Using new information and communication technologies for covering mental health needs worldwide

Transcription

1 Using new information and communication technologies for covering mental health needs worldwide Dr. phil. Eva Heim, Psychiatrische Dienste Solothurn Prof. Dr. Thomas Berger, University of Bern

2 Challenges in global mental health Scarcity of available resources Inequities in their distribution Inefficiencies in their use Stigma about mental disorders

3 Increasing evidence It s time for disruptive innovation in psychotherapy Simon & Ludman (2009). The Lancet, 374. Is Internet treatment for depressive and anxiety disorders ready for prime time? Andrews et al. (2010). The Medical Journal of Australia, 192. New treatment approaches: integrating new media in the treatment of war and torture victims Knaevelsrud et al. (2007). Torture, 17.

4 By increasing access and lowering costs, new communication technologies could provoke some much-needed disruptive innovation in psychotherapy.

5 By increasing access and lowering costs, new communication technologies could provoke some much-needed disruptive innovation in psychotherapy.

6 Increasing evidence It s time for disruptive innovation in psychotherapy Simon & Ludman (2009). The Lancet, 374. Is Internet treatment for depressive and anxiety disorders ready for prime time? Andrews et al. (2010). The Medical Journal of Australia, 192. New treatment approaches: integrating new media in the treatment of war and torture victims Knaevelsrud et al. (2007). Torture, 17.

7 Internet treatment programs for anxiety and depressive disorders are becoming available and offer costeffective alternatives to face-to-face treatment with medication or cognitive behaviour therapy.

8 Internet treatment programs for anxiety and depressive disorders are becoming available and offer costeffective alternatives to face-to-face treatment with medication or cognitive behaviour therapy.

9 Increasing evidence It s time for disruptive innovation in psychotherapy Simon & Ludman (2009). The Lancet, 374. Is Internet treatment for depressive and anxiety disorders ready for prime time? Andrews et al. (2010). The Medical Journal of Australia, 192. New treatment approaches: integrating new media in the treatment of war and torture victims Knaevelsrud et al. (2007). Torture, 17.

10 The Internet provides a protected environment where participants can easily control and regulate the degree of intimacy they want to share without the fear of real-life judgment, rejection, or devaluation.

11 The Internet provides a protected environment where participants can easily control and regulate the degree of intimacy they want to share without the fear of real-life judgment, rejection, or devaluation.

12 Information and communication technologies in psychotherapy Internet-based therapy Computer-assisted therapy Smartphone-assisted therapy

13 Amount of therapist-support Low Unguided self-help Middle Guided self-help High , Chat, Skype

14 Effectiveness of guided self-help for anxiety and depression Meta-analysis (2011): Overall effect size d= 0.02, in favour of guided self-help when compared to face-to-face therapy At follow-up (up to 1 year) no significant difference was found No significant difference was found between the drop-out rates in the two treatments formats Cuijpers P, Donker T, van Straten A, Li J, Andersson G (2010) Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies. Psychological Medicine 40:

15 Guided vs. unguided self-help for the treatment of depression 2 Meta-analyses (2007, 2009): Unguided internet-based treatment is less effective (d=.24) than guided internet-based treatment (d=.61 resp. 1.14) Spek, V. et al. (2007). Internet-based cognitive-behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychological Medicine, 37, Andersson, G & Cuijpers P. (2009). Internet-based and other computerized psychological treatments for adult depression: A metaanalysis. Cognitive Behaviour Therapy; 38, Direct experimental comparison (Berger et al., 2011): Effect size higher for guided self-help (d=.66) than for unguided self-help (d= 1.14). Direct comparison showed no statistically significant difference but a tendency in favour of guided self-help. Berger T, Hämmerli K, Gubser N, Caspar F. (2011). Internet-Based Treatment of Depression : A Randomized Controlled Trial Comparing Guided with Unguided Self-Help. Cognitive Behaviour Therapy; 40,

16 Guided self-help for depression Developed by an enterprise (GAIA AG, Hamburg, Germany) Independent evaluation by University of Bern; no interests to declare Already evaluated in an unguided version (deprexis & TAU significantly superior to waitlist & TAU; Meyer et al., 2009)

17 10 content modules, consistent with a cognitive-behavioral model: (1) psychoeducation, (2) behavioral activation, (3) cognitive modification, (4) mindfulness and acceptance, (5) interpersonal skills, (6) relaxation, physical exercise and lifestyle modification (7) problem solving, (8) expressive writing and forgiveness, (9) positive psychology interventions, (10) dreamwork

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19 dialogue-based, interactive, responsive

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21 Internet-based therapy for the treatment of PTSD Comparison of Interapy with waiting list, d = 1.40 Greater reduction of co-morbid depression and anxiety in treatment condition than in the waiting list condition. These effects were sustained during the 3-months follow-up period. High ratings of the therapeutic alliance and low dropout rates indicated that a positive and stable therapeutic relationship could be established online. Knaevelsrud, C. & Maercker, A. (2007). Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial. BMC Psychiatry, 7, 13.

22 Did you miss face-to-face communication with your therapist, for example with regard to support and instructions? No Yes I don't know

23 How did you experience the fact being treated through the Internet instead of face-to-face? Pleasant Unpleasant I don't know

24 What was the contact between you and your therapist like? Personal Impersonal I don't know

25 Chinese My Trauma Recovery

26 Chinese My Trauma Recovery Urban context: 90 survivors of different trauma type post-treatment d= month follow-up d=0.87 Rural context: 93 survivors mainly of the 2008 Sichuan earthquake post-treatment d= month follow-up d=0.99 Wang, Z.; Wang, J.; Maercker, A. (2013). Chinese My Trauma Recovery, A Web-Based Intervention for Traumatized Persons in Two Parallel Samples: Randomized Controlled Trial. Journal of Medical Internet Research, 15(9), e213

27 Interapy for traumatized patients in Iraq Easily implemented Little psychological or medical training needed Accessible for large number of people Adaptable to the environment regarding safety Low cost Privacy for victims Knaevelsrud, C.; Wagner, B; Karl, A. & Mueller J. (2007). New treatment approaches: integrating new media in the treatment of war and torture victims. Torture, 17(2),

28 Who are the users? Example 1: Depression & Anxiety No difference between Internet and outpatient clinic in terms of severity of symptoms Internet clinic sample more consistent with the national sample in terms of age and sex Internet and outpatient clinic samples showed higher educational levels than the national sample Employment status was similar across groups Titov, N.; Andrews, G.; Kemp, A. & Robinson, E. (2010). Characteristics of Adults with Anxiety or Depression Treated at an Internet Clinic: Comparison with a National Survey and an Outpatient Clinic. PLoS ONE 5(5), e10885.

29 Who are the users? Example 2: Smoking cessation Participants were similar to community samples of smokers and smokers enrolled in traditional, face-toface smoking cessation programs in terms of gender, age, education, nicotine dependence, and number of cigarettes smoked currently. Smoking patterns were very similar across regions of the world Barrera; A.; Pérez-Stable, E; Delucchi, K.; Muñoz, R. Global reach of an Internet smoking cessation intervention among Spanishand English-speaking smokers from 157 countries. Int J Environ Res Public Health, 6(3),

30 Internet interventions can be used... When no other interventions are available For patients who cannot travel to clinics due to distance, physical limitations, time limitations, or economic limitations While patients are on waiting lists During routine treatment, as an adjunct After treatment, to prevent relapse or recurrence For patients who fear stigma For patients whose providers do not speak their language To extend health care beyond treatment into prevention Muñoz R. (2012). Using evidence-based internet interventions to reduce health disparities worldwide. J Med Internet Res, 12, e60.

31 Smart phones Text-message or voice call interventions e.g. for reminders, monitoring, improving adherence, etc. Daily text messages for strengthening the therapeutic alliance Regular motivation messages (e.g. smoking cessation) Mobile cameras Norris, L.; Swartz, L., & Tomlinson, M. Mobile phone technology for improved mental health care in South Africa: possibilities and challenges. South African Journal of Psychology, 43(3),

32 MultiCASI An audiovisual diagnostic tool for illiterate individuals Standardised psychological questionnaires without the help of interpreters High validity (reduction of social desirability) Knaevelsrud, C.; Wagner, B; Karl, A. & Mueller J. (2007). New treatment approaches: integrating new media in the treatment of war and torture victims. Torture, 17(2),

33 Computer-assisted therapy for adolescents in Chile Yo pienso, siento y actuo mejor (YPSA-M), I think, feel and act better 10 lessons Guided by a therapist in face-to-face sessions RCT currently running

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36 Planned research project Development of an ICBT programme for adolescents in two Latin American countries (Bolivia and Chile) based on existing programmes developed at the University of Bern and in Chile. Randomized Controlled Trial (RCT) to test the effectiveness of the programme versus treatment as usual in Chile. Feasibility Study in Bolivia to examine the applicability of the programme with adolescents from middle- and low-income groups. Cost-Effectiveness Analysis (CEA) in Bolivia and Chile to provide decision-makers with evidence on the possible advantages of ICBT for adolescents.

37 Research consortium Universidad Mayor de San Simón de Cochabamba, Research Centre of the Faculty of Humanities 1 University of Bern, Institute of Psychology Swiss TPH, Swiss Centre for International Health 2 3 University of Heidelberg, Centre for Psychotherapy Research London School of Hygiene and Tropical Medicine, Centre for Global Mental Health World Health Organization Department of Mental Health and Substance Abuse Previous collaborations Newly established collaborations Research project on the decision of battered women to stay with or leave a violent partner (Heim, 2009) Millennium Nucleus Psychological Intervention and Change in Depression, Chile 2 Previous collaboration and exchange on ICBT 3 Common EU research project on the effectiveness of online depression treatment 4 The Chilean German Doctoral Programme (CHGDP), , current research project on optimizing health care for depression through Information and Communication Technologies. 5 Previous research projects on depression in adolescents, ongoing RCT on ccbt in Chile (Araya et al., 2013; Barroilhet, 2012)

38 ICT: Solution for global mental health disparities? PRO Effective Low cost Accessibility Privacy Independent from time and space Enhances self-reliance Can be used by many users at the same time CONTRA / OPEN QUESTIONS Access to new media and internet ( information gap ) Literacy (alphabetic, health and digital) Only for specific disorders Cost-effectiveness?

39 Amount of therapist support Low Unguided self-help Middle Guided self-help High , Chat, Skype

40 Conclusions Increasing interest in possible use of ICT in psychotherapy Increasing evidence on effectiveness of selfhelp programs Little is known on cost-effectiveness Little is known on factors that foster or hinder uptake and adherence Innovative approaches for sustainable implementation are needed

41 To reduce health disparities worldwide, the international community should develop a system to provide evidence-based Internet interventions at no cost to the users (...) The number of people who could benefit from such evidence-based Internet interventions would be massive. (...) The geographical reach of evidence-based Internet interventions is literally worldwide. This initiative is a worthy and feasible challenge for the 21 st century. Muñoz R. (2012). Using evidence-based internet interventions to reduce health disparities worldwide. J Med Internet Res, 12, e60.

42 Thank you!