**6. Limitations and strengths**

expressed more familiarity. However, the most important change we made was making the program more flexible and increasing interactions with the therapist. We worked collaboratively with our patients to determine timeframes that best worked with their schedules and presenting symptoms. For those whose symptoms were less distressing, we provided one or two modules per week, and for those who were struggling more with their symptoms, we gave them as much time as they needed to complete the modules. However, our therapists did check in weekly to let the patients know that they were available for support and to answer any questions regarding the modules. They also provided phone sessions when needed, to better explain the concepts and to troubleshoot. **Table 2** shows key differences between iCBT 1.0 and 2.0.

A.K. was enrolled in iCBT 2.0 and did well. It took her about 4 months to complete the program, meaning she needed a few weeks per module, and she requested five telephone sessions. However, working collaboratively with A.K. and allowing her the time she needed, resulted in the best outcome for her. When she completed the program, her symptoms of depression, anxiety, and stress had decreased; she had added a number of a number of plea-

iCBT allowed A.K. to receive a gold standard treatment for her symptoms – a patient who otherwise would have fallen through the cracks. Many patients like A.K. never receive the services they need or others who can decline to the point of needing a hospitalization while waiting to gain access to services. We had a program that, if scaled up, could serve more patients without sacrificing quality. But was our iCBT as effective as our in-person CBT? We allowed patients to choose between traditional (group) CBT and iCBT. We collected outcome measures using the short version of Depression, Anxiety, Stress Scale (DASS 21) and the Quality of Life Enjoyment and Satisfaction Questionnaire for all patients receiving CBT whether it was in person or Internet-delivered. This allowed us to make a direct comparison between the two. To date we have had 80 patients complete this program. Preliminary data shows that those who have completed iCBT show a significant reduction in their symptoms of depression, anxiety, and stress with comparable results to our in-person CBT. The dropout rate is even lower for iCBT at 33% than our drop-out rate of 40% for the in person (group) CBT.

iCBT allowed TSH patients to receive CBT with easier and quicker access, at a lower cost. We found a way to serve more patients with no additional resources and without sacrificing quality. For the record, A.K. has welcomed her first child to the world this year, and hopes to

return to the workforce in the coming months.

212 Cognitive Behavioral Therapy and Clinical Applications

Modules 8 6 Deadlines Strict Flexible

**Table 2.** iCBT 1.0 vs. 2.0.

**iCBT 1.0 iCBT 2.0** Focus General CBT Behavioral Activation, then CBT

Contact Email Email + Phone Calls

Content Powerpoint Slides Powerpoint Slides + Videos

surable activities to her weekly schedule; she was socializing outside of the house.

Despite substantial research on iCBT in recent years, the limitations and strengths of this treatment modality remain relatively unchanged.

There are several notable limitations of iCBT. The first is the poor adherence. Several studies have looked at potential barriers to adherence. These barriers include lack of motivation, skepticism about iCBT, time constraints, and symptom improvement (reviewed in [59]). Several studies of primary-care-managed iCBT indicated that the lack of engagement may contribute to decreased adherence [26, 60, 61]. Further, depressive symptoms have been reported to interfere with patient engagement even among patients who felt favorably about the program [35], indicating that baseline disease severity can contribute to poor adherence. This hypothesis is supported by several studies showing an inverse association between adherence and baseline symptom severity or baseline psychological distress in patients with anxiety (reviewed in [62]). Oversight by a therapist, primary-care physician, or a trained staff member may be needed for some patients to adhere to iCBT. When patients regularly meet or speak with an individual or if their progress is being monitored regularly, they are more likely to continue to put effort into the program because someone is holding them accountable (reviewed in [60]). However, given the high heterogeneity of the results, it seems likely that the level of support required varies depending on the individual patient's needs and preferences.

The second limitation of iCBT is misdiagnosis or inappropriate treatments. In an ideal world, trained individuals would diagnose patients and refer them to the appropriate iCBT program. The reality is that patients often rely on self-assessment of their mental status and select a program they think might help them. Many programs mitigate this issue by including the same validated diagnostic surveys researchers used to measure symptoms. Inclusion of these surveys has proven highly effective (reviewed in [60]). Further, advances in tailored and transdiagnostic iCBT have created an a la carte treatment plan that can be used to address comorbidities and patient-specific issues that might not be included in disease-specific iCBT [24]. It seems likely that this limitation will prove overblown as more trials are conducted, but it cannot yet be ruled out as a concern.

The third limitation is accessibility. A 2015 Pew Research Center survey showed that Internet and smartphone use is on the rise; however, there are some significant disparities in access. In countries with advanced economies, such as Canada, 90% of adults report they use the Internet or own a smartphone. In countries with developing economies, such as those in sub-Saharan Africa, the percent of adults who use the Internet or own a smartphone falls into the teens. There are large age, education, and income gaps for Internet usage and smartphone ownership. Further, in many countries, men have more access to Internet than women [63]. All of these disadvantaged groups, many of whom are the target audience for iCBT, could potentially be underserved. There is also the issue of comfort using a computer. ICBT is less likely to be used by patients who are not comfortable with technology [64], which is why userfriendliness is critical for achieving effective, sustained responses [65].

The fourth limitation is the variable quality of iCBT programs available. There is almost no barrier to creating a website or an app, and the number of iCBT programs available make it difficult to identify those that might be helpful. For example, a recent study attempted to characterize mobile phone apps for depression that were available on any app marketplace as of March 5, 2013. Apps were included if they used "depression" in the title or app description, targeted health consumers (i.e., patients, caregivers), and had an English language interface. Their search yielded 1054 apps; however, only 243 met the inclusion criteria. Of the 190 app developers, only 9.5% were medical centers, universities, or institutions; 29.5% were clearly labeled as coming from a commercial developer; and the rest did not provide any affiliation. Regarding content, only 29.6% of the 243 included apps reported an external or expert source as the basis of their app [17]. To the best of our knowledge, there has been no research on the potential harms of using a poor-quality iCBT program.

**7. Conclusions and future directions**

850,000 registered users.

replaced as therapy gets modernized.

David Gratzer1,2\*, Faiza Khalid-Khan<sup>3</sup>

2 University of Toronto, Toronto, Canada

\*Address all correspondence to: david.gratzer@camh.ca

1 Centre for Addiction and Mental Health, Toronto, Canada

3 Ontario Shores Centre for Mental Health Sciences, Whitby, Canada

**Author details**

Increasingly, payers – governments, employers, private insurance companies – are considering new ways of offering CBT. At the same time, people are looking to the Internet for solutions for their mental health problems. Australia has invested in iCBT, as have private companies; iCBT websites and apps are more and more popular; MoodGym has more than

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

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

215

While we applaud the interest in evidence-based care, we offer a word of caution: not all iCBT programs are created equal. Yes, the literature is now rich in research studies on iCBT for common illness – for mental health illnesses, and also for physical health problems. And while the growing if young literature does support the use of iCBT, effectiveness is clearly tied to patient engagement. Clearly, therapist-guided iCBT has better results than non-therapist-guided iCBT. As the experimentation grows, we suggest two forces will transform iCBT – and therapy itself. First, with declining stigma and increased demand for care, iCBT will be considered more of an option, given its effectiveness, and its advantages over traditional CBT – that is, the convenience and accessibility of iCBT, coupled with its lower costs and privacy. Second, as technology advances, iCBT could well be improved, moving beyond visually-pleasing graphics and – empowered with AI – entering into a world where programs learn from and adapt to the patients that they serve, offering CBT concepts, perhaps delivered with machine-learned empathy.

With regard to the latter point, we note that several products have already been developed with AI. An Indian group developed a therapy chatbot called Wysa. This interactive program claims to learn signs of anger and distress from its patients, and then employs evidencedbased therapy techniques when appropriate. Wysa is simple – but it is available 24 hours a

We are in the early days of AI and mental health. Over time, iCBT programs will grow more sophisticated. How therapy changes exactly, of course, is impossible to predict. This much is clear: the 1970s, Beck-style approach to CBT, with one therapist and one patient, is being

and Shawnna Balasingham<sup>1</sup>

day, 7 days a week – already offering more flexibility than its human therapist rivals.

Despite the limitations, there are numerous strengths of iCBT programs. The first is the flexibility and privacy of iCBT, which can increase patient empowerment. The only thing a patient needs to get treatment is an Internet connection [14, 19]. Treatment is not confined to office hours, which means it can accommodate work schedules and personal responsibilities. It also lets patients have access to treatment as symptoms arise. Geography is not an issue with iCBT. In countries with iCBT, studies have shown that it can be remarkably successful in rural areas where access to mental healthcare is limited [55, 61, 66, 67]. For countries that lack programs specific to their population and culture, well-researched programs can be adapted for a fraction of the cost of making a new program and still yield substantial gains [68]. iCBT provides treatment options for patients who cannot access treatment due to physical, psychological, or mobility issues [10]. Regarding privacy, iCBT lets patients address their symptoms anonymously. This anonymity might help circumvent the social stigma associated with treatment and encourage patients who might not otherwise have sought treatment to get the help they need [19, 69].

The second benefit of iCBT is its increased efficiency. Even for cases of therapist-supported or tailored iCBT, which require clinician input, fewer resources are needed to treat an individual, and responses to patient concerns can be addressed whenever the therapist has time available [19]. One study comparing in-person CBT and iCBT showed that iCBT patients required only 7.5% of the time that in-person patients needed to achieve similar gains [70]. Further, much of the iCBT support can be performed by trained staff rather than a clinician [37, 71]. Many of the behaviors that therapists teach patients, such as task reinforcement, psychoeducation, and deadline flexibility [72], can be performed by trained staff rather than a clinician. Overall, iCBT has been shown to be more resource efficient even with clinician input, which would give more patients access overall.

The third strength of iCBT is its cost efficiency. Numerous studies have evaluated the costs of iCBT [16, 73]. It has been shown to be cost effective and reduce societal cost compared with waitlisted controls and in-person CBT [16, 36, 73]. As discussed above, it is relatively inexpensive to adapt an existing iCBT program [68], indicating that iCBT could potentially be implemented cost effectively.
