Online CBT Addresses Large Mental Healthcare Gap

An online cognitive behavioral therapy (eCBT) program reduces stress and improves symptoms of posttraumatic stress disorder (PTSD) among correctional workers, results of a pilot study showed.

“This study is seeking to address a very big gap in our mental health system; that is, the treatment of mental health disorders in correctional workers,” Gilmar Gutierrez, MD, Department of Psychiatry, Faculty of Health Sciences, Queen’s University and Queen’s University Online Psychotherapy Lab, Kingston, Ontario, Canada, told Medscape Medical News.

“The results suggest that online psychotherapy is a convenient and effective way to provide mental health support to these workers,” he added.

The findings were presented on May 6, 2024, at the American Psychiatric Association (APA) 2024 Annual Meeting.

Barriers to Care

Correction workers are at higher risk of developing mental health problems than the general population. They have a fourfold increased risk for suicidal ideation, suicidal attempts, and death by suicide, and a threefold increased risk for other mental illnesses, said Gutierrez.

The working environment inside prisons can be difficult, and employees are often exposed to dangerous situations, he added.

Several barriers prevent correctional workers from accessing mental health services, including demanding work schedules, a culture of stigma, service inaccessibility, and superiors who are often unsympathetic.

“A lot of the correctional workers report their administration often didn’t give them the time off for a mental health appointment,” said Gutierrez. In addition, services that are available are not specific to their unique circumstances, he noted.

Previous research suggests that eCBT is as efficacious as in-person CBT — with several additional benefits, including the flexibility and convenience of accessing therapy from the comfort of home, said Gutierrez.

It also provides an added element of privacy. “Sometimes people do much better when they’re not face-to-face with a therapist because even just being there in person can create elements of anxiety,” he said, adding that accessing therapy at home “gives them more ability to express their emotions.”

Located approximately 3 hours east of Toronto, Kingston has a population of about 132,400 and is home to six penitentiaries, including medium- and maximum-security facilities like the infamous Kingston Penitentiary, which opened in 1835 and closed its doors in 2013.

The analysis included 89 correctional workers, mean age of 43 years and 32% female. Participants were randomized to treatment as usual (TAU), which could be not accessing any services or perhaps seeing a family doctor, or to the intervention.

Those in the intervention could opt for the PTSD, anxiety, or depression versions of the program, depending on which symptoms they wanted to address. All participants completed questionnaires.

Convenient, Flexible

Each week, participants in the treatment arm received an online module that included a session-specific assignment. The assignments consisted of a series of questions or exercises on the basis of the content covered in the session.

At the end of each module, participants submitted the assignment, which was reviewed by a therapist who provided personalized feedback. Participants could also use the platform’s chat function to contact their therapist at any time.

Researchers collected data at three timepoints: Baseline (week 0), midpoint (week 6), and the end of treatment (week 12).

At each timepoint, researchers used the PTSD Checklist (PCL-5), the Depression Anxiety Stress Scales (DASS), the Patient Health Questionnaire-9 and the Quick Inventory of Depressive Symptomatology, the DASS-Anxiety and the General Anxiety Disorder-7, the DASS-Stress and quality of life using the Quality of Life Enjoyment and Satisfaction Questionnaire.

Results showed the intervention was significantly more effective than the control at reducing stress with a medium effect size at 12 weeks (DASS-Stress: d = 0.69; P = .035). The intervention also reduced PTSD symptoms with a medium effect size at 12 weeks (PCL-5: d = 0.73; P = .026). The quality of life also appeared to improve in the intervention group.

In graphs illustrating linear regression slopes over time, Gutierrez noted downward trends reflecting symptom reduction for several outcomes in the intervention group, while “everything is either flat or goes higher” for the control group.

All 13 of the correctional workers who participated in post-intervention qualitative assessments had positive perceptions of the program. “They found the online platform user-friendly and easy to understand, and they liked how the content was effective at representing their daily reality and work environment,” said Gutierrez.

They also appreciated the convenience, flexibility, and easy-to-understand format, he added. After 12 weeks, participants who were randomized to TAU had the option of receiving the eCBT intervention.

The investigators hope to expand the study to include more participants, although he noted it’s very challenging to recruit this population. In part, that’s because of distrust among prospective study participants who worry about personal information getting back to their workplace administration, he said.

‘A Good Idea’

Commenting for Medscape Medical News, Elspeth Cameron Ritchie, MD, chair of psychiatry at MedStar Washington Hospital Center in Washington, DC, who has worked in various forensic and prison settings, said this online program “is a really good idea and certainly another tool that can be helpful.”

She agreed correctional workers are vulnerable and have a very difficult job. It’s risky in terms of being hurt, and while police officers are held in high regard by the public, correctional officers are not, she said.

An important issue affecting access to treatment is the difficulty the correctional workers face getting in and out of the facility for therapy appointments — having to go through metal detectors and other screens. “You can’t just take your lunch break and go and seek treatment,” she noted.

Telemedicine could be an alternative, although it can require costly equipment. “Often these places are short-funded and short-staffed, and having a dedicated computer to provide telemedicine on can be difficult,” she added.

Gutierrez and Cameron reported no relevant conflicts of interest. The study was funded by the Canadian Institutes of Health Research.