When a patient I will call Sarah—a woman in her early 40s, a teaching assistant with two teenage children—came to my clinic with moderate depression, she hoped for a referral to a therapist. She described low mood, anhedonia, and disrupted sleep for several months. There was no suicidal ideation, no psychosis, no substance use. A textbook case for NHS talking therapy. I logged the referral to the local Improving Access to Psychological Therapies (IAPT) service. Then we waited. Fourteen months later, she still had not received an appointment. By then, her symptoms had worsened, and she had already tried the only other first-line option I could offer: an antidepressant. She wanted counselling, not medication. But the system had no room for her. (Details of this patient story have been changed to protect anonymity; it is a composite of several real cases.)

The GP's Diary: A 14-Month Wait for Therapy

This story is not unusual. In England, IAPT services received roughly 1.6 million referrals in the most recent reporting year. Only about 20% of patients start treatment within six weeks, and many wait far longer. For patients with moderate depression and no acute risk, the wait can stretch past a year. As a GP, my toolkit is narrow: I can prescribe medication, signpost to third-sector support, or refer to IAPT. When the waiting list is long, medication becomes the de facto offer, even for patients who prefer psychological therapy.

Sarah chose to start an antidepressant because she felt she had no other option. She took it for six months, reported modest improvement, but still wanted to address the underlying patterns of negative thinking and avoidance that the medication did not touch. She asked about private therapy, but at roughly £50–80 per session, that was not feasible. So she stayed on the waiting list, checking her mail each month, hoping for a letter that never came.

Her experience echoes a national pattern. A 2023 survey by the Royal College of Psychiatrists found that one in four patients waited more than a year for talking therapy after referral. The pandemic deepened the backlog, and recovery has been slow. Commissioners have looked for ways to stretch limited clinician time. One solution has been to shift IAPT toward digital-first delivery—online cognitive behavioral therapy (iCBT) that patients complete on their own, with no therapist contact. For patients like Sarah, this is increasingly the only offer.

Why Digital CBT Became the Default Offer

NHS IAPT services have moved toward an online-first model, partly driven by necessity. Self-guided iCBT modules for depression and anxiety can be accessed from home, require no clinician time for delivery, and can be scaled to thousands of patients simultaneously. The National Institute for Health and Care Excellence (NICE) has reviewed the evidence and recommends iCBT as a treatment option for mild to moderate depression, particularly when supported by a therapist. But in practice, the 'supported' part is often dropped.

The basic tier of many IAPT digital services consists of a series of modules—typically six to eight sessions—covering cognitive restructuring, behavioral activation, and relapse prevention. Patients log in, read content, complete exercises, and receive automated feedback. There is no weekly phone call, no email check-in, no human being asking how the week went. The system assumes that the patient's motivation and the program's design are sufficient to produce improvement.

Evidence reviews, including a 2021 meta-analysis in JAMA Psychiatry, show that guided iCBT—where a therapist provides brief weekly support via phone or messaging—produces moderate effect sizes (g ≈ 0.6–0.8) comparable to face-to-face therapy. Unguided iCBT, however, yields small effects (g ≈ 0.2–0.3). The difference is clinically meaningful. Yet many NHS digital services offer unguided iCBT as the default, with guidance reserved for those who fail to improve or who request it. The rationale is efficiency: one therapist can support dozens of patients in guided programs, but unguided programs require no therapist at all.

Commissioners argue that unguided iCBT is better than nothing—and for patients on a 14-month waiting list, it may be the only option. But the evidence suggests that 'better than nothing' is a low bar. Dropout rates in unguided iCBT trials range from 40% to 50%, and real-world adherence is often lower than in trial conditions. Patients who complete the program may see modest gains, but many do not finish.

What the Evidence Says About Unsupported iCBT

A 2021 network meta-analysis in JAMA Psychiatry compared guided and unguided iCBT for depression across 39 randomized trials. The authors found that guided iCBT was significantly more effective than unguided iCBT, and that unguided iCBT was only marginally better than waitlist control. The effect size for unguided iCBT was small—roughly 0.2 to 0.3 standard deviations. For context, that is about half the effect of antidepressant medication in primary care trials.

Real-world data from NHS digital services reinforce these findings. A 2022 audit of one large IAPT digital program found that only 30% of patients completed all modules. Among completers, average improvement on the PHQ-9 depression scale was about 3 points—a modest change that may not reach clinical significance for many. Non-completers showed minimal improvement. The program was free, accessible, and evidence-based, but without human support, it failed to engage a majority of users.

Some researchers argue that unguided iCBT still has a role as a low-intensity first step. Patients who are mildly depressed or who prefer self-directed work may benefit. But for those with moderate to severe depression—the very patients who are waiting the longest for therapy—the evidence suggests that unguided iCBT is unlikely to be sufficient. The risk is that digital services become a way to triage patients away from face-to-face care, rather than a genuine treatment option.

One Patient's Experience With an App and No Clinician

Let me return to Sarah. After 14 months of waiting, she received a letter from IAPT offering her a place in a digital CBT program. She was given a login, a set of modules, and instructions to complete them over eight weeks. No therapist was assigned. She started with enthusiasm, completing the first two modules on behavioral activation. She set small goals—taking a walk each day, calling a friend—and felt a brief lift in mood.

But by week three, the novelty wore off. The modules felt generic, written for an abstract 'depressed person' rather than for her. She had trouble applying the cognitive restructuring exercises to her specific worries about her job and her teenage son. There was no one to ask for clarification, no one to encourage her when she missed a day. She stopped logging in. When I saw her two months later, her PHQ-9 score had risen from 14 to 18. She felt that the app had been a waste of time and that she had failed at it.

Her reaction is common. Patients often interpret non-completion as a personal failure, which can worsen shame and self-criticism—core features of depression. The absence of a human presence means there is no one to reframe the experience, to say that the program was not a good fit, or to offer an alternative. The GP is left to pick up the pieces: increase the antidepressant, re-refer to IAPT (another wait), or suggest private options. None of these feel like progress.

This case illustrates a fundamental tension. Digital CBT can be effective when delivered with support, but the NHS version often strips away that support to save clinician time. Patients who struggle are left without a safety net. The app becomes a gatekeeper: if you can complete it, you get some benefit; if you cannot, you are back on the waiting list, possibly worse off than before.

Waiting List Math: Supply, Demand, and Triage

The numbers behind the waiting lists are stark. IAPT services in England receive about 1.6 million referrals annually, but only around 1 million start treatment within the year. Of those who start, many receive only a few sessions. The target is for 75% of patients to access treatment within six weeks, but this target has not been met consistently since before the pandemic. In some areas, the average wait for face-to-face therapy exceeds 12 months.

Digital CBT reduces the demand for clinician time per patient, but it does not reduce the overall demand for services. In fact, it may increase it by lowering the barrier to referral. Patients who might not have sought therapy now sign up for an app, and those who complete it may still need additional support. The net effect on waiting lists is unclear. Some commissioners argue that digital services free up clinician time for complex cases. Others worry that they create a two-tier system: a quick, low-quality digital option for the many, and a slow, high-quality face-to-face option for the few.

Triage tools are used to decide who gets which service. Most IAPT services use the PHQ-9 and GAD-7 scores, along with a risk assessment, to route patients. Those with mild to moderate scores and no risk factors are offered digital CBT. Those with severe scores or risk are offered face-to-face or guided therapy. But the cutoffs are arbitrary, and patients with moderate depression who would benefit from human support may be triaged to digital because of capacity constraints. The triage tool becomes a rationing tool.

Some areas have experimented with blended care: digital modules plus brief, regular check-ins from a psychological well-being practitioner. These models show promise. A pilot in North East England offered patients six weeks of iCBT with a 15-minute phone call each week. Completion rates rose to 65%, and effect sizes were comparable to face-to-face therapy. The cost per patient was roughly £150, compared to £400 for full face-to-face therapy. But blended care still requires clinician time, and scaling it to meet demand is challenging.

What GPs Wish Commissioners Understood

From the GP perspective, the shift to digital-first therapy has created new problems. First, digital tools are not a substitute for the therapeutic alliance. Patients who feel heard and understood by a clinician are more likely to engage and improve. An app cannot provide that. Second, patients with social isolation, low digital literacy, or chaotic lives struggle to engage with self-guided programs. These are often the same patients who need therapy the most.

Third, the evidence on unguided iCBT is clear: it works for some, but not for many. GPs are left to manage the fallout when patients fail to complete the program or do not improve. We have no easy way to escalate care; the waiting list for face-to-face therapy is still long. Fourth, the cost savings of unguided iCBT may be illusory. When dropout rates are high and outcomes modest, the cost per successfully treated patient may be similar to guided care. A 2023 health economics analysis in the British Journal of Psychiatry found that guided iCBT was more cost-effective than unguided iCBT when accounting for completion rates and outcomes.

Finally, GPs want a stepped care model that actually steps. Currently, the steps are: digital self-help, then medication, then a long wait for face-to-face therapy. What is missing is a middle step: low-intensity guided iCBT with brief human support. If a patient fails to respond to unguided iCBT after four weeks, they should be offered a phone call, not just a re-referral. Commissioners need to invest in that middle step, rather than assuming that digital alone will solve the waiting list problem.

A Workable Path Forward for Primary Care

What would a better system look like? First, embed digital triage in GP practice websites so that patients can self-refer to low-intensity support while waiting for an appointment. This would reduce the burden on GPs and give patients an immediate option. Second, offer low-intensity guided iCBT as the default digital offer, with a 15-minute weekly phone call from a trained practitioner. The evidence supports this model, and pilots have shown it is feasible.

Third, use patient-reported outcome measures (PROMs) to track progress and trigger step-up care. If a patient's PHQ-9 score does not improve after four weeks of guided iCBT, the system should automatically offer a face-to-face assessment. This would prevent patients from languishing in ineffective treatment. Fourth, commission hybrid services that combine digital modules with in-person groups or individual sessions, tailored to patient preference and severity.

Pilot results from North East England and other regions show that blended care can reduce waiting times and improve outcomes. But scaling these models requires investment in training and infrastructure. The alternative—continuing to offer unguided iCBT to patients who need more—is not a solution. It is a stopgap that risks turning digital therapy into a dumping ground for those the system cannot serve.

Yet even these steps leave unresolved tensions. For instance, blended care still depends on a workforce of psychological well-being practitioners, which is itself under strain. A 2024 workforce survey by the British Psychological Society reported that one in three IAPT practitioners considered leaving due to burnout and low pay. Scaling guided iCBT without addressing staff retention may simply shift the bottleneck from waiting lists to clinician availability. Moreover, some patients may prefer the anonymity of fully self-guided programs and might not engage with phone calls. A one-size-fits-all approach, even if guided, risks alienating those who value privacy or have limited time for scheduled calls.

There is also the question of equity. Patients from deprived backgrounds are less likely to have reliable internet access or quiet spaces at home for digital therapy. A 2022 analysis by the Health Foundation found that digital exclusion disproportionately affects older adults, those on low incomes, and people with disabilities. If digital-first becomes the only first step, these groups may be left behind. Commissioners must ensure that non-digital alternatives remain available and that digital services are designed with accessibility in mind.

Finally, the evidence base for iCBT in routine practice is still evolving. Most trials have short follow-up periods and exclude patients with complex comorbidities. Real-world effectiveness may be lower than trial results suggest. A pragmatic randomised controlled trial in the UK, published in The Lancet Digital Health in 2023, compared guided iCBT with face-to-face therapy for depression in primary care. It found that face-to-face therapy was superior at six months, though the difference was small. The authors concluded that iCBT is a reasonable option for patients who prefer it or cannot access face-to-face care, but it should not be considered equivalent.

For Sarah, the path forward remains uncertain. She is back on the waiting list, now with a higher PHQ-9 score. She has agreed to try a different antidepressant, but her hope is fading. She asks me, 'Is there anything else?' I wish I had a better answer. The digital program did not help her, and the face-to-face therapy she needs is still months away. She is not alone. Thousands of patients across the UK are stuck in the same gap: too unwell to be left alone, but not unwell enough to jump the queue. The question is whether the system can learn from their experience, or whether digital therapy will remain a stopgap that serves the system more than the patient.

This article is for informational purposes only and does not constitute personalised medical advice. Readers should consult their own GP or mental health professional for advice tailored to their individual circumstances.