Internet-Based CBT Works for Depression, Phobias, Anxiety

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 annual meeting of the American Psychiatric Association.

"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 metaanalysis 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 One 2010;5:e13196).

"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."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

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. (Behav. 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. About 90% of patients said they would recommend the treatment to a friend.

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," Dr. Andrews 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.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

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

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 annual meeting of the American Psychiatric Association.

"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 metaanalysis 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 One 2010;5:e13196).

"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."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

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. (Behav. 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. About 90% of patients said they would recommend the treatment to a friend.

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," Dr. Andrews 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.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

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

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 annual meeting of the American Psychiatric Association.

"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 metaanalysis 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 One 2010;5:e13196).

"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."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

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. (Behav. 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. About 90% of patients said they would recommend the treatment to a friend.

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," Dr. Andrews 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.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

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