By Tina Rosenberg on The New York Times
June 19, 2015 7:00 AM
“Elle is a mess. She’s actually talented, attractive and good at her job, but she feels like a fraud — convinced that today’s the day she’ll flunk a test, lose a job, mess up a relationship. Her colleague Moody also sabotages himself. He’s a hardworking, nice person, but loses friends because he’s grumpy, oversensitive and gets angry for no reason.
If you suffer from depression or anxiety as Elle and Moody do, spending time with them could help. They are characters in a free online program of cognitive behavioral therapy called MoodGYM, which leads users through quizzes and exercises — therapy without the therapist.
Cognitive behavioral therapy is a commonly used treatment for depression, anxiety and other conditions. With it, the therapist doesn’t ask you about your mother — or look at the past at all.
Instead, a cognitive behavioral therapist aims to give patients the skills to manage their moods by helping them identify unhelpful thoughts like “I’m worthless,” “I’ll always fail” or “people will always let me down.” Patients learn to analyze them and replace them with constructive thoughts that are more accurate or precise. For example, a patient could replace “I fail at everything” with “I succeed at things when I’m motivated and I try hard.” That new thought in turn changes feelings and behaviors.
The success of cognitive behavioral therapy is well known; many people consider it the most effective therapy for depression. What is not widely known, at least in the United States, is that you don’t need a therapist to do it. Scores of studies have found that online C.B.T. works as well as conventional face-to-face cognitive behavioral therapy – as long a there is occasional human support or coaching. “For common mental disorders like anxiety and depression, there is no evidence Internet-based treatment is less effective than face-to-face therapy,” said Pim Cuijpers, professor of clinical psychology at the Vrije Universiteit Amsterdam and a leading researcher on computer C.B.T.
MoodGYM, the pioneer, was developed by Australian psychologists in 2001. Now there are several similar programs in wide use and with good evidence behind them (and lots of junk programs that are completely ineffective).
MoodGYM and its kin are important because untreated mental illness is a huge global problem. Depression is the leading cause of disability for women worldwide, and the second-leading cause for men. If medical care is hard to come by in much of the world — in rural Indiana as well as rural India — mental health care is often impossible to get. In the United States, at least half of major depression goes untreated, and in very poor countries the figure is close to 100 percent.
Why don’t people get treated? Many don’t know they have a treatable disease, or don’t believe that treatment will help them. Some know they have a problem, but the stigma of mental illness keeps them from facing it and seeking help.
Online therapy can’t do much about those barriers. But it can help people who stay sick because there are no therapists nearby, who fear being judged or embarrassed in therapy, who can’t take time off from work, or for whom the cost of treatment is too high. It allows people to carry therapy around in their pockets, use it at 2 a.m., and pay nothing or nearly nothing.
In the late 1990s, Helen Christensen, a mental health researcher at the Australian National University in Canberra, and her colleague Kathleen Griffiths worked with local designers to create MoodGYM, which was adopted by Australia’s national health system six years ago. Christensen is now the chief scientist at the mood-disorder research Black Dog Institute (named after Winston Churchill’s famous term for his own depression), where she researches and designs more online programs. Among these are BiteBack for teenagers and MyCompass, which aims to treat anxiety, stress and depression in mature adults (MoodGYM is pitched younger, although older people use it, too). MyCompass is designed in small chunks, “something you can do at the bus stop on your mobile phone,” said Christensen. Both are available to anyone with a computer worldwide.
MoodGYM was controversial when it first came out. “People did feel threatened,” said Christensen. “They said it’s unethical, harmful – you’re doing damage and you don’t know it. Or you’re stopping people from getting the real help they need.”
But MoodGYM has been widely successful, without the predicted consequences. About 100,000 Australians use it each year, as do people in 200 countries.
Australia is ground zero, but other online cognitive behavioral therapy programs are also widely used in the Netherlands, Sweden and Britain. In 2007, the British National Health Service began covering a program called FearFighter for phobias and anxiety, and another program, Beating the Blues, for depression. Both can be used for no cost through participating National Health Service doctors, or bought to use alone. Beating the Blues costs the equivalent of $237. FearFighter is $154, or $313 if you want telephone support from clinicians.
In a medical setting, most doctors use online therapy in what’s called a stepped model. Patients with mild to moderate problems start with the computer program, checking in every so often with a therapist or case manager. Those who don’t get better are then treated face to face by a therapist and, if that doesn’t work, by a specialist. (Patients with very serious issues start with in-person therapy.)
Online therapy is effective against an astonishing variety of disorders. A Swedish survey of studies found that online C.B.T. has been tested for 25 different ones. It was most effective for depression, anxiety disorders, severe health anxiety, irritable bowel syndrome, female sexual dysfunction, eating disorders, cannabis use and pathological gambling. “Comparison to conventional C.B.T. showed that [online] C.B.T. produces equivalent effects,” the researchers concluded.
Cuijpers said there were fewer studies of online therapy to treat insomnia, pain and alcohol abuse, but what’s been done has shown good effects. (Last week the Upshot published one contributor’s story of his success using online C.B.T. for insomnia.)
MoodGYM, like some other programs, can be completely self-guided. People who use these programs alone tend to see a small but significant effect — the program helps, but not as much as the same program with occasional human contact. That could be check-ins with a therapist, but it doesn’t have to be. The human could be a case manager or possibly a peer. Encouragement and support are what count, not expertise.
The main reason self-guided C.B.T. doesn’t work as well is that people tend to stop using it. The human touch encourages people to stick with it. One study of adolescents found that almost 60 percent of users stopped MoodGYM after the first module when they were working unsupported on their own. When the same program was used with monitoring and support, only 10 percent stopped.
“Well, it’s called Mood Gym,” said Marcia Valenstein, a psychiatrist at the University of Michigan Medical School who is researching online C.B.T. with peer support among veterans at the Veterans Affairs Ann Arbor Healthcare System. “Even the gym gym people are enthusiastic and go for a day or so — and then they stop.”
Michigan is one of the few places in America working with cognitive behavioral therapy online. Others are Kaiser Permanente in Oakland and the University of Pittsburgh. (The University of Pittsburgh Medical Center is a co-owner of the American version of Beating the Blues.)
Why so few? One possible reason for America’s resistance is that doctors fear lawsuits; what if a patient whom a doctor starts with an online program commits a mass murder? (Perhaps wide access to online therapy plus gun control would be a good plan.)
Also, the American medical system likes to have testing done in the United States before it takes something seriously. The extensive research with Australian, British, Swedish and Dutch patients might not be persuasive here.
Perhaps most important is the lack of an influential champion. Ideas don’t spread by themselves. And just as important would be bringing online C.B.T. to the attention of the World Health Organization. Poor countries are where it’s needed most.
The reception for online cognitive behavioral therapy isn’t uniformly warm — and the dissenters are not just therapists worried about being put out of business (if only untreated depression were that scarce a commodity). One big issue is that someone seriously ill might waste time tootling around with an online program, not realizing he needs more help. Or he might use a program that isn’t right for him. It’s safer, of course, if a therapist sees the patient and then prescribes online therapy. That’s an efficient use of therapists — but it still requires a therapist, and that negates some of online C.B.T.’s advantages.
Over all, the benefits of online cognitive behavioral therapy are persuasive. It allows people who could not otherwise get therapy to get it — and can help psychotherapists and specialists focus on more complex cases. It saves money for patients and health systems. And the online clinic never closes. When you can’t sleep for worry and it’s 3 a.m., your therapist is there for you
Customization is another benefit. Bruce L. Rollman, an internist who is a professor of psychiatry at the University of Pittsburgh School of Medicine, is studying an online program that uses cognitive behavioral therapy to treat depression in a range of cases, even as he employs face-to-face therapy in research with heart patients — a group in which depression is common. Depression can kill in many ways. One is by keeping you from dealing with other illnesses; people who are depressed are less likely to take their meds and do their exercises. So one way to treat heart disease is to treat any accompanying depression. “And if you apply depression treatment to high-cost patients, you are much more likely to save money,” said Rollman.
Ricardo Muñoz, a professor of clinical psychology at Palo Alto University, sees online C.B.T. as a tool for preventing depression. “We know that if a person develops a major depressive episode, the likelihood of another one goes to 50 percent, up from 17 percent,” he said. “After that, the likelihood of another goes to 70 and then 90 percent. Obviously, we need to be preventing the first one.”
Face-to-face cognitive behavioral therapy, which teaches people skills they can use to improve their mood, is well-suited for prevention of depression. But the health insurance system is not. No one will pay for face-to-face therapy for someone who doesn’t yet have a disorder. There is a clear need here for the online version.
Why stop there? Muñoz envisions translating and adapting the basic therapy to tailor it to different syndromes, co-illnesses and languages: a Swahili-speaking kidney dialysis patient with depression could get exactly the right program. “I dream of systematically filling in a grid in which columns are health issues (smoking, depression, anxiety, obesity, pain, alcohol and other substance abuse and so on) and the rows are languages (English, Spanish, Chinese, etc.),” he wrote in an email. “This is totally within our ability to do right now. We have the knowledge and the digital tools.””