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Evidence for providers

CBT provided on a computer, called online CBT (or sometimes ‘computerised CBT’ or ‘CCBT’), has been shown to be a very effective treatment, and Beating the Blues® has been shown to be the best programme for people with depression and anxiety positive outcomes on their mental health after completing the programme.

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Published Papers

In 2008 a New Zealand demonstration of Beating the Blues® in the Primary Health Care setting was undertaken. The demonstration involved four Primary Health Organisations (PHOs) in Northland and was delivered by Opening Doors Limited, Whangarei.

General Practitioners (GPs) and primary mental health practitioners in 4 areas of Northland, identified as having an interest in the use of computerised CBT were invited to be part of the demonstration. Patients were referred by both the participating GPs and primary mental health practitioners. Patients were identified by clinical assessment and the use of the Beating the Blues® suitability and exclusion criteria. A total of 100 patients participated in the Beating the Blues® programme.

Delivery methods

The delivery method for Beating the Blues® was identified through close liaison between Opening Doors and each PHO to meet the particular needs of the PHO and the communities they serve. Delivery methods varied from use in GP clinics, use supported by an administration worker, to delivery by representatives from the Māori population.

Evaluation measures

Evaluation included use of the CORE Outcome Measure (CORE-OM) to assess individual patient progress and the overall clinical efficacy of Beating the Blues® for the groupThe CORE-OM was completed by patients as part of the programme before they began session 1 and after session 8. Developed by the CORE Systems Group (clinicians and researchers representing psychiatry, psychotherapy, counselling and psychology) the CORE-OM provides information on four separate areas of clinical importance:

  • Well-being –e.g. how patients feel about themselves
  • Problems – e.g. symptoms
  • Functioning – e.g. close relationships, social life and general functioning
  • Risk – e.g. an indicator of risk of harming self or others.

Demographic information including ethnicity and culture identified was collected as part of the initial referral information. In addition, patients completed a brief questionnaire at the end of the programme to assess the acceptability of the programme and their satisfaction with the treatment overall.

Outcome of the demonstration

CORE-OM scores pre and post Beating the Blues® indicated clinical change and benefit from the treatment (see Figure 1).

Figure 1

Figure 1. CORE-OM scores pre and post treatment for Northland demonstration

* The CORE-OM includes 34 questions within 4 Clinical Dimensions (Wellbeing, Problems, Functioning, Risk). Each Clinical Dimension has a maximum score of 4, with a higher score indicating a higher level of reported problems and higher levels of distress and conversely, a lower score indicating clinical improvement.

Clinical and patient feedback reported a real need and benefit to delivering Beating the Blues® as a treatment choice within New Zealand PHO services. Patient questionnaire feedback indicated that a majority (62%) of patients were satisfied with this form of help and were also happy with the programme presentation and content.

Conclusion

The findings of the Northland demonstration support the use of Beating the Blues® in the New Zealand primary care setting. The programme was well-received by clinicians and patients, and shown to be effective for individual patients with depression and/or anxiety in effecting clinical change.

Learmonth,D., Trosh,J., Rai,S., Sewell,J., & Cavanagh,K. (2008) A Computer based treatment for Anxiety and Depression in a Secondary/Tertiary Care Specialist CBT Service. Counselling and Counselling Research, 8:2, 117-123

Abstract

This study documents 6 years of Beating the Blues in use in a specialist CBT centre. Over 600 patients have been through the program and 70% of those completing the program were fully discharged without any face to face therapy. The requirement for face to face in the group using Beating the Blues was cut to a quarter of that normally required.

Learmonth, D., and Rai, S. ( 2008) Taking computerized CBT beyond primary care.. British Journal of Clinical Psychology 47,111-118

Abstract

Beating the Blues was delivered in an NHS specialist CBT care centre as part of routine care. In this setting the median period of problem duration was 5-10 years and 80% of patients indicated that they had taken prescribed medication prior to treatment at the centre. 68.3% of patients completed the program, and 48.3% of completers achieved both reliable and clinical change.

Mitchell, N., & Dunn, K (2007) Pragmatic evaluation of the viability of CCBT self-help for depression in higher education. Counselling and Psychotherapy Research, 7(3): 144-150

Abstract

A significant reduction in Beck Depression scores were observed in students ( mean age 25.6 years) completing Beating the Blues in a Higher Education Counselling Service. The results suggest that CCBT may be an effective intervention for depressed students.

Learmonth, D., & Rai, S. (2007) Establishing the effectiveness of computerised cognitive behavioural therapy for secondary/tertiary mental health care service users with and without physical co-morbidities. Health Psychology Update, Volume 16, Issue 3, 42-48

Abstract

This study presents pre and post-Beck Depression scores of service users with physical co-morbidities such as IBS, headaches, and chronic fatigue syndrome. These results are compared with a wait-list control group and with a standard intervention group (physical co-morbidities absent). The control group showed no statistically significant change whilst the co-morbidity group and the standard intervention group both showed similar statistically significant change pre and post-treatment.

The study provides compelling evidence that Beating the Blues is of value to service users presenting with a wide variety of physical co-morbidities.

Cavanagh, K., Shapiro, D., Van den Berg, S., Swain, S., Barkham, M. & Proudfoot, J. (2006). The effectiveness of computerised cognitive-behavioural therapy in routine primary care. British Journal of Clinical Psychology, Volume 45, Number 4, 499-514

Abstract

This open study supports the results of the randomised controlled trials and indicates that the findings of the RCTS can be generalised to routine care environments. It also demonstrates, by benchmarking, that the outcomes achieved by Beating the Blues are similar to those delivered by face to face CBT

Hunt, S., Howells, E., Stapleton, B ( 2006) The Addition of a Computerised Cognitive Behavioural Therapy Program, to a Stepped Care, Primary Care Mental Health Service. The Journal of Primary Care Mental Health, Volume 9, Number 2, 34-38.

Abstract

The paper describes the integration of ‘Beating the Blues’ into a stepped care, primary care mental health service. For the 54 clients completing the program, ‘Beating the Blues’ was found to significantly reduce depression, raise general health and increase work and social adjustment. Client feedback was also very positive- the vast majority found the program enjoyable, easy and pleasant to access, and helpful in working towards overcoming their depression and anxiety.

Cavanagh, K & Shapiro, DA (2004) Computer treatment for common mental health problems. Journal of Clinical Psychology, 60, 239-251.

Abstract

This paper presents a review of the development of computer treatment programs over 4 decades and reports a small meta-analytic study demonstrating large effect sizes in favour of computer treatments for anxiety and depression for pre-/post- treatment outcomes and usual care/waitlist comparators.

S. Van Den Berg, D.A Shapiro, D. Bickerstaffe, & K. Cavanagh (2004) Computerized cognitive-behaviour therapy for anxiety and depression: a practical solution to the shortage of trained therapists. Journal of Psychiatric and Mental Health Nursing, Vol 11, Issue 5, p 508

Abstract

Computerized cognitive behaviour therapy (CCBT) programs have been developed to help meet the enormous need for evidence-based psychological treatment of common mental health problems in the context of a severe shortage of trained therapists to meet that need. Randomized controlled trials have confirmed the efficacy of such programs. We present the experience of a community mental health team (CMHT) resource centre with one such program, Beating the Blues, together with outcome data on a small sample of its clients. We conclude that experience and data, taken together, demonstrate the practical benefits of CCBT in routine practice.

Fox, E., Acton, T., Wilding, B. & Corcoran, S. (2004) Service development report: an assistant psychologist’s perspective on the use of computerised CBT in a GP practice in Barnet. Quality in Primary Care, 12, 161-165.

Abstract

Fox et al (2004) present their experience of implementing a Beating the Blues service within a primary care setting. The pilot service, which was managed locally by an assistant psychologist, received 62 referrals, in a ten-month period, of whom 56 were suitable for the program. 39 of these patients attended an initial appointment with the service, and 27 of these completed all eight interactive sessions of Beating the Blues. The paper goes on to discuss the local and personal experiences of the authors in implementing the program.

McCrone, P., Knapp, M., Proudfoot, J., Ryden, C., Cavanagh, K., Shapiro, D., Ilson, S., Gray, J., Goldberg, D., Mann, A., Marks, I.M. & Everitt, B (2004) Cost-effectiveness of Computerised Cognitive Behavioural Therapy for Anxiety and Depression in Primary Care. British Journal of Psychiatry. 185, 55-62.

Abstract

McCrone et al. present an analysis of the cost-effectiveness of offering Beating the Blues in general practice settings (N=274). In the context of the superior clinical outcomes of Beating the Blues, no significant differences were found in healthcare service costs between two groups, indicating the computer treatment is a cost-effective intervention. Moreover, patients receiving Beating the Blues evidenced a significant cost in terms of practitioner certificated’ absence from work. Further, the cost-utility analysis revealed benefits at a highly competitive cost per Quality-Adjusted Life Year.

Proudfoot, J., Ryden, C., Everitt, B., Shapiro, D., Goldberg, D., Mann, A., Tylee, A., Marks, I., & Gray, J. (2004). Clinical effectiveness of computerized cognitive behavioural therapy for anxiety and depression in primary care. British Journal of Psychiatry, 185, 46-54.

Abstract

Following randomisation of a further 107 participants (in addition to the 167 reported upon above: cohort I) from four additional general practice groups, analysis of the expanded sample confirmed the efficacy of Beating the Blues within sub-samples based on clinical, demographic and setting variables. The program’s efficacy was unaffected by concurrent drug treatment, duration of pre-existing illness, the severity of existing illness or treatment setting.

However, in relation to anxiety, significant benefits of using Beating the Blues were found only for patients with more severe illness at outset (those scoring 18 or more on the Beck Anxiety Inventory on entry to the study). Of 128 patients commencing Beating the Blues in the combined sample, 89 (70%) completed all eight sessions of the program and the post-treatment outcome measures, suggesting that patients are as likely to persist with computerized as traditional treatment approaches. On completing the program, patients reported significantly higher treatment satisfaction than those receiving a comparative 8 weeks of usual care.

Proudfoot, J., Swain, S., Widmer, S., Watkins, E., Goldberg, D., Marks, I., Mann, A. &.Gray, J.A. (2003b). The development and beta-test of a computer-therapy program for anxiety and depression: hurdles and preliminary outcomes. Computers in Human Behavior, 19, 277-289.

Abstract

This paper describes the development and beta-test of an eight-session computer therapy program for anxiety and depression, ‘Beating the Blues’. Developed by a multi-functional team, the program uniquely combines multi-media interactive computer technology with empirically-validated cognitive-behavioural therapy (CBT) techniques and crucial non-specific aspects of therapy.

The paper describes how the project proceeded through its development phase, the unexpected hurdles that occurred and the lessons learnt. As an integral part of the development, the program was beta-tested with 20 patients. Despite the small numbers and the fact that the eight sessions were completed at an accelerated rate, feedback was positive. Patients reported it was helpful, easy to use, and of those who had had previous treatment for their problems, the majority indicated it compared at least as well as other forms of therapy. The beta-test also highlighted where changes were needed to the program. These were implemented prior to the release of the program for the next phase of testing.

Lastly, the beta-test indicated that the program had sufficient promise for it to be evaluated formally by randomized controlled trial.

Proudfoot, J., Goldberg, D., Mann, A., Everitt, B., Marks, I. & Gray, J. (2003a). Computerized, interactive, multimedia cognitive behavioural therapy reduces anxiety and depression in general practice: a randomised controlled trial’, Psychological Medicine, 33, 217-227.

Abstract

Background. Cognitive-behavioural therapy (CBT) brings about significant clinical improvement in anxiety and depression, but therapists are in short supply. We report the first phase of a randomized controlled trial of an interactive multimedia program of cognitive-behavioural techniques, Beating the BluesTM (BtB), in the treatment of patients in general practice with anxiety, depression or mixed anxiety/depression.

Method. One hundred and sixty-seven adults suffering from anxiety and/or depression and not receiving any form of psychological treatment or counselling were randomly allocated to receive, with or without medication, BtB or treatment as usual (TAU).

Measures were taken on five occasions: prior to treatment, 2 months later, and at 1, 3 and 6 months follow-up using the Beck Depression Inventory, Beck Anxiety Inventory and Work and Social Adjustment Scale.

Results. Patients who received BtB showed significantly greater improvement in depression and anxiety compared to TAU by the end of treatment (2 months) and to 6 months follow-up. Symptom reduction was paralleled by improvement in work and social adjustment. There were no interactions of BtB with concomitant pharmacotherapy or duration of illness, but evidence, on the Beck Anxiety Inventory only, of interaction with primary care practice. Importantly, there was no interaction between the effects of BtB and baseline severity of depression, from which we conclude that the effects of the computer program are independent of starting level of depression.

Conclusions. These results demonstrate that computerized interactive multimedia cognitive behavioural techniques under minimal clinical supervision can bring about improvements in depression and anxiety, as well as in work and social adjustment, with and without pharmacotherapy and in patients with pre-treatment illness of durations greater or less than 6months. Thus, our results indicate that wider dissemination of cognitive-behavioural techniques is possible for patients suffering from anxiety and/or depression.

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