Good Days Ahead teaches people proven cognitive behavioral therapy (CBT) techniques in order to enable them to better manage their depression and anxiety. Users complete seven lessons in which they follow one person (Lisa) as she works to better manage her depression at home, at work, and when speaking with a friend. Concepts are illustrated through videos of Lisa’s interactions with others, as well as through videos of a therapist. Users have the option to watch the content be delivered by either a female therapist (Susan Rushing, MD, JD) or a male therapist (Jesse Wright, MD, PhD). Personal progress is charted through the occasional administration of the Patient Health Questionnaire depression scale (PHQ-8).
Each lesson in Good Days Ahead begins by having a therapist describe a concept, then asks the user to apply the concept to a protagonist (Lisa), and finally asks the user to apply the concept to themselves. The focus of the lessons is on identifying, labeling, and modifying automatic thoughts. Use of Thought Change Records is encouraged as a strategy for modifying automatic thoughts. Users are additionally encouraged to create activity schedules so that they can identify the degree of mastery and pleasure associated with each activity, and determine whether it may be helpful to modify the amount of time spent on the activity. The program concludes with a lesson on uncovering and changing schemas (core beliefs and assumptions which drive how we think about ourselves). As the CBT techniques presented in Good Days Ahead are somewhat different from those presented in competing offerings, the program may be helpful for people seeking additional approaches to CBT.
Ease of Use and User Experience
Good Days Ahead consists of a series of videos, multiple choice questions, and fill-in-the-blank questions hosted on a secure website. Users are logged out after periods of inactivity to protect their privacy. An account must be registered and a registration fee of $50 must be paid to enroll in the basic version of the course. Users progress through a series of seven lessons which involve watching a video about how one person experienced depression and then learned to manage it. The lessons are complemented by videos of psychiatrists explaining concepts related to cognitive behavioral therapy. Users are asked to answer a long series of multiple choice questions based upon the content of the course, are asked to apply the concepts to Lisa’s life, and then to apply them to their own lives. The system remembers users’ responses to questions so that prior responses can be used as starting points as users advance through the material. Although the course is easy to use, some users may be discouraged by the sheer volume of multiple choice questions that they must answer to complete some of the lessons. The content is linear, and it is not possible to advance without attempting all of the multiple choice questions. The site appears to the user to have been built as a self-help tool, and does not require a relationship with a clinician. An additional version designed for use in conjunction with a clinician exists, but was not tested. Two times when testing occurred in the early morning, the server running Good Days Ahead was inaccessible.
Good Days Ahead has a completely web-based interface. The content is primarily delivered through webpages containing videos, text, multiple choice questions, and fill-in-the-blank questions. The site is intended to be viewed in a browser, and appeared equally functional in Chrome running on a Windows 10 computer and in Safari running on an iPhone 6s. As responsive design is not incorporated into the site, it appears identically on a computer and a smartphone. Thus, it is likely preferable to view the site on a computer rather than on a mobile device.
Appropriateness of Content
The content is appropriate for a person experiencing depression, or a combination of anxiety and depression. As anxiety management is not a focal part of the content, there are other tools which may be more appropriate for a person dealing purely with anxiety. The content is equally appropriate for men and women. For reasons which are unclear, users are given the choice of a female or male narrator, but are not given the choice of a female or male protagonist. As a result of the use of a female protagonist (Lisa), the examples portrayed may be slightly more relatable to women. The protagonist is a married woman with children, at the midpoint of her career. Over the course, she is shown dealing with depression while interacting with her manager, her husband, and a friend. These scenarios make the content more appropriate for adults than for children or teens, as the scenarios presented are less relatable to young audiences. While the primary purpose of the protagonist is to provide an example that can be used to teach users to apply CBT techniques, users with a greater degree of similarity to the protagonist may find the material more applicable. This is a greater issue for Good Days Ahead than competing CBT tools, as only one protagonist is presented.
Appropriateness of Feedback
To the extent possible, feedback is provided. Users are given immediate explanations to the answers to multiple choice questions. When users are asked to help Lisa complete various cognitive behavioral therapy exercises, explanations of the appropriate responses are provided. Feedback is not provided to users when they attempt to apply cognitive behavioral therapy techniques to situations in their own lives, but doing so would likely be technologically challenging. The “homework” is completed through web-based forms, and is a direct part of the workflow of the site. As a result, users may be more likely to complete the homework than they would on other sites with printable homework assignments.
Unlike many other training tools, Good Days Ahead asks users questions which have clear-cut correct and incorrect answers. Users are educated about the reasoning behind the appropriate answers throughout the program. Thus, users are continuously tested as they progress through the program. This provides a reasonable cognitive challenge, but may also hurt the self-esteem of some users struggling with the content. No prior knowledge of cognitive behavioral therapy or mental health terminology is necessary to complete the program.
Ease of Account Management
It was initially unclear how to join the site. To register, it was necessary to email the company to request an account. The company then sent an invoice which could be paid via PayPal. Empower Interactive, Inc., the creator of Good Days Ahead, focuses on institutional sales, and thus currently requires consumers to contact it via email to register. The clinician-assisted version of Good Days Ahead has a mechanism through which clinicians can enroll patients.
There are two peer-reviewed studies, and one academic poster, that support the performance of Good Days Ahead. The two studies evaluated a DVD-ROM version of Good Days Ahead, which was a predecessor to the current online version. The first study examined drop-out rates, affinity scores, and primary outcome measures, and determined that there was a high degree of user acceptance for the program.[i] A randomized controlled trial comparing traditional CBT, Good Days Ahead, and placement on a waitlist was conducted, and it was found that dropout rates were similar between traditional CBT and Good Days Ahead. Furthermore, there were no significant differences found in the primary outcome measures examined between the two forms of CBT. Traditional CBT and Good Days Ahead were significantly more effective at reducing depression than placing patients on a waitlist. Good Days Ahead was demonstrated to be more effective than traditional CBT at improving patient knowledge regarding CBT.[ii] In a poster presented in 2014, based on the findings of a National Institute of Mental Health-funded, multi-site study, it was shown that traditional CBT with 16.6 hours of therapist time was equally effective at reducing depression scores as a combination of Good Days Ahead with one-third (5.5 hours) the therapist time.[iii]
Qualitative Review of Program Efficacy
The program is likely to be efficacious, as it is based upon proven material and uses an effective teaching model. Users listen to a lesson, apply the lesson to someone else’s life with guidance (Lisa), and then apply the lesson to their own life without guidance. This model of learning is likely to be more effective than simply reading about the techniques presented or applying them to one’s own life without the guidance that is presented. The homework assignments presented are integrated into the workflow of the course, and thus require less initiative to complete on the part of the user than the homework assignments found in many similar programs.
Estimate of Efficacy Relative to Similar Products
Good Days Ahead competes most directly with This Way Up, which is also designed to help people cope with anxiety and depression through cognitive-behavioral therapy. Good Days Ahead may be a useful “second line therapy” for people who have not found that This Way Up fully addressed their needs. This Way Up has a self-help program which is free, is grounded in a larger amount of scientific research, and uses a more common approach to cognitive behavioral therapy. Good Days Ahead offers a somewhat different set of CBT techniques than is offered by most CBT programs. As a result, it may be helpful to people who have had an unsuccessful prior online CBT experience.
The self-help version of the program costs $50. The clinician-supported version of the program is available to organizations which have a contract with Empower Interactive, Inc.
[i] Wright JH, Wright AS, Salmon P, Beck AT. Development and initial testing of a multimedia program for computer-assisted cognitive therapy. American Journal of Psychotherapy. 2002 Jan 1;56(1):76.
[ii] Wright JH, Wright AS, Albano AM, Basco MR, Goldsmith LJ, Raffield T, Otto MW. Computer-assisted cognitive therapy for depression: maintaining efficacy while reducing therapist time. American Journal of Psychiatry. 2005 Jun 1;162(6):1158-64.
[iii] Wright JH, Brown G, Eels T, Wisniewski S, Barrett MS, Balasubramani GK, Thase ME. Computer-assisted Cognitive-Behavioral Therapy for Depression: Acute Treatment Phase Outcome. Poster Presented at the National Network of Depression Centers Annual Meeting, 2014.