Computer-assisted CBT outperforms usual treatment in primary care patients with depression

Computer-assisted cognitive behavior therapy had significantly greater effects on depressive symptoms vs. treatment as usual among primary care patients with depression, according to results of a randomized clinical trial.

“Multiple meta-analyses have found that [computer-assisted cognitive behavior therapy (CCBT)] is associated with improved depressive symptoms if the computerized elements of treatment are partnered with clinician support,” Jesse H. Wright, MD, PhD, of the department of psychiatry and behavioral sciences at the University of Louisville School of Medicine in Kentucky, and colleagues wrote in JAMA Network Open. “A meta-analysis of CCBT for depression that included only studies in primary care suggested that CCBT may have somewhat weaker associations with improved depression in primary practices than other settings.

“However, the number of studies in primary care was small (n = 8), and the reasons for possible disparities in outcomes were unclear,” they added. “Concerns regarding previous CCBT research include potential bias of recruitment strategies (eg, online advertisements, requirement for internet access) that preferentially select those with high levels of education and computer skills, limited inclusion of persons with lower income and lack of internet access and insufficient attention to implementation issues.”

Wright and colleagues aimed to determine whether clinician-supported CCBT outperformed treatment as usual among primary care patients with depression, as well as to determine the feasibility and implementation of this intervention among a primary care population with significant numbers of individuals with low income, limited internet access and low levels of educational attainment. They included adult primary care patients from clinical practices at a single academic institution with scores of 10 or greater on the Patient Health Questionnaire-9 (PHQ-9) who were randomly assigned to CCBT or treatment as usual for 12 weeks of active treatment. Researchers conducted follow-up assessments 3 months and 6 months following treatment completion.

CCBT consisted of a nine-lesson computer program, as well as up to 12 weekly telephone support sessions lasting around 20 minutes with a master’s level therapist, combined with treatment as usual, which included the standard clinical management procedures at the primary care sites. Although treatment as usual was uncontrolled, researchers recorded use of antidepressants and psychotherapy other than CCBT.

The PHQ-9 served as the primary outcome measure and the Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder-7 and the Satisfaction with Life Scale for quality of life as the secondary outcome measures. They were administered at baseline, 12 weeks and 3 and 6 months following treatment completion. Researchers assessed satisfaction with treatment via the Client Satisfaction Questionnaire-8.

Among the 175 patients, 84.5% were women, 27.2% were African American, 1.2% were American Indian or Alaska Native, 2.5% were Hispanic and 8.6% were multiracial. A total of 61.5% reported an annual income of less than $30,000. Wright and colleagues randomly assigned 95 patients (54.3%) to CCBT and 80 patients (45.7%) to treatment as usual, with dropout rates of 22.1% for CCBT and 30% for treatment as usual. Results of an intent-to-treat analysis showed significantly greater improvement in PHQ-9 scores among those who received CCBT compared with treatment as usual at posttreatment (mean difference, 2.5; 95% CI, 4.5 to 0.8) and 3-month (mean difference, 2.3; 95% CI, 4.5 to 0.8) and 6-month (mean difference, 3.2; 95% CI, 4.5 to 0.8) follow-up points. CCBT also correlated with significantly higher posttreatment response and remission rates ([response, 58.4%; 95% CI, 46.4-70.4%]; [remission, 27.3%; 95% CI, 16.4%-38.2%]) compared with treatment as usual ([response, 33.1%; 95% CI, 20.7%-45.5%]; [remission, 12%; 95% CI, 3.3%-20.7%]).

“The findings of this randomized clinical trial suggest that CCBT with a modest amount of clinician support has potential for wider-spread implementation as an effective, acceptable and efficient treatment for depression in primary care,” Wright and colleagues wrote. “The method of CCBT described here may be useful in primary care patients with depression who have low levels of income, education or reading proficiency, as well as in those who lack internet access.”