RESUMO
BACKGROUND: Adherence to computerized cognitive behavioral therapy (cCBT) programs in real-world settings can be poor, and in the absence of therapist support, effects are modest and short term. Moreover, because cCBT systems tend toward limited support and thus low-intensity treatment, they are typically most appropriate for people experiencing mild to moderate mental health difficulties. Blended therapy, that is, combining direct therapist contact with cCBT or psychoeducational materials, has been identified as one possible approach to address these limitations and widen access to individual CBT for depression. Building on the initial success of blended therapy, we explore an integrated approach that seeks to seamlessly combine face-to-face contact, electronic contact, and between-session activities. Integration also considers how the technology can support therapists' workflow and integrate with broader health care systems. The ultimate aim is to provide a structure within which therapists can deliver high-intensity treatments, while also greatly reducing face-to-face contact. OBJECTIVE: The research aimed to explore patients' and therapists' views on using a system for the delivery of individual treatment for depression that integrates face-to-face therapist contact with access to online resources and with synchronous online therapy sessions that allow collaborative exercises, and to establish design requirements and thus key design considerations for integrated systems that more seamlessly combine different modes of communication. METHODS: We conducted a series of four user-centered design studies. This included four design workshops and seven prototype testing sessions with 18 people who had received CBT for depression in the past, and 11 qualitative interviews and three role-play sessions with 12 CBT therapists experienced in the treatment of depression. Studies took place between July and December 2017 in Bristol, United Kingdom. RESULTS: Workshops and prototyping sessions with people who had received CBT identified three important requirements for integrated platforms delivering CBT therapy for depression as follows: (1) features that help to overcome depression-related barriers, (2) features that support engagement, and (3) features that reinforce learning and support the development of new skills. Research with therapists highlighted the importance of the therapist and client working together, the impact of technology on therapists' workflow and workload, challenges and opportunities related to the use of online resources, and the potential of technology to support patient engagement. We use these findings to inform 12 design considerations for developing integrated therapy systems. CONCLUSIONS: To meet clients' and therapists' needs, integrated systems need to help retain the personal connection, support both therapist- and patient-led activities, and provide access to materials and the ability to monitor progress. However, developers of such systems should be mindful of their capacity to disrupt current work practices and increase therapists' workload. Future research should evaluate the impact of integrated systems on patients and therapists in a real-world context.
RESUMO
BACKGROUND: Technology can play an important role in supporting mental health. Many studies have explored the effectiveness, acceptability, or context of use of different types of mental health technologies. However, existing research has tended to investigate single types of technology at a time rather than exploring a wider ecosystem that people may use. This narrow focus can limit our understanding of how we could best design mental health technologies. OBJECTIVE: The aim of this study was to investigate which technologies (smartphone apps, discussion forums and social media, and websites and Web-based programs) people use to support their mental health and why, whether they combine and use more than one technology, what purpose each technology serves, and which features people find the most valuable. METHODS: We conducted an online survey to gather responses from members of the public who use technology to support their mental health and well-being. The survey was advertised on social media and via posters at a university. It explored usage patterns, frequently used features, and engagement with technology. To gain deeper insights into users' preferences, we also thematically analyzed open-ended comments about each technology type and suggestions for improvements provided by the respondents. RESULTS: In total, 81 eligible participants completed the survey. Smartphone apps were the most commonly used technology, with 78% of the participants (63/81) using them, either alone (40%) or in combination with other technologies (38%). Each type of technology was used for specific purposes: apps provided guided activities, relaxation, and enabled tracking; social media and discussion forums allowed participants to learn from the experiences of others and use that knowledge to understand their own situation; and Web-based programs and websites helped to find out how to deal on a day-to-day basis with stress and anxiety. The analysis of open-ended responses showed that although many people valued technology and felt it could support targeted activities, it was not seen as a substitute for traditional face-to-face therapy. Participants wanted technology to be more sophisticated and nuanced, supporting personalized and actionable recommendations. There was evidence that participants mistrusted technology, irrespective of the type, and had broader concerns regarding the impact of overuse of technology. CONCLUSIONS: People use different types of technology to support their mental health. Each can serve a specific purpose. Although apps are the most widely used technology, mixing and matching different types of technology is also common. Technology should not be seen as a replacement for traditional psychotherapy, rather it offers new opportunities to support mental health as part of an overall ecosystem. People want technology to be more nuanced and personalized to help them plan informed actions. Future interventions should explore the use of multiple technologies and their combined effects on mental health support.
RESUMO
BACKGROUND: Hundreds of mental health apps are available to the general public. With increasing pressures on health care systems, they offer a potential way for people to support their mental health and well-being. However, although many are highly rated by users, few are evidence-based. Equally, our understanding of what makes apps engaging and valuable to users is limited. OBJECTIVE: The aim of this paper was to analyze functionality and user opinions of mobile apps purporting to support cognitive behavioral therapy for depression and to explore key factors that have an impact on user experience and support engagement. METHODS: We systematically identified apps described as being based on cognitive behavioral therapy for depression. We then conducted 2 studies. In the first, we analyzed the therapeutic functionality of apps. This corroborated existing work on apps' fidelity to cognitive behavioral therapy theory, but we also extended prior work by examining features designed to support user engagement. Engagement features found in cognitive behavioral therapy apps for depression were compared with those found in a larger group of apps that support mental well-being in a more general sense. Our second study involved a more detailed examination of user experience, through a thematic analysis of publicly available user reviews of cognitive behavioral therapy apps for depression. RESULTS: We identified 31 apps that purport to be based on cognitive behavioral therapy for depression. Functionality analysis (study 1) showed that they offered an eclectic mix of features, including many not based on cognitive behavioral therapy practice. Cognitive behavioral therapy apps used less varied engagement features compared with 253 other mental well-being apps. The analysis of 1287 user reviews of cognitive behavioral therapy apps for depression (study 2) showed that apps are used in a wide range of contexts, both replacing and augmenting therapy, and allowing users to play an active role in supporting their mental health and well-being. Users, including health professionals, valued and used apps that incorporated both core cognitive behavioral therapy and non-cognitive behavioral therapy elements, but concerns were also expressed regarding the unsupervised use of apps. Positivity was seen as important to engagement, for example, in the context of automatic thoughts, users expressed a preference to capture not just negative but also positive ones. Privacy, security, and trust were crucial to the user experience. CONCLUSIONS: Cognitive behavioral therapy apps for depression need to improve with respect to incorporating evidence-based cognitive behavioral therapy elements. Equally, a positive user experience is dependent on other design factors, including consideration of varying contexts of use. App designers should be able to clearly identify the therapeutic basis of their apps, but they should also draw on evidence-based strategies to support a positive and engaging user experience. The most effective apps are likely to strike a balance between evidence-based cognitive behavioral therapy strategies and evidence-based design strategies, including the possibility of eclectic therapeutic techniques.