Chatbot for Mental Health Support using Natural

Language Processing
Omkar
AINUL Bobhate
SHABBIR ALAM
Department of Computer Engineering
Shah and Anchor Kutchhi Engineering College
Email:
Email:[email protected]
[email protected]

Abstract—Mental health has become a growing concern glob- IV. NLP T ECHNIQUES
ally, with increasing stress, anxiety, and depression among all age
groups. In this project, we present a chatbot system that offers
Several NLP techniques are utilized in the development of
mental health support using Natural Language Processing (NLP) the chatbot. These include:
techniques. The chatbot interacts with users, provides emotional • Tokenization: The text is broken down into smaller parts,
support, and recommends resources. It uses intent classification such as words or sentences, to understand the user’s input.
and rule-based NLP to respond appropriately. This system serves
• Stemming and Lemmatization: Reduces words to their
as a supportive digital companion and enhances mental health
awareness. root forms for better recognition of similar words, aiding
Index Terms—Chatbot, NLP, Mental Health, Intent Classifica- in more accurate intent classification.
tion, Machine Learning, Python, Flask • Intent Classification: The system classifies the user’s
input into predefined intents (e.g., anxiety, greeting, mo-
tivation) using machine learning models.
I. I NTRODUCTION
• Response Generation: Based on the classified intent, the

In the modern era, mental health challenges such as stress, system generates appropriate responses that are empa-
anxiety, and depression are increasingly prevalent. With lim- thetic and supportive.
• Bag-of-Words Model: This technique is used for feature
ited access to mental health professionals, technology-driven
support systems like chatbots can help bridge this gap. This extraction, representing the text as a collection of word
project proposes an intelligent chatbot that uses Natural Lan- occurrences.
guage Processing (NLP) to communicate with users empathet- V. S TRENGTHS , L IMITATIONS , AND S COPE OF NLP
ically, detect intents, and provide basic mental health support. T ECHNIQUES
The strengths of the NLP techniques used include:
II. L ITERATURE R EVIEW • Accuracy: The intent classification using neural networks

Prior work in the field of conversational agents has led to provides a high degree of accuracy in interpreting user
the development of various mental health chatbots. Notable inputs.
• Scalability: The system can handle a variety of intents
examples include Woebot, Wysa, and Replika. These systems
leverage AI to simulate conversations, offer behavioral therapy, and can be extended with additional intents and re-
and track mood. Some use scripted interactions, while others sponses.
• Simplicity: The use of rule-based approaches alongside
employ deep learning models to understand context. A variety
of studies have focused on utilizing NLP techniques to better machine learning makes the system easy to implement
interpret user inputs and provide meaningful responses. Most and interpret.
systems are designed to ease mental health challenges such as However, there are certain limitations:
anxiety, stress, and depression by offering emotional support • Lack of Context Awareness: The system struggles to
or guiding individuals to appropriate resources. remember past interactions, leading to possible misinter-
pretations in ongoing conversations.
• Limited Emotional Understanding: While the system
III. A PPLICATION
can detect intent, it may not fully grasp the emotional
The chatbot serves as a digital assistant that can offer mental state of the user in every context.
health support through conversations. By using NLP, the • Dependence on Training Data: The accuracy of intent

chatbot helps identify common issues such as stress, anxiety, classification depends on the quality and diversity of the
and depression, offering timely and empathetic responses. It training dataset.
acts as a companion for users to express their feelings, while The scope of NLP in mental health applications is expand-
also providing general information on mental health resources, ing. Future advancements could include more sophisticated
self-help techniques, and motivation. models, such as BERT or GPT-based architectures, which
provide a deeper understanding of context and can offer more XI. C ONCLUSION AND F UTURE W ORK
natural and empathetic responses. Further improvements could This project demonstrates a functional mental health support
address the limitations and enable the chatbot to provide more chatbot built using NLP and a neural network-based intent
personalized and emotionally intelligent support. classifier. The chatbot successfully engages in meaningful
conversation and offers basic support. Future enhancements
VI. R ELATED W ORK include adding sentiment analysis, context-aware replies, and
Prior work in the field of conversational agents has led to deep learning models like BERT for improved understanding.
the development of mental health chatbots like Woebot, Wysa, ACKNOWLEDGMENTS
and Replika. These systems leverage artificial intelligence to
The author thanks the project supervisor, fellow students,
simulate conversations, provide behavioral therapy, and track
and mental health professionals who provided feedback and
mood. While some use scripted interactions, others employ
guidance.
deep learning for contextual understanding. Our system strikes
a balance by using an intent-based model, which ensures inter- R EFERENCES
pretability, accuracy, and lightweight deployment for student [1] R. Sharma and M. Kumar, 2̆01cAI Chatbots for Mental Health: Review
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[2] D. Jurafsky and J. Martin, Speech and Language Processing, 3rd ed.,
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[3] T. Mikolov et al., 2̆01cEfficient Estimation of Word Representations in
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• Intent Dataset: Contains sample user inputs grouped by [5] A. Vaswani et al., 2̆01cAttention is All You Need,2̆01d arXiv preprint
intent (e.g., greeting, anxiety, motivation, stress relief). arXiv:1706.03762, 2017.
[6] M. Abdaoui, A. Berrada and M. Essaaidi, 2̆01cSurvey on Chatbot Design
• NLP Engine: Tokenizes, stems, and vectorizes text using Techniques in NLP,2̆01d Procedia Computer Science, vol. 175, pp. 684-
bag-of-words. 691, 2020.
• Model Training: A simple neural network is trained [7] J. Devlin et al., 2̆01cBERT: Pre-training of Deep Bidirectional Trans-
formers for Language Understanding,2̆01d arXiv:1810.04805, 2018.
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Health Informatics Journal, vol. 27, no. 4, pp. 1461-1474, 2021.
• Web Interface: A Flask frontend enables interaction. [10] H. Nguyen and H. Duong, 2̆01cA Study on AI Chatbot Technologies in
Mental Healthcare,2̆01d IEEE Access, vol. 8, pp. 145497-145507, 2020.
VIII. M ETHODOLOGY [11] C. W. Leong, 2̆01cDesign and Evaluation of a Mental Health Chat-
bot,2̆01d Journal of Medical Systems, vol. 44, no. 8, 2020.
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in Healthcare,2̆01d Journal of Information Technology Research, vol.
1) Data Preprocessing: Input patterns are tokenized and 13, no. 2, 2021.
stemmed using NLTK. A bag-of-words model is built [13] A. Milne-Ives et al., 2̆01cThe Effectiveness of Artificial Intelligence
Conversational Agents in Health Care,2̆01d Journal of Medical Internet
for each sentence. Research, vol. 22, no. 10, 2020.
2) Neural Network Training: We use a feedforward neural [14] A. Hussain and S. Athula, 2̆01cExtended Interaction Models for Chat-
network with input, hidden, and output layers. The out- bots in Mental Health,2̆01d International Journal of Human-Computer
Studies, vol. 147, 2021.
put layer uses softmax activation for intent classification. [15] F. Khan et al., 2̆01cChatbot Based Mental Health Support System for
3) Integration: The model is exported and integrated with University Students,2̆01d IEEE Xplore, 2022.
a Flask web server that manages user input and bot [16] M. Denecke et al., 2̆01cMental Health Chatbots in Mobile Applica-
tions,2̆01d Frontiers in Psychology, vol. 12, 2021.
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[18] R. Kumar, 2̆01cAI in Digital Mental Health,2̆01d Computers in Human
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[19] S. Zhang et al., 2̆01cSurvey of the State of the Art in Natural Language
The system uses the following technologies: Generation,2̆01d ACM Computing Surveys, vol. 53, no. 6, 2021.
• Python 3.10 for development [20] B. Liu and I. Lane, 2̆01cDialogue Systems for Mental Health Counsel-
ing,2̆01d in Proc. EMNLP Workshop on Health NLP, 2022.
• NLTK for text preprocessing (tokenization, stemming)
• NumPy, scikit-learn, PyTorch for training and modeling
• Flask for the web interface
• HTML/CSS/JavaScript for frontend design

X. R ESULTS AND E VALUATION

The chatbot was tested on various user inputs and showed
an average accuracy of 92
Computers, Materials & Continua Tech Science Press
DOI: 10.32604/cmc.2023.034655
Review

Artificial Intelligence-Enabled Chatbots in Mental Health: A Systematic

Review
Batyrkhan Omarov1, *, Sergazi Narynov2 and Zhandos Zhumanov2

1
International University of Tourism and Hospitality, Turkistan, Kazakhstan
2
Alem Research, Almaty, Kazakhstan
*Corresponding Author: Batyrkhan Omarov. Email: [email protected]
Received: 23 July 2022; Accepted: 22 September 2022

Abstract: Clinical applications of Artificial Intelligence (AI) for mental

health care have experienced a meteoric rise in the past few years. AI-
enabled chatbot software and applications have been administering significant
medical treatments that were previously only available from experienced
and competent healthcare professionals. Such initiatives, which range from
“virtual psychiatrists” to “social robots” in mental health, strive to improve
nursing performance and cost management, as well as meeting the mental
health needs of vulnerable and underserved populations. Nevertheless, there
is still a substantial gap between recent progress in AI mental health and the
widespread use of these solutions by healthcare practitioners in clinical set-
tings. Furthermore, treatments are frequently developed without clear ethical
concerns. While AI-enabled solutions show promise in the realm of mental
health, further research is needed to address the ethical and social aspects
of these technologies, as well as to establish efficient research and medical
practices in this innovative sector. Moreover, the current relevant literature
still lacks a formal and objective review that specifically focuses on research
questions from both developers and psychiatrists in AI-enabled chatbot-
psychologists development. Taking into account all the problems outlined
in this study, we conducted a systematic review of AI-enabled chatbots in
mental healthcare that could cover some issues concerning psychotherapy and
artificial intelligence. In this systematic review, we put five research questions
related to technologies in chatbot development, psychological disorders that
can be treated by using chatbots, types of therapies that are enabled in
chatbots, machine learning models and techniques in chatbot psychologists,
as well as ethical challenges.

Keywords: Chatbot; conversational agent; machine learning; artificial

intelligence; NLP; NLU; systematic review

This work is licensed under a Creative Commons Attribution 4.0 International License,
which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
5106 CMC, 2023, vol.74, no.3

1 Introduction
Presently the world wide mental health care system is going through challenging times. According
to the World Health Organization, one in four people affected by mental illness at some point
in their lives [1]. Mental disorder is still the leading cause of health-related economic hardship
around the world [2]. In particular, depression and anxiety are the most frequent causes, affecting an
estimated 322 million (depression) and 264 million (anxiety) individuals globally [3]. In spite of such
growing burden, there seems to be an acute shortage of mental health professionals worldwide (9 per
100, 000 people), principally in Southeast Asia (2.5 per 100,000 people) [4]. Despite the fact that there
are efficient and well-known therapies for numerous mental and neourological disorders, only half
of people, afflicted by mental disorder, receive them [1]. The main obstacles to successful and wide-
ranging treatment have been highlighted as a lack of resources and qualified medical professionals, as
well as social discrimination, stigma and marginalization [1]. Growing public expectations are raising
the bar for healthcare systems to overcome the obstacles and offer an accessible, cost-effective, and
evidence-based treatment to medically indigent individuals [5].
In light of such circumstances, information technology tools were hailed as a panacea for resolving
longtime issues such as societal stigma and a supply and demand mismatch in the provision of mental
health treatment. It is anticipated that AI-enabled technologies will offer more available, affordable,
and perhaps less stigmatizing approaches than the conventional mental health treatment paradigm [6].
As a result of the lack of access to mental health treatment, there is an urgent need for flexible solutions.
Consequently, there has been a surge of interest in developing mobile applications to complement
conventional mental health therapy [7]. Although therapeutic efficacy of these new approaches has
been similar to traditional methods in studies [8], the regular administration and integration of such
digital mental health support products were shown to be rather low. Poor commitment and acceptance
have been linked to the difficulty of technology to adequately engage patients as well as the failure of
clinical trial results to improve quality of patient care in real-life conditions [9].
The resurgence of digital mental health treatments is being fueled by a renaissance in AI technolo-
gies. Conversational agents or Chatbots are AI-enabled software systems that can communicate with
people using natural language across a text or voice-based interaction [10]. This technology has been
constantly developing and is currently utilized in digital assistants such as Apples’s Siri, Yandex’s Alice,
Amazon’s Alexa and other virtual assistants, as well as consumer interfaces in electronic shopping
and online banking [11]. Other applications of the technology include development of a new kind
of digital mental health service called mental health chatbots, which has the potential to have a
long-term influence on psychotherapy treatment [12]. The automated chatbots can provide evidence-
based treatments by simulating social communication in a funny and unprejudiced manner, addressing
problems including low commitment, inadequate clinician availability, and stigma in mental health
care [13].
Number of consumer behavior tendencies has identified the urgent need to further our compre-
hension of artificial intelligence (AI) enabled chatbots in mental health treatment. Furthermore, text-
based chatbots such as Ruhh or Xiaoice have gained popularity by offering private chats [14], as well as
AI-enabled virtual assistants on mobile phones and gadgets. Statistical surveys point to an increasing
willingness among consumers to receive a treatment from conversational agents or chatbots. The
number of users who have downloaded mental health chatbots demonstrates the growing popularity
of these self-service technologies.
Despite the increasing scholarly attention to this concept, numerous studies on AI-enabled chatbot
applications contexts are fragmented in terms of psychological or technical specialists. Considering
CMC, 2023, vol.74, no.3 5107

the importance of this issue to both psychologists and AI developers, a literature review is required
to integrate previous studies in order to obtain an overview of the current state of research, applied
technologies, as well as to identify existing challenges, ethical issues and outline potential avenues for
future research.
Consequently, it is critical to explain how and why patients would utilize a chatbot for mental
health assistance in overcoming obstacles and enhancing the delivery of AI-enabled chatbot-based
psychiatric services and patient results. Therefore, the main objective of this study is to investigate user
response and create a theoretical model that may be used to assess the acceptability of AI-enabled
chatbots for mental health assistance. As a result, the following research questions are proposed:
• Question 1: What kind of technologies are used in chatbot development?
• Question 2: What aspects of mental health do the chatbots target?
• Question 3: What kind of therapy are used in the fight against mental problems in chatbots?
• Question 4: What types of machine learning models are currently being applied for mental
health?
• Question 5: To what extent do the papers describe ethical challenges or implications?
This review is organized as follows: Section 2 introduces man concepts in chatbot development.
Section 3 explains methodology of the systematic literature review. Section 4 provides an analysis of
the 35 identified studies and searches the answer of each research questions. Section 5 discusses the
study implications, limitations, and the scope for further research. Section 6 concludes the review.

2 Main Concepts
Conversational agents or chatbots are software systems that consist of a conversational user
interface. They may be categorized as open-domain if they can communicate with users about any
subject, or task-specific if they help with a particular activity. The following are some basic principles
in chatbot technology.
Initially, pattern matching is based on sample stimulus-response blocks. Sentences entered by the
user serve as stimuli, and responses are created in reaction to those stimuli [15]. ALICE and Eliza were
the first chatbots that use computer vision. However, a significant disadvantage of this approach was
that the responses were robotic, repetitive, and impersonal. Additionally, it couldn’t preserve prior
responses, which might result in debates repeating [16]. In the 1990s the Artificial Intelligence Markup
Language (AIML) was created. It is an Extensible Markup Language (XML) based tag-based markup
language, which is employed in natural language modeling for speakers of the stimulus-response
communication system, such as conversational agents. As shown in Fig. 1, AIML is organized around
categories, which are composed of chatbot replies and user input patterns.

Figure 1: AIML for a chatbot development

Latent Semantic Analysis (LSA) and AIML are widely used to create chatbots. In the form of
a vector representation, the technology is used to find correlations among words [17]. LSA is able
to react to unanswered questions, while AIML may be used to address template-based questions
like welcomes and general inquiry [18]. It is noteworthy to mention an expert system Chatscript,
5108 CMC, 2023, vol.74, no.3

which is a combination of a complex programming language engine, in contrast to AIML, and dialog
management system.
RiveScript is an another plain text programming language with a line-based syntax for building
chatbots. With Go, Python, Perl, and JavaScript tools, it is free and open-source [19]. Language
recognition relies heavily on Natural Language Processing (NLP), which is used by Google and Apple’s
Siri. The ability of technology to recognize human natural language textual data and speech-based
commands depends on two fundamental elements: natural language understanding (NLU) and natural
language generation (NLG) [20].
By analyzing the final interpretation of the text’s true meaning using pragmatic analysis and
discourse integration, NLU determines how a particular word or phrase should really be interpreted.
To produce an intelligible answer, NLG uses text realization and text planning. To put it another
way, language generation is in charge of forming linguistically acceptable sentences and phrases.
Understanding the complexities of real human language is a major problem for NLP.
Language’s structure is ambiguous in terms of syntax, lexis, and other speech components like
similes and metaphors. A single word may be interpreted as a noun or a verb; a single phrase can
be transmitted in a variety of ways; and a single input can have many interpretations, among other
possibilities.

3 Methodology
In this Systematic literature review, both qualitative and quantitative research methods were
applied [21,22]. Following subsections describes article and data collection process for the review.

3.1 Article Collection, Inclusion and Exclusion

The collection of articles started by defining a search string. This string is composed of five search
terms: “Chatbot” and “Conversational Agent”, “Machine Learning”, “Deep Learning”, “Artificial
Intelligence”. Eq. (1) explains query string for article search.
‘‘ ‘‘
((“Chatbot OR “Conversational Agent ) AND.
‘‘ ‘‘ ‘‘
.(“Machine Learning OR “Deep Learning OR “Artificial Intelligence )) AND (1)
‘‘
(PUBLICATION DATE IN BETWEEN 2017 AND 2021) AND(Article type = “Research ),
Seven databases were used including three technical, three medical databases and Scopus abstract,
as well as citation database. IEEE Xplore, Sciencedirect, Springer databases were used for technical
paper searching, while Pubmed, Cinahl, Medline databases were used for searching papers in medical
area. During the paper selection, several rules were set as all the papers should be published between
2017 January and 2021 June, searched keywords must appear in the Title, abstract or keywords, and the
papers should be published in a peer reviewed journal. Table 1 demonstrates inclusion and exclusion
criteria for further analysis of the extracted papers. Four inclusion and eight exclusion criteria were
defined to organize the papers for further exploration. In the Fast filtering stage, duplicated articles,
articles without full text, wrong categorization articles, non-english articles, and non-research articles
were removed from the list. Afterwards, following the results of exploring Titles, Abstracts, and
Keywords, non-related, wrongly and implicitly related articles were removed. As a result of analyzing
full texts, papers were subsequently classified into three categories as theoretical solution, practical
solution, and experimental solution. Fig. 2 demonstrates each step of article collection, inclusion, and
exclusion of the research papers.
CMC, 2023, vol.74, no.3 5109

Table 1: Inclusion-exclusion criteria for article collection

I/E Criterion Method
Inclusion Duplicate articles Multiple instances of the same article in one or more
databases.
Without full-text Papers without access to the full-text of the article
Wrong The source of the article is incorrectly classified. For
categorization example, “Lecture Notes in Computer Science” is a
collection of conference proceedings but not a peer-reviewed
journal
Non-english Papers are not written in English
article
Non-research Article are not a research article, e.g., an editorial note
article
Non-related Chatbot and AI used to solve the problems that does not
related to mental health
Wrongly related Papers that not related to chatbot
Exclusion Implicitly related Article’s study focus on chatbot is not stated clearly
Theoretical Papers present theoretical propositions in AI-enabled
solution chatbot problem
Practical solution Papers present practical implementations in AI-enabled
chatbot problem
Experimental Papers present practical implementations in AI-enabled
solution chatbot problem by providing experiments in control or
experimental groups

Figure 2: Flowchart of the research

3.2 Data Collection

In the data collection process, the concrete data used to answer the research questions are collected.
For the first research question “What kind of technologies are used in chatbot devel-opment?”, the data
5110 CMC, 2023, vol.74, no.3

of interest are: programming languages for chatbot development like Java, Clojure, Python, C++,
PHP, Ruby, etc; Natural language understanding cloud platforms like DialogFlow [23], wit.ai [24],
Microsoft’s language understanding (LUIS) [25], Conversation AI [26], etc; and Chatbot development
technologies like Rasa [27], Botsify [28], Chatfuel [29], Manychat [30], etc.
For the second research question “What aspects of mental health do the chatbots target?”, the
data of interest are: Psychological disorders that can be tackled by applying chatbot applications as
depression, anxiety, panic disorder, suicidal thinking, mood disorders, etc.
For the third research question “What kind of therapy are used in the fight against mental
problems in chatbots or conversational agents?”, the data of interest are: types of therapy that applied
into the chatbot in order to fight the psychological disorders. Cognitive Behavior Therapy (CBT)
[31], Dialectical Behavior Therapy (DBT) [32], Positive Psychology [33] methods can be served as an
example.
For the fourth research question “What types of ML models and applications are currently being
applied for mental health?”, the data of interest are: machine learning techniques that applied in a
chatbot development. Supervised, Unsupervised, Semi-supervised models as support vector machines
(SVM), random forest (RF), decision trees (DT), k-nearest neithbours (KNN), latent Dirichlet
allocation (LDA), Logistic Regression, and other models were examined in this stage.
For the fifth research question “To what extent do the papers describe ethical challenges or
implications?”, the data of interest are: open questions and challenges that reference to ethical issues.

4 Systematic Literature Review

4.1 Question 1: What Kind of Technologies are Used in Chatbot Development?
During the development of chatbots, a variety of techniques are used [34]. Developers may choose
various approaches, platforms, methodologies, and tools to construct a chatbot by expecting what it
will offer and to which class it belongs. Additionally, it helps consumers by letting them know what to
expect. The requirements for developing a chatbot include correct representations, a technique for
producing responses, and a library of neutral responses to utilize when a user’s words cannot be
understood [35]. In order to use a modular development approach, each system must primarily be
divided into its component parts in accordance with the corresponding standards [36]. Fig. 3 presents
the overall chatbot architecture. A user initiates the process by posing a query to a chatbot, such as
“What is the definition of environment?” using a messaging platform like WhatsApp, Facebook, or a
text or voice-input application like Amazon Echo [37].
Language comprehension: When a user request is received by the chatbot, the component parses
it to identify the user’s intent and any relevant information (intent: “translate,” entities: [word:
“environment”]) [38]. A chatbot must determine what to do after coming up with the best feasible
interpretation [39]. It might respond right away in reaction to the new information, keep in mind what
it has learnt and wait to see what happens next, ask for more background information, or ask for
clarification. After the request has been comprehended, the actions are done and data is obtained.
The chatbot uses its sources of data, which may be a database or other websites reachable through an
API, to carry out the necessary activities or get the relevant information [40].
CMC, 2023, vol.74, no.3 5111

Figure 3: Overall chatbot artchitecture

As a result of the user message analysis component’s retrieval of intent and context information
[41], the Response Generation Module uses NLG [39] to generate a human-like response for the user.
A range of open-source and paid programs may be used to create chatbots. The range of chatbot-
related solutions is still growing at an accelerating pace [42]. One of two methods may be used to
create a chatbot: either a cutting-edge platform or a programming language like C++, Python, Java,
Clojure, or Ruby. Currently, there are six main NLU cloud platforms that developers may use to
create NLU applications such as Google DialogFlow, Facebook wit.ai, Microsoft LUIS, IBM Watson
Conversation, Amazon Lex, and SAP Conversation AI [43]. Each of these systems is built on machine
learning. They have certain common features, but also considerably vary in other aspects. RASA [27],
Botsify [28], Chatfuel [29], Manychat [30], Flow XO [44], Chatterbot [45], Pandorabots [42], Botkit
[42], and Botlytics [42] are some well-known chatbot development platforms.
Chatbots may be created using a variety of technologies. These tools also use different methods,
from low-code form-based platforms to programming language frameworks, libraries, and services
[46]. Because of this diversity, determining which tool is best for building a particular chatbot is quite
challenging, since not every tool supports every conceivable functionality. Furthermore, due to the
fact that chatbot specification often contains tool-specific unintended details, the conceptual model
of the chatbot may be difficult to achieve. As a result, irrespective of the implementation technology,
thinking, comprehending, verifying, and testing chatbots becomes difficult. Finally, certain systems
are proprietary, which makes it nearly impossible to migrate chatbots and leads to vendor lock-in.

4.2 Question 2: What Aspects of Mental Health do the Chatbots Target?

A sizable number of papers discussed the use of machine learning to assist in the detection
or diagnosis of mental health problems. Numerous of these research concentrate on the early
identification of depression or its symptoms, most often through analyzing speech acoustic features
or tweets from Twitter. Identifying emotional states from mobile sensing data sources, phone typing
dynamics [47], stress evaluations from position [48], biometric and accelerometer data [49], and stress
evaluations from location are further uses. Besides, recent advances in the analysis of human-robot
or agent interventions [50] facilitate to assess emotional and mental health condition of the patients.
Additionally, questionnaire data and text analysis was employed to automatically identify and retrieve
diagnostic data from historical writings or clinical reports [51].
The majority of the papers discussed techniques for identifying and diagnosing mental health
problems as well as for anticipating and comprehending psychological health concerns. The most
frequent methods used sensor data [52], electronic health record data [53,54], or text [55] to predict
5112 CMC, 2023, vol.74, no.3

future suicide risks. A few examples contain the examination of suicide notes as well as later periods
[56]. Studies on an individual basis have attempted to forecast many things, such as patient stress [57],
the likelihood of re-hospitalization for outpatients with severe psychological issues [58], and manic or
depressive episodes concerning people with bipolar disorder [59].
A small number of studies focused mostly on Reddit2 posts to better identify the language
elements of psychological wellness content posted in online communities. This work used text-mining
algorithms by identifying helpful and harmful comments in online mental health forums [60,61].
The use of machine learning to gain more understanding of what elements (such as psychological
symptoms, contextual influences, and others) may have the greatest impact on a person’s mental
health and their relationship to mental health outcomes presented some additional isolated findings
outside of these three major categories [62]. A prototype system was described that the user engages
in conversation with a female avatar who screens for signs of anxiety and sadness [63]. According to
the users’ responses and emotional state, the screening questions are modified and encouragement is
supplied in this adaptive system.
In the case of anxiety, low-quality data from two randomized controlled trials (RCTs) revealed
no statistically significant difference between chatbots and anxiety severity information. In contrast,
one quasiexperiment found that utilizing chatbots significantly reduced anxiety levels. There are
two possible explanations for these conflicting results. Firstly, pretest-posttest studies are not quite
as reliable as RCTs for assessing the effectiveness of an intervention, in part, due to low internal
consistency brought on by sampling error. Second, the conversational agent in the exploration, in
contrast to the two RCTs, featured a virtual view, enabling chatbots to communicate with users both
verbally and nonverbally [64].
A narrative synthesis of three research found no statistically significant difference in subjective
psychological wellbeing between chatbots and the control group. The inclusion of a nonclinical sample
in the three research explains the nonsignificant difference. In other words, since the individuals were
already in excellent mental health, the impact of utilizing chatbots may be minimal.
Chatbots substantially reduced levels of discomfort, according to two researches, combined in a
narrative manner. This result should be taken with care since both trials had a significant risk of bias.
Studies in a comparable setting found results that were similar to ours. To be more specific, an RCT
found that online chat therapy reduced psychological discomfort substantially over time [65].
Both RCTs evaluating chatbot safety found that virtual conversational agents are safe for use in
psychological problems, as no adverse events or injury were recorded when chatbots were employed
to treat depression patients. However, given the significant potential of bias in the two trials, this data
is insufficient to establish that chatbots are safe.

4.3 Question 3: What Kind of Therapy are Used in the Fight against Mental Problems in Chatbots or
Conversational Agents?
Chatbots in Clinical Psychology and Psychotherapy. A chatbot is a type of computer program that
mimics human interaction via a text- or voice-based conversational interface. The foundations of the
underlying model might range from a collection of straightforward rule-based replies and keywords
screening to complex NLP algorithms [66]. Psychology and virtual conversational agents share a
long history together. The initial purpose of ELIZA, the first well-known chatbot, was to emulate
a Rogerian psychotherapist [30], as well as the intriguing philosophical and psychological problems
they raise. A few dozen chatbots have reportedly been developed to cure a range of illnesses, including
CMC, 2023, vol.74, no.3 5113

depression, autism, and anxiety, according to recent assessments. Chatbots have a high rate of user
happiness, and there is a wealth of early efficacy evidence [67].
After a basic and short dialogical engagement, the simplest of these chatbots may be utilized
as virtual agents or recommendation system interfaces, guiding users to receive appropriate mental
health information or treatment material. While an AI agent capable of mimicking a human therapist
is unlikely to arrive in the near future, more advanced AI agents with excellent NLP may replicate
a small conversation using therapeutic methods. Though such therapeutic chatbots are not meant to
replace real therapists, they may offer their own kind of connection with users. They can communicate
at any time, and they may be used by people who are embarrassed or feel insecure to visit a therapist.
There are several examples of advanced treatment mental health virtual assistants that recently
emerged: Woebot [68], Wysa [69], and Tess [70]. Through brief daily talks and mood monitoring,
Woebot offers CBT to clients suffering from sadness and anxiety. The Woebot group saw a considerable
decline in depression, as measured by the PHQ-9, after two weeks of use, in contrast to the knowledge
control group, which got an e-book on depression from the NIMH but did not see a similar decline.
Chatbots and conversational agents for mental disorders show great promise, but more investiga-
tions are needed to get reliable results and verify them in bigger samples and over longer periods of
time. Work on psychosocial chatbots will also need to address the issue of emotional and empathetic
AI, in addition to the technical complexity of language processing methods. Table 2 describes most
used real-world chatbot applications for mental health by indicating mental issues and therapies that
can be treated by mobile chatbot applications. Table 3 describes neural networks, machine learning
techniques and features that can be solved for mental health treatment.

Table 2: Most used real-world chatbot applications for mental health

Study Year Chatbot Mental issue Therapy Type
[56] 2017 Shimbot Mental well-being Positive Mobile app
psychology, CBT
[57] 2018 KokoBot Empatic support Cognitive Available on
reappraisal skills, messaging
and facilitate platforms, as well
peer-to-peer as mobile and
interactions desktop browsers
[58] 2019 Vivibot Emotional, social, Positive Access via
psychological psychology facebook
support for young messenger
people after cancer
treatment, anxiety
reduction
[59] 2018 Pocket Depression, anxiety DBT Mobile app
skills
[68] 2017 Woebot Depression, anxiety CBT Mobile app
(Continued)
5114 CMC, 2023, vol.74, no.3

Table 2: Continued
Study Year Chatbot Mental issue Therapy Type
[69] 2018 Wysa Mental well-being, CBT, DBT, Mobile app
depression, mood motivational
disorders interview, positive
behavior support,
behavioral
reinforcement
[70] 2018 Tess Depression, anxiety CBT Mobile app

Table 3: Chatbot development for mental health

Study Mental issue Technique Feature
[54] Depression Bayesian networks, fuzzy logic Questionnaire, EHR
[55] Bipolar Classification methods Questionnaire, EHR
disorder
[56] Early detection Classification and clustering methods Questionnaire
of mental issue
[57] Mood disorder Multi-task encoder-decoder recurrent Questionnaire
neural networks (RNN)
[58] Depression Class-bridge multi-dimensional Health records
Bayesian networks
[59] Depression in Gradient boosting machine, logistic Questionnaire
older age regression, convolutional neural
people network, regularized greedy forests
[60] Mental Framework for diagnosis and Data collected from
problems prognosis of psychiatric symptoms chatbots and wearables
[68] Mental Multi-modal machine learning Text, video, audio
problems methods
[69] Depression Multi-modal, humanoid robot Multi-modal robot
interaction framework for depression interactions data
detection
[70] Depression Machine learning models Multi-modal
human/agent
interaction data

Digital Interventions in Mental Health. A realistic supply-demand analysis of psychiatric services

in 2020 leads to the conclusion that without additional technological advancements, treatment
requirements will be difficult to fulfill. The use of digital mental health interventions (DMHI) among
older patients has its own set of challenges and benefits. In an opinion piece focusing on healthcare
inequities, Seifert et al. examine how new technologies may either alleviate or amplify gaps that already
exist across the age spectrum, depending on knowledge, training, and public health objectives [71].
CMC, 2023, vol.74, no.3 5115

However, DMHIs do not have to completely replace conventional therapy; they may be used
in conjunction with or prior to regular treatment. In a research conducted in the United Kingdom,
Duffy et al. used internet-based cognitive behavioural therapy (ICBT) as a preceding step to a high-
intensity face-to-face intervention to treat 124 individuals with severe depression and anxiety. From
baseline through the end of the ICBT therapy, and from the end of the ICBT treatment to the end of
the service, there were significant decreases in all main outcome measures. The findings suggest the
use of ICBT to decrease inconvenient waiting times and increase efficiency [72].
The potential of technology-enabled treatment for mental wellness is likely to be best shown by the
virtual reality and artificial intelligence developments taking place within the larger area of DMHIs.
Virtual reality has been researched for almost as long as it has been used for gameplay in terms of its
potential therapeutic use for psychiatric diseases, but the number of scientific investigations into VR
therapies has increased dramatically in recent years, notably for anxiety disorders. Baragash et al. ana-
lyze this reality in their opinion piece and suggest educational, exercise, and research strategies to
fully take advantage of what virtual reality treatments have to provide. However, VR’s reach is limited
among patients and clinicians [73].
Radiography and pathology are two medical fields that are being transformed by AI and ML,
and these technologies also hold the promise of providing tailored, low-cost therapies that can be
easily scaled to medicine as a whole. Conversely, what is their prospective area of expertise and
weakness in relation to mental health? Some recently studies investigate how artificial intelligence
enabled conversational agents may influence psychological and psychiatric treatment at the level of
diagnosis, data gathering, and therapy and provide four alternative approaches as a framework for
further research and regulation.
Psychological health therapies must be documented in patient records maintained by clinical
professionals and healthcare providers, whether they are technological or not. Williams argue that,
for the purpose of empowering and autonomy, people should have access to their medical records.
Patient portals often limit access to information on mental wellbeing regardless of the fact that the
electronic medical record, which is now extensively used, substantially simplifies this process for the
reasons and arguments described by the authors.
Finally, DMHIs serve as an illustration of how technology may be useful in the field of psy-
chological disorders. A comparable and equally large body of research has focused on the negative
aspects of technology, including addiction, entertainment, bullies, and online impulsivity. Despite
certain parallels, as Baldwin et al. explore in a perspective piece, these two academic disciplines have
mostly emerged independently of one another. To understand the issues at the intersection of computer
science and psychology, cooperation between scholars on both sides is essential.
To sum up, the studies indicate that DMHI achievements are on equal level with traditional
programs, and some underserved peoples are receiving a promising and interesting way of treatment,
not mentioning that, on the whole, industry experts and healthcare providers are eager to use the
newest technological advancements, like augmented worlds and cognitive computing, for psycholog-
ical disorder, diagnosis, and therapeutic interventions. The disadvantages of DMHI include technical
restrictions, the absence of big datasets, as well as long-term studies, and the possible paradoxical
outcomes wherein electronic resources can occasionally reinforce rather than lessen healthcare issues.
Given the relatively low availability of traditional mental health treatments and the urgent need to
meet the rising demand, DMHIs are probably an integral component of any solutions to treatments
access issues.
5116 CMC, 2023, vol.74, no.3

4.4 Question 4: What Types of Machine Learning Techniques are Currently Being Applied for Mental
Health?
Classification and supervised learning are the most common machine learning tasks and tech-
niques. A variety of machine learning methods, including classification, regression, and clustering,
may be used to basic tasks like detecting correlations and pattern identification in high-dimensional
datasets to provide more simple, human-interpretable forms. Authors divided the articles in their
corpus into four machine learning groups as supervised, unsupervised, semi-supervised learning; and
new methods.
Unsupervised learning clusters data using mathematical methods to offer new insights. The
dataset just includes inputs and no intended output labels in this case. Clustering techniques react to the
presence or absence of similarities in each piece of data to identify patterns and assist organize the data.
Only two studies [68,69] used clustering to differentiate language usage in online conversations and
extract diagnoses from psychiatric reports, respectively. However, data clustering was often used as a
first step in classification (as mentioned above) to assist in the selection of features or the identification
of labels for the development of supervised learning models [60,71].
Only one article specifically stated that they used semi-supervised learning models [73] to mix their
model includes both labeled and unlabeled data, and only a few studies (n = 6) mentioned that they
used new approaches. Deep learning techniques have been used to provide customized suggestions
for stress-management measures [68], while custom machine learning models have been employed
to develop multi-class classifiers [69]. The remaining studies either applied pre-existing classifiers on
newly collected data [70] or presented key ideas without using machine learning [67].
Finally, NLP including voice and text, is a subset of machine learning that mostly employs
unsupervised methods. For instance, by extracting keywords such as anxiety, depression, stress, topics,
or idiomatic expressions from phrase in order to extract necessary features from human speech to
develop different classification models or assess its semantic sentiment, numerous studies [67] utilized
vocabulary and other text-mining methods [72]. Few researches such as [54,57] have examined the
acoustic, paralinguistic aspects of speech, including prosody, pitch, and speech rate estimates.
As a result, the studies mostly used supervised machine learning methods to see whether, and
how effectively, specific mental health behaviors, states, or disorders might be categorized using newly
created data models, in line with the cluster of the articles’ emphasis on mental health evaluation. With
the purpose to assist data labeling and feature selection for classification, the majority of unsupervised
learning methods were used. This is consistent with [73] clinical systemic review results. However, other
avenues for utilizing ML methods, such as allowing customization, remain unexplored.

4.5 Question 5: To What Extent do the Papers Describe Ethical Challenges or Implications?
Psychiatric care has been established as a sector that presents unique ethical and legal issues, as
well as the necessity for regulation, by its very nature. The advancement of AI, as well as its increasing
application in a variety of fields, including psychological disorders, has determined the necessity
to ethically scrutinize and control its use. Consequently, we’ve arrived at the crossroads, where the
confluence of artificial intelligence and mental health presents its own set of new questions [56].
While AI-enabled chatbots offer a lot of potential advantages, they also pose a lot of ethical
issues that need to be addressed. One major source of worry is the prevention of damage. Robust
investigations are required to ensure non-maleficence in therapeutic interactions, as well as to
anticipate how to deal with situations in which robots fail or behave in unanticipated ways [61]. While
CMC, 2023, vol.74, no.3 5117

traditional medical devices are subjected to extensive risk assessments and regulatory oversight before
being approved for therapeutic use, it is unclear whether AI-enabled devices—such as chatbots and
conversational agents and publicly accessible mental health apps—should be subjected to the same
scrutiny.
As one of the most recent areas of psychological and psychiatric research and treatment, artificial
intelligence enabled applications need guidance on design, biomedical integration, and training [64].
Existing legal and ethical frameworks are often out of step with these developments, putting them
at danger of failing to offer adequate regulatory advice. While there are ‘gaps’ between the usage of
certain apps and established ethical standards, damage may only be addressed retrospectively [67].
In order to combine useful insight into artificial intelligence design and development, deliberate
discussion and reflection on the correlation between changes concerning embodied AI and mental
health treatment are considered necessary. Sure, it is challenging to foresee the ethical challenges
highlighted by present and future chatbot developments. This entails developing higher-level guidance
from medical and psychiatric councils on how medical professionals may successfully develop abilities
for employing embodied intelligence in the clinical practice [68,69,71].
As AI becomes more incorporated into mental wellbeing, it’s critical to consider how intelligent
apps and robots may alter the current landscape of services. With an aim to provide corresponding
treatment, the availability of embodied AI alternatives may justify the removal of current services,
resulting in either fewer mental health care service options or options that are mainly AI-driven. If
this happens, it may exacerbate current healthcare problems. As a result, it’s crucial to consider AI’s
integration in the context of other mental health care tools. At their present state of development,
embodied AI and robots cannot substitute comprehensive, multi-tiered psychological treatment to
the full extent. Therefore, it is critical to guarantee that the integration of artificial intelligence services
does not serve as a pretext to eliminate multi-layered psychological disorders treatment provided by
qualified experts.

5 Discussion
It’s essential to note that consumers saw medical chatbots as having many advantages, including
anonymity, ease, and quicker access to pertinent information. This supports the suggestion of previous
research that consumers are just as willing to share emotional and factual information with a chatbot
as if they were with a human companion. Conversations with chatbots and humans had comparable
levels of perceived comprehension, disclosure closeness, and cognitive reappraisal, suggesting that
individuals psychologically interact with chatbots in the same way they do with people. A few
participants in mental health settings mentioned the apparent anonymity, but the preferences for
specific chatbot usage in healthcare contexts need to be investigated further. Our results back up the
qualitative research findings that investigated chatbot user expectations in terms of comprehension
and preferences. Users are usually unsure what chatbots can accomplish, but they believe that this
technology will improve their experience by giving instant access to relevant and useful information.
They also recognize the chatbot’s lack of judgment as a unique feature, but it was formerly pointed
out that establishing rapport with a chatbot would require trust and meaningful interactions. These
reasons for using chatbots need to be thoroughly examined further in order to determine how this
technology may be securely integrated into healthcare.
5118 CMC, 2023, vol.74, no.3

6 Conclusion
Patient motivation and engagement must be properly and thoroughly evaluated in order to
optimize the benefits of AI technologies as their employing in treatment of psychological disorders
becomes more ubiquitous. Although many individuals have open access to medical conversational
agents, the majority of concerned people is still hesitant to resort to the assistance of AI-enabled
solutions, according to our research. Therefore, intervention engineers should utilize theory-based
techniques in order to tackle user anxieties as well as to provide efficient and moral services suitable
of narrowing the healthcare and well-being gap. Future studies are required to determine how clinical
chatbots might be effectively employed in healthcare and preventative medicine, especially by enabling
individuals to take a more active role in treatment of their own health problems.
The main topics of this review are the definition of technologies for the development of chatbots
for mental health, identifying mental problems that can be solved using chatbot applications, as well as
the description of artificial intelligence methods for chatbot applications and the definition of ethical
problems in the development of chatbot applications for mental health.
The target audience for the psychological health software has been determined as an underserved
and vulnerable part of the population that urgently needs medical support. Consequently, the creators
of these apps should take inconsistent information and a lack of data carefully. It is critically important
that users should be informed if an app was developed as part of an experiment that will end after a
certain amount of time or has already been terminated.
The demands of vulnerable and underserving populations should be better understood by
designers from the viewpoints of both end-users and experts. These insights go beyond the actual
mental health problems to include questions such as how people who need mental health support can
use these programs to get benefits, when and why they should stop using them, and what it implies for
their wellness. Application developers shouldn’t generalize “unknown detrimental impact for a single
condition” as a wholly null effect because “not known unfavorable impact for a single circumstance”
may not be applicable or proven for digital behavior.
Like conventional learning techniques, each individual has their own preferable learning style
while using virtual applications. Two main advantages of employing a digital instrument are the
ability to quantify and adjust for variation of learning approaches. In each unique case, there is still
a lot to learn about digital learning techniques. While patients’ individual mental health state further
complicates the variety in learning methods, AI-based personalization is considered to be the main
concept in the psychological health app market. The extent of personalization is a further issue brought
up in this research. A framework for assessing mental health programs should contain metrics to gauge
characteristics like customization—how personalized the app is, how relevant it is to the patient’s
condition, and how this personalization affects the condition being targeted as well as the patient’s
general wellbeing.

Funding Statement: This work was supported by the grant “Development of an intellectual sys-
tem prototype for online-psychological support that can diagnose and improve youth’s psycho-
emotional state” funded by the Ministry of Education of the Republic of Kazakhstan. Grant No.
IRN AP09259140.

Conflicts of Interest: The authors declare that they have no conflicts of interest to report regarding the
present study.
CMC, 2023, vol.74, no.3 5119

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