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Guided Online Self-help. For Generalised Anxiety Disorder, (GAD) Phobias and Panic Disorder. Contents 1 The Programme 2 NICE CCBT review 3 Local Research 4 Google Analytics 5 Technical Stuff. The Serenity Programme. What is it?.

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Guided Online Self-help

For Generalised Anxiety Disorder, (GAD) Phobias and Panic Disorder

Contents

1 The Programme

2 NICE CCBT review

3 Local Research

4 Google Analytics

5 Technical Stuff



What is it
What is it?

A unique, theoretically integrative blended learning approach to treatment of stress and anxiety disorders

A blend of face-to-face contact alongside an interactive Internet programme and telephone support ...

Serenity Programme 2013


Assessment
Assessment

Begins with a two-hour

semi-structured assessment

Bespoke template-driven documentation, assessment using CORE, GAD-7 & PHQ-9

Serenity Programme 2013


35 interactive assessment tools including
35 Interactive Assessment Tools, Including ...

GAD-7 (Generalised Anxiety)

PHQ-9 (Depression)

WSAS (Work Adjustment)

PEQ (User Satisfaction)

PHQ-15 (Somatisation)

IES-R (Trauma)

PDSS (Panic Disorder)

OCI (OCD)

AUDIT (Alcohol Use)

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The programme
The Programme

Presented in an attractive interactive workbook (in depth programme) and online multimedia format (brief psychoeducational programme)

Assistive technology for people with dyslexia, visual impairment, physical or reading difficulties

Serenity Programme 2013


The programme1
The Programme

Assessment meeting

Modules

1 and 2

Support call

Takes most people at least three months to complete ...

Module 3

Goal setting meeting

Module 4

Support call

Module 5

Support call

Module 6

Support call

Module 7

Support call

Module 8

Support call

Module 9

Final meeting

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Workbooks
Workbooks

Password protected interactive workbooks , users download & keep to form a comprehensive client-held record

Use on your PC or print and complete by hand (average reading age of 11 years)

With more than 60 tasks and exercises

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Benefits to the user
Benefits - to the user

Increased choice

Increased confidentiality

Range of options: Internet, CD, paper, USB drive, iPad

Infrequent contact, longer term approach (CDM** model)

Reduced need to travel

Time flexibility - night shift workers, carers, single parents

User involvement during design process, CQI*

**CDM = Chronic Disease Management

*CQI = Continuous Quality improvement

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Benefits to the service
Benefits - to the service

Prevents wasteful ‘admit > treat> discharge > readmit’ cycle

Equity - services for agoraphobia, social phobia, avoidant and fearful, single mothers, young men, people with disabilities

No inherent geographical boundary problems

100% increase in throughput

Available in 71 languages

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Benefits to the wider community
Benefits - to the Wider Community

Materials shared, reducing familial transmission of harm

Use of model alone or as adjunctive treatment - EAP, CFS, MUS, anxiety in COPD and MI etc.

Less paper, less travel, less cost, less waste, less pollution - more efficient use of time!

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Evaluation
Evaluation

Interview with researcher, repeated measures (DASS, CORE-OM, HADS, PHQ-9)

Studies with Beneficiaries of ‘Want 2 Work’ programme

John Moore’s University Student Stress Study

Ongoing NHS Study

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Awards
Awards

Awards from WaMH in PC

WIsH (2006)

RCN (2008)

BJN (2008)

Best Nurse-led Project 2010

In RCN ‘Top 30’ UK Health Modernisation Projects 2011

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Nice ccbt reviews
NICE CCBTREVIEWS


Ccbt considered by nice
CCBT Considered by NICE

  • Depression

    • Beating the Blues - Ultrasis plc.

    • COPE

    • Overcoming Depression: A 5-areas approach (Calypso) Media Innovations

    • Anxiety

    • Fear Fighter - ST Solutions

    • OC Fighter (formerly BTSteps) - ST Solutions

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Beating the blues ultrasis plc
Beating the Blues (Ultrasis plc.)

  • CBT-based for people with anxiety and / or depression

  • 15-minute introductory video and eight 1-hour interactive computer sessions

  • Sessions at weekly intervals in routine care settings

  • Homework projects are completed between sessions, weekly progress reports delivered to the healthcare professional at the end of each session

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Cope st solutions ltd
COPE (ST Solutions Ltd.)

  • For non-severe depression

  • COPE was developed as an IVR plus workbook-based system - also available as a network version (netCOPE)

  • A 3-month programme with five main treatment modules

  • People can phone as and when they wish

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Od media innovations ltd
OD (Media Innovations Ltd.)

  • Overcoming Depression: a Five Areas Approach – available as a CD-ROM-based CBT system for people with depression

  • Six weekly sessions of 45 – 60 minutes

  • Sessions are delivered in a mixture of text, cartoon illustrations and animation

  • Practitioner reviews the person's use of the disc on three occasions over the course

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Fearfighter st solutions ltd
FearFighter (ST Solutions Ltd.)

  • A 9-step CBT-based package for phobias, panic and anxiety disorders

  • Originally developed for stand-alone computer, later developed for use on the Internet

  • Brief therapist contact, 5 minutes before and up to 15 minutes after each session

  • Therapist contact by telephone or e-mail for web version

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Ocfighter st solutions ltd
OCFighter (ST Solutions Ltd)

  • BTSteps (now OCFighter) a 9-step CBT-based self-help programme for OCD

  • BTSteps developed as an IVR*system plus workbook, an Internet version is under development and will obviate the need for IVR and workbook, helpline support is provided

*Interactive Voice Response

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Nice technology a ppraisal 51
NICE Technology Appraisal 51

  • Depression and anxiety: computerised cognitive behaviour therapy (CCBT)

  • Issued in 2002

  • Replaced by TA97 in 2006

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Acd 1 key points
ACD-1* – Key Points

  • CCBT (Beating the Blues, Cope, Overcoming Depression) is recommended for the treatment of mild and moderate depression

  • A judgement that as CBT is a known and effective approach for depression then CCBT packages as a whole are likely to produce similar positive ‘group effects’

* Appraisal Consultation Document

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Nice technology a ppraisal 97
NICE Technology Appraisal 97

  • Computerised cognitive behaviour therapy for depression and anxiety

  • Review of Technology Appraisal 51

  • Issued in 2006, modified in 2013

  • Replaced TA51 'Depression and anxiety: computerised cognitive behaviour therapy (CCBT)'

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Acd 2 oir
ACD-2 – OIR*

  • ‘Cope’ and ‘Overcoming Depression’ not recommended for the treatment of depression except as part of ongoing or new clinical trials… gathering data on costs and benefits…compared to an appropriate comparator

  • OCFighternot recommended for the treatment of OCD, except as part of ongoing or new clinical studies

*Only in Research

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Rct emphasis 1 of 2
RCT Emphasis 1 of 2

  • ‘There is no RCT evidence for COPE or Overcoming Depression for the management of depression. Therefore, the Committee could not establish with a reasonable degree of certainty that either of these packages is a clinically or cost-effective method of treating people with depression over and above other management options such as TAU’*

*Treatment as usual

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No class effect
No ‘Class Effect’

  • ‘Furthermore, it was not able to conclude that the CCBT packages for depression could be considered to be equivalent as in a 'class', because of the differences between the packages' presentation, style and complexity’

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Btsteps rct
BTSteps RCT

  • ‘The Committee considered the RCT evidence for BTSteps for the management of OCD in which BTSteps was compared with TCBT and relaxation. The Committee noted that in the randomised clinical trials BTSteps was never more effective than TCBT. It also noted that patients were more satisfied with TCBT than with BTSteps’

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Response to consultee, commentator and public comments on the ACD-2, 2005

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Media innovations 1 of 2
Media Innovations 1 of 2 the ACD-2, 2005

  • ‘The current wording … makes a de facto judgement that a class effect for CCBT does not exist and reverses the thrust of the original 2002 review’

  • ‘This is a major and unwarranted decision which will significantly reduce development in this area, produce a monopoly situation, and importantly reduce patient and practitioner choice’

Serenity Programme 2013


Media innovations 2 of 2
Media Innovations 2 the ACD-2, 2005 of 2

  • ‘The removal of any form of recommendation for Overcoming Depression or COPE will create an effective monopoly position for one commercially developed package …’

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St solutions
ST Solutions the ACD-2, 2005

  • ‘The committees' recommendation to not recommend OCFighter despite the strong evidence is likely to cause harm to the thousands of patients who will not be treated due to lack availability of services. The NHS is unable … to provide CBT services to 75% of the patients who require CBT treatment and who are in hospital.’

Serenity Programme 2013


Ultrasis
Ultrasis the ACD-2, 2005

  • ‘The revised document is, in general, an accurate reflection of the evidence base for CCBT and will stimulate appropriate and informed provision of the technology in the NHS and beyond’

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Updates
Updates the ACD-2, 2005

  • Recommendations in TA97 relating to the treatment of depression have been replaced by recommendations in the two depression clinical guidelines (CG90 & CG91, and in CG123 in 2011)

  • Recommendations relating to the treatment of anxiety disorders been replaced by entries in the GAD & Panic Disorder guideline (CG113) in 2011, and the Social Anxiety guideline (CG159) in 2013

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Research recommendations 1 of 3
Research Recommendations 1 of 3 the ACD-2, 2005

  • The clinical and cost effectiveness of two CBT-based low-intensity interventions (CCBT and guided bibliotherapy) compared with a waiting-list control for the treatment of GAD and Panic Disorder

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Research recommendations 2 of 3
Research the ACD-2, 2005Recommendations 2 of 3

  • Future studies should be RCTs & include an ITT*analysis, to take account of drop-outs, and record and report any adverse effects … They should also collect appropriate information on costs and health-related quality of life – data should be collected using generic preference-based measures (in conjunction with condition-specific instruments) because they facilitate the calculation of QALYs**

*Intention-to-treat

** Quality adjusted life-year

Serenity Programme 2013


Research recommendations 3 of 3
Research Recommendations 3 of 3 the ACD-2, 2005

  • Pragmatic RCTs for CCBT packages in a stepped-care programme

  • Comparisons of CCBT with other self-help comparators e.g. bibliotherapy and exercise

  • Comparisons of CCBT with placebo

  • Comparisons of CCBT with brief and longer duration TCBT*as well as group TCBT

  • Head-to-head trials between the packages for depression

*Therapist-delivered Cognitive Behaviour Therapy

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Local research
Local the ACD-2, 2005research


Enrolment the ACD-2, 2005

Assessed for eligibility

(n = 113)

Excluded (n = 27 )

Declined to participate (n = 22)

Out of catchment area (n= 4)

Did not meet criteria (n = 1)

Assessment

Assessment Interview

(n = 86)

Participant withdrew after assessment & before treatment began

(n = 4)

82

Intervention

Number of participants in active treatment

74

Participant withdrew due to change in personal circumstances

(n = 8)

61

Out of contact, unknown reason

(n = 13)

57

55

‘Stepped up’ to more intensive therapy

(n = 4)

52

Change of helper

(n = 2)

Participant elected to continue without support

(n = 3)

Partial programme completion, consensual discharge

(n = 24)

Full programme completion, consensual discharge

(n = 28)


For the 52 participants either fully or partially completing the programme, initial mean anxiety scores on the HADS were 14.42 and after three months, 9.1 – an almost 37% reduction in symptom scores (t = 10.18, p<0.0001). The chart below shows initial anxiety scores in red, post-test scores in blue.

This cohort comprised of 24 males and 28 females, with an average age of 42.8 (range 19 - 82). Partial completion was considered to be a successful intervention when symptom levels were reduced and both participant and professional agreed discharge to be appropriate and timely.

Serenity Programme 2013


For the 52 participants fully or partially completing the programme, initial mean depression scores on the HADS were 9.6 and after three months, 5.8 – an almost 40% reduction in symptom scores (t = 6.62, p<0.0001). The chart below shows initial depression scores in red, post-test scores in blue.

Of these 52 participants, 48 were either employed or in full- or part-time education.

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Mixed-methods quasi-experimental study - semi-structured interview and repeated measures using HADS, PHQ-9 and CORE-OM

'... navigation was easy...'  CM, Colwyn Bay

'...the website was compelling and encouraging...'   KJ, Rhyl

'...programme gives great insight and understanding to anxiety and the reasons why it is happening...'  CR, Rhyl

'...it was good for changing thought patterns...'  JC, Abergele

'...really liked the points of interest, helpful hints, and breakdown of what was wrong and how I could deal with it...'  RW, Colwyn Bay

'..it’s absolutely super, I’m really, really very impressed with it, it’s a wonderful thing to have...'   AD, Denbigh

 '...instantly appealed as it immediately seemed to address my problems...'  JT, Rhyl

 '...layout was very user-friendly...'  CA, Rhyl

 '...I liked the gentle approach...' SP, Rhyl

 '...not loads of medical jargon, so could understand what was being said...'  SW, Rhyl

'...it’s good to know someone else understands how I feel...'   SW, Rhyl

 '...think the programme is good and should be rolled out to others...'  HR, Prestatyn


Google analytics
Google interview and repeated measures using HADS, PHQ-9 and CORE-OMAnalytics


Overview - October 8 2012 - October 8 2013 interview and repeated measures using HADS, PHQ-9 and CORE-OM

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Countries interview and repeated measures using HADS, PHQ-9 and CORE-OM - October 8 2012 - October 8 2013

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Cities interview and repeated measures using HADS, PHQ-9 and CORE-OM - October 8 2012 - October 8 2013

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UK interview and repeated measures using HADS, PHQ-9 and CORE-OM - October 8 2012 - October 8 2013

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Engagement interview and repeated measures using HADS, PHQ-9 and CORE-OM- October 8 2012 - October 8 2013

~ 27% of users engaged for 3 to >30 minutes …

… and looked at a lot of pages!

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Technical issues
Technical interview and repeated measures using HADS, PHQ-9 and CORE-OMissues


Internet Explorer interview and repeated measures using HADS, PHQ-9 and CORE-OM- October 8 2012 - October 8 2013

Almost 1/3 of all visitors

use Internet Explorer

About 86% of which

was obsolete!

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Technical Challenges interview and repeated measures using HADS, PHQ-9 and CORE-OM

  • XP can’t run IE browsers > 8, Vista can’t run IE browsers > 9

  • No consistent support for CSS3 or HTML5 before IE10

  • Microsoft support for Windows XP ends in April 2014

  • No more security updates for Windows XP or IE8

  • 22 updates for XP released on ‘Patch Tuesday’ 08-10-13

  • Google Apps dropped IE8 support in November 2012

  • jQuery 2.0 dropped IE6, 7 and 8 support earlier this year

  • IE is currently at version 10, with 11 preview already released

  • IE11 will be standard in Windows 8.1 (from October 18, 2013)

  • BCU has ~10,000 machines running IE 6, 7 or 8

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Mobile Devices interview and repeated measures using HADS, PHQ-9 and CORE-OM- October 8 2012 - October 8 2013

Almost 1/4 of all visitors

Used a mobile device

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Thanks for listening
Thanks for Listening! interview and repeated measures using HADS, PHQ-9 and CORE-OM

Questions?

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Bibliography
Bibliography interview and repeated measures using HADS, PHQ-9 and CORE-OM

  • NICE Appraisal Consultation Document – CCBT

  • NICE Appraisal Consultation Document 2 – CCBT (review)

  • Response to consultee, commentator and public comments on the ACD

  • Depression in adults: The treatment and management of depression in adults (CG90)

  • Depression in adults with a chronic physical health problem: Treatment and management (CG91)

  • Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: Management in primary, secondary and community care (CG113)

  • Social anxiety disorder: Recognition, assessment and treatment (CG159)

  • NICE Guide to the single technology appraisal process (2009)

  • NICE Informing a decision framework for when NICE should recommend the use of health technologies only in the context of an appropriately designed programme of evidence development (2012)

  • Guidance on the use of computerised cognitive behavioural therapy for anxiety and depression (TA51, 2002)

  • Computerised cognitive behaviour therapy for depression and anxiety: Review of Technology Appraisal 51 (TA97, 2013)

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