Computerized Cognitive Behavioral Therapy
for Depression and Addiction in Primary Care Mood and Alcohol or Drug use Disorders
Mood disorders: underlying feature is disruption to general mood and emotions:
Depression: Lifetime 21%, past 12 months 4%; Bipolar Disorder: past 12 months 2%.
Alcohol or drug use (AOD) disorders: Tobacco dependence: 17% past 12 months.
Alcohol abuse/dependence lifetime 14%, 1 in 15 (12/12).
Other drugs: lifetime 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 increased: 38% in 1997 vs. 35% in 2007.
Physical disorders=80%. Despite government initiatives
Estimated annual investment $3.2 billion. Australia — BOiMHC — 12 free sessions with
Average time to treatment from onset of disorder (Australia):
23 years for Alcohol Abuse. 18 years for Alcohol Dependence.
Current Treatment Coverage: Depression=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 example: Prevalence of depression is 2-3 times higher
than in general population: 35% 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 4 trials of antidepressants.
Treatment guidelines do not support medication as first line for most patients.
The example of depression/anxiety… Cognitive Behavior Therapy (CBT):
Recommended 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 Therapy: Change problematic thinking patterns — change
behavior and change feelings. Integrated with behaviorist techniques:
What 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*D: 2/3 of depressed outpatients had at least one other psychiatric disorder.
25-50% of people experience>1 mental disorder Comorbid depression and substance use
¼ 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 silos: High-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 internationally:
44% 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 study: Critical 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 services:
Networks, partnerships, fidelity. Improved access (unmet need):
Anonymity, accessibility, convenience. Potential of e-mental health treatment
Internet access is rapidly increasing: 88.8% 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 access: Higher 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 research:
Small 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
AIM: replication trial of a prior SHADE trial: In both a rural and urban setting;
Assess the efficacy of SHADE relative to: Therapist-delivered equivalent
Non-specific treatment control group that matched for therapist contact Eligibility Criteria
Inclusion Criteria:>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 conditions: Face-to-face.
Therapist treatment: 9 further sessions;
Motivational interviewing (MI) and CBT (MI/CBT). SHADE treatment:
9 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’ duration: 20 minutes: homework and week revision;
20 minutes: introduce new MI/CBT strategies; 20 minutes: revise session and prepare for
coming week. Homework central to MI/CBT
The MI/CBT treatment protocol Key treatment techniques:
Case 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 Model: AOD 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 therapy: 64mins + 16mins/wk
Therapist-delivered CBT/MI: 64mins + 58mins/wk PCT: 64mins + 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 produce similar, sustained reductions in depression,
alcohol, cannabis use. No specialist CBT, MI or comorbidity training
required. First face-to-face session now online.
Weekly therapist contact: 10-15 minutes
Suicide risk assessment (built-in) e-mental health treatments
SHADE (depression + addiction) FEARFIGHTER (panic, phobias, general anxiety)
MoodCalmer (depression) Beating The Blues (mild depression)
OCFighter (OCD) BRAVE (child/adolescent anxiety)
RESTORE (insomnia) CBT4CBT (alcohol/substance use addiction)
Smoking cessation (Munoz) Real world dissemination models
UK: NICE guidelines recommend for
FEARFIGHTER (phobia, panic, anxiety) MoodCalmer, Living Life to Full, Beating the
Blues (mild-moderate depression) OCFighter (Efficacious for OCD).
Canada: RESTORE: first line treatment for insomnia
in a stepped care model.
USA: APA endorsement of CBT treatments as the first
line of treatment for insomnia, anxiety, OCD. SHADE dissemination work
Healthy Lifestyles Treatment E-health…technology, attitudes, commitment
Use of e-health initiatives more a question of costs, client and provider preference
Clinical Trials Network (USA) Perceived social norms about technology adoption
were most influential among clinicians. Small dissemination study in Substance Use Service
80% clients willing to use e-mental health 34% exposed by clinicians
The vital piece in the puzzle…. The Coach!
Internet treatment a useful step within a larger therapeutic process:
Clinic-based delivery Home-based delivery
Reduced time for clinician input Depression 10-15 minutes/week
Insomnia — 5 minutes/week No CBT/MI training required to support
Clinical system to assist with monitoring Integrating behavioral health into primary
care: E-health Treatments are as effective as face-to face.
SHADE, RESTORE, FEARFIGHTER, OCFIGHTER Patients find it as acceptable as face-to-face treatment.
Patients have ready access to the Internet.
Clinicians can use it to save time while offering more comprehensive, specialized treatment:
No training required; Little change to usual practice. Acknowledgements
Chief Investigators Frances Kay-Lambkin
Amanda Baker Brian Kelly
Terry Lewin Vaughan Carr
Statistician Terry Lewin