Information technology can pull mental health care advance into the 21st century
Psychiat Bullet 2004 Aug by Marks IM
150 years ago physical disease was known to be widespread but was usually untreated. Anxiety/depression is now like that. Up to 20% of all people are sufferers and 84% were untreated in a UK community survey (Bebbington et al 2000 a & b). `Developed' countries are underdeveloped in treating anxiety/depressive disorders even though those improved in randomised controlled trials (RCTs) of brief behavioural-cognitive therapies (CBT). UK waiting lists for CBT are often 1 to 2 years. Routine-therapy outcome are rarely reported. The delivery and monitoring and also teaching of therapy largely lag behind in a 19th century model and could advance by more use of information technology (IT). IT could catalyse a model of community care based mainly at home to enhance access to effective self-help, audit of outcome, and professional training.
The NHS could organise IT access of 2 kinds. First, when healthcare professionals diagnose an anxiety or depressive disorder in the course of a consultation, they could print out and give to the patient an approved information leaflet including self-help guidance. Second, professionals could prescribe for patients a password for round-the-clock access to interactive self-help guidance at home via either the internet or by phone using interactive voice response (IVR), plus brief helpline advice from a live therapist if they get stuck. A prerequisite for prescribing such passwords is NHS funding for these just as the NHS funds medication prescriptions.
Computer-aided CBT (CCBT) self-help was successful in a NHS self-help clinic in west London (Marks et al 2003). The clinic's 4 CCBT systems - for agoraphobia/ panic, social and specific phobias, general anxiety, obsessive-compulsive disorder (OCD), and non-suicidal depression had been effective in open studies and RCTs. Sufferers initiated referral by completing and sending the clinic a completed screening questionnaire which they had obtained from GP surgeries, mental health centres or elsewhere. This triggered an offer of a 30-minute screening interview with a therapist face to face or by phone.
Most referrals were suitable and given access to an appropriate CCBT system. From home, patients could phone two of the systems (Cope for depression [Osgood-Hynes et al 1998] and BTSteps for OCD [Greist et al 2002]) using IVR and a manual to assist calls. Phobia/panic referrals originally used the FearFighter CCBT system (Marks et al 2004) in the clinic; later patients used internetFearFighter at home when it became available. General anxiety sufferers used the Balance system (Yates 1996 unpublished) in the clinic. CCBT users had brief advice from a therapist by phone for CCBT at home or face to face for CCBT in the clinic.
The clinic's outcome was encouraging. CCBT users improved significantly in distress and disability. The therapist managed 4 times more referrals by delegating routine aspects of care to CCBT than was possible without it. Therapist contact with patients was reserved for brief initial screening (which too could be done largely by IT) and to give brief advice if progress was slow. CCBT could reduce the per-patient cost of CBT by almost half for large numbers of patients.
Computer-aided self help at home offers benefits to:
A. Patients:
D. Researchers: speeded-up study of many psychotherapy processes, as CCBT systems can be modified to vary therapeutic ingredients and every key press of patients can be recorded and analysed.
E. Students and their teachers: self-education tools to save teaching time; in a RCT, medical students learned as much from a FearFighter variant as from a face- to-face tutorial (McDonough & Marks 2002). IT-aided self-help can be accessed by internet or phone not only at home but also at GP surgeries or other primary and secondary care settings, libraries, pharmacies and supermarkets, together with brief advice from a helper.
Who the helpers should be needs testing. So far they have mainly been nurses, psychiatrists or psychologists familiar with each self-help system. Non-clinical administrators too advised a few users after going through all of FearFighter's steps as pretend patients. Just 2 days suffice to learn enough about a given self-help system to qualify as helpers. Helpers could be based locally, or regionally or nationally at call centres resembling those of NHS Direct.
Adverse effects? Some professionals fear CCBT might make them redundant but in fact it is mainly a clinician-extender, not replacer, allowing staff to use their time better on tasks that a computer cannot do. Medicolegal issues will arise eventually when patients sue as they do after face to face therapy.
In conclusion, with careful organisation, funding and monitoring by the NHS and teaching establishments, computer self-help systems could greatly speed access to effective treatment, outcome audit, and teaching.
Acknowledgement: The author has intellectual property rights in Cope, BTSteps and FearFighter.
REFERENCES
-Greist JH, Marks IM, Baer L, Kobak KA, Wenzel KW, Hirsch, MJ, Mantle JM, Clary CM (2002) Behaviour therapy for obsessive compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. J Clin Psychiatry, 63; 138-145.
-Marks IM, Mataix-Cols D, Kenwright K, Cameron R, Hirsch S, Gega L (2003) Pragmatic evaluation of computer-aided self help for anxiety and depression. Brit J Psychiatry, 183, 57-65
-Marks IM, Kenwright M, McDonough M, Whittaker M, Mataix-Cols D (2004) Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomised controlled trial in phobia/panic disorder.Psychol Med, 34, 1-10.
- McDonough M, Marks IM (2002) Teaching medical students exposure therapy - randomised comparison of face-to-face versus computer instruction. Medical Education, 6, 1-6
-Osgood-Hynes DJ, Greist JH, Marks IM, Baer L, Heneman SW, Wenzel KW, Manzo PA, Parkin JR, Spierings CJ, Dottl SL, Vitse HM (1998) Self-administered psychotherapy for depression using a telephone-accessed computer system plus booklets: An open US-UK study. J Clin Psychiatry, 58, 358-365.
Psychiat Bullet 2004 Aug by Marks IM
150 years ago physical disease was known to be widespread but was usually untreated. Anxiety/depression is now like that. Up to 20% of all people are sufferers and 84% were untreated in a UK community survey (Bebbington et al 2000 a & b). `Developed' countries are underdeveloped in treating anxiety/depressive disorders even though those improved in randomised controlled trials (RCTs) of brief behavioural-cognitive therapies (CBT). UK waiting lists for CBT are often 1 to 2 years. Routine-therapy outcome are rarely reported. The delivery and monitoring and also teaching of therapy largely lag behind in a 19th century model and could advance by more use of information technology (IT). IT could catalyse a model of community care based mainly at home to enhance access to effective self-help, audit of outcome, and professional training.
The NHS could organise IT access of 2 kinds. First, when healthcare professionals diagnose an anxiety or depressive disorder in the course of a consultation, they could print out and give to the patient an approved information leaflet including self-help guidance. Second, professionals could prescribe for patients a password for round-the-clock access to interactive self-help guidance at home via either the internet or by phone using interactive voice response (IVR), plus brief helpline advice from a live therapist if they get stuck. A prerequisite for prescribing such passwords is NHS funding for these just as the NHS funds medication prescriptions.
Computer-aided CBT (CCBT) self-help was successful in a NHS self-help clinic in west London (Marks et al 2003). The clinic's 4 CCBT systems - for agoraphobia/ panic, social and specific phobias, general anxiety, obsessive-compulsive disorder (OCD), and non-suicidal depression had been effective in open studies and RCTs. Sufferers initiated referral by completing and sending the clinic a completed screening questionnaire which they had obtained from GP surgeries, mental health centres or elsewhere. This triggered an offer of a 30-minute screening interview with a therapist face to face or by phone.
Most referrals were suitable and given access to an appropriate CCBT system. From home, patients could phone two of the systems (Cope for depression [Osgood-Hynes et al 1998] and BTSteps for OCD [Greist et al 2002]) using IVR and a manual to assist calls. Phobia/panic referrals originally used the FearFighter CCBT system (Marks et al 2004) in the clinic; later patients used internetFearFighter at home when it became available. General anxiety sufferers used the Balance system (Yates 1996 unpublished) in the clinic. CCBT users had brief advice from a therapist by phone for CCBT at home or face to face for CCBT in the clinic.
The clinic's outcome was encouraging. CCBT users improved significantly in distress and disability. The therapist managed 4 times more referrals by delegating routine aspects of care to CCBT than was possible without it. Therapist contact with patients was reserved for brief initial screening (which too could be done largely by IT) and to give brief advice if progress was slow. CCBT could reduce the per-patient cost of CBT by almost half for large numbers of patients.
Computer-aided self help at home offers benefits to:
A. Patients:
- unlimited guidance round the clock by internet or phone-IVR, with live helpline back-up as needed;
- freedom from having to travel to a clinic which is a problem for housebound agoraphobics, people at work, and hard-pressed parents;
- option to disclose sensitive information to a computer, which many prefer to confiding in a person;
- sense of self-empowerment;
- access to the most updated self-help, as internet and phone-IVR systems are updated more easily than dispersed CD-ROMS and books.
- ability to effectively treat far more patients per day, because the self-help systems are clinician-extenders (not replacers) which cut per-patient time and cost;
- saving of the space and expenses needed to offer CCBT in a clinic and update the systems at intervals.
D. Researchers: speeded-up study of many psychotherapy processes, as CCBT systems can be modified to vary therapeutic ingredients and every key press of patients can be recorded and analysed.
E. Students and their teachers: self-education tools to save teaching time; in a RCT, medical students learned as much from a FearFighter variant as from a face- to-face tutorial (McDonough & Marks 2002). IT-aided self-help can be accessed by internet or phone not only at home but also at GP surgeries or other primary and secondary care settings, libraries, pharmacies and supermarkets, together with brief advice from a helper.
Who the helpers should be needs testing. So far they have mainly been nurses, psychiatrists or psychologists familiar with each self-help system. Non-clinical administrators too advised a few users after going through all of FearFighter's steps as pretend patients. Just 2 days suffice to learn enough about a given self-help system to qualify as helpers. Helpers could be based locally, or regionally or nationally at call centres resembling those of NHS Direct.
Adverse effects? Some professionals fear CCBT might make them redundant but in fact it is mainly a clinician-extender, not replacer, allowing staff to use their time better on tasks that a computer cannot do. Medicolegal issues will arise eventually when patients sue as they do after face to face therapy.
In conclusion, with careful organisation, funding and monitoring by the NHS and teaching establishments, computer self-help systems could greatly speed access to effective treatment, outcome audit, and teaching.
Acknowledgement: The author has intellectual property rights in Cope, BTSteps and FearFighter.
REFERENCES
-Greist JH, Marks IM, Baer L, Kobak KA, Wenzel KW, Hirsch, MJ, Mantle JM, Clary CM (2002) Behaviour therapy for obsessive compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. J Clin Psychiatry, 63; 138-145.
-Marks IM, Mataix-Cols D, Kenwright K, Cameron R, Hirsch S, Gega L (2003) Pragmatic evaluation of computer-aided self help for anxiety and depression. Brit J Psychiatry, 183, 57-65
-Marks IM, Kenwright M, McDonough M, Whittaker M, Mataix-Cols D (2004) Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomised controlled trial in phobia/panic disorder.Psychol Med, 34, 1-10.
- McDonough M, Marks IM (2002) Teaching medical students exposure therapy - randomised comparison of face-to-face versus computer instruction. Medical Education, 6, 1-6
-Osgood-Hynes DJ, Greist JH, Marks IM, Baer L, Heneman SW, Wenzel KW, Manzo PA, Parkin JR, Spierings CJ, Dottl SL, Vitse HM (1998) Self-administered psychotherapy for depression using a telephone-accessed computer system plus booklets: An open US-UK study. J Clin Psychiatry, 58, 358-365.
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