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Web-Based CBT appears effective for depression: expert analysis from the annual meeting of the american psychiatric association.

HONOLULU - The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the meeting.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia.

"If our profession could get a handle on effective treatment for internalizing disorders, we'd make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and meta-analysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One2010; 5:el3196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It's powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment (Be-hav Res. and Therapy 2011 [doi: 10.1016/j. brat. 2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average.

In general, adherence to Internet-based CBT in Dr. Andrews's studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," he said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

Dr. Andrews said he has no relevant conflicts of interest.

Results based on data review of 1,746 patients with depression, social phobia, panic disorder, and GAD.

RELATED ARTICLE: Is the Web an Extender?

Dr. Andrews's report of a robust effect of Web-based CBT for people with internalizing disorders is both exciting and puzzling. Nonspecific factors might complicate outcome analysis here as with drug studies, for example, the placebo effect. There is no reason to think that placebo effects are any weaker in psychotherapy trials than they are in drug trials. A bit more than half of depressed individuals respond to SSRIs, but since a third respond to placebos, the "signal," i.e., specific drug effect, is less than 20%, which may also be the case here. Internet technology has growing power, and is connecting people and providing information in ways barely thought possible a decade ago. The Web may well prove to be a physician extender, reaching people who cannot get to our offices, better matching patient problems with therapist expertise, and providing model means of providing treatmen

David Spiegel, M.D., is the Jack, Lulu & Sam Willson Professor and associate chair of the department of psychiatry and behavioral sciences at Stanford (Calif) University. He also is a medical adviser to this news organization.
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Author:Boschert, Sherry
Publication:Clinical Psychiatry News
Date:Jun 1, 2011
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