A randomised controlled trial on the effectiveness of Sir John Kirwan's "the Journal" in secondary care treatment of patients with depression/dysthymia

Depression is common and disabling but the evidence is that fewer than half of people with depression seek any treatment and few receive any help from specialised mental health professionals. In secondary care treatment is often limited to drug therapies because of long waiting lists to see psychological therapists face to face despite recommendations by NICE and others about the importance of non-drug therapies. One way to address this problem is to use computerised e-therapies which deliver structured cognitive behavioural treatment via a computer. The appeal of e–therapies is that they solve several problems. Firstly, they are convenient for users. They can be used at any time and can be accessed in different locations. Secondly, there is no waiting for appointments. Lastly, for health providers e-therapies address the workforce issue of a lack of trained providers of effective interventions. If e-therapies can be shown to be acceptable, feasible and effective there is no reason why these computerised therapies could not replace humans leaving qualified professionals to focus on more complex management problems. This may lead to the development of new roles. This has been explicitly recognised by Health Workforce New Zealand who stated that mental health services in New Zealand are in a “poor state of repair”, that they need to focus on better use of information technology and health providers need to change professional roles. The new role to be tested in this proposal is an e-case manager. The attraction of e-therapies has led to a boom in applications directed at the health market. However, there is a lack of evidence for the effectiveness of many e-therapies. Previous randomised controlled trials of e-therapies for depression have mainly been in people recruited through the internet or in clinical populations with mild or “sub-clinical” disorders. The difficulty with these populations is that there is a high rate of spontaneous remission so showing that the e-therapy is no different to usual care has little meaning. A further problem is that many people fail to complete the course of e-therapy (although this also applies to face to face therapies). There is a need for randomised controlled trials of e-therapies in clinical populations using novel techniques to maximise the dose of e-therapy without losing the potential health workforce benefits. A potentially attractive solution is to enable clinician-assisted computerised cognitive behaviour therapy. In this model the clinician acts in the role of a coach to support the patient progress through the computerised treatment - the clinician does not need to deliver the non-drug therapy themselves. There is some evidence that this can result in significant improvements in depression with reduced demands on clinician time. However the problems with these trials are that they are small and have been done using participants with relatively less severe depression who may not have seen clinicians as part of their usual care. To date there have been no trials of clinician assisted e-therapy in secondary care. “The Journal”,a free internet based programme for the self-management of depression was developed in New Zealand and capitalises on the social marketing appeal of John Kirwan, an ex All Black who has described his experiences of depression to help destigmatise mental illness. The self-help programme is based on the cognitive behavioural techniques of behavioural activation and problem solving. Usage data shows that the depression.org web site was visited by 700,000 people in its first year with 20,000 registered with The Journal and 13,000 active users. About 1500 people a month register to start the programme with about three quarters of people recording significant improvement. There is no data on who uses the programme but peaks in registration coincide with TV adverts promoting the www.depression.org.nz site. Although the programme was designed for depression of mild to moderate severity, the evidence shows that nearly a third of people who access the programme have more severe depression. However, only one in twenty people who start the programme complete all six lessons and one in ten report no change or a worsening of symptoms. The current data does not show who these people are, how to improve the rate of completion or whether the improvement would have happened without The Journal. A further argument for a trial of The Journal is that despite considerable investment in this programme by the New Zealand tax payer it has not been subjected to any clinical trials and its effectiveness is unproven. This proposal is for a randomised controlled trial of The Journal in people referred to secondary mental health services with depression using a clinician assisted model in the form of an e-case manager. We hypothesise that patients who are coached by the e-case manager to progress through The Journal will improve quicker, require fewer face to face appointments with clinicians and be more satisfied with their care than people who receive usual care. We also hypothesise that use of the e-case manager will be more cost effective than usual care. The e-case manager will provide support for participants for their journey through The Journal either in weekly face to face or telephone sessions over a total period of 12 weeks. These sessions should last no longer than one hour. The e-case manager will also provide information/feedback to clinicians involved in participant's usual care.