Cognitive Behavioral Therapy For Depression Essay Scholarship

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Abstract

Background

Cognitive behavioural therapy (CBT) is a key intervention, enabling workers on sick leave with common mental health problems to return to work. It can be delivered by a variety of methods including face-to-face therapy and the Internet. It is not known which is the optimal method of delivery.

Aims

To establish the optimum method of delivering CBT to workers with common mental health problems.

Methods

We undertook a systematic search of the OvidMEDLINE and EMBASE biomedical databases from the start of electronic records to 31 July 2013 for randomized trials comparing one method of delivering CBT with another for treatment of mild-to-moderate depression, anxiety and adjustment disorders. We included publications that assessed at least one of four outcomes: clinical or cost-effectiveness, accessibility and acceptability. A scoping search found no studies in the workplace. We therefore focussed on interventions in the 18–65 year age group.

Results

We found six studies comparing methods of delivery of CBT for anxiety disorders but found no trials which compared methods of delivery for mild-to-moderate depression. All delivery methods led to an improvement in anxiety symptoms. Internet-delivered CBT with some input from a therapist was found to be as clinically effective as face-to-face CBT and more cost-effective.

Conclusions

Internet CBT should be made available in workplaces for workers with anxiety disorders as part of a stepped care plan.

Anxiety, cognitive behavioural therapy, common mental health disorders, occupational health, workers.

Introduction

It is estimated that one in six workers in the UK experience mild-to-moderate anxiety and depression at any one time [1]. These so-called common mental health disorders (CMHDs) are the leading cause of sickness absence in most high-income countries and account for ~35% of disability benefits [2]. Randomized controlled trials have shown that cognitive behavioural therapy (CBT) is effect ive in treating CMHDs and the UK National Institute for Health and Care Excellence (NICE) recommends CBT for the treatment of depression and anxiety disorders as a stand-alone treatment or in combination with medication, self-help, exercise and other talking therapies as part of a stepped care model [3].

However, access to CBT services is restricted by the high level of demand, limited availability of therapists and, in the workplace, by the cost to the business of the time the worker needs to spend away from their job. Internet- and computer-based delivery could improve access to CBT, as could bibliotherapy. Although computerized CBT has been shown to be effective in improving emotional distress in workers with stress-related absenteeism [4], it is not clear whether it is as effective as therapist-delivered CBT in reducing symptoms associated with CMHDs.

The aim of this review was to establish the optimum method of delivering CBT for workers with mild-to-moderate depression or anxiety including panic, social phobia and adjustment disorders.

Methods

We used the population intervention control outcome approach to compile a search strategy [5]. Our initial population was workers with mild-to-moderate depression, anxiety (including panic and social anxiety disorders) or adjustment disorder. Post-traumatic stress disorder and obsessive compulsive disorder are considered stress disorders in the ICD-10, thus we excluded these from our search. CBT interventions were face to face (individual or group), computer, telephone and bibliotherapy. As we sought to compare delivery methods to find the optimum, we only included randomized control trials, which compared one method of CBT with another. Outcomes were clinical improvement, cost-effectiveness, acceptability and accessibility to the worker. We undertook a scoping search using >50 search terms (both medical subject headings and text words) relating to the above subjects but found no studies on workers or studies set in workplaces. We therefore amended our search criteria to include studies in any setting where the intervention was applied to the broad working age population of 18–65 year olds.

We performed a computerized literature search, restricting publication type to randomized controlled trials. We searched databases from inception to 31 July 2013, using the following search terms: OvidMEDLINE: ‘*Depression/’ [focus] or anxiety or panic or adjustment disorder and ‘Cognitive therapy’ [subjects] PsychInfo: ‘*Postpartum depression/ or *Endogenous depression/ or *Reactive depression/ or *Spreading depression/ or *Depression (emotion) or *Recurrent depression/ or *Beck depression inventory’ [focus] or anxiety or panic or adjustment disorder and ‘Cognitive therapy’ [subjects]. EMBASE: ‘*Depression/’ [focus] or anxiety or panic or adjustment disorder and ‘Cognitive therapy’ [subjects]. We hand searched key publications for additional references and consulted with leading experts in the field to identify any relevant missing publications. We limited the review to studies in English.

Three reviewers (E.G., V.N. and K.B.) independently selected publications based on title and then abstract. They retrieved full texts of abstracts that met the inclusion criteria. Two reviewers (E.G. and V.N.) independently selected the full publications, which met the inclusion criteria and compared results. Where there was disagreement, a fourth reviewer (I.M.) was consulted to decide whether or not the publication should be included in the review. The critical appraisal tool for randomized controlled trials by the Critical Appraisal Skills Programme (CASP) [6] was used for the quality assessment of publications. The reviewers excluded publications if they did not meet the requirements of the CASP trial validity screening questions, i.e. the trial must have had a clearly focused question and the assignment of patients to treatment groups must have been random. I.M. extracted data from the remaining publications and assessed the internal and external validity of the research. Since it is recognized that the use of scales with summary scores to distinguish high- and low-quality studies is questionable [7], we assessed internal validity of the studies by considering possible biases including selection and attrition bias. In addition, we assessed blinding of participants, therapists and researchers and treatment allocation. We also assessed if the reported randomization was truly random.

Results

We identified 1447 references by the electronic literature search after de-duplication (Figure 1). Title screening resulted in 544 studies being selected for further scrutiny. After screening the abstracts, we retrieved 317 full text articles. We added no additional papers following hand-searching or consultation with experts in the field. Six papers met our inclusion criteria. Of these, all focused on patients with anxiety disorder including social anxiety, phobias and panic disorder (Table 1). Hedman et al. published two papers on one group of subjects, one comparing the clinical effectiveness of Internet-delivered CBT (iCBT) versus face-to-face group therapy and the other comparing cost-effectiveness [8,9]. Two studies were set in Australia and the remainder in Sweden. The age range of the populations in the studies incorporated the working age of 18–65, although if studies did extend the upper age limit slightly, they were still included as the vast majority of participants were in the working age range. The trials in our review compared iCBT with either individual or group face-to-face therapy and in all bar one [10], the iCBT included some contact with a therapist.

Table 1.

Characteristics of the included trials

Author and year of publication Study characteristics Participant characteristics Intervention Results Internal validity 
Andrews et al. (2011) [10] Aim: to compare the effectiveness of iCBT with face- to-face group CBT in patients with social phobia.Recruitment: via psychiatry clinics.Setting: Australia N = 25 iCBT: shyness programme, including six online lessons, e-mails, forums, text messaging and homework. Total treatment time: 8 weeks. Social anxiety levels were reduced in both groups. Small sample size. Follow-up time of 8 weeks, may not have given sufficient time for the intervention to be effective. 
Mean age (SD): 31.9 (7.8) 
Gender, female: 41% No significant difference between the two groups (P > 0.05) in outcome measures of social anxiety and associated disability measured at 8 weeks post-intervention. 
Unclear whether the researchers were blinded to treatment allocation. 
Face-to-face group: weekly meetings under the guidance of the same clinician used in iCBT group. Group therapy time = 4h weekly for 7 weeks. Content followed a standardized programme. 
The average total clinician time was 240min, 13× more than the iCBT patients. 
Hedman et al. (2011) [8,9]  Aim: to evaluate the clinical and cost-effectiveness of iCBT with cognitive behavioural group therapy for the treatment of social anxiety disorder. N = 126 iCBT: 15 weekly text modules with a homework component. The patient had access to a therapist via an online secure messaging system who had to restrict time spent on each patient to <10min per week. Social anxiety levels were markedly reduced in both groups. At post-treatment and 6 months follow-up, respectively, the 95% CI of the mean difference on the LSAS was 0.68–17.66 and −2.5 to 15.69, favouring iCBT. This was well within the non-inferiority margin of 10 LSAS points for the lower bound. Well-designed randomized controlled non-inferiority trial. 
Mean age: 
 iCBT: 35.2 
 Face-to-face group: 35.6 
By design, there was no randomization to an active placebo condition, so the reduction in levels of social anxiety in the two groups may have been due to regression to the mean. 
Gender, female: 
 iCBT: 38% 
 Face-to-face group: 34% 
Recruitment: via primary care physicians and psychiatrists.Setting: Sweden 
Face-to-face group: one initial individual session followed by 14 group sessions over 15 weeks. Groups were led by two therapists and had six to seven participants. 
The gross total costs were significantly reduced at 6 months follow-up, compared with pre-treatment in both groups. As both treatments were equivalent in reducing social anxiety and gross total costs, iCBT was more cost-effective due to lower intervention (therapist time) costs. 
Bergstrom et al. (2010) [11] Aim: to compare the effectiveness of iCBT and group- administered CBT for panic disorder and to establish the cost-effectiveness of these interventions. N =104 Both treatments were 10 weeks long. A majority of patients responded to treatment (defined as 40% decrease in panic disorder severity scale). Treatment effects were maintained at 6 months follow-up. No significant differences were found between the two treatment groups in terms of reduction of symptoms. By design, there was no randomization to an active placebo condition, so the reduction in levels of panic disorder in the two groups may have been due to regression to the mean. 
Mean age (SD): 
 iCBT: 33.8 (9.7) iCBT: 10 self-help modules based on established CBT principles. Homework assignments with psychologist feedback. Non-mandatory online discussion forums. 
 Face-to-face group: 34.6 (9.2) 
Gender, female: 
 iCBT: 64% Face-to-face group: 59% 
Recruitment: via psychiatrists, primary care physicians and self-referral. Screened by psychiatry nurse for presence of symptoms.Setting: Sweden 
Face-to-face group: psychologist-led self-help programme during weekly 2h sessions with the support of printed hand-outs. iCBT was more cost-effective than group treatment both at post-treatment and follow-up. Conclusions from cost-effectiveness analysis limited as calculations were solely based on therapist time. 
Carlbring et al. (2005) [12] Aim: to compare the effectiveness of individual CBT with self-help iCBT for panic disorder. N = 49 iCBT: 10 modules, 25 pages long via the web. Homework included biblio therapy, essays and assignments with e-mail feedback from therapists. Mean total time spent per participant was ~150min. Clinical effectiveness: the majority of participants reported a reduction in their symptoms post-treatment, but there was no significant difference in anxiety/panic disorder measures in the two groups. P > 0.05. Study conducted by a research group closely affiliated with the Internet programme used. 
Mean age (SD): 
 iCBT: 34.2 (6.0) 
 Face-to-face individual: 35.8 (9.3) 
Therapists only had modest experience in working with patients with panic disorder. 
Recruitment: general population via advertisement in the media.Setting: Sweden 
Gender, female: 
 iCBT: 68% Face-to-face individual: 75% 
Face-to-face individual: participants received 10 weekly individual sessions, lasting 45–60min, between which they were expected to do homework. Acceptability: most were satisfied with treatment, but felt the pace was too high, especially the iCBT group. 
Kiropoulos et al. (2008) [13] Aim: to compare an iCBT programme for panic disorder with individual face-to-face CBT. N = 86 iCBT: panic online programme and psychologist interaction via e-mail. Participants were asked to read and practice one module per week. Clinical effectiveness: both treatment arms reported improvement in their symptoms, but there was no significant difference between treatment arms for panic attacks or depression/anxiety. P > 0.05 Small sample size. Selection bias due to self-selection of participants who would be willing to use an Internet-based treatment and have ready access to the Internet. 
Mean age: 38.96 
Gender, female: 
 iCBT: 72% 
 Face-to-face individual: 73% 
Recruitment: general population via advertisement in the media and mental healthy websites.Setting: Australia 
Face-to-face individual: a 12 week manualized CBT programme during which participants attended 1h weekly sessions with a psychologist. Participants were designated weekly reading. 
Acceptability: participants rated both treatments as satisfying but participants in the face-to-face group reported higher enjoyment with communicating with their therapist. Attrition rates in the two arms did not differ. 
Author and year of publication Study characteristics Participant characteristics Intervention Results Internal validity 
Andrews et al. (2011) [10] Aim: to compare the effectiveness of iCBT with face- to-face group CBT in patients with social phobia.Recruitment: via psychiatry clinics.Setting: Australia N = 25 iCBT: shyness programme, including six online lessons, e-mails, forums, text messaging and homework. Total treatment time: 8 weeks. Social anxiety levels were reduced in both groups. Small sample size. Follow-up time of 8 weeks, may not have given sufficient time for the intervention to be effective. 
Mean age (SD): 31.9 (7.8) 
Gender, female: 41% No significant difference between the two groups (P > 0.05) in outcome measures of social anxiety and associated disability measured at 8 weeks post-intervention. 
Unclear whether the researchers were blinded to treatment allocation. 
Face-to-face group: weekly meetings under the guidance of the same clinician used in iCBT group. Group therapy time = 4h weekly for 7 weeks. Content followed a standardized programme. 
The average total clinician time was 240min, 13× more than the iCBT patients. 
Hedman et al. (2011) [8,9]  Aim: to evaluate the clinical and cost-effectiveness of iCBT with cognitive behavioural group therapy for the treatment of social anxiety disorder. N = 126 iCBT: 15 weekly text modules with a homework component. The patient had access to a therapist via an online secure messaging system who had to restrict time spent on each patient to <10min per week. Social anxiety levels were markedly reduced in both groups. At post-treatment and 6 months follow-up, respectively, the 95% CI of the mean difference on the LSAS was 0.68–17.66 and −2.5 to 15.69, favouring iCBT. This was well within the non-inferiority margin of 10 LSAS points for the lower bound. Well-designed randomized controlled non-inferiority trial. 
Mean age: 
 iCBT: 35.2 
 Face-to-face group: 35.6 
By design, there was no randomization to an active placebo condition, so the reduction in levels of social anxiety in the two groups may have been due to regression to the mean. 
Gender, female: 
 iCBT: 38% 
 Face-to-face group: 34% 
Recruitment: via primary care physicians and psychiatrists.Setting: Sweden 
Face-to-face group: one initial individual session followed by 14 group sessions over 15 weeks. Groups were led by two therapists and had six to seven participants. 
The gross total costs were significantly reduced at 6 months follow-up, compared with pre-treatment in both groups. As both treatments were equivalent in reducing social anxiety and gross total costs, iCBT was more cost-effective due to lower intervention (therapist time) costs. 
Bergstrom et al. (2010) [11] Aim: to compare the effectiveness of iCBT and group- administered CBT for panic disorder and to establish the cost-effectiveness of these interventions. N =104 Both treatments were 10 weeks long. A majority of patients responded to treatment (defined as 40% decrease in panic disorder severity scale). Treatment effects were maintained at 6 months follow-up. No significant differences were found between the two treatment groups in terms of reduction of symptoms. By design, there was no randomization to an active placebo condition, so the reduction in levels of panic disorder in the two groups may have been due to regression to the mean. 
Mean age (SD): 
 iCBT: 33.8 (9.7) iCBT: 10 self-help modules based on established CBT principles. Homework assignments with psychologist feedback. Non-mandatory online discussion forums. 
 Face-to-face group: 34.6 (9.2) 
Gender, female: 
 iCBT: 64% Face-to-face group: 59% 
Recruitment: via psychiatrists, primary care physicians and self-referral. Screened by psychiatry nurse for presence of symptoms.Setting: Sweden 
Face-to-face group: psychologist-led self-help programme during weekly 2h sessions with the support of printed hand-outs. iCBT was more cost-effective than group treatment both at post-treatment and follow-up. Conclusions from cost-effectiveness analysis limited as calculations were solely based on therapist time. 
Carlbring et al. (2005) [12] Aim: to compare the effectiveness of individual CBT with self-help iCBT for panic disorder. N = 49 iCBT: 10 modules, 25 pages long via the web. Homework included biblio therapy, essays and assignments with e-mail feedback from therapists. Mean total time spent per participant was ~150min. Clinical effectiveness: the majority of participants reported a reduction in their symptoms post-treatment, but there was no significant difference in anxiety/panic disorder measures in the two groups. P > 0.05. Study conducted by a research group closely affiliated with the Internet programme used. 
Mean age (SD): 
 iCBT: 34.2 (6.0) 
 Face-to-face individual: 35.8 (9.3) 
Therapists only had modest experience in working with patients with panic disorder. 
Recruitment: general population via advertisement in the media.Setting: Sweden 
Gender, female: 
 iCBT: 68% Face-to-face individual: 75% 
Face-to-face individual: participants received 10 weekly individual sessions, lasting 45–60min, between which they were expected to do homework. Acceptability: most were satisfied with treatment, but felt the pace was too high, especially the iCBT group. 
Kiropoulos et al. (2008) [13] Aim: to compare an iCBT programme for panic disorder with individual face-to-face CBT. N = 86 iCBT: panic online programme and psychologist interaction via e-mail. Participants were asked to read and practice one module per week. Clinical effectiveness: both treatment arms reported improvement in their symptoms, but there was no significant difference between treatment arms for panic attacks or depression/anxiety. P > 0.05 Small sample size. Selection bias due to self-selection of participants who would be willing to use an Internet-based treatment and have ready access to the Internet. 
Mean age: 38.96 
Gender, female: 
 iCBT: 72% 
 Face-to-face individual: 73% 
Recruitment: general population via advertisement in the media and mental healthy websites.Setting: Australia 
Face-to-face individual: a 12 week manualized CBT programme during which participants attended 1h weekly sessions with a psychologist. Participants were designated weekly reading. 
Acceptability: participants rated both treatments as satisfying but participants in the face-to-face group reported higher enjoyment with communicating with their therapist. Attrition rates in the two arms did not differ. 

View Large

CBT led to a reduction in anxiety symptoms in the majority of the participants in all studies included in our review. There was no significant difference between the treatment groups in the trials except one [8], where iCBT was found to be superior to group face-to-face therapy. Improvement was maintained for the periods measured in the trials (between the end of treatment and up to 6 months post-treatment).

Only two trials compared the cost-effectiveness of delivery methods [9,11] and both found iCBT cheaper due to less therapist time. Acceptability was directly measured in two trials: one compared iCBT with face-to-face individual therapy [12] and the other compared iCBT with face-to-face group therapy [13]. Participants were satisfied with their treatment but in one trial, participants reported that they found the pace of work too high especially in the iCBT group, where only 28% of participants finished all modules in the intended 10 week time frame [12]. Kiropoulos found that participants in the face-to-face group reported a higher level of enjoyment in their communication with the therapist compared with the iCBT subjects [13]. Accessibility of treatment was not reported in any of the studies.

Discussion

All modes of delivery of CBT included in this review led to an improvement in symptoms of anxiety. Internet-based CBT was more cost-effective due to a reduction in therapist time compared with face-to-face therapy, either in a group or individual setting, even when the iCBT included some interaction with therapists by telephone or e-mail. We found no randomized controlled trials comparing face-to-face CBT with any other method of delivery apart from iCBT. We found no trials comparing methods of delivery of CBT for mild-to-moderate depression in the working age group.

This review is limited by the absence of studies set in workplaces. We cannot be sure that our findings can be extrapolated to workers with anxiety disorders, particularly if they are related to work where complex factors may lead to perpetuation of their symptoms. Furthermore, the employment status of the participants was not stated in any of the studies we reviewed. Therefore, although all the participants were broadly of working age, some may have been unemployed. Unfortunately, none of the studies we reviewed focussed on accessibility, which may be an important factor in anxiety disorders where individuals may find it difficult to attend face-to-face therapy sessions.

Our finding that iCBT is effective in reducing symptoms of anxiety disorders is supported by a meta-analysis which found that iCBT was superior to the control group (who were usually on a waiting list and therefore not eligible for inclusion in our review). The number needed to treat was 2.15, but the analysis also included studies where CBT was used as a treatment for major depressive disorders [14]. This analysis also found that adherence to and satisfaction with iCBT was good. Employers are usually interested in the effectiveness of a clinical intervention in reducing absenteeism from work or improving productivity in the workplace. Although none of the trials in our review were set in workplaces, a re-analysis of data from five Australian trials, which were included in the aforementioned meta-analysis, showed that iCBT for generalized anxiety disorder (two studies), depression (two studies) and social phobia (one study) resulted in significant reductions in self-reported absenteeism compared with control groups (who were on a waiting list) [15].

All participants in the trials in our review reported that they were satisfied with their treatment. This concurs with the findings of a randomized controlled trial set in workplaces for employees with mild-to-moderate depression, which compared the clinical effectiveness of a freely available iCBT package (MoodGYM) with directing workers to mental health information websites [16]. This trial found that workers were broadly positive about using iCBT; moreover, some of the workers preferred the ‘faceless’ approach to therapy.

We recognize that anxiety may present as part of a mixed depressive/anxiety disorder, and since we found no trials comparing CBT delivery methods in working age people with mild-to-moderate depression, we can only draw conclusions on the optimal mode of delivery for working age people where anxiety is the prominent disabling symptom. The principal advantage of using iCBT as part of stepped care of anxiety disorders in workers is that for many of these individuals, attending face-to-face sessions, especially group therapy, may increase symptoms of anxiety and therefore reluctance to attend. Moreover, iCBT may be more acceptable to workers who may regard referral to face-to-face therapy as stigmatizing, due to their perception of the use of mental health services. iCBT could be provided by the employer for use at home or at work in order to allow employees the flexibility to work through the modules at their own pace and, in some cases, without the need for the worker to be put on a waiting list for face-to-face therapy. However, it may not be suitable for all. In most industries, a ‘digital divide’ of workers still exists so that some employees do not have the necessary confidence, skills or access to information technology to participate in an Internet-based treatment. Provided that caveat is heeded, our findings that iCBT with some therapist input is as clinically effective and more cost-effective than face-to-face therapy for anxiety suggest that it should be made available to workers as part of a stepped care approach for those with anxiety disorders.

Key points

  • Internet-delivered cognitive behavioural therapy with some therapist input is as clinically and cost-effective as face-to-face cognitive behavioural therapy for working age people with anxiety disorders.

  • We found no studies comparing delivery methods of cognitive behavioural therapy for people with mild-to-moderate depression.

  • There is a need to establish which method of receiving cognitive behavioural therapy is most acceptable to workers with common mental health disorders.

Conflicts of interest

None declared.

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