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Computerised Cognitive Behavioural Therapy (CCBT)
CCBT stands for ‘Computerized Cognitive Behavioral Therapy’, also known as ‘ Internet-based Cognitive Behavioral Therapy’(ICBT) or ‘Computer-aided Cognitive Behavioral Therapy’. It has been described by the National Institute for Clinical Excellence (NICE) as an alternative form of therapy for delivering the principles of Cognitive Behavioural Therapy, using an interactive computer interface delivered by a personal computer, the Internet, or via an interactive voice response system.

As medication is often the first kind of treatment given to people who suffer from depression and anxiety disorders, and as these medicines have undesirable side-effects, CBT has been recommended to be an alternative therapy for these mental health problems. However, the available qualified therapists do not meet the increasing need of mental health treatment. Therefore, computerized CBT was suggested in order to fill this gap. It has emerged to compensate for the lack of face-to-face contact with therapists and due to vague referral criteria and pathways, although it can be an adjunct to face-to-face therapy.

This self-help approach would enable patients to access care earlier and thus reduce chronicity. Patients who are using CCBT programs can be completely independent (self-guided) or require maximum help and use it as therapy preparations. The major advantages of CCBT or ICBT that it is convenient for patients and can be operated at their own pace, and it allows patients to take control of their own recovery. Compliance to treatment and motivation to be proactive in the therapy were found to be increased when delivering CBT via computers. For suitability of treatment, it is recommended that patients or participants are assessed before going through CCBT to ensure that they are suitable for this kind of intervention. Some studies have emphasized that CCBT cannot be suitable for some cases such as severely depressed patients who have suicidal ideas.

Although CCBT has been shown to be efficacious in treating several psychological disorders such as depression and anxiety disorders, it has been criticised for its lack of the personal interaction with a therapist beside other limitations that will be discussed later in this article.

Beating the blues
Beating the Blues is a cognitive behavioural therapy which is for people suffering from anxiety and depression (National institute for health and clinical excellence ). Beating the blues was created by Dr Proudfoot, at Kings college London This type of therapy is conducted via online interactive sessions, usually on a weekly basis on the website it states that the therapy involved is to enable a person to understand the feelings they are having and the actions which they partake in. The programme teaches the client coping skills to enable them to function normally, it also involves goal setting as well as helping the person to identify negative thought patterns, an example of this could be if a clients friend doesn't reply to a text message, a negative reaction to this could be that they are ignoring them, rationalising this could mean thinking of other reasons why they haven't replied such as them being out of signal range. The general practitioner is also involved within the therapy to a minimal degree, they are given progress reports about how the service user is progressing, this also includes reports of any suicidal thoughts. An issue with this programme is the minimal amount of GP involvement, this will be elaborated on further in the limitations section of this article.

COPE
COPE is made by ST solutions ltd, is a 3 month long treatment of 5 modules for those suffering from non-severe depression, it uses combined voice recognition and a workbook, it requires a reading age of at least 11 years due to the complexity of some of the material. Those who state they have any suicidal thoughts or idealisation are prompted to contact their Doctor, COPE is mainly designed for those with the less severe instances of depression, due to issues involving the safety of those who are more depressed and having suicidal thoughts and possibly actions. ST solutions ltd will soon be releasing an internet version of their programme which will make the programme more accessible to other people who do not want to go to a Doctor to ask for the COPE programme.

Overcoming depression: a five area approach
Overcoming depression is a cognitive behavioural therapy based therapy using CD-ROMs and a workbook, it is used in the treatment of mild to moderate depression. The workbook involves asking the person a variety of questions so that they can analyse their thought patterns and identify any negative thoughts, they then help the person to challenge and change these. The programme is made up of 6 sessions which last up to an hour each, one per week for 6 weeks. This programme has a minimum reading age of 9-12 years, due to complexity of the reading material involved. In the NICE guidelines it states the practitioner should check on the person's progress three times over the course of the therapy, and on the programme it suggests work should be done with the health care advisor's help if needed.

Fearfighter
Like COPE, FearFighter is also created by ST solutions Ltd, it is for treatment of anxiety and panic disorders including phobic disorders such as Arachnophobia. At first fearfighter was on a CD-ROM, this has now progressed into being on the internet (netFF). Fearfighter requires a minimum reading age of 11. The therapy is in 9 steps, although this is dependent on the severity of the illness, steps are usually between 2 and 9. The therapy helps the person to cope with their thoughts and feelings about a particular phobia or anxious situation, and tries to stop the person from repeating avoiding stressful situations as this makes the phobia/ anxiety worse. The therapist is also involved within the therapy with a short meeting before each session and after the session is over, this is done in person for the CD-ROM but differs in the internet based one with contact being made via e-mail or phone.

OCFighter (previously called BTSteps)
OCFighter is an internet based treatment for people suffering from Obsessive compulsive disorder, which is based on Exposed with ritual prevention(similar to Systematic desensitization). Treatment is in 9 steps, they require a minimum reading age of 11 years. The treatment helps to identify what a person's triggers to their OCD behaviour are, and helps to let the person understand how doing such behaviours is a coping mechanism. Within the therapy goal setting is involved and regular questionnaires to check on the persons progress over the course of the 9 steps. There is also helpline support when required, previously this programme was interactive voice recognition based with additional worksheet work, this has now progressed to an online programme.

Clinical effectiveness
In 2006, the National Institute for Clinical Excellence NICE has recommended two of the CCBT packages, which are FearFighter, for panic and phobias patients, and Beating the Blues (BtB), for moderate and mild depression cases. However, NICE has not endorsed the use of COPE, Overcoming depression and BTSteps (now known as OCFighter) because of the lack of strong evidence regarding their clinical effectiveness.

A 2006 economic evaluation, which included studies from 1966 to March 2004, has shown some evidence that the clinical effectiveness of CCBT isequal to therapist-led cognitive bahavioural therapy (TCBT) in treating anxiety disorders (panic and phobias) and depression. However, CCBT has been proved to be more effective than TCBT in terms of reducing therapist's time. In comparison to treatment as usual(TAU), CCBT has been shown to be clinically more effective in treating anxiety and depression.

In two recent randomized controlled studies, Proudfoot et al.(2003-2004) have compared one group who received the CCBT packge ‘Beating the Blue’ with another group who received usual treatment, which is whatever prescription given by general practitioners. They found that the symptoms of depression and anxiety among those who received BtB have declined remarkably compared to the other group. Moreover, the former group was more satisfied than the those who receive usual treatment.

For those who live in rural areas or in places where there is not enough therapists, and those who do not prefer face-to-face contacts, CCBT can be a good choice to control their symptoms. A recent study conducted by Hayward and MacGregor (2007) has confirmed the efficacy of the CCBT package ‘FearFighter’ in reducing the symptoms of anxiety disorders in some patients, especially those in rural areas who lack the accessibility to face-to-face therapy.

There have been very few studies which compare computerized CBT programs with therapist-based CBT. Therefore, more studies and research are needed in order to assess the CCBT programs and to compare them with either face-to-face therapy or other self-help therapy such as bibliotherapy.

Cost effectiveness
A 2004 randmoised controlled trial suggested that the use of CCBT is acceptable to patients, clinically effective and cost-effective treatment when used in general practice. A 2004 randomised controlled trial showed that service cost was higher for CCBT than usual treatment -whatever prescription given by general practitioners- in primary care patients, but it yielded considerable clinical benefits and proved reductions in days of lost employment which outweigh the extra service cost . An economic evaluation of the depression software BtB alongside a randomised controlled trial, which found that BtB was cost-effective against TAU in terms of cost per quality-adjusted life-year (QALY) (less than £2000).

A 2010 randomised controlled trial concluded that online CBT delivered by a therapist can be cost-effective treatment for depression and a useful alternative to face-to-face CBT, only in case society is willing to pay at least £20 000 per quality-adjusted life-year (QALY).

Possible Advantages
There is general agreement about the potential advantages of CCBT：
 * Treatment is available at any time and place, can provide treatment for people who are unable to obtain face-to-face therapy during usual clinic hours or in some geographical areas(e.g. rural residents who have to travel long distances to gain access to high-quality mental health services).
 * It is a potentially useful treatment option to cope with problems such as the absence of enough therapists or lengthy waiting lists . It can also teach patients the basic constructs in CBT as well as the language of therapy, which may potentiate subsequent therapist-led cognitive bahavioural therapy (TCBT).
 * CCBT can be attractive to specific individuals, for example, patients with mental health problems such as agoraphobia and social phobia, and young people who are typically familiar with computers and competent in their use.
 * In addition, it can also potentially prevent the stigma or embarrassment of seeking specialist mental health services  . This may be specifically relevant to individuals who traditionally avoid finding help in therapy or who may not usually consult a health professional.
 * On the basis of cognitive behaviour principles in the treatment, CCBT can potentially promote self-monitoring.
 * CCBT systems provide the opportunity for users to review the material as often as desired.
 * As be based upon on computers, programmes makes appropriate and consistent feedbacks to the input received from the patients.
 * The standardized dissemination of CCBT provided with a higher degree of fidelity than individualized treatments, as well as keep off suffering some of the deficiencies of human therapists such as memory problems and fatigue.

Limitations
However, some practical issues should be considered when determining the potential utility of CCBT：
 * CCBT would not be the best delivery method of cognitive behavioral therapy for all patients . In the NICE (2011) Guidance on Common Mental Health Disorders indicated that CCBT only provide low-intensity interventions for people with persistent subthreshold symptoms and mild to moderate common mental health disorders in the stepped-care model.
 * This approach may not be useful for patients who are short of minimal computer skills, or individuals who have negative attitudes towards computers .Not all patients will be open to the idea of using a computer.
 * Some CCBT programmes have minimum reading age.
 * With little supervision, using intervention and treatment sessions can be postponed infinitely . Furthermore, most CCBT studies present high drop-out and non-completion rates  , for example, one study reported completion rates of 1% of registered users ; a meta-analysis of studies of CCBT for depression mean dropout rate is 32% (range 0-75%)  .It is unclear whether this is because patients got better and felt that they did not need treatment or because they felt that they were not improving.
 * The lack of detection of worsening clinical state could result in client safety issues and possibly danger, although some programmes include items to assess the patient's clinical state . The worst-case scenario would involve a patient committing suicide while using a prescribed CCBT programme.
 * Due to CCBT is short of personal interaction and the therapeutic relationship, TCBT receives more patient preference and satisfaction, and as a result, patients misunderstanding and misapplication of CCBT programmes without tailoring to individual needs, and ineffective use leading to disillusionment in therapy can also be identified as potential problems.