Internet-delivered Cognitive Therapy (iCT) for young people with Post Traumatic Stress Disorder (PTSD)

Context
A trauma is an event that involves serious injury, violence, or death, such as violent assaults or serious road traffic accidents. By the age of 18 years, most adolescents will have been exposed to a traumatic event. About 1 in 6 adolescents who are exposed to a trauma will develop Post Traumatic Stress Disorder (PTSD).

PTSD is a serious mental health problem. It is characterised by frightening disturbances in memory (flashbacks and nightmares about the trauma), sudden changes in emotion (fear, anger, sadness), changes in thinking (feeling guilty, having an exaggerated sense of danger), and changes in behaviour (trying to avoid trauma reminders). Adolescents with PTSD can have problems concentrating and remembering. This can mean that they under-achieve in school exams, which may have life-long consequences on their future job prospects. PTSD in adolescence reduces quality of life, worsens physical health, and can lead to serious mental health problems such as depression in adulthood. Without treatment, PTSD may last for many years.

Highly effective treatments for PTSD exist. Based on international research, the Department of Health recommends that adolescents with PTSD receive a treatment called Trauma-Focused Cognitive Behavioural Therapy. Our group has developed a version of this treatment, called Cognitive Therapy for PTSD (CT for PTSD). Our research has shown that after completing a 10-week course of Cognitive Therapy, 77-90% of young people no longer have PTSD. However, this highly effective treatment is not often available in the NHS. The reason is that there are not enough trained therapists to deliver it. This means that most adolescents with PTSD do not get the effective treatment that they deserve.


Aims and objectives
One way of increasing the availability of therapy for adolescents with PTSD is to deliver it over the internet, rather than face-to-face. Accessibility of treatment is improved when using the internet because trained therapists could treat up to five times as many patients as they can when offering traditional face-to-face appointments.

Our objective is therefore to develop an Internet-delivered Cognitive Therapy (iCT) programme for the treatment of PTSD in adolescents, based on our effective face-to-face Cognitive Therapy.

We will develop a secure, interactive, multi-media, iCT software programme, designed specifically for adolescents, to be delivered on computers, tablets, and smart phones.

We will then evaluate this new iCT program, in a pilot Randomised Controlled Trial, comparing it to traditional Face-to-Face CT for PTSD, and to a Wait List comparison condition. Our trial is designed to investigate whether iCT is acceptable to young people; to evaluate whether it is feasible and practical to deliver treatment in this way; and to explore how well iCT works for symptoms of PTSD, depression, and anxiety.

Applications and benefits
Our proposed iCT programme offers a new approach. It will deliver a full course of evidence-based Cognitive Therapy to treat PTSD. It will be designed specifically for adolescents, with input from young service-users at every stage of development. It will use technology to improve the treatment delivery, e.g. via a smartphone App. It will be interactive and include online treatment from a trained therapist, but it will reduce therapist time to around 20% of that required in face-to-face treatment.

There are many potential benefits. iCT will increase the availability of treatment. Adolescents will be able to access a highly-effective treatment in a way that is more convenient (it can be accessed when they choose) and more efficient (they do not need to travel to a clinic). The potential benefit to the NHS and other health-providers is that up to five times more patients can be treated, with no increase in cost. iCT offers the potential for very significant benefits for young people, their families, and the NHS

Need. Post-Traumatic Stress Disorder (PTSD) in youth is a common problem in the UK and globally. Most young people are exposed to traumatic events before they are 18 years old; about 15% will develop PTSD which may persist for years if untreated. PTSD is associated with impaired social and academic functioning, poor quality of life, increased suicidal behaviour, and significant comorbidity. Highly effective psychological treatments exist but are not commonly available in the NHS. There is an urgent need to disseminate these effective treatments for PTSD in youth.

Solution. We will build software for an Internet-delivered version of our effective face-to-face Cognitive Therapy for PTSD, which will be accessible online via computers, tablets, and smart-phones. Internet delivered Cognitive Therapy (iCT) for PTSD offers huge potential for very wide, cost-effective dissemination of a highly effective treatment.

Rationale. We have developed a specialist treatment, Cognitive Therapy for PTSD, and shown in 2 RCTs that it is highly effective in treating PTSD when delivered face-to-face to adolescents. We have also developed Computerised CBT (C-CBT) for depression, and shown that it is enthusiastically embraced by adolescents, and clinically effective. Work with adults shows that PTSD is a condition which can be successfully treated with internet-delivered CT. The gap in provision is for internet-delivered CT for PTSD in youth.

Plan. The project has 2 phases. In the first phase, we will build software for internet-delivered Cognitive Therapy (iCT) for PTSD. In the second phase, we will evaluate iCT in an RCT (vs Face-to-Face Cognitive Therapy and a Wait List (delayed treatment) condition) to provide feasibility data on acceptability, compliance, retention, and delivery of the intervention, and to provide point estimates of the effect sizes (and confidence intervals) of iCT on PTSD and co-morbid problems.

Who will benefit from this research?

Young people with PTSD, as the end users of the proposed iCT programme, are the ultimate beneficiaries of the proposed research.

Non-academic intermediate beneficiaries are providers of mental health services to young people. This includes NHS Child and Adolescent Mental Health Services (CAMHS), NHS Looked After Children (LAC) services, and third sector (charitable) providers. Within this group, beneficiaries include clinicians who treat young people, as well as service managers and policy makers who are responsible for workforce planning and service delivery.

Academic beneficiaries include researchers and clinicians who are developing, evaluating, disseminating, and implementing evidence-based treatments for young people with mental health problems.


How will they benefit from this research?

Young people will benefit directly from accessing an effective evidence-treatment for PTSD, which is otherwise difficult to access. Treatment will be more convenient for young people (they can choose when to do treatment), and more efficient (they will not have to take time off school to attend clinic, or spend time travelling to clinic). We anticipate that internet delivery of our effective treatment will not result in a loss of effectiveness, and so young people would benefit from a reduction in symptoms, improved health, better functioning, and an enhanced quality of life.

Statutory and third-sector providers of mental health treatment for young people will benefit from knowledge about how access to treatment can be significantly widened, without increases in cost, and while maintaining clinical effect. Widening access to clinically effective treatment in a cost-effective manner has potential to make substantial improvements to the efficiency of NHS provision nationally. If the current project yields positive results as we expect, our ultimate aim is for iCT to be delivered nationwide via NHS and other clinical services.

New knowledge about the acceptability, feasibility, and initial clinical effect of iCT will be available to potential beneficiaries at the end of the current project. Assuming positive results under the current proposal, subsequent funding for a fully powered RCT will be sought at the end of this project. We would begin to seek further funding for a fully-powered RCT in the last nine months of this project.