The computer will see you now

When it comes to treating patients with common mental health conditions, a growing number of doctors are recommending the iPad over the consulting room. People with anxiety and depression routinely receive treatment over the internet and, in fact, almost a decade of research shows that online cognitive behavioural therapy (CBT) can be as effective as face-to-face therapy.

Internet-based CBT (iCBT) presents the same material that is conveyed in traditional face-to-face therapy in lessons viewed online. For many, online therapy is more convenient than in person therapy because it allows them to complete lessons in their own time, rather than missing work to attend face-to-face appointments. It also reduces other barriers to treatment such as the stigma associated with mental illness and reluctance to talk to a health professional. It is a way to discretely access mental health care without having to disclose your “life story” to a stranger.

There are several iCBT programs around the world, with the international leaders emerging primarily from research groups in Australia, Sweden and The Netherlands. CBT is an evidence-based, short-term treatment that focuses on learning skills to shift unhelpful thoughts and behaviour that maintain distress. Typically, the online program includes six to 12 modules to be completed in three months as well as homework that consolidates the learning and encourages the practice of skills in daily life. Most courses include questionnaires to monitor progress.

One of Australia’s most-used iCBT programs, This Way Up, is a not-forprofit venture between St Vincent’s Hospital and UNSW. This Way Up offers courses for depression and anxiety disorders consisting of six lessons.

The material is presented in an illustrated format in which patients follow the central character with the target disorder as they learn about their symptoms and the steps to recovery. Each lesson is followed by a written summary as well as exercises for the patient to complete, such as identifying and modifying unhelpful thinking patterns.

Patients pay $59 for the course and receive guidance from their “prescribing” health clinician, usually a psychologist or general practitioner (GP). The guidance involves emails encouraging the patient to continue with the course and patients are invited to contact their clinician with questions. The clinician also monitors patient distress scores across lessons and makes contact if these scores rise.

Despite the limited nature of clinician contact, it appears to make a big difference to course completion rates. A study in Psychological Medicine showed that people who received guided iCBT were more likely to complete the course and that their symptoms reduced more than people receiving unguided iCBT.

Two recent systematic reviews by researchers in Australia and The Netherlands, which examined 125 randomised control trials (RCTs) of iCBT across clinical disorders, indicated that iCBT delivered substantial outcomes to patients, and five studies have shown that iCBT is as beneficial as face-to-face CBT. Of patients who complete This Way Up courses, 80% improve and 60% no longer score in the clinical range for their disorder. Treatment satisfaction is also remarkably high, with 85 per cent of patients in RCTs rating their experience of iCBT as “good to excellent”.

Probably the biggest advantage of iCBT is its ability to dramatically enhance access to evidence-based treatments for mental health disorders. It is widely recognised that there are simply not enough trained specialists in CBT to meet the huge demand of individuals who could benefit from this intervention. Online therapy is also useful for rural patients who do not have as much access to health care services. As one would imagine, iCBT is far more cost-e­ffective than face-to-face therapy, thereby placing a lesser burden on the health care system and freeing up clinician time to manage more “difficult-to-treat” patients.

Like other forms of treatment for anxiety and depression, both psychological and pharmacological, not all people benefit from iCBT. To date, there is little evidence to identify from the outset who will benefit and who will not. Although older patients tend to complete more of the lessons in the course, there is no evidence that age, gender, or symptom severity influence the degree to which patients benefit. It is also worth considering that online therapy requires a fair degree of patient motivation and this may not suit all people. Clinician guidance, automated email alerts, and paying for the course have been shown to increase completion rates, but there is room for improvement.

So, should you leave your doctor for a computer? Your GP is always a good starting point if you are experiencing symptoms of anxiety and depression but, given the increasing body of evidence supporting online treatment for these disorders, it may be time to keep an open mind to internet-based therapy.

See mindhealthconnect. org.au, an initiative of the Federal Government, for the online programs on o­ffer in Australia.

Elizabeth Mason PhD is a clinical psychologist at the Clinical Research Unit for Anxiety and Depression (CRUfAD) at St Vincent’s Hospital in Sydney and a Conjoint Lecturer at UNSW. 

This article first appeared in the Law Society Journal.