Cost-effectiveness of therapist-delivered online cognitive–behavioural therapy for depression: randomised controlled trial
Open accessAbstract
Background: Therapist-delivered online cognitive–behavioural therapy (CBT) has been found to be effective for depression in primary care. Aims: To determine the cost-effectiveness of online CBT compared with usual care. Method: Economic evaluation at 8 months alongside a randomised controlled trial. Cost to the National Health Service (NHS), personal costs, and the value of lost productivity, each compared with outcomes based on the Beck Depression Inventory and quality-adjusted life-years (QALYs). Incremental analysis indicated the NHS cost per QALY gain. Results: Online CBT was more expensive than usual care, although the outcomes for the CBT group were better. Cost per QALY gain based on complete case data was £17 173, and £10 083 when missing data were imputed. Conclusions: Online CBT delivered by a therapist in real time is likely to be cost-effective compared with usual care if society is willing to pay at least £20 000 per QALY; it could be a useful alternative to face-to-face CBT.
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CCBT may help minimize the impact of inadequate numbers and unequal distribution of appropriately trained therapists, and subsequent long wait times, as well as the financial demands of treatment, travel times, and stigma associated with accessing mental health services.
“It may help minimize the impact of inadequate numbers and unequal distribution of appropriately trained therapists, and subsequent long wait times, as well as the financial demands of treatment, travel times [19,33], and stigma associated with accessing mental health services.”
From Computerized cognitive behavior therapy for anxiety and depression in rural areas:a systematic review (2015) · cites this paper as [33]
The Method (p. 1) identifies therapist shortages and inconvenient access as reasons to consider computerised CBT. Implications for policy (p. 7) says therapist-delivered online CBT can reduce travel time and cost, increase access, connect patients with therapists elsewhere, and offer anonymity. The copy does not establish shorter waiting times or reduced patient treatment expenses, and its main intervention still requires a trained therapist. (LLM, conf=0.84)
Experimental — accuracy not yet measuredYouthful online engagement makes online intervention delivery attractive, particularly with possible reductions in costs, geographic barriers, and access inequities.
“Youthful online engagement makes online intervention delivery attractive, particularly with possible reductions in costs, geographic barriers, and access inequities [3-6].”
From Online Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth With Major Depressive Disorders: Randomized Controlled Trial. (2021) · cites this paper as [5]
The Implications for policy (p. 7) say online CBT can reduce travel time and cost and improve access, including when travel is difficult because of rurality. The paper does not link its appeal to young people's online engagement or establish a reduction in access inequities; it also says the cost of widespread implementation is unknown. (LLM, conf=0.87)
Experimental — accuracy not yet measured
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“To our knowledge, only a limited number of studies assessed cost-effectiveness of blended treatment for depressed adults [74,75] and one review with 12 included studies was performed on the cost-effectiveness of internet and mobile-based interventions for treatment and the prevention of depression in adults [76].”
BackgroundAcceptability of Computerized Cognitive Behavioral Therapy for Adults: Umbrella Review
Treanor, C., Kouvonen, A. M., Lallukka, T. M., & Donnelly, M. (2021) · JMIR Mental Health · doi:10.2196/23091 · Cited by 35 · see citing works
“Compared to face-to-face CBT, cCBT may remove or minimize barriers associated with uptake and be more accessible (eg, for rural dwellers and individuals who have mobility issues) and affordable; thereby, it may reduce waiting times and be more cost-effective [12,13].”
BackgroundLeurent, B., Gomes, M., Cro, S., Wiles, N., & Carpenter, J. R. (2019) · Health Economics · doi:10.1002/hec.3963 · Cited by 32 · see citing works
“For the purpose of this article, we follow broadly the CEA methods described in Hollinghurst et al. (2010) with some simplifications made to allow a clearer focus on the relevant methodology (e.g., focussing only on unadjusted cost ‐ utility analysis and costs from the National Health Service and…”
InfluentialSelf-citationGeraedts, A. S., van Dongen, J. M., Kleiboer, A. M., Wiezer, N. M., van Mechelen, W., Cuijpers, P. J., & Bosmans, J. E. (2015) · Journal of Occupational and Environmental Medicine · doi:10.1097/jom.0000000000000423 · Cited by 31 · see citing works
Duarte, A., Walker, S., Littlewood, E., Brabyn, S., Hewitt, C., Gilbody, S., & Palmer, S. (2017) · Psychological Medicine · doi:10.1017/s0033291717000289 · Cited by 30 · see citing works
“…et al. 2010; Hollinghurst et al. 2010; Warmerdam et al. 2010), smaller sample size in earlier studies (McCrone et al. 2004; Gerhards et al. 2010; Hollinghurst et al. 2010; Warmerdam et al. 2010), estimation of QALYs by mapping from a depression-speci fi c measure (Beck ’ s Depression Inventory;…”
MethodResultInfluentialAardoom, J. J., Dingemans, A. E., van Ginkel, J. R., Spinhoven, P., Van Furth, E. F., & Van den Akker‐van Marle, M. E. (2016) · International Journal of Eating Disorders · doi:10.1002/eat.22587 · Cited by 30 · see citing works
Kaldo, V., Lundin, A., Hallgren, M. Å., Kraepelien, M., Strid, C., Ekblom, Ö. B., Lavebratt, C., Lindefors, N., Öjehagen, A., & Forsell, Y. (2017) · Occupational and Environmental Medicine · doi:10.1136/oemed-2017-104326 · Cited by 29 · see citing works
“7 A notable strength of the current trial is that it includes a large number of participants, enabling the detection of smaller effects on sick leave and employment.”
BackgroundMurphy, H., & Perera-Delcourt, R. P. (2012) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/j.2044-8341.2012.02076.x · Cited by 28 · see citing works
Computer-Assisted CBT and Mobile Apps for Depression: Assessment and Integration Into Clinical Care
Wright, J. H., & Mishkind, M. C. (2020) · FOCUS The Journal of Lifelong Learning in Psychiatry · doi:10.1176/appi.focus.20190044 · Cited by 25 · see citing works
Poulsen, R. M., Hoff, A., Fisker, J. P., Hjorthøj, C. R., & Eplov, L. F. (2017) · Trials · doi:10.1186/s13063-017-2272-1 · Cited by 26 · see citing works
Piera-Jiménez, J., Etzelmueller, A., Kolovos, S., Folkvord, F., & Lupiáñez‐Villanueva, F. (2021) · Journal of Medical Internet Research · doi:10.2196/27410 · Cited by 25 · see citing works
“…(€26,484 per quality-adjusted life-year) was in the lower zone of the wide range of values reported for guided interventions (ie, €19,616 [54] to €157,900 [55]; approximately US $19,616 and $189,825, respectively) and below that of unguided interventions (ie, €40,412 [56] to €178,700…”
Baldofski, S., Kohls, E., Bauer, S., Becker, K., Bilić, S., Eschenbeck, H., Kaess, M., Moessner, M., Salize, H. J., Diestelkamp, S., et al. (2019) · Trials · doi:10.1186/s13063-018-3156-8 · Cited by 25 · see citing works
Stawarz, K., Preist, C., Tallon, D., Wiles, N., Kessler, D., Turner, K., Shafran, R., & Coyle, D. (2020) · JMIR Mental Health · doi:10.2196/15972 · Cited by 24 · see citing works
“Moreover, there is evidence showing that using instant messaging to deliver and receive therapy is acceptable and can be effective [14-17].”
BackgroundSelf-citationThe Estimation of Utility Weights in Cost-Utility Analysis for Mental Disorders: A Systematic Review
Sonntag, M., König, H., & Konnopka, A. (2013) · PharmacoEconomics · doi:10.1007/s40273-013-0107-9 · Cited by 23 · see citing works
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“4 based on the treatment of other chronic conditions [20-25].”
Backgrounddel Hoyo, Y. L., Oliván‐Blázquez, B., Luciano, J. V., Mayoral, F., Roca, M., Gili, M., Andres, E. M., Serrano‐Blanco, A., Collazo, F., Araya, R., et al. (2013) · BMC Psychiatry · doi:10.1186/1471-244x-13-21 · Cited by 22 · see citing works
“Recently, cost-effectiveness studies on CDP have been published with satisfactory results [17-20].”
BackgroundIntegrating the Digital and the Traditional to Deliver Therapy for Depression
Stawarz, K., Preist, C., Tallon, D., Thomas, L., Turner, K. M., Wiles, N., Kessler, D. S., Shafran, R., & Coyle, D. (2020) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3313831.3376510 · Cited by 24 · see citing works
“The decision to use instant messaging as the main mode of communication during sessions was based on evidence that delivering therapy this way can be effective [27, 33], although we added an option for the therapist to initiate a telephone call if necessary.”
MethodSelf-citationEkberg, S., Barnes, R., Kessler, D. S., Malpass, A., & Shaw, A. (2013) · Language Internet · Cited by 21 · see citing works
Self-citationPsychological advocacy toward healing (PATH): study protocol for a randomized controlled trial
Brierley, G., Agnew-Davies, R., Bailey, J., Evans, M. A., Fackrell, M., Ferrari, G., Hollinghurst, S. P., Howard, L. M., Howarth, E., Malpass, A., et al. (2013) · Trials · doi:10.1186/1745-6215-14-221 · Cited by 19 · see citing works
“primary and secondary outcomes [57].”
Self-citationEconomic evaluation of audio based resilience training for depression in primary care
Koeser, L., Dobbin, A., Ross, S., & McCrone, P. (2013) · Journal of Affective Disorders · doi:10.1016/j.jad.2013.01.044 · Cited by 19 · see citing works
“Tracks covered relaxation, positive suggestion, visualisation and mindfulness techniques which promote distance from negative thoughts similar to CBT, fostering well being and emotional resilience.”
MethodInfluentialDominguez-Rodriguez, A., Martínez-Arriaga, R. J., Herdoiza-Arroyo, P. E., Bautista-Valerio, E., de la Rosa-Gómez, A., Castellanos Vargas, R. O., Lacomba-Trejo, L., Mateu-Mollá, J., Lupercio Ramírez, M. D. J., Figueroa González, J. A., et al. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph191912749 · Cited by 18 · see citing works
“[38] analyzed the cost-effectiveness of psychological online interventions, citing a study [39] which concluded that internet-delivered cognitive behavioral therapy had a cost per qualityadjusted life year of £20 000compared to treatment as usual.”
BackgroundPatient’s Perspectives of Telepsychiatry: The Past, Present and Future
Naik, S. S., Manjunatha, N., Kumar, C. N., Math, S. B., & Moirangthem, S. (2020) · Indian Journal of Psychological Medicine · doi:10.1177/0253717620963341 · Cited by 18 · see citing works
Economic Evaluation of Cognitive Behavioral Therapy for Depression: A Systematic Review
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“Interestingly, there is limited research on the effects of work accommodations on depression and WP outcomes [28, 30]; however, there is a body of research on clinical interventions focusing on reducing depressive symptoms and sickness absence [51, 52].”
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Assessing the costs and cost-effectiveness of ICare internet-based interventions (protocol)
Beecham, J., Bonin, E.-M., Görlich, D., Baños, R., Beintner, I., Buntrock, C., Bolinski, F., Botella, C., Ebert, D. D., Herrero, R., et al. (2019) · Internet Interventions · doi:10.1016/j.invent.2018.02.009 · Cited by 13 · see citing works
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“…ICBT for depression was associated with a cost of €1817 for each additional reliably improved participant (Warmerdam et al., 2010) and has been estimated to be cost-effective at a societal willingness to pay of £20,000 per additional QALY compared to usual care (Hollinghurst et al., 2010).”
BackgroundModelling the cost-effectiveness of preventing major depression in general practice patients
Hunter, R. M., Nazareth, I., Stephen Morris, A., & King, M. (2013) · Psychological Medicine · doi:10.1017/s0033291713002067 · Cited by 13 · see citing works
“…No major depression Beta 0.86 (0.004) Kind et al. 1999 Depression Beta 0.58 (0.015) Peveler et al. 2005; Kendrick et al. 2006; Mann et al. 2009; Hollinghurst et al. 2010 Recovered Beta 0.79 (0.018) Kendrick et al. 2006 Risk algorithm costs Cost of GP nurse (£/15min) Gamma 2.00 Curtis, 2012…”
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Rajeshkumar, L., Mishkind, M., Coleman, J. J., Pahwa, M., LaPreze, D., Solenske, S., & Wright, J. H. (2024) · Journal of Psychiatric Practice · doi:10.1097/pra.0000000000000815 · Cited by 7 · see citing works
Cost-Effectiveness of a Web-Based Program for Residual Depressive Symptoms: Mindful Mood Balance
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Dissemination of computer-assisted cognitive-behavior therapy for depression in primary care
Antle, B. F., Owen, J. J., Eells, T. D., Wells, M. J., Harris, L. M., Cappiccie, A., Wright, B., Williams, S. M., & Wright, J. H. (2018) · Contemporary Clinical Trials · doi:10.1016/j.cct.2018.11.001 · Cited by 10 · see citing works
Ali, S., Alemu, F. W., Owen, J. J., Eells, T. D., Antle, B. F., Lee, J. T., & Wright, J. H. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.44599 · Cited by 9 · see citing works
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“The first of these was excluded because it did not distinguish between patients who received guided (~40%) and unguided (~60%) iCBT [27], the second because it delivered real-time online sessions with a therapist rather than multimedia modules [41], and the third because it did not contain the features that mark out a…”
BackgroundCummings, A. (2022) · Practice · doi:10.1080/09503153.2022.2044769 · Cited by 9 · see citing works
“2017), as well as costeffectiveness (Hollinghurst et al. 2010).”
From Melancholia to Depression
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Variation in effect of intervention studies in research on sickness absence
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Reducing the Burden of Suicidal Thoughts Through Online Self-Help
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“Although generic utility measures have also been used for valuations of depression [14,16-23], their suitability for mental health states has been questioned.”
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Electronic interventions for depression in adolescents: hot idea or hot air?
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- Authors
- Hollinghurst, S., Peters, T. J., Kaur, S., Wiles, N., Lewisand, G., & Kessler, D.
- Affiliations
- University of Bristol (GB)
- Corresponding author
- Hollinghurst, Sandra
- Venue
- British Journal of Psychiatry
- Publisher
- Royal College of Psychiatrists
- Published
- 2010-10
- Volume
- 197
- Issue
- 4
- Pages
- 297-304
- ISSN
- 0007-1250 (ISSN-L)
- 1472-1465
- OpenAlex
- W2142171252
- Cited by
- 123
- References
- 34
- Citations by year
- 2026: 2 · 2025: 10 · 2024: 8 · 2023: 5 · 2022: 8 · 2021: 8 · 2020: 15 · 2019: 6 · 2018: 5 · 2017: 10 · 2016: 7 · 2015: 10 · 2014: 9 · 2013: 10 · 2012: 8
- FWCI
- 9.54
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The British Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Explore Bristol Research (publishedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Bristol Research (University of Bristol) (submittedVersion)
- Funders
- National Institute for Health and Care Research (CL-2007-25-001)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Keywords
- internet-based cognitive behavioral therapy, depression, cost-effectiveness, primary care, usual care, quality-adjusted life years, cost per QALY, productivity loss, missing data imputation
- MeSH terms
- Adolescent, Adult, Aged, Cost-Benefit Analysis, Depressive Disorder, Health Services, Humans, Medical Records, Middle Aged, Psychiatric Status Rating Scales, State Medicine, Therapy, Computer-Assisted, Cognitive Behavioral Therapy, Health Care Costs, Outcome Assessment, Health Care, Cost of Illness, Sick Leave, Quality-Adjusted Life Years, Young Adult
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