iCBT for depression: Twice the benefit for half the cost; but think about efficiency,

safety and funding Gavin Andrews AO, MD Professor of Psychiatry, UNSW at St Vincent’s Hospital, Sydney

gavina@unsw.edu.au

Problem: Meds do not work well

Antidepressants are not superior to placebo in mild and moderate depression (NNT=16),

Show a medium effect in severe depression (NNT=11)

Substantially better in very severe depression (NNT=4)

Fournier et al JAMA 2010

“No fully satisfactory treatments for major depression are available” Kupfer et al Lancet 2011:

iCBT in Internalising disorders- 50 research trials, 4,000Ss, mean ES = 1.2, NNT <2, Adherence 77%

MDD

N of trials 13

N of Ss 2067

Effect Size 1.0

NNT <2

Adherence 75%

Thiswayup.org.au/clinic: History

• CRUfAD is a specialist treatment

service – had a long waiting list for face

to face CBT

• Developed internet based CBT (iCBT)

• Now 400 referred new patients a year

• 19/20 choose iCBT

• NO WAITING LIST

Thiswayup.org.au/clinic: Scope

• iCBT courses TEACH control of emotions, thoughts and behaviour for

GAD, OCD, Panic, Social phobia,

Depression, mixed ANX/DEP

• 6 lessons, 10 weeks, $55

Thiswayup.org.au/clinic: Reach

• 3500 GPs/Psychologists have registered

• 7500 patients have registered, half from non metro practices

• Include with GAD-7 or PHQ-9 score > 9

• Exclude people who can’t learn: dementia, autism, schizophrenia, bipolar disorder, psychotic depression, substance abuse, or who are on benzodiazepines or are suicidal.

Depression Lesson 1

•Depression

Symptoms

Explained

Activity Planning

Recording Positives

Depression Lesson 3

Facing Fears

Gradually

Depression Lesson 4

Depression general practice (n=420)

PHQ-9 Sub-threshold (0-9)

PHQ-9 Mild (10-14)

PHQ-9 Moderate (15-19)

PHQ-9 Severe (20-27)

Pre-treatment 420 complete treatment for Major Depressive Disorder

N=154 (37%)

N=124 (30%)

N=142 (34%)

Post-treatment 60% recover 20% improve 20% do not

N=84 (20%) N=48 (11%) N=42 (10%) N=246 (59%)

“Better off dead” days (n=420)

PHQ-9 Question 9 “Not at all”

PHQ-9 Question 9 “Several days”

PHQ-9 Question 9 “More than half the days”

PHQ-9 Question 9 “Nearly every day”

Pre-treatment: 60% report ‘better off dead’ days

Post-treatment: 32% report ‘better off dead’ days but at reduced frequency

N=93 (22%) N=26 (6%) N=18 (4%) N=283 (67%)

N=166 (40%) N=148 (35%) N=66 (16%) N=40 (10%)

#1 Probably Cost effective

• Two trials with good evidence in Depression. $29,000/QALY Hollingshurst et al BJPsych 2010 ; Proudfoot et al BJ

Psych 1994

• iCBT vs f2f CBT for social phobia is cheaper and better Hedman et al 2011 ; Andrews et al 2012

• iCBT NNT <2; Meds for Depression NNT>5

• Pure self help effectiveness studies: adherence 2% - 12%; too low to be effective.

#2 Safety: harm and suicide

• iCBT research refused the severe and suicidal. GPs did not, showed courses safe and effective

• Simon et al 2013. 11,500 depressives with PHQ-9 Q9=2/3. 6 suicides within 30 days.

• In our research trials we call patients with a score of 2/3, most say ‘I’m OK, just a bad time’.

• In Thiswayup.org.au the system tells the GP.

#3 DoH can’t think of how to pay

• DoHA has been serious about iCBT for ten years – TGA “you have software that informs and people use

it to recover – it is not a Treatment.” – Medical Benefits Schedule pays medical professionals

for their time/expertise – Pharmaceutical Benefits Schedule subsidizes useful

medicines – Medical Services advisory committee subsidises

professional procedures or devices.

• iCBT is proven, cost effective, as yet unfunded remedy for depressive and anxiety disorders,

Come in, the computer will see you now

• Can internet delivered automated CBT be as good as a live, well trained therapist? As Meds? Well, yes.

• Certainly for the average to severe case, whether or not comorbid, even for physical comorbidity

• Patients stay engaged, don’t get bored, tired, or distracted. Can review material. Adherence 60%.

• Therapist drift does not occur. Being reliable is better than sporadic brilliance.

• And what a good thing it is, clinicians now have time for the difficult-to-get-better complex cases.

• www.thiswayup.org.au/clinic 20+ RCTs; 6+ field studies