Computerised self help for depression in primary care
Authors: C. Dowrick
Journal: BMJ (2015)

In guided self help, patients are supported in using self help materials in the form of pamphlets, booklets, or (increasingly) internet based materials. An expanding evidence base has prompted national and international guidelines to recommend guided self help for patients presenting in primary care with symptoms of mild to moderate depression. 3 For patients benefits include ease of access and lack of stigma; for health systems it enables wider reach at lower cost than face to face psychological interventions. A linked paper by Gilbody and colleagues (doi:10.1136/bmj. h5627), however, casts doubt on this recommendation (REEACT study). In a multicentre randomised controlled trial, they tested one free and one commercial computerised cognitive behavioural therapy (cCBT), with weekly telephone support from a technician, against usual GP care for primary care patients with depression symptoms. Four months later they found no difference in outcome between the three groups. There were some benefits from the free cCBT at 12 months, but these were not sustained a year later. The authors noted three main problems. There was a lack of engagement with the technology: only about one in six participants completed all their assigned cCBT sessions, with most logging on for only one. Technical support was limited in practice, with an average total contact time of six minutes for each participant. And there was substantial attrition, with almost a quarter of participants dropping out by four months. It is important to reflect on trials with negative outcomes, especially as publication bias is as likely for psychological as for pharmacological interventions. 6 The evidence from this trial is not in itself sufficient to overturn existing guidelines. The study population was not characteristic of patients with mild tomoderate depression: median scores on themainmeasure of depression were in the range for moderately severe depression, and about a quarter of study participants had seen a psychiatrist. Such patients are not usually considered suitable for low intensity interventions such as guided self help. Secondly, the trial did not constrain interventions in the group assigned to usual GP care, a fifth of whom reported accessing internet self help materials; this could confuse the comparison with the two groups assigned to cCBT. But these findings do have important implications. The lack of patient engagement with cCBT packages, despite participants consenting to take part in a trial with these explicitly presented as key elements, suggests that guided self help is not the panacea that busy GPs and cost conscious clinical commissioning groups would wish for. Adherence to guided self help tends to be lower than for face to face psychological therapy. Patients in primary care might be less inclined to follow psychologically oriented advice than those in specialist mental health settings. Many depressed patients do not want to engage with computers, especially if they see their mental health problems as relational in nature; they prefer to interact with human beings. When people are depressed, the technological complexities associated with internet use can become daunting. Even if patients are willing to interact with machines and master the technology, they might find themselves at odds with intrinsic assumptions of CBT about the need to combat avoidance behaviours, preferring to persist with behaviour patterns that offer them a sense of control and safety. There are also two unresolved questions about guidance for self help materials. Should the guidance be offered by clinicians rather than technicians? Participants in this and other studies 10 have expressed preference for therapist support. Cliniciansmight confer greater benefits, being able to develop therapeutic alliances and understand the patient’s problems; technicians might have good understanding of the computerised systems and (importantly) be less expensive. A meta-analysis supports this view, finding higher adherence and effect sizes for therapist than for technical support, though a trial examining this specific question found equivalent benefits. Further primary studies are needed to provide a definitive answer to this question. How much human guidance is needed? It is perhaps not surprising that a few minutes of telephone contact with a technician, however well trained, did not have appreciable effects on participants’ depressive symptoms. An Australian trial, reporting more positive findings for guided self help for depression, offered an average of 60 minutes’ contact time during an eight week programme, ten times more than in the REEACT trial. Additional research could determine the optimal amount of human guidance offered in support of cCBT