Tools of Engagement: Practical Considerations for Utilizing Technology-Based Tools in CBT Practice

The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

Automated stress detection using mobile application and wearable sensors improves symptoms of mental health disorders in military personnel

Leading causes in global health-related burden include stress, depression, anger, fatigue, insomnia, substance abuse, and increased suicidality. While all individuals are at risk, certain career fields such as military service are at an elevated risk. Cognitive behavioral therapy (CBT) is highly effective at treating mental health disorders but suffers from low compliance and high dropout rates in military environments. The current study conducted a randomized controlled trial with military personnel to assess outcomes for an asymptomatic group (n = 10) not receiving mental health treatment, a symptomatic group (n = 10) using a mHealth application capable of monitoring physiological stress via a commercial wearable alerting users to the presence of stress, guiding them through stress reduction techniques, and communicating information to providers, and a symptomatic control group (n = 10) of military personnel undergoing CBT. Fifty percent of symptomatic controls dropped out of CBT early and the group maintained baseline symptoms. In contrast, those who used the mHealth application completed therapy and showed a significant reduction in symptoms of depression, anxiety, stress, and anger. The results from this study demonstrate the feasibility of pairing data-driven mobile applications with CBT in vulnerable populations, leading to an improvement in therapy compliance and a reduction in symptoms compared to CBT treatment alone. Future work is focused on the inclusion of passive sensing modalities and the integration of additional data sources to provide better insights and inform clinical decisions to improve personalized support.

Digital Mental Health Services: Moving From Promise to Results

The papers in this special issue make a compelling case for the value of digital mental health services (DMHS; including technology-based interventions, assessments, and prevention programs) to help address some of the currently unmet needs in mental health care. At the same time, the papers highlight the work that needs to be accomplished for DMHS to fulfill their promise. We review the papers' contributions in terms of (a) the imperative to increase access to evidence-informed, high-quality care, especially for underserved populations, both in the United States and globally; (b) ways to use DMHS to improve the ways that clinical care is provided to make treatment provision more effective and efficient; and (c) the current state of the research on DMHS for emotional disorders. We then consider lessons learned and recommendations to move the field forward, such as increasing (and making transparent) the research base on DMHS, adopting regulatory standards for DMHS, attending carefully to training issues for DMHS and best practices for dissemination and implementation, designing specifically for digital platforms, and being intentional about efforts to reduce disparities regarding who benefits from DMHS.

Digitized thought records: a practitioner-focused review of cognitive restructuring apps

Mental health (MH) apps can be used as adjunctive tools in traditional face-to-face therapy to help implement components of evidence-based treatments. However, practitioners interested in using MH apps face a variety of challenges, including knowing which apps would be appropriate to use. Although some resources are available to help practitioners identify apps, granular analyses of how faithfully specific clinical skills are represented in apps are lacking. This study aimed to conduct a review and analysis of MH apps containing a core component of cognitive behaviour therapy (CBT) – cognitive restructuring (CR). A keyword search for apps providing CR functionality on the Apple App and Android Google Play stores yielded 246 apps after removal of duplicates, which was further reduced to 15 apps following verification of a CR component and application of other inclusionary/exclusionary criteria. Apps were coded based on their inclusion of core elements of CR, and general app features including app content, interoperability/data sharing, professional involvement, ethics, and data safeguards. They were also rated on user experience as assessed by the Mobile App Rating Scale (MARS). Whereas a majority of the CR apps include most core CR elements, they vary considerably with respect to more granular sub-elements of CR (e.g. rating the intensity of emotions), other general app features, and user experience (average MARS = 3.53, range from 2.30 to 4.58). Specific apps that fared best with respect to CR fidelity and user experience dimensions are highlighted, and implications of findings for clinicians, researchers and app developers are discussed.

Key learning aims

(1)