Research roundup: Evidence for digital therapeutics in combatting ADHD, PTSD, and SUD

Attention-deficit/hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), and substance use disorders (SUD) affect millions of Americans. According to the Centers for Disease Control and Prevention, six million children (about twice the population of Arkansas) have been diagnosed with ADHD from 2016–2019, with symptoms of ADHD following many of them into adulthood.

About 6% of the U.S. population (18 million people) will have PTSD at some point in their life (National Center for PTSD, 2023). Despite these estimates, there are challenges with accurately recording the number of people who may have had traumatic experiences. This can be due to challenges accessing care, combatting stigma, and more. When it comes to SUD, 20.4 million people in the US were diagnosed in 2019 (NIDA, 2022). Of those that have been diagnosed with SUD, only 10.3% of people actually receive treatment.

There are numerous interventions that have been shown to be effective in combatting these mental health conditions. Interventions may include psychotherapy, psychoeducation, skills training, and/or pharmacotherapy. These interventions are traditionally in person and face-to-face. While traditional methods are still primarily used, alternative methods have emerged to help those who may not be able to access traditional methods.

The global pandemic we have experienced over the past three years has shed light on the concern over access to therapeutic care in traditional formats. Barriers to adequate treatment include inconvenience, cost, and not knowing where to turn for help (APA, 2020). The use of nontraditional methods such as telehealth and digital therapeutics have begun to show effectiveness in therapeutic populations.

In this installment of research roundup, we continue to explore the latest evidence on the efficacy of digital therapeutics for mental health conditions including ADHD, PTSD, and SUD. The first article examines the efficacy of digital therapeutics in children with ADHD. The second study examines the real-world effectiveness of a digital therapeutic for symptoms of PTSD, while the third study examines the safety of digital therapeutics for SUD.

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.

He, F., Qi, Zhou, Y., Cao, A., Yue, X., Fang, S., & Zheng, Y. (2023) Meta-analysis of the efficacy of digital therapies in children with attention-deficit hyperactivity disorderopens in new window. Frontiers in Psychiatry 14:1054831

Drug therapies for ADHD (the primary line of treatment) tend to bring about adverse side effects for patients, which suggests the need for effective alternative therapies. Alternative nonpharmacological treatments for ADHD include physical therapy, neurofeedback, and counseling. Digital therapeutics have begun to emerge within this space, in which strategies have been designed to improve impairment in cognitive functions and attention control found in ADHD.

Researchers conducted a meta-analysis to evaluate the clinical efficacy of digital therapies for symptomatic and functional improvements in patients with ADHD. Researchers explored clinical trials of pediatric patients with a primary diagnosis of ADHD, who also received a digital intervention via online or mobile applications. These digital interventions included standalone and those used in combination with therapies. Overall symptoms of ADHD were assessed using the ADHD rating scale (ADHD-RS). Attention control (inattention) was evaluated by the Continuous Performance Task (CPT), and executive function/working memory was assessed by the Behavioral Rating Inventory of Executive Function questionnaire (BRIEF).

Thirty-one studies, consisting of 2,169 participants (4–17 years old) were included in the meta-analysis. Results indicated that digital interventions significantly improved symptoms of inattention and decreased reaction time in ADHD patients. Across five of the 31 studies, hyperactivity scores were slightly decreased, executive functioning scores were increased, and there was clinically significant improvement in hyperactivity symptoms and inattention based on ADHD-RS scores. Digital interventions also significantly decreased reaction time in the CPT, with improvement of inattention symptoms in ADHD patients. Digital therapy can be a promising strategy for ADHD patients, specifically when it comes to attention control, and improving cognitive skills.

Cuyler, R. N., Katdare, R., Thomas, S., & Telch, M. J. (2022) Real-world outcomes of an innovative digital therapeutic for treatment of panic disorder and PTSD: A 1,500 patient effectiveness studyopens in new window. Frontiers in Digital Health 4:976001

Capnometry guided respiratory intervention (CGRI) is an FDA cleared prescription digital therapeutic for the treatment of panic disorder and PTSD. CGRI includes a 28-day home-based treatment that provides breath-to-breath feedback of respiratory rate and exhaled carbon dioxide (C02) levels using a sensor and tablet. Specifically, hypersensitivity to carbon dioxide is a common risk factor for PTSD. Goals of CGRI include normalizing respiratory style and increasing patients’ mastery for coping with symptoms of stress, anxiety, and panic. In addition to physiological data capturing, CGRI provides telehealth training/coaching via video teleconference.

Researchers reported on pre and posttreatment self-reported symptom changes, measures of respiratory rate, carbon dioxide levels, drop out and adherence rates drawn from an automatic data repository. Participants used CGRI in their homes, supported by telehealth coaching. The main outcome measure from this analysis was the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), pre and posttreatment.

The study included 174 PTSD patients, treated between 2017–2021. Patients with PTSD showed a significant pre-to-posttreatment reduction in total PCL-5 scores and adherence, with a treatment response rate of 72.4% and adherence rate of 75%. CGRI appears to be an important treatment option for PTSD, as the real-world outcomes can be comparable to established treatments.

Maricich Y. A., Nunes E. V., Campbell, A., Botbyl, J. D., & Luderer, H. F.(2022) Safety and efficacy of a digital therapeutic for substance use disorder: Secondary analysis of data from a NIDA clinical trials network studyopens in new window. Substance Abuse, 43(1), 937–942.

Traditional treatments for substance use disorders strongly focus on face-to-face interactions. Due to the low rate of those diagnosed ever receiving treatment, there is a need to establish more evidence for digitally delivered behavioral interventions for SUD. Therapeutic Education System (TES), a noncommercial version of the FDA authorized ReSET, is a digital therapeutic for SUD that patients can access via an internet connected device. The TES software includes 32 core educational models, focused on cognitive behavioral techniques, relapse prevention skills, education about risky behaviors and preventing the transmission of infections.

In this secondary analysis, researchers reanalyzed data between 2010–2012, which included patients with primary alcohol, cannabis, cocaine, or other stimulant use disorder, while excluding data from those with opioid use disorder. Patients were randomly assigned to 12 weeks of either outpatient treatment as usual (TAU) or TES digital therapeutic group which included a combination of individual, group face-to-face counseling, and pharmacotherapy for some patients (which were completed in clinic or offsite). Abstinence in weeks 9–12 and retention in treatment were also measured.

The final sample included 399 participants (206 in TES group, 193 in TAU group). Results showed that abstinence and retention in therapy was significantly higher in the TES group, compared to the TAU group. Patients in the TES group also had lower dropout rates. The predicted probability of abstinence during the last four weeks of treatment was three times more for the TES group than TAU, regardless of treatment site. Data observing group differences in safety showed that there was no difference in adverse event rates between the two groups. The use of TES alongside traditional methods safely increased abstinence and retention in treatment among patients with SUD.

These studies contribute to the growing body of literature that demonstrates the utility of digital therapeutics in mental health treatment. Researchers emphasized the importance of collaboration with traditional methods, as well as the use of digital therapeutics in enhancing the therapeutic alliance. For example, the use of alternative treatment methods such as digital therapies can enhance the therapeutic alliance by giving clinicians real time information about patients and their progress.

In addition, real world effectiveness was highlighted as an important factor for providers to better understand the impact of digital therapeutics. For example, the use of digital therapeutics in these studies demonstrated increased rates of abstinence from substances, even if patients were not receiving treatment in a physical clinic. This is an important consideration as mental health providers continue advocating for expansive access to care.

As providers grapple with the increase in demand for treatment from disadvantaged populations, it is important that evidence based alternative methods are available. 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.