Internet-delivered Cognitive Behaviour Therapy at Step 3 of IAPT
Condition: Depression; Anxiety
MeSH terms: Depression; Depressive Disorder; Anxiety Disorders
Study type: Interventional

Summary: 
      This study will explore the potential impacts of internet-delivered cognitive behavioural
      therapy (ICBT) at step 3 of the IAPT model. To do this, interventions administered as a
      prequel to face-to-face therapy will be analysed and compared based on their impacts in
      regards to access, outcomes (psychological) and costs. A qualitative segment will also be
      conducted in order to investigate the acceptability and usability of the platform for
      clinicians and the possibility of developing a therapeutic alliance through an online medium.
    

Detailed description: 
      Depression and anxiety disorders (panic disorder, social anxiety disorder, specific phobias
      and generalized anxiety disorder) have been ranked high among the leading causes of disease
      burden throughout the world, displaying high rates of lifetime incidence, early age onset,
      high chronicity, and role impairment. Depression and anxiety are associated with impairment
      in several areas of functioning including social, occupational and personal. The cost to the
      person and the economy is great, for instance, 105 billion pounds is the estimated cost of
      depression in the UK with 30% of that being consumed through occupational costs. This has
      consequently had to be augmented through unemployment benefit to the tune of 7-10 billion.

      Improving Access to Psychological Therapies (IAPT):

      In 2007 the Department of Health UK announced the introduction of the Improving Access to
      Psychological Therapies (IAPT) programme. The aim of the programme was to extend access to
      clinically approved psychological interventions for depression and anxiety. In doing this,
      the hope was to be able to tackle and help alleviate the burden of psychological distress and
      its associated costs. In accordance with the model, a five-step approach to psychological
      care for people with depression and anxiety was introduced and implemented within NHS mental
      health services The model can be interpreted as a hierarchical care model of mental health,
      where each step is catered to provide treatment based on the severity of symptoms presented
      by the patient. This includes watchful waiting by general practitioners care at step 1, step
      2 relates to low-intensity psychological interventions, step 3 involves high-intensity
      psychological interventions, step 4 comprises of specialist mental health care, and step 5
      consists of inpatient treatment for mental health problems.

      The use of cCBT in IAPT As recommended by the National Institute for Health and Clinical
      Excellence the IAPT programme offers computerised cognitive behaivoural therapy (cCBT) as a
      low-intensity, Step 2 intervention for individuals presenting with mild to moderate symptoms
      of depression and/or anxiety. cCBT and internet-delivered cognitive behavior therapy (iCBT)
      are delivered by PWPs and support is offered through electronic communication means or by
      telephone support. However, traditionally they have often suffered with poor engagement and
      consequently poor clinical outcomes. More recent developments in the field have produced more
      robust technological platforms, where content is delivered through a variety of media that
      increase engagement, enhance productivity, and produce better clinical effectiveness. In
      accordance with what has been utilised in the IAPT model, research has demonstrated the
      effectiveness of cCBT and iCBT in treating symptoms of depression and anxiety . There is now
      a substantial body of research evidence that supports the efficacy and effectiveness of
      online delivered cognitive behavior therapy for depression and anxiety.

      Alongside the use of antidepressants, patients at Step 3 IAPT are commonly treated using
      face-to-face psychological interventions include cognitive behavior therapy, interpersonal
      therapy, and behavioural activation. In practice, online delivered interventions have been
      used in some cases for those at step 3 and also as a facilitator for those who are stepping
      down from Step 3. However, to date, there have not been studies conducted that have examined
      the potential of online interventions at step 3 and their impact on access rates, clinical
      and functional outcomes, and costs.

      Methodology Objective of the trial To explore the potential of using internet-delivered CBT
      (iCBT) for people in IAPT services as a prequel to high intensity therapy (HIT) for
      depression and anxiety disorders.

      Research Questions The objective can be further dismantled into;

        1. Can SilverCloud achieve positive clinical outcomes for patients?

        2. Will patients experience the online intervention as satisfactory?

        3. Can an online intervention for depression and anxiety realise cost saving benefits?

        4. Do clinicians find the experience of delivering the intervention as satisfactory (usable
           and acceptable)?

        5. Can a therapeutic alliance be established online?

      Design The current study will be a mixed methods, uncontrolled feasibility design. The study
      will utilise both patient and clinician participants. For patients, the study will examine
      quantitatively clinical outcomes for patients in regards to depression and anxiety,
      functional outcomes in terms of work and social functioning and cost effectiveness in regards
      to step-3 services. Therapeutic alliance will also be examined using both patient and
      clinician participants. Qualitatively, patient satisfaction and clinician experience of the
      usability and acceptability of the online intervention will be explored. The study will also
      qualitatively explore the nature of the therapeutic alliance online through use of a
      semi-structured interview with clinician participants.
    

Intervention name(s): SilverCloud
Intervention type(s): Behavioral
Intervention description(s): SilverCloud Health is a leading provider of online therapeutic solutions to support and promote positive behavior change and mental wellness. SilverCloud delivers interventions for all of the anxiety disorders (panic disorder, social anxiety, phobias, GAD, health anxiety, OCD), depression and also comorbid depression and anxiety. The programs for the treatment of depression and anxiety employ several innovative engagement strategies for improving the user experience. These are divided into several categories: personal, interactive, supportive, and social. Research on the SilverCloud interventions has yielded significant clinical outcomes (Richards et al., 2015).
Allocation: Non-Randomized
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Depression; Anxiety; Online interventions; CBT; IAPT