Treatment of anxiety and depression via the Internet Will computers replace clinicians?

1. Treatment of anxiety and depression via the Internet Will computers replace clinicians? Nickolai Titov CRUfAD School of Psychiatry UNSW/St Vincent’s Hospital Sydney, Australia APS, September 2009

2. Will computers replace clinicians?

3. NO! • Internet CBT offers an important opportunity to: • Reach people who don’t access treatment • Showcase the best of psychology/psychiatry

4. Don’t get distracted by the medium!

5. Part 1: Context.

6. 2007 NSMHWB: Service Utilization Who did the seek help from? • Any health professional 35% (41% vs 28%) • VisitedGP23% (30% vs 18%) • Visited Psychologist/Psychiatrist 15% • More likely to see a MHP if severe/comorbidity • Comparable treatment seeking for a physical disorder 80%

7. Barriers to Treatment • Costs • Direct: Costs of treatment • Indirect: Travel time, time off work/other responsibilities • Convenience • Location – tyranny of distance • Waiting lists • Anonymity • Stigma/Fear of therapy • Severity/Perceptions • Cost-benefit ratio • “Treatment doesn’t work”, “I would rather treat myself”

8. Converging Factors for I-CBT Marks and Cavanagh (2009) 1. Demand for therapy • Exceeds its affordable, convenient, and confidential supply by qualified therapists 2. Advances in IT • Increasing potential of IT platforms 3. Some therapy tasks are suited for computer programs • Psycho-education • Teaching 4. Funding increasing • England/Wales: NICE • Australia: MoodGym, Anxiety Online

9. Part 1: Context - Summary • 20% of Australians have a mental disorder • 35% of those seek treatment each year • 85% DO NOT see a Psychologist or Psychiatrist • Psychological treatment is effective • Significant barriers to treatment • Converging factors for I-CBT/low intensity interventions • 80% of Australians regularly access the Internet • Internet speed and reliability and software platforms are improving … Leading to a growth in I-CBT …

10. Part 2 I-CBT: Definitions and Examples

11. Definitions Internet Therapy • Treatment of common mental disorders where therapist has contact with patient via the Internet Internet-based Cognitive Behavioural Therapy (I-CBT) • Administration of CBT via the Internet • Highly structured, same materials and outcome measures as face to face treatment • Varying levels of therapist support and different types of communication

12. - Phobias/panic disorder - Depression - OCD/PTSD - General anxiety/stress - Eating disorders - Substance misuse - Bipolar disorder - Miscellaneous: pain, tinnitus, insomnia Used to Treat

13. Who Uses I-CBT? Severity of VirtualClinic patients same as Anxiety Disorders Clinic

14. About the VirtualClinic • Aim to develop and evaluate Internet-based programs for common mental disorders: • Social Phobia • Panic Disorder • Depression • Generalized Anxiety Disorder

15. Treatment Components • Topics Include: • Psycho-education • Behavioural activation • Graded exposure • Cognitive therapy • Problem solving • Communication skills • Relapse prevention

16. 6 Lessons – Psycho-Education 6 Summaries/ Homework 6 Forums Additional Resources Stories from previous participants Messaging

21. Part 3 Does I-CBT Work? General Results

22. Does I-CBT Work? • Meta-analyses: • Spek et al (2006). Effective for anxiety and depression • Cuijpers et al. (2007). Criterion – 2 positive and independent RCTs: I-CBT supported in PTSD, panic, social anxiety, mild to moderate depression Clinician-Assisted > Self-Guided

23. Completed + Current Projects: Stage 1 = Proof of Concept – Does it work? Stage 2 = Parameters – Therapist vs. non therapist support Stage 3 = Effectiveness – vs. Face to Face, real world clinics 16 Studies: Total n = 1200+

24. Indicative Results Note: All Results ITT Results sustained at 3/6 months

25. Comorbid Conditions Improve Pre-post treatment scores from Titov et al (2009). SP Only meets DSM-IV criteria for social phobia; Dep, PHQ-9 score consistent with meeting criteria for Major Depressive Episode; GAD, GAD-7 score consistent with meeting criteria for GAD.

26. Part 4 Summary/ Conclusions

27. Summary • Depression and anxiety affect more than 2 million Australian adults each year • Less than 40% seek treatment in a 12 month period • Only 15% see a Psychologist and/or Psychiatrist • Psychological therapies are effective, butnot enough therapists + significant barriers to treatment seeking • Clinician-assisted Internet-based CBT (I-CBT) is effective • I-CBT provides an important opportunity for psychologists and psychiatrists to: • Educate people about symptoms and treatment • Encourage resilience and reduced vulnerability • Encourage more people to seek specialized treatment

29. References Australian code for the Responsible Conduct of Research. Joint NHMRC/AVCC Statement and Guidelines on Research Practice. 2007. Guidelines for providing psychological services and produces on the Internet. APS. 2004. Marks IM, Cavanagh K. Computer-aided psychological treatment: Evolving issues. Annual Review in Clinical Psychology 2009; 5:121-141. Quality Framework for Telephone Counselling and Internet-based Support Services. September 2008. Australian Government: Department of Health and Ageing. Titov N. Status of computerized cognitive behavioural therapy for adults. Australian and New Zealand Journal of Psychiatry 2007; 41:95-114.

30. Websites VirtualClinic: CRUfAD, St Vincent’s Hospital/UNSW www.virtualclinic.org.au Anxiety Online: Swinburne University of Technology www.anxietyonline.org.au MoodGYM: Australia National University www.moodgym.anu.edu.au Panic Centre: Evolution Health www.paniccenter.net beyondBlue www.beyondblue.org.au Black Dog Institute: UNSW www.blackdoginstitute.org.au

31. www.virtualclinic.org.au Thank you … nickt@unsw.edu.au