Web-Based Cognitive Behavioral Therapy Blended With Face-to-Face Sessions for Major Depression: Randomized Controlled Trial

Abstract

BackgroundMeta-analyses of several randomized controlled trials have shown that cognitive behavioral therapy (CBT) has comparable efficacy to antidepressant medication, but therapist availability and cost-effectiveness is a problem.ObjectiveThis study aimed to evaluate the effectiveness of Web-based CBT blended with face-to-face sessions that reduce therapist time in patients with major depression who were unresponsive to antidepressant medications.MethodsA 12-week, assessor-masked, parallel-group, waiting- list controlled, randomized trial was conducted at 3 medical institutions in Tokyo. Outpatients aged 20-65 years with a primary diagnosis of major depression who were taking ≥1 antidepressant medications at an adequate dose for ≥6 weeks and had a 17-item GRID-Hamilton Depression Rating Scale (HAMD) score of ≥14 were randomly assigned (1:1) to blended CBT or waiting-list groups using a computer allocation system, stratified by the study site with the minimization method, to balance age and baseline GRID-HAMD score. The CBT intervention was given in a combined format, comprising a Web-based program and 12 45-minute face-to-face sessions. Thus, across 12 weeks, a participant could receive up to 540 minutes of contact with a therapist, which is approximately two-thirds of the therapist contact time provided in the conventional CBT protocol, which typically provides 16 50-minute sessions. The primary outcome was the alleviation of depressive symptoms, as measured by a change in the total GRID-HAMD score from baseline (at randomization) to posttreatment (at 12 weeks). Moreover, in an exploratory analysis, we investigated whether the expected positive effects of the intervention were sustained during follow-up, 3 months after the posttreatment assessment. Analyses were performed on an intention-to-treat basis, and the primary outcome was analyzed using a mixed-effects model for repeated measures.ResultsWe randomized 40 participants to either blended CBT (n=20) or waiting-list (n=20) groups. All patients completed the 12-week treatment protocol and were included in the intention-to-treat analyses. Participants in the blended CBT group had significantly alleviated depressive symptoms at week 12, as shown by greater least squares mean changes in the GRID-HAMD score, than those in the waiting list group (−8.9 points vs −3.0 points; mean between-group difference=−5.95; 95% CI −9.53 to −2.37; P<.001). The follow-up effects within the blended CBT group, as measured by the GRID-HAMD score, were sustained at the 3-month follow-up (week 24) and posttreatment (week 12): posttreatment, 9.4 (SD 5.2), versus follow-up, 7.2 (SD 5.7); P=.009.ConclusionsAlthough our findings warrant confirmation in larger and longer term studies with active controls, these suggest that a combined form of CBT is effective in reducing depressive symptoms in patients with major depression who are unresponsive to antidepressant medications.Trial RegistrationUniversity Hospital Medical Information Network Clinical Trials Registry: UMIN000009242; https://u...

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“…Improvement of the symptoms was confirmed in 3 disorders; it was found that the therapeutic alliance was achieved at a high level, and patients’ satisfaction was extremely high. Therefore, this study showed the feasibility of ICBT with real-time support of therapists to Japanese patients except for depression [86].…”

Blended cognitive behavioural therapy for adolescents with panic disorder co-morbid with autism spectrum disorder: a case study

“…Simply calculated, this required about one-third the time of a regular 45-to 90-min CBT session. Previous RCTs among Japanese patients with major depressive disorders have indicated that blended CBT was the most effective and promising for trainee therapists; using web-based support, therapists can more confidently implement CBT, even with relatively less experience (Nakao et al, 2018). Hence, greater numbers of patients may be treated as it becomes easier for doctors to request treatment sessions with less-experienced therapists.…”

“…One promising treatment approach is blended CBT, which combines digital aid materials and/or computer programs with built-in human interactions (e.g. psychoeducation) in addition to support for therapists in capturing abstract thought processes (Nakao et al, 2018;van der Vaart et al, 2014). Blended CBT is a simple, low-intensity application that can be offered as a manualised guided self-help intervention.…”

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Improving the Course of Depressive Symptoms After Inpatient Psychotherapy Using Adjunct Web-Based Self-Help: Follow-Up Results of a Randomized Controlled Trial

“…In blended treatments, face-to-face interventions are combined with Web-based or mobile-based interventions and integrated in 1 treatment scheme [16]. Nakao et al [17] compared a Web-based program combined with face-to-face sessions with regular cognitive behavioral therapy in an RCT with N=40 participants and could show that blended CBT was effective in reducing depressive symptoms in patients with major depression. There are also first promising studies on blended group psychotherapy; in a qualitative study, patients reported in in-depth interviews that blended group therapy could be motivating, increasing the consolidation of the results of face-to-face psychotherapy, among other things, because of the possibility of between-session monitoring and Web-based reinforcement of exercising tasks [18].…”