All posts by Michael Knable


Comment on: “Computerized cognitive behavior therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomized controlled trial”, Gilbody S et al, British Medical Journal BMJ 2015;351:h5627

This is an important study that sought to evaluate cCBT for the treatment of depression in primary care settings. The study was conducted in the United Kingdom, where cCBT has been promoted and reimbursed by the National Health Service since 2006. Depression is a common illness and most patients are treated by primary care physicians rather than specialists. Antidepressants are frequently offered to patients, but access to psychotherapy and other forms of treatment for depression is often quite limited.

Previous studies of cCBT tend to support the efficacy of this intervention, however these studies have been criticized for having small sample sizes, highly selected participants (in that they may be from academic settings and screened for complicating factors that are common in the “real world”), and for lack of bias (in that they are often supported by companies with a commercial interest in the outcome).

The REEACT study was a “real world” study conducted at large primary care practices in various parts of the United Kingdom.  Patients with depression were randomized to receive: usual care from primary care physicians, usual care supplemented by a commercial cCBT (Beating the Blues) or usual care supplemented by a “free to use” cCBT (MoodGYM). Incidentally, both Beating the Blues and MoodGYM have been reviewed favorably by PsyberGuide. Follow-up data were collected at 4, 12 and 24 months after randomization. Patients assigned to cCBT received weekly support phone calls from trained technicians.

After entering the study, follow-up data were obtained for 76% at 4 months, 70% at 12 months, and 67% at 24 months. Thus, almost one quarter of the subjects had dropped out by 4 months. At four months, 50% of people using Beating the Blues, 49% of people using MoodGYM and 44% receiving usual care were still depressed. Therefore, the authors concluded that there was no demonstrable benefit for any of the three treatment arms. There also did not appear to be differences at 12 and 24 months. Most interestingly, the median number of sessions completed for Beating the Blues was 2, and for MoodGYM was 1. Only 18% of patients completed all 8 sessions of Beating the Blues and only 16% completed all 6 sessions of MoodGYM.

The authors conclude that cCBT programs appear to be effective when they are led by developers but do not appear to be effective in an independent study in a standard primary care setting. They believe that the main reasons for the negative study were low adherence and engagement rather than lack of efficacy.

This study raises several questions for me:

  1. Can depression be treated reliably in primary care settings? I think “high contact” specialty care will be necessary for most patients with significant depression.
  2. Can we develop computer programs that are engaging enough to overcome the inertia and lack of motivation that are part of depressive illnesses?
  3. If “high contact” care is needed for patients with major depression, can therapies delivered on-line (such as tele-psychiatry or on-line social networks of support) solve our access to care issues and be more effective than cCBT?

The state of bi-polar apps

I recently came across a very interesting paper that I think points out the timely need for PsyberGuide and its mission to objectively review apps for mental illness. The paper is entitled: “Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality,” published in the Journal of Medical Internet Research.

The study was conducted by Jennifer Nicholas and her colleagues in Sydney Australia. They attempted to identify all English apps for bipolar disorder and to check on various aspects of their content. They found 517 apps, 82 of which met their very simple criteria for further review. Of these apps, only 22% had a stated privacy policy, only 36% of the apps that claimed to provide psychoeducation contained the accepted “core principles” of this technique, and only 15% of apps that claimed to provide psychoeducation followed best practice guidelines. None of the apps had been evaluated in a research study and only 31% cited a source for the information they contained. In addition, neither the comprehensiveness of the psychoeducation content, nor the adherence to best practice guidelines, was correlated to user ratings. Finally, many of the symptom monitoring apps failed to measure critical data elements such as medication adherence or sleep patterns.

This article points how easily it might be for users to buy an app that differs widely from accepted standards of care, and which therefore, could potentially lead to harm.

Electronic Case Management Techniques

A lot has been written in recent years about “access to care” problems for people with mental illnesses. For example, we know that a large sector of the United States lacks professionals who can treat mental disorders  and according to a recent report by Merritt Hawkins, psychiatry as a medical specialty has one of the highest numbers of vacant positions. Not only is access to care difficult for patients who live in rural or underserved urban areas, but communication between the various provider organizations (hospitals, residential programs, partial hospitalization programs, and outpatient clinics) that serve patients with mental illness tends to be poorly coordinated, which further complicates patients’ search for long-term stability. For these reasons, we at PsyberGuide are very interested to learn if digital technologies can close these access to care and communication gaps. To that end, we have been following several companies that are working in the “electronic case management” area.


Wellframe is a private, venture-backed company based in Boston whose purported customers are health insurance plans, provider organizations and pharmaceutical companies. They have developed the “Intelligent Care Management Platform” that uses a smart-phone app health checklist combined with HIPAA compliant Clinical Dashboard to track patient progress in many different health conditions, including psychiatry. They claim that their system allows care managers to meaningfully interact with more patients and reduce the number of costly phone and in-person sessions. They also claim that the system leads to better treatment adherence and consumer self-management. The company has sponsored one pilot studying looking at the use of their platform to improve the physical health of psychiatric patients ( They have also recently concluded agreements with large behavioral health organizations to study their platform in young adults with mental illnesses in Boston, and in a population of veterans in Chicago.


Mindoula  is a private company based in Maryland. They claim to provide around the clock connectivity between case managers (“Mindoulas”) and psychiatric patients using traditional methods (phone or in-person meetings) or a HIPAA-compliant digital platform that includes a smart phone app. The website is directed at consumers themselves, but the company claims that they can also serve individual and group medical practices, therapists, residential programs, hospitals, college counseling services and geriatric care groups. It is not clear from their website whether they have concluded contracts with larger organizations or are focused mainly on individual patients at this point.


ThriveStreams  is a venture backed company based in Brooklyn, NY. They have developed ThriveTracker, which is a smartphone app designed to improve the management of mood disorders by tracking mood ratings, sleep patterns and therapy sessions. Recently, the company has also developed ThriveSync, a platform similar to the two mentioned above, that combines a provider dashboard with a smart phone app to allow for active monitoring of patients with mood disorders, and hopefully for the development of more individualized and timely interventions. It is not clear from their website that any major contracts have yet been awarded.

We are quite sure that there will be many more such companies and technologies hitting the market soon and we will be tracking them closely. If you are a provider or a consumer and have had any experience with these systems we would be happy to have your input and comments.


The Promise of Technology: Efficient Systems, Better Care, and Improved Outcomes

I participated in this panel at the Kennedy Forum National Conference on June 9 in Boston. I gave an overview of PsyberGuide and our efforts to provide unbiased information on the usefulness and quality of digital applications for mental health. I described our most recent summary of the PsyberGuide internal rating system, the availability of expert reviews, and the difficulties we have had in collecting consumer input directly on our site. I received very positive feedback from many in the audience about the usefulness of our data.

Other members of the panel included: Lisa Marsch, Ph.D. is the Director of the Center for Technology and Behavioral Health at Dartmouth College. This center has received funding from NIDA and other sources to better incorporate digital technologies into clinical practice. Anne Altman is the General Manager of US Federal Government and Industries for IBM Corporation. Anne spoke about the efforts of her company to improve data analytic capabilities for government agencies that provide or evaluate healthcare. Bill Crouse, M.D. is Senior Director, Worldwide Health for Microsoft Corporation. Bill is an internist who is responsible for implementing technologic solutions in the healthcare industry. Stephen Kennedy Smith is Co-Founder and Executive Vice President of Pear Therapeutics, a company that is trying to develop and market linked prescriptions of pharmaceuticals with digital applications that may enhance efficacy.

The discussion was lively and thought provoking and I continue to be very impressed with the overall efforts of the Kennedy Forum to improve mental health care in this country.

App Curation and Prescription Services for Providers

While PsyberGuide is intended to be a service that gives information about apps and software marketed directly to consumers, there is a growing trend in the industry to develop “curation services” for providers or health care systems. In these systems, apps are evaluated or rated and providers that sign up for the service can e-prescibe products to their patients. Two of these services are:


AppScript was developed by IMS Health, which is a very large (15,000 employees), publicly traded, healthcare consulting company based in Danbury Connecticut. AppScript claims to have evaluated more than 40,000 health care apps with a proprietary evaluation procedure. AppScript allows providers to register for their platform, and after reviewing products, prescribe them to patients by e-mail. The site contains apps for a variety of medical conditions. There is a specific category for Depression, which contains 8 rated apps, and a category called Mental Health and Behavioral Disorders, which contains 12 rated apps. Of the 8 apps for Depression, 6 have also been evaluated on PsyberGuide, and there appears to be general agreement between the two sites’ ratings. The remaining 2 apps in the Depression section are rating scales based on the Geriatric Depression Scale and the Beck Depression Inventory, and these are therefore are not self-directed treatment apps. Of the 12 apps in the Mental Health and Behavioral Disorders Category, only 1 of the products has also been evaluated on PsyberGuide. The AppScript site gives a detailed description of the apps including information on the manufacturer and cost. There does not yet appear to be significant data published on the site from patient and peer ratings. I found the site clever, attractive and easy to use and no fee was required for me to sign up.


SocialWellth is a private company based in Las Vegas, Nevada. One of SocialWellth’s main investors is Cigna Corporation, the large health insurance company. In December 2014, SocialWellth acquired Happtique, which was started by the Greater New York Hospital Association, and which provided the basis for their healthcare app evaluation platform called mWellth. Apps are screened for functionality, consumer appeal and usability. Apps are then further evaluated for privacy and security issues, such as malware and encryption problems. Finally, an in-depth certification review is performed which includes assessments of research foundation, usability, and self-management capability. About 500 apps have been evaluated in this way. When providers use mWellth, they are able to log in, select a patient from an electronic database, and add a prescription for an app. The patient then receives an SMS message with a link to the app, and after using it, further data regarding patient use of the app are shared with the prescriber. As of this writing, I was not able to determine how to set up an account with SocialWellth, to examine the number of apps that might be relevant for mental illness, or if there was a fee associated with the service.


Abilto is a company that connects therapists trained in Cognitive Behavioral Therapy with patients suffering from a variety of medical conditions. The goal is to improve the outcome in problems such as heart disease, diabetes, pain, cancer, post-partum conditions, asthma, chronic obstructive pulmonary disease and bereavement, by focusing on the emotional components of these conditions, which may include depression, anxiety or stress. The company has been able to show that their program results in reduced hospital admissions, length of hospital stay and medical costs.

Abilto’s customers are health insurance plans and employers. Individual patients must work through one of these entities in order to gain access to Abilto. Once a patient is enrolled, they participate in an 8- week course of specialized cognitive behavioral therapy delivered by licensed clinical social workers by phone or video chat. They have a team of providers covering all 50 states.

Abilto is one of the growing numbers of companies offering a form of telepsychiatry or teletherapy and is not a self-directed computer assisted therapeutic technique. We have so far not reviewed teletherapy companies on PsyberGuide but we are interested in hearing from anyone who has participated with their services. Please contact us or leave a comment.


CommonGround is a web-based application that helps people to organize their health information into a particular format, to which the treatment team can respond in an efficient, personalized and comprehensive way. ( Common Ground was developed by Pat Deegan, Ph.D. who works at Dartmouth Psychiatric Research Center, and who has lived with psychosis and recovered from it. The description of CommonGround, its potential benefits, and especially its graphical illness-tracking module, are all very appealing. CommonGround has been in use for several years and appears to be backed up by a substantial amount of research ( We are not listing CommonGround with the consumer-based products since it is usually purchased by institutions rather than individuals.

Have you used this software?

We would be very interested to hear from practitioners or consumers who have used this software as to how it worked for them. Please contact us or leave a comment.

SAMHSA: Suicide Safe App

PsyberGuide concentrates on products aimed for consumer use, but we are also interested in supports for providers. One such product, recently released by The Substance Abuse and Mental Health Services Administration, is an app for health care providers, mainly primary care clinicians, called Suicide Safe ( The app is designed to help recognize and begin treatment planning for patients with potential suicidal behavior. The core of the app is the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) card, which can be downloaded separately (, and which is widely used in mental health settings. In addition, the app offers a variety of illustrative case studies, tips on interview techniques to handle this sensitive subject, a treatment facility locator, and a training and resource section that contains crisis lines, continuing education resources and other materials.

This is definitely a worthwhile endeavor since, as SAMHSA notes in their announcement, 45% of people that commit suicide have visited a primary care setting in the month prior to the event, as opposed to only 20% that have visited a specialized mental health setting. However, I downloaded the app on my iPhone and felt that it was not particularly easy to use in this format. It works better on an iPad or on a computer. There is a great deal of useful information on the app but it looks as if you are scrolling through a dense web page rather than an easy to use app. A better strategy might have been to take users through a web-based tutorial and then allow them to download a version of the SAFE-T that automatically categorized the risk level and then led to a range of appropriate treatment suggestions.

U.K.’s National Health Service Promoting On-Line Therapies

In the United Kingdom, the National Health Service (NHS) has taken a very active role in improving access to care with on-line therapeutic technologies. The NHS has recently released a description of five on-line services that they have endorsed, which were also studied by the National Institute for Health and Care Excellence.

Two of the products endorsed by the NHS have already been listed on PsyberGuide since they can be used relatively independently. Beating the Blues is a cognitive behavioral therapy (CBT) program for people with depression, anxiety or stress, which earned 10 of 14 points on the PsyberGuide scoring system and 4 of 5 stars on the NHS site. Similarly, Fear Fighter is a self-directed CBT program that earned identical ratings on the PsyberGuide and NHS sites. Big White Wall, Leso Digital Health and Silver Cloud have not been listed on PsyberGuide as they require substantial interaction with live therapists or supporters. Big White Wall and Leso Digital Health earned excellent ratings on the NHS site. Interestingly, many of the programs endorsed on the NHS site are paid for by the NHS. This is a situation that we have not yet encountered in the U.S., where insurance reimbursement for self-directed therapies by computer is still in its infancy. If anyone has experience with these products please share your comments with us.

PsyberGuide at the Kennedy Forum

I had the privilege of giving a presentation about PsyberGuide to the Kennedy Forum on March 18. The Forum is led by former Congressman Patrick Kennedy, who has been one of our nation’s greatest leaders on issues related to mental health, particularly with regard to reimbursement parity, access to care and coordination of research policy. Although PsyberGuide is currently focused on computer and device assisted therapies that can be used by individuals, the larger question of interest to the Forum is: How can technology be used to improve access to care and coordination among the various entities in the mental health “system”?

I started off my presentation with some of the more discouraging facts about access to care in mental health. For example, according to a report in the Wall Street Journal, the Department of Health and Human Services estimates that 55% of the 3,100 counties in the United States do not have a practicing psychiatrist, psychologist or social worker. According to the Substance Abuse and Mental Health Services Administration, 22.3% of patients admitted to hospital with a diagnosis of schizophrenia were readmitted to hospital within 30 days of discharge, and for mood disorders that fraction was 15.2% .  Furthermore, only 31% of callers to mental health clinics were able to determine if they would get an appointment compared to 78% of callers seeking help from medical clinics (Rhodes et al: Referral without access: for psychiatric services, wait for the beep. Annals of Emergency Medicine 2009:54:272-278).  Faced with these facts, we at PsyberGuide wonder to what extent therapies delivered over the internet, or therapies provided by software under direct control of consumers could help improve access to care.

The Kennedy Forum is focusing on 5 “Pillars”:

  1. Ensuring mental health parity compliance in health plans
  2. Establishing ways to promote provider accountability through evidence-based outcome measures
  3. Implementing collaborative practice models that promote the integration of mental health and substance use disorders into mainstream health care
  4. Using technology to optimize digital communications and enhance assessment and treatment tools
  5. Promoting brain fitness and wellness which includes identifying opportunities to translate neuroscience research findings into interventions

I was very encouraged by the energy, enthusiasm and focus of the Forum and am glad that they are advocating for these important issues.  You can track their work, or sign up for the newsletter or make a donation to them, on their site, or you can find them on Facebook or Twitter.