January 16th, 2020 - Daniel Duffy, Clinical Trials Associate and PhD Candidate at SilverCloud Health
iCBT’s utility to those with more severe or complex needs
Internet-delivered cognitive behaviour therapy interventions (iCBT) have been utilised, with much success, in populations with mild-moderate presentations of Depression and Anxiety (e.g. Richards et al., 2015; Olthuis et al., 2016; Palacios et al., 2018). However, their utility to those with more severe or complex needs is less established.
Nonetheless, research around these populations has illustrated that clients in higher severity ranges of depression tend to benefit equally as well to iCBT as those in lower severity categories (Bower et al., 2013), with decreases in reported levels of suicidal ideation also being observed for similar cohorts (Watts et al., 2012).
As a front-line treatment for depression housed within a stepped care model, it can be argued that patients can benefit from initial iCBT treatment until therapeutic resources for high-intensity therapy become available. Therefore, it is suitable, provided the intervention is safely delivered, to further explore the utility of iCBT to individuals with more severe presentations of depression.
In 2015, SilverCloud conducted Ireland’s first large-scale randomised control trial of its depression intervention (Space from Depression; Richards et al., 2015). A considerable number of individuals were excluded from the main paper due to scoring above the mild-moderate threshold for symptoms of depression, but the data from this cohort was later revisited for a secondary analysis (Richards et al., 2018).
As a first step in exploring the potential benefits of the intervention to severe populations, the secondary analysis illustrated a reliable improvement rate (a shift of 9 or more points on the Beck Depression Inventory) of 64% within the sample from pre to post-treatment. This finding, along with a decrease in levels of reported suicidal ideation, parallels the results of the existing scientific literature base and provided a rationale for further investigation.
The feasibility trial in IAPT
A feasibility trial (the corresponding research paper has just been published on January 9th, 2020) was therefore conducted within the NHS IAPT programme, where the intervention was implemented within a Step 3 (high intensity therapy) pathway as a prequel to face-to-face therapy (Duffy & Enrique et al., 2019)
First of its kind in IAPT, the feasibility trial examines the impact of the iCBT interventions (Space from Depression, Space from Anxiety, Space from Depression and Anxiety) on clinical outcomes of depression, anxiety, work and social functioning and on clinician-patient levels of therapeutic alliance. The trust that hosted the study, like many other IAPT providers, experienced a range of waiting list times across its service localities. However, it had recently transformed its model of service provision to provide all patients with a “therapeutic package” upon entering step-3 services, including SilverCloud as a significant component.
Within this innovative service model, 123 participants were recruited over a 12-month period and on average, spent 47 days in iCBT treatment.
Results of the study
Specifically, for this sample, the need for an intervention is reflected in the long waiting times clients experienced when accessing treatment, with wait times for high intensity therapy averaging 158 days. Implementing iCBT can provide clients in these pathways with a front-line intervention in contexts where resources are scarce and help to significantly reduce waiting times, in this instance by 30%.
For clinical outcomes, significant reductions were observed in participants from point of entry to point of exit of the iCBT treatment component for:
• depression (Mean reduction of 3.6 points on PHQ-9),
• anxiety (Mean reduction of 3.2 points on GAD-7) and
• work and social functioning (Mean reduction of 2.4 points on WSAS).
Of particular importance, those who completed their entire course of treatment within the pathway (SilverCloud and Face-to-Face therapy), achieved a 46% recovery rate. This compares favourably against the 50% national recovery rate, given that there is no extant benchmark available to untangle the recovery rates across the different stepped care levels.
Future implications
These results contrast with the current guidance and practice in IAPT for the treatment of depression and anxiety, which advocate for the use of iCBT interventions specifically in mild-moderate (step 2) presentations. Nonetheless, this study builds on previous findings from existing literature and paves the way for future, randomised investigations into the effectiveness of iCBT for this patient cohort in IAPT. SilverCloud Health are excited to see what the future brings in this domain of research as it represents considerable progress towards getting care to all patient populations. You can find the full publication of our study here.
