Depressed and Anxious Primary Care Patients' Use of an Internet-Delivered Computerized CBT Program

Transcription

1 Depressed and Anxious Primary Care Patients' Use of an Internet-Delivered Computerized CBT Program Bea Herbeck Belnap, DrBiolHum Charles Jonassaint, PhD, MHS University of Pittsburgh School of Medicine

2 Presenter Disclosure Information Online Treatments for Mood and Anxiety Disorders in Primary Care: NIMH R01 MH Agency for Healthcare Research & Quality: PCOR K12HS Speakers bureau/honoraria/advisory board/ownership interest: None

3 : Improving Quality of Primary Care for Anxiety Disorders 5 Telephone-Delivered Collaborative Care Trials : : : Reduce Limitations from Anxiety : Bypassing the Blues

4 Rollman BL, Herbeck Belnap B et al. Psychosomatic Med. 2009; 71:217 Rollman BL, Herbeck Belnap B et al. Gen Hosp Psych. 2003; 25:74 Collaborative Care Care Manager: Telephoned patient over to: - Assess treatment preferences - Impart self-management skills (workbooks) - Promote adherence/adjust pharmacotherapy - Monitor treatment outcomes - Facilitate MHS referral when appropriate Communicated with PCP to: - Provide feedback - Make recommendations for pharmacotherapy

5 Collaborative Care vs. CBT for Depression and Anxiety # Trials Effect Size NNT Collaborative Care ( ) 5.26 CBT (face-to-face) ( ) 2.60 Archer J. et al. Cochrane Database Syst Rev. 2012; 10:CD Cujpers P. et al. Canadian J Psych. 2013; 58:376-85

6 How to meet the need? Increased prevalence Evidence-based treatment Poor access/high cost Increased health disparities

7 Collaborative Care vs. CBT for Depression and Anxiety # Trials Effect Size NNT Collaborative Care ( ) 5.26 CBT (face-to-face) ( ) 2.60

8 Collaborative Care, CBT, & CCBT for Depression and Anxiety # Trials Effect Size NNT Collaborative Care ( ) 5.26 CBT (face-to-face) ( ) 2.60 CCBT Major depression ( ) 2.39 Panic ( ) 2.26 Generalized anxiety ( ) 1.75 CCBT, all ( ) 2.15 Andrews G, et. al. PLoS ONE. 2010; 5:e13196

9 Potential Advantages: CCBT vs. Face-to-Face CBT 1) Convenient 2) Available 24/7 3) Less stigma 4) Reproducible 5) Scalable 6) Similar strong effect size

10 NIMH R01 MH Bruce L. Rollman, MD, MPH Bea Herbeck Belnap, Dr Biol Hum Jordan F. Karp, MD Kaleab Abebe, PhD Armando J. Rotondi, PhD Kenneth J. Smith, MD Michael B. Spring, PhD

11 Computerized CBT (CCBT)

12 Proudfoot J, et al. Br J Psych. 2004; 185: Beating the Blues Usual Care = 114 Patients ES = 0.62; p<0.001 CCBT = 127 Patients

13 Beating the Blues Proudfoot J, et al. Br J Psych. 2004; 185: 46-54

14 Teaching CBT Techniques

15 Video Clips of Case Studies

16 Apply to Own Problems

17 Study Design CCBT+ Internet Support Group N=302 EpicCare BPA Activated at 26 Primary Care Practices 704 Patients Enrolled & Randomized Usual Care N=101 2' Hypothesis CCBT-Alone N=301 1' Hypothesis Eligibility: yo Internet and telephone access PHQ-9 and/or GAD-7 10

18 Enrollment 8/2012-9/2014 EMR Referrals 2,884 Contacted for telephone screen 2,266 (79%) Consented to screen 1,785 (79%) PHQ-9 or GAD-7 10 & eligible 954 (53%) Consented to trial & randomized 704 (74%) Randomized to a CCBT group 603 (86%)

19 Enrollment by Race Race N(%) White 499 (83%) Black/African American 91 (15%) Asian 10 (2%) American Indian/Alaskan Native 2 (<1%) Native Hawaiian/Pacific Islander 1 (<1%)

20 Sociodemographics ALL (N=603) Non-White (N=104) White (N=499) Age, mean (SD)* 42.8 (14.2) 39.1 (13.7) 43.6 (14.2) Male* 21% 13% 22% >High School Ed. 82% 80% 83% Depression-only PD/GAD-only Both 39% 7% 45% 37% 8% 45% 39% 7% 44% PHQ-9, mean (SD) 13.3 (5.0) 14.1 (5.0) 13.1 (5.0) Pharmacotherapy* 88% 76% 90% *Indicates p < 0.05

21 Sessions Started & Completed Non-White (N=104) White (N=499) Started 1 st session** 76% (79) 87% (432) Completed all 8 sessions 32% (25) 43% (186) Sessions completed, mean (SD) 3-months 6-months 4.3 (2.7) 5.0 (2.7) 4.8 (2.5) 5.5 (2.7) **Indicates p < 0.01

22 BtB Sessions Completed Non-White vs. White % Sessions Completed * Of the 480 (83%) patients who started the program

23 Everyone Benefitted from BtB: 50% Decline PHQ-9 63% 60% 60% 56% 61% 67% 64% All p >.05

24 Decline in Average PHQ-9 Scores by Race Average PHQ-9 Score p=.057 Sample Sizes: Non-white White Sessions

25 Decline in Average GAD-7 Scores by Race Average GAD-7 Score Mean session completed Non-white white Sample Sizes: Non-white White Sessions

26 Limitations Online Treatments Trial ongoing - Study blind in-place Patient self-entered symptoms - Treatment arms combined - Usual Care not (yet) included - Medication use not examined

27 Conclusions 1 care patients will engage with CCBT. Self-reported symptom decline were similar across race, age and gender. Trial results (pending) to determine if: Blinded symptom scores show similar decline across sub-groups ISG improves clinical outcomes

28 Future of CCBT Tailored programs > Engagement - Culturally relevant materials - Customization (Medical conditions, Health Behaviors) Technologic improvements - Mobile and tablet (ver. 2.0) - Adaptive designs/predictive analytics - Internet Support Groups - Electronic health record integration

29 Questions?

30 Predictors of Engagement Logit predicting (1=Completers vs. 0=Non-completers), adjusting for age and gender ñphq-9 score ê probability of BtB completion (b= -.11; p=.02) ñgad-7 score ê probability of BtB completion (b= -.11; p=.04)

31 Among BtB Completers: 50% Decline GAD-7

32 Among BtB Completers: 50% Decline GAD-7