The Future of Digital Mental Health Treatment

New international expert consensus statement reports key directions for DMHT.

Posted Jan 31, 2021 | Reviewed by Gary Drevitch

The field of Digital Mental Health Treatment (DMHT) has exploded over the past decade. DMHT includes a wide range of technology-related interventions, such as internet-based Cognitive Behavioral Therapy (CBT), smartphone apps, virtual reality, therapeutic video games, and more recently treatments using artificial intelligence (e.g., therapist bots). Some estimate the number of mental health apps to be well over 10,000 available. DMHTs have the potential to disrupt the current model of mental healthcare, providing access to treatment for many more people, as well as augmenting existing treatments to make them more effective.

However, most of the DMHTs currently available are unlikely to improve mental health care. For example, in a 2016 review, researchers evaluated over 100 CBT smartphone apps (Huguet et
al., 2016); and only 10% actually included CBT principles. Moreover, most apps lacked privacy policies, and none had been tested in clinical trials to determine their efficacy and safety.

Another well-known issue is the difficulty in engaging users beyond the first download (see Torous et al., 2018). Keeping users engaged is hard, even in randomized controlled trials that include compensation and extra attention from research staff. Outside of tightly controlled research studies, app use dramatically falls off after initial download. Thus, there are significant challenges that must be addressed before the potential of DMHT can be realized. 

Europe and Australia have started to overcome these barriers and implement DMHTs in their healthcare systems, whereas the United States has not. A group of 23 international experts published a consensus statement this month outlining the future for DMHTs in the United States. In the "Banbury Forum Consensus Statement on the Path Forward for Digital Mental Health Treatment," these experts reviewed the evidence base supporting DMHTs, as well as the barriers to wide adoption by healthcare systems in the United States.

Here are some of the highlights:

  • DMHTs completed entirely as self-help are helpful; but only if people actually use them. Unfortunately, the evidence suggests that most people stop using DMHTs when they are delivered entirely on their own. 
  • Guided DMHTs are effective. Guided means having some human connection, which could be a clinician or a trained layperson. The connection could be through phone calls or messaging. There is clear support from meta-analyses of randomized controlled trials that specific guided  DMHTs are effective for treating depression, anxiety, and PTSD
  • Guided DMHTs are effective for all severity levels, from mild to severe.
  • Guided DMHTs have been found effective for kids, adults, and older adults.
  • Guided DMHTs are cost-effective.

They went on to make 3 specific recommendations:

  • The United States health care system should adopt DMHTs and offer them to anyone with anxiety, depression, or PTSD.
  • Reimbursement mechanisms (i.e., insurance coverage) are needed before DMHTs can be widely adopted.
  • Ongoing evaluation of DMHTs effectiveness within the healthcare system is needed. 

The authors conclude: "Enabling reimbursement would allow health care organizations to make DMHTs broadly available, with evidence standards that would support the selection of DMHT products and services that are effective and can be sustainably implemented." 

This consensus statement resonates with my personal experience developing and delivering DMHTs at McLean Hospital. For example, in our work we have observed that the coaching role is critical for keeping people engaged with the DMHT. Our coaches check in with users each week and provide support, accountability, and problem solving around app use.

Lack of reimbursement has also been a challenge. Without reimbursement, it is difficult to develop a sustainable system for delivering DMHTs.

As a researcher and clinician who values treatments that work, I especially appreciate the expert group's third recommendation to conduct ongoing evaluation. DMHTs have rich data that can be explored, such as the number of times people open an app and how long they spend on specific components. We can use this data to determine how people are using these tools and patterns of use that are associated with clinical benefit. Developing an infrastructure for ongoing evaluation will help systems determine which tools are effective, for whom, and when.

References

Mohr, D. C., Azocar, F., Bertagnolli, A., Choudhury, T., Chrisp, P., Frank, R., ... & Banbury Forum on Digital Mental Health. (2021). Banbury Forum Consensus Statement on the Path Forward for Digital Mental Health Treatment. Psychiatric Services, appi-ps.

Firth, J., Torous, J., Nicholas, J., Carney, R., Pratap, A., Rosenbaum, S, & Sarris, J. (2017). The efficacy of smartphone-based mental health interventions for depressive symptoms: a meta-analysis of randomized controlled trials. World Psychiatry, 16(3), 287-298.

Torous, J., Nicholas, J., Larsen, M. E., Firth, J., & Christensen, H. (2018). Clinical review of user engagement with mental health smartphone apps: evidence, theory and improvements. Evidence-based mental health, 21(3), 116-119.