The evidence base...the management of depression
Nick Goodwin
Depression is a condition that is very commonly associated with old age and/or living with one or more long-term conditions and can range from ‘mild’ to ‘moderate’ to ‘severe’. Treatment of depression usually involves a combination of drugs (antidepressants), therapy and self-help.
Of the therapies and self-help techniques, cognitive behavioural therapy (CBT) is the most well known and proven approach. It involves a fixed number of sessions (usually six to eight), either individually or in groups, over a 10–12 week period. CBT is based on the principle that the way we feel is partly dependent on the way we think about things. It teaches you to behave in ways that challenge negative thoughts – for example, being active to challenge feelings of hopelessness.
Other approaches include counselling with a psychologist or psychiatrist to support individuals in finding solutions to problems; and group-based anxiety-management classes and/or interpersonal therapy (IPT) that focus on relationships with other people, such as difficulties with communication or coping with bereavement. There is some evidence that IPT can be as effective as medication or CBT, but more research is needed.
Improving Access to Psychological Therapies
Providing psychological therapies as a method for managing depression was given a boost in 2005 when the government made a manifesto pledge in their General Election campaign. In May 2007, the Improving Access to Psychological Therapies (IAPT) Programme was launched. It aims to investigate ways to improve the availability of psychological therapies, especially relating to people with depression or anxiety disorders. It also aims to promote a more person-centred approach to therapy. The IAPT programme recommends the use of CBT – not least because it has been recommended by NICE as the most effective psychological therapy to be used in the NHS.
Can such therapies be effectively delivered remotely using telehealth technologies?
In February 2006, NICE produced a number of recommendations for the use of computerised cognitive behavior therapy (CCBT) for depression and anxiety [1]. CCBT is a generic term that is used to refer to a number of methods of delivering CBT via an interactive computer interface. It can be delivered on a personal computer over the internet or via the telephone using interactive voice response (IVR) systems. As with CBT, pre-therapy assessment is recommended to ensure that people are suitable for therapy, and individuals require ongoing monitoring and support. It is suggested that a wide range of health or social care personnel could be used to facilitate the sessions.
The NICE CCBT guidance was heavily influenced by a 2004 update to a 2002 systematic review undertaken by a research team at the School of Health and Related Research (ScHARR) [2]. The research suggested that there was some evidence to support the effectiveness of CCBT for the treatment of depression. However, all of the 20 studies included for review reported considerable drop-out rates and little evidence was presented regarding participants’ preferences and the acceptability of the therapy. The research team argued that more research was needed to determine the place of CCBT in the potential range of treatment options offered to individuals with depression.
The NICE guidance recommended that a person with mild or moderate depression could be offered the computerised approach called Beating the Blues while another application – FearFighter – could be used for a person with a more serious long-term mental illness such as panic or phobia. As the NICE guidance [1] relates: 'Beating the Blues is a CBT-based package for people with anxiety and/or depression. It consists of a 15-minute introductory video and eight one-hour interactive computer sessions. The sessions are usually at weekly intervals and are completed in the routine care setting (that is, GP practice). Homework projects are completed between sessions and weekly progress reports are delivered to the GP or other healthcare professional at the end of each session. These progress reports include anxiety and depression ratings and reported suicidality. No minimum reading age is specified' [p10].
Other approaches to CCBT were recommended only as part of an ongoing or new clinical trial designed to generate robust and relevant data on the clinical effectiveness of these specific CCBT packages.
Other applications of CCBT are currently being tested and piloted. In May 2009, for example, a large US research study into the feasibility of telehealth problem-solving for depressed home-bound adults was launched funded by the National Institute of Mental Health (NIMH). The study seeks to identify the feasibility and effectiveness of remote problem-solving therapy to a community of users less able to access routine care. Closer to home, Brent PCT have been working on how CCBT fits into local strategies and care pathways.
The WSDAN Evidence Database
In addition to the evidence highlighted above, the WSDAN evidence database reports on an additional 14 published studies to suggest that there can be significant benefits to people in the treatment of depression using ‘remote’ techniques, but that relatively little is known on the efficacy of other forms of e-therapy.
While the depression studies identified in the WSDAN database varied greatly in design and purpose, the majority were – broadly speaking – concerned with comparing forms of telephone and/or e-mail based monitoring and support versus ‘standard care’.
A common finding to all of these studies was that regular care management and psycho-social support offered remotely resulted (mostly significantly) in better adherence to medications, lower prevalence of depression, and better patient satisfaction. This appeared to be the case regardless of whether the professional offering the support was a case manager, nurse, pharmacist, psychotherapist, psychiatrist or behaviour health specialist.
For example, one randomised control trial of veterans in the USA examined the outcomes of a programme of providing treatment via ‘telepsychiatrists’ compared with ‘usual care’. The overall sample included 395 veterans and the intervention ran for 12 months, after which it was found that those in the experimental condition were more likely to: adhere to treatment at six and 12 months; to respond to treatment by six months; and to ‘remit’ by 12 months. Those who received treatment via telepsychiatrists reported better health-related quality of life and satisfaction scores than those in the control group [3].
Only one study in the WSDAN database – from Western Australia – specifically examined the impact of a therapy programme [4]. In this study, the researchers focused on the impact of an online disease management programme – Recovery Road – for reducing levels of depression and improving adherence to treatment. There were 98 service users, 69 of whom received automatic reminders via email and 29 of whom received a more personalised package of case management including email and telephone reminders following non-adherence. Within both groups, adherence to the programme decreased over the course of eight Recovery Road sessions. After the eight sessions, there was a greater level of adherence among those who received personalised case management as opposed to automated messages (84 per cent versus 55 per cent). The findings of the study are in line with the NICE recommendations that not all approaches to e-therapy appear effective as standalone treatment modalities.
Summary
The results of these studies show that significant positive outcomes can be gained from telehealth-based depression management, specifically for adherence to medication and in (self-reported) depression prevalence. There also appears to be an association between outcomes and the degree of ‘personalisation’ of care that such approaches can provide.
However, future research should attempt to establish the cost-effectiveness of remote versus face-to-face and group models of depression management rather than just comparing the models with ‘standard care’. Moreover, the potential value for undertaking CCBT remotely – as opposed to (or compared with) general telephone-based support – would be an interesting avenue of enquiry.
Nick Goodwin is co-project lead for WSDAN
References
[1] NICE (2006). Computerised cognitive behaviour therapy for depression and anxiety. NICE Technology Appraisal 97, 22 February
[2] Kaltenthaler E, Brazier J, De Nigris E, Tumur I, Ferriter M, Beverley C, Parry G, Rooney G, Sutcliffe P. (2004) 'Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation'. NIHR NCC Health Technology Assessment; vol.10: no.33
[3] Fortney JC, Pyne JM, Edlund MJ, Williams DK, Robinson DE, Mittal D, Henderson KL (2007) A randomized trial of telemedicine-based collaborative care for depression. Journal of General Internal Medicine, vol.22, no.8, pp.1086-93
[4] Robertson L, Smith M, Tannenbaum D (2005) Case management and adherence to an online disease management system, J Telemed Telecare, vol.11, suppl. 2, pp.S73-5.