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Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation |
Kaltenthaler E, Brazier J, De Negris E, Tumur I, Ferriter M, Beverley C, Parry G, Rooney G, Sutcliffe P |
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CRD summary This generally well-conducted review found some evidence that computerised cognitive behavioural therapy (CBT) was as effective as therapist-led CBT in treating phobia/panic, and was more effective than treatment as usual for depression/anxiety. Computerised CBT was not as effective as therapist-led CBT for the treatment of obsessive compulsive disorder. The authors' conclusions are likely to be reliable. Authors' objectives To update the National Institute for Health and Clinical Excellence (NICE) guidance on the clinical and cost-effectiveness of computerised cognitive behavioural therapy (CBT) alone or as part of a package of care for depression and anxiety (including phobias). Searching Fifteen electronic databases were searched from 1966 to March 2004 without language or publication status restrictions. Search terms were reported. Additionally, reference lists of relevant articles and 29 health services' research-related resources were searched (including HTA organisations, guideline-producing bodies, generic research and trial registers and specialist mental health sites). Study selection Studies of adults with depression and/or anxiety where cognitive behavioural therapy (CBT) is delivered alone or as part of a package of care, either via a computer interface or over the telephone with a computer response, compared with standard treatments were eligible for inclusion. Depression and/or anxiety could include generalised anxiety, panic disorders, agoraphobia, social phobia, specific phobias, and obsessive compulsive disorder. If randomised controlled trials (RCTs) were not available, non-RCTs could be included.
The following outcomes were eligible: improvement in psychological symptoms, interpersonal and social functioning, quality of life, preference, satisfaction, acceptability of treatment and site of delivery.
The included studies used a variety of packages including computerised CBT (Beating the Blues, Cope, Overcoming Depression, Fear Fighter, and BT Steps). The computerised CBT programmes MoodGym, ODIN and Computer-aided Vicarious Exposure and Balance were also used; concurrent therapy/medication was reported in a number of the studies. The number of sessions and session duration varied between studies; most studies reported therapist contact (therapists varied; nurses, psychiatrists, lay interviewers, students, receptionists/secretary were included). The comparators also varied including: therapist-led CBT; waiting-list control group; treatment as usual; relaxation; different modes of delivery; another computerised CBT package; numbers of sessions; a web-based information programme; and scheduled support. Two studies used computerised CBT as a treatment adjunct for therapist-led CBT. A wide variety of instruments were used to measure outcomes.
The authors did not state how many reviewers selected the studies. Assessment of study quality Methodological quality of the included RCTs was assessed using the Critical Appraisal Skills Programme (CASP) checklist; the Downs and Black checklist was used for non-RCTs.
The authors did not state how many reviewers assessed validity. Data extraction Effect sizes (ES) (within-group and between-group) were calculated for each study where possible.
Data were extracted by one reviewer and checked by another; disagreements were resolved by discussion. Methods of synthesis The studies were combined in a narrative synthesis. Studies of obsessive compulsive disorder were considered separately. Results of the review Twenty-four studies were included in the review (two were academic in confidence, data not shown) with 2,291 participants; 13 were RCTs (n=1,752 participants) and nine were not RCTs (non-comparative, non-comparative RCTs, historical comparative study, or pseudo-randomised trial; n=539 participants). Of the four RCTs that included software packages, randomisation was reported in all four, two reported blinded assessment and three reported power calculations. One RCT reported losses to follow-up with reasons. Nine RCTs and one pseudo-randomised trial did not include packages: randomisation was reported in seven, two reported blinded assessment and two reported power calculations. Six trials reported losses to follow-up. The non-RCTs were of lower quality, as most did not include a comparator group, or an inappropriate comparator group was included.
Depression/anxiety (ten studies): One RCT found that Beating the Blues was more effective than treatment as usual. Two uncontrolled studies (one evaluating Cope, the other evaluating Overcoming Depression) showed improvement in depression from baseline. Two RCTs comparing computerised CBT with an information website gave mixed results. One pseudo-randomised trial found computerised CBT effective compared with the waiting-list control group.
Phobia/panic disorders (ten studies): One RCT reported that Fear Fighter was as effective as therapist-led CBT and more effective than relaxation. One RCT found that Fear Fighter was similarly effective to another computerised CBT package. One historical comparative study found that computerised CBT and therapist-led CBT were both effective; one comparative study, comparing two delivery methods of Fear Fighter, found both groups improved. Computerised CBT was found to be more effective than the waiting-list control group (one RCT), less effective than relaxation (one RCT) and less effective than therapist-led CBT (one RCT). Three RCTs of Computer-aided Vicarious Exposure reported mixed results.
Obsessive compulsive disorder (four studies): Therapist-led CBT was significantly more effective than BT Steps in one RCT, although both therapies showed improvement from baseline and were more effective than relaxation. One RCT showed that schedule support was more effective than on-demand support. Two comparative trials showed that less than half the patients that completed BT Steps improved from baseline.
Therapist time: Three studies did not report this outcome; two reported no direct contact; the remainder reported therapist time from five minutes to 115 minutes. Cost information For depression the following costs were reported: for Beating the Blues, the incremental cost per quality-adjusted life-year (QALY) compared with treatment as usual was £1,801 and the chance of being cost-effective at £30,000 per QALY was 86.8%; for Cope, the incremental cost per QALY compared with treatment as usual was £7,139 and the chance of being cost-effective at £30,000 per QALY was 62.6%; and for Overcoming Depression, the incremental cost per QALY compared with treatment as usual was £5,391 and the chance of being cost-effective at £30,000 per QALY was 54.4%.
For phobia/panic disorders, the incremental cost per QALY of Fear Fighter over relaxation was £2,380.
For obsessive compulsive disorder, the incremental cost-effectiveness of BT Steps over relaxation was £15,581 and therapist-led CBT over BT Steps was £22,484. Authors' conclusions There was some evidence that computerised CBT was as effective as therapist-led CBT in the treatment of phobia/panic disorders, and some evidence that computerised CBT was more effective than treatment as usual in treating depression/anxiety. Computerised CBT was not as effective as therapist-led CBT in obsessive compulsive disorder. Computerised CBT appeared to reduce therapist time compared with therapist-led CBT. CRD commentary The research question was supported by clear inclusion criteria. No language or publication restrictions were used, reducing the possibility of publication or language bias. The process of data extraction was performed by one reviewer and checked by another, reducing the risk of reviewer error and bias, but it was not reported whether similar steps were taken for validity assessment or study selection.
Study quality was assessed and taken into consideration. A narrative synthesis appeared appropriate considering the differences between studies in terms of participants, interventions, comparators and outcomes.
This review was generally well-conducted and the conclusions are likely to be reliable. Implications of the review for practice and research Practice: The authors did not state any implications for practice.
Research: The authors stated that the position of computerised CBT within a stepped care programme, and its relationship to other efforts to increase access to CBT and other psychological therapies, needs to be identified. Computerised CBT needs to be compared with other therapies that reduce therapist time (particularly bibliotherapy). Further research of computerised CBT via the Internet is also needed. A number of additional methodological recommendations were also detailed in the report. Funding Health Technology Assessment programme, project number 04/01/01. Bibliographic details Kaltenthaler E, Brazier J, De Negris E, Tumur I, Ferriter M, Beverley C, Parry G, Rooney G, Sutcliffe P. Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation. Health Technology Assessment 2006; 10(33): 1-186 Other publications of related interest Kaltenthaler E, Sutcliffe P, Parry G, Beverley C, Rees A, Ferriter M. The acceptability to patients of computerized cognitive behaviour therapy for depression: a systematic review. Psychological Medicine 2008;38(11):1521-1530.
Kaltenthaler E, Parry G, Beverley C, Ferriter M. Computerised cognitive-behavioural therapy for depression: systematic review. British Journal of Psychiatry 2008;193(3):181-184. Indexing Status Subject indexing assigned by NLM MeSH Anxiety Disorders /therapy; Cognitive Therapy; Cost-Benefit Analysis; Depression /therapy; Great Britain; Humans; Models, Econometric; State Medicine; Therapy, Computer-Assisted /economics AccessionNumber 12006008471 Date bibliographic record published 21/02/2007 Date abstract record published 08/09/2010 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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