Digital Mental Health

Question 1

Are digital activities popular?

Answer 1

Yes - they are everywhere
UK adults spend on average 24 hours a week online
90% of UK households have internet access
89% are current internet users - 86% daily users
77% of adults access internet on the go - 98% 16-24 and 29% 65+

Question 2

How are digital technologies changing mental health care?

Answer 2

Digital front door - moving primary care contacts to be digital first - first thing you should do is go online

Simple digital transactions - booking appointments and getting prescriptions online

Seeking health info-advice online

Professional and peer support online

Question 3

What are some of the problems with seeking help online?

Answer 3

Sometimes people may wrongly self-diagnose by using the internet

Question 4

How can people be assessed online?

Answer 4

Online assessment using standardised questionnaires

Assessment and monitoring via wearables and real time self-report - techniques online which help with stressors

Question 5

Are digitally support therapies recommended?

Answer 5

Widespread in the NHS primary care
Recommended by NICE as first treatment for mild-moderate depression, panic and generalised anxiety disorder

Digistised computerised CBT were first recommended for depression 10 years ago - this isn’t a new idea: access for all be around for a long time and CCBT

Question 6

What is CCBT recommended for?

Answer 6

Low intensity interventions for depression, panic disorder and generalised anxiety disorder

Not recommended for PTSD, OCD and social phobia

Question 7

What is the history of computer therapists?

Answer 7

1970’s - early work published, thinking common computer therapy should focus on systematic densentisation for low phobias and anxiety

Question 8

What is systematic desensitisation?

Answer 8

Focus on the most feared situation someone could tolerate and working down to something which is completely intolerable
Offer stimuli through exposure technology - paired with a relaxation technique
Press one key when they feel uncomfortable and another when comfortable, go through a hierarchy, when they feel ready, exposure along hierarchy can continue

Question 9

Do you need interaction with a therapist for SD to work?

Answer 9

No - it does not require interaction with a therapist to be successful - the live therapist in not required

some evidence computer therapy is better, could be because place of agency is within the individual, not the therpapist doing anything

Question 10

Is virtual reality exposure therapy good?

Answer 10

Been shown to be just as effective as when the actual object is there - can be set up for a variety of fears

For anxiety, meta-analysis of randomised control trials find no difference between VR experiences compared to vivo exposure therapy

Question 11

What are the types of digital delivered / supported therapies?

Answer 11

Unguided digital interventions
Guided digital interventions 
Blended digital/face to face interventions
Real time online therapies
Asynchronous online therapies
Digitally augmented therapies

Question 12

What are guided digital interventions?

Answer 12

Minimal support - phone and email then once a week have a check in call about program: these are quite common in IAPT services, adding a small amount of support can do a lot to increase engagement as they know they have to go back

Question 13

What are blended digital/face to face interventions?

Answer 13

50/50 split between online and seeing a therapist - work might be divided so do general things on the computer, but specific things delivered by a therapist

Question 14

What are real-time online therapies?

Answer 14

Video conference, webinar

Question 15

What are asynchronous online therapies?

Answer 15

Therapy conducted by email/messaging

Question 16

What are digitally augmented therapies?

Answer 16

SMS, email, apps etc

Question 17

What are the techniques / structure used in CCBT?

Answer 17

Many based on the idea of CBT
Modern programs guide the user through the important ingredients of therapy in a self help, multi media format, such as:
psychoeducation 
assessment of current problems with feedback and change monitoring
action plans and goals
guided change techniques
homework
narrator or therapist
communication by email

Question 18

What are examples of websites that the NHS recommend?

Answer 18

Beating the blues
Living life to the full
Mood gym
Kleur je leven
Mindful mood balance

Question 19

What do these websites include?

Answer 19

Behavioural activation - case studies to bring examples, look at people experiencing similar things
Include assessment, feedback, monitoring, guided discovery, review

Get a reminder of what has been done in the session - paper copies you can look back on to support on going learning

Question 20

What did proudfoot et al 2004 / Mccrone et al find in his RCT?

Answer 20

Looked at beating the blues vs usual care in the NHS
Gp patients aged 18-75 with depression/anxiety, with or without medication
276 participants from primary care
outcome: beck depression inventory, beck anxiety inventory, work and social adjustment scale, health service usage
Pre, post, 1 month, 3 month and 6 month follow up

Results:
Pre - experience was equal
Beating the blues offers clinical experience over and above treatment as usual
2/3rd completed all 8 sessions
Benefits were maintained to 6 month post treatment
Standard treatment did get better but not as good
Cost ratio demonstrating that beating the blues is a cost-effective intervention for depression primary care

Question 21

What did Andrews et al 2010 find in his meta-analysis of CCBT RCTs?

Answer 21

A lot more studies since Proudfoot
22 randomised control trials which had looked at CCBT for major depressive disorder, panic and generalised anxiety disorder
Large effect size compared to control

Question 22

What has guided self-help versus face to face CBT found? Cuipers et al 2010

Answer 22

Comparing computerised CBT and face to face CBT of the same kind
Overall, no difference between guided self-help and face to face CBT

Question 23

Do digital therapies work?

Answer 23

They support well-being and build resilience to clinical interventions
They have shown to be a less intensive, cost-effective way to deliver empirically validated treatments for a variety of psychological problems

Question 24

Are apps recommended?

Answer 24

Most NHS trusts also recommended apps to support mental health, NHS apps library offers a range of apps
wellness apps - headspace (25 million downloads across 190 countries, > 1 million subscribers and Calm
Chat-bots - using language processing capabilities in computing to generate conversations through messaging (can be done with robots)

Question 25

Is there evidence for smart-phone based interventions?

Answer 25

Meta-analysis of research trials support the effectiveness of smartphone based mental health interventions to reduce symptoms
anxiety 9 RCTs
Depression 18 RCTs

Question 26

What are examples of local IAPT digital initiatives?

Answer 26

Silver cloud - computerised CBT
IESO - email therapies
Mind district platform offering blended care approach for children and young people services
Skype therapies
Digital workbook for STEPPS in development

Question 27

What are the advantages of using Digital technology?

Answer 27

Increase access and choice of effective, evidence based practise for some people, who wouldn’t normally access it

Increase flexibility in location and pace of engagement - can do it from work, whenever you want

Increase confidentiality / reduce stigma

Offering up to date and consistent information and intervention

Increase self-efficacy, mastery and learned resources

Cost-effectiveness

Question 28

What are the disadvantages of using digital technology?

Answer 28

Digital exclusion and inaccessibility - who is at risk? Ensure offline services are also available for people who don’t want to use them

Scope and solutions - what range of issues can digital tools support / what kinds of interventions can be meaningfully translated digitally?

Absence of human/therapeutic relationship - could be risks with not having it

Engagement, motivation and need for support - added benefit from brief phone or email support, dropout rates can be high for unsupported digital interventions, but support therapies similar to face-to face - people drop out more from non-guided help

Question 29

Are they positive about it?

Answer 29

Research suggests users are more positive about digital interventions than therapists
Potential users indicate positive expectations and high treatment credibility for CCBT

Question 30

Are therapists hopeful?

Answer 30

Therapists may be less hopeful about CCBT than their clients - therapists are scared about this, computers doing their job, need education about it

Question 31

What are the future opportunities for digital mental health?

Answer 31

Increasing reach and impact in the NHS

Enhancing services through user-centred design

Increasing engagement and impact through gamification

Global dissemination of evidence-based interventions

Big data/predictive analytics

Digital training for healthcare staff