dr Parekh noted that the APA released a policy statement in 2011 that falls under the umbrella of telemedicine and telepsychiatry. In part, it reads that the use of videoconferencing in this type of treatment "is a validated and effective practice of medicine that increases access to care."

Especially given the ongoing shortage of mental health providers, "it's been a big effort of the APA to look at access," she added.

She later told Medscape Medical News that the new meta-analysis "was great because it brings attention to Internet-based CBT and addresses the issue of access."

The policy statement and these findings "open up a wonderful conversation around how we can implement and leverage the Internet for some good here," said Dr Parekh.

"Having more options in our field is really important. And I think this sends a message to our patients that we can be flexible to provide the best treatment available and that they want."

The investigators and Dr Parekh have disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2017 Annual Meeting. Poster abstract P1-151, presented May 20, 2017.

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