Rheumatology

November 2013

Clinical

Internet-based cognitive behaviour therapy for depression and anxiety

Volume 42, No.11, November 2013 Pages 803-804

Handbook of Non Drug Intervention (HANDI) Project Team

This article is part of a series on non drug treatments summarising indications, considerations, evidence and sources of information for clinicians and patients.

Internet-based, or computerised, cognitive behaviour therapy (CBT) can be used to treat patients with depression or anxiety. Patients are engaged in structured programs of care, with several programs available either at no cost or moderate cost. Internet CBT (iCBT) may be particularly suited to patients with mobility issues or living in rural or remote areas. Although there are no adverse effects, clinicians should assess patients for risk issues and the need for more immediate assistance before recommending iCBT. Monitoring effectiveness of any intervention for the patient is important. iCBT has National Health and Medical Research Council (NHMRC) Level I evidence of efficacy. 

The condition

About 85% of patients with depression have significant anxiety. Cognitive behaviour therapy (CBT) is the main psychological treatment approach for depression and anxiety.

The intervention

CBT is available as internet-based (iCBT) or computerised (CCBT), programs. iCBT engages patients in structured programs of care. The content is similar to and based on CBT programs provided by a therapist; however iCBT programs vary in style, degree of complexity, content and the level of involvement by clinicians.

Several different iCBT programs are available either at no cost or low-to-moderate cost. The Australian National University, which developed MoodGYM, has a website (https://beacon.anu.edu.au/service/website/browse/1/Depression) that rates the various websites for depression. Some of the websites also cover anxiety. Mindhealthconnect (www.mindhealthconnect.org.au) also offers information about and access to online programs. More information is provided in the Resources section.

What should I consider?

Indications

Treatment programs have been studied in patients with mild-to-moderate, moderate-to-severe and severe depression. Internet intervention may offer help for individuals without access to effective treatments. iCBT may be particularly useful for patients in rural and remote locations, and for patients with mobility issues.

Precautions

iCBT may not be suitable for patients with additional disorders or conditions, such as borderline personality disorder, antisocial personality disorder or substance dependence. More immediate and direct means of assistance may be necessary for some patients. Practitioners should assess a patient’s risk of self-harm or suicide before recommending iCBT. Practitioners should also alert patients who use iCBT to report a lack of improvement or worsening of anxiety or depression.

Evidence

NHMRC Level I evidence (systematic review of randomised controlled trials).

Anything else?

Slow or unreliable internet access may limit availability of some programs. For these patients, access to programs could be offered in the GP practice. Bibliotherapy, a form of guided self-help through the use of structured books or other written material, is an alternative for patients without internet access.

Resources

Each of the following sites offers clinician access and guidance.

  • MoodGYM (https://moodgym.anu.edu.au/welcome) is a free online training program developed by the Centre for Mental Health Research, Australian National University. It uses CBT and interpersonal therapy. MoodGYM is available in several languages. It was used in the Christensen trial.
  • THIS WAY UP clinic (https://thiswayup.org.au/clinic/) offers several courses developed by staff at the Clinical Unit of Anxiety and Depression at St Vincent’s Hospital, Sydney and the University of New South Wales Faculty of Medicine. Patients require a GP referral and there is a small fee. Progress can be monitored by the referring GP. Courses available include depression, generalised anxiety disorder and mixed depression and anxiety. Clinicians have free access.
  • AnxietyOnline (www.anxietyonline.org.au) offers assessment and treatment programs for social anxiety disorder, post traumatic stress disorder, general anxiety disorder, depression and panic disorder. Anxiety Online is an initiative of the National eTherapy Centre at Swinburne University of Technology and is funded by the Department of Health and Ageing.
  • beyondblue (www.beyondblue.org.au) has free online programs including Workplace Mental Health Awareness and The Desk (for students)

Key references

  • Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: a randomised controlled trial. BMJ 2004;328:265.
  • Kaltenthaler E, Brazier J, De Nigris E, et al. Computerised cognitive behavioural therapy for depression and anxiety update: as systematic review and economic evaluation. Health Technol Assess 2006;10:1-168.
  • National Collaborating Centre for Mental Health. Depression: the NICE guideline on the treatment and management of depression in adults (updated edition). London: National Institute for Health and Clinical Excellence, 2010. Available at www.nice.org.uk/nicemedia/live/12329/45896/45896.pdf [Accessed 1 March 2013]

Acknowledgements

Members of the HANDI Project Team include Professor Paul Glasziou, Dr John Bennett, Dr Peter Greenberg, Professor Sally Green, Professor Jane Gunn, Associate Professor Tammy Hoffmann and Associate Professor Marie Pirotta.

Competing interests: None.
HANDI is supported by a grant from the Jack Brockhoff Foundation.
Provenance and peer review: Commissioned; not peer reviewed.

Correspondence afp@racgp.org.au

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