Internet-based cognitive behavioural therapy helps fight depression in Singapore

For patients presenting with mild-to-moderate depressive symptoms in Singapore, internet-based cognitive behavioural therapy (iCBT) yields meaningful reductions in symptoms of depression, anxiety, and psychological distress, as shown in a study.

In a group of 53 patients (mean age 33.1 years, 53.3 percent male) randomized to either undergo iCBT for 4 weeks or wait 4 weeks before undergoing the same intervention (wait-list control), iCBT produced moderate to large effect sizes for Patient Health Questionnaire-9, Generalised Anxiety Disorder-7, and Kessler-10 Item scores. [Front Psychol 2021;doi:10.3389/fpsyg.2021.668384]

The treatment gains were sustained at the 3-month follow-up. Furthermore, the investigators noted that the effect sizes were generally consistent with those obtained from similar iCBT studies and other transdiagnostic face-to-face programmes. [J Affect Disord 2012;136:459-468; PLoS One 2013;8:e62873; J Cognit Psychother 2009;23:20-33]

“This current study is the first of its kind to provide preliminary evidence for the efficacy and acceptability of iCBT for depression in Singapore,” they said.

Most of the participants (90 percent) were highly satisfied with the programme. They were willing to recommend it to others, saying that they were most pleased with the convenience, teaching skills, and ability to revisit the materials at their convenience.

The iCBT implemented in the study consisted of six online modules adapted from the THRIVE programme, which is a community mental health self-help programme developed by Khoo Teck Puat Hospital. Each module had a specific focus, namely introduction to depression, problem solving, understanding the influence of thoughts and beliefs in depression, overcoming negative thoughts and beliefs, and planning meaningful activities (parts 1 and 2). About 61 percent of participants who received treatment completed all six modules.

Considering that the introduction of delivering CBT via the internet is relatively new to the population in Singapore, the investigators shored up the delivery of iCBT with face-to-face support provided by a clinician, instead of relying solely on email or phone support.

“It should be noted that these face-to-face sessions were not therapy sessions, and the role of the psychologists in the present study was solely to provide support and encouragement, as well as to assist the participants in applying the content of the modules,” according to the investigators.

The goal was to maintain contact and, in turn, promote adherence to the online treatment and reduce dropout rates, they pointed out.

“Given the limited application of internet treatments to Asian populations, depressed individuals in Singapore might be hesitant to participate in iCBT programmes due to their unfamiliarity with what such programmes entail,” they said. “As such, a hybrid iCBT model which includes regular face-to-face sessions may be more acceptable … [as opposed to] offering only phone or email support.”

Indeed, some participants in the study found the face-to-face sessions beneficial and preferred more of such sessions. Likewise, in a previous survey that involved Chinese-speaking international students in Australia, more respondents were partial to face-to-face treatments than internet treatments. [Couns Psychol Q 2013;27:96-108]

“Talking to a clinician allowed them to express their feelings and receive guidance on applying their learned techniques,” the investigators said.

There were some limitations to the study, they admitted. Among them was the relatively small sample size and high attrition rates in the completion of outcome measures over time. Furthermore, instead of formal diagnostic assessments, the study relied more on the diagnoses provided by the patients' psychiatrists and used thresholds from self-reported measures as a surrogate for clinical remission.

Nevertheless, the investigators said they performed the necessary analyses and were quite confident of the reliability of their findings.

“In light of the ongoing COVID-19 global crisis, iCBT has assumed increasing importance as it can allow for the continual provision of mental health services when access to traditional services are disrupted… [T]his study provides valuable information for further development of local internet-based programmes and early groundwork for their broader adoption in Asian cultures,” they said. [Lancet Psychiatry 2020;7:e17-e18]