From the Editor

VR. e-therapies.

New technology is changing the way we think about the delivery of psychiatric services. But new isn’t necessarily better. Can care really be transformed? What does the literature say?computere-therapy: more than clever pictures of computers and stethoscopes?

In a two-part Reading of the Week, we look at technology and psychiatry.

Last week, Virtual Reality.

This week, e-therapies.

This week, we consider a new paper that has just been published. Its looks at self-guided Internet-based CBT showing that for every eight people treated, one benefits (consider this in the context of minimal cost).

And, in the other selection, we look at the Finnish experience with Internet-based CBT.



Self-Guided Work and e-Therapy

 “Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data”

Eirini Karyotaki, Heleen Riper, Jos Twisk, Adriaan Hoogendoorn, Annet Kleiboer, Adriana Mira, Andrew Mackinnon, Björn Meyer, Cristina Botella, Elizabeth Littlewood, Gerhard Andersson, Helen Christensen, Jan P. Klein, Johanna Schröder, Juana Bretón-López, Justine Scheider, Kathy Griffiths, Louise Farrer, Marcus J. H. Huibers, Rachel Phillips, Simon Gilbody, Steffen Moritz, Thomas Berger, Victor Pop, Viola Spek, Pim Cuijpers

JAMA Psychiatry, April 2017


Many studies have found that depressive symptoms can be effectively treated with psychotherapy, pharmacotherapy, or both. Nevertheless, many people with depressive symptoms do not seek help, and even well-resourced health care systems find it difficult to marshal enough qualified therapists to offer psychological interventions. Access barriers to psychotherapy include limited availability of trained clinicians, high cost of treatment, and fear of stigmatization. As a consequence, a significant number of individuals with depressive symptoms remain untreated.

Self-guided internet-based cognitive behavioral therapy (iCBT) without therapist support can allow physicians, such as general practitioners, to provide easy and affordable access to psychological treatments and reduce the cost of such treatments. A meta-analysis found a small but significant effect size of self-guided iCBT compared with control conditions. However, recent large trials found a range of effects, varying from small to moderate effect sizes to no effect.

These contradicting findings drew much attention and raised concerns about the benefits of these interventions. Randomized clinical trials (RCTs) and study-level systematic reviews often lack adequate power and precision in their estimates. Statistically underpowered samples also preclude identification of clinically useful moderators or predictors of treatment outcome.

karyotakiEirini Karyotaki

Here’s what they did:

  • A total of 13,384 abstracts were reviewed, through a search of a super-database including PubMed and the Cochrane Library.
  • Papers were selected that were randomized clinical trials with self-guided iCBT vs. control in people with depression. Inclusion criteria included age over 18, and elevated depression symptoms on a self-reported scale.
  • The authors did a traditional meta-analysis.
  • And the authors did an additional meta-analysis, whereby they collected data from the individual studies (by contacting authors for additional data, including demographic data, as well as for information on treatment adherence and co-morbidities) and then standardizing and analyzing the extended data set. This second meta-analysis was thus somewhat different: “Meta-analyses using individual participant data (IPD) estimate aggregate effect sizes using IPD from RCTs. The IPD maximize power to detect a true effect while allowing the exploration of study variability (eg, level of support, treatment adherence, setting) and participant characteristics as moderators of treatment outcome.”
  • Several statistical analyses were done; the authors made several calculations, including numbers needed to treat.

Here’s what they found:

  • “The systematic search resulted in 16 eligible articles of 1885 full-text articles screened. We were able to obtain IPD from 13 of the 16 eligible trials (81%), yielding a total of 3876 participants.”
  • “RCTs examined iCBT, with interventions comprising 5 to 11 online sessions. Four of the included trials provided support related to the technical aspects of the online platforms, whereas 9 trials were purely self-guided. The control conditions used were attention placebo, no treatment, treatment as usual, or waiting list. The included studies were conducted in 6 countries…”
  • Basic demographics of these 3876 participants: The mean age was 42.0; the majority (66.0%) were female; most were employed (71.9%).
  • The traditional meta-analysis: “The results of the traditional meta-analysis revealed that self-guided iCBT outperformed the control conditions at posttreatment assessment (g = 0.33).” (See the graph below.)
  • The IPD meta-analysis: In terms of symptom severity, “the 2-stage IPD meta-analysis resulted in a pooled effect size ofg = 0.27 in favor of self-guided iCBT… None of the examined study-level variables (type of comparator condition, recruitment, level of support, and treatment duration) were significantly associated with treatment outcome.” And, in terms of treatment response, they calculated an NNT of 8. (!)


The finding that self-guided iCBT results in a significant effect on depression outcomes is consistent with previous literature. However, the present IPD meta-analysis provides stronger evidence and improves the precision of the estimates because of the novel methodologic approach used. Moreover, previous literature did not examine NNTs. The current findings indicate that we need to treat 8 individuals with depressive symptoms with self-guided iCBT to expect a 50% symptom reduction. Although this NNT is relatively large and its clinical relevance could be doubted, it can still have a considerable effect when large groups of patients use the treatment, especially considering the low costs of self-guided iCBT. 

A few thoughts:

  1. This is a good study.
  1. And it adds nicely to a growing literature on iCBT. The authors don’t oversell – the NNT (or the average number of patients who need to be treated to prevent one additional bad outcome) is 8. 
  1. But the authors do a nice job of putting this in perspective. As they note:it can still have a considerable effect when large groups of patients use the treatment, especially considering the low costs of self-guided iCBT.” We can then see self-guided CBT as relevant (and inexpensive) for some patients struggling with depression, perhaps the first step in a stepped-care approach.


Finland and e-Therapy

 “What can the UK learn from Finland’s approach to mental health?”

Sarah Johnson

The Guardian, 5 April 2017

When Aino Korhonen, 69, saw an advert for online mental health therapy in a newspaper, she went to her GP and asked if she could be referred to try it.

The lifelong Helsinki resident had been diagnosed with depression and had attended a few sessions with a psychologist but the two didn’t get along. She remembers: “We didn’t [seem to] talk the same language. I went a couple of times and it didn’t help me at all.”

“Korhonen knew it was time to try something different when she turned up for an appointment only to sit and wait until she was informed that the psychologist was ill. ‘I was shocked. Somehow they hadn’t managed to contact me. I decided this wasn’t working. I couldn’t come here and not see anybody. I needed something else.’ she says. Her GP agreed.

While online therapy is viewed with some scepticism in the UK, in Finland the service, Mental Health Hub, is used by every hospital district in the country.

johnsonSarah Johnson

So begins an article from The Guardian written by journalist Sarah Johnson.

Johnson describes the Finnish experience:

  • The Mental Health Hub offers a questionnaire to help people better determine their needs; there are also self-help resources.
  • Three years ago, the Hub began offering more: people can now access online therapies for depression, anxiety, and alcohol misuse, which include videos and written exercises.
  • “In November 2016 the hub had 80,000 unique users, compared with 53,0000 in November 2015 – a rise of 70% year on year.”
  • “The total number of unique users in 2016 was 545,000, equal to roughly 10% of the Finnish population…”

The article describes the journey of Korhonen as she recovers from depression.

For Korhonen the service was invaluable. She remembers: “I started doing it and good heavens this was very good for me. I could do it very early in the morning because I normally wake up early. I could do it last thing in the evening. The exercises were very versatile. It really worked for me. I started appreciating myself. I changed my harmful beliefs into something creative. I got rid of my automatic negative thoughts. I changed them into positive ones.”

finlandFinland: a country of Northern Lights, cold winters, and e-therapies

A few thoughts:

  1. e-Therapies are relatively unknown here – but outside of Canada, countries like Australia, the UK, Sweden and Finland experiment with the concept. There is a rich international experience.
  1. Roughly 10% of the Finnish population accessed some aspect of the Mental Health Hub – wow.
  1. As we conclude the second part of our two-part series on technology and psychiatry, it’s difficult not to feel optimistic. VR and e-therapies have the potential to help deliver care better, and help address access issues.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.