How digital therapy can increase access to effective treatments for social anxiety disorder and PTSD

This month's guest expert is Anke Ehlers, Professor of Experimental Psychopathology at the University of Oxford.

Around 93,000 people received England’s NHS Talking Therapies for depression, anxiety and post-traumatic stress disorder (PTSD) when it launched in 2008. Today, 670,000 patients access these therapies. This is planned to go up to 900,000 in 2028.

Among the treatments offered in these services, the specialised cognitive therapies for social anxiety disorder and PTSD developed by our team are the results of research funded by Wellcome for 30 years. They are recommended by the NICE - National Institute for Health and Care Excellence as first-line treatments for these conditions.

The research, co-led by Professor David Clark and I, aimed to identify which specific cognitive factors maintain mental health conditions such as social anxiety disorder and PTSD. We then investigated how these factors could be changed through treatment to help patients recover.

Despite the progress with making treatments more effective and building services that deliver them, many people who need treatment for social anxiety disorder or PTSD can’t access them. Some reasons for this include that there are not enough trained therapists to treat these common conditions, patients being unable to attend treatment due to their working hours or childcare responsibilities, and patients not wanting to be seen attending a psychological therapy service because of the perceived stigma.

We decided to develop internet-delivered versions of our face-to-face talking therapies to address some of these barriers.

Exploring the potential of digitally enabled cognitive therapies

When we started this work, we were not sure to what extent digital therapy would be acceptable to patients with social anxiety disorder or PTSD in the UK, and whether it works as well as face-to-face therapy. However, there were promising signs from other international research that digital treatments can work.

Our team developed online versions of our therapies for social anxiety disorder and PTSD for patients to work through in their own time, with support from their therapist via calls or in-app messaging. These include modules with written guidance, video demonstrations and testimonies from other patients. So, if patients have a question or get stuck on a module, they can contact their therapist and don’t have to wait until their next scheduled call to make progress.

In randomised clinical trials, we found that the digital therapies were highly effective, and as effective as face-to-face therapy delivered by therapists. The studies showed an encouragingly low dropout rates of under 10%. That is really low in the field of internet treatments.

Some people may think internet-delivered therapies may only work for people with mild symptoms of social anxiety disorder or PTSD. This was not the case. In our PTSD trial, we even found that the advantages were greater for those with severe or complex symptoms.

Findings show digital therapies can be as effective as face-to-face

One important characteristic of the therapies we developed is that patients are offered an evidence-based treatment, and the outcomes are collected. Recording outcomes is the norm in many areas of medicine, like surgery, but in mental health, it’s often not routinely done. The NHS Talking Therapies for anxiety and depression services collect outcomes from over 99% of their patients. It means services can be improved based on real-life evidence.

We trained NHS Taking Therapies therapists to deliver the digital therapies in two studies. We found that their patients had very similar recovery rates as those we found in the clinical trials where specialists guided patients through the digital therapy. Drop-out rates also remained low.

The response from therapists about the internet-delivered treatments was positive too, even though some reported having felt hesitant at first about the new way of working. They said it helped them understand the treatments better, and consequently, their face-to-face sessions had improved too.

We’re planning randomised controlled trials to further compare the two delivery methods of therapy.

We want to widen the impact of our digital therapies for social anxiety disorder and PTSD

In the next stage of our research, we want to disseminate these therapies more widely into the NHS, in partnership with tech company Koa Health.

The treatment has also generated interest internationally and we’re considering translating the programmes into different languages. Our colleagues in Hong Kong and Japan have already translated the internet-delivered social anxiety disorder programme, with similarly good outcomes in two randomised controlled trials.

What excites me about the next stage of research is that through the wider dissemination into NHS Talking Therapies services, the treatments will hopefully help a large number of patients recover from these disabling conditions.

It is also exciting that the data we will be collecting will help us further understand why some people may benefit less than others. We could then refine the treatment content so that in the future even more patients will hopefully benefit.

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