Implementation of a computer-assisted cognitive-behavioral therapy program for adults with depression and anxiety in an outpatient specialty mental health clinic.

Abstract

Computer-assisted psychotherapy programs have demonstrated efficacy and potential for improving access to mental health services. However, little is known about their implementation, uptake and acceptability in real-world settings. As a quality improvement effort, we designed and implemented a computer-assisted cognitive-behavioral therapy (cCBT) program for adults in an outpatient specialty mental health clinic. We sought to increase access to psychotherapy services while maintaining good patient uptake and acceptability. The program included two pathways: (I) a cCBT-only pathway in which new clinic patients had access to online modules and up to ten 30-min telehealth appointments with a mental health clinician; and (II) an augmented-psychotherapy pathway in which clinicians recommended and incorporated online modules to patients already established in the clinic. The online content for the program was a vendor website that included 9 modules with written content, videos and interactive exercises to teach cognitive-behavioral skills. Twenty-seven patients started the program over 12 months (18 in the cCBT-only pathway and 9 in the augmented-psychotherapy pathway). Twelve patients (44.4%) completed all 9 modules of the program and 18 (66.7%) completed at least half the program. Engagement was higher in the cCBT-only pathway than in the augmented-psychotherapy pathway. Twelve of 18 cCBT-only patients responded to an acceptability survey with 83.3% indicating they were satisfied and 41.7% indicating the program met their needs. Clinician satisfaction was good among all three participating clinicians. The cCBT-only program provided timely access to psychotherapy services for new patients but uptake was very low with just 2.4% of new patients contacting the clinic for psychotherapy starting in the cCBT-only pathway. Many new callers elected to receive external referrals for more traditional forms of psychotherapy. Based on this low uptake, computer-assisted psychotherapies may fit best in settings where patients have not yet identified the specific type of care they wish to seek. Systems looking to adopt similar programs may also benefit from allowing ample time to develop industry partnerships, carefully considering the customizability and technical support available for online products, and introducing the programs to patients early in treatment.