1a: Charles F. Reynolds III, Distinguished Professor of Psychiatry at the University of Pittsburgh’s School of Medicine, introduces staff members from Dr. Bruce Rollman’s Online Treatment Trial who are being interviewed in this podcast.
2a: Amy Anderson and Chris Wiltrout talk about what led them to work as care managers (CMs) for the Online Treatment Trial and what they considered a workable caseload.
2b: Ideal characteristics for a care manager include having a genuine interest in improving the lives of others, skill in “active listening,” and persistence in reaching patients. CMs found that the combination of positive relationships, an online tool, and a well-designed database all were important in guiding them to help patients.
2c: Phone interventions allowed care managers to reach patients that would not have been reached otherwise. CMs were consistent in following-up with patients to keep them from falling out of the loop and not getting help. They held patients accountable and emphasized the value for patients in learning techniques they could use going forward.
2d: During weekly case review sessions care managers met with the study PCP, psychologist and psychiatrist and discussed patients who were not improving enough with the CCBT program. They made treatment recommendations such as medication changes, behavioral changes, and wellness advice. CMs felt it was essential to have this backup; it allowed “novices” to have confidence in helping patients.
2e: Amy points out that most patients in the study were recruited through “Best Practice Alerts” on EpicCare and so care managers communicated to their PCPs via electronic medical records. Monthly updates were sent to PCPs and in the case of more complex recommendations, Drs. Rollman or Karp would get involved in communicating with the physicians. PCPs came to see CMs as an asset to their patient’s care.
2f: CMs discuss times when they felt “out-on-a-limb” and how essential it was to have a multi-level safety net. About three-quarters of patients exhibited some suicidal ideation over a 6-month-period, so CMs relied heavily on a suicide protocol developed by Dr. Belnap to determine the severity of suicidal thoughts. Suicidal ideation was shared with patients’ PCPs.
3a: Computerized Cognitive Behavioral Therapy (CCBT) included eight sessions, each lasting 45 minutes to an hour and patients were encouraged to complete a session each week. The program was extremely easy to use even for a wide range of ages, but those with low computer literacy needed CMs to walk them through steps such as accessing the internet and how to create an account. One of the biggest barriers was that people would lose internet access. CCBT provided helpful reports and could be programmed to send automated emails to patients.
3b: Care managers completed the CCBT modules for themselves and found this very helpful in relating to their patients; it allowed them to share their own experiences as an example.
3c: More than 80% of participants used the CCBT program. One important factor was timing – patients were sent their passwords as soon as they were randomized, CMs strived to send out welcome emails the same day and these included a link to the website along with instructions. CMs discuss the importance of working on a case-by-case basis and the value in trying to understand and adapt to the hurdles patients were encountering.
3d: Care managers felt that sleep hygiene was one of the most critical parts of the CCBT program, along with the less familiar skills such as engaging with a “thought record” and learning how to recognize your “thinking errors” such as catastrophizing and using black and white thinking.
3e: The human factor was essential – having someone as a coach, an active listener, offering support, and encouraging patients. While the program laid out sessions very clearly, it made a difference to have CMs call back a week later and reiterate the same info and not let a week’s session end just because a patient had completed it.
3f: Dr. Reynolds points out how critical sleep hygiene is to prepare for learning CCBT. CMs felt that focusing on it early would have given patients a tangible skill to build on before tackling less tangible “thinking skills.”
3g: Care managers discuss ways to improve the CCBT program, including making it smartphone-ready, allowing patients to choose the sequence of the modules and shortening the length of the modules.
4a: Patients randomized to the Internet Support Group (ISG) had access to both the CCBT and a password-protected ISG. The ISG was a combination of a social media tool and a resource tool; allowing patients to share tips and problems in their lives. It was a private website and only people randomized to the ISG group had access to it. Patients had the option to communicate privately between themselves, request a support group and use private messaging, but these functions were all underutilized.
4b: Chris details ways in which he tried to engage patients in the Internet Support Group. This involved automatic email notifications as well as case-by-case monitoring of the group and proactively sending messages to pique patients’ interest in what someone else had posted.
4c: Dr. Reynolds points out that the ISG served as another level of surveillance for patient’s safety and also their reassurance. Chris talks about how important it was for patients to see that staff were taking action in exceptional situations like when someone expressed suicidal thoughts or posted they were taking their medication wrong. The ISG staff not only communicated with the patient, but posted about how they handled it so other patients would know the posts were noticed.
4d: Several cases required intervening based on what patients had posted on the website. To catch this, study staff shared the duty of closely monitoring the website. When one patient posted suicidal thoughts, Dr. Rollman spoke with them on the phone and responded to the comment on the website – thanking the patient for talking with him and discussing how they’d been feeling.
4e: Patients requested a chat feature for the ISG. The website functioned like other social websites in other ways, but there wasn’t a feeling that there was a live person responding as you were typing. Patients were more likely to be posting when they were experiencing stress or looking for a solution to a problem, but after they posted a comment it might be a day or two before anyone responded.