When the government announced earlier this year that computerised cognitive behavioural therapy (cCBT) would be made available on the NHS, the move was broadly welcomed by mental health charities and service user groups. Several months later, however, there is increasing disquiet at the slow rate at which it is being taken up by primary care trusts and concern is growing that mental health service users are, once again, waiting on promises that will never be delivered.
For years mental health service users have been pressing for greater access to “talking therapies” such as cognitive behavioural therapy (CBT). Used with or instead of drug treatments, these therapies have achieved impressive results – about 50% of patients with depression, for instance, show improvements with CBT that are similar to those of patients treated with antidepressant drugs. Yet a course of CBT requires several face-to-face counselling sessions with a specially trained therapist. With these being somewhat thin on the ground in most cash-strapped PCTs, many patients have either ended up on lengthy waiting lists or been denied the treatment altogether.
However, last week the government announced it would be investing millions in talking therapies, allowing 900,000 more people to be treated by recruiting an extra 3,600 therapists.
But it will be a few years before the benefits of this investment are felt on the ground. In the meantime the development of computerised CBT has been viewed with great interest by mental health specialists, their patients and the government. It was hoped that the techniques of CBT – reducing patients’ dysfunctional emotions by altering their behaviour and thinking patterns – could be integrated into an interactive computer programme, thereby offering the benefits of CBT without the need for a therapist.
Initially there was scepticism that this might simply be a way of fobbing patients off with a cut-price version of what is, after all, a highly specialised psychological technique. However, early results using cCBT show remarkable promise and a recent study by City University in London suggested that NHS waiting times for anxiety and depression treatment could be cut by as much as 25% if cCBT was more widely used.
Paul Corry, director of public affairs at mental health charity Rethink, believes that as long as suitable support remains available from mental health professionals, cCBT could play a valuable role in the treatment of mental illness.
“cCBT treatment can be better for some people than the alternative of no treatment,” he says. “But it must not be delivered on the cheap. The package must include proper assessment by health professionals and include support with the offer of alternative treatment if cCBT proves ineffective.”
Although Corry believes that “in an ideal world, those who need CBT would be able to access it from a trained therapist as and when they need it”, he points out that in the real world this rarely happens.
“It can be hard to access, with waiting lists in some places lasting for years. And accessing the treatment in the first place isn’t the only challenge. For some people, the time-limited course of sessions available on the NHS is too short and they may not be able to connect with the therapist assigned to them.” For these people, cCBT could be a valuable alternative.
Last year the National Institute for Health and Clinical Excellence (Nice) conducted a major review of cCBT in the treatment of depression, anxiety, phobias and obsessive compulsive disorder. While not providing a blanket endorsement of cCBT in the disorders studied, it recommended the use of two particular programmes – Beating the Blues for people with mild and moderate depression and FearFighter for people with panic and phobia (see panel, below).
In March this year, the Department of Health’s cCBT implementation guidance promised that the two programmes would be offered in every PCT in England. By the end of March each PCT was expected to have undertaken a local needs assessment, bought the software licences, ensured it had enough hardware, trained its staff and developed referral protocols.
Uptake so far, however, has been patchy. Ultrasis, the manufacturer of Beating the Blues, estimates that 500,000 people have been denied the treatment since Nice’s recommendations were published in February 2006.
“Unfortunately there’s not been much evidence of [cCBT] being taken up by PCTs and that is very disappointing,” says Andrew McCulloch, chief executive of the Mental Health Foundation, who is at a loss to explain why PCTs are so reluctant to adopt a therapy that is much cheaper than long-term drug therapy or therapist-delivered CBT.
“It’s hard to say why PCTs aren’t taking it up,” he says. “It shouldn’t be for financial reasons as cCBT is not a hugely expensive therapy and far cheaper than using trained therapists. I think it’s more that the idea of cCBT is not yet embedded in the thinking of PCTs. It may also be because there are only two products to choose from.”
Indeed, McCulloch believes that the use of cCBT should be extended beyond the current Nice guidance and, in certain circumstances, may be more effective than therapist-delivered CBT.
“It does have certain advantages over face-to-face therapy,” he says. “It’s more private, you can take it at your own pace and for some people that seems to work better. I’d also like to see more products on the market. For instance there’s good evidence that cCBT is useful in the treatment of obsessive compulsive disorder and phobias, so we do need a range of products.”
With an estimated six million people in the UK suffering from depression or anxiety disorders, there is a clear demand for therapies such as cCBT. The government last year launched two demonstration sites in Doncaster and Newham dedicated to developing models on how evidence-based psychological services should be adopted. Now may be the ideal moment for the government to ensure that these models, once developed, are actually implemented.
WHAT IS cCBT?
Computerised cognitive behavioural therapy describes a number of approaches by which cognitive behavioural therapy is delivered through an interactive computer programme. The user may access the software through a CD-Rom, over the internet or by telephone. Staff can facilitate the sessions.
The Nice guidance recommends the use of two programmes:
● Beating the Blues, manufactured by Ultrasis, is aimed at people with mild to moderate depression and anxiety. The package comprises a 15-minute introductory video and eight one-hour interactive computer sessions, usually organised weekly. The package also includes homework projects that are completed between sessions and weekly progress reports are made available to the GP or another healthcare professional at the end of each session. The progress reports include anxiety and depression ratings and suicidal tendencies.
● FearFighter, made by ST Solutions, is a computer-based package for phobic, panic and anxiety disorders. The program, which is available online, is divided into nine steps with brief therapist contact and support provided by trained support workers through telephone calls, or e-mails at different intervals throughout treatment. Progress reports are available to the GP or other healthcare professionals and can be accessed at any time over the internet using a clinical outcome and patients’ progress monitoring system.