A pair of articles published this week in JAMA point to the potential promise of using digital interventions to help youth and adults who are experiencing symptoms of mental illness.
One article describes two separate trials involving adults aged 21 years and older who had clinically significant depressive symptoms (Patient Health Questionnaire-9 score of 10 or greater) and were being treated for hypertension and/or diabetes in São Paulo, Brazil, and Lima, Peru.
One group of participants received a smartphone with an app that regularly sent users automated behavioral activation sessions that could be completed in 10 minutes or less. The behavioral activation sessions focused on encouraging participation in activities pleasant or meaningful to the patient. Nurse assistants met with participants in the intervention group for an initial face-to-face meeting to go over the app and followed up by phone with participants who did not appear to be using the app. The second group received enhanced usual care, which included regular evaluations for depressive symptoms over the course of the trial and referral to specialists as needed. Participants in both groups received regular health services for depression, diabetes, or hypertension.
“[A] significantly greater proportion of participants who received the digital intervention compared with enhanced usual care experienced at least a 50% reduction in depressive symptoms at three months (40.7% vs. 28.6% in Brazil; 52.7% vs. 34.1% in Peru), although the differences were no longer statistically significant at six months,” reported Ricardo Araya, M.D., Ph.D., of King’s College London and colleagues. “In the intervention group, worsening of depressive symptoms occurred in 10% of patients and worsening of suicide ideation occurred in 6% of patients vs. worsening by 12% and 7% in the control group,” they added.
The second article describes a trial in Sweden comparing outcomes in children and adolescents aged 8 to 17 years with obsessive-compulsive disorder (OCD) who received either online cognitive-behavioral therapy (CBT) for 16 weeks followed by traditional in-person CBT if necessary (stepped-care group) versus in-person CBT alone (control group).
The online CBT program consisted of 14 modules, which included text, movies, and exercises centered on education, exposure with response prevention, and relapse prevention. The families of patients in the stepped-care group were assigned a therapist whom they could contact via an online platform. Participants in the control group received manualized in-person CBT with up to 14 sessions over 16 weeks. Youth in either group who were classified as nonresponders at three months were offered up to 12 sessions of in-person CBT between the three-month follow-up and six-month follow-up. Responder status was defined as those who experienced at least a 35% reduction on the Yale-Brown Obsessive-Compulsive Scale from baseline to follow-up.
“After six months, the mean Children’s Yale-Brown Obsessive-Compulsive Scale score was 11.57 in those treated with internet-delivered CBT vs. 10.57 in those treated with in-person CBT”—a difference that suggests the treatments are similarly effective, reported Kristina Aspvall, Ph.D., of the Karolinska Institutet and colleagues. “Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups.”
“Although these two studies featured different countries (high-income vs. low-/middle-income), different digital technology approaches (self-help app vs. computerized stepped care), different diseases (depression vs. OCD), and different ages (children and adolescents vs. adults), they shared underlying commonalities around the universal application of digital mental health, including the importance of human support, the need to monitor and assess digital interventions, and the need for assessment in the clinical population,” wrote psychiatrist John Torous, M.D., in an accompanying editorial. Torous is the director of the Digital Psychiatry Division in the Department of Psychiatry at Beth Israel Deaconess Medical Center and leads APA’s work group on the evaluation of smartphone apps. “Both studies also offer behavioral treatments that are low risk and thus may not be considered a high priority for clinician monitoring. … However, both studies show that low risk does not mean that there is no risk or need to follow and monitor patient progress.”
Torous concluded, “The two studies reported in this issue of JAMA are timely contributions that underscore how digital interventions can help patients today. They also highlight how high-quality research can advance digital health science and raise the next generation of questions to make digital approaches even more effective and clinically important.”
For related information, see the Psychiatric Services article “User Engagement in Mental Health Apps: A Review of Measurement, Reporting, and Validity.”
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