Almost 8 percent of Americans 12 and older dealt with
depression at some point between 2009 and 2012. With that many of us feeling
blue, would not it be nice if we could simply hop on the computer in our pajamas,
without any of the stigma of asking for help, and find real relief?
Online programs to fight depression are already
commercially available, and while they sound efficient and cost saving, a study
out of the U.K. reports that they are not effective, primarily because
depressed patients are not likely to engage with them or stick with them.
So, it is highly unlikely, that a computer
program will replace your therapist in the nearest future.
The bottom line: The computer programs
offered little or no benefit compared to more typical primary care for adults with
depression. That is largely because the patients were generally “unwilling to
engage” with the programs, and adherence faltered, researchers conclude, adding
that the study “highlighted the difficulty in repeatedly logging on to computer
systems when [patients] are clinically depressed.”
In an accompanying editorial, Christopher Dowrick, a
professor of primary care medicine at the University of Liverpool, stated what
may seem obvious: Many depressed patients, he wrote, don’t want to interact
with computers; rather, “they prefer to interact with human beings.” He noted
that the poor result “suggests that guided self help is not the panacea that
busy [primary care doctors] and cost conscious clinical commissioning groups
would wish for.”
As part of the study, 691 patients suffering from
depression were randomly assigned to receive the usual primary care, including
access to mental health care, or the usual care plus one of two computer-assisted
options that offer cognitive behavior therapy (CBT), a form of therapy that
encourages patients to reframe negative thoughts. Patients were assessed at
four, 12 and 24 months; those using the computer programs (one called “Beating
the Blues” and the other “MoodGYM“) were also contacted weekly by phone and
offered encouragement and technical support.
The context of all this is that demand for mental health
services generally exceeds supply around the globe, and health systems are
seeking ways to bridge the gap. According to the new paper, demand for
cognitive behavioral therapy, for instance, “cannot be met by existing
therapist resources.” So, the thinking goes, maybe a computer can ease some of
the caseload. And in some cases, it works. Indeed, Britain’s National Institute
of Health and Care Excellence (NICE) guidelines recommend computerized CBT as
an “initial lower intensity treatment for depression….” based on studies that
showed it can be effective.
However, results of this latest study may nudge
clinicians and policymakers to rethink the computer’s role in therapy.
Here are the results, summed up in news release:
* Results showed that cCBT offered little or no benefit
over usual GP care.
* By four months, 44% of patients in the usual care
group, 50% of patients in the Beating the Blues group, and 49% in the MoodGYM
group remained depressed….
* Only 18% of patients completed all eight sessions of
Beating the Blues, and 16% completed all six sessions of MoodGYM.
* Almost a quarter of patients dropped out of the study
by four months…
“Participants wanted a greater level of clinical support
as an adjunct to therapy, and in absence of this support, they commonly
disengaged with the computer programs,” explain the authors.
In his editorial, Dowrick asks: “How much human guidance
is needed? It is perhaps not surprising that a few minutes of telephone contact
with a technician, however well trained, did not have appreciable effects on
participants’ depressive symptoms….When considering how to help patients
presenting with mild to moderate depressive symptoms, GPs have many evidence
based interventions to choose from. They should remember that therapeutic
benefit is derived from their own contact with their patients, especially if
they convey a sense of hope and optimism and establish a positive relationship
with the patient.”
This is not to say there is no place for technology in
therapy. Some mental health providers say that a sort of hybrid approach, with
a combination of live interaction and an online component, can be extremely
effective.
D’Arcy, a 48-year-old mother in Hopkinton, Mass.,
suffered from high levels of anxiety and stress, aggravated by a variety of
health conditions that, in one year alone, required six operations.
Things got so bad, she said, that she developed an
intense reaction to ambulance sirens: Every time she heard one, she
hyperventilated and her body froze in place with fear.
She didn’t seek counseling, though, until the summer of 2013,
when a doctor treating her broken wrist commented that she was particularly
high strung.
D’Arcy was referred to cognitive behavioral therapist
Ana-Maria Vranceanu, an associate professor in psychology at Harvard Medical
School and a clinical psychologist at Massachusetts General Hospital. But
D’Arcy’s drive to Boston’s MGH from her home was grueling, requiring her to
spend four hours in the car for a 45 minute therapy session. So, after
traditional CBT for 12 weeks, she switched to virtual therapy, and now all of
her visits are done on her iPad.
“It’s a split screen — half the screen is her, half the
screen is me, and we talk,” said D’Arcy, who asked that her full name not be
used. (She also gets homework assignments at the end of each session.) “I thought
I’d get distracted by the stuff around me, but it doesn’t happen at all. I
actually think I’m more focused because we’re just looking at each other. And
it’s less stressful because I don’t have to drive.”
Now D’Arcy only connects with her therapist every third
week. “I really like the tele-therapy thing, but my personality would require
creating a trusting relationship with the therapist first. I wouldn’t just
automatically trust someone that I only met online. My teenagers might be
different, though. They’re much more willing to use technology as a primary
vehicle for doing everything. Face-to-face means less to them right now.”
Dr. Vranceanu, D’Arcy’s therapist, says she’s had “great
success” with an Internet-based program called Vydio, used in the MGH
Telepsychiatry program, which allows face-to-face sessions as well as the
ability to exchange documents. “My patients love it, and adherence to treatment
is almost perfect,” she wrote me in an email. “Generally there is growing
support that therapy over the Internet works just as well as face-to-face
therapy, and adherence rates are higher. So we know for sure that being in the
same room with a patient is not necessary for adherence and efficacy.”
Regarding the British study, Vranceanu writes:
Things are trickier with cCBT platforms. I think cCBT is useful for teaching general
CBT skills that are useful in daily life (e.g., understanding that perceptions
are skewed, restructuring negative automatic thoughts, learning about cognitive
errors, engagement in pleasurable and mastery activities, accessing social
support, etc). cCBT can also be very useful for teaching and monitoring
adherence to a medical regimen. However, when dealing with mental health issues
like clinical depression or anxiety, symptoms such as lack of motivation, low
energy can make it really hard for someone to follow through on their own with
a protocol.
Further, depression can encompass difficulties with
concentration, and so this can make some of the CBT concepts difficult to grasp.
There are studies that show that cCBT can help with mild and moderate
depression, but some meta analysis and meta regression has suggested that these
effect sizes may have been overestimated…
It seems that a lot of work needs to be done to understand
whether there are some patients for whom cCBT works, based on type of symptoms
and personality. The busy highly educated VP with mild depression may do well
with cCBT while the moderately depressed socially isolated student may need the
therapeutic relationship to instill motivation for learning and adhering to
CBT, and might drop out or not adhere to cCBT. In sum, I think the
inconsistency in research findings and difficulties with adherence are a clue
that we need to look at person specific factors that predict adherence.
Yes, we cannot discount the therapeutic alliance. Many
decades ago it was found to be the active ingredient in all therapies. However,
CBT types of therapy rely on the therapeutic alliance much less than other
forms of therapy such as psychodynamic or interpersonal. CBT therapy can be
compared with taking classes in the college. Also, some patients may need the
face to face contact more than others. Generally, cCBT could be very helpful
for prevention of depression in patients with family history and highs stress.
For patients in primary care, cCBT supplemented by phone calls or with report
back to the therapist (though email, etc.) can help a patients develop the
motivation necessary to adhere to treatment. A model of combined face to face
or Skype like CBT sessions followed by cCBT may also be successful.
Indeed, it may come down to the specifics of the patient,
and his or her particular diagnosis and demographic. For instance, studies have
found that age can make a difference, with younger people finding
technology-based treatment more effective compared to older adults.
Joseph Greer, a clinical psychologist at MGH’s Cancer
Center, reiterates that due to the very nature of depression, characterized by
a lack of energy and motivation, using technology can be a challenge. “So,
perhaps this isn’t going to be effective for people with extreme depression,
but it may be better for mild or moderate depression,” he said in an interview.
However, he said, technology could be a great resource
for people who would never go see a therapist or access mental health care
otherwise. Or it can be used as the first step in a therapeutic program: if the
person doesn’t respond initially, there might be follow-up with face-to-face
interventions, he said.
Greer is in the process of testing a self-administered
mobile app that offers cognitive behavioral therapy to advanced cancer patients
suffering from anxiety. “We wanted to use technology as a way to reach more
people,” Greer said. “But the question still remains, is adherence going to be
a problem?”
Because whether it’s anxiety, depression or some other
disorder, Greer said, treatment tends to be better “when there’s a human being
involved — the research shows that…A human, in real time, can tailor the
intervention to the patient’s specific needs — that’s much more difficult with
technology. You can do your best to make an algorithm with some tailoring in
it, but that’s very hard to create, and at some point you can only go so far in
that tailoring logic. When there’s a person involved, that tailoring is an
essential part of the job.”
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