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      Virtual Digital Psychotherapist App–Based Treatment in Patients With Methamphetamine Use Disorder (Echo-APP): Single-Arm Pilot Feasibility and Efficacy Study


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          Substance use disorder is one of the severe public health problems worldwide. Inequitable resources, discrimination, and physical distances limit patients’ access to medical help. Automated conversational agents have the potential to provide in-home and remote therapy. However, automatic dialogue agents mostly use text and other methods to interact, which affects the interaction experience, treatment immersion, and clinical efficacy.


          The aim of this paper is to describe the design and development of Echo-APP, a tablet-based app with the function of a virtual digital psychotherapist, and to conduct a pilot study to explore the feasibility and preliminary efficacy results of Echo-APP for patients with methamphetamine use disorder.


          Echo-APP is an assessment and rehabilitation program developed for substance use disorder (SUD) by a team of clinicians, psychotherapists, and computer experts. The program is available for Android tablets. In terms of assessment, the focus is on the core characteristics of SUD, such as mood, impulsivity, treatment motivation, and craving level. In terms of treatment, Echo-APP provides 10 treatment units, involving awareness of addiction, motivation enhancement, emotion regulation, meditation, etc. A total of 47 patients with methamphetamine dependence were eventually enrolled in the pilot study to receive a single session of the Echo-APP–based motivational enhancement treatment. The outcomes were assessed before and after the patients’ treatment, including treatment motivation, craving levels, self-perception on the importance of drug abstinence, and their confidence in stopping the drug use.


          In the pilot study, scores on the Stages of Change Readiness and Treatment Eagerness Scale and the questionnaire on motivation for abstaining from drugs significantly increased after the Echo-APP–based treatment ( P<.001, Cohen d=–0.60), while craving was reduced ( P=.01, Cohen d=0.38). Patients’ baseline Generalized Anxiety Disorder-7 assessment score ( β=3.57; P<.001; 95% CI 0.80, 2.89) and Barratt Impulsiveness Scale (BIS)–motor impulsiveness score ( β=–2.10; P=.04; 95% CI –0.94, –0.02) were predictive of changes in the patients’ treatment motivation during treatment. Moreover, patients’ baseline Generalized Anxiety Disorder-7 assessment score ( β=–1.607; P=.03; 95% CI –3.08, –0.14), BIS—attentional impulsivity score ( β=–2.43; P=.004; 95% CI –4.03, –0.83), and BIS—nonplanning impulsivity score ( β=2.54; P=.002; 95% CI 0.98, 4.10) were predictive of changes in craving scores during treatment.


          Echo-APP is a practical, accepted, and promising virtual digital psychotherapist program for patients with methamphetamine dependence. The preliminary findings lay a good foundation for further optimization of the program and the promotion of large-scale randomized controlled clinical studies for SUD.

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          Most cited references38

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          Reliability and validity of the Chinese version of the Patient Health Questionnaire (PHQ-9) in the general population.

          Depression is one of the most common mental illnesses. The reliability and the validity of the Patient Health Questionnaire (PHQ)-9, a depression screening tool, have not been examined in the general population in China. Thus, this study evaluated the reliability and the validity of the Chinese version of the PHQ-9 in detecting major depression in residents of a Chinese community.
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            Delivering Cognitive Behavior Therapy to Young Adults With Symptoms of Depression and Anxiety Using a Fully Automated Conversational Agent (Woebot): A Randomized Controlled Trial

            Background Web-based cognitive-behavioral therapeutic (CBT) apps have demonstrated efficacy but are characterized by poor adherence. Conversational agents may offer a convenient, engaging way of getting support at any time. Objective The objective of the study was to determine the feasibility, acceptability, and preliminary efficacy of a fully automated conversational agent to deliver a self-help program for college students who self-identify as having symptoms of anxiety and depression. Methods In an unblinded trial, 70 individuals age 18-28 years were recruited online from a university community social media site and were randomized to receive either 2 weeks (up to 20 sessions) of self-help content derived from CBT principles in a conversational format with a text-based conversational agent (Woebot) (n=34) or were directed to the National Institute of Mental Health ebook, “Depression in College Students,” as an information-only control group (n=36). All participants completed Web-based versions of the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), and the Positive and Negative Affect Scale at baseline and 2-3 weeks later (T2). Results Participants were on average 22.2 years old (SD 2.33), 67% female (47/70), mostly non-Hispanic (93%, 54/58), and Caucasian (79%, 46/58). Participants in the Woebot group engaged with the conversational agent an average of 12.14 (SD 2.23) times over the study period. No significant differences existed between the groups at baseline, and 83% (58/70) of participants provided data at T2 (17% attrition). Intent-to-treat univariate analysis of covariance revealed a significant group difference on depression such that those in the Woebot group significantly reduced their symptoms of depression over the study period as measured by the PHQ-9 (F=6.47; P=.01) while those in the information control group did not. In an analysis of completers, participants in both groups significantly reduced anxiety as measured by the GAD-7 (F1,54= 9.24; P=.004). Participants’ comments suggest that process factors were more influential on their acceptability of the program than content factors mirroring traditional therapy. Conclusions Conversational agents appear to be a feasible, engaging, and effective way to deliver CBT.
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              Chatbots and Conversational Agents in Mental Health: A Review of the Psychiatric Landscape

              The aim of this review was to explore the current evidence for conversational agents or chatbots in the field of psychiatry and their role in screening, diagnosis, and treatment of mental illnesses. A systematic literature search in June 2018 was conducted in PubMed, EmBase, PsycINFO, Cochrane, Web of Science, and IEEE Xplore. Studies were included that involved a chatbot in a mental health setting focusing on populations with or at high risk of developing depression, anxiety, schizophrenia, bipolar, and substance abuse disorders. From the selected databases, 1466 records were retrieved and 8 studies met the inclusion criteria. Two additional studies were included from reference list screening for a total of 10 included studies. Overall, potential for conversational agents in psychiatric use was reported to be high across all studies. In particular, conversational agents showed potential for benefit in psychoeducation and self-adherence. In addition, satisfaction rating of chatbots was high across all studies, suggesting that they would be an effective and enjoyable tool in psychiatric treatment. Preliminary evidence for psychiatric use of chatbots is favourable. However, given the heterogeneity of the reviewed studies, further research with standardized outcomes reporting is required to more thoroughly examine the effectiveness of conversational agents. Regardless, early evidence shows that with the proper approach and research, the mental health field could use conversational agents in psychiatric treatment.

                Author and article information

                JMIR Mhealth Uhealth
                JMIR Mhealth Uhealth
                JMIR mHealth and uHealth
                JMIR Publications (Toronto, Canada )
                31 January 2023
                : 11
                : e40373
                [1 ] Shanghai Mental Health Center Shanghai Jiao Tong University School of Medicine Shanghai China
                [2 ] Shanghai Key Laboratory of Psychotic Disorders Shanghai China
                [3 ] Center for Excellence in Brain Science and Intelligence Technology (CEBSIT) Chinese Academy of Sciences Shanghai China
                Author notes
                Corresponding Author: Min Zhao drminzhao@ 123456smhc.org.cn
                Author information
                ©Tianzhen Chen, Liyu Chen, Shuo Li, Jiang Du, Hang Su, Haifeng Jiang, Qianying Wu, Lei Zhang, Jiayi Bao, Min Zhao. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 31.01.2023.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on https://mhealth.jmir.org/, as well as this copyright and license information must be included.

                : 17 June 2022
                : 8 September 2022
                : 15 November 2022
                : 20 December 2022
                Original Paper
                Original Paper

                tablet,android program,substance use disorder,methamphetamine use disorder,digital agent,virtual digital human


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