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
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: 27-30 2 Lopez et al., 2006 Lancet 36: 1747-1757
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
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;184:526-533.
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): e13196. doi:10.1371/journal.pone.0013196.
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
Buntrock et al., JAMA 2016 406 adults in Germany with subthreshold depression Randomised at chance Internet guided cognitivebehavioural & problemsolving therapy Web-based psychoeducation 12 month follow-up
Depression: 27% intervention vs 41% control
Topper, Emmelkamp, Watkins & Ehring (in revision); ZonMW funded 251 x Dutch 15-19 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
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: 24-34 2 Watkins 2008 Psychological Bulletin 134: 163-206 Abstract global Why? style 2 Depression Anxiety
% Participants remaining without a diagnosis of depression Preventing depression in high-risk Dutch 15-19 year olds 100 90 group intervention 80 internet intervention waitlist control 70 60 50 40 post-treatment 3-month follow-up 12-month follow-up Cumulative proportion of participants remaining without a self-reported diagnosis of depression (PHQ-9).
% Participants remaining without a diagnosis of generalized anxiety disorder Preventing anxiety in high-risk Dutch 15-19 year olds 100 90 80 70 group intervention internet intervention waitlist control 60 50 40 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).
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: 473 474
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: 473 474
Standard Clinical Trial Standard clinical trials only determine if overall treatment package better than comparison e.g., Cognitive-Behavioural Therapy vs. antidepressant vs. placebo
Alternative: Factorial Trial engineering In factorial, patients allocated by chance to different combinations of treatment components, revealing which factors have biggest effects
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
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
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
Depression Anxiety
What do patients say who have used the therapy (Jon)
What do patients say who have used the therapy (Ann)
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.
e.r.watkins@exeter.ac.uk Thank you