2. Potential Agenda
• Who and what we are
• Description of Web Based CCBT
• Programs and Data
• Platform
• Workflow examples
Web address: www.cobalttx.com
3. Broad Suite of Programs
• Anxiety, phobias, panic attacks
o FearFighter These disorders affect:
• Insomnia and sleep problems
o RESTORE • >25% of all primary
care patients
• Alcohol, substance use and depression • >85% of all behavioral
o SHADE outpatients
• Obsessive Compulsive Disorder (OCD) • Majority of Rx costs
o OCFighter
• Depression
o MoodCalmer and COPE
4. Program Commonalities
• Efficacy
o Developed in academic institutions
o Computerized and on the web
o Proven efficacy in randomized, controlled trials
o Published in peer reviewed journals
• Clinician guided
o Lower level of expertise needed
o Few minutes needed per session
o Can use telemedicine
• Security
o HIPAA
o Patient data transferable to EMR
• Platform
o Client administration
o Clinician administration
5. CBT and CCBT
• Cognitive Behavioral Therapy (CBT)
o Breaks harmful cycle of thoughts and behaviors
o Can improve outcomes in co-morbidities
o First line for insomnia, panic, phobias, OCD (APA)
• Computerized CBT (CCBT)
o Puts 70-95% of therapy (repetitive elements and homework) into
interactive modules
o Allows for broad geographic access
o Increases efficiency: clinician time lowered by 70-100% depending on
diagnosis and treatment
o Allows lower level of clinician/coach: peers, others
o In UK NHS for several years for Panic, Phobias, etc. (NICE)
6. CCBT Experience
• Techniques: efficient communication - video narration,
vignettes, voiceover
• Examples of each:
o Video narration: RESTORE Narration
o Efficient: FearFighter Program Explanation
o Use of Multimedia: Fight or Flight
o Interactivity: MoodCalmer Pleasurable Activities Planner
o Vignettes: SHADE, MoodCalmer, FearFighter
• Weekly sessions replicate traditional therapy structures
7. Efficiencies
• Direct Cost Savings: Cost per unit improvement varies based on software costs and level
of training of “guide” (e.g. at $200 per patient, administered by PhD or MD FearFighter
demonstrates 63% savings; Savings increase quickly with lower price and lower training
level).
• Helping Mental Health Clinicians: One clinician can see many more patients (e.g. with
Restore one PhD has gone from managing 145 patients a year to approx. 650 without
sacrificing outcomes). Non-CBT trained clinicians, including peer counselors and those in
primary care, can support validated CBT programs where appropriate.
• Decreasing “Step ups” in Care: Patients can receive a medication free option and often
avoid long term medications or face-to-face therapy (e.g. referrals for face-to-face
specialty care in a clinic decreased by 66% for insomnia when patients were offered
online program).
• Rural and “Clinically Isolated” Access: No geographic or specialty boundaries – can
work with Tele-Medicine, CBOCs or call-center “guides”.
• Available Immediately: Veterans can access validated options as an alternative or while
they wait for appointments.
8. Data – Brief Overview
• Depression – 52% reduction in symptoms for completers
and 41% ITT.
• Anxiety – 63% reduction in symptoms, works for panic
disorders and phobias including social anxiety and
includes exposure therapy.
• OCD – 3.4 hour reduction in symptoms/week – full
Exposure and Response Prevention (ERP) program.
• Insomnia – 4/5 patients improve – reduces specialty care
by 2/3. Improves workplace performance.
• Alcohol/Drugs – large reductions in drinking and drug
use: hazardous use declines 72% in 12 months.
9. Possible Workflows?
• Immediate Access: Immediately after evaluation, appropriate
patients can have brief visits (5-10 min) and begin with
programs.
o Can combine with telepsych
o May work well for primary care sites
o Can have computers on site [or at home]
• Clinic Sign Up: Signed up in clinic and followed/monitored in
clinic.
• Anonymous: Option for those who are reluctant to access
behavioral health care in-clinic to contact # anonymously.
o Insomnia may be a good fit to engage those who may not view it as a
“mental illness” and therefore may not view the engagement as “therapy”.
10. Workflows?
• Immediate access via phone number: Those who may benefit from
assistance are given # they call. Are signed up and “coached” by
clinicians. Allows for immediate access and minimal impact on
current clinic workflow.
o May work well for primary care sites.
o May work well for families who are now going off site to TriCare vendors.
Given # to call Phone clinician
Patient is • Can begin program signs up and
identified with immediately follow up
insomnia, • Call center can also • Can follow up in clinic
depression, monitor for crisis per traditional SOP
anxiety, etc. • Progress can be
viewed by Clinic
11. Workflows?
• Clinic Sign Up: Signed up in clinic and followed /
monitored in clinic.
o Primary care
o Behavioral
Clinician in clinic Primary or
logs in, assigns specialty clinician
Patient is
username and signs up and
identified with
password follow up
insomnia,
depression, • Can put computers • Can follow up in clinic
in clinics per traditional SOP
anxiety, etc.
• Progress can be
viewed by clinic
12. Workflows?
• Anonymous: Option for those who are reluctant to access
behavioral health care in-clinic to contact # anonymously.
o Insomnia may be a good fit to engage those who may not view it
as a “mental illness” and therefore may not view the engagement
as “therapy”.
Advertisements in Call # and engage
primary care, with clinician
newsletters, etc. operator
• Can have specific • May engage the
Immediately
campaigns for each reluctant available
disorder • Allows for those in
crisis to have another
reason to reach out
13. Insomnia
• 30%-40% say they suffer each year (NIH)
• 10%-15% say they suffer chronically (NIH)
• Increases direct medical costs by $924-$1,143 over a six month period1
• Insomnia causes 2x missed work days and 2.5x errors at work compared to those without
insomnia2
• Treating insomnia improves outcomes in a variety of conditions including depression and heart
disease3
• Relative risk for MDD: 4.04
• Medication for insomnia linked to 1.36 OR for mortality when hypnotic or anxiolytic used in
previous month5
• CBT for sleep, combined with medication, improves remission for MDD from 33.3% to 61.5%6
• Sleep problems facilitate alcohol relapse7
1. Cost Burden of Untreated Insomnia—Ozminkowski et al SLEEP, Vol. 30, No. 3, 2007
2. Insomnia, Who Pays the Costs?—Godet-Cayré et al SLEEP, Vol. 29, No. 2, 2006
3. Clinical Correlates of Insomnia in Patients with Chronic Illness - Arch Intern
Med. 1998;158:1099-1107
4. Breslau, Biol Psy 1994
5. Belleville, C Jour Psy 2010
6. Manber et al SLEEP 2008
7. Brower et al 1998, Alcoholism
14. RESTORETM for Insomnia
• 81% improve
o 43% “Significantly improved”
o 30% receive >1hour additional sleep
• Improvement in fatigue indexes
• Improvement in sleep efficiency
RESTORE with Psychiatric and Medical Comorbidity:
15. Anxiety: Panic and Phobia
FearFighter
• Approximate 50% reduction on panic and phobia scales
o No outcome difference from face-to-face
• Cost per patient (with same outcome) approximately
45% lower
• Cost per unit of improvement 63% lower vs. face-to-face
(when software is $200/pp and by PhD and MD– drops
as price drops and pay grade drops and therefore can go
far lower)
• Clinician time reduced by 73%
• 9 week program plus ability to access ongoing “booster”
Source: NHS Economic Evaluation Database
17. SHADE: Components
• Suicide Screening
o Symptom questionnaire
o Automated notifications
• Education
o Alcohol Vignettes
Identify
Automatic Thoughts
Relaxation
o Drugs distortions
Mindfulness
o Depression Cravings
Planning
Feedback
o CBT Create new
thought
Learn
balanced
Actions
Activities
patterns view
•
o Worksheets
o Relaxation exercises Motivation Cognitive Behavior
o Mindfulness exercises
o Monitoring of use and mood
o Planning for the future
• Homework
o Log and analyze activities
o Monitor and analyze thoughts, feelings and behaviors
o Relaxation exercises
o Mindfulness activities
18. SHADE: Data – Heavy use, 18-34 y.o.
Focus on Binge Drinking, Age 18-34:
• Binge Drinking All Ages (n=342):
o Computer better than all arms(Focused, PCT, BI); No difference from
F2F
o Binge rates decrease: 24% at 6 mos; 30% at 12 mos.
• P values range from 0.001 to 0.032
• Binge Drinking Age 18-34 (n=74)
o Computer: 20% reduction at 6 mos.; 32% reduction at 12 mos.
o Computer better that any focused or brief therapy - no difference from
F2F (p values range from .001-.03)
• Significant finding: Many prefer computer to F2F
Sources: Addiction, 104, 378-388; Unpublished data
19. SHADE: Data - Cannabis
Focus on Cannabis and Hazardous use:
• Hazardous alcohol and/or drug “use days”:
o F2F and Computer no difference (both better than control)
o 6 mos: reduction of 44%; 12 mos: 50%
o P<0.001 at 12 months
• Cannabis use generally:
o F2F and Computer best
o 6 mos: reduction of 58%; 12 mos: 72%
o P<0.001 at 12 months
Sources: Addiction, 104, 378-388; Unpublished data
25. CCBT Workflow
Clinician gives Clinician refers for
“program” Log In “Step Up” care, if
• Patient presents with details to patient •Patient access program necessary
complaint (insomnia, online (home or clinic)
anxiety, etc.) •Follow ups as •Patient/client completes
•Clinician creates new prescribed (PRN, program
account for telephonic, in-person, •Clinician logs in to
• Treatment options patient/client(≈2min) weekly, biweekly, etc. monitor compliance and
discussed progress PRN
Clinician Logs In to Clinician “guides”
“Back End” patient as needed
