Using technology to link more patients with mental health services: Internet-Based Cognitive Behavioural Therapy

By Eftyhia Helis

If you or a loved one has ever needed access to mental health support, how quickly were you able to connect with a mental health professional? What services and treatment options were available to you? If you are a health care professional, how easy is it to get mental health support for your patients?

According to a report produced for the Mental Health Commission of Canada, by the time Canadians reach 40 years of age, half will have or have had a mental illness. Depression and anxiety are among the most common mental health disorders in Canada, and both can be treated effectively. Cognitive behavioural therapy (CBT) is the most commonly used psychological treatment for these conditions. This treatment provides patients with coping strategies and skills to change dysfunctional thoughts, behaviours, beliefs, and attitudes; and it is an effective treatment if provided in a timely manner.


However, accessing psychological care is not always easy. Depending on where you live and how “urgent” your issue is, you could be on a wait list for more than a year for certain mental health services (e.g., seeing a psychiatrist), just wait a few weeks, or not wait at all. Variances in health system capacity and availability of trained staff may be among the reasons for these differences. Affordability is also an issue — psychological services are out of reach for many people as most provincial and territorial health insurance plans will not pay for services provided outside of the public system.

CBT is usually delivered as a series of face-to-face sessions with a therapist; however, technology has made it possible for treatment to be provided over the internet with no need for client and therapist to meet in person. Internet-delivered (iCBT) can be accessed anywhere on a computer, smartphone, or tablet as long as there is an internet connection. iCBT programs typically include a series of structured, goal-focused modules and readings, activities, and may include text, audio, or video messaging. As it is delivered remotely, iCBT may be a good option for individuals who are unable to access face-to-face treatment because of long wait times, poor access to treatment (e.g., in rural or remote areas), cost, and perceived stigma or privacy concerns.

Several iCBT programs are available in Canada either via private vendors (where patients pay for treatment) or, in some provinces, as a publicly funded service. As the demand for innovative approaches to mental health care grows, understanding whether and how iCBT works, and for whom and in what circumstances, is important for clinicians and health care facilities considering iCBT, for decision makers who need to determine policies on the appropriate use of iCBT in this context, as well as for patients.

CADTH, in collaboration with Ontario Health (Quality), reviewed the available evidence on iCBT for mild and moderate major depression and anxiety disorders. The review found that iCBT is effective for reducing symptoms of mild-to-moderate major depression and select anxiety disorders, and for improving quality of life. Because the evidence was stronger for guided iCBT (where the user receives support from a therapist) than for unguided iCBT (self-directed programs), it is recommended that guided iCBT be offered. As patient needs vary, the guidance of a therapist during iCBT may allow treatment to be tailored according to a patient’s individual priorities and needs, which may also help patients adhere to, and succeed with, treatment.

Still, iCBT may not be right for all patients. Some may feel uncomfortable interacting with a therapist remotely or may be unable to if they do not have a computer, internet access, or adequate computer literacy. iCBT might also be unsuitable for those with a visual impairment or other special needs. There are also concerns about data security, privacy, and confidentiality when receiving treatment online. And, despite of the lower cost of iCBT compared with that for face-to-face sessions, many people do not have access to coverage for the treatment.

iCBT is also being considered for other mental health conditions, including post-traumatic stress disorder (PTSD). CADTH recently reviewed the evidence on iCBT for PTSD but found only limited and low quality evidence. So, although there may be a role for iCBT in the treatment of PTSD, more research is needed.

With increasingly more iCBT platforms becoming available, a variety of options exist for patients and health care professionals. However, iCBT may be not be a solution that suits the needs and comfort level of all patients and health care providers or be appropriate for every mental health condition. On the other hand, incorporating iCBT into existing clinical pathways — either with a stepped care approach, as a short-term option, or in combination with face-to-face therapy — could help more Canadians access effective mental health care when they need it.

The reviews mentioned in this article, and many other reviews of health technologies, are freely available at www.cadth.ca. To learn more about CADTH, visit our website, follow us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your region.

Eftyhia Helis is a Knowledge Mobilization Officer at CADTH.