Technology-mediated interventions for common mental health problems and training of health professionals
Submitting Institution
University of East AngliaUnit of Assessment
Psychology, Psychiatry and NeuroscienceSummary Impact Type
HealthResearch Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
Dr Lina Gega's research has been instrumental to the development and
take-up of computerised Cognitive Behavioural Therapy (cCBT) and other
technology-mediated interventions for common mental health problems in the
UK and internationally. Gega's adjunct on-line methods form a key
foundation for the training of professionals to support cCBT, and the
National Institute for Health and Care Excellence (NICE) guidelines now
include cCBT for first line intervention for common mental health
problems. These developments have resulted in a greater patient reach for
cCBT internationally, with resultant decreases in waiting time for
patients (with associated economic benefit) and improved outcomes.
Underpinning research
Common mental health conditions, including anxiety disorders, depression
and obsessive compulsive disorders (OCD), represent a major cost to
society, both in terms of significant reductions in quality of life for a
relatively large proportion of the population and the associated drain on
economic resources of treatment. It is estimated that, per 1000 people
aged 16-74 years in England and Wales, 187 present with mixed anxiety and
depression, 95 for generalized anxiety disorder, 62 for depressive
episode, and 38, 13 and 38 for phobia, panic disorder and OCD respectively
(Psychiatric Morbidity Survey, 2000). Health practitioner time is
expensive and training of health professionals is both costly and time
consuming. In an ideal world, interventions for common mental health
problems should take place in a patient's home (or similar setting),
without the need for visits to clinics, thus freeing up the time of health
professionals, reducing waiting lists, and improving outcomes for these
patients.
Computerised CBT provides a means of improving patient access to
psychological therapies, reducing clinician time (and cost), and
ultimately improving outcomes for patients. Gega at the University of East
Anglia (UEA) (in post until February, 2013) pioneered two new developments
of cCBT, leading to specific impacts within the REF period. She has
established the conditions under which cCBT is effective and how the reach
of cCBT can be broadened to the training of health professionals across a
range of treatment regimes. Marks, Kavanagh and Gega (2007; output 1)
is a complete critical review and analysis of the effectiveness of cCBT,
and together with key meta- analyses (outputs 2, 3), shows the
conditions under which cCBT is most efficacious. Further Randomised
Control Trials (RCTs, e.g., outputs 4, 5), both completed and
ongoing, show how much adjunct human support (and by whom) should be given
to cCBT (the Beating the Blues programme in this case) to enhance outcome
and cut staff costs. In combination, the meta- analyses and RCTs (outputs
2-5) show that technology-based interventions are efficacious for
both the treatment of common mental health disorders and the training of
health professionals.
Gega also developed a key screening tool, the "CCBT SQ", to establish the
suitability of individuals for cCBT, and whether adjunct support is
required during on-line treatment. The success of cCBT involves the
recognition that patients differ in the levels of support they require for
CBT, and hence the extent to which they are able to undertake cCBT with or
without adjunct support, or not at all (output 1). The CCBT SQ
(Screening Questionnaire) was developed in output 1, further
refined in the early stages of grant 1, and fully documented in
later grants and research protocols concurrent with impact (outputs 4,
5).
The underpinning research for the impact has been funded by a series of
grants awarded to Gega totaling over £2 million during the current REF
period funded by the National Institute for Health Research `Research for
Patient Benefit' (NIHR RfPB) programme, and the Health Technology
Assessment (NIHR HTA) programme. All grants were multi-site, with Gega as
Principal Investigator (PI) at UEA.
References to the research
Output 1 is an Authored Book:
1) Marks, I. M., Cavanagh, K., & Gega, L. (2007). Hands-on
Help: Computer-aided Psychotherapy. Maudsley Monographs No. 49 (196
pages). Hove: Psychology Press. [ISBN.184169679X]. 176 citations on google
scholar (the book is not available on Scopus).
Outputs 2-5 are Peer Reviewed Journal Articles:
2) Marks, I. M., Cuijpers, P., Cavanagh, K., van Straten, A., Gega,
L., & Andersson, G. (2009). Meta-analysis of computer-aided
psychotherapy: Problems and partial solutions. Cognitive Behaviour
Therapy, 38(2), 83-90.
Gega made a substantial contribution to the organisation of the
conduct of the study, to the carrying out of the study, to analysis and
interpretation of study data, and helped draft the output and critiqued
the output for important intellectual content.
3) Cuijpers, P., Marks, I. M., van Straten, A., Cavanagh, K., Gega,
L., & Andersson, G. (2009). Computer-aided psychotherapy for
anxiety disorders: A meta-analytic review. Cognitive Behaviour
Therapy, 38(2), 66-82.
Gega made a substantial contribution to the organisation of the
conduct of the study, to the carrying out of the study, to analysis and
interpretation of study data, and helped draft the output and critiqued
the output for important intellectual content.
4) Gega, L., Swift, L., Barton, G., Todd, G.,
Reeve, N., Bird, K., Holland, R., Howe, A., Wilson, J.,
& Molle, J. (2012). Computerised therapy for depression with clinician
vs. assistant and brief vs. extended phone support: study protocol for a
randomised controlled trial. Trials, 13(151), 1-11.
5) Gega, L., Smith, J., & Reynolds, S. (2013).
Cognitive behaviour therapy (CBT) for depression by computer vs.
therapist: Patient experiences and therapeutic processes. Psychotherapy
Research, 23(2), 218-231.
Key Research Funding Underpinning the Research and Associated Impact:
2008-2011. Support for computerised therapy for patients with
depression: a factorial randomised controlled comparison of brief vs.
enhanced support given by clinicians vs. assistants. Sponsor:
NIHR Research for Patient Benefit (RfPB) Programme grant. Value: £249,161.
Gega was PI and Lead Applicant, with Reynolds, Howe, Holland, Barton and
Swift (UEA) and Rennie (NHS Norfolk). Gega's role involved the inception
and design of the trial, management of a research team of clinicians,
assistants, students and lay members across three Trusts, coordination of
a patient advisory group, write-up and dissemination.
2011-2013. Obsessive Compulsive Treatment Efficacy Trial
(OCTET). Sponsor: National Institute for Health Research
(NIHR) Health Technology Assessment (HTA) Programme grant. Value:
£1,768,802. This was a multi-site trial with Gega as local PI and
Co-Applicant, with Lovell (Lead Applicant), Bower, Bee and Roberts
(Manchester), Reynolds (UEA), Gilbody and MacMillan (York), Barkham and
Hardy (Sheffield), Byford (Institute of Psychiatry, King's College London)
and Lidbetter (Anxiety UK). Gega's role involved overseeing recruitment
and treatment in one of four main research sites, providing training and
supervision of trial staff across all sites, organising service user
representation for the trial and providing expert advice on the
computerised self-help intervention across sites.
Details of the impact
Gega's research has played a significant role in three interconnected
impacts: (1) the development of cCBT in the UK and abroad and improvement
of its reach, 2) the development of on-line training and direct training
for health professionals, and 3) in the development of policy for the
treatment of common mental health disorders through cCBT. The first two
strands of impact are direct. The third strand emerges from the first two
strands.
The CCBT SQ developed by Gega (outputs 1, 4, 5) has been used as
the screening and triage tool by FearFighter™ during the REF census period
[sources 1, 2]. FearFighter™ is the main cCBT tool for the
treatment for panic and phobia. It has been used by thousands of patients
across the world, has been endorsed as being proven to be clinically
effective as well as cost effective, and is recommended as an option for
delivering CBT in all the relevant policy guidelines for a range of common
mental health conditions, including the National Institute for Health and
Care Excellence (the NICE Final Appraisal Determination (FAD), CG123,
Common Mental Health Disorders, May, 2011; Technology Appraisal TA97,
2008; NICE guideline 90; [sources 3, 4, 6]). FearFighter™ has been
taken up by over 50% of the Primary Care Trusts in the UK as a consequence
of the policy recommendations and evidence base for its efficacy and
efficiency. It has also been adopted in other countries as a recognised
form of standard treatment. Appropriate screening and triage is critical
to the correct application of the resource, and therefore the efficacy
rates this method of intervention has achieved. The company that produces
FearFighterTM, CCBT Limited, recognises that "the significant
addition of the screening tool to FearFighter™ has improved take-up rates
for the program as well as contributing to clinical outcome" and that "the
addition of the screen to FearFighter™ has contributed to FearFighter™
being adopted in international policy guidelines as a recommended cCBT
program." [sources 1, 2].
The CCBT SQ establishing the suitability of individuals for cCBT,
together with the findings from meta-analyses and trials in Gega's funded
work at UEA, also form a key part of the provision of on- line training in
the use of cCBT for health professionals. Gega has been instrumental in
the provision of on-line training for clinicians to support the use of
computerised packages. She was invited to produce the first and only
postgraduate on-line training module in cCBT for the Royal College of
Psychiatrists [source 7] in the context of Improving Access to
Psychological Therapies (IAPT). This on-line module has been viewed by
over 28,000 people (Google analytics; source 8) in 37 different
countries across 5 continents (Europe, Asia, North America, South America,
Oceania), and has been fully completed by over 600 clinicians. The module
has been described as an "exemplary project in the field" [source 5],
and the importance of the on-line training internationally has been
recognised [source 5]. More broadly, cCBT has been adopted by IAPT
as a core part of the improvement of the reach of psychological therapies
for common mental health conditions [source 9].
Gega has also been involved in the effective conditions of use of cCBT
for another common mental health disorder - depression. Beating the Blues
is the other recommended cCBT package in the National Institute of Health
and Clinical Excellence guidelines for depression and anxiety NICE [sources
4, 6]. Gega has provided part of the evidence base for its use (Outputs
1, 4, 5). Moreover, Gega is playing a key role in its roll out
across the UK, introducing cCBT clinics in GP surgeries right across
Suffolk and Norfolk (with the Suffolk MIND partnership) with Beating the
Blues combined with onsite and/or telephone support (dependent on CCBT SQ
outcomes) [source 10], building on her research base showing that
adjunct support improves outcome.
The final interconnected thread in the impact of Gega's research is
through the direct training of health professionals in the use of cCBT.
Gega has personally trained clinicians in the UK in the use of cCBT across
four counties - Norfolk, Suffolk, Northumberland, Yorkshire - in
particular focussing on the screening of potential participants for cCBT,
and on the adjunct support required to reach maximum efficacy. Over 200
clinicians to date have been directly trained by Gega in the UK, and
direct training by Gega has been extended to Belgium. Her online training
protocols and adjunct methods have also been adopted internationally in
the training regimes countries offer for those overseeing and
administering cCBT [source 5].
Sources to corroborate the impact
1) Letter from CCBT Limited, the company that produces FearFighter™,
corroborating Gega's contribution to FearFighter™, and the reach of
FearFighterTM. (Dated July, 2013).
"Dr Gega's work has been influential in the development of
FearFighter™ in several respects during the dates of relevance
(2008-2013). Her body of research published at the University of East
Anglia has been important as a backdrop to the acceptance of cCBT
generally, and FearFighterTM specifically...
[but] the most important contribution Dr Gega has made to FearFighter™
is the introduction of the screening tool for it ...The significant
addition of the screening tool to FearFighter™ has improved take-up
rates for the program as well as contributing to clinical outcome.
Moreover, the addition of the screen...has contributed to FearFighter™
being adopted in international policy guidelines as a recommended cCBT
program (e.g. NICE guidelines in the UK)."
2) Letter from Professor Isaac Marks, the originator and former Medical
Director of FearFighter™ corroborating Gega's contribution to cCBT in
terms of the addition of the CCBT SQ to FearFighter™, the provision of
on-line training, and evidence for the value of cCBT. (Dated July, 2013).
"Dr Gega's research has yielded crucial evidence for the value of cCBT
e.g. the monograph by Marks, Cavanagh & Gega (2007) was an
influential and critical review of cCBT. It, and articles she has
published since, specified the types of support required for cCBT
programs to be of most benefit, and evaluated the suitability of cCBT
for particular clinical groups" and [the] "use of the screening tool
alongside FearFighterTM was important to
ensure that patients were suitable for the program and offered adequate
support to help them complete it."
3) National Institute for Health and Clinical Excellence (2011, and
on-going). CG 123, Common Mental Health Disorders. http://www.nice.org.uk/nicemedia/live/13476/54520/54520.pdf.
This policy document and set of recommendations endorses FearFighterTM
as an on-line treatment.
4) National Institute for Health and Clinical Excellence (2008, and
ongoing). Review of Technology Appraisal TA97.
http://www.nice.org.uk/nicemedia/live/11568/56395/56395.pdf.
This policy document and set of recommendations endorses FearFighterTM
and Beating the Blues as on-line treatments, and amends earlier
recommendations published in 2006
(http://www.nice.org.uk/nicemedia/live/11568/33185/33185.pdf).
5) Letter from Professor Pim Cuijpers, Head of the Department of Clinical
Psychology, Free University, Amsterdam, Vice-director of the EMGO
Institute of Health and Care Research of the VU University and the VU
University Medical Center, corroborating Gega's impact upon the uptake of
cCBT internationally. (Dated July, 2013).
This source confirms that Dr Gega's research has played "an important
role in the development and implementation of cCBT internationally",
describing the cCBT training course for the RCP as "an exemplary project
in the field" and corroborating that it "has been viewed and used by
many (colleagues) in the Netherlands and elsewhere". Output 1),
commissioned by the Institute of Psychiatry, "has been one of the most
influential in the field, including the Netherlands and other European
countries."
6) National Institute for Health and Clinical Excellence (2009, and
ongoing). Guideline 90, Depression: The treatment and management of
depression in adults.
http://www.nice.org.uk/nicemedia/pdf/cg90niceguideline.pdf.
This policy document and set of recommendations endorses FearFighterTM
and Beating the Blues as on-line treatments.
7) Online CPD Computer-Aided Cognitive Behaviour Module authored by Dr
Gega and Professor Isaac Marks for the Royal College of Psychiatrists.
The Module can be viewed at http://www.psychiatrycpd.co.uk/learningmodules/computer-
aidedcognitivebehav.aspx.
8) Email from Royal College of Psychiatrists corroborating the numbers of
people accessing the CPD module [source 7]. (Dated July, 2013).
9) Improving Access to Psychological Therapies Service Recommendations
(2007, and ongoing).
http://www.iapt.nhs.uk/silo/files/iapt-outline-service-specification.pdf.
10) Email from Consultant Psychologist/Clinical Lead for Norfolk and
Suffolk Wellbeing Services, corroborating Dr Gega's role in training on
the implementation of computerised CBT in the Norfolk and Suffolk region.
(Dated September, 2013).