10th May 2016 Silvia Andernello

IT competences supporting patients affected by depression: which way to go?

Our public mental health service (notably ASLTO3 Department of Mental Health) manages the treatment of patients affected by depression often in collaboration with general practitioners, who most of the times represent the first clinical contact for patients. The Mental Health Centers belonging to the ASLTO3 Department usually take care of patients mainly as outpatients, by prescribing antidepressant drugs and/or psychotherapeutic treatment, as appropriate: more precisely, severe depression is usually treated by administering drugs and providing psychiatric counselling, whereas mild to moderate patients that do not represent a clinical emergency will receive psychotherapy on a waiting list basis. As typically waiting lists delay the beginning of psychological interventions, computerized cognitive-behavioral therapy may thus represent a viable therapeutic option to allow patients to start to work effectively on their symptoms.

The possibility to treat these low to moderate patients  with a Cognitive Behavioral Therapy implemented through IT tools (CCBT) was considered a new, interesting, approach in our context. It was challenging trying to find a solution to cover the gap between patients’ needs and the availability of psychotherapists who can care for them.

ASLTO3 is performing the MasterMind clinical  pilot:

  • having chosen the CCBT IfightDepression© (IFD) tool released by the European Alliance Against Depression (EAAD)
  • having adopted the CCVC tool Easymeeting© in the common clinical practice.

As far as today, around 120 patients have been enrolled for the cCBT pilot, and more than 80 for the cCVC pilot ( with most of patients getting both treatments).

On the other hand, we promoted and are promoting the Mastermind cCBT and cCVC  pilot at different levels of the healthcare system: Mental Health Centers psychiatrics and psychologists, GPs, primary care psychologists, advertisement in public healthcare facilities and hospitals, Facebook dedicated project page.

Enrolled patients have been divided into two groups: patients using the cCBT only, and patients using both cCBT and cCVC. The  study  is currently going on by giving patients direct specialized support through the Mental Health Center from the Collegno-ASLTO3 headquarter by phone/email and cCVC.

From the pure IT perspective, we must consider that there is no specific IT innovation in this project: a cCBT tool is, in any case, a Website with authenticated credential access, and cCVC is a pure videoconferencing service. Both services can be performed by adopting different tools: at the moment, we didn’t have the goal to find the “best performing IT tool”, even if this would have to be done, in case, in the future, the clinical trial would become a common clinical practice. Nevertheless, from the clinical point of view, the adoption of a cCBT tool for caring about depressed patients and of a cCVC tool for both patients and clinicians communication, has to be definitely considered a new perspective at ASLTO3.

During the first months of work, we noted some interesting issues that might be of interest for all the partners:

  • Involving psychiatrists was less difficult than expected, especially for cCVC. Some training was done and specific resources were targeted and enrolled: they demonstrated to be, unexpectedly, very well interested in the adoption of the cCVC tool, in order to solve some issues in the clinical and managerial practice, that we didn’t expected so far.
  • Despite the low IT technical skills patients needed to have, in order to be eligible for the MasterMind clinical  pilot, some patients still experienced difficulties in using cCBT.
  • Involving GPs was not so easy. Several training was done and is still in place, to make them aware and confident about the new instruments and methodology; they got dedicated tablet PC, also to excite their curiosity. They were, in our mind, the promoters of the Mastermind clinical  study, however, sometimes, we found them suspicious, or, simply, indifferent. Probably, this is due to the fact that no IT had ever been used before to treat patients affected by mild to moderate depression in our territory, until now. The role of GPs as a “bridge” between patients and the Mental Health Center, enrolling patients, is still to be improved.
  • Involving psychologists was and is a delicate work. Specific dedicated training has been done, and more training is planned, specific resources have been targeted and involved,  but we have to be cautious as some of them fear to be “substituted” by the IT tools.  We suppose that only the practice will demonstrate them that these tools are an opportunity that complement their work, while they don’t substitute their role at all.

Despite some difficulties, big steps further have been done. The practical daily experience gets some useful lessons learned, which need anyway further investigation, but that can be very useful to plan the future approach for new diagnosis, care and assistance paths in the field of depression care.

Lesson learned about patients outcomes:

  • cCBT. Patients seemed to be satisfied by using the IT tools from home, available 24h/7gg,
  • Patients using cCBT only, have shown difficulties in using the tool. They lost motivation because of this and a new, more user friendly tool, is absolutely necessary. This led to the fact that some of them paused the treatment, or even totally abandoned it without any more contact. Their digital divide is still present , however, we are more likely to say they felt abandoned, needing a human, specialized interface: a psychologist helping them to interpret their needs and care for them.
  • The patients using both the cCBT and vCVC tools together (blended approach) didn’t pause or stop the treatment, they demonstrated to be happy with the trial, and those ones already finishing the treatment felt better. Still, we don’t have complete data yet, but the issue has been proven to exist. Also, travelling patients benefitted to be always in contact with the Mental Health Center by cCVC. The blended approach has shown to cover the gap between the patients and the Mental Health Center specialists, reducing significantly space and time between them. Patients showed to be curious about this new treatment, and they were able to improve their mental health status, while maintaining a certain degree of human contact with the therapist.
  • On the other hand, some patients have shown to use the cCBT tool, and to lower accesses to their GPs. We don’t’ know, however, if this means that they were improving or simply, they lost motivation at all, so this needs to be further investigated.

Lesson learned about psychologists outcomes:

  • The  blended form of treatment is an help for psychologists, and so it has to be understood by them. It addresses patients, who, the otherwise, would have never come to the Mental Health Center to be cared, probably getting worse and needing more costly clinical interventions, as a consequence. This message we shall bring in next psychologist training, in order to foster the  collaboration. Psychologists have to be confident, that the blended approach can help, but it can’t substitute the traditional face to face treatments.
  • Caring for more than one patient at a time, by cCBT and cCVC, is a new approach that needs further investigation.

Lesson learned about psychiatrist outcomes:

  • The new blended cCBT and cCVC treatment has been considered noteworthy.
  • The adoption of the cCVC tool has shown to be very useful in their daily practice. Psychiatrists from Mental Health Centers and clinicians in the Hospital wards, respectively, have adopted the cCVC for performing both their discussion about inpatients clinical cases (twice a week) and the managerial meetings (discussing organization issues). This, in the psychiatry context, has to be considered an absolute novelty, at least in Italy.
  • The cCVC success leads to the idea, still be further investigated, to adopt cCVC also for specific tele-consulting services,  for example: from Mental Health Centers to Hospital wards or surgeries clinicians.  This could be particularly useful to remotely support care cases located in small, remote  hospitals (example: rural and mountain areas).

In conclusion: “IT competences supporting patients affected by depression: which way to go?”. The discussion is still open! However, some useful steps forward have been done by us. What do you think about it?

Dr. Enrico Zanalda ASLTO3, Dr. Marco Cavallo ASLTO3, MSc. Eng. Silvia Andernello, CSI Piemonte.

 

The Mastermind Piedmont team

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