The use of communication technologies

The use of communication technologies (e.g., the Internet, email, video conferencing, telephone) to prevent and/or treat mental and substance use disorders has been recognized by the Center for Substance Abuse Treatment (CSAT) as important in helping meet unaddressed treatment needs (CSAT, 2009a). This review covers the therapeutic use of such technologies, whether they are delivered via telephones or computers, as well as their use in supervising and training program staff members. It is not concerned with most other uses of new technologies (e.g., electronic record keeping, computer modeling, biotechnology, social media). Although technology-assisted care (TAC) provides a number of opportunities to enhance behaviour health services ( HYPERLINK “” Eonta et al., 2011), this review focuses on interventions that use technologies as a primary means of delivering services.

As with the rest of this Treatment Improvement Protocol (TIP), the literature review focuses on research involving adults. Because a good deal of the research in this area has been conducted outside the United States, studies involving foreign populations are identified as such; those that are not so identified should be assumed to have taken place in the United States. This review focuses on the past 10 years of research, with occasional references to older, seminal literature. When possible, it uses other reviews to summarize earlier studies. The review generally does not draw conclusions, but instead tries to present several points of view so that readers who are interested in the issue may seek out the appropriate literature and draw their own conclusions. Thus, readers should not accept the presentation of one article’s findings as an endorsement of one position over another.

The first two sections after “Overview” provide some of the basic information about the technologies included in this TIP and give some idea about how they are currently being used in behavioral health as well as more general claims about their effectiveness. The larger sections that follow discuss the use of such technologies to address prevention and treatment specifically of mental and substance use disorders and are organized by the disorder addressed. Those sections may include research on one or multiple types of technology, depending on what recent literature is available.

Go to:Understanding Technologies
The “Understanding Technologies section covers basic technologies that are being used in the treatment and prevention of mental and substance use disorders:
Telephone/Audio CounselingVideo/Web Conferencing
Self-Directed, Web-Based, and Computer-Based Therapeutic Tools
Web-Based Text Communication
Mobile (Handheld) Technologies
These categories are not exclusive. One intervention may involve components that use any number of these technologies, and there is almost always some overlap with other categories (e.g., mobile technologies typically use phone and/or text communication).

Although the system of categorizing interventions by the technology used is common in the literature, it is not the only way to categorize them, and there are other features of these interventions that can be used to distinguish one from another. For example, interventions can be categorized as either synchronous (involving communications occurring in real time) or asynchronous (occurring outside real time, with some delay between the sending and receiving of the communication;  HYPERLINK “” Suler, 2004;  HYPERLINK “” Yellowlees et al., 2010). The larger portion of this review discusses interventions according to the disorder or problem targeted by the intervention.

This section introduces these technologies, presents basic findings about their use and effectiveness (drawing on other reviews when available), and also highlights interventions that can be used to address multiple substance use and mental disorders (as opposed to interventions directed at a single disorder or group of disorders, such as anxiety disorders).

Telephone/Audio CounselingCounseling has been conducted via telephone for quite some time, and many counselors report positive results using that technology ( HYPERLINK “” Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly, 2004). Potential benefits for clients of telephone-based services, relative to in-person services, include lower expense, greater convenience, greater anonymity, and a greater sense of control (Reese, Conoley, & Brossart, 2002). Telephones, either using live interviewers or automated systems, have been successfully used to screen and assess mental and substance use disorders and cognitive impairment ( HYPERLINK “” Kobak, Williams, & Engelhardt, 2008; Marks et al., 1998; Martin-Khan, Wootton, & Gray, 2010; Rohde, Lewinsohn, & Seeley, 1997; Simon, Revicki, & VonKorff, 1993;  HYPERLINK “” Tunstall, Prince, & Mann, 1997;  HYPERLINK “” Xu et al., 2012). However, some disorders (e.g., adjustment disorder with depressed mood) may be more difficult to assess by phone than in person (Rohde et al., 1997).

Telephones have also been used to improve treatment/medication compliance ( HYPERLINK “” Maust et al., 2012), monitor recovery from mental and substance use disorders ( HYPERLINK “” Godleski, Cervone, Vogel, & Rooney, 2012), and motivate potential clients to enter treatment (Seal et al., 2012). Adding phone calls to a Web-based intervention may also improve treatment compliance and outcomes (Graham et al., 2011;  HYPERLINK “” Titov, Andrews, Choi, Schwenke, & Johnston, 2009). Leach and Christensen (2006), in a literature review on telephone-based interventions for mental and substance use disorders, located 14 studies involving interventions for depression (6 studies), anxiety (3), eating disorders (3), substance use disorders (1), and schizophrenia (1). They concluded that such interventions could reduce symptoms of anxiety and depression as well as disordered eating behaviors. They also found limited and somewhat flawed evidence that such interventions could reduce alcohol use for individuals with alcohol use disorders and hospitalization rates for people with schizophrenia. However, most of the studies they reviewed had methodological problems, such as small sample sizes, high dropout rates, and a lack of randomization, which limited their ability to draw firm conclusions about effectiveness. They also noted that effective telephone-based interventions were highly structured and made use of homework assignments for clients. Another review by Mohr, Vella, Hart, Heckman, and Simon (2008), which included 12 trials of phone-based interventions for depression, also found that such interventions were associated with significantly greater reductions in depressive symptoms than were control conditions; these interventions were also associated with reductions in symptoms from baseline to posttreatment follow-up that were comparable with those observed in many in-person interventions.

Other studies have found telephone-based interventions to be more effective than no-treatment controls and/or about as effective as some standard treatments for smoking cessation (Cummins, Bailey, Campbell, Koon-Kirby, & Zhu, 2007;  HYPERLINK “” Rabius, McAlister, Geiger, Huang, & Todd, 2004; Regan, Reyen, Lockhart, Richards, & Rigotti, 2011), continuing care for substance use disorders ( HYPERLINK “” Farabee et al., 2012; McKay, Lynch, Shepard, & Pettinati, 2005; McKay et al., 2011; Stout, Rubin, Zwick, Zywiak, & Bellino, 1999), depression (Mohr, Carmody, Erickson, Jin, & Leader, 2011; Mohr et al., 2012; Mohr et al., 2008;  HYPERLINK “” Piette et al., 2011), obsessive–compulsive disorder (OCD;  HYPERLINK “” Kenwright, Marks, Graham, Franses, & Mataix-Cols, 2005; Lovell, Fullalove, Garvey, & Brooker, 2000), problem gambling ( HYPERLINK “” Rodda & Lubman, 2012), posttraumatic stress disorder (PTSD) symptoms ( HYPERLINK “” DuHamel et al., 2010), and the promotion of positive behavior change related to healthy eating and exercise ( HYPERLINK “” Eakin, Lawler, Vandelanotte, & Owen, 2007). Self-guided treatment, using phone calls from counselors, has also been found to be effective for anxiety disorders ( HYPERLINK “” Cuijpers, Donker, van Straten, Li, & Andersson, 2010). Also, telephone-based cognitive–behavioral therapy (CBT) can improve health outcomes for people with physical disorders (Muller & Yardley, 2011).

Dorstyn, Mathias, and Denson (2011) conducted a meta-analytic review of telephone-based counseling interventions for people with acquired physical disabilities (e.g., spinal cord injuries, severe burns) but not, for the most part, people with mental or substance use disorders; they found that such interventions were associated with significant improvements in the use of coping skills, in community integration, and in symptoms of depression immediately following telephone counseling as well as more modest, but lasting, improvements in quality of life.

Telephone helplines, or hotlines set up so that individuals in need of services can call into a centralized location and speak with a counselor, have also been effective in suicide prevention (Gould, Kalafat, Harris Munfakh, & Kleinman, 2007), tobacco cessation (Cummins et al., 2007; Stead, Perera, & Lancaster, 2007), and addressing general mental health concerns, including panic attacks (Burgess, Christensen, Leach, Farrer, & Griffiths, 2008). In their interviews with therapists, Day and Schneider (2000) found that some counselors felt that treatment using audio only caused them to miss important information (e.g., body language, client’s physical state), but other counselors observed that a lack of the visual element increased the ease of communication between client and therapist. Clients who had tried telephone-based services generally expressed satisfaction with them and found those services helpful for a variety of behavioral health problems (Reese et al., 2002; Reese, Conoley, & Brossart, 2006). Many clients also expressed a preference for telephone counseling. In one survey of clients who had received both telephone-based and in-person counseling, 96 percent stated they would be willing to seek telephone-based services again; by comparison, only 63 percent said they would be willing to use in-person services again (Reese et al., 2006).

Video/Web Conferencing
Video services for behavioral health are typically provided through video conferencing using computers connected to the Internet (Zack, 2004), but they can also be transmitted using videophones connected to phone lines, although that is a lower-quality option ( HYPERLINK “” Godleski, Nieves, Darkins, & Lehmann, 2008). Video conferencing, which provides both audio and video, has been used in a variety of behavioral health settings, usually to provide what would otherwise be an in-person service to clients who are not able to reach the provider’s location. A comprehensive review of these services (entitled Evidence-Based Practice for Telemental Health) is available from the American Telemedicine Association (ATA; 2009). The review is focused on interactive video conferencing because reviewers found that this technology had the largest research base in support of its use of any of the technologies they considered.

Backhaus et al. (2012) reviewed 65 studies involving the use of video conferencing specifically for the provision of psychotherapy. They concluded that: