**7. Conclusions and future directions**

it difficult to identify those that might be helpful. For example, a recent study attempted to characterize mobile phone apps for depression that were available on any app marketplace as of March 5, 2013. Apps were included if they used "depression" in the title or app description, targeted health consumers (i.e., patients, caregivers), and had an English language interface. Their search yielded 1054 apps; however, only 243 met the inclusion criteria. Of the 190 app developers, only 9.5% were medical centers, universities, or institutions; 29.5% were clearly labeled as coming from a commercial developer; and the rest did not provide any affiliation. Regarding content, only 29.6% of the 243 included apps reported an external or expert source as the basis of their app [17]. To the best of our knowledge, there has been no research on the potential harms of using a poor-quality

Despite the limitations, there are numerous strengths of iCBT programs. The first is the flexibility and privacy of iCBT, which can increase patient empowerment. The only thing a patient needs to get treatment is an Internet connection [14, 19]. Treatment is not confined to office hours, which means it can accommodate work schedules and personal responsibilities. It also lets patients have access to treatment as symptoms arise. Geography is not an issue with iCBT. In countries with iCBT, studies have shown that it can be remarkably successful in rural areas where access to mental healthcare is limited [55, 61, 66, 67]. For countries that lack programs specific to their population and culture, well-researched programs can be adapted for a fraction of the cost of making a new program and still yield substantial gains [68]. iCBT provides treatment options for patients who cannot access treatment due to physical, psychological, or mobility issues [10]. Regarding privacy, iCBT lets patients address their symptoms anonymously. This anonymity might help circumvent the social stigma associated with treatment and encourage patients who might not otherwise have sought treatment to get the help

The second benefit of iCBT is its increased efficiency. Even for cases of therapist-supported or tailored iCBT, which require clinician input, fewer resources are needed to treat an individual, and responses to patient concerns can be addressed whenever the therapist has time available [19]. One study comparing in-person CBT and iCBT showed that iCBT patients required only 7.5% of the time that in-person patients needed to achieve similar gains [70]. Further, much of the iCBT support can be performed by trained staff rather than a clinician [37, 71]. Many of the behaviors that therapists teach patients, such as task reinforcement, psychoeducation, and deadline flexibility [72], can be performed by trained staff rather than a clinician. Overall, iCBT has been shown to be more resource efficient even with clinician

The third strength of iCBT is its cost efficiency. Numerous studies have evaluated the costs of iCBT [16, 73]. It has been shown to be cost effective and reduce societal cost compared with waitlisted controls and in-person CBT [16, 36, 73]. As discussed above, it is relatively inexpensive to adapt an existing iCBT program [68], indicating that iCBT could potentially be

iCBT program.

214 Cognitive Behavioral Therapy and Clinical Applications

they need [19, 69].

implemented cost effectively.

input, which would give more patients access overall.

Increasingly, payers – governments, employers, private insurance companies – are considering new ways of offering CBT. At the same time, people are looking to the Internet for solutions for their mental health problems. Australia has invested in iCBT, as have private companies; iCBT websites and apps are more and more popular; MoodGym has more than 850,000 registered users.

While we applaud the interest in evidence-based care, we offer a word of caution: not all iCBT programs are created equal. Yes, the literature is now rich in research studies on iCBT for common illness – for mental health illnesses, and also for physical health problems. And while the growing if young literature does support the use of iCBT, effectiveness is clearly tied to patient engagement. Clearly, therapist-guided iCBT has better results than non-therapist-guided iCBT.

As the experimentation grows, we suggest two forces will transform iCBT – and therapy itself. First, with declining stigma and increased demand for care, iCBT will be considered more of an option, given its effectiveness, and its advantages over traditional CBT – that is, the convenience and accessibility of iCBT, coupled with its lower costs and privacy. Second, as technology advances, iCBT could well be improved, moving beyond visually-pleasing graphics and – empowered with AI – entering into a world where programs learn from and adapt to the patients that they serve, offering CBT concepts, perhaps delivered with machine-learned empathy.

With regard to the latter point, we note that several products have already been developed with AI. An Indian group developed a therapy chatbot called Wysa. This interactive program claims to learn signs of anger and distress from its patients, and then employs evidencedbased therapy techniques when appropriate. Wysa is simple – but it is available 24 hours a day, 7 days a week – already offering more flexibility than its human therapist rivals.

We are in the early days of AI and mental health. Over time, iCBT programs will grow more sophisticated. How therapy changes exactly, of course, is impossible to predict. This much is clear: the 1970s, Beck-style approach to CBT, with one therapist and one patient, is being replaced as therapy gets modernized.
