Smartphone shrink

Statistics Canada says one in five Canadians will have a mental health problem at least once in their lifetime.  
Many of them will have trouble finding a therapist. But a study just published in the Canadian Medical Association Journal says help may be as close as your smartphone, tablet or computer connected to the Internet.

We're talking about a client going on-line and receiving Cognitive Behavioural Therapy or CBT from an individual therapist or program across town or across the country.  CBT is based on the notion that a person's thoughts, emotions and behaviours influence each other.  Patients with emotional issues can't control the world but can control how they interpret things that happen to them.  Using CBT, the therapist helps the client identify things they want to deal with more constructively and helps the client develop specific strategies.

The authors of the CMAJ paper - psychiatrist Dr. David Gratzer and social worker Faiza Khalid Khan at The Scarborough Hospital in Toronto - reviewed more than a thousand studies that looked at the effectiveness of Internet-based CBT. They found CBT to be effective in patients with mild to moderate depression as well as patients with anxiety.

Internet-CBT was also found to help patients cope better with the emotional fallout of physical diseases including diabetes, cancer and multiple sclerosis. It has been shown to work better than placebo and in some studies has done about as well as in-person CBT.  To be clear, the treatment that's out there is Internet plus in-person visits, not one or the other.

The authors say CBT is uniquely suited to the Internet for several reasons.  CBT has self-contained modules.  It has clearly defined goals.  It requires minimal supervision by a therapist.  That's because the therapy can be scripted to such an extent that the client is on auto-pilot.  And, there are other factors in the success. It's convenient; clients are able to do the treatment day or night - whenever they want.  Doing therapy from your own home means being shy and fearing the stigma of going to a therapist are not deal breakers. 

Internet-based CBT has its share of critics. The main objection is that Internet-based CBT must suffer to some degree from a lack of face-to-face communication between therapist and client even though it should be less of a concern with CBT because it's more structured.  But that concern is one reason why Internet-based CBT as proffered in studies has a component of face-to-face therapy.

Critics acknowledge that patients feel better in the short term after five to ten treatments but say that in the long run, they are no better than those who had no treatment in the first place. Critics believe CBT has no long-lasting benefit because it fails to address the root causes of emotional distress like early childhood trauma.  They say the only way to deal with that is through long-term psychotherapy.  Some of the strongest criticisms against CBT come from countries like the UK, where CBT is paid for under the public system.

The message from the article in CMAJ is that CBT delivered via the Internet is here to stay and that it should be integrated into mainstream psychiatric care.  It's effective - at least in the short term - and it's a lot cheaper than traditional CBT delivered by a professional in person.  As to the lack of long term benefits, we can say exactly the same thing about antidepressants.  There's little evidence that pills work in the long term, and yet doctors prescribe them to some patients for years; quite the contrary.  There's growing evidence that the long term use of antidepressants itself causes or at least contributes to chronic depression.  

In my opinion, Internet-based CBT is worth a try.

Dr. Brian Goldman is host of White Coat, Black Art.  His latest book The Secret Language of Doctors is published by Harper Collins.