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RAI XXIV.09.Internet


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Instituto Nacional de Psiquiatría (México)
XXIV Reunión Anual de Investigación
6 de octubre del 2009
Intervención por Internet para la depresión. Efectos del programa y obstáculos para su difusión
Presenta: Dr. Gregory N. Clarke

Published in: Health & Medicine
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RAI XXIV.09.Internet

  1. 1. Internet CBT for DepressionModest Effects, Population-Level Potential, Solutions to Dissemination Barriers<br />Greg Clarke PhD<br />Kaiser Permanente<br /> Center for Health Research (CHR)<br />Portland Oregon<br />
  2. 2. My Recent Research Activities, Interests<br />Youth depression CBT, pharmacotherapy<br />Targeted prevention of youth depression <br />Insomnia CBT for adolescents<br />Dissemination of mental health evidence-based treatments (EBTs)<br />Internet CBT for adult depression<br />Focus of today’s talk<br />
  3. 3. Overview of Talk<br />Gaps in depression care<br />Low availability (Reach), poor quality (Implementation)<br />Low intensity interventions as part of solution<br />Bibliotherapy interventions generally<br />Internet-delivered CBT in particular<br />Review of literature, our specific randomized trials<br />Implementation models, issues<br />Stepped care, population level dissemination<br />
  4. 4. Gaps in Depression Care:Quality Improvement is Needed!<br />High prevalence, 2-3x risk in females<br />Significant psychiatric and social morbidity<br />Greatly increased risk of completed suicide <br />Poor quality of life, increased cost to society<br />Several strong evidence-based treatments (EBTs): Antidepressants, CBT, IPT, etc.<br />And yet -- poor quality of care in community <br />
  5. 5. Traditional Depression Treatments: Poor Reach (lack of availability)<br />Depression EBTs are often not available to persons needing them in the community<br />Stigma, poor follow-though with referrals<br />Structural or systemic barriers (e.g., few mental health specialists co-located with primary care services)<br />Higher costs of specialty MH care <br />Insufficient capacity to deliver high quality care <br />
  6. 6. Feasibility of DisseminatingTraditional Psychotherapy<br />Can’t we address low accessibility by promoting wider dissemination of traditional treatments?<br />US trends in recent decades:<br />Declining psychotherapy rates<br />But higher antidepressant rates<br />Unlikely to see ‘public health’ dissemination of traditional, face-to-face psychotherapies<br />Might be easier in Mexico, with its universal healthcare & centralized public health<br />
  7. 7. Traditional Depression Treatments: Poor Implementation<br />Even when evidence-based treatments (EBTs) are available they are often poorly delivered (low Implementation or Adherence)<br />Low provider adherence to quality guidelines<br />Due to limited time, training gaps, reimbursement limits<br />Low patient adherence to dosing or behavioral instructions<br />Due to side effects, costs, ambivalence, stigma<br />
  8. 8. Barriers to Increasing Reach, Implementation of Traditional Treatments<br />Pharmacotherapy<br />Adverse side effects<br />Patient ambivalence<br />Premature discontinuation, poor adherence<br />Small effect above placebo?<br />With generic SSRIs, cost is not so much of a problem<br />Face-to-Face Psychotherapy<br />Cost, reimbursement limits<br />Few trained in EBT therapies<br />Few MH specialists in some settings (e.g., rural areas)<br />Discomfort with disclosure<br />Stigma<br />
  9. 9. Low Intensity Treatments: a Partial Solution to Dissemination Problems?<br />Low intensity treatments may have a role to play in addressing the gap in depression care<br />Several variants, with or without supportive therapist contacts:<br />Bibliotherapy – books, pamphlets<br />DVDs, video<br />Computerized interventions (most often CBT)<br />Internet-delivered interventions (most often CBT)<br />
  10. 10. Different Types of Low Intensity Therapy<br />Pure Internet CBT (aka self-administered therapy)<br />Bibliotherapy, video, Internet site with no or very little direct contact with live therapist or coach<br />Guided Internet CBT (aka minimal contact therapy)<br />Instructional materials + modest contact with live therapist or coach, often by telephone or email rather than in-person<br />Typically 2 to 4 cumulative hours of therapist contact vs. 12 to 26 hrs contact in traditional EBT psychotherapies<br />
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  14. 14. MoodHelper: 4 Content Modules<br />Improve Your Mood <br />Tutorials in behavioral or cognitive therapy<br />We consider this the “curative” element<br />Depression Facts<br />Measure Your Mood<br />Journals<br />Private “blog” which could be selectively published for viewing by others<br />
  15. 15. Customization:<br />1of 3 pages of preference questions<br />
  16. 16. Customization:<br />Pts add or remove activities from ranked list<br />
  17. 17. Customization:<br />These boxes allow Pts to personalize goals, rewards<br />
  18. 18. This Contract summarizes all the choices made by the Pts on the previous pages<br />
  19. 19. Interactivity:<br />Pts are asked to return and record mood and activities for each day<br />
  20. 20. Daily mood and activity data is graphed to see patterns<br />Narrative feedback provided is on <br />subsequent pages (“You never report <br />doing two fun activities. We suggest <br />dropping these and adding 2 more.”)<br />
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  22. 22. Low-Intensity Treatments may Improve Reach<br />Low Intensity EBTs (particularly Internet, books) can be used at home, are anonymous, are available 24/7 <br />More individuals potentially served, at a lower cost<br />May be best—or only—option for rural areas, or anywhere MH specialists are in short supply<br />Are some patients who decline traditional treatments those who would prefer low-intensity CBT as 1st step?<br />More comfortable with anonymity, no face-to-face disclosure?<br />“Gateway” experience to prepare for traditional therapy?<br />
  23. 23. Is Internet Access Good Enough?<br />Source: Pew Internet & American Life Project, August 2008, except * December 2008<br />
  24. 24. Spanish Internet CBT Site – Coming Soon<br />We are currently translating the Internet CBT program into Spanish:<br />Bilingual, bicultural telephone coaches<br />Translation led by Nangel Lindberg PhD<br />Researcher, co-investigator at our Center<br />Trained in clinical psychology at UCLA<br />Native of Mexico Distrito Federal (Mexico City)<br />Many years experience translating from English to Spanish<br />Website will be tested in future randomized trial<br />
  25. 25. Do Bibliotherapy EBTs ‘Compete’ with Traditional Treatments?<br />Internet interventions are not meant to replace or directly compete with traditional treatments<br />Despite this, some trials have found that Internet CBT may yield effects equal to traditional Tx’s<br />Our view: these alternatives occupy different niches in the progression of treatment intensity<br />See stepped care models later<br />
  26. 26. Is CBT the only Viable Approach for Internet Interventions?<br />Most, or perhaps all, Internet mental health interventions are based on CBT<br />Other approaches should work equally well if:<br />They can be delivered in a psycho-educational format<br />If they have a set of guidelines and skills to train<br />Examples – not an exhaustive list: <br />Acceptance and Commitment Therapy (ACT)<br />Dialectical Behavior Therapy (DBT)<br />Motivational Enhancement Therapy (MET)<br />
  27. 27. Diminished Therapeutic Relationship vs Anonymity<br />Traditional psychotherapists dismiss Internet therapy due to the lack of face-to-face contact:<br />Reduces ability to read nonverbal cues<br />May diminish or eliminate therapeutic relationship<br />However, 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<br />
  28. 28. Summary of Best ‘Fit’ for Internet EBTs<br />Monotherapy for persons with less severe disorder<br />As augmentation to traditional treatments (combo Tx)<br />The early stages of a stepped care protocol <br />“Bridging” care while waiting for traditional treatment?<br />For persons not ready for—or uncomfortable with—traditional face-to-face therapy <br />A low risk, low demand way to test the waters?<br />Where mental health specialists are in short supply <br />For population-scale dissemination<br />
  29. 29. Research on Internet CBT<br />
  30. 30. Effects of Internet CBT<br />Meta-analyses of Internet CBT <br />Effect Size (ES) d = 0.27 to 0.50 range<br />Larger effects when compared to waitlist<br />Smaller effects when compared to active control conditions<br />Our 2005 and 2009 trials<br />ES’s of d = .28 and .20, respectively, in the full samples<br />Compared to a “strong” control condition called treatment as usual (TAU), consisting mainly of antidepressants +/or face-to-face psychosocial (therapy) visits<br />
  31. 31. Relative Effects of Pure vs Guided Internet Therapy<br />Only one study has directly compared Pure versus Guided Internet CBT (for social phobia) <br />A large effect (ES of ~ d = 1.00) for Guided Bibliotherapy<br />A small-medium ES of d =.38 for Pure Bibliotherapy<br />Meta-analyses find similar results across studies<br />Guided Bibliotherapy seems to be more clinically potent than Pure Bibliotherapy <br />However, it is more costly than Pure Bibliotherapy<br />
  32. 32. Direct Costs: Traditional Psychotherapy vs. Guided vs. Pure Bibliotherapy CBT<br />Costs per individual Pt. Staff salary, fringe, overhead figured @ $70/hr. <br />*few studies so far, most targeting anxiety<br />
  33. 33. Indirect Cost Advantagesof Internet Interventions<br />Patient Cost-Time Advantages:<br />Less time spent traveling to clinics, waiting, medical visits, and participating in intervention<br />Fewer lost work hours<br />&lt;Pt cost of Internet access is a disadvantage&gt;<br />Societal, Organizational Cost Advantages:<br />Reduced need for office space, facility costs, infrastructure<br />More widespread depression treatment = reduced unemployment, retained human capital, more tax revenue?<br />Lower rates of depression in offspring?<br />
  34. 34. Our Two Internet CBT Programs<br />ODIN<br />Overcoming Depression on the InterNet<br />Cognitive restructuring (CR) only<br />Pure self help – older, “retired” version<br />Two published RCTs; 2002 and 2005<br /><br />Updated security, software platform <br />added behavioral Tx<br />Pure self help (Guided version piloted in case series)<br />Small (n=160) RCT (2009)<br />
  35. 35. Two ODIN Trials<br />Older, less sophisticated website (c. 1999)<br />Two RCTs of similar design (N’s = 301, 259):<br />Access to website vs. no access<br />TAU control condition in both studies<br />2nd trial added either telephone or postcard reminders to return and use the CBT site<br />Enrolled self-identified “depressed” adults (Mean score on baseline CES-D =~ 30)<br />
  36. 36. ODIN1 and ODIN2 Results<br />No overall benefit for 2002 ODIN11 trial<br />Interpreted as due to low dose, particularly return use<br />Modest effect for 2005 ODIN2 trial 2 with reminders to return and use treatment:<br />Small effect size (ES) = .28 sd in entire sample<br />Moderate ES = .55 sd in severely depressed subjects<br />At 32 week follow-up 20% fewer ODIN S’s were in the moderately depressed range (56%) compared to TAU (76%)<br />1 Clarke et al (2002). J Med Internet Res,4(3), e14 <br />2Clarke et al. (2005). J Med Internet Res,7(2), e16<br />
  37. 37. Control<br />F(1,523)=4.93, P=.03, ES sd = .28<br />Treatment<br />
  38. 38. Updated:<br />ODIN was created in 1999<br />Obsolete programming, security<br />ODIN employed cognitive restructuring only<br />MoodHelper was developed in 2005:<br />Added behavioral therapy<br />Improved interactivity, customization, security<br />
  39. 39. MoodHelper Pilot RCT<br />HMO members with depression Dx, services<br />Mean age 22.6 yrs (range 18-24), 81% female, 82% white<br />160 enrolled, randomized to:<br />Treatment-as-usual (TAU) control condition<br />TAU + MoodHelper + postcard reminders<br />Patient Health Questionnaire (PHQ-8) at baseline (week 0), and 5, 10, 16, and 32 weeks follow-up<br />
  40. 40. PHQ-8 Outcomes: Total Sample<br />t=-1.97, error df=442, p = .05<br />Overall ES d = .20 <br />
  41. 41. PHQ-8 Outcomes: Female only<br />t=-1.96, df=363,p=0.05<br />Female only ES d = .42<br />
  42. 42. MoodHelper Pilot Summary<br />~ 20% never used MoodHelper beyond initial session, despite reminders<br />Effects observed even in context of TAU control<br />However, effects modest at best (d=.20 to .42)<br />Reminder: traditional CBT produces an ES of .25 -.35 when compared to other treatments*<br />Combination of traditional CBT + Rx has only modest advantage of ES d = .35 over monotherapy Rx alone** <br />*Gloaguen et al. J Affective Disorders. 1998;49, 59-72.<br />**Cuijpers et al. Depress Anxiety. 2009;26(3):279-88.<br />
  43. 43. Can Small Effects Still be Clinically Significant?<br />ES d = ~.25 for Pure Self-Help, ~.40 for subgroups, ~ 1.00 for Guided Self-Help<br />Are small, medium effects clinically relevant?<br />For subthreshold Pts, prevent progression into full syndrome?<br />Small average effects still may include some persons with individually medium to large effects<br />Small effects may still be useful when (a) delivered at public health scale, and (b) for low cost<br />The “new norm” in era of incremental improvements on TAU, combination treatments (CBT augment to Rx yields d = .35)<br />
  44. 44. Internet Research Challenges <br />Enrollment: often &lt; 5% of approached persons<br />Retention: high dropout, with some studies reporting retention &lt; 10% (we average ~ 75%-85%)<br />High Initial Development Costs<br />Frequent Updating Costs: security, new features, social networking, Twitter, etc.<br />Limited Assessment: usually brief self-report <br />
  45. 45. Curative Features of Internet Programs<br />Interactivity: <br />Pt enters scores, data, and information is returned<br />Pt is sent automated text messages, email reminders<br />Personalization, Customization:<br />Feedback is customized to fit the individual’s data<br />Example: providing different skills depending on stage of change<br />Extensive Media, Video<br />
  46. 46. Internet Interventions: A Role in Stepped Care?<br />Well-suited to the initial, low-intensity stages of stepped care models<br />Treatments generally arranged from least intensive to progressively more costly and intensive<br />Several variants possible:<br />Progressing from self-help to more traditional treatments <br />Increasing intensity of services just within self-help variants<br />
  47. 47. Hypothetical Stepped Care Model <br />Entry Stage<br />TAU Rx + Pure Internet CBT<br />low-intensity services<br />Intermediary Stages<br />TAU Rx + <br />Guided Internet CBT<br />Top <br />Stage<br />Newest<br /> Rx +/- full course <br />EBT Psychotherapy<br />Stage 2: Add Guided Internet CBT to Rx<br /><ul><li>Stage 3: More intensive & costly treatments (newer antidepressants, face-to-face psychotherapy)
  48. 48. Stage 1: Uncomplicated depression cases offered generic antidepressants & a book or Internet CBT</li></li></ul><li>Questions?<br />