A new study has demonstrated that cognitive behavioural therapy (CBT) delivered via internet programmes had similar clinical effectiveness and greater cost-effectiveness in comparison with standard NHS 'talking therapy' care.
Internet-delivered CBT also enabled patients to be treated sooner and in around half the time of traditional treatments.
Internet-based programs are becoming increasingly popular and may offer one solution to high demand on mental health services. The National Institute for Health and Care Excellence (NICE) has stated there are "wide variations" in access across the NHS, resulting in many patients "not getting the treatment and support they need".
Earlier this year, NICE approved the use of CBT-based digital mental health technology for children and young people, and recommended nine digitally enabled therapies for adults with anxiety disorders or depression. NICE said that digitally-enabled therapies could increase the treatment options available, reduce demands on mental health professionals, and potentially prevent progression to more severe symptoms, which could be more costly to treat.
Clinical Effectiveness of Mental Healthcare "Unquantified"
However, the authors of the new study said that "the clinical effectiveness of mental healthcare remains unquantified, and long treatment times are common". There was limited understanding of the drivers of health and economic costs of different treatment methods for common mental health disorders such as depression and anxiety. Such understanding was "critical to meet the accelerating demands for care", they said.
So first author Ana Catarino from internet CBT provider ieso in Cambridge, which is a business partner to the NHS, along with colleagues from the University of York, and Dorset Healthcare University NHS Foundation Trust (DHC), set out to compare internet-delivered CBT with the NHS Talking Therapies (NHS TT) programme (formerly known as Improving Access to Psychological Therapies, IAPT).
NHS TT include a range of interventions such as counselling, CBT, and group therapy, with around one third of patients being given CBT. According to NHS Digital, in its most recent annual report on access to NHS psychological therapies, use of 'talking therapies' for anxiety and depression increased by over one-fifth betweeen 2020-21 and 2021-22. CBT was in the top three most popular treatments, with the highest rates of therapy-based recovery (40.7% to 51.6%).
The researchers analysed real world data from the records of 27,540 NHS patients with a primary diagnosis of depression or anxiety who had been discharged between January 2018 and December 2020 after receiving either standard treatment through NHS TT services or internet-delivered CBT. The proportion of patients receiving recurrent treatment for any mental health condition was calculated from patients discharged from DHC NHS TT services between October 2015 and September 2020.
The team calculated clinical effectiveness and cost estimates using data from DHC and ieso datasets, supplemented with additional data from published literature for costs that were not directly available. They constructed health economic models that captured a range of costs and accrued benefits associated with different severities of the two conditions, with a 2-year time horizon for waiting plus treatment time, and the cost of any additional treatment undertaken within two years of initiation of the original treatment.
Background costs — additional medical costs associated with the mental health condition, for example, an increased likelihood of GP appointments — were estimated based on a previous analysis conducted on behalf of NICE, and were assumed to be the same for internet-delivered CBT and NHS TT services in general.
Internet-CBT Patients Treated Sooner in Half the Time
The study, published in Nature Mental Health, showed that the main cost drivers were treatment effectiveness, time from referral to end of treatment, and treatment-associated costs. Internet-delivered CBT enabled patients to be treated sooner and showed similar levels of recovery in a shorter treatment time – around half the time of traditional treatment.
The authors noted that the cost savings of internet-delivered CBT were higher for depression than anxiety, and for more severe presentations. The latter they suggested was due to increased associated background costs.
They concluded that the study highlighted the key healthcare and human costs from waiting times and treatment duration. "Treatment costs are generally outweighed by the increased draw on other medical services, and in the loss of health-related quality of life that comes from poor mental health," they said. In other words, the "substantive costs" of mental health conditions "are driven by not intervening in an adequate or timely manner."
"Substantial" Policy Implications
The team concluded that CBT offers similar clinical effectiveness with shorter treatment times, providing one means of reducing waiting times and speeding recovery. "The potential for these findings to inform mental healthcare policy is substantial," they said.
Asked to comment by Medscape News UK, Lucy Schonegevel, director of policy and practice at Rethink Mental Illness, said: "Given the pressures faced by an under-resourced NHS attempting to deal with rising need, we should welcome digital solutions such as internet-based CBT, which could help people access support much more quickly."
However she pointed out that not everyone is digitally literate. "Digital solutions should never completely substitute face-to-face treatment, and a range of treatment options should be offered that are appropriate for each individual."
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