The Efficacy and Effectiveness of Online CBT - Jeroen Ruwaard

138 Chapter 7. General DiscussionCost-effectiveness. Modern healthcare is managed healthcare. The economic evaluationof an intervention is as important as the more traditional clinical evaluation. Atpresent, cost-benefit comparisons between face-to-face treatment and online treatmentare complicated by the limited availability of routine practice data and by uncleardefinitions of relevant health-economic variables. Nonetheless, scant research hasshown that online treatment is cost-effective (e.g., Bergström et al., 2010; Tate et al.,2009), and it would be instructive to conduct a cost-effectiveness study for the presenttreatment as well.Pre-treatment withdrawal. Pre-treatment withdrawal, voluntary drop-out that occursduring or even prior to the screening, demands attention. Throughout the studies,a considerable percentage of the applicants withdrew, during or even prior to thescreening (40% in the routine practice study). While pre-treatment withdrawal ratesare often not reported, research shows that high withdrawal rates are common, inboth online and offline research (Issakidis & Andrews, 2004; Melville et al., 2010).The application of survival analysis methods, as suggested by Eysenbach (2005), mightprovide insight into the reasons for this withdrawal. Pre-treatment withdrawal mightbe caused by the ease with which one can apply for online therapy. This may result inimpulsive applications (we found some indications that applicants, who started thescreening without a referral, were less likely to start treatment). A second possibility isthat patients withdraw from online treatment because they are unwilling to relinquishtheir anonymity (de Haas et al., 2009; Postel et al., 2009).In the Netherlands, several organisations have started to provide free anonymousonline CBT to clients who are unwilling to disclose their identity. Although thismay be understandable given the alternative (no treatment), this raises questionsabout reimbursement, professional responsibility and parental consent (Lange &Ruwaard, 2010). Is it fair to provide treatment for free to some and not to others?Could providers of anonymous treatment be held responsible in case of crisis? Is itdesirable that a person under 16 can start treatment when her parents are unaware ofthis? These questions require more discussion before wide-spread implementation ofanonymous treatment should be considered.