Blended CBT for Depression

This thesis investigates the applicability of blended CBT for depression in specialized mental health care. Because blended treatment was still a new concept at the time of the start of this thesis, a treatment protocol was first developed (Chapter 2). Subsequently, the costs and effects of this blended CBT were investigated by comparing it with the existing (standard) face-to-face CBT when provided to 102 individuals with major depressive disorder in specialized mental health care (Chapters 3 and 4). Further, we used the trial data to examine the working relationship between therapists and patients in blended CBT compared with standard CBT (Chapter 5). No significant differences were found between blended CBT and face-to-face CBT in clinical effects and costs. A cost-effectiveness analysis - comparing the differences in costs and effects - showed that from a social perspective blended CBT was not cost-effective compared to face-to-face CBT. From a healthcare practitioner's perspective, blended CBT had a high probability of being cost-effective compared to face-to-face CBT. Patients and therapists were satisfied with the blended treatment and were able to build a good working relationship. Because a strict protocol was used, there was more certainty about the treatment interventions that a patient had been offered than is often the case in regular treatment. This supports decision-making about what to do after the blended CBT, i.e. complete therapy, continue therapy or referral to another health care provider. Blended CBT seems to contribute to a shorter duration of therapy. This can have a beneficial effect on waiting times for treatment. If the goal is to reduce the therapist's investment of time, further adjustments to the treatment protocol are needed, for example by reducing the time spent on online feedback. More research is needed to assess the applicability and effects of blended CBT. For example, a larger research group contributes to a more reliable estimate of costs and effects. In addition, it is desirable to also look at the results of blended treatment in the longer term. Based on the findings in this thesis, it can be concluded that blended CBT for depression is a treatment worth developing and researching further. In Chapter 6, data over a six-year period from the Netherlands Study on Depression and Anxiety (NESDA) was used to investigate predictors for people with an anxiety or mood disorder to be treated in in specialized mental health care (Chapter 6). Roughly a quarter of individuals with a depression or anxiety diagnosis at baseline made the transition from no care or primary care to specialized mental health care (198 out of 701, 28.3%). Some clinical factors were confirmed that are included in formal referral guidelines (National Institute for Health and Care Excellence (NICE), 2011; Spijker et al., 2013; van Balkom et al., 2013; van Hemert et al., 2012), namely suicidal ideation and prior psychological or pharmacological treatment. Other clinical factors, such as severity of symptoms and comorbidity, did not appear to be predictive of transition. Patients’ openness to experience and their perceived unmet need for help did increase the odds of transition to specialized mental health care, indicating that motivation for receiving treatment may be a more critical factor than the severity of symptoms. Finally, the non-clinical factors younger age and more years of education were found to be predictive of transition to specialized mental health care.