The findings have important implications for transforming the way mental health care is delivered in primary care settings.
Bruce Rollman, MD, MPH
According to findings of a recent study, care manager-guided computerized cognitive behavioral therapy (CCBT) alone proved more effective than primary care physicians’ (PCP) usual care at improving mental-health-related quality of life, mood and anxiety among those with depression and anxiety.
The study examined the effectiveness of combining an internet support group (ISG) with CCBT via a collaborative care program versus CCBT alone. Investigators also evaluated whether CCBT is more effective than usual care.
“These collaborative care models where you have a care manager who telephones or emails a patient or meets face to face, they’ve been proven to be effective in dozens of trials, for treating anxiety and depression in primary care,” Bruce Rollman, MD, MPH, director, Center for Behavioral Health and Smart Technology, Professor of Medicine, Psychiatry, Biomedical Informatics, and Clinical and Translational Science, University of Pittsburg, told MD Magazine. “These programs work, but they require a care manager or office staff to encourage people to use the program and complete the sessions.”
In the 3-arm randomized clinical trial, primary care physicians from 26 primary care practices referred 2884 patients in response to an electronic medical record (EMR) prompt from Aug. 2012—Sept. 2014. The EMR launched automatically for all patients aged 18–75 years whenever anxiety, generalized anxiety, panic or depression was entered as a diagnosis.
Eligible study patients were required to have internet and email access; a score of a 10 or greater on either the 7-Item Generalized Anxiety Disorder (GAD-7) scale, or the 9-Item Patient Health Questionnaire (PHQ-9); and no alcohol dependence as determined by the Alcoholic Use Disorders Identification Test, active suicidality, or other serious mental illness.
Researchers concluded that 704 patients met all eligibility criteria. Following the baseline assessment, investigators randomized patients in a 3:3:1 ratio to CCBT alone (n=301), CCBT and ISG (n=302), or usual care under their PCP (n=101).
Investigators utilized the Beating the Blues CCBT program that consists of a 10-minute introductory video followed by 8, 50-minute interactive sessions that care managers encouraged patients to complete every 1—2 weeks.
Each session included easily understood text, audiovisual clips and homework assignments. Patients completed the GAD-7 and PHQ-9 at the start of each CCBT session, self-tracking their symptoms.
Care managers guided patients through 8 CCBT sessions over the course of 6 months, relaying patient progress to primary care physicians. Treatment durability from the sessions was assessed 6 months later as a follow-up.
Another arm of the trial was patient registration to an ISG, patients could access via smartphone or computer to communicate through a variety of discussion boards created by the care manager moderator. Curated links to external resources that included local $4 generic pharmacy programs, ‘find-a-therapist’, various crisis hotlines, YouTube videos on insomnia, nutrition, exercise and other topics, were embedded to the EMR’s patient portal to integrate with routine care.
Researchers included status indicators on members’ profiles, email notifications of new ISG activities and automated highlighting of recent comments on members’ home pages personalized to their ISG profile and past activities, invited member-guest moderators and included various contests encouraging log-ins and comments.
By 6 months, 504 of 603 patients (83.6%) with CCBT access completed at least 1 session, and 221 (36.7%) completed all 8. The mean number of sessions completed was 5.4.
Overall, 228 of 302 patients (75.5%) in the CCBT and ISG arm logged into ISG at least once and 141 (61.8%) made at least 1 online comment or post.
Study findings compared different versions of the trial, noting that different age groups reacted differently to trial variations. Those 60—75 years old positively responded to the CCBT and ISG trial, while those aged 35–59 years old demonstrated no benefit to the ISG group.
Both age groups, however, showed improvements over usual standard care.
The study highlights the need for patient engagement and CCBT when dealing with mental health disorders. The simplicity of CCBT and follow-up care means that care managers can take on more patient cases, with a slight or no drop in the quality of care and attention.
At the 6-month assessment, those receiving CCBT plus an ISG reported similar improvements in mental-health-related quality of life, mood and anxiety symptoms compared to those in the computerized CBT-alone group.
Compared to those receiving usual care, patients in the CCBT-alone group reported significant 6-month effect size improvements in mood (effect size, 0.31) and anxiety (effect size, 0.26) which occurred 6 months later.
Completing more CCBT sessions produced a greater effect size improvements, suggesting a dose-response effect.
“Beating the blues and other computerized CBT programs like it could be used effectively in primary care as first-line treatment for uncomplicated depressed and anxious primary care patients,” Rollman said. “They [the programs] could be a safe and effective way to provide mental health care at scale.”
The study demonstrates that online CCBT offered more benefit to those than the standard usual care, but that ISG presented no additional benefits.
“In terms of the ISG, there have been no major randomized trials, it’s all been anecdotal information, where people say they found something interesting and helpful,” Rollman added. “And it might be helpful, but we were unable to find anything in a randomized trial to show benefit.”
The study "Effectiveness of Online Collaborative Care for Treating Mood and Anxiety Disorders in Primary Care " was published in JAMA Psychiatry in January 2018.