Can digital therapeutics help the course of mental health management?
Hospital Times Deputy Editor, Niamh Macdonald, spoke to Dr Charlotte Lee, UK Director of Big Health, about how digital therapeutics could transform the NHS approach to mental health management.
With the ongoing pandemic still limiting face to face appointments, digital tools have become profoundly important in maintaining access to mental health services. Mental health apps for conditions such as anxiety and depression have been around since well before the pandemic, offering a pharmacy’s worth of self-management options. However, there is limited regulation around these tools and it is not always clear which have NHS approval.
Digital therapeutics, like Big Health’s Sleepio and Daylight apps, are an attempt to label what is good and effective, taken through an evidence pipeline akin to a drug. Effective digital therapeutics should allow users to self-manage their symptoms, reducing the chances of a visit to the GP or hospital.
The Daylight app is a digital therapeutic for anxiety, while the Sleepio app targets insomnia. Both have been through clinical trials, which saw 71 per cent of patients using Daylight achieve clinical improvement and 76 per cent of patients using Sleepio to achieve clinical improvement.
All residents of Scotland have access to Big Health’s Sleepio and Daylight apps through the NHS, making it the first country in the world to offer digital therapeutics nationally. Draft guidance for Sleepio has also been issued by NICE – representing the first time the regulator has evaluated a digital therapeutic.
“Digital therapeutics are designed to create an extra level of trust and credibility with evidence to say, nine times out of 10 this is going to be very good for you, compared with all of these other products where you don’t even have a statistic. It is about ensuring that when people decide to use a digital therapeutic, they know there is evidence behind it.”
“The service cannot rely on training and recruitment to tackle this demand. It’s not really a case of whether these tools are ‘nice to haves’ or not, they are fundamental to the evolution and indeed survival of mental health services.”Dr Charlotte Lee
A new strategy
During the pandemic, the NHS was forced to switch almost overnight to a digital first model for mental health services. According to a report by The Nuffield Trust, prior to the pandemic around 80 per cent of GP appointments took place face-to-face, falling to just under half of appointments by June 2020.
This digital momentum has shifted attitudes towards digital tools such as therapeutics, making them an increasingly accepted and integrated aspect of care delivery. Dr Lee says that before the pandemic, the NHS “just had one strategy for dealing with increased demand, which was to increase staff numbers”. This, she argues meant “It was extremely difficult to get into some of these services because of the barrier to entry in terms of the culture and the expectation around what digital could actually do for the service.”
Dr Lee describes pre-pandemic mentality to digital adoption as “rapid but pragmatic”. Covid-19 forced the hands of providers, quickly dissipating previous hesitation towards digital forms of care. “There were no questions around whether digital was the right way to go because there was no other option.”
The NHS now faces extreme pressure in moving through an increasingly ominous care backlog and ever-increasing service demand. Despite a record number of 1.5 million people receiving NHS mental health support in June, there was an estimated 1.6 million waiting for treatment in September.
“The service cannot rely on training and recruitment to tackle this demand. It’s not really a case of whether these tools are ‘nice to haves’ or not, they are fundamental to the evolution and indeed survival of mental health services.”
Preventive and proactive care
Dr Lee argues that while the NHS has proven effective at pandemic crisis management, its focus on preventative healthcare has often been lacking.
“The NHS has not been able to achieve a standardised level of prevention and self-care available in the population. They have not been able to collect the data across the population which shows that this is working and is going to be able to prevent people from seeing their GP as often or save money because people are less anxious, so they aren’t going to A&E. With digital therapeutics and the ability for digital innovation to integrate into health records, the longitudinal view is much greater.”
While large populations have relatively low levels of need when it comes to urgent access to mental health services, there are instances where self-management is not adequate and face-to-face services are necessary. Dr Lee believes this can be managed as a stepped service pathway, which caters for ‘high volume’ population that require ‘low touch’ services, as well as a ‘low volume’ population that require ‘high touch’.
She says, “Within the NHS, providers need to be able to harness innovation to connect different services into an integrated pathway that centres around the patient” says Dr Lee.
Developing rich, patient centred pathways can allow for people to be escalated from digital therapeutics into face-to-face care and you can do it in a blended way, such an initial Zoom call to make a diagnosis or establish a relationship.
Equality in mental health services
Navigating a route to recovery for the mental health sector will not be possible without digital tools and therapeutics. However, in striving to increase digital implementation – those without access to digital (either through limited connectivity or in digital skillsets) cannot be left behind. This is partly why GPs and other providers in England have recently found themselves under pressure to increase face-to-face appointments.
“We can’t reach 100 per cent of the population but we have got an untenable situation where those who do not have digital means in England can’t get access and the system is under huge amounts of pressure to see everyone face-to-face so the level of inequality that you would have looking at the system without digital therapeutics is much greater than you have with it.”
Digital therapeutics may not be the answer to solving inequality in access to mental health services, but they offer a trustworthy solution that can be turned to by users in a suitable time and place for them. This can free up capacity for more personalised face-to-face services to reach out to those who are digitally excluded, while providing immediate support for those on a daunting waiting list for treatment.