The option holds promise for those deterred from treatment by distance, cost, and stigma.


Article Content

As the COVID-19 pandemic prevented many people from obtaining in-person care, it simultaneously spurred experimentation in substituting telehealth for office visits. Results varied, depending on the type of clinical problem, but one area in which internet-based treatment has been a verified success is in the delivery of cognitive behavioral therapy (CBT) for depression.


The development carries potential for treating many more people with depressive symptoms than ever before. Depression is extremely common, affecting 16.6% of the population at some point in their lives, and it is considered a major public health issue. Yet even before the pandemic, millions of people went untreated annually. Reasons include cost, lack of access to trained clinicians, lack of health insurance, and perceived stigma.


CBT is a form of psychotherapy that teaches patients cognitive and behavioral skills to reduce depressive symptoms. Technological advances have made it possible to deliver CBT over the internet (iCBT) in two forms, guided and unguided. Guided iCBT programs offer modules for the individual to work through along with therapeutic support via e-mails, texts, and/or brief phone calls from mental health professionals or trained paraprofessionals. Unguided iCBT programs offer the modules without additional therapeutic support.


A recent study in JAMA Psychiatry evaluated results from published randomized clinical trials of iCBT. Among 36 studies involving 8,107 participants with depression, guided iCBT was compared with unguided iCBT, and one or both forms of iCBT was compared with a control.


Both guided and unguided iCBT reduced symptoms of depression compared with "treatment as usual" or waiting, and results persisted six months and 12 months later. While guided iCBT was more effective than unguided CBT initially, the differences diminished after six and 12 months.


Results for mild depression were similar with guided and unguided iCBT. For moderate, moderately severe, or severe depression, guided iCBT was more effective at improving symptoms than unguided iCBT.


The researchers cautioned against viewing iCBT as a one-size-fits-all therapy, particularly in patients with moderate to severe depression for whom clinicians might choose to offer only guided iCBT programs. Still, the ability to use iCBT from home-and complete the modules at times that are compatible with work or caregiving schedules-holds promise for wider access to depression treatment.-Joan Zolot, PA


Karyotaki E, et al JAMA Psychiatry 2021;78(4):361-71.