Computerized Cognitive Behavior Therapy for Anxiety and Depression in Rural Areas: A Systematic Review

J Med Internet Res. 2015 Jun 5;17(6):e139. doi: 10.2196/jmir.4145.


Background: People living in rural and remote communities have greater difficulty accessing mental health services and evidence-based therapies, such as cognitive behavior therapy (CBT), than their urban counterparts. Computerized CBT (CCBT) can be used to effectively treat depression and anxiety and may be particularly useful in rural settings where there are a lack of suitably trained practitioners.

Objective: To systematically review the global evidence regarding the clinical effectiveness and acceptability of CCBT interventions for anxiety and/or depression for people living in rural and remote locations.

Methods: We searched seven online databases: Medline, Embase Classic and Embase, PsycINFO, CINAHL, Web of Science, Scopus, and the Cochrane Library. We also hand searched reference lists, Internet search engines, and trial protocols. Two stages of selection were undertaken. In the first, the three authors screened citations. Studies were retained if they reported the efficacy, effectiveness or acceptability of CCBT for depression and/or anxiety disorders, were peer reviewed, and written in English. The qualitative data analysis software, NVivo 10, was then used to run automated text searches for the word "rural," its synonyms, and stemmed words. All studies identified were read in full and were included in the study if they measured or meaningfully discussed the efficacy or acceptability of CCBT among rural participants.

Results: A total of 2594 studies were identified, of which 11 met the selection criteria and were included in the review. The studies that disaggregated efficacy data by location of participant reported that CCBT was equally effective for rural and urban participants. Rural location was found to both positively and negatively predict adherence across studies. CCBT may be more acceptable among rural than urban participants—studies to date showed that rural participants were less likely to want more face-to-face contact with a practitioner and found that computerized delivery addressed confidentiality concerns.

Conclusions: CCBT can be effective for addressing depression and anxiety and is acceptable among rural participants. Further work is required to confirm these results across a wider range of countries, and to determine the most feasible model of CCBT delivery, in partnership with people who live and work in rural and remote communities.

Keywords: anxiety; cognitive therapy; depression; eHealth; mHealth; mental health; rural health.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Anxiety / therapy
  • Anxiety Disorders / therapy*
  • Cognitive Behavioral Therapy / methods*
  • Depression / therapy
  • Depressive Disorder / therapy*
  • Female
  • Humans
  • Internet*
  • Male
  • Patient Acceptance of Health Care
  • Patient Compliance
  • Rural Health
  • Rural Population
  • Telemedicine / methods*
  • Therapy, Computer-Assisted / methods*
  • Urban Population