Background
Reports from the World Health Organization say that depression will cause the second highest level of disability worldwide by the year 2020 [
1]. It is also known that 25% of the population will experience depression symptoms at some point in their lives [
2]. Studies confirm that 25-35% of patients visiting primary care suffer from a psychiatric disorder and that more that 80% of these cases are minor psychiatric disorders, mainly depression and anxiety [
3]. It is known that family physicians only refer 5-10% of the psychiatric pathologies that they detect to mental health services [
4]. Despite this low referral rate, mental health services in Western countries are overburdened. Given the high prevalence of minor psychiatric disorders, health officials worldwide assume that it is not possible to count on the availability of mental health professionals or economic resources to meet this need, and the situation will become even more unfavourable in the near future [
5]. For this reason, cost-effective alternatives are being proposed for the treatment of minor psychiatric disorders in general, and depression in particular, that do not involve (or only minimally involve) mental health services. The therapeutic solutions that are most frequently investigated are brief psychotherapies that can be administrated from a personal computer, such as conflict resolution therapy [
6], bibliotherapy [
7], self-help programs [
8] and computer-assisted psychotherapy programs [
9].
The term “computer-assisted psychotherapy” is used to refer to any psychotherapy program (all programs currently available use cognitive-behavioural therapy) that uses the patient’s responses to perform some type of decision-making about treatment [
10]. This term excludes videoconferences and self-help programs that involve exclusively bibliotherapy, chats, or support groups, among other approaches. Computer programs decrease the work of psychotherapists by more than 80% but do not eliminate it completely. In fact, it has been shown that treatment programs with no human intervention are associated with a higher frequency of dropouts, so their effectiveness is lower. Patients tend to access therapy from a home computer and usually complete short sessions, approximately 20 minutes long, at least once a week for 3–6 months [
10]. Research has assessed the effectiveness of computer-assisted psychotherapy for treating psychiatric disorders as varied as anxiety, depressive disorders, alcohol abuse, and psychosomatic illnesses [
11‐
13]. Recent research on the cost-effectiveness of computer-assisted psychotherapy has yielded very satisfactory results [
14,
15].
In the specific case of depression, studies show that computer-assisted psychotherapy is effective for the treatment of light and moderate depression [
9]. This result has led the National Institute for Health and Clinical Excellence of the British National Health Service to support the widespread use of a computer-assisted psychotherapy program (“Beating the Blues”) in the treatment of depression [
10]. Other studies show that computer-assisted psychotherapy is very effective, indicating that the program could be viable not only at the primary care level but also in the mental health services context. Computer-assisted psychotherapy could be recommended as a first treatment step for self-help in treating depression and anxiety before visiting a psychiatrist or psychologist [
16]. Recent studies have evaluated computer-assisted psychotherapy programs, such as “Blues Begone”, in which there is no psychotherapist present and the program can be administered completely by the patient [
17]. The effectiveness of this type of program is also very high, and its use has been evaluated through naturalistic studies and randomised trials [
17,
18]. The effect size is 0.5 (Cohen’s
d) when analysed by intention to treat and 1 (Cohen’s
d) when only the patients who complete the program are analysed. In addition, effectiveness is maintained 6 months after finishing the therapy program [
18]. Other computer-assisted intervention models are being tested in which treatment is delivered by a therapist in real time via the Internet, and the results of these tests are positive in terms of effectiveness and acceptability [
19].
This type of therapy produces a very positive expectation in patients and a high degree of satisfaction [
20,
21]. However, there are some limitations to its systematic use. The completion rate for patients in clinical trials is 56%. In most cases, patients withdraw for personal reasons, not because of problems with the technology or the social environment. Interestingly, the attitudes of professionals towards this type of psychotherapy are more negative than the attitudes of patients themselves [
20,
21]. There are few previous studies on the acceptability of computer-based psychotherapy, particularly in the primary care setting [
20].
Objectives
The first objective of this research is to describe the profile of depressed patients who would benefit the most from online-assisted psychotherapy. The second objective is to identify expectations, experiences, and attitudes among both patients and health professionals that may serve as barriers to or facilitators of online-assisted psychotherapy by considering the types of information that they require throughout the therapeutic process for adequate intervention development.
Discussion
Online computer-assisted psychotherapy seems to be an effective and cost-effective approach to treating mild to moderate depression [
14,
16‐
18]. In fact, referring patients to computer-assisted psychotherapy after consultation in primary care could relieve some of the burden on mental health services, which are presently unable to meet the demand for mental health care [
5]. Knowledge of the expectations, experiences, and attitudes of those involved in the therapeutic process is very important if this new form of treatment is to be implemented successfully. To date, research on these issues has been restricted to the perspective of the patient [
32‐
35] without adequately addressing the perspectives of health officials who would be involved in recommending this type of intervention. Interestingly, these professionals show greater resistance to the use of this kind of intervention than the patients themselves do. The majority of patients who discontinue computer-assisted psychotherapy treatment do so for personal reasons and not because of problems with the technology or the social environment [
20,
21]. The changes introduced to clinical practice and the doctor-patient relationship by computer-assisted psychotherapy make it important to identify the profile of patients who could benefit most from this therapeutic approach. In addition, it is very important to understand the difficulties that may arise during the therapeutic process to address them and to identify facilitators for completing the treatment.
Qualitative research methods provide a thorough understanding of the perceptions, beliefs, and values of the people being studied, and they are very useful in the health field [
48,
49]. These methods provide the opportunity to explore the points of view of both patients and medical personnel involved in the therapeutic process, thus helping researchers to understand them [
29]. This study does not quantify the hypothetical positive or negative aspects of online therapeutic intervention or the correlations between opinions and other types of variables [
25,
50]. Through this research, an attempt is made to understand the values and experiences of the participants in the context of the study, which are valid to the extent that they contribute to the knowledge and understanding of the therapeutic reality of this type of intervention.
Jesús Montero-Marín, Javier García-Campayo, Miquel Roca, Antoni Serrano-Blanco, Margalida Gili, Fermín Mayoral, Juan V. Luciano, Yolanda López del Hoyo and Bárbara Oliván belong to the REDIAPP (Research Network on Preventative Activities and Health Promotion, RD06/0018/0017).
Competing interests
The authors declare that they have no competing interests.
Authors’ contribution
JM-M, JMC, ASB, MR, MG, RB, CB, RA and JG-C conceptualised the study. JM-M wrote the manuscript and all authors participated in critically revising for important intellectual content and have given final approval of the version to be published.