Personalising digital mental health treatment
In the age of smartphones and virtual reality, NHS trusts must evolve their approach to reach patients, and can look towards a future of clinically proven personalised digital therapeutic treatments to better treat and manage mental health conditions.
Now, more than ever, reliable and sustainable ways to communicate information between patients and healthcare professionals are essential to find and deliver treatment.
We know that using technology to improve patient experience works, yet the experience for many patients within the NHS hasn’t significantly changed over the past 10-20 years. In primary care, people are usually still required to visit a GP or mental health service for a face-to-face appointment, during business hours, on a working day.
While some aspects of the process are modernised, with appointments and order repeat prescriptions available to request online, the NHS has only begun to scratch the surface of the digital solutions that could help deliver more efficient and potentially more effective mental health care to local communities.
Good mental health services are vital to the health of the country and the NHS Long Term Plan has identified the use of decision-support tools and machine learning as key to augment the ability to deliver personalised care and predict future behaviour.
Ultimately, the objective of an increasingly digital approach aims to facilitate health care services to become more accessible and personalised, and to strive for better outcomes for people using mental health services.
Reaching all mental health patients
Around 17.7% of adults in England meet the diagnostic criteria for at least one common mental health disorder. Of the 1.6 million mental healthcare patients referred to Improving Access to Psychological Therapies (IAPT), 76.6% require Step 2 primary care, and over half of them go on to require Step 3 therapy. These statistics are what the government uses to set patient access targets.
In order to attract patients to use therapy, traditional bricks and mortar services have worked hard to engage with the healthcare system in order to reach the access targets. They have educated GPs, traditionally the gatekeepers to NHS therapy services, about talking therapy as an alternative or complementary treatment to medication. From our interaction with services around the country, we have observed that these traditional routes to find individuals suffering from mental health conditions are well exploited leaving little scope for increasing patient numbers. The access target has been continually raised and services are starting to struggle to hit it because the methods used only reach a certain population.
Unless talking therapy service providers start thinking about how they could do things differently they will simply not be able to keep bringing in increasing numbers of patients and meet government targets for referrals. The shortfall varies from area to area, but most are typically a few percentage points below where they should be. These few percentage points can represent tens of thousands of people nationally who should have been referred to talking therapy but have either not been made aware of or simply can’t access services available to them due to work, caring or transportation challenges.
We know inequality exists in access to treatment generally. NHS trusts are working to increase referrals from hard to reach communities such as black and minority ethnic groups, individuals with long term conditions, those too unwell to travel and older populations. Having a different way of accessing treatment is key for these groups, and the NHS trusts must evolve their approach in order to meet target patient numbers for treatment.
Solutions to these challenges involve using both traditional and digital marketing to reach patients beyond the traditional reach of primary care. Integrated methods of communication that include digital at every step of engagement are needed to enable more people to seek treatment, continue to engage, and remain in touch with the support they need.
From targeting, to referral and the therapy itself, these methods are making a big difference for patient reach in some areas in the UK. For example, in Surrey, an ongoing integrated campaign comprising digital content campaigns over social media, search engine optimisation, radio advertising, leaflet door drops, outdoor large format advertising and community outreach has contributed to digital treatment accounting for 20% of all step 3 patients. This complements bricks and mortar provider marketing efforts and has continually resulted in success for Surrey in achieving access targets since the approach was adopted. The costs of these marketing efforts are solely born by the provider.
Not all digital therapy apps are clinically effective
In their private search for help, more and more people are downloading self-care apps on their mobile phones. While they have a place in subclinical depression and anxiety, patients that are clinically at ‘caseness’ later realise that most of these do not offer the level of help they require, and their failure to get the help may have resulted in a deteriorating condition.
Many mental health apps focus on delivering ‘one size fits all’ self-guided wellness programmes but neglect the core human elements of one to one care that drives effective engagement in order to complete a required ‘dose’ of therapy. It is our responsibility to ensure that people understand that consumer market generic apps and digital tools are not sufficient treatments for Step 2 or Step 3 patients.
Step 2 and 3 patients are best supported by qualified psychological well-being practitioners or high-intensity therapists, as specified in the current NICE guidelines. These guidelines assess the efficacy of all treatments and make recommendations based on the suitability of that treatment. It is important to remember that they are only guidelines. NICE approved Step 2 treatments are for individuals with mild to moderate mental health difficulties such as depression, panic disorder, social phobia and obsessive-compulsive disorder (OCD). Step 3 treatments are for people with moderate to severe mental health difficulties, including generalised anxiety disorder (GAD) and post-traumatic stress disorder (PTSD).
Prior to the start of treatment, all individuals should receive a comprehensive personalised assessment. Their clinical, work and social outcomes should be evaluated using standardised measures that are appropriate to the conditions they suffer from. An efficient application should be able to prompt patients and raise awareness of a problem, facilitate the initial connection with the help they need, provide tailored digitally-enabled therapy, and support recovery and maintain long-term wellbeing.
Although the UK health industry supports the notion that the future of healthcare lies in digital personalisation and artificial intelligence, digital service providers need to remember that these services are first and foremost for people. Personalised experience driven by data and a better understanding of clinical outcomes could solve the problem and change the dynamic between the patient and the clinician. The technology is simply the enabler to better treatment.
Achieving personalised digital therapeutics
The way people use NHS services has changed over the past ten years; patients now expect to have the option of accessing services online, at a time and a place convenient for them. The NHS has also publicly shared its desire to take steps towards increasing online accessibility and the use of technology to support good, effective and safe care.
Meanwhile, the healthcare technology industry is starting to use and analyse medical data to a much deeper level, creating insight and understanding that was never possible before thanks to the development of new techniques in machine learning. Data scientists are applying deep learning to pools of clinical data to extract clinical insights in a way that could fundamentally change our understanding of how treatments work.
Mental health therapy’s greatest challenge is a lack of systematic methods for measuring the treatment delivered because psychotherapy is comprised of a series of one-to-one discussions.
Technology can address this challenge with functionalities like real-time instant messaging. The patient and therapist conversations can be captured as transcripts and translated into quantitative and qualitative data.
Thanks to deep learning models, we can then extract knowledge accumulated across thousands of hours of cognitive behavioural therapy (CBT) in a way that would be impossible for a human to do. We now know, for example, which elements of a treatment session are most likely to have a positive effect, and those that have a negative effect on the predicted outcome of a patient’s therapy.
Digital platforms enable us to use deep learning to understand what works and to constantly improve outcomes. Data-powered clinical decision support tools already give therapists the best chance of making an accurate diagnosis. These digital tools consequently enable the delivery of more effective and personal treatment which increases the chances of engagement and recovery.
Over the next decade deep learning and other computational approaches will not only revolutionise traditional treatments but will bring about new and improved digital apps and services brought to market. Assessments and treatments will be undertaken with a better understanding of the genetic, behavioural and environmental context of the patient.
People will always want the reassurance of a real person to talk to. However, personalised and scalable digital therapeutics will be developed and become available which will complement and enable the very best in human clinical practice in a personalised way to better meet the needs of each individual.
In today’s device-driven world, the use of apps has become commonplace. But as an industry we must strive for better when it comes to mental health apps. By quantifying and analysing associations between interventions and outcome to gain an understanding of therapy-related language and the most effective aspects of psychotherapy, we can create digital therapeutics tools to make mental health treatment more efficient, effective and accessible to all.
About the author
Charlotte Housden is COO of Ieso Digital Health.