Note from the National Guideline Clearinghouse (NGC): The National Institute for Health and Clinical Excellence (NICE) commissioned an independent academic centre to perform a systematic literature review on the technology considered in this appraisal and prepare an assessment report. The assessment report for this technology appraisal was prepared by the School of Health and Related Research (ScHARR), University of Sheffield. (See the "Companion Documents" field.)
Search Strategies
The search aimed to identify all references relating to the clinical and cost effectiveness of computerised cognitive behavioural therapy for anxiety and depressive disorders, with particular emphasis on the literature published since the original NICE guidance (No. 51).
Sources Searched
Fifteen electronic bibliographic databases were searched, covering biomedical, health-related, science, social science, grey literature (including current research). A list of databases is provided in Appendix 1 of the Assessment Report (see "Availability of Companion Documents" field). In addition, the reference lists of relevant articles were checked and various health services research related resources were consulted via the Internet. These included health technology assessment (HTA) organisations, guideline producing bodies, generic research and trials registers and specialist mental health sites. A list of these additional sources is given in Appendix 2 of the Assessment Report (see "Availability of Companion Documents" field).
Search Terms
A combination of free-text and thesaurus terms was used. 'Population' search terms (e.g., depression, anxiety, panic, agoraphobia, phobia, obsessive compulsive disorder, etc.) were combined with 'intervention' terms (e.g., cognitive therapy, behavio(u)r therapy, psychotherapy, etc. AND computer, computerised, internet, computer-assisted instruction, multimedia, etc.). This was supplemented by more specific searches on named packages, such as Overcoming Depression, Beating the Blues, Restoring the Balance, Fearfighter, Cope, BT Steps, etc. Copies of the search strategies used in the major databases are included in Appendix 3 of the Assessment Report (see "Availability of Companion Documents" field).
Search Restrictions
No date, language, study or publication type restrictions were applied. This is because the searches included an additional population group (obsessive compulsive disorder) to the original NICE guidance.
Cost Effectiveness
In addition to the searches conducted above, searches were conducted in Medline, Embase, NHS EED and OHE HEED to specifically identify economic literature relating to anxiety and depressive disorders. The methodological search filters used are provided in Appendix 4 of the Assessment Report (see "Availability of Companion Documents" field).
Inclusion and Exclusion Criteria
The following inclusion criteria were used.
Subjects: adults with depression or anxiety with or without depression as defined by individual studies. To include generalised anxiety, panic disorders, agoraphobia, social phobia and specific phobias and obsessive-compulsive disorder.
Intervention: Cognitive behavioural therapy (CBT) delivered alone or as part of a package of care either via a computer interface (personal computer or Internet) or over the telephone with a computer response including the following software packages: Beating the Blues, Overcoming Depression, FearFighter, Cope and BT Steps.
Comparators: current standard treatments including therapist-led CBT, non-directive counselling, primary care counselling, routine management (including drug treatment) and alternative methods of CBT delivery (such as bibliotherapy and group CBT).
Outcomes: Improvement in psychological symptoms, interpersonal and social functioning, quality of life, preference, satisfaction, acceptability of treatment, site of delivery.
Study type: Papers were assessed according to the accepted hierarchy of evidence, whereby systematic reviews of randomised controlled trials are taken to be the most authoritative forms of evidence, with uncontrolled observational studies to be the least authoritative. Unpublished studies were included. Non-randomised controlled trial (RCT) evidence was included in this review in the absence of RCT evidence.
Studies from the previous review: Studies from the previous review of the included software packages were included if they were RCTs. Previous non-RCT evidence of the soft ware packages was included in this review in the absence of RCT evidence.
The following disorders did not fall within the remit of this review:
- Post traumatic stress disorder
- Post-natal depression
- Manic depression
- Depression with psychotic symptoms
- Past Tourette's syndrome
- Schizophrenia
- Bipolar disorder
- Psychosis
- Psychosurgery
- Current co-morbid major depression
- Serious suicidal thoughts or unstable medical conditions in the past 6 months
- Alcohol or substance abuse
Figure 1 in the Assessment Report shows a summary of study selection and exclusion. A list of excluded studies (including excluded studies from the previous review) is provided in Appendix 5 of the Assessment Report. (See the "Availability of Companion Documents" field.)