Internet-Based CBT for Anxiety and Depression
Anxiety and depression are two conditions that pervade our population. According to data collected from CDC gathered self-reports of US adults (over age 18) between April 2020-April 2023, on average about 30% reported experiencing symptoms of an anxiety disorder. During that same time period, about 24% of US adults reported symptoms a depressive disorder. Common symptoms of anxiety are increased heart rate, rapid breathing, restlessness, feelings of panic or doom, and generalized weakness. Common depressive symptoms include sensations of emptiness or failure, hopelessness, loss of interest, angry outbursts, fixation on the negative, and fatigue. Both disorders can impact appetite (either stimulate or suppress), affect sleep, impair cognitive functions, school or work performance, social interactions and day-to-day functioning.
To address the increased prevalence of anxiety and depression over the last 25 years, new therapeutic options in the form of web-based, technology delivered programs have been developed. In the era of the smartphone, interventions have been expanded to include various apps designed to address mental health and management of Irritable Bowel Syndrome (IBS) through the mind-gut connection.
“Cognitive Behavioral Therapy (CBT) is one of the mainstay treatments for anxiety and depression.”
Cognitive Behavioral Therapy (CBT) is one of the mainstay treatments for anxiety and depression. Traditionally, it is a structured form of 1:1 psychotherapy during which a patient and CBT trained provider examine thoughts that trigger emotions experienced and subsequent behaviors enacted. The focus is on recognizing catastrophic thoughts as they occur, learning to discern their accuracy, and either re-directing or reframing those thoughts to help reduce feelings of sadness or anxiety. With the advancement of internet and technology over the past two decades, Internet-based CBT (iCBT) has been developed and broadened accessibility to this therapeutic approach. The majority of web-based and smartphone apps marketed for mental health and IBS utilize iCBT, as its formulaic approach lends itself to these electronic platforms. Some iCBT programs may involve virtual interactions with trained therapists while others are entirely self-directed. Various activities may be included such as reading about strategies, watching videos, and performing exercises that involve thought recognition and stress reduction. Progression through the program is tracked as patients complete modules which may serve as a form of positive feedback when visualizing advancement and skill acquisition.
Some advantages of iCBT programs are that they can be worked through at the individual’s own pace, accessed anonymously from anywhere at any time, and are potentially more cost effective than in-person treatment. Patients who feel stigma because of their condition can receive help without needing to walk into a therapist’s office and there is also a time-saving component when travel to and from appointments is eliminated. When compared to conventional CBT, one drawback to iCBT is that it cannot provide human empathy – a key component of 1:1 therapist/patient interactions. For self-directed iCBT, adherence can be poor which subsequently impacts outcomes. However, adherence improves when intermittent therapist or group interactions are included in iCBT programs. For depression, some evidence suggests that guided iCBT may be better than unguided, particularly for moderate to severe disease.
A 2018 meta-analysis reviewed results of 64 randomized control trials (RCTs) evaluating the efficacy of iCBT for depression and anxiety. It found that there was high effectiveness of iCBT for both conditions and improvement was maintained at 3 and 36 month follow up. In that review, 9 studies compared iCBT with conventional face-to-face CBT and 3 compared iCBT with bibliotherapy, finding comparable effectiveness of all three forms of treatment.
“…the FDA approved Mahana as the first digital CBT therapeutic for IBS after an RCT of 558 adults showed more than 60% of enrolled patients reported a clinically significant reduction in the severity of their symptoms”
Several clinical trials have demonstrated the effectiveness of conventional, therapist-delivered CBT . In June 2021, the FDA approved Mahana as the first digital CBT therapeutic for IBS after an RCT of 558 adults showed more than 60% of enrolled patients reported a clinically significant reduction in the severity of their symptoms (decreased abdominal pain, bloating and increased bowel function) at 3 months. Mahana requires a prescription from a healthcare provider and requires users to engage on the smart phone app or webpage for at least 10 minutes a day over 3 months. A second iCBT smartphone app, Zemedy, uses 10 modules which users work through over 8 weeks while engaging with a chatbot via text that presents information, guides exercises, and reinforces plans. No prescription is required. Results of an RCT of Zemedy including 121 adults demonstrated significant improvement in quality of life, GI symptoms, visceral sensitivity, and depression scores on rating scales. These effects were maintained at 3 month follow up.
“…web based therapies have the potential to become first line therapies for a large number of IBS patients.”
In our world where technology is pervasive, web or smart phone based therapeutic interventions, particularly iCBT, have shown promise for improving mental health and disorders of gut brain interaction. Most importantly, these techniques make these effective therapies accessible to patients anywhere in the US without the need for therapists trained in CBT and in IBS. Such web based therapies have the potential to become first line therapies for a large number of IBS patients. While iCBT may be the only feasible or appealing option for some patients, when possible these therapies are used in conjunction with traditional treatments such as in person therapy and medications. Future studies will need to examine further the impact and potential of electronically delivered programs for management of mental health and IBS.
MariaLisa Itzoe, DO, MPH is an Internal Medicine resident at Pennsylvania Hospital of the University of Pennsylvania, with a passion for helping patients who experience disorders of brain-gut interaction. She has a special interest in neuro-gastroenterology and health communication. MariaLisa is also a certified yoga instructor who loves cooking and sharing nutritious meals with family and friends.