Some thoughts from a GP on the recent media storm about eMH
A recent article in the BMJ by Gilbody et al of the REEACT trial (BMJ 2015; 351:h5627) reported that this large RCT had failed to show any benefit from the use of online CBT for patients with depression beyond the benefit derived from “care as usual” by their general practitioner.
Superficially that seems to be a damning conclusion for eMH for depression but, as usual, the devil is in the detail.
Adults presenting to general practice with symptoms of depression were randomised to usual care OR usual GP care plus a commercial online intervention (Beating the Blues) OR usual GP care plus a free online intervention (MoodGYM). Both these online treatment programs have a long track record and proven efficacy in research trials. (This study was not designed to test the efficacy of those programs but whether or not they provided benefit over and above usual GP care).
We know intuitively that not everyone will find online interventions acceptable. Randomisation means of course that no attempt appears to have been made to assess the suitability of the patient for an online intervention or of its acceptability to the patient. Perhaps in practice such assessment might be wise.
All we know from the article about recruitment to the study is that “Potential participants were recruited either directly by their GP or by letter of invitation if their clinical record indicated that they had depression.” No comment is made about the way in which GPs were asked to introduce the idea of online intervention or the wording of the “invitation”. My clinical experience tells me that patients respond to my enthusiasm and encouragement and will be more or less likely to register for a program and persevere with it according the way the idea of online help is presented to them. Perhaps in this study this is reflected in the fact that only 83% of those in the Beating the Blues arm and 77% of those in the MoodGYM arm actually accessed the programs at all. Interestingly 19% of those randomised to usual GP care alone had accessed an online program on their own initiative or the recommendation of others by the 4 month mark.
In terms of compliance it is worth noting that for those randomised to the Beating the Blues program the median number of sessions completed was 2 out of 8 while for those in the MoodGYM arm the median number of sessions completed was one out of 6.
The paper refers to the use of online programs as “supported” but it is worth noting that the support was from technicians rather than GPs or mental health professionals. This is not the usual definition of “support” in this context. Technical support was attempted a median of 13 times for each group. There is however no mention of any attempt at clinical support and we know from previous studies that clinical support definitely does make a difference to outcomes. The number of visits to the GP was the same in each group which may further indicate no additional support was given by GPs around the online program use.
This study does not mean eMH will not work in general practice. It means that it may not be helpful if we do not choose the patients to whom we recommend it wisely and support them while they use it.
Go to the BMJ http://www.bmj.com/content/351/bmj.h5627/rapid-responses for a research based response to the article
Gerhard is a full professor of Clinical Psychology at Linköping University, Sweden since 2003, an
d affiliated researcher at the Karolinska Institute, Sweden. Professor Andersson is an internationally recognized researcher in the field of CBT delivered through information and communication technology, as well as the author of the book “The Internet and CBT: a clinical guide”.
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