Computers, Internet and Psychotherapy

The demand of psychotherapy often exceeds the availability of therapists. Two studies published in the journal Psychotherapy and Psychosomatics review how modern computer and communication technologies can provide novel opportunities for the provision of stepped care for patients with mental disorders.

In a a review and an accompanying editorial by Prof. Isaac Marks and collaborators point out that therapist time is not saved by conducting cognitive behavior therapies (CBT) via e-mail, telephone or video-conference exchanges between patient and therapist in real time. However, time can be saved when treatment tasks are delegated to patient-computer interactions.

Many patients may also prefer to access CBT at home by computer for reasons of greater confidentiality, lessening of stigma and reduction of time needed to travel to a therapist.

This concept was explored by Indra Tumur and colleges in a analysis of 4 studies to compare the effectiveness of a computerized cognitive behavior therapy (CCBT) program, BTSteps, for the treatment for obsessive-compulsive disorder (OCD) against the traditional therapist-led cognitive behaviour therapy (TCBT) and relaxation.

They found that CCBT was as good as TCBT for reducing time spent in rituals and obsessions and and was superior to RLX treatment. Improvement of OCD persisted beyond the end of the CCBT treatment. Therapist guided CBT was more effective than CCBT for all patients overall though not in those who went on to start self-exposure.

In the third study, University of Heidelberg researchers investigated the effectiveness of group therapy delivered through an Internet chat room following inpatient treatment.

The main goal of the program was to reduce the risk of losing the therapeutic benefits gained during the inpatient treatment. 114 patients participated in one of two parallel groups of 8-10 patients that met with a group therapist in an Internet chat room.

The groups met weekly for 12-15 weeks for 90 min. Controls were 114 patients who did not participate in the chat groups and were matched by application of propensity score methods.
The main criterion was derived from comprehensive assessments of changes in health status comprising the psychological and physical condition of the patients.

Assessments were conducted at admission, discharge and 12 months after discharge. 12 months after discharge, chat participants showed a substantially lower risk (24.7%) for negative outcome than controls (38.5%). Furthermore, a low dropout rate and the high session attendance suggest this novel offer met patients' needs, and thus, opens new avenues for optimizing care for patients with mental disorders.

Baer L, Greist J, Marks IM. Computer-Aided Cognitive Behaviour Therapy Psychother Psychosom 2007;76:193-195 (no abstract)Tumur I, Kaltenthaler E, Ferriter M, et al. Computerised Cognitive Behaviour Therapy for Obsessive-Compulsive Disorder: A Systematic Review Psychother Psychosom 2007;76:196-202
[Abstract]
Golkaramnay V, Bauer S, Haug S, et al. The Exploration of the Effectiveness of Group Therapy through an Internet Chat as Aftercare: A Controlled Naturalistic Study Psychother Psychosom 2007;76:219-225 [Abstract]

Mental Health Courts Reduce Incarceration, Save Money

Psychiatric Times
July 01, 2007 Vol. 24 No. 8
by Arline Kaplin

Figures from the US Department of Justice indicate that more than half of prison and jail inmates have a mental health problem. Mental health courts (MHCs) were designed to divert mentally ill persons convicted of nonviolent crimes to supervised treatment instead of incarceration, but while the number of MHCs has grown substantially over the past decade, limited information has been available about outcomes and costs.

Now a study from the RAND Corporation has demonstrated that an MHC in Pennsylvania was successful in increasing mental health services and reducing jail time for participants while reducing costs to taxpayers.1 The study, sponsored by the Council of State Governments Justice Center, was the first to evaluate the fiscal impact of an MHC anywhere in the United States, according to economist John Engberg, PhD, one of the authors. It found that the court saved taxpayers $3.5 million over a 2-year period, Engberg told Psychiatric Times.

While the study focused on the Allegheny County MHC in Pittsburgh, the findings are applicable to many other MHCs in the United States, the study's director, M. Susan Ridgely, explained in a press statement.

Based on drug court models, an MHC is a special docket of a criminal court. "Essentially, mental health courts offer participants an opportunity to avoid incarceration if they agree to comply with community supervision and mandated treatment. Compliance is monitored through a series of reinforcement hearings before a dedicated jurist," the RAND research team wrote.
To determine the fiscal impact of the Allegheny County MHC, 1 of 4 such courts in Pennsylvania, the RAND researchers gathered information on the treatment, criminal justice, and entitlement program costs from 6 state and county public agencies. These costs were compared with the costs government would have incurred during a comparable period had MHC participants gone through the traditional criminal court system and the costs before and after an arrest in the years prior to their entry into the MHC program. From the study population of 352, the researchers extracted data on 3 subsamples to develop their analyses.

The MHC participants were predominantly male (62%), and half were between the ages of 29 and 44. Slightly more than half (54.6%) were white (non-Hispanic) and 41.2% were black.
When the participants entered the MHC program, diagnoses were missing for nearly one third. Among the remainder, 20.5% had bipolar disorder; 21.6% had schizophrenia, schizoaffective disorder, or other psychotic disorders; 6.3% had major depression; and 13.1% had depressive disorder, not otherwise specified. About half of the population showed evidence of alcohol or drug abuse. Although Global Assessment of Functioning scores were missing for one quarter of the participants, the majority scored below 50, indicating that they had severe symptoms and impairment.

In their report conclusions, the RAND researchers determined that the Allegheny County MHC program "is a success in achieving its mission to divert nonviolent offenders with serious mental illnesses out of the penal system and into community-based health treatment and other services"; that the diversion of seriously mentally ill individuals into the MHC program did not pose any increased risk to public safety; and that the MHC program "did not result in substantial incremental costs, at least in the short term," over the status quo.
In the short run, Engberg elaborated, Allegheny County broke even financially. The MHC program resulted in an increase in the use of mental health treatment services, but a reduction in jail time. The decrease in jail expenditures mostly offset the cost of the treatment services, he explained.

In the second year of study, both the average mental health services and jail costs were reduced, the latter dramatically, suggesting that the MHC program may help decrease total taxpayer costs over time, Engberg said. Allegheny County and the state, he added, also benefited because Medicaid, which is jointly funded by the state and federal government, primarily pays for mental health costs. MORE from Psychiatic Times Article....