Examining computerised solutions to Cognitive Behavioural Therapies
26 October 2016, House of Commons, London
Purpose of holding the roundtable discussion
The purpose of this roundtable was to explore the potential and limitations of computerised Cognitive Behavioural Therapy (cCBT) tools to help people deal with their mental health needs. The roundtable was attended by a variety of stakeholders including leading academics, civil servants, practitioners, service providers and representatives from mental health charities. To spark the discussion, RAND Europe presented the findings of its recent Research Report, Review of computerised cognitive behavioural therapies: Products and outcomes for people with mental health needs. This led to a rich and robust exchange of views on the options for and limitations of providing mental health therapy through computers and mobile devices. We thank our co-sponsors, Ingeus, a provider of employment programmes and other social services, for their support.
This summary presents:
- The context for RAND Europe’s study and the roundtable discussion
- Points raised during the roundtable discussion
- Key findings of RAND Europe’s study on cCBT
- Attendees at the roundtable discussion
Context for computerised Cognitive Behavioural Therapies
In 2014 RAND Europe conducted important research in the areas of psychological well-being and work and improving service provision and outcomes. Findings from this study led to the Department for Work and Pensions and Department of Health taking up three of four pilot schemes recommended. These were:
- Embedding vocational support based on the principles of Individual Placement and Support (IPS) into primary care settings
- Enhancing support to those out of work, using group work approaches based on JOBS II to build resilience against setbacks faced when job-seeking
- Providing a combination of psychological and employment-related telephone support to people with common mental health problems who are out of work.
The outstanding policy recommendation of that study involves the use of online assessment and interventions for common mental health problems (such as depression, anxiety or insomnia), including cCBT. Since 2014 there has been a notable increase in the provision of computerised solutions to CBT and evidence behind these.
Following on from this, Ingeus commissioned RAND Europe in 2016 to examine new developments in cCBT in greater detail and to look at the emerging evidence base for clinical improvement and work- related outcomes. The key findings of the review formed a basis for the ensuing roundtable discussion, chaired by the Rt. Hon. Norman Lamb MP, held against the backdrop of the UK government’s plans to provide specialist support for people with common mental health conditions who are out of work, and to test new interventions, such as cCBT, if shown to support employment outcomes alongside mental health recovery. The government subsequently released its proposals in a consultation document, Improving Lives: The Work, Health and Disability Green Paper in October 2016.
There were three main themes that stood out from the discussion. The first related to how computerised CBT is conceived of, for and for whom it should be made available, and how this should be achieved. The second pertained to the evidence gap in the field and the factors that inhibit collecting sound data. Intricately related to these are issues of equity, user perceptions and return to investment, which were also discerned during the discussion. Finally, participants touched upon the roles that stakeholders can play to facilitate tackling such barriers. Maintaining close communication and cooperation between stakeholders stood out as a key element to be pursued when moving forwards.
The roundtable discussion identified problems faced when implementing and evaluating cCBT tools. While it did not resolve them, it provided pointers towards areas that require particular attention when developing future cCBT tools.
Defining cCBT tools and users
The field of cCBT is charged with complexity. On the one hand there is the question of how cCBT is conceived of when talking about it. cCBT tools form just one segment of a much wider spectrum of e-therapy interventions and mental health treatment methods more broadly. The term describes a number of online platforms or mobile applications to help tackle common mental health illnesses, such as depression, anxiety or insomnia. cCBT tools can be used as a primary treatment intervention with minimal therapist involvement, or as a supplement to a therapist-delivered programme. Therefore, this type of treatment should not be considered as encompassing a single approach – its array of modes and multiple dimensions should not be forgotten. In itself, cCBT is a collection of interventions that can be used to tackle a variety of mental health problems. Therefore, it might be more accurate to conceive of cCBT as an ‘app’, since each tool is different depending on the mental health need it tackles and how it is designed.
Another complex issue encountered when talking about cCBT is how to define its audience: for whom is this type of therapy most appropriate? When addressing this question it is necessary to consider the type and severity of the mental health issues affecting each individual, their socio-economic status and their attitudes towards e-therapy more broadly, as well as how their transition from or to another type of treatment is managed. How cCBT is facilitated and monitored will have implications on who uses these tools, and is therefore closely linked to accessibility and equity. These two factors can be considered both in terms of cost, e.g. making cCBT tools economically accessible for audiences from lower socio- economic groups, and in terms of physical access, for example providing individuals with the space and equipment to easily use these tools.
The severity of the mental health needs of individuals may also determine the appropriateness of using this type of therapy. It is plausible that for individuals with mild and moderate severities of mental health needs cCBT is effective. However, if specifically focusing on cCBT tools to help Jobcentre Plus audiences return to work, cCBT might not be as effective. Gaining greater information about how the effectiveness of cCBT tools changes depending on the characteristics of individuals will require further research.
The existing gaps in the evidence base
The above exchange of views led onto another prominent topic of discussion during the meeting. When compared to the evidence pool available for more traditional types of mental health treatments, the evidence about cCBT tools’ effectiveness is more limited. This is in part in uenced by the complex nature of these tools. Given the variety of forms they can acquire and measures used to assess them, comparing the results of effectiveness studies can be difficult. Therefore, particularly for tools tackling work-related issues, establishing employment measures and aligning them in future research could help improve the quality of data that can be obtained about cCBT tools. A more systematic process of data collection could help generate a nationwide comparable evidence pool.
Another limiting factor for collecting cCBT data relates to the design of studies. A recurrent problem experienced, for example when undertaking Randomised Control Trials, is high levels of attrition. Another challenge relates to high levels of dropout from cCBT treatments and the possible impacts these levels may have on effectiveness. This links back to how the usage of these tools is facilitated and monitored. To address this issue feasibility studies might be a first step before evaluating effectiveness through trials. Increasing our understanding about how people perceive these tools and how best to present them in a manner that is appealing to users is relevant to increase the evidence about uptake. The problem of attrition also points to the importance of the quality of the design of the platforms themselves, which are built without considering the need to retain user engagement – more commonly taken into account in commercially oriented apps. Many current platforms still look like they are using early 1990s technology, and as such are likely to be less appealing to cohorts who are digitally native and used to higher quality.
Similarly, information about the cost-effectiveness of cCBT treatments is scarce. Little is known about the actual cost of delivery and, for example, maintaining and updating the software or training practitioners on how to refer patients to cCBT therapy. Improving the quality of evidence regarding cost- effectiveness is important to make policy decisions to promote the use of cCBT, and goes hand in hand with considerations about the groups for whom cCBT is best suited and who show the lowest risk of negative effects.
Finally, there are gaps in the evidence about how the costs and benefits of cCBT compare with standard practice, especially where cCBT would be offered in addition to existing services. It was also apparent that while a lack of evidence was important, the way in which cCBT was constructed, for example through the ‘sense-making’ of stakeholders, was also important.
Increasing the evidence pool in these aspects represents a potential area for expansion that can help fill the existing funding gap.
The roles of stakeholders
Finally, the roles of stakeholders in improving the evidence base, use and future development of cCBT tools were discussed. The need to maintain communication between stakeholders, namely the public sector, providers, employers, researchers and practitioners, stood out. For example, referring to already- existing technologies within the private sector can help keep cCBT tools up to date both in terms of their functionalities and their interfaces, helping ensure the tools remain appealing to users. However, bringing cCBT to work might be difficult, as people with mental health needs are particularly vulnerable at a workplace. Thus, employers can play a key role in creating a safe environment and promoting the use of cCBT tools by introducing measures to increase workplace well-being and by training line managers on how best to deal with the mental health needs of employees. Still, the costs this may cause companies need to be considered; measures could include introducing incentives for employers to provide workplace well-being programmes or to help develop cCBT tools. Establishing partnerships between government and employers will be important to achieve this. Looking at similar initiatives in other countries, for example the Netherlands, is a potential starting point to further increase the evidence base on what works for whom, in what contexts and under which conditions.
RAND Europe research findings
The review of cCBT carried out by RAND Europe shows that:
- cCBT tools have grown significantly since 2014. A wide range of tools now exist to meet a diverse range of mental health needs.
- cCBT tools are available in a number of countries, including Australia, China, Denmark, Ireland, Japan, Norway, Spain, Sweden, the Netherlands, the UK and the US.
- cCBT tools are not the ‘silver bullet’ to solving common mental health problems, but were found to be largely effective at providing support to people with mental health needs.
- Some groups with mental health needs might be less likely than others to participate in treatment (or trials) with computerised CBT tools. For example, the average user was found to be a woman in her late thirties with a university degree and in full-time employment, but unemployed men were far less likely to use the tools (or participate in trials).
- Condition-specific cCBT tools were found to reduce the symptoms of other disorders. For example, a tool to help those with insomnia could simultaneously reduce symptoms of depression.
- While only some studies examine work-related outcomes, apart from mental health improvements, those that do show on average small positive changes as well.
List of attendees
Dame Carol Black, Nuffield Trust
Miriam Broeks, RAND Europe
Felicity Dormon, NHS England – Adult IAPT programme
Barry Fletcher, Ingeus
Joanna Hofman, RAND Europe
Luke Jeavons, Ingeus
Richard Jones, NHS
Tim Kendall, Sheffield Health and Social Care NHS Foundation Trust
Peter Kinderman, British Psychological Society
Norman Lamb, MP
Tom Ling, RAND Europe
Ayaz Manji, MIND
David McDaid, London School of Economics
Kirsty McHugh, ERSA
Phil Mercer, DWP
Steve Pilling, University College London
Lynne Saylor, RAND Europe
Alex Skinner, DWP
Charlotte Spencer, DWP
Karen Steadman, The Work Foundation
Sara Tai, University of Manchester
Justin Varney, Public Health England
Norman Worner, South West London and St George’s Mental Health NHS Trust