Provides a summary of the evidence for internet-delivered cognitive behaviour therapy, and looks at the three RACGP Handbook of Non-Drug Intervention (HANDI) recommendations for non-drug treatments for depression and arranged for the developers to comment.

Background
Gotzsche, in Lancet Psychiatry, argued that antidepressants produce more harm than good and should be used sparingly. Karange et al showed that GP prescriptions of antidepressants in Australia are continuing to rise, especially in children. A rethink about the treatment of depression is indicated.

Objective 
This paper provides a summary of the evidence for internet delivered cognitive behaviour therapy, and looks at the three RACGP Handbook of Non-Drug Intervention (HANDI) recommendations for non-drug treatments for depression and arranged for the developers to comment.

Discussion
The systems identified by HANDI are beneficial in major depression and are supported by evidence. They have not been shown to harm or to be beneficial in depression associated with schizophrenia, bipolar disorder or substance dependence. Although little input is required from general practitioners who prescribe these courses, they may form part of a more comprehensive treatment plan. Australia is a world leader in automated internet-delivered cognitive behaviour therapy. Australian clinicians should take advantage and use these courses.

&nbsp

Gavin Andrews

English

Analysis and Policy Observatory (APO)

838  REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 12, DECEMBER 2014
Patients and technology
We can manage 
depression better 
with technology
Background 
Gotzsche, in Lancet Psychiatry, argued that antidepressants 
produce more harm than good and should be used sparingly. 
Karange et al showed that GP prescriptions of antidepressants 
in Australia are continuing to rise, especially in children. A 
rethink about the treatment of depression is indicated.
Objective
This paper provides a summary of the evidence for internet-
delivered cognitive behaviour therapy, and looks at the 
three RACGP Handbook of Non-Drug Intervention (HANDI) 
recommendations for non-drug treatments for depression and 
arranged for the developers to comment.
Discussion
The systems identified by HANDI are beneficial in major 
depression and are supported by evidence. They have 
not been shown to harm or to be beneficial in depression 
associated with schizophrenia, bipolar disorder or substance 
dependence. Although little input is required from general 
practitioners who prescribe these courses, they may form part 
of a more comprehensive treatment plan. Australia is a world 
leader in automated internet-delivered cognitive behaviour 
therapy. Australian clinicians should take advantage and use 
these courses.
Keywords
Doctor–patient relations, consultation; mental health;  
medical informatics
Problem: medication for depression is 
unsatisfactory 
Being invited to write about technology that could help with the 
management of people who have a mental disorder was a welcome 
challenge. The focus was narrowed in light of two articles that 
have indicated that current use of antidepressants may have 
to be reconsidered. There has been a growing acceptance that 
antidepressants are not good treatments for mild and moderate 
major depressive disorder1 and a recent polemic entitled ‘Why I think 
antidepressants cause more harm than good’ defined a problem.2 
The author concluded that the average number needed to treat (NNT) 
with selective serotonin reuptake inhibitors (SSRIs) or serotonin and 
noradrenaline reuptake inhibitors (SNRIs) to get one person better 
was greater than ten. His more disturbing conclusion was that harm 
was frequent: serious sexual difficulties in half and difficulties in 
discontinuing in a similar proportion, so that the number needed to 
harm was two. In addition, he reported an increased suicide risk in the 
young, and increased mortality from falling in the aged. He concluded 
that any medicine that produces more harm than good has to be used 
sparingly. The second problem is that prescriptions of SSRIs/SNRIs 
by Australian general practitioners (GPs) are increasing.3 In 2009–12, 
prescriptions for antidepressants increased 16% overall, and 36% in 
children aged 10–14 years, GPs being the principal prescribers.
Solution step 1: decide if it is major 
depression
If these numbers are correct, then GPs could be doing more harm than 
good. It is not that we want to do harm, but that the pressures of the 
consultation may be such that we have to be seen to be instantly 
useful and antidepressant medication has seemed a useful remedy for 
patient predicaments.
Major depressive disorder requires the persistence of five or 
more of the nine Criterion A symptoms listed in the Diagnostic 
and Statistical Manual of Mental Disorders, 5th edition (DSM-5) 
– depression, loss of pleasure, weight change, sleep change, 
Gavin Andrews
REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 12, DECEMBER 2014  839
Solution step 3: decide which iCBT 
program to use
Australia has many providers of iCBT and, short of doing a systematic 
review, the author, who is the developer of such programs, sought an 
independent method to inform practitioners about selected programs. 
The RACGP has developed the Handbook of Non-Drug Intervention 
(HANDI).7 The HANDI program ‘aims to make “prescribing” a non-
drug therapy almost as easy as writing a prescription’. This program 
lists three iCBT programs for depression or anxiety (MoodGYM, THIS 
WAY UP Clinic, Mental Health OnLine) and we asked the provider 
of each to describe their programs in 200 words or less. The HANDI 
listings and the providers’ descriptions are listed below. 
Beacon and MoodGYM
‘Beacon (http://beacon.anu.edu.au) is an application providing ratings 
of online depression applications. MoodGYM (http://MoodGYM.anu.
edu.au) is a free, online CBT-based training program for depression, 
available in multiple languages.’8
E-hub self-help services (ehub.anu.edu.au) state that they 
provide a number of evidence-based self-help online programs, 
including MoodGYM, targeting depression. The subject of 37 peer-
reviewed papers, MoodGYM has been shown to be effective in 
reducing depressive symptoms in a range of settings, populations 
and countries by a number of research groups within and outside 
Australia, with and without guidance, and across the healthcare 
spectrum from prevention to treatment. There is evidence that 
MoodGYM is an effective adjunct to usual care in general practice 
and by psychologists. Effect sizes vary across studies but a trial 
within Australia’s Lifeline yielded a between-group effect size 
for unguided MoodGYM of 1.24 (NNT = 2) at 6-months post-
intervention.9 Randomised controlled trials (RCTs) have also reported 
that MoodGYM is effective in reducing anxiety and alcohol use 
and in improving wellbeing. E-hub also hosts Beacon, a guide to 
depression and other online behavioural internet applications across 
the world. This resource provides practitioners and consumers with 
a description of each application and its accessibility, together with 
the evidence base underpinning each application (accompanied by 
a consumer-friendly smiley-face rating) and consumer ratings of 
the application. E-hub services are provided by the ANU’s National 
Institute for Mental Health Research (formerly the Centre for Mental 
Health Research). 
How to use: intending patients log on to www.MoodGYM.anu.edu.au 
THIS WAY UP 
THIS WAY UP Clinic offers several courses developed by staff at 
the Clinical Unit of Anxiety and Depression at St Vincent’s Hospital, 
Sydney, and the University of New South Wales Faculty of Medicine. 
Patient use requires a GP referral and there is a fee of $55. Progress 
can be monitored by the referring GP. Courses available include 
depression, generalised anxiety disorder and mixed depression and 
anxiety. Clinicians have free access.’8
retardation, loss of energy, feelings of worthlessness, diminished 
concentration, thoughts of death – in a person who has never had 
an episode of mania. It tends to be recurrent and is not usually about 
being sad or depressed over a stressful life event. It is best measured 
with the Patient Health Questionnaire (PHQ-9),4 where a score of 
10–19 indicates mild or moderate depression and a score of 20–27, 
severe depression. In primary care, 13% of patients will score as 
mild, moderate or severe;5 many of the milder cases are responses 
to adversity, not symptoms of a major depressive disorder. For these 
milder cases advice about problem-solving and lifestyle review is 
preferred to medication. 
Solution step 2: use cognitive behaviour 
therapy
Cognitive behaviour therapy (CBT) is the treatment of choice for mild 
and moderate depression, while CBT and medication together is the 
treatment of choice for severe depression. CBT from an experienced 
clinical psychologist is not easy to find. Internet-delivered cognitive 
behaviour therapy (iCBT) was developed to meet this need, and 
because the internet allows therapy across Australia’s distances. 
The iCBT courses differ from CBT provided by clinicians doing 
telepsychiatry in that the content is automated, there is no enquiry into 
a patient’s history and there is little variation in content according to 
individual patient differences. 
iCBT courses are essentially ‘CBT 101’ – psychoeducation about 
the target disorder and a model for recovery, a model that involves 
control of thoughts, emotions and behaviours that are characteristic 
of the target disorder. Most courses are arranged in a sequence 
of weekly lessons that progressively build on the previous lesson, 
followed by ‘homework’ that consolidates the learning and requires 
that the participant put into practice what has been learned, 
essentially by conducting a series of self-formulated behavioural 
experiments. Courses are therefore most suited to people with 
recurrent depression as they know well why it is important to use 
knowledge to get well and stay well. Most courses use distress 
or depression questionnaires at each lesson to assess participant 
progress and alert the participant and the prescribing clinician if 
additional actions are required. There are no reports that iCBT is of 
benefit for depression in people with schizophrenia, bipolar disorder or 
drug dependence, including benzodiazepine dependence.
Five meta-analyses of iCBT for major depression have shown 
superiority to the progress of the control group. The most recent 
meta-analysis6 of 20 RCTs conducted by six independent research 
groups reported on the benefits of iCBT for depression or depressive 
symptoms. The mean effect size was 0.96, NNT = 2. The authors 
considered that iCBT for depression met the American Psychological 
Association’s criteria for a well-established treatment. There are 
four conclusions from this research on iCBT for depressive disorders: 
improvement is considerable, adherence and satisfaction are high, and 
neither a precise diagnosis and face-to-face contact with a therapist 
nor therapist guidance seem to be essential. 
FOCUS We can manage depression better with technology
840  REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 12, DECEMBER 2014
disorders including social anxiety disorder, post-traumatic stress 
disorder, general anxiety disorder, panic disorder and obsessive 
compulsive disorder. It is run by the National eTherapy Centre at 
Swinburne University of Technology, Melbourne.’8
Mental Health Online says that their website provides information 
on mental health, mental health self-assessment and a range of 
self-directed CBT-based programs. In addition to self-help materials 
for depression, which is the most common diagnosis among users, 
programs are provided for each of the main anxiety syndromes. Use 
of these programs is associated with large effect sizes for post-
therapy symptom reduction.19 Because comorbidity with depression 
and anxiety is the norm rather than the exception, Mental Health 
Online will be introducing a ‘multi-disorder’ program in 2014, 
which addresses anxiety and depressive symptoms together by 
automatically tailoring content of core CBT materials on the basis 
of self-reported symptoms. Similarly to other sites, Mental Health 
Online includes self-help materials designed for the person to 
work through at their own pace, which can be completed either 
independently or with the support of an online therapist. Therapist 
contact helps to maintain engagement with self-directed materials 
to maximise outcomes. Traditionally, this has primarily involved 
weekly, secure email messaging via the site. However, developments 
on Mental Health Online illustrate the increasing sophistication of 
online communication; the site is trialling real-time online instant 
messaging, audio communication and videoconferencing, possible via 
a smartphone as well as web browser.
THIS WAY UP (www.thiswayupclinic.org) states that there are six 
courses that can be accessed, either from a clinician’s referral or by 
people navigating on their own. The courses for major depression, 
mixed anxiety and depression, generalised anxiety disorder, panic 
disorder, social phobia and obsessive compulsive disorder have 
been shown, in published and replicated RCTs, to be superior to the 
progress of control groups (NNT = 2).10–12 In four courses the benefits 
have been replicated by independent researchers,13 and there is 
evidence of effectiveness when used in primary care.14,15 Each course 
consists of six illustrated lessons coupled with written material that 
serves to reinforce the message from the lesson and lists the tasks 
for the forthcoming week. A distress measure precedes every lesson 
and the prescribing clinician and the patient are alerted if distress 
rises. The strength of the clinician-prescribed system is the feedback 
provided. In practice, adherence is high (55–60%) and 80% of people 
who complete the course improve. No harm is reported, but 20% do 
not improve and will require review and other treatment. Work loss 
days and suicidal ideation are halved.16,17 THIS WAY UP seems to be 
one of the more powerful treatments available for depression  
(Table 1).18
How to use: go to the home page, www.thiswayupclinic.org
Mental Health Online
‘Mental Health Online (www.mentalhealthonline.org.au), previously 
known as Anxiety Online, is a website which provides online 
assessment and treatment programs for depression and anxiety 
Table 1. How to use iCBT: an example from THIS WAY UP 
Example from THIS WAY UP
Patients:
• Register ‘as patient’ on www.thiswayupclinic.org. Enter your details. Prescription/registration code is provided by 
clinician or emailed to you. Your registration is complete when payment is made 
• Before you start the course, run through our technical requirements
• From the time you register, THIS WAY UP Clinic will give you 90 days to complete your course. We recommend that 
you ensure you have 3–4 hours per week to commit to the course
• Between each lesson, you will have a lock-out period of 5 days. This is time for you to revise your homework and put 
all the lessons learnt into practice
• When you have completed all lessons, we will give you an extra 90 days to review the course content
• You will receive email reminders from us if you have missed your next scheduled lesson
• We will send your clinician updates on your progress
Clinicians:
• Register ‘as clinician’ at www.thiswayupclinic.org . You will receive an email to activate your account
• When you have a patient who is suitable for a THIS WAY UP course go to www.thiswayupclinic.org (keep it in 
favourites) and login, it will bring you to a prescription page
• Type in the patient’s email and the course you want them to do. Click ‘Send’ and the system will do the rest. Tell them 
to check their junk mail just in case the email is caught by the filter
• You will get an email when they have finished lesson 1. You may wish to call the patient (or have another staff member 
call on your behalf) to say you are pleased. Check again after they have done lesson 2. If you receive an alert that their 
K10 score is worsening call and ask if they are OK, if not schedule an extra consultation to discuss
FOCUSWe can manage depression better with technology
REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 12, DECEMBER 2014  841
Conclusion 
Australia is a world leader in automated iCBT. The systems identified 
by HANDI are beneficial in major depressive disorder and are 
supported by good evidence. They have not been shown to harm, or 
to be beneficial in depression associated with schizophrenia, bipolar 
disorder or substance dependence. GPs can prescribe these courses 
as part of their mental health plan (tick the self-help box); GP input 
and follow-up are determined according to patient needs. Australian 
clinicians should take advantage of and use these courses.
Key points
• Major depressive disorder is a frequent reason for consultation in 
general practice.
• Medication is a weak treatment for mild and moderate depression 
and harmful side effects are common.
• CBT is a treatment of choice and can be delivered over the internet.
• The RACGP’s HANDI project reviewed three Australian services 
that provide iCBT and each service is worthy of consideration by 
Australian practitioners.
Author
Gavin Andrews AO, MD, Professor of Psychiatry, CRUfAD, The 
University of NSW at St Vincent’s Hospital, Sydney, NSW. gavina@
unsw.edu.au
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.
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Antidepressant drug effects and depression severity: a patient-level meta-analysis.

Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009;3: CD007954.

Anxiety online: a virtual clinic: Preliminary outcomes following completion of five fully automated treatment programs for anxiety disorders and symptoms.

Australian College of General Practitioners. HANDI. Making nondrug interventions easier to find and use. Available at www.racgp.org.au/

Clinician-assisted Internet-based treatment is effective for depression: A randomized controlled trial.

Cognitive behaviour therapy via the internet for depression: A useful strategy to reduce suicidal ideation.

Computer Therapy for anxiety and depressive disorders is effective, acceptable and practical health care. PLoS One 2010;5:1–6.

Effectiveness of computerised cognitive behaviour therapy for anxiety disorders in secondary care.

Effectiveness of internet cognitive behavioural therapy (iCBT) for depression in primary care: A quality assurance study. PLoS One 2013;8:e57447.

Handbook of Non-Drug Intervention Project Team. Internet-based cognitive behaviour therapy for depression and anxiety. Aust Fam Physician 2013;42:803–04.

Internet treatment for depression: a randomized controlled trail comparing clinician vs. technician assistance. PLoS One 2010;5:e10939.

Internet-Based CBT for Depression with and without Telephone Tracking in a National Helpline: Randomised Controlled Trial. PLoS One 2011;6:e28099.

Lindefors N Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost– effectiveness. Expert Rev Pharmacoecon Outcomes Res 2012;12:745–64.

Longitudinal trends in the dispensing of psychotropic medications in Australia from 2009–2012: Focus on children, adolescents and prescriber specialty.

Occupational impact of internet-delivered CBT for depression and anxiety: reanalysis of data from five randomised controlled trials.

The effectiveness of transdiagnostic internet cognitive behavioural (iCBT) treatment for anxiety and depression in primary care.

The PHQ-9: validity of a brief depression severity measure.

Up-scaling clinician assisted internet-based cognitive behavioural therapy (iCBT) for depression: A model for dissemination into primary care. Clin Psychol Rev 2014;doi. 10.1016/j.cpr.2014.05.006/j. cpr.2014.05.006 [Epub ahead of print].

Why I think antidepressants cause more harm than good. Lancet Psychiatry 2014;1:104–06.

We can manage depression better with technology

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We can manage depression better with technology

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