Internetsupported selfhelp in stepped care for depression and anxiety

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Internet-supported self-help in stepped care
for depression and anxiety

• Pim Cuijpers
• ISRII/ASPR e-Health Workshop
• Canberra, 1 December 2009

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Overview

• What is guided self-help?
• Is it as effective as face-to-face
  psychotherapies?
• Internet-based guided self-help in stepped-care
  for depression and anxiety

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What is guided self-help?
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Types of treatment

• Many different types of psychotherapy
• Content
• CBT
• Psychodynamic
• Interpersonal
• Etc
• Treatment format
• Face-to-face treatments (individual, group)
• Guided self-help
• Unguided self-help

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Internet treatments

• Format
• Unguided self-help
• Guided self-help
• Treatment
• Other interventions support groups, information,
  etc

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Unguided self-help

• Effect sizes are smaller (Spek et al., 2007)
• Internet-interventions for depression/anxiety
• Unguided d0.26, gt NNT6.85
• Guided d1.00 gt NNT1.91
• If unguided interventions reach 4 times more
  participants, the impact on public health is
  larger than guided interventions
• Unguided is much cheaper!

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What is guided self-help

• Psychological treatment,
• where the patient or client takes home
• a standardized psychological treatment
• works through it more or less independently
• Book, Internet, stand-alone computer, television,
  video, audio
• Support by a professional therapist or coach
• face-to-face, telephone, email, chat
• support in working through the treatment

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Guided self-help (GSH)

• Has been used for many problems and disorders,
  including depression and anxiety disorders
• Usually based on cognitive behavior therapy
• Cognitive restructuring
• Problem-solving therapy
• Exposure
• Etc
• Goal
• Prevention
• Treatment

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Is guided self-help as effective as face-to-face
psychotherapies for depression and anxiety?
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The Dodo Bird Verdict
Everybody has won, and all should have prizes
Lewis Carroll Alice in Wonderland
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Are all psychotherapies equally effective?

• Effects are comparable
• Two possibilities
• Common nonspecific factors
• therapeutic alliance between therapist and
  client,
• belief in the treatment,
• Clear rationale for development of problems
• Various therapy-specific mechanisms, too many
  possible mediators and moderators, insufficient
  statistical power /insensitive methods

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Differences between psychotherapies?
Cuijpers et al., J Consult Clin Psychol 2008
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Minimal interventions?

• How much does a treatment need to be effective?
• Is a guided self-help treatment (GSH) as
  effective as face-to-face treatment?

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Research on GSH

• Goes back to the 1960s
• Dozens of studies and meta-analyses have shown
  that GSH is effective compared to control
  conditions
• Effect sizes are comparable to individual and
  group therapy
• Studies directly comparing GSH and FTF are better
  equipped to examine differences

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Meta-analyses of GSH for depression and anxiety,
compared to control groups
Van t Hof et al., CNS Spectr 2009
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Effects of psychotherapy for adult depression,
compared to control groups
Cuijpers et al., Psychother Res 2008
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Effects of psychotherapy for adult depression
according to treatment format
Cuijpers et al., Psychother Res 2008
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Meta-analysis of studies comparing GSH and FTF
treatments

• Systematic search
• 21 studies included
• 24 comparisons
• 810 participants (429 FTF, 381 GSH)
• 6 depression, 15 anxiety (7 panic, 8 phobias)
• FTF 16 individual, 8 group treatment
• GSH 15 self-help book, 4 stand-alone computer, 3
  Internet, 2 audio recordings
• Power calculation
• 14 studies with N50 to detect effect size of
  d0.3
• or 18 studies with N40
• or 24 studies with 30 participants

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Overall outcomes
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Differences between GSH and FTF for depression
and anxiety Effect sizes
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Difference in drop out rates

• 18 studies, 21 comparisons
• RR of dropping out 1.14 (95 CI 0.771.67)
  (higher in GSH)
• Not significant (p0.52)
• Heterogeneity (I2) was zero, not significant
  (Q17.05, pgt0.1).

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Cumulative meta-analysis

• The results of each new study are added to the
  total of the studies that have been conducted
  previously
• Historical analysis
• Allows to see when results became significant (or
  sufficient power)

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Guided self-help vs face-to-face treatment for
depression / anxiety disorders (Cuijpers et al.,
submitted)
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Results cumulative meta-analysis

• In 1994 sufficient evidence available to be sure
  that GSH is as effective as FTF
• Not or hardly applied in routine care
• Internet-interventions offer a new possibility
  to use this knowledge in practice

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Internet-based guided self-help in stepped-care
for depression and anxiety
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How to apply internet-based self-help
interventions?

• Recruitment from the general population
• In specific settings, such as the school, or
  work-setting
• In health care Stepped-care

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Principles of stepped care

• Begin with intervention with lowest intensity and
  costs
• Less diagnostics at beginning
• Increase in intensity and costs with each new
  step
• Monitoring after each step

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Stepped care

• Watchful waiting
• monitoring
• Guided self-help (through Internet or book)
• monitoring
• Brief face-to-face therapy (CBT or PST)
• monitoring
• Longer term face-to-face therapy medication
• Monitoring

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2 trials

• Prevention of depressive and anxiety disorders in
  older primary care patients (finished)
• Treatment of depressive and anxiety disorders in
  primary care patients (running)
• Third trial in preparation cancer patients with
  depression

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Treatment of depression/anxiety

• Recruitment through screening of GP patients
• Diagnostic interview
• Inclusion criteria
• Mild to moderate anxiety and/or depression
• Exclusion criteria
• Current treatment
• Not motivated
• Does not speak Dutch
• Randomisation 200 patients
• Stepped care
• Care as usual
• No results yet!

Seekles et al., BMC Public Health 2009
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Stepped care for prevention of depression

• Part of larger project of GP group
• Screening of patients 75 years or older (N5207)
• Those scoring above cut-off on CES-D, but had no
  DSM-IV depressive disorder were included
• Randomized to
• Stepped-care (N86)
• Care-as-usual (N84)

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Stepped-care

• Four steps
• Watchful waiting
• Guided self-help (Coping with depression and
  anxiety)
• Brief psychotherapy (PST)
• Referral to GP for medication
• Steps of 3 months
• Screening every 3 months

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Results

• Stepped care incidence of 11.6 (10/86)
• Control group incidence 23.8 (20/84)
• RR0.49 (95 CI 0.240.98)
• NNT8.2

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Conclusion

• Long and strong tradition that GSH is effective
  in the treatment of depression and anxiety
• Internet-based treatments may offer new
  possibilities to implement this knowledge in
  routine care
• Long way to go in the further development of
  Internet-based treatments
• GSH in stepped care
• Implementation!

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Thank you for your attention!

• Contact p.cuijpers_at_psy.vu.nl