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