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The National Institute for Health and Care Excellence (NICE) has published draft guidance conditionally recommending digital therapies for adult depression and anxiety.
Prof Peter B Jones, Professor of Psychiatry at Cambridge University and Chair of the MQ Science Council, said:
“I’m pleased to see these recommendations from NICE. Digital therapies for common mental disorders such as depression and anxiety have been available for some years but there has been no high-level clinical and scientific guidance for potential users as they try and navigate what is, in effect, a commercial marketplace. However, the process was necessarily one of rapid evaluation to decide whether the products show promise. Fuller independent research should follow.”
Dr Simon Bradstreet, Associate Research Fellow at the School of Health and Wellbeing, University of Glasgow, said:
“Digital tools have an important role to play in increasing access to evidence-based approaches, like CBT, for people with anxiety and depression. One of the biggest challenges we face in digital health is ensuring the levels of engagement required to achieve the intended therapeutic benefits. It’s very easy to lose interest and motivation in digital tool – particularly at times of distress. That’s why it is sensible that these approaches are all blended with human support. It will also be important to test the reach of these new tools because if they are only accessible to certain groups in society that we inadvertently worsen existing health inequalities.”
Prof Chris Hollis, Director of the NIHR MindTech MedTech Co-operative, said:
Do these apps work as well as in-person therapy?
“These apps all use CBT techniques and are supported by a trained therapist through text and video. NICE has reviewed the available evidence which shows that supported digital therapies can be as effective as in-person therapy. Some digital therapies – such as virtual reality CBT for social anxiety and agoraphobia may in fact be superior and appear to work faster than traditional in-person therapy.”
Are there any disadvantages of an app over a real-life person?
“Using apps can be more convenient of people as they remove the need for travel and the content can be accessed anytime, anywhere. For the NHS they can be a more efficient way of delivering therapy to more people and reducing waiting times.”
What’s the evidence around remote/digital support for the listed mental health issues?
“NICE has reviewed the therapist-supported apps for these conditions and has found promising evidence for their effectiveness. Following this review – the next step will be to collect ‘real-world’ evidence of effectiveness and value in NHS clinical settings.”
Could this allow more people to access support therapy quickly – and is that automatically a good thing?
“NICE estimate that 40,000 people with these conditions could benefit from these digital therapies. These apps are not being released direct to the public – rather all people receiving these apps will first have a clinical assessment – which is important as it ensures that the right help is directed early to the people who need it. Furthermore, they will be supported by trained therapists who can ensure that people using the apps are directed to mor intensive and/or different help if required.”
Dr Jo Daniels, Senior Lecturer in Clinical Psychology at the University of Bath, said:
“There is an extensive and compelling body of research supporting the use of online or virtual Cognitive Behavioural Therapy (CBT) in recent years which has grown substantially since the pandemic. Recognition of this development in the new NICE guidelines is an important step forward, paving the way for increased access to evidence-based psychological therapies. This move is particularly timely given the transition that many have made to home working, meaning they may now be able to access psychological therapies with fewer barriers.
“While many may still prefer in-person therapy, it is vital we have a repertoire of options available for different levels of need, and this is where the newly endorsed online packages have the opportunity to make a significant difference. It is reassuring that NICE recognise the role of appropriately qualified therapists in supporting the delivery of these interventions.”
Dr Roman Raczka, chair of the British Psychological Society’s Division of Clinical Psychology, said:
“We welcome the committee’s conditional recommendation on digital therapies for adults with an anxiety disorder or depression. Clinically evaluated digital therapy developments for anxiety and depression offer new opportunities to reshape mental health pathways benefiting patients, professionals and systems alike. It is, however, really important that the digital therapy is delivered with practitioner or therapist support to monitor patient safety and manage progress.”
Prof David M Clark, Professor of Experimental Psychology Emeritus at the University of Oxford and co-developer of two of the listed products (iCT-PTSD and iCT-SAD), said:
“Psychological therapies aim to teach us skills to deal with troubling emotions. Traditionally, this has been done in one-to-one, armchair conversations with a therapist. However, the internet is also a wonderful learning vehicle. Digitally enabled therapies allow us to learn many of the skills through the internet at a time that works for each of us, with additional but brief guidance from a professional. At their best, as in a recent clinical trial with social anxiety disorder, they can achieve similar results to traditional therapy, while requiring less therapist time, which means more patients can receive help. However, they do not suit everyone, so patients should be offered a choice between traditional and digitally enabled therapy”.
Prof Jenny Yiend, Professor of Cognitive Psychopathology at the Institute of Psychiatry, Psychology & Neuroscience, King’s College London, said:
“Apps and other digital therapies won’t be right for everyone, but those of us working in this area believe that they could be really helpful for many patients, many of whom might otherwise wait a long time to get in-person treatment.
“Digital therapies can feel impersonal, which some people don’t like. But if you’re the kind of person who finds it hard to open up or trust other people (even therapists), then an app can be a great way to receive treatment.
“Digital therapy is a new and fast-moving field. Many potential treatments are still at the early stages of development and testing. It is important that we use the same evidence standards that we use for any other therapy before recommending them to patients and this will take time. But there is lots of work going on to build that evidence base. NICE’s conditional recommendation gives people a useful ‘heads up’ about digital therapies currently in the pipeline.
Dr Dean Burnett, Honorary Research Associate at Cardiff University, said:
Do these apps work as well as in-person therapy?
“By and large, it’s probably still too early to say for certain whether apps can be as effective as in-person therapy, as they’re still a relatively new and developing technology. It would also depend heavily on the nature of the condition being treated. E.g. mild cases of depression or anxiety disorders may benefit just as much from apps as in-person therapy, while more severe cases would be more responsive to in-person therapy. But then, talking therapies are known to be of limited use with the more serious manifestations of disorders in any case. Talking therapies require a minimum level of engagement and effort from the patient, and it’s hard to provide this when in the grips of a serious mental episode.
“Overall, according to current data and what we know about how the brain works, such apps are unlikely to be as effective as in-person therapy, but that’s not the same as them being ineffective. They can still potentially be very helpful, just less so than an actual therapist. But then every treatment has differing levels of efficacy, and sometimes convenience/ease of use/accessibility trumps potency.”
Are there any disadvantages of an app over a real-life person?
“One of the obvious issues is that a therapist, being there in-person, can react to the patient and guide the session according to their needs. This is one of the strengths of psychotherapy, and it’s often something highlighted by practicing therapists; that the patient contributes to their treatment as much as the practitioner, it’s essentially a bespoke treatment for each individual. Indeed, the more rigid ‘one size fits all’ approach of psychiatry and medicine is often something psychologists and psychotherapists criticise it for.
“Logically, however advanced and well-designed it may be, a software program cannot be as reactive and adaptable to a patient’s needs as a trained therapist (which is presumably why all the new treatments include an actual therapist or similar available for support at all times, and they aren’t just trusting the programs to do it all). So, an app is likely to introduce a degree of rigidity and inflexibility into the psychotherapeutic approach, which presumably would be less beneficial for patients than if they all saw a human therapist to the same extent.
“There’s also the fact that the human brain is incredibly adept at recognising when it’s interacting with a real person and when it isn’t. This is why AI chats and artwork and canned laughter can be so jarring; we immediately recognise that we’re not dealing with a real person, but an artificial representation of one. And a strong connection between patient and therapist is often a key part of successful treatment. In these new cases, the patients are (presumably) aware that they’re using an app and not something pretending to be a person, and that there will also be an actual therapist involved in the process, so this aspect shouldn’t be a concern per se. But if we’re talking about getting to a point where apps could be used instead of actual therapists, then this would be an increasingly prominent hurdle.”
What’s the evidence around remote/digital support for the listed mental health issues?
“There’s just so much of it right now so impossible to narrow down, but it certainly tends towards the positive. But my overall impression is that it’s currently a useful augmentation to, rather than replacement for, traditional talking therapies. There are also other interesting approaches being explored, like the use of word recognition software that listens to therapy sessions and can work out if a patient is on the verge of an episode/relapse by analysing the terms they use (if they start using more emotionally negative terms, it suggests a worsening mindset). There’s also the use of VR and similar for PTSD and even psychedelic therapies. There’s a lot going on right now. But because technology is so broad a term and so regularly advancing, the picture is always changing.”
Could this allow more people to access support therapy quickly – and is that automatically a good thing?
“One of the most obvious and simple advantages of these apps is that they make treatment more accessible to patients, in the physical sense. Often times, the basic act of leaving home, travelling to a clinic, sitting through therapy, then returning, is beyond the capacity of those in the throes of a serious mental health episode. Even if they aren’t, one key feature of most mental health disorders like those listed is the loss of motivation or energy to do anything productive. So, being able to access therapy remotely and/or via digital means will allow a lot more people to engage with it, as it requires far less mental effort, something such patients usually can offer very little of to begin with.
“Overall, this would logically be a very good thing. The one downside I can see is that, if all digital approaches required the same level of support from a trained therapist, then we could quickly get to the point where the supply of therapists is overtaken by the demand. And if it is the case that remote/digital therapies aren’t 100% as effective as in-person therapies, then we may end up with all available therapists engaged with patients remotely, and doing less in-person sessions, meaning more time is being spent on less effective interventions.
“It’s a remote possibility at present, but given the ever-perilous state of mental healthcare provision in the UK, it’s not something we should ignore either.”
Declared interests
No reply to our request for DOIs was received.