Digital Technologies in the Treatment of Anxiety: Recent Innovations and Future Directions
Purpose of Review
This review aims to provide a comprehensive overview of the efficacy, limitations, and future of e-health treatments for anxiety. Within this, we provide detail on “first-generation” e-health approaches, such as computerized therapies. Additionally, we assess the emergence and early efficacy of newer methods of treatment delivery, including smartphone apps and virtual reality interventions, discussing the potential and pitfalls for each.
There is now substantial clinical research demonstrating the efficacy of internet-delivered cognitive behavioral therapy in the treatment of anxiety. However, the ability of these interventions for engaging patients in “real-world” settings is unclear. Recently, smartphone apps for anxiety have presented a more popular and ubiquitous method of intervention delivery, although the evidence base supporting these newer approaches drastically falls behind the extensive marketing and commercialization efforts currently driving their development. Meanwhile, the increasing availability of novel technologies, such as “virtual reality” (VR), introduces further potential of e-health treatments for generalized anxiety and anxiety-related disorders such as phobias and obsessive compulsive disorder, while also creating additional challenges for research.
Although still in its infancy, e-health research is already presenting several promising avenues for delivering effective and scalable treatments for anxiety. Nonetheless, several important steps must be taken in order for academic research to keep pace with continued technological advances.
Keywordse-Health VR m-Health Technological Affective disorders Internet
Compliance with Ethical Standards
Conflict of Interest
Joseph Firth is supported by a Blackmores Institute Fellowship.
John Torous is supported by a NARSAD Young Investigator Award from the Brain & Behavior Research Foundation and a Dupont Warren Fellowship from the Harvard Medical School Department of Psychiatry.
Rebekah Carney each declare no potential conflicts of interest.
Theodore D. Cosco is supported by a Canadian Institutes of Health Research Postdoctoral Fellowship (MFE-146676) and holds equity in Eos Analytics Ltd.
Helen Christensen is funded by a NHMRC John Cade Fellowships (1056964).
Jerome Sarris is supported by an NHMRC Research Fellowship (1125000).
Jill Newby is supported by a NHMRC/MRFF Career Development Fellowship (1145382).
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 7.• Carlbring P, Andersson G, Cuijpers P, Riper H, Hedman-Lagerlöf E. Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cogn Behav Ther. 2018;47(1):1–18. A meta-analysis of 20 studies comparing iCBT to face-to-face therapy showing these two forms of treatment have equal efficacy. CrossRefPubMedGoogle Scholar
- 8.•• Andrews G, Newby JM, Williams AD. Internet-delivered cognitive behavior therapy for anxiety disorders is here to stay. Curr Psychiatry Rep. 2015;17(1):533. This paper provides a concise summary of how iCBT has recently emerged as an effective treatment for anxiety disorders. The paper also presents compelling considerations for future work, along with discussing clinical implementation of this relatively new style of psychological therapy. CrossRefPubMedGoogle Scholar
- 11.Christensen H, Griffiths KM, Korten A. Web-based cognitive behavior therapy: analysis of site usage and changes in depression and anxiety scores. J Med Internet Res. 2002;4(1)Google Scholar
- 13.• Olthuis JV, Watt MC, Bailey K, Hayden JA, Stewart SH. Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults. Cochrane Database Syst Rev. 2016;(3) The recent Cochrane review showing that iCBT is an efficacious treatment for multiple forms of anxiety disorders and favorable comparison to many types of both active and waitlist control conditions. Google Scholar
- 18.Newby JM, Smith J, Mahoney A, Mason E, Uppal S, Andrews G. Internet-based cognitive behavioural therapy versus psychoeducation control for illness anxiety disorder and somatic symptom disorder: a randomised controlled trial J Consult Clin Psychol in press.Google Scholar
- 20.• Mahoney AE, Mackenzie A, Williams AD, Smith J, Andrews G. Internet cognitive behavioural treatment for obsessive compulsive disorder: a randomised controlled trial. Behav Res Ther. 2014;63c:99–106. A randomized trial of iCBT vs usual treatment for OCD. Results showed high efficacy and adherence in the iCBT condition, with 54% of completers achieving symptomatic remission. CrossRefGoogle Scholar
- 21.Klein B, Mitchell J, Abbott J, Shandley K, Austin D, Gilson K, et al. A therapist-assisted cognitive behavior therapy internet intervention for posttraumatic stress disorder: pre-, post- and 3-month follow-up results from an open trial. J Anxiety Disord. 2010;24(6):635–44.CrossRefPubMedGoogle Scholar
- 23.Newby JM, Mackenzie A, Williams AD, McIntyre K, Watts S, Wong N, et al. Internet cognitive behavioural therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care. Psychol Med. 2013:1–14.Google Scholar
- 26.• Hedman E, Ljótsson B, Rück C, Bergström J, Andersson G, Kaldo V, et al. Effectiveness of Internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care. Acta Psychiatr Scand. 2013;128(6):457–67. A large-scale cohort study showing that iCBT is also feasible and effective when delivered under “real-world” conditions, in the context of psychiatric care. CrossRefPubMedGoogle Scholar
- 27.• Nordgren LB, Hedman E, Etienne J, Bodin J, Kadowaki Å, Eriksson S, Lindkvist E, Andersson G, Carlbring P. Effectiveness and cost-effectiveness of individually tailored Internet-delivered cognitive behavior therapy for anxiety disorders in a primary care population: A randomized controlled trial. Behav Res Ther 2014; 59(0):1–11. A treatment trial of iCBT for anxiety with an embedded cost-effectiveness evaluation. Results provide compelling evidence that iCBT is not only efficacious, but also cost-effective for anxiety—capable of reducing the economic burden of these conditions. Google Scholar
- 35.Boettcher J, Åström V, Påhlsson D, Schenström O, Andersson G, Carlbring P. Internet-based mindfulness treatment for anxiety disorders: a randomized controlled trial. Behav Ther 2014(0).Google Scholar
- 36.• Dahlin M, Andersson G, Magnusson K, Johansson T, Sjögren J, Håkansson A, et al. Internet-delivered acceptance-based behaviour therapy for generalized anxiety disorder: A randomized controlled trial. Behav Res Ther. 2016;77:86–95. A single-arm pilot study examining the feasibility of internet-delivered acceptance-based behavior therapy in the treatment of anxiety, showing promising (but preliminary) early findings. CrossRefPubMedGoogle Scholar
- 39.•• Firth J, Torous J, Nicholas J, Carney R, Rosenbaum S, Sarris J. Can smartphone mental health interventions reduce symptoms of anxiety? A meta-analysis of randomized controlled trials. J Affect Disord. 2017; This large-scale meta-analysis shows that, overall, smartphone ‘mental health apps’ can reduce symptoms of anxiety. ➔ It also presents important data on the relative effectiveness of smartphone apps compared to active/inactive control conditions, along with systematically reviewing the content and effectiveness of individual apps for anxiety. Google Scholar
- 45.Cuijpers P, Karyotaki E, Reijnders M, Ebert D. Was Eysenck right after all? A reassessment of the effects of psychotherapy for adult depression. Epidemiology and Psychiatric Sciences. 2018:1–10.Google Scholar
- 46.• Sucala M, Cuijpers P, Muench F, Cardoș R, Soflau R, Dobrean A, et al. Anxiety: there is an app for that. A systematic review of anxiety apps. Depress Anxiety. 2017; A systematic review of mental health apps available on the iTunes and Google Play store. The search identified 52 apps advertised for anxiety. The review found there is a paucity of evidence or empirical evaluation supporting their claims. Google Scholar
- 48.Torous J, Firth J, Huckvale K, Larsen ME, Cosco T, Carney C, Chan S, Pratap A, Yellowlees PM, Wykes T et al. The emerging imperative for a consensus approach towards the rating and clinical recommendation of mental health apps. J Nerv Ment Dis. 2018:in press.Google Scholar
- 50.Torous J, Staples P, Slaters L, Adams J, Sandoval L, Onnela J, Keshavan M. Characterizing smartphone engagement for schizophrenia: results of a naturalist mobile health study. Clin Schizophr Relat Psychoses 2017.Google Scholar
- 53.Proudfoot J, Clarke J, Birch M-R, Whitton AE, Parker G, Manicavasagar V, Harrison V, Christensen H, Hadzi-Pavlovic D. Impact of a mobile phone and web program on symptom and functional outcomes for people with mild-to-moderate depression, anxiety and stress: a randomised controlled trial. BMC Psychiatry Vol 13 2013, ArtID 312 2013; 13.Google Scholar
- 54.Dillon A, Kelly M, Robertson IH, Robertson DA. Smartphone applications utilizing biofeedback can aid stress reduction. Frontiers in Psychology Vol 7 2016, ArtID 832 2016; 7.Google Scholar
- 55.• Stubbs B, Vancampfort D, Rosenbaum S, Firth J, Cosco T, Veronese N, et al. An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: a meta-analysis. Psychiatry Res. 2017; A recent meta-analysis of RCTs examining the impact of physical activity interventions on anxiety. Exercise was found to significantly reduce anxiety, with moderately large effects. Technological interventions for anxiety should therefore also consider the potential benefits of increase individuals’ physical activity levels. Google Scholar
- 57.•• Jacka FN, Mykletun A, Berk M, Bjelland I, Tell GS. The association between habitual diet quality and the common mental disorders in community-dwelling adults: the Hordaland Health study. Psychosom Med. 2011;73(6):483–90. This article is a clear and comprehensive overview of recent developments in the use of virtual reality in mental healthcare. The paper explains the potential for use across multiple disorders, including anxiety, while also examining some potential barriers/limitations towards this. CrossRefPubMedGoogle Scholar
- 65.Newby JM, Jiang MYW. Affordable virtual reality tools for the treatment of mental health problems. Psychol Med 2017;1.Google Scholar