DIY CBT for Comorbidities in Epilepsy

Commentary

A Feasibility Trial of an Internet-Delivered and Transdiagnostic Cognitive Behavioral Therapy Treatment Program for Anxiety, Depression, and Disability Among Adults With Epilepsy.

Gandy M, Karin E, Fogliati VJ, McDonald S, Titov N, and Dear BF. Epilepsia 2016;57:1887–1896.

OBJECTIVE: Anxiety and depression are highly prevalent in people with epilepsy (PWE) and contribute to increased disability. Unfortunately, there are numerous barriers (e.g., cost, distance, and stigma) and service gaps (e.g., lack of services and trained clinicians) that prevent many PWE from accessing traditional face-to-face psychological services. The aim of the present study was to examine the feasibility of a new transdiagnostic Internet-delivered cognitive behavioral therapy (iCBT) program, the Chronic Conditions Course, to simultaneously treat symptoms of anxiety, depression, and disability. METHODS: A single-group feasibility open trial was employed involving 27 adults with epilepsy. The program comprises five online lessons delivered over 8 weeks and is provided with weekly contact from a mental health professional via e-mail and telephone. RESULTS: High treatment completion rates and levels of satisfaction were reported. Evidence of significant improvements in our primary outcomes (within-group Cohen's d [d]; average [avg.] reductions) of anxiety (d ≥ 1.28; avg. reduction ≥ 54%), depression (d ≥ 1.24; avg. reduction ≥ 54%), epilepsy-specific depression (d ≥ 0.95; avg. reduction ≥ 35%), and disability (d ≥ 0.62; avg. reduction ≥ 33%) were observed at posttreatment, which were sustained at or further improved to 3-month follow-up. On our secondary outcomes there were significant improvements for life satisfaction (d ≥ 0.70; avg. improvement ≥ 26%) but not for perceived cognitive difficulties (d ≥ 0.48; avg. reduction ≥ 15%). Highlighting the potential of the approach, relatively little clinician time was required per participant (mean 80.62 min, standard deviation [SD] 54.78), and the trial involved a broad range of geographically dispersed patients. SIGNIFICANCE: The findings of the current study support the feasibility and potential of transdiagnostic Internet-delivered treatments for adults with epilepsy. Further largescale controlled trials are warranted.

Approximately one-third of people with epilepsy have psychiatric comorbidity, mainly depression and anxiety, which contribute greatly to the burden of the disease. Epilepsy patients with comorbid depression and anxiety use more health services, have higher rates of suicide, lower treatment adherence, lower quality of life, and worse seizure control. Efforts to educate neurologists to screen their epilepsy patients for depression and anxiety and facilitate management are underway, but it remains challenging for patients to follow through with psychiatric treatment due to limited availability of services and funding, stigma associated with mental illness, and travel limitations. Furthermore, adherence to psychiatric follow-up is poor in general (1), so it is not surprising that non-adherence in patients with epilepsy and comorbid psychiatric symptoms is also high (2).

Recently, patient self-management programs to supplement epilepsy care have proven beneficial and cost-effective (3), bypassing the major problem of lack of access to mental health clinicians. Several online self-help treatment programs have demonstrated efficacy with chronic conditions including irritable bowel syndrome, and chronic pain (4, 5). Internet-delivered cognitive behavioral therapy (iCBT) has been shown to be effective in depression and anxiety in chronic illness, including epilepsy. A randomized controlled trial for an online treatment for depression in epilepsy (6) demonstrated feasibility but only a small effect size in the intention to treat arm. Distance-delivery CBT, such as project UPLIFT, showed benefit in an uncontrolled trial of depression in epilepsy (7).

The percentage of people with access to the internet (even those with low resources) is high and lends itself to overcome some of the socioeconomic barriers in some groups of patients with epilepsy. Internet-delivered interventions have the added therapeutic value of empowering patients by making them responsible for their own care. For patients with high level of stigma against mental health problems or those who feel their symptoms are too mild to merit formal treatment, internet-based interventions allow them to get gradually comfortable with mental health treatment.

Transdiagnostic interventions use the same treatment to target two or more commonly co-existing conditions, such as depression and anxiety (8). In the case of epilepsy, depression and anxiety are highly comorbid (9); therefore, a transdiagnostic intervention for both conditions is fitting and captures the clinical reality of psychiatric comorbidities in epilepsy. Prior studies that only focused on depression in epilepsy had modest results possibly due to the limited focus on one condition, instead of both.

In their article, “a feasibility trial of an Internet-delivered and transdiagnostic CBT treatment program for anxiety, depression, and disability among adults with epilepsy,” Gandy et al. explored the feasibility, acceptability, and effectiveness of the “chronic conditions course” in a single-group, open-trial design. The “chronic conditions course” is a transdiagnostic internet-delivered CBT (iCBT) program previously developed for patients with chronic pain, which produced reduction in symptoms of depression, anxiety, and disability. Patients were recruited by applying via an Australia-based website for clinical trials, and the program was promoted via the Epilepsy Action Australia Facebook page.

While recruitment via internet-based self-referral reflects the trend in self-management, this may also signal a selection bias toward motivated patients, and limits the applicability of this intervention to a broader group of patients, such as those less likely to seek help on their own. The study included self-rating measures to assess symptomatic progress in depression, anxiety, and disability over the course of the treatment. There were no exclusion criteria for patients who were minimally symptomatic at baseline.

The intervention was feasible and highly acceptable to patients and there was a high level of completion (81%). The fact that the treatment was transdiagnostic probably contributed to its high acceptability because the intervention reflected many of struggles that patients face in an integrated fashion, instead of focusing on just one portion of them.

The minimal involvement of clinicians is also an appealing feature of the intervention. Although clinician time averaged approximately 10 minutes per week (inclusive of phone calls and e-mails), the power of human contact cannot be underestimated, even if it was mainly to corroborate and encourage treatment participation. A controlled study where one arm does not include any clinician involvement would help sort out the added value of these contacts.

The program is based on CBT, the treatment modality with the strongest evidence to target depression and anxiety. The course required very few additional resources to tailor it to epilepsy, which highlights the adaptability of these kinds of treatments. Access to the program was flexible, allowing participants to pace themselves on how to incorporate the content.

There were some limitations to this study. At the recruitment level, the fact that no corroboration of the epilepsy diagnosis was required from a physician or other health provider raises concern about the accuracy of the diagnosis. Some participants, for instance, may have had psychogenic nonepileptic seizures. The design did not include a control group, which limits the ability to assess the efficacy of the program for treating depression, anxiety, and disability symptoms. The exclusion of severely depressed patients and inclusion of participants falling below even the minimum threshold for clinical disease brings into question whether it is an intervention tailored to address clinical depression and anxiety, or if it is just suited for minimally symptomatic patients.

While the program aims to target depression, anxiety, and disability symptoms as primary outcome measures, seizure tracking as a secondary measure could have helped clarify whether self-management also impacts seizure control. This may have been difficult to accomplish in patients with relatively well-controlled seizures. By the same token, it could be argued that the severity of the depression and anxiety was quite low as well at baseline, and there was reduction in those measures nonetheless.

Finally, an important limitation is the fact that there were no restrictions on other interventions during treatment participation. Therefore, patients may have received additional therapies for depression, anxiety, and disability while participating in the program, limiting our ability to assess the impact of the program on its own.

With distance-delivery treatments becoming more popular and accessible, the evaluation of this program is quite timely. While it is unclear whether the intervention is effective at this point, transdiagnostic iCBT is a feasible intervention that assesses for depression, anxiety, and disability. This adds to a growing armamentarium of interventions to help the lives of people with epilepsy.

Self-management has added a valuable dimension to epilepsy care. Interventions like transdiagnostic iCBT help to empower patients. Further studies that include a control group, focus on more clinically symptomatic patients, and formally corroborate the epilepsy diagnosis could place transdiagnostic iCBT as a treatment intervention for depression and anxiety. The secondary impact of these types of interventions on seizure frequency should also be carefully studied, so we can understand which treatment helps which aspect of the overall health of people with epilepsy.