What are some of the new ways of receiving therapy for anxiety and depression? Let's begin with your laptop. Internet-based cognitive behavioral therapy, when combined with some in-person care, can benefit people with depression, anxiety, and emotional distress caused by illness, a new review of past studies finds. 

Dr. David Gratzer, psychiatrist, and Faiza Khalid-Khan, social worker, at Scarborough Hospital in Toronto, say further studies are needed to identify the most effective combination of counselling sessions, Internet-based treatments, and, possibly, medication for patients. Ultimately, combined treatments appear to be effective for helping people who do not suffer from severe mental health conditions but still need some gentle help during a tough time.

"We think that providers need to be flexible," Gratzer told Medical Daily in an email. "Some patients may feel more comfortable coming to an outpatient clinic and doing the computer work there even though they could do this from home (if they have Internet)."

What is CBT?

Cognitive behavioral therapy (or CBT as it is commonly known) is a form of psychotherapy which is based on Beck’s Negative Cognitive Triad, the researchers explain. People who are depressed have developed negative views of themselves, the world, and their future, according to Dr. Aaron Beck, the "father of CBT." Naturally, these three beliefs — believing you are incompetent/unworthy, believing the world is a hostile place, and believing the future will be emotionally painful — reinforce and compound one another. Commonly, depressed people also make certain assumptions which make them even more vulnerable to depression, such as "I must do things perfectly or not at all" or "I must get people’s approval."

As described by Psychology Today, CBT effectively weeds out beliefs that prevent a patient from feeling and doing their best.

In practice, a CBT therapist will isolate a patient's specific automatic negative thoughts, and then help the patient to change the resulting unconscious patterns. Because CBT has such clearly defined goals, it can be sculpted into self-contained, scripted modules with no real need for a therapist. CBT, then, is uniquely suited to online delivery and can be tailored to a specific condition (such as anxiety). Yet how effective is it? To find out, Gratzer and Faiza Khalid-Khan investigated by conducting a review of 1,104 studies published between 2000 and 2012. They focused on three conditions in particular: anxiety, depression, and emotional distress associated with physical illness.

While many of the early studies were not rigorously designed, the quality of studies has improved over time, the researchers discovered. Flexibility (patients can participate in online therapy whenever and wherever they want) helped many people stick with treatment, while the online anonymity helped shy or very depressed patients overcome their reluctance to speak. Some studies showed patients who used Internet-delivered CBT had better results than patients receiving placebo (sham) therapies and equal or even better outcomes than patients receiving traditional in-person CBT, the researchers report. These results were seen for depressed patients and those with physical illnesses, such as multiple sclerosis.

An important question addressed in the review: How did Internet-delivered CBT work for children and older adults?

Kids and Oldsters

In several studies, young anxiety patients (between the ages of 8 and 18) responded to conventional CBT and even gained long-term results. One study found individual CBT and Internet-delivered CBT both produced significant improvements of symptoms for students. Another study looked at what happened when MoodGYM (a five-week, online CBT program) was incorporated into the curriculum at 30 Australian schools. Students with the highest rates of adhering to the program showed significantly greater improvement in anxiety symptoms compared to students not enrolled in the program. This was true both immediately after treatment and at six-month follow-up. 

Generally, the older adults also did well with new technologies. For instance, one research team designed their study to provide 90 days access to a six-lesson Internet-delivered CBT program for anxiety. While older patients enrolled less frequently in this Internet-delivered program, once enrolled, they were substantially more likely to complete the program than younger adults. Importantly, no significant differences in gains existed among older or younger adult patients, with one exception. Older adults with social phobia had greater symptom reduction.

"These data showed that a modestly trained individual with no prior counselling qualifications could guide Internet-delivered CBT, with adherence and outcomes similar to those achieved with clinician guidance," wrote Gratzer and Khalid-Khan. Effective and cost-efficient, the researchers suggest further study would help Canadian health care professionals learn how to best use online treatments.

Source: Gratzer D, Khalid-Khan F. Internet-delivered cognitive behavioral therapy in the treatment of psychiatric illness. CMAJ. 2015.