Is computerised CBT really helpful for adult depression?-A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity

Mirai So, Sosei Yamaguchi, Sora Hashimoto, Mitsuhiro Sado, Toshi A Furukawa, Paul McCrone, Mirai So, Sosei Yamaguchi, Sora Hashimoto, Mitsuhiro Sado, Toshi A Furukawa, Paul McCrone

Abstract

Background: Depression is a major cause of disability worldwide, and computerised cognitive behavioural therapy (CCBT) is expected to be a more augmentative and efficient treatment. According to previous meta-analyses of CCBT, there is a need for a meta-analytic revaluation of the short-term effectiveness of this therapy and for an evaluation of its long-term effects, functional improvement and dropout.

Methods: Five databases were used (MEDLINE, PsycINFO, EMBASE, CENTRAL and CiNii). We included all RCTs with proper concealment and blinding of outcome assessment for the clinical effectiveness of CCBT in adults (aged 18 and over) with depression. Using Cohen's method, the standard mean difference (SMD) for the overall pooled effects across the included studies was estimated with a random effect model. The main outcome measure and the relative risk of dropout were included in the meta-analysis.

Results: Fourteen trials met the inclusion criteria, and sixteen comparisons from these were used for the largest meta-analysis ever. All research used appropriate random sequence generation and Intention-to-Treat analyses (ITT), and employed self-reported measures as the primary outcome. For the sixteen comparisons (2807 participants) comparing CCBT and control conditions, the pooled SMD was -0.48 [95% IC -0.63 to -0.33], suggesting similar effect to the past reviews. Also, there was no significant clinical effect at long follow-up and no improvement of function found. Furthermore, a significantly higher drop-out rate was found for CCBT than for controls. When including studies without BDI as a rating scale and with only modern imputation as sensitivity analysis, the pooled SMD remained significant despite the reduction from a moderate to a small effect. Significant publication bias was found in a funnel plot and on two tests (Begg's p = 0.09; Egger's p = 0.01). Using a trim and fill analysis, the SMD was -0.32 [95% CI -0.49 to -0.16].

Conclusion: Despite a short-term reduction in depression at post-treatment, the effect at long follow-up and the function improvement were not significant, with significantly high drop-out. Considering the risk of bias, our meta-analysis implied that the clinical usefulness of current CCBT for adult depression may need to be re-considered downwards in terms of practical implementation and methodological validity.

Figures

Figure 1
Figure 1
Process of study selection: PRISMA flow diagram.
Figure 2
Figure 2
Comparison: CCBT versus control, Outcome: Reduction in depression symptoms at post-treatment.
Figure 3
Figure 3
Comparison: CCBT versus control, Outcome: Reduction in depression symptoms at long follow-up.
Figure 4
Figure 4
Comparison: CCBT versus control, Outcome: Improvement in function at post-treatment.
Figure 5
Figure 5
Comparison: CCBT versus control, Outcome: Relative risk of attrition at post-treatment.
Figure 6
Figure 6
CCBT versus control: subgroup analyses – type of control (Waitlist and TAU), Outcome: Reduction in depression symptoms at post-treatment.
Figure 7
Figure 7
Funnel plot of comparison: CCBT versus control, outcome: reduction in depression symptoms at post-treatment. White circles: included comparisons. Black circles: imputed comparisons using the trim-and-fill methods. White diamond: pooled observed standard mean difference. Black diamond: pooled imputed standard mean difference.

References

    1. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. 2007;370(9590):851–858. doi: 10.1016/S0140-6736(07)61415-9.
    1. Busch FN, Sandberg LS. Combined Treatment of Depression. Psychiatric Clinics of North America. 2012;35(1):165–179. doi: 10.1016/j.psc.2011.10.002.
    1. Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C. Combined pharmacotherapyandpsychological treatment for depression: a systematic review. Arch Gen Psychiatry. 2004;61(7):714–719. doi: 10.1001/archpsyc.61.7.714.
    1. Beck AT. Cognitive therapy and the emotional disorders. Oxford, England: International Universities Press; 1976. p. 356.
    1. Department of Health. Treatment choice in psychological therapies and counselling. Evidence-based clinical practice guideline. In. London: DOH; 2001.
    1. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clin Psychol Rev. 2006;26(1):17–31. doi: 10.1016/j.cpr.2005.07.003.
    1. Dimidjian S, Hollon SD, Dobson KS, Schmaling KB, Kohlenberg RJ, Addis ME, Gallop R, McGlinchey JB, Markley DK, Gollan JK. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. J Consult Clin Psychol. 2006;74(4):658–670.
    1. Cuijpers P, Smit F, Van Straten A. Psychological treatments of subthreshold depression: a meta-analytic review. Acta Psychiatr Scand. 2007;115(6):434–441. doi: 10.1111/j.1600-0447.2007.00998.x.
    1. IsHak WW, Ha K, Kapitanski N, Bagot K, Fathy H, Swanson B, Vilhauer J, Balayan K, Bolotaulo NI, Rapaport MH. The Impact of Psychotherapy, Pharmacotherapy, and Their Combination on Quality of Life in Depression. Harv Rev Psychiatry. 2011;19(6):277–289. doi: 10.3109/10673229.2011.630828.
    1. Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N, Ramin S, Chaudron L, Lockwood C. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians andGynecologists. Gen Hosp Psychiatry. 2009;31(5):403–413. doi: 10.1016/j.genhosppsych.2009.04.003.
    1. Mergl R, Henkel V, Allgaier A-K, Kramer D, Hautzinger M, Kohnen R, Coyne J, Hegerl U. Are treatment preferences relevant in response to serotonergic antidepressants and cognitive-behavioral therapy in depressed primary care patients? Results from a randomized controlled trial including a patients’ choice arm. Psychother Psychosom. 2011;80(1):39–47. doi: 10.1159/000318772.
    1. Cuijpers P, van Straten A, Smit F, Mihalopoulos C, Beekman A. Preventing the onset of depressive disorders: a meta-analytic review of psychological interventions. Am J Psychiatry. 2008;165(10):1272–1280. doi: 10.1176/appi.ajp.2008.07091422.
    1. NICE. Common Mental Health Disorders: Identification and Pathways to Care. Clinical Guideline 123. London, UK: National Institute for Health and Clinical Excellence; 2011. [ ]
    1. Lovell K, Richards D. Multiple Access Points and Levels of Entry (MAPLE): ensuring choice, accessibility and equity for cbt services. Behav Cogn Psychother. 2000;28(04):379–391.
    1. Kaltenthaler E, Brazier J, De Nigris E, Tumur I, Ferriter M, Beverley C, Parry G, Rooney G, Sutcliffe P. Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation. Health Technol Assess. 2006;10(33):iii. xi-xiv, 1–168.
    1. Kaltenthaler E, Parry G, Beverley C. Computerized cognitive behaviour therapy: a systematic review. Behav Cogn Psychother. 2004;32(01):31–55. doi: 10.1017/S135246580400102X.
    1. Selmi PM, Klein MH, Greist JH, Sorrell SP, Erdman HP. Computer-administered cognitive-behavioral therapy for depression. Am J Psychiatry. 1990;147(1):51–56.
    1. Andersson G, Cuijpers P. Internet-based and other computerized psychological treatments for adult depression: a meta-analysis. Cogn Behav Ther. 2009;38(4):196–205. doi: 10.1080/16506070903318960.
    1. Barak A, Hen L, Boniel-Nissim M, Shapira N. A Comprehensive Review and a Meta-Analysis of the Effectiveness of Internet-Based Psychotherapeutic Interventions. J Technol Human Serv. 2008;26(2–4):109–160.
    1. Gellatly J, Bower P, Hennessy S, Richards D, Gilbody S, Lovell K. What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression. Psychol Med. 2007;37(9):1217–1228. doi: 10.1017/S0033291707000062.
    1. Spek V, Cuijpers P, Nyklicek I, Riper H, Keyzer J, Pop V. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med. 2007;37(03):319–328. doi: 10.1017/S0033291706008944.
    1. Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS One. 2010;5(10):e13196. doi: 10.1371/journal.pone.0013196.
    1. Gerhards SAH, de Graaf LE, Jacobs LE, Severens JL, Huibers MJH, Arntz A, Riper H, Widdershoven G, Metsemakers JFM, Evers SMAA. Economic evaluation of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial. Br J Psychiatry. 2010;196:310–318. doi: 10.1192/bjp.bp.109.065748.
    1. McCrone P, Knapp M, Proudfoot J, Ryden C, Cavanagh K, Shapiro DA, Ilson S, Gray JA, Goldberg D, Mann A. Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. Br J Psychiatry. 2004;185:55–62. doi: 10.1192/bjp.185.1.55.
    1. Warmerdam L, Smit F, van Straten A, Riper H, Cuijpers P. Cost-utility and cost-effectiveness of internet-based treatment for adults with depressive symptoms: randomized trial. J Med Internet Res. 2010;12(5):e53. doi: 10.2196/jmir.1436.
    1. Wright JH, Wright AS, Albano AM, Basco MR, Goldsmith LJ, Raffield T, Otto MW. Computer-assisted cognitive therapy for depression: maintaining efficacy while reducing therapist time. Am J Psychiatry. 2005;162(6):1158–1164. doi: 10.1176/appi.ajp.162.6.1158.
    1. Waller R, Gilbody S. Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence. Psychol Med. 2009;39(5):705–712. doi: 10.1017/S0033291708004224.
    1. Fewtrell MS, Kennedy K, Singhal A, Martin RM, Ness A, Hadders-Algra M, Koletzko B, Lucas A. How much loss to follow-up is acceptable in long-term randomised trials and prospective studies? Arch Dis Child. 2008;93(6):458–461. doi: 10.1136/adc.2007.127316.
    1. Thase ME, Sullivan LR. Relapse and Recurrence of Depression. A practical approach for prevention. CNS Drugs. 1995;4:261–277. doi: 10.2165/00023210-199504040-00004.
    1. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4(6):561–571. doi: 10.1001/archpsyc.1961.01710120031004.
    1. Beck AT, Steer RA, Ball R, Ranieri WF. Comparison of Beck Depression Inventories-IA and-II in Psychiatric Outpatients. J Pers Assess. 1996;67(3):588–597. doi: 10.1207/s15327752jpa6703_13.
    1. Intention to treat issues: Special topic in statistics. [ ]
    1. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–1101. doi: 10.2307/2533446.
    1. Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–634. doi: 10.1136/bmj.315.7109.629.
    1. Duval S, Tweedie R. A nonparametric trim-and-fill method of accounting for publication bias in meta-analysis. J Am Stat Assoc. 2000;95:89–99.
    1. Andersson G, Bergstrom J, Hollandare F, Carlbring P, Kaldo V, Ekselius L. Internet-based self-help for depression: randomised controlled trial. Br J Psychiatry. 2005;187:456–461. doi: 10.1192/bjp.187.5.456.
    1. Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ. 2004;328(7434):265. doi: 10.1136/.
    1. Clarke G, Reid E, Eubanks D, O'Connor E, DeBar LL, Kelleher C, Lynch F, Nunley S. Overcoming depression on the Internet (ODIN): a randomized controlled trial of an Internet depression skills intervention program. J Med Internet Res. 2002;4(3):E14. doi: 10.2196/jmir.4.3.e14.
    1. Clarke G, Kelleher C, Hornbrook M, Debar L, Dickerson J, Gullion C. Randomized effectiveness trial of an Internet, pure self-help, cognitive behavioral intervention for depressive symptoms in young adults. Cogn Behav Ther. 2009;38(4):222–234. doi: 10.1080/16506070802675353.
    1. de Graaf LE, Gerhards SAH, Arntz A, Riper H, Metsemakers JFM, Evers SMAA, Severens JL, Widdershoven G, Huibers MJH. Clinical effectiveness of online computerised cognitive-behavioural therapy without support for depression in primary care: randomised trial. Br J Psychiatry. 2009;195(1):73–80. doi: 10.1192/bjp.bp.108.054429.
    1. Meyer B, Berger T, Caspar F, Beevers CG, Andersson G, Weiss M. Effectiveness of a novel integrative online treatment for depression (Deprexis): randomized controlled trial. J Med Internet Res. 2009;11(2):e15. doi: 10.2196/jmir.1151.
    1. Perini S, Titov N, Andrews G. Clinician-assisted Internet-based treatment is effective for depression: randomized controlled trial. Aust N Z J Psychiatry. 2009;43(6):571–578. doi: 10.1080/00048670902873722.
    1. Ruwaard J, Schrieken B, Schrijver M, Broeksteeg J, Dekker J, Vermeulen H, Lange A. Standardized web-based cognitive behavioural therapy of mild to moderate depression: a randomized controlled trial with a long-term follow-up. Cogn Behav Ther. 2009;38(4):206–221. doi: 10.1080/16506070802408086.
    1. Spek V, Nyklicek I, Smits N, Cuijpers P, Riper H, Keyzer J, Pop V. Internet-based cognitive behavioural therapy for subthreshold depression in people over 50 years old: a randomized controlled clinical trial. Psychol Med. 2007;37(12):1797–1806.
    1. van Straten A, Cuijpers P, Smits N. Effectiveness of a web-based self-help intervention for symptoms of depression, anxiety, and stress: randomized controlled trial. J Med Internet Res. 2008;10(1):e7. doi: 10.2196/jmir.954.
    1. Vernmark K, Lenndin J, Bjarehed J, Carlsson M, Karlsson J, Oberg J, Carlbring P, Eriksson T, Andersson G. Internet administered guided self-help versus individualized e-mail therapy: A randomized trial of two versions of CBT for major depression. Behav Res Ther. 2010;48(5):368–376. doi: 10.1016/j.brat.2010.01.005.
    1. Warmerdam L, van Straten A, Twisk J, Riper H, Cuijpers P. Internet-based treatment for adults with depressive symptoms: randomized controlled trial. J Med Internet Res. 2008;10(4):e44. doi: 10.2196/jmir.1094.
    1. Titov N, Andrews G, Davies M, McIntyre K, Robinson E, Solley K. Internet treatment for depression: a randomized controlled trial comparing clinician vs. technician assistance. PLoS ONE [Electronic Resource] 2010;5(6):e10939. doi: 10.1371/journal.pone.0010939.
    1. Clarke G, Eubanks D, Reid E, Kelleher C, O'Connor E, DeBar LL, Lynch F, Nunley S, Gullion C. Overcoming Depression on the Internet (ODIN) (2): a randomized trial of a self-help depression skills program with reminders. J Med Internet Res. 2005;7(2):e16. doi: 10.2196/jmir.7.2.e16.
    1. Hollon SD, Stewart MO, Strunk D. enduring effects for cognitive behavior therapy in the treatment of depression and anxiety. Annu Rev Psychol. 2006;57(1):285–315. doi: 10.1146/annurev.psych.57.102904.190044.
    1. Van Londen L, Molenaar RP, Goekoop JG, Zwinderman AH, Rooijmans HG. Three- to 5-year prospective follow-up of outcome in major depression. Psychol Med. 1998;28(3):731–735. doi: 10.1017/S0033291797006466.
    1. Kennedy N, Foy K, Sherazi R, McDonough M, McKeon P. Long-term social functioning after depression treated by psychiatrists: a review. Bipolar Disord. 2007;9(1–2):25–37.
    1. Revicki DA, Wood M. Patient-assigned health state utilities for depression-related outcomes: differences by depression severity and antidepressant medications. J Affect Disord. 1998;48(1):25–36. doi: 10.1016/S0165-0327(97)00117-1.
    1. MacLeod M, Martinez R, Williams C. Cognitive Behaviour Therapy self-help: who does it help and what are its drawbacks? Cambridge Univ Press. 2009;37(1):61–72.
    1. Watanabe N, Hunot V, Omori IM, Churchill R, Furukawa TA. Psychotherapy for depression among children and adolescents: a systematic review. Acta Psychiatr Scand. 2007;116(2):84–95. doi: 10.1111/j.1600-0447.2007.01018.x.
    1. Rickels K, Schweizer E, Csanalosi I, Case G, Chung H. Long-term treatment of anxiety and risk of withdrawal. Prospective comparison of clorazepate and buspirone. Arch Gen Psychiatry. 1988;45(5):444–450. doi: 10.1001/archpsyc.1988.01800290060008.
    1. Shao J, Zhong B. Last observation carry-forward and last observation analysis. Stat Med. 2003;22(15):2429–2441. doi: 10.1002/sim.1519.
    1. Unnebrink K, Windeler J. Intention-to-treat: methods for dealing with missing values in clinical trials of progressively deteriorating diseases. Stat Med. 2001;20(24):3931–3946. doi: 10.1002/sim.1149.
    1. Prusoff Ba KGLPES. Concordance between clinical assessments and patients’ self-report in depression. Arch Gen Psychiatry. 1972;26(6):546–552. doi: 10.1001/archpsyc.1972.01750240058009.
    1. Moran PW, Lambert JM. In: The Measurement of Psychotherapy Outcome in Research and Evaluation. Lambert MJ, Christensen ER, De Julio SS, editor. New York: Wiley; 1983. A review of current assessment tools for monitoring changes in depression; pp. 263–303.
    1. Lambert MJ, Hatch DR, Kingston MD, Edwards BC. Zung, Beck, and Hamilton Rating Scales as measures of treatment outcome: a meta-analytic comparison. J Consult Clin Psychol. 1986;54(1):54–59.
    1. Moran PW. A Review of Current Assessment Tools for Monitoring Changes in Depression. Brigham Young University: Department of Psychology; 1982.
    1. Edwards BC, Lambert MJ, Moran PW, McCully T, Smith KC, Ellingson AG. A meta-analytic comparison of the Beck Depression Inventory and the Hamilton Rating Scale for Depression as measures of treatment outcome. Br J Clin Psychol. 1984;23(2):93–99. doi: 10.1111/j.2044-8260.1984.tb00632.x.
    1. Vangberg HCB, Lillevoll KR, Waterloo K, Eisemann M. Does personality predict depression and use of an internet-based intervention for depression among adolescents? Depression Res Treatment. 2012;2012:11.
    1. Mitchell N. Computerised CBT self-help for depression in Higher Education: Reflections on a pilot. Counselling and Psychotherapy Res. 2009;9(4):280–286. doi: 10.1080/14733140902993343.
    1. Merry SN, Stasiak K, Shepherd M, Frampton C, Fleming T, Lucassen MFG. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ. 2012;18:344:e2598.
    1. Clark DM. Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. Int Rev Psychiatry. 2011;23(4):318–327. doi: 10.3109/09540261.2011.606803.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi