As I recall, some influential people in NICE and/or the NHS really wanted this to work because it's vastly cheaper and more available than in-person CBT. This result is consistent with a longstanding but controversial hypothesis that the overall quality of the therapist-client relationship is far more important than the nuts and bolts of whatever theory the therapist follows [1].
Here's one relevant quote: "The effectiveness of stand-alone bibliotherapy was evaluated in five published studies by a team of investigators headed by Dr. Forrest Scogin from the University of Alabama. These researchers evaluated the effectiveness of Dr. David Burns' "Feeling Good" as well as Dr. Peter Lewinsohn's "Control Your Depression," as self-administered treatments for depression. The investigators concluded that Feeling Good was as effective as a full course of individual psychotherapy or as treatment with the best antidepressant drugs."
I played with a free online cbt and got much further than their average participant in this study.. I'm not sure if there is any use to cbt for depression, but I would suspect that it would work better in a preventative fashion.
I.e. I did notice that I can let thinking about some social interactions go where they would bother me in the past, but if I was depressed when I played with it, then maybe I would just notice how bad I was at benefiting from CBT at the moment where I should be letting something go.
The study did not seem to separate the results of those who completed online CBT from the majority who did not.
An interesting excerpt:
"Take-up of computerised CBT was low, despite regular calls to encourage participants to use the programmes. The median number of sessions completed was two out of eight for Beating the Blues and one out of six for MoodGYM. Only 18% of people who started Beating the Blues completed all modules and 16% for MoodGYM."
Online CBT definitely is not effective if patients don't complete it despite receiving phone calls. I can imagine that getting the motivation to log in and do it is really difficult when you're already feeling hopeless-- even not-depressed people have enough trouble building and sticking to habits as it is.
But I still wonder if online CBT was effective for the small portion of participants who did complete it? What were the characteristics of those who did complete the app? Perhaps we can learn something.
CBT app builders should also consider that self-care options for depression have existed for a long time in the form of books. Can an app do a substantially better job than books? The idea of solving medical issues remotely has been tried for decades.
> But I still wonder if online CBT was effective for the small portion of participants who did complete it?
MoodGym and Beating the Blues have some evidence behind them. NICE was recommending Beating the blues because they have some evidence of efficacy for it.
Maybe there's a simple fix. Something like Flo to keep people engaged with it, or some kind of gamifaction.
> NICE was recommending Beating the blues because they have some evidence of efficacy for it.
You know how 'traditional chinese medicine' came about? Mao needed to invent something to give to the peasants that wasn't expensive as real health care.
Really off topic, and I'm probably being pedantic, but I don't see the conclusion that you've given from what's presented in the article, re: blaming Mao for the modern ideology that perpetuates chinese medicine. I mean, it's true that a dialectical approach would probably lead to the adoption of most ideologically useful form of medicine, but a distinct separation of 'chinese medicine' and 'western medicine' seems directly antithetical to what Mao was saying... the fact that Mao wanted to address rural/traditional medicine and integrate into a medical tradition doesn't imply that Mao is the reason for orientalism and mysticism with regard to that medicine, especially since those things obviously far predate Mao.
This is obviously refuted by the fact that Chinese ex-pats associated with the KMT in Taiwan (i.e. the very people who fled Mao) have been practicing "traditional Chinese Medicine" to varying degrees since their pre-Mao childhoods. To believe that Slate article is to believe that somehow Chinese herb shops appeared in Taiwan in response to propaganda from either Mao or the US Government and that these peoples' childhood memories were subsequently "revised". That makes absolutely no sense.
Edit: Perhaps what you mean is that the Western notion of Chinese medicine as a viable alternative to Western medicine was invented by Mao? That might have some shred of truth. But it's a very narrowly defined truth, and a very semantic one.
Revision of distant childhood memories is very common. We all trust our memories too much, especially in a legal context. Childhood memories are just as, if not more, malleable.
It's more useful to think of memories as Michael Bay's version of "Pearl harbor".
Yes. But it's one thing to question whether the chicken soup your mother made used canned or homemade stock. It's quite another to question whether she ever actually made chicken soup when you were sick, and then repeat that for the millions of other people who remember having chicken soup.
> despite regular calls to encourage participants to use the programmes
People aren't going to use it if it sucks or isn't giving them value. I looked into Beating the Blues a while ago - it's not exactly a great experience. Being reminded just isn't enough.
> Can an app do a substantially better job than books?
I think so.
Books are passive content that you consume in your own time. And, it certainly is helpful. But an app can do so much more towards offering a much richer, more engaging experience. But - and this is crucial - you have to get it right. And I think it is MUCH easier to get a book right, than an app. A book is just the content - an app is a manifestation of that content; if the book could talk, what would it say? ask? how would it do it and how often?
We'll see. My side project is to scratch some CBT & behavioral itches I have had with an app. I could be entirely wrong, but I wont know till I finish and see if it is of use for me.
Hey, any chance you'd be open to telling me a bit about what you're working on? I'm on a bit of a... journey to get beyond the 'shitty contract webdev work', and the direction I'm looking to go is technology applied to psychology (therapy and/or lifestyle, in particular). My first thought was also some CBT-related app.
Sure. Well, It's an app to help you be a better person of your own design. CBT is one of the libraries to choose from, but there are others for leadership, relationships, health and so forth.
Hrm, I would not identify it as an appification of CBT - You can use it to help implement CBT or other behavioral/cognitive changes, but the actual understanding would need to be done previously, to get the most benefit. Although I suppose even without any previous knowledge or awareness, some value could be derived.
Completion dates are low much like for reasons that completion dates for MOOCs are low.
I have a scheduled time and place for meeting a doctor. Not going will inconvenience many people, so there's a lot of social pressure to go. I've already put it in my calendar, so mentally I've accepted that I'll be doing this for a couple hours. When I go, the next meeting will be scheduled, locking me into a virtuous cycle of commitment.
An online thing I can do on my own time? Ha! We've gotten pretty good at ignoring reminder emails, no set time was put into place, and there's no set rhythm.
The "right" way to test the effectiveness of the program is to still get people scheduled to go to a doctor's office, but instead of talking to a doctor, you use a computer (and schedule the next visit).
For people like me, the main advantage of college wasn't access to the professor's, it's the set timeframe, place, and penalties for not showing up. Same sort of thing applies here I think
>>The online stuff was in addition to GP care, not in lieu of it.
And it made no difference.
From the article:
>> There was no significant difference between usual GP care, Beating the Blues plus usual care, or MoodGYM plus usual care at four, 12 or 24 months.
So I would say there was no indication that the online CBT was of any benefit whatsoever.
Yes, that seems like a much more useful takeaway (at least, assuming that the usual standard of GP care is better than a sugar-pill placebo twice daily; shouting things at a brick wall; playing with kittens; and even 'folk' remedies like pouring a mixture of garlic, powdered chilli, raw eggs and old yoghurt down your trousers.)
If so, then it seems like you could replace expensive (for the NHS, and therefore the taxpayer) one-to-one consultation sessions with visiting a website on your phone/tablet/whatever. It frees up doctor time for other patients, or just allows them to pursue other parallel avenues of treatment with the same patient. In fact it would probably also have the side benefit that, because there is none of the stigma or awkwardness associated with going to a doctor for mental health problems, more people are likely to try and get their problems sorted out.
Generally a win all round?
EDIT OK, I read the article after seeing the sibling comment, and the online CBT is in addition to the usual GPs treatment; sadly not the amazing win that I thought ;( I should trust the headline writers more, but unfortunately buzzfeed and their click-baity ilk have trained me to have a certain wariness and skepticism these days!
to echo df3's point: this study showed that online CBT wasn't that helpful but didn't couldn't tell if it was a compliance issue or a modality issue.
This is a classic problem in drug trials as well: you get data on how the drug works in a controlled setting (when the patients are monitored) but in the real world: do people take their meds reliably?
It may be that many people suffering depression benefit from the (not specifically trained -- this is the point) GP talking to them as a forcing function. The diet companies know this well.
The original title is "Online cognitive behavioural therapy is no more effective than usual GP care for people with depression" which by no means is the same as the title here because CBT, ahem, has other meanings. Sorry.
1. Mindful meditation [free] -> Daily practice (30+ minutes)
John Kabat-Zinn [0] masters the link between science and meditation and has published very valuable books (including guided/audio meditation exercises) [1]. There are a couple of scientific studies which prove effectiveness [2] [3].
Benefits (mid- and long-term) are similar to those of meditation. It however requires one to literally read/understand/know everything about the substance before applying it (minimum literature: "The psychedelic explorer's guide" by Fadiman). Also, order a test kit and test before you ingest. Certain "edge cases"/people should not try it. In addition, you may be able to access your spiritual dimension, which increases quality of life even further (it is less immediate with meditation).
You may combine micro-dosing LSD with meditation for accessing the meditative state easier (it's quite a challenge for depressed people).
Is this another way of saying "was found to be just as effective as the more expensive standard treatment"?
> There was no significant difference between usual GP care, Beating the Blues plus usual care, or MoodGYM plus usual care at four, 12 or 24 months.
No significant difference, so it's every bit as good.
> CBT delivered online or via a computer was thought to offer a potential low-cost alternative.
And it costs less.
So yes, they found it is less expensive and works just as well as the standard treatment, but choose to phrase it in a way to indicate the study had failed by saying "is no more effective" which misleadingly implies it might be less effective, rather than the more accurate "is just as effective", which is more clear and accurate given that there was "no significant difference".
The title is confusing. The article describes that the addition of CBT to the usual care did not improve the outcomes. I would suspect that for these types of illnessss it would be unethical not to prescribe regular care.
If the GP care was ineffective, of course the CBT modeled after that care was equally ineffective. To expect any different is just silly.
I would be interested to see a study of obvious alternatives - perhaps an online interactive exercise program, something that provided a positive social interaction, or how the use of a sleep tracker could affect depression.
40 comments
[ 2.4 ms ] story [ 96.3 ms ] thread[1] https://en.wikipedia.org/wiki/Dodo_bird_verdict
there is good evidence that merely _reading_ the book "feeling good" by David burns (father of CBT) is as effective as medication.
this indicates the relationship matters, because we're talking about people who didn't _act_ on the book, but merely _read_ it.
Here's one relevant quote: "The effectiveness of stand-alone bibliotherapy was evaluated in five published studies by a team of investigators headed by Dr. Forrest Scogin from the University of Alabama. These researchers evaluated the effectiveness of Dr. David Burns' "Feeling Good" as well as Dr. Peter Lewinsohn's "Control Your Depression," as self-administered treatments for depression. The investigators concluded that Feeling Good was as effective as a full course of individual psychotherapy or as treatment with the best antidepressant drugs."
I.e. I did notice that I can let thinking about some social interactions go where they would bother me in the past, but if I was depressed when I played with it, then maybe I would just notice how bad I was at benefiting from CBT at the moment where I should be letting something go.
An interesting excerpt: "Take-up of computerised CBT was low, despite regular calls to encourage participants to use the programmes. The median number of sessions completed was two out of eight for Beating the Blues and one out of six for MoodGYM. Only 18% of people who started Beating the Blues completed all modules and 16% for MoodGYM."
Online CBT definitely is not effective if patients don't complete it despite receiving phone calls. I can imagine that getting the motivation to log in and do it is really difficult when you're already feeling hopeless-- even not-depressed people have enough trouble building and sticking to habits as it is.
But I still wonder if online CBT was effective for the small portion of participants who did complete it? What were the characteristics of those who did complete the app? Perhaps we can learn something.
CBT app builders should also consider that self-care options for depression have existed for a long time in the form of books. Can an app do a substantially better job than books? The idea of solving medical issues remotely has been tried for decades.
MoodGym and Beating the Blues have some evidence behind them. NICE was recommending Beating the blues because they have some evidence of efficacy for it.
Maybe there's a simple fix. Something like Flo to keep people engaged with it, or some kind of gamifaction.
http://www.health.org.uk/flo
Or maybe Recovery College combined with online CBT?
http://www.health.org.uk/recovery-college
You know how 'traditional chinese medicine' came about? Mao needed to invent something to give to the peasants that wasn't expensive as real health care.
http://www.slate.com/articles/health_and_science/medical_exa...
Edit: Perhaps what you mean is that the Western notion of Chinese medicine as a viable alternative to Western medicine was invented by Mao? That might have some shred of truth. But it's a very narrowly defined truth, and a very semantic one.
It's more useful to think of memories as Michael Bay's version of "Pearl harbor".
People aren't going to use it if it sucks or isn't giving them value. I looked into Beating the Blues a while ago - it's not exactly a great experience. Being reminded just isn't enough.
> Can an app do a substantially better job than books?
I think so.
Books are passive content that you consume in your own time. And, it certainly is helpful. But an app can do so much more towards offering a much richer, more engaging experience. But - and this is crucial - you have to get it right. And I think it is MUCH easier to get a book right, than an app. A book is just the content - an app is a manifestation of that content; if the book could talk, what would it say? ask? how would it do it and how often?
We'll see. My side project is to scratch some CBT & behavioral itches I have had with an app. I could be entirely wrong, but I wont know till I finish and see if it is of use for me.
Hrm, I would not identify it as an appification of CBT - You can use it to help implement CBT or other behavioral/cognitive changes, but the actual understanding would need to be done previously, to get the most benefit. Although I suppose even without any previous knowledge or awareness, some value could be derived.
I have a scheduled time and place for meeting a doctor. Not going will inconvenience many people, so there's a lot of social pressure to go. I've already put it in my calendar, so mentally I've accepted that I'll be doing this for a couple hours. When I go, the next meeting will be scheduled, locking me into a virtuous cycle of commitment.
An online thing I can do on my own time? Ha! We've gotten pretty good at ignoring reminder emails, no set time was put into place, and there's no set rhythm.
The "right" way to test the effectiveness of the program is to still get people scheduled to go to a doctor's office, but instead of talking to a doctor, you use a computer (and schedule the next visit).
For people like me, the main advantage of college wasn't access to the professor's, it's the set timeframe, place, and penalties for not showing up. Same sort of thing applies here I think
And it made no difference.
From the article: >> There was no significant difference between usual GP care, Beating the Blues plus usual care, or MoodGYM plus usual care at four, 12 or 24 months.
So I would say there was no indication that the online CBT was of any benefit whatsoever.
If so, then it seems like you could replace expensive (for the NHS, and therefore the taxpayer) one-to-one consultation sessions with visiting a website on your phone/tablet/whatever. It frees up doctor time for other patients, or just allows them to pursue other parallel avenues of treatment with the same patient. In fact it would probably also have the side benefit that, because there is none of the stigma or awkwardness associated with going to a doctor for mental health problems, more people are likely to try and get their problems sorted out.
Generally a win all round?
EDIT OK, I read the article after seeing the sibling comment, and the online CBT is in addition to the usual GPs treatment; sadly not the amazing win that I thought ;( I should trust the headline writers more, but unfortunately buzzfeed and their click-baity ilk have trained me to have a certain wariness and skepticism these days!
This is a classic problem in drug trials as well: you get data on how the drug works in a controlled setting (when the patients are monitored) but in the real world: do people take their meds reliably?
It may be that many people suffering depression benefit from the (not specifically trained -- this is the point) GP talking to them as a forcing function. The diet companies know this well.
1. Mindful meditation [free] -> Daily practice (30+ minutes)
John Kabat-Zinn [0] masters the link between science and meditation and has published very valuable books (including guided/audio meditation exercises) [1]. There are a couple of scientific studies which prove effectiveness [2] [3].
2. LSD [$5-10/dose + $25/multi-use test kit] -> One-time experience (every 6 months max.)
Benefits (mid- and long-term) are similar to those of meditation. It however requires one to literally read/understand/know everything about the substance before applying it (minimum literature: "The psychedelic explorer's guide" by Fadiman). Also, order a test kit and test before you ingest. Certain "edge cases"/people should not try it. In addition, you may be able to access your spiritual dimension, which increases quality of life even further (it is less immediate with meditation).
You may combine micro-dosing LSD with meditation for accessing the meditative state easier (it's quite a challenge for depressed people).
[0] https://en.wikipedia.org/wiki/Jon_Kabat-Zinn
[1] https://thepiratebay.org/torrent/4180277/Mindful_Way_Through...
[2] http://news.harvard.edu/gazette/story/2011/01/eight-weeks-to...
[3] http://www.vox.com/2015/8/27/9214697/meditation-brain-neuros...
https://www.theguardian.com/global/2017/jan/08/how-dropping-...
Hm, interesting phrasing.
Is this another way of saying "was found to be just as effective as the more expensive standard treatment"?
> There was no significant difference between usual GP care, Beating the Blues plus usual care, or MoodGYM plus usual care at four, 12 or 24 months.
No significant difference, so it's every bit as good.
> CBT delivered online or via a computer was thought to offer a potential low-cost alternative.
And it costs less.
So yes, they found it is less expensive and works just as well as the standard treatment, but choose to phrase it in a way to indicate the study had failed by saying "is no more effective" which misleadingly implies it might be less effective, rather than the more accurate "is just as effective", which is more clear and accurate given that there was "no significant difference".
> There was no significant difference between usual GP care, Beating the Blues plus usual care, or MoodGYM plus usual care at four, 12 or 24 months.
So if "usual GP care" is the baseline, online CBT doesn't add to that baseline.
CBT - Cognitive Behavioral Therapy GP - General practitioner (normal doctor?)
I would be interested to see a study of obvious alternatives - perhaps an online interactive exercise program, something that provided a positive social interaction, or how the use of a sleep tracker could affect depression.