As the COVID-19 pandemic is accelerating the use of digital health technologies, researchers are exploring the application of these technologies in the mental health space. In a recently published systematic review and individual patient data network meta-analysis (NMA), scientists found strong evidence that treating depression with guided internet-based cognitive behavioural therapy (iCBT) was associated with more effectiveness than unguided iCBT. But more importantly, they discovered that both iCBT modalities outperformed the treatment as usual (TAU) and waiting list regardless of depression severity.
These recent findings are phenomenal for the expansion of options available for the treatment of global mental health disorders such as depression. One major conclusion is that unguided iCBT can improve long-term outcomes when patients don’t have access to guided iCBT, for example in situations where patients have constrained economic and employer resources.
Depression: A Global Disability
About 322 million people—4.4% of the world’s population—are living with depression, according to the World Health Organization (WHO). Depression is a serious mood disorder that influences how patients feel, think, and deal with everyday activities like sleeping, eating, or working. It is the largest contributor to global disability and a major contributor to suicide deaths.
Traditional depression treatments typically include psychotherapy, pharmacotherapy, and adjunct interventions. However, psychotherapy is not available to most populations in the world because of costs, lack of trained clinicians, and stigma. Also, the COVID-19 pandemic has led to the displacement of many psychotherapy services that were available in the past.
Today, depression treatments, such as cognitive behavioral therapy (CBT), are increasingly delivered as online therapy for depression. According to Dr. Derek Richards, Chief Science Officer of Silvercloud Health, “In the last 12 months there has been a growing interest in the use of digital mental health interventions.”
Guided Versus Unguided Internet Cognitive Behavioral Therapy (iCBT)
In this systematic review, unguided iCBT was defined as CBT delivered via the internet where automated and technical support was permitted, but not support related to the therapeutic content.
Guided iCBT was defined as CBT delivered via the internet that involved therapeutic support, either synchronous or asynchronous, delivered by a professional or a paraprofessional (nonspecialists in mental health care but trained to deliver iCBT).
Investigating the Relative Efficacy of Guided Versus Unguided iCBT for depression
Below, we describe the key findings of this NMA that combined data from 36 studies about iCBTs for depression worldwide. There were 8107 participants with symptoms of depression from 12 countries.
The authors focused on the differential effects of the examined interventions on depression symptom severity on the Patient Health Questionnaire–9 (PHQ-9) at posttreatment. The PHQ-9 was the most commonly used scale across the eligible studies (available for 4703 participants across 15 studies). Other depression scales were converted into PHQ-9 scores using established conversion algorithms.
Key Findings:
The researchers found strong evidence that baseline depression severity was associated with effect sizes for guided and unguided iCBT, such that the higher the baseline severity, the larger the benefit of therapeutic guidance.
Also, using individual patient data (IPD), the researchers showed that treating depression with guided internet-based cognitive behavioural therapy (iCBT) was associated with more effectiveness than unguided iCBT.
Additionally, the benefits of guided iCBT were more substantial in individuals with moderate to severe depression. In individuals with mild/subthreshold depression, the effectiveness of guided and unguided iCBT was similar.
Interestingly, both iCBT modalities outperformed the treatment as usual (TAU) and waiting list regardless of depression severity.
Perhaps the most important discovery was that although guided iCBT was more effective than unguided iCBT, the differences between both treatments diminished over the long-term. This means that unguided iCBT can improve long-term outcomes when patients don’t have access to guided iCBT.
Conclusion
This NMA has shown that guided iCBT is associated with more effectiveness than unguided iCBT for individuals with moderate to severe depression. However, the authors established that unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. This means that many people living with depression may still benefit from iCBT without therapeutic guidance, expanding treatment coverage worldwide.
The results speak clearly to a “digital-first” approach that can encompass public mental health or population health interventions to target prevention and subthreshold symptoms and further the ability to step-up to a supported intervention if symptoms are moderate or severe. These results contribute to the growing research base that is supporting digital mental health interventions like Silvercloud Health.
Integrate Digital Mental Health Platforms like Silvercloud Health
Silvercloud Health is a global leader in developing and delivering mental health and wellbeing interventions. The adoption of digital mental health platforms like Silvercloud is supported by an increasing and robust empirical base supporting their effectiveness in the treatment and management of mental health and wellbeing.
Clinicians, health systems, and employers should choose digital mental health platforms like Silvercloud Health to target prevention and decrease mild/subthreshold symptoms of depression in the long term
