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NICE recommends Nine Digital CBT Options for Adults With Anxiety or Depression

The National Institute for Health and Care Excellence (NICE)  has recommended six digitally enabled therapies for adults with anxiety disorders and three for adults with depression, whilst further data is gathered.

To coincide with Mental Health Awareness Week, NICE has recommended the bumper package of digital treatment options for those with depression or an anxiety disorder. The digital treatments use cognitive behavioural therapy (CBT) techniques via an app or website, and include the support and involvement of a NHS Talking Therapies clinician or psychological wellbeing practitioner.

According to NHS Digital, 1 in 6 people reported experiencing a common mental health problem such as anxiety and depression in any given week in England. In 2021-22, there were over half a million (527,094) referrals accessing NHS Talking Therapies for depression and anxiety services with a presenting complaint of anxiety and stress related disorders.

In its guidance, NICE stated that mental health services were in high demand and that access varies widely across the NHS, meaning that many people were not getting the treatment and support they need. 

"Mental health services are struggling with chronic staff shortages, which are making it difficult for them to provide patients with quick and effective treatment," said Dr David Rigby, co-chair of the Royal College of Psychiatrists; digital psychiatry special interest group, when asked to comment for Medscape News UK.

The charity Anxiety UK told Medscape News UK that it welcomed "any developments that will improve or enhance treatment options and expand the choice of treatments available for those living with anxiety, stress and/or anxiety-based depression".

Best Care to People Fast

Digitally enabled therapies could increase the treatment options available and reduce the time needed by mental health professionals to deliver treatment, NICE underlined. They offer an alternative way for people to access help in a way that may be more suited to their personal needs by offering flexibility around both time and location of treatment, a NICE spokesperson said.

For depression, digital treatment options required on average 90 minutes of therapist time, compared with the 8 hours each patient would receive with standard care. For anxiety disorders, digitally enabled therapies required on average 4 hours of clinician or practitioner time, compared with 10 hours required for standard care. NICE said that, as these therapies required less therapist time than standard care, clinical resources could be freed up, and that this time could be used elsewhere to increase access or reduce waiting times.

"We know NHS Talking Therapies services are in demand and people are facing waits of several weeks," highlighted Mark Chapman, interim director of medical technology and digital evaluation, at NICE. He said that part of the solution could be the use of digitally enabled therapies, which could increase the number of people receiving the treatment they need sooner.However, NICE cautioned, the number of people waiting to be seen overall will depend on how many people opt for digitally enabled therapies.

Mr Chapman emphasised that, although a major priority was to get the best care to people fast, the choice of a digitally enabled therapy must be "the right one for the individual".

Commenting to Medscape News UK , Head of Information at MIND, Stephen Buckley, urged that improvement in this area was "crucial" as "far too many people" were going without the mental health support they needed and deserved.

Mr Buckley said that the "most effective treatment options are those where people get a say in what works for them, we know lots of people – especially young people – really benefit from face-to-face treatment". So, digital therapies cannot be used as a replacement for face-to-face support, he counselled.

"Many people will benefit from digital therapies, especially around getting an appointment quicker and at a time which is more flexible and convenient," he explained, "but for others, we know that digital therapies can be hard to navigate, and people tell us about their concerns around confidentiality, privacy, and trust."

"Digital therapies may ease the pressure that services are under, but they are not a long-term solution to the problem," warned Dr Rigby. Therapies could make it easier for some vulnerable patients to access vital mental health support that they otherwise wouldn’t receive, stressed Dr Rigby. "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," he pointed out.

Digital Treatment Use Possible Whilst Evidence Gathered

Prior to commencing treatment, patients would undergo a formal assessment with an NHS Talking Therapies clinician or practitioner, to ensure that the correct intervention was matched to both clinical needs and the person's preferences.

NICE pointed out that there was relevant published evidence that showed a potential benefit for adults with anxiety disorders for 6 of the 11 digitally enabled therapies. In light of this, the regulator recommended that the six digitally enabled therapies could be used as treatment options for adults with anxiety disorders, while further evidence was generated on their clinical and cost effectiveness.

Two (listed below) could be used once they had Digital Technology Assessment Criteria (DTAC) approval, and an NHS Talking Therapies for anxiety and depression digitally enabled therapies assessment. Those two are:

  • Beating the Blues (365 Health Solutions) for generalised anxiety symptoms or unspecified anxiety disorder
  • Space from Anxiety (SilverCloud) for generalised anxiety symptoms or unspecified anxiety disorder
The other four (listed below) could only be used once they had CE or UK Conformity Assessed (UKCA) mark approval, DTAC approval, and an NHS Talking Therapies for anxiety and depression digitally enabled therapies assessment. Those four are:
  • iCT-PTSD (OxCADAT) for post-traumatic stress disorder (PTSD)
  • Spring (Cardiff University) for PTSD
  • iCT-SAD (OxCADAT) for social anxiety disorder
  • Perspectives (Koa Health) for body dysmorphic disorder (BDD)
For adults with depression, the three digitally enabled therapies (listed below) could be used as treatment options, while further evidence was generated on their clinical and cost effectiveness, and once they had Digital Technology Assessment Criteria (DTAC) approval and an NHS Talking Therapies for anxiety and depression digitally enabled therapies assessment. Those three are:
  • Beating the Blues (365 Health Solutions)
  • Deprexis (Ethypharm Digital Therapy)
  • Space from Depression (SilverCloud).

NICE stressed that further evidence covering a number of areas should be generated for all the digital treatment options it had recommended. These included rates of recovery, rates of deterioration, rates and reasons for stopping treatment, rates of relapse, patient experience, and health-related quality of life.

Professor Tony Kendrick, professor of primary care at the University of Southampton, stressed that information also needed to be examined on the effects on the demographic profile of people accessing the therapies, and on the effects on waiting times, and broader measures of access "beyond the people" who accessed the apps.

He said that the point that further evidence of effectiveness and cost-effectiveness needed to be gathered was "well made", but: "We also need more evidence, however, on the possible risk of widening inequality of access to treatments," he counselled. "The risk is that people who are less Internet savvy will miss out, although if therapies become more available as a result of the wider adoption of digital therapies then it may help everyone."

Miranda Wolpert, director of mental health at Wellcome, believed that digital mental health therapies would become an "increasingly important and potentially scalable" way to reach people with mental health problems around the world and could "help people who experience anxiety and depression as early as possible, potentially transforming lives".