Readers: Here is Hilda Bastian’s terrific new post assessing which websites provide scientifically sound psychological help online. In addition to blogging for PLOS on Absolutely Maybe, Hilda’s day job is editor of PubMed Health and PubMed Commons. Follow her on Twitter@hildabast and at hildabastian.net.
Before we go on, you should know there are no sunshine-y quick fixes coming in this post. The kind of websites we’ll be looking at take a lot of effort. And there’s no guarantee the effort will pay off. There isn’t with any therapy for anxiety and depression.
Anxiety and depression can be stinkingly tough conditions to budge. Life is so much tougher when one or both are dragging you down. Any demanding therapy is tougher, too. It’s odd, really, that so many are quick to judge others, and themselves, as weak when they struggle with this.
Extra obstacles, it seems to me, deserve extra recognition. It’s a bit like that classic cartoon by Bob Thaves, commenting on Ginger Rogers, the female half of the legendary Astaire and Rogers dancing duo. Sure, Astaire was great, but don’t forget she “did everything he did backwards…and in high heels.”
Despite the strength that life with depression and anxiety calls on, the stigma of weakness clings, along with the notion that you can just “snap out of it”. There are other ways to think about this. David Dobbs writes of one: “…the sensitivity that opens the person to depression becomes a strength that lets them overcome not just it, but other obstacles”.
Although it’s not easy to change, the way we think about things can affect our moods and behavior. We can get caught in uncontrollable brooding and ruminating about the future or past. All of that can get us caught in vicious cycles that keep us down.
That’s not the cause of everyone’s depression and anxiety, nor the reason it continues. But it is common. And changing that kind of deeply ingrained pattern of thinking and behaving can help. Cognitive behavior therapy (CBT) is one way to work through that process.
Between any situation and our reaction or response to it, there is a choice, even if it’s made unconsciously. The work of CBT is to try to change those of our automatic reactions that are futile and misery-inducing.
Take catastrophizing, for example. That’s when we start imagining consequences we feel are likely – how this could lead to this and this and this – and that would be, inevitably, disastrous.
CBT techniques aim to lessen the impact of this kind of cognitive tailspin. And reduce the kind of self-talk that we would condemn as unacceptable bullying in others (“Why don’t you just get a grip, you…”).
I’m not a mental health professional. I became interested in online therapy when colleagues and I were analyzing studies of the internet’s effects. That was many years ago, so our study is way out of date. The internet hadn’t been around all that long then. But evidence suggested that CBT could work just as well in do-it-yourself (DIY) computerized or online form.
Rigorously studying the impact of psychological therapies is critical. That’s not just so that we don’t waste our time with things that don’t help. Even good ideas with the best of intentions can end up hurting people.
That happened, for example, with “iChill”. That’s internet-based CBT that, it was hoped, would prevent generalized anxiety disorder. But a randomized trial found not only didn’t it prevent the condition, it might have caused worry and depression.
Adverse effects of psychological therapies are the subject of an interesting research program at the University of Sheffield, called AdEPT. They have yet to report the results of this work, but they have started an interesting website, Supporting Safe Therapy.
Time to answer the question we started with: Which websites can reduce anxiety and depression?
There have been dozens of trials now, particularly of CBT-based internet sites or computer programs – and for many conditions. There are also plenty of good systematic reviews, analyzing these trials. (I’ve written explainers aboutsystematic reviews and meta-analyses, if you’re interested in learning more about this kind of research.)
To find websites with evidence of benefit, focusing specifically on anxiety and depression, and not requiring therapist support, I relied on four systematic reviews published in 2013 and 2014. (They’re listed at the end of the post.)
Although there are quite a few, I could only find three that were free globally, in English – and they’re all from Australia:
- eCouch (modules for depression, generalized anxiety and worry, social anxiety, relationship breakdown, loss and grief)
- MoodGym (preventing and coping with depression)
- This Way Up: Worry and Sadness Program (anxiety and depression)
If you’re in the UK, you might be able to get a prescription to websites endorsed after NHS review – like Beating the Blues (and FearFighter for panic and phobia). If you’re in Australia, there’s also the BRAVE-Online program for children and young people. There are solid resources available in the Netherlands and Sweden, but I don’t have the language skills for developing that list.
Some universities and colleges have programs available to their students. And you can see more resources here, but they might not have the scientific assessment behind them that the others do. There are books, too, which I hope to come back to in the future.
What can you expect if you try a website like this? It’s not a way to get instant relief from suffering. It requires work. But on average, many people who try them benefit – how many, and by how much, varies. And there’s not enough research for me to feel confident putting numbers around this.
Online CBT websites won’t suit everybody, though – maybe not even most people. Lots of people abandon them. We don’t really know if working at them harder or longer makes them more effective. And there hasn’t been enough research on how useful (or not) these are for people from different cultures, or for people who have addictions or other mental health problems as well as anxiety or depression.
There is online CBT therapy that’s therapist-guided as well as the DIY kind. Researchers are mixed in their opinions about whether therapists, face-to-face or supporting an online program, make a difference. That’s probably at least partly because they are often therapists themselves.
We collectively spend a great deal of time and money on books, websites, programs, counselors/therapists/gurus – endless theories, lots of people getting rich, on claims they can make us happier. A lot of that is wasted. Most of it isn’t backed up by good science – and much of it, we know, is going to be counter-productive or worse.
Yet, it’s still uncommon in most countries for information on anxiety and depression to even mention internet CBT is an option. Given how many people’s livelihoods are tied up in mental health care one way or another, it’s probably not surprising that free, DIY online therapy faces headwind. That’s a shame. Because even if only a small fraction of the people who try it benefit, it could ease much suffering.
Here’s a good detailed explanation of CBT.
If you know of somewhere there’s a directory of online therapy websites, linked with the sites and the evidence evaluating them, please add it in the comments or contact me.
The four systematic reviews I relied on for finding these websites:
- Aleisha Clarke and colleagues on preventing mental health problems in young people (2014)
- E Bethan Davies and colleagues on improving depression and anxiety in university students (2014)
- Eric Dedert and colleagues on treating depression and anxiety (a review for the VA, 2013)
- Dawn Querstret and Mark Copley on rumination and/or worry (2013)
I also found these very useful: “Internet-delivered cognitive behavior therapy for anxiety disorders is here to stay” by Gavin Andrews and colleagues (2015) and “Web-based intervention programs for depression: a scoping review and evaluation” by Tian Renton and colleagues (2014).
The “Why don’t you just…” image in this post is my own (CC-NC license). (Cartoons at Statistically Funny.) Photos also by me (CC-BY): The bark of a tree in California, the firehouse in Cleveland Park, DC and in my home.
* The thoughts Hilda Bastian expresses here at Absolutely Maybe are personal, and do not necessarily reflect the views of the National Institutes of Health or the U.S. Department of Health and Human Services.