Why Do General Practitioners Recommend or Not Recommend Computer-Delivered Cognitive Behavioural Therapy (CCBT) for Depression?

Date

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350 million people are affected worldwide

By 2020, depression will be the 2nd highest cause of disability worldwide

Facts about Depression

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One in six New Zealanders will experience depressionduring their lifetime

Depression in NZ

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2 main types of treatment:

1.Pharmacotherapy2.Psychotherapy

Treatment of Depression

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Most common type of psychotherapy for depression

Cognitive Behavioural Therapy (CBT)

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- Expensive

- Difficult to access especially in rural areas

- Few specialists offer CBT

- Long waiting lists

Disadvantages of CBT

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Computer-delivered Cognitive Behavioural Therapy (CCBT)

Kaltenhaler and Cavanagh (2010) - a different method of delivering CBT usually through the use of a computer interface but it uses patient inputs to make psychotherapeutic decisions.

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- Often free of charge- Easily accessible- Offers flexibility- Increases privacy

Advantages of CCBT

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Breakdown of Beating the Blues usage in New Zealand between March, 2011 and March, 2014 (MOH, 2014)

Usage of CCBT in NZ

Prescribed Not activated

Activated

5931 2636 3295

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about 600,000 people diagnosed with depression between 2011- 2012

NZ Health Survey 2011-2012 (MHF)

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Act as gatekeepers to the use of CCBT programs

Role of GPs

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Service providers have negative attitudes towards CCBT which may have compromised the use of CCBT.

Du E, Quayle E, McLeod H (2013)

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To determine the attitudes and perceptions of GPs towards CCBT for depression

Objective of the Study

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Qualitative approach

Data gathering: Semi-structuredInterviews

Data analysis: General Inductive Approach

Methods

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10 GP participants; No Maori GPs

Recruitment: Referrals fromProfessors/Lecturers working at the University of Auckland (Convenience Sampling)

Methods

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Acquired from the University of Auckland Human Participants Ethics Committee (UAHPEC)

Ethics approval

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Sex: 5 males ; 5 females

Location:9 urban GPs; 1 rural GP

Age group: 6 GPs(40-50 age group);2 GPs(50-60 age group);2 GPs(30-40 age group)

Demographics of Participants

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9/10 participants – Positive Perception of CCBT

9/10 participants – Aware of CCBT

General Summary of Results

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7/10 participants – had used CCBT for their patients

7/10 participants – would continue to use CCBT for their patients in the future

General Summary of Results

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Theme 1 – Advantages of CCBT

Theme 2 – Disadvantages of CCBT

Theme 3 – Indications for the Use of CCBT

5 Themes

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Theme 4 – Contraindications for the use of CCBT

Theme 5 – Requirements for the use of CCBT

5 Themes

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Positive features of CCBT

What makes CCBT favourable to use

Theme 1 – Advantages of CCBT

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-Free-No waiting list-Increased accessibility -Increased Flexibility-Increased privacy

Theme 1 – Advantages of CCBT

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“Well , I think they are a good thing in terms of enabling people to get access to therapies in their own time, cheaply if they are free, and the privacy thing. So, I think there are good reasons for them and accessibility.”  

Theme 1 – Advantages of CCBT

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Negative features of CCBT

What makes CCBT unfavourable for use

Theme 2 – Disadvantages of CCBT

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Lack of GP knowledge about CCBTSafety issuesPatients do not usually finish the programs

Theme 2 – Disadvantages of CCBT

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Theme 2 – Disadvantages of CCBT

“I haven’t referred any adolescents with depression for computerised therapies. I guess because I don’t know of a successful tool or computerised therapy tailored to adolescents. Then if I knew one then I might refer.”

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Reasons for referring patients with depression to CCBT

Theme 3 – Indications for Use of CCBT

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Mild to moderate depressionSevere depression on the waiting list for a specialistComplement to face to face therapy

Theme 3 - Indications for Use of CCBT

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Patients who do not like face to face therapy

Adolescent patients

Theme 3 – Indications for Use of CCBT

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“Umm, yes. I have referred patients for computerised therapies. Why do I refer those people? The criteria are that they are mild. Ok? At most,moderate.”

Theme 3 – Indications for Use of CCBT

 

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Reasons for not referring patients to CCBT

Theme 4 - Contra-indications to the Use of CCBT

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No access to computersElderly patientsSevere depression

Theme 4 - Contra-indications to the Use of CCBT

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“I think as a young person is diagnosed with a significant anxiety and depression we are not going to rely on any therapy by itself in isolation.”

Theme 4 - Contra-indications to the Use of CCBT

 

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What GPs would require about CCBT in order for them to have more confidence in referring their patients to CCBT.

Theme 5 –Requirementsto the use of CCBT

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More studies regarding the effectiveness of CCBT

Access to computers

Patients need to be motivated

Theme 5 –Requirementsto the use of CCBT

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“I do use it already, I suppose. Umm, it would be good to get some more numbers. It is my understanding that it is as effective as face-to- face treatments. Umm, but I suppose if I have some more facts on its efficacy and you know what population is best suited for would help me to direct my treatment towards them.”

Theme 5 –Requirementsto the use of CCBT

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Most of the GPs had a positive perception of CCBT

The majority of the GPs had used CCBT in their patients and will continue to use them in the future

Conclusion

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GPs may not be the reasonfor the decreased uptake of CCBT programs for depression.

Conclusion

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Small study sample

Sampling bias

Limitations of the Study

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Qualitative Research Approach ------ In-depth interviews----Gather Rich data

Small Study Sample

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1.The research is a Dissertation

2.There is a general impression that GPs do not frequently refer patients to CCBT.

3 Factors for Sampling Bias:

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3.The study is anexploratory study which made use of convenience sampling.

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-Fast- Inexpensive- Produces valid results

Advantages of Convenience Sampling:

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Further studies using a cross sectional study design of a larger group of GP participants

Further qualitative studies on patients who drop out from the programs

Recommendations

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Awareness and knowledge of CCBTmust be increased through direct marketing and advertising of CCBTto service providers as well as increasing awareness through symposia and seminars

Recommendations

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Evidence from studies about CCBT should be made readily available to GPs

Recommendations

End

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