A review of computerised cognitive behavioural therapy (ccbt) for depression Helen Rhodes & Stewart Grant

Transcription

1 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.

2 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 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 2 The Cumbria Partnership Journal of Research Practice and Learning 2(1)

3 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 The Cumbria Partnership Journal of Research Practice and Learning 2(1) 3

4 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, 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 4 The Cumbria Partnership Journal of Research Practice and Learning 2(1)

5 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 The Cumbria Partnership Journal of Research Practice and Learning 2(1) 5

6 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 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 6 The Cumbria Partnership Journal of Research Practice and Learning 2(1)

7 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, helenrhodescbt@talktalk.net References Andersson, G.; Cuijpers, P. (2008). Pros and cons of online cognitive behavioural therapy. The British Journal of Psychiatry, 193, 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, 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, Cavanagh, K.; Shapiro, D.A. (2004). Computer treatment for common mental health problems. Journal of Clinical Psychology, 60(3), 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, Christensen, H.; Griffiths, K.M.; Jorm, A. (2004). Delivering interventions for depression by using the internet: Randomised controlled trial. British Journal of Psychiatry, 328, 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, 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, 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, Department of Health (2007). Improving access to psychological therapies: Positive practice guide. Retrieved 16 March 2008, from Department of Health (2007). Improving access to psychological therapies (IAPT) programme: Computerised cognitive behavioural therapy (ccbt) implementation guidance. Retrieved 16 March 2011, from Department of Health (2008). Improving access to psychological therapies: National guideline for regional delivery. Retrieved 22 February 2010 from 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, 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

8 regression. Psychological Medicine, 37, 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), Kaltenthaler, E.; Cavanagh, K. (2010). Computerised cognitive behavioural therapy and its uses. Progress in Neurology and Psychiatry, 14(3), 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), 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, 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, 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, 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, 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, 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, Mitchell, N.; Gordon, P.K. (2007). Attitudes Towards Computerized CBT for Depression Amongst a Student Population. Behavioural and Cognitive Psychotherapy, 35, NICE (2002). Computerised cognitive behaviour therapy for depression and anxiety. London: National Institute for Health and Clinical Excellence. Retrieved 14 April 2009, from 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 NICE (2004b). Management of depression in primary and secondary care. London: National Institute for Health and Clinical Excellence. Retrieved 26 April 2009, from NICE (2005). Depression in children and young people. London: National Institute for Health and Clinical Excellence. Retrieved 26 May 2011, from NICE (2006). Depression and anxiety computerised cognitive behavioural therapy (ccbt). London: National Institute for Health and Clinical Excellence. Retrieved 14 April 2009, from 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 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 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, 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, Pulse News (2009). Inquiry into gaps in ccbt provision. (online). Retrieved 23 May 2009 from 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), 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, Stallard, P.; Richardson, T.; Velleman, S. (2010). Clinicians attitudes towards the use of computerized 8 The Cumbria Partnership Journal of Research Practice and Learning 2(1)

9 cognitive behavioural therapy (ccbt) with children and adolescents. Behavioural and Cognitive Psychotherapy, 38, Taylor, C.B.; Chang, V.Y. (2008). Issues in the dissemination of cognitive-behaviour therapy. Informa Healthcare, 62(47), Titov, N. (2007). Status of computerized cognitive behavioural therapy for adults. New Zealand Journal of Psychiatry, 41(2), Ultrasis (2011). Beating the Blues cognitive behavioural therapy. Retrieved 4 March 2010 from 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, 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, 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, Williams, C. ; Garland, A. (2002). Identifying and challenging unhelpful thinking. Advances in Psychiatric Treatment, 8, Williams, C.; Martinez, R. (2008). Increasing access to CBT: Stepped care and CBT self-help models in practice. Behavioural and Cognitive Psychotherapy, 36, 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, The Cumbria Partnership Journal of Research Practice and Learning 2(1) 9