January 25th, 2016 by

Comment on: “Computerized cognitive behavior therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomized controlled trial”, Gilbody S et al, British Medical Journal BMJ 2015;351:h5627

This is an important study that sought to evaluate cCBT for the treatment of depression in primary care settings. The study was conducted in the United Kingdom, where cCBT has been promoted and reimbursed by the National Health Service since 2006. Depression is a common illness and most patients are treated by primary care physicians rather than specialists. Antidepressants are frequently offered to patients, but access to psychotherapy and other forms of treatment for depression is often quite limited.

Previous studies of cCBT tend to support the efficacy of this intervention, however these studies have been criticized for having small sample sizes, highly selected participants (in that they may be from academic settings and screened for complicating factors that are common in the “real world”), and for lack of bias (in that they are often supported by companies with a commercial interest in the outcome).

The REEACT study was a “real world” study conducted at large primary care practices in various parts of the United Kingdom.  Patients with depression were randomized to receive: usual care from primary care physicians, usual care supplemented by a commercial cCBT (Beating the Blues) or usual care supplemented by a “free to use” cCBT (MoodGYM). Incidentally, both Beating the Blues and MoodGYM have been reviewed favorably by PsyberGuide. Follow-up data were collected at 4, 12 and 24 months after randomization. Patients assigned to cCBT received weekly support phone calls from trained technicians.

After entering the study, follow-up data were obtained for 76% at 4 months, 70% at 12 months, and 67% at 24 months. Thus, almost one quarter of the subjects had dropped out by 4 months. At four months, 50% of people using Beating the Blues, 49% of people using MoodGYM and 44% receiving usual care were still depressed. Therefore, the authors concluded that there was no demonstrable benefit for any of the three treatment arms. There also did not appear to be differences at 12 and 24 months. Most interestingly, the median number of sessions completed for Beating the Blues was 2, and for MoodGYM was 1. Only 18% of patients completed all 8 sessions of Beating the Blues and only 16% completed all 6 sessions of MoodGYM.

The authors conclude that cCBT programs appear to be effective when they are led by developers but do not appear to be effective in an independent study in a standard primary care setting. They believe that the main reasons for the negative study were low adherence and engagement rather than lack of efficacy.

This study raises several questions for me:

  1. Can depression be treated reliably in primary care settings? I think “high contact” specialty care will be necessary for most patients with significant depression.
  2. Can we develop computer programs that are engaging enough to overcome the inertia and lack of motivation that are part of depressive illnesses?
  3. If “high contact” care is needed for patients with major depression, can therapies delivered on-line (such as tele-psychiatry or on-line social networks of support) solve our access to care issues and be more effective than cCBT?

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