Online Cognitive Behavioral Therapy: An e-Mental Health Approach to Depression and Anxiety

By Nazanin Alavi and Mohsen Omrani

This book aims to provide the clinicians with details of online cognitive behavioral therapy (CBT) to facilitate care delivery for patients struggle with depression and anxiety. Chapters cover some of the most fundamental concepts for successful treatment, including experiments, action plans evidence, and the guidelines for managing, thoughts, feelings, and other key concerns.  Designed to be a reader-friendly guide, each chapter opens with a summary of the content and a recap of concepts covered in previous sections, making this highly functional for individual chapter or whole book use.  Each chapter also includes recommended tables and chart to facilitate the documentation of each recommended session, making this highly practical resource a vital tool for those who treat patients suffering from these particular mental health concerns.

 

Online Cognitive Behavioral Therapy is a unique guide to practical Mental e-Mental Health approaches that is valuable to psychiatrists, psychologists, counselors, social workers, and all clinicians who wish to treat anxiety and depression patients remotely.

• Language: English
• Publisher: Springer
• Release date: Dec 27, 2018
• ISBN: 9783319991511

Book preview

© Springer Nature Switzerland AG 2019

Nazanin Alavi and Mohsen OmraniOnline Cognitive Behavioral Therapyhttps://doi.org/10.1007/978-3-319-99151-1_1

1. Introduction

Nazanin Alavi¹  and Mohsen Omrani²

(1)

University of Toronto, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada

(2)

Brain Health Institute (BHI), Rutgers University, Piscataway, NJ, USA

Keywords

Therapy barrierResource allocationCognitive behavioural therapyOnline CBTAsynchronous careDepressionAnxiety

Mental Health Disorders and Treatment Gaps

Mental illnesses affect a large portion of every modern society, but unt il recently, the magnitude and pervasiveness of the problems they cause have been mostly neglected. It is estimated that one in five adults lives with some kind of diagnosable mental disorder. Mental illnesses have significant social and financial burden on society, and account for ~12% of the global burden of disease. In fact, in the USA in 2013, mental illness expenditure surpassed that of any other condition, including heart disease or cancer, to top the list of the most costly health conditions. The global direct and indirect economic cost of mental illnesses is estimated to be around US$2.5 trillion. While direct treatment costs comprise the majority of the economic burden for most diseases, the major economic burden of mental illnesses arises from indirect costs like lost employment and decreased productivity. For instance, while the direct annual cost of mental illnesses in the USA is estimated at US$200 billion, the indirect costs outweigh the direct costs by two to six times. People afflicted with serious mental illnesses lose at least US$190 billion of earnings each year, and they only comprise 20% of cases of mental illnesses annually. Yet, despite the prevalence and the lasting consequences of these diseases, less than half of these patients receive the care they need: 40–45% in developed countries and just 15% in developing countries. Two major barriers in delivering mental health services can be contemplated to explain this huge gap: limited access to care, and inefficient resource allocation.

Limited Care Access

Many diffe rent factors contribute to li miting patients’ access to mental health care. One factor is limited geographical access. Many vast countries like Russia, Canada, the USA, Brazil, and Australia have such a low population density that providing consistent mental health coverage throughout the whole country is impossible. For instance, two thirds of the US population lives in cities that only comprise 3.5% of the land area of the country. This means that in non-urban areas (which comprise 96.5% of the land area of the US, and are home to ~120 million Americans) the population density is just 34 people per square mile. For comparison, this number in Western Europe is 463 people per square mile, with a population not much larger (~195 million people).

The other barrier in receiving care is cultural limitations. When patients and caregivers do not have similar cultural backgrounds, or cannot even speak the same language, providing mental health support becomes complicated. This is the challenge that many developed countries are facing given the unprecedented rise in global migration. According to the International Organization for Migration (IOM) , there are currently 244 million people living in a country other than the one they were born in. Further, according to a study by van Tubergen and Kalmijn [11], 25% of this migrant population either do not know their host country's language or cannot speak it well. This situation has only worsened following the rapid rise in the number of refugees, currently at 22 million globally, displaced from their homelands because of war or natural disasters. In many cases, these refugees cannot choose their final destination, and thus cannot prepare themselves to learn their new host language. This is especially problematic, given that these refugees are particularly vulnerable to depression, anxiety, and post-traumatic stress disorders (PTSD) , for which no support might be available in their host country.

Financial limitations is the other factor restricting patients’ access to mental health. According to a report by the US Substance Abuse and Mental Health Services Administration (SAMHSA) , more than half of patients with a mental health problem that did not receive care for their problem mentioned that they could not afford the cost. An effective treatment for mental disorders is psychotherapy , which is very expensive and unaffordable for the majority of patients. For instance, a full round of psychotherapy might require 12–15 sessions at a rate of US$150–200 an hour. One major challenge is that in many countries, even those with free public health services like Canada, psychotherapy is not covered by the healthcare system. That is why, each year, CAD$950 million is spent on private-practice psychologists by Canadians, insurance companies, and workers’ compensation boards. It is estimated that 30 per cent of this money is paid out-of-pocket by patients, which illustrates the heavy burden on these individuals. It has been shown that when these financial barriers are lifted, many patients tend to seek the help needed for their problems. For instance, the Affordable Care Act (ACA) mandated insurance companies to cover mental health care to the same extent as physical health care, and following this change, the percentage of patients with serious psychological disorders who needed mental health care in the past 12 months but could not afford it decreased from 28.4% in 2012 to 16.7% in 2015, according to the US National Center for Health Statistics [5].

Another major factor precluding patients from receiving help is the social stigma attached to mental illness. According to the SAMHSA 2011 report, 30% of US patients refrained from receiving help because of the stigma of these diseases, and how that might affect them in society. This stigma is especially important in the adolescent and military populations, where peer opinion is very important. According to research by Iversen et al. [8], the most common barriers to members of the military in seeking mental health treatment are those related to the stigma of seeking such help. For instance, more than 70% of those interviewed agreed with statements like, Members of my unit might have less confidence in me or My unit bosses might treat me differently. Unfortunately, this problem seems to continue even after these members leave the military. A recent report by the Australian Defence Force (ADF) estimates that 46% of ADF veterans within the past five years met 12-month diagnostic criteria for a mental disorder. These numbers become more alarming considering that in the USA, an estimated 18–22 veterans die by suicide every day.

Inefficient Resource Allocation

In additio n to barriers limitin g access to mental health care, existing services are not sufficiently or efficiently distributed. Mental health services are grossly underfunded, especially in developing countries. Approximately 28% of countries do not have a dedicated budget for mental health services, and among those that have such budgets, 37% spend less than 1% of their health budgets on mental health. Even in more developed countries, there is a huge discrepancy between the ratio of the economic burden of mental health illnesses and their health expenditure or research allocation. For instance, in Canada, mental illnesses comprise 26% of the economic burden of all diseases each year. However, only 7% of public health expenditure is allocated to these diseases. A similar situation exists in research funding allocation. For instance, despite the fact that mental health diseases comprise the largest chunk of the economic burden of disease and the largest health care expenditure, the funding allocated to the National Institute of Mental Health (NIMH) comprises only 5% of NIH funding (~US$1.6 billion), whereas heart disease, cancer, and diabetes receive US$1.3, US$5.7, and US$1 billion in research funding respectively from NIH. Note that the health expenditure for cancer and diabetes combined is less than that for mental disorders.

In addition to insufficient funds, there is a shortage in mental health workers as well. For instance, there is only one psychiatrist per 11,600 people in the USA. Considering that one in five people need mental health care each year, that comes down to one psychiatrist for approximately 2320 patients. Besides the shortage in the number of psychiatrists, their distribution is also skewed. According to a study by Andrilla et al. [2], 65% of non-metropolitan counties in the USA lack a psychiatrist, as compared to 27% of metropolitan counties without a psychiatrist. The problem goes beyond just psychiatrists: almost half and more than 80% of non-metropolitan counties lacked any psychologists or psychiatric nurse practitioners, respectively. These numbers are 19% and 41% for metropolitan counties, respectively.

The insufficient and inefficient distribution of mental health care services causes long wait times. The average wait time to see a psychiatrist in 15 major US cities is approximately a month. Obviously, with the demand for therapy being higher in countries with public health care, like the UK or Canada, the wait times soar as well, with cases having to wait six months to a year to see a psychiatrist. The shortage in the service supply becomes more complicated because of a high no-show rate of psychiatric appointments. Up to 35% of psychiatric appointments are no-shows, which is a waste of precious clinician time. Interestingly, many studies have recognized that the wait time to see a clinician is the most important predictor of no-show rate [7], forming a vicious circle of longer wait times and higher no-show rates.

Solution

With the e ver-increasing proliferation of the Internet, one approach to bridging the treatment gap is delivering psychiatric treatment online. Using this service delivery method, geographical access limitation would no longer be an issue. Cultural barriers could also be overcome by assigning therapists to