These recommendations were developed by the CADTH Health Technology Expert Review Panel (HTERP) and aim to address the following decision problems:
Should internet-delivered cognitive behavioural therapy (iCBT) be used to treat individuals with post-traumatic stress disorder (PTSD)?
If so, what factors and considerations should guide the implementation of internet-delivered cognitive behavioural therapy in the treatment of individuals with PTSD?
The recommendations were generated following HTERP deliberations based on evidence reviewed in a CADTH Health Technology Assessment (HTA) report.1 The HTA included a review of the clinical effectiveness and safety, cost-effectiveness, patients’ and caregivers’ perspectives and experiences, ethical issues, and implementation considerations related to the use of iCBT for the treatment of PTSD.
The target population for these recommendations is individuals with PTSD. The target users of these recommendations are Canadian health care decision-makers, those in provincial and territorial ministries of health, and mental health researchers.
HTERP suggests that there is a potential role for iCBT in the treatment of adults with PTSD; however, HTERP considers that, at present, the relevant evidence is insufficient and of low quality. Better-quality evidence is required to inform future implementation and policy decisions for the use of iCBT in the treatment of adults with PTSD. Future studies should report:
standardized outcomes stratified by patient characteristics
short- and long-term evaluation of clinical effectiveness, safety, and cost-effectiveness.
Regarding the possible implementation of iCBT for the treatment of PTSD, HTERP recommends:
initial diagnostic assessment and referral to establish patient suitability with regards to the appropriateness of the iCBT intervention, including safety and access considerations
that the iCBT be therapist-guided
the use of iCBT as one component of a stepped care model or in conjunction with other therapies, as appropriate
ensuring the appropriateness of programs based on symptom severity, culture, context, and the type of trauma
ensuring that personal health information is appropriately safeguarded and securely managed, in accordance with the privacy regulations in the jurisdiction where the care is being provided.
Technology
Cognitive behavioural therapy (CBT) is one of the most frequently used psychotherapies for treating PTSD and its effectiveness is supported by a large body of evidence.2–5 CBT combines the principles of cognitive and behavioural therapies; the aim of CBT is to provide individuals with coping strategies and mechanisms to solve current problems and to change dysfunctional thoughts, behaviours, beliefs, and attitudes.6 CBT for PTSD consists of psychoeducation on common reactions to trauma, anxiety management strategies (e.g., breathing relaxation techniques), controlled confrontation (exposure) with trauma-associated memories, and cognitive restructuring of maladaptive cognitions, such as perceiving the world as dangerous.7,8
CBT is traditionally delivered through face-to-face sessions between the individual and a therapist. However, access to traditional CBT can be impeded by a number of factors such as financial costs and the ability to pay, perceived stigma, potentially scarce geographic availability (e.g., in rural or remote areas), and long wait times.9–13 iCBT, which involves the delivery of CBT through an online platform with or without the support of a therapist (or other practitioner),8 is increasingly being considered or implemented as a way to improve access to treatment and services for mental health conditions, including PTSD.14–16 It is viewed as an alternative that may help address the financial, geographical, social, and other barriers associated with the traditional model of delivery of psychotherapeutic care. However, a number of issues related to iCBT, such as limited or no therapist support or the varying quality of existing programs, have led to questions about its use for the treatment of PTSD.
Overall, there is a need for evidence to guide policy and the appropriate use of iCBT in the context of caring for patients with PTSD in Canada.
