Why CCBT ?
Computerised CBT: Interventions For Depression
• Increasing Access (numbers, populations)
• But digital divide
Stuart Linke
• Risk that ccbt is offered instead of therapy
• Innovation (new types of intervention)
• Review what is currently available • But risk of deployment without good evidence
• Quick(ish) look at the evidence
• Cultural impact (education, democratisation, social
• Integrating CCBT in stepped care support/networking)
• Privacy concerns
• Social risks – (peer pressure, cyber bullying)
• Share some thoughts about developing a new
intervention
Beating The Blues (BtB)
e-couch
• Tailored information – route determined by
questionnaires and self ratings
• Education
• Self–help tool kit
• Personalised work books
• Now being extended to include modules for the
Generalised Anxiety Disorder and Social Anxiety
Overcoming Depression Is there an evidence base?
5 areas approach
Chris Williams
Health Technology Appraisal (2006)
NICE “Gold Standard”
• Found two RCTs (one unpublished) and one non-
comparator trial (unpublished) that met NICE criteria
“for a treatment to claim efficacy it must have….
• Decision based on one RCT of Beating The Blues
• a definitive RCT and (Two authors declared they were minority partners in the commercial
exploitation of Beating The Blues, two that they were occasional
consultants and one was employed by Ultrasis)
• an independent replication…..by researchers with no
allegiance to the therapeutic approach”
Cost Effectiveness (McCrone et al, 2004)
Beating The Blues BtB cost effective compared to TAU.
Design Sample Primary Drop-out Intention to • However
Outcome Treat Analysis – No comparison made with other low cost methods of delivering
CBT e.g.
RCT Primary ES=0.65 36% at ES=0.2
• Groups
BtB vs TAU Care (BDI) 6 • Bibliotherapy
(n=274) months • Free Internet based programmes
Naturalistic Moderate 0.6 47% 0.29
• Costing of facilitated (supported) access to BtB and overheads
Trial Depression reduction reduction probably underestimated.
(n= 219) (CORE-
OM) • Cost effectiveness assumes maximum efficiency (e.g. few missed
sessions, consistent referral rate, low attrition) in routine practice
• Current license cost of BtB is the similar to a full-time worker
Design Sample Primary Drop-out Intention to
MoodGym Outcome Treat Analysis
RCT 343 referrals BDI
Design Sample Primary Drop-out Intention to Internet 117 (34%) Web support
Outcome Treat Analysis intervention with randomised improved
and without web outcomes
RCT Recruited by Depression 3 months MoodGym and
based support (n=85) but no
•MoodGym survey Questionnaire = 17% Blue Pages
difference at 6
•Blue Pages (n= 525) same but better
month follow-up
than control
•Control (n-71)
(6 weekly
All showed •Cognitive therapy 45 referrals Hamilton and
telephone 12 months
improvement •Computer for treatment BDI
contacts) = 38%
assisted cognitive Both active
Full automation 2794 79.6% therapy conditions
(no contacts) participants superior to
•Wait list control
control at 3 and
6 months follow-
up
Barriers to the uptake of CCBT Anderson and Cuijpers
Editorial Brit Jnl Psychiatry (2008)
Waller and Gilbody 2008
Systematic review of quantitative and qualitative • Is it really Depression?
evidence – Most studies are self-report and not clinician diagnosed
– Likely that community screening picks up sub-clinical symptoms
– More a public health intervention rather than a clinical tool
– Of those entering a trial 79% complete and of those 56% use the
intervention as intended
• Service delivery
– Trend for people in the CCBT arm twice as likely to drop out – Drop outs can be substantial outside research studies
– Interventions work better with support
– Participants rate the interventions highly on satisfaction, content,
clarity and usefulness • Is it enough?
– Help seeking for regular CBT tends to increase after online CBT
– Therapists raised concerns about potential harms, effectiveness
and compliance
Conclusions Beating The Blues should be part of
Stepped Care
• Research is at an early stage
– Few outcome studies with equivocal results
– Very little process research NICE
• Acceptability is questionable – evidence of high drop out
rates in trials and in community settings …..these websites may be used as
an adjunct to any of the steps within
a stepped care model and health
professionals providing interventions
• Are the interventions suitable for a clinical population? to people with depression and anxiety
should be encouraged to offer access
to these websites as an adjunct to
• Is there a professional consensus about their use? BABCP
evidence based approaches.
Step 1 Step 2 Step 3 Step 4
Low Mood Moderate Major Severe Depression &
Symptoms Depressive “Double Depression”
Episodes
Course Fluctuating Fluctuating Time limited/ Recurrent/Relapsing/
multiple Persistent
episodes
NICE Watchful Waiting Brief CBT CBT MBCT for relapse
Guidance (8 sessions) (16 sessions) prevention
Low
IAPT Intensity High Specialist Treatment
Intensity
CCBT Free access Facilitated access email
(e.g. “Mood (e.g “Beating The groups
Gym”, “Living Blues”)
Life To The
Full”)
Barriers High drop out Limited access Few groups/ Nothing Available
rate – “digital unknown drop out variable
divide” rate benefits
Developing a new internet intervention “….unipolar depression is a chronic,
“….unipolar depression is a chronic,
for recurrent depression lifelong illness, the risk for repeated
lifelong illness, the risk for repeated
episodes exceeds 80%, patients will
episodes exceeds 80%, patients will
Features experience an average of 4 lifetime
experience an average of 4 lifetime
• Approach suitable for “Long Term Conditions” major depressive episodes of 20 weeks
major depressive episodes of 20 weeks
duration each” (Judd, 1997)
duration each” (Judd, 1997)
• Specific content
• Collaborative care model – active follow-up
• Distinctive “voice” suited to the user group guided by a
psychological model
• Make use of “social networking” capacities and
developments in interactive technologies.
• Language and Navigation
User criteria for Internet Interventions for long- – Jargon is fine (and welcome) if explained (don’t over
term conditions simplify)
– Tone
• Good quality information • no nonsense – tell it how it is
– trustworthiness • authoritarian but friendly
– opportunity to “drill down” – No lengthy log-in
– transparency about status of information – Easy navigation
– practical • Interactivity
– shared personal experiences (forums, chat rooms, – Tailoring
blogs) – Self-assessment questionnaires
– up to date – Online support groups
– appearance – not too busy but not too tabloid – Ask the expert sessions
GP Communications Module
Communications Module • Automated feedback to GP of
– Website Use
– Questionnaire scores/rating scales
Behavioural interventions (similar to supervision module of PC-MIS)
Tailored Behavioural Activation – Prescriptions
Information Exercise – Sick/Fit notes
Medication
Psychological
• Messages to user
Nutrition Interventions – From GP/surgery
Support services
Peer support (moderated) – Copy of system communications to GP
Chatroom, listserve,
facebook, “psychspace”
• Transparency/permissions/ethics/governance
Implicit psychological models underpinning CCBT programmes CBT for Chronic Depression (Moore and Garland)
Standard cognitive triad Chronic cognitive triad
Step 2/Step 3 Step 3/Step 4
Standard CBT (Beck) Specialist CBT
self motivated highly avoidant
accessible cognitions meta cognitive processes
cognitive triad chronic depressive triad
maintained by cognitive “evolutionary” model
distortions
Standard CBT interventions “Third wave” interventions
Psychological Features - CBT
• Engaging with avoidance Questions
• Behavioural
• Emotional
• What will enable people to use an Internet
• Cognitive Intervention while they are depressed?
• Focus on specific beliefs about depression
• Attention to pacing and persistence
• Which model of depression (medical, social,
• Attention to social & systemic factors psychological) makes most sense to people with
chronic depression?
• Reducing self-critical thinking
• Compassionate mind training
• Self acceptance • What tone of voice is best?
• Mindfulness (reducing downward mood spirals)
Summary
• The way CCBT is being deployed is not consistent
with all the evidence. OR
• Current CCBT interventions for depression may
not address the needs of some clinical groups
• Process research into a different type of
Over to you……………….
intervention is required.