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NICE Recommends Digitally Enabled Therapies For Depression and Anxiety

The National Institute for Health and Care Excellence (NICE) has made a conditional recommendation for eight digitally enabled therapies using cognitive behavioural therapy (CBT) techniques to be made available to treat depression and anxiety in adults.

NICE also launched a consultation on the decision, and added that these therapies will help "address depression and anxiety disorders, including PTSD and body dysmorphia", a NICE spokesperson said, while they reassured that each of the digital technologies included the "support and involvement" of an NHS talking therapies clinician.

It is estimated that 1 in 6 people report experiencing a common mental health problem, such as anxiety and depression, in any given week in England, according to NHS Digital.

Commenting for Medscape News UK, Lucy Schonegevel, associate director of policy and practice, Rethink Mental Illness, said: "As the NHS grapples with rising demand for mental health services in the wake of the pandemic and the cost of living crisis, it’s encouraging to see new technologies recommended that can potentially add to the range of evidence-based treatments on offer."

Improved Access

At the moment, there is high demand for NHS talking therapies, with some people currently waiting up to 6 weeks to access help, according to NHS Digital. The number of people accessing talking therapies through the NHS for conditions such as anxiety and depression increased by over one fifth (21.5%) from 1.02 million in 2020-21 to 1.24 million referrals in 2021-22, according to NHS Digital's report Psychological Therapies: Annual Report on the use of IAPT services, England 2021-22.

NHS Digital highlighted that overall referral numbers were up 24.5% – from 1.46 million in 2020-21 to 1.81 million in 2021-22. This was "higher than pre-pandemic levels" of 1.69 million in 2019-2020, they pointed out. The authors said that 91.1% of people accessed IAPT services within 6 weeks, up 1.1% from 90% in 2020-21.

However, a NationalWorld independent analysis of NHS data published in October last year found that, although the NHS targets of at least 75% of IAPT patients starting treatment within 6 weeks and 95% within 18 weeks, were being met, the vast majority of patients then have to "wait at least a month" between their first and second treatment sessions. They criticised that in "one part of the country, up to 9 in every 10 patients had to wait more than 3 months to get their second bout of therapy".

NICE highlighted that digital therapies offer an "alternative" way for people to access help, and may be more suited to their personal needs by offering "flexibility" around both time and location of treatment. The NICE review committee commented that the evidence for these technologies demonstrated the "positive impact" of CBT on the relevant conditions, and how the technologies can "improve access".

"Digital technologies stand to help make therapy more accessible and can prove to fit more conveniently into people’s everyday lives, plus they can help improve efficiency in stretched organisations like the NHS," Ms Schonegevel pointed out.

Professor Stephen Pilling, specialist committee member and head of the clinical, educational and health psychology department at University College London, expressed pleasure with the recommendation from NICE, and also felt that the interventions could make a major contribution to "increasing access to, and choice of, evidence-based psychological interventions".

People Put in Charge of Their Journey to Positive Mental Health

The eight therapies - conditionally recommended while further evidence is generated - are:

  • "Perspectives" – for body dysmorphic disorder (BDD) - with support provided by a high intensity therapist trained in treating BDD
  • "Beating the Blues" and "Space from Anxiety" (SilverCloud) – for generalised anxiety symptoms or unspecified anxiety disorder, with support provided by a psychological wellbeing practitioner or high intensity therapist
  • "iCT-PTSD" and "Spring" – for post-traumatic stress disorder (PTSD), with support from a high intensity therapist trained in treating PTSD
  • "iCT-SAD" – for social anxiety disorder, with support provided by a high intensity therapist trained in treating social anxiety disorder
  • "Beating the Blues", "Deprexis", and "Space from Depression" (Silvercloud) – for depression

Mark Chapman, interim director of medical technology and digital evaluation at NICE, said that the eight technologies "have promise", and emphasised that each one had demonstrated it has the "potential to provide effective treatment".

Elizabeth Mullenger, lay specialist member on the NICE committees, said: "These technologies will allow us to be in charge of our treatment, gaining a sense of autonomy as we navigate our own journey towards positive mental health."

These new recommendations are the sixth and seventh 'early value assessments' (EVA) from NICE, which make use of a new NICE rapid assessment process that seeks to identify promising medical technology for rapid deployment into the NHS.

Last year, as part of a NICE pilot for EVA, the regulator recommended five self-guided digital CBT for children and young people with symptoms of mild to moderate anxiety, which included games, videos, and quizzes, based on CBT principles.

Choice Remains Paramount

The NICE committee believed the use of these technologies could lead to more people with mental health conditions being seen in NHS talking therapies services, as digitally enabled therapies may need less practitioner or therapist time for delivery than other psychological interventions.

"Digital technology could transform the experience of people living with mental illnesses," said Ms Mullenger. "It can be incredibly isolating to be on a long waiting list for in-person treatment. You might know that help is coming, you just don’t know when.

"Having access to a digital therapy could help prevent this lonely feeling. Sometimes people need support most in the middle of the night, or after a busy day at work, and it’s hard to know where to turn. Having access to digital therapy, can give people the help they need, when they need it," she added.

Professor Dame Til Wykes, specialist committee member and head of the School of Mental Health and Psychological Sciences at King’s College London, said she was pleased that these interventions will be offered with therapist supervision to identify any additional support early, and importantly, that patients will have a "choice of whether to use them or not".

However, Ms Schonegevel beseeched that "no-one is locked out" of vital mental health support as some services move online, and emphasised the cruciality that people were still presented with a "choice of treatments" appropriate to their needs. 

"The relationship between a patient and their therapist is crucial in determining whether their treatment is effective, which is why everyone must be able to choose the method of support that works best for them, explained Dr David Rigby, co-chair of the Royal College of Psychiatrist's Digital Psychiatry Special Interest Group, when asked to comment for Medscape News UK. "It is also important that people who do not have access to the required technology are still able to receive in-person care in a timely manner," he alerted. 

Isolation Dilemma

The therapies have the potential to help more than 40,000 people, said NICE.

"While thousands of people stand to benefit from the introduction of new, digitally enabled therapies, the number of people accessing such support will be a drop in the ocean considering the 1.24 million referrals for NHS talking therapies received in 2021-22," cautioned Ms Schonegevel, who pointed out that the digital therapies are "far from a magic bullet" to address rising demand for NHS services.

Dr Rigby agreed. "Mental health services are struggling with chronic staff shortages, which are making it difficult for them to provide patients with quick and effective treatment. Digital therapies may ease the pressure that services are under, but they are not a long-term solution to the problem," he said.  

"Digital therapies can make it easier for some vulnerable patients to access vital mental health support that they otherwise wouldn’t receive. We know some people may prefer to be treated online because they struggle with anxiety or because they find it more convenient to receive care from the comfort of their own home," added Dr Rigby.

Commenting to the Science Media Centre, Dr Dean Burnett, honorary research associate at Cardiff University, said: "Often times, the basic act of leaving home, travelling to a clinic, sitting through therapy, then returning, is beyond the capacity of those in the throes of a serious mental health episode."

However, Dr Rigby illuminated the fact that during the pandemic some people "really struggled" with online sessions and were very relieved to return to face-to-face care. 

Jess D’Cruz, information content manager at Mind, told Medscape News UK that the charity was pleased to see innovation in mental health therapies that can help people have "greater choice in how they are supported", and "allow all of us to find a therapy that works for ourselves".

However, she emphasised that online support "isn't right or accessible for everyone", so it's important that "we all have a range of support offered to us".

Professor Wykes, commented: "Digital therapies may offer welcome additional help for people with a diagnosis of anxiety or depression. They may help enough to reduce the need for face-to-face contact be that in person or virtually. But we don't know enough about who will improve and who will need extra help."

Dr Burnett added: "By and large, it's probably still too early to say for certain whether apps can be as effective as in-person therapy, as they're still a relatively new and developing technology."

While Dr Rigby cautioned that : "More work still needs to be done to assess the benefits of talking therapies that are regularly delivered remotel."

Prof Jenny Yiend, professor of cognitive psychopathology at the Institute of Psychiatry, Psychology & Neuroscience, King's College London, told the Science Media Centre: "Digital therapy is a new and fast-moving field, and apps and other digital therapies won’t be right for everyone. Digital therapies can feel impersonal, which some people don't like. But if you're the kind of person who finds it hard to open up or trust other people (even therapists), then an app can be a great way to receive treatment."

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