Embargoed: Eight digitally enabled therapies to treat depression and anxiety in adults conditionally recommended by NICE

Eight digital enabled therapies to treat depression and anxiety disorders in adults have been conditionally recommended by NICE in draft guidance issued today (Wednesday 1 March 2023).

A consultation has begun on the decision to conditionally recommend the digital enabled therapies which address depression and anxiety disorders, including PTSD and body dysmorphia. Each of the digital technologies includes the support and involvement of an NHS Talking Therapies clinician and use CBT techniques.

The eight therapies are conditionally recommended while further evidence is generated. They are the 6th and 7th early value assessments to have been undertaken using a new NICE rapid assessment process that seeks to identify promising medical technology for rapid deployment into the NHS.

Combined, the therapies have the potential to help more than 40,000 people.

One in six people report experiencing a common mental health problem such as anxiety and depression in any given week in England, according to NHS Digital and there is high demand for NHS talking therapies with some people currently waiting up to 6 weeks to access help.

These digitally enabled therapies, some of which are already in use, are conditionally recommended for use following a formal assessment with an NHS Talking Therapies therapist, as they may not be the right choice for everyone.

Mark Chapman, interim director of medical technology and digital evaluation, at NICE, said: “Our rapid assessment of these eight technologies has shown they have promise.

“Developed using tried and tested CBT methods, each one has demonstrated it has the potential to provide effective treatment to the many thousands of people who live with these conditions.

“We want these new treatment options to be available for people to use as quickly as possible and we also want to make sure they are clinically effective and represent good value for the NHS. The additional evidence collected during this period will help us do that.

“We also want to hear what people involved in this area think – both clinicians and the people who will be using these digital technologies. We know CBT can work well for many people and we know that digitally enabled technology can help the NHS get support to people faster.”

Digital therapies offer an alternative way for people to access help in a way that may be more suited to their personal needs by offering flexibility around both time and location of treatment.

The medical technology advisory committee heard from clinical and patient experts as part of their consideration of the evidence for the eight technologies. The evidence included the positive impact of CBT on these conditions and how these technologies can improve access.

Elizabeth Mullenger, lay specialist member on the NICE committees, said: “Digital technology could transform the experience of people living with mental illnesses. It can be incredibly isolating to be on a long waiting list for in-person treatment. You might know that help is coming, you just don’t know when.

“Having access to a digital therapy could help prevent this lonely feeling. Sometimes people need support most in the middle of the night, or after a busy day at work, and it’s hard to know where to turn. Having access to digital therapy, can give people the help they need, when they need it.

“These technologies will allow us to be in charge of our treatment, gaining a sense of autonomy as we navigate our own journey towards positive mental health.”

Professor Dame Til Wykes, specialist committee member and Head of the School of Mental Health and Psychological Sciences at King’s College London, said: “Digital therapies may offer welcome additional help for people with a diagnosis of anxiety or depression. They may help enough to reduce the need for face-to-face contact be that in person or virtually. But we don’t know enough about who will improve and who will need extra help.

“I am pleased that these interventions will be offered with therapist supervision to identify any additional support early and importantly that patients will have a choice of whether to use them or not.”

Professor Stephen Pilling, specialist committee member and head of the clinical, educational and health psychology department at University College London, said: "I am pleased to welcome the committee's recommendation on the digital therapies for adults with an anxiety disorder or depression. These interventions can make a major contribution to increasing access to and choice of evidence-based psychological interventions as set out in NICE guidelines. Their implementation in the NHS Talking Therapies for Anxiety and Depression service, with its excellent routine outcome monitoring programme, means that it will be possible to further assess their benefits in routine practice before their clinical and cost effectiveness can be fully evaluated by NICE using this real-world evidence collected by the NHS."

Six technologies were conditionally recommended for helping adults with anxiety disorders.

For body dysmorphic disorder (BDD):

-         Perspectives with support provided by a high intensity therapist trained in treating BDD.

For generalised anxiety symptoms or unspecified anxiety disorder:

-         Beating the Blues and Space from Anxiety (SilverCloud) with support provided by a psychological wellbeing practitioner or high intensity therapist.

For post-traumatic stress disorder (PTSD):

-         iCT-PTSD and Spring with support from a high intensity therapist trained in treating PTSD. 

For social anxiety disorder:

-         iCT-SAD with support provided by a high intensity therapist who is trained in treating social anxiety disorder.

For depression, the committee conditionally recommended the use of three online CBT programmes Beating the Blues, Deprexis, and Space from Depression (Silvercloud) as treatment options.

Digitally enabled therapies in NHS Talking Therapies services must be delivered with practitioner or therapist support including regular monitoring and management of patient safety and progress.

The committee believes the use of these technologies could lead to more people with mental health conditions being seen in NHS Talking Therapies services as digitally enabled therapies may need less practitioner or therapist time for delivery than other psychological interventions.

The technologies must achieve regulatory approval prior to their NHS use. This will include Digital Technology Assessment Criteria (DTAC) conformity approval from NHS England, CE or UKCA marking and compliance with the NHS Talking Therapies digitally enabled therapies (DET) assessment criteria

A consultation has now begun on both sets of recommendations. Comments can be submitted via nice.org.uk until Wednesday 15 March 2023.

-ENDS-

1. Both draft guidance will be available at www.nice.org.uk from 00.01 GMT on 1 March 2023.
2. An embargoed copy of the guidance is attached to this message.
3. NICE MedTech guidance applies to England.
4. Cardiff University, the developers of Spring, are one of 22 projects awarded a share of £5m to drive forward cutting-edge treatments and technologies to support veterans’ healthcare by the Office for Veterans’ Affairs’ Health Innovation Fund.

• Beating the Blues (365 Health Solutions) is an online computerised CBT programme for people with mild to moderate depression and anxiety, including GAD. It has 8 sessions, with each session including 3 or 4 modules that take 10 to 15 minutes to complete. The sessions contain interactive material, videos, and practical hands-on tools that help people to understand their mental health problems and learn techniques to change their thinking and behaviours. The programme lasts about 8 to 12 weeks and can be accessed using any internet enabled device. Beating the Blues can be used as low intensity unguided self-help or with one-to-one support which allows the patient and practitioner or therapist to see regular progress reports and to adjust the intensity of the course as needed.
• Deprexis (Ethypharm Digital Therapy) is a web-based program based on elements from CBT intended to help those with unipolar depression or depressive disorders. It is intended to be used as a supplement to care-as-usual. Deprexis integrates 10 modules on topics related to depression. During these modules, the technology adapts its approach according to the needs and preferences of the user. Worksheets, exercises, audio sequences, short texts and illustrations are also available to in order to guide people through the program. It can be used according to the user’s preferences with any computer, laptop, smartphone or tablet with internet access. Progress can be tracked using the PHQ-9 questionnaire and moodcheck (to monitor mood). These questionnaires (in addition to progression charts) can then be downloaded to be shared with a healthcare professional.
• iCT-PTSD (OxCADAT) is an internet version of cognitive therapy for posttraumatic stress disorder based on Ehlers and Clark’s cognitive model of PTSD. It is delivered in a series of modules alongside therapist support. The order of modules is individualised depending on a person’s individual needs and treatment plan. Modules consist of psychoeducation, videos, case examples, monitoring sheets, behavioural experiments and assignments. People can also track progress using measures including GAD-7 and PHQ-9.
• iCT-SAD for social anxiety disorder (OxCADAT) is an internet-based programme based on Clark and Wells’ cognitive therapy for social anxiety disorder. It is delivered in a series of modules alongside therapist support. Modules consist of psychoeducation, videos, case examples, monitoring sheets and assignments. It also includes video feedback, attention training, behavioural experiments and memory focussed techniques. Therapists can view completed modules and provide support using built-in messaging.
• Perspectives (Koa Health) is an online CBT programme with interventions for adults with BDD, OCD and depression. It is a 12-week programme that delivers core components of CBT using treatment modules. Each module includes psychoeducation, interactive exercises and CBT skills. People are also asked to complete weekly questionnaires, including PHQ-2, QIDS-SR and CGI, to track their symptoms. Perspectives also provides information on local emergency services and suicide hotlines should a person need urgent support. It is designed to be used in IAPT services with a practitioner or therapist who monitors progress and provides support via calls or asynchronous messaging. The programme is delivered through a mobile app and includes a web-based administration panel for practitioners or therapists.
• Space from Anxiety and Space from Depression (SilverCloud) offers online CBT programmes that include adults with symptoms of anxiety and low mood and depression. It aims to teach users skills and strategies to manage their symptoms. The programme comprises of modules that contain quizzes, videos, information, personal stories, interactive activities, homework suggestions and summaries. In addition, the interventions incorporate mindfulness tools and resources, positive psychology, and motivational interviewing techniques. Practitioners or therapists can guide people through the programme using built-in messaging within the platform. SilverCloud recommends that all programmes are used with a supporter who regularly reviews progress, provides feedback and unlocks content. Silvercloud has other programmes which can be used for a range of other mental health conditions, including a programme for anxiety and depression combined. However, experts state that the programmes for individual indications are primarily used in IAPT services. SilverCloud has screening tools incorporated into the programme, including the PHQ-9, which can be used to flag risk and send risk alert emails to the user’s supporter or relevant members of the care team. Programmes can be accessed at any time using any smartphone, tablet, or computer.

• Spring (Cardiff University) is an online guided self-help programme for people with PTSD. It is audio narrated throughout and includes 8 steps based on core components of CBT with a trauma focus. The programme includes characters with PTSD to different traumatic events, video content and a toolkit to easily access key components and information. It is interactive and user input dictates feedback to key activities within the programme. Spring is designed to be delivered with practitioner or therapist support. Practitioners or therapists can review a person’s progress via a healthcare professional dashboard to help guide the patient through the programme. Ongoing support is provided as part of the service and the support team offer technical and clinical support. Spring can be accessed through a computer, tablet or smartphone.