Telemedicine for Mental health: innovations in digital e-interventions for depression and anxiety

Transcription

1 Telemedicine for Mental health: innovations in digital e-interventions for depression and anxiety Professor Ed Watkins University of Exeter ehealth Week, Amsterdam, 8-10 TH June 2016

2 The Global Challenge of Depression 1 1 in 5 people during lifetime; 151 Million per year Recurrent, disabling, major personal cost WHO 2 estimates No.1 disease burden by 2020 Economic cost: 92 billion per year in Europe 1 Collins et al., 2011 Nature 475: Lopez et al., 2006 Lancet 36:

3 A Major Treatment Gap WELL ILL 1. Effectiveness - 1/3 full recovery - 50% further depression 2. Availability - Majority not receive evidenced treatment - Traditional approaches have limited scalability 3. Acceptability - Patient preference

4 A Major Prevention Gap Treatment alone insufficient as depression highly recurrent Assuming 100% coverage and adherence to evidence-based treatments, c. 1/3 of depression s disease burden could be averted 1 1. Andrews et al. Br J Psychiatry. 2004;184:

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6 1. More available therapy via e-health As effective & feasible as face-to-face treatment 1 Increases access, coverage, convenience of therapy (anytime/anyplace) & mitigates stigma Potential to reach v. large numbers of people & reduce therapist time per patient 1. Andrews et al.. PLoS One, 2010; 5(10): e doi: /journal.pone

7 2. e-health Prevention for Depression Despite potential to be widely available, almost no trials of e-health to prevent depression Two v. recent innovative trials in Netherlands & Germany

8 Buntrock et al., JAMA adults in Germany with subthreshold depression Randomised at chance Internet guided cognitivebehavioural & problemsolving therapy Web-based psychoeducation 12 month follow-up

9 Depression: 27% intervention vs 41% control

10 Topper, Emmelkamp, Watkins & Ehring (in revision); ZonMW funded 251 x Dutch year olds with elevated worry/rumination Randomised at chance Internet guided cognitivebehavioural therapy targeting rumination Group CBT for rumination Usual care 12 month follow-up

11 Rumination (repetitive negative thought) (a key mechanism in depression) Loss Concrete specific How? style Multiple Vulnerabilities Problem Solving, Recovery Stress 1 Watkins & Nolen-Hoeksema 2014 J. Abnormal Psychology 123: Watkins 2008 Psychological Bulletin 134: Abstract global Why? style 2 Depression Anxiety

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17 % Participants remaining without a diagnosis of depression Preventing depression in high-risk Dutch year olds group intervention 80 internet intervention waitlist control post-treatment 3-month follow-up 12-month follow-up Cumulative proportion of participants remaining without a self-reported diagnosis of depression (PHQ-9).

18 % Participants remaining without a diagnosis of generalized anxiety disorder Preventing anxiety in high-risk Dutch year olds group intervention internet intervention waitlist control post-treatment 3-month follow-up 12-month follow-up Figure 3. Cumulative proportion of participants remaining without a self-reported diagnosis of generalized anxiety disorder (GADQ- IV).

19 3. Using e-health to understanding how therapy works & build better therapy We don t know how therapy (e.g. CBT) works 1 : What are the active ingredients? 1 Editorial 2012 Nature 489:

20 Understanding how therapy works Who responds best? What aspects of therapy do patients prefer & want? Goal: To systematically build stronger, simpler, briefer, preferred therapy in an evidence-based way 1 Editorial 2012 Nature 489:

21 Standard Clinical Trial Standard clinical trials only determine if overall treatment package better than comparison e.g., Cognitive-Behavioural Therapy vs. antidepressant vs. placebo

22 Alternative: Factorial Trial engineering In factorial, patients allocated by chance to different combinations of treatment components, revealing which factors have biggest effects

23 IMPROVE 2 trial NHS patients and self-referred patients from internet (Facebook) with depression Randomized to 1 of 32 variants of internet-cbt, with written online support from therapist All patients receive treatment, no waiting-list control, allowing everyday NHS use Internet allows strict control of elements

24 IMPROVE-2 components Compare presence vs. absence of 7 factors: across all cells, each factor present 50%, absent 50% Functional Analysis Yes or No Relaxation Yes or No Thought Challenging Yes or No Activity Scheduling Yes or No Self-Compassion Yes or No Absorption Yes or No Concreteness Training Yes or No

25 Benefits We can test which components have biggest effects on symptoms & preferred by patients to build a better therapy Keep strongest elements; remove weak or unhelpful elements Cutting edge NHS-based research, unique worldwide To date, recruited 365 patients with depression

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27 Depression Anxiety

28 What do patients say who have used the therapy (Jon)

29 What do patients say who have used the therapy (Ann)

30 Conclusions E-health can treat and prevent depression & anxiety It provides a means to find active ingredients to make therapy more potent, briefer, and more cost-effective Digital interventions can make therapy more widely available and are scalable to make therapies near universally available.

31 Thank you