How to treat large numbers of patients with depression and anxiety

To adequately treat high numbers of patients with common mental health problems, such as depression and anxiety, requires a treatment strategy that can offer mass availability. Blues Begone (BBG) is such a technology as it offers effective home based treatment. Clinic settings using BBG can accept virtually unlimited numbers of referrals and monitor patient progress with a very low number of worker hours as all treatment takes place outside of the clinic. This document details the clinical and cost effectiveness of the Blues Begone services and benchmarks them against Improving Access to Psychological Therapies (IAPT) demonstration site in Doncaster; Beating the Blues, and face to face CBT in a traditional clinic setting.

NICE 2009 Clinical Practice Recommendations CCBT

Computerised Cognitive Behaviour Therapy (cCBT) for people with persistent subthreshold depressive symptoms or mild to moderate depression should:
• be provided via a stand-alone computer-based or web-based programme
• 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 outcome
• typically take place over 9 to 12 weeks, including follow-up.
NICE (2009) 7.4.1.3 pp183

Improving Access Psychological Therapies (IAPT)

IAPT was set up to increase the availability of CBT for primary care patients. This initiative has now yielded data showing that the primary care population does not seem to require complex psychological interventions and that with relatively few hours of contact patients can be helped to recovery (Clark, Layard and Smithies 20082). IAPT services appear to offer what I consider to be a first step into real patient empowerment. They do offer cCBT, but they do with large number of workers facilitating the patient contact and this still creates the bottle neck of trained professionals having to mediate between the patient and the cCBT.
Clark, D.M., Layard, R. & Smithies, R. (2008) Improving Access to Psychological Therapy: Initial Evaluation of the Two Demonstration Sites. CEP Discussion Papers, dp0897. London: Centre for Economic Performance, LSE. the minimum amount of treatment needed to adequately resolve the patient’s difficulties. However, the approach is relatively labour intensive and therefore expensive to provide (Department of Health 2007).

 Beating the Blues

Beating the Blues is a computerised multi-media CBT program that offers 8 one hour interactive sessions on a computer terminal located in a surgery, library or other centrally accessed location. Beating the Blues is now available online.

Internet applications

Data on UK oriented internet applications is sparse. For example, we are not aware of any data showing the effectiveness of ‘Living Life to the Full’, a commonly recommended internet application. Data on internet applications from other countries is more abundant but does not often report data using the standardised assessment tools used in Blues Begone trials, making direct comparison difficult. What is apparent, from published data is that internet applications show massive rates of attrition with very few patients actually completing treatment as planned.

Face to Face CBT

The accessibility quality, duration of therapy and length of waiting list varies greatly for face to face CBT in NHS settings, if it is available at all outside of an IAPT service. Therefore The Oxford specialist CBT service was chosen as a benchmark service. It has published data on numbers of referrals, duration of therapy and treatment outcomes using standardised measures.

Blues Begone

Blues Begone engages the user and keeps their interest for better clinical outcomes
Blues Begone (BBG) is a computerized cognitive behaviour therapy (cCBT) program that is designed to be used without any additional human support. It offers 30 episodes of cCBT that can be used for between 20 – 40 hours depending upon the level of engagement of the user.

 Blues Begone: The program

BBG assesses each individual using the 56 item Purves Depression Questionnaire (PDQ) and then compiles itself into a personalised ‘Roadmap to Recovery’ that is intended to closely reflect the patients clinical requirements as identified by the PDQ. This roadmap is further modified, over subsequent sessions, as additional user information is gathered to become more focused on the patient’s problems, as well as to reflect their progress. The Roadmap to Recovery typically contains up to 304 items. BBG provides 90,000 words of textual information delivered in various forms including web pages, PowerPoint presentations, small information chunks, spoken text, instructions for activities, daily hints and religion specific tips if the user requests it (for Christian, Hindu, Muslim and Jewish religions).
BBG offers up to 22 CBT activities such as, thought record, down arrow technique and training on faulty thinking. Many tasks have been modified from paper formats to be more functional and can be easily completed without additional help. Homework assignments are created and monitored by BBG using summaries and feedback following the scheduled completion. There are 120 talking heads that offer instruction, feedback, encouragement and greetings. There are 20 extensive conversations between animated characters delivering psycho-education and a substantial clinical case illustration that runs over 6 episodes, extended throughout the program, totalling approximately 60 minutes. BBG has made extensive use of cartoons and dynamic illustration. There are 30 stand alone cartoons and animations that illustrate the key points of each daily agenda. In addition, there are 365 smaller cartoons that are embedded in web pages and other presentations. Very few items are ever repeated in order to maintain a sense of novelty.

Blues Begone promotes investment in recovery

The user keeps BBG as a permanent resource. From the beginning they are recommended to use BBG on most days at roughly the same time each day. Each day their current mood and tension levels are assessed, they are asked about sleep quality, medication use, exercise and activity levels. In this way BBG learns about the user, talks to them using personalised computer generated voices, both with and without talking heads incorporating context aware messages and feedback. Following the completion of each episode, the user has the option of moving onto the next episode or repeating the current episode, giving the user complete control over their self help experience. All users complete the program when they have worked through the 30 episodes. Experience suggests that users take, on average, 8 weeks to work through the whole BBG program. Following completion of BBG the program it goes into relapse prevention mode where the user can access all parts of the program, make bespoke episodes to address particular problems or go through the whole program again.
Blues Begone was tested extensively with NHS patients in primary care and found to have excellent completion rates, excellent acceptance rates (people like to use it) and clinical effectiveness equal to 12 sessions of specialist CBT delivered in face to face sessions. See the data in the open trial of Blues Begone as a self help treatment for depression and anxiety.
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