The Role of Technology in the Treatment of Depression

Abstract

Major depressive disorder (MDD) is a common psychiatric condition associated with significant public health and individual burden. Despite the existence of many evidence-based treatment options, between one third and a half of individuals with MDD do not seek treatment. Barriers to treatment include stigma, cost, low availability of trained clinicians (especially in rural areas), and long waitlists. Further, even when patients have access to in-person therapy, it can be difficult to apply concepts learned during treatment in the “real world” (i.e., outside of the therapist’s office). Technology has been used to address these barriers and has the potential to further increase access to effective treatments and improve their efficacy. This chapter reviews technologies that have been employed to facilitate the delivery of psychosocial treatments for MDD. We review the historical background, describe different applications of technology-facilitated interventions, and provide clinical recommendations.

FAQs: Common Questions and Answers

• Q1. How do I receive training on these issues of telehealth tele-behavioral health?

• A1. Many professional associations, like the Association for Behavioral and Cognitive Therapies (ABCT), the Association for Psychological Science (APS), the American Medical Association (AMA) Digital Health Innovations, and the American Psychological Association (APA), have special interest groups focused on the use of technology in clinical settings. These special interest groups often allow for networking and sharing of additional relevant resources and training opportunities. Some organizations, including APA, the American Telemedicine Association, and the Healthcare Information and Management Systems Society, offer webinars, online trainings, and certificates in using technology in clinical treatment (e.g., http://www.apa.org/education/ce/1360403.aspx) [114]. The Center for Connected Health Policy (CCHP) is the federally designated National Telehealth Policy Resource Center (NTRC-P) and serves as an independent center of excellence in telehealth policy providing technical assistance to 12 federally funded telehealth regional resource centers. These centers provide a range of technical and informational support to telehealth providers and organizations nationwide. The CCHP prepares a report each year on US state telehealth laws and policy. Furthermore, there are also conferences that are focused on this topic, including the annual Connected Health Conference, the annual Telehealth Summit, and the American Telemedicine Association Conference. Additional strategies to become familiar with the latest research findings is to read publications like the Journal of Medical Internet Research (JMIR) that showcase research on new technology. Finally, many hospitals and community clinics provide employee training on these topics.

• When providing technology-assisted treatments , clinicians may not know where to find the appropriate devices to deliver the treatment and which devices may be appropriate. Hospitals are starting to provide videoconferencing services, and they are designing specific tools to use with patients. Clinicians interested in providing videoconferencing services should use the software supported by the hospital where they practice. Similarly, for those interested in using a smartphone app for behavior change or a wearable sensor to collect data, there may already be particular apps and devices approved by your institution. If you are in private practice, many of the professional associations listed above can provide a community of other providers that may be able to share important resources. The most important factor to consider when choosing to integrate any type of technology into your practice is the privacy of your patients’ information.

• Q2. Which is/are the best computerized programs or apps for treating depression?

• A2. Given that new computerized programs and mHealth apps are constantly being developed, rather than recommending specific tools here, we will offer guidance on how to go about choosing one. First, when possible, we recommend selecting programs and apps that have been evaluated (and shown to be efficacious) in a research study. This may not always be possible, since despite the myriad of mHealth interventions, only a minority have been examined with appropriate research methods such as randomized controlled trials. Some researchers have started to compare different apps in a systematic way and to publish meta-analyses and reviews to provide some guidance to this end [66]; however, given the speed with which new apps are developed, these reviews quickly become outdated. Moreover, most reviews examine programs and apps that have already been evaluated in research studies, and thus exclude those that have not undergone prior research testing. Given these factors, as well as the fact that conducting literature searches of available studies can be time-consuming for busy practitioners, we encourage clinicians to look to clearing houses in which different apps are continuously evaluated; for example, the PsyberGuide (psyberguide.org), Beacon (https://beacon.anu.edu.au/), and the Anxiety and Depression Association of America (https://adaa.org/finding-help/mobile-apps) are good resources [115,116,117]. In addition, the National Health Service (NHS), the publicly funded national healthcare system for England, created a webpage listing several apps for mental health problems including depression [118].

• Another helpful way to also decide which is the “best” app for a given individual with depression is by asking colleagues or experts in the field or giving preference to apps endorsed by or associated with academic medical centers, universities, or research groups working in this area, as well as patient advocacy organizations. In our practice, we often tend to search the app store and read reviews by other users, attending to whether feedback provided by other users aligns with what the given patient is looking for in a mHealth tool.

• When choosing a computerized program or mHealth app for treating depression, it is also important to consider what specific problems or symptoms under the broader umbrella of depression the patient would like to address (e.g., sleep, energy, positive activity, low mood). This can help inform what might be most appropriate app for the individual patient (rather than a “one-size-fits-all” approach); for example, if a patient describes sleeping excessively and withdrawing from previously enjoyable activities, an app that incorporates specific procedures to improve sleep (e.g., sleep diaries, sleep hygiene) and behavioral activation strategies may be the best fit. For an individual who describes significant low mood and ruminative patterns of negative thoughts (e.g., “stuck in my head”), a CBT-based app that includes cognitive restructuring and mindfulness strategies may be best suited to the individual. Clinicians treating patients with more severe forms of depression and at higher risk for suicidal behavior may want to ensure that any recommended computerized program or app has a feature for patients to utilize in a crisis, such as direct access to suicide hotlines and emergency services, ability to enter an individualized safety plan, and/or automatic alerts triggered to their provider.

• Q3. What should I keep in mind when evaluating apps ?

• A3. In addition to the information provided above, we direct readers to a user-friendly framework for evaluating apps proposed by Torous and colleagues [119] called ASPECTS: Actionable, Secure, Professional, Evidence-Based, Customizable, and Transparent . In brief, when deciding what app to recommend to a given individual, Torous and colleagues [119] encourage clinicians to consider whether an app either collects data or produces results that are clinically meaningful and relevant (Actionable), has adequate protections against breaches of confidentiality (Secure; see below), and is in line with legal and ethical standards such as the Health Insurance Portability and Accountability Act (HIPAA) (Professional; see below). Providers are further recommended to take into account whether an app has empirical support (Evidence-based, as noted above) can be flexibly tailored to each individual patient (Customizable; e.g., ability to turn features of the app on and off, add or skip content modules or monitoring of specific symptoms as relevant) and gives clear information as to how, where, and when data within the app will be used (Transparent). Though each “aspect” may not apply to every patient or every app, we believe that this framework provides a good starting point for the discussion and decision-making process around recommending and even prescribing apps. The American Psychiatric Association (APA) also provides a similar framework for evaluating apps that includes four key areas: safety/privacy, evidence, ease of use, and interoperability (i.e., ability to share information between the clinician and patient), available at https://www.psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-model [120].

• Q4. How do I make sure that the data collected by apps are kept private?

• A4. Given the sensitive nature of data pertaining to mental health, it makes good sense that data security is at the forefront of both clinicians’ and patients’ minds when deciding whether or not to use a given mHealth tool. Though a comprehensive review of app security is beyond the scope of this chapter, users are encouraged to look for several key security features. For one, use of a password or two-factor authentications to access the app—the presence of which can be easily verified—is critical [119]. It is also important that data collected via an app are encrypted on the device itself—this will protect against a breach of data in the event of a lost or stolen device—as well as during the transmission process and eventual storage of data [119]. With regard to technologies that permit clinician-patient communication through devices, it is also important to consider confidentiality and safety of the information exchanged. Many text messaging services, for example, are often unencrypted; if this is the case, it is essential that the patient be made aware that their communications are not secure via an informed consent process (see below). To verify these features, Torous and colleagues recommend consulting experts in information technology at a local hospital or university. Patients may also decide to refrain from entering any identifiable data into mHealth apps or similar programs.

• Q5. What are the legal implications of recommending apps and other technologies to my patients?

• A5. As detailed by Armontrout and colleagues [121], legal issues associated with use of technology in mental health treatment include (but are not limited to) privacy and security, program validation and malfunction (e.g., what if a patient dies by suicide soon after their provider recommends use of an app in adjunct to ongoing care? What if an error occurs within an app designed to promote medication adherence and a patient subsequently experiences a serious adverse event due to taking an incorrect dose?), failure to act upon information (e.g., suicidal ideation), breaches of confidentiality, and required licensing requirements (e.g., use of apps involving clinician support across state lines). Given that utilizing mHealth technologies in mental health treatment is a relatively recent advancement, a consensus as to the corresponding legal implications has not yet been clearly achieved. The good news is that there are resources available to clinicians seeking up-to-date knowledge and recommendations in this area. For example, APA has a “Telepsychiatry Toolkit” available online that offers information regarding legal issues in telehealth. Information pertaining to telehealth laws is also available on the American Telemedicine Association and Federal State Medical Boards website at http://www.americantelemed.org [122]. Providers are encouraged to familiarize themselves with relevant laws from HIPAA, the Food and Drug Administration (FDA), and the Federal Trade Commission (FTC)—all organizations that provide rules and governance that, depending on the context, may apply to use of mHealth technologies in practice [111]. Clinicians may also choose to seek legal advice as needed regarding use or recommendation of a tool or device during clinical care.

• Part of routine clinical practice is, of course, to have patients provide informed consent before beginning treatment. When incorporating mHealth technologies into treatment, clinicians are encouraged to obtain and document informed consent detailing the possible harms from apps or device use, as well as the associated limits of confidentiality. This can be incorporated into routine informed consent for services and reported in the clinician’s visit note or as a separate form/procedure to be filed separately in the patient’s record.

• When incorporating mobile technologies into provision of treatment for depression, it is also important to review and set clear expectations with about safety procedures corresponding to the use of mHealth apps and other tools. For example, when utilizing technologies that permit clinician-patient communication outside of the practice setting (e.g., text message, chat portals, telehealth), what will happen if a patient reports acute suicidal ideation to their provider outside of the session or during a remote treatment session? What if a worsening of suicidal ideation is communicated during off hours via text message or a chat portal and the message is not seen for a day or more? These expectations may differ from clinician to clinician, setting to setting, and even patient to patient; thus, it is important that each patient understands exactly what will happen in each of these (and other related) scenarios and that the patient’s understanding is clearly documented. As noted above, when working with higher-risk patients, clinicians may encourage use of apps or online programs that offer tailored support in the event of a psychiatric crisis.

• Q6. Will using technology in my practice create more work for me?

• A6. Using technology in the context of clinical care (e.g., to track symptoms or as adjuncts to in-person therapy) does not necessarily create extra work and, when used correctly, has the potential to increase efficiency. Consider how, by encouraging patients to enter self-report data via a web portal prior to coming to session, a clinician may view a chart of their progress before the patient arrives to the clinic. Rather than spending the first part of the visit completing questionnaires and reviewing symptoms, the clinician may immediately turn to treatment planning and intervention delivery, thereby potentially decreasing session duration. Though more research support is needed, a key rationale for use of mHealth technologies is to improve the outcomes and efficiency of standard in-person treatment; for example, by encouraging patients to use technologies that facilitate medication adherence or skills practice outside of session, it is possible that progress will be more rapid and marked, thereby decreasing the likelihood of time-intensive and emotionally draining adverse outcomes for providers (e.g., suicide attempts, ER visits, hospitalizations). Apps that aim to provide a “pocket therapist ” may also reduce the number and duration of contacts (e.g., paging, phone calls, text messages) that clinicians manage outside of session. In line with the “Actionable” factor proposed by Torous and colleagues [119] noted above, however, it is important that providers consider how data collected via technologies will guide and be incorporated into the clinical decision-making process. If the information provided by technology is not actionable for the clinician or patient, it is unlikely to either increase efficiency or improve clinical outcomes.

• It is important to note that many clinical activities involving technology use outside of the session (such as texting with patients and tracking symptoms though a web-based dashboard) are not currently reimbursed. As noted, one exception is telehealth, which some insurance companies have begun to reimburse in acknowledgment of its benefits for population management. It is likely that with increased insurance coverage of these activities, the feasibility of clinicians using these technologies more widely will increase. Use of any new technology is likely to have a learning curve for the patient and clinician alike; given this, along with the inevitable technological glitches that can arise, there may be a preference for using programs and apps with easily accessed technological support and/or utilizing more complicated technologies (e.g., wearable monitors) in treatment settings where an information technology office is available as needed.

• Q7. As technology-based mental health treatment grows in popularity and becomes more accessible, what will be left for a therapist to do?

• A7. As mental health treatment is increasingly delivered online and via mobile apps, with promising results overall, therapists might have concern about the implications for their practice and even wonder: “Does this mean I’ll be out of a job?!” This worry is understandable to a certain extent; however, it is highly unlikely that technology will eliminate the need for in-person therapy, for several key reasons. First, and as noted above, generally web-based or computerized therapies that include some clinician involvement have been shown to have better engagement (meaning less dropout) and be more effective than entirely self-guided web-based treatments [79,80,81]. Second, there will always be reasons why some individuals prefer in-person therapy over online modalities, such as lack of comfort with technology, distrust that these technologies truly keep one’s private information confidential, and, regarding self-guided treatments without human support specifically, desire for face-to-face interaction and to develop a strong therapeutic alliance and relationship with another human as part of the therapeutic process. Given that the therapeutic alliance is an important predictor of outcomes in face-to-face therapy [123], the potential negative impact on outcomes resulting from not having the opportunity to develop an alliance in the context of self-guided, web-based treatment underscores the need for further research on self-guided (e.g., mobile app) treatments. Interestingly, recent findings suggest that iCBT with human support may be associated with stronger therapeutic alliance than face-to-face therapy [124], though these conclusions are based on a very small number of studies that have examined therapeutic alliance and its relationship to treatment outcome in therapist-supported iCBT. Third, and as we note above, online therapies are also unlikely to be appropriate (at least as stand-alone care) for patients with more severe or acute psychopathology. Mobile apps are increasingly being integrated into the context of in-person therapy (e.g., to facilitate skills practice outside of session, to monitor one’s symptoms in-between visits) to enhance in-person care, rather than replace it. Fourth, and also as mentioned earlier, adherence and compliance with non-clinician-supported mobile or web-based interventions remain one of the biggest challenges to these treatments achieving maximal effectiveness. Having regularly scheduled therapy sessions with another human may hold some patients more accountable in their treatment engagement and thus, for some individuals, serve as a critical part of their recovery. Lastly, as some technology-based treatments are not currently reimbursed by insurance, this may be a key consideration for individuals choosing between in-person visits and web-based care. In summary, though it is our belief that technology-assisted treatments have the potential to increase access to mental health care for many individuals who need these services but might not otherwise receive them , we do not expect, at least in the near future, to see a decreased demand for face-to-face services.