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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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slide1

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)

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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!

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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)\'

Serenity Programme 2013

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

Serenity Programme 2013

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

Serenity Programme 2013

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’

Serenity Programme 2013

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’

Serenity Programme 2013

slide30

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

Serenity Programme 2013

media innovations 1 of 2
Media Innovations 1 of 2
  • ‘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 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 …’

Serenity Programme 2013

st solutions
ST Solutions
  • ‘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 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’

Serenity Programme 2013

updates
Updates
  • 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

Serenity Programme 2013

research recommendations 1 of 3
Research Recommendations 1 of 3
  • 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

Serenity Programme 2013

research recommendations 2 of 3
Research Recommendations 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
  • 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

Serenity Programme 2013

slide40

Enrolment

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)

slide41

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

slide42

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.

Serenity Programme 2013

slide43

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

slide49

Engagement - October 8 2012 - October 8 2013

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

… and looked at a lot of pages!

Serenity Programme 2013

slide51

Internet Explorer - October 8 2012 - October 8 2013

Almost 1/3 of all visitors

use Internet Explorer

About 86% of which

was obsolete!

Serenity Programme 2013

slide52

Technical Challenges

  • 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

Serenity Programme 2013

slide53

Mobile Devices - October 8 2012 - October 8 2013

Almost 1/4 of all visitors

Used a mobile device

Serenity Programme 2013

thanks for listening
Thanks for Listening!

Questions?

Serenity Programme 2013

bibliography
Bibliography
  • 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)

Serenity Programme 2013

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