Research roundup: Evidence for digital therapeutics

According to Mental Health America, 50 million (19.8%) Americans experience a mental illness. For those with a mental illness, over 27 million (56%) do not receive treatment (MHA, 2022). This raises concerns over access to therapeutic care, especially in the traditional face-to-face format. Barriers for adequate treatment include inconvenience, cost, and not knowing where to turn for help (APA, 2020).

While patients have difficulty accessing care, providers are experiencing their own challenges. According to the 2022 covid-19 Practitioner Impact Survey, six in 10 practitioners reported they no longer have openings for patients, 46% have been unable to meet demand for treatment, and 75% have longer waitlists than before the pandemic. With concerns over accessing mental health care, from both a patient and provider perspective, more focus has been put into increased research and innovation of additional treatment methods, including digital therapeutics.

Digital therapeutics involve the use of software programs to deliver evidence-based and validated interventions to treat mental and behavioral health disorders, such as chronic insomnia, panic, and substance use disorders (APA, 2023). Digital therapeutics are becoming viable options to address these barriers to care, including the potential to expand access to marginalized communities.

In this installment of Research Roundup, we explore the latest evidence on the efficacy of digital therapeutics for mental health conditions including depression, anxiety, and insomnia. The first article examines the efficacy of studies which utilize internet-based cognitive behavioral therapy (CBT), with or without therapeutic guidance, in treating depressive symptoms. The second study focuses on remote CBT for symptoms of generalized anxiety disorder (GAD) in adults. The third study examines the efficacy of digital therapeutics in reducing symptoms of insomnia and depression.

Note: In addition to reviewing the research summaries, psychologists are encouraged to further explore the literature to determine what may be useful to them in their own practice, particularly as it relates to patients’ values, culture, preferences, and individual treatment needs.

Karyotaki, E., Efthimiou, O., Miguel, C., Bermpohl, F. M. g., Furukawa, T. A., & Cuijpers, P. (2021). Internet-based cognitive behavioral therapy for depression: A systematic review and individual patient data network meta-analysisopens in new window. JAMA Psychiatry, 78(4), 361–371.

CBT has been fundamental in treating symptoms of depression. Compared to traditional methods, there are now options for CBT to be delivered through a digital platform over the internet (iCBT) with or without therapeutic guidance. Prior research has shown that therapeutic guided iCBT is associated with greater effectiveness in decreasing symptoms (as measured by the PHQ-9) in those with moderate and severe depression, when compared to unguided iCBT. Even though there was no significance in effectiveness of guided iCBT with mild depression, it is important to optimize treatment for each participant and consider the importance of therapeutic guidance in collaboration with digital therapeutics.

In this current study, researchers evaluated previous data from patients who received treatment via iCBT, to assess its effectiveness in decreasing depressive symptoms, and possible differences between therapeutic guided and unguided methods. Researchers also observed the long-term efficacy of iCBT postintervention. This meta-analysis provides personalized estimates of short term and long-term relative efficacy of guided and unguided iCBT for depression using patient information. This information allows for more accessibility and new avenues for treatment decision making.

Thirty-nine randomized control trials (RCTs), representing 9,751 adults and 12 countries, were included in this meta-analysis. Depressive symptoms were indicated by their scores on PHQ-9. Participants’ PHQ-9 scores from the 6-month and 12-month postintervention mark were also analyzed. Because both therapeutic unguided and guided iCBT were associated with better outcomes than control conditions over the long term, unguided iCBT has considerable potential for improving long-term results of interventions with constrained economic and workforce resources.

Trenoska Basile, V., Newton‐John, T., & Wootton, B. M. (2022). Remote cognitive-behavioral therapy for generalized anxiety disorder: A preliminary meta-analysisopens in new window. Journal of Clinical Psychology, 78(12), 2381–2395.

Remote therapy includes internet delivered, application delivered, videoconference delivered, and telephone delivery methods. Remote CBT is emerging as an effective treatment for GAD and is opening the door for more delivery methods within stepped care treatment. Both face-to-face and remote CBT are important approaches to treat anxiety disorders.

Researchers examined the efficacy of remote CBT from previous studies and addressed limitations with remote CBT using a meta-analysis. Researchers investigated how remote treatment methodologies compare against each other, differentiating between prevention studies and efficacy studies to gain more clarity on decreasing symptoms of GAD in adults. This meta-analysis helped inform health care policies around stepped care approaches to treatment.

Researchers conducted an electronic search of articles related to remote CBT treatments that target symptoms of GAD in adults, as shown by scores on the GAD-7 and the Penn State Worry Questionnaire (PSWQ). The intensity of remote treatment was also analyzed within these studies. Analyses were conducted between the remote CBT treatment methods and the articles’ control condition, by comparing posttreatment scores of each group.

The final literature search included 10 studies and 1,071 participants, with 11 remote treatment conditions included in the analysis. The types of remote treatment included: iCBT, application-based CBT, videoconferencing-delivered CBT, and telephone-delivered CBT. All remote treatment CBT methods were effective in combatting symptoms of GAD, regardless of intensity level. Remote CBT for GAD is an efficacious treatment with large within group effect sizes. High and low intensity remote CBT treatment showed large within group effect sizes from pre- to posttreatment.

Cheng, P., Luik, A. I., Fellman-Couture, C., Peterson, E., Joseph, C. L. M., Tallent, G., Tran, K. M., Ahmedani, B. K., Roehrs, T., Roth, T., & Drake, C. L. (2019). Efficacy of digital CBT for insomnia to reduce depression across demographic groups: A randomized trialopens in new window. Psychological Medicine, 49(3), 491–500.

Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be an effective, first-line treatment for insomnia. It also has been shown to reduce depressive symptoms among those with chronic insomnia. Furthermore, there is a growing body of research demonstrating that digitally delivered CBT-I (dCBT-I) is efficacious. Given barriers to in-person care, such as lack of specialized providers, geographic distance to care, and cost, dCBT-I has the potential both to increase accessibility and lower the cost of treatment. However, the efficacy of dCBT-I for the treatment of insomnia and depression needs to be demonstrated across diverse groups.

The authors of this study sought to explore the efficacy of dCBT-I to reduce symptoms of insomnia and depression among a demographically diverse sample. This study was a placebo-controlled, randomized trial. There were 1,385 participants who met criteria for insomnia. They were randomized into either the dCBT-I or online sleep education condition. Ultimately, analyses were based on 358 dCBT-I participants and 300 online sleep education participants. Measures of insomnia (ISI) and depression (QIDS) were given pre- and posttreatment.

Compared to the online sleep education group, the dCBT-I group showed clinically significant improvements in their symptoms of insomnia and depression: insomnia symptoms reduced two-fold and depressive symptoms reduced by 2.5 times. Demographic factors did not moderate the treatment effects. Attrition rates were higher among individuals with low SES; whereas Black-identified and White-identified participants had comparable levels of attrition.

Taken collectively, these studies contribute to the growing body of literature that demonstrates the utility of digital therapeutics in mental health treatment. Authors in these studies emphasize the importance of service delivery in addressing mental illness. In addition, it is also important to ensure a stepped care model, where the most effective yet least resource-intensive treatment can be utilized for each patient. For example, delineating the differences between the use of high intensity vs. low intensity remote CBT care, as providers work with varying severities of mental health concerns.

Additionally, further research regarding the efficacy of digital therapeutics in treating mental illness, alongside more traditional therapeutic deliveries, is needed. As increased educational resources about the different treatment methodologies becomes available, the better clinicians can help their patients in the treatment-planning process. Psychologists play a critical role in this area and bring unique expertise in integrating various modalities into care. Digital technologies serve as another tool psychologists can use as part of their treatment plans, extending their reach to address the needs of patients, families, organizations, and communities. The research on digital therapeutics is promising, yet continued research is needed, as treatment looks different, for diverse populations.