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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
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