DrugInfo seminar: Stepping out of the SHADE. The use of ehealth approaches in the management of co-morbid depression and alcohol/other drug use programs

Stepping out of the SHADE

The use of e-health approaches to the treatment of comorbid depression and alcohol/other drug

misuse

Frances Kay-Lambkin, Amanda Baker, Brian Kelly, Terry Lewin, Vaughan Carr

The SHADE Project

National Drug & Alcohol Research CentreUniversity of New South Wales, Australia

Centre for Brain and Mental Health Research

Self Help for Alcohol/other drug use & DEpression

Depression and substance use comorbidity...

•Comorbidity is important because…▫Increases burden of illness and disability▫Negative mood cited most often as cause of relapse

across a range of substances mild depression elevates the risk of relapse to drinking

three-fold in comparison to people without depressive symptomatology

▫Consistent association between suicidality, depression and alcohol use problems

▫No clear treatment model▫Difficulties accessing treatment

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Treating depression and substance use comorbidity

•Reducing the burden of disease involves developing and disseminating efficacious treatments▫Australia: 62% of people with mental illness do not

seek any professional help. Stigma, economic, geographic disadvantage

▫Even more the case with comorbid depression and problematic alcohol/other drug use

•Research sparse

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Health System Challenges...

• “Increased health care service demands, costs and complexities are already testing the limits of the financial, physical and human resources of the Australian Health System...These challenges will not be solved by doing more of the same, particularly given the limits of available human and financial resources...”

AIHW (2008)AHMAC (2008)

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The potential of e-health to respond to these challenges...•E-health = rapidly expanding field of health

information and communication technology•Widespread recognition within health sector that

better use of e-health initiatives should play a critical role in improving the Australian healthcare system

• Increasing acceptance for individuals to take a more active role in protecting their health and participating in their own health care

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The potential of e-health approaches

•Treatment can be accessible at times and in locations that suit clients

•May reduce stigma associated with treatment•Clients can work at their own pace, tailoring the

provision of information and strategies•May be able to circumvent some of the challenges of

treatment access▫Particularly for comorbidity

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The potential of e-health approaches

• In Australia...▫72% of households in 2009 reported home access to

the internet• In Canada...

▫Current drinkers significantly more likely than abstainers to have at home internet access (73% vs 50%)

▫Illicit drug users (cannabis and cocaine) report equivalent rates of home internet access to non-users

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RCTs of E-health interventions for…

•Depression•Panic disorder•Chronic tension/migraine•Trauma• Insomnia•Obesity•Complicated grief•Eating Disorders•Alcohol Problems

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The SHADE ProjectComputerized, clinician assisted, combination CBT/MI for depression

and alcohol/other drug use problems

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The SHADE Project•Developed in the Hunter (NSW)•Project run in collaboration with Centre for Rural

and Remote Mental Health (rural and urban)•Target depression (and co-occurring alcohol use,

cannabis use problems)▫Use CBT

•Compare face-to-face treatment with computer treatment (SHADE) with supportive treatment (PCT)

•Follow-up people up for 3 years

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Depression

-70.0

-60.0

-50.0

-40.0

-30.0

-20.0

-10.0

0.0

10.0

20.0

Baseline Baseline - 3 months Baseline - 6 months Baseline - 12 months Baseline - 24 months Baseline - 36 months

Perc

enta

ge re

ducti

on in

dep

ress

ive

sym

ptom

s rel

ative

to b

asel

ine

Therapist-delivered CBT/MI

Clinician-assisted SHADE

PCT (control)

No change

50% reduction

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Alcohol use

-100

-80

-60

-40

-20

0

20

40

Baseline Baseline - 3 months Baseline - 6 months Baseline - 12 months Baseline - 24 months Baseline - 36 months

Perc

enta

ge re

ducti

on in

alco

hol c

onsu

mpti

on re

lative

to ba

selin

e

Therapist-delivered CBT/MIClinician-assisted SHADEPCT (control)

No change

50% reduction

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Binge Drinking

-40.0

-35.0

-30.0

-25.0

-20.0

-15.0

-10.0

-5.0

0.0

5.0

10.0

Baseline Baseline - 6 months Baseline - 12 months Baseline - 24 months Baseline - 36 months

Perc

enta

ge re

ducti

on in

bing

e drin

king

freq

uenc

y

Therapist-delivered CBT/MI

Clinician-assisted SHADE

PCT (control)

No change

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Cannabis use

-100

-80

-60

-40

-20

0

20

40

60

Baseline Baseline - 3 months Baseline - 6 months Baseline - 12 months Baseline - 24 months Baseline - 36 months

Perc

enta

ge re

ducti

on in

mar

ijuan

a con

sum

ption

rela

tive

to b

asel

ine

Therapist-delivered CBT/MI

Clinician-assisted SHADE

PCT (control)

No change

50% reduction

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SHADE...• Andersson & Carlbring (2009)

▫ “[SHADE] has the potential to fit in well with existing health-care services...”• Key challenges in the uptake of e-health in clinical practice:

▫ Access to technology▫ Reluctance of healthcare providers to adopt technology or change their practice

without compelling reasons to do so Research trials attest to efficacy Lack of evidence from service-based dissemination trials

▫ Lack of understanding about the potential for e-health systems to augment health care DoHA-funded consultation Most common response by community was confusion (“online AA?”, “like MMN or

something?”, “what, talking to someone online...?”)

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So, what’s the upshot for e-health?•? Enhanced adherence to best (or evidence-based)

practice•? Empowering clients to better manage their own

health•Can be applied to the complexities of comorbid

depression and alcohol/other drug use▫? Reduced time and cost addressing comorbidity

•Use of e-health initiatives may be a question of costs, client preference and provider preference

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AcknowledgementsChief Investigators• Frances Kay-Lambkin• Amanda Baker• Brian Kelly• Terry Lewin• Vaughan CarrStatistician• Terry LewinFunding• AERF

Institutions

Address for correspondence: [email protected]

Centre for Brain & Mental Health

Research

Therapists• Ali Beck• Katrina Bell• Richa Gupta• Juanita Todd• Leigh Underwood• Anna Britton• Victoria Clack• Jenny Geddes• Alyna Turner• Melanie Haile• Sue Startup• Holly Devir• Frances Kay-Lambkin

Follow-up Interviewers• Madeleine DeVille• Lisa Phillips• Veronica Clipsham