by Stefan Stöcklin, University of Zurich

Prognostic Risk Index (PROG) as a Function of 4 Treatment Submodalities in Samples of Randomized Clinical Trials on Face-to-Face Therapy (FTF) and Internet-Based Therapy (IBT) for Depression. Credit: JAMA Psychiatry (2023). DOI: 10.1001/jamapsychiatry.2023.3861

The demand for therapy places for people suffering with mental health problems is currently sky high. Depression and anxiety disorders in particular are driving more and more people in Switzerland to seek psychotherapy, and the numbers continue to rise. Although provision of mental health care in Switzerland is generally considered good, those seeking help are now having to wait longer than usual to see a therapist.

In times of such need, online therapy programs and smartphone apps seem to offer an inexpensive alternative. They may also appeal to people who would feel reticent about going to a psychotherapist. Instead of relying on a specialist, digital tools can teach people techniques from behavioral therapy and help them to help themselves.

But these easy-to-access services are not without problems. "We currently know far too little about the efficacy of internet-based therapies," says Birgit Watzke, professor of clinical psychology and psychotherapy research at UZH. "In many cases, their effects have not yet been sufficiently proven." Watzke firmly advises against using such apps without professional support, except in clear cases of very minor symptoms, such as mild depression.

Tricky comparisons

Her critical attitude is no knee-jerk reaction. Watzke and her team have been researching internet-based therapies for several years and are currently developing their own app. The clinical psychologist has just published a study in JAMA Psychiatry shedding light on the problems of internet-based therapies. The study focused on test subjects who had taken part in other trials examining traditional psychotherapy sessions or internet-based therapies.

First author Mariia Merzhvynska measured the severity of the participants' depression and came to the conclusion that, on the whole, those who used the internet-based therapies had less severe symptoms from the start. In other words, it is hard to compare the research findings for conventional versus internet-based therapies because the patient groups differ. For the comprehensive study, the research team analyzed a total of 109 randomized clinical trials, 57 of which involved traditional psychotherapies and 48 internet-based therapies, with a total number of participants of more than 18,000.

From a clinical perspective, it's a problem if internet-based therapies are marketed as a miracle replacement for conventional therapy sessions, as happens in some parts of the internet. As Watzke points out: "At the moment, we simply do not know enough about which kinds of patients would benefit from internet-based therapies." It is difficult to interpret the relevant studies due to the different participant samples, as the JAMA study shows.

Delicate self-diagnosis

One reason for this difficulty is posed by the conditions of participation: in many internet-based studies, participants can enroll based on a self-diagnosis, which opens the door to manipulation. No specialists are involved in the selection process. In a clinical study, in contrast, experts decide who is admitted and assess the participants. That makes a significant difference in cases of depression, as the spectrum is broad and ranges from mild symptoms to severe distress that can lead to suicide.

Moreover, depression can occur in combination with other problems such as a personality disorder or psychosis, complicating the diagnosis. For Watzke, it is necessary to examine which forms of mental disorders could benefit from internet-based therapies by conducting extremely precise and careful studies that adhere to the established norms. Otherwise, there's a risk that people will be prescribed ineffective therapies.

Despite all these reservations, Watzke sees a "promising future" for internet-based interventions. However, she envisages them less as a replacement for conventional therapies than as a complement—in the context of "blended therapy" or integrative treatment. The InMind app for smartphones currently being developed by Watzke's working group together with colleagues from the Department of Informatics is intended to fulfill such a role.

Smart journal

This digital assistant can be used between psychotherapy sessions to help patients consolidate the therapeutic effects. Patients can use it to record feelings, thoughts and observations about their daily life, as well as reflections on the therapy session. "The app is like a 'smart' journal which encourages people to reflect on their therapy and to implement discoveries from the sessions in their everyday lives," says Markus Wolf, senior teaching and research assistant in Watzke's team, who is involved in developing the app.

Following an initial positive evaluation of the app by psychotherapists and other experts, it will be tested on the first group of patients next year. If the tool also proves useful in practice, it will be rolled out more widely in the future.

Accompaniment required

The InMind app can be described as a simple digital support tool for use with traditional outpatient psychotherapy. Its claims are thus less overblown than certain internet "therapies," where a distinction must be made between self-help programs that involve in-person therapy and those that don't.

Markus Wolf draws a comparison between self-help tools such as Moodgym or Deprexis and the self-help books that were popular at the end of the last century. The programs are well made, and some are also scientifically tested, he says, but at the end of the day they are still just a digital form of self-help. "Basically, the effect of using internet-based therapies without accompanying psychotherapy is low," say Markus Wolf and Birgit Watzke in unison.

In view of the rising number of people suffering from mental health difficulties, the two experts believe there is a risk that untested programs which cannot deliver on their promises start to proliferate. That would cause more suffering for the very people who need help. Instead, Watzke and Wolf want to see a sophisticated range of services developed. In their view, the future lies in harnessing an intelligent blend of conventional and digital methods, with the aim of combining psychotherapy sessions and internet interventions in the most effective way possible.

More information: Mariia Merzhvynska et al, Prognostic Risk Factors in Randomized Clinical Trials of Face-to-Face and Internet-Based Psychotherapy for Depression, JAMA Psychiatry (2023). DOI: 10.1001/jamapsychiatry.2023.3861

Journal information: Journal of the American Medical Association  , JAMA Psychiatry 

Provided by University of Zurich