Just how effective is digital mental health support and intervention? Dr Kate Bunyan, chief clinical innovation officer at Doctor Care Anywhere, shares her expertise to answer the key questions
What do we mean by mental health?
Put simply, it’s everything that isn’t your physical health. So how you feel about things, how you’re processing things, how you relate to the world around you, and to other people, are all parts of your mental health. We all have physical health, we all have mental health, it’s the other side of us; we are two sides of a coin.
I think the term ‘mental health’, until probably quite recently, has been used in not a very positive way. I think now people have an appreciation, probably like never before, of what it is and that we all have it. We have good and bad times with it
I think people are starting to recognise within themselves that mental health is a spectrum, it’s not something you switch on and off. So ‘mental health’ isn’t ‘mental health illness’; mental health illness is a huge smorgasbord of different conditions, just like physical illnesses are a big collection of different things.
People are recognising that within themselves they move along that spectrum of feeling well to not feeling well, and that doesn’t mean they need to have a diagnosis for it.
I think the feeling of understanding a little bit more, that mental health is something that we all handle, has really come through since COVID.
What was the demand for mental health services in the UK before COVID?
The demand was extraordinary. One in six people in the UK will have had a mental health symptom in the last week. Nearly half of adults surveyed in a large national survey felt that they have had a diagnosable mental health condition at some point in their life. A fifth of men and a third of women have had diagnoses confirmed by a professional.
That’s a huge volume of the population who needs some form of management. So the demand was huge, but the number of people who get access to help for their mental health problems has been much smaller. That demand and supply mismatch was really significant in the UK for years before we got to COVID.
I think regardless of the type of health that you’re looking at, there just aren’t enough humans to provide all the support and treatment that the population needs to help them get to the health point that they’d like to be at. And that comes into much sharper focus, with mental health management, where we end up having to say we’ve got to be pretty sick before we can even consider trying to help you as a system.
We need to find ways of keeping the humanity in healthcare, but not necessarily done just by humans, because we just can’t match that need.
How has the pandemic impacted demand for mental health services?
There was a report that came out last year, when we were coming out of the first wave of the pandemic, that said, even at that point, there were going to be 10 million people in the UK who needed additional or new psychiatric support directly as a result of the pandemic. The report also said that should we have further lockdown, that number will grow. That is a huge amount of new resource requirements because of the pandemic.
Demand from people who don’t feel ill but don’t feel themselves has exploded through COVID, because all our normal coping strategies were restricted. Normally, we would offload to a friend or a relative, we would go for a walk, we would get out, we’d go on holiday, we get some sunshine; all those normal things that we use to help build our own resilience and get through the trials and traumas of life disappeared.
So for 18 months, nearly two years, we have had to look very inwards to how we sort ourselves out. Then you add in the difficulties with work that people have had, being in or out of work, furloughed or not, people who have been struggling with home working versus in the office working, people who have had the virus or have been impacted by the acute side, and all of those things we’ve not seen the end of yet. Those are ongoing conversations, ongoing challenges for everybody to have to grapple with.
What are the current pathways available to people seeking mental health treatment in the UK?
Formally, you’ve got the NHS in the UK, so you can absolutely still go and talk to your GP, you can present to health services in in all the different ways that we have available to seek help. But I think what we’re really seeing the huge expansion of tools for self-help, and employers wishing to step in and support mental health for their workforce. Granted, that only then works for a workforce. So that doesn’t necessarily help those who are not in a workplace.
But I think it’s recognising that you go on the App Store, there are thousands of apps there that people claim can support mental health. There’s an increasing awareness of the need to tap into something; there are websites, chats, YouTube channels, you name it, social media is now exploding with different ways of trying to look at this. They’re not all great tools, but it is at least opening up the pathways to recognise just going to your GP doesn’t solve it for everybody.
Is digital mental health primarily talking therapy via video calls?
No, in a nutshell, and I think this is where it all gets really exciting. Whilst there is a lot of potential anxiety and doom and gloom about just how bad this could be, I think the exciting thing is digital can be so many things in the mental health space.
Telehealth is absolutely going to be part of that, that ability to access a consultation 24/7 from wherever you want to, wherever you’re comfortable, that’s really empowering for people and enables people to get over that barrier of I just don’t want to walk into my GP surgery. So being able to access video and telephone calls, to get that support, is really useful.
Technology also then enables us to look at well how can we knit together the pathways, as healthcare is really complicated. But if we’re going to make it work for people, we need to use technology to put the complicated bit on the back end and make it really seamless for the user on the front end. So you don’t need to think about where you need to get to and how you get around the system, that’s taken care of, and technology lends itself to that pathway integration process, streamlining all of that.
You’ve got technology being able to play an active role in actually helping to treat people as well, so you’ve got apps that will now enable you to go through CBT for example, which is a really common technique used in mental health therapy. VR technology is now also evolving in this space.
And then, at the other end of the scale, you’ve got the wellness space there. How can I just process what I’m going through? I don’t want to describe myself as ill. But I’m not me. Where does that sit? Apps are a great help for that a lot of them that are scientifically-based and evidence proven, are anchored in good therapeutic techniques. Mindfulness has an increasing evidence base to it now, ways of just being able to think differently, slow down, get some space.
Where does Doctor Care Anywhere fit in to the marketplace?
We’re very much a primary care provider of joined up provision. We’ve been able to grow our base sufficiently during the pandemic so we’re now able to support not just in the moment, I’ve got knee pain, I need to see a doctor, but actually starting to think about how can we help people with their preventative and proactive health management. So thinking about health, not illness, being less medical and clinical about it and more holistic.
DCA is able to provide that joined up care, one place to come in, and then start to find all of these different facets. So how do you find the right apps? How do you know what is evidence-based? What can you trust? We are able to bring that all together, and we hope that we’re able to provide that one starting point and support people through their journeys from there.
What kinds of mental health treatment work well, or less well, by a digital platform?
I think key to this is recognising that everybody is different. It could be the case that two people are female but what they like for breakfast could be totally different, because being female and liking breakfast just aren’t related.
Mental health is the same. We all express and feel our mental health differently. Something that tries to be everything to everybody in a very vanilla flavour will probably also miss the mark for everybody. It’s one of the greatest challenges in in global health. How do you make something that works for as many people as possible without failing to touch anybody at all? And I think again, that’s where digital comes in, because it enables you to have that complexity of the menu behind the scenes and fit you to what might work for you.
So a digital provider is able to better understand what you do like, are you a cereal and milk person? Well, let’s always show you cereal based solutions to your breakfast, instead of suggesting you try toast and Marmite, when we know that that’s not going to be what you need.
Fundamentally, mental health management is a lot about behaviour change. It’s a lot about helping people to understand themselves. It’s a lot about how they understand themselves in the context of what they what they’ve done, where they’ve been, where they are now. And how they manage everything as you go along. Because you don’t just get rid of your mental health. Just like you don’t get rid of physical health, you are all of all of it, you need to learn to live with all of that.
Are the risks of misdiagnosis greater with digital mental health treatment?
There isn’t a lot of research at this stage but what I would say is that my gut feel is misdiagnosis happens in an analogue world and I suspect misdiagnosis will still happen in a digital world. The key is understanding when you got the right tool for the right problem. And again, it’s beholden on the providers of digital mental health solutions to ensure that they have the means to be able to correctly identify whether digital is the wrong format for the person that’s coming to them and then divert them to the right format, instead.
So I think there’s no reason why digital per se needs to lead to more diagnostic errors. But we need to make sure that providers have the means to match the problem to the solution appropriately. And not all digital is the same, video conferencing is very different to telephone calls and you get a different experience out of a telephone call than you do out of a video call. We’re all learning that as we’ve all been through that journey through the pandemic. Digital means lots of different things. It’s about knowing you’ve got the right tool at the right time in the right person’s journey.
Are there any other misconceptions about digital mental health that need to be addressed?
Probably that not all apps are equal, that there are a lot of people who really want to help people, and have designed great looking apps to support people. But you need an evidence base to show that it actually does something. And ideally, you need an evidence base to show it does no harm.
Sometimes mental health management takes us into really difficult places. For example you might bring together a group of people digitally to a peer support group. If you have no nobody with actual mental health management experience as part of that group and you miss the fact that you’ve got individuals who are expressing suicidal problems who are talking a lot about that with without any moderation, without any signposting to the help that they need, harm can occur.
It’s about making sure that the services are actually fit for purpose that they’re going to provide the support that you’re looking for.
