Gavin Andrews, St Vincents Hospital Sydney - Depression: Twice the Benefit for Half the Cost


Published on

Professor Gavin Andrews AO, Director, UNSW School of Psychiatry, St. Vincent’s Hospital Sydney delivered this presentation at the 15th Annual Health Congress 2014. This event brings together thought leaders and leading practitioners from across the Australian health system to consider the challenges, implications and future directions for health reform.

For more information, please visit

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Gavin Andrews, St Vincents Hospital Sydney - Depression: Twice the Benefit for Half the Cost

  1. 1. iCBT for depression: Twice the benefit for half the cost; but think about efficiency, safety and funding Gavin Andrews AO, MD Professor of Psychiatry, UNSW at St Vincent’s Hospital, Sydney
  2. 2. Problem: Meds do not work well Antidepressants are not superior to placebo in mild and moderate depression (NNT=16), Show a medium effect in severe depression (NNT=11) Substantially better in very severe depression (NNT=4) Fournier et al JAMA 2010 “No fully satisfactory treatments for major depression are available” Kupfer et al Lancet 2011:
  3. 3. iCBT in Internalising disorders- 50 research trials, 4,000Ss, mean ES = 1.2, NNT <2, Adherence 77% MDD N of trials 13 N of Ss 2067 Effect Size 1.0 NNT <2 Adherence 75%
  4. 4. History • CRUfAD is a specialist treatment service – had a long waiting list for face to face CBT • Developed internet based CBT (iCBT) • Now 400 referred new patients a year • 19/20 choose iCBT • NO WAITING LIST
  5. 5. Scope • iCBT courses TEACH control of emotions, thoughts and behaviour for  GAD, OCD, Panic, Social phobia,  Depression, mixed ANX/DEP • 6 lessons, 10 weeks, $55
  6. 6. Reach • 3500 GPs/Psychologists have registered • 7500 patients have registered, half from non metro practices • Include with GAD-7 or PHQ-9 score > 9 • Exclude people who can’t learn: dementia, autism, schizophrenia, bipolar disorder, psychotic depression, substance abuse, or who are on benzodiazepines or are suicidal.
  7. 7. Depression Lesson 1 •Depression Symptoms Explained
  8. 8. Activity Planning Recording Positives Depression Lesson 3
  9. 9. Facing Fears Gradually Depression Lesson 4
  10. 10. Depression general practice (n=420) PHQ-9 Sub-threshold (0-9) PHQ-9 Mild (10-14) PHQ-9 Moderate (15-19) PHQ-9 Severe (20-27) Pre-treatment 420 complete treatment for Major Depressive Disorder N=154 (37%) N=124 (30%) N=142 (34%) Post- treatment 60% recover 20% improve 20% do not N=84 (20%) N=48 (11%) N=42 (10%)N=246 (59%)
  11. 11. “Better off dead” days (n=420) PHQ-9 Question 9 “Not at all” PHQ-9 Question 9 “Several days” PHQ-9 Question 9 “More than half the days” PHQ-9 Question 9 “Nearly every day” Pre-treatment: 60% report ‘better off dead’ days Post- treatment: 32% report ‘better off dead’ days but at reduced frequency N=93 (22%) N=26 (6%) N=18 (4%)N=283 (67%) N=166 (40%) N=148 (35%) N=66 (16%) N=40 (10%)
  12. 12. #1 Probably Cost effective • Two trials with good evidence in Depression. $29,000/QALY Hollingshurst et al BJPsych 2010 ; Proudfoot et al BJ Psych 1994 • iCBT vs f2f CBT for social phobia is cheaper and better Hedman et al 2011 ; Andrews et al 2012 • iCBT NNT <2; Meds for Depression NNT>5 • Pure self help effectiveness studies: adherence 2% - 12%; too low to be effective.
  13. 13. #2 Safety: harm and suicide • iCBT research refused the severe and suicidal. GPs did not, showed courses safe and effective • Simon et al 2013. 11,500 depressives with PHQ-9 Q9=2/3. 6 suicides within 30 days. • In our research trials we call patients with a score of 2/3, most say ‘I’m OK, just a bad time’. • In the system tells the GP.
  14. 14. #3 DoH can’t think of how to pay • DoHA has been serious about iCBT for ten years – TGA “you have software that informs and people use it to recover – it is not a Treatment.” – Medical Benefits Schedule pays medical professionals for their time/expertise – Pharmaceutical Benefits Schedule subsidizes useful medicines – Medical Services advisory committee subsidises professional procedures or devices. • iCBT is proven, cost effective, as yet unfunded remedy for depressive and anxiety disorders,
  15. 15. Come in, the computer will see you now • Can internet delivered automated CBT be as good as a live, well trained therapist? As Meds? Well, yes. • Certainly for the average to severe case, whether or not comorbid, even for physical comorbidity • Patients stay engaged, don’t get bored, tired, or distracted. Can review material. Adherence 60%. • Therapist drift does not occur. Being reliable is better than sporadic brilliance. • And what a good thing it is, clinicians now have time for the difficult-to-get-better complex cases. • 20+ RCTs; 6+ field studies