Apps, Feature Content, ICS

Feature: the role of online cognitive behavioural therapy within an integrated care system

Featuring content from Amwell.

For our Digital ICS feature series, we heard from Amwell on the role of online cognitive behavioural therapy (iCBT) within an integrated care system, with focus on the use of their SilverCloud platform at Warwickshire East Primary Care Network and Berkshire Healthcare NHS Foundation Trust.

The use of iCBT has been shown to be effective in treating a range of mental health problems. A 2014 review of multiple studies found that online CBT was effective in treating depression, anxiety, and PTSD. Another study found that online CBT was just as effective as in-person CBT for the treatment of anxiety.

Mobile apps have also emerged as a popular digital treatment for mental health problems, with features such as mood tracking, meditation and cognitive-behavioural exercises.

To explore the topic further, we attended a webinar from Amwell on their SilverCloud platform, which focused on the benefits of implementing digital health pathways as part of an ICS. The webinar featured Dr Faris Al-Ramadani, clinical director at Warwickshire East Primary Care Network and a GP partner; Judith Chapman, clinical services consultant and former clinical director at Berkshire Healthcare NHS Foundation Trust; and Douglas Hiscock, senior SilverCloud product lead at Amwell.

Doug described how the SilverCloud platform can help with relieving some of these pressures: “One of the hardest parts of running a service is knowing the right care that needs to be delivered at the right time for people who have been referred in. You might have a very low-level issue that you need support with, but you can wait a considerable amount of time. Our programme allows people to work outside of the traditional boundaries of having to attend sessions every week at a certain time. The patient goes on the programme, works through it at their own pace, and then the clinician will support them when and if they need that support. This allows the service to create more capacity to see more complex patients, and they can then triage people into the right care at the right time as quickly as possible.”

He described how the platform offers a number of features designed to help patients with their mental health journey, such as a mood monitor and a worry tree. The mood monitor aims to help patients make connections between their thoughts, feelings and behaviours, to structure their thinking and support them in finding new ways of handling emotions. The worry tree, meanwhile, supports patients in distinguishing between a real concern and a hypothetical concern, which also helps therapists in identifying where a person might need direct and immediate help.

Judith shared how Berkshire Healthcare NHS Foundation Trust started working with the SilverCloud platform. To begin, she said, the trust “looked at the steps that we needed to put in place to become successful and introduce it to the right patients. We did this on the understanding that perhaps people with more severe needs might want a face-to-face intervention, but actually, if we could help everybody on a mild to moderate level, then our clinicians’ time would be freed up to help people with more severe needs.”

The trust introduced the platform to 50 percent of their patient base, and positive feedback from patients encouraged them to continue. “I was overwhelmed by how positive the response was,” Judith noted.

She also observed that the platform was “very useful for reaching younger people and particular cohorts such as men and the unemployed. The concept of having a therapist in their pocket seemed to really appeal. One of our patients said it’s like a paracetamol – everyone should have it so you can dip into it when you need it.”

With certain conditions, such as depression, Judith acknowledged that there are periods of relapse and remission. “People need help when they need it. That’s what the digital platform can do.”

Faris agreed: “At the point of need for treatment, motivation varies. You need to connect with people when the iron is hot, so to speak.”

He noted that his practice had become aware of barriers to their existing treatments before implementing SilverCloud. “Some of those barriers are demographic – for example, we found that younger people are less likely to access NHS Talking Therapies, and geography can be an issue if people are located further away from NHS Talking Therapies.

“We wanted to find something that would help our patients access treatment sooner, in a way that was more suitable to them. It’s about increasing their options to find the thing that works best for them.”

Faris also commented on the “period of increased digital awareness” that came out of the COVID-19 pandemic. “It seemed like the perfect opportunity to try and deliver a digital solution and this seemed like a natural fit. It was about providing that extra option to our patients, essentially in the hopes that if we can intervene sooner then we can prevent progression to a more serious and high acuity illness.”

On how the trust adapted to the digital solution, Judith said: “It’s about culture and it’s also about leadership – having a vision and looking at how you can bring the staff along with you, and how you can maintain the vision. It does take a lot of time and persistence; it’s not an easy path, but it’s a very rewarding one.

“Looking to the future, I think it’s exciting that there is ongoing development of the SilverCloud platform for people with more complex mental health needs on the SilverCloud platform,” she said. “This will enable clinicians to be confident that they can support anyone with this solution, at whatever level they present at.”

Faris added: “I would say that it’s always about the focus on the patient, keeping them in the line of sight. Digital solutions can help to solve many of the challenges that we face, whether that’s recruitment or access. We also want to raise the bar and look at how we can improve what we are doing, to make sure that we’re not just plugging gaps. We don’t just want to solve deficiencies; we want to move up to the next level.

“There’s a shift within the NHS now towards personalised care, and I think that enabling our patients to have greater access to different treatments is definitely a way to go forwards in the future. In order to promote self-help, we need to empower people to access tools much sooner and make them more readily available.”

Another key challenge in this area is the need to ensure that digital treatments are effective and safe.

As of 1 March 2023, the National Institute of Health and Care Excellence (NICE) has conditionally recommended a number of digital enabled therapies which address depression and anxiety disorders. Each of the therapies has been developed using CBT methods, and NICE confirms that each has demonstrated potential to provide effective treatment.

SilverCloud is among the conditional recommendations; NICE suggest its use for helping adults with anxiety disorders and as a treatment option for depression, along with conditionally recommending its use for helping children and young people with mild to moderate symptoms of anxiety or low mood through its programmes ‘space from anxiety for teens’, ‘space from low mood for teens’ and ‘anxiety for teens’.

To find out more about the SilverCloud platform, please click here.