Digitally enabled therapies for adults with depression: early value assessment
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3 Committee discussion
Unmet need
3.1 Mental health services are in high demand and the availability of treatment options that need higher levels of therapist involvement can involve long waiting times. Digitally enabled therapies can increase the treatment options available and reduce the time needed by mental health professionals to deliver treatment.
3.2 Patient experts noted that early access to treatment could alleviate mild symptoms of depression and prevent escalation. Digitally enabled therapies can also provide flexible access to therapy and remove barriers to treatment such as travel-related issues, taking time off work and give access to people who are not able to leave the house. The use of these technologies could free up clinical resources and time that could be used to support those who need more personalised face-to-face care. The committee concluded that there is an unmet clinical need and access to effective mental health treatments needs to be improved.
Implementation
3.3 Digitally enabled therapies will be used in NHS Talking Therapies with existing service protocols. All the technologies included in this assessment are being used in the NHS or have planned pilots for their use. The committee acknowledged that a recommendation for use with further evidence generation would support adoption of these technologies and provide a mechanism for collecting real world clinical efficacy data.
3.4 Practitioners and therapists need training and support to effectively deliver digitally enabled therapies. The clinical experts advised that practitioners and therapists also need to be comfortable using digital technologies and need to have access to the necessary systems. Technologies should be integrated into a service's system rather than being a standalone technology. This would assist with data collection and reporting.
Patient considerations
3.5 Treatment options should be discussed by healthcare professionals, the person considering treatment and (when appropriate) carers. Discussions should consider clinical assessment, the person's preferences and needs, and the level of support needed. Clinical and patient experts agreed that personal choice should be a main consideration when offering a digitally enabled therapy. People who want to use a digitally enabled therapy are more likely to engage with the content. This may allow people to feel they are taking responsibility for their treatment which may create a sense of achievement. Clinical experts also said that other factors including risk and depression severity should also be considered. This is because anyone at high risk (such as those with suicidal ideation) or those with reduced ability to engage with a digitally enabled therapy (such as people with reduced concentration) would be better suited to therapies with more therapist involvement. The committee concluded that personal choice and clinical judgement is of most importance when deciding on the suitability of the use of digitally enabled therapies.
3.6 Patient experts said that people need to be reassured that their care can be escalated or an alternative treatment offered without being put to the end of a waiting list, if a digitally enabled therapy does not improve symptoms. Clinical experts confirmed that symptom scores would be routinely monitored and if symptom severity is not improving, further therapist support or an alternative intervention should be considered.
3.7 Patient experts said that appropriate privacy and security measures should be in place to reassure people using the technology. People would also need to be told about any additional support measures in place, especially when the technology is used outside of working hours.
Clinical-effectiveness overview
3.8 The evidence shows that Space from Depression, Deprexis and Beating the Blues have a potential benefit for adults with depression. There was limited or no evidence within the scope of this assessment for Minddistrict, Iona Mind and Wysa. The evidence base consists of 46 papers, reporting on 32 studies. There were 14 randomised controlled trials, 1 meta-analysis, 1 non-randomised pilot study and 13 non-comparative studies. Of these,12 studies were done in the UK using Beating the Blues or Space from Depression. The external assessment group (EAG) noted that the populations were broadly relevant but in 18 of the 32 studies the population was not restricted to depression and included adults with anxiety and other affective disorders. Most comparative studies also had waitlist or usual care controls. Some of the evidence was done outside of the UK which may limit the generalisability of the evidence. The committee concluded that the evidence base is sufficient to recommend use of Space from Depression, Deprexis and Beating the Blues, while further evidence is generated. But, there was not enough evidence for Minddistrict, Iona Mind and Wysa to make a recommendation for use. See the assessment report for further details.
Equality considerations
3.9 Digitally enabled therapy may not be suitable for everyone. Adults with limited access to equipment, internet connection or low digital literacy skills may be less likely to benefit from digitally enabled therapies. The committee concluded that face-to-face treatment options may be more appropriate for some adults.
3.10 Additional support and resources may also be needed for people with visual or hearing impairments, problems with manual dexterity or who are unable to read or understand English. The companies said that they have taken steps to improve accessibility of their technologies, including having a low reading age for the content, audio recording options, and consideration of diversity and inclusivity in their content design. One technology, Deprexis, is also available in 9 languages.
Costs and resource use
3.11 The economic modelling on Beating the Blues, Deprexis and Space from Depression showed that they could be a cost-effective option for people with less severe depression. For more severe depression, only Deprexis could be included in the model. The results showed that Deprexis and generic computerised CBT with support could be cost-effective options for people with more severe depression. But, the technologies are less likely to be the most cost-effective treatment option when compared with other standard care treatment options. The EAG noted that the main cost drivers are the effectiveness of the treatment and the follow-up treatment for people whose symptoms have not improved with a digitally enabled therapy. There was not enough clinical evidence on Iona Mind, Minddistrict or Wysa to evaluate the technologies quantitatively in the economic model. The committee concluded that there was enough evidence to recommend the use of Beating the Blues, Deprexis and Space from Depression while further evidence is generated. Evidence on measures of clinical effectiveness as well as resource use is needed to reduce uncertainty in the economics modelling.
Evidence gap overview
3.12 The most important evidence gaps for the technologies relate to the comparator and the outcomes reported. The main evidence gaps are:
A minority of the studies were done in an NHS Talking Therapies service setting and some evidence was collected outside of the UK. Most comparative studies used waitlist or usual care as a control rather than the standard care options used in NHS Talking Therapies services. The committee concluded that the quality and quantity of the evidence for 3 of the technologies was enough to demonstrate that the technologies had promise of a clinical benefit. Evidence generation within an NHS Talking Therapies setting, with appropriate comparators, would be needed.
Over half of studies included people with depression and other affective disorders. The clinical experts advised that the co-morbidity of depression and anxiety is high and so this would not be a major limitation of the evidence base. The committee acknowledged that data collection in an NHS Talking Therapies service should include baseline measures of depression and anxiety symptoms.
Published evidence was not available for some outcomes listed within the scope of this evaluation and there was some heterogeneity in how outcomes were reported. Further evidence generation should collect a wide range of outcomes to assess clinical effectiveness of the treatments, the level of rates and reasons for stopping treatment, adverse events, further treatment, and patient experience data.
The evidence did not report any adverse events related to the use of the technologies. The committee considered that few studies reported adverse events and more evidence is needed. The clinical experts said that they did not expect to see more adverse events for digitally enabled therapies compared with standard care once these were used with local service protocols. This includes offering digitally enabled therapies as one of a range of treatment options for people who do not need regular in-depth safety reviews or face-to-face care.
The EAG noted that the economic modelling is limited by a lack of clinical evidence comparing the technologies with treatment as usual within an NHS Talking Therapies service. Longer follow up of up to 2 years, depression severity subgroup analyses of treatment effects and reporting of resource use after treatment with digitally enabled therapies would also address uncertainty in the model. The economic model was also limited by not including costs relating to set up, training and administration.
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