Two-way messaging therapy for depression and anxiety: longitudinal response trajectories

Abstract

Background: Telemedicine is a strategy for overcoming barriers to access evidence-based psychotherapy. Digital modalities that operate outside session-based treatment formats, such as ongoing two-way messaging, may further address these challenges. However, no study to date has established suitability criteria for this medium. Methods: A large outpatient sample (n = 10,718) engaged in daily messaging with licensed clinicians from a telemedicine provider. Patients consisted of individuals from urban and rural settings in all 50 states of the US, who signed up to the telemedicine provider. Using a longitudinal design, symptoms changes were observed during a 12 week treatment course. Symptoms were assessed from baseline every three weeks using the Patient Health Questionnaire (PHQ-9) for depression, and the Generalized Anxiety Disorder (GAD-7) for anxiety. Demographics and engagement metrics, such as word count for both patients and therapists, were also assessed. Growth mixture modeling was used to tease apart symptoms trajectories, and identify predictors of treatment response. Results: Two subpopulations had GAD-7 and PHQ-9 remission outcomes (Recovery and Acute Recovery, 30.7% of patients), while two others showed amelioration of symptoms (Depression and Anxiety Improvement, 36.9% of patients). Two subpopulations experienced no changes in symptoms (Chronic and Elevated Chronic, 32.4% of patients). Higher use of written communication, patient characteristics, and engagement metrics reliably distinguished patients with the greatest level of remission (Recovery and Acute Recovery groups). Conclusions: Remission of depression and anxiety symptoms was observed during delivery of psychotherapy through messaging. Improvement rates were consistent with face-to-face therapy, suggesting the suitability of two-way messaging psychotherapy delivery. Characteristics of improving patients were identified and could be used for treatment recommendation. These findings suggest the opportunity for further research, to directly compare messaging delivery with a control group of treatment as usual.

Open trial of an adaptation of cognitive processing therapy for message-based delivery.

“…The lack of diversity might limit the generalizability of our results, because race and gender in particular play a role in exposure to and development of PTSD as well as treatment seeking behaviors (Roberts et al, 2011). However, the study make-up is similar to that reported elsewhere for the platform (Hull et al, 2020) and for the use of telehealth in more traditional therapy settings as well (Titov et al, 2017). Future research should address the limitations of this study by including a fully-powered randomized design, objective assessments, a more standardized comparison condition, a more diverse and larger sample, and systematic documentation of reasons for dropout.…”

“…TAU was conducted with clients who enrolled in Talkspace through the platform's normal onboarding and intake processes. While therapists who utilize the platform report a variety of therapeutic approaches and areas of expertise (see Hull et al, 2020 for a full description of the therapy network), those therapists who endorsed a specialty in treating PTSD and who identified CBT as one of their orientations were selected for this study. Clients who were being treated by these clinicians primarily for their PTSD-related symptoms were selected.…”

“…Some messaging therapy platforms offer asynchronous communication, which does not require participants to be present and respond to one another at the same time. Such platforms may facilitate engagement in treatment among those who seek discrete and affordable support, at times that are convenient and not disruptive to their busy schedules (Hull et al, 2020). Given the effectiveness of texting in engaging and retaining clients in psychotherapy, asynchronous texting therapy delivered by experienced therapists thus might increase client access to and engagement in EBTs.…”

“…While somewhat less is known about the effectiveness of asynchronous texting therapy, a small study demonstrated evidence of significant symptom change in nearly half of the individuals who sought treatment for a variety of presenting problems (Hull & Mahan, 2017). In more recent asynchronous texting studies with larger samples, 66% of the clients who received treatment for depression and anxiety reported significant symptom change (Hull et al, 2020), and nearly half of the individuals who sought treatment for PTSD experienced clinically significant improvement (Malgaroli et al, 2020). In the latter study, the therapy modalities used to address PTSD were at the discretion of the therapist, and individuals could engage with their therapists 5 days per week through video messaging or texting.…”

Analyzing Digital Evidence From a Telemental Health Platform to Assess Complex Psychological Responses to the COVID-19 Pandemic: Content Analysis of Text Messages

“…Talkspace also allows psychotherapists to schedule live video sessions with patients within their regions of licensure. Studies have shown that Talkspace is acceptable and feasible for increasing patients’ access to care [ 6 ]. Talkspace has been used by over 2000 therapists who each serve an average of 15-20 patients at any given time (ie, throughout the United States and worldwide).…”