Internet-Delivered Psychotherapy for Anxiety Disorders and Depression

Case Study

Luke, a 44 year-old Australian man, was referred by his primary care physician to the MindSpot Clinic for treatment of his depression. The MindSpot Clinic is a national Australian treatment service that provides telephone or Internet-delivered psychological assessment and treatment services for people with anxiety disorders or depression. Assessment at the Clinic indicated that Luke had moderate levels of depression and moderate levels of generalized anxiety. The Clinic therapist discussed with Luke the nature and content of the Internet-delivered treatment, and Luke consented to treatment.

Luke was assigned to a 10-week therapist-guided Internet treatment that targeted symptoms of both depression and generalized anxiety. Luke’s physician received an assessment report from the Clinic, which included details about Luke’s symptoms and the treatment course.

Luke received automated e-mails at the start of each week, which provided details about the recommended reading and homework for that week. He logged in weekly and read all five of the assigned lessons during the 10-week course. He also received automated e-mails during treatment, which facilitated his engagement by reinforcing his progress and normalizing the challenges associated with recovery from anxiety and depression. Homework assignments, which were provided in PDF format, summarized the key points for each lesson and provided examples of how to apply the skills described in that lesson. Each week new resources were made available that addressed symptoms frequently experienced by people with anxiety and depression including managing difficulties with sleep, relationships, and communication.

Luke completed online symptom measures each week that helped his assigned online therapist monitor his progress and safety. Luke had weekly telephone contact with his therapist at the same time each week for between 10 and 20 minutes. The therapist reviewed Luke’s progress over the previous week, answered questions, reinforced progress, and helped Luke resolve difficulties that could affect his progress. The therapist also encouraged Luke to take the antidepressant medication prescribed by his primary care physician.

At posttreatment, Luke’s symptoms had reduced to the mild and asymptomatic ranges for depression and generalized anxiety, respectively. Luke’s therapist assisted him in developing goals for the next 6 months, and provided Luke with ongoing access to the online materials. Luke’s primary care physician received a report from the Clinic summarizing his activity and progress.

Clinical Context

Epidemiological surveys indicate the prevalence of anxiety and depressive disorders is high, with approximately 25% of people in the United States meeting diagnostic criteria each year (1). These conditions often have an onset in childhood or early adulthood, they are often chronic, and are associated with considerable disability (2). Epidemiological surveys also indicate that less than 50% of the people who met the diagnostic criteria for an anxiety or depressive disorder in the previous 12 months reported they had sought specialist advice or treatment in that period (3). Unfortunately, there is also evidence to indicate that fewer than 50% of people with these conditions, who also sought specialist advice or treatment, received an evidence-based assessment or intervention (4).

There are multiple barriers to treatment seeking. These include stigma and the direct and indirect costs of treatment, with examples of the latter including the time taken off from paid employment or nonpaid responsibilities to attend treatment. Factors associated with low mental health literacy are additional barriers to treatment and these include limited understanding about symptoms, limited knowledge of the existence and effectiveness of treatments, and stigma. Other barriers include difficulty accessing treatment due to the limited number of trained health professionals, particularly outside of metropolitan regions, and typically long waiting lists (5). Growing acknowledgment of these barriers and the limited ability of traditional individual face-to-face treatment to meet the estimated need has led to interest in innovative approaches to assessment and treatment (6). One strategy for improving access to treatments for people with anxiety and depression involves delivering psychological interventions via the Internet. Internet-delivered psychological interventions have evolved rapidly and extend on principles and evidence established by face-to-face psychotherapy, computerized interventions (7), and bibliotherapy interventions (8).

Internet-delivered psychological interventions vary along several continua including the extent of structure in the intervention, the extent to which a therapist follows a script, the amount of therapist involvement and contact, and the level of functionality offered by the software. For example, some Internet-delivered treatments involve considerable contact between a patient and therapist (e.g., 1–2 hours of contact time per week), others involve regular but brief contact (e.g., 5–15 minutes per week), and others are entirely self-guided. Moreover, some Internet-delivered treatments present therapeutic information in a printed format, while others include text, video, and audio clips. Recent developments in Internet-delivered treatments include the use of symptom and activity trackers accessible via a mobile phone, which may also be used to prompt and reinforce symptom management and treatment activities (9, 10).

The model of Internet-delivered treatment that has been the focus of the greatest amount of research activity is Internet-delivered cognitive behavior therapy (iCBT) (11, 12), although, to a much lesser extent, other models of psychotherapy including psychodynamic and interpersonal psychotherapies have also been delivered via the Internet (13, 14). Thus, we will focus this report on structured iCBT interventions, both therapist and self-guided, that aim to increase knowledge and awareness of symptoms, and teach practical skills to assist people to manage these symptoms. However, it should be noted that there are an increasing number of applications (or apps) which are available for monitoring symptoms and behaviors, but which are not primarily designed as a treatment [but for an exception, see Ly et al. (15)]. It should also be noted that the Internet and technology are frequently and widely used by patients and their significant others to seek information about mental health (16), and to engage in online support groups (17).

Treatment Strategy and Evidence

Most iCBT interventions require patients to generate a unique patient identifier, often an e-mail address and a password, which are used to access a secure website through which treatment materials are provided and secure electronic interaction with a therapist can occur. Increasingly, treatment materials can be accessed via smartphones or graphics tablets, however, limitations of screen size and system-related limitations of these media often restrict the amount and type of material that can be effectively delivered. During a typical iCBT intervention (see Case Study), patients are encouraged to log in at least weekly to read and revise the contents which are arranged in lessons or modules, and which are usually systematically delivered according to a timetable (18). There is considerable variation between iCBT interventions in the number of lessons or modules provided, the organization of the modules, and in the duration of the interventions, but most iCBT interventions are generally provided over 4–16 weeks. Consistent with face-to-face psychological treatments, patients are often assigned homework, which summarizes the key messages from the lessons and provides activities or tasks designed to teach new skills or consolidate key messages. Patients are also often regularly required to complete online symptom and other outcome measures relevant to their presenting problem, which facilitates the monitoring of progress, safety, and outcomes.

iCBT interventions that involve therapist contact can be loosely divided into those that involve either real-time or delayed communication with patients. Examples of the former include contact via telephone, video, or messenger services, while examples of the latter include secure e-mail or other text-based communications. In practice, however, therapists may use a combination of communication media during treatment based on patient preferences, the available media, and the risk profile of the patient. The latter point is particularly relevant for patients with changes in symptom scores that indicate a deterioration in wellbeing. Such patients usually require communication in real-time to assess safety, rather than a text-based message, which the patient may not access for several days. As indicated above, the amount of time therapists spend working with patients varies considerably between interventions. Some iCBT interventions require therapists to spend at least 1 hour per week reading and responding to writing assignments (19) or communicating with patients. Other iCBT interventions involve only minimal guidance via e-mail (or via a secure text-based communication system), which requires considerably less time than face-to-face therapy (20, 21). However, in most therapist-guided iCBT interventions therapists will log in at least weekly to review patient progress, make contact with patients, check that the patient has read, understood, and practiced the information or skills taught in the course, and assist the patient to resolve difficulties or barriers that will hinder recovery. The content and aims of such contact may be highly scripted or may be relatively unstructured and informed by general guidelines.

In addition to therapist-guided iCBT, some iCBT interventions are entirely self-guided—patients may work through them at their own pace (22, 23). Although self-guided and involving no clinician contact, these iCBT interventions may include automated but strategically timed messages, reminders, and prompts delivered via e-mail, announcements, and mobile telephone short message service messages, which aim to facilitate engagement and adherence (24).

Outcomes

More than 150 clinical trials evaluating Internet-delivered psychological treatments for anxiety disorders and depression have now been reported, many of which are randomized controlled trials (25). Meta-analyses consistently report the efficacy of these interventions in reducing symptoms of anxiety, depression, and disability relative to control conditions (26–30). One important caveat is that with few exceptions (e.g., 31, 32), therapist-guided iCBT has consistently resulted in superior clinical outcomes relative to self-guided iCBT, which is typically associated with lower effect sizes and higher dropout rates (27, 33–35). For example, one meta-analysis reported an overall effect size (Cohen’s d) of 0.41 for studies evaluating the efficacy of iCBT for depression (27). However, this effect size increased to 0.61 when studies evaluating self-guided versions were removed. Underestimating the important differences between therapist and self-guided iCBT may partially explain discordant results reported in a recent meta-analysis (36), which confounded therapist-guided and self-guided iCBT for depression and concluded iCBT for depression was less effective than reported by previous meta-analyses, which had considered these differences. Notwithstanding the previous literature, we suspect that self-guided interventions will become increasingly effective. Consistent with this, some recent studies which evaluated well-developed iCBT interventions have found similar outcomes when the intervention is offered in therapist-guided and self-guided formats (37, 38).

An inspection of outcomes for iCBT for specific disorders of anxiety and depression is instructive. In a surprisingly short time treatments have been developed and tested for depression (39–43), generalized anxiety disorder (44, 45), social anxiety disorder (46–48), panic disorder (49, 50), obsessive compulsive disorder (51, 52) posttraumatic stress disorder (19, 53, 54), severe health anxiety (55), and specific phobia (56). Although most studies have involved adults, there are also studies on children and adolescents (57, 58), older adults (59–61), and an emerging number of studies with people from non-Western backgrounds (62, 63; unpublished paper of R. Kayrouz, B.F. Dear, L. Johnston, and N. Titov). The majority of these studies have reported large effect sizes (Cohen’s d > 0.80) on symptom measures relevant to the disorders of interest, relative to control conditions. These gains have been sustained at follow-up 5 years after treatment completion (64), and patient satisfaction with treatment is often high, although it should be noted that there is considerable heterogeneity in the outcomes of self-guided iCBT.

The consistent and converging evidence for the clinical effectiveness, acceptability, and cost-effectiveness of iCBT, which includes results replicated independently by multiple research teams, provides considerable confidence in the validity of the results of iCBT. This robust evidence base has led to attempts at implementing iCBT in regular clinical settings. A recent review of iCBT in clinical settings identified four randomized controlled studies and eight open studies conducted in outpatient clinics (65). All studies clearly showed that the promising effects for iCBT in clinical trials appear to be replicated when the treatment is transferred to a regular clinic. Moreover, direct comparisons of face-to-face psychological treatment and iCBT have shown equivalent outcomes (66), with gains sustained in the long term (67).

Issues and Questions

Delivering psychological interventions via the Internet offers multiple opportunities but also raises important issues and questions. These include questions about the validity of online and automated diagnosis, the management of patient safety, the duty of care and legal issues associated with working with people across different jurisdictions, how iCBT can be integrated with existing models of care, and questions about the role of the therapist in iCBT. These questions and related issues are considered in the following sections.

An accurate and reliable diagnosis and measurement of symptoms is as important in Internet-delivered treatments as in traditional face-to-face treatments. However, a key question is whether or not a patient can be adequately diagnosed via the Internet? Similar to diagnosis in a face-to-face clinic, the answer to this question depends on multiple factors, including whether responses to questions can be checked with the patient and additional questions asked, the complexity and nature of the patient’s symptoms, and the ability of the patient to respond reliably and validly. Self-report measures of clinical symptoms can be administered via the Internet without compromising psychometric characteristics (68–70) which reduces the risk of missing items and allows crucial items to be automatically highlighted for the clinician, including questions about elevated suicide risk. The additional advantages of online administration of questionnaires are that summary scores can be automatically generated and algorithms developed to help therapists monitor progress and actively intervene in cases where a patient’s symptoms are increasing in frequency, severity, or both. Notwithstanding these advantages of online administration, at this point in time, there remain important outstanding questions about the validity of diagnoses created by automated online questionnaires. Where possible the validity of responses to online questionnaires should be checked, particularly in cases where comorbidity and the complexity of symptoms raise questions about likely diagnoses. This additional interview can take place by telephone, video, or face-to-face, which will not only increase the validity of conclusions about diagnosis, but will also facilitate the quality of recommendations about treatment options for the patient.

Patient Safety

A key priority for all mental health services is the assessment, monitoring, and management of patient safety before, during, and after treatment. To date, there is no evidence to indicate that iCBT is associated with increased risk to the safety of patients, but negative effects have occasionally been reported (71). Indeed, there are several aspects of iCBT which may facilitate the assessment, monitoring, and management of patient safety (72). First, regular monitoring of symptoms may reduce the risk of significant deterioration, decompensation, or crisis in patients by identifying patients who are beginning to deteriorate before they reach crisis. Second, such monitoring, combined with informed decision rules based on patient characteristics and treatment progress can be used to develop an escalating series of responses and actions by a therapist, designed to help maintain patient safety in an evidence-based manner, and to identify patients who require other or more intensive forms of treatment. Third, iCBT systems can provide a wealth of data about a patient’s use of and engagement with the treatment intervention, which when combined with data about symptoms, can be used to generate automated alerts and systems to inform clinical supervision, especially for high risk patients. Similar to face-to-face mental health services, an outstanding challenge for iCBT is how to manage patients with elevated symptoms who withdraw from treatment and do not respond to attempts at contact by the therapist. Such risks can be mitigated by making safety plans a condition of use of a service and by informing primary health care practitioners about their patient’s engagement or disengagement with the iCBT service. Such safety plans can include consenting that a therapist will contact significant others in situations where a patient’s safety appears to be at risk.

By virtue of its innovative nature and ability to provide services across traditional geographic and jurisdictional boundaries, iCBT often raises questions about clinical and legal governance (73). For example, an iCBT service may provide treatment to patients in different states or even countries, and each jurisdiction may have different requirements or guidelines about clinical governance, duty of care, health professional practice regulations, indemnity, information technology (IT) security, and storage of health records. Although some of these questions and challenges are similar to those experienced by other industries providing services via the Internet, including online sales and marketing services, health services often have more stringent privacy regulations than other industries. For these reasons, readers are strongly encouraged to seek advice and guidance from their legal teams before providing online mental health services.

Role of the Therapist

iCBT also raises questions about the nature of psychotherapy and the validity of assumptions about the role and importance of the therapist for successful psychotherapy. For example, one key but generally unspoken assumption in psychotherapy is that the therapist is essential for effective treatment, and that therapist training, expertise, and skill are the most important predictors of clinical outcomes (74). On the one hand, the results of meta-analyses of outcomes of iCBT are consistent with this assumption. For example, meta-analyses consistently show that iCBT interventions that include therapist-guidance achieve better outcomes than self-guided treatments (33–35). On the other hand, the results of several studies indicate that patients who are able to persevere with self-guided iCBT may obtain significant benefits. Consistent with this, there is an emerging body of literature indicating that self-guided treatments that use automated reminders, which provide encouragement, can result in high adherence rates and good clinical outcomes (31, 75), and that such reminders can be particularly helpful in the early stages of treatment (32). Notwithstanding these results, there are important advantages to guided iCBT. First, a therapist can conduct an assessment, which will help determine the suitability of iCBT for a patient and, if suitable, can help prepare the patient for participating in iCBT. Second, the therapist can tailor an intervention for a patient’s specific symptoms and difficulties and can assist the patient to identify and address barriers to engaging in treatment or address difficulties with applying the intervention to their situations. Related to this, when a patient communicates with a therapist via text messaging or secure e-mail, the therapist can consult colleagues and other experts before answering and providing feedback (76). Third, there are clear indications that support increases adherence and prevents dropout, an important issue given that at least some self-guided interventions have suffered from high dropout rates (e.g., 77). Fourth, therapists can actively recommend and assist patients to access other services, including social, health, and crisis services, prior to, during, or after iCBT. There remain outstanding questions in the literature about the timing of support with one promising line of research indicating evidence of benefit when support is offered either before or after treatment, or on demand (78).

Approaches to Use

In addition to questions about when therapist support should be provided, there are also questions about the optimum frequency and form of therapist support that should be provided. Although earlier reviews indicated a dose-response relation between the duration of therapist support and the clinical outcome, more recent results indicate that outcomes for treatments in which substantial support is given do not appear to differ from treatments which include 10 minutes or less of therapist time per client per week (79). Studies also indicate that equivalent clinical outcomes can be obtained whether support is provided by an expert therapist or nonexpert coach, providing the latter is under careful clinical supervision and the iCBT is highly structured and has been previously evaluated with expert therapists (39, 80–82). This body of research is important given the shortages of mental health professionals in many parts of the world. It is unclear whether similar outcomes can be obtained with less-structured interventions. These issues are inherently related to the cost-effectiveness of iCBT. Guided iCBT has been reported to be cost-effective relative to traditional treatments administered face-to-face (83, 84). However, the provision of guidance is indeed more costly than self-guided treatments, and self-guided treatments with small clinical effects can still be cost-effective (85). Thus, from a public-health perspective, the minimal costs of providing iCBT without guidance can, in some cases, be justified if they are safe. However, more research is needed; in particular, it would be helpful to conduct comparisons of the effects of less costly forms of guidance such as from carefully trained and supervised coaches, peers, and from models of support that are provided on-demand.

There are other outstanding questions regarding the type of therapist support required to optimize outcomes, including questions about the relevance of therapist factors to iCBT, which are widely held to be important in face-to-face treatments (86). Several studies indicate small or no differences in outcomes between therapists in iCBT (87, 88). However, other studies indicate that some therapist-related behaviors are important. For example, in a study in which the therapist correspondence was coded, it was found that a lenient attitude toward homework was associated with worse clinical outcome (21). Consistent with this, observations from our online research and clinical work indicate that better outcomes are associated with adherence to clinical scripts and workflows, which direct patients to key material and minimize therapist drift.

Therapeutic alliance is another factor that is widely regarded as important in psychotherapy outcome research, and an emerging body of literature has explored this issue in the context of iCBT. Several studies have collected data from patients on how they rate the therapeutic alliance with their online therapists (89), and most show no association with outcome, even if alliance ratings tend to be fairly high (90, 91). There are a few studies in which alliance early in the treatment predicts outcome (92, 93), however, we suspect that therapeutic alliance is likely to be more important in less structured iCBT.

Integration of Existing Services

An additional set of questions relate to how therapists might actually use iCBT in their own practice. At least three approaches can be taken. First, therapists can use aspects of technology to create their own iCBT. This might involve the use of the telephone, video conferencing, and e-mail or instant messaging technology, combined with online questionnaires, written treatment materials, and other treatment resources. Second, therapists may elect to simultaneously provide a patient with psychotherapy, while referring that patient to receive iCBT from another service for problems other than those addressed by the therapist. For example, a therapist may elect to provide a patient with psychotherapy addressing relationship distress, while referring the patient to receive iCBT to address a depressive disorder. To our knowledge, the efficacy of this combined approach has not been systematically explored. Anecdotally, our experience is that patients have a threshold for the amount of therapy they can tolerate and, in some cases, participating in more than one therapy at a time may result in conflicting messages between therapy sources, a sense of overload, poor compliance, and therapy burnout. A related approach that we have observed, which has been more successful, is when a therapist provides a patient with face-to-face treatment, but uses the content and structure of an existing iCBT intervention to guide therapy and homework tasks. A third approach is to sequence iCBT and face-to-face treatment within a stepped-care model. For example, where iCBT is used as a first treatment step followed by more intense face-to-face treatments when needed (94). However, this may be more appropriate when self-guided iCBT constitutes the first step and to a lesser extent when guided iCBT is the first step. Our experience is that configuration may also occur in the opposite direction, that is, patients who have failed face-to-face treatments may subsequently improve following iCBT. Such cases are likely to reflect issues associated with treatment readiness rather than about any specific modality of treatment. Nevertheless, more research is needed to address these issues and explore the optimal use of iCBT in stepped-care models.

A final and related set of questions concerns how iCBT can be integrated with existing mental health services. On the one hand, this is a simple question as individual therapists may develop their own iCBT intervention or use an existing one. On the other hand, this is a complex question and requires consideration of the local existing services and the gaps in those services. For example, many mental health systems prioritize resources to the most severe patients, including those with psychotic disorders. In such systems services for people with anxiety disorders and mild to moderate levels of depression are often considered lower-funding priorities and such people may thus remain underserved by existing services. In such situations iCBT represents a promising strategy for increasing the capacity of existing services to provide clinically effective treatments to such people. Two promising examples of iCBT services that have attempted to integrate into regular health care include the Internet Psychiatry Unit in Stockholm, Sweden, and the MindSpot Clinic (www.mindspot.org.au), which provides services nationwide in Australia. Another promising example of using iCBT is following face-to-face therapy as a way to reduce relapse rates (95). This may be a way to prevent relapse, as it is well known that for many psychiatric problems relapse occurs even after successful therapy. Notwithstanding such examples of how iCBT can be implemented, there is a considerable effort required to educate mental health professionals about the strengths and limitations of such services before they are accepted and integrated more broadly into regular health care systems.

Recommendations

It is highly likely that iCBT will play an increasing role in the provision of mental health services. This section describes our recommendations for the safe and effective use of iCBT in clinical practice.

An obvious but important starting point for mental health professionals who wish to use iCBT is to become familiar with the interventions and their evidence base. Although we expect the situation will change, at present, the majority of iCBT interventions are directed at patients who do not intend to see a mental health professional and who wish to use a self-guided intervention, although therapist-guided iCBT is becoming increasing available. Key information mental health professionals should consider when evaluating iCBT interventions include comparing the published results for the interventions based on clinical trials with the published results for the interventions based on use in the iCBT service. Other key information includes completion rates, dropout rates, and acceptability to patients. This will help the mental health professionals to identify iCBT interventions which are only effective and acceptable with a small percentage of the population versus those with more promising attributes. We also encourage mental health professionals to consider the range of symptoms or disorders targeted by an iCBT intervention. This latter point is important, as with few exceptions, the majority of commercially available iCBT treatments target general symptoms of anxiety and depression, and may not target conditions such as obsessive behavior, compulsions, or symptoms related to trauma.

Mental health professionals should also aim to familiarize themselves with the content and structure of iCBT interventions they may use or refer patients to, as this will facilitate their discussions with patients about using iCBT as a treatment option. This will also facilitate discussions with patients about the advantages and disadvantages of using iCBT and allows for the development of realistic expectations. Our experience is that a large proportion of patients with anxiety and depression benefit from iCBT, providing they understand what is required and have the necessary time and resources to actively participate.

Should a mental health professional decide to refer a patient to a therapist-guided iCBT intervention provided by an external service, it is recommended that consideration be given to issues relating to duty of care and clinical responsibility. One strategy for clarifying these issues is to seek written confirmation of who has duty of care, and when it is transferred. This will facilitate safe and effective management of the patient, who should also receive written confirmation about who is managing their care. The mental health professional should also inquire about the ability of the iCBT service to provide clinical reports or updates detailing their patient’s engagement and progress through the iCBT treatment.

Another key recommendation is that mental health professionals maintain realistic expectations about iCBT and that these expectations are clearly communicated to their patient. iCBT will teach the patient specific skills, which they can apply to help manage their symptoms, often with support from a therapist who can help tailor the materials. However, some patients prefer less structured therapy and may not benefit from iCBT. Moreover, given the complexity of the human condition, iCBT is not a panacea, and like other psychotherapy, requires time and commitment by the patient. Should therapy not start to be effective within 3 to 4 weeks, we strongly encourage discussion with the patient about barriers to their engagement, and whether other treatment services or models would be more helpful. We are cautious, however, of referring patients to other services until we have helped a patient identify barriers to treatment success, because unless resolved, these barriers are likely to affect their engagement with other treatments.

With respect to mitigating risk associated with legal or IT issues, as indicated above, we strongly recommend that mental health professionals seek guidance from their employer or legal and IT advisors before using iCBT within their practice. The issues described in the previous sections may help direct these discussions. Mental health professionals may also find it helpful to consult their professional or regulatory body, which may have developed guidelines and protocols for the safe and effective use of iCBT and related technology. Because of rapid developments in this field, such guidelines and protocols are likely to be regularly updated and, therefore, should be regularly reviewed. IT specialists should be consulted about relevant legal requirements and best-practice models for information collection, storage, back-up, destruction, and restoring systems in the event of an IT failure. Our experience is that these legal and IT issues are complex, change frequently, and require support and advice by specialists.

In conclusion, and notwithstanding the considerable challenges and outstanding questions about how iCBT can be most effectively employed, we foresee that Internet-delivered psychological treatment will eventually blend with face-to-face services. Such blended mental health services should represent the best features of face-to-face and iCBT services, with the latter helping to increase access to evidence-based care for people who might not otherwise receive or seek treatment.