silvercloud hse annual report 2025.pdf

National Guided Digital CBT Service Report

December 2025

Prepared for the Health Service Executive (Ireland)

Contents

Messages from the HSE teams A Note to Our Readers Report Summary Platform and Programme Overview Key Takeaways Return on Investment Analysis David’s Case Study Letter to Referring Clinicians Clinical Operations Team How to Refer? Risk Management Report Background Invitations and Activations User Demographics and Baseline Information User Satisfaction Status of Accounts Programme Completers Sub-group Analysis Service Development Highlights Concluding Recommendations Clinician Resources

4 5 6 8 10 13 14 17 18 21 23 25 26 28 32 33 35 38 39 48 49

Messages from the HSE teams

A number of the key stakeholders from the Health Service Executive share a deeper insight into the national service, with some core messages to their clinician peers.

Dr Aoife O’Sullivan (GP UCC Student Health, ICGP Clinical Lead for Mental Health) shares an overview of SilverCloud; an evidence-based supported CBT service now available for patients in Ireland with mild-to-moderate levels of depression and anxiety.

Dr. Aoife Kearney, Senior Clinical Psychologist (Primary Care Psychology) shares her perspective on embracing a new service like SilverCloud to the benefit of her patients.

Fiona Ward (Director of Counselling, HSE National Counselling Service) shares how trust is built within the programme, and how the clinician support role is crucial for identifying and responding to any risk issues.

Derek Chambers (General Manager, Policy Implementation, HSE Mental Health Operations) describes the partnership between HSE and SilverCloud in more detail, noting that this service brings a unique approach in democratising access to mental health supports while also tackling long waiting lists for traditional services.

A Note to Our Readers

Dear Reader,

® ® In partnership with the Health Service Executive (HSE), SilverCloud by Amwell has been successfully rolled out nationwide, making our Guided Digital Cognitive Behaviour Therapy (CBT) programmes accessible to adults across Ireland. This collaboration between public and private sectors demonstrates the power of innovation in addressing the growing demand for accessible mental health support across the country.

This report provides a comprehensive overview of the SilverCloud service, drawing on insights from over 55,000 adult referrals in Ireland since the project launched in mid-2021. In 2025 alone, we have seen the number of completed adult referrals reach an annual high of 16,500. For this fourth consecutive annual analysis, readers will find a complete service overview, in-depth cohort analysis, and a detailed breakdown of clinical outcomes. Additionally, the report highlights recent service developments that continue to improve accessibility, quality, and user experience within the SilverCloud platform.

This initiative comes at a crucial time for our public health system, which has made significant investments to support effective mental health services for all. Our independently commissioned Return On Investment analysis that concluded last year (Pg 10) underscores the immense value of this public-private investment: SilverCloud delivers comparable or even superior therapeutic outcomes, while achieving approximately 75% cost savings, compared to traditional low-intensity therapies. This analysis demonstrates how SilverCloud, as part of our partnership with the HSE in Ireland, consistently provides better value for money, with lower costs per intervention and high rates of effectiveness, even outperforming comparable services in NHS England.

Following our call last year to expand digital mental health support to children and young people, we are delighted to share that this has come to fruition. In partnership with the Irish Society for the Prevention of Cruelty to Children (ISPCC) and with support from the HSE, we have launched new SilverCloud digital mental health programmes tailored for young people and their caregivers. These free, guided CBT-based programmes focus on early intervention for mild-to-moderate mental health difficulties – such as anxiety and low mood – providing timely support that helps reduce wait times and alleviate pressure in primary care psychology and CAMHS (Child and Adolescent Mental Health Services). This investment in our youth’s well-being is already making a difference and will help build a healthier future for all.

However, we recognise a persisting disparity in service uptake. Approximately 73% of SilverCloud users are female, which means men remain underrepresented. Improving engagement among men is a key priority going forward, to ensure equitable access to our digital mental health services for all who need them.

In addition, our evaluation of the new Space for Sleep programme revealed significant room for growth. While sleep difficulties are widespread, only about 6% of clients have been prescribed to Space for Sleep so far. This low uptake by referrers represents a clear opportunity to strengthen support for people experiencing sleep difficulties. By increasing awareness of the programme’s suitability, we can drive greater use and improve the overall effectiveness of the service.

Liam Ryan Country Manager Ireland

Meanwhile, our collaboration with the Irish College of General Practitioners (ICGP) has significantly improved the referral process. Through targeted GP education initiatives and the launch of an internal GP Practice Database, our Clinical Operations team reduced the Healthlink referral rejection rate from 45% to just 15%. Further gains are expected as these initiatives continue to mature, ensuring that more people referred to SilverCloud can access care without unnecessary delays.

Country Manager Ireland Amwell

Report Summary

This report provides an evaluation of the Health Service Executive’s (HSE) national guided digital ® ® Cognitive Behavioural Therapy (CBT) service provided by SilverCloud by Amwell to expand access to mental health care across the Republic of Ireland.

The report begins with an overview of the Clinical Operations team and how it has expanded in tandem with the growth of the service over the last 4 years.

The subsequent sections of the report first provide a main evaluation of SilverCloud within the HSE examining referrals, activations, client demographics, programme usage, and clinical outcomes. Second, evaluations are reported for three updates to the implementation of the service. These updates include designating SilverCloud as unsuitable for clients with severe depression, initiatives to improve Healthlink referrals and referral acceptance rates, and the addition of Space for Sleep to the SilverCloud programme offerings. Last, concluding remarks and recommendations are made.

The number of accepted referrals and account activations for 2025 is projected to remain at the historical high of ~16,500 accepted referrals with a 65% activation rate.

GPs continue to be the source of the highest number of referrals, representing ~93% of the total referrals with an activation rate of 65%.

Activation rates are substantially lower from Primary Care Psychology (PCP), Jigsaw, and Community Mental Health Teams (CMHT) referral sources (~45-57%), though these three sources constitute only 2.5% of all referrals.

The majority of clients continue to be female (72%), White Irish (87%), and aged between 18-44 years (75%).

There is a persisting discrepancy in the proportions of clients who are male (27%) versus female (72%) and who are older (9%) vs. middle aged (40%) clients.

Space from Depression and Anxiety surpassed Space from Anxiety as the most frequently used programme with 45% of overall activated accounts.

At the start of treatment most clients (91%) report positive expectations about their potential to benefit from SilverCloud. Once using SilverCloud, the overall user satisfaction rating with SilverCloud remains high at 94%.

The subsequent section of the report focuses on programme usage and treatment-related improvements for programme completers.

The total proportion of programme completers that transitioned to recovery in either depression or anxiety was 51%. These rates are similar to those observed in Talking Therapies (formally IAPT) services in the UK. **

Sub-group analyses in programme completers clarified that improvements in depression and anxiety are evident across all age levels and independent of whether someone identifies as male, female or other.

Individuals aged 18-24 or who identify their gender as ‘Non-binary or Other’ have lower reliable improvement and recovery rates than other age and gender groups.

The third section of the report presents some updates around service development that

have been implemented since the last report:

The detailed change in suitability criteria for the use of SilverCloud has reduced the number of clients who indicate severe depression (PHQ-9 ≥20) and flag risk, clients who may need higher intensity interventions than SilverCloud.

While the introduction of the Healthlink referral has benefitted GPs, it also presented difficulties with rejected referrals due to the omission of necessary information. The SilverCloud Clinical Operations team combined the use of targeted educational initiatives and the launch of an internal GP Practice Database to reduce referral rejection rate from 45% to 15%, with further improvements ongoing.

Since its implementation, ~6% of clients have been prescribed Space for Sleep. Examination of the symptom profiles and percentage of clients being prescribed this programme suggest it is meeting a clear client need.

Incorporating the Space for Sleep programme has improved insomnia symptoms in a significant portion of clients. However, the findings and feedback from supporters identified clear areas of limitation and how the programme could be improved.

The final section of the report provides the conclusions and recommendations that can be

drawn from the evaluation of HSE’s national guided digital CBT service to date. These include:

Examining why clients aged 18-24 or who identify as non-binary/other gender experience less benefit from SilverCloud could yield ways to further improve service outcomes for these individuals.

Increasing awareness in males and older adults about the availability and potential benefits of the digital CBT service could reduce demographic discrepancies in who uses SilverCloud.

The SilverCloud suite of subclinical programmes (e.g., Resilience, Stress Management, and Sleep Hygiene) could be a potentially better option for the 33% of clients who start with minimal or mild symptoms.

After changing suitability criteria for use of SilverCloud to exclude clients with severe depression, almost half of the remaining risk instances occurred in clients who met criteria for severe anxiety symptoms (35 out of 80 at-risk clients). This category of anxiety could be used as a suitability criterion to further reroute clients who are more likely to show risk to more appropriate treatments.

Given the changes in suitability criteria, when examining the overall performance of the service on clinical outcomes, it will be important to keep in mind that reliable improvement rates will be lower than before, although an increase in recovery rates should also be expected.

The SilverCloud Clinical Operations team has combined the use of targeted educational initiatives and the launch of an internal GP Practice Database to reduce the Healthlink referral rejection rates from 45% to 15%.

Space for Sleep provision could be improved by efforts such as administering the full PHQ-9 and GAD-7, refining programme suitability or content around clients with more complex symptoms or circumstances, examining what factors distinguish clients who do versus do not engage with the programme, adding reminders to complete the sleep diary, and making the criteria for unlocking the sleep prescription more accessible.

*A user meets the criteria for reliable improvement when they show a decrease of at least 5-points on the PHQ-9 scale or at least 4-points on the GAD-7 scale from pre- to post-treatment. **A user meets the criteria for recovery when they move from caseness (>9 on PHQ-9 or >7 on GAD-7) to non-caseness (i.e. below these thresholds) post-intervention.

Platform and Programme Overview

Evidence-based Guided Digital CBT Programmes

SilverCloud ® by Amwell ® is a result of nearly 20 years of clinical research with leading academic institutions. The suite of mental health programmes now available, designed for those experiencing mild to moderate symptoms of anxiety or low mood, have been recommended and approved for use by NICE (The National Institute for Health and Care Excellence, UK).

The SilverCloud ® platform can be used by patients/clients on their journey towards better mental well-being and to help them cope with whatever they may be going through.

Individuals can access the SilverCloud platform quickly, easily, and confidentially, on their mobile, tablet, or computer device.

SilverCloud programmes combine psychoeducation, behavioural activation, as well as cognitive restructuring and mindfulness-based techniques, delivering interactive, skill-building tools to manage mental health and wellness.

SilverCloud programmes can be used in various scenarios, including a standalone intervention, whilst the patient/client waits for their appointment, in conjunction with existing therapy sessions, or as a recovery toolkit post therapy.

While completing the 6–8-week SilverCloud programme, patients/clients are assigned a Supporter who communicates with them asynchronously via the SilverCloud platform, in the form of a written review. The Supporter’s role is to provide personalised guidance and support based on the patient/client’s progress through the SilverCloud programme.

A referral from a nominated approved clinician pathway* is required to access the SilverCloud platform.

*We can accept referrals from General Practitioners, Primary Care Psychology, Community Mental Health Teams, the National Counselling Service/Counselling in Primary Care, and Jigsaw.

Research, and recent experience, continues to show that people engage well

with digital mental health support. Access to an evidence-based programme

such as SilverCloud to address anxiety and depression is a really important

and helpful addition to the range of supports being provided by the HSE.

Derek Chambers,

GM Policy Implementation,

HSE Press Release,

HSE Mental Health Operations

30 November 2022

® SilverCloud programmes available through the HSE partnership

The five SilverCloud programmes currently available through the HSE partnership are:

Anxiety

Depression

Depression & Anxiety

Generalised Anxiety Disorder

New Programmes will become available.

Please note: due to the use of sleep restriction techniques within the programme, the Sleep programme is not suitable for people with bipolar disorder, untreated sleep apnoea, parasomnias, or seizure disorder.

To learn more about the HSE partnership and download individual programme descriptors, please visit: www.silvercloudhealth.com/hse

Referral criteria for SilverCloud programmes

Be Aged 18+

All individuals referred must:

Reside in the Republic of Ireland

Have good literacy and computer literacy skills

Suitable:

Disturbed sleep

High self-efficacy

Openness to guided self-help

Panic attacks

Not Suitable:

Acute distress or Post-traumatic stress disorder (PTSD)

SilverCloud programmes are NOT a crisis support tool.

Severe mental health difficulties / had inpatient stays

Key Takeaways-Referrals

~16,500 accepted referrals The majority of users have been in 2025 female (73%), white Irish (87%), and

aged between 18-44 years (75%)

91% of users indicated that The Depression & Anxiety they believed SilverCloud Digital programme is the most used

CBT could work for them (45%) before commencing treatment

Key Takeaways-Our Referrers

93% of referrals are from GPs GPs have the highest activation rate at 65%

Firstly, Thank you for all your support over the past few months.

I really appreciate it. I find this site a huge help to me as I

can log on anytime day or night whenever the feelings hit. I

can do it on the times of my choosing, both good days or bad

days. It's getting better gradually. More grumpy days than

actual depression days, and believe me when I say, there IS a

difference between those moods. Thank you again for all your help. I might eventually get used to this technology crack!!

Nancy (pseudonym), Sligo, 45-54yrs

Key Takeaways-Who we are helping

Rates of Reliable Improvement: Rates of Recovery: 63% of users with clinical levels 51% of users with clinical levels of

of anxiety or depression achieved anxiety or depression transitioned reliable improvement. to recovery.

All 26 counties of the Overall user Republic of Ireland satisfaction rate is

94%

Thanks for the ongoing support and the new modules ... This course is proving to be a positive

influence for me. the structure it provides, and taking some reflection time daily, is very helpful

Marc, Dublin, 45-54yrs

Return on Investment Analysis

As reported last year, Amwell commissioned an independent and comprehensive analysis of the performance of its SilverCloud platform within Ireland's national guided digital Cognitive Behavioural Therapy (CBT) service, focusing on service improvement and cost-effectiveness through a return-on-investment (ROI) framework. Benchmarking was performed against similar services offered by NHS England’s Talking Therapies for Anxiety and Depression (TTad), formerly known as IAPT services.

Impact of Service on Clinical Outcomes The SilverCloud platform demonstrated strong service performance in terms of improving mental health outcomes.

The SilverCloud platform demonstrated strong service performance in terms of improving mental health outcomes. Key outcomes include:

• Recovery: where the user moved from clinical case status to non-clinical levels of anxiety or depression. • Reliable Recovery: where the user achieved both significant reductions in symptoms and transitioned to non-

• Reliable Recovery: where the user achieved both significant reductions in symptoms and transitioned to nonclinical levels of anxiety or depression.

Users of the SilverCloud platform demonstrated higher levels of recovery over alternative low-intensity therapies, such as guided self-help. Similarly, SilverCloud users achieved a reliable recovery rate that was comparable to, and in some cases slightly better than, other low-intensity interventions. This demonstrates SilverCloud’s consistent effectiveness in delivering positive mental health outcomes.

SilverCloud's fixed cost per service user in Ireland’s national digital CBT-based service is substantially lower than the average cost of similar therapies in NHS England’s TTad services. In comparison, the cost of other low-intensity therapies in the TTad system is estimated to be 2 to 4 times higher per course of therapy.

Cost Savings SilverCloud's fixed cost per service user in Ireland’s national digital CBT-based service is substantially lower than

The report highlights:

• SilverCloud's cost-effectiveness: The cost per course of therapy is significantly lower than alternatives such as guided self-help or psychoeducational peer support. • Return on Investment: SilverCloud delivers comparable or better therapeutic outcomes while generating

• Return on Investment: SilverCloud delivers comparable or better therapeutic outcomes while generating approximately 75% savings in return on investment. In other words, the SilverCloud platform achieves the same results at a fraction—roughly 25%—of the cost associated with other low-intensity therapies.

Benchmarking and Sensitivity Analysis The report conducted sensitivity analyses to explore the effects of varying costs in NHS England’s services. Even

The report conducted sensitivity analyses to explore the effects of varying costs in NHS England’s services. Even under conservative estimates (e.g., assuming the lowest cost for a trainee therapist), SilverCloud continued to show a favourable ROI compared to the NHS’s therapy services.

David’s Case Study

Topic: Anxiety and Low Mood

Background

David is 47 years old, recently became a father for the first time, and works full time. David’s mental health challenges began to build during a demanding period at work, combined with the pressures of adjusting to life with a newborn. The constant pace gradually started to affect his sleep, concentration and ability to switch off, leading to persistent worry and periods of low mood.

David's Story

David’s routine was predictable but relentless. He worked full-time, commuted 30 minutes each way, and came home to support his partner with their new baby. Although he was proud to provide for his family, he often felt stretched thin. Despite trying to keep everything under control, he began to feel increasingly withdrawn and disconnected from friends and colleagues. The ongoing pressure made it harder to maintain his usual resilience.

Seeking Help

David had never used a digital mental health programme before and wasn’t sure if it would suit him. What made it workable was the ability to use it privately and on his own schedule, without needing to speak to anyone. The programme gave him clear steps to follow and short check-ins through the platform, which let him see how he was doing and where to focus next. This helped him stay engaged while still feeling in control of the process.

Like many men navigating new family responsibilities alongside work demands, he was finding it harder to manage rising levels of stress and anxiety.

This eventually led him to speak to his GP, who introduced him to the “Depression & Anxiety” programme on SilverCloud.

I always saw myself as someone who could cope, no matter how

busy things got. But after our baby arrived, I noticed small things

started to get on top of me. I was tired, distracted, and didn’t feel

like myself. I wanted to be fully present at home, but I felt like I was running on empty.

One morning on my commute, I realised I couldn’t keep ignoring

how I was feeling. I contacted my GP later that week, and he

recommended trying SilverCloud. It felt like the right first step.

Using SilverCloud

The structure of the CBT-based programme helped David break down his thoughts and understand why his anxiety had intensified. The flexibility to work through modules on his lunch break or after the baby’s bedtime meant he could build it into his routine without added pressure. He found particular value in the modules focused on worry management and sleep. These gave him practical tools he could use both during difficult moments and in planning healthier long-term habits. Impact David’s experience shows how accessible digital mental health support can make a meaningful difference, especially for people juggling work, commuting and new family demands. The programme equipped him with tools to understand and manage his symptoms, helping him regain balance and confidence.. Advice to Others

The Mood Monitor helped me track patterns I hadn’t noticed. Activity Scheduling made a bigger difference than I expected. Even

small changes gave me a sense of control again.

SilverCloud helped me reset my approach to stress. My partner

noticed I was calmer and more engaged at home. I felt more grounded and more like myself again.

If you’re struggling but unsure where to start, I’d say give it a

try. Looking after your mental health is just as important as

looking after your physical health. The support is there, and

it can make a real difference.

Scan to See Clinician

Information Page

Letter to Referring Clinicians

Dear Clinicians, ® ® In collaboration with the Health Service Executive (HSE), SilverCloud by Amwell is delighted to provide the National Guided Digital Cognitive Behaviour Therapy (CBT) Service for adults. In the last year, we have added our Space for Sleep programme to the treatment range, for patients who need such a targeted intervention. Our programmes bring evidence-based, clinically validated mental health support directly to those who need it, empowering them to take charge of their mental health.

The clinical results speak for themselves:

63% of service users with clinical levels of anxiety or depression who completed a programme achieved reliable improvement. *

51% of service users with clinical levels of anxiety or depression who completed a programme

transitioned to recovery. **

A 94% satisfaction rating underscores the platform's effectiveness.

Through the SilverCloud platform, your patients can access a programme immediately, and at a time that suits them. The flexibility of our digital platform means that your patients can work at their own pace, learning CBT techniques to make meaningful changes toward improved mental well-being.

In April 2025, in collaboration with the HSE and in line with UK’s National Institute for Health and Care Excellence (NICE) guidance , SilverCloud updated its suitability criteria to focus on clients with mild-to- moderate presentations and to route those with severe depression symptoms (PHQ-9 ≥20) toward higher- intensity care. Since this change, the proportion of clients flagging clinical risk has halved, while overall recovery rates have improved. These findings confirm that SilverCloud continues to deliver strong clinical outcomes for appropriate users, while ensuring those with more acute needs are directed to the level of care most suited to them.

® Your patients’ journey with SilverCloud includes guidance in the form of written reviews from a trained Supporter, who provides feedback, empathy, and encouragement, ensuring each person’s experience is personalised and supportive. Our digital mental health programmes support adults experiencing mild to moderate anxiety or low mood and are not suitable for more severe presentations.

In conclusion, please note that our programmes have a continued recommendation or approval from the NICE. While Ireland does not currently have an equivalent national framework, NICE guidelines are widely regarded as the gold standard for evidence-based healthcare, including digital mental health solutions. They provide a reliable benchmark for ensuring quality and effectiveness.

Warm regards,

Elaine Martin

Director, Clinical Operations Amwell

** A service user meets the criteria for reliable improvement when they show a decrease of at least 5-points on the PHQ-9 scale or* at least 4-points on the GAD-7 scale from pre- to post-treatment. *** A service user meets the criteria for recovery when they move from caseness (>9 on PHQ-9 or >7 on GAD-7) to noncaseness (i.e.* below these thresholds) post-intervention. ©2025 American Well Corporation. All rights reserved. Amwell® and SilverCloud® are registered trademarks of American Well Corporation.

Clinical Operations Team

The SilverCloud Clinical Operations team supporting the HSE service has grown substantially over the past number of years. Starting out with a team comprised of just one Administrator, one Clinical Supervisor and eight Supporters in April 2021, the team is now made up of 34 members which include Supporters, Administrators, Clinical Supervisors, a Senior Supporter, Clinical Lead and a Director of Clinical Operations.

The team is passionate about access to evidence-based digital mental health treatment, and each member strives to ensure that the experience for both referring clinicians and service clients is positive, efficient, and effective.

Elaine Martin, Director of Clinical Operations

Elaine Martin is a Chartered Counselling Psychologist with a history of working in the public, voluntary and private sectors. She is committed to innovative ways of sharing psychology to improve well-being and effect social change. As a psychologist working in HSE primary care, she introduced bibliotherapy to Ireland in 2006 and expanded it nationwide with the 'Power of Words' scheme in 2009. Working as a Principal Psychologist Specialist, she developed psychology services for the Anti-Human Trafficking Team & Women’s Health Service of the HSE. She has a special interest in the subject of cultural identity and the Irish Psyche in particular. She is the current chairperson of the International Cognitive Analytic Therapy Association.

Dr Corinne Pearson, Clinical Lead/Clinical Supervisor

Corinne is a Chartered Clinical Psychologist (DClinPsy; PgDip; MSc, BSc) who is dual registered in the UK & Ireland (HCPC & PSI). She is experienced in Clinical Leadership and supporting services in navigating regulatory standards involving the development of robust clinical governance processes.

Cathy Culloty, Clinical Supervisor

Cathy is a registered Psychotherapist and Clinical Supervisor with over 10 years of experience. She brings a wealth of clinical experience through her work in the student counselling service in Dublin City University and her previous role as the Director of Clinical services at the Goldsmith Clinic.

Dr Lisa Smith, Clinical Supervisor

Since graduating from University College London as a Clinical Psychologist (Registered in the UK (Registered in the UK and Ireland with the HCPC, BPS and PSI), Lisa has over 13 years’ experience of working in the NHS and in private practice. She has extensive experience in both CAMHS and adult mental health in a range of different settings from early intervention community teams to inpatient care. She is a highly experienced clinician with a passion for early intervention and improving accessibility to mental health services.

Dr Ellie Murphy, Clinical Supervisor

Ellie is a Chartered Counselling Psychologist, registered in the UK with the HCPC and BPS, bringing over 15 years of experience across the Ministry of Defence, the Foreign Office, the NHS, and the private sector. She possesses substantial clinical expertise and is committed to upholding the highest professional standards and best practice guidelines within the field of psychological therapy.

Clinical Operations Team

Erika Carroll, Senior Supporter

Erika joined SilverCloud as a Supporter in November 2023 and has been the Senior Supporter on the team for the past year. With a MSc in Applied Psychology from Trinity College Dublin, Erika brings a wealth of expertise to her role. As a research assistant in Trinity College, Erika specialised in staff wellbeing, working closely with the HSE to improve outcomes for staff. With over three years of experience volunteering with the NiteLine Student Listening Service, Erika has developed strong skills in active listening and empathetic engagement which she takes into her client work in SilverCloud. Erika provides a non-judgemental and compassionate space for her clients and peers, helping them to share their thoughts, feel heard and grow.

Orla Corbett, Associate Manager of Clinical Administration

With extensive experience as a clinician specialising in Applied Behaviour Analysis, Orla has supported children and adults with neurodevelopmental, learning, and mental health needs across diverse healthcare and educational settings in both Ireland and the UK. She successfully transitioned to the commercial sector, taking on a B2B role with a medical device company focused on objective testing for neurodevelopmental conditions. In this capacity, Orla managed remote services throughout Europe and emerging global markets. She brings valuable expertise in patient care, strong organisational capabilities, and a dedication to advancing remote technologies.

Calvin Ashe, Clinical Operations Coordinator

Calvin joined SilverCloud in March of 2022 with a BSc in Psychology. Calvin has a keen interest in online mental health solutions. Calvin strives to ensure the highest standards of clinical governance and procedures to ensure the successful running of the service. Calvin has used his attention to detail and organisational skills in his role in Clinical Administration at SilverCloud.

Rebekah Hare, Clinical Operations Coordinator

Rebekah joined the service’s Clinical Administration team after working as a Supporter. She holds a BSc in Psychology from UCD alongside a Masters in Sports, Exercise, and Performance Psychology from UL. Rebekah has provided early intervention mental health workshops in schools across Leinster. Furthermore, she has plenty of administrative experience to bring to her role. Rebekah has a keen interest in the benefits of exercise for mental health as well as the psychology of motivation and compassion focused therapy. This allows her take care of her own mental health whilst also helping others to do so.

Rebecca Lock, Clinical Operations Coordinator

Rebecca joined SilverCloud in March 2024 as a Supporter and later went on to join the Clinical Administration team in December 2024. She holds an MSc in Clinical Psychology and has worked in a variety of mental health settings, with a passion for finding everyday solutions to improve mental wellbeing. She uses this passion to help the Clinical Administration team create positive change in SilverCloud for both clients and colleagues and contribute to the day-to-day running of the service.

Clinical Operations Team

Emma Colloton, Clinical Operations Coordinator

Emma joined SilverCloud in June 2025 with a BA Hons. in Social Care Practice. Emma brings experience in both social care and administrative roles, along with an understanding of client-centred support services. Emma is passionate about making mental health support more accessible to all. Emma applies her organisational abilities and interpersonal skills to her role in Clinical Administration.

It is incredibly rewarding when clients share how much better

they are feeling. From a Supporter’s perspective, I can see how hard they are working, completing the modules, engaging with

the material, and applying it to their daily lives. Their effort is

reflected in their questionnaire scores, and I am often struck

by how much strength and courage it takes for someone who

is feeling unwell to try something new, notice old patterns of thought, and challenge them. I really appreciate how SilverCloud

emphasises person-centred care, with the client being the expert in their own journey. The programme gives them strategies they

can draw on from their toolbox, and clients often comment that

they are less fearful of feeling bad again because they now have

new ways of thinking and strategies to help during those times. I

feel privileged to witness this transformation, and it is meaningful to have even a small role, offering encouragement, validation, and

guidance toward parts of the programme or a call with a clinical supervisor that may support them further.

Leilah Seris, Behavioural Health Coach (Supporter)

I have found working as a Supporter with SilverCloud to be an

incredibly valuable and rewarding experience. Not only have I benefitted in my clinical experience, but I have also found the

service massively inspiring as a model first-step mental health support. I have greatly enjoyed having the opportunity to work with

such a caring and dedicated team, as well as with such a wide array

of clients nationally, from all backgrounds and all walks of life. I

really believe in our service, and the positive impact that we have.

Timothy KellyLester, Behavioural Health Coach (Supporter)

How to refer?

Referrals to SilverCloud

® programmes can be made by:

General Practitioners National Counselling Service/ Community Mental Health Teams Primary Care Psychologists Counselling in Primary Care Jigsaw

What information to include in a referral?

1Patient/Client Information:

Patient/Client’s full name Patient/Client’s e-mail address (mandatory to set up access to the SilverCloud platform) Patient/Client’s phone number Patient/Client’s DOB*

** Please note this service is only suitable for those aged 18 and over.*

2Referrer and GP Information* (if the referrer is not a GP):

Referrer’s and GP’s full name Referrer’s HSE or Jigsaw e-mail address and GP’s Practice Healthmail address Referrer’s and GP’s phone number GP Practice Name Referrer's job title

** GP details are required in case of risk escalation.*

3Programme Details:

Name of the programme the patient/client is being referred to: Depression Anxiety Depression and Anxiety GAD (Generalised Anxiety Disorder) Sleep

Where the referring clinician does not specify which programme the patient or client is being referred to, the patient or client will be able to choose one of the following three programmes: Depression, Anxiety or Depression and Anxiety. Please do not send any other patient information. In referring your patient, you are making the clinical judgement that the SilverCloud programme is an appropriate intervention currently and that your patient meets our inclusion criteria. We will only exclude your patient should it become apparent that our intervention is not suitable or that your patient no longer meets inclusion criteria. Once a referral is received, our team will contact the patient/client by e-mail within 2 business days and invite them to create their account on the SilverCloud platform. We ask that referrers advise their patient/client to look out for an e-mail from SilverCloud in their inbox, Spam or Junk folder. Once your patient/client creates their SilverCloud account, we will notify you. Please note, GPs must include their Practice Healthmail e-mail address for patient/client-related communication from our Clinical Team.

Any incomplete, inaccurate or inappropriate referral will be rejected.

To access and/or download our How to Refer Guide visit: www.silvercloudhealth.com/hse

Available referral pathways

Healthmail: Referrals to SilverCloud programmes can be made securely via Healthmail. E-mail your referral to silvercloud@healthmail.ie using your Healthmail, @hse.ie or @jigsaw.ie e-mail address. Please ensure to include all required information in your referral, as outlined in the section “What information to include in a referral?” Tip: A referral letter template can be set-up in most Patient Management Systems used by General Practitioners,

e.g., Socrates, HealthOne, Helix. Healthlink: General Practitioners can refer patients to the SilverCloud programmes via Healthlink, which is integrated into Patient Management Systems (PMS) used in Ireland, e.g., Socrates, HealthOne, Helix. To make a referral, select the SilverCloud service and the corresponding SilverCloud programme from the list of available Healthlink referral options in your PMS. Patient/client e-mail address MUST be included in the referral. Our team needs it to invite you patient/ client to the SilverCloud platform. GP’s Healthmail e-mail address MUST be included in the referral. Our team needs it to issue clinical updates, discharge notifications and manage potential risk. Please note that referrals with no e-mail address for either the patient/client AND/OR GP will be rejected. Tip: If your PMS doesn’t display an appropriate field to input your Healthmail e-mail address, please include it in the “Reason for Referral” section of the Healthlink referral form. If the patient email is already captured in the patient chart, it will automatically be displayed in the Healthlink referral. e-Referral: All clinicians will soon be able to refer their patients/clients to the SilverCloud programmes via e-Referral. Once launched, you will see this referral pathway listed in the “How to Refer” section of our website, www.silvercloudhealth.com/hse

If you have any questions, please contact Paulina.Chmara@amwell.com (Referrer Education Programme Lead).

Risk Management

The SilverCloud ® service is overseen by a panel of Clinical Supervisors, who are responsible for handling risk occurrences. Risk occurrences are assessed by our Clinical Team on a case-by-case basis. This is a necessary step in our risk management process, as it allows our Clinical Team to determine whether the SilverCloud programme is best suited to meet the needs of the patient/client. Eligibility and risk assessment/management processes are continuously reviewed to ensure they remain aligned with the evolving needs of clients and best clinical practices.

Risk screening

As part of the sign-up process, the patient/client completes a series of screening questionnaires, including the PHQ-2 / PHQ-9 (assessing depression severity) and GAD-2 / GAD-7 (assessing anxiety severity)*. This step allows our Clinical Team to identify potential risk.

Our Supporters are also trained to screen for risk throughout the duration of the programme. This is done by monitoring the patient/client’s engagement with the programme, responses on readministered screening questionnaires and monitoring for concerning content, e.g., disclosures of past/current abuse.

** Clients referred to the Sleep programme complete the PHQ-2 and GAD-2. If their scores are in the clinical range,* they are presented with the PHQ-9 and/or GAD-7.

Managing flagged risk

1Prior to programme commencement:

If a patient/client’s responses on the PHQ-9 indicate a level of potential risk of harm, the P4 screener is automatically activated. The P4 screener looks at history of harm, current thoughts, current intent, as well as protective factors. If there is any indication of potential risk on the P4, a patient/client's responses are then reviewed by a Clinical Supervisor/Clinical Lead with 3 potential outcomes:

i Patient/client is assessed as safe to start the SilverCloud programme, and no phone call

from the Clinical Supervisor/Clinical Lead is required. Access to the programme is granted and a Supporter is assigned to the patient/client.

ii Patient/client is assessed as requiring a phone call from a Clinical Supervisor/Clinical

Lead to complete the assessment of safety and suitability of the SilverCloud programme. This phone call must be completed before the patient/client can start the programme. A request to schedule a phone call is issued to the client via SMS/text or email and the risk is communicated to the referrer and GP. If the patient/client does not respond to the e-mail request, they are discharged from the SilverCloud service.

iii Patient/client’s risk screening assessment via screening questionnaire indicates that

there may be significant difficulty staying safe and that the SilverCloud programme will not meet the patient/client’s current needs. The patient/client is discharged without having to complete a phone call and the risk is communicated to the referrer and GP.

Where the need for a phone call is identified, , the client is contacted via SMS/text message or email by: clinical-admin-ireland@silvercloudhealth.com

Please note that the above listed e-mail address CANNOT accept referrals.

All e-mail referrals MUST be sent to our Healthmail inbox: silvercloud@healthmail.ie

All requests to schedule a call provide a 2-week window for the patient/client to schedule a call with a Clinical Supervisor/Clinical Lead. The phone assessment is then completed, and the patient/client is either considered safe to progress with the SilverCloud programme, or it is determined that the SilverCloud programme is not an appropriate support for the patient/client’s current needs, in which case the patient/client is discharged and our Clinical Team notifies the referrer and client’s GP (if different) of this outcome.

2Throughout the programme:

Our Clinical Team may also need to contact the patient/client if potential risk is flagged (automatically) by a review questionnaire, or by the patient/client’s Supporter (who monitors any content shared by the patient/ client on a weekly basis).

When it is determined that a phone call would be helpful to complete any review/assessment/check-in, the Administration Team contacts the patient/client via SMS/text or email, to schedule a phone call with a Clinical Supervisor/Clinical Lead. Usually reviews are allowed to continue, and the patient/client is informed that their participation in the phone call is voluntary.

Where there are significant concerns regarding safety, the Clinical Supervisor/Clinical Lead may attempt to “cold call” the client or determine that reviews are stopped until a phone call can be made. The patient/client is made aware of this in the e-mail correspondence.

When a phone call is required, the Clinical Supervisor/Clinical Lead will determine the outcome such as: continued engagement with the programme, discharge with recommendations for other therapeutic supports, continuation but change of programme etc.

At all times when receiving Supporter reviews, the Supporter will monitor content for any concerns/risk related issues.

Where there are concerns that the risk is too high for the programme, that other therapeutic input is needed to meet the patient/client’s needs, or that the programme is no longer appropriate to support the patient/ client’s current needs, the patient/client is discharged, and the referrer and client’s GP (if different) is notified of this outcome.

Report Background

This report provides an evaluation of the national guided digital CBT service provided by

the HSE in partnership with SilverCloud

® by Amwell ® to expand access to mental health care across the Republic of Ireland.

This service has been accessible to individuals who receive a referral from one of five referring groups: General Practitioners, HSE Primary Care Psychology, HSE Counselling in Primary Care, HSE Community Mental Health Teams, and Jigsaw.

Since the service was launched in April 2021 several target milestones have been reached

and reported on and published on www.silvercloudhealth.com/hse.

The current report provides an overview of key service-level metrics such as referrals and account activations, user-level data such as user demographics, baseline symptomatology, clinical outcomes, programme usage and user satisfaction. This report also provides summaries of various service development activities that have been implemented and evaluated within the last year. Data in this report range from the start of use of SilverCloud within the HSE in 2021 to September 30th, 2025.

Invitations and Activations

Referrals are the prescriptions made by clinicians who can refer patients to the SilverCloud platform. Complete and accepted referrals take the form of an invitation to SilverCloud that the patient receives through a secure email. Within the email patients can click on a link to navigate to the SilverCloud platform where they can create and activate their account. The proportion of invitations accepted by patients relative to the total number of invitations sent is how activation rate is measured.

Figure 1. shows the volume of invitations and account activations from 2021 to September 30th, 2025. The volume of invitations and activations has increased since the service was launched in 2021. From January to September 30th, 2025, 11,405 clients have been invited to SilverCloud. Based upon the average monthly referral total, it is projected that by the end of the year the annual total of invitations will increase to ~16,500 invitations, which is similar to the volume of invitations in 2024. Consistent with the pattern observed in previous years, general practitioners (GPs) remain the source of the most referrals in 2025, constituting 92.6% of referrals. Counselling in Primary Care was the next highest source of referrals with 2.9%.

Number of invitations & activated accounts

The activation rate of accounts in 2025 was 64.7%, which represents ~1% increase in activation rate in comparison to 2024. It is notable that activation rates had remained at 61% in 2021 and 2022 but increased to ~65% in 2023 to 2025. This increase may be due to Clinical Operations efforts beginning in 2023 to educate clinicians on the service and appropriate referrals.

Figure 1. Invitations, account activations from 2021 to September 30th 2025.

The activation rates in 2025 (Jan. - Sept.) across each referral source are presented in Table 1. The activation rates range from 45.4% to 65.0%, with GPs accounting for the highest activation rate at 65%. The activation rates from GPs and Counselling in Primary Care (CIPC) are generally comparable to similar nationwide digital CBT initiatives in the United Kingdom (UK), where average activation rates of 65% have been reported for similar referral sources within the National Health Service (NHS). However, activation rates for Primary Care Psychology (PCP), Jigsaw, and Community Mental Health Teams (CMHT) are notably lower, though sample size is fairly small for PCP and Jigsaw and these sources combined constituted only 2.5% of all referrals.

Referral Group	Total Invitations Sent	Total Accounts Activated	Activation Rate(%)
GPs	10544	6864	65.0%
Counselling in Primary Care	347	223	64.2%
Primary Care Psychology	124	71	57.2%
Jigsaw	11	5	45.4%
Community Mental Health	379	213	56.2%
Total	11406	7376	64.7%

Table 1. Invitations and activations in 2025 for each referral source.

Summary

In comparison to 2024, the number of invitations and account activations for 2025 is projected to remain at the historical high of ~16,500 accepted referrals with a 65% activation rate.

Overall, activation rates have risen and are comparable to those of other NHS-UK services, which have achieved a similar rate of 65%.

User Demographics and Baseline Information

During the account activation process, clients are asked demographic questions about gender, education, ethnicity, age, work status, relationship status, and sexual orientation. They are also asked whether they have been prescribed any psychiatric medication and to rate how likely they think SilverCloud would work for them. Finally, baseline depression and anxiety symptomology is assessed through the PHQ-9 and the GAD-7

Figure 2. presents the distribution of service clients’ gender, education levels, ethnicity and age. Clients have been primarily female (72.1%), white Irish (87.0%), have at least a college or university degree (61.5%), and aged between 18-44 years (74.8%).

Figure 2. Pie charts illustrating the distributions of client gender, education, ethnicity and age.

The client distributions for education and ethnicity are consistent with the demographics of the general population of Ireland. However, there are a lesser proportion of males and adults over 65 than in the general Irish population, which consists of 50% male and 15% adults over the age of 65 (CSO.ie). These imbalances may reflect that females and people in the 18-44 age are more likely to present to their clinicians with depression and anxiety and be more accepting of digital therapeutics. However, this pattern may also reflect clinicians believing that the platform is better suited for females or younger populations.

Table 2 presents client distributions of work status, relationship status, sexual orientation, medication use, and treatment expectations. Most clients were employed at least part-time (72.3%), were either married or in a relationship (60.4%), and were heterosexual (88.2%). Additionally, approximately half of the clients were prescribed and taking psychiatric medication (54.1%), while 7.3% were prescribed such medication but were not taking it.

Overall, clients had positive expectations toward using SilverCloud as a treatment as 91.3% indicated that they believed that SilverCloud Digital CBT was at least somewhat likely to work for them. This is encouraging as research has demonstrated that positive treatment expectations are associated with positive psychotherapy treatment experiences and good clinical outcomes (e.g. Tambling, 2012).

The distribution of the counties of residence of service clients is provided in Figure 3. Most clients resided in Dublin (29.0%; n = 8,993). The counties with the least number of clients were Longford (n=147), Leitrim (n=239), and Roscommon (N=250).

		n	%
Work Status	Employed part or full time	9,520	72.3%
Unemployed	3,653	27.7%
Relationship Status	Single	9,293	33.8%
In a relationship	8,592	30.2%
Married	8,694	30.6%
Separate or divorced	1,577	5.5%
Widowed	269	0.9%
Sexual Orientation	Heterosexual	18,735	88.2%
Bisexual	1,266	6.0%
Gay or lesbian	752	3.5%
Other	489	2.3%
Medication	Not prescribed	11,800	38.6%
Prescribed and taking	16,549	54.1%
Prescribed but not taking	2,224	7.3%
Expectations	Extremely likely	983	3.3%
Very likely	6,987	23.2%
Somewhat likely	19,549	64.8%
Not very likely	2,367	7.8%
Not at all likely	275	0.9%

Table 2. Work status, relationship status, sexual orientation, medication use, and treatment expectations.

Figure 3. Distribution of counties of residence of clients.

Most clients also completed the PHQ-9 (95.8%) and GAD-7 (95.9%) at baseline. Across all clients, 67.9% of clients met the criteria for clinical levels of depression (>9 PHQ-9) and 78.0% had clinical levels of anxiety (>7 GAD-7). 61.5% met the clinical level on both the PHQ-9 and GAD-7. The distributions of baseline PHQ-9 and GAD-7 severity scores are shown in Figure 4.

Figure 4. Proportion of clients at PHQ-9 and GAD-7 severity categories.

Figure 5 presents the frequency of programme use across all clients. The most used programme is ‘Space from Depression and Anxiety’, which is a change from the 2024 report where ‘Space from Anxiety’ was the most used programme. This increase in popularity of ‘Space from Depression and Anxiety’ may reflect that this programme was added in July 2023 as an option for clients to select in the Client’s Choice pathway. The high prevalence of this programme is also in line with the high co-morbidity of depression and anxiety in clients given that 62% scored at clinical levels on both the PHQ-9 and GAD-7.

Figure 5. The proportions of clients who used each of the SilverCloud CBT programmes.

User Satisfaction

There have been 228,016 module ratings across all module evaluation questionnaires to date. The overall user satisfaction rating is 94% (percentage of all the ratings that were marked as “agree” or “strongly agree”). More specifically, 95.1% agreed that the modules were interesting, 95.1% agreed that the modules were relevant, 93.6% agreed the modules were helpful, and 93.7% agreed the program is helping them make progress. Figure 6 displays the breakdown of ratings across all module questionnaire responses.

45, 000

40, 000 37,914 38,297 36,984 35, 000 33,923

30, 000

25, 000 20,260 20, 000 17,220 Number of Clients 15,484 15,155 15, 000

10, 000

5,000 2,320 2,361 3,097 3,088 480 460 509 464 0 M odul e was M odul e was M odul e was Programme helpi ng Interesting Rel evant Helpful me make progress

Strongly Disagree Disagree Agree Strongly Agree

Figure 6. User Satisfaction Ratings. At the end of each module, clients can evaluate the module by rating four statements

on a scale from “strongly disagree” to “strongly agree. Clients can rate as many of the statements as they want or skip the module evaluation questionnaire entirely.

Summary

The observed distributions for education levels and ethnicity are consistent with the demographics of the general population of Ireland. However, the imbalance in the proportion of female and male clients and the low representation of older adults do not reflect the population demographics of Ireland.

While Dublin continues to stand out as the county within which most service clients reside, every county in the Republic of Ireland now has at least 100 service clients, indicating good nationwide reach.

Most clients (91%) have positive expectations about their potential to benefit from SilverCloud.

67.9% of clients met the criteria for clinical levels of depression and 78.0% met clinical levels for anxiety. Space from Depression and Anxiety (as opposed to Space from Anxiety) is now the most frequently used programme with 44.5% of clients having used it. The user satisfaction rating continues to be very high at 94%. ©2025 American Well Corporation. All rights reserved. Amwell® and SilverCloud® are registered trademarks of American Well Corporation.

Status of Accounts

A breakdown of the status of accounts as of September 30th, 2025, is presented in Table 3. Of the 33,727 clients who have activated a SilverCloud account to date, 88.7% have been marked as completed, and 3.0% are currently in treatment. The remaining 8.4% of accounts are either deleted (i.e. user has requested for their account to be deleted), excluded (i.e. client has been excluded while a risk assessment is being conducted or due to providing insufficient information during the sign-up process), new referral (i.e. client has recently accepted their invitation to create an account, but they are yet to be assigned a clinical supporter), paused (i.e. client has requested for their reviews and clinical support to be temporarily put on hold), or unsuitable (i.e., user did not meet criteria for use of SilverCloud, e.g., severe depression symptoms during sign-up assessments or indicating risk such that SilverCloud was unsuitable).

Completed	Current	Deleted	Excluded	New Referral	Paused	Unsuitable
88.7%	3.0%	0.4%	0.5%	0.1%	0.1%	7.3%

Table 3. Status of accounts.

Clients marked as Completed can be assigned different reasons for completion (see Figure 7). The definitions corresponding to each of the five reasons for completion are as follows:

Ended earlier than planned: These clients engaged beyond the first login but either received 2 less than 75% of planned support, did not respond to outreach, or did not complete any follow-up assessment.

Moved to other option: These clients were moved to other support, such as face-to-face 4 therapy.

Ended at request of client: These clients opted out, e.g. due to stressful events such as 5 bereavement or exams.

Figure 7. Summary of the reasons clients’ accounts were marked as completed

Programme Completers

The remaining section of the report focuses on the subset of clients who met the criteria for ‘Ending as planned’ (n = 13,755). All of these clients have completed both baseline and follow-up clinical assessments at least 4 weeks apart and received at least 75% of planned support.

Programme Engagement

Programme engagement metrics are presented in Table 4. Similar to previous reports, programme usage suggests a high level of engagement with the service among clients who end treatment as planned, although there is substantial variability across clients.

	Mean(STD)	Median(IQR)
No.of Logins	32.4(53.7)	20.0(11-36)
No.of Reviews	6.9(1.1)	6.0(6-8)
Time Spent(mins)	325.2(528.7)	189.9(89.1-382.2)
Avg Time per Session(mins)	11.2(8.4)	9.1(5.7-14.2)

Table 4. Engagement and use of the platform.

Clinical Outcomes for Depression and Anxiety Programmes

	Baseline Severity	Improvement rate
PHQ-9	Minimal	435/1,097(39.7%)
Mild	2,208/3,486(63.3%)
GAD-7	Minimal	361/902(40.0%)
Mild	2,012/3,466(58.0%)

As in previous reports, it is important to distinguish between those who present with minimal-to-mild versus moderate-to-severe symptoms. For example, ‘recovery’ metrics cannot be calculated for individuals who started with minimal-to-mild symptoms as they did not meet the threshold levels for clinical caseness at the outset, and these clients also have minimal room for reliable improvement. Hence, for this cohort, improvements are solely calculated based on an improvement of at least 1 point in PHQ-9 or GAD-7 (see Table 5).

Table 5. Improvement rates for clients with minimal and mild severity at baseline

Reliable Improvement and Recovery Rates

For clients who had at least moderate levels of depression or anxiety at baseline, rates of recovery and reliable improvement were calculated. A client meets the criteria for recovery when they move from caseness (>9 on PHQ-9 or >7 on GAD-7) to non-caseness (i.e. below these thresholds) post-intervention. A client meets the criteria for reliable improvement when they show a decrease of at least 5-points on the PHQ-9 or at least 4-points on the GAD-7 from pre- to post-treatment.

Nearly identical with the proportions reported in the 2024 annual report, the total proportion of clients achieving reliable improvement in either depression or anxiety is 63.0%. The total proportion of clients that transitioned to recovery in either depression or anxiety is 50.9%. Rates of reliable improvement and recovery for PHQ-9 and GAD-7 for each severity level and overall are shown in Table 6.

Consistent with the patterns typically reported in the published literature on these metrics, rates of reliable improvement increase with higher levels of baseline severity, with the highest rates of reliable improvement occurring in clients who had more severe levels of depression and anxiety at baseline. In contrast, rates of recovery decrease as baseline severity increases because clients need a higher magnitude of change to reach the threshold for recovery.

	Baseline Severity	Reliable Improvement"n"(%)	Recovery"n"(%)
PHQ-9	Moderate	1,456/3,771(38.6%)	2,185/3,771(57.9%)
Moderately Severe	1,782/3,231(55.2%)	1,158/3,231(35.8%)
Severe	874/2,109(59.8%)	423/2,109(20.1%)
Total	4,505/9,146(49.3%)	3,796/9,146(41.2%)
GAD-7	Moderate	2,039/3,763(54.2%)	1,816/3,763(48.3%)
Severe	3,219/5,297(60.8%)	1,400/5,297(26.4%)
Total	5,674/10,391(54.6%)	4,023/10,391(38.7%)

Table 6. Reliable improvement and recovery rates for clients that had at least moderate levels of depression or anxiety at baseline

Baseline to follow-up changes in the proportions of clients in each severity category for depression and anxiety are presented in Figure 8. There is a clear reduction in the proportion of clients in the higher levels of symptom severity and an increase in the proportion of clients in the minimal and mild categories.

PHQ-9 Severity Categories

GAD-7 Severity Categories

Figure 8. Baseline and follow-up distributions of symptom severity for depression and anxiety as measured by

the PHQ-9 and GAD-7, respectively.

Overall, rates of reliable deterioration from baseline to post-intervention as measured by the PHQ-9 and GAD-7 have also been very low. For the PHQ-9 the rate of reliable deterioration is

Sub-group Analysis

Subgroup analyses examined the impact of the programmes on clinical outcomes across gender and age groups. Statistically significant improvements on the PHQ-9 and GAD-7 from baseline to follow-up are evident across all age levels (all p < .001), and independent of whether someone identifies as male, female or other (all p < .001).

The reliable improvement and recovery rates on the PHQ-9 or GAD-7 across gender and age groups for all programme completers who had at least moderate levels of depression and/or anxiety at baseline are presented in Table 7. Despite the relatively low numbers of 65+ adults being referred to the service, those that were referred had similar or better outcomes in comparison to other adult age groups on the programmes (e.g., 68.3% reliable improvement vs. 54.5-65.3% reliable improvement). In contrast, adults aged 18-24 had noticeably lower rates of reliable improvement and recovery in comparison to the other adult age groups (e.g., 57.5% reliable improvement vs. 64.6-68.3% reliable improvement).

In terms of gender, males and females had similar reliable improvement and recovery rates. However, individuals identifying as 'Non-binary or Other' had rates of reliable improvement and recovery that were 5-9% lower than males and females.

		Reliable Improvement on PHQ-9 or GAD-7(%)	Recovery on PHQ-9 or GAD-7(%)
Age	18-24(N=2,464)	57.5%	40.1%
25-34(N=3,074)	64.6%	50.2%
35-44(N=2,893)	64.5%	54.0%
45-54(N=1,675)	63.9%	56.6%
55-64(N=835)	65.3%	58.0%
65+ (N=240)	68.3%	68.5%
Gender	Female(N=8,362)	63.8%	50.5%
Male(N=2,836)	61.0%	52.6%
Non-binary/Other(N=104)	55.9%	41.3%

Clients in the severe range showed the highest rates of reliable improvement, but only 1 in 5 have achieved recovery, indicating that while this cohort can benefit from SilverCloud, they likely require more intensive support to achieve recovery. This supports the decision on April 23rd, 2025 to not offer SilverCloud to these clients and instead recommend more intensive treatment.

Summary

Service Development Highlights

The following subsections of the report provide summaries of the results and impact of some changes made since May 2024 to the implementation of SilverCloud within the HSE.

1. Examining the Impact of Screening out Clients with Severe Depression Symptoms from the service

Beginning on April 23, 2025, the HSE suitability criteria for SilverCloud was changed to designate the intervention as unsuitable for clients with severe depression symptoms, instead recommending that they be routed to other more intensive treatments suitable to their needs. This decision was based on 1.) NICE guidance which recommends interventions such as SilverCloud as the first line of treatment for less severe depression but the last line of treatment for more severe depression. 2.) SilverCloud was designed for clients with mild-to-moderate symptoms, 3.) clients with severe symptoms (vs. moderate or moderately-severe) are the least likely to recover from their symptoms during use of SilverCloud, and 4.) the higher needs of this client group which a low-intensity service cannot meet.

In practice, clients who scored in the severe range on the PHQ-9 at sign-up were not offered a programme. Instead, they were referred back to their referrer, and GP where appropriate, who was informed of their acuity and any risk that was indicated on the PHQ-9. Since this criterion was implemented, 17.9% of clients have presented to SilverCloud with severe depression scores on the PHQ-9 and have been referred back for other treatment.

To examine the effects of this change, this evaluation compared the frequency of risk flagged, demographics, baseline symptoms, and clinical outcomes before versus after the exclusion of clients with severe depression (i.e., before vs. after April 23rd, 2025). Only clients who completed sign-up for SilverCloud and who were not excluded, designated unsuitable, or who were current clients were retained for these analyses (clients before April 23rd, 2025 N=28,649, clients on or after April 23, 2025 N=2,323).

Prior to April 23rd, 8.7% of clients (2,492/28,649 clients) flagged risk on the P4 screener during their use of SilverCloud. In contrast, only 3.4% of clients (80/2,243 clients) flagged risk on the P4 on or after April 23rd, indicating that clients at higher risk were routed back to their referrer earlier with a recommendation of more appropriate treatment services. Of the 80 clients who flagged risk, 35 of these clients met criteria for severe anxiety symptoms, suggesting that this category of anxiety could be used as a suitability criterion to further Percent of clients flagging risk on P4 screener decrease risk within SilverCloud.

8.7% 3.4%

on P4 screener

Percent of clients flagging risk

Before April 23, 2025 April 23, 2025 & Later

Figure 1. Percent of clients flagging risk on the P4 screener before April 23rd, 2025 vs. on April 23rd, 2025 and later

Examining the profiles of clients (e.g., demographic characteristics) revealed insubstantial differences in the proportions of gender, age, ethnicity, and education levels for clients before April 23rd vs. on and after April 23rd. Figures 2 and 3 depict the proportions of these demographics for these time periods. Differences in gender, ethnicity, and education level category proportions were all less than 1%. Differences in age categories were less than 2.5%, with a trend for fewer clients under age 45 and an increase for clients age 45 or greater.

Gender

Age

Figure 2. Gender and age proportions before April 23rd, 2025 vs. on April 23rd, 2025 and later.

Ethnicity

Education

Figure 3. Ethnicity and education level proportions before April 23rd, 2025 vs. on April 23rd, 2025 and later.

In terms of baseline symptoms, there was an expected drop in baseline depression severity as PHQ-9 mean scores (Before April 23rd = 13.04 vs. From April 23rd = 11.40) and percentage of clients meeting screening criteria for clinical depression decreased (Before April 23rd = 68.2% vs. From April 23rd = 63.8%). Baseline anxiety symptom severity remained fairly similar as mean scores on the GAD-7 declined by 0.5 points (Before April 23rd = 12.69 vs. From April 23rd = 12.12) and percentage of clients meeting screening criteria for clinical anxiety remained the same (Before April 23rd = 78.0% vs. From April 23rd = 77.9%.)

For clinical outcomes, clinical reliable improvement and recovery rates were examined in the subsample of clients whose use of SilverCloud ‘ended as planned’ (clients before April 23rd, 2025 N=12,821, clients on or after April 23, 2025 N=934). Reliable improvement rates on the PHQ-9 decreased by ~4%, while recovery rate increased by 6.5% This trend is also expected given that clients with higher symptoms severity are the most likely to have reliable improvement while also being the least likely to recover.

	Time Period	Reliable Improvement(%)	Recovery(n)(%)
PHQ-9	Before April 23,2025	49.5%	40.8%
On April 23,2025 or after	45.6%	47.3%
GAD-7	Before April 23,2025	54.5%	38.4%
On April 23,2025 or after	56.1%	42.5%

Table 1. Clinical outcomes on PHQ-9 and GAD-7 for clients before April 23rd, 2025 vs. clients on or after April 23, 2025.

Overall, changing criteria for use of SilverCloud to exclude clients with severe depression has reduced the number of clients who flag risk by half. Almost half of the remaining risk instances occurred in clients who met criteria for severe anxiety symptoms, suggesting that this category of anxiety could be used as a suitability criterion to further decrease risk within SilverCloud. Outside of expected changes to baseline depression severity, this change in access criteria has minimally affected the demographic of clients who received SilverCloud. However, when examining the overall performance of the service on clinical outcomes, it will be important to keep in mind that reliable improvement rates will be lower than before, although an increase in recovery rates should also be expected.

2. Initiatives to Improve the Acceptance rate of Healthlink Referrals

The Healthlink referral pathway to SilverCloud became available to Irish GPs in October 2023; however, its initial implementation encountered high rates of referrals being rejected. This report details causes of these difficulties and initiatives that have been implemented to solve them.

Healthlink is a secure messaging service that facilitates the transfer of patient information between healthcare providers and has been introduced into the four accredited Patient Management Systems (PMS) used by GPs in Ireland, namely HealthOne, Helix Practice Manager, Socrates and CompleteGP. 1,2 Healthlink enables Irish GPs to send referrals directly from their PMS, allowing for a quicker, more streamlined referral process, and a reduction of the administrative burden on the clinician. Its use allows for patient information to be pulled directly from the PMS and populated into a referral form, reducing the workload and errors associated with manual data transcription. It also allows for a referral to be transmitted in real time, removing the risk of correspondence delays typically associated with traditional channels of referral submission, such as post or fax. Moreover, an acknowledgement or rejection of referral can be returned directly into the PMS, facilitating traceability and eliminating the need for a follow-up call to confirm referral delivery.

Prior to the introduction of the Healthlink referral pathway, all referrals to the SilverCloud service in Ireland were handled exclusively via Healthmail. Healthmail is a secure clinical email system, facilitating the transfer of patient-identifiable clinical information within a private bounded network. It is currently used as the primary means of communicating service-related notifications by SilverCloud. Information shared via Healthmail arrives in the form of an e-mail and may still require manual processing by the clinician or administrative staff. Unlike Healthmail, Healthlink facilitates the transfer of structured data between clinical systems, enabling a higher degree of automation.

Since its introduction, Healthlink has quickly become the primary referral pathway to the SilverCloud service. As of September 2025, 81% of referrals are made through Healthlink. While the use of Healthlink provides significant benefits to GPs in Ireland, its introduction into the SilverCloud referral pathway also introduced a range of challenges that affected our ability to process referrals efficiently.

In November 2023, 46% of referrals submitted to our service via Healthlink were unable to be processed due to missing information. The most common rejection reason was “missing practice Healthmail address,” followed by “missing patient email address”. These details were often omitted from the referral because they are not automatically populated in Healthlink’s National Standard Referral Form. For instance, Healthlink’s National Standard Referral Form does not automatically send the practice Healthmail address, despite it automatically sending other practice information such as address or phone number. It also does not have a dedicated “Practice Healthmail email address” field for clinicians to list the Healthmail email address in the referral. Moreover, a patient’s email address may not have been captured on the patient’s electronic health record and therefore not shared in the referral to SilverCloud.

eHealth Ireland (n.d.). GP Practice Management Systems. Retrieved from https://www.ehealthireland.ie/case-studies/gp-practice-management- systems/#:~:text=There%20are%20four%20accredited%20GP%20Practice%20Software%20Systems.,Clanwilliam%20Investments%20Ltd.%20CompleteGP%20 is%20an%20independent%20company.
eHealth Ireland (n.d.). Training Materials. Retrieved from https://www.ehealthireland.ie/technology-and-transformation-functions/access-to-information- a2i/healthlink1/training-material/#:~:text=Some%20of%20the%20most%20popular%20user%20guides%20and,If%20you%20require%20additional%20 assistance%20please%20contact%20support.healthlink%40hse.ie ©2025 American Well Corporation. All rights reserved. Amwell® and SilverCloud® are registered trademarks of American Well Corporation.

To address these challenges, we implemented multiple strategies to improve the success of referrals submitted to the SilverCloud service. First, we now ask GPs to manually enter the patient’s email address and practice Healthmail email address in the “Reason for Referral” section of the Healthlink referral form to ensure that this information is sent. Second, incomplete Healthlink referrals are now rejected and sent back to the referring clinician with information regarding why the referral was rejected. Third, a series of service notifications were emailed (using Healthmail) in November, December and January (2023-2024) to current and past referrers. These notifications focused on educating clinicians about referral requirements and acknowledging the challenges posed by the introduction of Healthlink, namely that GPs had to learn how to use a new referral programme and that some information was not shared via the Healthlink referral form by default.

Figure 1 below shows the percent of rejected Healthlink referrals over time in addition to the dates of key

initiatives to improve referrals. As depicted, the percentage of rejected referrals submitted via Healthlink decreased to ~20% by June 2024, supporting the conclusion that our efforts to address referral challenges were successful. However, the rejection rate plateaued and did not further improve for several months after June 2024.

Figure 1. Percent of Healthlink referrals rejected over time.

To address this plateau, an additional initiative was launched in April 2025: the development of a living internal “GP Practice Database”. This database comprises verified contact details for each referring practice, including a phone number and a monitored, practice-wide Healthmail email address. This database can then be easily used to fill in missing required referring practice information. By September 2025, the percentage of rejected referrals via Healthlink had further decreased to ~15%, supporting the utility of this database.

In summary, the introduction of the Healthlink referral pathway into the SilverCloud service in October 2023 represented a key service enhancement. Its use enabled GPs to initiate referrals directly from their PMS and leveraged the benefits of system automation, making the referral process faster and more convenient for GPs. While the introduction of the Healthlink referral benefitted GPs, it also had difficulties with incomplete referrals as key contact information, such as patient email address and practice Healthmail email address, were often omitted. This resulted in a high number of rejected referrals. To address these issues, SilverCloud combined the use of targeted educational initiatives and the launch of an internal GP Practice Database to improve referrals. These initiatives decreased the referral rejection rate from 45% to 15%. Efforts to grow the GP Practice Database continue and are projected to lead to further improvements in referral acceptance rates. These rates could continue to be improved by integrating Healthlink with SilverCloud’s / the service’s PCMIS case management system.

Evaluating the Space for Sleep Programme

Space for Sleep was implemented within the HSE in June 2024 where it can be prescribed for suitable clients. Since this date, approximately 6% of HSE clients have been prescribed Space for Sleep. To shed light on the performance of this programme and gather learnings to improve its implementation, this evaluation was conducted in two parts. First, client data from the 408 HSE clients who have been discharged from the programme

conducted in two parts. First, client data from the 408 HSE clients who have been discharged from the programme were used to evaluate client baseline symptom profiles, programme engagement, and clinical outcomes. Second, Space for Sleep supporters were surveyed to assess their opinions, attitudes, and experiences with the

Second, Space for Sleep supporters were surveyed to assess their opinions, attitudes, and experiences with the programme to reveal potential points of improvement. The full evaluation report is available upon request to the

Analysis of the client baseline symptoms (via BIS, PHQ-2, GAD-2, and WSAS scores) of these 408 clients identified three common symptom profiles presenting to Space for Sleep.

Profile 1 - Moderate insomnia with low comorbid mood symptoms and moderate functional impairment (N=59,14.4%),

Profile 2 - Severe insomnia with low comorbid mood symptoms and moderate functional impairment (N=248, 60.7%), and

Profile 3 - Severe insomnia with elevated comorbid mood symptoms and severe functional impairment (N=101, 24.7%).

In addition to the overall sample, client engagement and clinical outcomes were evaluated for each of these profile groups.

Figure 1 presents the estimated overall as well as profile specific probability of a client meeting the screening

threshold for insomnia on the Bergen Insomnia Scale (BIS) from Week 0 to Week 8 in the programme. Over all clients, there was ~35% decrease in the probability of meeting insomnia criteria from week 0 to week 8. All three symptom profiles had significant decreases in the probability of insomnia and there were not statistically significant differences in the magnitude of these decreases between the profiles.

The whole sample and each profile exhibited decreases in PHQ-2 and GAD-2 scores (see Figure 2; all p’s < .001). Clients with Profile 3 symptoms tended to have greater improvements in comorbid mood symptoms than clients in the other profiles. Although these results indicate that clients with elevated mood symptoms benefit from the programme, supporters expressed concerns regarding programme suitability for clients with severe anxiety and depression symptoms. Because only the GAD-2 and PHQ-2 were routinely administered to clients during use of Space for Sleep and provide limited insight into the extent and severity of these symptoms, a deeper analysis of how severe depression and anxiety symptoms influenced programme engagement and outcomes was not possible. Future inclusion of GAD-7 and PHQ-9 would allow for such an analysis.

Examining insomnia outcomes for clients who engaged vs. did not engage demonstrated that only clients who engaged exhibited significant decreases in probability of meeting insomnia criteria (~45% decrease) from week 0 to week 8 (see Figure 4). Feedback from the supporters suggests that there was a substantial group of clients with comorbidities or circumstances for whom the programme did not have adequate or appropriate content. Examples included clients with severe anxiety or depression, chronic pain, menopause, shift work, who were new parents, or who used sleep medication. It may be that these cases consist of many clients who did not engage with the programme. Therefore, it may be worth considering whether these factors should be excluding characteristics when determining client suitability for the programme or if the programme can be better adapted for these clients. Supporters also expressed a desire for further training on CBT-I and how it connects with programme content and tools. Incorporating best supporting practices and tips for these cases into training could aid supporters’ ability to engage these clients with the content. Overall, future work examining what differentiates clients who engage vs. do not engage could be used to enhance programme suitability guidelines, delivery of support, and programme content.

Figure 3. Login segments for clients in Space for Sleep.

Figure 4. Estimated probability of meeting BIS insomnia criteria from Week 0 to Week 8 for engagers vs. non-engagers.

Supporters also indicated that clients struggled to consistently complete the sleep diary tool. Because it is required to complete seven consecutive days of the sleep diary in order to receive a sleep prescription, clients often did not get a sleep prescription to follow. Examining the sleep log data demonstrated that, of clients who progressed far enough in the program to access the sleep prescription, only 29% (51/230 clients) completed the seven consecutive days of sleep logs required to unlock the sleep prescription. Supporters further noted that because the sleep prescription is a key ingredient that makes the programme effective, the stringency of the sleep diary requirement undermined programme effectiveness. It was suggested that the sleep diary requirement could be modified to be more lenient so that more clients can receive the sleep prescription, for instance by requiring the diary to be completed five out of seven days instead. Based upon sleep log data, changing the sleep log requirements for unlocking the sleep prescription to six or five days would increase the rate of clients receiving a sleep prescription to 33% and 38%, respectively.

Altogether, the findings highlight that the Space for Sleep programme is addressing a previously unmet client need and has improved insomnia symptoms in a significant portion of clients. However, the findings and feedback from supporters identified clear areas of limitation and how the programme could be improved.

Concluding Recommendations

Overall, the findings from this report are broadly consistent with previous reports and continue to demonstrate the success of the HSE’s digital CBT service. Recommendations for consideration are as follows:

Clients aged 18-24 or who identify as non-binary/other gender had lower reliable improvement and recovery rates. Further work exploring why these individuals experience less benefit from SilverCloud could further improve service outcomes.

There is a persisting discrepancy in the proportions of clients signing up for Silvercloud who are male (27.3%) versus female (72.1%) and who are older (9.1%) vs. middle aged (40.1%) clients. Developing awareness in these demographics about the availability and potential benefits of the digital CBT service could reduce these discrepancies.

Approximately 33% of clients start with minimal and mild symptoms. The SilverCloud suite of subclinical programmes (e.g., Resilience, Stress Management, and Sleep Hygiene) could be a potentially better option for these patients.

After changing suitability criteria for use of SilverCloud to exclude clients with severe depression, almost half of the remaining risk instances occurred in clients who met criteria for severe anxiety symptoms (35 out of 80 clients). This category of anxiety could be used as a suitability criterion to further route clients who are more likely to show risk to more appropriate treatments.

Space for Sleep provision could be improved by efforts such as administering the full PHQ-9 and GAD-7, refining programme suitability or content around clients with more complex symptoms or circumstances, examining what factors distinguigh people clients who do vs. do not engage with the programme, adding reminders to complete the sleep diary, and making the criteria for unlocking the sleep prescription more lenient

This report has been prepared by the Amwell Science team:

Dr. Garrett Hisler Dr. Daniel Duffy Dr. Angel Enrique Digital Health Scientist Director-Research Snr Manager Digital Health Scientist

Clinician Resources

Clinician Leaflet

Sleep Programme Descriptor

Clinic Poster

Clinician Handbook

ROI Analyses and Benchmarking

Anxiety Programme Descriptor

SilverCloud® by Amwell®

Notes

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