In my previous blog I considered the major treatment gap for depression and considered some of the key challenges that need to be overcome to address the global burden of depression. Clinical research and treatment delivery needs to focus on increasing the efficacy and potency of psychological treatments, in part by better understanding how therapy works, and to increase the coverage and accessibility of effective therapies. Tackling these gaps needs to be a call to arms for researchers and therapists.
One potential way to ensure that more of those in need receive helpful treatment for depression is the use of internet-based treatments. Internet-delivered CBT treatment is easily accessible, widely available, cost-effective, and increases treatment reach. Moreover, clinical trials have suggested that internet-based CBT treatment is a practical and effective treatment for depression and anxiety.
Another part of the solution is using different methodologies to determine how therapy works and to identify the active ingredients of therapy, so that we can more systematically build a better therapy. Up to now, we don’t really know how particular therapies work or what components of therapy are helping people to get better.
For example, in a previous blog I summarized evidence that a treatment we developed - rumination-focused CBT - reduced symptoms of depression in chronic and severe depression (see paper). However, I also noted that this treatment has a number of different elements such as trying to identify and change habits, becoming more compassionate, increasing absorption in activities, and becoming more concrete and specific in thinking and planning. Critically, we don’t know whether all, some, or indeed none of these elements contribute to the beneficial effects of the therapy. It could be that treatment effects are solely due to the positive alliance with the therapist and not due to any of these specific treatment factors. Or it could be that only some of these elements are required for symptom improvement, with other elements acting to dilute the treatment effect and making the therapy unnecessarily long, tiring, effortful, and expensive without adding benefit. Or it may be that some combinations of components work better than others because the elements may mutually interact with each other to produce effects stronger than simply adding together the two components. For example, learning to be more concrete may make it easier to spot the cues to your habits, and in turn being aware of these cues may facilitate the most beneficial use of becoming more concrete as a counter to interrupt habitual responses.
At this point, we simply don’t know because research has not examined the effects of individual treatment components or their interactions. The standard approach to evaluating treatments – the randomised controlled trial – cannot unpack these effects.
Over the last few years, researchers have begun to apply methodologies used in engineering to optimize processes and procedures within behavioral interventions. Foremost amongst these researchers is Prof Linda Collins, Director of the Methodology Centre, at Penn State University. She advocates an approach called Multiphase Optimization Strategy or MOST (for further details).
This approach starts with component selection experiments, which utilise randomization within a factorial design to assess multiple individual treatment components from behavioral interventions and to select active and to reject inactive or counter-productive components. Follow-up refining experiments are then used to investigate optimal dosages and combinations of these components. The resulting engineered treatment is then evaluated against existing treatments in a randomized controlled trial. Critically, unlike standard comparative randomized controlled trials, this approach provides direct evidence about the effects and interactions of individual components within a treatment package, necessary for methodically enhancing and simplifying complex interventions. This approach provides the opportunity to systematically and incrementally build better treatments. Current research studies are using the MOST approach to improve public health interventions to reduce smoking and drug abuse.
Perhaps surprisingly, this approach has not yet been applied to improving psychotherapy for common mental health problems such as depression. Because of the treatment and knowledge gap described earlier, it seems a logical next step to improve our therapies. In fact, it seems such a sensible thing to do that my research group is now seeing if we can apply this innovative approach to psychological treatments for depression. By using the MOST approach, we hope to find out what are the active ingredients of cognitive-behavioral therapy for depression.
Moreover, we are investigating this treatment development within an e-health internet-delivery format in order to build-in increased treatment coverage from the start. We thus are trying to kill two birds with one stone: to understand the active ingredients of therapy to refine a better treatment concurrently with increasing the accessibility and availability of therapy by developing an internet-based treatment.
This study is called IMPROVE-1 (Implementing Multifactorial Psychotherapy Research in Online Virtual Environments) and is funded by a Wellcome Trust Institutional Strategic Support Fund held by the University of Exeter. The IMPROVE-1 trial (for further details see here) provides free and open access online cognitive-behavioural therapy for people with major depression, supported by online guidance from a trained therapist. The treatment study is open to participants from anywhere in the world with good English who are experiencing moderate to severe levels of depression, who are interested in receiving internet cognitive-behavioural therapy, who are not actively suicidal, and are not currently receiving psychotherapy. The first step in entering the study is to go to our online mood screener, which assesses and gives feedback on level of depression, and checks suitability for the study. If you are interested in taking part in the study, please go to the mood screener.
If you are willing, please ‘like’ and ‘share’ the Facebook page and tell your friends about the study, to help spread the word about this research.
We hope that this research will provide an important first step in developing better psychological treatments for depression that begin to address the major treatment gap.
I will post updates on what we learn from the study on this blog as the research progresses, and I hope that this be of interest to Psychology Today readers.