Implementing internet-delivered cognitive behavioural therapy for depression and anxiety in routine care: an exploratory study of implementation
Citation:
Duffy, Daniel, Implementing internet-delivered cognitive behavioural therapy for depression and anxiety in routine care: an exploratory study of implementation, Trinity College Dublin.School of Psychology, 2022Download Item:
Duffy_PhDThesis_2022.pdf (PDF) 3.040Mb
Abstract:
Internet-delivered cognitive behaviour therapy interventions (iCBT) for depression and anxiety have proven their clinical utility through a number of controlled trials, but few studies have been conducted in routine care settings. Trials in routine care tend to produce inferior outcomes to efficacy trials, and overcoming this difference is hindered by the fact that methods of translating research findings to practice for iCBT are relatively unreported on. Implementation science methodologies have been proposed to bridge this evidence-to-practice gap and, in this regard, the current thesis utilized an evidence and practice based approach to identify factors and strategies relevant to the successful implementation of iCBT in routine care across 3 studies.
Study 1 consisted of a mixed methods systematic review to examine the iCBT literature around depression and anxiety for adults for relevant implementation insights, where identified studies were qualitatively synthesised across 2 domains of inquiry; implementation insights derived from iCBT research and considerations for the successful implementation of iCBT in care settings. Study 2 conducted a qualitative investigation into the experiences of service providers and patients from a primary care mental health service in England, and commercial iCBT representatives in regards to the implementation of iCBT across 2 domains of interest; experience of iCBT implementation and implementation context. Studies 1 and 2 utilised the descriptive-interpretive approach to analyse the qualitative data. Study 3 consisted of a 2-round Delphi study, where a panel with experience in implementing iCBT in routine care settings and researching it as part of academia were invited to rank 31 implementation strategies generated from a synthesis of findings from study 1 and study 2.
Study 1 identified 40 eligible papers and subsequently established a number of factors relevant to iCBT implementation from the literature, including the facilitative and hindering impacts of both clinician and patient attitudes towards iCBT, the importance of managing staff associated with administering iCBT (e.g managing resources, leadership), managing the delivery of the iCBT service (e.g. training clinicians, risk management, referral pathways) and accounting for context (e.g. costings and impact of governmental legislation). Study 2 recruited 19 participants across the three stakeholder groups. Service providers (n=6) emphasised the importance of leadership in driving iCBT implementation, systematic training initiatives to build iCBT-related competencies, collecting feedback to improve iCBT practice and creating work structures to aid facilitate iCBT use. Commercial iCBT representatives (n=6) reported on the work they do to support service providers (e.g. training, facilitating needs, building iCBT treatment pathways) and identifying the correct people within services to support iCBT implementation. Patients (n=7) reported an overall positive experience of the receiving iCBT, but highlighted the need for more guidance in how to effectively structure and tailor their iCBT usage. Contextual barriers broadly related to factors that limit iCBT implementation, such as negative therapist attitudes, technological issues and the rigid requirements of health systems, and facilitators included COVID-19 increasing clinician exposure to iCBT, persevering with iCBT use over time and health system support for iCBT and related digital interventions.
Study 3 recruited 9 individuals to participate in ranking the list of strategies resulting from the synthesis of findings from studies 1 and 2. 24/31 strategies achieved consensus at conclusion of round 2. In several instances, participants provided qualitative rationales to support their ranking and re-ranking of items across rounds, but this data was not consistent. Of note, items with the highest level of consensus related to technological governance of iCBT, having leaders that set clear service goals for intervention usage, designing iCBT-appropriate care pathways and defining patient eligibility to receive these interventions. 4 items transitioned consensus categories across rounds 1 and 2, which may be attributed to error-rates in responses (?oscillatory movements?). Each study included in the thesis contains a relevant discussion section, where the findings are explored in regards to both the wider iCBT and implementation science literature bases. The final chapter contains an overall discussion on the meaning and relevance of the work, as well as its applied utility to iCBT implementations conducted by a commercial iCBT organisation. In conclusion, the curated list of strategies offered by the current thesis provides a novel contribution to the field by identifying strategies that have relevance to the conduct of iCBT research and its real world implementation.
Sponsor
Grant Number
The Irish Research Council
SilverCloud Health LTD
Trinity College Dublin (TCD)
Description:
APPROVED
Author: Duffy, Daniel
Advisor:
Timulak, LadislavPublisher:
Trinity College Dublin. School of Psychology. Discipline of PsychologyType of material:
ThesisAvailability:
Full text availableLicences: