Pragmatic evaluation of computer-aided self-help for anxiety and depression
Marks IM, Mataix-Cols D, Kenwright M, Cameron R, Hirsch S and Gega L;
Commented by , 28 Jul 2003
Aim of the study
Marks et al have developed 4 computer-aided self-help cognitive-behavioural therapy programs for anxiety and depression: FearFighter (for phobia/panic), Cope (for depression/anxiety), BTSteps (for obsessive–compulsive disorder) and Balance (for general anxiety/depression). In this article, they present results from open, unrandomised and uncontrolled studies of the 4 programs.
Method
Patients were screened for suitability using a screening questionnaire followed by a screening interview. Patients meeting criteria for inclusion were attributed to the computer-aided self-help program corresponding to the problem area for which they had requested help in the first place.
Outcome was assessed using the difference between pre-treatment and post-treatment scores obtained on the following instruments:
- Patient Global Impression of Improvement (PGI), Work and Social Adjustment (WSA)
- Fear Questionnaire (for phobia/panic)
- Beck Depression Inventory and Hamilton Rating Scale for Depression (for depression)
- Beck Anxiety Inventory (for generalised anxiety disorder)
- Yale–Brown Obsessive–Compulsive Scale (for obsessive–compulsive disorder)
Results
At post-treatment 80% of patients rated themselves as better to some degree on the PGI. Improvement on the WSA total score was significant for FearFighter, Cope and Balance users.
Completers of each system also improved significantly from pre- to post-treatment on measures specific to their problem. It should be noted, however, that of the 210 patients suitable according to the screening interview, 42 (20%) refused computer-aided CBT and 60 (29%) dropped out early or gave no post-treatment data.
Discussion
Patients with anxiety and depression can often be markedly improved by cognitive behavioural therapy (CBT). Due to a shortage of therapists or resources, CBT is, however, not easily available, and patients often have to wait for months before they can be included in a CBT program.
CBT programs are highly structured and mostly presented in a manualized format, with often separate manuals for therapists and patients. Such programs are amenable for inclusion in computer-aided programs that can be used by patients without or with only limited additional help from a therapist. They can be made available on CD-ROMs or on the Internet and can be used either as stand alones or in association with the treatment by a clinician.
The four programs developed by Marks et al are among the most promising in the field of computer-aided self-help. The results of the current study show that most patients have no major difficulties in using the programs and that the programs appear to be highly effective in many cases.
The programs are currently limited by the following:
- they may be cost-effective, but they are certainly not for free, and health authorities are wary of funding such programs
- a considerable proportion of patients seem to have difficulties using the programs without additional help from a clinician
On the whole, and although final proof for the effectiveness of the programs developed by Marks et al can only be obtained on the basis of randomized controlled trials, the results of the “pragmatic” evaluation described in the study are interesting enough to warrant use on a wider scale and further investigation.