In part one of the blog series, Dr. Katie Young, Digital Health Scientist explored why mental health might have changed during the pandemic, and reviewed the evidence assessing whether mental health has changed during the pandemic. She also discussed the importance of knowing whose mental health has worsened during the pandemic so we can improve our understanding of the needs of those at greatest risk. In part two, we discuss the major changes, challenges and opportunities brought about by COVID-19 to the digital mental health treatment landscape.
A little over 2 years ago few people would have predicted that digital health solutions would play such a pivotal role in the provision of mental health care. Although digital and telehealth services were available prior to the pandemic, the onset of COVID-19 has precipitated mass and rapid uptake of these services to minimise, where possible, the reliance on face-to-face interactions between patients and healthcare professionals. The rapid switch to digital services nonetheless raises questions about how accessible technology-based healthcare is, how acceptable it is from a patient perspective, and of course, how effective services are. In this blog post, we describe how the pandemic has affected the use of digital interventions for mental health, how acceptable and effective these interventions were shown to be during the pandemic, and challenges that remain in ensuring equitable access to high-quality psychological interventions for all.
A rapid report from the World Health Organisation (WHO) found that 93% of countries reported disruptions to mental health services during the early months of the pandemic1. In response, 70% of countries reported increased use of telehealth services, and 54% reported increased use of self-help or digital formats of psychological interventions. At SilverCloud, we observed an initial 10% average increase in the use of our programmes from March 2020 to April 2020 across the largest 25 NHS providers in England and Wales that use SilverCloud for their online CBT2. Comparing the same locations showed a 38% increase in programme use in Jan-Feb 2021, compared to the same period in 2020, an effect that was sustained in the same period in 2022. We have also had over 15,000 individuals sign up for our ‘Space from COVID-19' programme, which was developed specifically to support people impacted by COVID-19. These trends mirror effects seen elsewhere, with evidence of increasing interest and uptake across a range of online digital mental health support options during the pandemic2,3.
Some of the challenges preventing greater adoption of digital services prior to the pandemic included a lack of technological infrastructure, the time costs of switching to new systems, and concerns about the exclusion of individuals with limited access to, or expertise with, technology4. At the same time, digital services offer several advantages to patients over in-person appointments, including increased flexibility for when and where services are available, elimination of transportation issues, a more ’on-demand’ approach to psychological support, as well as shorter waiting lists to access services. A review of 77 papers assessing attitudes towards digital and telehealth interventions during the pandemic found that, across studies, 48%-100% of patients who were already receiving treatment at the start of the pandemic were willing to move to tele-/digital health services4. While this is certainly encouraging, it is important to consider the challenges faced by those unwilling or unable to move to remote treatments. Overall, although some studies reported preferences to return to face-to-face appointments where possible, digital services were reported as being acceptable to patients and clinicians4.
Concerns remain about the equity of access to digital psychological interventions. One study analyzing data from a large NHS service in the UK found that despite an overall increase in the frequency of remote appointments during the pandemic, children, adolescents, and older adults were less likely than working-age adults to receive remote consultations5. Even prior to the pandemic, there were concerns around disparities in access to digital healthcare, with reduced access among people from lower socioeconomic backgrounds, those with limited access to, or knowledge about, technology, those from rural areas, and individuals from minority ethnic groups6. Work to address these disparities includes adapting interventions to work within technological restrictions of different user groups, and including culturally-adapted content. One example of this is a trial of SilverCloud’s ’Space from Depression’ programme that had been culturally adapted for use in Colombia. This study found that the culturally-adapted intervention resulted in significant decreases in depression symptoms7. As we continue to adapt programmes for use in diverse settings, it will be important to consider culturally appropriate implementation strategies and approaches to optimise engagement to ensure equity of access.
Rapid changes in the provision of healthcare services naturally lead to questions about the efficacy of delivering treatments remotely. Although studies examining clinical outcomes of digital mental health interventions during the pandemic are relatively scarce, one review of emerging evidence demonstrated that telehealth and remote services were as effective as face-to-face care4. Prior to the onset of the pandemic, internet-delivered cognitive behavioural therapy had an established evidence base, showing that online interventions demonstrate comparable efficacy to face-to-face therapy8. At SilverCloud, we have 12 years of clinical research demonstrating the effectiveness of our online programmes for anxiety and depression. Among users of our ’Space from COVID-19’ programme, 90% of users reported that they found the programme interesting, helpful, relevant, and supportive, while 66.2% showed an improvement in depression symptoms (PHQ-9), and 68.0% showed an improvement in anxiety symptoms (GAD-7).
The increased demand for remote mental health care has also increased investment in digital mental health care innovation9, leading to a rapid proliferation of novel interventions and tools to support mental wellbeing. A challenge for such rapid growth and development is that evidence to support the clinical efficacy of these tools is severely limited in many cases10. Intervention development is an iterative process, so it is likely that not all novel interventions will be immediately effective. For example, one online self-help intervention developed to reduce psychological distress during the COVID-19 pandemic failed to show any reductions in symptoms of anxiety, depression, or stress11. Long-term commitment to scientifically informed development of novel interventions will be critical for the sustainable growth of digital mental healthcare provision.
The use of digital interventions offers a unique opportunity to leverage novel technologies to enhance the flexibility and personalisation of mental health treatments. Digital tools allow unprecedented insight into which aspects of interventions patients engage with, and what they find most beneficial for their mental health. This information would simply not be possible to gather from face-to-face interactions without onerous record-keeping and lengthy questionnaires. This data-driven understanding offers an enormous opportunity to enhance the effectiveness of interventions, providing the right content to the right users at the right time. For example, at SilverCloud we have partnered with Microsoft Research to use machine learning techniques with big data to better understand who digital interventions work best for and why12. Most recently, this work has led to the development of a prediction tool informing SilverCloud coaches about whether a particular individual is likely to respond to treatment, offering opportunities to provide tailored or enhanced support for specific individuals to increase their likelihood of benefiting from treatment13.
In summary, the pandemic has led to wider adoption and reliance on remote digital tools for the provision of quality mental health care while minimising in-person contact. Overall, there is evidence of widespread adoption of existing remote healthcare technologies (telehealth services and online/digital psychological treatments), with changes in the mode of delivery largely found to be acceptable to both patients and clinicians. There has also been an increase in the availability of novel digital interventions, although, with the limited evidence available to date, the efficacy of these treatments remains untested in many cases. High-quality, rigorous science has a key role to play in the continued development of digital tools for mental healthcare. Leveraging novel technologies will also offer opportunities to enhance the personalisation and flexibility of digital care for each individual user. Ensuring equity of access and effectiveness of interventions for all will be critical to ensure a reduction in, rather than widening of gaps in treatment provision among historically marginalised groups.
Interested in learning more about how to critically evaluate the evidence base of your digital health solution? Download our entire information sheet – Five questions to ask when reviewing the evidence and claims of digital mental health companies.
References
1. World Health Organization. (2020). The impact of COVID-19 on mental, neurological and substance use services: results of a rapid assessment.
2. Inkster, B., & Digital Mental Health Data Insights Group (DMHDIG). (2021). Early warning signs of a mental health tsunami: a coordinated response to gather initial data insights from multiple digital services providers. Frontiers in digital health, 2, 578902.
3. Mahoney, A. E., Elders, A., Li, I., David, C., Haskelberg, H., Guiney, H., & Millard, M. (2021). A tale of two countries: Increased uptake of digital mental health services during the COVID-19 pandemic in Australia and New Zealand. Internet Interventions, 25, 100439.
4. Appleton, R., Williams, J., San Juan, N. V., Needle, J. J., Schlief, M., Jordan, H., ... & Johnson, S. (2021). Implementation, Adoption, and Perceptions of Telemental Health During the COVID-19 Pandemic: Systematic Review. Journal of medical Internet research, 23(12), e31746.
5. Patel, R., Irving, J., Brinn, A., Broadbent, M., Shetty, H., Pritchard, M., ... & McGuire, P. (2021). Impact of the COVID-19 pandemic on remote mental healthcare and prescribing in psychiatry: an electronic health record study. BMJ open, 11(3), e046365.
6. Schueller, S. M., Hunter, J. F., Figueroa, C., & Aguilera, A. (2019). Use of digital mental health for marginalized and underserved populations. Current Treatment Options in Psychiatry, 6(3), 243-255.
7. Salamanca-Sanabria, A., Richards, D., Timulak, L., Connell, S., Perilla, M. M., Parra-Villa, Y., & Castro-Camacho, L. (2020). A culturally adapted cognitive-behavioral internet-delivered intervention for depressive symptoms: randomised controlled trial. JMIR Mental Health, 7(1), e13392.
8. Andrews, G., Basu, A., Cuijpers, P., Craske, M. G., McEvoy, P., English, C. L., & Newby, J. M. (2018). Computer therapy for the anxiety and depression disorders is effective, acceptable, and practical health care: an updated meta-analysis. Journal of anxiety disorders, 55, 70-78.
9. Wang, E & Zweig, M., 2021. A defining moment for digital behavioral health: Four market trends. https://rockhealth.com/insights/a-defining-moment-for-digital-behavioral-health-four-market-trends/
10. Torous, J., Myrick, K. J., Rauseo-Ricupero, N., & Firth, J. (2020). Digital mental health and COVID-19: using technology today to accelerate the curve on access and quality tomorrow. JMIR mental health, 7(3), e18848.
11. Brog, N. A., Hegy, J. K., Berger, T., & Znoj, H. (2022). Effects of an internet-based self-help intervention for psychological distress due to COVID-19: Results of a randomized controlled trial. Internet Interventions, 27, 100492.
12. Chien, I., Enrique, A., Palacios, J., Regan, T., Keegan, D., Carter, D., ... & Belgrave, D. (2020). A machine learning approach to understanding patterns of engagement with internet-delivered mental health interventions. JAMA network open, 3(7), e2010791-e2010791.
13. https://www.healthtechdigital.com/mental-health-and-machine-learning/