A Global Review of Cost-effectiveness Research on Computer-aided Psychotherapy for the Treatment of Mental Health Disorders
Maryan Zirkle, MD, MA
Advanced Post-Doc Fellow: Clinical Informatics, Veterans Administration Hospital & MS student, Department of Informatics and Epidemiology, Oregon Health & Sciences University, Portland, OR
Computer-aided psychotherapy (CP) is becoming increasingly useful in supporting efforts to diminish mental health issues on a global scale. The limited supply of properly trained therapists and the overwhelming mental health needs in existence throughout the world, make an alternative solution necessary. CP might be the best example of such a solution as it is assumed that it serves to be a clinical and cost-effective means of delivering successful therapy to patients suffering from mental health disorders. This may be true, although it is hard to speak in general terms due to the limited number of quality cost-effectiveness analyses on the topic of CP and the inadequate number RCTs of mental health CP systems currently in the literature. Conclusive statements can be made relative to cost-effectiveness with respect to a hand full of CP systems created. This is due to the very small group of researchers concentrating on this field of mental health informatics. The information gained from these studies is specific to the CP system and the type of mental health disorder treated.
"New [Computer-aided Psychotherapy] systems and research are mushrooming across the world in the way fax, computers, printers and email spread in the late twentieth century." -I.M Marks
Computer-aided psychotherapy (CP) is becoming increasingly useful in supporting efforts to diminish mental health issues on a global scale. CP is considered to be “…any computing system that aids talking treatments by patient input to make at least some computations and treatment decisions”.1 As with the innovation of any new technology, the addition of computer-aided training into current treatment will incur some costs, but if there is no data on the cost-effectiveness of such new technology, there is very little guidance to determine whether the expense is worth the investment.2 There is slow growing evidence based research on the clinical and cost-effectiveness of computer-aided psychotherapy that deliver cognitive behavioral treatments3. While it is painfully obvious that mental health disorders are common and lend themselves to substantial health care and lost production costs, it is only largely assumed that CP systems have a high probability to be cost-effective, compliments to current treatment because, in fact, these studies are actually rare and those found are only concerned with decidedly specific mental health topics.
What is computer-aided psychotherapy?
Computer-aided psychotherapy can be delivered using four different methods:
Self guided treatments are highly interactive and might utilize many forms of media, such as video, audio, text and animations. These treatments can be delivered via the Internet or as stand-alone computer programs. Self guided treatments have existed for over forty years and through this type of treatment it became more and more obvious that users would reveal added personal information in this situation.1, 4
Distance therapies involve connecting patients remotely with their therapist via email, asynchronous messaging, video conferencing, or telephone.1,4,5
In session support systems provide specialty treatment during face to face sessions. This method is not as useful as the other styles because it does not generally alleviate the barriers to participating in in-person psychotherapy. Therefore, these types of programs are often omitted from analysis of CP systems as they do not usually enhance the delivery of evidence based treatments (EBTs).1
Hybrid styles of treatment link online self guided programs with additional asynchronous and synchronous access to mental health professionals similar to the distance therapy approach.1
Computer-aided psychotherapy is used currently in several different areas of mental health: 6
Obsessive Compulsive Disorders
Post Traumatic Stress Disorder
The use of CP systems has even been considered for issues of tinnitus distress, jet lag, and headache due to the mental suffering and anguish experienced with these ailments. Depending on the circumstance and preference of the patient, there are equally valid reasons to consider these systems an advantage and/or a disadvantage to mental health treatment. However, one looming all too evident truth is: The limited supply of EBT trained therapists and the demand for their existence creates a much needed alternative that could be satisfied with the use of CP.7 Not to mention, the availability and accessibility to cognitive behavior therapists is also not optimal in many countries and would make these techniques more widely available via CP.7
Basics of cost-effective analysis
Cost effective analysis is a technique that compares the relative value of various clinical strategies. Usually a new strategy (i.e. CP) is compared with current practice (i.e. therapist only treatment) in the calculation of the cost-effectiveness ratio: 8 ￼ If a strategy is considered cost-effective it means that the new strategy is a good value, however, being cost-effective does not mean that the strategy saves money, nor does saving money mean something is cost-effective.8 Some other important terms to understanding cost-effective analysis are:
The incremental cost-effectiveness ratio (ICR) of an intervention in health care is the ratio of the change in costs of a therapeutic intervention (compared to the alternative, such as doing nothing or using the best available alternative treatment) to the change in effects of the intervention.8
The cost-effectiveness acceptability curve (CEAC) demonstrates the uncertainty of the estimate of cost-effectiveness.9 The curve is used widely in applied studies and often in mental health. This is an alternative to producing confidence intervals around incremental cost-effectiveness ratios. This demonstrates a probability that an intervention is cost-effective compared to the alternative.8, 10
The Years Lived with Disability (YLD) determines the cost per YLD gained. It is a standard metric that allows for a comparison between health gain and cost across treatments and their disorders.8
The effect size is a way of quantifying the size of the difference between two groups. It is easy to calculate, well understood and can be applied to measured outcomes. It is used to quantifying the effectiveness of a particular intervention, relative to some comparison. It provides an understanding of how well something works within its context. Thus, effect size is an important tool in reporting and interpreting effectiveness.10
The net benefit approach assumes a value, set by society, of an improvement in a patient’s health status and a cost of attaining that improvement. This benefit is considered achieved if the value, set by society, of the improvement is more than the cost of producing it.7
Systems evaluated for their cost-effectiveness
There were a handful of studies done on the cost-effectiveness of CP systems. It is important to understand the system and the analysis in order to be able to examine the overall implications of these studies.
FearFighter (FF) is a CP system designed for phobia/panic delivered to its user via the Internet. This program takes only three months to complete and relieves several barriers to regular, face to face treatments. This system does not require its users to be computer savvy, in fact it advertises itself as being useful for individuals with “zero computer skills”.11 This system can be accessed based on referral from a physician and on the rare occasion, by self referral.11
This is an interactive voice response (IVR) system used for mild to moderate depression. Users are provided with written workbooks to read about cognitive behavioral therapy (CBT) before they call the computer from home, office, or elsewhere depending on what is most convenient.12
Balance-Anxiety and Depression
This is a system accessed by a PC with a CD-ROM drive from home or at the clinic. This system treats general anxiety/depression. It is more basic than the other systems and uses the least amount of time with the least amount of interaction.13
BTSteps-Obsessive compulsive disorder
This is another IVR system for the treatment of obsessive compulsive disorder. Users are given a manual and told to read a given step and call a computer from home, office, etc. to successfully work toward completion of the step. This process repeats itself at the patient’s liberty.12
Beating the Blues-Depression and Anxiety
Beating the Blues (BTB) is used to treat depression and anxiety through the use of CBT and has been recommended by the NHS for the UK. It is an eight week program where patients spend 50 minutes a week on their issues at their convenience. It has been reported that 7 out of 10 users have been successful in overcoming their depression.14, 15, 16
Shyness Program-Social Phobia
This is an internet-based clinician-assisted CP with CBT system to treat social phobia. The treatment consisted of six online lessons, homework, online forum discussion, and secure messaging email with the therapist.17
Summary of system cost-effectiveness evaluations
The McCrone et al study used data from another RCT study conducted previously as a way to compare the cost-effectiveness of FF and a relaxation therapy. Cost-effectiveness was analyzed through incremental cost-effectiveness ratios and the net benefit approach. The ratings used were a self-rated main problem and a global phobia item of an acceptable fear questionnaire. The limitations of this study included secondary analysis of data, no data collection on production losses, follow-up information gathered within a short period of time relative to the baseline data, lack of a sample size large enough to have more generalized results, outcome measures of single-item scores, and a dropout rate was greatest for those using the CP FF system.7 Another study by Marks et al (2003) examined the use of CP with CBT for four different systems, including FF, that dealt with a variety of areas surrounding anxiety and depression. This study will be discussed in more detail in the next section.
Cope, Balance, and BTSteps
A study done by Marks et al (2003) gave a pragmatic evaluation of four CP systems dealing with different areas of anxiety and depression: FearFighter, Cope, Balance, and BTSteps. This study used a variety of CP methods with several different rating outcome measures. FearFighter, Cope, and BTSteps exceeded the clinically meaningful effect size of .8 on at least one measure.13 The limitations of this study included the inability to sort out how much of the patients’ self-rated improvement what attributable to the CP system, the effect of the many psychotropic medications at least half the patients were receiving at the time, and the inability to conclude whether using less-highly trained CP with CBT providers would lessen the cost without decreasing the effectiveness of clinical care.13
Beating the Blues
A study by McCrone et al conducted an analysis of the cost-effectiveness of Beating the Blues (BTB) in a general practice setting. This work indicated that CP was a cost-effective intervention when using this CP system for depression and anxiety. It also reveals benefits at a “highly competitive cost per quality-adjusted life year.”16
The Titov et al study (2009) examined the cost-effectiveness of the Shyness Program relative to face to face treatment of social phobia disorders. Outcome measures were based on self-rated outcome and acceptability questionnaires. Cost-effectiveness was calculated using years lived with disability (YLD) averted based on between group effect sizes. This was to determine the cost per YLD gained. The YLD averted was calculated as one-quarter that of face to face group treatment.18 Limitations of this study include the limited statistical analysis conducted, the lack of representation of both indirect and direct costs for both the CP group and the face to face group, and it was assumed that these two groups of patients were equal in their ailments and needs for treatment when they were not randomly assigned through a RCT.18
The Olmstead et al study sought to determine the cost-effectiveness of CP with CBT from both the clinic and patient perspective. The actual CP system used was not named and therefore is not listed under the systems evaluated for cost-effectiveness. Still, the comparison was made between CP in addition to regular clinical practice for substance dependence and just regular clinician assisted clinical practice. The analysis was based on a RCT with the primary patient outcome measure being drug-free specimens. ICERs and CEACs were used to determine cost-effectiveness.6 The results based on the outcome measures of drug-free specimens, conveyed it did require additional costs, although the cost-effectiveness evaluation is dependent on the value that decision makers put on the unit of effect: drug-free specimens.2
Overall, despite any limitations of these analyses, we can take away some key results:
There is a cost advantage of CP with CBT over face to face CBT that estimates to increase from 15% per patient for 350 patients per year to 41% per patient for 1350 patients per year.13 CP via self exposure methods using FF can be as effective as clinician guided exposure and less expensive.7 FearFighter improves anxiety and phobias as much as face to face therapy, is more accessible, is more cost efficient, and is more time efficient.11 The advantage to the use of FF would increase if lower level mental health workers were used as support during CP use and would decrease if treatment was given solely by clinicians.7 The total cost of CP with CBT nationally has the potential to rise if those who have never been treated were to seek treatment due to the diminished barriers, as it could offset the savings from the lower per-patient costs mentioned previously.13 CP with CBT can lessen the clinicians’ time spent on each patient and diminish the cost incurred by each patient when the number of patients participating increases.13 BTB is a cost effective CP system for treating depression and anxiety.16 The Shyness Program appears to be very cost-effective and acceptable to participants.18 The Shyness Program is able to produce a similar gain in health status at four times the efficiency of face to face group treatment for social phobias.18 Computer-aided psychotherapy in addition to clinician led treatment for substance dependence disorder appears to be a good value for both the clinic providing the service and the patient receiving the treatment.2 For those individuals who respond well to CP with CBT, the systems can be cost-effective, but for those who do not respond well to such systems, the level of care can be increased by adding additional face to face CBT.19
It is evident that studies attempting to evaluate CP systems using CBT for effectiveness of clinical care are reporting that it is an acceptable treatment for those specific mental health problems. However, there is not much data available on the overwhelming cost-effectiveness of the CP systems to make any broad statements to its cost efficient nature for all systems or for all mental health disorders. In fact, it is unfortunate that only studies done from the UK, Australia, and the USA were located for review. It makes for a difficult time when trying to analyze global cost-effectiveness. There surely needs to be more research done on the systems in use and their abilities to provide cost-effectiveness.
1. Marks IM, Cavanagh K, Gega L. Hands-on Help: Computer-aided Psychotherapy. 2007.
2. Olmstead TA, Ostrow CD, Carroll KM. Cost-effectiveness of computer-assisted training in cognitive-behavioral therapy as an adjunct to standard care for addiction. Drug and Alcohol Dependence 2010;110: 200-207.
3. Marks IM, Cavanagh K, Gega L.Computer-aided psychotherapy: revolution or bubble? The British Journal of Psychiatry. 2007;191:471-473.
4. Cartreine JA, Ahern DK, Locke SE. A roadmap to computer based psychotherapy in the United States. Harvard Review of Psychiatry. 2010;18:80-95.
5. Andrews G, Cuijers P, Craske M, McEvoy P, Titov N. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis[Online].(2010; 5:10 e13196). Available from: URL: www.plosone.org.
6. Titov N. Internet-delivered psychotherapy for depression in adults. Current Opinion in Psychiatry. 2011;24 (1): 18-23.
7. McCrone P, Marks IM, Mataix-Cols D, Kenwright M, McDonough M. Computer-aided self-exposure therapy for phobia/panic disorder: a pilot economic evaluation. Cognitive Behaviour Therapy 2009; 38 (2): 91-99.
8. Primers on Cost-Effectiveness Analysis [Online] (2000). Available from: URL:http://www.acponline.org/clinical_information/journals_publications/ecp/sepoct00/primer.htm
9. Fenwich E, Byford S. A guide to cost-effectiveness acceptability curves. British Journal of Psychiatry 2005; 187: 106-8.
10. Coe R. It’s the effect size, stupid: what effect size is and why it is important. Paper presented at the annual conference of the British Education Research Association [Online] (2002). Available from: URL: http://www.leeds.ac.uk/educol/documents/00002182.htm
11. FearFighter. [Online] Available from: URL: http://www.Fearfighter.com.
12. Marks I. The maturing of therapy: some brief psychotherapies help anxiety/depressive disorders but mechanisms of action are unclear. British Journal of Psychiatry 2002; 180: 200-204.
13. Marks IM, Mataix-Cols D, Kenwright M, Cameron R, Hirsch S, Gega L. Pragmatic evaluation of computer-aided self-help for anxiety and depression. British Journal of Psychiatry 2003; 183: 57-65.
14. Cavanagh K, Shapiro DA, Van Den Berg S, Swain S, Barkham M, Proudfoot J. The acceptability of computer-aided cognitive behavioural therapy: a pragmatic study. Cognitive Behaviour Therapy 2009; 38:235-246.
15. Beating the Blues. [Online] Available from: URL: www.beatingtheblues.co.uk
16. Cavanagh K and Shapiro D. Computer treatment for common mental health problems. Journal of Clinical Psychology 2004; 60: 239-251.
17. Titov N, Andrews G, Schwencke G, Drobny J, Einstein D. Shyness 1: distance treatment of social phobia over the internet. Australian and New Zealand Journal of Psychiatry 2008; 42: 585-94.
18. Titov N, Andrews G, Johnston L, Schwencke G, Choi I. Shyness prgramme: longer term benefits, cost-effectiveness, and acceptability. Australian and New Zealand Journal of Psychiatry 2009; 43: 36-44.
19. Green K and Iverson K. Computerized cognitive-behavioral therapy in a stepped care model of treatment. Professional Psychology: Research and Practice 2009; 40:96-103.
Submitted by Maryan Zirkle