In spite of their uneven level of empiric support, there is a great deal of enthusiasm about computer-assisted therapies, and they have been adopted extremely rapidly in some health care systems outside the United States, consistent with the prevailing ethos of the Internet that “everything should be freely and immediately disseminated to anyone.” However, like any potentially effective treatment or novel technology, computer-assisted therapies also carry risks, limitations, and cautions often minimized or overlooked by their proponents, and a pressing need exists for research on their safety and efficacy. Although computer-assisted therapies, like other behavioral therapies, are seen as comparatively low risk and safe [27
], the potential for harm exists and has not yet been studied systematically.
For several reasons, we advocate a more cautious, empiric, and balanced approach as US psychiatry enters this brave new world. First, the evidence supporting the efficacy of computer-assisted therapies remains inchoate and equivocal, and the potential for harmful effects is largely unexplored. As reviewed previously, the quality of the interventions themselves is highly variable, and the existing randomized clinical trials are few and often flawed. Many of the trials seen as supporting the efficacy of computer-assisted treatments involve comparisons to weak wait-list control conditions, with extremely high rates of attrition and only short-term outcome measures that are based solely on unverified patient self-reports (essentially demonstrating only that computer-assisted treatment X is perceived by users as “better than nothing”). Furthermore, many of the existing studies, particularly those featuring weaker methodologic standards, have been conducted only by their developers, who have significant financial interest in demonstrating the efficacy of their approaches. The field should soon develop a strong set of methodologic standards, including those for management of conflicts of interests, to avoid the problems that have beset some pharmaceutically sponsored research.
Although they are likely to be rare, there are negative or unintended effects that may be associated with indiscriminate or rash promulgation of computer-assisted therapies. For example, individuals who rely on Web-based intervention alone and have poor outcome may be discouraged or delay in seeking further needed treatment. This is a particular concern in light of the many Web-based studies that have extremely high attrition rates and have failed to reach even a majority of participants for follow-up evaluation. Thus, it is of great importance to study outcomes for those who fail to respond to or who drop out of computer-assisted therapies. It also should be remembered that no system is completely secure, and threats to confidentiality should be seriously considered by providers and patients, particularly for vulnerable populations or those engaged in illicit behavior.
Moreover, for the foreseeable future, computer-assisted therapies should complement and extend, rather than replace, careful clinician monitoring and assessment to ensure that the appropriate program is accessed by the appropriate patients. There are multiple potential negative effects of patients accessing computer-assisted therapies with inadequate or no clinician oversight, particularly for patients at the extreme ends of the severity spectrum. An addicted patient could cease substance use, detoxify too quickly, and develop complications of withdrawal. Attempts to follow through on suggested techniques may entail risks (eg, suggesting increased contact with children for an estranged parent, or cutting off contacts with people in the social network who are associated with drug use), including unmonitored suicidal or homicidal ideation. Offering the opportunity for peer support through “chat” features for users may have multiple unintended consequences, both positive and negative (eg, for illegal drug users).