Design of Health TechnologiesDesign of Health Technologieslecture 17lecture 17

John CannyJohn Canny11/07/0511/07/05

IT for Mental HealthIT for Mental HealthQ: Why computer therapy?

A: Many cases of depression and anxiety disorders go untreated – patients are ashamed to seek help, and may fear the consequences at work and home.

A: Therapy is expensive and beyond the reach of many patients.

Computer therapy is very cheap and available by comparison. It looks like a good option, as long as it works…

Marks et al.Marks et al. CBT (Cognitive Behavior Therapy)

via Computer.

What is CBT?

CBT is a method used to treat depression and anxiety via a recognition of “distorted thinking,” and “cognitive restructuring.” It may also involve classical conditioning when used to treat Obsessive Compulsive Disorder.

Marks et al.Marks et al.Considered 4 systems, which patients were advised

to use at least 6 times over 12 weeks: Fearfighter: for phobia/panic

Cope: for depression/anxiety

Balance: for general anxiety/depression

BTSteps: for Obsessive Compulsive Disorder

Patients had some direct contact with therapists for advice, and help with the system.

Marks et al.Marks et al.

Fearfighter: was PC or web-based.

Cope and BTSteps: were phone-based. The system used voice, while users responded with phone key presses.

Balance: was PC-based using a CD-Rom.

Marks et al. OutcomesMarks et al. Outcomes

Improvements were found in all groups.

Typical improvements were 20-40% in standard measures of anxiety or depression.

Significances were not high, and there was a large variation in difference (meaning some patients reported getting worse).

Nevertheless, this kind of treatment seems to have worked well.

Marks et al. OutcomesMarks et al. Outcomes

CO MPUT ER - A ID ED SE LF -H EL PCO MPUT ER - A ID ED SE LF -H EL P

computer,0% clinician;4computer,0% clinician;4¼50% computer,50% computer,50% clinician; 850% clinician; 8¼0% computer, 100%0% computer,100%clinician) the mean rating was 4.9clinician) the mean rating was 4.9(s.d.(s.d.¼2.2), suggestinga marginalprefer-2.2), suggestinga marginal prefer-encefor therapistovercomputerguidance.encefor therapistovercomputerguidance.There were no significantdifferencesinThere were no significantdifferencesinsatisfactionor preference(therapistsatisfactionor preference(therapist v.v.computer)betweenusersof the differentcomputer)betweenusersof the differentsystems(datanot shown).systems(datanot shown).

Featur es of use of comp ut er -aidedFeat ur es of use of comp ut er -aidedCB TCB T

A meanof 58 days(s.d.A meanof 58 days(s.d.¼49) elapsedfrom49) elapsedfrompatients’ startingto endingthe computer-patients’ startingto endingthe computer-aidedCBT. Over that period they had aaidedCBT. Over that period they had ameanof 64 (s.d.meanof 64 (s.d.¼48) minutesof support48) minutesof supportfrom a clinician, of which 25 minfrom a clinician, of which 25 min(s.d.(s.d.¼23) were spent on extra treatment23) were spent on extra treatment

6161

Ta ble2Ta ble2 Self-ratedoutcome: mean (s.d.) atpre- andpost-treatment, 95%confidenceintervals,percentageimprovement andeffect sizesfor all patients withavailableSelf-ratedoutcome: mean(s.d.) atpre- andpost-treatment, 95%confidenceintervals,percentageimprovement andeffect sizesfor all patients withavailable

post-treatmentdata (lower scorepost-treatmentdata(lower score¼improvement)improvement)

ScaleScale nn Pre-treatmentPre-treatment Post-treatmentPost-treatment Pre postdifferencePre postdifference Improvement%Improvement%11 Effect sizeEffect size22

MeanMean (s.d.)(s.d.) MeanMean (s.d.)(s.d.) MeanMean (95%CI )(95%CI) MeanMean (s.d.)(s.d.)

AllAll ((nn¼108)108)

Work andSocial Adjustment (range:0 40)Work andSocial Adjustment (range:0 40) 107107 20.620.6 (9.6)(9.6) 14.714.7 (9.5)(9.5) 5.9***5.9*** (4.5to 7.3)(4.5to 7.3) 27.527.5 (33.6)(33.6) 0.60.6

Work (range: 0 8)Work (range:0 8) 8 686 4.24.2 (2.7)(2.7) 3.53.5 (2.5)(2.5) 0.7***0.7*** (0.3to1.1)(0.3 to1.1) 17.917.9 (51.4)(51.4) 0.30.3

Home Management (range:0 8)Home Management (range:0 8) 9090 3.53.5 (2.2)(2.2) 2.42.4 (2)(2) 1.1***1.1*** (0.7 to1.4)(0.7 to1.4) 30.630.6 (42.6)(42.6) 0.50.5

Social Leisure(range: 0 8)Social Leisure(range:0 8) 9090 4.84.8 (2.3)(2.3) 3.23.2 (2)(2) 1.7***1.7*** (1.4 to 2)(1.4 to 2) 33.333.3 (29.4)(29.4) 0.70.7

PrivateLeisure(range: 0 8)PrivateLeisure(range:0 8) 9090 3.93.9 (2.3)(2.3) 2.62.6 (2)(2) 1.3***1.3*** (0.9 to1.7)(0.9 to1.7) 31.931.9 (45.5)(45.5) 0.60.6

Relationships(range: 0 8)Relationships(range:0 8) 9090 4.14.1 (2.3)(2.3) 2.82.8 (2)(2) 1.2***1.2*** (0.8 to1.5)(0.8 to1.5) 28.528.5 (42.5)(42.5) 0.60.6

FearFighterFearFighter((nn¼27)27)

FQ GlobalPhobia(range: 0 8)FQ GlobalPhobia(range: 0 8) 2525 5.65.6 (1.7)(1.7) 3.23.2 (1.6)(1.6) 2.3***2.3*** (1.7 to 3)(1.7 to 3) 40.740.7 (24.4)(24.4) 1.41.4

FQ Total Phobia(range:0 120)FQ Total Phobia(range:0 120) 2626 49.049.0 (27.1)(27.1) 32.332.3 (22.5)(22.5) 16.6***16.6*** (12.1to 21.2)(12.1to21.2) 39.939.9 (24.8)(24.8) 0.60.6

FQ Anxiety/Depression(range:0 48)FQ Anxiety/Depression(range:0 48) 2626 23.523.5 (11.5)(11.5) 12.112.1 (8.6)(8.6) 11.1***11.1*** (7.6 to14.6)(7.6 to14.6) 47.347.3 (25.7)(25.7) 1.01.0

Work andSocial Adjustment (range:0 40)Work andSocial Adjustment (range:0 40) 2727 17.917.9 (9.5)(9.5) 11.811.8 (9.5)(9.5) 6.1***6.1*** (3.9 to 8.3)(3.9 to 8.3) 36.436.4 (39.0)(39.0) 0.60.6

CopeCope((nn¼39)39)

BeckDepressionInventory(range:0 63)BeckDepressionInventory (range:0 63) 2323 27.427.4 (9)(9) 16.216.2 (7.1)(7.1) 11.2***11.2*** (6.9 to15.5)(6.9 to15.5) 37.737.7 (29.4)(29.4) 1.21.2

HRSD (range:0^51)HRSD (range:0^51) 3030 16.816.8 (5.2)(5.2) 13.313.3 (6.2)(6.2) 3.5*3.5* (0.9 to 6.1)(0.9 to 6.1) 15.215.2 (41.9)(41.9) 0.70.7

Work andSocial Adjustment (range:0 40)Work andSocial Adjustment (range:0 40) 3838 24.024.0 (8.2)(8.2) 16.416.4 (8.8)(8.8) 7.6***7.6*** (4.6 to10.6)(4.6 to10.6) 29.429.4 (31.1)(31.1) 0.90.9

BalanceBalance((nn¼33)33)

BeckAnxietyInventory (range: 0 63)BeckAnxietyInventory (range: 0 63) 3030 20.720.7 (11.9)(11.9) 13.413.4 (9.3)(9.3) 7.3***7.3*** (4.2to10.3)(4.2to10.3) 25.125.1 (50.2)(50.2) 0.60.6

BeckDepressionInventory(range:0 63)BeckDepressionInventory (range:0 63) 2828 2222 (10)(10) 15.615.6 (6.8)(6.8) 6.3***6.3*** (3.8 to 8.9)(3.8 to 8.9) 20.820.8 (34.8)(34.8) 0.60.6

Work andSocial Adjustment (range:0 40)Work andSocial Adjustment (range:0 40) 3333 20.020.0 (9.6)(9.6) 16.016.0 (9.8)(9.8) 4.0***4.0*** (1.9 to 6.1)(1.9 to 6.1) 18.718.7 (32.2)(32.2) 0.40.4

BTStepsBTSteps((nn¼9)9)

YBOCSTotal (range:0 40)YBOCSTotal (range:0 40) 99 23.223.2 (7.4)(7.4) 14.014.0 (8.1)(8.1) 9.2*9.2* (1.6 to16.7)(1.6to16.7) 35.735.7 (42.5)(42.5) 1.21.2

YBOCS Obsessions(range:0 20)YBOCSObsessions(range:0 20) 99 10.710.7 (5.1)(5.1) 6.36.3 (4.1)(4.1) 4.4*4.4* (0.7 to 8.1)(0.7 to 8.1) 13.213.2 (119.9)(119.9) 0.90.9

YBOCSCompulsions(range:0 20)YBOCSCompulsions(range:0 20) 99 12.412.4 (3.5)(3.5) 7.67.6 (5)(5) 4.7*4.7* ((77 0.04to 9.5)0.04to 9.5) 33.833.8 (41.5)(41.5) 1.41.4

Work andSocial Adjustment (range:0 40)Work andSocial Adjustment (range:0 40) 99 17.217.2 (12.4)(12.4) 12.112.1 (10.2)(10.2) 5.15.1 ((77 0.3to10.5)0.3to10.5) 25.025.0 (27.8)(27.8) 0.40.4

FQ,FearQuestionnaire;HRSD, HamiltonRatingScale forDepression;YBOCS,Yale Brown Obsessive CompulsiveScale.FQ,FearQuestionnaire;HRSD, HamiltonRatingScaleforDepression;YBOCS,Yale Brown Obsessive CompulsiveScale.1. Formula:((Pre-treatmentmean Post-treatmentmean)/Pre-treatmentmean)1. Formula:((Pre-treatmentmean Post-treatmentmean)/Pre-treatmentmean)66 100.100.2. Formula:(Pre-treatmentmean Post-treatmentmean)/Pre-treatments.d.2. Formula:(Pre-treatmentmean Post-treatmentmean)/Pre-treatments.d.*Significantmeandifferenceat*Significant meandifferenceatPP55 0.05.0.05.***Significantmeandifferenceat***Significantmeandifferenceat PP55 0.001.0.001.

Fig. 2Fig. 2 Patient Gl obal Impressionof Improvement scoreatpost-treatment (Patient Gl obal Impressionof Improvement scoreatpost-treatment (nn¼107).107)

VR and Phobias (North et al.)VR and Phobias (North et al.) VR therapy via SD (Systematic Desensitization) is

becoming very popular.

SD is a process of gradually introducing a disturbing stimulus (e.g. view from a high place) in otherwise pleasant surroundings.

This process gradually suppresses the anxiety response.

VR and PhobiasVR and Phobias

VR for SD has several advantages:

Patients often have difficulty imagining the stimulus themselves.

They are often afraid of experiencing it directly – which may also be expensive and time-consuming.

VR affords patient privacy and confidentiality during treatment.

VR and PhobiasVR and Phobias

Several case studies reported in the North paper:

Aerophobia (flying) two subjects reported improvements

Agoraphobia (described as a fear of situations from which it is difficult to escape) study with 60 patients, showed strong improvement in the treatment group.

Acrophobia (heights) with 20 college students, strong improvement in the treatment group.

VR and PhobiasVR and Phobias

Physiological signs in patients undergoing VR therapy typically mirrored real reactions –

Anxiety, muscle tension, palpitations, shaking, sweating and dizziness.

VR and PhobiasVR and Phobias

A very high degree of realism did not seem to be necessary for effective VR therapy.

Most environments had simple graphics, limited sound and vibration effects (and no G-forces apparently).

Subjects sense of presence in the virtual world increased spontaneously with repeated treatments.

This generally follows the therapeutic trend.

VR and imagination (Vincelli et VR and imagination (Vincelli et al.)al.) Imagination and memory play a central role in

classical therapy. Most psychotherapy is based on the analysis and

modification of mental images. Many anxiety disorders result from the

maintenance of oppressive images (Beck). Imagined stimuli elicit most of the physiological

responses of real stimuli: pulse, pupil size, muscle tension, blood glucose, skin temperature,…

Penfield (1963) showed that imaginative stimuli arise in areas of cortex devoted to sensory perception.

VR and imaginationVR and imagination

Some specific therapies using imagination include: “Projection in time” – rationally reconstructing the

future

“De-catastrophizing an image” – modifying a disturbing image

“Image modeling and substitution” –interrupting a negative train of images

“Covert conditioning” – subtle conditioning using imagined rather than real stimuli

VR and imagination - SDVR and imagination - SD

Systematic Desensitization (SD) is one of the more popular approaches in VR therapy.

SD consists of placing the patient in a pleasant state, and then introducing an anxiety-provoking stimulus. As this process is repeated the anxiety response is inhibited.

Limitations of VR therapy - Limitations of VR therapy - MiltonMiltonAcknowledges successes in many areas: Phobias Body Image, eating disorders, sexual

dysfunction, treating autism.

But there are some major limitations to more widespread use.

Limitations of VR therapyLimitations of VR therapy

Cost of building models:

Virtual worlds require some kind of 3D CAD system. These tools are notoriously hard to use.

Detail is needed not only in visual appearance, but also in their physics (objects should behave normally if the user picks them up).

Human models (avatars) can be enormously complex, but are mostly rigid manequins.

Limitations of VR therapyLimitations of VR therapy

Cost of rendering environment:

The original systems used a CAVE, and array of screens with 3d input devices, and costs running into millions.

More recently, stereoscopic displays and 3D mice are available at low cost. But the level of “immersion” is much lower.

Limitations of VR therapyLimitations of VR therapy

Limitations of Study methods:

Many studies of VR methods have not used careful enough criteria for defining the condition under study – acrophobia, aerophobia. Most often patients self-submit to the experiment or are referred because of existing treatment.

Tools such as DSM-IV could be used to more carefully chart the condition in the patients who participate in studies.

HutchWorld (not in readings)HutchWorld (not in readings) Hutchworld is a virtual community attached to

the Hutchison Cancer Research Center.

Designed to provide social support for cancer patients and their families.

Based on Microsoft’s Vworld’s system.

HutchWorldHutchWorld Built on an earlier system called CHESS

(Comprehensive Health Enhancement Support System) that provide information for chronically ill patients, esp. those with HIV.

Researchers found that CHESS users used the system more than once per day. They also found that users made heavier use of the social support functions of the site, more than the informational functions.

HutchWorld – Design HutchWorld – Design GuidelinesGuidelines Recreating the actual building was more

effective than an abstract environment.

Access was restricted to patients, caregivers and their families.

Information was restricted to “public”information, not sensitive or specialized medical information.

HutchWorld – Design EvolutionHutchWorld – Design Evolution The 3D Vworlds version had some serious

shortcomings:

It was difficult to achieve a critical mass of users and the space often appeared empty.

Users could not “lurk” in the space since their avatar was visible if they were there.

Users did not return after a negative first experience.

HutchWorld – Design EvolutionHutchWorld – Design Evolution The second prototype was designed to support

asynchronous communication.

This allowed patients to check in when they wanted to – many patients were awake in the early hours of the morning. The Hutchworld system provided a social channel even if no-one else was online.

“Information portal” functions were integrated in the system so users could do much more than message. They still had a visible avatar while visiting the site.

HutchWorld – Design EvolutionHutchWorld – Design Evolution The second prototype was designed to support

asynchronous communication.

This allowed patients to check in when they wanted to – many patients were awake in the early hours of the morning. The Hutchworld system provided a social channel even if no-one else was online.

“Information portal” functions were integrated in the system so users could do much more than message. They still had a visible avatar while visiting the site.

Discussion QuestionsDiscussion Questions

Mental health is an important topic in itself, but also interacts with other medical therapies (e.g. as in Hutchworld and CHESS).

Discuss ways of integrating mental health support with other health care delivery systems.

A lot of research is directed at “high-end” (VR) therapies, but several successful systems were much simpler. Discuss means of deploying “low-end” computer therapies, and what kinds of conditions might be treated with them.