What was the aim of the evidence review?
Depression is one of the most common reasons for people seeing their GP. There is a good evidence base for Cognitive Behavioural Therapy (CBT) in depression but demand for this cannot be met by existing face to face services. Computer delivered CBT therefore offers an attractive alternative and is recommended by NICE guidelines.
Who completed the evidence review?
Dr Ed Mann, GP Clinical Evidence Fellow with North Somerset Clinical Commissioning Group (funded by the West of England Academic Health Science Network and North Somerset Clinical Commissioning Group).
What did they do?
Ed looked at reviews and meta-analyses of the evidence around using digital media (apps/computer programmes) in treating depression.
How long did it take?
Approximately three days’ work over six weeks.
What did they find?
There is conflicting evidence on computer CBT (iCBT) in depression and anxiety. There does seem stronger evidence that it may work in the ‘pre-GP’ phase of a patient’s illness. In North Somerset however, patients already have direct access to CBT and other self-help via Positive Step, without seeing a GP. Because of this it seems difficult to recommend the Clinical Commissioning Group (CCG) invest in commercial CBT e.g. ‘Beating the Blues’ at £50 per patient or £31,500 per year. A recent UK study found that neither differed from each other and neither offered any advantage over usual GP care. MoodGYM, has less evidence and may not work but is free, will not harm and may benefit some patients.
NB: Positive Step offer support through GP surgeries for people with common mental health difficulties. MoodGYM is an online self-help programme designed to teach cognitive behavioural therapy skills to people vulnerable to anxiety and depression.
Who was the evidence shared with and why?
The evidence was shared with the North Somerset CCG Mental Health Transformation Programme because they were looking into ideas to help shape their development of new services.
How were the findings used in local decision-making?
There was not strong evidence to recommend the CCG spending money on iCBT from the evidence reviewed.
The CCG found the evidence review useful because “It looked at specific models (and the evidence behind them) currently available on the market. It also pulled in the current commissioning context and demonstrated a knowledge of the current pathway and therefore opportunities to transform. It then weighed up the pros/cons.”
What has changed as a result?
No investment was made.
Successes and challenges
The main challenge was that the types of computer intervention differed widely as did the control groups. Many of the studies involved patients before they presented to primary care i.e. earlier on in their illness. Retention was also a major problem with computer CBT, with advocates suggesting that if retention could be improved, effectiveness would be better and sceptics suggesting that the lack of retention is inherent in it not being a ‘human’ process.
- Anderson. (2009). Internet-based and other computerized psychological treatments for adult depression : a Meta Analysis. Cognitive Behavoural Therapy, 196-205.
- Andrews G, C. P. (2010). Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-Analysis. . PLoS ONE, 5(10): e13196. doi:10.1371/journal.pone.0013196.
- Cuijpers, P. (2009). Computer-Aided Psychotherapy for Anxiety Disorders: A meta-analytic review. Cognitive Behavioural Therapy, 66-82.
- E Kaltenthaler, J. B. (2006). Computer CBT for depression and anxiety -a sytematic review and economic evaluation. Health Technology Assessment.
- Gilbody. (2015). Computerised cCBT as treatment for depression in primary care REEACT trial. BMJ, 351.
- NICE. (2009). Depression in adults: the treatment and management of depression in adults.
- Richards. (2012). Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clinical Psychology Review, 329-42.
- Twomey. (2016). Effectiveness of a freely available computerised CBT programme (MoodGYM) for depression: Meta-analysis. Australian and New Zealand Journal of Psychiatry 1-10, 1-10.