A review of computerised cognitive behavioural therapy
(cCBT) for depression
Helen Rhodes & Stewart Grant
CITATION
Rhodes, H.and Grant, S. (2012). A review of computerised cognitive
behavioural therapy (cCBT) for depression. Cumbria Partnership Journal
of Research Practice and Learning, 2(1), 2-9.
LETTERS/NEWS/BOOK REVIEWS/REVIEWS
A review of computerised cognitive behavioural therapy
(cCBT) for depression
Helen Rhodes & Stewart Grant
Abstract
This paper examines the existing literature and trials that have been carried out on the use of computerised
Cognitive Behavioural Therapy (cCBT) in the treatment of depression. There are several areas needing to be
further explored including: the efficacy of appropriate cCBT programmes for specific conditions to treat adults,
adolescents and children; clinicians’ attitudes towards cCBT and the impact on service delivery; and clinical helper
involvement with cCBT programmes.
Keywords
computerised cognitive behavioural therapy; depression; review
Introduction
One in six people in England are affected by
depression and anxiety disorders, with depression
being the most common disorder in the United
Kingdom (Department of Health, 2007). It is projected
that by 2020 depression will become the second most
common cause of disability, to heart disease (World
Bank, 1993). The increase in people suffering with
depression, and the impact it has on their lives, has
also become a huge financial burden on the economy
due to people being unable to work because of their
mental health. The London School of Economics
calculated that it costs the taxpayers £7 billion a year
due to unemployment resulting from depression and
chronic anxiety (London School of Economics Centre
for Economic Performance Mental Health Policy Group,
2005; Layard, 2005).
Cognitive Behavioural Therapy (CBT) is one of the
primary interventions in the treatment of anxiety and
depression (NICE, 2004a, b, 2005). This is due to the
National Institute for Health and Clinical Excellence
(NICE, 2007), recognising CBT’s effectiveness
through the huge amount of evidence-based research
supporting its efficacy (Green & Iverson, 2009). In
spite of this encouraging evidence base and the
recognised efficacy of CBT, it appears that CBT is
underused in practice settings (Taylor & Chang, 2008).
For example, of the population of people who are
treated for depression, only 8% receive psychotherapy
(Bebbington, 2000). The Department of Health (2008)
reported that in the United Kingdom only a third of
people who have a diagnosable depression are in
receipt of some form of treatment. Due to a shortfall
in resources of identified CBT therapists, Lovell
and Richards (2000) recognised there was a need
to consider alternative methods of delivering CBT.
In their seminal paper Lovell and Richards (2000),
argued that CBT services had opted for delivering the
more traditional ways of expert-level CBT. Because
2
of this the evidence base for more low intensity,
simpler, interventions had been overlooked (Lovell &
Richards, 2000). The question that this study raised
was ”is there any clear evidence that one-to-one
expert-delivered CBT is the only evidence-based way
of delivering CBT” (Williams & Martinez, 2008, p.676).
Due to this point, and the recognition of the shortage
of trained CBT therapists, there had been a need
for attention to be directed to consider alternative
methods of delivering psychological therapies, which
can offer an acceptable and quicker treatment
pathway (Lovell & Richards, 2000). From this the
second phase of CBT service delivery and training was
characterised (Williams & Martinez, 2008).
Developments in cCBT
Developments in self-help approaches have been
progressing over recent years to the point where the
NICE guidelines now recommend the provision of CBTbased guided self-help interventions, to be provided
for patients with mild to moderate anxiety and
depression as part of the stepped care model (NICE,
2004a, b). What the stepped care model advocates
is that the treatment which has the least intensity,
but which will provide significant gain to a person’s
health, is offered first, and thereby the more intensive
treatments are then only offered if required (Lovell
& Richards, 2000). For example, a low intensity
intervention would be self-help, with treatment from a
CBT therapist being an intensive treatment. The aims
of the self-help approach is to enable efficient selfmanagement through developing patients’ knowledge,
skills and coping strategies, with minimal therapist
contact (MacLeod, Martinez & Williams, 2009). Selfhelp materials can be delivered in a variety of forms,
with the written format being the most common
(Keeley, Williams & Shapiro, 2002). Other methods
of administering CBT self-help can be by audiotape,
video, the internet and cCBT, as recommended by
The Cumbria Partnership Journal of Research Practice and Learning 2(1)
A review of computerised cognitive behavioural therapy (cCBT) for depression
NICE guidelines (2006).
One of the areas that the evidence base for a
self-help method has been developing, is the growing
amount of evidence supporting the efficacy of using
computerised CBT (cCBT) (Marks et al., 2003).
The aim of cCBT is to be able to deliver empirically
supported CBT on the internet or via standalone
programmes (Green & Iverson, 2009). In the 1980s
the first computer programme for depression was
developed by Selmi et al. (in Wright et al., 2005).
Research completed using a randomised control
trial (RCT) found this programme was as effective
as standard cognitive therapy for mild to moderate
depression (Wright et al., 2005). Unfortunately the
software relied on text presentations, and due to it not
being updated it did not continue to be used in clinical
practice (Wright et al., 2005). The development of
this computer programme suggests that the demands
on resources to treat clients requiring support to
manage their mental health condition is not a recent
phenomenon.
It was the work by Proudfoot et al. (2003, 2004)
which was revolutionary in the development of the
evidence base for cCBT, and in doing so gaining
the acknowledgement of its efficacy as an effective
treatment option. Proudfoot et al. (2003, 2004)
completed two large RCTs in primary care settings
looking at the efficacy of using the cCBT programme
Beating the Blues, as an alternative to treatment as
usual (TAU) by a General Practitioner. According to de
Graaf et al. (2008) these two studies by Proudfoot et
al. are the only studies investigating the efficacy of
cCBT in a primary care setting.
Initially Proudfoot et al. (2003), completed an open
trial with 20 outpatients who had chronic depression,
and the outcome of the feasibility and benefits of the
programme Beating the Blues (BtB) was supported
(Cavanagh & Shapiro, 2004). The outcome from the
research was that the BtB group showed reduction
in symptoms of anxiety and depression which were
significantly greater than the Treatment As Usual
(TAU) group. The measures used in the study were
the Beck Depression Inventory (BDI) (Beck, Steer &
Brown, 1996), and the Beck Anxiety Inventory (BAI)
(Beck, Epstein, Brown & Steer, 1988). The outcomes
also showed that the reduction in symptoms was
not dependent on the pharmacotherapy, and it also
showed that BtB was effective with mild and more
severe depression (Green & Iverson, 2009).
Proudfoot et al. (2004) then went on to complete
a further study using an expanded study population
from the 2003 study. This study focused on the
interactions of the BtB programme based on clinical,
demographic and setting variables, with an aim of
increasing the efficacy of BtB. In this study BtB had
n=132 and TAU had n=116 participants, who were
again patients from primary care who were suffering
with anxiety and/or depression. The outcomes from
this study were similar to the 2003 study with greater
reduction in anxiety and depression symptoms in
the BtB group, and again the reduction was similar
whether or not prescribed medication was being taken
(Green & Iverson, 2009). Patient satisfaction was also
significantly higher in the BtB group compared to the
TAU group (Cavanagh & Shapiro, 2004). From these
two studies the outcomes suggest that BtB is more
effective in reducing the symptoms of depression
and anxiety compared to the TAU from a General
Practitioner, and this reduction happens regardless
of the length and severity of illness, and whether
someone is or is not taking pharmacotherapy (Green
& Iverson, 2009). After six months there was a follow
up of the participants and the gains were maintained
over the General Practitioner TAU group (Proudfoot et
al. 2003, 2004).
To test the generalisability of the findings in
Proudfoot et al. (2003, 2004) research trials,
Cavanagh et al. (2006) used a naturalistic, nonrandomised open trial design, to test the effectiveness
of cCBT BtB with anxiety and/or depression clients in
a routine care setting. The clients n=219 experienced
statistically and clinically significant improvement in
their symptoms of depression and anxiety, and again
these gains were maintained when re-measured from
the follow up data available n=40, after six months
(Green & Iverson, 2009). Outcomes from these
research trials provide preliminary support that cCBT
can be used as a first line treatment for common
mental health problems like depression and anxiety
within a stepped care model (Green & Iverson, 2009).
NICE (2004a, 2004b) now considers that the
evaluations completed on specific cCBT programmes,
demonstrate enough evidence that cCBT is clinically
efficacious, for example Beating the Blues for mild to
moderate depression, and Fearfighter for phobias or
panic. Due to this NICE (2006) initially recommended
that the interactive multimedia CBT programme BtB
is a treatment of choice in primary care settings
for mild to moderate depression, through their
technology appraisal process (NICE, 2002; TA07).
This recommendation has now been superseded
by the updated NICE (2009) Depression in Adults
guideline (CG90). Within this guidance cCBT is one
of a choice of low intensity interventions which can
be offered to a person who has persistent subthreshold depressive symptoms, or mild to moderate
depression. It also recommends that the choice of
intervention should be guided by the individual’s
preference (NICE, 2009). The rationale for this change
is due to the fact that guided self-help, group-based
physical activity programmes, and cCBT have all
been identified as effective to treat persistent subthreshold depressive symptoms and mild to moderate
depression (Kaltenthaler & Cavanagh, 2010). Within
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A review of computerised cognitive behavioural therapy (cCBT) for depression
these interventions there is not one of them which
has any specific advantage over another, thereby
increasing opportunity and options to people accessing
support (Kaltenthaler & Cavanagh, 2010). There has
also been a change in relation to the provision of
a cCBT programme by the NICE (2009) guidance,
due to the removal of an endorsement of a specific
cCBT programme. This is due to the recognition
that the likelihood is there will be several computer
programmes that could be useful to patients (NICE,
2009). Although this change has been implemented,
BtB cCBT programme remains the only programme
with an RCT evidence base within the United Kingdom
(Ultrasis, 2011).
In relation to more enduring depression,
Learmonth and Rai (2008) identified that further
research is still required to ascertain BtB’s
effectiveness within secondary care mental health
services, where CBT resources are just as limited
as primary care. Proudfoot’s (2003, 2004) research
indicated that BtB was found to be effective with
more enduring mental health. At the present time the
NICE (2009) recommendation for the use of cCBT,
is that it is one option of treatment which should be
offered for mild to moderate depression in primary
care settings, with no mention of secondary care
settings to date. One study which has been completed
in secondary care looking at the effectiveness of
cCBT, was carried out at the Chelmsford and Essex
Centre’s Specialist CBT Unit. The inclusion of cCBT as
a treatment option within this study was viewed as an
innovative model of care, and the study was planned
due to the demands of long waiting lists (Learmonth
et al., 2008). This study was a naturalistic open study
where services users who were on a waiting list for
face-to-face CBT, were offered the option of receiving
cCBT (Learmonth & Rai, 2008). The purpose of the
study was to reduce the waiting lists, and by doing
so meet the demands for increasing the service
capacity in specialist CBT Units (Learmonth & Rai,
2008). What the study explores is as follows: ”what
is the uptake rate of service users referred to the
cCBT programme? What is the rate of dropout of the
BtB in a NHS secondary care service? Who is more
likely to dropout of the programme? What rate of
service users completing the BtB programme need
immediate referral for further interventions? What
are treatment outcomes for this population of service
users? What is the effectiveness of BtB in a specialist
CBT Centre?” (Learmonth et al., 2008, p.118). Over
a sixty-month period cCBT was offered to 829 people
who were referred to the specialist unit, and of these
555 took up the offer. From the statistical analyses
using the BDI and BAI (Beck, Steer & Brown, 1996;
Beck, Epstein, Brown & Steer, 1988), the results
showed that there is a positive outcome for services
users suffering from chronic anxiety and depression,
4
who used cCBT with minimal supervision in a CBT
specialist unit (Learmonth et al., 2008). For example,
from the 555 participants on the study, 71% (394)
completed all eight sessions on the BtB programme,
with a significant difference found in the pre and
post BDI and BAI scores. Due to this significant
difference made by cCBT, only 21.3% of the 394
completers were referred on for further treatments,
and on average only 3.5 sessions were needed for
those requiring face-to-face treatments after BtB,
compared to the usual 15 sessions (Learmonth et
al., 2008). Due to this the results suggest that BtB
could be a feasible solution to offer as an intervention
option in a secondary care setting, particularly with
the current shortfall of therapists. Learmonth and Rai
(2008), recognise that although these findings are
encouraging, there would be a need to corroborate
them with an RCT using an enlarged sample size, with
follow up data examining whether the improvements
found are due to the attribution of the intervention
used (Learmonth & Rai, 2008).
The outcomes from these key research studies
have become of paramount importance for the
efficacy and development of the provision of cCBT.
Further studies have since been completed testing
out the findings of these studies, for example a
study completed in the Dutch health care system
by de Graaf et al. (2008). Their study showed
that cCBT provided an acceptable alternative to
pharmacotherapy, that it can save on clinicians’
time, and that it was cost effective in comparison to
face-to-face CBT treatment (de Graaf et al., 2008).
Furthermore, research studies by Kaltenthaler et
al. (2006), and Titov (2007), also found that due
to the high accessibility of cCBT, referrals by GPs
to secondary services reduced, as did waiting lists
for more traditional CBT. These studies continue to
provide further evidence of the promising efficacy of
cCBT.
Challenges of implementing cCBT into practice
An issue which was identified by clinicians’ previous
studies was the absence of a therapeutic relationship
(Whitfield & Williams, 2004; MacLeod, Martinez
& Williams, 2009). This is an important issue as
interpersonal interaction is seen as a key therapeutic
aspect of psychotherapy in building the therapeutic
alliance (Green & Iverson, 2009). These concerns
were also highlighted in a recent study completed
by Stallard, Richardson and Velleman (2010),
when researching clinicians’ attitudes to the use
of cCBT with adolescents and children. The key
concern highlighted was the lack of support the
cCBT programme would provide to the children
and adolescents through lack of therapist contact
and therapeutic relationship. Again these concerns
developed fears in clinicians that this could lead to a
young person not understanding the concepts of the
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A review of computerised cognitive behavioural therapy (cCBT) for depression
programme, and the programme not being responsive
to the individual’s needs (Stallard, Richardson &
Velleman, 2010).
Gellatly et al. (2007) (in Williams & Martinez,
2008), completed a seminal overview looking at the
way services should be delivering self-help. Within
this exploration the report confirmed that support
was required in the delivery of CBT self-help. This
conclusion was made due to the outcome from the
study that unsupported pure self-help had an effect
size of 0.06, compared to 0.8 for supported or guided
self-help—advising that supportive monitoring and
encouragement is all that would be required (Gellatly
et al., 2007). This is the level of support that was
provided in Proudfoot et al.’s (2004) study, where
a nurse provided brief support with no longer than
five minutes being spent with each patient at the
beginning and end of each BtB session. Due to the
success of the outcome from the trial, this level of
clinical help for the cCBT group was deemed adequate
(Proudfoot et al., 2004). A study providing cCBT for
depression without support in a primary care setting
was recently trialled, with findings that demonstrated
that there was no benefit to clients offering cCBT
unsupported as an alternative or as an addition to the
TAU (de Graaf, Huibers & Riper, 2009).
In contrast, the British Journal of Psychiatry
reported on promising follow up data from a previous
study looking at the effects of MoodGYM, which is a
self-administered internet programme, which does not
provide any clinical guidance (Andersson & Cuijpers,
2008). MoodGYM is a free online programme which is
accessible to anyone and can be accessed anywhere,
providing an opportunity for the user to assess their
mood and then receive four sessions which cover
the basic CBT practices (Taylor & Chang, 2008).
Over 100,000 people worldwide have accessed the
programme (Taylor & Chang, 2008), and Christensen,
Griffith’s and Jorm’s (2004) research reports that the
significant reduction of depressive symptoms in these
people is associated with the use of the MoodGYM
programme. According to a meta-analysis completed
by Spek et al. (2007), although there may be a
reduction in the symptoms of depression in using
MoodGYM, this reduction will be markedly less than
with those programmes that do provide guidance.
Advantages of cCBT
Through the highlighted research studies many
advantages of using cCBT have been identified.
Some examples of the advantages firstly include
the flexibility of accessing cCBT due to it being webbased, so it could be accessed on a personal computer
at home, on a mobile device such as a Blackberry,
palmtop, iPhone, over the internet, via a telephone
using interactive voice response, or on a standalone
computer in a healthcare setting (Kaltenthaler &
Cavanagh, 2010). These various options enable
people to be able to have the flexibility to access
cCBT at a time and place which is suitable to them,
and provides privacy (Green & Iverson, 2009). This is
an important point as it enables a hidden population
potentially suffering from depression and/or anxiety,
and who are reluctant to seek help, to access
information and support autonomously (Richards et
al., 2009). Secondly it can be used for people who
present with less severe symptoms or who could use
it whilst on a waiting list for one-to-one CBT, to start
the psychoeducation. This would aim to keep up
with the demand for CBT and enable quicker access
to psychological therapies (Fox, Acton, Wilding &
Corcoran, 2004). Thirdly cCBT can be used as an
additional resource to supplement one-to-one CBT, for
example using certain aspects of the cCBT programme
to supplement homework tasks (Green & Iverson,
2009). Fourthly there is potential for considerable cost
savings due to the decrease in therapist time required
per person (Kaltenthaler & Cavanagh, 2010). This
finding is also verified by the Department of Health
(2007), from the cost benefit analysis completed by
NICE. They based their figures on an assumption that
if 64% of CBT was provided by cCBT, then it would
translate into a significant cost saving of between
£116 million and £136 million in England, compared to
face-to-face therapy.
Disadvantages of cCBT
Waller and Gilbody (2009) reviewed the barriers
to the uptake of computerised programmes. They
identified that it may be less accessible if people have
a visual impairment, poor IT provision, and a lower
educational level. To clarify this final point the average
reading age of the traditional CBT model is 17 years
of age (Williams & Garland, 2002). To put this in some
context The Sun newspaper has a reading age of 11
years, compared to The Times newspaper which has a
reading age of 17 years (Martinez, Whitfield, Dafters &
Williams, 2008). Martinez and Williams (2008) report
that the majority of self-help materials have a reading
age of over 13 years. Within this report it is also
recognised that approximately 20% of the population
have difficulties when reading written materials
which are at a reading age of 11 years (Martinez &
Williams, 2008). The Department of Health’s (2007)
IAPT cCBT implementation guidance advises that the
BtB programme assumes a minimum reading age
of 10 to 11 years. With this in mind it is hoped that
accessibility to BtB will disadvantage only the smallest
number of the population who may want to access it.
Having said this materials used for self-help should
be chosen to reflect the wide range of abilities and
different preferences for ways to work, to encompass
all needs of the population accessing support (Williams
& Martinez, 2008).
Further disadvantages of the BtB programme were
identified in a service-development study from the
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A review of computerised cognitive behavioural therapy (cCBT) for depression
Clinical Psychology Department in Barnet and the
Barnet Primary Care Trust (PCT), in conjunction with
the Torrington Speedwell Practice in North Finchley
(Fox, Acton, Wilding & Corcoran, 2004). This study
evaluated the implementation and running of the cCBT
package BtB. Feedback from some of the clients who
had used the BtB programme was that they found
it quite ‘patronising’ and ‘condescending’, and the
responses from the computer which are automatic
were found by some to be ‘offensive’ and ‘insincere’
(Fox, Acton, Wilding & Corcoran, 2004). Although
these were identified in the outcomes of the study,
it was also recognised that there was only a few
negative comments, and that the majority of clients
responded well to the overall programme delivery
(Fox, Acton, Wilding & Corcoran, 2004).
Another disadvantage to cCBT can be the
low uptake of this delivery option, for example
in a research study by Whitfield, Hinshelwood,
Pashely, Campsie and Williams (2006), only 28%
of referrals expressed an interest in self-help at a
clinical psychology service. The research completed
by Mitchell and Gordon (2007) explored what the
attitudes of a university student population of n=122
would be towards the use of cCBT. The result from
this study was that only 9.8% would state cCBT as a
preference over other interventions for depression.
Interestingly though, once a demonstration of a cCBT
programme has been provided the preference rates
rose. This finding could also link to the suggestion
from the research completed by Whitfield and
Williams (2004) in relation to the barriers around
CBT therapists not utilising the cCBT facility due to
lack of knowledge and understanding around the
cCBT programme. This observation suggests that
more promotion of the material involved in cCBT
programmes is needed for both professionals and
clients to become engaged with being fully committed
to accessing this promising technology (Waller &
Gilbody, 2009). If professionals who provide the
services are positive about the self-help options
then this can influence the uptake of interventions
immensely with clients (Whitfield, Hinshelwood,
Pashely, Campsie & Williams, 2006).
Dropout rates can also be high with up to
50% of people who start a self-help programme
for depression leaving during some stage of the
programme (MacLeod, Martinez & Williams, 2009).
Due to this it was felt that more needed to be known
about what characteristics a person would have, that
would help them to be motivated to gain the most
effect from using CBT self-help (MacLeod, Martinez &
Williams, 2009). Patient characteristics are identified
in the recommendations of the NICE guidelines for
the use of anti-depressants, but no such equivalent
recommendation exists for the use of self-help (NICE
Guidelines 2004a, b), this factor could be due to the
6
relatively new introduction of the stepped care model
(MacLeod, Martinez & Williams, 2009). To try and
gain this information MacLeod, Martinez and Williams
(2009) in their research reviewed the opinions of CBTaccredited practitioners about the patient selection
procedure for CBT self-help. The research involved
a national survey of expert CBT practitioners where
a questionnaire was randomly sent to 50% of the
British Association for Behavioural and Cognitive
Psychotherapy (BABCP)-accredited practitioners.
The factors that practitioners identified in patients
as predicting a more successful outcome with selfhelp were: a lower degree of hopelessness, higher
motivation in therapy, self-efficacy, and a tendency
to adhere to therapy (MacLeod, Martinez & Williams,
2009).
Implications of the stepped care model
As can be seen from the research explored above
it is widely recognised that there is a need to have
a rethink about what psychological treatments
are offered, and how they are offered (Williams &
Martinez, 2008). As already identified earlier in this
paper, the guidance states that the majority of people
who are seeking help for psychological disorders,
should initially be offered a “relatively brief lowintensity intervention” (Department of Health, 2008,
p.22). The rationale for this procedure is to enable
more intensive therapies to be reserved for those
people who do not benefit from the more simple
treatments, and this is known as a stepped care model
of treatment (NICE, 2004b). A more simple treatment
giving a low intensity intervention would be cCBT, with
the face-to-face treatment from a CBT therapist being
recognised as a high intensity intervention (Green &
Iverson, 2009). The difficulty is that there can remain
a perception that an intervention which is classed
as low intensity, such as cCBT, can be viewed as
second-best to high intensity interventions (Williams
& Martinez, 2008). An example of this would be the
terms used in stepped care where a patient may be
‘stepped up’ or ‘stepped down’, which could make an
implication that there is a hierarchy of treatments,
with, for example, face-to-face being ‘better’ (Williams
& Martinez, 2008). A research study into this point was
completed by Keeley, Williams and Shapiro (2002),
where 500 BABCP-accredited practitioners were
surveyed about their views on the use of psychological
self-help approaches. The outcome from this study
was that of the practitioners who responded, 68.5%
believed that the intervention of therapists was more
effective than self-help (Keeley, Williams & Shapiro,
2002). This outcome would correlate with MacLeod,
Martinez and Williams’ (2009) more recent survey
of BABCP-accredited practitioners. This research
found that although the recommendation for the use
of self-help materials had increased to 99.6% from
88.7%, the use of these materials appears to be
The Cumbria Partnership Journal of Research Practice and Learning 2(1)
A review of computerised cognitive behavioural therapy (cCBT) for depression
almost entirely focused on supplementing therapists’
one-to-one work, with minimal evidence of selfhelp being used as a waiting list initiative (MacLeod,
Martinez & Williams, 2009). To date these opinions
remain unclear as to their levels of correctness due to
few comparisons having been completed (Williams &
Martinez, 2008). It has been suggested by Cujipers
et al. (2006) from their research that one-to-one and
self-help are both equally effective. It is also confusing
as to whether the range of low intensity interventions
vary in their level of effectiveness, for example
interventions for depression via computer and bookbased interventions, seem to be equivalent in their
outcome (Gellatly et al., 2007). This demonstrates
an example that more research is required to be
able to answer many of the important questions,
and currently no other studies are being undertaken
to directly compare the low intensity with the high
intensity CBT (Williams & Martinez, 2008). However
in consideration of the above research, perhaps it is
also important to consider the validity of how people
like to work and learn, as CBT shares much in essence
with adult learning models as a self-help form of
psychotherapy (Williams & Martinez, 2008). Reflecting
on this point perhaps there may be advantages to
matching a person to an intervention, rather than
stepping a person into an intervention, and that this
is based on choice rather than an issue of superiority
(Marks, Cavanagh & Gega, 2007).
As can be seen from this exploration of current
and future developments in research there are several
significant areas needing to be further explored, for
example more evidence-based research focusing
on the efficacy of appropriate cCBT programmes
for specific conditions to treat adults, adolescents
and children; the need for continuing monitoring of
clinicians’ attitudes towards cCBT and the impact this
has on its service delivery; and continuing exploration
around the controversial subject of clinical helper
involvement with cCBT programmes, so that cCBT can
be efficacious whilst being cost effective.
Affiliations
Helen Rhodes, Northumberland, Tyne and Wear Trust,
UK
Stewart Grant, Dumfries & Galloway NHS Board, UK
Contact information
Helen Rhodes, [email protected]
References
Andersson, G.; Cuijpers, P. (2008). Pros and cons
of online cognitive behavioural therapy. The British
Journal of Psychiatry, 193, 270-271.
Bebbington, P. (2000). The need for psychiatric
treatment in the general population. Cambridge:
Cambridge University Press.
Beck, A.T.; Epstein, N.; Brown, G.; Steer, R.A.
(1988). An inventory for measuring clinical anxiety:
Psychometric properties. Journal of Consulting and
Clinical Psychology, 56, 893-897.
Beck, A.T.; Steer, A.; Brown, G.K. (1996). Beck
Depression Inventory Manual (2nd ed). San Antonio:
Psychological Corporation.
Beck, A.T.; Steer, R.A.; Garbin, M.G. (1988).
Psychometric properties of the Beck Depression
Inventory: Twenty five years of evaluation. Clinical
Psychology Review, 8, 77-100.
Cavanagh, K.; Shapiro, D.A. (2004). Computer
treatment for common mental health problems.
Journal of Clinical Psychology, 60(3), 239-251.
Cavanagh, K.; Shapiro, D.A.; van den Berg, S.;
Swain, S.; Barkham, M.; Proudfoot, J. (2006). The
effectiveness of computerised cognitive behavioural
therapy in routine care. British Journal of Clinical
Psychology, 45, 499-514.
Christensen, H.; Griffiths, K.M.; Jorm, A. (2004).
Delivering interventions for depression by using the
internet: Randomised controlled trial. British Journal of
Psychiatry, 328, 265-268.
Costello, E.J.; Mustillo, S.; Erkanli, A.; Keller, G.;
Angold, A. (2003). Prevalence and development of
psychiatric disorders in childhood and adolescence.
Archives of General Psychiatry, 60, 837-844.
Cuijpers, P.; van Straten, A.; Smit, F. (2006).
Psychological treatment of late-life depression: a meta
analysis of randomized controlled trials. International
Journal of Geriatric Psychiatry, 21, 1139-1149.
de Graaf, L.E.; Gerhards, S.A.H.; Evers, S.M.A.A.;
Arntz, A.; Riper, H.; Severens, J.L.; Widdershoven, G.;
de Graaf, L.E.; Huibers, M.J.H.; Riper,H. (2009).
Use and acceptability of unsupported online
computerized cognitive behavioural therapy for
depression and associations with clinical outcome.
Journal of Affective Disorders, 116, 227-231.
Department of Health (2007). Improving access
to psychological therapies: Positive practice guide.
Retrieved 16 March 2008, from http://www.doh.gov.uk
Department of Health (2007). Improving access
to psychological therapies (IAPT) programme:
Computerised cognitive behavioural therapy (cCBT)
implementation guidance. Retrieved 16 March 2011,
from http://www.doh.gov.uk
Department of Health (2008). Improving access to
psychological therapies: National guideline for regional
delivery. Retrieved 22 February 2010 from http://www.
doh.gov.uk
Fox, E.; Acton, T.; Wilding, B.; Corcoran, J.S.
(2004). Service development report: An assistant
psychologist’s perspective on the use of computerised
cognitive behavioural therapy in a GP practice in
Barnet. Quality in Primary Care, 12, 165-9.
Gellatly, J.; Bower, P.; Hennessy, S.; Richards,
D.; Gilbody, S.; Lovell, K. (2007). What makes selfhelp interventions effective in the management of
depressive symptoms? Meta-analysis and meta-
The Cumbria Partnership Journal of Research Practice and Learning 2(1)
7
A review of computerised cognitive behavioural therapy (cCBT) for depression
regression. Psychological Medicine, 37, 1217-1228.
Green, K.E.; Iverson, K.M. (2009). Computerised
cognitive-behavioral therapy in a stepped care model
of treatment. Professional Psychology, Research and
Practice, 40(1), 96-103.
Kaltenthaler, E.; Cavanagh, K. (2010).
Computerised cognitive behavioural therapy and its
uses. Progress in Neurology and Psychiatry, 14(3),
22-29.
Kaltenthaler, E.; Brazier, J.; De Nigris, E.; Tumur,
I.; Ferriter, M.; Berverly, C.; Parry, G.; Rooney,
G.; Sutcliffe, P. (2006). Computerised cognitive
behavioural therapy for depression and anxiety
update: A systematic review and economic evaluation.
Health Technology Assessment, 10(33), 1-186.
Keeley, H.; Williams, C.J.; Shapiro, D. (2002).
A United Kingdom survey of accredited cognitive
behavioural therapists’ attitudes towards the use
of structured self-help materials. Behavioural and
Cognitive Psychotherapy, 30, 193-203.
Layard, R. (2005). Happiness: Lessons from a new
science. London: Penguin.
Learmonth, D.; Rai, S. (2008). Taking computerised
CBT beyond primary care. British Journal of Clinical
Psychology, 47, 111-118.
London School of Economics Centre for Economic
Performance Mental Health Policy Group (2005). The
Depression Report: A new deal for depression and
anxiety disorders. London: LSE.
Lovell, K.; Richards, D. (2000). Multiple access
points and levels of entry (MAPLE): Ensuring choice,
accessibility and equity for CBT services. Behavioural
and Cognitive Psychotherapy, 28, 379-392.
MacLeod, M.; Martinez, R.; Williams, C. (2009).
Cognitive behaviour self-help: Who does it help and
what are its drawbacks? Behavioural and Cognitive
Psychotherapy, 37, 61-72.
Marks, I.M., Mataix-Cols, D., Kenwright, M.,
Cameron, R., Hirsch, S., Gega, L. (2003). Pragmatic
evaluation of computer-aided self-help for anxiety and
depression. British Journal of Psychiatry, 183, 57-63.
Marks, I.M.; Cavanagh, K.; and Gega, L. (2007).
Hands on help: Computer-aided psychological
therapies. London: Maudsely Monograph.
Martinez, R.; Whitfield, G.; Dafters, R.; Williams,
C.J. (2008). Can people read self-help manuals for
depression? A challenge for stepped care model and
book prescription schemes. Behavioural and Cognitive
Psychotherapy, 36, 89-97.
Mitchell, N.; Gordon, P.K. (2007). Attitudes Towards
Computerized CBT for Depression Amongst a Student
Population. Behavioural and Cognitive Psychotherapy,
35, 421-430.
NICE (2002). Computerised cognitive behaviour
therapy for depression and anxiety. London: National
Institute for Health and Clinical Excellence. Retrieved
14 April 2009, from http://www.nice.org.uk/pdf/
8
ccbtassessmentreport.pdf
NICE (2004a). Management of anxiety (panic
disorder, with or without agoraphobia and generalized
anxiety disorder) in adults in primary, secondary and
community care. London: National Institute for Health
and Clinical Excellence. Retrieved 26 April 2011 http://
www.nice.org.uk
NICE (2004b). Management of depression in
primary and secondary care. London: National
Institute for Health and Clinical Excellence. Retrieved
26 April 2009, from http://www.nice.org.uk
NICE (2005). Depression in children and young
people. London: National Institute for Health and
Clinical Excellence. Retrieved 26 May 2011, from
http://www.nice.org.uk
NICE (2006). Depression and anxiety—
computerised cognitive behavioural therapy (cCBT).
London: National Institute for Health and Clinical
Excellence. Retrieved 14 April 2009, from http://www.
nice.org.uk/TA97
NICE (2007). Improving access to psychological
therapies (IAPT) programme—computerised cognitive
behavioural therapy (cCBT) implementation guidance.
London: National Institute for Health and Clinical
Excellence. Retrieved 14 April 2009, from http://www.
nice.org.uk
NICE (2009). Depression: Management of
depression in primary and secondary care—full
guidance, CG90. London: National Institute for Health
and Clinical Excellence. Retrieved 26 April 2011, from
http://www.nice.org.uk
Proudfoot, J.; Goldberg, D.; Mann, A.; Everitt, B.;
Marks, I.; Gray, J. (2003). Computerised, interactive,
multimedia cognitive behavioural therapy reduces
anxiety and depression in general practice: A
randomised control trial. Psychological Medicine, 33,
217-227.
Proudfoot, J.; Ryden, C.; Everitt, B.; Shapiro, D.A.;
Goldberg, D.; Mann, A.; Tylee, A.; Marks, I.; Gray,
J.A. (2004). Clinical efficacy of computerised cognitive
behavioural therapy for anxiety and depression in
primary care: randomised control trial. British Journal
of Psychiatry, 185, 46-54.
Pulse News (2009). Inquiry into gaps in cCBT
provision. (online). Retrieved 23 May 2009 from
http://www.pulsetoday.co.uk
Richards, D.; Timulak, L.; Tone, Y.; Rashleigh, C.;
Naughton, A.; Flynn, D.; McLoughlin, O. (2009). The
experience of implementing, recruiting and screening
for an online treatment for depression in a naturalistic
setting. Counselling Psychology Review, 24(2), 52-63.
Spek, V.; Cuijpers, P.; Nyklicek, I.; Riper, H.; Keyzer,
J.; Pop, V. (2007). Internet-based cognitive behaviour
therapy for symptoms of depression and anxiety: A
meta analysis. Psychological Medicine, 37, 319-328.
Stallard, P.; Richardson, T.; Velleman, S. (2010).
Clinicians’ attitudes towards the use of computerized
The Cumbria Partnership Journal of Research Practice and Learning 2(1)
cognitive behavioural therapy (cCBT) with children
and adolescents. Behavioural and Cognitive
Psychotherapy, 38, 545-560.
Taylor, C.B.; Chang, V.Y. (2008). Issues in the
dissemination of cognitive-behaviour therapy. Informa
Healthcare, 62(47), 37-44.
Titov, N. (2007). Status of computerized cognitive
behavioural therapy for adults. New Zealand Journal
of Psychiatry, 41(2), 95-114.
Ultrasis (2011). Beating the Blues cognitive
behavioural therapy. Retrieved 4 March 2010 from
www.ultrasis.com
Waller, R.; Gilbody, S. (2009). Barriers to the
uptake of computerized cognitive behavioural therapy:
A systematic review of the quantitative and qualitative
evidence. Psychological Medicine, 39, 705-712.
Watkins, E.; Williams, R. (1998). The efficacy
of cognitive behavioural therapy. Oxford: Blackwell
Science.
Whitfield, G.; Williams, C. (2004). If the evidence
is so good—why doesn’t anyone use them? A national
survey of the use of computerised cognitive-behaviour
therapy. Behavioural and Cognitive Psychotherapy, 32,
57-65.
Whitfield, G.; Hinshelwood, R.; Pashely, A.;
Campsie, L.; Williams, C. (2006). The impact of
a novel computerized CBT CD-ROM (Overcoming
Depression) offered to patients referred to clinical
psychology. Behavioural and Cognitive Psychotherapy,
34, 1-11.
Williams, C. ; Garland, A. (2002). Identifying and
challenging unhelpful thinking. Advances in Psychiatric
Treatment, 8, 377-386.
Williams, C.; Martinez, R. (2008). Increasing
access to CBT: Stepped care and CBT self-help models
in practice. Behavioural and Cognitive Psychotherapy,
36, 675-683.
World Bank (1993). World development report
1993: Investing in health. Retrieved 8 February 2009
from www-wds.worldbank.org
Wright, J.H.; Wright, A.S.; Albano, A-M,; Basco,
M.R.; Goldsmith, L.J.; Raffield, T.; Otto, M.W. (2005).
Computer-assisted cognitive therapy for depression:
Maintaining efficacy while reducing therapist time.
American Journal of Psychiatry, 162, 1158-1164.
The Cumbria Partnership Journal of Research Practice and Learning 2(1)
9