Computerized Cognitive Behavioral Therapy for Depression and Addiction in Primary Care Mood and Alcohol or Drug use Disorders Mood disorder nderlying feature is disruption to general mood and emotion epressio ifetime 21%, past 12 months 4%; Bipolar Disorde ast 12 months 2%. Alcohol or drug use (AOD) disorder 38Tobacco dependenc 7% past 12 months. Alcohol abuse/dependence lifetime 14%, 1 in 15 (12/12). Other drug ifetime 6%, 1 in 45 (12/12). Treatment access for mental disorders In Australia, the proportion of adults with current mental health problems using traditional services has not increase 1338% in 1997 vs. 35% in 2007. Physical disorders = 80%. Despite government initiatives Estimated annual investment $3.2 billion. Australia -- BOiMHC -- 12 free sessions with a psychologist. Average time to treatment from onset of disorder (Australia 3 years for Alcohol Abuse. 18 years for Alcohol Dependence. Current Treatment Coverag 52Depression=60%. Alcohol use disorder=11%. Treatment provision to under-served or difficult-to-access populations is difficult. In primary care settings... Principal point of contact for >50% of patients with mental illness. For exampl 14Prevalence of depression is 2-3 times higher than in general populatio 2135% of patients meet criteria for some form of depression. 10% meet criteria for major depression. "The integration of mental health into primary care is the most salient means of addressing the burden of mental health conditions...[and is] urgently important..." World Health Organization The example of depression/anxiety... Medication is usually first (and often) only treatment offered. Unwanted side effects. Not cost effective for non-compliant patients. STAR*D and CO-MED trials indicated 1/3 of patients did not achieve remission after trials of antidepressants. Treatment guidelines do not support medication as first line for most patients. The example of depression/anxiety... Cognitive Behavior Therapy (CBT ecommended by treatment guidelines. Effective, often preferred, but difficult to access. Too few therapists. Expensive to access. Waiting lists. Reluctance to enter treatment. Cognitive Behavior Therapy (CBT) 1960's -- Aaron Beck -- Cognitive Therap 53Change problematic thinking patterns -- change behavior and change feelings. Integrated with behaviorist technique hat we do shapes how we feel and what we believe. Short-term goal-oriented therapy. Focus on helping patients identify and change what is maintaining their problem right now. CBT Model Comorbidity compounds these issues... 23% of US population are estimated to be impacted by comorbid mental health and alcohol or drug use disorders annually. STAR* /3 of depressed outpatients had at least one other psychiatric disorder. 25-50% of people experience >1 mental disorder Comorbid depression and substance use ? of people with mental disorders experience more than one class of mental disorder. Lifetime mental disorder = 3 x tobacco dependence, 2 x alcohol use disorder + 4 x drug use disorder. Diagnostic and sub-diagnostic levels of disorder important. Higher rates in treatment-seeking populations and clinical services. Integrated care = optimal patient outcomes Depressive symptoms are associated with poorer alcohol treatment outcomes (Burns et al. 2005). Heavy drinking produces depressive symptoms (Paljarvi et al. 2009). Remission of problem drinking increases the chance of remission in depression (Hasin et al. 1996). Treatment for mood disorder should not be withheld from people who misuse alcohol (Grant et al. 2004). Treatment for comorbid mental disorders Australian treatment silo 14High-prevalence mental disorders + AOD disorders = Substance Use Agencies. Low-prevalence mental disorders = Mental Hlth Services. General Practice = 2 patients every day. Similar systemic and clinical barriers impede integration of care internationall 4% of people with comorbid disorders receive treatment for either disorder, and only 7% receive treatment for both disorders. Health System Challenges... "Increased health care service demands, costs and complexities are already testing the limits of the financial, physical and human resources of the Australian Health System...These challenges will not be solved by doing more of the same, particularly given the limits of available human and financial resources..." How do you respond? Need to integrate behavioral health into clinical practice. Need to screen for depression, substance abuse, tobacco use, etc. New York State stud 52Critical elements in place -- assessment + capable staff 92% supported treating comorbid problems Actual delivery of effective treatment a challenge The potential of e-health to respond "an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through internet and related technologies. ..not only a technical development, but also a state-of-mind...an attitude, and a commitment for networked, global thinking to improve health care locally, regionally, and worldwide by using information and communications technology." The potential of e-mental health treatment Treatment can be accessible at times and in locations that suit clients May reduce stigma associated with treatment Clients can work at their own pace, tailoring the provision of information and strategies May be able to circumvent some of the challenges of treatment access Potential of e-mental health treatment Reduce therapist time whilst maintaining efficacy. Work with more patients Expand expertise Facilitate conventional service delivery. Introduce innovative service etworks, partnerships, fidelity. Improved access (unmet need nonymity, accessibility, convenience. Potential of e-mental health treatment Internet access is rapidly increasin 5588.8% of Australians have access to the Internet 83.6% of UK have access to the Internet 78.6% of North Americans have access to the Internet 48.2% South Americans World Average -- 34.3% 32.8% Central Americans 32.4% the Carribean Internet access in Australia Highest rates of acces igher income earners. Higher levels of educational attainment. Households with children ?15 years. What about people with mental disorders? What about people with alcohol/other drug use disorders? Internet access in Australia Studies conducted by NDARC/CTNMH Epidemiological survey of NSW rural population Included people with depression and alcohol use problems Treatment trial among people with psychosis Recruited from mental health services in HNE Health Treatment trial among people with comorbid alcohol/other drug use problems and PTSD Recruited from AOD services in Sydney Access to technology...bridging the digital divide Previous use of the Internet for... Consider using the Internet... Emergence of e-mental health treatments Cognitive Behavioral Combines CBT and multimedia options FearFighter (Marks, et al 2002) RESTORE (Vincent, et al, 2009) MoodCalmer, UK (Marks, et al UK, 2003) MoodGym (Christensen et al., Aust, 2004) Anxiety online (Klein et al., Aust, 2001-2006) ODIN (Clarke et al., 2002, 2006, USA) Emergence of e-mental health treatments Single-focused treatments. Mild end of severity spectrum. Methodological issues with researc mall sample sizes, credibility of comparable approaches, empirical support of clinician-delivered parent therapy, role of clinician-assistance. Could the same principles and technology be applied to more complex problems such as comorbidity? 2005-2012 AI eplication trial of a prior SHADE tria n both a rural and urban setting; Assess the efficacy of SHADE relative t herapist-delivered equivalent Non-specific treatment control group that matched for therapist contact Eligibility Criteria Inclusion Criteri 16 years of age; ?17 on BDI-II; Current drinking above recommended levels; Or hazardous cannabis use; Or hazardous methamphetamine use. Assessments Three treatment conditions... Session 1 common across all condition ace-to-face. Therapist treatmen further sessions; Motivational interviewing (MI) and CBT (MI/CBT). SHADE treatmen further sessions; MI/CBT. Person Centered Therapy (PCT) 9 further sessions; Face-to-face. The MI/CBT treatment protocol Integrates both depressive and AOD use approaches. Apply existing CBT and MI strategies used for people without comorbidity. Use examples related to both the depression and AOD use problems. Content of SHADE and therapist MI/CBT identical. A typical session 60 minutes' duratio 0 minute omework and week revision; 20 minute ntroduce new MI/CBT strategies; 20 minute evise session and prepare for coming week. Homework central to MI/CBT The MI/CBT treatment protocol Key treatment technique ase formulation; Motivational interviewing; Managing thoughts; Coping with cravings; Behavioral activation (activity scheduling); Problem solving; Mindfulness meditation; Drink/drug refusal skills; Relapse Prevention. Motivational Interviewing Miller & Rollnick Consider stage of change Work with ambivalence Build motivation for change Strengthen commitment CBT Mode OD use and Depression CBT Model -- AOD use and Depression Target the "A" Avoid/manage high-risk situations Seemingly irrelevant decisions Target the "B" Identify/monitor patterns of thinking Challenge/change faulty thinking patterns Target the "C" Behavioural activation Coping with cravings Monitor cravings and mood Thought Monitor Behavioural Activation Coping with Cravings Person Centered Therapy (PCT) Sellman et al. -- Christchurch School of Medicine Content/direction set by participant Supportive, reflective listening Genuineness or congruence Unconditional positive regard Accurate empathy No CBT/MI strategies Matched for therapist contact Clinician contact + preference Clinician contact SHADE computerized therap 4mins + 16mins/wk Therapist-delivered CBT/M 4mins + 58mins/wk PC 4mins + 41mins/wk Treatment preference = 148 (55%) Therapist = 133; Computer = 15 Not related to treatment outcome Treatment preference matched allocation = 92 (37%) Not related to treatment outcome Demographics (N=274) Males 57% Mean Age 40 yrs Education Age at leaving school 16 yrs Employment Status Employed at least part-time 42% Disability benefit 20% Unemployment benefit 24% Primacy Depression 54% Substance use 16% Inter-related 30% Not related to treatment outcome Clinical Data -- Depression (N=274) MDD (SCID) 12 months 63% Lifetime 83% BDI-II 31.70 (SD=9.20) 67% in severe category (>27) Current antidepressant 50% Clinical Data -- Alcohol and/or drugs (N=274) BDI-II (N=134) Alcohol (n=88) Cannabis (n=52) Hazardous drug use (n=134) Acceptability No relationship between treatment preference and retention, alliance or perceptions. If no preference, significantly greater benefit for alcohol use from SHADE. Content and modality of SHADE delivery acceptable "Helped me take more control in my life" SHADE Synthesis Therapist-delivered CBT/MI and clinician-assisted SHADE equivalent Clinician-assisted SHADE treatment promising Uses at least 50% less clinician time to produce2 similar, sustained reductions in depression, alcohol, cannabis use.2 No specialist CBT, MI or comorbidity training required.2 First face-to-face session now online. Weekly therapist contac :3110-15 minutes Suicide risk assessment (built-in)2 e-mental health treatments SHADE (depression + addiction)2 FEARFIGHTER (panic, phobias, general anxiety) MoodCalmer (depression)2 Beating The Blues (mild depression) OCFighter (OCD)2 BRAVE (child/adolescent anxiety) RESTORE (insomnia)2 CBT4CBT (alcohol/substance use addiction) Smoking cessation (Munoz)2 Real world dissemination models U :12NICE guidelines recommend for the NH EARFIGHTER (phobia, panic, anxiety)2 MoodCalmer, Living Life to Full, Beating the Blues (mild-moderate depression)2 OCFighter (Efficacious for OCD). Canad :18RESTOR irst line treatment for insomnia in 2 a stepped care model. US :48APA endorsement of CBT treatments as the first line of treatment for insomnia, anxiety, OCD.2 SHADE dissemination work Healthy Lifestyles Treatment2 E-health...technology, attitudes, commitment Use of e-health initiatives more a question2 of costs, client and provider preference Clinical Trials Network (USA)2 Perceived social norms about technology adoption were most influential among clinicians.2 Small dissemination study in 2 Substance Use Service 80% clients willing to use e-mental health2 34% exposed by clinicians The vital piece in the puzzle....2 The Coach! Internet treatment a useful step within a2 larger therapeutic proces linic-based delivery2 Home-based delivery Reduced time for clinician input2 Depression 10-15 minutes/week Insomnia -- 5 minutes/week2 No CBT/MI training required to support Clinical system to assist with monitoring2 Integrating behavioral health into primary car -health2 Treatments are 3 as effective as face-to face. SHADE, RESTORE, FEARFIGHTER, OCFIGHTER3 Patients find it 3 as acceptable as face-to-face treatment. Patients have ready access 3 to 3 the Internet. Clinicians can use it to save time while offering3 more comprehensive, specialized treatmen o training required;3 Little change 3 to usual practice.3 Acknowledgements Chief Investigators3 Frances Kay-Lambkin Amanda Baker Brian Kelly Terry Lewin Vaughan Carr Statistician Terry Lewin Funding5 AERF