Background: Growing demands for mental health services have resulted in increased interest in virtual interventions delivered online and via mobile applications. Internet-based Cognitive Behavioural Therapy (iCBT) is an evidence-based intervention where users progress on their own time through online modules to modify maladaptive thinking and behaviour patterns and develop coping skills. While the efficacy of iCBT for anxiety and depression has been demonstrated in randomized controlled trials, we leveraged linked, health-administrative data to examine its real-world effectiveness, compared to standard CBT.
Methods: In this retrospective cohort study, we compared individuals receiving iCBT (self-led, online modules with minimal, asynchronous therapist support) via a pilot program to those receiving standard CBT (scheduled, one-one-one, therapist-led sessions) in Ontario, Canada between Jan 2020 and Aug 2021. We utilized a Difference-in-Differences analysis to assess pre-post change in depression (PHQ-9) and anxiety (GAD-7) symptoms and examined mental health-related service utilization (emergency department visits, hospitalizations, and outpatient visits to psychiatrists and primary care providers) using Logistic and Negative Binomial regressions for binary and count outcomes, respectively.
Results: Among N=167 individuals enrolled in iCBT and N=300 controls receiving standard CBT, we found that treatment modality was a significant predictor of pre-post symptom change (p<0.01 for DID coefficients), with standard CBT clients experiencing a greater reduction in depression and anxiety symptoms (a 4-point reduction in PHQ-9 and 3.6-point reduction in GAD-7), compared to iCBT clients (2.3-point reduction in PHQ-9 and 0.35-point increase in GAD-7), though sensitivity analyses restricting to treatment completers somewhat attenuated this finding. While both groups experienced a reduction in MH-related service use, iCBT clients were more likely to continue visiting both acute care (ORadj=2.92, 95% CI 1.29-6.64) and outpatient physicians (RRadj=1.32, 95% CI 1.03-1.69) 1-year post-treatment, adjusted for age, comorbidities, and baseline symptom severity.
Conclusions: In routine care, self-led iCBT appears to be less effective than standard CBT in terms of anxiety and depression symptoms and in terms of mental health-related service utilization. While iCBT remains a promising approach for leveraging technological innovation to meet access needs, the benefits of regular therapist contact cannot be overlooked.
Presented by:
Jenny Gatov, University of Toronto
Jenny is a PhD student at the Institute of Health Policy, Management and Evaluation (IHPME), specializing in Health Informatics. Her dissertation focuses on evaluating the real-world impact of Internet-based Cognitive Behavioural Therapy (iCBT) in Ontario. She is currently conducting quantitative studies using linked health-administrative data to analyze patient characteristics, treatment completion, and outcomes, and is planning a qualitative study to support the broader implementation of iCBT in the province. With a background in psychology and a Master’s in epidemiology from the Dalla Lana School of Public Health, Jenny has over 10 years of experience in mental health services research using population-based methods and published over 20 peer-reviewed papers to date. Before pursuing her PhD, she led the COVID-19 mathematical modeling portfolio at Toronto Public Health and contributed to planning vaccine implementation in the city. Currently, she works as the Data & Analytics Lead at Creative Destruction Lab, a startup accelerator mentorship program that focuses on early-stage, science-based ventures.
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