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Internet Cognitive Behaviour Therapy for Anxiety and Depression is a Disruptive Innovation

Gavin Andrews AO, MD
Professor of Psychiatry, Clinical Research Unit for Anxiety and Depression, UNSW at St Vincent’s Hospital

Each week I see 8 new patients referred to a specialist anxiety and depression clinic for cognitive behaviour therapy. On average, three are not suitable referrals, one will need face to face treatment which now will begin the following week, and four will do their pre programmed therapy over the internet. I presume the four will complete their first session that evening. For twenty-five years we have had a waiting list for treatment. We no longer do so, even though we will treat 500 new patients this year. The change surprises me.

Escalating health care costs herald a crisis that can only be solved by innovations in health care. In ‘The Innovators Prescription’ (McGraw Hill. 2008) Christensen argues that technological innovations that simplify, constitute ‘disruptive innovations’ and can, if accompanied by a novel business plan, an active user base and regulatory approval, produce radical changes. Pre-programmed computerised cognitive behaviour therapy delivered over the internet (iCBT) for depressive and anxiety disorders may have the potential to be a ‘disruptive innovation’.

Anxiety and depressive disorders are the principal cause of disability in the world and in developed countries they generate significant costs to the patient, the practitioner and to the health budget. In practice they respond to antidepressants or cognitive behaviour therapy, but adherence is poor and satisfaction with the outcomes is low.

Efficacy: There have been three systematic reviews of iCBT in these disorders. The latest (Andrews et al., PLoS ONE 2010) was confined to people who had met diagnostic criteria for a specific anxiety or depressive disorder. Twenty two randomised controlled trials of good quality were identified in depression, panic disorder, social phobia and in generalised anxiety disorder. Strong benefits occurred in all disorders and the mean Hedges effect size was 0.88, NNT = 2.15. There was one study from Switzerland, the US and Spain, two from the UK, six from Sweden and 11 from Australia. That eight groups of investigators, working independently in 6 countries achieved similar results strengthens the findings. Sixty four percent of the studies reported follow-up data (median 26 weeks), and in none was there evidence of relapse. Adherence was good (median 80%) and 86% of patients reported that they were satisfied.

There are three issues of interest: comparability with face to face CBT, importance of clinician guidance, and importance of a precise diagnosis. There are six direct comparisons of iCBT with face to face CBT. The results and satisfaction were comparable, but the staff time required for iCBT was significantly less. There are three studies of iCBT programs in which a technician who only provided encouragement was compared with a clinician providing clinical advice. There was no difference in outcome whether supervision was by technician or clinician. Two computerised programs from the Institute of Psychiatry, London, one aimed at panic and phobias and the other aimed at depression and anxiety states did not require a precise diagnosis and were sufficiently cost-effective to be recommended for routine use in the UK National Health Service. An internet transdiagnostic iCBT program for panic, social phobia and generalized anxiety disorder also showed strong benefits confirming that a precise diagnosis may not be essential for a good outcome in patients with anxiety and depressive disorders. There are four conclusions from this research on anxiety and depressive disorders: improvement with iCBT is considerable, adherence and satisfaction are high, and neither a precise diagnosis, face to face contact with a therapist, nor therapist guidance seem to be essential.

Effectiveness: For the past two years we have made the courses for anxiety and depressive disorders that were the focus of our iCBT trials available to general practitioners and other clinicians on www.crufadclinic.org.  Many clinicians are pleased and say “It is like having an intern in the practice.” In the 6 months April-September 2010, 34% of the 1036 people who began the first lesson completed all lessons within the 90 days allowed (mean Cohens effect size for completers ES=1.0 on an outcome measure of psychological distress). There is a strong dose response relationship so adherence is important (see figure). Changes in the protocol in September 2010 are resulting in improved adherence. It is now over 54% in patients who began in October/December 2010 and have had time to complete.

Figure : Pre-post Cohen’s effect sizes for changes on a measure of psychological distress taken prior to each lesson. Data from patients being managed in general practice who completed all lessons [n= 402]

In our specialist clinic where people are referred for face to face treatment, we have made the iCBT courses standard of care, and 97% accept the offer of iCBT. In the six months April – September 2010, 70% of patients completed all lessons within the 90 days allowed (ES=1.1). iCBT, we conclude, is beneficial and acceptable to people referred for face to face CBT – they don’t have to travel to the hospital for treatment and can do the lessons at home whenever it is convenient. The saving in staff time has been considerable, the waiting list is nonexistent and the clinicians are presently under-employed. In summary, initial studies indicate that iCBT is effective in primary and specialist practice. There is a need for large effectiveness trials across different therapy types.

Cost: Administering and maintaining the system costs $100 per person on a throughput of 1,000 patients per year. Once the program is running the additional cost of treating an extra patient is small, less than $50 if another practice provides supervision, less than $100 if we provide the supervision. At $200 per completed course of treatment this is considerably less than the $1300 per case per year estimated as the cost of optimal face to face treatment. And the NNT is less, so the gain in efficiency could be tenfold.

Christensen argued that to succeed, a ‘disruptive innovation’ had to have a different business model to the system it is replacing. iCBT is a sophisticated technology that simplifies, and so meets the first of Christensen’s requirements for a ‘disruptive innovation’ in health care, but is there an appropriate business model? iCBT is usually done at home. In an audit of patients coming to our clinic for a 6-10 visit course of face to face treatment that was free, the average out of pocket costs (transport, parking, time off work, child care) to attend the clinic was $29 a visit so a user pays business model at $200 per course might be practical.

Stepped care: Anxiety and depressive disorders are often chronic. The strong results from iCBT confront traditional thinking. Patients in these studies seem to be as chronic and as severe as regular patients and remission has not been a feature of the control groups. Nevertheless iCBT is best seen as the first step in a stepped care design wherein patients who don’t fully recover, and an NNT of 2 means 50% do not, can proceed to face to face treatment with CBT or medication. But that 50% do recover with iCBT is contrary to what we think about the nature of anxiety and depressive disorders. We do need to know the changes in temperament, information processing and brain functioning that accompany the clinical improvement so that we can understand how iCBT works.

iCBT for anxiety and depressive disorders is effective and efficient. It simplifies therapy. The cost is affordable and the treatment can be accessed by most. Prudently used, it should be acceptable to regulators, whether or not a registered clinician retains clinical responsibility. It meets Christensen’s criteria for a ‘disruptive innovation’.

Crufadclinic.org is a not-for-profit initiative of St Vincent’s Hospital and the UNSW, Sydney. The system (operating system and courses) are available for purchase by health care organisations. Contact nwong@stvincents.com.au for terms and conditions.

About the Author

Gavin Andrews AO, MD, is Professor of Psychiatry at UNSW at St Vincent’s Hospital, Sydney Australia. His Clinical Research Unit for Anxiety and Depression (CRUfAD) is concerned with the diagnosis and treatment of anxiety and depressive disorders in adults. CRUfAD provides treatment services to more than 2,000 people a year, both in the clinic and over the web.

Professor Andrews has been an academic staff member of the School of Psychiatry at UNSW since 1964. He has published many papers and books, his Hirsch index exceeds 50 and he is on the ISI MostHighlyCited list for psychology and psychiatry with more than 10,000 citations to his work. He is the Director of the UNSW School of Psychiatry at St Vincent’s Hospital where he heads the Anxiety and Depression Clinic, the Clinical Research Unit for Anxiety and Depression, and the World Health Organization Collaborating Centre in Classification of Mental Disorders.

Gavin Andrews research interests began with stuttering, a neurodevelopmental disorder, extended to depression, epidemiology, treatment of common mental disorders, classification of mental disorders, cost effectiveness, and Internet treatment of internalising disorders.

Please browse this website – http://gavinandrews.com/ – to find out about publications and links to online therapy by Gavin Andrews