Digital therapeutics and what they can do for mental health

Background on digital therapeutics and what they can do for mental health | Image Credit: © Syda Productions - © Syda Productions - stock.adobe.com.

It is no secret pediatricians play an unequivocally important role in effectively promoting healthy, active living through direct care, advocacy, and multiple forms of support.¹ With growing responsibilities, lack of access to specialty care, and burnout, finding additional tools to help deliver the high standard of care for which pediatricians aim can only help.²

When it comes to mental health issues among the pediatric population, digital therapeutics could help make a positive impact. According to Jason Kahn, PhD, researcher at Boston Children’s Hospital, instructor of psychiatry at Harvard Medical School, and chief scientific officer and founder of the Mightier digital therapeutic, these tools can be a stop-gap until specialized care is available.

“I think a lot of pediatricians will be familiar with a lot of the core of the problem that's going on with kids and adults, but kids especially, which is access,” Kahn said. “We don't have a lot of psychiatrists, psychologists, even clinical social workers who can keep up with the demand that we are seeing when we look at kids with ADHD, anxiety, autism, depression, or any number of conditions that we’re seeing. All these prevalence rates are going up. Where digital therapies can step into the void if they can provide tools so kids can build skills, competencies, and strengths that can help them succeed and thrive while they are potentially on a waiting list for more specialized providers, these skills can then transfer into their lives. With these tools, we see kids having more success and getting help earlier when available.”

But what are digital therapeutics? They are technologies such as video games, that are designed to help overcome some limitations seen with conventional mental health care to reduce the risk of further development of these problems. According to a 2022 study published in Frontiers in Psychiatry, investigators noted these limitations can include limited access to specialty care, lack of intervention engagement, and unsustainable treatment effects. These digital therapies are developed to demonstrate “therapeutic effects on targeted mental health problems,” stated the investigators.³

Kahn, founder of Mightier—a digital therapeutic that targets emotional regulation to help the child maintain the ability to think and keep control while playing video games built inside the device—explains why background and data are important aspects of digital therapeutics, and how Mightier works.

“A digital therapeutic should be able to tell your patient, or the pediatrician, the evidence, what the target is, what the age is, how it's going to improve, and expectations for dosage. When all those parts play out, we should be able to say, 'this is what we expect when a kid is exposed to this,’” said Kahn. “For me, a digital therapeutic is something where the evidence is really well understood and we can put that in patients' hands, or kids’ hands in my case, and see some well-understood benefit.”

“The way Mightier works itself is that it's built on top of video games. Kids wear a heart rate monitor while they play, [which] allows us to take the moments of frustration that happen in the video game and then start to give kids feedback during those moments of frustration so they see themselves facing a challenge. Then they see their body change in the context of that challenge,” Kahn said in an interview with Contemporary Pediatrics.

“Rather than just end there, we give the kid a course of action,” he added. “What we do to the game itself is a little counterintuitive to adults because we make the game harder. The child wants to be successful and they understand the language of a game, so they say, [theoretically], 'my body's an input. My emotions are an input. I'm going to be now incentivized to figure out a way to cool down.' We're also giving the kids help as they do this. We're showing them deep breathing exercises. We're showing them progressive muscle relaxation. A bunch of tools that they would be getting in a therapy office we're giving them so they understand what will help their body calm down at the moment, and we watch this progression as kids go through.”

Kahn added that repetition is a key part of digital therapeutics, as the child can demonstrate over time how their frustration, focus, and body changes. This data is then used to transition the process into other aspects of the child’s life.

“At the beginning, when they start Mightier, they use these resources, tools, they take the hints that we give them, and they'll use that to cool their body down,” he said. “As they do hundreds, if not thousands of these repetitions because it's a video game, it happens a lot and happens fast, they start becoming more automatic and more self-directed on how to cool down their body. That's the dream, right? We can see that transition in the game, and then we do have data that connects it and takes it from the game. Watching these kids become successful is really what we hope for.”

A 2021 proof of concept randomized controlled trial (NCT 01551732) that featured Mightier, referred to as Regulate and Gain Emotional Control (RAGE-Control) in literature works, was published in Frontiers in Psychiatry Investigators, including Kahn, compared reduction in aggression, anger, oppositionality, and global severity between 2 treatment conditions, which were Anger Control Training (ACT) augmented with Mightier and ACT with a sham version of the game. Heart rate during gameplay was monitored and examined to explore associations between symptom changes and heart rate changes.^3,4

There were 40 youths with clinically significant anger dyscontrol aged 10 to 17 years included in the trial, which was conducted at Boston Children’s Hospital between July 2011 and February 2013. According to the investigators, the sample size was determined by power analysis, targeting 80% power to detect effect sizes (ES = 0.63–1.68) from a prior, preliminary, open-label study. Individuals were assigned randomly to 10 sessions of ACT with Mightier (n = 20) or ACT with the sham video game (n = 20). In the first 5 sessions, patients learned a specific coping skill to regulate their mood and behavior, then spent 15 minutes playing Mightier or the sham version of the game, during which they were instructed to use the previous coping skill learned. In sessions 6-10, structured problem solving was involved, “applying coping skills to real-life current problems and continued practice with the assigned version of RAGE-Control,” wrote the authors.⁴

Results demonstrated that both treatments similarly reduced self-reported anger, but mightier treatment led to larger improvements in aggression (CI: –17 to –1.0, ES: 0.55, P = 0.015), oppositionality (CI: −9.0 to −7e-6, ES: 0.48, P = 0.032), and global severity (CI: −1.0 to −5e-6, ES: 0.51, P = 0.023) compared to the sham video game. Participants using Mightier also experienced larger pre-to-post decreases in heart rate, which was significantly associated with larger pre-to-post decreases in aggression and oppositional behaviors.⁴

“Emotional regulation is this ability when you are frustrated, when you have hot emotions, to sort of maintain your cool, maintain your ability to think and stay present and then be successful,” Kahn said. “We see emotional regulation on both the deficit side and the strength side. Kids who have neurodevelopmental diseases like ADHD or autism typically have less emotional regulation. It also shows up in anxiety sometimes. On the flip side, we do see that kids who are particularly resilient and particularly successful in social settings tend to have a lot of emotional regulation.”

Kahn and coauthors of the study concluded that findings supported that augmenting traditional treatment with technology through skill practice can translate to real-life behavioral change and enhancements. Kahn stated awareness of digital therapeutics might be low, and he wants health care providers to know these technologies exist and can help facilitate care.

“We're asking pediatricians to do more and more, and I don't think we've done a great job helping pediatricians understand how the digital mental health landscape is evolving and changing, and what options are available to them,” he said. “Trying to get the word out and have pediatricians understand what these tools are, I think, is one of the biggest challenges, especially in the context of asking pediatricians to be all sorts of people and wear all sorts of hats for the patients coming into their offices.”

Jason Kahn, PhD disclosed the following to Contemporary Pediatrics:

Board membership - Neuromotion Inc d/b/a Mightier

Employment - Neuromotion Inc d/b/a Mightier

Grants received/research funding - NIH - R44MH124574

References:

1. Muth ND, Bolling C, Hannon T, Sharifi M. The role of the pediatrician in the promotion of healthy, active living. Pediatrics. March 2024; 153 (3): e2023065480. 10.1542/peds.2023-065480

2. Zarefsky M. Most pediatricians have burnout. Here’s what it takes to fix that. American Medical Association. January 8, 2024. Accessed August 8, 2024. https://www.ama-assn.org/practice-management/physician-health/most-pediatricians-have-burnout-here-s-what-it-takes-fix

3. Choi E, Yoon EH, Park MH. Game-based digital therapeutics for children and adolescents: Their therapeutic effects on mental health problems, the sustainability of the therapeutic effects and the transfer of cognitive functions. Front Psychiatry. 2022;13:986687. doi:10.3389/fpsyt.2022.986687

4. Ducharme P, Kahn J, Vaudreuil C, et al. A “proof of concept” randomized controlled trial of a video game requiring emotional regulation to augment anger control training. Front Psychiatry. 2021;12:591906. doi:10.3389/fpsyt.2021.591906