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Guided Online Self-help

Guided Online Self-help. For Generalised Anxiety Disorder, (GAD) Phobias and Panic Disorder. Contents 1 The Programme 2 NICE CCBT review 3 Local Research 4 Google Analytics 5 Technical Stuff. The Serenity Programme. What is it?.

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Guided Online Self-help

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  1. Guided Online Self-help For Generalised Anxiety Disorder, (GAD) Phobias and Panic Disorder Contents 1 The Programme 2 NICE CCBT review 3 Local Research 4 Google Analytics 5 Technical Stuff

  2. The Serenity Programme

  3. What is it? A unique, theoretically integrative blended learning approach to treatment of stress and anxiety disorders A blend of face-to-face contact alongside an interactive Internet programme and telephone support ... Serenity Programme 2013

  4. Assessment Begins with a two-hour semi-structured assessment Bespoke template-driven documentation, assessment using CORE, GAD-7 & PHQ-9 Serenity Programme 2013

  5. 35 Interactive Assessment Tools, Including ... GAD-7 (Generalised Anxiety) PHQ-9 (Depression) WSAS (Work Adjustment) PEQ (User Satisfaction) PHQ-15 (Somatisation) IES-R (Trauma) PDSS (Panic Disorder) OCI (OCD) AUDIT (Alcohol Use) Serenity Programme 2013

  6. The Programme Presented in an attractive interactive workbook (in depth programme) and online multimedia format (brief psychoeducational programme) Assistive technology for people with dyslexia, visual impairment, physical or reading difficulties Serenity Programme 2013

  7. The Programme Assessment meeting Modules 1 and 2 Support call Takes most people at least three months to complete ... Module 3 Goal setting meeting Module 4 Support call Module 5 Support call Module 6 Support call Module 7 Support call Module 8 Support call Module 9 Final meeting Serenity Programme 2013

  8. Workbooks Password protected interactive workbooks , users download & keep to form a comprehensive client-held record Use on your PC or print and complete by hand (average reading age of 11 years) With more than 60 tasks and exercises Serenity Programme 2013

  9. Benefits - to the user Increased choice Increased confidentiality Range of options: Internet, CD, paper, USB drive, iPad Infrequent contact, longer term approach (CDM** model) Reduced need to travel Time flexibility - night shift workers, carers, single parents User involvement during design process, CQI* **CDM = Chronic Disease Management *CQI = Continuous Quality improvement Serenity Programme 2013

  10. Benefits - to the service Prevents wasteful ‘admit > treat> discharge > readmit’ cycle Equity - services for agoraphobia, social phobia, avoidant and fearful, single mothers, young men, people with disabilities No inherent geographical boundary problems 100% increase in throughput Available in 71 languages Serenity Programme 2013

  11. Benefits - to the Wider Community Materials shared, reducing familial transmission of harm Use of model alone or as adjunctive treatment - EAP, CFS, MUS, anxiety in COPD and MI etc. Less paper, less travel, less cost, less waste, less pollution - more efficient use of time! Serenity Programme 2013

  12. Evaluation Interview with researcher, repeated measures (DASS, CORE-OM, HADS, PHQ-9) Studies with Beneficiaries of ‘Want 2 Work’ programme John Moore’s University Student Stress Study Ongoing NHS Study Serenity Programme 2013

  13. Awards Awards from WaMH in PC WIsH (2006) RCN (2008) BJN (2008) Best Nurse-led Project 2010 In RCN ‘Top 30’ UK Health Modernisation Projects 2011 Serenity Programme 2013

  14. NICE CCBTREVIEWS

  15. CCBT Considered by NICE • Depression • Beating the Blues - Ultrasis plc. • COPE • Overcoming Depression: A 5-areas approach (Calypso) Media Innovations • Anxiety • Fear Fighter - ST Solutions • OC Fighter (formerly BTSteps) - ST Solutions Serenity Programme 2013

  16. Beating the Blues (Ultrasis plc.) • CBT-based for people with anxiety and / or depression • 15-minute introductory video and eight 1-hour interactive computer sessions • Sessions at weekly intervals in routine care settings • Homework projects are completed between sessions, weekly progress reports delivered to the healthcare professional at the end of each session Serenity Programme 2013

  17. COPE (ST Solutions Ltd.) • For non-severe depression • COPE was developed as an IVR plus workbook-based system - also available as a network version (netCOPE) • A 3-month programme with five main treatment modules • People can phone as and when they wish Serenity Programme 2013

  18. OD (Media Innovations Ltd.) • Overcoming Depression: a Five Areas Approach – available as a CD-ROM-based CBT system for people with depression • Six weekly sessions of 45 – 60 minutes • Sessions are delivered in a mixture of text, cartoon illustrations and animation • Practitioner reviews the person's use of the disc on three occasions over the course Serenity Programme 2013

  19. FearFighter (ST Solutions Ltd.) • A 9-step CBT-based package for phobias, panic and anxiety disorders • Originally developed for stand-alone computer, later developed for use on the Internet • Brief therapist contact, 5 minutes before and up to 15 minutes after each session • Therapist contact by telephone or e-mail for web version Serenity Programme 2013

  20. OCFighter (ST Solutions Ltd) • BTSteps (now OCFighter) a 9-step CBT-based self-help programme for OCD • BTSteps developed as an IVR*system plus workbook, an Internet version is under development and will obviate the need for IVR and workbook, helpline support is provided *Interactive Voice Response Serenity Programme 2013

  21. NICE Technology Appraisal 51 • Depression and anxiety: computerised cognitive behaviour therapy (CCBT) • Issued in 2002 • Replaced by TA97 in 2006 Serenity Programme 2013

  22. ACD-1* – Key Points • CCBT (Beating the Blues, Cope, Overcoming Depression) is recommended for the treatment of mild and moderate depression • A judgement that as CBT is a known and effective approach for depression then CCBT packages as a whole are likely to produce similar positive ‘group effects’ * Appraisal Consultation Document Serenity Programme 2013

  23. NICE Technology Appraisal 97 • Computerised cognitive behaviour therapy for depression and anxiety • Review of Technology Appraisal 51 • Issued in 2006, modified in 2013 • Replaced TA51 'Depression and anxiety: computerised cognitive behaviour therapy (CCBT)' Serenity Programme 2013

  24. ACD-2 – OIR* • ‘Cope’ and ‘Overcoming Depression’ not recommended for the treatment of depression except as part of ongoing or new clinical trials… gathering data on costs and benefits…compared to an appropriate comparator • OCFighternot recommended for the treatment of OCD, except as part of ongoing or new clinical studies *Only in Research Serenity Programme 2013

  25. RCT Emphasis 1 of 2 • ‘There is no RCT evidence for COPE or Overcoming Depression for the management of depression. Therefore, the Committee could not establish with a reasonable degree of certainty that either of these packages is a clinically or cost-effective method of treating people with depression over and above other management options such as TAU’* *Treatment as usual Serenity Programme 2013

  26. No ‘Class Effect’ • ‘Furthermore, it was not able to conclude that the CCBT packages for depression could be considered to be equivalent as in a 'class', because of the differences between the packages' presentation, style and complexity’ Serenity Programme 2013

  27. BTSteps RCT • ‘The Committee considered the RCT evidence for BTSteps for the management of OCD in which BTSteps was compared with TCBT and relaxation. The Committee noted that in the randomised clinical trials BTSteps was never more effective than TCBT. It also noted that patients were more satisfied with TCBT than with BTSteps’ Serenity Programme 2013

  28. Response to consultee, commentator and public comments on the ACD-2, 2005 Serenity Programme 2013

  29. Media Innovations 1 of 2 • ‘The current wording … makes a de facto judgement that a class effect for CCBT does not exist and reverses the thrust of the original 2002 review’ • ‘This is a major and unwarranted decision which will significantly reduce development in this area, produce a monopoly situation, and importantly reduce patient and practitioner choice’ Serenity Programme 2013

  30. Media Innovations 2 of 2 • ‘The removal of any form of recommendation for Overcoming Depression or COPE will create an effective monopoly position for one commercially developed package …’ Serenity Programme 2013

  31. ST Solutions • ‘The committees' recommendation to not recommend OCFighter despite the strong evidence is likely to cause harm to the thousands of patients who will not be treated due to lack availability of services. The NHS is unable … to provide CBT services to 75% of the patients who require CBT treatment and who are in hospital.’ Serenity Programme 2013

  32. Ultrasis • ‘The revised document is, in general, an accurate reflection of the evidence base for CCBT and will stimulate appropriate and informed provision of the technology in the NHS and beyond’ Serenity Programme 2013

  33. Updates • Recommendations in TA97 relating to the treatment of depression have been replaced by recommendations in the two depression clinical guidelines (CG90 & CG91, and in CG123 in 2011) • Recommendations relating to the treatment of anxiety disorders been replaced by entries in the GAD & Panic Disorder guideline (CG113) in 2011, and the Social Anxiety guideline (CG159) in 2013 Serenity Programme 2013

  34. Research Recommendations 1 of 3 • The clinical and cost effectiveness of two CBT-based low-intensity interventions (CCBT and guided bibliotherapy) compared with a waiting-list control for the treatment of GAD and Panic Disorder Serenity Programme 2013

  35. Research Recommendations 2 of 3 • Future studies should be RCTs & include an ITT*analysis, to take account of drop-outs, and record and report any adverse effects … They should also collect appropriate information on costs and health-related quality of life – data should be collected using generic preference-based measures (in conjunction with condition-specific instruments) because they facilitate the calculation of QALYs** *Intention-to-treat ** Quality adjusted life-year Serenity Programme 2013

  36. Research Recommendations 3 of 3 • Pragmatic RCTs for CCBT packages in a stepped-care programme • Comparisons of CCBT with other self-help comparators e.g. bibliotherapy and exercise • Comparisons of CCBT with placebo • Comparisons of CCBT with brief and longer duration TCBT*as well as group TCBT • Head-to-head trials between the packages for depression *Therapist-delivered Cognitive Behaviour Therapy Serenity Programme 2013

  37. Localresearch

  38. Enrolment Assessed for eligibility (n = 113) Excluded (n = 27 ) Declined to participate (n = 22) Out of catchment area (n= 4) Did not meet criteria (n = 1) Assessment Assessment Interview (n = 86) Participant withdrew after assessment & before treatment began (n = 4) 82 Intervention Number of participants in active treatment 74 Participant withdrew due to change in personal circumstances (n = 8) 61 Out of contact, unknown reason (n = 13) 57 55 ‘Stepped up’ to more intensive therapy (n = 4) 52 Change of helper (n = 2) Participant elected to continue without support (n = 3) Partial programme completion, consensual discharge (n = 24) Full programme completion, consensual discharge (n = 28)

  39. For the 52 participants either fully or partially completing the programme, initial mean anxiety scores on the HADS were 14.42 and after three months, 9.1 – an almost 37% reduction in symptom scores (t = 10.18, p<0.0001). The chart below shows initial anxiety scores in red, post-test scores in blue. This cohort comprised of 24 males and 28 females, with an average age of 42.8 (range 19 - 82). Partial completion was considered to be a successful intervention when symptom levels were reduced and both participant and professional agreed discharge to be appropriate and timely. Serenity Programme 2013

  40. For the 52 participants fully or partially completing the programme, initial mean depression scores on the HADS were 9.6 and after three months, 5.8 – an almost 40% reduction in symptom scores (t = 6.62, p<0.0001). The chart below shows initial depression scores in red, post-test scores in blue. Of these 52 participants, 48 were either employed or in full- or part-time education. Serenity Programme 2013

  41. Mixed-methods quasi-experimental study - semi-structured interview and repeated measures using HADS, PHQ-9 and CORE-OM '... navigation was easy...'  CM, Colwyn Bay '...the website was compelling and encouraging...'   KJ, Rhyl '...programme gives great insight and understanding to anxiety and the reasons why it is happening...'  CR, Rhyl '...it was good for changing thought patterns...'  JC, Abergele '...really liked the points of interest, helpful hints, and breakdown of what was wrong and how I could deal with it...'  RW, Colwyn Bay '..it’s absolutely super, I’m really, really very impressed with it, it’s a wonderful thing to have...'   AD, Denbigh  '...instantly appealed as it immediately seemed to address my problems...'  JT, Rhyl  '...layout was very user-friendly...'  CA, Rhyl  '...I liked the gentle approach...' SP, Rhyl  '...not loads of medical jargon, so could understand what was being said...'  SW, Rhyl '...it’s good to know someone else understands how I feel...'   SW, Rhyl  '...think the programme is good and should be rolled out to others...'  HR, Prestatyn

  42. GoogleAnalytics

  43. Overview - October 8 2012 - October 8 2013 Serenity Programme 2013

  44. Countries - October 8 2012 - October 8 2013 Serenity Programme 2013

  45. Cities - October 8 2012 - October 8 2013 Serenity Programme 2013

  46. UK - October 8 2012 - October 8 2013 Serenity Programme 2013

  47. Engagement - October 8 2012 - October 8 2013 ~ 27% of users engaged for 3 to >30 minutes … … and looked at a lot of pages! Serenity Programme 2013

  48. Technical issues

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