Moving towards digital mental health treatment: opportunities and limitations

Author: Joanna Hofman, Research leader, RAND Europe

Introduction

According to the 2014 Adult Psychiatric Morbidity Survey, one in five working age people in England has a mental health condition at a given point in time. Mental ill-health affects not just an individual’s health but it is also associated with high costs to the UK economy recently estimated between £74 billion and £99 billion per year.

Digital mental health treatments include a variety of options, such as computerised Cognitive Behavioural Therapy, virtual reality or gaming

In 2014, RAND Europe looked at what approaches can improve employment outcomes for people with common mental health problems (such as depression or anxiety disorders). Among the recommendations, the 2014 study suggested improving access to online interventions (for example by building on computerised Cognitive Behavioural Therapy (cCBT)) for common mental health problems.

This is because internet-based tools are widely accessible; they can reach people who do not actively seek help in traditional services or prefer using a computer or an application, rather than talking to a therapist; and because there was some emerging evidence on the effectiveness of these tools.

Since 2014 there has been a notable increase in the provision of digital solutions to mental health and the evidence behind these. There are a number of online platforms that offer a wide spectrum of treatment options, including computerised cCBT. cCBT interventions deliver CBT via an interactive digital interface that uses patient input to make psychotherapy decisions.

In traditional CBTs a number of protocols aim to address different mental health problems. These protocols share certain characteristics and a general approach to treatment and yet they can demonstrate considerable differences. They allow for different levels of compliance with the sequence and content of the treatment and the adherence to the protocols vary among therapists.

This diversity is also present in the design of cCBT platforms: they may follow a linear treatment (with a set number of sessions followed in a given frequency and order) or may allow users to choose from a menu of options. The level of take-up and engagement with the treatment depends on each user.

Some cCBT tools are entirely self-administered, others offer additional guidance. Such support can be provided by a therapist, psychologist, psychiatrist or support group. It may be delivered by email, eChat platform, face-to-face contact, telephone, videoconferencing, online feedback, or any combination thereof. However, the intensity of additional guidance is typically low.

But apart from cCBTs, there are other options, including virtual reality (VR) gaming. VR is an interactive environment created by a computer where an individual can repeatedly face their problematic situations and practice how to overcome challenges. While in the past the technology was very expensive and limited to laboratories, now a VR kit is more affordable and has the potential for more common use.

Serious games can be provided via personal computer without the need for an internet connection. Game can focus on tasks and their results or challenge players to find solutions for problems. They may also train the players’ working memories by short and timed challenges. Some games could combine physical exercises with game elements.

Some online mental health services are available through the NHS and more is yet to come

The following online mental health services have been approved for use by the NHS:

  • Big White Wall supports people with depression and anxiety;
  • FearFighter assists people with anxiety and phobias;
  • Ieso Digital Health offers support for those with depression, anxiety, pain management, obsessive compulsive disorder (OCD), phobias and stress management;
  • SilverCloud helps people with depression, anxiety, eating issues and OCD;
  • Sleepio provides assistance to people with sleep problems.

With press reports on a dramatic increase in the number of online mental health appointments in last years, one can expect that alternatives to traditional face-to-face therapies are on the rise. The future will likely bring further developments: the National Institute of Health Research is funding a project to enable psychological therapy to be delivered via VR in the NHS.

But the increase reliance on digital mental health comes with opportunities and limitations.

Opportunities offered by digital mental health treatments sit primarily with their promising results and easier/wider access to services

The 2016 study reviewed the growing evidence behind existing online tools, platforms and applications that offer assessment and support for mental health needs. In light of this review cCBT tools appear to have a positive effect on mental health outcomes, particularly for depression, anxiety orders and insomnia.

A systematic review concluded that VR can transform the assessment, understanding and treatment of mental health problems if combined with targeted translational interventions. Another recent study suggested that serious gaming interventions may be effective for reducing disorder-related symptoms supporting earlier findings in this area.

A wider provision of cCBT and digital technologies can be a means to enable wider public access to psychological therapies. This is particularly important at the time when the provision of specialist mental health services is still a concern.

Limitations of these forms of treatment are inherently linked to their online character

Relying on cCBT (and more broadly online interventions) also presents some challenges. Potential limitations of using the Internet to deliver psychological interventions include:

  • Difficulty ensuring the correct diagnosis due to a lack of visual and auditory cues;
  • Issues with confidentiality as risks occur when storing and transmitting online data;
  • Equality issues due to computer literacy of users and affordability of some technologies;
  • Issues with the quality of service due to computer literacy of therapists;
  • Risks of inadequate response in crisis situations due to anonymity of the service.

As much as some may hope, cCBTs and more broadly digital tools are not the ‘silver bullet’ to solving common mental health problems. Some groups appear less likely to participate in treatment (or trials) of cCBT tools than others and the outcomes vary depending on the characteristics of participants.

Conclusion

There are likely to be individuals with specific characteristics or certain conditions for whom online interventions (and cCBT in particular) are more or less suitable. Establishing who can access these tools and benefit from these and under what conditions is critical to provide other type of interventions to those for whom digital tools do not work.