Computer-assisted Cognitive Behavior Therapy (CCBT) has been researched extensively through several National Institutes of Health (NIH) funded studies since 1995. CCBT uses digital tools and a highly systematic approach to teach users cognitive behavior therapy (CBT) principles to identify, understand and manage their mental health conditions. CCBT was as effective as traditional cognitive-behavior therapy while significantly reducing clinician time and costs required for successful treatment, thus improving efficiency, accessibility, and clinical outcomes.
Cognitive-Behavior Therapy (CBT)
Initially developed by Dr. Aaron Beck, founder of the Beck Institute, Cognitive Behavior Therapy is a widely used form of psychotherapy for treating mental health conditions. It is based on the concept that what we think (our cognitions) has a controlling effect on our emotions (feelings) and our behavior (actions). For example, people with depression often feel hopeless, suffer from low self-esteem, and predictions of adverse outcomes. When they think this way, they become sad and fearful, isolate themselves socially, and reduce participation in constructive activities. By targeting these cognitions and feelings, CBT helps patients identify triggers, understand emotions, and control behaviors to build resilience to reduce symptoms and prevent relapse. Clinicians and patients jointly create action plans to implement solutions and practice using CBT skills daily. CBT has had more research demonstrating effectiveness in treating mental health conditions than any other psychotherapy technique. It has been scientifically tested in over 400 clinical trials and found to be effective across the spectrum of behavioral disorders.
Computer-Assisted CBT (C-CBT)
In the late 1990’s Dr. Jesse Wright of the University of Louisville and his colleague, Dr. Michael Thase of the University of Pennsylvania, conceived and built a systematic, computer-assisted approach to deliver CBT. CCBT involves using a multimedia computer program to systematically provide CBT training with videos, interactive exercises, quizzes, assessments, and tools that adapt to the user as they progress through the program. MindStreet pioneered the field of CCBT with the release of its Good Days Ahead (GDA) program to manage mild to severe depression and associated anxiety. GDA uses a hybrid approach where a clinician uses CCBT as an adjunctive tool to help treat patients. CCBT is not intended to replace talk therapy. Clinician involvement typically includes triage, screening, onboarding, supervision, and motivation using an integrated human-computer approach for best results. Published studies have demonstrated excellent acceptance and adherence to CCBT by patients.
In a 2002 study conducted by Dr. Jesse Wright and his associates, CCBT was rated for acceptance using 1-to-5 point affinity scales. Based on affinity scores and primary outcome measures, CCBT was deemed acceptable and offered a substantial promise of effectiveness.
Dr. Wright et al. reported a pivotal randomized controlled trial using an earlier version of Good Days Ahead in 2005. The study compared 45 drug-free patients clinically diagnosed with depression assigned to CBT (traditional CBT talk therapy, nine sessions in 8 weeks); CCBT (initial session of 50 minutes, eight sessions of 25 minutes, and eight 25-minute computer sessions); and a waitlist control group.
The durability of treatment gains was also assessed with follow-up ratings 3- and 6- months post-treatment. Results indicated that both CCBT and CBT had lasting positive effects over this period. Dropout rates were similar for all three patient groups (2 for CCBT and CBT and 1 for the waitlist). There were no significant differences in the primary outcome measures (HAMD and BDI-II) between CCBT and CBT. Both treatments were significantly better than the waitlist in reducing symptoms of depression.
CCBT also proved superior to the waitlist in improving dysfunctional attitudes, while traditional CBT did not outperform the waitlist in this regard. Also, CCBT was more effective than CBT and the waitlist in enhancing awareness, as measured by the Cognitive Therapy Awareness Scale (CTAS).
Over the past two-plus decades, studies of CCBT have been evaluated in several meta-analytic studies, which have shown solid evidence of effectiveness using clinician-supported CCBT. Recently, Dr. Wright and colleagues completed another NIH-funded, multi-site study comparing CBT talk therapy (16.6 hours) with computer-assisted CBT with just one-third of the therapist time (5.5 hours). With over 150 patients participating between the two sites (the University of Louisville and the University of Pennsylvania), both groups saw a significant and equivalent reduction of depression scores and 84% completion rates. In addition, substantial pre-post effect sizes were observed for both CBT (2.0) and CCBT (2.4).
The most recent study of CCBT with Good Days Ahead was presented at the National Network of Depression Centers Annual Meeting and is being prepared for publication. In this study, 175 depressed patients from primary care practices were randomly assigned to CCBT (with 12 clinician support sessions of 20 minutes each) or treatment as usual (TAU). Depression, anxiety, and quality of life ratings favored CCBT over TAU after treatment, and there was substantial evidence of lasting effects of CCBT at 3 and 6 months post-treatment.
Other significant studies of CCBT with Good Days Ahead are underway at the University of Pennsylvania, Yale University, University of Michigan, Indiana University, and Purdue University, with many others in the research pipeline, including one with Ketamine and another using fMRI to observe the impact of CCBT on brain activity.
- Thase ME, McCrone P, Barrett MS, Eells TD, Wisniewski SR, Balasubramani GK, Brown GK, and Wright JH: Improving Cost-effectiveness and Access to Cognitive Behavior Therapy for Depression: Providing Remote-Ready, Computer-Assisted Psychotherapy in Times of Crisis and Beyond. Psychotherapy and Psychosomatics, Epub May 12, 2020, 89:307-313, doi: 10.1159/000508143, August 2020
- Wright JH and Mishkind M: Computer-assisted CBT and Mobile Apps for Depression: Assessment and Integration into Clinical Care. Focus.psychiatryonline.org, Focus 2020, 0:1-7; , Published online April 24, 2020
- Wright JH, Mishkind M, Eells TD, and Chan SR: Computer-assisted cognitive-behavior therapy and mobile apps for depression and anxiety. Current Psychiatry Reports, 21(7):62, doi: 10.1007/s11920-019-1031-2, 21(7), PMID: 31250242, June 27 2019
- Wright JH, Owen JJ, Eells TD, Richards D, Richardson T, Brown GK, Barrett M, Rasku MA, Polser G, and Thase ME: Computer-assisted Cognitive-Behavior Therapy for Depression: A systematic review and meta-analysis. Journal of Clinical Psychiatry, doi: 10.4088/JCP.18r12188, 80(2): 18r12188, PMID: 30900849, March 2019
- Antle BF, Owen JJ, Eells TD, Wells MJ, Harris LM, Cappiccie A, Wright B, Williams SM, and Wright JH: Dissemination of computer-assisted cognitive-behavior therapy for depression in primary care. Contemporary Clinical Trials, doi: 10.1016/j.cct.2018.11.001, 78:46-52, PMID: 30572162, 2019
- Wright JH, McCray LW, Eells TD, Gopalraj R, and Bishop LB: Computer-Assisted Cognitive-Behavior Therapy in Medical Care Settings. Current Psychiatry Reports, 20:92, doi: 10.1007/s11920-018-0947-2, Epub 7, PMID: 30194498, September 2018
- Wells MJ, Owen JJ, McCray LW, Bishop LB, Eells TD, Brown GK, Richards D, Wright JH: Computer-assisted Cognitive-behavior Therapy for Depression in Primary Care: Systematic Review and Meta-analysis. Primary Care Companion for CNS Disorders. Primary Care Companion CNS Disorders, doi: 10.4088/PCC.17r02196, 20(2):17r02196, PMID: 29570963, March 2018
- Thase ME, Wright JH, Eells TD, Barrett MS, Wisniewski SR, Balasubramani GK, McCrone P, and Brown GK: Improving the Efficiency of Psychotherapy for Depression: Computer-Assisted Versus Standard CBT. American Journal of Psychiatry, doi:10.1176/appi.ajp.2017.17010089, 175(3):242-250, PMID: 28969439, March 2018
- Eells TD, Barrett MS, Wright JH & Thase ME: Computer-assisted cognitive-behavior therapy for depression. Psychotherapy, 51(2):191-197, June 2014
- Wright JH, Wright AS, Albano AM, Basco MR, Goldsmith LJ, Raffield T, Otto MW: Computer-assisted cognitive therapy for depression: maintaining efficacy while reducing therapist time. American Journal of Psychiatry 162:1158-1164, 2005.
- Wright JH, Wright AS, Salmon P, Beck AT, Kuykendall J, Goldsmith J, and Zickel MB: Development and initial testing of a multimedia program for computer-assisted cognitive therapy. American J. of Psychotherapy. 56(1):76-86, 2002.