**5. The Scarborough Hospital experience**

The authors have been actively involved in the development and implementation of an iCBT program at The Scarborough Hospital (TSH, now part of the Scarborough and Rouge Hospital). This hospital serves Toronto, Canada's diverse east end, and receives roughly 500 outpatient referrals a month. Here we review a case, and then consider the program and outcome data.

A.K. is a 27-year-old woman who suffers from severe anxiety. In the 2 years before her first outpatient appointment with the TSH clinic, she had left her apartment just a half dozen times – all to attend doctor's appointments. She was originally referred by her neurologist (who she had been seeing for non-specific dizziness). In her early 20s, A.K. had a major depressive episode, and a past trial of an SSRI antidepressant. At TSH, she was seen by the first author of this paper, then referred for therapy with diagnoses of Generalized Anxiety Disorder and Panic Disorder. A.K. was bright and motivated – and ready for therapy. But when first offered a referral for CBT she hesitated: it was almost impossible for her to take the bus to the clinic, how could she come on a weekly basis? Like A.K., there are many patients that need CBT but have difficulty accessing the help they need – think of the single mother with childcare obligations and the small businessman who needs to attend meetings during the day.

In 2014, the TSH Mental Health Outpatient Program was completely revamped to increase access to evidence-based interventions. Staff were provided training in CBT, and patients were provided a combination of group and individual CBT sessions. After building staff capacity to provide CBT, we shifted our focus to increasing access to our interventions. We started by offering evening hours for more convenience but better access to in-person CBT did not address access barriers for people like A.K.

Every industry has turned to digital solutions for faster, easier, and more efficient services – could these types of solutions work in mental health service delivery as well? We developed a mental health app library in which apps vetted by our staff were included in our treatment regimen. Therapists used these apps to augment the in-person CBT, allowing patients to keep up with the material even if they had missed several sessions. But it was not enough to just offer CBT, we wanted to ensure that those in need had every chance of receiving it. It was this line of thinking that led to the development of our iCBT.

Patients playing SuperBetter had larger reductions in depression symptoms, based on CES-D scores, than waitlisted controls at 1-month (Cohen's d = 1.05). The game has also been evalu-

These different programs are very different in their approach to iCBT. And, of course, there are many other programs available. And while we acknowledge that there is no one right approach to iCBT, we recognize that many of the products on the market today have little or no evidence to support their effectiveness. We offer this advice: potential iCBT users should be careful when deciding on a program (or programs) to use. Users should look for government endorsements, affiliations with academic and/or medical institutions, and published results in peer-reviewed journals. If the program includes therapist support or uses therapists as a content source, a list of their qualifications should be easily accessible on the program's website. However, users should still check the therapist's credentials [9]. Users also should be careful not to be deceived by certifications, as they are not necessarily an indicator of quality. While many of the high-quality programs available do charge a fee, users should be wary of programs that try to sell them products or "cures" [17]. A little due diligence should help users identify a program that can help them address their symptoms rather than simply sepa-

The authors have been actively involved in the development and implementation of an iCBT program at The Scarborough Hospital (TSH, now part of the Scarborough and Rouge Hospital). This hospital serves Toronto, Canada's diverse east end, and receives roughly 500 outpatient referrals a month. Here we review a case, and then consider the program and

A.K. is a 27-year-old woman who suffers from severe anxiety. In the 2 years before her first outpatient appointment with the TSH clinic, she had left her apartment just a half dozen times – all to attend doctor's appointments. She was originally referred by her neurologist (who she had been seeing for non-specific dizziness). In her early 20s, A.K. had a major depressive episode, and a past trial of an SSRI antidepressant. At TSH, she was seen by the first author of this paper, then referred for therapy with diagnoses of Generalized Anxiety Disorder and Panic Disorder. A.K. was bright and motivated – and ready for therapy. But when first offered a referral for CBT she hesitated: it was almost impossible for her to take the bus to the clinic, how could she come on a weekly basis? Like A.K., there are many patients that need CBT but have difficulty accessing the help they need – think of the single mother with childcare obliga-

In 2014, the TSH Mental Health Outpatient Program was completely revamped to increase access to evidence-based interventions. Staff were provided training in CBT, and patients were provided a combination of group and individual CBT sessions. After building staff capacity to provide CBT, we shifted our focus to increasing access to our interventions. We started by offering evening hours for more convenience but better access to in-person CBT did

tions and the small businessman who needs to attend meetings during the day.

ated in an NIH-funded clinical trial but the results are pending.

rate them from their own money.

210 Cognitive Behavioral Therapy and Clinical Applications

outcome data.

**5. The Scarborough Hospital experience**

not address access barriers for people like A.K.

After a literature review looking at various international models of iCBT, and in collaboration with Queen's University (where they were piloting a small iCBT program for adolescents), we developed our own modules closely mirroring our in-person CBT. The iCBT model consists of a therapist-guided Internet version, where patients complete the program on their own schedule and from a convenient location of their choice (where they have access to the Internet). Originally, patients were provided a total of eight modules that outline the main principles of CBT. This includes the importance of noticing the connections between our thoughts, feelings, and behaviors, scheduling mastery and pleasurable activities, utilizing breathing and relaxation exercises, and reviewing thought logs and restructuring inaccurate thoughts to more accurate ones. Each patient referred is assigned a therapist who communicates largely through email. The patient is emailed a module on a weekly basis for 8 weeks, and is asked to read the module and fill out the attached worksheets to be completed within a week.

Before launching the program, staff were provided 4 hours of training in providing e-therapy from a psychiatry resident at Queen's University. We launched our program with the hope that we could replicate the results achieved in Sweden or Australia. However, a review of the results at 6 months showed that we had completely missed the mark. We had an alarming 90% dropout rate; many patients reported that they did not find the program helpful.

To understand the high dropout rate, we reached out to the patients in the program and asked how the program had failed to meet their needs. We gathered their feedback by asking questions such as, "Why did you drop out?" and "What three things would help you complete the program?" The responses were eye opening and a common theme emerged – the program was too rigid. Some patients felt that the deadlines for homework completion were too anxiety provoking; they could not possibly read through the modules and begin working on their thoughts within a week. The pace was overwhelming, so they did what made them feel better – they avoided the program altogether. Others who were higher functioning found the pace too slow and were eager to get through the concepts faster. Some found the concepts too confusing and wanted more examples and videos to better highlight the material. And some ran into technical issues – they could not download the document and type directly onto them. We had designed the program with what we thought the patients needed without asking them what would work best for them. The result was an inflexible program that did not take individual needs into account. We went back to the drawing board to incorporate the useful feedback provided by our patients and 3 months later relaunched our second version, iCBT 2.0.

With iCBT 2.0, we streamlined the modules to a total of six modules (from eight). We included more examples and visuals to better highlight the material. We addressed the technical concerns by creating the homework sheets as Microsoft Word documents, with which patients 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.

**6. Limitations and strengths**

treatment modality remain relatively unchanged.

Despite substantial research on iCBT in recent years, the limitations and strengths of this

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

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

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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.

friendliness is critical for achieving effective, sustained responses [65].

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 user-

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

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

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.


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