Global Psychiatrist Shortage – iCBT option

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A SERMO physician discusses how internet CBT may help treat depression with the global psychiatrist shortage issue healthcare is facing.

Computers and technology continue to make inroads in medicine.  Some technology is time-consuming and an interference for physicians (discussed many times on SERMO).  However, computer-assisted CBT has been shown to be an effective treatment for depression, much needed in areas without psychiatrists.

I first became aware of the use of computers to evaluate depression when Greist and Jefferson opted to computerize specific depression inventories. (1)  Greist, and colleagues in Madison, WI, collaborated with Isaac Marks of the UK, developing an IVR in 1998 which has been updated, but still allows patients to call in and work with a computer aided program to record feelings and symptoms of depression.

Does technology have a role in the evaluation and treatment of depression?  Given the shortage of psychiatrists, researchers who span the globe have evaluated internet cognitive behavioral therapy (iCBT) as a treatment of mild to moderate depression.  This iCBT is usually therapist guided, and will consist of 7 to 8 structured modules.  Patients communicate with the therapist via the internet or email and receive homework assignments.  The use of iCBT does not dismiss the roles of psychiatrists.  Researchers note that the patients they have treated with iCBT would otherwise be waitlisted.  Also, iCBT can remove burdens from the psychiatrist, and can be used in a primary care setting when no psychiatrists are available. (2, 3, 4, 5)

The 21st century has brought global analyses of physician-guided internet “treatment” for depression compared to weekly (CBT) with a psychiatrist.  Research has been conducted in Australia, the U.S., the U.K., Sweden, New Zealand, and Switzerland.  Findings across studies are similar, demonstrating that physician-guided internet treatment works as well as CBT for treatment of mild to moderate depression.

Birgit, et al. (6) from the University of Zurich, Switzerland randomly assigned 62 patients to therapist directed internet CBT or 8 weeks of face to face CBT.  After each therapy session, patients receiving internet-based treatment were instructed to complete one predetermined written task, such as questioning a negative self-image.  Patients who received the internet treatment and those with face to face CBT both had 50% reductions in symptoms of depression.  Interestingly, only the internet group had a long-term reduction in symptoms (6).  Similar results were reported by Titov, et al. of Australia / New Zealand.  Titov et al. (7) went a step further and compared physician-assisted iCBT to technician-assisted iCBT.  They found comparable improvement between the two groups.

How do patients respond to the computer interactions vs. face to face treatment with physicians?  Investigators found that iCBT was well accepted by both patients and physicians involved with the treatment.  Gun, et al. of Australia explored levels of acceptability of internet treatment programs for depression.  Over 75% of patients and physicians expressed acceptance.  Patients with mild to moderate depression had the highest satisfaction scores, while those with severe depression did not do well and dropped out of the program (8).

There is a significant body of research on iCBT, with sample size varying from small to medium.  The results have been reproducible in different settings and across continents.  An excellent review of iCBT trials was completed by Isaac Marks, MD (9), a world renowned psychiatrist, practicing in the UK, and formerly from South Africa. Appropriate selection of patients to those with mild and moderate depression vs. severe depression is essential.  For those who do not have access to a psychiatrist, or where the wait is long, iCBT is an acceptable treatment and can be conducted in a primary care setting.

Bibliography

  1. Greist, JH and Jefferson, JW. Healthcare Technology Systems, Inc., Madison, WI and the University of Wisconsin. Personal communication.
  2. Andersson G: Using the internet to provide cognitive behavior therapy. Behav Res Ther 2009, 47:175–180.
  3. Ritterband et al. Directions for the International Society for Research on Internet Interventions (ISRII).  J Med Internet Res 2006, 8:e23
  4. Kessler et al. Therapist Delivered Internet Psychotherapy for Depression n Primary Care. A Randomized Controlled Trial. Lancet 2009, 374:628–634
  5. Andersson et al. Development of a New Approach to Guided Self Help Via the Internet.  The Swedish Experience. J Technol Human Serv 2008, 26:161–181
  6. Birgit, et al. Internet Based versus Face-to-face Cognitive Behavioral Intervention for Depression: A Randomized Controlled Non­Inferiority Trial. J Affect Disord. 23 July 2013
  7. Titov, et al. Internet Treatment for Depression: A Randomized Controlled Trial Comparing Physician vs Clinician Assistance.  PLoS One. 2010 Jun; 5(6):e10939. doi: 10.1371
  8. Gun, et al. Acceptability of Internet Treatment of Anxiety and Depression.  Australas Psychiatry. 2011 Jun;19(3):259­64
  9. Marks, I, et al. Hands-on-Help: Computer-aided Psychotherapy.  Maudsley Monographs number 49.  Psychology Press.  2007

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