Forging digital paths to treat addictions
While our increasing reliance on smartphones and computers may bring its own risks, CAMH’s Dr. John Cunningham sees technology’s potential to improve care for people with addictions. He’s developing and studying digital ways to bring effective treatments to more people, particularly individuals who would not typically seek help.
“We know that the majority of people with substance use or gambling problems don’t access treatment,” says Dr. Cunningham, Senior Scientist with CAMH’s Institute for Mental Health Policy Research and Canada Research Chair in Addictions. “A lot of this has to do with stigma and embarrassment. There’s a desire for self-reliance too, in both addictions and mental health.
“A question that drives my research is: What can we do to take treatment to people, rather than make them come to you? Online is an environment people are in,” he says.
Dr. Cunningham has been developing and evaluating self-change interventions throughout his research career, starting with paper-based tools. In 1998, he launched one of the first online interventions for alcohol use. The brief, personalized feedback tool, called Check Your Drinking, continues to be used nearly 20 years later, in Canada and internationally. Now, he’s investigating many digital approaches to bring treatments to people where they are.
From the web to apps
“My approach is to take interventions that have the evidence base and really concentrate on finding ways to make them available to more people, rather than creating new interventions,” says Dr. Cunningham. This focus on evidence is particularly important as a growing number of mental health apps, often untested through research, are launching.
In a study published in January 2017 in the journal Substance Use, Dr. Cunningham and lead author Dr. Nicolas Bertholet of the University Hospital of Lausanne in Switzerland adapted the Swiss-developed website Alcooquizz into an app for iPhone and Android devices. The pilot study in Switzerland and Canada showed that an app may be an effective way to deliver an alcohol intervention. App users reported reductions in their alcohol consumption – on average, weekly alcohol use declined by 27 per cent, from 15 drinks per week to 10.9. One in three users (34 per cent) said they used the app at a party, while 20 per cent used it during a drinking episode, settings where it’s particularly challenging to reach people with an intervention.
Another research area is whether a combination of online interventions can improve outcomes for people with co-occurring addiction or mental health disorders. Dr. Cunningham is heading two randomized controlled trials of problem gambling with Dr. Christian Hendershot at CAMH and other co-investigators. Both trials involve an online gambling intervention based on the work of Dr. David Hodgins at the University of Calgary. One study is evaluating the problem gambling intervention on its own versus a version combined with the Australian-developed MoodGYM, an intervention for depression and anxiety. The second study is assessing the same problem gambling intervention alone or used with the alcohol intervention Check Your Drinking, first developed by Dr. Cunningham.
The Alcooquizz app, based on the Swiss-developed website, may be an effective way to deliver an alcohol intervention
Testing an agile research model
While studies may take years to complete, Dr. Cunningham is testing “ways of doing smaller trials quickly and most cost effectively” to gather – and apply – insights in a shorter period, he says.
An environment he’s exploring is Amazon’s Mechanical Turk, a crowdsourcing website that connects more than 500,000 people available to work from their home computers with short-term work tasks posted by businesses. Last year, he initiated a pilot study on the site, asking Mechanical Turk users to complete a survey about their alcohol consumption. Using algorithms and automated follow-up methods, his team was rapidly able to identify people who met the study requirements and invite them to join a three-month study of the online intervention Check Your Drinking. Within less than four hours after completing the survey, more than 400 people had signed up to participate in the study. The trial showed that Mechanical Turk is a viable way to find participants for research into an online intervention. He now has four other studies under way using Mechanical Turk.
These smaller, shorter trials may be especially useful to learn from users and adapt during development of a digital intervention, rather than waiting until the app is fully built, or they can serve as pilot studies before a large-scale trial, says Dr. Cunningham.
Where creativity meets science
Once he has pinpointed how to adapt an evidence-based treatment to make it available to more people, the next challenge is figuring out how to evaluate if the new approach works. “That’s where the real creativity can come in – determining how to construct a study to evaluate an intervention, with the goal of helping people with addictions,” says Dr. Cunningham. “That’s what gives me the most joy as a researcher.”