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Study: Online CBT for Depression Just as Effective as In-Person Treatment

Someone receiving online therapy.

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Key Takeaways

  • Cognitive behavioral therapy (CBT) delivered remotely was found to be just as effective as in-person CBT for depression treatment.
  • At the same time, certain CBT techniques used in an online setting, like relaxation techniques, exacerbated depression symptoms.
  • This study is part of a larger movement to optimize and personalize CBT treatment for patients.

Over the course of the pandemic, telehealth saw a rise in popularity. But even as states lift restrictions, online therapy may be here to stay. New research finds that a popular treatment for depression—cognitive behavioral therapy (CBT)–was just as effective when delivered remotely.

In this analysis, researchers at the University of Gothenburg in Sweden compared the effectiveness of CBT delivered in-person versus online. Then, they analyzed whether this remote method worked equally for all kinds of patients.

Björkelund and colleagues found that in-person CBT and internet-based CBT (iCBT) were similarly effective for patients. But this varied for different CBT techniques as well as the severity of depression.

The evidence suggests that clinicians should consider certain caveats and personal patient traits when tailoring their treatment.

“If you’re going to use iCBT in health care, the programs have to be regulated just as well as drugs are, but that’s not the case today," Cecilia Björkelund, MD, senior professor of Family Medicine at the University of Gothenburg and study author, said in a press release. "With this study, we’re taking a real step forward."

The study was published in early May in The Lancet Psychiatry.

What Is Cognitive Behavioral Therapy (CBT)?

CBT is based mainly on the principle that psychological problems are at least in part due to unhelpful thinking and behavioral patterns. Therefore, this type of therapy usually involves efforts to change thought patterns.

Often, the psychologist and patient/client collaborate to develop an understanding of the problem and design a treatment strategy. This strategy can consist of various methods, including:

  • Cognitive restructuring: Techniques used to deconstruct unhelpful thoughts and rebuild them in a more balanced way that reflects reality.
  • Relaxation techniques: Techniques such as diaphragmatic breathing and progressive muscle relaxation.
  • Behavioral activation: Identifying specific goals and pleasurable activities that are consistent with the life you want to live, and that you can participate in when it would be helpful to affect your mood.

Online CBT Can Be Just as Helpful

For this meta-analysis, the authors used 76 studies on iCBT from around the world, analyzing more than 17,000 patients with depression.

They found that for patients with mild to moderate depression, iCBT was as effective as traditional, in-person CBT for treating symptoms. However, for severely depressed patients, this wasn't the case. The researchers recommend mental health professionals avoid online therapy altogether for severely depressed individuals.

In general, given the findings, the authors advise that clinicians take specific precautions to ensure that the iCBT techniques they're using are as safe and effective for patients as possible.

For example, relaxation techniques and exercises were harmful to participants online. These strategies at times exacerbated depression symptoms and induced anxiety.

Still, authors did find certain techniques to be helpful and neutral for iCBT. For instance, behavioral activation was found to be very helpful for patients.

On the other hand, cognitive restructuring was neither harmful nor helpful. Study author Toshi A. Furukawa, MD, PhD, dean of Kyoto University School of Public Health, says this finding is difficult to interpret since cognitive restructuring "is the heart of CBT."

"It is possible that cognitive restructuring is not helpful, or maybe it is a little bit too difficult to teach through internet CBT," he says.

What This Means for You

If you're interested in CBT or iCBT, talk to a mental health expert to find the best option for you. And if you know someone who might benefit from the online version (for example, the research also found that iCBT was especially good for the elderly), you could recommend it and/or seek out a psychologist who provides it.

Personalizing Online Therapy

These findings, in particular, highlight the importance of personalization in health care.

As a psychiatrist and cognitive behavioral therapist, Furukawa says, “my usual thinking is that patients are deficient in CBT skills, and we teach them CBT skills." But with the rising recognition of how individual differences affect treatment, it may be a bit more complicated.

For the review, Furukawa and colleagues also considered individual participant data—including age, sex, relationship status, and baseline severity of depression.

However, Furukawa adds, with those four variables—age, sex, relationship status, and baseline severity—"you cannot describe a person."

Because of this, Furukawa and colleagues are now conducting what is called a "fully factorial trial," where more characteristics—like preexisting CBT skills—are measured amongst participants. Previous findings suggest that preexisting CBT skills enhance iCBT.

"It's turning out that perhaps the people who have already some skills learn the most," Furukawa says.

For example, some people already have a behavioral-activating style, or can do cognitive restructuring on their own. In other words, if they already have a solid base maybe it'll be easier for them, through iCBT, to build on and strengthen it.

"For many, [iCBT is] a superb way of getting access to therapy without having to go to a therapist," Björkelund said in the press release.

While iCBT can remedy accessibility problems, Furukawa is set on optimizing it for the individual.

"I do hope that this study stimulates discussion and interest in what [iCBT] packages you build, and also how you are going to personalize or match them to individual patients," Furukawa says.

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  1. Furukawa, TA, Suganuma, A, Ostinelli, EG, et al. Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data. The Lancet Psychiatry8(6), 500–511. doi:10.1016/s2215-0366(21)00077-8

  2. American Psychological Association. What is Cognitive Behavioral Therapy? Updated July 2017.