Les «E-Therapies» en prévention du suicide : de quoi ont-elles l air, fonctionnent-elles et quelles sont les avenues pour la recherche?

Transcription

1 Les «E-Therapies» en prévention du suicide : de quoi ont-elles l air, fonctionnent-elles et quelles sont les avenues pour la recherche? Professor Simon Hatcher The University of Ottawa

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3 What do they look like?

4 E-therapies 1. First generation books on-line 2. Second generation some on-line interaction fill in questionnaires, answer quizzes, learning by gaming (SPARX) 3. Third generation integration with mobile phones/ /smart devices 4. Fourth generation smart environments and mobile therapist

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11 Benefits of e-therapies Convenient for users (access from home, no waiting lists) Can be tailored for specific groups Addresses work force problems Cost effective (?)

12 Problems with new technologies Reinforce inequalities access and language Limited evidence of effectiveness Ethics of monitoring Rapidly outdated Privacy and risk issues Seductive (!)

13 Do they work? Recommended by NICE for mild to moderate depression and anxiety But evidence not strong and in non-clinical populations.

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15 National depression initiative Reduce stigma Educate GP s guidelines, training John Kirwan Depression.org.nz Social marketing E-therapy for mild to moderate depression Telephone help line

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19 #1 #2 #3 CRISE - SUMMER INSTITUTE MONTRÉAL Journal Lesson Activity 13,020 2,350 1,700 1,100 1,200 #6 3, June 2010 to July ,000 visitors 20, 000 registered with The Journal 13,020 active users

20 PHQ-9 CRISE - SUMMER INSTITUTE SCORES MONTRÉAL GIVEN AT START, MIDWAY AND END Sample completing end PHQ-9 score PHQ-9 SCORE INITIAL SCORE MIDWAY SCORE END SCORE (392) % Under 10: Not depressed to 14: Mild depression to 19: Moderate depression or more: Severe depression Mean score: % decrease 56% decrease overall

21 CHANGE IN PHQ-9 FROM START TO END CHANGE IN PHQ-9 FROM START TO END Improvement Improvement 10 to Improvement 5 to Improvement 1 to No change 3.3 Worsening 1 to Worsening 5 or more 1.5 Sample completing end PHQ-9 score (392) %

22 Reasons for not continuing Those who did not complete all six Those who registered but did not begin REASONS FOR NOT CONTINUING (101) (68) % % Not had time Needed more support to keep going Satisfied with what had got 32 NM Wanted to be able to skip some sessions Felt too unwell Didn't feel able to do what was being asked of me 26 9 Because of Journal no longer feeling depressed 24 NM Couldn't be bothered For reasons nothing to do with Journal am no longer feeling depressed 18 NM No longer depressed NM 31 Journal not working properly technical problems Sessions take too long Did not know or forgot how to get back into Journal to continue Videos were downloading too slowly 12 NM Had other computer problems Did not receive NM 16 Did not know how to continue once received NM 13 Improvements did not last long enough to be worth continuing 11 NM Doing Journal made me feel more depressed 11 NM Did not think what done so far was useful 10 NM Did not think it would be useful 8 10 Too many sessions required to complete Journal 7 6 Content didn't interest me 5 4 None of these/ not answered 1 4 NM = Not measured; Circled items are most mentioned main reason

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24 CRISE - Appeal SUMMER INSTITUTE of MONTRÉAL option for integrating The APPEAL OF DATA BEING AVAILABLE TO PRACTICE Total* GPs Journal Practice nurses Primary mental health (135) (69) (30) (36) % % % % Appeals a lot (4) Appeals somewhat (3) Appeals a little (2) Does not appeal (1) Don't know Mean * Excludes receptionists

25 What is the research agenda? Address different levels of suicide prevention patients, family, clinicians Community e-therapies Education for gatekeepers Decision support for primary care Clinican supported computer care in primary care Secondary care decision support, more intense computer supported care, home monitoring

26 Effectiveness studies needed RCT s (must include ITT analysis, report adverse effects, economic analysis) Do RCT s at primary care level as that is where most people present Where do e-therapies fit within stepped care Comparisons with self-help, placebo and therapist delivered therapy Head to head comparisons of different e-therapies

27 How do they work (or not work) Acceptability Feasibility (access, low tech alternatives) Minority preferences How to interact with humans to produce change in behaviour Reasons for drop outs What training is needed for clinicians to use computerised therapies Privacy, risk and ethical issues