Yesterday I read what I thought was a balanced and thoughtful article on Nature. It's long but worth reading to the end. Today I read an article in the Guardian commenting on the Nature paper that is—I believe—less well thought out. I will make comments on both.
Let me start with the Nature article. This is my TL:DR version. The article talks about the fact that there is an obvious need to provide mental health services at scale. It is very hard to achieve this scale in the developed world—let alone the developing world. Lots of people have smartphones so maybe they can provide a way to solve this. It laments that while the idea had caught on, tons of the apps available have not been tested in any way. It goes on to say that some have gone through some testing but most haven't and that the science is in its infancy but growing. It also highlights the issue of data confidentiality and privacy, as some apps don't take basic precautions to protect users' data. There is no clear regulation for them and some could be well-intentioned but actually harmful.
Note how all of the comments could also be made of herbal remedies and vitamin complexes sold in supermarkets or 'health shops'. They could also be made of self-help books out there. Some are very good, some are potentially harmful and they remain unregulated. I believe they should both be clearly regulated as well.
It is in our interest here at Thrive that apps become more regulated and there is a clear way for consumers which are 'scientifically proven' and which are 'lifestyle products'. We make the effort of developing our apps based on proven methods that have been already shown to be helpful in trials and then we test our apps ourselves in collaboration with various universities. Yet, you as a consumer cannot tell we have really done this other that because we tell you we have. In the UK the National Information Board is working to resolve this and is creating a certification system for apps, but it will be a while yet before it is ready. We are are currently participating in the pilot trials to check that the way they test apps really works.
Who is the Guardian guarding?
I could not agree more with the main point the author makes: most mental health problems are isolating and we need support from others when we are going through them. The evidence bears that out, people with mental health problems with good social support do better than those without.
She also makes another very important point, with which I also wholeheartedly agree. Mental health problems are very frequent yet they carry a lot of stigma and this is part of the problem. This stigma creates a very unhelpful situation for the person making her or him unwilling to seek help (only 1 in 3 seek help on average) and, as people are not aware of what to do, knowing that the person has a mental health condition makes them pull away. She says that she wants to live in a world where it is 'neither brave nor unexpected to talk about mental health problems'. Spot on, I want to live in that world to.
My problem is with the way she connects this two very important issues to apps. She seems to draw the conclusion that since apps are on your phone that they will increase isolation and make the problem worse, not better. This, I believe, comes from a misunderstanding of how technology would be ideally used. She says in her article:
To truly help people achieve recovery, or at least management, of mental health issues, we need to regard it as a community epidemic. Maybe some apps can contribute to that. But real, living humans will play a far more important part.'
I don't think anyone disputes that people are the most important component of the solution. Both Seamless and Petfinder, apps that she mentions at the top of her article, use mainly people to provide their solutions. People empowered by technology to achieve more in less time with fewer resources. To date we have not invented yet a truly intelligent computer. When that happens all bets are off, but for the moment only people can solve the problem.
She ignores the fact that most of the evidence-based apps are about making communication easier between people. Some apps can provide training for carers to care better. They can be way to give the public at large some training in mental health first aid so people know what to do to help. Their very popularity can help reduce stigma as it might be easier to talk about the apps you use than the condition itself. If you use an app that gives you access to a massive community of other people affected it can help you connect with others, realise you are not alone and give you the courage you need to seek further help. Without the technology you would never meet those people. They can make communication between therapists and individuals more effective, quicker and easier for the person affected. They can teach you the basics and help you complete exercises between therapy sessions saving valuable time to focus on what is important with the therapist. They can detect problems early and prompt you to seek face to face care if necessary. They can also help you find this care.
Let's take the extreme case though—an app as a purely self-help tool to treat say mild depression. I will assume that it passes the Nature test, it has been designed using evidence-based methods already established by research, it has undergone a clinical trial and it handles the data privately and securely. It does not have any community features and it does not serve as a communication platform between the person and a therapist. In an ideal world, as she says, everybody would be talking to everybody about their mental health and there would not be any reluctance to seek help. Two issues with that:
- it is unlikely that everybody would chose to talk to someone else. This 2011 study by Britt Klein and colleagues highlights that when given the choice 98% people opted not to have a therapist and chose to go through a completely automated programme. The Guardian author assumes that her preference is everyone's preference. I have had many people sitting in my clinic telling me 'going to talk to somebody' is not for them and could I just give them a tablet, please.
- If we cannot cope with only 1 in 3 seeking help now, how will we ever cope if the other 2/3 manage to come forward?
At present most services focus on the most severe conditions and the ones that carry the most risk leaving the great majority waiting for a very long time for help. with the best will in the world you can never have enough people to give face to face therapy to all that would benefit. It is not just training people, it is also supervising them, making sure they are up to date and that they are doing their jobs well. Remember, this huge number of 'therapists' would be looking after people during a very vulnerable time. Unfortunately that creates the opportunity for abuse and you would have to have the resources to also ensure that doesn't happen, yet he Care Quality Commission in the UK is stretched as it is. But don't take my word for it, here is a paper published in the American Journal of Psychiatry where the two authors do the math and come to the conclusion that we need technology to help solve the problem; training more people will never be enough.
Let me take mild clinical depression for a minute. It is the most common presentation of depression by far with 73% of all cases (from this 2011 paper in JABFM). It is only 'mild' in relative terms; it is still a significant condition that will cause people suffering and render them unable to function normally for quite some time. We know that medication is not particularly good with mild depression; psychological treatments are better. The problem is that they take time. You need to see a person during working hours once or twice a week for a few weeks. Bearing in mind how common it is how do you pay enough therapists to do this without bankrupting even the most extravagant of health budgets? The answer is you can't even with programmes like Increased Access to Psychological Therapy.
- We need to reduce stigma around mental health
- We need to support people with mental health problems in the same way we support people with any health problem
- Technology has a tremendous potential to increase access, facilitate help-seeking behaviour and connect people with mental health problems to peers, therapists and carers
- Apps need to be evaluated as any other intervention should
- Apps need to guarantee user privacy and confidentiality
- The public should be informed about what interventions have been thoroughly tested and which have not and the public needs to take an interest in this