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Computer-aided cbt self-help for anxiety and depressive disorders: experience of a london clinic and future directions

Computer-Aided CBT Self-Help for Anxiety andDepressive Disorders: Experience of aLondon Clinic and Future Directions Lina Gega, Isaac Marks, and David Mataix-ColsLondon University This article describes a broad-spectrum, computer-aided self-help clinicthat raised the throughput of anxious/depressed patients per clinician andlowered per-patient time with a clinician without impairing effectiveness.
Many sufferers improved by using one of four computer-aided systems ofcognitive behavior therapy (CBT) self-help for phobia/panic, depression,obsessive-compulsive disorder, and general anxiety. The systems are acces-sible at home, two by phone and two by the Web. Initial brief screening bya clinician can be done by phone, and if patients get stuck they can obtainbrief live advice from a therapist on a phone helpline. Such clinician-extender systems offer hope for enhancing the convenience and confi-dentiality of guided self-help, reducing the per-patient cost of CBT, andlessening stigma. The case examples illustrate the clinical process andoutcomes of the computer-aided system. 2003 Wiley Periodicals, Inc.
J Clin Psychol/In Session 60: 147–157, 2004.
Keywords: computer-aided treatment; self-help; cognitive behavior therapy;phobia; panic; obsessive-compulsive disorder; depression; generalizedanxiety; Internet-accessed therapy; interactive voice response This article describes the first-ever clinic to use four computer-aided cognitive behaviortherapy (CCBT) systems to guide interactive self-help for sufferers from anxiety anddepressive disorders. The clinic ran a free service in London for 15 months, in the lastfew months of which clients were to use all four, not just two, of the systems at homesupplemented by brief live support on a phone helpline as needed. This article gives threedetailed case illustrations to give practitioners a taste of CCBT. It also summarizes the Correspondence concerning this article should be addressed to: Isaac Marks, 43 Dulwich Common, LondonSE217EU, United Kingdom; e-mail:
JCLP/In Session, Vol. 60(2), 147–157 (2004) Published online in Wiley InterScience ( DOI: 10.1002/jclp.10241 148
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outcome of a cohort reported in detail elsewhere (Marks, Mataix-Cols, & Gega, 2003)and draws lessons for the future.
1. The demand for cognitive behavior therapy (CBT) for anxiety and depressive disorders exceeds the supply of suitably trained therapists, so waiting lists areoften long.
2. Many sufferers prefer to avoid the stigma commonly incurred by seeing a therapist.
3. Many people prefer to confide sensitive information to a computer rather than Why Have Computer-Aided Self-Help at Home? 1. It is more convenient to do CCBT at home rather than to travel somewhere to have it. This difficulty is compounded in sufferers who become housebound dueto agoraphobia, social anxiety, obsessions, or compulsions.
2. Doing CCBT at home guided by a system on a distant computer which is accessed by Internet or by phone eases the incorporation of new advances onto that systemso that sufferers can benefit from them before they are widely known. Even in themental health field, a surprising number of professionals do not know that anxietyand depressive disorders have long been treated successfully by appropriate CBT,and that with only brief input from a professional, self-help has been effective.
3. Doing CCBT at home guided by a system on a distant central computer reached by Internet or phone eases audit by that system of the outcome of masses ofpatients doing CBT.
None of these reasons would suffice if CCBT yielded inferior results to traditional CBT either face-to-face or by phone. However, evidence is accumulating that CCBTworks well (National Institute of Clinical Excellence of England, 2002).
The clinic defined CCBT systems as those which help the patient rather than the therapistmake most of the decisions about how to devise, execute, and complete CBT, includingappropriate homework and relapse prevention. The clinic chose to use FearFighter forphobia/panic (Kenwright, Liness, & Marks, 2001; Marks, Kenwright, McDonough, Whit-taker, & Mataix-Cols, in press), Cope for nonsuicidal depression (Osgood-Hynes et al.,1998), and BTSteps for obsessive-compulsive disorder (Greist et al., 2002). These CCBTsystems all (a) allowed a therapist to delegate to them most of the tasks required to guidea patient through CBT self-help for anxiety or depressive disorders with a savings of atleast two thirds of the therapist’s time per patient, (b) could give patients access at homeeither immediately (by phoning Cope and BTSteps) or eventually (via FearFighter on theWeb), and (c) were already of proven value in past research trials.
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The clinic added a fourth CCBT system called Balance (Yates, 1996) for generalized anxiety/mild depression. This is a shorter, less interactive system and takes over fewerCBT tasks than the other three systems. In CD-ROM form, patients also could use Bal-ance at home; a modified Internet version is now available as well.
Though CCBT is sometimes wrongly described as Internet therapy and FearFighter can be accessed via the Internet, none of the clinic’s systems constituted Internet therapy.
“Internet therapy” best denotes treatment where the patient and therapist communicate byInternet (thus easing patient–therapist communication when it is convenient for one partyto send a message and the other to answer it after a delay). In this regard, it resembles aphone voice-mail system. Internet therapy has its therapeutic decisions made not by acomputer but by a live therapist in real time just as in face-to-face or phone therapy.
Internet therapy thus does not save much of the therapist’s time.
In contrast to Internet therapy, the FearFighter, Cope, and BTSteps computer sys- tems help the patient make most CBT self-help decisions and thus save a great deal oftherapists’ time. The therapist’s role in the clinic was restricted to briefly screening thepatient and offering live advice (latterly solely by phone) if the patient got stuck duringCCBT.
The clinic’s patients accessed the Cope and BTSteps CCBT systems by phoning a computer on an interactive voice response (IVR) system. This was not phone therapy inthe usual sense of that term. Patients phoning the Cope and BTSteps IVR systems read amanual before phoning the computer to do CCBT, and the computer helped them makemost therapy decisions during the calls, thus saving therapist time.
Design and Operation of the CCBT Clinic The clinic’s broad-spectrum design was intended to give anxiety and depression sufferersaccess to one of four CCBT self-help systems. It publicized its service in local generalpractitioner offices, community mental health centers, psychiatric outpatient clinics, localnewspapers, Yellow Pages, patient organizations, and elsewhere. The clinic acceptedself-referrals who completed a screening questionnaire they had obtained from one of theaforementioned facilities or by phoning the clinic.
Inclusion criteria were presence of an anxiety or depressive disorder, motivation to do self-help, and no substance abuse, psychosis, or active suicidal plans. From the screen-ing questionnaire, the staff judged referrals’ likely suitability for CCBT and offered thema 30-min screening interview by phone, or face-to-face at the clinic in the case of earlierreferrals. Broad diagnoses were made using a checklist summarizing relevant ICD-10diagnostic criteria. Diagnoses were: 71 depression, 60 phobia/panic disorder, 35 gener-alized anxiety disorder, 35 obsessive-compulsive disorder (OCD), 26 stress/adjustmentdisorder, 7 mixed anxiety/depression, and 6 somatoform disorder. The clinic’s staff weremainly two nurse practitioners totaling only one full-time-equivalent clinician; in addi-tion, a research psychologist took on a mainly research rather than a clinical role.
Staff gave patients who proved suitable at the screening interview an identification num-ber allowing access to the clinic’s four CCBT self-help systems that most suited them:FearFighter for phobia/panic, Cope for nonsuicidal depression, BT-Steps for (OCD), orBalance for general anxiety/mild depression. Patients knew that information given to the 150
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CCBT system was confidential to staff and could not be accessed without knowing thepatient’s identification number and password (Many said they told the computer sensitivethings they would not confide to a human.) None of the systems stored personal names oraddresses.
Patients were told they could use their system as much as they wished. They were advised to use FearFighter, Cope, or BT-Steps at least six times over 12 weeks. Duringoffice hours, they also had six brief scheduled therapist contacts by phone or face-to-facefor advice. Users of Balance (which is more basic than the other three systems) wereasked to use it at least three times over four weeks and to have three brief therapistcontacts by phone or face-to-face over the four weeks.
Patients accessed FearFighter on a PC mostly at the clinic, and occasionally at a freeInternet café or medical center. When FearFighter became available on the Web, somecould access it around the clock on a computer at home or elsewhere linked to the Internet.
The clinic gave Cope and BT-Steps users self-help booklets to guide their free phone calls made mostly from home to either Cope’s or BT-Steps’s IVR system in a computer inMadison, WI, U.S.A. Users could phone the computer from home at any time for as longand as often as they desired, and drove their interviews by key presses on their telephonekeypad. The computer faxed to the clinic weekly reports of patients’ phone calls, theirduration, and the modules accessed, and for Cope patients, suicide risk. Had risk becomehigh, which never happened, this would have been immediately faxed or phoned to theclinic.
Balance users accessed the system by a PC with a CD-ROM drive at the clinic, their home, a free Internet café, or a physician’s office.
Case Illustration 1: Cope for Depression Presenting Problem /Client Description Jo was a 40-year-old woman, unemployed, divorced, and living on her own. Prompted bya poster she saw at her general practitioner’s office, she contacted the self-help clinic. Shecompleted and sent in a screening questionnaire and was offered a screening interviewthe same week. She chose to have it face-to-face rather than by phone as she preferred todisclose personal information to a professional whom she could see and judge as trust-worthy. At her 30-min screening interview, she described racing thoughts, sleeplessness,agitation and inability to relax, fear of death, tearfulness, suicidal ideas, tiredness, andheartburn. She drank over 50 units of alcohol a week, smoked 35 cigarettes a day, andused cocaine about once a month. She also took prescribed and black-market sedatives.
Jo had an unsupportive partner and financial problems.
She had been physically and sexually abused repeatedly during childhood and mar- riage, and had attempted suicide many years before. She also had been depressed sinceage 16 years. Her physicians prescribed diazepam until she was 25, and she becameaddicted to sedatives. Jo felt dismissed by and a nuisance to her physicians, saying thatmedication was their easy option and they were unaware of psychological treatments fordepression. She was angry that she could not afford private treatment and was on a longwaiting list. She worried that she could not choose whether her therapist was a man or awoman, a qualified therapist or a trainee, and the type of treatment she would receive.
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Jo was diagnosed with severe generalized anxiety disorder and recurrent moderate depres-sion suitable for CBT with Cope.
The clinic offered Jo phone access to Cope’s phone-IVR self-help system for depressionand a set of Cope explanatory booklets with sections to read before making each Copecall. She completed Cope over 12 weeks, during which time she worked on all of itsmain self-help modules: constructive thinking, behavioral activation, and assertivenesstraining. She spent a total of 2.5 hr making 16 Cope phone calls. She also received twohours (seven phone contacts) of live therapist support, divided equally between prog-ress reviews (asking her to complete pen-and-paper ratings and monitoring her state),general support (including discussing relationship difficulties and referring her to a rela-tionship counselor), and treatment advice (weekly monitoring of her alcohol and sedativeconsumption, and listing pros and cons of using these as a way of coping).
By a three-month follow-up, Jo had improved considerably. Her pre, post, and follow-upratings were 60% improvement in depression [Beck Depression Inventory; Beck, Ward,Mendelson, Mock, & Erbaugh, 1961 (30, 15, and 10, respectively)]; 37% reduction inanxiety [Beck Anxiety Inventory; Beck, Epstein, Brown, & Steer, 1988 (46, 29, and 27,respectively)]; and 30% improvement in work and social adjustment [Mundt, Marks,Greist, & Shear, 2002 (22, 12, and 15, respectively; score range ϭ 0– 40)]. She felt muchbetter, less anxious and depressed, and no longer desperate. She drank 30% less alcoholand smoked 50% less, but relationship and financial problems still distressed her. She didnot take antidepressant medications due to side effects, and during her three-monthfollow-up tried two outside counseling sessions, which she stopped as she found themunhelpful. Jo said that the clinic had helped her when she was desperate, and that Copegave her focus and a goal to work towards. She also valued her brief regular phonesupport with a clinician. She thought many people could benefit from the Cope systembut probably did not know about it. She therefore became involved in patient advocacyand local campaigns to raise awareness of treatment for depression, including Cope. Sheappeared empowered to deal better with the future relapses that seemed likely.
Case Illustration 2: FearFighter for Agoraphobia/Panic Disorder Presenting Problem /Client Description A physician advised Dee, a single woman of 28 years, to contact the clinic. Dee had notworked for three years due to panic attacks when out alone or anticipating doing so. Theattacks had begun five years earlier, seven months after nearly drowning on vacationabroad. Since then, she had not traveled abroad. She reported severe general anxietyevery morning and agitated depression. An anxiety management course and fluoxetinehad not improved her condition for long. She also had begun dothiepin (75 mg/day) twoweeks before screening. Dee completed and returned a screening questionnaire. Duringher 30-min screening interview face to face, she said she felt tense and agitated in themorning and tired and sluggish in the evening. She had been tearful for most days during 152
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the past few weeks and worried whether she would be able to get a job or enjoy socialoutings and vacations in the future. Dee avoided using public transport and going toshops, pubs, and restaurants unaccompanied as well as going to unfamiliar places farfrom home. She feared that if unaccompanied she would panic with nobody available tohelp her, and if far from home, she would be unable to get back to a safe place quickly.
Dee was diagnosed with agoraphobia with panic disorder suitable for self-exposure guidedby FearFighter.
The clinic gave Dee immediate access to the FearFighter self-help system for phobia/panic. She spent five hours at the clinic on the system over five sessions, plus 55 min oflive therapist support. She completed FearFighter’s nine steps, including education aboutthe nature of fear and the principles of exposure, advice on how to get a friend or relativeto be a cotherapist, guidance on how to set specific and measurable goals and then carryout effective exposure, suggestions on anxiety management and how to troubleshootcommon difficulties, and reward for ongoing exposure and monitoring anxiety. Therapistsupport was divided between progress review (homework achieved, monitoring moodand anxiety) and treatment advice (fine tuning exposure tasks to maximize gains). Thetherapist taught Dee diaphragmatic breathing to control her anxiety symptoms enough tomake her initial exposure tasks tolerable. As she moved up her anxiety hierarchy, thetherapist encouraged her to do focused exposure without such anxiety control by revis-iting the habituation rationale.
By a one month follow-up, Dee felt much improved, used public transport, had a full-time job, and had been to a crowded concert and abroad where her problem had begun.
She no longer had general anxiety and was not depressed. Her pre, post, and follow-upratings were Fear Questionnaire (FQ) agoraphobia: 75% improvement (33, 8, and 9,respectively); FQ blood-injury: 83% improvement (12, 2, and 3, respectively); FQ socialphobia: 67% improvement (18, 6, and 8, respectively); FQ global phobia: 50% improve-ment (2, 1, and 1, respectively); FQ anxiety/depression: 80% improvement (35, 7, and 8,respectively); and work & social adjustment: 88% improvement (25, 3, and 4, respectively).
Before trying FearFighter, Dee had said that she would prefer a therapist over computer-guided treatment, but at posttreatment evaluation she said she would choose75% computer-guided and 25% therapist-guided treatment. She rated the clinic as 0 (“verygood” on a scale in which 8 was “very poor”) and thought that a similar approach couldhelp people overcome problems similar to hers. Prognosis appeared good.
Case Illustration 3: BTSteps for OCD Presenting Problem /Client Description Jim, a 51-year-old married man, contacted the clinic after seeing a poster in a physician’soffice. He had been severely disabled by OCD and social phobia for over 15 years, and Computer-Aided CBT Self-Help
had lived on disability benefits since then. An intense fear of contamination led Jim toavoid touching most objects at home unless he completed a self-cleaning routine of handwashing. He spent more than three hours a day on these rituals. Most of all, he dreadedand avoided touching the telephone; he feared contamination would spread to anythinghe touched afterwards and to other parts of his body. He strongly avoided public toilets;if he ever had to use one, he felt compelled to change and wash his clothes upon arrivinghome. He always carried a bottle of cleaning fluid on him to wash his hands. The OCDimpaired his daily life and family relationships markedly and depressed him. Jim felt a“prisoner” to his OCD and had seriously considered suicide in the past. Both an elderbrother (reported to have had schizophrenia) and a younger brother (who abused drugs)had committed suicide, which had greatly upset him.
At the time of his screening interview. Jim was on clomipramine (40 mg/day) and diazepam (15 mg/day). Past unsuccessful treatments had included “talking therapy” withpsychologists, psychiatrists, and counselors and a one-week inpatient admission. He hadnever had a trial of exposure therapy.
He was diagnosed as having OCD suitable for self-exposure, with self-imposed ritualprevention to be guided by BTSteps. Despite his avoidance of touching the telephone, henevertheless agreed to use it to access BTSteps.
At the end of the 65-min screening interview, the clinician explained the rationale ofexposure and ritual prevention. Jim decided to confront his fear of using the phone byusing BTStep’s phone self-help system. The clinician gave him a BTSteps manual withseveral sections to read before making corresponding calls to the BTSteps phone-IVRself-help system. Jim could access BTSteps’s computer-guidance system from the com-fort of his home any time day or night. By pressing keys on his telephone keypad, Jimdecided which of 800 different voice files of individually tailored advice the computerwould play for him.
Jim phoned the BTSteps computer-guidance system 62 times, for a total of 513 min over 10 weeks. He also had weekly phone support contacts with the clinician, whichtotaled 153 min. Of the 10 phone support calls, eight were from the clinician to Jim andtwo from Jim to the clinician. Of the 153 min of clinician time, 60 were spent reviewingprogress, 53 on general support (e.g., How are you today? How’s your family?), and 40on treatment advice (e.g., how to prevent rituals more effectively).
The four hours the clinician spent with Jim on face-to-face screening and phone support was at least 50% less than is usual with severe and chronic OCD, although it isfour times more than the total of an hour of screening and support that is usual for usersof BTSteps (Greist et al., 2002).
After 10 weeks of treatment, Jim was using the phone regularly without washing hishands, no longer divided his house into clean and unclean objects, and used public toiletsanywhere he went. His scores on the Yale–Brown Obsessive-Compulsive Scale (Good-man et al., 1989) fell markedly to almost normal levels (Total: 20 to 4; Compulsions: 14 154
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to 3; Obsessions: 6 to 1). His mood also improved, with Beck Depression Inventoryscores falling from 27 to 17.
At the end of self-help for his OCD, Jim’s social phobia remained unchanged, but he said he felt confident he could use the principles of self-exposure therapy learned duringhis OCD treatment to tackle his social anxiety. At a two-month follow-up, his OCDremained much improved, and he had begun doing voluntary work as a deliberate methodto expose himself to social situations. Prognosis was promising.
Over 12 months of intake, the self-help clinic received 355 screening questionnaires. Ofthese 355 referrals, 8% were unsuitable on the questionnaire. The remainder (327 refer-rals) were offered a screening interview with a clinician, of whom 266 attended; of these,210 (79%) were suitable for and offered CCBT. Of the 210 suitable clients, 42 (20%)refused CCBT and 60 (29%) dropped out early or gave no posttreatment data. Unsuita-bles, refusals, dropouts, and completers did not differ on initial severity, demographicvariables, or computer literacy. Of all referrals, slightly over half were women, and athird were unemployed or students. Where information was available, over half had acurrent partner, and half had a postschool educational qualification.
The sample was chronic (mean problem duration ϭ eight years) with moderately severe problems. Where information was available, 39% had given up work or were onlong-term sick leave due to their problem, almost half were having current treatmentfrom their physician or a mental health professional, and about half were on psychotropicmedication. The vast majority had had past treatment for their problem, although only20% had had CBT; 35% used computers most days at work.
By posttreatment, improvement on work /social adjustment was significant for FearFighter, Cope, and Balance users. Completers of each self-help system also improvedsignificantly from pre- to posttreatment on measures specific to their problem. The clin-ically meaningful effect size of 0.8 or more was exceeded by FearFighter users on theFQ’s global phobia and anxiety/depression scores, by Cope users on depression and onwork /social adjustment, and by BTSteps users on the obsessive-compulsive Total andObsessions and Compulsions subscores. Balance users did not attain this clinically mean-ingful effect size on any measure. Completers improved comparably to completers inother studies that used the same CCBT systems and measures.
Patients were fairly satisfied with their CCBT system, and even more satisfied with their live support and the self-help clinic as a whole. They rated a marginal preference fortherapist over computer guidance. Satisfaction and preference (therapist vs. computer)ratings were similar among users of the four different systems.
A mean of 58 days elapsed from patients’ starting to ending CCBT. Over that period, they had a mean of 64 min of support from a clinician. About half the patients had livesupport by phone and half face-to-face at the clinic. The clinic’s patients who accessedthe computer by phone spent very similar total times calling the computer as in previousstudies—two hours on Cope calls and four hours on BTSteps calls.
CCBT plus brief access to live advice enabled therapists to treat many more patients perhour than is possible without CCBT. Used in this way, CCBT is a clinician extender, nota clinician replacer. Apart from 30 min of screening, staff gave a per-patient overall meanof about an hour of support distributed over three months. This support seems vital for Computer-Aided CBT Self-Help
most sufferers if they are to complete self-help successfully. The reduction of per-patienttime with a clinician is achieved by delegating to a computer self-help system most of theroutine tasks involved in therapy, reserving for the clinician only those tasks which arenot manageable by a computer at present.
The mean of about one hour’s live support from a clinician is well below the mean of at least eight hours per clinician usually needed by chronic anxious/depressed patients,although total treatment time per client differs from one CBT therapist to another. Duringthe clinic’s year of intake, the full-time-equivalent of one clinician dealt with 355 refer-rals and delegated most therapy tasks to CCBT. Throughput per clinician at the clinic thusfar exceeded the 50 referrals a year that CBT therapists on average screen and treat(Marks, 1985), although therapists vary greatly in this regard.
The greater throughput of patients per therapist with the help of CCBT did not appear to sacrifice effectiveness. Anxiety and depression sufferers at the clinic improved signif-icantly and clinically meaningfully, and were fairly satisfied with CCBT despite a pref-erence for face-to-face care. When nearby physicians and a secondary CBT servicerecommended the clinic to many patients, this markedly reduced patients’ consultationswith the physicians and the physicians’ referrals to secondary mental health services. Italso slightly shortened the waiting list for face-to-face CBT in secondary care.
During most of the clinic’s period of operation, clients accessed two of the four systems (Cope and BTSteps) by phone at home, but the rest attended the clinic in personto use a stand-alone PC for the other two systems. Eventually, FearFighter and a modi-fied form of Balance also became accessible at home on the Web. It then became possibleto offer most patients CCBT self-help entirely at home without having to attend the clinicin person. In this final phase, the clinic became a virtual center, with clients obtainingCBT self-help advice at home via one of the four CCBT systems that were available anytime of day or night. When users got stuck, they sought brief advice by phone from staffduring office hours. Patients only obtained access to CCBT after they had been deemedsuitable in a 30-min screening interview with CBT staff by phone. Thus, staff were ableto treat more patients than had been possible before they used CCBT.
A rough cost comparison of CCBT with purely face-to-face CBT was calculated. It assumed the same throughput of patients managed per therapist using CCBT as in theclinic, a U.S. $97-per-hour cost of a CBT therapist (Netten & Curtis, 2000) and licensecosts of CCBT as noted by a U.K. regulatory body. Assuming administrative costs likethose of the clinic and 15% overheads, the estimated per-patient cost advantage of CCBTover face-to-face CBT would rise from about 15% per patient for 350 patients a year to41% per patient for 1,350 patients per year. This advantage rises with volume savings asthe number of patients rises, and discounts any value from CCBT at home giving clientsimmediate rather than delayed access to CBT, unrestricted access, easier disclosure ofsensitive information, and removal of the need to travel to a therapist. This rough esti-mate of cost effectiveness needs to be validated.
In contrast to its lower per-patient cost, the total cost of CCBT nationally might rise if so many users who were previously untreated sought CCBT to offset savings fromlower per-patient costs. Widespread dissemination of CCBT might eventually reducedemands on primary and secondary services and lessen medication use and chronicity.
Despite its apparent cost effectiveness, the self-help clinic eventually had to close due tolack of funding—a problem common with new healthcare technologies. It may take yearsfor healthcare funders and clinicians to widely agree to fund CCBT to reap its benefits.
Although a pragmatic evaluation such as our study may reveal more about imple- mentation issues than a randomized controlled trial, it cannot tell us how much the patientsmay have improved due to the passage of time, contact with a service, CBT, CCBT, the 156
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clinician’s brief help, or the psychotropic drugs which some clients took, nor is it knownif similar gains might have accrued from offering an appropriate CBT self-help book plusaccess to a helpline. The amount of improvement should be regarded with caution becausealmost half of the clients were noncompleters (refusers plus dropouts), even though com-pleters and noncompleters were indistinguishable at the start.
CCBT is developing rapidly. Patients can now be screened and, if suitable, help them-selves entirely at home by accessing two of the four CCBT systems used by the clinic byphone and two on the Internet. Those who get stuck during self-help can receive supportfrom a clinician on a live helpline. As referrals can now be screened for CCBT andsupported by clinicians entirely by phone while doing CCBT at home, self-help clinicscan act as call centers for wide areas.
The model suggested is stepped care, with CCBT self-help as a potential first port of call for most anxiety/depression sufferers. Those who fail to improve sufficiently withCCBT could go on to have live clinician-guided help.
Some might benefit from posted self-help instructions (Burgess, Gill, & Marks, 1998) or self-help books, perhaps with access to a live helpline. Books may cost less thanCCBT, but are less interactive and harder to modify on a large scale. It also is hard totrack patients’ progress with books whereas CCBT on the Internet or a central IVR com-puter eases the assessment of outcome on a mass scale.
Major hurdles at present include the reluctance of healthcare funders to pay for CCBT and the lack of personnel trained to support it. It can take many years for newtechnology to become routine in the health services.
Beck, A.T., Epstein, N., Brown, G., & Steer, R.A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897.
Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measur- ing depression. Archives of General Psychiatry, 4, 561–571.
Burgess, M., Gill, M., & Marks, I.M. (1998). Postal self-exposure treatment of recurrent night- mares: Randomised controlled trial. British Journal of Psychiatry, 172, 257–262.
Goodman, W.K., Price, L.H., Rasmussen, S.A., Mazure, C., Fleischman, R.L., Hill, C.L., Heninger, G.R., & Charney, D.S. (1989). The Yale–Brown Obsessive Compulsive Scale: I. Develop-ment, use and reliability. Archives of General Psychiatry, 46, 1006–1011.
Greist, J.H., Marks, I.M., Baer, L., Kobak, K.A., Wenzel, K.W., Hirsch, M.J., Mantle, J.M., & Clary, C.M. (2002). Behaviour therapy for obsessive compulsive disorder guided by a computer orby a clinician compared with relaxation as a control. Journal of Clinical Psychiatry, 63, 138–145.
Kenwright, M., Liness, S., & Marks, I.M. (2001). Reducing demands on clinicians by offering computer-aided self-help for phobia/panic. Feasibility study. British Journal of Psychiatry,179, 456– 459.
Marks, I.M., Kenwright, M., McDonough, M., Whittaker, M., & Mataix-Cols, D. (in press). Saving clinicians’ time by delegating routine aspects of therapy to a computer: A randomised con-trolled trial in phobia/panic disorder. Psychological Medicine.
Marks, I.M., Mataix-Cols, D., Kenwright, K., Cameron, R., Hirsch, S., & Gega, L. (2003). Prag- matic evaluation of computer-aided self help for anxiety and depression. British Journal ofPsychiatry, 183, 57– 65.
Marks, I.M., & Mathews, A.M. (1979). Brief standard self-rating for phobic patients. Behaviour Research and Therapy, 17, 263–267.
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Mundt, J.C., Marks, I.M., Greist, J.H., & Shear, K. (2002). Work and Social Adjustment Scale: A simple accurate measure of impairment in functioning. British Journal of Psychiatry, 180,461– 464.
Netten, A., & Curtis, L. (2000). Unit cost of health and social care 2000. Personal Social Services Research Unit, University of Kent, UK. Retrieved September 2002, from /PSSRU/ NICE (National Institute of Clinical Excellence of England). (2002). Appraisal consultation doc- ument & final appraisal determination on computer-aided CBT. Retrieved September 2002,from Osgood-Hynes, D.J., Greist, J.H., Marks, I.M., Baer, L., Heneman, S.W., Wenzel, K.W., Manzo, P.A., Parkin, J.R., Spierings, C.J., Dottl, S.L., & Vitse, H.M. (1998). Self-administered psy-chotherapy for depression using a telephone-accessed computer system plus booklets: Anopen U.S.–U.K. study. Journal of Clinical Psychiatry, 58, 358–365.
Yates, F. (1996). Evaluation of the Balance computer intervention. Unpublished report to the Men-


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