Canadian
Psychiatric Association
In Review Series Editorial
Open for Business: Chatbots, E-therapies,
and the Future of Psychiatry
David Gratzer, MD1,2 and David Goldbloom, MD1,2
Keywords
access to care, barriers to treatment, e-mental health, mental health services
More than 2 decades ago, the IBM supercomputer Deep Blue
beat world chess champion Gary Kasparov in a 6-match
series. The 1997 win marked a turning point—drawing on
artificial intelligence (AI), it was the first time a computer
had bested a human champion under tournament conditions.
Looking back, Mr. Kasparov commented, “A game of chess
was vulnerable to very powerful machines with sufficient
algorithms and bigger databases and very-high-speed
processors.”1
Could Mental Illness Also Be Vulnerable
to Very Powerful Machines?
For most people, the stakes are far higher than a game of
chess. Across the world, people with mental health problems
and illnesses face significant challenges in accessing care.
Only half of Canadians with depression receive “potentially
adequate treatment.”2 Although patients prefer psychother-
apy to medications, the former is often unavailable as a
treatment choice; in a recent study, just 13% of British
Columbians with depression had any access to therapy or
counseling.3 The availability of (human) psychiatric services
is unlikely to change in the coming years.4 Even in England,
where cognitive behavioural therapy (CBT) is publicly
funded, the attrition rate is high, suggesting that access to
traditional, in-person services may not be helpful or conve-
nient to some.5 In developing countries, basic mental health
care may be absent; according to the World Health Organi-
zation (WHO), 45% of the world’s population lives in coun-
tries with less than 1 psychiatrist per 100,000 people.6
This In Review series offers 2 articles on digital psychia-
try that could potentially help bridge the access gap.
In “Chatbots and Conversational Agents in Mental
Health: A Review of the Psychiatric Landscape,” Vaidyam
et al.7 consider programs “that use machine learning and
artificial intelligence methods to mimic human-like beha-
viors and provide a task-oriented framework with evolving
dialogue able to participate in conversation.” Chatbots are
increasingly used in society for access to general information
Association des psychiatres
du Canada
The Canadian Journal of Psychiatry /
La Revue Canadienne de Psychiatrie
2019, Vol. 64(7) 453-455
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Article reuse guidelines:
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DOI: 10.1177/0706743719850057
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(think Amazon’s Alexa or Apple’s Siri), but what about for
access to mental health care? The authors provide a literature
review with 10 relevant studies. Chatbots have various roles,
including providing CBT for people with depression and
anxiety, encouraging medication adherence, and offering
psychoeducation. The authors find high satisfaction rates
among users and little risk of harm—although results are
hard to compare, given the lack of uniform reporting or even
measuring. They conclude that “chatbots are an emerging
field of research in psychiatry, but most research today
appears to be happening outside of mental health.” Still, they
find great potential, if they warn that the use of chatbots must
be done “correctly and ethically.”
We share in that enthusiasm: unlike human therapists,
chatbots remember and learn from everything people have
told them and are always available; in addition, they are not
distracted from the task at hand by unrelated thinking, as we
human clinicians can be; users have their undivided, if arti-
ficial, attention as well as intelligence.
If Vaidyam et al.7 consider a very new development
(chatbots), Andersson et al.8 consider an intervention first
used around the time Kasparov and Deep Blue faced off:
Internet-delivered CBT (iCBT), psychotherapy based on
CBT principles, delivered via the Internet by an individual
or program remote from the client. In “Internet Interventions
for Adults with Anxiety and Mood Disorders: A Narrative
Umbrella Review of Recent Meta-Analyses,” the authors
note a rich literature and focus on iCBT for anxiety and
mood disorders in adults, drawing from recent years. They
find 9 meta-analyses and note diverse applications of iCBT,
with different lengths of treatment but collectively involving
1
Centre for Addiction and Mental Health, Toronto, Ontario
2
Department of Psychiatry, University of Toronto, Toronto, Ontario
Corresponding Author:
David Gratzer, MD, Centre for Addiction and Mental Health, 250 College
St, Toronto, Ontario, M5T 1R8, Canada.
Email: david.gratzer@camh.ca
454
human therapist guidance in addition to web-based access to
CBT modules. They conclude, “Overall, evidence is now
accumulating suggesting that therapist-supported Internet
interventions, and in particular iCBT, can be effective. In this
overview, we found meta-analytic support for panic disorder,
social anxiety disorder, GAD, PTSD, and major depression
with moderate to large average effect sizes overall.”
The conclusion, reinforced with respectable effect sizes,
bolsters our view that solutions to access for evidence-based
interventions can successfully use innovative approaches—
like iCBT.
And there is much going on in digital psychiatry not
covered by these 2 articles. Consider the following:
 Virtual reality (VR). VR is exposure therapy 2.0, and
studies suggest promising results for anxiety disorders.9
 Digital phenotyping. Drawing on passive data collec-
tion from smartphones, digital phenotyping seeks to
consider everything from sleep habits to geographic
movement to keystroke speed to find patterns that
may indicate early relapse in known mental
illnesses.10
 Apps. There are over 315,000 mobile health apps;
some are designed for people with psychiatric condi-
tions, helping patients remember when to take medi-
cations or track their mood over time or improve their
sleep.11 (Chatbots, which could be apps, are consid-
ered earlier.)
While not offering a solution for every patient in every
circumstance, digital psychiatry may even be attractive to a
subset of patients who would prefer a digital interaction to a
human one, whether for financial and other pragmatic con-
siderations (e.g., a single parent of 3 children, on public
assistance, for whom getting to an office appointment is a
major logistical problem and even financial hardship) or for
more psychological and interpersonal reasons (e.g., someone
with autism spectrum disorder for whom the lack of human
connection with a chatbot may be helpful).
These are early days. While there are many apps, they are
of a heterogeneous quality; in a recent article, Shen et al.12
find that, when a basic quality standard was applied (such as
revealing the source of information), only 25% of the apps
studied met that standard. We note that AI in health care is an
active field of both medical research and clinical experimen-
tation, yet to date, the results have been mixed; IBM Wat-
son’s project with the MD Anderson Cancer Center was
cancelled after 4 years, in part because of basic problems
with electronic health records.13
While the experimentation continues to be vigorous, we
offer a few notes of caution.
Privacy in a Facebook World
Where does all this digital information go? How is it pro-
tected? Can it be hacked (in the same way someone can
The Canadian Journal of Psychiatry 64(7)
break into a psychiatrist’s office and purloin her charts)?
These questions are important to consider as people increas-
ingly turn to digital solutions. Clinicians worry about the
security of electronic health records. For our patients who
actively use apps, the information they populate on their
smartphones may be more personal.
Enthusiasm (and Entrepreneurialism)
Overtaking Evidence
Digital tools are shiny new things. Apps and online tools
proliferate. The continuous updating of versions and so-
called bug fixes defy traditional research evaluation metho-
dology where a pill’s ingredients are fixed by patent or a
psychotherapy is manualized and audited. We need new
research paradigms for new solutions. And the interests of
Bay Street and Wall Street—market penetration and return
on investment—may not be the interests of clinicians.
The Potential Harm of Digital Tools
Is there a number needed to harm for an app? In a recent
article, Torous et al.14 note that some apps provided unhelp-
ful answers when people discuss suicidal thoughts. And an
available tool is not necessarily used. For example, PTSD
Coach app, developed by the US Veterans Administration,
reports having been downloaded more than 150,000 times—
yet only 14% of individuals had used the app the day after
downloading it.15
What role could digital psychiatry have in the future?
The concept of stepped care, matching severity and com-
plexity of need to intensity of service, used to begin with
self-help in the form of reading a book. For more than 2
decades, generations of clinicians have recommended texts
such as Mind over Mood. (The old term bibliotherapy,
already in vogue in 19th-century American asylums, was
revived to sound more medical and interventionist than
“read this book.”) As digital tools develop, they may enter
this world, aiding self-help and augmenting therapies,
likely for people with lower acuity of illness.
Although we note possible pitfalls with digital psychiatry,
we also see great potential, empowering patients and
enabling them to get more timely access to care more
broadly defined. We also see task-shifting not simply to
other human professionals but also to computers, leaving the
more complex needs to psychiatrists. Very powerful
machines, thus, could remake psychiatry.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
La Revue Canadienne de Psychiatrie 64(7)
ORCID iD
David Gratzer, MD https://orcid.org/0000-0002-4578-0050
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