Digitally enabled therapies for adults with anxiety disorders: early value assessment

Digitally enabled therapies deliver psychological interventions in a digital format with regular support from a practitioner or therapist. NICE has assessed 11 digitally enabled therapies as an option for treating anxiety disorders in adults while evidence is generated. The criteria for including technologies in this early value assessment (EVA) are in the scope on the NICE website. The technologies are:

• Beating the Blues (365 Health Solutions) for mild to moderate depression or anxiety including generalised anxiety disorder (GAD). This technology is no longer available to the NHS.

• Cerina (NoSuffering) for GAD and obsessive compulsive disorder (OCD) consists of 7 sessions with anxiety management exercises, journals and self-care resources. It also uses evidence-based tools to measure symptom severity.

• iCT‑PTSD (OxCADAT) for post-traumatic stress disorder (PTSD) based on Ehlers and Clark's cognitive model of PTSD. It includes modules with memory and meaning-focused techniques, psychoeducation, case examples, monitoring sheets, videos, behavioural experiments and assignments. It also administers all outcome measures for PTSD recommended in NHS Talking Therapies in anxiety and depression services and exports them to local services' IT systems.

• iCT‑SAD (OxCADAT) for social anxiety disorder based on Clark and Wells' cognitive therapy for social anxiety disorder. Modules include psychoeducation, case examples, monitoring, video feedback, attention training, behavioural experiments and memory-focused techniques. It administers all outcome measures for social anxiety disorder recommended in NHS Talking Therapies in anxiety and depression services and exports them to local services' IT systems.

• Iona Mind (Iona Mind) for GAD or depression creates personalised support plans with guided exercises and uses machine learning to adapt the programme to a person's needs. It also has functionality to identify crisis events and provide signposting.

• Minddistrict (Minddistrict) for GAD, health anxiety, social anxiety, OCD, panic disorder and phobias. Interventions can be personalised by adapting and combining components in line with a person's needs.

• Perspectives (Koa Health) for body dysmorphic disorder (BDD) is a 12-week CBT programme with psychoeducation, interactive exercises, CBT skills and symptom tracking. It also provides information on local emergency services and suicide helplines for urgent support.

• Resony (RCube Health) for GAD is a 6-week automated programme based on CBT, mindfulness and gratitude journalling. It also has physiological techniques based on non-directive resonance breathing, applied relaxation and heart rate variability training.

• SilverCloud programmes for anxiety disorders include Space from Anxiety, Space from GAD, Space from Health Anxiety, Space from OCD, Space from Panic, Space from Phobia and Space from Social Anxiety. Programmes incorporate CBT with mindfulness, positive psychology and motivational interviewing. Modules include informational content, videos, interactive activities and homework.

• Spring (Cardiff University) for PTSD from a single event is a guided self-help programme with 8 steps based on core components of CBT with a trauma focus. It is interactive and user input determines feedback to activities within the programme.

• Wysa (Wysa) for mild to moderate anxiety or depression is an artificial intelligence-based app with CBT programmes and a chatbot that encourages self-reflection and engagement. It also has a risk alert system with grounding exercises, a crisis care plan and crisis numbers.

NHS Talking Therapies for anxiety and depression services provide evidence-based psychological therapies for anxiety and depression using a stepped care approach. This means offering the least intrusive intervention first, in line with patient needs and preferences. NHS Talking Therapies for anxiety and depression services deliver low intensity psychological interventions at step 2 of the care pathway and high intensity psychological interventions at step 3. Digitally enabled therapies are most commonly offered as a step 2 low intensity intervention with the support of a psychological wellbeing practitioner who facilitates treatment and reviews progress. Digitally enabled therapies may also be offered as high intensity psychological interventions if they include the same therapeutic content as recommended in the following NICE guidelines:

• Common mental health problems: identification and pathways to care

• Generalised anxiety disorder and panic disorder in adults: management

• Obsessive-compulsive disorder and body dysmorphic disorder: treatment

• Post-traumatic stress disorder

• Social anxiety disorder: recognition, assessment and treatment.
  
  This should be supported by a high intensity therapist trained in the specific therapies.

The comparator is standard care low intensity and high intensity psychological interventions delivered in NHS Talking Therapies for anxiety and depression services. This varies depending on the condition:

• BDD: high intensity psychological interventions include individual or group CBT with exposure and response prevention (ERP).

• GAD: low intensity interventions include individual guided or unguided self-help or psychoeducation groups. High intensity psychological interventions include CBT and applied relaxation.

• Health anxiety: high intensity CBT for health anxiety.

• OCD: low intensity interventions include brief individual or group CBT with ERP. High intensity psychological interventions include more intensive CBT with ERP.

• Panic disorder with or without agoraphobia: low intensity interventions include guided or unguided self-help. High intensity psychological interventions include individual CBT.

• PTSD: high intensity psychological interventions include individual trauma-focused CBT, eye movement desensitisation and reprocessing (EMDR) or supported trauma-focused computerised CBT.

• Social anxiety disorder: high intensity individual CBT for social anxiety disorder (based on the Clark and Wells model or the Heimberg model) as first-line treatment. CBT-based supported self-help or short-term psychodynamic psychotherapy may be offered if individual CBT is declined.