The evidence base on how digital health solutions can support mental health continues to grow. Health systems look to the evidence base to determine which approaches, products and medicine to include in their offerings. The advent of apps, and the translation of clinical protocols into user experience opens up the potential to support more people across the globe. Cognitive Behavioral Therapy (CBT) has been a prominent form of psychological therapy to address depression and anxiety since the 1960s and was developed by Aaron Beck. The central tenets of CBT propose that psychological problems are rooted in faulty or unhelpful ways of thinking, and are learned patterns of unhelpful behavior which improve by learning new coping strategies. The path to healing involves gaining recognition of thought distortion, understanding the behavior and motivation of others and increasing confidence in addressing issues rather than avoiding them. This therapy has often been conducted in one-on-one sessions and has translated well to group settings. More recently, CBT is offered as a phone-based modality which is more convenient for people to access. In the last few years, CBT-based apps have also gained prominence.
The app space to support mental health is nascent, and a new paper in JAMA Psychiatry by Pim Cuijpers from the University of Amsterdam examines the effectiveness and acceptability of CBT delivered in multiple modalities which include individual and group therapy, phone-based care, and guided and unguided online self-care. This paper is an essential addition to our understanding as it compares five CBT modalities to control groups such as usual care and wait-list groups.
The network meta-analysis included 155 studies with 15,191 participants, of those, half met criteria for a depressive disorder and the remainder scored above the cutpoint on self-reported measures of depression including the Beck Depression Inventory and the PHQ-9, validated assessments of depression. Findings suggest that all five modalities were effective in delivering CBT when compared to usual care and wait-list controls. Acceptability, however, was another matter. Phone-based CBT was the most accepted form with guided self-help being the least accepted.
The low acceptance rate reported in this study has implications for the dissemination of app-based CBT tools. Apps are becoming ubiquitous; understanding barriers to acceptance will be necessary to scale these solutions globally. Do we need to ensure the app is introduced as part of clinical care by a known provider? Are apps perceived as less supportive than a clinician? How might apps perform when augmenting ongoing care? Would having support within the app increase acceptance? I am posing more questions than answers as we are still on our learning curve. Available apps are deployed in a variety of ways, and we will continue to learn about optimal ways to implement these solutions. The burden of mental illness is growing globally across all age ranges so digital health solutions can play a role in easing suffering.
Thanks for reading – Trina
(Opinions are my own)
Effectiveness and Acceptability of Cognitive Behavior Therapy Delivery Formats in Adults With Depression. A Network Meta-analysis
What is Cognitive Behavioral Therapy