Computerised CBT (cCBT) is an established and evidence-based treatment for depression and some anxiety disorders. This paper aimed to replicate the study of Meisel et al. (2018), to understand more about therapist beliefs regarding offering cCBT within a service-evaluation. Meisel et al. (2018) found that although most staff in an inner-city IAPT service were confident offering cCBT to clients, staff believed there was not a strong evidence-base, and training on cCBT was identified as a solution to low cCBT uptake. The unexpected COVID-19 pandemic provided an opportunity to collect additional data to understand the impact of significant societal changes and service delivery methods to see if this led to a change in attitudes towards cCBT as Wind et al. (2020) hypothesised.

Data on staff beliefs about the provision of cCBT from one rural UK Talking Therapies service is presented across three time points: pre-COVID pandemic, post-COVID pandemic, and following additional cCBT training. Staff completed a survey at each time point, containing agree/disagree ratings and free-text questions, obtaining perspectives on cCBT including advantages, barriers/problems, and confidence. This paper reports staff opinions with commentary on how they have changed over time. Between time points 1 and 3, agreement with the statement ‘supporting clients using cCBT requires a high level of skill’ increased by 29%. Several beliefs did not change, despite moving towards more remote working in the pandemic, and training. Although the paper illustrates some changes in beliefs over time, it does not provide support for changes in therapist beliefs, with reasons for this examined.

Key learning aims

1. (1) Following reading this paper, the reader will understand changes in staff beliefs and attitudes towards cCBT that occurred between pre-pandemic and post-pandemic time points in one NHS Talking Therapies service.

2. (2) The reader will also be aware of the beliefs that have not changed following both the pandemic and additional staff training on cCBT and will be able to consider why this might be and whether it may be generalisable across wider services.

3. (3) The reader will be aware of potential interventions that could be introduced to try and address the ‘stubborn beliefs’ around cCBT that are not consistent with the evidence-base and may limit patient access to this option.

Digital CBT refers to the use of digital tools, platforms or devices to deliver or enhance cognitive behavioural therapy assessment, formulation, treatment, training and supervision. The ‘Advances in Digital CBT’ special issue aimed to document examples of innovative digital CBT practice in this rapidly developing field. In this paper, we have briefly summarised and synthesised the advances demonstrated in this group of articles. These include developments in our understanding of mental health apps, the use of digital tools as an adjunct to therapy, the effectiveness of remotely delivered CBT in routine clinical practice, our understanding of user experiences and involvement, and in digital CBT research methods. We consider the extent of current knowledge in these areas and identify where gaps in evidence lie and how the field could be taken forward to address these. Lastly, we reflect on the broader digital CBT picture and offer our suggestions of six key directions for future research: using robust study designs to evaluate and optimise digital tools; translating and culturally adapting digital tools and practices; understanding and addressing digital exclusion; exploring, reporting and addressing possible negative effects; improving user involvement in design and evaluation; and addressing the implementation gap for digital tools. We suggest that further advances in these areas would be of particular benefit to the digital CBT field.

Online peer support platforms have been shown to provide a supportive space that can enhance social connectedness and personal empowerment. Some studies have analysed forum messages, showing that users describe a range of advantages, and some disadvantages to their use. However, the direct examination of users’ experiences of such platforms is rare and may be particularly informative for enhancing their helpfulness. This study aimed to understand users’ experiences of the Support, Hope and Recovery Online Network (SHaRON), an online cognitive behavioural therapy-based peer support platform for adults with mild to moderate anxiety or depression. Platform users (n = 88) completed a survey on their use of different platform features, feelings about using the platform, and overall experience. Responses were analysed descriptively and using thematic analysis. Results indicated that most features were generally well used, with the exception of private messaging. Many participants described feeling well supported and finding the information and resources helpful; the majority of recent users (81%) rated it as helpful overall. However, some participants described feeling uncomfortable about posting messages, and others did not find the platform helpful and gave suggestions for improvements. Around half had not used the platform in the past 3 months, for different reasons including feeling better or forgetting about it. Some described that simply knowing it was there was helpful, even without regular use. The findings highlight what is arguably a broader range of user experiences than observed in previous studies, which may have important implications for the enhancement of SHaRON and other platforms.

Online cognitive behaviour therapy (CBT), self-help and guided self-help (GSH) interventions have been found to be efficacious and cost-effective for treatment of anxiety and depression, but there are limited data from low- and middle-income countries on culturally adapted digital interventions for these common mental disorders. The aim of this study was to investigate the feasibility and acceptability of an online culturally adapted CBT-based guided self-help (CaCBT-GSH) for patients with anxiety and depression in Pakistan. This randomized controlled trial recruited 39 participants from primary care in Karachi, Pakistan and randomized them to two groups. The intervention group received seven modules of CaCBT-GSH plus treatment as usual (TAU) over 12 weeks. The control group was a waitlist control plus TAU. The primary outcomes were feasibility and acceptability. Clinical outcomes included results from the Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule 2 (WHODAS 2). Assessments were carried out at baseline and at 12 weeks. All 39 individuals who met eligibility criteria for the study agreed to participate. Adherence to the intervention was excellent, with 85% (17/20) completing more than five modules. Statistically significant improvements were found in all clinical outcomes in the intervention group. This was the first trial of an online CaCBT-GSH intervention, which was found to be feasible and acceptable to Pakistani patients with anxiety and depression. CaCBT-GSH may help improve symptoms, depression, anxiety and overall functioning in this population. The results provide rationale for a larger, confirmatory randomized controlled trial of digital CaCBT-GSH.

Background: Evidence for the efficacy of computer-based psychological interventions is growing. A number of such interventions have been found to be effective, especially for mild to moderate cases. They largely rely on psychoeducation and ‘homework tasks’, and are specific to certain diagnoses (e.g. depression). Aims: This paper presents the results of a web-based randomized controlled trial of Manage Your Life Online (MYLO), a program that uses artificial intelligence to engage the participant in a conversation across any problem topic. Method: Healthy volunteers (n = 213) completed a baseline questionnaire and were randomized to the MYLO program or to an active control condition where they used the program ELIZA, which emulates a Rogerian psychotherapist. Participants completed a single session before completing post-study and 2-week follow-up measures. Results: Analyses were per protocol with intent to follow-up. Both programs were associated with improvements in problem distress, anxiety and depression post-intervention, and again 2 weeks later, but MYLO was not found to be more effective than ELIZA. MYLO was rated as significantly more helpful than ELIZA, but there was no main effect of intervention on problem resolution. Conclusions: Findings are consistent with those of a previous smaller, laboratory-based trial and provide support for the acceptability and effectiveness of MYLO delivered over the internet for a non-clinical sample. The lack of a no-treatment control condition means that the effect of spontaneous recovery cannot be ruled out.

Background: Ensuring rapid access to psychological interventions is a priority of mental health services. The involvement of peer workers to support the delivery of more accessible treatment options such as computerized cognitive behaviour therapy (CCBT) is recognized. Aims: To evaluate the implementation of a third sector remote CCBT @Home eTherapy service for people experiencing common mental health problems supported by individuals with lived experience. Method: Supported CCBT packages with telephone support were delivered over a 30-month period. Self-complete measures identifying levels of depression, anxiety and functioning were administered at each treatment appointment. Results: Over 2000 people were referred to the @Home eTherapy service; two-thirds attended an initial assessment and 53.4% of referrals assigned to CCBT completed treatment. Statistically significant improvements in anxiety, depression and functioning were found, with 61.6% of treated clients meeting recovery criteria. Conclusions: The service meets Improving Access to Psychological Therapies (IAPT) key performance targets, and is comparable to other IAPT services using CCBT. Evidence for the successful implementation of such a service by a third sector organization is provided.

Few studies have explored therapists’ views on computerized cognitive behavioural therapy (cCBT) and this study aimed to provide an in-depth understanding of accredited therapists’ views on cCBT's role in treating depression. Twelve therapists constituted this self-selected sample (eight female, four male). Mean age was 52 years (range 46–61). The data obtained from a semi-structured questionnaire were analysed using thematic analysis. Three themes were identified and discussed: (1) the standardized nature of cCBT for depression, (2) the importance of the therapeutic relationship in cCBT, and (3) the pros and cons with cCBT as an alternative to CBT. The therapists in this study emphasized that innovations in CBT delivery formats (e.g. internet-based, computerized) show promise. However, participants expressed some views that clash with the evidence-based viewpoint. More work is needed to improve the implementation of evidence-based practice and policy.

Background: Bulimia nervosa (BN) is an eating disorder with many physical, psychological and social consequences. Guided self-help (GSH) is recommended in the treatment of BN (NICE, 2004). One of the ways in which to provide GSH is via the internet using evidence-based packages with regular support from a clinician or trained support worker. Aims: The aim of this community-based survey was to investigate attitudes towards online self-help for eating disorders and the support required whilst using such an approach. Method: Two-hundred and fifty-three participants with bulimic symptoms completed the survey. The sample was recruited primarily online. The mean age was 29.11 years (SD = 8.67; min = 16, max = 64). Results: Attitudes towards online self-help (SH) for eating disorders were very positive. The inclusion of some form of support to accompany such an intervention was important to the majority of participants. Remote mediums of support such as e-mail, a forum and text messaging were most often selected as helpful. Most participants expressed a preference for weekly support contacts and for flexible support lengths that could respond to support needs as required. Conclusions: Online self-help for eating disorders is a desirable treatment option for many individuals. The information gathered regarding preferences in the type, medium, duration and frequency of support could be used in the development of future self-help strategies in order to maximize uptake, retention and outcomes.

Background: Randomized controlled trials have established that individual cognitive therapy based on the Clark and Wells (1995) model is an effective treatment for social anxiety disorder that is superior to a range of alternative psychological and pharmacological interventions. Normally the treatment involves up to 14 weekly face-to-face therapy sessions. Aim: To develop an internet based version of the treatment that requires less therapist time. Method: An internet-delivered version of cognitive therapy (iCT) for social anxiety disorder is described. The internet-version implements all key features of the face-to-face treatment; including video feedback, attention training, behavioural experiments, and memory focused techniques. Therapist support is via a built-in secure messaging system and by brief telephone calls. A cohort of 11 patients meeting DSM-IV criteria for social anxiety disorder worked through the programme and were assessed at pretreatment and posttreatment. Results: No patients dropped out. Improvements in social anxiety and related process variables were within the range of those observed in randomized controlled trials of face-to-face CT. Nine patients (82%) were classified as treatment responders and seven (64%) achieved remission status. Therapist time per patient was only 20% of that in face-to-face CT. Conclusions: iCT shows promise as a way of reducing therapist time without compromising efficacy. Further evaluation of iCT is ongoing.

Background: Depressive disorder is common in adolescents and largely untreated. Computers offer a way of increasing access to care. Computerized therapy is effective for depressed adults but to date little has been done for depressed adolescents. Aims: The objective of this study was to examine the feasibility, acceptability, and effects of The Journey, a computerized cognitive behavioural therapy (cCBT) program for depressed adolescents. Method: Thirty-four adolescents (mean age 15.2 years, SD = 1.5) referred by school counsellors were randomly assigned to either cCBT or a computer-administered attention placebo program with psychoeducational content (CPE). Participants completed the intervention at school. Data were collected at baseline, post-intervention and at a 1-month follow-up. The primary outcome measure was the Child Depression Rating Scale Revised (CDRS-R); secondary outcome measures were: RADS-2; Pediatric Quality of Life Inventory; Adolescent Coping Scale (short form); response and remission rates on CDRS-R. Completion rates and self-reported satisfaction ratings were used to assess feasibility and acceptabililty of the intervention. Results: Ninety-four percent of cCBT and 82% of CPE participants completed the intervention. Eighty-nine percent liked The Journey a lot or thought it was “okay” and 89% of them would recommend it for use with others as is or after some improvement. Adolescents treated with cCBT showed greater symptom improvement on CDRS-R than those treated with CPE program (mean change on cCBT = 17.6, CI = 14.13–21.00; CPE = 6.06, CI = 2.01–10.02; p< .001). Conclusions: It is feasible, acceptable and efficacious to deliver computerized CBT to depressed adolescents in a school setting. Generalizability is limited by the size of the study.

Background: Adolescents excluded from mainstream education have high mental health needs. The use of computerized Cognitive Behavioural Therapy (cCBT) has not been investigated with this group. Aims: To test the efficacy of the SPARX cCBT programme for symptoms of depression among adolescents in programmes for students excluded or alienated from mainstream education. Method: Adolescents (32; 34% Maori, 38% Pacific Island, 56% male) aged 13–16 with Child Depression Rating Scale Revised (CDRS-R) scores indicating possible through to almost certain depressive disorder were randomized to SPARX to be completed over the following 5 weeks (n = 20) or to waitlist control (n = 12). Assessments were at baseline, 5 weeks and 10 weeks. Those in the wait condition were invited to complete SPARX after the 5 week assessment. Results: Most participants (n = 26, 81%) completed at least 4 levels of SPARX and 22 (69%) completed all 7 levels. Among the 30 (94%) participants who began treatment as randomized and provided 5-week data, significant differences were found between cCBT and wait groups on the CDRS-R (baseline to 5-week mean change –14.7 versus –1.1, p<.001), remission (78% vs. 36%, p = .047) and on the Reynolds Adolescent Depression Scale (–4.6 vs. +3.2 p = .05) but not on other self-rating psychological functioning scales. In intent-to-treat analyses CDRS-R changes and remission remained significant. Gains were maintained at 10-week follow-up. Conclusions: SPARX appears to be a promising treatment for students with symptoms of depression who are in alternative schooling programmes for those excluded from mainstream education.

Background and aims: The efficacy and effectiveness of a computerized cognitive behavioural therapy (CCBT) package, Beating the Blues, has been demonstrated in a large randomized controlled trial and several pragmatic studies in the National Health Service (NHS). The current study tests the generalizability of this finding to the implementation of CCBT in a service user-led, third sector Self Help Clinic. Method: 510 referrals for the Beating the Blues program were received over a 16 month period in routine care. The Patient Health Questionnaire Depression (PHQ-9) and Anxiety (GAD-7) Scales were administered pre-treatment and during each treatment session. The 10-item Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM), Work and Social Adjustment Scale and Patient Experience Questionnaire were also administered pre-treatment and immediately on completing treatment. Results: More than two-thirds of referrals were suitable for treatment and completed a baseline assessment; 84% of these started the Beating the Blues program. Two-hundred and twenty-six people meeting caseness criteria at baseline completed at least two sessions of CCBT. Of these, 50% met recovery criteria at their final point of measurement. Completer and intention-to-treat analysis also demonstrated statistically and clinically significant improvements on key outcome measures. Conclusion: CCBT can be effectively implemented in a service user-led, third sector Self Help Clinic, increasing access to psychological therapies to meet local needs for tier two interventions for depression and anxiety.

Background: Computer based treatment for depression and anxiety has been available for several years and has demonstrated useful clinical effects. Most existing computerized CBT products in the UK that are designed to treat depression and co-morbid anxiety require patients to visit a clinic and require staff input to manage the process. Such intervention adds to the costs and bottlenecks in delivering a clinically effective treatment with mass availability. Internet treatment options are becoming more readily available, although data to support use are not yet strong, and most still require human assessment and telephone support. Blues Begone® is a new computerized CBT program that has been designed to be used at home with minimal human support. Method: This pilot project provides data from an open trial of Blues Begone® with both primary and secondary care patients. Results: One hundred patients started Blues Begone®, 58 completed the program, 72% (n = 42) of completers achieved reliable change and (n = 36) 62% achieved both reliable and clinically significant change, and may be considered to have recovered by the end of the program. Conclusion: These data provide the first demonstration of the potential viability of Blues Begone® as a home based computerized treatment for depression and anxiety.

Some studies of computerized cognitive behaviour therapy (CCBT) have found evidence of its effectiveness, yet a number have reported low uptake and/or completion rates. This study investigated attitudes towards CCBT for depression amongst 122 university students. The credibility of CCBT, expectancy-for-improvement and perceived likelihood of using it were all poor, although a minority (9.8%) stated a preference for CCBT over other interventions. When 20 of the original sample received a demonstration of a CCBT programme for depression, significant increases in credibility, expectancy-for-improvement and in perceived likelihood of using CCBT were found. Numbers stating a preference for CCBT increased to 30%. At both stages, most students stated a preference for CCBT to be accompanied by counselling. Qualitative analysis provided information about factors that might influence these attitudes. Implications for service delivery are discussed.