Meeting the challenges of integrating behavioral health into primary care settings requires out of the box thinking and clinician openness to working in new ways. While there has been growing recognition of the benefits of the Collaborative Care Model to improve both health and behavioral health outcomes, other evidence-based integration solutions such as the use of internet-based cognitive behavior therapy (iCBT) in the context of primary care have received less attention in this country.
The largest evidence base supporting internet-based CBT comes out of the United Kingdom where iCBT programs for depression and anxiety were recommended by the National Institute for Clinical Excellence for use by the National Health Service based on clinical trials results. The California Health Foundation’s review of dozens of peer reviewed studies also confirms the efficacy of iCBT citing cost effectiveness, patient acceptance and benefits to primary care workflow.1 Watkins et al. found that iCBT is as effective as pharmacotherapy for the treatment of mild to moderate depression in the short-term and is sometimes superior in the long term.2
The Value Proposition of iCBT In Primary Care
iCBT offers primary care providers a turnkey solution to integrating behavioral health into their practices. It has the advantages of being rapidly scalable, instantly accessible, produces cost savings and has demonstrated the capacity to free up time for primary care providers to spend time with other patients while enhancing patient satisfaction and self-efficacy. Importantly, the instant accessible of iCBT solves the screening dilemma of identifying more patients in need of care than the facility has capacity to serve.
Although Cognitive Behavioral Therapy (CBT) is widely recognized as an effective, evidence-based first-line treatment for the most common behavioral health disorders seen in primary care, numerous barriers to delivery of CBT remain. Primary among them is the shortage of clinicians who are trained in CBT for depression and anxiety. Even fewer clinicians are trained to provide CBT for insomnia and hazardous drug and alcohol use. Despite the reduction of barriers to seeking and receiving behavioral health care in primary care settings, other barriers such as cost, convenience, confidentiality, and fear of stigmatization and discrimination still exist.
Additionally, a review of the findings from 144 studies involving 90,000 subjects showed that the most frequently cited reasons for not seeking needed mental health care are the desire to handle problems on one’s own and thinking that the problem will get better on its own.
The delivery of web-based cognitive behavioral therapy is particularly well suited to addressing the identified barriers to seeking and receiving behavioral health care. Not only does internet-based CBT (iCBT) lower the cost of care by 50% -75%, it makes treatment available 24 hours a day, 7 days a week, anywhere that there is access to the web with no wait list. At the same time, iCBT uniquely fulfills the stated desire for self-sufficiency for individuals reluctant to seek outside help because these programs can be completed online with as little help from a mental health professional as the patient wishes.
For individuals who are particularly concerned about stigma, privacy and confidentiality, the option of being able to access care outside of an office setting, and in the privacy of one’s own home or location of choice, is also particularly appealing.
Workflow
There are many options for organizing the workflow when patients are iCBT offered as a treatment option in primary care settings. For example, using a tablet, a patient could be screened in the waiting room and have the screening results transmitted immediately to the electronic medical record for review by the primary care provider. Providers are then able to review the results with the patient and provide iCBT as a first line treatment option when appropriate. Patients can then be assisted by staff to enroll in iCBT while still at the clinic or given a toll-free number to call where they will receive enrollment assistance from a trained counselor who can also provide telephonic, text or chat supports while completing the program. The latter option, comprehensive Internet-based cognitive behavioral therapy (ciCBT), where wrap-around telephonic, chat and text supports are provided has been pioneered by the Mental Health Association of New York City in partnership with Cobalt Therapeutics with good results. Currently, MHA-NYC is making ciCBT available free of charge to New York State residents who are still experiencing emotional distress as a result of Superstorm Sandy. The iHelp: Sandy Stress Relief program can be accessed by calling 1-866- 793-2765 or online at iHELPCBT.com.
Most iCBT programs are delivered over 4-8 weeks with the expectation that the patient will complete one module a week. At the end of each module patients fill out a brief questionnaire such as the PHQ-9 or GAD which makes it possible to track compliance and patient progress through the clinician back-end. If any concerns regarding patient progress arise, it is then possible to reach out to the patient to assess the situation and modify the treatment plan. Although most patients access the iCBT from home, work stations can also be set up in primary care offices where behavioral health clinicians or medical support staff can briefly check-in with patients and provide encouragement and support.
The Evidence
Not all internet based cognitive behavioral therapy programs are created equal. Some have been studied in randomized controlled studies and published in peer reviewed journals while others have entered the marketplace without scrutiny. For those programs that have been studied, the data shows that internet based cognitive behavioral therapy is, on the whole, as effective face to face therapy and in some cases more effective.3 A review of 97 iCBT systems in a Maudsley monograph also showed that online users of iCBT are more likely to complete the programs if they are first screened, given access by a password and then briefly supported by phone, email or other contact.
The empirical evidence supporting the use of internet-based cognitive behavioral therapy for insomnia provides a particularly compelling example of benefit for primary care patients, providers and payers alike. According to the National Institutes of Health, 30%-40% of the population suffer from insomnia each year and 10-15% are chronic sufferers.4 Over a six month period indirect medical costs are $924- $1,143 higher for individuals suffering from insomnia.5 Sleep problems have also been shown to facilitate alcohol relapse.6 Successful treatment of insomnia improves outcomes for a variety of other conditions including depression and heart disease.7
In June 2009 the American Academy of Sleep Medicine issued a press release to publicize the results of a study authored by Norah Vincent Ph.D. and published in the journal SLEEP that demonstrated the effectiveness of the online cognitive behavioral therapy program RESTORE for chronic insomnia. Significant improvement was shown in insomnia severity, daytime fatigue, and sleep quality. The prospect of widespread availability of online cognitive behavioral treatment for insomnia has tremendous potential for improving population health as well as depression.
Summary
Although effective internet based cognitive behavioral therapies have been available and widely used within primary care settings in the United Kingdom, Australia and the Netherlands for many years, until now, there have been few incentives within the U.S. health care system to adopt innovations such as iCBT. With the passage of the Affordable Care Act and increased emphasis on achieving the triple aim, internet based cognitive behavioral therapy is ideally poised to help transform the health and behavioral health delivery systems by increasing access to better care, producing better health outcomes and lowering the cost of care.
Footnotes
1, Sarasohn- Kahn,J. The Online Couch: Mental Health Care on the Web, prepared for the California Health Foundation, June 2012.
- Watkins, E. and Williams R. “The efficacy of Cognitive Behavioral Therapy in the Management of Depression (ed. S. Checkley. Oxford: Blackwell Science, 1998.
- Marks et al. Computer-aided psychotherapy for anxiety disorders: A meta-analytic review. Cognitive Behavior Therapy, 38 (2).
- Ozminkowski et al. Cost Burden of Untreated Insomnia. SLEEP, Vol. 30, No. 3, 2007.
- Godet-Cayré et al. Insomnia, Who Pays the Costs?— SLEEP, Vol. 29, No. 2, 2006.
- Brower et al. Brower et al. Alcoholism, 1998
- Clinical Correlates of Insomnia in Patients with Chronic Illness – Arch Intern Med. 1998;158:1099-1107
