**1.1. Key points**

• Strong evidence from controlled randomized trials shows that iCBT can be used in clinical practice for some patients.

hospital where we implemented an iCBT program. We also review the current strengths and limitations of iCBT. Finally, we consider future directions for this field, with an eye on AI.

The Internet and CBT: A New Clinical Application of an Effective Therapy

http://dx.doi.org/10.5772/intechopen.72146

203

iCBT continues to be a hot area of research in psychiatry. A PubMed search of "Internet cognitive behavioral therapy" yielded over 1600 articles, about 300 more than a search conducted just 2 years ago [9]. The literature has been reviewed extensively by ourselves and others [9–18]. Among the best-studied interventions are those for depression, anxiety, and physical illness. Presented here are some of the most recent systematic reviews, meta-analyses, and randomized controlled trials about treatment effectiveness and address some of the most

Treatment of depression with iCBT has been well studied. For example, two meta-analyses of iCBT for adult depression – covering 12 studies and four studies, respectively – found pooled effect sizes of 0.41 (95% CI 0.29, 0.54) [19] and 0.22 (95% CI, 0.03–0.41), respectively, for iCBT compared with any type of control [20]. A third meta-analysis of iCBT, covering nine studies – in university students – showed a standardized mean difference of −0.43 (95% CI −0.63, −0.22) supporting iCBT over non-treatment [15]. When comparing iCBT with treatment as usual, a randomized controlled trial showed a significant effect size (0.2; 95% CI 0.00, 0.50) favoring iCBT [21]. Overall, the present data support iCBT as an effective treatment for depression that could have a greater benefit than standard treatment. (For a more comprehensive review of this literature, please see our CMAJ paper, available at: http://www.cmaj.ca/content/cmaj/

But how can iCBT be done effectively? Could iCBT be offered without any therapist support – essentially, with patients told to use a website or an app? There is strong evidence in favor of therapist support of iCBT, including the results of a meta-analysis comparing iCBT with controls (effect size 0.61; 95% CI 0.45, 0.77) [19] and a Prioritization Summary conducted by the Australian and New Zealand governments (significant improvements in depressive

This raises a question: is self-guided CBT of any benefit? Researchers conducted a meta-analysis evaluating the efficacy of self-guided iCBT for the treatment of depressive symptoms. The authors identified 16 eligible RCTs and obtained patient data of 3876 participants from 13 of the 16 studies. They performed traditional and patient-level meta-analyses. iCBT was more effective at reducing symptom severity than controls, including placebo, no treatment, treatment as usual, or waiting list (β = −0.21; Hedges g = 0.27). iCBT also had a greater treatment response than controls (β = 0.53; odds ratio, 1.95; 95% confidence interval [CI]: 1.52, 2.50). Their analysis also showed an association between higher adherence and greater symptom reductions (β = −0.19; P = 0.001) and treatment response (β = 0.90; P < 0.001). Based on

pressing concerns and promising developments in the new field of iCBT.

symptoms through 8 months of follow-up; seven included studies) [22].

**2. Literature review**

**2.1. Depression**

early/2015/11/02/cmaj.150007.full.pdf)


Mental disorders are disabling and common. Depression, for example, has greater global burden of disease than any physical disorder [1]. 29% of people will experience some form of mental disorder in their lifetime [2]. Yet care is often difficult to access: only 45% of people in developed countries receive care, and the percentage of people who receive treatment is just 15% in developing countries [3]. Even when patients have access to mental healthcare, it may be inadequate. In North America, between 30 and 79% of patients treated for depression receive sub-standard treatment. In a study of patients in British Columbia, Canada, who received treatment for depression, Puyat et al. found that only 13% received any psychotherapy or counseling; women, older patients, and patients in rural areas were less likely to receive adequate psychotherapy or counseling [4].

Cognitive Behavioral Therapy (CBT) is an evidence-based treatment. Beck's Cognitive Triad, the conceptual basis of CBT, is built on the principle that people's thoughts, emotions, and behaviors are connected. By taking control of their thoughts, patients can reframe how they interpret the events around them [5]. CBT has been shown to be equivalent to medication for mild and moderate anxiety and depression. Combining psychopharmacology with CBT may have a synergistic effect [6]. However, CBT requires time and resources, which partly explains its limited availability, even in public healthcare systems like Canada's. Therefore, many primary care physicians and psychiatrists do not offer CBT [7]. As a recent JAMA Psychiatry editorial noted: "Traditionally, psychotherapy developers focused on interventions for specific diagnoses to be implemented by mental health professionals in mental health settings. Once established as evidenced based, these therapies often failed to be disseminated into mental health centres, let alone… primary care clinics" [8].

While access to mental healthcare is not always available, more and more people have access to the Internet and smartphones, even in the developing world [3]. CBT is a good intervention for technology-based applications because the concepts are easily adapted into broadly applicable sessions (or modules) that can be distributed by email, the web, or apps [9]. Not surprisingly, numerous programs have been developed. Studies show Internet-assisted CBT (or iCBT) is cost-effective for patients; it is also more convenient for patients and providers compared with traditional CBT (a literature review follows).

In this chapter, we will look at the effectiveness of iCBT for several illnesses, based on new evidence from recent randomized controlled trials and meta-analyses. We consider iCBT in the real world, by looking at some popular apps and websites. We present a case from a Canadian hospital where we implemented an iCBT program. We also review the current strengths and limitations of iCBT. Finally, we consider future directions for this field, with an eye on AI.
