The British Journal of Psychiatry (2017)
210, 362–367. doi: 10.1192/bjp.bp.116.192435
Telephone-supported computerised
cognitive–behavioural therapy: REEACT-2
large-scale pragmatic randomised controlled trial
Simon Gilbody, Sally Brabyn, Karina Lovell, David Kessler, Thomas Devlin, Lucy Smith, Ricardo Araya,
Michael Barkham, Peter Bower, Cindy Cooper, Sarah Knowles, Elizabeth Littlewood, David A. Richards,
Debbie Tallon, David White and Gillian Worthy, on behalf of the REEACT collaborative
Background
Computerised cognitive–behavioural therapy (cCBT) for
depression has the potential to be efficient therapy but
engagement is poor in primary care trials.
Aims
We tested the benefits of adding telephone support to cCBT.
Method
We compared telephone-facilitated cCBT (MoodGYM)
(n = 187) to minimally supported cCBT (MoodGYM) (n = 182)
in a pragmatic randomised trial (trial registration:
ISRCTN55310481). Outcomes were depression severity
(Patient Health Questionnaire (PHQ)-9), anxiety (Generalized
Anxiety Disorder Questionnaire (GAD)-7) and somatoform
complaints (PHQ-15) at 4 and 12 months.
Conclusions
Telephone facilitation of cCBT improves engagement and
expedites depression improvement. The effect was small to
moderate and comparable with other low-intensity
psychological interventions.
Results
Use of cCBT increased by a factor of between 1.5 and 2 with
Copyright and usage
B The Royal College of Psychiatrists 2017.
Depression is the most common mental health disorder in
community settings and is estimated to become the second largest
cause of global disability by 2020.1 It is one of the most common
reasons for consulting with a primary care physician and its
associated personal and economic burden is considerable.2
Although antidepressants remain an important treatment option,
many patients and healthcare professionals would like to access
psychological therapy as an alternative or adjunct to drug
therapy.3 Cognitive–behavioural therapy (CBT) has emerged as
a leading evidence-supported form of brief psychological therapy
for people with depression.4 However, demand for CBT cannot be
met from existing therapist resources.5 One promising alternative
to therapist-delivered CBT is the use of self-help interventions
including the provision of therapy via computer.6 In recent years
a number of interactive programs have been developed that enable
CBT to be delivered by computer (computerised CBT (cCBT)).
If effective, such programs have the potential to expand the
provision of psychological therapy in primary care and may
represent an efficient and effective form of care for depression.7
In an earlier large-scale pragmatic trial (the first Randomised
Evaluation of the Effectiveness and Acceptability of Computerised
Therapy (REEACT) trial)8,9 we compared two commonly used
cCBT packages (MoodGYM or Beating the Blues) v. usual primary
care under real-world conditions to test their effectiveness
(rather than efficacy). Participants were proactively offered
technical support and weekly encouragement to use the computer
packages, but we purposely did not augment the content of
psychological therapy over the telephone. The cCBT in the first
REEACT trial was therefore a form of supported self-help, but
was not one that was guided by a clinician. The first REEACT
trial is, at the time of writing, the largest publicly funded
362
telephone facilitation. At 4 months PHQ-9 scores were 1.9
points lower (95% CI 0.5–3.3) for telephone-supported
cCBT. At 12 months, the results were no longer statistically
significant (0.9 PHQ-9 points, 95% CI –0.5 to 2.3). There
was improvement in anxiety scores and for somatic
complaints.
Declaration of interest
None.
independently conducted primary care trial of cCBT. The main
finding of the trial was that for the primary outcome of depression
severity at 4 months there was no significant benefit when
participants were offered technically supported cCBT in addition
to usual general practitioner (GP) care. The most likely
explanatory mechanism of lack of effect was poor uptake and
use of computer packages by trial participants under real-world
conditions.9
Systematic reviews have highlighted the potential for cCBT to
be effective but have also further demonstrated variable effect sizes
and substantial between-study heterogeneity.10,11 One important
source of between-study heterogeneity is the level of support that
is made available to people who are offered treatment with cCBT.
cCBT requires a person with depression to engage with a self-help
computer-based technology. Research has shown that people with
depression often do not engage with cCBT, and only a minority
actually complete all of the planned sessions of the computer
package.12 This observation is consistent with a broader body of
research into the uptake and effectiveness across the range of
self-help interventions for depression such as bibliotherapy (selftreatment using written materials).13 Research in the area of
self-help treatments for depression has demonstrated that entirely
self-guided materials (with no professional support) are likely to
be less effective than self-help technologies where there is a level
of guidance and professional support (‘guided self-help’).
Unsupported self-help treatment (including unsupported
computer-delivered self-help) has been shown in systematic
reviews to have minimal or relatively small effect sizes.13 In
contrast, more intensively and professionally supported
treatments have generally been found in efficacy trials to have
moderate effect sizes claimed to be comparable with those
Telephone-supported computerised cognitive–behavioural therapy
achieved with face-to-face therapy.14 To our knowledge the
comparative effectiveness of minimally supported cCBT v. more
intensively supported cCBT has not been directly tested in
large-scale, independently-conducted, head-to-head, pragmatic
trials (although there are some head-to-head comparisons in
smaller-scale trials15). We postulated on the basis of these findings,
and on the basis of emerging trial-based evidence summarised in
systematic reviews (for example Andersson & Cuijpers10), that
people with depression might engage with cCBT and it might
show an effect, but only if offered alongside a high level of
facilitation and support. We designed the present study (the
REEACT-2 trial, trial registration: ISRCTN55310481) to test this
hypothesis and to generate trial-based evidence on the best means
of delivering cCBT in primary care mental health services.
Method
Study design and patients
The REEACT-2 trial was designed to examine the additional
benefits of telephone facilitation and structured guidance
alongside a free-to-use computer-delivered CBT package
(MoodGYM). The comparator was minimally supported cCBT.
Participants in both arms were given access to MoodGYM, an
accompanying booklet, a freephone number for technical support
and continued with usual GP care. MoodGYM is a free-to-use,
internet-based, interactive CBT program for depression developed
and copyrighted at the Australian National University Centre for
Mental Health Research. The online program is accompanied by
a booklet with exercises and quizzes and consists of five interactive
modules released sequentially and lasting approximately 30–
45 min and a sixth session that is predominantly consolidation
and revision. Study participants were asked to complete one
session each week. The program provides patients with CBT
techniques to overcome patterns of unhelpful thinking using
cartoon characters to represent habits of thought.
group, they were supplied with a free helpline number to ring if
they had technical problems or needed advice and a booklet
explaining MoodGYM, but they did not receive regular phone
calls. This comparator intervention replicated UK National Health
Service care in most settings and represented what would happen
if a patient were given the website of a cCBT package such as
MoodGYM by their GP or primary care mental health worker
without being offered proactive support.
The study population comprised patients selected from
primary care with depression or low mood as determined by a
score of ten or more on the Patient Health Questionnaire
(PHQ)-9.16 This cut-off point is known to detect clinical
depression (major depression) in primary care populations17 with
acceptable sensitivity and specificity. The REEACT-2 participants
were recruited from a mix of rural and urban UK primary care
practices in and around Bristol, Avon, Somerset, Gloucestershire,
Manchester, Sheffield, Derbyshire, South Yorkshire, Humberside,
East Yorkshire, Durham, Tyneside and Northumberland.
Participants meeting the following criteria were eligible to
enter the study: (a) aged 18 or above; (b) not currently in receipt
of cCBT or specialist psychological therapy; (c) a score of 510
overall (indicating moderate, moderately severe or severe
depression) and 53 for question 9 (measuring suicidal thoughts)
on the PHQ-9 depression instrument.16 Both individuals with
incident and prevalent primary care cases of depression were
included. In line with the pragmatic nature of this trial, patients
were eligible to participate whether or not they were in receipt
of antidepressant medication or had comorbid physical illness
or non-psychotic functional disorders. We excluded people
currently in receipt of psychological therapy. We also excluded
potential participants who: (a) were actively suicidal as identified
by their GP or as reported by item 9 on the PHQ-9; (b) had been
bereaved within the past year; (c) had given birth within the past
year; (d) had a diagnosis of psychotic depression; (e) had a
primary diagnosis of alcohol or drug misuse; (f) were not able
to read and write in English.
Experimental arm
Participants in the telephone-facilitated cCBT (experimental) arm
were allocated a telephone support worker (TSW) who provided a
programme of weekly telephone calls. The background of the
TSWs was that of a graduate-level support worker. The telephone
facilitation programme comprised eight telephone calls to be
completed alongside the cCBT program within 14 weeks of first
contact from the TSW (and before the 4-month follow-up time
point). The purpose of the first and longest session (30–40 min)
was to introduce the participant to the principles of CBT and
the MoodGYM program and booklet, explain the process and help
the participant identify difficulties and goals, and feel confident
about engaging with the intervention. The following six sessions
were between 10 and 20 min long and were intended to provide
motivation and to help participants identify any barriers to
engagement with cCBT and to the achievement of their goal(s).
The final session helped participants to consolidate what they
had learned from cCBT and discuss their next steps and, if
appropriate, how they might use the MoodGYM program in the
future. The telephone facilitation programme was delivered
according to a manual developed by co-investigator K.L. in
conjunction with the REEACT-2 team. TSWs received 1 day of
training in the delivery of the intervention. Clinical supervision
was given to trial TSWs by investigators K.L., D.K. and S.G.
Comparator arm
All participants in the control group were registered as users of
MoodGYM and given a unique password. As with the intervention
Randomisation and masking
Simple randomisation was performed using a computer-generated
random number sequence. At the end of the baseline appointment
study researchers telephoned a secure randomisation line at the
York Trials Unit and were given participant allocation and
MoodGYM login details. Participants were informed immediately.
Outcome measures
The pre-specified primary outcome was depression severity and
symptomatology as measured on a validated self-report continuous
measure (PHQ-9)16 at 4 months. The secondary outcome
measures were: PHQ-9 at 12 months (as a continuous measure);
PHQ-9 at 4 and 12 months (dichotomous measure at cut-point
PHQ-9 510);16 anxiety (Generalised Anxiety Disorder
Questionnaire (GAD-7));18 somatoform complaints (PHQ-15);19
health-state utility (EuroQol – EQ5D); 20 and service use using
the adapted Client Service Receipt Inventory (CSRI)21 at 4 and
12 months.
The REEACT-2 trial was powered on the basis of an ability to
detect a between-group difference in PHQ scores. We sought to
recruit 350 patients with depression – 175 participants per arm.
The REEACT-2 trial was designed to have sufficient power to
detect a Cohen’s d effect size of 0.30 with 80% power allowing
for loss to follow-up of 20% in line with our empirically based
estimates from the first REEACT trial. The final sample size for
363
Gilbody et al
the two arms was 369 and we exceeded the pre-specified sample
size.
Statistical analysis
All outcomes were summarised descriptively by intervention
group and at each time point using mean, median, standard
deviation, range and number of patients for continuous outcomes
and number of patients and percentage for discrete outcomes. The
primary outcome was the severity of depression as measured by the
PHQ-9 as a continuous measure at 4 months. Statistical analyses
were performed in SAS version 9.3.
The PHQ-9 score was summarised and analysed as a continuous
outcome. This was summarised for each assessment time point
(baseline, 4 and 12 months) using mean, standard deviation,
median and range, and the number of missing values. Plots were
presented showing the mean and 95% confidence interval at each
time point. A repeated measures mixed regression model was used
to analyse the change in PHQ-9 score over time. This included all
randomised participants (intention to treat) and provides reliable
estimates assuming the data are missing at random. The outcome
was the PHQ-9 score at 4 and 12 months and the model included
the baseline PHQ-9 score, treatment group, age, gender, baseline
GAD-7 score and time. The treatment6time interaction was
included to evaluate if the difference between treatments changed
over time. The mean difference, 95% confidence interval and
P-values are presented for all terms in the model. Effect sizes
(Cohen’s d) were calculated for the between-group differences in
mean PHQ-9 score at 4 and 12 months using the difference
between the means and corresponding standard errors from the
mixed model. The standard errors were converted to standard
deviations using the corresponding sample size in each treatment
group.
The dichotomous analysis (not depressed (PHQ-9510)/
depressed (PHQ 9510)) compared minimally supported cCBT
with telephone-facilitated cCBT using a logistic regression model
adjusting for the baseline PHQ-9 score, age, gender, baseline
GAD-7 score and treatment. The dichotomous analysis was on
a complete case basis (only including those with a 4-month
assessment). A sensitivity analysis was performed using simple
imputation and a worst case scenario. This assumed that all
participants with a missing outcome were still clinically depressed
with a PHQ-9 score 510.
The GAD-7 and the PHQ-15 scores were analysed as continuous
outcomes using the same repeated measures mixed models
described for PHQ-9 above. Resource use data and health state
utilities (derived from the EQ5D) formed the basis of a full
Table 1
economic evaluation and are described in the full study report.22
Adherence by participants to the computer program was
measured by requesting information from the website providing
MoodGYM (hosted by the developers of MoodGYM at the
Australian National University). We obtained computer usage
data on the number of times each participant logged on to the
MoodGYM program and whether each module was 25, 50, 75
or 100% complete. Adverse events were classified according to
their seriousness and relationship to the intervention.
Results
A total of 369 participants were randomised to the two-armed
comparison of minimally supported cCBT (n = 182) with
telephone-facilitated cCBT (n = 187). The first participant was
randomised on the 24 June 2011 and the last on the 25 April
2013. The flow of participants through the trial is shown in the
CONSORT diagram (online Fig. DS1). The two groups were well
balanced at baseline for gender, age, ethnicity and education. The
mean age of participants was 40.6 years (s.d. = 13.8) (online Table
DS1). The study population was mostly White British (94%) and
64.5% were women. The minimally supported cCBT and
telephone-facilitated cCBT groups were balanced at baseline for
employment. The majority (61.5%) of participants were employed
and of these 23.6% were absent from work because of depression
at the time of their baseline assessment. The severity of depression
at baseline (as ascertained by the median PHQ-9 score) was 16
(range 10–25), which corresponds with a moderate to high level
of severity.
PHQ-9 as a continuous outcome
At the 4-month primary outcome the between-group difference in
PHQ-9 scores was 1.9 points (95% CI 0.5–3.3) in favour of
telephone-facilitated cCBT, with a standardised effect size
(Cohen’s d) of 0.32 (P = 0.009) (online Table DS2). At 12 months,
there was no longer evidence of a between-group difference in
PHQ-9 scores (0.9, 95% CI –0.5 to 2.3). Using a repeated
measures analysis over the whole trial period the between-group
difference in PHQ-9 scores was 1.4 (95% CI 0.2–2.6) in favour
of telephone-facilitated cCBT with a standardised effect size
(Cohen’s d) of 0.27 (P = 0.0253) (online Table DS2). Table 1 and
Fig. 1 show the PHQ-9 scores at each assessment time point
(baseline, 4 and 12 months) for both groups.
Depression severity (Patient Health Questionnaire (PHQ-9) scores) at each time point
Baseline
Month 4
Month 12
Minimally
supported cCBT
Telephonefacilitated cCBT
Minimally
supported cCBT
Telephonefacilitated cCBT
Minimally
supported cCBT
Telephonefacilitated cCBT
PHQ-9 continuous score
n
Mean (s.d.)
Median (range)
182
16.4 (4.1)
16 (10–25)
187
16.8 (3.9)
17 (10–26)
128
10.4 (6.4)
10 (0–27)
141
8.5 (6.3)
7 (0–24)
132
9.2 (6.2)
9 (0–25)
142
8.2 (6.4)
7 (0–27)
PHQ-9 dichotomised score
n
Depressed, n (%)
Not depressed, n (%)
182
182 (100)
0
187
187 (100)
0
128
66 (51.6)
62 (48.4)
141
51 (36.2)
90 (63.8)
132
57 (43.2)
75 (56.8)
142
46 (32.4)
96 (67.6)
54 (30)
46 (25)
50 (27)
45 (24)
Missing at follow-up, n (%)a
0
0
cCBT, computerised cognitive–behavioural therapy.
a. Percentage of those originally randomised (minimally supported cCBT n = 182 and telephone-facilitated cCBT n = 187) missing at follow-up.
364
Telephone-supported computerised cognitive–behavioural therapy
18 –
15 –
Treatment
17 –
Minimally supported cCBT
16 –
Telephone-facilitated cCBT
Minimally supported cCBT
13 –
Telephone-facilitated cCBT
12 –
15 –
11 –
14 –
10 –
13 –
9–
PHQ-15
PHQ-9
Treatment
14 –
12 –
11 –
8–
7–
6–
10 –
5–
9–
4–
8–
3–
7–
2–
6–
0
1–
1
2
3
4
5
6
7
8
Time, months
9
10
11
12
13
0–
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Time, months
Fig. 1
Depression severity at each assessment.
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Fig. 3
Severity of somatoform complaints at each assessment.
Severity is mean and 95% confidence interval Patient Health Questionnaire (PHQ)-15
score. Results from a repeated measures, mixed model adjusting for baseline score,
age, gender, baseline Generalized Anxiety Disorder Questionnaire (GAD)-7 score and
time. cCBT, computerised cognitive–behavioural therapy.
Treatment
Minimally supported cCBT
70 –
Telephone-facilitated cCBT
Logged on and completed sessions (%)
GAD-7
Severity is mean and 95% confidence interval Patient Health Questionnaire (PHQ)-9
score. Results from a repeated measures, mixed model adjusting for baseline score,
age, gender, baseline Generalized Anxiety Disorder Questionnaire (GAD)-7 score and
time. cCBT, computerised cognitive–behavioural therapy.
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Time, months
Fig. 2
Anxiety severity at each assessment.
Severity is mean and 95% confidence interval Generalized Anxiety Disorder
Questionnaire (GAD)-7 score. Results from a repeated measures, mixed model
adjusting for baseline score, age, gender and time. cCBT, computerised
cognitive–behavioural therapy.
PHQ-9 as a dichotomous outcome
After 4 months 66 (51.6%) of the 128 participants in the
minimally supported cCBT group and 51 (36.2%) of the 141 in
the telephone-facilitated cCBT group had a PHQ-9 score 510
(Table 1). The odds of no longer being depressed (defined as
PHQ-9 510) at 4 months were increased twofold in the
telephone-facilitated cCBT group compared with minimally
supported cCBT (odds ratio (OR) = 2.05, 95% CI 1.23–3.42).
The benefit of telephone-facilitated cCBT was no longer significant
at 12 months (OR = 1.63, 95% CI 0.98–2.71 P = 0.06).
Other secondary outcomes
For secondary outcomes there was a significant between-group
difference in anxiety scores (GAD-7) in favour of telephonefacilitated cCBTwhen all time points were considered (between-group
60 –
Minimally supported MoodGYM
Telephone-facilitated MoodGYM
50 –
40 –
30 –
20 –
10 –
0–
Session 1 Session 2 Session 3 Session 4 Session 5
Fig. 4 MoodGYM usage, session by session, as ascertained
by computer login records.
difference 1.2, 95% CI 0.1–2.3, P = 0.037) (Fig. 2 and online Table
DS3). For somatic complaints there was a borderline significant
difference in favour of telephone-facilitated cCBT when all time
points were considered (between-group difference 1.1, 95% CI
0.0–1.8, P = 0.051) (Fig. 3 and online Table DS4).
Adherence and adverse events
When computer records were scrutinised there were few
participants who completed all five sessions in either minimally
supported (10.4%) or telephone-facilitated cCBT (19.4%) (online
Table DS5). Usage was generally increased by a factor of between
1.5 and 2 when telephone facilitation was offered, with 46.2% of
participants in receipt of telephone facilitation completing two
or more sessions v. 29.1% of participants with minimal support
(Fig. 4). There was a total of ten serious adverse events, none of
which was thought to be related to the trial. All were reviewed
by the Trial Steering Committee and the Data Monitoring and
Ethics Committee.
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Gilbody et al
Discussion
Main findings
REEACT-2 is one of the largest trials of computer-delivered CBT
to date. The trial tested whether the addition of structured
telephone facilitation substantially increased engagement with
computer-mediated CBT and resulted in improved outcomes.
We purposely designed a pragmatic trial to test effectiveness under
real-world conditions rather than efficacy under ideal but
restrictive conditions in order to maximise the external validity
of our results.23 The main finding of the REEACT-2 trial is that
the addition of structured telephone facilitation resulted in
significant reductions in depression severity compared with cCBT
with technical support alone. The effect size was moderate and
was most evident in the short term (4 months) and had
diminished by 12 months. Telephone facilitation of cCBT
therefore expedited depression improvement, although the
absence of benefit at 12 months is unsurprising given the average
duration of an episode of depression is less than 12 months. When
depression was considered as a binary outcome, the odds of no
longer being depressed were twice as high in the telephonefacilitated group at 4 months. Benefits in terms of psychological
outcomes were also observed using a validated anxiety scale and
for somatoform complaints when outcomes were averaged over
a 12-month period. Engagement with the technology was
increased through the addition of telephone facilitation.
Comparison with findings from other trials
The REEACT-2 trial drew upon a manualised form of telephone
support, which can readily be delivered after a relatively brief
period of training. At present computerised CBT is offered by
many healthcare systems as a minimally supported low-intensity
psychological intervention and as part of a stepped care
framework. The intervention trialled in the REEACT-2 study
therefore represents an enhancement of care that can be readily
delivered at scale in primary care settings. The results of this trial
should be considered alongside other trials and systematic reviews
of cCBT and low-intensity interventions for common mental
disorders. Our earlier study (the REEACT trial)8 was similarly a
large-scale pragmatic trial of cCBT where one arm included the
free-to-use cCBT package (MoodGYM). In that previous trial
we offered a low-intensity form of technical telephone support
and found that usage was low and there were no additional clinical
benefits of cCBT when it was added to usual primary care. This led
us to speculate that an enhancement in the level of support and
guidance might increase uptake and effectiveness. Evidence that
the addition of guidance to cCBT is associated with a greater level
of effectiveness comes from systematic reviews, where pooled estimates of the effect size of trials with therapist guidance are larger
than the pooled effect size obtained from unsupported cCBT.10
Evidence also comes from a systematic review of small-scale
head-to-head comparisons of unsupported v. supported cCBT
in a range of common mental disorders.15 This hypothesis has
now been directly tested in the present randomised controlled trial
that, to our knowledge, is the first test of this in a large-scale (adequately powered) direct randomised head-to-head comparison. The
results of the REEACT 2 trial are also comparable with other primary care based psychological treatments,24 but the effect
size observed in REEACT-2 is smaller compared with other
developer-led trials of cCBT.10 The additional benefit of guided
support is in line with the results of a systematic review of three
small-scale studies in depression.15
366
Strengths and limitations
The REEACT-2 trial has several strengths in its design. First, this
trial was pragmatic in design and recruited from primary care,
whereas most trials to date have recruited from online populations
or by participant advertisement. This addresses a major shortcoming of the literature identified by Andersson & Cuijpers in
their 2009 review.10 The results of REEACT-2 are therefore more
generalisable to clinical populations encountered in primary care.
Second, the trial was significantly larger than other trials to date
(see Baumeister et al15) and had sufficient power to detect more
modest effect sizes. Third, we conducted a pragmatic trial of
effectiveness rather than efficacy by trialling a low-intensity
enhancement to cCBT that could be delivered at distance to a
range of people fulfilling very broad depression inclusion criteria
(typical of those encountered in primary care). Fourth, the period
of follow-up was 1 year and this allows some conclusions to be
drawn about the durability of effect. Finally, we were able to study
the actual use of computer technology by our trial participants
with reference to computer records.
There were also limitations to the REEACT-2 study. First, in
view of the pragmatic nature of the design there was loss to
follow-up of around a quarter of the participants overall, and
we know very little about the outcomes of these participants.
Second, we did not measure outcome with a clinical interview
to establish the presence of depression according to accepted
classification systems. Instead we relied on self-report measures
of depression severity; although these are well-validated against
diagnostic systems.25 Third, even with the provision of telephone
facilitation, only a small proportion of participants in either arm
completed all sessions of the cCBT program. There is possibly
more still that can be offered to enhance the uptake of computer
therapy. Finally, the level of depression severity at baseline was
moderate to high, and this is at the upper range of severity
recommended in some stepped care systems.4 However, the
positive results of the REEACT-2 trial provide supportive evidence
that low-intensity interventions can be offered to this group and
will result in improved outcomes. This finding is consistent with
recent reviews of the effectiveness of low-intensity interventions
across the range of severities of depression.26
Implications
The implications for practice and policy that emerge from the first
REEACT and REEACT-2 trials are twofold. The first is that
minimally supported cCBT results in very low levels of uptake
and confers little over usual care. We would therefore suggest that
healthcare systems do not offer this form of unsupported
treatment as part of stepped care. However, unsupported cCBT
should still be offered as a form of direct access treatment to
non-clinical populations, although the benefits that might be
expected are likely to be small. The second implication is that
the addition of structured telephone facilitation (such as that
designed in REEACT-2 to work alongside MoodGYM) will result
in greater levels of engagement with computer technology. In turn
this will produce moderate clinical improvements and reductions
in the proportion of people who continue to experience
depression over a 4- to 12-month period. Telephone support is
a low-intensity enhancement of care that can be offered at scale
and could be readily implemented in most healthcare settings as
part of a stepped care system.
Funding
This project was funded by the UK NIHR Health Technology Assessment programme (project number HTA 06/43/504). The views and opinions expressed therein are those of the
Telephone-supported computerised cognitive–behavioural therapy
authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the
Department of Health. The funder played no role in the study design, in the collection,
analysis or interpretation of the data, in the writing of the paper or in the decision to
submit the article for publication. All authors were independent from the funders. Data
sharing: reasonable requests for patient level data should be made to the corresponding
author and will be considered by the REEACT publications management group. Consent
for data sharing was not obtained but the presented data are anonymised and risk of
identification is low.
Acknowledgements
We would like to thank especially the patients from primary care who agreed to be
recruited to take part in this trial. Thanks also to members of the Primary Care Research
Network (PCRN), GPs, research nurses, administrative and other staff at participating GP
practices, the Mental Health Research Network (MHRN) and the site research teams. In
addition, we would like to thank the Trial Steering Committee and Data Monitoring and
Ethics Committee members for overseeing the study. We thank too Gwen Brierley who
was the trial manager at the start of the trial and who co-wrote the trial protocol and
REC applications; Anna Thake, D.T., S.K. and D.W. who were the trial coordinators at the
sites; the many researchers, clinical studies officers and research nurses who recruited
participants to the study and collected data; the York Trials Unit for providing the
randomisation service, for managing the data and conducting the analysis of the clinical
data; and the team of telephone support workers. We would also like to extend our
gratitude to the developers of MoodGYM, in particular to Kylie Bennett and Ada Tam, for
providing us with participant logins and usage data.
The REEACT-2 trial is dedicated to the memory of Professor Helen Lester (1961–2013)
who contributed time and wisdom at every stage of the REEACT trial programme.
Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health
Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing,
Midwifery and Social Work, University of Manchester, Manchester; David Kessler,
MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University
of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of
Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of
Global Mental Health, London School of Hygiene and Tropical Medicine, London;
Michael Barkham, PhD, Centre for Psychological Services Research, University
of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research,
University of Manchester, Manchester; Cindy Cooper, PhD, School of Health
and Related Research, University of Sheffield and Clinical Trials Research Unit,
University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care
Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD,
Department of Health Sciences, University of York, York; David A. Richards, RN,
PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie
Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol;
David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield;
Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
Correspondence: Simon Gilbody, Department of Health Sciences, Mental
Health Services Research, Department of Health Sciences, University of York,
York YO10 5DD, UK. Email: simon.gilbody@york.ac.uk
First received 25 Aug 2016, final revision 29 Oct 2016, accepted 3 Nov 2016
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