Abstract
Utilization of internet-delivered cognitive behavioural therapy (iCBT) for treating depression and anxiety disorders in stepped-care models, such as the UK’s Improving Access to Psychological Therapies (IAPT), is a potential solution for addressing the treatment gap in mental health. We investigated the effectiveness and cost-effectiveness of iCBT when fully integrated within IAPT stepped-care settings. We conducted an 8-week pragmatic randomized controlled trial with a 2:1 (iCBT intervention: waiting-list) allocation, for participants referred to an IAPT Step 2 service with depression and anxiety symptoms (Trial registration: ISRCTN91967124). The primary outcomes measures were PHQ-9 (depressive symptoms) and GAD-7 (anxiety symptoms) and WSAS (functional impairment) as a secondary outcome. The cost-effectiveness analysis was based on EQ-5D-5L (preference-based health status) to elicit the quality-adjust life year (QALY) and a modified-Client Service Receipt Inventory (care resource-use). Diagnostic interviews were administered at baseline and 3 months. Three-hundred and sixty-one participants were randomized (iCBT, 241; waiting-list, 120). Intention-to-treat analyses showed significant interaction effects for the PHQ-9 (b = −2.75, 95% CI −4.00, −1.50) and GAD-7 (b = −2.79, 95% CI −4.00, −1.58) in favour of iCBT at 8-week and further improvements observed up to 12-months. Over 8-weeks the probability of cost-effectiveness was 46.6% if decision makers are willing to pay £30,000 per QALY, increasing to 91.2% when the control-arm’s outcomes and costs were extrapolated over 12-months. Results indicate that iCBT for depression and anxiety is effective and potentially cost-effective in the long-term within IAPT. Upscaling the use of iCBT as part of stepped care could help to enhance IAPT outcomes. The pragmatic trial design supports the ecological validity of the findings.
Highlights
Stepped-care models have been proposed as a potential solution[1] to bridge the substantial gap between the prevalence of common mental health disorders, including depression and anxiety, and the access rates for evidence-based treatments[2,3]
Intervention-arm participants (25.70%) either self-reported or were recorded by Improving Access to Psychological Therapies (IAPT) to have received further mental health treatment (Supplementary Table 13). This large-scale randomized controlled trial (RCT) conducted within IAPT showed that internet-delivered cognitive behavioural therapy (iCBT) for depression and anxiety is effective as a standalone intervention when fully integrated and operated in non-specialised routine stepped-care settings
The pragmatic trial design increases the ecological validity of the observed effectiveness of iCBT for depression and anxiety
Summary
Stepped-care models have been proposed as a potential solution[1] to bridge the substantial gap between the prevalence of common mental health disorders, including depression and anxiety, and the access rates for evidence-based treatments[2,3]. IAPT services offer evidence-based treatments to individuals experiencing depression and/or anxiety, providing low-intensity interventions alongside traditional treatments (e.g. face-to-face therapy)[5]. In the UK, iCBT has previously been investigated within a primary care context (the REEACT trials)[13,14] Outcomes from these trials were discouraging, finding iCBT to be neither more effective nor cost-effective than treatment as usual by general practitioners alone. We sought to evaluate the effectiveness and cost-effectiveness of iCBT for depression and anxiety in a pragmatic clinical trial within IAPT routine stepped care. Treatment period compared to waiting-list control and be considered cost-effective based on criteria set out by the National Institute for Health and Care Excellence (NICE; UK).
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