G. Karwig 1, M. Maxwell 2, P. Abhyankar 2, F. Harris 2, C. Rummel-Kluge 3, E. Arensman 1, U. Hegerl 3, & PREDI-NU Consortium

Transcription

1 Computerised Cognitive-Behavioural Therapy Interventions: Outcomes of a Systematic Review and Implications for Internet-Based Self-Help Programmes for Depression G. Karwig 1, M. Maxwell 2, P. Abhyankar 2, F. Harris 2, C. Rummel-Kluge 3, E. Arensman 1, U. Hegerl 3, & PREDI-NU Consortium 1 National Suicide Research Foundation, Ireland; 2 University of Stirling, Stirling, UK; 3 University of Leipzig, Germany. Technology for Wellbeing Conference, Dublin, 25 th September /11/2014 slide no 1

2 Background Evidence from meta and systematic reviews has demonstrated that computerised cognitive behavioural therapy (ccbt) interventions can be effective treatments for anxiety and depression. However, besides evidence of effectiveness there is little knowledge to guide the development and delivery (implementation) of such interventions. the adoption of self-help approaches by professionals is limited in many countries & patients adherence to these interventions can represent a significant challenge. Primary aim of review: to identify best-practice recommendations for implementation of self-help e-health technologies to inform the development of a protocol for internet-based self-management of mild to moderate depression in Europe (PREDI-NU project)

3 Method - capturing both the literature on the effectiveness of ccbt (via systematic reviews or meta-reviews) as well as identifying contextual details that may impact on outcomes, uptake and retention, reach/access to the intervention; - identifying key mechanisms or processes involved in implementing the interventions in order to explore not only what works, and for who, but also to identify other lessons learned and gaps in knowledge. - Informed by the Realist approach to reviewing evaluations of complex interventions (Pawson et al., 2004) 21/11/2014 Slide no 3

4 Inclusion/exclusion criteria Inclusion Criteria Adults (25+ years) and young people (15-24 yrs) Exclusion Criteria Children/infants <15yrs Mild-moderate depression: unipolar disorder, dysthymia, endogenous or reactive depression, affective disorder, psychological distress Computer/internet/cd/dvd guided or non-guided self-help based on CBT for treating/managing depression Publication types: systematic reviews or reviews of reviews of effectiveness; peer-reviewed primary studies related to the process of implementation; national guidelines; all languages Study types: all study types; qualitative studies, process evaluations Moderate to severe depression; personality disorders/bipolar disorder; anxiety; postnatal depression; seasonal affective disorder; stress; psychosis; depression related to co morbidities such as diabetes, epilepsy, MS, cancer. CBT based programmes for prevention of depression that are not accessed via the internet/computer/dvd; CBT delivered by a therapist online Publication types: non-peer reviewed articles, case reports, opinion pieces, papers not based on research or meta-synthesis; non-systematic literature reviews; books/book chapters; letters; errata; conference proceedings; dissertations; study protocols/designs Primary effectiveness studies; cost-effectiveness/economic evaluation studies 21/11/2014 Slide no 4

5 PRISMA diagram Total hits selected for full text retrieval 1119 removed based on title & abstract 7 refs added manually (4 by experts + 3 guidelines from internet search) 102 selected for full text retrieval 58 included studies 44 refs removed as met exclusion criteria

6 Types of articles No. of studies Meta reviews and systematic reviews of effectiveness 22 Guidelines 5 Patient experience and attitudes to ccbt 5 Implementation, usage/adherence predictors, provider experience 12 Development of ccbt programmes and feasibility testing 9 Descriptions of ccbt programmes 3 Other 2 Total 58

7 Type and quality of evidence 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs (including cluster RCTs) with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs (including cluster RCTs) with a low risk of bias 1- Well conducted meta-analyses, systematic reviews of RCTs, or RCTs (including cluster RCTs) with a risk of bias 2++ High quality systematic reviews of these types of studies, or individual, non-rcts, case-control studies, cohort studies, CBA studies, ITS, and correlation studies with a very low risk of confounding, bias or chance 2+ High quality systematic reviews of these types of studies, or individual, non-rcts, case-control studies, cohort studies, CBA studies, ITS, and correlation studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal 2- Non-RCTs, case-control studies, cohort studies, CBA studies, ITS and correlation studies with a high risk or chance of confounding bias, and a significant risk that the relationship is not causal 1&2 (++/+/-) Systematic reviews that include evidence from study types 1 and 2. For example, may include RCTs, controlled studies and non-controlled studies. 3 Other studies: Cross sectional studies, non-controlled studies, before and after studies without a ITS design, qualitative studies and other types of evaluations.

8 Meta-reviews, Reviews, and Meta-Analyses Population Adults only 11 Young people only 2 Mixed (Adults and Young people) 7 Life-point not stated 2 Does ccbt work? No. of studies Consistent evidence that ccbt is effective in reducing depressive symptoms (20 reviews; 10 with 1+/++) Strong evidence of effectiveness among Adults Some evidence of effectiveness among Young people As effective as therapist-led CBT Evidence of long term sustainability of effect is mixed and limited. More studies needed to compare ccbt packages for relative effectiveness.

9 Results: What works? Non-guided interventions can be effective if individuals adequately motivated but More evidence that guided are more effective than non-guided However, no clear evidence on optimal length, nature, mode, content of guidance & personnel type required Robust evidence for Beating the Blues, MoodGYM, Colour your Life; no evidence for Cope & Overcoming depression; ODIN not effective

10 Results: For whom does ccbt work better? Mild to moderate depression Self-selecting/media-recruited people versus clinical settings Existing depressive symptoms Well-educated, computer literate Under what circumstances does ccbt work better? More engagement with the material & tasks Prior belief/expectancy that it will reduce depression

11 Results continued: What enhances completion of ccbt material? Ease of access Opportunity to select components/modules Some level of human contact/support Interventions with greater structure and shorter duration Higher initial expectations about ccbt How can implementation of ccbt be improved? Delivering as part of a stepped-care model Testing the program for usability Providing patients with detailed information at referral to enable informed choice Familiarizing GPs with ccbt through information provision Providing GPs with strict and clear referral guidelines

12 Building the bridge with ifightdepression Guidance incorporated as key element of protocol for implementation of tool, with specific guidelines developed regarding provision of guidance Evaluation focus on acceptability of the ifightdepression tool and feasibility of its use, with both professionals and patients Information on the protocol for development and implementation of the tool detailed within journal article submitted for publication, including specific details on implementation and guidance of the tool transparency Standardised approach to implementation of tool and assessment and guidance of patients across different countries 21/11/2014 Slide no 12

13 Future of ccbt? NICE guidelines 2009 recommend use of ccbt within a stepped-care approach: ccbt for people with persistent subthreshold depressive symptoms or mild to moderate depression should: - Include an explanation of the CBT model, encourage tasks between sessions, and use thought-challenging and active monitoring of behaviour, thought patterns and outcomes - Be supported by a trained practitioner, who typically provides limited facilitation of the programme and reviews progress and outcomes 21/11/2014 Slide no 13

14 Thank you! The PREDI-NU project team at its final project meeting in Brussels (2014) 21/11/2014 Slide no 14