crise - institut 2012 - simon hatcher - e-therapies in suicide prevention : what do they look like,...

Les « E-Therapies » en prévention du suicide : de quoi ont-elles l’air, fonctionnent-elles et quelles sont

les avenues pour la recherche?

Professor Simon Hatcher

The University of Ottawa

CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL

What do they look like? CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL

E-therapies

1. First generation – “books on-line”

2. Second generation – some on-line interaction – fill in questionnaires, answer quizzes, learning by gaming (SPARX)

3. Third generation – integration with mobile phones/email/smart devices

4. Fourth generation – smart environments and “mobile therapist”


Benefits of e-therapies

• Convenient for users (access from home, no waiting lists)

• Can be tailored for specific groups

• Addresses work force problems

• Cost effective (?)


Problems with new technologies

• Reinforce inequalities – access and language

• Limited evidence of effectiveness

• Ethics of monitoring

• Rapidly outdated

• Privacy and risk issues

• Seductive (!)


Do they work?

• Recommended by NICE for mild to moderate depression and anxiety

• But evidence not strong and in non-clinical populations.


National depression initiative

• Reduce stigma

• Educate GP’s – guidelines, training

• John Kirwan – Depression.org.nz

– Social marketing

– E-therapy for mild to moderate depression

– Telephone help line


#1

#2

#3

#6

Journal Lesson Activity

13,020

2,350 1,700 1,200 1,100

3,700

650

June 2010 to July 2011 700,000 visitors 20, 000 registered with The Journal 13,020 active users


PHQ-9 SCORES GIVEN AT START, MIDWAY AND END

PHQ-9 SCORE

Sample completing end PHQ-9 score

INITIAL SCORE MIDWAY SCORE END SCORE

(392)

%

Under 10: Not depressed 17.1 56.6 75.3

10 to 14: Mild depression 22.7 24.0 15.3

15 to 19: Moderate depression 29.1 10.5 4.1

20 or more: Severe depression 31.1 8.9 5.4

Mean score: 15.84 9.84 6.92

56% decrease

overall

30% decrease


CHANGE IN PHQ-9 FROM START TO END

CHANGE IN PHQ-9 FROM START TO END

Sample completing end

PHQ-9 score

(392)

%

Improvement 15+ 21.2

75.3

90.1

Improvement 10 to 14 24.0



No change 3.3

Worsening 1 to 4 5.1 6.6

Worsening 5 or more 1.5


Reasons for not continuing

REASONS FOR NOT CONTINUING

Those who did not complete

all six

Those who registered but did not begin

(101) (68)

% %

Not had time 45 34

Needed more support to keep going 38 24

Satisfied with what had got 32 NM

Wanted to be able to skip some sessions 28 10

Felt too unwell 26 28

Didn't feel able to do what was being asked of me 26 9

Because of Journal no longer feeling depressed 24 NM

Couldn't be bothered 23 18

For reasons nothing to do with Journal am no longer feeling depressed 18 NM

No longer depressed NM 31

Journal not working properly – technical problems 15 15

Sessions take too long 14 12

Did not know or forgot how to get back into Journal to continue 14 32

Videos were downloading too slowly 12 NM

Had other computer problems 11 21

Did not receive email NM 16

Did not know how to continue once received email NM 13

Improvements did not last long enough to be worth continuing 11 NM

Doing Journal made me feel more depressed 11 NM

Did not think what done so far was useful 10 NM

Did not think it would be useful 8 10

Too many sessions required to complete Journal 7 6

Content didn't interest me 5 4

None of these/ not answered 1 4

NM = Not measured; Circled items are most mentioned main reason


Appeal of option for integrating The Journal

APPEAL OF DATA BEING AVAILABLE TO PRACTICE

Total* GPs Practice nurses

Primary mental health

(135) (69) (30) (36)

% % % %

Appeals a lot (4) 36 25 47 47

Appeals somewhat (3) 29 30 27 28

Appeals a little (2) 20 28 13 11

Does not appeal (1) 14 17 13 8

Don't know 1 0 0 6

Mean 2.9 2.6 3.1 3.2

* Excludes receptionists


What is the research agenda?

• Address different levels of suicide prevention – patients, family, clinicians

• Community e-therapies

• Education for gatekeepers

• Decision support for primary care

• Clinican supported computer care in primary care

• Secondary care – decision support, more intense computer supported care, home monitoring


Effectiveness studies needed

• RCT’s (must include ITT analysis, report adverse effects, economic analysis)

• Do RCT’s at primary care level as that is where most people present

• Where do e-therapies fit within stepped care

• Comparisons with self-help, placebo and therapist delivered therapy

• Head to head comparisons of different e-therapies


How do they work (or not work)

• Acceptability

• Feasibility (access, low tech alternatives)

• Minority preferences

• How to interact with humans to produce change in behaviour

• Reasons for drop outs

• What training is needed for clinicians to use computerised therapies

• Privacy, risk and ethical issues


crise - institut 2012 - simon hatcher - e-therapies in suicide prevention : what do they look like,...

Health & Medicine

computer care

depressed nm

mild depression

nmdoing journal

primary care clinican

primary care level

benefits of e

stepped care comparisons