Digitally enabled therapies for adults with anxiety disorders: early value assessment

Unmet need

3.1 Mental health services are in high demand and access varies widely across the country, with many not getting the treatment and support they need. The patient experts reported many barriers to face-to-face treatment, including transport costs, travel issues and difficulty taking time off work to attend sessions. Digitally enabled therapies allow more flexible access to therapy and could fulfil a need for support. Early access to treatment could alleviate mild symptoms and prevent escalation, which could help with daily living and productivity. Digitally enabled therapies may especially benefit people who are socially anxious or are unable to leave home for treatment. They may reduce the time needed by mental health professionals to deliver treatment, which could free up clinical resources 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

3.2 Digitally enabled therapies would be used in NHS Talking Therapies with existing service protocols. All technologies included in this assessment are being used in the NHS or have planned pilots for use. The committee acknowledged that a recommendation for use with further evidence generation would support increased adoption of these technologies and provide a mechanism for collecting real-world clinical efficacy data.

3.3 The committee carefully considered the safety and risks of using these technologies while further evidence is generated. The clinical experts advised that NHS Talking Therapies services have established protocols, which include initial clinical assessment, matching the right treatment to people's needs and preferences, and ongoing monitoring and management of patient safety. Some digitally enabled therapies also have inbuilt functionalities to promote safety, for example technologies may alert the practitioner or therapist of potential concerns so that they can contact the patient when needed. The practitioner or therapist may also contact the patient if they see worsening in patient reported outcomes or if the patient has stopped using the programme. Decline in mental health or functioning while using digitally enabled therapies should be identified by the practitioner or therapist and treatment should be escalated when needed, in line with the stepped care approach.

3.4 The clinical experts advised that digitally enabled therapies would need less practitioner or therapist time than other interventions, such as face-to-face therapy. Practitioner or therapist support would usually involve a review of patient progress, content completed and patient safety. This review may be done using messaging or sometimes a telephone call. The level of support may vary by services, with some practitioners or therapists also delivering parts of the intervention content. Reviews may be weekly or fortnightly depending on the service.

3.5 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

3.6 Digitally enabled therapies can increase treatment options and offer people more choice in their mental healthcare. The patient experts shared that this could help people feel they are taking responsibility for their treatment and may create a sense of achievement. But clinical and patient experts stressed that it must be a genuine patient choice and not a default treatment or stopgap to reduce waiting lists. People who want to use digitally enabled therapies are more likely to engage with the content and to see benefits. Digitally enabled therapies may not be suitable for everyone. People who need more support or who have more severe functional impairment may need more intensive interventions. Treatment options should be discussed by healthcare professionals, patients and (when appropriate) carers and should consider clinical assessment, patient preferences and needs, and the level of support needed.

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.

Equality considerations

3.8 Digitally enabled therapy may not be suitable for everyone. It is delivered through a smart device or computer with internet connectivity. Adults with limited access to these technologies or who are less comfortable or skilled at using digital technologies may be less likely to benefit from digitally enabled therapies. They may need considerable adaptations to access the therapy, which may not be available in all services. The committee concluded that other treatment options such as face-to-face therapy may be more appropriate for some adults with anxiety disorders.

3.9 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 are taking steps to improve the accessibility and inclusivity of the technologies, including having a low reading age for the content, audio playback and consideration of diversity and inclusivity in their design. OxCADAT has translated its programme iCT‑SAD into other languages and other companies are also exploring this for theirs. One company said that its programme has also been used with in-person translators.

Clinical-effectiveness overview

3.10 There was relevant published evidence, showing a potential benefit for adults with anxiety disorders, for 6 of the 11 digitally enabled therapies:

There was no relevant published evidence for:

3.11 The evidence consisted of 19 published studies, specifically 4 randomised controlled trials, 1 comparative observational cohort study, 12 single-arm studies with no direct comparator, and 2 secondary analyses of randomised controlled trials. The external assessment group (EAG) reported that the digitally enabled therapies were found to reduce anxiety symptoms in the anxiety disorders they were designed to treat. The limited comparative evidence showed larger reductions in anxiety symptoms with digitally enabled therapies than waitlist controls or usual care. The EAG noted that waitlist controls were not in scope as a standard care comparator. This should be considered when interpreting these outcomes. Spring had outcomes comparable to standard care interventions for PTSD, as did iCT-SAD for social anxiety disorder. The EAG advised that it was not appropriate to generalise evidence from specific technologies to other digitally enabled therapies or conditions. The committee also considered unpublished and real-world evidence from the technologies' use in NHS Talking Therapies services. It concluded that the evidence base was limited for all of them, but the available evidence suggested potential benefits that could address the unmet needs. See the assessment report for further details.

Costs and resource use

3.12 The simple decision tree model showed that digitally enabled therapies could be a cost effective option for adults with anxiety disorders when compared with standard care in NHS Talking Therapies. Specifically:

There was not enough evidence on the efficacy of Cerina, Iona Mind, Resony and Wysa to model their cost effectiveness.

3.13 The EAG noted that a main driver of the model was the clinical effectiveness of the technologies. The limitations and uncertainties in the clinical evidence therefore created limitations and uncertainties in the economic model. Other limitations of the model increased the uncertainty of the results (see sections 9.3 to 9.5 of the assessment report). The committee considered that, despite these limitations, digitally enabled therapies were likely to cost less than standard care because they needed less therapist time than other NHS Talking Therapies interventions. But if they are less effective, they may be more costly in the long term. Further evidence on clinical effectiveness and resource use is needed to reduce uncertainty in the cost modelling.

Evidence gap overview

3.14 For technologies with published evidence, important evidence gaps relate to the population, comparators and main outcomes. The committee concluded that there was enough evidence of a potential benefit of these technologies for them to be used in the NHS while further evidence is generated to address these gaps. Important evidence gaps for these technologies are: