Researchers found computerized CBT failed to show any significant benefits against depression.
Study coauthor Simon Gilbody, professor of psychological medicine and health services research at the University of York in the UK, and colleagues recently published their findings in The BMJ.
Cognitive behavioral therapy (CBT) is a form of talk therapy that aims to help patients with mental health problems overcome negative thoughts and behaviors that may be contributing to their condition.
Studies have indicated that the traditional form of CBT - involving face-to-face sessions with a mental health counselor - is beneficial for patients with depression, particularly those with mild to moderate forms of the condition.
In light of its potential benefits, there has been growing interest in computerized CBT (cCBT) for depression, where CBT is delivered by an interactive computer program rather than face-to-face therapy.
In the UK, the National Institute of Health Care and Excellence (NICE) recommend the use of cCBT as an initial "lower-intensity" treatment for depression, with the aim of improving patient access to psychological treatments.
The primary cCBT program approved for the treatment of mild to moderate depression by the UK's National Health Service is "Beating the Blues," in which a patient engages in eight weekly interactive therapy sessions. The commercial program has also been introduced in the US.
According to Gilbody and colleagues, however, there is limited evidence as to how effective cCBT is for patients with depression in a primary care setting; most studies assessing the therapy have been conducted in specialist centers or by the researchers who have developed the programs.
Comparing cCBT with standard care
As such, the team conducted a randomized control trial to assess the effectiveness of the Beating the Blues program and "MoodGYM" - a free-to-use cCBT program - against depression when they were added to patients' standard care.
- Major depression affects around 14.8 million adults in the US
- Depression is more common among women than men
- The average age of major depression onset in the US is 32.5.
The researchers enrolled 691 patients with depression from 83 general practices across England, randomly placing them in one of three groups: standard primary care, standard primary care with the Beating the Blues program, and standard primary care with the MoodGYM program.
The Beating the Blues program consisted of eight 1-hour sessions a week, while the MoodGYM program was made up of six 1-hour weekly sessions.
Both programs encouraged the patient to engage in cCBT practices between online sessions, and each patient was called weekly by a technician, supporting them through the program and encouraging them to continue.
The researchers note that the age, sex, educational background, severity of depression, duration of depression and use of antidepressant medication were similar in each group.
At 4, 12 and 24 months after treatment allocation, the depression of patients and their health-related quality of life were assessed.
cCBT ineffective due to low patient adherence and engagement
Compared with the standard primary care group, the team found patients in the cCBT groups experienced no significant improvement in depression.
Around 44% of patients in the standard care group, 50% of patients in the Beating the Blues group and 49% in the MoodGYM group remained depressed at 4 months.
What is more, the team found that the commercial Beating the Blues program was no more effective than the free-to-use MoodGYM program. "This is an important finding for those who commission services and purchase commercial products on behalf of publicly funded health services," they note.
The researchers say that rather than lack of efficacy, the poor outcomes of cCBT were primarily down to low adherence to the treatment and low engagement.
They note that only 18% of patients completed all eight Beating the Blues sessions, while only 16% completed all six MoodGYM sessions; by 4 months, 24% of patients had dropped out of the study.
Patients reported that they did not want to engage with computer programs, according to the researchers, and that they found it difficult to repeatedly log on to computer systems when feeling depressed.
"Participants said they wanted a greater level of clinical support as an adjunct to therapy, and, in the absence of this support, they commonly disengaged with the computer programs," add the authors.
Current cCBT guidelines 'should be reconsidered'
Based on their findings, the researchers believe current guidelines recommending the use of cCBT for depression should be reviewed:
"The overall conclusion is that supported computerized cognitive behavior therapy confers modest or no benefit over usual GP care and suggests that the routine promotion and commissioning of cCBT be reconsidered in light of our findings.
There is a range of treatments for depression that might be considered instead of cCBT. These include telephone-guided self-help, bibliotherapy, low-intensity psychological workers supporting self-help technologies, and therapist-delivered cognitive behavior therapy."
In an editorial linked to the study, however, Prof. Christopher Dowrick, of the University of Liverpool in the UK, says the evidence from this study alone is insufficient to overturn the current guidelines, though he admits they "do have important implications."
"Many depressed patients do not want to engage with computers, they prefer to interact with human beings," he notes, "partly because the technological complexities associated with Internet use can become daunting."
"Even if patients are willing to interact with machines and master the technology," he continues, "they might find themselves at odds with intrinsic assumptions of CBT, preferring to persist with behavior patterns that offer them a sense of control and safety."
However, a recent study reported by Medical News Today suggested that even the benefits of conventional CBT for depression may be overstated. Published in PLOS ONE, the study found that psychotherapy - involving CBT and interpersonal therapy (IPT) - was 25% less effective than stated by previous research.