Impact of an automated Internet-based cognitive behavioral therapy program on suicide thinking and risk among United States rural adults

Abstract

Cognitive behavior therapy (CBT) is an evidence-based psychotherapy for mental disorders, including depression. Internet-based CBT (iCBT) programs increasingly are showing similar impact to clinician-delivered CBT. We assessed the impact of Thrive, a fully-automated iCBT depression treatment program on suicidal thinking. Participants were randomly assigned to the intervention (INT) group (n = 218) or a waitlist control group (WLC, n = 230). Intent-to-treat analyses tested for group differences at 8-weeks in suicidal thinking (CHRT-SR3 subscale, primary outcome), and secondary outcomes including depression symptoms (PHQ-9), anxiety symptoms (GADS-7), work and social adjustment (WSAS), and resilience (CD-RISC-10). Using self-reports, participants were evaluated at baseline, 4 and 8 weeks for each outcome. Thrive program adherence (n = 218) was assessed by number of lessons completed. Although not statistically significant, the INT group was 38.7% less likely than the control group to present with suicidal thinking at 8 weeks (odds ratio 0.61, p = 0.10). Comparison of 8-week depression symptom slopes showed statistically significant effects favoring the INT group (WLC = − 3.04 vs Thrive = − 4.32, p = 0.007) (d = 0.08); no other significant group differences were observed. Lessons completed were significantly related to lower PHQ-9 (p = 0.026) and GAD-7 scores (p < 0.01). Study results are consistent with a previous study showing nonsignificant effect of an automated iCBT program for reducing suicidal thinking, but a significant positive impact on depression symptoms among rural US adults. Future studies should test whether strategies for boosting lesson completion are successful in enhancing the efficacy of Thrive to reduce suicide risk. Trial Registration: National Institutes of Health Trial ID: NCT03595254.