The document discusses a web-based platform that provides cognitive behavioral therapy programs for various behavioral health conditions like anxiety, insomnia, depression, and substance use through interactive online modules with clinician support, highlighting the programs' efficacy, security, and ability to improve access and efficiency of care delivery compared to traditional face-to-face therapy.
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