**5.4. Blended delivery using of iCBT**

of demand and the lack of trained clinicians. Therefore, iCBT is considered as a supportive tool implemented as a prequel to high-intensity therapy at step 3, for individuals with depression and anxiety disorders. In this particular case, a therapeutic package is offered to those eligible for step 3 that includes iCBT before commencing face-to-face or group treatment. Individuals using iCBT are informed that they can withdraw from the treatment at any point and still avail of other services. Service users are monitored weekly, and any deterioration in their symptoms is attended to. If an appointment for face-to-face therapy becomes available, they are then

Service users are given immediate access to the platform so that they can start their treatment while being supported by their clinician. Each week throughout the intervention, service users complete a minimum data set, as per the national requirements regarding IAPT services, which includes the care provided to each service user and his/her clinical progress. The clinician reviews these assessments and the progress of the service user on a weekly basis. In this sense, the clinicians are not only expected to review the progress of the service users, but also to keep service users adhered to the intervention by acknowledging the efforts that the service users are taking, and by encouraging them to logon to the platform and practice the exercises. Once the service user finishes with the interventions, they can follow some potential trajectories in the treatment pathway. Firstly, the service user may recover and therefore get discharged from the service. Secondly, the service user might continue needing high-intensity therapy and consequently, would take up face-to-face or group therapy. Finally, it may be the case that the service user would prefer to continue with other low-intensity treatments (i.e., bibliotherapy). In sum, iCBT at stage 3 is expected to reduce the burden of the waiting lists by providing a treatment at the time the service users are waiting to start with the high-intensity therapy.

In the US, healthcare systems are service bodies that provide physical and mental healthcare to large populations with diverse and changing needs of some primary, secondary and tertiary settings. They are also known as accountable care organisations (ACOs), which consists of one or several care providers uniting to provide mapped-out models of care under a pre-

Healthcare commission solutions are innovative, cost-effective, and evidence-based with proven clinical outcomes. Where users of healthcare services enter a treatment pathway principally through primary care, iCBT can be an efficient first step for those that present with mild to moderate mental health difficulties. Service users frequently present with depression and anxiety to primary care clinics, and physicians generally refer service users to face-to-face treatment services, which often have long waiting lists. Deploying an iCBT intervention into primary care can address these difficulties without the need for a referral to higher intensity face-to-face ser-

In considering the successful implementation of an iCBT intervention in primary care, the service user pathway is important. When service users present for routine assessment, they can be administered either the 9 or 4 item version of the Patient Health Questionnaire to assess symptom severity. If the service user is within a clinical range of symptoms, they can

vices, allowing for a form of treatment which is more efficient in its use of resources.

offered to begin this high-intensity treatment.

232 Cognitive Behavioral Therapy and Clinical Applications

**5.3. Primary care using iCBT in US health systems**

defined and limited budget.

In many US and UK behavioural health services, CBT is the treatment of choice and is typically delivered face-to-face for a period of between 12 and 16 sessions, depending on the presenting problem. Many of these health services face the continuous challenge of meeting the demands with a lack of trained resources to see people face-to-face. Recently, such services are investigating the utility of incorporating iCBT in innovative ways. In some cases, an implementation is a blended approach, where services now deliver a model of care that includes both face-to-face and internet-delivered CBT. This can be achieved in many different formats, for instance where service users are assessed and after that complete their first faceto-face session with their CBT therapist. After that, the service user has access to the iCBT platform where they are encouraged to access the intervention in the time between the sessions. In this model, the sessions are spaced at intervals of every two or even 3 weeks. The intention is that the service user receives both face-to-face support, but also has access to content and tools between sessions that enable and support their trajectory through their therapy.

This model of implementing a blended service has the advantage of increasing throughput of service users, embracing the benefits of early intervention to treatment, and preventing dropout from long waiting lists. In these ways, successfully implementing a blended care model could have significant implications for service development and delivery.
