depressed and anxious primary care patients' use …...depressed and anxious primary care...
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Bea Herbeck Belnap, DrBiolHumCharles Jonassaint, PhD, MHS
University of Pittsburgh School of Medicine
Depressed and Anxious Primary Care Patients' Use of an
Internet-Delivered Computerized CBT Program
Presenter Disclosure Information• Online Treatments for Mood and Anxiety
Disorders in Primary Care:NIMH R01 MH093501
• Agency for Healthcare Research & Quality:PCOR K12HS022989
• Speakers bureau/honoraria/advisory board/ownership interest:
None
5 Telephone-Delivered Collaborative Care Trials
1999-2004: Improving Quality of Primary Care for Anxiety Disorders
2004-2010: Reduce Limitations from Anxiety
2012-2015:
2003-2009: Bypassing the Blues
2013-2018:
Collaborative CareCare Manager:Telephoned patient over to:
- Assess treatment preferences- Impart self-management skills (workbooks)- Promote adherence/adjust pharmacotherapy- Monitor treatment outcomes- Facilitate MHS referral when appropriate
Communicated with PCP to:- Provide feedback- Make recommendations for pharmacotherapy
Rollman BL, Herbeck Belnap B et al. Gen Hosp Psych. 2003; 25:74Rollman BL, Herbeck Belnap B et al. Psychosomatic Med. 2009; 71:217
Collaborative Care vs. CBT for Depression and Anxiety
# Trials Effect Size NNT
Collaborative Care† 30 0.34 (0.27-0.41) 5.26
CBT (face-to-face) †† 115 0.71 (0.62-0.79) 2.60
† Archer J. et al. Cochrane Database Syst Rev. 2012; 10:CD006525†† Cujpers P. et al. Canadian J Psych. 2013; 58:376-85
How to meet the need?
• Increased prevalence • Evidence-based treatment• Poor access/high cost• Increased health disparities
Collaborative Care vs. CBT for Depression and Anxiety
# Trials Effect Size NNT
Collaborative Care 30 0.34 (0.27-0.41) 5.26
CBT (face-to-face) 115 0.71 (0.62-0.79) 2.60
Collaborative Care, CBT, & CCBT for Depression and Anxiety
†Andrews G, et. al. PLoS ONE. 2010; 5:e13196
# Trials Effect Size NNT
Collaborative Care† 30 0.34 (0.27-0.41) 5.26
CBT (face-to-face) 115 0.71 (0.62-0.79) 2.60
CCBTMajor depression 6 0.78 (0.59-0.96) 2.39
Panic 6 0.83 (0.45-1.21) 2.26Generalized anxiety 2 1.12 (0.76-1.47) 1.75
CCBT, all† 22 0.88 (0.76-0.99) 2.15
Potential Advantages:CCBT vs. Face-to-Face CBT
1) Convenient2) Available 24/73) Less stigma4) Reproducible5) Scalable6) Similar strong effect size
Bruce L. Rollman, MD, MPHBea Herbeck Belnap, Dr Biol Hum
Jordan F. Karp, MDKaleab Abebe, PhD
Armando J. Rotondi, PhDKenneth J. Smith, MD
Michael B. Spring, PhD
NIMH R01 MH093501
Computerized CBT (CCBT)http://www.beatingthebluesus.com/
Beating the BluesES = 0.62; p<0.001
Usual Care = 114 Patients
CCBT = 127 Patients
Proudfoot J, et al. Br J Psych. 2004; 185: 46-54
Beating the Blues
Proudfoot J, et al. Br J Psych. 2004; 185: 46-54
Teaching CBT Techniques
Video Clips of Case Studies
Apply to Own Problems
EpicCare BPA Activated at
26 Primary Care Practices
704 Patients Enrolled &
Randomized
CCBT-AloneN=301
CCBT+ Internet Support GroupN=302
Usual CareN=101
1' H
yp
oth
esis
2' Hypothesis
Study Design
Eligibility:• 18-75 yo• Internet and telephone access• PHQ-9 and/or GAD-7 ≥ 10
Enrollment8/2012 - 9/2014
EMR Referrals 2,884
Contacted for telephone screen 2,266 (79%)
Consented to screen 1,785 (79%)
PHQ-9 or GAD-7 ≥10 & eligible 954 (53%)
Consented to trial & randomized 704 (74%)
Randomized to a CCBT group 603 (86%)
Enrollmentby Race
Race N(%)
White 499 (83%)
Black/African American 91 (15%)
Asian 10 (2%)
American Indian/Alaskan Native 2 (<1%)
Native Hawaiian/Pacific Islander 1 (<1%)
Sociodemographics
ALL(N=603)
Non-White(N=104)
White(N=499)
Age, mean (SD)* 42.8 (14.2) 39.1 (13.7) 43.6 (14.2)Male* 21% 13% 22%>High School Ed. 82% 80% 83%
Depression-onlyPD/GAD-onlyBoth
39%7%
45%
37%8%
45%
39%7%
44%
PHQ-9, mean (SD) 13.3 (5.0) 14.1 (5.0) 13.1 (5.0)Pharmacotherapy* 88% 76% 90%
*Indicatesp<0.05
Sessions Started & Completed
Non-White(N=104)
White(N=499)
Started 1’st session** 76% (79) 87% (432)Completed all 8 sessions 32% (25) 43% (186)Sessions completed, mean (SD)
≤ 3-months≤ 6-months
4.3 (2.7)5.0 (2.7)
4.8 (2.5)5.5 (2.7)
**Indicatesp<0.01
BtB Sessions CompletedNon-White vs. White
% S
essi
ons
Com
plet
ed
* Of the 480 (83%) patients who started the program
Everyone Benefitted from BtB: ≥50% Decline PHQ-9
63% 60% 60% 56%61%
67%64%
All p >.05
Decline in Average PHQ-9 Scores by Race
Aver
age
PHQ
-9 S
core
Sessions31 | 20633 | 22338 | 25041 | 27048 | 30857 | 33466 | 38679 | 432Sample Sizes:
Non-white | White
p=.057
Decline in Average GAD-7 Scores by Race
Aver
age
GAD
-7 S
core
Sessions31 | 20633 | 22338 | 25041 | 27048 | 30857 | 33466 | 38679 | 432Sample Sizes:
Non-white | White
Mean session completedNon-white | white
Limitations
• Online Treatments Trial ongoing- Study blind in-place
Patient self-entered symptoms
- Treatment arms combined- Usual Care not (yet) included- Medication use not examined
Conclusions
• 1’ care patients will engage with CCBT.• Self-reported symptom decline were similar
across race, age and gender. • Trial results (pending) to determine if:
• Blinded symptom scores show similar decline across sub-groups
• ISG improves clinical outcomes
Future of CCBT• Tailored programs −> Engagement
- Culturally relevant materials - Customization (Medical conditions, Health Behaviors)
• Technologic improvements- Mobile and tablet (ver. 2.0)- Adaptive designs/Predictive analytics - Internet Support Groups- Electronic health record integration
Questions?
Predictors of Engagement
Logit predicting (1=Completers vs. 0=Non-completers), adjusting for age and gender
•ñPHQ-9 score ê probability of BtB completion •(b= -.11; p= .02)
•ñGAD-7 score ê probability of BtB completion •(b= -.11; p= .04)
Among BtB Completers: ≥50% Decline GAD-7
Among BtB Completers: ≥50% Decline GAD-7