Realizing the Potential of CBT into the Digital Age - Understanding the Current Landscape, Opportunities, Pitfalls, and Needed Evidence Base John Torous, Hannah Wisniewski, Ryan Hays Beth Israel Deaconess Medical Center

Guiding Informed Decision Making Torous et al., Current Psychiatry. 2018 March;17(3):21-25

Causing Harm? Bidargaddi N, Musiat P, Winsall M, Vogl G, Blake V, Quinn S, Orlowski S, Antezana G, Schrader G. Efficacy of a Web-Based Guided Recommendation Service for a Curated List of Readily Available Mental Health and Well-Being Mobile Apps for Young People: Randomized Controlled Trial. Journal of medical Internet research. 2017 May;19(5).

Dichotomies in Digital Mental Health Torous J, Haim A. Dichotomies in the Development and Implementation of Digital Mental Health Tools. Psychiatric Services. 2018 Sep 27:appi-ps.

A Story Driven by Access Patterson et al., American journal of preventive medicine. 2018 Jun 30;54(6)

But Smartphone Access Does not Equal Mental Health Access

Even in College Students… Study of 741 College Students Regarding Mental Health Apps. 26% “open to using” 81% preferred to see a person vs an app 7% had ever used a mental health app Kern et al., mHealth. 2018;4.

Even in Businesses….

What Could Go Wrong?

Starcevic et al., Clinical Neuropsychiatry. 2017;14(1):5-10. Internet “Addiction” Is it a diagnosis? Is it a comorbidity? What is known today? Starcevic et al., Clinical Neuropsychiatry. 2017;14(1):5-10.

Neuroimaging and Circuity Interpersonal Therapy Spectrum of Conditions Potential Pathophysiology Research Challenges Clinical Definitions Targeted Treatments Co-morbidity Frontal <-> Limbic Neuroimaging and Circuity Interpersonal Therapy Structural Changes Functional Changes Heterogenous Definitions Limited Sample Sizes Lack of Longitudinal Data Non-Representative Samples CBT Impulse Control Behaviors Single Condition Sleep Medications Reward Deceits Other Interventions Anxiety Exiting Constructs Spectrum of Conditions Addiction Novel Treatments Substance Abuse

Pilot vs Implementation BibTeX Gilbody et al., BMJ. 2015 Nov 11;351:h5627.

Project Evo and ‘Dosing’ “This app is designed as a video game that modulates cognitive control abilities, a common neurological deficit seen in depression” Arean PA, Hallgren KA, Jordan JT, Gazzaley A, Atkins DC, Heagerty PJ, Anguera JA. The use and effectiveness of mobile apps for depression: results from a fully remote clinical trial. Journal of medical Internet research. 2016 Dec;18(12).

Project Evo and ‘Dosing’ Arean PA, Hallgren KA, Jordan JT, Gazzaley A, Atkins DC, Heagerty PJ, Anguera JA. The use and effectiveness of mobile apps for depression: results from a fully remote clinical trial. Journal of medical Internet research. 2016 Dec;18(12).

Sleepio and Side Effects Espie CA, Emsley R, Kyle SD, Gordon C, Drake CL, Siriwardena AN, Cape J, Ong JC, Sheaves B, Foster R, Freeman D. Effect of digital cognitive behavioral therapy for insomnia on health, psychological well-being, and sleep-related quality of life: a randomized clinical trial. JAMA psychiatry. 2019 Jan 1.

Apps Vs Control Firth et al., Journal of affective disorders. 2017 Aug 15;218:15-22. Firth et al., World Psychiatry. 2017 Oct;16(3):287-98.

App Active Ingredient… Firth et al., World Psychiatry. 2017 Oct;16(3):287-98.

Headspace and Digital Placebo Noone and Hogan. A randomised active-controlled trial to examine the effects of an online mindfulness intervention on executive control, critical thinking and key thinking dispositions in a university student sample. BPJ Psychology. 2018

What do CBT Apps Do Stawarz K, Preist C, Tallon D, Wiles N, Coyle D. User Experience of Cognitive Behavioral Therapy Apps for Depression: An Analysis of App Functionality and User Reviews. Journal of medical Internet research. 2018;20(6):e10120.

What do CBT Apps Do Stawarz K, Preist C, Tallon D, Wiles N, Coyle D. User Experience of Cognitive Behavioral Therapy Apps for Depression: An Analysis of App Functionality and User Reviews. Journal of medical Internet research. 2018;20(6):e10120.

A Different Approach to CBT Apps https://intellicare.cbits.northwestern.edu/

Rise of Digital Therapeutics

Digital CBT and the FDA….

New Regulatory Pathways https://www.fda.gov/downloads/MedicalDevices/DigitalHealth/DigitalHealthPreCertProgram/ucm605685.pdf

Let’s Go Backwards

JITAI: Linking Sensing to Interventions Torous et al., Digital biomarkers. 2017;1(1):87-91. Insel et al., JAMA. 2017 Oct 3;318(13):1215-6.

N=1 Dropping Out of CBT

Digital Phenotyping and Mood Association of mobility ~ depressive symptoms was statistically significant for only one (of 30) participants Bauer et al., Journal of Medical Internet Research. 2018;20(6):e10001.

Digital Phenotyping in Mood (Cont) “After correcting for multiple comparisons, no significant association between semantic location and mood or anxiety.” Saeb et al., JMIR mHealth and uHealth. 2017 Aug;5(8).

Activity Symptoms Environment Physical Activity Symptom Surveys Cognitive Testing Time Stamps Geo-Location / GPS

LAMP Tech Demo (Later)

Thank You! Digitalpsych.org jtorous@bidmc.harvard.edu