Internet CBT for DepressionModest Effects, Population-Level Potential, Solutions to Dissemination BarriersGreg Clarke PhDKaiser Permanente Center for Health Research (CHR)Portland Oregon

My Recent Research Activities, InterestsYouth depression CBT, pharmacotherapyTargeted prevention of youth depression Insomnia CBT for adolescentsDissemination of mental health evidence-based treatments (EBTs)Internet CBT for adult depressionFocus of today’s talk

Overview of TalkGaps in depression careLow availability (Reach), poor quality (Implementation)Low intensity interventions as part of solutionBibliotherapy interventions generallyInternet-delivered CBT in particularReview of literature, our specific randomized trialsImplementation models, issuesStepped care, population level dissemination

Gaps in Depression Care:Quality Improvement is Needed!High prevalence, 2-3x risk in femalesSignificant psychiatric and social morbidityGreatly increased risk of completed suicide Poor quality of life, increased cost to societySeveral strong evidence-based treatments (EBTs): Antidepressants, CBT, IPT, etc.And yet -- poor quality of care in community

Traditional Depression Treatments: Poor Reach (lack of availability)Depression EBTs are often not available to persons needing them in the communityStigma, poor follow-though with referralsStructural or systemic barriers (e.g., few mental health specialists co-located with primary care services)Higher costs of specialty MH care Insufficient capacity to deliver high quality care

Feasibility of DisseminatingTraditional PsychotherapyCan’t we address low accessibility by promoting wider dissemination of traditional treatments?US trends in recent decades:Declining psychotherapy ratesBut higher antidepressant ratesUnlikely to see ‘public health’ dissemination of traditional, face-to-face psychotherapiesMight be easier in Mexico, with its universal healthcare & centralized public health

Traditional Depression Treatments: Poor ImplementationEven when evidence-based treatments (EBTs) are available they are often poorly delivered (low Implementation or Adherence)Low provider adherence to quality guidelinesDue to limited time, training gaps, reimbursement limitsLow patient adherence to dosing or behavioral instructionsDue to side effects, costs, ambivalence, stigma

Barriers to Increasing Reach, Implementation of Traditional TreatmentsPharmacotherapyAdverse side effectsPatient ambivalencePremature discontinuation, poor adherenceSmall effect above placebo?With generic SSRIs, cost is not so much of a problemFace-to-Face PsychotherapyCost, reimbursement limitsFew trained in EBT therapiesFew MH specialists in some settings (e.g., rural areas)Discomfort with disclosureStigma

Low Intensity Treatments: a Partial Solution to Dissemination Problems?Low intensity treatments may have a role to play in addressing the gap in depression careSeveral variants, with or without supportive therapist contacts:Bibliotherapy – books, pamphletsDVDs, videoComputerized interventions (most often CBT)Internet-delivered interventions (most often CBT)

Different Types of Low Intensity TherapyPure Internet CBT (aka self-administered therapy)Bibliotherapy, video, Internet site with no or very little direct contact with live therapist or coachGuided Internet CBT (aka minimal contact therapy)Instructional materials + modest contact with live therapist or coach, often by telephone or email rather than in-personTypically 2 to 4 cumulative hours of therapist contact vs. 12 to 26 hrs contact in traditional EBT psychotherapies

MoodHelper: 4 Content ModulesImprove Your Mood Tutorials in behavioral or cognitive therapyWe consider this the “curative” elementDepression FactsMeasure Your MoodJournalsPrivate “blog” which could be selectively published for viewing by others

Customization:1of 3 pages of preference questions

Customization:Pts add or remove activities from ranked list

Customization:These boxes allow Pts to personalize goals, rewards

This Contract summarizes all the choices made by the Pts on the previous pages

Interactivity:Pts are asked to return and record mood and activities for each day

Daily mood and activity data is graphed to see patternsNarrative feedback provided is on subsequent pages (“You never report doing two fun activities. We suggest dropping these and adding 2 more.”)

Low-Intensity Treatments may Improve ReachLow Intensity EBTs (particularly Internet, books) can be used at home, are anonymous, are available 24/7 More individuals potentially served, at a lower costMay be best—or only—option for rural areas, or anywhere MH specialists are in short supplyAre some patients who decline traditional treatments those who would prefer low-intensity CBT as 1st step?More comfortable with anonymity, no face-to-face disclosure?“Gateway” experience to prepare for traditional therapy?

Is Internet Access Good Enough?Source: Pew Internet & American Life Project, August 2008, except * December 2008

Spanish Internet CBT Site – Coming SoonWe are currently translating the Internet CBT program into Spanish: AnimoOnline.orgBilingual, bicultural telephone coachesTranslation led by Nangel Lindberg PhDResearcher, co-investigator at our CenterTrained in clinical psychology at UCLANative of Mexico Distrito Federal (Mexico City)Many years experience translating from English to SpanishWebsite will be tested in future randomized trial

Do Bibliotherapy EBTs ‘Compete’ with Traditional Treatments?Internet interventions are not meant to replace or directly compete with traditional treatmentsDespite this, some trials have found that Internet CBT may yield effects equal to traditional Tx’sOur view: these alternatives occupy different niches in the progression of treatment intensitySee stepped care models later

Is CBT the only Viable Approach for Internet Interventions?Most, or perhaps all, Internet mental health interventions are based on CBTOther approaches should work equally well if:They can be delivered in a psycho-educational formatIf they have a set of guidelines and skills to trainExamples – not an exhaustive list: Acceptance and Commitment Therapy (ACT)Dialectical Behavior Therapy (DBT)Motivational Enhancement Therapy (MET)

Diminished Therapeutic Relationship vs AnonymityTraditional psychotherapists dismiss Internet therapy due to the lack of face-to-face contact:Reduces ability to read nonverbal cuesMay diminish or eliminate therapeutic relationshipHowever, Pts who choose to forego traditional treatments because of stigma or discomfort with disclosure may appreciate the anonymity of Internet therapy, even with telephone contacts

Summary of Best ‘Fit’ for Internet EBTsMonotherapy for persons with less severe disorderAs augmentation to traditional treatments (combo Tx)The early stages of a stepped care protocol “Bridging” care while waiting for traditional treatment?For persons not ready for—or uncomfortable with—traditional face-to-face therapy A low risk, low demand way to test the waters?Where mental health specialists are in short supply For population-scale dissemination

Research on Internet CBT

Effects of Internet CBTMeta-analyses of Internet CBT Effect Size (ES) d = 0.27 to 0.50 rangeLarger effects when compared to waitlistSmaller effects when compared to active control conditionsOur 2005 and 2009 trialsES’s of d = .28 and .20, respectively, in the full samplesCompared to a “strong” control condition called treatment as usual (TAU), consisting mainly of antidepressants +/or face-to-face psychosocial (therapy) visits

Relative Effects of Pure vs Guided Internet TherapyOnly one study has directly compared Pure versus Guided Internet CBT (for social phobia) A large effect (ES of ~ d = 1.00) for Guided BibliotherapyA small-medium ES of d =.38 for Pure BibliotherapyMeta-analyses find similar results across studiesGuided Bibliotherapy seems to be more clinically potent than Pure Bibliotherapy However, it is more costly than Pure Bibliotherapy

Direct Costs: Traditional Psychotherapy vs. Guided vs. Pure Bibliotherapy CBTCosts per individual Pt. Staff salary, fringe, overhead figured @ $70/hr. *few studies so far, most targeting anxiety

Indirect Cost Advantagesof Internet InterventionsPatient Cost-Time Advantages:Less time spent traveling to clinics, waiting, medical visits, and participating in interventionFewer lost work hours<Pt cost of Internet access is a disadvantage>Societal, Organizational Cost Advantages:Reduced need for office space, facility costs, infrastructureMore widespread depression treatment = reduced unemployment, retained human capital, more tax revenue?Lower rates of depression in offspring?

Our Two Internet CBT ProgramsODINOvercoming Depression on the InterNetCognitive restructuring (CR) onlyPure self help – older, “retired” versionTwo published RCTs; 2002 and 2005MoodHelper.orgUpdated security, software platform added behavioral TxPure self help (Guided version piloted in case series)Small (n=160) RCT (2009)

Two ODIN TrialsOlder, less sophisticated website (c. 1999)Two RCTs of similar design (N’s = 301, 259):Access to website vs. no accessTAU control condition in both studies2nd trial added either telephone or postcard reminders to return and use the CBT siteEnrolled self-identified “depressed” adults (Mean score on baseline CES-D =~ 30)

ODIN1 and ODIN2 ResultsNo overall benefit for 2002 ODIN11 trialInterpreted as due to low dose, particularly return useModest effect for 2005 ODIN2 trial 2 with reminders to return and use treatment:Small effect size (ES) = .28 sd in entire sampleModerate ES = .55 sd in severely depressed subjectsAt 32 week follow-up 20% fewer ODIN S’s were in the moderately depressed range (56%) compared to TAU (76%)1 Clarke et al (2002). J Med Internet Res,4(3), e14 www.jmir.org/2002/3/e14/ 2Clarke et al. (2005). J Med Internet Res,7(2), e16 www.jmir.org/2005/2/e16/

ControlF(1,523)=4.93, P=.03, ES sd = .28Treatment

Updated: MoodHelper.orgODIN was created in 1999Obsolete programming, securityODIN employed cognitive restructuring onlyMoodHelper was developed in 2005:Added behavioral therapyImproved interactivity, customization, security

MoodHelper Pilot RCTHMO members with depression Dx, servicesMean age 22.6 yrs (range 18-24), 81% female, 82% white160 enrolled, randomized to:Treatment-as-usual (TAU) control conditionTAU + MoodHelper + postcard remindersPatient Health Questionnaire (PHQ-8) at baseline (week 0), and 5, 10, 16, and 32 weeks follow-up

PHQ-8 Outcomes: Total Samplet=-1.97, error df=442, p = .05Overall ES d = .20

PHQ-8 Outcomes: Female onlyt=-1.96, df=363,p=0.05Female only ES d = .42

MoodHelper Pilot Summary~ 20% never used MoodHelper beyond initial session, despite remindersEffects observed even in context of TAU controlHowever, effects modest at best (d=.20 to .42)Reminder: traditional CBT produces an ES of .25 -.35 when compared to other treatments*Combination of traditional CBT + Rx has only modest advantage of ES d = .35 over monotherapy Rx alone** *Gloaguen et al. J Affective Disorders. 1998;49, 59-72.**Cuijpers et al. Depress Anxiety. 2009;26(3):279-88.

Can Small Effects Still be Clinically Significant?ES d = ~.25 for Pure Self-Help, ~.40 for subgroups, ~ 1.00 for Guided Self-HelpAre small, medium effects clinically relevant?For subthreshold Pts, prevent progression into full syndrome?Small average effects still may include some persons with individually medium to large effectsSmall effects may still be useful when (a) delivered at public health scale, and (b) for low costThe “new norm” in era of incremental improvements on TAU, combination treatments (CBT augment to Rx yields d = .35)

Internet Research Challenges Enrollment: often < 5% of approached personsRetention: high dropout, with some studies reporting retention < 10% (we average ~ 75%-85%)High Initial Development CostsFrequent Updating Costs: security, new features, social networking, Twitter, etc.Limited Assessment: usually brief self-report

Curative Features of Internet ProgramsInteractivity: Pt enters scores, data, and information is returnedPt is sent automated text messages, email remindersPersonalization, Customization:Feedback is customized to fit the individual’s dataExample: providing different skills depending on stage of changeExtensive Media, Video

Internet Interventions: A Role in Stepped Care?Well-suited to the initial, low-intensity stages of stepped care modelsTreatments generally arranged from least intensive to progressively more costly and intensiveSeveral variants possible:Progressing from self-help to more traditional treatments Increasing intensity of services just within self-help variants

Hypothetical Stepped Care Model Entry StageTAU Rx + Pure Internet CBTlow-intensity servicesIntermediary StagesTAU Rx + Guided Internet CBTTop StageNewest Rx +/- full course EBT PsychotherapyStage 2: Add Guided Internet CBT to RxStage 3: More intensive & costly treatments (newer antidepressants, face-to-face psychotherapy)Stage 1: Uncomplicated depression cases offered generic antidepressants & a book or Internet CBT

Stage 3: More intensive & costly treatments (newer antidepressants, face-to-face psychotherapy)

Stage 1: Uncomplicated depression cases offered generic antidepressants & a book or Internet CBT

Questions?