Online Psychotherapy for Mood Disorders: Are We There Yet?

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TABLE. Efficacy of ICBT for various anxiety disorders[6]

RESEARCH UPDATE

Psychotherapy for bipolar disorder has been firmly established as a necessary ingredient in the comprehensive care of bipolar disorders.¹ Prominent among these techniques are psychoeducation, as pioneered by the Barcelona research team²; social rhythm therapy, originally from the Pittsburgh group³; and behavioral therapies that focus on changing sleep habits, including a bipolar-specific variation of CBT-I (cognitive-behavioral therapy for insomnia) with strikingly positive results recently reviewed here.⁴

Unfortunately, even simple therapies like CBT-I are amazingly hard to find-even with 90% of the CBT-I therapy packaged in a free app from Stanford’s sleep lab (also recently reviewed for Psychiatric Times). Indeed, an entire CBT-I therapy is available as an online program, which also has randomized trial evidence for its efficacy, but it costs $130.⁵ Granted, that’s little more than the co-pays many patients will face for 6 to 8 sessions of face-to-face CBT-I. However, only 60% of the study subjects completed the program⁵ (but people drop out of therapy too, right?).

In the long run, the ideal would be an online bipolar psychotherapy, with randomized trial evidence for performing as well as seeing a live therapist, and free access. That might seem a “pie in the sky” dream, but look how close we are to just such an arrangement.

Internet-based CBT

A recent Cochrane review examined available randomized trial data for the efficacy of Internet-based cognitive-behavioral therapy (ICBT) for various anxiety disorders.⁶ Thirty-eight studies with a net of 3214 participants met the criteria for inclusion. These studies examined “therapist-supported ICBT,” often called guided ICBT. In this method, the CBT itself is provided via an online program, while a therapist helps patients get started and adhere to the program using telephone calls, texts, or e-mail. The Cochrane review results are shown in the Table.

Note carefully the comparisons being made. Face-to-face CBT, the traditional model that is so widely practiced currently, was not superior to therapist-supported ICBT. There is no comparison here of unguided ICBT and traditional face-to-face therapy. Of course, that would be extremely useful: can an Internet-based therapy alone really perform as well as face-to-face?

Most individual studies of unguided ICBT have shown good results, for those who complete the program, but completion rates can be low. For example, in one large trial, only half of the exercises were completed by the ICBT group.⁷ Thus the effect size* for all comers was 0.4-versus 0.6 for those who completed the program-but 0.9 for completers whose depression scores were high before the study began. (*Recall that an effect size of 0.5 is generally regarded as substantial, while an effect size of 1.0 is quite large: it means the intervention group improved by an entire standard deviation.) Thus, just as some meta-analyses have shown for antidepressants (eg, Fournier and colleagues⁸), ICBT appears more likely to show results when used by patients with significant depression, as opposed to mild symptoms.

What about bipolar psychotherapies: are any available online? Not much so far.⁹ Take the face-to-face Barcelona psychoeducation program, for example, which had very strong benefit for patients; indeed, their improvement relative to the control supportive therapy was still evident 5 years after the intervention.¹⁰ Using an efficient group approach, Drs. Colom and Vieta conducted psychoeducation groups of 8 to 10 patients, for 20 weekly meetings. Their entire program is detailed in a treatment manual that is available in English (it includes not just their session details but handouts, pitfalls encountered, even the good jokes they told).¹¹

The problem is that the Barcelona program is not widely used, despite the results and the manual. However, a trial of online psychoeducation for bipolar disorder is underway.¹² I’ve used my website for this purpose for years, but it is not a therapy program and its efficacy has not been studied. Data on the value of formal online psychoeducation in bipolar disorders will be quite valuable.

Disclosures:

Dr. Phelps is Director of the Mood Disorders Program at Samaritan Mental Health in Corvallis, Ore. He is the Bipolar Disorder Section Editor for Psychiatric Times. Dr. Phelps stopped accepting honoraria from pharmaceutical companies in 2008 but receives honoraria from McGraw-Hill and W.W. Norton & Co. for his books on bipolar disorders.

References:

1. Swartz HA, Swanson J. Psychotherapy for bipolar disorder in adults: a review of the evidence. Focus (Am Psychiatr Publ). 2014;12:251-266.

2. Colom F, Vieta E, Martinez-Aran A, et al. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry. 2003;60:402-407.

3. Haynes PL, Gengler D, Kelly M. Social rhythm therapies for mood disorders: an update. Curr Psychiatry Rep. 2016;18:75.

4. Harvey AG, Soehner AM, Kaplan KA, et al. Treating insomnia improves mood state, sleep, and functioning in bipolar disorder: a pilot randomized controlled trial. J Consult Clin Psychol. 2015;83:564-577.

5. Ritterband LM, Thorndike FP, Ingersoll KS, et al. Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial. JAMA Psychiatry. 2017;74:68-75.

6. Olthuis JV, Watt MC, Bailey K, et al. Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database Syst Rev. 2016;3:CD011565.

7. Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the Internet: randomised controlled trial. BMJ. 2004;328:265.

8. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010;303:47-53.

9. Barnes CW, Hadzi-Pavlovic D, Wilhelm K, Mitchell PB. A web-based preventive intervention program for bipolar disorder: outcome of a 12-months randomized controlled trial. J Affect Disord. 2015;174:485-492.

10. Colom F, Vieta E, Sánchez-Moreno J, et al. Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial. Br J Psychiatry. 2009;194:260-265.

11. Colom F, Vieta E. Psychoeducation Manual for Bipolar Disorder. Cambridge, UK: Cambridge University Press; 2006.

12. González-Ortega I, Ugarte A, Ruiz de Azúa S, et al. Online psycho-education to the treatment of bipolar disorder: protocol of a randomized controlled trial. BMC Psychiatry. 2016;16:452.