Can Digital Mental Health Make a Difference?

There is no disputing that we are currently facing a crisis in mental health care. Even before the coronavirus crisis, there simply weren't enough psychologists, psychiatrists, and other health professionals for people in need.

Nearly one person in five suffers from some form of mental or substance abuse disorder, and the costs to society, including reduced productivity, death rates, and medical disability expenses, are a major drain on health care systems across the U.S. But, despite a rising need for mental health services, the actual number of health professionals providing these services is barely holding steady. According to a 2019 report released by the Health Resources and Services Administration, the supply of workers in selected behavioral health professions will be approximately 250,000 workers short of the projected demand in 2025. And a 2017 report from the physician search firm Merritt Hawkins, titled "Review of Physician and Advanced Practitioner Recruiting Incentives," indicates that psychiatrists will be in particularly short supply.

At present, the U.S. Department of Health and Human Services estimates that 111 million Americans live in "mental health professional shortage" areas, a problem that will likely grow worse with time. Not only are most current professionals 55 or older and facing retirement over the next decade, but most new graduates prefer to practice in the larger cities. As a result, many rural areas have little or no available resources for people in need. Even though many of them may seek help from primary care physicians and emergency hospitals, this is often not as effective as getting help from professionals with specialized mental health training. While graduate schools continue to provide new therapists, the current shortage will likely get even worse in time.

But can digital mental health help make a difference? We are currently seeing a sharp rise in the use of video teleconferencing, telephone therapy, Internet-delivered text therapy, and a proliferation of new smartphone apps, all designed to provide some form of treatment for people experiencing mental health problems. The kind of services offered typically offered fall into two basic categories:

• Synchronous — Basically involving real-time communication between clinicians and patients through video conferencing, telephone conversations, or webchat. By allowing real-time interactions, synchronous services are similar in many ways to traditional in-person treatment.
• Asynchronous — This involves any kind of client-clinician contact that isn't in real-time. This includes email conversations, accessing information through websites, and using automated services provided through websites, phone apps, and audio or video presentations aimed at teaching relaxation and other coping skills.

For now, at least, asynchronous services such as treatment-based phone apps are still in the very early stages of acceptance, and the jury is still out on how effective they can be with many clients. At present, though, there are more than 300,000 mental health apps currently available, and more are coming on-stream every day. In 2018 alone, 400 million of these apps were downloaded, a 15 percent increase over downloads in 2016 and 2017. Most of this increase comes from U.S. and Chinese consumers and reflects the growing trust that users have with digital apps handling sensitive health care data, especially considering the full range of medical services that are becoming available online.

Among the smartphone apps that provide access to telemedical care, the most highly rated is Teladoc. Founded in 2002, Teladoc is the oldest telemedicine company in the United States. With an expert network of 55,000 medical professionals covering 450 medical specialties, Teladoc users can receive non-emergency advice on virtually all medical issues, including mental health problems.

Though some medications can be prescribed remotely, users can also be directed to emergency services depending on the nature of the crisis. There are numerous other "doctor on-demand" services that can be accessed remotely, and they are increasingly being used for mental health services by people who are either unwilling or unable to get help in-person.

It's probably no surprise that telepsychology and telepsychiatry are becoming especially popular in countries facing major challenges in providing care to people living in rural areas. Since the stigma against mental illness is often strong in many places, being able to access these services from the privacy of one's own home is particularly popular. There is also the appeal of reduced costs since providing these services eliminates the need for traveling long distances or having to find accommodation in other cities while receiving treatment.

Which is why many insurance and government agencies are encouraging this new trend. In the United States, for example, Medicare and Medicaid provide reimbursement for many different mental health services, including seeing patients in their own homes via webcam and high-speed Internet service. To avoid problems with doctor-patient confidentiality, specialized platforms have been developed that are compliant with federal standards for safety and privacy.

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As the digital option becomes increasingly available, many psychiatrists and psychologists have started using telehealth services to deal with patients who might otherwise have difficulty accessing their services. This includes patients who have mobility problems, elderly patients, or patients who would otherwise need to commute long distances to get help. Emergency telehealth services allowing clinicians to deal with patients in crisis (i.e., people who are actively suicidal or experiencing acute psychotic episodes) are also becoming increasingly used to provide faster assessment and treatment. As a result, many facilities that are traditionally understaffed, such as prisons, critical care units, or community mental health centers, can provide direct care from trained mental health professionals instead of relying on primary care physicians alone.

Early research suggests that telemental health is extremely popular with clients and treatment providers alike. While there is an age bias at work with younger clients being more open to digital services, older adults can often benefit as well. Female clients also appear more accepting than male clients overall (so long as concerns about privacy are satisfied). Based on personal satisfaction alone, telemental health seems ready to go.

But how effective are telepsychology and telepsychiatry services compared to more traditional mental health care services? This is a harder question to answer since it often depends on which services are being provided. Studies looking at using videoconferencing to conduct clinical interviews with children, seniors, or people with neurological problems suggest that it can be an adequate alternative to in-person interviews in making diagnoses and treatment recommendations.

As for actual treatment effectiveness, a 2019 study examining synchronous telepsychology interventions for depression, anxiety, post-traumatic stress disorder, and adjustment disorder indicates that video-teleconferenced therapy sessions and sessions conducted over the telephone can be as effective as face-to-face treatment. With web-chat-based treatment, however, there still aren't enough studies to make any kind of real conclusion on the effectiveness of this kind of treatment. Only further research will establish whether this is a valid alternative to other forms of telemental health, and for now, therapists and clients will need to use their own best judgment of how and when these services are offered.

Many more studies are still needed, especially in exploring many of the ethical issues surrounding telemental health, including guaranteeing client-therapist confidentiality, as well as making these services cost-effective compared to traditional approaches. We also need to explore how effective telemental services can be in treating and assessing clients across the age spectrum, as well as seeing how useful it can be with clients from different cultures. For now, we're still in the relatively early stages of making telemental health services more available to people in need. Though it won't replace face-to-face treatment for many people, it can still be a viable alternative to avoid having to travel long distances for help.

It will likely take a while before telemental health care lives up to its early promise, however. Not only are many mental health professionals slow to take advantage of new technology, but many people needing help also aren't even aware this option exists. There are also issues in terms of confidentiality and the actual quality of services being provided. Not every online web-based or smartphone-based application is going to meet standards set by agencies such as HIPAA or professional regulatory bodies.

For now, it's important for potential users to do their homework and talk to their own primary care physicians about whether in-person or telemental services are the best option. Still, this is an area that is constantly changing. What we will be seeing in 20 years time is anyone's guess.