Design and formative evaluation of a virtual voice-based coach for problem-solving treatment: Observational study

BACKGROUND: Artificial intelligence has provided new opportunities for human interactions with technology for the practice of medicine. Among the recent artificial intelligence innovations, personal voice assistants have been broadly adopted. This highlights their potential for health care-related applications such as behavioral counseling to promote healthy lifestyle habits and emotional well-being. However, the use of voice-based applications for behavioral therapy has not been previously evaluated. OBJECTIVE: This study aimed to conduct a formative user evaluation of Lumen, a virtual voice-based coach developed as an Alexa skill that delivers evidence-based, problem-solving treatment for patients with mild to moderate depression and/or anxiety. METHODS: A total of 26 participants completed 2 therapy sessions-an introductory (session 1) and a problem-solving (session 2)-with Lumen. Following each session with Lumen, participants completed user experience, task-related workload, and work alliance surveys. They also participated in semistructured interviews addressing the benefits, challenges and barriers to Lumen use, and design recommendations. We evaluated the differences in user experience, task load, and work alliance between sessions using 2-tailed paired t tests. Interview transcripts were coded using an inductive thematic analysis to characterize the participants\u27 perspectives regarding Lumen use. RESULTS: Participants found Lumen to provide high pragmatic usability and favorable user experience, with marginal task load during interactions for both Lumen sessions. However, participants experienced a higher temporal workload during the problem-solving session, suggesting a feeling of being rushed during their communicative interactions. On the basis of the qualitative analysis, the following themes were identified: Lumen\u27s on-demand accessibility and the delivery of a complex problem-solving treatment task with a simplistic structure for achieving therapy goals; themes related to Lumen improvements included streamlining and improved personalization of conversations, slower pacing of conversations, and providing additional context during therapy sessions. CONCLUSIONS: On the basis of an in-depth formative evaluation, we found that Lumen supported the ability to conduct cognitively plausible interactions for the delivery of behavioral therapy. Several design suggestions identified from the study including reducing temporal and cognitive load during conversational interactions, developing more natural conversations, and expanding privacy and security features were incorporated in the revised version of Lumen. Although further research is needed, the promising findings from this study highlight the potential for using Lumen to deliver personalized and accessible mental health care, filling a gap in traditional mental health services

The Relationship Between Religiosity and Nursing Home Service Utilization

On any given day, 3.9% to 4.2% of the US population can be found residing in nursing homes, and as such, research has focused on identifying underlying factors associated with nursing home utilization. However, one important factor is missing from the extant literature, religiosity, defined as one’s religious beliefs and behaviors. Religiosity is important to consider due to its salience in the lives of most Americans, with 81% reporting a belief in God (Gallup, 2022), 76% engaging in prayer, and with older adults exhibiting the highest levels of involvement in religious activities (Pew Research Center, 2014a, 2014b, 2015). This study examined the relationship between three dimensions of religiosity (organizational, non-organizational, and intrinsic) and nursing home utilization. It also assessed the relationship between religiosity and number of nights spent in a nursing home. Furthermore, potential mediating (health behaviors) and moderating (sex, race/ethnicity) factors were examined. A total of 7,564 respondents (\u3e 51 years) from the 2006 wave of the Health and Retirement Study, with no prior nursing home use, were assessed every two years, until 2014. Generalized Estimating Equations Multinomial Logistic Regressions were used to model the relationship between religiosity and subsequent NH use, and Binomial Poisson Regressions were employed to examine the relationship between religiosity and number of nights spent in a nursing home, while controlling for other factors. Results indicate that high levels of organizational religiosity (e.g., service attendance), compared to moderate and low levels, are associated with higher rates of nursing home utilization (B = 0.13, p \u3c .001), while higher levels of non-organizational religiosity (e.g., private prayer) are associated with a lower likelihood of nursing home use (B = -0.03, p \u3c .05). No relationship was found between intrinsic religiosity and nursing home use and any dimension of religiosity and number of nights spent in a nursing home. Furthermore, while health behaviors were not found to have a mediating effect, sex and race did serve as moderators in these relationships. The positive association between service attendance and nursing home utilization may reflect the sharing of information about available resources through one’s social support networks, including congregations. In contrast, individuals who were more likely to pray independently, may lack the social support provided by congregations, and as a result, experience more limited knowledge transfers about available resources

Association Between User Interaction and Treatment Response of a Voice-Based Coach for Treating Depression and Anxiety: Secondary Analysis of a Pilot Randomized Controlled Trial

BackgroundThe quality of user interaction with therapeutic tools has been positively associated with treatment response; however, no studies have investigated these relationships for voice-based digital tools. ObjectiveThis study evaluated the relationships between objective and subjective user interaction measures as well as treatment response on Lumen, a novel voice-based coach, delivering problem-solving treatment to patients with mild to moderate depression or anxiety or both. MethodsIn a pilot trial, 42 adults with clinically significant depression (Patient Health Questionnaire-9 [PHQ-9]) or anxiety (7-item Generalized Anxiety Disorder Scale [GAD-7]) symptoms or both received Lumen, a voice-based coach delivering 8 problem-solving treatment sessions. Objective (number of conversational breakdowns, ie, instances where a participant’s voice input could not be interpreted by Lumen) and subjective user interaction measures (task-related workload, user experience, and treatment alliance) were obtained for each session. Changes in PHQ-9 and GAD-7 scores at each ensuing session after session 1 measured the treatment response. ResultsParticipants were 38.9 (SD 12.9) years old, 28 (67%) were women, 8 (19%) were Black, 12 (29%) were Latino, 5 (12%) were Asian, and 28 (67%) had a high school or college education. Mean (SD) across sessions showed breakdowns (mean 6.5, SD 4.4 to mean 2.3, SD 1.8) decreasing over sessions, favorable task-related workload (mean 14.5, SD 5.6 to mean 17.6, SD 5.6) decreasing over sessions, neutral-to-positive user experience (mean 0.5, SD 1.4 to mean 1.1, SD 1.3), and high treatment alliance (mean 5.0, SD 1.4 to mean 5.3, SD 0.9). PHQ-9 (Ptrend=.001) and GAD-7 scores (Ptrend=.01) improved significantly over sessions. Treatment alliance correlated with improvements in PHQ-9 (Pearson r=–0.02 to –0.46) and GAD-7 (r=0.03 to –0.57) scores across sessions, whereas breakdowns and task-related workload did not. Mixed models showed that participants with higher individual mean treatment alliance had greater improvements in PHQ-9 (β=–1.13, 95% CI –2.16 to –0.10) and GAD-7 (β=–1.17, 95% CI –2.13 to –0.20) scores. ConclusionsThe participants had fewer conversational breakdowns and largely favorable user interactions with Lumen across sessions. Conversational breakdowns were not associated with subjective user interaction measures or treatment responses, highlighting how participants adapted and effectively used Lumen. Individuals experiencing higher treatment alliance had greater improvements in depression and anxiety. Understanding treatment alliance can provide insights on improving treatment response for this new delivery modality, which provides accessibility, flexibility, comfort with disclosure, and cost-related advantages compared to conventional psychotherapy. Trial RegistrationClinicalTrials.gov NCT04524104; https://clinicaltrials.gov/study/NCT0452410