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REEACT: The Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy

This randomised controlled trial of computerised cognitive behaviour therapy for the treatment of depression in primary care, showed benefits to be minimal and uptake for therapy to be relatively low.

Why did we do this research?

Many patients and health-care professionals would like access to psychological therapy as an alternative or adjunct to antidepression medication. A leading evidence-supported form of brief psychological therapy for people with depression is cognitive behaviour therapy (CBT), however, demand exceeds existing therapist resources. Computerised CBT (cCBT) represents an alternative form of therapy delivery that has the potential to enhance access to psychological care.

In this study we compared the clinical effectiveness and cost-effectiveness of computerised cognitive behaviour therapy (cCBT) as an adjunct to usual general practitioner (GP) care against usual GP care alone, for a free-to-use cCBT and a commercial pay-to-use cCBT program for adults with depression, and to determine the acceptability of cCBT and the experiences of users.

What did we do?

We undertook a pragmatic, multicentre, three-armed, parallel, randomised controlled trial with economic and qualitative evaluations. The design included a fully randomised patient preference approach. Participants were randomised using simple randomisation with allocation concealed. Participants were randomised to receive: (1) a free-to-use cCBT program (MoodGYM) plus usual GP care; (2) a commercial pay-to-use cCBT program (Beating the Blues) plus usual GP care; or (3) usual GP care alone. 

Potential participants were identified through GP practices. Those aged 18 years and over with a score of 10 or above on a validated depression severity instrument were eligible to participate.

What did we find?

Clinical effectiveness: 210 patients were randomised to Beating the Blues, 242 patients were randomised to MoodGYM and 239 patients were randomised to usual GP care (total 691). There was no difference in the primary outcome, depression measured at four months, either between Beating the Blues and usual GP care or between MoodGYM and usual GP care. 

The benefits previously observed in developer-led trials were not found in this large pragmatic trial. The benefits of cCBT when added to routine primary care were minimal, and uptake of this mode of therapy was relatively low. There remains a clinical and economic need for effective low-intensity psychological treatments for depression with improved patient engagement.

What have we learned? 

There is a clinical and economic need for brief, low-intensity self-help interventions for depression. The finding that computer-based therapies had low uptake and were not well regarded underlines both the need to further understand barriers to uptake of such therapies and the need for trials of alternative forms of guided self-help or brief psychological intervention.

Although technically supported cCBT is largely ineffective and inefficient, a more highly supported form of cCBT with therapeutic advice, guidance and psychological support may in fact improve outcomes at an acceptable level of cost. 

In the longer term, if computers are to be used to deliver psychological treatment with minimal therapist input, then there needs to be improved patient experience and engagement through greater personalisation of treatment packages. This requires further research and innovation at the human–computer interface.

Outputs

Cost Effectiveness: Duarte A, Walker S, Littlewood E, et al. Cost-effectiveness of computerized cognitive–behavioural therapy for the treatment of depression in primary care: findings from the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial. Psychological Medicine. 2017;47(10):1825-1835. doi:10.1017/S0033291717000289

Clinical Results: Gilbody, S., Brabyn, S., Lovell, K., Kessler, D., Devlin, T., Smith, L., Araya, R., Barkham, M., Bower, P., Cooper, C., Knowles, S., Littlewood, E., Richards, D. A., Tallon, D., White, D., Worthy, G., & REEACT collaborative (2017). Telephone-supported computerised cognitive-behavioural therapy: REEACT-2 large-scale pragmatic randomised controlled trial. The British journal of psychiatry : the journal of mental science, 210(5), 362-367. https://doi.org/10.1192/bjp.bp.116.192435

Gilbody, S., Littlewood, E., Hewitt, C., Brierley, G., Tharmanathan, P., Araya, R., Barkham, M., Bower, P., Cooper, C., Gask, L., Kessler, D., Lester, H., Lovell, K., Parry, G., Richards, D. A., Andersen, P., Brabyn, S., Knowles, S., Shepherd, C., ... REEACT Team (2015). Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. British medical journal, 351, Article h5627. https://doi.org/10.1136/bmj.h5627

HTA Report: Littlewood, E., Duarte, A., Hewitt, C., et al. A randomised controlled trial of computerised cognitive behaviour therapy for the treatment of depression in primary care: the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial. Health Technol Assess. 2015:19(101):viii, xxi-171.DOI: 10.3310/hta191010.

Qualitative: Knowles SE, Lovell K, Bower P, et al Patient experience of computerised therapy for depression in primary care BMJ Open 2015;5:e008581. doi: 10.1136/bmjopen-2015-008581

Feasibility protocol: Wright B, Tindall L, Littlewood E, et alComputerised cognitive behaviour therapy for depression in adolescents: study protocol for a feasibility randomised controlled trialBMJ Open 2014;4:e006488. doi: 10.1136/bmjopen-2014-006488

Hornstein S, Zantvoort K, Lueken U, et al. Personalization strategies in digital mental health interventions: a systematic review and conceptual framework for depressive symptoms. Front Digit Health. 2023:22;5:1170002. DOI: 10.3389/fdgth.2023.1170002.

Kheirkhah F, Faramarzi M, Shafierizi S, et al. Preliminary examination of acceptability, feasibility, and effectiveness of internet-based cognitive behavioral therapy for treatment of depression and anxiety in infertile women. Heliyon. 2023:25(5):e15760. DOI: 10.1016/j.heliyon.2023.e15760.

Kählke F, Buntrock C, Smit F, et al. Systematic review of economic evaluations for internet- and mobile-based interventions for mental health problems. NPJ Digit Med. 2022:23;5(1):175. DOI: 10.1038/s41746-022-00702-w.

Leach B, Parkinson S, Gkousis E, et al. Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review. J Med Internet Res. 2022:14;24(7):e33911. DOI: 10.2196/33911.

Stearns-Yoder KA, Ryan AT, Smith AA, et al. Computerized Cognitive Behavioral Therapy Intervention for Depression Among Veterans: Acceptability and Feasibility Study. JMIR Form Res. 2022:25;6(4):e31835. DOI: 10.2196/31835.

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