Interactive Well-Being Lab www.sussex.ac.uk/iwl 1

Computerised Cognitive Behavioural Therapies

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Mood and Anxiety Disorders• 1 in 5 people suffer from anxiety or depression

at any one time (ONS, 2000)• Approximately 1/3 seek help for these common

problems from their GP (Bebbington, 2005)• 10% of those seeking treatment receive any

kind of counselling or talking therapy • Fewer (1%-5%) access evidence based talking

therapies such as cognitive behavioural therapy• Service capacity is limited and CBT therapists

are inequitably distributed (Shapiro, Cavanagh & Lomas, 2003)

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Increasing access to psychological therapies

“A revolution in mental health care” (Bennet-Levy, Richards & Farrand, 2010, p3)

• Range of initiatives to increase early access to effective psychological interventions– Training (and supervision) of more staff to deliver

evidence based interventions– Restructuring services– Exploring alternatives to 1-to-1 therapies

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Low intensity interventions

• “reduce the amount of time the practitioner is in contact with individual patients” (Bennet-Levy, Richards & Farrand, 2010, p8)

– Advice clinics (psycho-education)– Brief interventions– Group CBT (‘high volume approaches’)– Guided and unguided self-help programmes

supported in book/workbook format or delivered on computers/the internet

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STEP 1: All known and suspected presentations of depression

STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression

STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression

STEP 4: Severe and complex depression; risk to life; severe neglect

Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions

Medication, high-intensity psychological interventions, combined treatments, collaborative careb and referral for further assessment and interventions

Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care

Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions

Focus of the intervention

The stepped-care model for depression

Nature of the intervention

National Institute for Health and Clinical Excellence, 20096

NICE (2009) depression guidelines

Low-intensity psychosocial interventions• For people with persistent subthreshold depressive

symptoms or mild to moderate depression, consider offering one or more of the following interventions, guided by the person’s preference:

– individual guided self-help workbooks based on the principles of cognitive behavioural therapy (CBT)

– computerised cognitive behavioural therapy (CCBT)– a structured group physical activity programme.

These should– be supported by a trained practitioner, who typically facilitates the

self help programme and reviews progress and outcome‑– consist of up to six to eight sessions (face-to-face and via telephone)

normally taking place over 9 to 12 weeks, including follow-up.

NICE indicated “low intensity” interventions for common mental

health problems

from http://www.iapt.nhs.uk/wp-content/uploads/iapt-data-handbook-appendices-v10.pdf

See also NICE (2011) Guidance on Common Mental Health Disorders. NICE.NB IAPT services designed to deliver these guidelines, 3500 new workers etcAim to identify and treat 100ks of people with anxiety and depression 8

NICE indicated “low intensity” interventions for common mental

health problems

from http://www.iapt.nhs.uk/wp-content/uploads/iapt-data-handbook-appendices-v10.pdf

See also NICE (2011) Guidance on Common Mental Health Disorders. NICE.NB IAPT services designed to deliver these guidelines, 3500 new workers etcAim to identify and treat 100ks of people with anxiety and depression 9

Increasing access to psychological therapies for common mental health problems such as depression, anxiety and insomnia

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Outline

• What is computerised cognitive behavioural therapy (CCBT)?

• Evidence of effectiveness for CCBT• Evidence of how best to support user’s CCBT journey

•Uptake•Engagement / Adherence•Completion and maintaining longer term outcomes

• Future research questions to be addressed 11

Computerised Cognitive Behavioural Therapies

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Computerised Psychological Therapies

• A structured, interactive program which guides the user through a psychological intervention

• Computerised Cognitive Behavioural Therapy– Psycho-education– Assessment of current problems with feedback and change

monitoring– Action plans and goals– Guided change techniques (e.g. behavioural activation, evaluating

negative automatic thoughts, problem solving)– Putting learning into practice (homework)

• Accessed via interactive computing device, and usually via the internet

– PC, smartphone, IVR, Tablet/Ipad

• Supported by trained healthcare staff– Trained in the delivery of low-intensity interventions– Typically brief, remote, weekly support sessions (by phone or email)

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Colour your life

Swedish group

One example…

www.beatingtheblues.co.uk

e.g. Behavioural Activation

When?Where?Barriers?

FeedbackGuidance

Psycho-education

Case examples to help learningGenuinenessWarmth

Assessment

Action planningCollaborationNegotiation of goals

Guided discoveryMonitoringReview

Multimedia which guides the user through the program and illustrates learning examples

Summary

Are these CCBT programs effective?

• Do they help users to make sense of their problems

• Do they lead to a reduction in difficulties and improved well being, sustained in the longer term?

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Randomised Controlled Trial: Beating the Blues vs usual care in NHS Primary Care

GP patients aged 18-75 with depression and/or anxiety, with or without antidepressant medication

276 participants from 12 primary care practices

Outcome measures: Beck Depression Inventory Beck Anxiety Inventory Work and Social Adjustment Scale Health Service Usage

Pre, Post, 1 month, 3 month and 6 month follow-up Proudfoot et al (2004) British Journal of Psychiatry 31

N = 276

Proudfoot et al (2004) British Journal of Psychiatry

Mean of 1 mo more DFD in 6 mo FU, Outcomes comparable to 8 FTF Sheff.

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25

20

15

10

5

0

Computerised-CBT for Depression

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0

5

10

15

20

Pre Post 1m FU 3m FU 6m FU

Beat

ing

the

Blue

s

Tre

atm

ent

as U

sual

RCT Beck Anxiety Inventory

Beck Anxiety Inventory Outcomes

Pre Post 1 mo FU 3 mo FU 6 mo FU

TAU

Beating the Blues

20

15

10

5

0

N = 276

Proudfoot et al (2004) British Journal of Psychiatry33

0

5

10

15

20

Pre Post 1m FU 3m FU 6m FU

Beat

ing

the

Blue

s

Tre

atm

ent

as U

sual

RCT Work and Social Adjustment

Work and Social Adjustment Scale

20

15

10

5

0

TAU

Beating the Blues

Pre Post 1 mo FU 3 mo FU 6 mo FUN = 276

Proudfoot et al (2004) British Journal of Psychiatry34

Summary of RCT outcomes

Beating the Blues offers clinical benefits over and above treatment at usual

2/3rds users complete all 8 sessions Intent-to-treat analysis shows that benefits are

maintained to 6-months post treatment

Outcome: cost ratios demonstrate that Beating the Blues is a cost-effective intervention for depression primary care

Lost employment costs are significantly lower following Beating the Blues than treatment as usual

McCrone, P., Knapp, M., Proudfoot, J., Cavanagh, K., Ryden, C., Ilson, S., Gray, JA, Shapiro, DA. (2004) British Journal of Psychiatry

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Further evidence of effectiveness of CCBT (Beating the Blues) for depression

• In routine primary care– (N=219, Cavanagh et al., 2006)

• In specialist CBT service (N=555; Learmonth et al., 2007)

• In student health services (Mitchell & Dunn, 2007; McHugh et al., 2010)

• In secondary care adult mental health service

(N = 23; Ormrod et al., 2010)

• In service user led self-help clinic (N= 510, Cavanagh et al., 2011)

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Reviews of the evidence for CCBT• Systematic review of

the evidence identified 175 studies, including 103 RCTs evaluating the use of 97 different Computerised Psychotherapy programs

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Evidence base for CCBT

Some evidence of effectiveness (at least in comparison to a waitlist control)

Marks, Cavanagh & Gega (2007)

PhobiasPhobias PanicPanic OCDOCD PTSDPTSD GADGAD StressStress DepressionDepression Eating disorders (BN)Eating disorders (BN) Problem drinkingProblem drinking

Substance misuseSubstance misuse PainPain TinnitusTinnitus InsomniaInsomnia Sexual problemsSexual problems SchizophreniaSchizophrenia Childhood anxiety, Childhood anxiety,

depression, headaches, depression, headaches, ASD, encopresis, asthmaASD, encopresis, asthma

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Meta-analysis of internet-based interventions (Barak et al, 2008)

Internet Interventions versus control conditions: Weighted Mean Effect Size = 0.53 (64 articles, 92 studies reviewed)

Internet Interventions versus face-to-face: no significant difference

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Meta-analysis of CCBT for Depression and Anxiety - Andrews et al 2010

Favours CCBT40

Guided self help versus face to face CBT

Cuijpers et al, 201041

Does CCBT ‘work’?

• “Computerized treatments have been shown to be a less-intensive, cost- effective way to deliver empirically validated treatments for a variety of psychological problems”

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CCBT appears to be a ‘good thing’

• But – – Not everyone tries them

• 38% (range 4% - 83%) of those invited to CCBT research trial start program (Waller & Gilbody, 2008)

– Not everyone sticks with them• Meta-analysis of studies of CCBT for depression

mean dropout rate 32% (range 0-75%; Kaltenthaler et al., 2008)

– Professionals not always be hopeful about the value of self-help in the therapeutic context

• e.g. Whitfield and Williams, 2004; Stallard et al., 2010

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How can we optimise the user experience of CCBT in order to

increase access to and benefit from psychological therapies?

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Turning on, tuning in and (not) dropping out

CCBT programs can be effective, but how can we ensure that those who may benefit are able to make use of these programs?

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The 4 ‘p’s of CCBT

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Problem

‘The patient’: who is suitable for CCBT?

• NICE recommends that anyone meeting criteria for GAD, panic, persistent subtheshold and mild-to-moderate depression should be offered the choice of CCBT– Willing and able criteria– No specific exclusion criteria (locally

determined)• e.g. high risk, primary substance/alcohol misuse

• There is no strong evidence to support the idea that younger people or males are more well suited to CCBT *

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The patient: who is suitable?• Pre-treatment expectancies predict

treatment completion (Cavanagh et al, 2010) and longer term treatment outcomes (12 months FU; Graaf et al., 2010)

• MacLeod et al (2009) Higher levels of patient motivation, program credibility, likely adherence, self-efficacy and a lower degree of hopelessness associated with benefits from self-help programs

• Ongoing research exploring the influence of individual differences in attitudes to helpseeking, attachment orientation etc.

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‘The problem’: what problems can be helped by CCBT?

• Both anxiety and depression (and others)• The need for support may vary by disorder

– Anxiety can benefit from unguided or minimally guided self-help

– Depression may require additional supportNewman et al (2011)

• Depression may be associated with reduced motivation, reduced activation, feelings of hopelessness and rumination – which may make it more difficult to engage with the programme (and CBT in general) – so more support needed

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‘The program’: which programs work?

• Evidence-based self-help interventions• Untested programs ‘based on the

principles of CBT’

• Program features to consider– Structure– Content: toolkit and techniques– Common factors (empathy, warmth, alliance,

structure etc)

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Set menu or a la carte?

Some evidence of improved adherence with greater structure (Celio et al, 2003)

Preliminary evidence from Andersson (2010) suggests both models can work

No head to head trials published Best evidence to date is for structured

programs 51

Content: What’s in the box?

• Tools and guided change techniques

• Little dismantling evidence available to date on what specifically works in CCBT

• Matching the users needs and preferences

• Importance of familiarity with the materials

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Common factors

There is considerable evidence of common factors embedded within widely used CCBT programs (Barazzone, Cavanagh & Richards, under review)

Users report a ‘therapeutic alliance’ with CCBT programs (Ormrod et al., 2010)

Ongoing research to understand more about these engagement processes

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‘The provider’: staff training and supportive context for CCBT

• Therapists with training in self-help are more confident and positive about self help (Keeley et al., 2002)

• Therapist expectancies and frequency of programme use are improved with training (McLeod et al., 2009)

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Encouraging uptake and engagement, and reducing drop-

out

• Identifying key problems and goals to work on

• Identifying appropriate self-help materials

• Supporting the person in their efforts to change

• Monitoring and review of progress From Baguley et al (2010) Good Practice Guidelines

for Self-Help in IAPT Services. IAPT.

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Phone or email support for CCBT

• A scheduled 10 minute contact, once a week– Service users tend not to call “helplines” (e.g. Kenwright et

al., 2004)

• Remote services supported by phone confer similar outcome and satisfaction to same programs in CCBT clinic (MacKinnon et al., 2008)

• No added value to more frequent contact (Klein et al., 2009)

• No added value to using >1 medium of communication (Andersson et al., 2003)

• Andersson et al (2009) A clear deadline provided for the duration of the treatment improves program completion

• Reminders sent by post-card, email, telephone or text may have an impact on program adherence and on outcome (Clarke et al., 2005)

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Managing expectations

• People’s ‘mental model’ of accessing psychological support or therapy may differ from the guided self-help treatment option– “I didn’t expect homework”– “I suppose I thought it would be some sort of

counselling…”– “I wasn’t sure about their [assistant

psychologist] role. I didn’t realise that she was going to work through the book with me”

– “I don’t know how long the sessions were supposed to be”

Macdonald et al., 2007

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Managing expectations

• User expectancies can be improved by a taster session with CCBT programs (Mitchell and Gordon, 2007)

• Novel features of the guided self-help service should be made explicit and rehearsed e.g.– The programme structure and content– The primary wellbeing practitioner role– What to expect from scheduled phone support– Session length (programme and support) and work in

between sessions– Ongoing monitoring and review etc

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Drop out from CCBT• Meta-analysis of studies of CCBT for depression mean

dropout rate 32% (range 0-75%; Kaltenthaler et al., 2008)

• Reasons for drop out from CCBT– Too busy / change of circumstances– Early gains / accomplishment of goals– Dissatisfaction with therapy or CCBT

• No significant difference in dropout rates between guided self help and FTF therapies in head-to-head RCTS (RRR = 1.14; Cuipers et al., 2010)

• Managing expectations, program matching, planned endings, progress review and strategies for managing difficulties with engagement may support completion

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Summary• CCBT can offer an effective method of treatment

for depression and anxiety• Promoting uptake, engagement, and completion

are key provider tasks .

• Chose programs with evidence of effectiveness• Information, taster sessions and training help• Brief weekly support is vital• Reminders and prompts may also help

• There is lots more research to be done!

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Selected books

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Good practice guidance for use of self-help

Baguley, C., Farrand, P., Hope, R., Leibowitz, J., Lovell, K., Lucock, M., O’Neill, C., Paxton, R.,

Pilling, S., Richards, D., Turpin, G., White, J. and Williams, C. (2010)

Good practice guidance on the use of self-help materials within IAPT services. Technical Report.

IAPT

This version is available at http://eprints.hud.ac.uk/9017/

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Home pages of some evidence based CCBT programs

– www.ccbt.co.uk – fearfighter, ocfighter, cope– www.beatingtheblues.co..uk – beating the blues– www.livinglifetothefull.com – living life to the full– www.moodgym.anu.edu.au - moodgym– www.anxietyonline.com – various programs for

anxiety problems– www.calipso.co.uk – overcoming depression,

overcoming bulimia– www.interapy.nl – various programs for stress,

anxiety, depression– www.livanda.se – various programs for stress,

anxiety, depression

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• Thanks!• kate.cavanagh@sussex.ac.uk

Interactive Well-being Lab• www.sussex.ac.uk/iwl

Cavanagh, K (2010) Turning on, tuning in and (not) dropping out. In J. Bennett-Levy (Ed). Oxford Guide to Low Intensity CBT Interventions. Oxford University Press: Oxford, UK.

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