Computer assisted cognitive behavioural therapy is likely to be ineffective in the treatment of depression because of low patient adherence and engagement, suggests the largest study of its kind published in The BMJ this week.
Current NICE guidelines recommend cCBT as a treatment for depression. But in light of the new findings, the authors say "the routine promotion and commissioning of cCBT be reconsidered" because it is "likely to be an ineffective form of low-intensity treatment for depression and an inefficient use of finite healthcare resources."
Cognitive behavioural therapy (CBT) is considered an effective "talking treatment" for depression, but is not always immediately available in the NHS. Computerised CBT (cCBT) has recently been developed and to increase access to this form of treatment.
However, it is unknown how effective cCBT is for patients with depression in a primary care setting, where most depression is managed, and the two most widely used computer programmes have not been compared.
So a team of researchers from the University of York carried out a randomised control trial to assess the effectiveness of cCBT when added to usual GP care, and compare two commonly used CBT packages to see if these have additional benefits.
In total, 691 patients with depression from 83 general practices across several locations in England were enrolled in the REEACT study. Each patient was randomly assigned to one of three groups: to receive usual GP care, or to receive usual GP care with one of two cCBT packages.
The groups were well balanced in terms of age, sex, severity and duration of depression, use of antidepressant drugs, and educational background.
The cCBT packages were the commercial "Beating the Blues" and the free-to-use "MoodGYM", and these consisted of eight and six 1 hour sessions respectively, and both encouraged homework between sessions.
Patients were called by a technician on a weekly basis to provide encouragement and support to complete the programmes.
Each patient's depression and health-related quality of life were assessed at 4, 12 and 24 months.
Results showed that cCBT offered little or no benefit over usual GP care. By four months, 44% of patients in the usual care group, 50% of patients in the Beating the Blues group, , and 49% in the MoodGYM group remained depressed.
"The main reason for this was low adherence and engagement with treatment, rather than lack of efficacy," explain the authors, and despite the "high level of technical support and weekly encouragement to use the computer packages" that formed part of the study.
Computer login records were analysed and showed that 83% of patients assigned to Beating the Blues, and 77% of MoodGYM participants accessed the programmes after allocation.
However, only 18% of patients completed all eight sessions of Beating the Blues, and 16% completed all six sessions of MoodGYM.
Almost a quarter of patients dropped out of the study by four months.
The study found that patients were "generally unwilling to engage with computer programmes, and highlighted the difficulty in repeatedly logging on to computer systems when clinically depressed."
"Participants wanted a greater level of clinical support as an adjunct to therapy, and in absence of this support, they commonly disengaged with the computer programmes," explain the authors.
Furthermore, the commercially developed Beating the Blues programme offered no benefit over the free-to-use MoodGYM. "This is an important finding for those who commission services and purchase commercial products on behalf of publicly funded health services," they say.
In an accompanying editorial, Professor Christopher Dowrick at the University of Liverpool says the evidence from this trial "is not in itself sufficient to overturn existing guidelines" but the findings "do have important implications."
He argues that many depressed patients "do not want to engage with computers, they prefer to interact with human beings" and believes the lack of patient engagement "suggests that guided self help is not the panacea that busy GPs and cost conscious clinical commissioning groups would wish for."
However, he urges GPs to remember that "their own contact with patients can be therapeutic" and that, in this context, "if patients make a positive choice in its favour, then guided self help is likely to remain a useful intervention."