Daniel Carlat, MD
Editor-in-Chief, Publisher, The Carlat Report.
Dr. Carlat has disclosed that he has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.
There are plenty of ways that we use technology in psychiatric practice these days—including e-prescribing, electronic health records, referring patients to websites for psychoeducation, etc. But when was the last time you referred a patient to their computer for psychotherapy? Well, it may be time to consider it.
First, let’s define some terms. This article is not about delivering therapy remotely via Skype or other technology. That would be called “teletherapy” or “telepsychiatry,” which is a well-established modality and is increasingly covered by insurance companies. Nor is this about “virtual therapy” in which your patient uses a fancy virtual reality device, like the Oculus Rift, to simulate being in a scary situation.
In this article, we’ll focus on potentially game-changing technology for busy psychiatrists called computer-assisted psychotherapy (CAP). Don’t have the time or the expertise to do therapy for a given patient? Are good therapists in short supply in your area? No problem—there are more and more websites offering experiences that come close to seeing a therapist. The modalities differ, but the most well-researched programs focus on cognitive behavioral therapy (CBT) for depression or anxiety disorders.
Evidence for Computer-Assisted Therapy
For a field that you may not have heard much about, you might be surprised that dozens of randomized controlled trials have already been conducted on different versions of CAP.
Before getting into the evidence, you should know about the inherent limitations of any study attempting to assess any kind of psychotherapy (for a lively discussion of the pitfalls of these studies, see Marks IM et al, Cogn Behav Ther 2009;38(2):83–90). The main problem is figuring out how to create a good control group. In medication trials, the usual control groups are either placebo or an active comparator—and preferably both.
In trials of psychotherapy, there’s no such thing as a true placebo control. The most common control group is the “wait-list,”—patients assigned to this group are told that their names will be put on a waiting list for treatment. Another tactic is to assign the control group to “treatment as usual” (TAU). This means telling patients to see their doctors and to follow their instructions—which might be a medication, some therapy, or nothing at all. Other studies use a bland non-specific treatment as a control, such as relaxation practice. None of these control groups can accomplish what a placebo can accomplish—which is to measure whether the active treatment has a specific curative component, beyond non-specific effects such as high expectations.
The best psychotherapy studies will randomly assign patients to three groups: the therapy being evaluated; another therapy already established as effective; and a no-treatment control (such as a wait-list group). But such ideal therapy studies are rare.
Another issue is that meta-analyses will tend to lump many different types of CAP together. Perhaps the most important distinction among them is how much therapeutic support patients are provided as augmentation to computer therapy.
With this in mind, let’s look at a recent meta-analysis evaluating the efficacy of CAP for depression (Richards D & Richardson T, Clin Psychol Rev 2012;32(4):329–342). Researchers combined nearly 3,000 patients from 19 randomized controlled studies (1,553 received CAP and 1,443 were controls). Most of the programs were based on CBT. Overall, CAP worked pretty well, with an effect size of 0.56, which is considered moderate and compares well to effect sizes of medications for depression.
Drilling into this data reveals something interesting, which is that those computer programs that included therapist support were far more effective (effect size 0.78) than programs without such support (effect size 0.36). What is “therapist support?” Some programs are meant as completely stand-alone treatment, whereas others include real therapist contact and support, which might be in the form of phone calls, emails, or brief supplemental in-person sessions. Thus, it appears that CAP works best when you “prescribe” the sessions to your patient and stay involved in some way. Other programs provided “administrative support” only, such as volunteers or administrative staff helping with technical issues. These programs had an effect size of 0.58, midway between therapist support and no support. The level of support also affected dropout rates with the highest dropouts in the no-support studies (74%) and the lowest in the therapist-supported studies (28%).
Road Tests of Computer-Assisted Psychotherapy
In order to give you a better feel for what CAP is like, both for you and your patients, we chose three popular programs to review: MoodGYM, Beating the Blues, and Good Days Ahead. Why did we choose these three, as opposed to the dozens of others in this increasingly crowded field? For a somewhat arbitrary reason, which was that a recently published article described these three programs in some detail, including a synthesis of the clinical trials that have evaluated each one (Eells TD et al, Psychotherapy 2014;51(2):191–197). We did not attempt a comprehensive Consumer Reports-type review of these products. Mostly, we wanted to give you a flavor of the experience of computer-assisted therapy in order to pique your interest.
Our methodology in evaluating the programs was informal—we logged on to the sites and poked around. When asked about our symptoms, we said we were mildly depressed and that we were down on ourselves for small stuff—such as getting the car stuck in the snow.
Howto access: Go to website and set up an account.
Efficacy evidence: MoodGYM was found to be more effective than weekly “checking in” phone calls for reducing depressive symptoms and for improving dysfunctional thinking in 525 moderately distressed individuals and effects were maintained for up to one year (Mackinnon A et al, Br J Psychiatry 2008;192(2):130–134).
Review: Developed by the Centre for Mental Health Research at the Australian National University, MoodGYM is the least flashy of the three programs we reviewed. It is based almost entirely on text, with a few drawings here and there, and is pretty funny. You are introduced to several prototype characters, one of whom, named “Noproblemos,” exemplifies healthy cognitions. “Cyber man,” on the other hand, “looks good on the outside but is a seething wreck inside.” You can click on the characters’ faces at various points throughout the program to learn about how distorted cognitions lead to negative emotions.
We meet these characters at various times throughout the modules and they are used to illustrate cognitive distortions—or, in MoodGYM’s jargon—“warped thoughts” such as all-or-none thinking and overgeneralization. There’s an initial psychoeducation component in which you get to practice identifying the character’s warped thoughts, and you learn how to generate “unwarping” statements. The key mnemonic used is WUTIWUF (What you think is what you feel), and it’s undeniably useful for quickly capturing the essence of CBT.
The “therapy” component is comprised of various forms and questionnaires to help you identify specific events, your warped thoughts in response, and how they lead to depression. For example, my event was, “I got my car stuck in the snow.” The program guided me through the process of identifying which type of warped thought this elicited (a “should statement”: “I should have prevented it”), followed by an unwarping thought: “I couldn’t have prevented it, it was too icy.”
Pros of MoodGYM:
It uses fun and colloquial language to make the material very accessible.
Cons of MoodGYM:
Too many quizzes to fill out—I felt too lazy to complete them, but without completing them you can’t go through the rest of the program. My experience is reflected by studies of MoodGYM, one of which found that only 138 of 3,174 users (4.3%) completed all five modules (Christensen H et al, Aust N Z J Psychiatry 2006;40(1):59– 62).
Too much text—which gets tedious.
Stand-alone (no support) which could mean higher dropouts and less efficacy.
Cost: Unclear. Currently available only through certain insurance companies and institutions.
How to access: Access is easiest in the United Kingdom, where the program was developed. Access in the US is limited. The University of Pittsburgh Medical Center, along with some behavioral healthcare providers in South Carolina, Kansas, and California, offer it and a project is currently underway to pilot it within the US Department of Veterans Affairs health system.
Efficacy evidence: This is the most studied of all CAPs, with multiple demonstrations of its efficacy as compared to treatment as usual (Eells et al, op cit.)
Review: Beating the Blues uses a combination of audio narration, animated graphics, and videos to accomplish psychoeducation and therapy. Of the three programs we reviewed, this did the best at providing an initial overview of the program. There are eight sessions, with each session containing three to five modules. These short modules take about 15 minutes to complete, which is an advantage for those with shorter attention spans.
The program uses videos of five different characters to illustrate automatic thoughts, feelings, and various techniques to improve one’s mood. As with the other programs, you are required to input your own experiences and automatic thoughts. The pacing of the program seemed well thought-out. For example, a fairly long and didactic lesson on basic CBT concepts was followed by an engaging module on pleasurable activities. This latter module guided me through steps on how to come up with mood-elevating things to do, and I could click on each of the characters to watch them describe their own anti-depressant activity, such as calling a friend.
Overall, it seemed like a very useful self-help treatment program, and I would imagine many patients benefitting.
Pros of Beating the Blues:
Sessions can be personalized and can build from one to the next, as with standard CBT.
Can be used with or without therapist support (report of patient progress is available to providers at end of each session).
Cost and Access: Prices are not published. For information, email Empower Interactive (the company that runs Good Days Ahead), at firstname.lastname@example.org.
Efficacy evidence: Two studies have endorsed its efficacy. It is one of few computerized treatments to be compared in a randomized trial to in-person CBT, and it proved to be just as effective for depression as traditional treatment.
Review: Good Days Ahead is a “supported” CAP, and is designed to be used as an adjunct to in-person CBT. As a clinician, you log in to your account and then you can invite patients to participate by inputting their email address. They will automatically be emailed by the system and can start participating.
There are nine lessons, and they rely heavily on videos. A psychiatrist narrator introduces and discusses CBT concepts. The core of the program is a series of videos following the story of Lisa, an employed married woman with depression.
In each vignette, Lisa interacts with somebody and we observe how she responds, often with a voiceover of her thoughts. For example, she is at her desk at work, and her boss calls her and wants to meet with her about a project. We hear her internal monologue: an automatic thought that her boss is going to reprimand her for taking too long on the project. There is a cut to the narrator who discusses Lisa’s reactions and uses it as a teaching opportunity to discuss the concept of automatic thoughts. This is followed by some brief quizzes to assess our understanding.
In some vignettes, there are alternate versions of the scene, with the first showing Lisa using distorted thoughts, and a second showing her successfully using CBT skills, such as developing rational thoughts. Through the different lessons we see Lisa gradually recovering from her depression.
The videos are well produced and the acting is pretty compelling. I found myself identifying with Lisa and rooting for her. As with the other programs, you are required to do assignments to identify your own automatic thoughts.
Although Good Days Ahead is not meant to be an independent therapy program, I believe it would be helpful for many patients even if not used in conjunction with therapy.
Pros of Good Days Ahead:
Developed for those with no previous computer experience (requires minimal typing skills and is written at the ninth-grade level).
Intended to be used with support, which usually means less drop out and better efficacy per studies.
Cons of Good Days Ahead:
Unclear pricing and availability.
Dr. Carlat’s Verdict: Computer-assisted psychotherapy, at least when based on cognitive behavioral therapy, shows a lot of promise. Consider adding it to your practice but learn about the various options, tinker with them, and check out accompanying clinician guides to get a sense of plusses and minuses of each.