**4. iCBT and the real world**

**3. Practical applications**

*Brain Injury:*

206 Cognitive Behavioral Therapy and Clinical Applications

*Heart disease:*

Recurrent headaches

adolescents [76].

As noted above, implementing iCBT in a primary-care setting would be important. To successfully do this, we must first understand how programs perform in the real world rather than the tightly controlled setting of a clinical trial. The REEACT trial was conducted in the UK, and considered how patients in a primary care setting could access iCBT (a pragmatic randomized controlled trial). The study included three groups of patients: those using a commercial program (Beating the Blues) in addition to general practitioner (GP) care, those using a free program (MoodGYM) in addition to GP care, and usual GP care (that is, access to antidepressants, counseling, psychological services, and secondary mental health services). Those patients who used iCBT also received weekly phone calls from trained technicians. In this trial, no differences in depressive symptoms or health state utility were observed between commercially available iCBT, free-to-use iCBT, and usual care. iCBT had a statistically significant benefit over usual care in the mental component of health-related quality of life and general psychological wellbeing at 12 months but not at 24 months. Even with telephone support, adherence was poor in both iCBT groups with only one completed session (as the median

**Box 1:** Evidence for using iCBT to treat psychological distress associated with physical illness.

Patients with acquired brain injury often have cognitive symptoms. These symptoms can potentially be addressed with iCBT. Recently, a systematic review of studies using iCBT to treat cognitive symptoms in adult patients with acquired brain injury was published. Among the 14 included high-quality randomized controlled trials, there was strong evidence that iCBT improved processing speed in patients with multiple sclerosis. There was moderate evidence that iCBT improved memory in patients with multiple sclerosis or brain tumors. However, more evidence from trials that use activities, participation, and body structure outcomes is needed to draw a strong conclusion [74].

Depressive and anxiety symptoms are common following myocardial infarction. CBT has been shown to be an effective treatment strategy for these symptoms, so researchers developed a therapist-supported, self-tailored iCBT program for patients following a myocardial infarction. In a randomized controlled trial comparing iCBT to standard care, patients in the iCBT group selected two to three modules from the ten available. Each module contained two to four steps, and patients were asked to complete a step per week. A pilot study showed that the study was acceptable (68% of eligible patients enrolled) and participants were sufficiently active (50% had completed at least one module

For children and adolescents with recurrent headaches, psychological interventions, including relaxation and CBT, have proved to be effective treatments. Researchers conducted a randomized controlled trial comparing the effects of iCBT, applied relaxation, and an educational control in children and adolescents with recurrent headaches. All patients received an educational module discussing headaches. The iCBT program had five additional modules that included stress management, cognitive-restructuring, and relaxation techniques. The applied relaxation program had more extensive relaxation training, which included the module provided to the iCBT group. All patients had email contact with a therapist. When comparing iCBT and applied relaxation with education, the numbers needed to treat were 2.0 and 5.2, respectively. Responder rate was significantly higher for iCBT (63%) at post-treatment compared with applied relaxation (32%) and education (19%) but not at the six-month follow-up. At post-treatment, iCBT had the largest within-effect sizes for headache duration and frequency as well as pain catastrophizing. Further studies are needed, but these results support the use of iCBT to treat recurrent headaches in children and

assignment within 3 weeks). The full trial is currently ongoing [75].

Beyond the research, there are more and more iCBT programs available to the public. While most iCBT programs contain eight to 12 self-guided goal-oriented modules [22, 38], they can vary in quality and type of care. Speaking to the latter point: iCBT has a broad spectrum of therapist involvement, ranging from none to high-level involvement. Some programs are free, while others


**Table 1.** Available features of iCBT.

are available for a fee. Depending on the country in which the patient lives, iCBT may be endorsed and even funded by government. **Table 1** shows a sample of the various options offered to patients by existing iCBT programs. Below, we explore a few of the currently available iCBT options.

While the CBT-I program has been studied extensively and has been shown to decrease insomnia symptoms and improve sleep efficiency, fragmentation, and onset latency [41–49], there has been little formal review of the CBT-I Coach app itself. A small pilot RCT assessed the app for feasibility, acceptability, and effects on adherence and sleep outcomes. All participants found the app helpful, and greater than 50% used the educational materials and reminders in the app [50]. Another study survey CBT-I clinicians prior to releasing CBT-I Coach and again 2 years after its release. Before the release of the app, clinicians thought that the app was at least moderately likely to improve care, and most (87%) intended to use the app. 2 years after the release of the app, ~60% of clinicians reported using the app and thought

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

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

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FearFighter is a web-based iCBT program offered by a for-profit company in the UK. The program offers nine sessions that offer patients basic information on CBT, and a focus on negative thinking and overgeneralizations. This program is somewhat unique is the inclusion of videos, helping patients better understand basic concepts. At the end of the program, participants

The program was endorsed by the UK's National Institute of Clinical Excellence (NICE), and can be "prescribed" by a primary care doctor (allowing for public coverage in some parts of that country), but patients can also self-refer. FearFighter have been the subject of numerous studies [51–56]. FearFighter has been shown to be superior to computer-guided non-exposure controls and as good as clinician-guided CBT for at least 3 months, though adherence to FearFighter was lower than clinician-guided therapy [56]. Both patients and clinicians were satisfied with how easy FearFighter was to use and the results of the program [52, 54–58].

SuperBetter is an online and app-based game designed to help build "social, mental, and emotional resilience" to overcome challenges in life. Players are encouraged to set a goal for themselves in real life. Based on the goal, the game will offer appropriate activities for the player. "Power-ups" are activities that you can do in real life to improve resilience. "Quests" are in-site activities the player can participate in to teach them coping skills. "Bad Guys" are physical or mental bad habits that the player must battle. The site recommends completing three Power-ups and three Quests as well as battling one Bad Guy per day. Players can earn points for improving their resilience. Once you have met your goal, you achieve an "Epic Win." If the player sets a new goal, then they start a new game. The site has custom daily and weekly questionnaires to track progress in terms of the amount of time a player is happy, expressed as a percentage, and their resilience. Players can also recruit "allies" (e.g., friends, family). Allies can view the player's progress and offer support in the form of likes or comments. The game is highly customizable and can be adapted to address any challenges, from

There is one randomized controlled clinical trial where patients with significant depression symptoms used SuperBetter. Players were asked to play the game 10 min a day for 1 month.

it improved homework adherence and outcomes [40].

general life changes to mental and physical illness.

are given access to worksheets and summaries for later reference.

**4.3. FearFighter**

**4.4. SuperBetter**
