Digital CBT refers to the use of digital tools, platforms or devices to deliver or enhance cognitive behavioural therapy assessment, formulation, treatment, training and supervision. The ‘Advances in Digital CBT’ special issue aimed to document examples of innovative digital CBT practice in this rapidly developing field. In this paper, we have briefly summarised and synthesised the advances demonstrated in this group of articles. These include developments in our understanding of mental health apps, the use of digital tools as an adjunct to therapy, the effectiveness of remotely delivered CBT in routine clinical practice, our understanding of user experiences and involvement, and in digital CBT research methods. We consider the extent of current knowledge in these areas and identify where gaps in evidence lie and how the field could be taken forward to address these. Lastly, we reflect on the broader digital CBT picture and offer our suggestions of six key directions for future research: using robust study designs to evaluate and optimise digital tools; translating and culturally adapting digital tools and practices; understanding and addressing digital exclusion; exploring, reporting and addressing possible negative effects; improving user involvement in design and evaluation; and addressing the implementation gap for digital tools. We suggest that further advances in these areas would be of particular benefit to the digital CBT field.

Mental health clinicians perform complex tasks with patients that potentially could be improved by the massive computing power available through mobile apps. This study aimed to analyse commercially available mobile and computer applications (apps) focused on treating psychiatric disorders. Apps were analysed by two independent raters for whether they took advantage of computer power to process data in a fashion that augments four main elements of clinical treatment including (1) assessment/diagnosis, (2) treatment planning, (3) treatment fidelity monitoring, and (4) outcome tracking. The evidence base for each of these apps was also explored via PsychINFO, Research Gate and Google Scholar. Searches of the Google Play Store, the Apple App Store, and the One Mind PsyberGuide found 722 apps labelled for mental health use, of which 163 apps were judged relevant to clinical work with patients with psychiatric disorders. Fifty-nine of these were determined to contain a computer-driven function for at least one of the four main elements of clinical treatment. The most common element was assessment/diagnosis (55/59 apps), followed by outcome tracking (34/59 apps). Six apps updated treatment plans using user input. Only one app tracked treatment fidelity. None of the apps contained computer-driven functions for all four elements. Twelve apps were supported in randomized clinical trials to show greater efficacy compared with either wait-list or other active treatments. Results showed that these four clinical elements can be meaningfully augmented, but the full potential of computer processing appears unreached in mental health-related apps.

Mental health (MH) apps can be used as adjunctive tools in traditional face-to-face therapy to help implement components of evidence-based treatments. However, practitioners interested in using MH apps face a variety of challenges, including knowing which apps would be appropriate to use. Although some resources are available to help practitioners identify apps, granular analyses of how faithfully specific clinical skills are represented in apps are lacking. This study aimed to conduct a review and analysis of MH apps containing a core component of cognitive behaviour therapy (CBT) – cognitive restructuring (CR). A keyword search for apps providing CR functionality on the Apple App and Android Google Play stores yielded 246 apps after removal of duplicates, which was further reduced to 15 apps following verification of a CR component and application of other inclusionary/exclusionary criteria. Apps were coded based on their inclusion of core elements of CR, and general app features including app content, interoperability/data sharing, professional involvement, ethics, and data safeguards. They were also rated on user experience as assessed by the Mobile App Rating Scale (MARS). Whereas a majority of the CR apps include most core CR elements, they vary considerably with respect to more granular sub-elements of CR (e.g. rating the intensity of emotions), other general app features, and user experience (average MARS = 3.53, range from 2.30 to 4.58). Specific apps that fared best with respect to CR fidelity and user experience dimensions are highlighted, and implications of findings for clinicians, researchers and app developers are discussed.

Internet-delivered cognitive behaviour therapy (ICBT) is effective for treating anxiety and depression among post-secondary students, although outcomes are modest. Booster lessons have been proposed for maintaining and improving outcomes but have not been investigated following ICBT for students. This study used a mixed-methods approach to examine student (N = 146) use of a self-guided booster lesson offered 1 month after a 5-week ICBT course, whereby the booster lesson provided a review of ICBT skills and suggestions for maintaining motivation and problem solving. A survey about the booster was administered shortly after the booster to understand student preferences for the booster lessons, reasons for completing/not completing the booster, and satisfaction with the booster. Approximately one-third of students (n = 47) utilized the booster lesson. Completing a greater number of lessons during the main ICBT course was associated with uptake of the booster. The booster survey was completed by 20 of the 47 (∼43%) students who completed the booster lesson and 42 of the 99 who did not (∼42%). Students varied in perceptions of the ideal timing of the booster (1–2 weeks to 3–6 months) and approximately 60% expressed preference for completing the booster independently. Among non-completers of the booster, academic-related time constraints were the primary barrier to booster completion. Among those who completed the booster, the booster lesson was perceived as worthwhile, satisfaction was high, and the length was perceived as appropriate. Future research should examine if flexible delivery of booster lessons in terms of timelines and therapist support would increase booster uptake.

Despite its impressive evidence base, there is a widening access gap to receiving cognitive behavioural therapy (CBT). Video conferencing therapy (VCT) offers an effective solution for logistical barriers to treatment, which has been salient throughout the Coronavirus pandemic. However, research concerning the delivery of CBT via VCT for children and young people (CYP) is in its infancy, and clinical outcome data are limited. The aim of this service evaluation was to explore the effectiveness of a VCT CBT intervention for CYP referred from Child and Adolescent Mental Health Services (CAMHS) in the UK. A total of 989 records of CYP who had completed CBT via VCT in 2020 with Healios, a digital mental health company commissioned by the National Health Service (NHS), were examined to determine changes in anxiety, depression and progress towards personalised goals. Routine outcome measures (ROMs) were completed at baseline and endpoint, as well as session by session. Feedback was collected from CYP and their families at the end of treatment. There was a significant reduction in symptoms of anxiety and depression and significant progress towards goals, with pre- to post-effect sizes (Cohen’s d) demonstrating medium to large effects (d=.45 to d=−1.39). Reliable improvement ranged from 31 to 80%, clinical improvement ranged from 33 to 50%, and 25% clinically and reliably improved on at least one measure; 92% reported that they would recommend Healios. This service evaluation demonstrates that Healios’ CBT delivered via VCT is effective for CYP receiving it as part of routine mental health care.

The COVID-19 pandemic increased population levels of depression and anxiety, and infection control measures obliged services to provide psychological therapies remotely. Evidence for the routine provision of psychological therapy via telephone and video-conferencing is limited. This study compared therapy outcomes for 5360 clients in two London Improving Access to Psychological Therapy (IAPT) services before and after homeworking produced a compete shift to remotely delivered therapy. Despite the psychological impacts of pandemic restrictions, and the use of a novel therapy modality in video-conferencing, recovery rates and net score change improved in both services, significantly in one. There was no significant worsening of outcomes for any demographic group or presenting disorder. The findings suggest that for those able to access it, therapy provided by telephone and video is a clinically effective option for IAPT services.

Online peer support platforms have been shown to provide a supportive space that can enhance social connectedness and personal empowerment. Some studies have analysed forum messages, showing that users describe a range of advantages, and some disadvantages to their use. However, the direct examination of users’ experiences of such platforms is rare and may be particularly informative for enhancing their helpfulness. This study aimed to understand users’ experiences of the Support, Hope and Recovery Online Network (SHaRON), an online cognitive behavioural therapy-based peer support platform for adults with mild to moderate anxiety or depression. Platform users (n = 88) completed a survey on their use of different platform features, feelings about using the platform, and overall experience. Responses were analysed descriptively and using thematic analysis. Results indicated that most features were generally well used, with the exception of private messaging. Many participants described feeling well supported and finding the information and resources helpful; the majority of recent users (81%) rated it as helpful overall. However, some participants described feeling uncomfortable about posting messages, and others did not find the platform helpful and gave suggestions for improvements. Around half had not used the platform in the past 3 months, for different reasons including feeling better or forgetting about it. Some described that simply knowing it was there was helpful, even without regular use. The findings highlight what is arguably a broader range of user experiences than observed in previous studies, which may have important implications for the enhancement of SHaRON and other platforms.

Adolescence is associated with heightened vulnerability to symptoms of depression and anxiety. In-person and computerised cognitive behavioural therapy (CBT) are effective treatment options, yet uptake and engagement remain low. Smartphone delivery of CBT offers an alternative, highly accessible method of delivering CBT. However, there is no freely available CBT smartphone application (app) specifically designed to reduce depression and anxiety symptoms in adolescents. The aim of this study was to design a new CBT smartphone app (ClearlyMe) that targets depressive and anxiety symptoms in adolescents. We engaged in a rigorous co-design process with adolescents (n=36), parents (n=15), and mental health professionals (n=32). Co-design involved: (1) discovery of users’ needs, views and preferences by conducting focus groups, (2) defining app features through ideation workshops and user consultations, (3) designing therapeutic CBT content and visual features, and (4) testing prototypes. Users were involved at every step and the process was iterative, with findings carried forward to ensure continued refinement of concepts and features. We found a preference for vibrant, cheerful colours and illustrations and non-endorsement of gamification and chatbots, which contrasted with findings from other studies. Preferences were largely consistent between the three user groups. However, adolescents preferred an app that could be used autonomously without professional support, whereas mental health professionals desired a product for use as a therapy adjunct to support CBT skill development. The importance of co-design, and particularly the inclusion of all stakeholders throughout the entire co-design process, is discussed in relation to the design of ClearlyMe.

Cognitive behavioural therapy (CBT) videoconferencing has been demonstrated to be an effective treatment for anxiety disorders and an equal alternative to face-to-face CBT. However, qualitative patient and therapist experiences of CBT videoconferencing have been less researched. Due to COVID-19, mental health services have shifted to remote therapy methods; thus, understanding patient and therapist experiences are crucial to better inform service policies and best practices. The current study focused on patient and therapist experiences of CBT videoconferencing at the Centre for Anxiety Disorders and Trauma (CADAT). Researchers used qualitative content analysis to explore patients’ (n = 54) and therapists’ (n = 15) responses to an online survey. Results yielded four themes: behavioural experiments work well if the problem lends itself to videoconferencing, overall practicalities but some home environment implications, privacy and technical issues, high telepresence and the negative impact on the therapeutic alliance, and COVID-19 influences attitude positively. The findings have clinical implications for CBT videoconferencing, including a need for specific training in assessment and intervention for therapists using videoconferencing.