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Research Article
Cognitive Behavioural Therapy through PowerPoint: Efficacy in
an Adolescent Clinical Population with Depression and Anxiety
Nazanin Alavi ,1,2 Matthew Stefanoff ,2Alyssa Hirji,3and Sarosh Khalid-Khan1
1Department of Psychiatry, Queen’s University, Providence Care Hospital, 752 King Street West, Postal Bag 603,
Kingston, Ontario, K7L 7X3, Canada
2Department of Psychiatry, University of Toronto, Centre for Addiction and Mental Health, 100 Stokes Street, Toronto,
Ontario, M6J 1H4, Canada
3Department of Psychology, Queen’s University, Humphrey Hall, Room 232, Queen’s University, Kingston, Ontario, K7L 2N6, Canada
Correspondence should be addressed to Nazanin Alavi; nazanin.alavi@camh.ca
Received 8 July 2018; Accepted 24 October 2018; Published 8 November 2018
Academic Editor: Namik Y. Ozbek
Copyright © Nazanin Alavi et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Limited help-seeking behaviours, among adolescents with mental health concerns and many barriers to accessing
mental health services, make innovative approachesto administering mental health therapies crucial. erefore, this study evaluated
the ecacy of e-CBT given via PowerPoint slides to treat adolescents withanxiety and/or depression. Method. adolescents referred
to an outpatient adolescent psychiatry clinic to treat a primary DSM-IV diagnosis of anxiety and/or depression chose between
weeks of e-CBT (n=) or weeks of live CBT (n=). e e-CBT modules were presented using PowerPoint delivered weekly
through email by either a senior psychiatry resident or an attending physician. Within each session, participants in both groups had
personalized feedback on their mandatory weekly homework assignment from the previous week’s module. BYIs were completed
before treatment and and aer nal treatment within both groups to assess changes in depression, anxiety, anger, disruption, and
self-concept. Findings. Before treatment, BYI scores did not sig. dier between groups. Aer treatment, e-CBTparticipants reported
sig. improved depression, anger, anxiety, and self-concept BYI scores while live CBT participants did not report any sig. changes.
Only the Beck Anxiety Inventory sig. diered between groups aer CBT. Conclusion. Despite the low sample size within this study,
using email to deliver e-CBT PowerPoint slides and individualized homework feedback shows promise as an alternate method of
CBT delivery that reduces barriers to receiving mental health treatment that occur internationally.
1. Introduction
Mental illness is the leading cause of disability among
adolescents worldwide [ ]. In an American study, it was found
that % of adolescents met the diagnostic criteria for at least
one DSM-IV disorder and % of the sample experienced
a severe impairment []. About / of the adolescents met
the diagnostic criteria for an anxiety disorder and %
met the criteria for a mood disorder []. If le untreated,
anxiety and depression can place a signicant burden on the
economy, impair individuals’ daily functioning, and reduce
quality of life [, ]. CBT has eectively improved both
anxiety and depression and so minimizes the strain of these
disorders on economic and personal levels. As every in -
adolescents has a chronic psychiatric disorder [], CBT may
be particularly important for this young population, as early
therapy is associated with a better long-term prognosis [].
Despite the ecacy of CBT and the benets of early inter-
vention, only % and % of adolescents with depressive
symptoms receive treatment in developed and developing
countries, respectively [, ]. Living in a rural area, a lack
of mental health resources and/or accessibility, and doubt
over the condentiality of treatment perpetuated by negative
stigmas have all been said to negatively impact the availability
and pursuit of treatment [, ]. To combat these barriers,
there has been a surge in the examination of innova-
tive treatments, many involving technology and the inter-
net.
With over . billion people worldwide using the internet
[], the research, development, and use of computer-based
Hindawi
International Journal of Pediatrics
Volume 2018, Article ID 1396216, 5 pages
https://doi.org/10.1155/2018/1396216
International Journal of Pediatrics
CBT (e-CBT) has been booming due to its potential to reduce
many barriers of traditional face-to-face therapies []. E-
CBT is very cost-eective and increases treatment acces-
sibility and adherence to individuals where mental health
resources are lacking [, ]. Many patients have reported
e-CBT as preferable due to its convenience, condentiality,
and reduction of perceived stigma []. Finally, e-CBT has
many practical advantages, such as the individualization of
programs and therefore treatments, along with self-pacing,
the ability to review material, and the ease of record keeping
and data collection []. As most adolescents are familiar and
comfortable with computers and the internet, e-CBT may be
particularly eective for treating mental health concerns of
this age.
While various programs for the online treatment of de-
pression and anxiety exist, many do not have an ecacy
comparable to live treatment. For example, MoodGYM is
a current e-CBT based on cognitive restructuring, pleasant
events scheduling, and interpersonal problem solving [].
It allows the participant to work through material at their
own pace and consists of sessions to be completed over
weeks. In a study of the ecacy of MoodGYM, adolescent
st year undergraduates with anxiety or depression were ran-
domised to either live CBT, MoodGYM, both combined, or
no treatment groups. All treatment groups had a reduction
in both depression and anxiety compared to the control
group, but the live CBT group had a greater decline in
depression than those using MoodGYM. Also, the combined
group had signicantly lower anxiety and depression aer
the intervention than the MoodGYM only group []. e
authors suggest that these ndings may be due to MoodGYM
being unsuitable for this age group because of the complexity
of the therapy components or the slow pace of the program
[].
Another program, BRAVE for Teenagers-Online, used for
adolescents with anxiety disorders consists of one-hour
long sessions which replicate the clinic-based version of the
program while incorporating standard CBT anxiety manage-
ment strategies []. Participants were assigned homework at
the end of each session and had a BRAVE trainer who moni-
tored their work, gave support, and feedback. All participants
were randomised to live CBT, e-CBT, or a wait-list control.
Signicantly more participants in the treatment groups no
longer met the criteria for an anxiety diagnosis aer treatment
than in the control group, with no dierences between the live
and e-CBT groups on ecacy or participant satisfaction [].
e % of adolescents with an anxiety disorder continued to
fall in both groups at the and month follow-ups, with
no sig. dierences between the treatment groups []. Taken
together, the MoodGYM and BRAVE ndings suggest that
e-CBT may be as eective as live CBT, but not all e-CBT
programs are equivalent.
is study examines the ecacy of e-CBT delivered
through PowerPoint slides combined with weekly computer-
based psychiatrist-given feedback to adolescents with anxiety
or depression; this study is the rst to examine ecacy using
this treatment modality. We hypothesized that e-CBT would
be as ecacious as live CBT in improving depression and
anxiety.
T : CBT topics by week of administration.
Week Topics Covered
Introduction,Goals
FivePartyModel
oughts
Connection between oughts, feelings,
Behaviour, Physical Reactions and Environment
‘Evidence’ and ‘Alternativeand Balanced
inking’
Experiments and Action Plans
Strategies to overcome the distress
8∗Summary and Feedback
∗Module only given to e-CBT participants.
2. Materials & Methods
2.1. Participants. Adolescent males (n= ) and females
(n=)aged-(M=., SD=.) who met DSM-IV
criteria for major depressive disorder and generalized anxiety
disorder were invited to participate in the study. Participants
were recruited from the outpatient Child and Youth Mental
Health Program at the Hotel Dieu Hospital site of the
Kingston Health Sciences Centre in Kingston, Ontario. Each
participant was recommended to participate in CBT for the
treatment of their primary diagnosis.
2.2. Measures. Participants were assessed using the Beck
Youth Inventories (BYI), a self-report instrument used to
assess youth aged -. e measure consists of composite
scores: the Beck Depression Inventory for Youth (BDI-Y),
the Beck Anxiety Inventory for Youth (BAI-Y), the Beck
Anger Inventory for Youth (BANI-Y), the Beck Disruptive
Inventory for Youth (BDBI-Y), and the Beck Self-Concept
Inventory for Youth (BSCI-Y). Each inventory consists of
items rated on a -point scale from (never) to (always).
Total raw scores can range from to , with higher scores
representing more of the construct.
2.3. Procedure. To maintain a naturalistic study design, each
participant chose between live and e-CBT. e e-CBT ses-
sions were designed to directly mirror the live CBT sessions,
but live CBT consisted of sessions, whereas the e-CBT
consisted of . e th e-CBT session only collected feedback
without giving any new content, so the live and e-CBT
sessions were considered to be equivalent.
For each online session, participants were sent about -
PowerPoint slides every Wednesday, consisting of general
information on a weekly topic, an overview of helpful skills
that relate to the weekly topic, and mandatory homework
sheets (Table ). e homework assignments were due every
Sunday. ey were received by either a senior psychiatry
resident or attending physician, who sent each e-CBT partic-
ipant individualized feedback, the next session’s slides, and
corresponding homework via email on the next Wednesday.
Homework completion and submission was mandatory to
progress to the next week’s session. If homework was not
International Journal of Pediatrics
T : Group dierence in BYI scales before receiving any CBT.
e-CBT (n=) Live (n=)
BYI Scale M SD M SD tdfp
BDI-Y . . . . . .
BAI-Y . . . . -. .
BANI-Y . . . . -. .
BDBI-Y . . . . . .
BSCI-Y . . . , -. .
returned by the deadline, a reminder email was sent. e
control group had weekly one-hour live CBT sessions, with
matching homework assignments.
e BYI was completed by all participants both before
treatment and aer completing their nal CBT session. All
BYIs were completed within appointments in the clinic for
both live CBT and e-CBT groups.
Descriptive statistics and independent sample t-tests were
used to examine demographic dierences between groups,
while repeated measures analysis of variance (ANOVA)
testing was used to determine the eect of time and treatment
modality on each BYI inventory. Pairwise comparisons were
conducted using a Bonferroni adjustment and all analyses
were done using SPSS.
isstudywasreviewedforethicalcompliancebythe
Research and Ethics Board of Queen’s University, Canada.
3. Results
Of the study participants, chose e-CBT and chose
live CBT. Age was not signicantly dierent between groups
(t()=-., p=.) with the mean age of e-CBT and
live CBT groups being . (SD=.) and . (SD=.),
respectively. Each group had male participant, females had
e-CBT, and had live CBT. Before treatment, the groups did
not dier signicantly on any BYI scores (Table ).
3.1. BDI-Y. e groups did not dier signicantly
(F(,)=., p=.) in BDI-Y scores aer treatment: the
e-CBT group had a mean score of . (SD=.) and the
live CBT group a mean score of . (SD=.). Pre- and
posttreatment BDI-Y scores did not dier signicantly within
the live CBT group (F(,)=., p=.), but within the
e-CBT group they fell signicantly over time (F(,)=.,
p=.).
3.2. BAI-Y. BAI-Y scores aer treatment were signicantly
lower (F(, )=., p=.) in the e-CBT group (M=.,
SD=.) than the live CBT group (M=., SD=.).
Additionally, pre- and posttreatment BAI-Y scores within the
live CBT group did not change signicantly (F(,)=.,
p=.), whereas the e-CBT group BAI-Y scores fell signif-
icantly over time (F(,)=., p=.).
3.3. BANI-Y. e e-CBT (M=., SD=.) and live CBT
(M=., SD=.) groups did not signicantly dier
(F(,)=., p=.) on posttreatment BANI-Y scores. e
pre- and posttreatment BANI-Y scores did not dier signif-
icantly within the live CBT group (F(,)=., p=.), but
BANI-Y scores within the e-CBT group fell signicantly over
time (F(,)=., p=.).
3.4. BDBI-Y. e groups did not dier signicantly (F(,)
=. p=.) in BDBI-Y scores aer treatment, with e-
CBT having a mean score of . (SD=.) and live CBT a
mean of . (SD=.). e pre- and post-treatment BDBI-
Y scores did not dier signicantly over time within the live
CBTgroup (F(,)=., p=.) or within the e-CBT group
(F(,)=., p=.).
3.5. BSCI-Y. e e-CBT (M=., SD=.) and live CBT
(M=., SD=.) groups did not dier signicantly (F(,
) =., p=.) on posttreatment BSCI-Y scores. e pre-
and posttreatment BSCI-Y scores did not dier signicantly
within the live CBT group (F(,)=., p=.), but the e-
CBT BSCI-Y scores rose signicantly over time (F(,)=.,
p=.).
4. Discussion
Results of this study suggest that e-CBT delivered via Pow-
erPoint is eective for improving depression and anxiety in
adolescents. Contrary to expectations, e-CBT via PowerPoint
with clinician-provided feedback may be more eective than
live CBT in reducing symptoms. e e-CBT group improved
signicantly in anxiety, depression, anger, and self-concept
aer treatment, whereas the live CBT group did not improve
signicantly over time in any of the BYI inventories. Despite
the signicant changes in the e-CBT group within of the
BYI inventories, the two groups only diered signicantly
posttreatment in anxiety, with e-CBT having signicantly
more reduction in BAI scores than live CBT. e signicance
of e-CBT on BAI scores is important as anxiety disorders
aect / of adolescents [], and unmanaged anxiety disorders
in adolescents correlate with an increased risk of illicit drug
dependence, depression, and academic underachievement
[].
e study’s ndings are unique in that the e-CBT ses-
sions related to signicant improvements in two inventories
not directly related to the adolescents’ primary diagnoses:
anger and self-concept. is suggests that the topics covered
within the e-CBT modules improve not only self-reported
depression and anxiety but also other problems with which
youth presenting to an outpatient psychiatric clinic may have
International Journal of Pediatrics
diculties. Surprisingly, however, this eect was only seen
when the modules were given via PowerPoint e-CBT.
ese ndings are inconsistent with previous ndings of
live CBT being more eective than e-CBT for depression and/
or anxiety in adolescents [, ]. is may be due to the use of
standardized e-CBT programs in previous studies, whereas
the current study used weekly PowerPoint slides with corre-
sponding individualized psychiatrist-provided feedback. is
personalized feedback allows for increased communication
between therapist and client via email and so more closely
resembles traditional face-to-face therapy. is personaliza-
tion of treatment may help explain why this intervention was
more eective than other online CBT programs.
While older research emphasized the negative aspects of
adolescents using the internet, more recently, it was found
to be benecial []. Since many adolescents are wary of
seeking treatment for mental health concerns, the existence
of a more accessible virtual treatment modality may increase
adolescents’ willingness to both seek out and participate in
treatment []. Within this study, a decreased reluctance
to participate in therapy could have led to an increased
engagement with treatment in the e-CBT group, further
contributing to the increased ecacy of e-CBT compared to
live CBT.
isstudywaslimitedbythesmallsamplesizeand
lack of treatment modality randomization. e absence of
randomization may introduce additional confounding vari-
ables. However, by giving patients the option to choose their
CBT delivery method, this study is a naturalistic approach to
examining ecacy by mirroring the decisions made in clini-
cal settings. Also, participants’ comfor t with using computers,
emails, and PowerPoint may have inuenced the ecacy of
e-CBT []. Since no measures were employed to evaluate
comfort with these technologies and programs, this is a
possible confounder and so it is likely that those comfortable
with computers chose the e-CBT option, potentially inating
the results of that group.
Future research should determine the eec ts of familiarity
with computers as a confounding variable on the ecacy of
e-CBT, in addition to randomizing the treatment modality
between patients to determine if the results of this study
were inuenced by patients’ ability to choose their method
of receiving CBT. Further studies of the ecacy of e-CBT via
PowerPoint in adolescents would also benet from a longer
follow-up period to determine the duration of the treatment
eects. However, previous studies examining e-CBT via
PowerPoint for depression given to adults were immediately
eective and the results were evident at the -month follow-
up [].
5. Conclusion
While further studies are warranted due to the small sample
size of the current study, they are the rst to show that
computer-based CBT via PowerPoint slides may be an eec-
tive way to improve depression and anxiety in adolescents.
is simple, innovative and user-friendly way to deliver CBT
to adolescents might reduce barriers to treatment such as
lack of resources, missing class for appointments, and the
high costs of soware development. It may be particularly
benecial for adolescents comfortable with technology who
may be concerned with stigma associated with attending live
CBT, by allowing treatment to be completed at home. Also,
this method of e-CBT may be more eective than other
standardized e-CBT programs previously examined because
it can be quickly and easily tailored to meet the needs of
each individual patient. Not only can the therapist address
individual concerns or elaborate on material when needed,
but e-CBT also can be easily adapted for other languages or
cultures that have specic needs. us, e-CBT via PowerPoint
is an innovative therapy that has promise as a new way to
deliver CBT to improve adolescent depression and anxiety
and can remove barriers that prevent youth from receiving
mental health treatment.
Data Availability
e data used to support the ndings of this study are
available in excel format in the following link: https://
docs.google.com/spreadsheets/d/yLsvPOLXcERXd rAu-
oTNbnkwohAhAQxYzIFPKA/edit?usp=sharing. e
data can also be obtained by the corresponding author upon
request.
Conflicts of Interest
e authors declare that they have no conicts of interest.
References
[]H.E.Erskine,T.E.Mott,W.E.Copelandetal.,“Aheavy
burden on young minds: e global burden of mental and
substance use disorders in children and youth,” Psychological
Medicine,vol.,no.,pp.–,.
[] K. R. Merikangas, J.-P. He, M. Burstein et al., “Lifetime preva-
lence of mental disorders in U.S. adolescents: results from the
national comorbidity survey replication-adolescent supplement
(NCS-A),” Journal of the American Academy of Child & Adoles-
cent Psychiatry, vol. , no. , pp. –, .
[] D.L.Homan,E.M.Dukes,andH.-U.Wittchen,“Humanand
economic burden of generalized anxiety disorder,” Depression
and Anxiety,vol.,no.,pp.–,.
[] J. Ruwaard, B. Schrieken, M. Schrijver et al., “Standardized
web-based cognitive behavioural therapy of mild to moderate
depression: A randomized controlled trial with a long-term
follow-up,” Cognitive Behaviour erapy,vol.,no.,pp.–
, .
[] M. J. Guralnick, “Eectiveness of early intervention for vulner-
able children: A developmental perspective,” American journal
of Mental Retardation,vol.,no.,pp.–,.
[]F.K.Arnberg,S.J.Linton,M.Hultcrantz,E.Heintz,andU.
Jonsson,“Internet-delivered psychologicaltreatments for mood
and anxiety disorders: A systematic review of their ecacy,
safety, and cost-eectiveness,” PLoS ONE,vol.,no.,.
[] R.Shafran,D.M.Clark,C.G.Fairburnetal.,“Mindthegap:
improving the dissemination of CBT,” Behaviour Research and
erapy,vol.,no.,pp.–,.
[] S.Sethi,A.J.Campbell,andL.A.Ellis,“euseofcomputerized
self-help packages to treat adolescent depression and anxiety,”
International Journal of Pediatrics
Journal of Technology in Human Services,vol.,no.,pp.–
, .
[] C.-C. Chen and C.-C. Wang, “Internet as indispensable every-
where: e introduction to the advances in internet tech-
nologies and applications special issue,” Journal of Computers
(Finland),vol.,no.,pp.-,.
[] I. Marks and K. Cavanagh, “Computer-aided psychological
treatments: Evolving issues,” Annual Review of Clinical Psychol-
ogy,vol.,pp.–,.
[] M. S. Khanna and P. C. Kendall, “Computer-assisted cognitive
behavioral therapy for child anxiety: Results of a randomized
clinical trial,” Journal of Consulting and Clinical Psychology,vol.
, no. , pp. –, .
[] N. Alavi, A. Hirji, C. Sutton, and F. Naeem, “Online CBT Is
Eective in Overcoming Cultural and Language Barriers in
Patients withDepression,” Journal of Psychiatric Practice,vol.,
no.,pp.–,.
[]S.H.Spence,C.L.Donovan,S.Marchetal.,“Arandomized
controlled trial of online versus clinic-based CBT for adolescent
anxiety,” Journal of Consulting and Clinical Psychology,vol.,
no.,pp.–,.
[] L. J. Woodward and D. M. Fergusson, “Life course outcomes of
young people with anxiety disorders in adolescence,” Journal of
the American Academy of Child and Adolescent Psychiatry,vol.
,no.,pp.–,.
[] P. M. Valkenburg and J. Peter, “Social consequences of the Inter-
net for adolescents: A decade of research,” Current Directions in
Psychological Science,vol.,no.,pp.–,.
[] H. D. Zachrisson, K. R¨odje, and A. Mykletun, “Utilization
of health services in relation to mental health problems in
adolescents: A population based survey,” BMC Public Health,
vol. , p. , .
[] N. Mitchell and P. K. Gordon, “Attitudes towards computerized
cbt for depression amongst a student population,” Behavioural
and Cognitive Psychotherapy,vol.,no.,pp.–,.
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