August 15, 2015

SSCP Journal Club - Week 7: A review of technology-assisted self-help and minimal contact therapies for anxiety and depression

This week's article is A review of technology-assisted self-help and minimal contact therapies for anxiety and depression: Is human contact necessary for therapeutic efficacy?  The article can be found here.

The present review provides a critical examination of studies (to 2010) of technology-assisted treatments for anxiety and depression. The review included treatments that were almost wholly self-administered (with almost no therapist contact throughout the course of treatment), those that were considered “self-help” (with up to 90 min of therapist guidance in using the treatment), those consisting of “minimal contact” (more than 90 min of therapist guidance), and those that serve merely as an adjunct to what is primarily in-person therapy.

Potential benefits of technology-assisted treatment
· Cost-effective: estimated savings of $540-$630 when compared to individual CBT (Newman, Kenardy, Herman, & Taylor, 1997; Newman, Consoli, & Taylor, 1999).
· Ease of dissemination of EBTs including access for rural communities  (e.g., Newman, Consoli, & Taylor, 1997; Palmer, Bor, & Josse, 2000; Yager, 2001).
·  Less time-intensive (Newman, 2000; Newman, Erickson, Przeworski, & Dzus, 2003).
· Improved logistics: structured instructions for use, provide immediate feedback to clients, portability, may lead to easier implementation.

Previous examinations of technology-assisted treatment- Previous reviews of technology-assisted treatments for anxiety and depression found overall that they were efficacious alternatives to traditional therapy treatments. Only 1 review (Newman et al., 2003) considered the optimum degree of therapist contact for specific disorders but only looked at studies until 2000. Over 100 relevant papers have been published since 2000 so an update is needed. (I would argue that a further update is now needed in 2015).

Purpose of current review:

· comprehensively review the treatment studies of different technological applications to psychotherapy for anxiety and mood through 2009, specific to each disorder.
· continue to include previously reviewed studies.
· provide conclusions regarding the degree of therapist contact that is advisable for specific anxiety and mood disorders.

Anxiety disorders. The authors then comprehensively reviewed the literature of treatments for the following anxiety disorders:

· “Mixed” anxiety disorders -the most cost-effective option for mixed anxiety disorders, may be self-administered bibliotherapy exposure (but this is based on 1 study; Ghosh et al., 1988) Most controlled findings for mixed anxiety disorders support the use of minimal contact treatments as the optimal level of therapist contact.

·  Obsessive-compulsive disorder – Although one quasi-experiment showed that when the technology- assisted intervention was used as an adjunct to therapist-delivered exposure and response prevention, participants required fewer sessions with the therapist but did as well (Nakagawa et al., 2000), additional limitations suggest that technology- assisted treatments are not optimal for OCD.

· Panic disorder- Effective treatment involving a computer-administered program appears to entail minimal therapist contact (as little as 150 min;  

· Social phobia- Promising reductions in social phobia symptoms have been shown with primarily self-help interventions focused on attention retraining and exposure delivered in a clinic as well as with minimal contact computer treatments used at home.

· Generalized anxiety disorder and posttraumatic stress disorder- For the treatment of GAD, primarily self-help attention retraining holds some promise and for the treatment of PTSD, minimal-contact Internet sites hold promise. However, due to methodological difficulties, more studies are needed before any conclusions can be drawn.

· Simple phobia- Almost all of the studies involved virtual reality or computer-assisted exposure methods used in a lab or clinic. Ultimately, more research is needed regarding the optimal amount of therapist contact.

Depression. The authors then comprehensively reviewed the literature of technology-based depression treatments:

· Subthreshold depression- Few studies employed self-administered interventions and all targeted individuals with subthreshold depression. Results suggest these interventions may not be optimal for such individuals. Compliance was low.  A self-help intervention that includes a brief motivational interview also holds some promise but needs further testing.

· Major depression - There were several methodological shortcomings to these studies. For clinical levels of depression, self-help and self-administered computer treatments have not been tested without receipt of additional medical services. The most cost-effective option tested for these individuals was a 250-minute minimal contact treatment (Wright et al., 2005) but replication is needed.

Overall conclusions:

Taken together, efficacy has been demonstrated for computerized interventions anxiety and depression. The most evidence was for studies of mixed anxiety disorders, panic disorder, and social phobia. More through examination is needed for treatments of GAD, OCD, and PTSD.

When treatments are used at home with little human contact, compliance is lower. Taking attrition and compliance rates into account, minimal contact therapies have been most beneficial for the greatest variety of disorders (although there is disorder specific variability). This suggests some degree of interaction with a therapist is important in the treatment of anxiety and depression.

Future Research:

· newer technological advances yet to be tested therapeutically:

     Skype or Voice over Internet Protocols (see Strong, 2010, July 30); interactive virtual reality, such as Second Life (Gorini, Gaggioli, Vigna, & Riva, 2008); automated ecological momentary intervention (Heron & Smyth, 2010).

· need to address methodological problems
 include follow-up assessments

o   assess if treatment led to clinically significant change

o   provide data about software quality, level of engagement/immersion

o   evaluate for diverse groups of individuals (incl. children), those with co-morbid conditions

·          make full use of existing technologies (e.g., mobile phone and palmtop software, automated text messaging, physiological feedback)

·          dismantling studies to determine the therapeutic and technological components of treatment

Discussion Questions:

1.    The authors conclude (based on the evidence available in 2010) that some contact with a live in-person therapist seems to be necessary for optimum treatment of anxiety and depression. There has been wide growth in the proliferation and use of technology (i.e., some folks seem to be with their cell phones 24/7) and the availability of options for integrating technology and EBTs (e.g., CBT apps). The self-administered/ self-help options described in the article have become increasingly sophisticated, user-friendly, and portable.

Do you think if an updated review was published today, that it would come to the same conclusion about the need for some therapist contact for the effective treatment of anxiety and depression?

2.    Suppose that an updated review came to the conclusion that some degree of therapist contact is not necessary for the optimum treatment of these disorders or that primarily self-help/ self-administered technology-based treatment was as effective (and more cost-effective) than in person contact with a therapist.  Does this have the potential to change the way that we practice therapy or the role of the clinician?

3.    Is there the possibility that in-person therapists could become more or less obsolete?  In much the same way that the cost-effectiveness of mid-level practitioners has changed the field of therapy, will the cost-effectiveness of technology-based treatments have a substantive effect on the field?

4.    The potential benefits of technology- assisted treatments have been made clear (such as cost-effectiveness, ease of dissemination especially to rural communities and other areas that lack trained mental health professionals and to those who do not pursue traditional treatment options due to stigma or lack of transportation). There has been less focus on the potential costs associated with these treatments.

The review noted the lower compliance and completion rates associated with at-home treatments. Are there other potential liabilities that arise with the implementation of technology-based treatment?

No comments:

Post a Comment