Over the past decade, the digitization of everyday life has meant that devices such as smartphones serve as conduits for everyday function and communication [1]. Interpersonal communication now includes digital media such as text messages, blogs, emails, and social media; much of this communication is chronicled and preserved in ways that did not exist until the advent of these technologies. Increasingly, psychiatry, and particularly the realm of psychotherapy, has begun to recognize the ways in which digital data can be incorporated into care. A vast literature exists in the domain of digital biomarkers and digital phenotyping [2-5], where sensors and devices track behavior and, in turn, generate objective measures of activity, sleep, mood, and parameters such as medication responses and side effects. However, a simpler and more intuitive use of this digital collateral information available through digital media and communication—such as text messages—has been relatively understudied.

Psychotherapy relies on patient recall of key information, events, and interactions. There is evidence to indicate that clinicians sporadically incorporate information from digital communications into therapy sessions and that including this information may have a positive impact on the psychotherapeutic process [6-8]. However, emerging evidence also indicates that the effectiveness of these approaches may be situational and that outcomes may vary depending on how data are presented and accessed. For instance, one study [9] found that the use of a dashboard that presented clinicians with broad metrics, such as time spent on a smartphone during the night, miles walked per week, and top searches on social media, led to no statistically significant changes in patients’ well-being scores. A follow-up study [10] also found that clinician use of such a digital dashboard did not improve well-being. Notably, both studies found that patients and clinicians alike appreciated the awareness the dashboard brought to patients’ digital use. Patients also reported feeling comfortable and positive about the dashboard experience [10]. This suggests that the impact of this approach may be subtle and nuanced, a notion that is being increasingly replicated in other studies [11]. However, neither study investigated whether there was a differential impact from evaluating more personal communication, such as email or text messages. Investigating this is relevant because Liu et al [12] demonstrated that the language in text messages strongly correlates with the severity of self-reported depressive symptoms. This finding was based on sentiment analysis of existing text messages; however, how it may translate into real-time inclusion of text messaging content into psychotherapy is unknown.

There are important implications for gaining a more sophisticated understanding of how access to broader information from digital communication and media impacts outcomes in psychotherapy. Spending time in a session reviewing digital content can take away from time spent engaged directly with patients [13], and it is not clear how this may impact rapport. It is also not clear whether any benefits are empirical or situational. Finally, because there is great interindividual variance in how individuals across the age span express emotion in electronic communication [14], there is a need for guidelines around how to optimize the use of electronic media. To address these knowledge gaps, we conducted a randomized controlled trial of an intervention in which research staff performed a personalized review of patients’ text message communication prior to a psychotherapy session. This information was aggregated into an interactive dashboard for clinicians to access during their sessions with patients. We sought to assess whether (1) access to collateral information about text communication impacted depression and anxiety, (2) using a dashboard to review this information during therapy sessions impacted the therapeutic alliance, and (3) accessing more collateral information, including digital communication, during therapy sessions impacted the way therapists planned treatment for each session.

We hypothesized that patients receiving care incorporating electronic media would experience greater reductions in depression and anxiety, improved health-related quality of life scores, and a stronger working alliance compared with those receiving treatment as usual (TAU). Additionally, we explored how clinicians used data during sessions and whether increased data access influenced their approach to care.

The study included 101 participants, with 52 (51.5%) assigned to the EME intervention group and 49 (48.5%) to the TAU control group (Figure 1). Most participants (n=87, 86.1%) were enrolled in a partial hospitalization program. Across the cohort, the mean age was 39.4 (SD 16.2) years, 63.4% (n=64) identified as female, and 80.2% (n=81) self-identified as White (Table 1). Participants reported an average of 16.3 (SD 2.3) years of education. The most common primary psychiatric diagnoses were depression (n=75, 74.3%) and anxiety (n=22, 21.8%). No significant differences were observed between the EME and TAU groups across demographic variables. The mean PHQ-9 score in our sample was 10.85 (SD 5.49; range 1‐23; median 10.5, IQR 8-16) and the mean GAD-7 score was 8.43 (SD 4.62; range 0‐20; median 8, IQR 5-12), indicating that the overall sample demonstrated at least moderate depression and anxiety severity. There were no significant differences between the EME and TAU groups in the severity of anxiety and depression. Because all participants were recruited with clinician input during the course of ongoing psychotherapy or as part of a partial hospital program, we did not lose any participants to attrition, and data from all participants were included in analyses.

Participants in the EME group exhibited greater reductions in PHQ-9 and GAD-7 scores from their first to last session compared with those in the TAU group; however, these differences were not statistically significant (PHQ-9 b=–0.62, 95% CI –2.87 to 1.62; P=.58; GAD-7 b=–0.26, 95% CI –1.90 to 1.39; P=.75). Among the subset of 65 participants with follow-up SF-36 data, no significant differences were observed between groups across SF-36 domains, except for pain (Table 2): EME participants demonstrated a 9.54-point greater increase in SF-36 pain subscale scores compared with TAU participants (95% CI 1.94-17.14; P=.02). This effect persisted within the subsample enrolled in the partial hospitalization program (b=8.55, 95% CI 0.55-16.55; P=.04).

Wilcoxon rank-sum tests further revealed no group differences in changes in WAI-SR item scores (Table 3) among participants with available follow-up data (n=41).

The association between treatment changes and the frequency of information access differed by assignment to the EME or TAU arms (P=.02). Specifically, treatment changes were positively associated with the number of times information was accessed in the EME group (b=0.72), but not in the TAU group (b=–0.01, 95% CI 0.12-1.34; P=.02; Figure 2). We also noted that no participants expressed reservations about allowing clinicians to read their actual text messages when requested.

This study examined whether incorporating data from electronic media into psychotherapy influences clinical outcomes and the therapeutic alliance between clinicians and patients. It also explored how integrating data from multiple sources informs clinical decision-making. At a time when ever-growing streams of data are becoming accessible to clinicians, this study addresses the fundamental question of whether and how these data can add value. In this study of 101 clinician-patient dyads, no statistically significant differences were observed in PHQ-9 or GAD-7 scores between the EME and TAU groups, suggesting that incorporating electronic media did not improve distal clinical outcomes related to anxiety and depression. Similarly, WAI-SR item scores did not differ between groups, indicating that the therapeutic alliance was unaffected by the inclusion of electronic media. Consequently, the study’s primary hypotheses were not supported. We did note a significant improvement in SF-36 pain subscale scores. This finding was unexpected and was not hypothesized, since the primary intervention did not target pain. This finding merits replication in other clinical populations, since the CI is wide.

Exploratory analyses indicated that accessing a greater number of information sources was associated with an increased number of clinical actions taken during visits. This finding encompassed all collateral information sources, not solely digital data. However, taking more clinical actions did not translate into improved outcomes when comparing groups. Nonetheless, this exploratory finding suggests that clinicians tend to make more changes during psychotherapy when provided with additional collateral information. One possible reason for the lack of support for the primary hypothesis may relate to characteristics of the study sample, as most participants were enrolled in a partial hospitalization program and received care for only 2 weeks, during which we gathered data for an average of fewer than 4 sessions per participant. This may simply not have been sufficient contact to capture change in downstream variables. However, at the individual level, there may be benefits to more clinical actions from accessing more data that are not captured by our selected outcome variables. These findings are consistent with existing studies [9,10] that provided clinicians with access to a dashboard displaying data from patients’ social media and internet use. These studies found that while providing clinicians with this dashboard was feasible and responses to dashboard access were generally positive, distal clinical outcomes did not improve. Our finding also provides a counterpoint to an extant literature that has suggested that access to informatics may universally improve outcomes [19].

This study has several limitations that must be factored into interpretation. We aimed to make this study as aligned with the broadest possible range of psychotherapy approaches as possible. In doing so, we limited the standardization of the treatment protocols. This heterogeneity may have influenced the lack of impact on the primary outcomes. Also, in personalizing search terms for each participant, we aimed to capture the fact that the expression of emotion may be different for different individuals—but this meant that the search terms were not standardized. Moreover, in giving clinicians broad leeway in how to use the data from text messaging, our design introduced variability that we were not able to fully adjust for in the analysis. Additional variability may have been introduced by the fact that the number of sessions per participant ranged from 4 to 13.

This project highlights several meaningful directions for future research. Chief among these is that there may be subtleties in the ways that accessing a person’s electronic media can impact psychotherapy, and these subtleties are likely specific to each individual. Although the primary hypotheses were not supported, the exploratory findings suggest that providing clinicians with additional collateral information, including digital data, can influence clinical decision-making [20]. However, broad outcomes such as improvement in depression or anxiety, particularly in a study where participants were tracked for as few as 2 weeks, may not capture this impact. We recommend that future work incorporate novel designs that can capture intraindividual changes in response to access to electronic media for psychotherapy.