Elsevier

Journal of Affective Disorders

Volume 155, February 2014, Pages 49-58
Journal of Affective Disorders

Research report
Effectiveness of Internet-based cognitive behaviour therapy for depression in routine psychiatric care

https://doi.org/10.1016/j.jad.2013.10.023Get rights and content

Abstract

Background

Efficacy of guided Internet-based cognitive behaviour therapy (ICBT) for depression has been demonstrated in several randomised controlled trials. Knowledge on the effectiveness of the treatment, i.e. how it works when delivered within routine care, is however scarce. The aim of this study was to investigate the effectiveness of ICBT for depression.

Methods

We conducted a cohort study investigating all patients (N=1203) who had received guided ICBT for depression between 2007 and 2013 in a routine care setting at an outpatient psychiatric clinic providing Internet-based treatment. The primary outcome measure was the Montgomery Åsberg Depression Rating Scale-Self rated (MADRS-S).

Results

Patients made large improvements from pre-treatment assessments to post-treatment on the primary outcome (effect size d on the MADRS-S=1.27, 99% CI, 1.14–1.39). Participants were significantly improved in terms of suicidal ideation and sleep difficulties. Improvements were sustained at 6-month follow-up.

Limitations

Attrition was rather large at 6-month follow-up. However, additional data was collected through telephone interviews with dropouts and advanced statistical models indicated that missing data did not bias the findings.

Conclusions

ICBT for depression can be highly effective when delivered within the context of routine psychiatric care. This study suggests that the effect sizes are at least as high when the treatment is delivered in routine psychiatric care by qualified staff as when delivered in a controlled trial setting.

Introduction

Major depression affects about 1/6 of the population during the life span, is associated with low quality of life, sleep difficulties, and a highly elevated risk of serious suicidal behaviours (Beautrais et al., 1996, Alonso et al., 2004, Fava, 2004, Kessler et al., 2005). In the treatment of depression, therapist guided Internet-based cognitive behaviour therapy (ICBT) has emerged as a promising option and has demonstrated efficacy in at least 15 randomised controlled trials conducted by independent research groups (for a review see Christensen et al., 2006, Andersson and Cuijpers, 2009, Hedman et al., 2012b, Richards and Richardson, 2012). These systematic reviews have also shown that guided ICBT tends to lead to better outcomes and fewer dropouts than unguided treatments. In short, ICBT could be described as Internet-delivered bibliotherapy with online therapist support, provided to patients who have undergone diagnostic assessment (Andersson, 2009). The most commonly used components in ICBT for depression are behavioural activation, cognitive restructuring, strategies for handling sleep difficulties, and problem solving training (e.g. Andersson et al., 2005, Perini et al., 2009, Ruwaard et al., 2009, Berger et al., 2011). Delivering CBT via the Internet has several important advantages including reduced therapist time, independence of geographic distance between patient and therapist, lower costs and thus a potential to increase accessibility to effective psychological treatment.

Even if the efficacy of ICBT has been shown in previous trials, there is a little knowledge on the treatment's effectiveness when delivered in routine psychiatric care. Investigating effectiveness is important before disseminating a new treatment on a large scale as the generalizability of findings from RCTs can be reduced by for example recruitment of participants from non-clinical populations (Shadish et al., 2000, Hunsley and Lee, 2007). We have found only three studies reporting on effectiveness of ICBT for depression, all demonstrating that ICBT can produce large effects sizes when delivered as routine clinical care (Ruwaard et al., 2012, Watts et al., 2012, Williams and Andrews, 2013). However, these studies have investigated the effects of ICBT within delivery systems where diagnostic assessment is not carried out face-to-face at the clinic providing ICBT before treatment start. Furthermore, the dosage of treatment and involvement of therapists differed substantially between studies. In the Dutch study, therapists spent about 20 h on each patient during a median of 22 weeks (Ruwaard et al., 2012) whereas the Australian programmes consisted of six lessons with automatized responses (Watts et al., 2012, Williams and Andrews, 2013).

Since 2007 the ICBT clinic in Stockholm, Sweden, provides ICBT within routine psychiatric care (Hedman et al., 2013). The clinic operates as a conventional psychiatric outpatient clinic, meaning for example that patients upon admittance come to the clinic and undergo a diagnostic assessment conducted by a psychiatrist, that licensed psychologists manage the online treatment contact, and that the clinic assumes full responsibility for the patient while enroled. To date, more than 1200 patients have received ICBT for depression at the clinic. As far as we know, no prior study has investigated if ICBT for depression can be effective when delivered in this type of conventional routine psychiatric care setting. Considering the many advantages of ICBT and that it could be used to increase accessibility to CBT, more knowledge on its effectiveness is urgently needed.

The aim of the present study was to investigate the effectiveness of ICBT for depression in a large cohort of consecutively recruited patients treated within routine psychiatric care. We predicted that patients would improve on measures of depressive symptoms. We also investigated effects on insomnia, suicidal ideation, and patient satisfaction.

Section snippets

Design

This was a cohort study investigating consecutively recruited patients (N=1203) who received guided ICBT for depression as routine care at a university hospital psychiatric clinic providing treatment for individuals in Stockholm County, Sweden. All patients who commenced treatment since the opening of the ICBT clinic were included in the study. A within-group design with repeated measurements was used. The study was approved by the Regional Ethics Review Board in Stockholm, Sweden.

Sample and recruitment

Table 1

Attrition, missing data and treatment adherence

Fig. 1 displays the flow of the 1203 participants through the study. On the primary outcome measure MADRS-S 1175 (98%) participants provided data at screening, 1166 (97%) at pre-treatment, 987 (82%) at post-treatment and 390 (37% counting denominator as n=1066 as six months had not passed since treatment completion for all participants at the time of data extraction) at 6-month follow-up. Missing data were primarily monotone (94.3%, n=776), reflecting that most participants completed screening,

Discussion

The aim of this study was to investigate the effectiveness of guided ICBT for depression delivered in a routine psychiatric care setting. The results from a treatment cohort comprising 1203 patients showed that the treatment was highly effective with large effect sizes from pre- to post-treatment and 6-month follow-up. More than half of the patients achieved remission after treatment and they also made significant improvements in terms of sleep difficulties and suicidal ideation. In addition,

Conclusions

In spite of these limitations, we conclude that therapist-guided ICBT for major depression can be highly effective when conducted in a routine psychiatric care context by qualified staff with significant effects also on suicidal ideation and sleep difficulties. The findings indicate that ICBT for depression is ready for implementation.

Role of funding source

The funding organization, Stockholm County Council, is a public institution and had no role in the design and conduct of the study; in the collection, management, and analysis of the data; or in the preparation, review and approval of the manuscript.

Conflict of interest

All authors report that they have no competing interests.

Acknowledgements

The authors wish to thank Monica Hellberg, coordinating nurse, and all participating staff at the ICBT clinic.

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