Mental healthcare gaps are being plugged by apps – should we be worried?
England is suffering the biggest hit to its mental health in generations exacerbated by the pandemic, and the NHS is working flat-out to respond to an unprecedented demand for specialist mental health care.
Dr Adrian James, President of the Royal College of Psychiatrists, says: “The warning of the long tail of mental ill-health caused by the pandemic has not been heeded. Many thousands of people will be left waiting far too long for the treatment they need unless the government wakes up to the crisis that is engulfing the country.”
Mental health services received a record 4.3 million referrals last year – the highest number to date – according to NHS data reviewed by the Royal College of Physiatrists. The analysis revealed there were another 3.3 million referrals to adult services and 1.025 million referrals of under-18s in England between January and December 2021. When the Omicron variant of Covid-19 arrived in December, a record one million people received specialist treatment for anxiety, depression, eating disorders and post-traumatic stress disorder.
There are 1.6 million people on the waiting list for specialised mental health treatment, with a further 8 million unable to join the waiting list but would still benefit from support, according to the NHS Confederation. There are worrying projections suggesting that 10 million people, including 1.5 million children and teenagers, will need new or additional support for their mental health over the next three to five years. The Confederation has pleaded for the government to publish a comprehensive recovery plan to deal with this “second pandemic” of mental health issues, where millions of patients are facing life-threatening waits for treatment.
Rather than twiddling thumbs and waiting for the government to deliver a concrete plan, many of those suffering from mental issues have resorted to downloading mental health applications – also known as “mHealth” – for help. The pandemic and subsequent lockdowns saw a 200 per cent rise in the use of mental health apps, and they continue to grow at an average rate of 55 per cent, according to the Organisation for the Review of Care and Health Apps (ORCHA).
“Every day 5 million people will download a health app and that’s increasing all the time,” said Liz Ashall-Payne, the founding CEO of ORCHA. Her organisation saw a 25 per cent increase in the downloads of health apps from pre-pandemic up until now.
An ORCHA 2021 report, which shed light on the nation’s collective mental health during lockdown, disclosed that searches for apps for critical mental health problems rose exponentially. Searches for depression rose by 156 per cent, OCD by 422 per cent, anxiety by 422 per cent, and stress by 113 per cent. The most searched apps were those relating to mindfulness and relaxation, which rose by 2438 per cent, and 437 per cent, respectively.
In a statement on ORCHA’s website, Ashall-Payne, said: “High quality mental health apps have more than proved their worth during the pandemic and beyond. Studies, including one in The Lancet, have shown that e-therapy can actually be more effective than face-to-face therapy – and less costly. Clinicians are increasingly looking at patients holistically and including mental health support as wider care pathways supporting stroke recovery or weight management, for example. Health apps are a perfect way to provide this extra support.”
There seems to be an app for every minutia of your daily routine, and this applies to mental health, where mHealth apps can be a cost-effective and scalable solution. There are now around 20,000 mental health, with the two most popular being downloaded are Calm and Headspace, which focus on mindfulness and meditation. While some applications like Talkspace and Betterhelp connect you with a licensed therapist, a substantial portion of the market is humanless; where chatbots offer cognitive behavioural therapy (CBT), there are automated mood trackers and apps designed to help PTSD through exercises such as deep breathing.
The market for these apps is vast; nearly 800 million people worldwide, or 11 per cent of the global population, live with a mental health condition. Deloitte Global predicts that global spending on mobile mental health apps will reach close to US $500 million in 2022, assuming an annual growth rate of 20 per cent.
ORCHA saw a 6,500 per cent increase in healthcare professionals recommending technologies to their patients throughout the pandemic, and more NHS Foundation Trusts are supplementing mental health provisions with mental health app libraries. As these apps are being prescribed to supplement treatment and help patients self-manage their mental health, it begs the question: how legitimate and effective are these mHealth apps?
A growing body of evidence supports the effectiveness of digital-first interventions, even for those with diagnosed mental health conditions from depression to body dysmorphia. Meta-analyses of trials covering more than 20 mobile apps found that using them alleviated and reduced symptoms. A similar analysis of anxiety treatment apps found that users had a reduction in symptoms after use, with the greatest reduction when the apps were paired with face-to-face therapy.
Though apps might have significant potential to address the shortage of psychiatrists and lack of mental health care, especially in rural regions, their efficacy remains contested. Research looking at randomised controlled trials of mobile app interventions with almost 50,000 patients did not find “convincing evidence” that any mobile app intervention greatly improved outcomes related to people’s anxiety, depression, thoughts of suicide, or feelings of well-being. Similarly, another UK study by the National Library of Medicine studied the effects of the most popular computerised CBT programmes (Beating the Blues and MoodGYM) and found that app-based CBT did not substantially improve depression outcomes compared with regular GP care.
There is also a risk of downloading an unapproved, non-recommended and a potentially unsafe app. No regulatory body actively vets mental health apps, leaving users to navigate a myriad of options that range from expert-recommended to potentially harmful in what has been deemed the “wild west of therapy.”
Evidence is also mounting that there are significant privacy risks where users’ “emotional data” can be hacked, as many apps are not transparent about their security features, and less than half of mobile apps for depression have a privacy policy. Talkspace, for example, which offers mental health treatment online, allegedly data-mined anonymised patient-therapist transcripts, with the goal of identifying keywords it could use to better market its product. Talkspace denies these allegations.
More recently, Crisis Text Line, a non-profit that “provides free, 24/7 mental health support via text message” to help people cope with traumas such as self-harm, emotional abuse and suicidal thoughts, was lambasted for sharing anonymised data from its users’ text conversations with Loris.ai, a company that makes customer service software.
This is highly problematic given the rise in demand for such apps due to the mental health crisis. Nicole Martinez-Martin, an assistant professor at the Stanford Centre for Biomedical Ethics, told TechRadar Pro that the Crisis Text Line case “exemplifies the power imbalances and potential harms that exist in the larger system” of digital mental health. She pointed to “regulation, as well as additional guidance at a few different levels, for developers and for clinicians using these types of technologies” as steps we can take to tackle these risks.
While the pandemic opened minds to the vast potential of technology and the accessibility of digital health, it has also exposed cracks in the system regarding security, privacy and efficacy issues. Of course, apps are an easy-to-access, affordable, convenient option for those seeking treatment. They can also provide avenues for anxious adolescents afraid to voice their concerns, for those afraid of the stigma, and for busy parents who don’t have time in their schedule to fit in face-to-face treatment.
It’s hard to deny that mHealth apps have vast potential in symptom improvement, but only if this works in tandem with therapy – rather than replacing it. While it may be a more efficient way to get help quick, having a safe and secure place to voice your anxieties and seeing your concerns validated in the eyes of a licensed professional is a pivotal part of successful treatment. By itself, an app will not mimic the human element of this relationship, but it can be a key ingredient in treatment, working as a symptom tracker, daily reminder, or a means to set goals and share progress.
If the appificiation of mental health is to continue at the pace it is and we are to tackle this “second pandemic” of a spectrum of mental health issues, these apps need to be scrutinised more closely, and seen as a tool but not a treatment in itself. If this happens alongside a fully-funded and long-term plan to reduce treatment waiting times, expand mental health services and staff, we will have a chance to turn the tide on this new pandemic.