Turning to Technology for Emotional Support

Canadian and American statistics both show that 1 in 5 individuals experience some form of a mental illness. This number becomes more staggering when we look further into patient sub-populations such as youth and adolescents, or those with lower incomes. Mental health issues are widespread and perhaps more so than many other chronic conditions, requires a truly personalized approach when it comes to caring for the patient. Although mental health has become a priority among healthcare providers, governing bodies (ex. Health Canada, FDA), employers, and even insurance providers, there remain unique challenges to this entire field of medicine.

While we have come a long way in increasing awareness, eradicating stigma, and providing more societal support, people who are affected by poor mental health — both the individuals themselves, and the friends and family around them, — still find it difficult to speak out. And the consequence of this is that they get no help.

This standstill has led to the rise of digital health applications targeting mental health disorders, most common of which include depression, anxiety, and substance abuse disorder. As with all software applications in the healthcare space, the key argument for technology implementation is to improve access for patients. In Canada, there are only 14.68 psychiatrists working in the mental health sector per 100,000 people. In the US, there are 10.54 psychiatrists per 100,000 people. Now when we look to low-income countries, the number drops to 0.1 psychiatrists per 100,000 people. With these statistics in mind, the Center for Disease Control and Prevention in the US reported that only 35% of people with severe depressive symptoms interacted with a mental health professional in 2013. The gap in mental healthcare is dismal!

Symptoms of mental health illnesses include a lack of motivation, fatigue, lethargy, apathy, low self-esteem, and many more. Barriers to receiving proper care are as much external as they are internal, which is why digital solutions seem so appealing. Technology not only improves reach to a broader demographic of patients, an external consideration, but it also allows patients to seek support without fear of judgment, which is a significant, initial, internal barrier.

Digital in mental health can come in the form of telemedicine, digital diagnostics, digital therapeutics, or simply education, and enhancing understanding and awareness of one’s symptoms. As of 2017, there were more than 10,000 mental health applications available on the respective App Stores of Apple, Android, and Google devices. Meru Health came out of a Finnish and Californian collaboration; its product is a digital tool structured as a 12-week program for individuals affected by depression, burnout, and anxiety. It is currently involved in a number of studies and pilots with academic and health system research groups to explore the acceptability, feasibility and efficacy of its platform. Cognoa, another California-based company, is exploring behavioural disorders among paediatric patients. From a diagnostic front, the digital platform seeks to support earlier identification of autism spectrum disorders (ASD) in children between 18 and 72 months, a critical age range in which rapid intervention can translate into improved long-term outcomes; from a therapeutic front, it is looking to improve social skills and responsiveness in children with ASD.

When we look at mental health, we see isolated cases of depression, anxiety, and substance abuse disorder, for example, but many of these also arise as a result of chronic co-morbidities the patient has. It is apparent why there is such a need and push for digital mental health interventions; as a clinician, whether or not you are rooted in the psychiatry discipline, you still see patients affected by mental health disorders.

There are a number of conditions in which depression manifests as a comorbidity — pain, arthritis, diabetes, multiple sclerosis, and many more. An individual’s mental health not only affects their mood, co-existing symptoms (from other conditions), and quality of life, but from a medication perspective, it can also affect treatment adherence. It has wide-ranging consequences even beyond the field of psychiatry itself.

An independent startup, WellBrain, is focusing on mindful meditation as a method to manage chronic pain and to curb addiction to pain medications. Its interactive software allows clinicians to assess patients’ mental health, which plays a role in the complex interplay of pain, depression, and addiction. Shifting the focus to industry giants, they, too, are recognizing the importance of mental health support in the patients they serve. In 2018, we came across the collaboration between Novartis' Sandoz-division and Pear Therapeutics to bring to market reSET and reSET-O for substance use disorder and opioid use disorder, respectively. More recently, in the last month, Sanofi announced its partnership with Happily Health, to create an application centered on cognitive behaviour therapy (CBT) to address mental health challenges in multiple sclerosis (MS) patients.

Before we get too excited about the multitude of apps available to combat mental health illnesses, we need to know what to look out for. How the average consumer discovers apps is still largely through the App Store. Simply typing in the word, “depression,” into the search bar will yield a laundry list of apps, ranging from brain training games to a journal-writing tool. The App Store description, therefore, becomes a marketing tool that developers can use. A paper "Using science to sell apps: Evaluation of mental health app store quality claims," by Larsen et al., reported that “for apps clinically relevant for depression, 38% of App Store descriptions included wording related to claims of effectiveness, whereas only 2.6% provided evidence to substantiate such claims.” We should recognize that a major challenge for patients and healthcare providers alike, is that many of these commercially available mental health apps rely on therapy techniques that have no evidence to support them.

There are companies out there conducting studies, but even with the few available randomized controlled trials (RCTs) or meta-analyses, — generally the highest-regarded levels of evidence, — they have only begun to look at patients with mild-to-moderate depression, which is often self-reported and not properly diagnosed. Much of the affected patients fall into the more severe categories of mental health illnesses and also encompass bipolar disorders, schizophrenia, and other types of anxiety disorders. Secondly, the trials conducted do not evaluate patients for more than 12 weeks, on average, so it becomes difficult to determine the long-term impact of these apps. From a company’s perspective, there are certainly significant challenges — regulatory and financial — that hinder their ability to design more effective trials, but in the end, these become limitations that we need to consider before deciding on a digital health tool.

The American Psychiatric Association (APA) published a guidance document, outlining five key considerations — Background information, Risk/Privacy & Security, Evidence, Ease of Use, and Interoperability, — to help patients, providers, and consumers in choosing a mental health app that works for them.

Digital platforms act as creative solutions that can bridge the obvious gaps in the field of mental health, but we must tread carefully in this movement. We do not want to risk our patients losing trust in these tools that hold true promise. We have to make sure that we do our due diligence and support our patients in navigating their options, because when it comes to mental health, our patients can feel more alone and lost than ever.

Thanks for reading, as always!