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Use of a Smartphone Application in the Treatment of Depression: The New Wave of Digital Tools in Psychological Treatment
Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Internet-delivered programs based on cognitive behavior therapy (CBT) have during the past decade shown to work in an effective way for the treatment of depression. Due to its accessibility and independence of time and location, smartphone-based CBT might represent the next generation of digital interventions. Depression is an affective disorder that affects as many as 350 million people worldwide. However, with CBT, depression can be treated, but access to this treatment is scarce due to limited health care resources and trained therapists. As a result of this, health care could highly benefit from the use of smartphones for delivering cost-effective treatment that can be made available to a large part of the population who suffer from depression. One treatment that should be especially suitable for the smartphone format is behavioral activation (BA), since it has strong empirical support as well as the benefits of being flexible and rather simple.

The overall aim of the thesis was to test and further develop a BA smartphone application, as well as to build a method for how this smartphone application could be used in a comprehensive and effective way in depression treatment. To fulfill this aim, four studies were conducted. The results showed that smartphones have the ability to be used in an effective way in the treatment of depression, including as an add-on to traditional face-to-face sessions. The results also showed that the smartphone format was experienced as a portable and flexible way of accessing the treatment – and thus could be more present in everyday life.

In conclusion, there is reason to believe that smartphones will be integrated even further in society and therefore may serve an important role in future mental health care. Since the first indications reveal that depression can be treated by means of a supported smartphone application, it is highly possible that applications for other mental health problems will follow. Furthermore, in this thesis, the same smartphone application has been tested in three different ways and there is potential to apply smartphones in a range of other formats, such as in relapse prevention and as a way to intensify treatment during periods when needed. From a psychiatric research point of view, as my research group has been doing trials on guided internet treatment for more than 15 years, it is now time to move to the next generation of information technology – smartphones.

Abstract [sv]

Internetbaserad kognitiv beteendeterapi (KBT) har under det senaste decenniet visat sig fungera effektivt i behandling av depression. På grund av dess tillgänglighet och flexibilitet i tid och plats har smartphonebaserad KBT potential att bli nästa generation av digitala behandlingar. Depression är en affektiv sjukdom som drabbar så många som 350 miljoner människor världen över. Med hjälp av KBT kan depression behandlas. Dock är tillgången till denna behandling knapp på grund av begränsade resurser i form av utbildade terapeuter. Därmed skulle sjukvården kunna dra stor nytta av användningen av smartphones för att leverera kostnadseffektiv behandling, som kan göras tillgänglig för människor som lider av depression. En behandling som kan vara särskilt lämplig för smartphone-formatet är beteendeaktivering (BA), eftersom den har starkt empiriskt stöd samtidigt som den är flexibel och relativt enkel. Det övergripande syftet med avhandlingen var att testa och vidareutveckla en smartphone-applikation baserad på BA, samt att bygga en behandlingsmetod för denna smartphone-applikation som skulle kunna användas för att effektivt behandla depression. För att uppnå detta syfte genomfördes fyra studier. Resultaten visade att smartphones kan användas på ett effektivt sätt i behandling av depression, bland annat som komplement till traditionella live-sessioner. Resultaten visade också initiala indikationer på att smartphoneformatet upplevdes som ett portabelt och flexibelt sätt att komma åt behandlingen - och därmed blev mer närvarande i vardagen.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. , 103 p.
Series
Linköping Studies in Arts and Science, ISSN 0282-9800 ; 640Linköping Studies in Behavioural Science, ISSN 1654-2029 ; 188
Keyword [en]
Behavioral activation, depression, smartphone, application, mobile app, internetadministered, digitally administered, blended treatment
Keyword [sv]
Beteendeaktivering, depression, smartphone, applikation, mobilapp, internetadministrerad, digital behandling, blandform
National Category
Psychiatry
Identifiers
URN: urn:nbn:se:liu:diva-113996DOI: 10.3384/diss.diva-113996ISBN: 978-91-7519-136-2 (print)OAI: oai:DiVA.org:liu-113996DiVA: diva2:786287
Public defence
2015-03-06, VAL, Hus Vallfarten, Campus Valla, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2015-02-05 Created: 2015-02-05 Last updated: 2015-02-05Bibliographically approved
List of papers
1. Development and initial evaluation of a smartphone application based on acceptance and commitment therapy
Open this publication in new window or tab >>Development and initial evaluation of a smartphone application based on acceptance and commitment therapy
2012 (English)In: SpringerPlus, ISSN 2193-1801, Vol. 1, no 11Article in journal (Refereed) Published
Abstract [en]

Background

An intervention, consisting of an ACT-based smartphone-application and a web-based         psychoeducation, has been developed. The smartphone-application, together with the         psychoeducation, aims to function as a self-help intervention for living consistently         with one's values. The study is an exploratory investigation of this new smartphone-based         tool.     

Case description

Primarily, the study aims at investigating a new field, providing a basis for generating         hypotheses for further research. The first aim of this initial, exploratory study         was to examine if this intervention had an effect on the variables of: valued actions,         psychological flexibility, and life satisfaction as well as the states of depression,         anxiety and stress, for a non-clinical sample of 11 Swedish Iphone users. This was         made with a quasi-experimental pretest-posttest design without control group. The         second aim was to investigate how the participants experienced the intervention, as         measured by a qualitative questionnaire.     

Discussion and evaluation

The group analyses showed that the participants increased their valued action and         psychological flexibility significantly during the intervention. Furthermore, value-based         actions and psychological flexibility showed small effect sizes when comparing pretest         and posttest score. However, the design of the study makes it impossible to draw any         certain conclusions. The qualitative questionnaire showed a general positive experience         of the intervention.     

Conclusions

The results from the present study indicated that the intervention should be studied         further. The findings also generated a number of hypotheses that could be investigated         in further research.

Place, publisher, year, edition, pages
SpringerOpen, 2012
National Category
Psychology
Identifiers
urn:nbn:se:liu:diva-84450 (URN)10.1186/2193-1801-1-11 (DOI)
Funder
Swedish Research Council
Available from: 2012-10-08 Created: 2012-10-08 Last updated: 2015-02-05
2. Behavioural activation versus mindfulness-based guided self-help treatment administered through a smartphone application: a randomised controlled trial
Open this publication in new window or tab >>Behavioural activation versus mindfulness-based guided self-help treatment administered through a smartphone application: a randomised controlled trial
Show others...
2014 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 4, no 1, e003440- p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Evaluating and comparing the effectiveness of two smartphone-delivered treatments: one based on behavioural activation (BA) and other on mindfulness.

DESIGN: Parallel randomised controlled, open, trial. Participants were allocated using an online randomisation tool, handled by an independent person who was separate from the staff conducting the study.

SETTING: General community, with recruitment nationally through mass media and advertisements.

PARTICIPANTS: 40 participants diagnosed with major depressive disorder received a BA treatment, and 41 participants received a mindfulness treatment. 9 participants were lost at the post-treatment.

INTERVENTION BA: An 8-week long behaviour programme administered via a smartphone application. Mindfulness: An 8-week long mindfulness programme, administered via a smartphone application.

MAIN OUTCOME MEASURES: The Beck Depression Inventory-II (BDI-II) and the nine-item Patient Health Questionnaire Depression Scale (PHQ-9).

RESULTS: 81 participants were randomised (mean age 36.0 years (SD=10.8)) and analysed. Results showed no significant interaction effects of group and time on any of the outcome measures either from pretreatment to post-treatment or from pretreatment to the 6-month follow-up. Subgroup analyses showed that the BA treatment was more effective than the mindfulness treatment among participants with higher initial severity of depression from pretreatment to the 6-month follow-up (PHQ-9: F (1, 362.1)=5.2, p<0.05). In contrast, the mindfulness treatment worked better than the BA treatment among participants with lower initial severity from pretreatment to the 6-month follow-up (PHQ-9: F (1, 69.3)=7.7, p<0.01); BDI-II: (F(1, 53.60)=6.25, p<0.05).

CONCLUSIONS: The two interventions did not differ significantly from one another. For participants with higher severity of depression, the treatment based on BA was superior to the treatment based on mindfulness. For participants with lower initial severity, the treatment based on mindfulness worked significantly better than the treatment based on BA.

TRIAL REGISTRATION: Clinical Trials NCT01463020.

Place, publisher, year, edition, pages
BMJ Publishing Group, 2014
Keyword
Behavioral Activation, Depression, Mindfulness, Smartphone Application
National Category
Psychology
Identifiers
urn:nbn:se:liu:diva-104626 (URN)10.1136/bmjopen-2013-003440 (DOI)000334311200010 ()24413342 (PubMedID)
Available from: 2014-02-19 Created: 2014-02-19 Last updated: 2017-12-06Bibliographically approved
3. Experiences of a guided smartphone-based behavioral activation therapy for depression: A qualitative study
Open this publication in new window or tab >>Experiences of a guided smartphone-based behavioral activation therapy for depression: A qualitative study
Show others...
2015 (English)In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 1, 60-68 p.Article in journal (Refereed) Published
Abstract [en]

Recently, a number of studies have investigated treatments administered via smartphones showing that this treatment format has a potential to be effective. However, we still have limited knowledge of how patients experience this treatment format. The objective of this study was to explore participants' views of a smartphone-based behavioral activation treatment. In-depth interviews were conducted with 12 strategically (participants with different overall experiences) selected participants, suffering from major depression according to the DSM-IV. The interview data were processed with the aid of thematic analysis. The analysis generated the three main themes: Commitment, Treatment and Lack of important components, with attached subthemes. In conclusion, the findings from the current study correspond with existing knowledge in the field of internet-based treatment. Considering that this kind of treatment is still quite new, the need for further research and development is considerable. Nevertheless, its availability, assimilation into users' everyday lives and possible motivational qualities speak of its potential.

Place, publisher, year, edition, pages
Elsevier, 2015
Keyword
Smartphone treatment, Depression, Behavioral activation, Mobile application
National Category
Psychology Interaction Technologies
Identifiers
urn:nbn:se:liu:diva-113993 (URN)10.1016/j.invent.2014.12.002 (DOI)
Available from: 2015-02-05 Created: 2015-02-05 Last updated: 2017-12-05Bibliographically approved
4. Smartphone-supported versus full behavioural activation for depression: a randomised controlled trial
Open this publication in new window or tab >>Smartphone-supported versus full behavioural activation for depression: a randomised controlled trial
Show others...
2015 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 5, e0126559Article in journal (Refereed) Published
Abstract [en]

Background

There is need for more cost and time effective treatments for depression. This is the first randomised controlled trial in which a blended treatment - including four face-to-face sessions and a smartphone application - was compared against a full behavioural treatment. Hence, the aim of the current paper was to examine whether a blended smartphone treatment was non-inferior to a full behavioural activation treatment for depression.

Methods

This was a randomised controlled non-inferiority trial (NCT01819025) comparing a blended treatment (n=46) against a full ten-session treatment (n=47) for people suffering from major depression. Primary outcome measure was the BDI-II, that was administered at pre- and post-treatment, as well as six months after the treatment.

Results

Results showed significant improvements in both groups across time on the primary outcome measures (within-group Cohen’s d=1.35; CI [−0.82, 3.52] to d=1.58; CI [0.51, 2.65]; between group d=−0.13 CI [−2.37, 2.09] to d=0.05 CI [−1.18, 1.27]). At the same time, the blended treatment reduced the therapist time with an average of 47%.

Conclusions

We could not establish whether the blended treatment was non-inferior to a full BA treatment. Nevertheless, this study points to that the blended treatment approach could possibly treat nearly twice as many patients suffering from depression by using a smartphone applica¬tion as add-on. More studies are needed before we can suggest that the blended treatment method is a promising cost-effective alternative to regular face-to-face treatment for depression.

Place, publisher, year, edition, pages
Public Library of Science, 2015
Keyword
Behavioural activation, major depression, smartphone application, mobile app, blended treatment
National Category
Psychology Interaction Technologies
Identifiers
urn:nbn:se:liu:diva-113994 (URN)10.1371/journal.pone.0126559 (DOI)000355183900033 ()26010890 (PubMedID)
Funder
Swedish Research Council, 2011-2476EU, FP7, Seventh Framework Programme, ICT4Depression Consortium
Available from: 2015-02-05 Created: 2015-02-05 Last updated: 2017-12-05Bibliographically approved

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