Online Psychiatric Counseling Appears Effective

Aug. 22, 2009— -- If you're feeling depressed but can't see a shrink in person, the next best thing may be instant messaging, according to a new British study.

Online cognitive behavioral therapy for depression -- with patients and therapists communicating in real time via instant messaging, or IM -- was not only effective, but could broaden access to treatment, researchers reported in the Aug. 22 issue of The Lancet.

After four months, 38 percent of patients who had participated in the Internet-based therapy program had recovered from depression, compared with 24 percent of those in a control group, according to Dr. David Kessler of the University of Bristol.

After eight months' follow-up, 42 percent of the treatment group -- but only 26 percent of controls -- had recovered.

Researchers said they undertook the study because of a "growing unease" about the increasing use of antidepressant medications and the lack of availability of psychological treatments such as cognitive behavior therapy (CBT), particularly in remote areas.

CBT is an approach to depression and other ailments aimed at identifying and modifying harmful, negative thinking patterns and the behaviors associated with them.

Studies and actual practice have already shown that CBT does not need to be delivered in a face-to-face setting. Telephone-based CBT programs with live therapists have been proven effective, the study's authors noted. On the other hand, they noted, computerized self-help programs -- in which software acts as therapist -- are inflexible, and patients are unlikely to keep up with them.

To investigate whether CBT with a therapist online is feasible and effective, Kessler and colleagues undertook a controlled trial which included 297 patients, aged 18 to 75, whose scores on a standard assessment know as the Beck Depression Inventory (BDI) were 14 or higher. About two-thirds were women.

Almost all had additional psychiatric diagnoses, such as generalized anxiety disorder, and more than two-thirds had baseline BDI scores higher than 28, indicating severe depression.Patients initially were assessed in person, and then randomly assigned to online CBT, or placed on an eight-month waiting list for live CBT, plus usual care from their primary care physician.

Internet Psych Counseling Shows Promise

Treatment online consisted of up to 10 sessions, each lasting 55 minutes, which were to be completed within 16 weeks if possible. At least five sessions were expected to take place by the first assessment at four months.

The primary goal was a BDI score below 10, representing recovery.

At four months, BDI scores had fallen from a average of 32.8 in the intervention group to 14.5, while scores in the control group decreased from a mean of 33.5 to 22. At eight months, the average BDI scores were 14.7 and 22.2, respectively.

Further analysis suggested that the therapy was most effective with patients who were the most severely depressed.

The investigators said online CBT may actually enhance the therapeutic effect of psychotherapy because written expression gives patients the opportunity to reflect, and a transcript of each session is available for review.

In an accompanying editorial, Dr. Gregory E. Simon and Dr. Evette J. Ludman of the Group Health Research Institute in Seattle noted that this type of treatment works well in depression, but that only a "tiny fraction" of patients who could benefit from it actually get it.

The also described some the challenges and opportunities offered by online communication.For example, while there's a loss of visual, nonverbal communication, the increased flexibility of IM allows more frequent contact, they said. Moreover, there is a potential shift in authority and control from the therapist's office to the patient's home.

Increased access to psychotherapy and lower costs using new communication technologies "could provoke some much-needed disruptive innovation in psychotherapy," they wrote.

"Traditional therapists might be horrified by the prospect of an overseas cognitive-behavioral call center or live-chat center, available whenever patients choose. But the expectations of health-care providers are not the same as evidence," they concluded.