Can computer-guided cognitive behavioral therapy improve depression treatment?

James Cartreine, PhD
James Cartreine, PhD, Contributing Editor

In the United States, depression is the top cause of disability, but only 21% of patients diagnosed with major depression get treatment that meets the guidelines of the American Psychiatric Association. Of people seeking depression treatment, those who’d like to be treated with live psychotherapy outnumber those who’d like to be treated with medication three to one, but those who want live therapy often don’t receive it. Access to psychotherapy is limited by the number of professionals in one’s region, cost, and logistics — not to mention stigma. And when people do get therapy, therapists may not provide care that is evidence-based.

One way to get high-quality psychotherapy to people who need it is to automate and computerize the treatment process and deliver it through websites and apps. This could potentially offer guidelines-based treatment to anyone, anywhere, anytime, at a modest cost. Stand-alone computerized cognitive behavioral therapy (CCBT) has been found to be effective for the treatment of depression, and is already available from a few entities. But it’s still not known how much, if at all, CCBT would improve treatment of depression in primary care, so a group of researchers in the United Kingdom recently tested the advantages of adding CCBT to standard treatment. They randomly assigned 691 people with depression into three different groups. One group received standard care, and the others received standard care plus one of two online CCBT programs.

Comparing CCBT with standard care for depression

As it turns out, standard depression treatment in UK primary care centers is quite good. Citizens are routinely offered antidepressant medications, psychotherapy, and access to community mental health teams, psychologists, psychiatrists, and counselors — a range of resources seldom available in US primary care practices.

There was a lot of crossover between the study groups. In the “standard care” group, 19% ended up using CCBT even though they weren’t specifically assigned to that treatment. Between 77% and 84% of all three groups used medication to treat their depression, and “live” mental health specialists were seen by 17% of one and 24% of the other CCBT group.

Against this backdrop — with many participants in the CCBT groups also receiving mental health specialty treatment and 19% of the standard-practice group receiving CCBT — no significant difference in depression treatment results was found. However, in the US, the findings may have been very different, considering the limited array of mental health resources in most primary care clinics.

It would be most interesting, and more important, to know the benefit of using CCBT for patients who receive nothing else — no medication and no access to mental health specialists. It’s for these patients that CCBT might be the most beneficial.

Challenges in getting people to use CCBT for depression treatment

Both of the CCBT websites had been tested in previous clinical trials and both had been found to be effective treatments — but they’re only helpful if people use them. Even though the two stand-alone CCBT websites were designed to be used over either 6 or 8 “sessions,” most people only used them once or twice, even though the study provided reminder calls to the participants. People with depression can experience fatigue, impaired concentration, and feelings of hopelessness. Getting them to consistently use CCBT websites on their own schedule is a challenge — even if these programs might be helpful in the end. More structure may be needed to keep people using CCBT.

What’s the take-home? The biggest challenge isn’t building a CCBT program that works; it’s building one that people will use. Just as you need to entertain before you can educate, any CCBT program needs to be extremely engaging to users — and to provide immediate value from the first session. And, although the treatment-anywhere-anytime concept is alluring, relying on people to schedule CCBT themselves on their own time, in their own homes, may lead to high levels of drop-off; after all, you can always get around to it later.

Comments:

  1. Mary

    Agree ! I do not think communing with a computer is going to better a person’s feelings about isolation !
    However, it is better than doing nothing and may lead someone to further treatment .

  2. Dr. Douglas Watt

    Nothing like a system for treatment for depression in this country that totally misses the forest for the trees.

    Why is depression increasing? Why is it the leading cause of disability, and (combining treatment and lost productivity costs), the most expensive disorder facing all Western societies? These don’t have easy answers, but surely part of it is a view of depression, promulgated by big Pharma, that depression is some version of a “chemical imbalance.” The reality is that virtually every neurochemical signaling system that’s been looked at – neuropeptides, hormones, amines, and even cytokines – appears to be altered in depression, mostly by the other players, suggesting that the entire system of modulatory controls rotates or pivots around an axis, and where it’s very hard to find any evidence for a single prime mover. Stress cascades, dynorphin, declining opioids and oxytocin, and the dynorphin mediated shutdown of reward seeking, dovetailing with increased pro-inflammatory signals in the CNS, all appear central. But depression isn’t simply an illness, it’s a conserved mammalian brain mechanism – every single mammal that we studied is capable of depression. So what are we missing?

    This “Chemical Imbalance’ meme has successfully atrophied the medical profession’s potential awareness of the enormous body of evidence (mostly from animal models but also from clinical anecdotes) that depression is intimately related to many forms of stress, particularly social loss, social isolation and social defeat. It is also intrinsically related to pro-inflammatory signals. It’s no coincidence that we have pro-inflammatory lifestyle factors running amok in our country (pro-inflammatory diet, sedentary lifestyle, sleep deprivation, as the big three). When you put together our pro-inflammatory lifestyle with our social isolation and our compulsive pursuit of materialism and consumerism, you have a formula for depression on a large scale. We have lost any real sense of connection to others, to nature, and for that matter to our better selves.

    So the notion that plunking people down in front of computers – a treatment which only recapitulates the deadly isolation that is pandemic in our society – is a viable treatment for depression is a sad testimony to how badly we have lost our way as a society and as a system of medical care.

    • Ros Nelson

      ” … (pro-inflammatory diet, sedentary lifestyle, sleep deprivation, as the big three). When you put together our pro-inflammatory lifestyle with our social isolation and our compulsive pursuit of materialism and consumerism, you have a formula for depression on a large scale. We have lost any real sense of connection to others, to nature, and for that matter to our better selves.”

      A refreshing and insightful comment. Thanks, Dr. Watt! Right on target.

      • Dr. Douglas Watt

        Thanks much Ros for the gracious comment!

        If you are interested in this unconventional point of view (at least unconventional from the standpoint of mainstream American psychiatry), I can send you several of our group’s extensive collection of papers and book chapters. We are also having an entire week-long seminar on this set of questions running Jan 18th to 22nd. If interested, let me know (DrDougWatt at the Gmail.com).

  3. Patricia DeMarrais

    It seems to me that this approach would naturally be less successful. Wouldn’t it lead to feelings such as “I’m such a worthless human being that no other human is interested in me or my problems; I have to talk to a machine.” I can’t believe this is a good solution for a person suffering from depression.

    • Mary

      Exactly what I thought as well. It’s hard enough for depressed folks to cope with feeling like they have to pay people to listen to them and give advice without the medical community pawning them off to pills and now machines.