IACAPAP Textbook of Child and Adolescent Mental Health

INTRODUCTION

Chapter

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e-THERAPYUSING COMPUTER AND MOBILE TECHNOLOGIES IN
TREATMENT
Karolina Stasiak & Sally Merry

Karolina Stasiak PhD, MA,BA
Research Fellow, University of
Auckland, New Zealand

Sally Merry MB, ChB, MD,
FRANZCP, CCAP
Associate Professor of Childand Adolescent Psychiatry,
University of Auckland, New
Zealand
Conflict of interest: K Stasiak
and S Merry (along with T
Fleming, M Shepherd and M
Lucassen) are the creatorsof SPARX and may gain
financially from its licensing.

Apple Macintosh
This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2013. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Stasiak K, Merry S. e-Therapy. Using computer and mobile technologies in treatment. In Rey JM (ed), IACAPAP
e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied
Professions 2013.

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DEFINITIONSThis is an emerging research and clinical field and consequently the terms used are new andevolving. There is some discrepancy in the terminology used by the various researchers. In thischapter we use the following definitions:e-Health(e-health or ehealth)An umbrella term that encompasses the use of information and communication
technology in the health sector.

e-Therapy(e-therapy or
etherapy)

A generic term that covers a broad range of psychological and behavioural therapies
delivered with the assistance of digital/computer technology (it is often usedinterchangeably with computerised therapy or computer delivered therapy). Modesof delivery can include a personal computer, the internet, telephone interactive voice
response (IVR) systems, or a combination of these. e-Therapy can include facilitated‘therapeutic chat rooms’ and therapy supported by email.

Computerised
cognitive
behavioural therapy(cCBT)A type of e-Therapy that involves the delivery of CBT via a computer interface.

m-Health(m-health ormhealth)An emerging field within the broader e-Health domain that involves the delivery of healthbased services on mobile devices (mobile phones, smart phones, tablets and devices
monitoring and collecting patients’ data). m-Health interventions vary and can take theform of mobile phones being used to collect and store clinical data, as well as to remindpatients of an upcoming appointment or provide text message-based counselling.

•

Effective e-Therapies exist for a range of disorders and client groups.

•

The vast majority of e-Therapies have been designed for those at the mild to moderate spectrum of mental
illness severity or for prevention.

•

The quality of studies examining the effectiveness of e-Therapy varies but continues to improve. More researchis needed with patients in real clinical settings as well as rigorous RCTs with longer-term follow ups.

•

Systematic reviews of e-Therapies for children and adolescents with depression or anxiety have shownpromising evidence for efficacy, safety and acceptability.

•

The development of and research into e-Therapies for children and adolescents lag behind those for adults but
young people’s enthusiasm for digital media suggests that this group may be an ideal target.

•

Rapid technological innovations are predicted to continue and have the potential to reshape e-Therapies into
sophisticated interventions that are routinely used in clinical practice.

•

There is scarce research into e-Therapies with diverse or minority patient groups. Cultural acceptability of
e-Therapies has received limited research attention.

•

The digital divide is slowly diminishing in the low- and middle-income countries as technology costs decrease;
however, significant resources are needed to bring effective e-Therapies into clinical practice in these countries.

•

m-Health programs use mobile phone and other mobile devices to deliver health interventions. They areparticularly well suited to low- and middle-income countries as mobile phones are cheaper and ownershiprates are rapidly growing.

•

e-Therapies can be delivered at a fraction of the cost of traditional mental health interventions. m-Healthinterventions are potentially even more cost effective and may have a wider reach.

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e-Therapy is an emerging and fast developing field of research and practicethat involves the application of digital technologies to assist or deliver psychotherapy.
Systematic research in this field began two decades ago with mixed results but
as computer technology matures so does e-Therapy. Each year more studies
are published, extending the application of e-Therapy to different populations,disorders and clinical settings. The potential ability to deliver more psychologicalcare to those who need it (and who otherwise might not be able to receive it), toextend the efficiency of scarce clinical resources and to improve monitoring ofoutcomes presents a great opportunity as we look to the future. The challenges in
evaluating and employing computer programs clinically cannot be understated.
Currently, the vast majority of e-Therapy programs has been developed for adults
and more work is needed to find the most suitable and engaging ways to do thisfor children and adolescents. Clinical implementation of e-Therapy has begun
in some countries but low-income nations face significant cost barriers. Mobile
phones may offer a more cost-effective solution and we describe some m-Healthinterventions that may be relevant to child and adolescent mental health.

HISTORICAL NOTE
The computer program often credited with being used in psychiatrictreatment for the first time was called ‘Eliza’ (Weizenbaum,1966). In fact, Eliza
was designed as a pilot project in the use of ‘natural language’ between a humanand computer. However, because it used a Rogerian, nondirective interview style—largely rephrasing many of the patient’s statements as questions and posing themback—it has often been mistakenly assumed that this was an attempt to emulatea therapist. At the time when computers were a mere novelty among the scientificfraternity and were virtually unknown to the general public, the program attracted
considerable negative attention. For many years Eliza has been used to highlightthe limitations of computers in psychotherapy.
The real beginning of e-Therapy research and practice began in the late1980s as the decade saw rapid technological development and the spreading use
of personal computers. It became apparent that computers’ unique attributes ofinteractivity, storage, analysis and display of data as well as multimedia features
could be used to offer self-help in a potentially more attractive and engaging format
than written materials (Wright & Wright, 1997). One of the first empiricallyevaluated interventions was a cCBT program for adults with depression (Selmi etal, 1990), which demonstrated that the computer-delivered therapy was as effective
as therapist-delivered CBT in a small trial.

Click on the image to view
an online version of Eliza.
It quickly becomes apparent
that the program simply
presents back the text writtenby the user and it cannot
adapt to form the flow of areal conversation.

The first e-Therapy programs were really simple and predominately text-based.
They essentially involved presenting written text describing self-help strategies tobe read off the screen. Interactivity was limited to multi-choice questions. As thetechnology matured the programs have become increasingly more sophisticated.
The new wave of e-Therapy programs allows for greater interactivity, relies moreheavily on multimedia (voice, video, animation), incorporates automated emails
and text messages (SMS) to enhance adherence or augment the content.
One of the most recent developments is ‘gamification’ or the convergenceof ‘serious games’ (games designed for a primary purpose other than pureentertainment) with e-Health and e-Therapy. While computer games havee-Therapy

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IACAPAP Textbook of Child and Adolescent Mental Healthreceived some negative attention, particularly around suggestions that violent
video/computer games may cause an increase in aggression (Anderson, 2004), thepotential of computer games applied to learning is enormous (Lieberman, 2006)
and, in particular, it is thought that serious games can make a positive contribution(Connolly et al, 2012). An example of a serious e-Health game is Re-Mission,
which was shown to improve behavioural outcomes for young patients withcancer in a multisite randomised controlled trial (Kato et al, 2008). An e-Therapy
program that uses a platform of a fantasy game to teach CBT skills for adolescentswith depression is SPARX (see below).

Gamification
The use of game mechanics
in a non-game context inorder to engage users.

Another innovation that seemingly brings science-fiction into reality
is the use of virtual reality in psychiatric care, particularly in the treatment of
posttraumatic stress disorder (PTSD) and anxiety disorders. Some of the researchhas been driven by the need to treat large numbers of returning soldiers fromwar and other conflict zones. Virtual reality involves a computer-generated

Click on the image toaccess Re-Mission

simulation of a three-dimensional image or environment. Users can interact
with it in a seemingly real or physical way by using special electronic equipment
such as a helmet with a screen inside or gloves fitted with sensors. Virtual reality
treatment offers the potential to create a sense of realism in a safe environment
under the guidance of a therapist who can, for example, guide the patient througha series of graded exposure exercises where the feared stimulus is simulated in
the safety of the virtual environment. Virtual reality is still a new technique thathas not been adopted in routine clinical care, predominantly due to the cost of
the equipment. However, laboratory evaluations have shown it to be a safe andeffective treatment in some conditions. For example, in a randomized controlled
trial (RCT) of 30 military personnel with combat related PTSD, those treatedwith graded exposure using virtual reality improved significantly more than thosegiven usual care (McLay et al, 2001). A meta-analysis of 21 studies of virtual reality
exposure therapy in the treatment of anxiety and specific phobias has shown it tobe promising although more rigorous research is needed (Parsons & Rizzo, 2008).
Very little is known about the use of virtual reality treatment with children andadolescents in psychiatric settings; however, some successes have been noted in

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IACAPAP Textbook of Child and Adolescent Mental Healthusing virtual reality video games as a distraction to reduce pain in children in anexperimental setting (Law et al, 2011).
Another recent innovation being investigated is the application of
biofeedback to e-Therapy. Biofeedback is a treatment technique in which people
are trained to improve their health by using signals from their own bodies. Oneof the applications in psychotherapy is to help tense and anxious clients learn torelax. Traditional biofeedback equipment may, for example, include a sensor thatpicks up electrical signals in the muscles, which are then translated into a form
that the patient can easily recognise (e.g., a flashing light or a sound). Biofeedback
exercises can be done with a therapist in a clinic; however, biofeedback may also
be incorporated into computer-assisted therapy. One exciting proposition is tointegrate biofeedback into a serious game to engage a child in a therapeutic exercise.
For example, biofeedback may be used in a computer game to teach an anxious
child how to relax in order to ‘win’ a quest. Biofeedback programs that use simple
galvanic skin response and heart rate variability sensors, which are placed on fingers
to detect stress-related physiological changes, are already available on the market
for adults and for children (http://www.somaticvision.com/products). One of thecommercially available programs is ‘The Journey to the Wild Divine’ (Bell, 2003) inwhich the user completes a range of tasks (e.g., building a bridge) by controllingthe environment through galvanic skin response and heart rate variability sensors.
This requires the user to slow down the breathing and reduce muscle tension.
Quality empirical evaluations of these games are rare although some studies havebeen published recently. For example, 24 clinic referred children aged 9-17 with
anxiety were randomised to a biofeedback game intervention (Journey to the Wild
Divine as well as another program, Freeze-Frame 2.0 (Childre, 2005)) combinedwith face-to-face therapy or to a waiting list. Those in the intervention group had
significantly reduced symptoms of anxiety and depression at the end of an 8-session
treatment compared to those on the waiting list (Knox et al, 2011). Other studies
which have shown emerging evidence of efficacy include stress management forchildren (Pop-Jordanova & Gucev, 2010) and relaxation training for children withattention deficit hyperactivity disorder (Amon & Cambell, 2008).
To date, computer-based programs have been developed to treat a rangeof mental health conditions including eating disorders, problem drinking, andobsessive-compulsive disorder, to name a few, but the most frequently targeted
conditions are depression and anxiety, which are the focus of this chapter. Most
e-therapies have targeted the mild to moderate end of the disorder spectrum or are
framed as preventive interventions to treat sub-threshold symptoms or prevent theonset of the full disorder. Whether e-therapies can be successfully and safely used
to treat the more severe end of these disorders is currently unknown.

Biofeedback sensors

Mental health professionals
need not be alarmed thatmachines will replace them.
Clinicians should view
e-Therapy programs as partof a growing clinical toolbox
and as opportunities toengage patients or support
traditional therapeutictechniques.

No computer program has yet matched full experience of meaningful
human-to-human interaction. It is our belief that this is not the goal of e-Therapy.
Computer programs that can be used therapeutically are designed to complement
or support clinical practice. Instead, it is important to consider the unique featuresof computer technology and what they can bring to the practice of psychotherapy.
Caring and skilled health professionals need not be alarmed that machines will
replace them. Instead, clinicians should view e-Therapy programs as part of a
growing clinical toolbox and as opportunities to engage patients or support
traditional therapeutic techniques.

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INTRODUCTION OF e-THERAPIES INTO CLINICALCARE
The UK’s National Institute for Health and Care Excellence (NICE) has
conducted reviews of cCBT for adult depression and anxiety (National Institutefor Clinical Excellence, 2004). The review highlighted that more research is stillneeded in several areas, including trials with patients of all ages, ethnicities andsocio-economic groups, as well as patients who are more representative of theclinical populations. Nevertheless, in a review published in 2006, some e-Therapy
programs were deemed to have sufficient evidence to be officially endorsed in
the review (National Institute for Health and Clinical Excellence, 2006). For
example, an online program called ‘Beating the Blues’(Proudfoot et al, 2004) was recommended for use in
the stepped-care management of mild to moderate
depression in primary and secondary care (National
Institute for Health and Clinical Excellence, 2006).
This is believed to be the first recommendation ofcCBT by a government regulatory body anywhere in
the world. ‘Beating the Blues’ is currently offered on‘prescription’ by general practitioners in parts of the
UK and in New Zealand for patients over 18 years
with mild to moderate depression. Subsequently,
the NICE 2009 review removed references to any
particular cCBT programs and instead NICE broadly
endorsed cCBT as an option for first line treatment ofmild or sub-threshold depression (National Institutefor Health and Care Excellence, 2009). To date, no e-Therapy program has been
recommended or adopted into routine clinical use in treating child and adolescentdepression or anxiety.

Virtual reality equipment.
Head-mounted display andwired gloves (courtesy ofNASA)

Computer hardware and software technology are rapidly improving
and further scientific breakthroughs in computer evolution are predicted. It is
important to recognise that current technologies are just beginning to be tapped bysoftware and hardware developers to deliver therapy for mental health problems.
In the near future, technological advances such as improved human-computerinterfaces, ultrafast broadband and the proliferation of smartphones (a smartphone
is a mobile phone with more advanced computing capability and connectivity
than a feature phone) are likely to result in a more widespread use of e-Therapy
clinically. Looking long-term, other innovations such as virtual reality and bodysensors are likely to reshape the way computers may be used in healthcare generally,
and in the treatment of mental health problems particularly. Wright and Wright(1997) eagerly predicted more than 15 years ago that “the therapist of the future
may have an extensive ‘toolbox’ of computer programs that can be prescribedfor a broad variety of uses” (p. 325). This prediction has not yet come fully tofruition, but e-Therapy programs are indeed making steady inroads into day-today clinical practice. It is not unreasonable to expect that future applications ofdigital technologies to healthcare delivery may dramatically change the field.

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WHY THE INTEREST IN COMPUTER TECHNOLOGYTO DELIVER INTERVENTIONS FOR MENTALHEALTH PROBLEMS?
There are four different yet complementary reasons behind the rationale
for using computers and mobile phone technology in therapy. The first is dictatedby the economic reality and demands of the modern mental health system and its
users. Health care resources are limited and inequitably distributed; it is impossible
for the available pool of trained clinicians to deliver care to all those in need,particularly in low-income countries where there may be a child psychiatrist per
million population. The second reason is driven by societal changes, especiallyin relation to attitudes about the use of computers and mobile technologies andtheir availability. Today, for many individuals throughout the world, computers
and mobile phones are an integral part of everyday life, at work and at home.
As personal computers become less expensive they become more commonplace

Table A.8.1

Factors that drive research and development of e-Therapy

Economic andworkforce factors

Societal acceptanceof computer
technologies

Features inherent
to information
technology

Individual
preferences

Mental health services areunder increasing strain –demands for care outstrip
available resources

Vast expansion ofcomputers, internet accessand mobile phone use overthe last two decades

Computers have uniquefeatures (interactivity andmultimedia) that are lacking
in other self-help options

Anonymity. e-Therapy canbe accessed in private,
without stigma

Long waiting lists especiallyfor specialist services

Cost of computers andmobile phones continues
to decrease reducing the‘digital divide’

Interactivity allows theprovision of feedback
to the user, facilitating
engagement in treatment
and self-monitoring

Some people are reluctant
to talk to a ‘stranger’
especially about sensitive
issuesScarce health careresources need to be better
distributed to treat more
peopleRapid technologicalinnovation is predicted
to increase even further.
Availability of the internet
and mobile phone networks,
while still variable, are likely
to be broader than the
network of mental healthprofessionals

Ability to store, analyse anddisplay data (which can beused to monitor treatment
outcomes and improve
evidence base)‘Dr Google’ – the internet
is increasingly the first portof call when searching for
health-related information

Low cost interventions
should be offered first withina stepped-care approach tohealthcare

M-health interventions holdparticular promise in lowincome nations, due to highphone penetration rates.

Treatment fidelity –computers can present
the same material reliably
without fatigue‘Digital natives’ – young
people growing up in
the age of information
technology are
enthusiastic users ofcomputers and readily
accept them

E-therapies can be widelydistributed at a fractionof the cost of traditional
therapies.

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IACAPAP Textbook of Child and Adolescent Mental Healthin ordinary households. Mobile phones have become almost ubiquitous in thehigh-income countries but the rate of mobile phone ownership in low andmiddle-income countries is increasing rapidly and is already more than 50%.
It is noteworthy also that the boundary between the traditional computers andmobile phones is becoming increasingly blurred. The third factor lies in featuresinherent to computer technology, with opportunities for delivering mental healthinterventions in ways vastly more engaging than traditional self-help approaches(e.g., self-help books). The final reason is due to individual preferences in how to
use mental health support. Some of the common arguments used to support the
introduction of e-Therapy are summarised in the Table A.8.1.
While the introduction of e-Therapy into healthcare has strong proponents,
some remain skeptical about its potential to benefit clients and believe that it may
lead to delays in appropriate care or may even cause harm. It would be unreasonable
to assume that the use of computers in mental health is not without shortcomings
or even major limitations. Some of the common arguments around the advantages
and pitfalls of e-Therapy are given in Table A.8.2.

SPECTRUM OF THERAPIST INVOLVEMENT IN
E-THERAPY
e-Therapy interventions vary in the degree of therapist input. At one end
are programs that are delivered as an adjunct to face-to-face therapy or which
entail a large therapist involvement via a chat-room or email. In some programs,
Table A.8.2

Pros and cons of e-Therapy

Commonly cited benefits of e-Therapy

Commonly cited criticisms of e-Therapy•

Patients can access it at their convenience••

Available 24/7 in the privacy and comfort of one’s
home without the need to travel or make an
appointment

Inability to deal with complex interpersonal problems,
to respond to non-verbal cues or build rapport (Murphy,2003).

•As technology use increases, people’s need for real faceto-face interaction may actually increase, making themreluctant to seek help from yet another machine (Murphy,
2003)

•

Evidence is limited to a number of select programs•

The Internet is a reservoir of misinformation (vaccination isa case in point) and poor quality programs. There are calls
to establish a set of guidelines to regulate e-Therapy toprevent ineffective programs•

Less access to the technology by those from lower socioeconomic groups and minorities may propagate, instead of
diminish, inequalities in access to treatment•

Computer use may be contributing to the very mental
health problems computerised therapy is trying to treat(e.g., young people using computers at the expense offorming ‘real’ relationships)•

Patients can work at their own pace – weekly
appointments may not suit everyone•

It suits those who are concerned about privacy
or stigma or are reluctant to engage in traditional
face-to-face therapy•

It can provide treatment to those who livein geographically isolated areas, otherwise
inaccessible

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Table A.8.3

Spectrum of therapist involvement in e-Therapies

therapists’ support is present but limited to emails or brief telephone calls (e.g.
BRAVE-ONLINE (Spence et al, 2008)). At the other end of the continuum are thepure self-help or unassisted e-Therapy programs (see Table A.8.3).

SELF-HELP THERAPY VS. CLINICIAN-ASSISTED
e-THERAPY
Up to eighty percent of young people with depression do not get professional
help (Fergusson et al, 1993). Therefore, it is important to facilitate people’s accessto free, effective e-Therapy, and many may choose to access it without clinicalsupport. On the other hand, in day-to-day clinical practice, it may be desirable
to provide the option of integrating e-Therapy with monitoring and additional
support provided by a clinician, particularly at this early stage of developmentof e-therapies. Research suggests that supported e-therapies may be associatedwith lower dropout rates (Christensen et al, 2004b). Furthermore, oversightfrom a clinician is associated with greater efficacy. A meta-analysis of 12 RCTs ofcomputerised psychological treatment for adult depression showed that e-Therapy
with professional support is significantly more effective than unsupported
programs (approximate effect sizes of 1.1 and 0.65 respectively (Andersson &Cuijpers, 2009)).
The decision about what level of therapist input is required in the provisionof e-Therapy lies with the client and with the clinician. Even self-help e-Therapy
programs can be used with clinical support or input if deemed appropriate fora given client. The clinician can ask the client to complete e-Therapy sessions
at home and then discuss what has been learnt during a therapy session—notdissimilar to ‘homework’ tasks used in most CBT treatments. If less involvement
is desired, clinicians can tell clients about various e-Therapy options and let theme-Therapy

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9IACAPAP Textbook of Child and Adolescent Mental Healthdecide which ones they want to try and then discuss their use of these programs at
a follow-up appointment.
There are many other ways in which computers or mobile phones can beused to support the delivery of mental health interventions. Examples include
simple things like texting or emailing reminders about upcoming appointments,
sending messages that reinforce coping strategies discussed in the therapy session,prescribing homework that can be completed and monitored online (both by theclient and therapist), asking the patient to rate mood or other symptoms etc.

e-THERAPY FOR CHILDREN AND ADOLESCENTS
Developmental Considerations
The current generation of young people is growing up using computerand mobile technologies (‘natives’), so it would seem obvious to design e-Therapy
interventions for this population. However, research with this age group lags
behind that of adult e-Therapy. The mean age of participants is in the range of
30-45 years in most studies (National Institute for Health and Clinical Excellence,2005) and the vast majority of cCBT depression and anxiety programs appear tohave been designed with an adult population in mind. Further, programs designed
for adults may not be appropriate for, accepted by, or appealing to children andadolescents. E-Therapy programs for children and adolescents need to take into
account developmental considerations in order to engage this audience successfully.
For example:•

The content in adult programs is not likely to be suitable for children
and adolescents. Matters relating to work performance or marital
problems are likely to be inappropriate. Instead, issues should be more
topical and relevant to young people’s lives such as school performance,
peer pressure, conflict with parents, dating and so forth•

Developmentally appropriate content should also be illustrated using
child or adolescent role models and scenarios that reflect their lives•

Content should be presented using simple language without difficult
expressions or jargon. Complex ideas (e.g., cognitive restructuring)should be simplified and applied to examples from young people’s
experiences•

The amount of text, duration and the number of modules need toensure maximal engagement and to motivate a young person tocomplete the program•

Parental involvement may be an appropriate component in programs
targeting children (see BRAVE-ONLINE below). Adolescents may
want to choose whether they involve their parents or complete theprogram independently•

The whole package (stylistic design, imagery and features) needs to be
designed to make it attractive to young people.

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BRAVE-ONLINEBRAVE-ONLINE, which is not yet available to the public, is an internet
CBT program for children and adolescents with anxiety (Spence et al, 2008). It
has two versions, for children aged 7 to 12 and for adolescents aged 13 to 18. The
program consists of 10 one-hour sessions for the young person (plus two booster
sessions) and parallel sessions for parents (5-6 modules). The program includes
text, colourful graphics, animation, sound effects, quizzes, games and interactive
forms. To avoid activities being skipped, most exercises require a response before
the next screen can be accessed. If a child or young person misses a session, thesystem sends out automatic reminders. The sessions can be accessed once a week.
BRAVE-ONLINE is a therapist-supported e-Therapy. Trained clinicians(referred to as BRAVE trainers) introduce themselves to the child or adolescent in
the first week of the program by email or phone and explain how, from now on, they
will be in contact with the family by email. The children or young people complete
BRAVE in their own time and log the exercises and homework tasks completed
on the website. The BRAVE trainers review these answers weekly and send weekly
emails with encouragement and feedback. Mid-program, the therapist telephones
the family to assist child and parent to create an appropriate exposure hierarchy(BRAVE ladder), which is then the focus of the remainder of the program. The
therapist’s time required is estimated at approximately 15-20 minutes per family.
The content is based on standard anxiety management CBT techniques
including psycho-education, relaxation training, recognition of physiologicalsymptoms of anxiety, cognitive strategies of coping self-talk, cognitive restructuring,
graded exposure, problem solving, and self-reinforcement. Sessions for parents
include strategies to empower them to help their child to implement anxiety
management skills and deal with situations in which their child gets anxious.
BRAVE-ONLINE has been evaluated in two RCTs. In a study with 73
children aged 7-12 who were randomised to BRAVE ONLINE or to waiting
list (March et al, 2009), immediately post-intervention, 30% of those treatedby BRAVE no longer met criteria for their initial diagnosis compared to 10% of
those on the waiting list, though the difference was not statistically significant.

Click on the image to access
BRAVE-ONLINE

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At 6-month follow-up, 75% of BRAVE-ONLINE participants were no longer
suffering from anxiety; however those previously on the waiting list were given
an intervention and thus no longer assessed. At the 6-month follow-up, 72%of parents and 62% of children had completed all their sessions. The adolescentversion of the program was tested with 115 clinically anxious adolescents aged
12 to 18 (Spence et al, 2011); 44 were allocated to BRAVE-ONLINE, 44 to an
equivalent CBT face-to-face clinic treatment, and 27 were on a waiting list. The
results showed that BRAVE-ONLINE was as effective as the face-to-face therapy
and both groups outperformed the waiting list. 12 months after the therapy,
78% of the BRAVE-ONLINE group no longer met criteria for their principal
anxiety diagnosis compared with 81% of those in the face-to-face therapy group.
Adolescents rated BRAVE-ONLINE and face-to-face therapy equally, thoughparents rated clinic therapy slightly more favourably.

SPARX
SPARX is an e-Therapy program for adolescents experiencing mild tomoderate depression. The program uses a 3-D fantasy gaming environment todeliver CBT. There are seven modules and each one takes about half an hour tocomplete. At the beginning and end of each module the user interacts, in thefirst person, with a character called the Guide, who provides psycho-education,assesses mood and sets and monitors real-life challenges, equivalent to homework.
The user chooses and customizes an avatar (the graphical representation of theuser) and is then transported to the game world to undertake interactive challenges
to restore balance in a world plagued by negativity and infested with GNATS(Gloomy, Negative, Automatic Thoughts). Upon successfully completing each
module, the user returns to the Guide who puts the skills learnt in the game world
into a ‘real life’ context.
The program is designed to target depression but it includes a number oftherapeutic techniques intended to treat symptoms of anxiety (as depression is
Click on the image to to learn
more about SPARXSPARX cast of characters

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12IACAPAP Textbook of Child and Adolescent Mental Healthfrequently comorbid with anxiety). The program includes psycho-education about
depression and teaches core CBT strategies, namely problem solving, relaxation
exercises, learning to identify negative thinking, cognitive restructuring and social
skills.
SPARX was originally developed in a CD-ROM form but it is being
converted for online delivery in 2013. There will be two modes of delivery:
unsupported (self-help) and SPARX monitored by a clinician (clinicians are able to‘prescribe’ it and track progress). SPARX is not yet available to the public.
There have been two RCTs of SPARX. In a large trial including 187 depressed
participants, 94 received SPARX and 93 were assigned to treatment as usual (whichon average consisted of four sessions of face-to-face counseling) (Merry et al,2012). SPARX was as effective as usual care in reducing symptoms of depression(interviewer- and self-rated), anxiety, hopelessness and improving quality of life.
The program was safe and participants rated it favourably. The second study wasa pragmatic randomised controlled trial with 32 adolescents who were excluded
from mainstream education (Fleming et al, 2011). Twenty were randomised tocomplete SPARX immediately and 12 were assigned to a waiting list condition(those on waiting list were invited to complete SPARX after five weeks). SPARX
was effective in reducing symptoms of depression (interviewer- and self-rated) and
improvements were maintained at a 10-week follow-up.

Click on the image to view avideo clip about SPARXSUMMARY OF EVIDENCE FOR e-THERAPYINTERVENTIONS FOR CHILD AND ADOLESCENT
DEPRESSION AND ANXIETYAs already highlighted, this is an emerging area of research, thus thenumber of high quality studies is small. Methodological shortcomings include
lack of controlled trials, reliance on self-report, recruitment via advertisements andrestrictive eligibility criteria. Nevertheless, a growing number of rigorous studies
has been recently appraised in two systematic reviews (Calear & Christensen,
2010, Richardson et al, 2010). Calear and Christensen (2010) reviewed onlyinternet-delivered interventions while the other review also included programs on
stand-alone computers. Combined, the two reviews identified 12 studies with six
interventions (two that target anxiety and four depression):
•
•
•
•
•
•

BRAVE-ONLINE (Spence et al, 2008) (anxiety)
Cool Teens (Cunningham et al, 2009) (anxiety)
CATCH-IT (Van Voorhees et al, 2009) (depression)
MoodGYM (https://moodgym.anu.edu.au‎) (Christensen et al, 2004a)
Grip op je dip online (Dutch: ‘Master Your Mood’) (Gerrits et al, 2007)(depression)
Stressbusters (Abeles et al, 2009) (depression).

Click on the image to access
Grip op je dip online (inDutch)

Participants in these studies were aged from 7 to 25 years. The programs
included treatment and selective, indicated and universal preventive interventions,were based largely on CBT principles and were delivered over 5-14 sessions. Fourof the 12 studies were RCTs. None of the RCTs was of a computerised treatment
of depression but two were RCTs of computer-assisted anxiety treatment. The

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IACAPAP Textbook of Child and Adolescent Mental Healthstudies ranged in size from case studies or pilot studies with small numbers ofparticipants to large trials. Interventions were delivered in a variety of settings andthe amount of therapist support varied from none to regular contact. Outcomesvaried between interventions and neither of the reviews conducted a meta-analysis.
However, Calear and Christensen (2010) listed the effect sizes, which ranged from
0.11 to 1.49 at post-intervention. The authors of both reviews concluded that,
overall, there is emerging evidence supporting the effectiveness of computerand internet-delivered interventions for anxiety and depression in children andadolescents. The fact that programs vary in format and delivery method and yet
produce consistently positive outcomes suggests that e-therapies can be versatileand offer an opportunity to successfully engage young people in the treatment or
prevention of anxiety and depression.
Further research is needed to identify the most effective implementation
model. Since these reviews were published, there have been more studies, including
evaluations of a computerised version of Think Good, Feel Good (a manualised
CBT program for children and adolescents) (Stallard et al, 2011, Attwood et al,2012). Trials of SPARX (Merry et al, 2012; Fleming et al, 2011) have also been
published showing that gamification may be an engaging and effective method todeliver e-Therapy. The field continues to grow and we expect to see more inventive
programs and research to emerge.

DOES e-THERAPY STACK UP FINANCIALLY?
Although development of a computer-assisted therapy is a complex and acostly undertaking, once developed, computer-assisted therapies are comparatively
less expensive to deliver than face-to-face interventions. The cost-analysis studies
to date show that e-therapies can be cost effective both by reducing therapist timeand improving patient outcomes relative to usual care (McCrone et al, 2004,
Cavanagh et al, 2006, Kaltenthaler et al, 2006). There are ongoing costs that need
to be factored in such as license fees, hosting of websites (and any data that is being
stored) and technical support. Additionally, computer programs and websites need
to be frequently updated to remain up-to-date. This cost-benefit argument extends
even further if we consider the ability to deliver beneficial effects to a great numberof people even with a modestly effective e-Therapy intervention.

m-HEALTH INTERVENTIONS
Implementation of e-therapies can be challenging in situations where accessto computers or the internet is limited, or if the resources for computer softwareand hardware are severely restricted. This may be particularly true in the case of
low and middle-income countries as well as in some rural or remote communities.
This is where mobile phone technology offers a definitive advantage. There areseveral features that make mobile phones ideal to deliver innovative e-Healthinterventions in the developing world (Rashid and Elder, 2009):••

e-Therapy

Portability and security – users can take phones along to give them asense of security
Mobile phones use radio spectrum and do not depend on expensive
infrastructure. Cell phone towers can be run by a generator

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IACAPAP Textbook of Child and Adolescent Mental Health

Mobile phones are ideal for delivering innovative e-Health interventions•••

Mobile phones are relatively simple devices that do not require specialist
knowledge from the user
Mobile networks can be used to send data; andThe mobile phone industry is highly competitive, driving the prices
down.

It is not surprising that mobile phone ownership continues to growaround the world and there is a particularly rapid adoption of this technology
in developing countries (World Health Organisation, 2011). Mobile phone
networks are common in countries where access to telecommunications used to be
restricted due to poor infrastructure. The number of mobile devices (many of these
may be devices other than mobile phones such as tablets or portable music players)connected to the network is predicted to reach 50 billion by 2020. It is likely that
the Internet will be predominantly accessed on mobile phones in the near future(Rainie & Anderson, 2008).
The cost of mobile phone handsets continues to drop. Mobile phones can bea fairly simple device capable of calling and texting but increasingly ‘smartphones’
are replacing the traditional handsets. Smartphones have a greater functionality
as they offer access to wireless internet. There are now over a million applications(‘apps’) available for download for the different models of smart phones. ‘Apps’
are software applications, which can be installed on the smart phone to add a new
function (program, game etc.). Many of the apps are free and others are relatively
inexpensive. A large number of apps concern common health-related topics (e.g.,

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IACAPAP Textbook of Child and Adolescent Mental Health

diet, fitness, relaxation etc.). Therefore, it was only a matter of time before apps
were used in m-Health interventions by researchers.
m-Health interventions vary in complexity from simple programs delivered
as text messages (SMS), to multimedia (audio/video) messages which aredisplayed on the phone’s screen, and through apps which allow an integration ofinternet content and other features. Text-based programs face the challenge of
having to deliver messages in 160 characters (including spaces), although sometelecommunication services allow stringing more than one message together. While
text-based interventions are the least advanced, to date they have been the mostwidely adopted and least expensive (Cole-Lewis & Kershaw, 2010). Audio/video
messages can be sent as a hyperlink that users can open on their internet-enabledphones (which do not have to be smart phones). This requires data transfer andthere may be a cost to the user. Apps can take various forms, from simple standalone applications to complex programs that require ongoing internet connectivity,
linking with social networks, and can include other features like Global Positioning
System (GPS) tracking. Apps typically require touch-screen navigation.
An example of a m-Health intervention for young people is MEMO
(Whittaker et al, 2012). MEMO is a multimedia CBT program designed toprevent depression in adolescents. It consists of two messages a day sent over nine
weeks (outside of school hours). The messages are a combination of video (shortfilm clips and animations) and text along with access to a simple internet site. The
videos include brief appearances from ‘celebrities’ and a series of video diaries actedout by young actors with a continuing storyline. The website provides a summaryof key messages and a downloadable relaxation video. The program is framed as‘living in a positive space’ to avoid the potential stigma associated with terms suchas mental health or depression. The program was evaluated in a large RCT with 855
high school students. The control group received a program matched for format,
duration and intensity but which contained non-CBT messages (healthy nutrition,
cyber safety and environmental awareness). The results about acceptability,
adherence and perceived usefulness have been published (Whittaker et al, 2012).
Over three-quarters of participants viewed at least half of the messages. Most(91%) in the intervention group reported they would recommend the program
to a friend. More participants in the intervention group than in the control groupsaid that MEMO helped them to be more positive, to get rid of negative thoughts,
to relax, to solve problems, to have fun, and to deal with school issues. Results
regarding the efficacy of the program have not yet been made available.
Computerised interventions, previously only available online on personal
computers, can be increasingly accessed on mobile devices (smart phones or tablets)
extending the reach of e-Therapy and blurring the boundaries between eHealthand m-Health. For example, a cCBT intervention (‘The Get Happy Program’) was
recently adapted for use on a mobile device (phone or iPad) (Watts et al, 2013).
In a pilot trial, the mobile phone adaptation was compared with the computerdelivered program in 35 adults diagnosed with major depression. Both programs
had six lessons and the same amount of therapist involvement. Participants in bothgroups experienced statistically significant improvements in depression symptoms
after the intervention, which persisted at a 3-month follow-up.

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IACAPAP Textbook of Child and Adolescent Mental HealthBecause mobile phones are devices that we carry with us most of the time,they offer an opportunity for real-time data collection. This may be beneficial tohelp people ‘tune in’ to their feelings or mood. ‘myCompass’ is an app designed
to help users track their symptoms of anxiety and depression (Harrison et al,2011). Users then receive feedback based on their results along with contextual
information about mental health and self-help strategies. The app is complemented
with cCBT modules, which users can access on their personal computer. Fortyfour adult participants took part in a six-week pilot study to evaluate the program.
Pre-post analysis showed significant improvement in stress, anxiety, depression,
overall psychological distress and functional impairment.
There are a number of issues to consider when designing and delivering
m-Health interventions (Boschen & Casey, 2008):
•

•

•

•

Compatibility—not all mobile phones are alike. What works on one
model, may not work on another (this does not apply to simple text/
SMS based interventions)
Cost. Charges (for data, calling and text/SMS) vary between countries
and networks. What may be inexpensive in one area, may be
unaffordable elsewhere
Mobile coverage may vary greatly between locations and there may beintermittent coverage that could potentially frustrate users and impede
the success of an intervention
Privacy and security. Consumers need to be assured the information
they provide via mobile phone telecommunications is secure andcannot be accessed by anauthorised parties (Proudfoot et al, 2010).

TXT2STOP
Txt2stop is a personalised smoking cessation program delivered on mobile
phone for people 16 years and older (Free et al, 2011). The program sends fivemessages a day for the first five weeks, followed by three messages a week for the
next 26 weeks. The program includes motivational messages and behaviour-change
techniques. The messages include positive feedback and highlight the benefits ofquitting, how to quit and stay smoke-free, and the consequences of smoking. The
messages also promote the use of a smoking cessation telephone helpline (available
to the program’s participants) and nicotine replacement therapy.
The program is personalized with an algorithm that takes into accountdemographic and other information collected from the users at the beginning,such as smoker’s concern about weight gain. There is also an interactive component
whereby people can text a pre-programmed keyword and receive specific advice.
For example, when the user texts ‘crave’ this prompts messages that aim to distractand support a person during an episode of craving.

TXT2STOP

Examples of messages(Free et al, 2011):— “This is it – QUIT DAY,
throw away all your fags.
TODAY is the start of being
QUIT forever, you can do it”— “Cravings last less than
5 minutes on average. To
help distract yourself, try
sipping a drink slowly until
the craving is gone”

The program was trialed in the UK in a large RCT (Free et al, 2011)
comparing it to a control program with text messages unrelated to quitting. 5,800
participants willing to quit took part. Participants in the text2quit group were morethan twice as likely to quit—and remain tobacco free at 6 months—compared tothe control group (11% vs. 5%; relative risk 2.20, 95% CI 1.80-2.68). The selfreported abstinence data was verified for 92% of the trial’s participants and theresearchers collecting and analyzing the data were blind to treatment allocation.

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e-Therapy

A.8

Depression
Experience
JournalYouthMentalHealth: A
parent’s
Guide

The Journal

Living Lifeto the Full

MoodGYM

Click on the figure toaccess the program

A life skills course that addresses
anxiety and depression using CBTstrategies.
Uses sound, text, video files and shorthandouts. Moderated discussion
forums are available.
Program based on problem solving
therapy, CBT and psychoeducation to
help people overcome depression

Designed to give parents theinformation, skills, and support tocope with emotional problems such as
depression or anxiety in their child.
Uses sound and text.
Designed to help families cope withhaving a child with depression.
Based on psychoeducation andnarrative therapy and provides asupportive online community.

•

•

•

•
•

•

•

•

CBT skills for people vulnerable todepression and anxiety.
Uses text, graphics and interactive
exercises.

•

Description

•

•

•
•

•

•

•

Target group

Adults (parents of children withdepression).

Adults (parents of children withmental health problems).

People over 16 years of age.
Tailored to New Zealanders but
may be suitable for others.

AdultsDesigned for adults but
evaluated in both adults andadolescents.
Available in English,
Norwegian, Dutch andChinese.

Some of the better-known e-Therapy resources available online at no cost

Name of the
program

Table A.8.4

•

•

•

•

•

A feasibility and acceptability
study (Demaso et al, 2006)
showed it was safe and useful,
reduced social isolation andincreased hope for recovery.

One study (Deitz et al, 2009)
showed improved knowledge
and self-efficacy in dealing
with their child’s mental healthproblems.

Evaluation is underway.

An evaluation is said to beunderway.

Has been shown to beefficacious in adults (e.g.,
Christensen et al, 2004a;
Christensen et al, 2006) andwith adolescents (O’Kearney
et al, 2006; O’Kearney et al,
2009; Calear et al, 2009).

Evidence of effectiveness

IACAPAP Textbook of Child and Adolescent Mental Health18e-Therapy

A.8

Bite Back

E-couchThe
Lowdown

Click on the figure toaccess the program

Gives information about emotional
problems including their causes,
treatments and ways to manage or
prevent them.
Includes five separate programs:
depression, anxiety and worry, social
anxiety, divorce and separation, andbereavement and loss.
A website with resources about positive
mental health and allows user to share
their stories and find inspiration.
The information is presented in a youth
friendly format and is based on positive
psychology.

•

•
•

•

•

Provides information about depression,
support for those experiencing it andaims to reduce stigma associated withdepression.
Includes a moderated message board
to share experiences and connect withothers.

•Description

•
•

•

•
•

Adolescents.
Tailored for Australia

Adults (may be suitablefor older adolescents)

Adolescents.
Tailored to New
Zealanders.

Target group

Some of the better-known e-Therapy resources available online at no cost (continuation)

Name of the
program

Table A.8.4•

Evaluation is underway.

Evidence of effectiveness

IACAPAP Textbook of Child and Adolescent Mental Health19

IACAPAP Textbook of Child and Adolescent Mental Health

The quit rate in the intervention group compares well to other traditional behaviouralforms of supporting smokers wishing to quit. The researchers concluded that anintervention like text2quit is easy to scale up for national or international delivery
though there may be some adaption and local evaluation required.

e-THERAPY AT YOUR FINGERTIPS
There are numerous freely available e-Therapy programs for a range ofproblems on the internet. Most are self-help program designed for people to accessand complete without therapist input. Some of the programs have undergone
peer-reviewed research while many more are untested. As a clinician, you may
be asked by your clients about e-Therapy or you might be interested in using it
clinically yourself. It is important that when you search for e-Therapy programs,
you establish its evidence base and then consider how suitable it will be for yourclient. A useful resource is ‘Beacon’, a site developed and managed by the Centre
for Mental Health Research at the Australian National University (Christensen etal, 2010). The Beacon site provides users with a directory of e-health applications(websites, mobile applications and internet support groups), and includes reviews,
expert ratings and user comments.
In Table A.8.4 we have listed some of the better-known e-Therapy
programs targeting depression and anxiety that you can access free of charge. We
have included programs which have been designed for adults but which may beappropriate for older adolescents—there are very few free programs for adolescentscurrently available online. We included programs which have been evaluated or
which are currently undergoing research.
Also of note is ‘Life Guide’, a resource developed at the University ofSouthampton. It allows researchers to easily and flexibly create and modify
internet-delivered interventions. The software is open source and free. Users canalso access examples of other peoples’ interventions, upload their own programsand discuss them with the site’s registered users. This initiative is an example of
how online eHealth interventions may evolve in the future if ideas can be sharedand international collaborations can be formed using digital media.

Click on the image toaccess the Beacon sitethat provides users witha directory of e-healthapplications (websites,
mobile applications andinternet support groups),
and includes reviews, expert
ratings and user comments.

CONCLUSIONS
Despite the promising results, widespread use of e-therapies has not becomecommon in day-to-day practice. We expect significant development and researchin this field in the near future. The tremendous potential of e-therapies can only
be realised if rigorous research is carried out and if e-therapies continue to evolve
taking advantage of the rapid technological advances. It is equally important toestablish, through implementation studies, how best to use e-therapies in clinicalpractice. We need to determine what e-therapies are most appropriate for whom,
what level of clinical input is required and when. Finally, e-therapies should
complement rather than replace clinical assessment and care, particularly at themoderate to severe end of the clinical spectrum.

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Click on the image to accessthe Life Guide website.

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IACAPAP Textbook of Child and Adolescent Mental Health

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