Treating Comorbid Depression During Care Transitions with Relational Agents

Depression is common among individuals with chronic illness such as congestive heart failure, chronic obstructive pulmonary disease, or chronic pain and is a strong predictor of poor clinical outcomes and high rates of avoidable 30-day readmissions. While depression is a treatable condition, few people with depression receive effective treatment. Cognitive behavioral therapy (CBT) is a proven approach to treating depression; however, attending treatment sessions can often be challenging for individuals with chronic disease.

This project developed the Sophie CBT System, an internet-accessed relational agent (RA), to deliver computerized CBT depression treatment to patients with chronic illness and comorbid depression. Sophie is a novel animated, computer-based, embodied character that interacts with patients, integrates best practices from provider-patient communication theory, and emulates the face-to-face behavior of an empathic provider emphasizing nonverbal communicative behavior such as gaze, posture, and gestures.

The specific aim of the project was as follows:

• Demonstrate the usability, feasibility, and acceptability of using an RA system to deliver CBT to treat comorbid depression in adults with chronic disease. 

Researchers recruited adults with a history of a chronic disease and comorbid depression to pilot test the system and provide feedback on character attributes, character script, and intervention module navigation via surveys and interviews. The study team also used the Working Alliance Inventory scale, a 36-item validated questionnaire, to measure how participants related and bonded with the Sophie character.

Findings suggested that using the Sophie CBT system to deliver self-administered cognitive behavioral therapy for depressive symptoms was feasible and acceptable for patients. The key themes that emerged from participant interviews were around addressing barriers to care, responses to character attributes, and navigating the system while forming a working alliance with Sophie. Overall, most participants agreed that the RA could be a valuable supplement to in-person therapy, but were less certain about using the system as self-guided depression therapy. Most participants also felt that working with Sophie removed much of the judgment and stigma involved with seeking behavioral health treatment because of the virtual platform. Study findings will inform further development of an RA-CBT system to treat comorbid depression and expand access and scalability for post-discharge mental health support in during care transitions.