What Is Online CBT for Depression and Anxiety?

Cognitive behavioral therapy (CBT) is an effective, evidence-based therapy for depression and anxiety. In recent years, most of us have noticed an increase in awareness and discussion – online, in the media, everywhere – about mental health topics. This awareness began in the mid-2010s, when rates of suicide among adolescents and young people began to increase. With the arrival of the coronavirus pandemic, awareness of mental health and related issues skyrocketed: now the entire nation understands the importance of accurate diagnosis and reliable, evidence-based treatment for mental health disorders, especially the two most commonly diagnoses mental illnesses, depression and anxiety.

As awareness increased, another thing happened: we recognized we need new approaches to treatment and delivery of mental health services, because many people can’t or won’t seek typical, in-person treatment, for a variety of reasons. Some fear stigma, others cite cost considerations, while others simply think they don’t have the time for treatment.

That’s why a recent study piqued our interest. The paper “A Precision Treatment Model for Internet-Delivered Cognitive Behavioral Therapy for Anxiety and Depression Among University Students: A Secondary Analysis of a Randomized Clinical Trial” examined a novel approach to using cognitive behavioral therapy (CBT) to treat university-aged students diagnosed with either depression, anxiety, or both.

The approach they tested was an internet-based program called iCBT: Space from Depression and Anxiety, developed by a company called SilverCloud. Researchers recruited over 1300 patients to measure the impact of internet delivered CBT as compared to typical outpatient treatment delivered by university support services. The study yielded promising results – but before we discuss those, we’ll briefly review the current state of mental health in the U.S., including rates of mental illness, depression, and anxiety.

Mental Health, Depression, Anxiety: Big Picture Statistics

First, the data on mental illness in the U.S., as published in the 2021 National Survey on Drug Use and Health (2021 NSDUH).

Mental Illness in the U.S.: The Latest Data

• Any Mental Illness (AMI):
  • Adults 18+: 22.8% (57.8 million)
    • Received treatment: 46% (26.4 million)
  • Serious Mental Illness (SMI):
    • Adults 18+: 5.5% (14.1million)
      • Received treatment: 64% (9 million)

Next, the data on depression and anxiety, as published by the World Health Organization and the National Institutes of Health (NIH).

Depression and Anxiety: The Latest Data

Depression:

• The World Health Organization (WHO) reports 3.8% of people in the world report depression
• The National Institutes of Health (NIH) report the following rates of depression for the U.S.:
• Age 18+: 8.4%
  • Received treatment: 61% (12.6 million)
• Age 18+ depression with severe impairment: 6%
  • Received treatment: 64.8% (9.1 million)

Anxiety:

• The WHO reports1% of people in the world have anxiety
• Women report anxiety at rates 50% higher than men
• The National Institutes of Health report the following rates of anxiety for the U.S.:
• Age 18+: 31.1% report any anxiety diagnosis
  • With severe impairment: 22.8%
• Received treatment, any impairment level: 43.2%

That’s the default situation we face in the U.S. Millions of people have depression and anxiety, millions of people engage in treatment, but there are still millions of people with depression and anxiety that don’t get the evidence-based treatment they need to manage their mental health disorder and live a full and fulfilling life.

The protocols in this study may help change that situation, and reduce the difference between the number of people who need treatment and the number of people who receive treatment, a.k.a. the treatment gap.

iCBT: How the Space from Depression and Anxiety Intervention Works

The iCBT intervention is an online therapeutic program, built on the principles of cognitive behavioral therapy (CBT), designed for people with co-morbid depression and anxiety. The program is accessible 24 hours a day, 365 days a year. In study we discuss in this article, one group participated in the standard iCBT program, another group participated in a guided iCBT program, and a third, control group, received treatment-as-usual.

We describe the iCBT program below. Self-guided participants decided how to complete the eight core modules over an eight-week period, while guided participants received weekly messages to customize the experience and provide individualized feedback. Participants in the treatment-as-usual (TAU) group participated in neither iCBT program, and instead participated in standard, university-sponsored outpatient CBT treatment.

Here’s an overview of the SilverCloud program modules:

Module 1: Getting Started

This module introduces patients to the concept of treatment, basic CBT concepts, and teaches patients the basics about anxiety and depression. Topics include:

• Education about depression and anxiety. This includes the neurobiology of mental health and the fundamentals of treatment and recovery.
• Applying CBT to anxiety and depression. This includes an explanation of how therapeutic techniques can apply directly to daily symptom management.
• Introduction of the thought-feelings-behavior (TFB) cycle. This includes a breakdown of the fundamental CBT concept that thoughts impact feelings, and in turn, feelings impact behaviors. For people with depression or anxiety, understanding this connection is the first step towards cognitive restructuring, i.e., changing counterproductive thoughts and feelings into productive thoughts and feelings.

Module 2: Understanding Emotion and Feeling

This module helps patients understand the power of their emotions and feelings and recognize their significant role in the TFB cycle. Topics include:

• Understanding the function of emotions. Therapists help patients learn about the importance of emotions: why we have them, how they can help us, and how we need to regulate our emotions when they’re imbalanced or counterproductive.
• Recognizing emotions can be difficult. This module helps patients understand that emotions can be painful and hard to work through – and that’s okay. Therapy can give tools to help.
• Understanding the emotion-body connection. Therapists help patients recognize their physical reactions to heightened emotional states. For instance, a tight feeling in the chest when anxious, and sinking feeling in the stomach when depressed, and more.
• Connecting lifestyle choices to the TFB cycle. Patients learn about how their lifestyle choices can exacerbate or improve their symptoms of depression and/or anxiety, and that they have the power to make choices the improve, rather than exacerbate, their symptoms.

Module 3: Identifying Unhelpful Behaviors

This module helps patients learn a CBT approach to recognizing the most common unhelpful behaviors among people diagnosed with depression and/or anxiety. Once a patient can identify counterproductive behaviors accurately, they can learn to replace them with productive behaviors. Topics include:

• Learning about the most common unhelpful behaviors associated with depression/anxiety
• Identifying those behaviors in daily life
• Learning how they exacerbate depression and anxiety symptoms
• Learning CBT techniques for transforming unhelpful behaviors related to depression/anxiety to helpful behaviors

Module 4: Facing Fears

This module helps patients understand the impact of avoidance behaviors associated with anxiety and withdrawal behaviors associated with depression. Topics include:

• Anxiety: why avoiding situations that cause anxiety can prolong/exacerbate anxiety
• Depression: why withdrawing from friends, family, and daily activities can prolong/exacerbate depression
• Learning how to identify safety behaviors (anxiety) and behaviors that promote reintegration (depression)
• Learning to face fears using graded exposure (anxiety) and learning to re-engage in daily life by identifying and engaging in life-affirming activities

Module 5: Identifying Unhelpful Thoughts

This module helps patients identify automatic, counterproductive thoughts. Therapists introduce several concepts about thoughts and the TFB cycle. Topics include:

• Defining automatic thoughts as unwanted, practiced thoughts and patterns of thought that exacerbate symptoms of depression and anxiety, and can lead to counterproductive behaviors
• Learning about the CBT concept of thought traps, e. automatic negative thoughts (ANTs) that exacerbate symptoms of depression and anxiety
• Learning how to live in the moment without judging ANTs – but understanding it’s possible to replace ANTs with productive thoughts and patterns of thought

Module 6: Challenging and Changing Unhelpful Thoughts

This module is the action component of the previous module. Module 5 teaches patients about unhelpful automatic thoughts, while this module teaches patients about the CBT concept of hot thoughts associated with depression and anxiety. Topics include:

• Defining hot thoughts as “instant negative reactions to perceived threats or problems.”
• Learning to identify the cognitive distortions often associated with hot thoughts, e., the mistaken assumptions that lead to the automatic, extreme, and negative reactions associated with hot thoughts
• Learning to use cognitive reappraisal to correct the underlying assumptions behind hot thoughts
• Practicing practical skills to identify and replace or restructure hot thoughts before they can lead to counterproductive behaviors
• Learning to use all the skills in this module to manage the TFB cycle, stay in the present moment, and understand when to use CBT skills to manage the thoughts associated with depression and anxiety

Module 7: Synthesis, or Putting it All Together

This module helps patients integrate all the information and skills they learn during the course of the eight-week program and apply them to daily life. Therapists help patients make a plan to return to independent symptom management, using CBT skills to work through the thoughts and feelings associated with depression and anxiety in a healthy and productive manner. Topics include:

• Preparing for independence. Therapists help patients get used to the idea of ending a formal treatment program
• Identifying triggers. Therapist and patient collaborate on creating a list of things that may trigger the onset of the symptoms of depression and/or anxiety.
• Making a list of skills. Therapist and patient collaborate on a list of coping skills and strategies to deploy when triggers occur, or symptoms return.
• Social network. Therapists reiterate the importance of social support in managing wellness, and help patients create a list of safe and healthy people in their lives they can go to when they need the informal support of a friend or confidant.
• The wellness plan. Therapist and patient review the contents of the previous three bullet points to create a plan that incorporates everything they learned during treatment, consolidates the positive gains they made during treatment, and serves as a roadmap to sustainable, long-term psychological and emotional wellbeing.

That’s the program, which is essentially a condensed, internet-based variation of a typical course of outpatient CBT treatment for patients with mild or moderate depression and/or anxiety. Patients with severe diagnoses would most likely receive a referral for a more immersive, intensive, in-person treatment program.

Let’s take a look at the results of the study.

Internet-Based CBT: Does it Work?

In a word, yes.

But that’s an oversimplification, of course. The data from this study is interesting, and not exactly what we expected to learn. Remember: researchers collected information from over 1300 university students diagnosed with depression or anxiety and divided them into three groups. One group participated in a guided online CBT treatment program (iCBT-Guided), another group participated in an unguided, online CBT treatment program (iCBT-Independent), and the third group participated in treatment-as-usual (TAU), which involved standard outpatient CBT delivered by a typical university mental health support program.

Here’s what they found.

iCBT-Guided Group

• 97% of patients had statistically higher chance of joint remission of depression and anxiety symptoms, compared to the independent group and the TAU group.
• Probability of remission for depression and anxiety: 51.8%
• Probability of remission, independent measures:
  • Anxiety: 62.7%
  • Depression: 61.5%

iCBT-Independent Group

• Probability of remission for depression and anxiety: 37.8%
• Probability of remission, independent measures:
  • Anxiety: 50.2%
  • Depression: 44.3%

TAU Group

• Probability of remission for depression and anxiety: 40.0%
• Probability of remission, independent measures:
  • Anxiety: 53%
  • Depression: 41.8%

We’ll briefly summarize these results, since they’re straightforward and relatively easy to understand: the primary takeaway is that, compared to treatment-as-usual and independent iCBT, patients in the guided iCBT group showed the greatest likelihood of remission from depression and anxiety symptoms. However, the most significant chances of remission were associated with depression, and opposed to anxiety – and some patients in the independent iCBT group showed a higher probability of remission that patients in the guided iCBT group and the TAU group.

How This Information Helps Patients with Depression, Anxiety, or Both

One thing the pandemic brought us was the reality of telehealth for depression and anxiety: while some patients with severe depression or anxiety need intensive, immersive, in-person care at levels far beyond what an online CBT program can offer, there are millions of people with mild or moderate depression and/or anxiety that may benefit from either guided iCBT or independent iCBT.

That’s important news: online CBT can offer real, positive results for people with depression and/or anxiety. This can help patients in a variety of situations for a variety of reasons. Online treatment – either guided or independent – solves many problems, and can mitigate barriers to care related cost, access, time, and others.

For patients with few resources to access reliable, evidence-based mental health treatment, these iCBT programs may change the game, and help millions of people in need of treatment get the treatment they need, so they can start their journey toward healing and recovery.