What are the challenges of digital mental health care solutions?

The demand for better mental health care is on the rise

The demand for accessible, low threshold  mental health care is on the rise and digital interventions are a good way of meeting this demand. With Covid 19 severely restricting traditional face-to-face appointments, digital solutions were forced to take a leap from nice-to-have add ons to providing efficient interventions and treatments. It is crucial that mental health services are scaling up to meet the increasing demand, but what kind of challenges are there in providing accessible and effective interventions?

Current barriers for mental health care

In a recent review Lattie et. al (2022) address some key issues in planning digital mental health interventions (DMHIs). In order to reach those in need, the mental health interventions face barriers such as the stigma attached to mental disorders, privacy issues, cost and time constraints and the lack of resources for proper interventions in primary health care. On the surface DMHIs seem to provide a good opportunity to overcome these barriers. As we see it, there are at least two important factors to consider: What are the methods and what is the purpose of the DMHI.

Self-help and beyond

The review examines both guided interventions that are used interlaced with traditional interventions and self-guided material that the patient is meant to use independently. Self-guided interventions are a very attractive idea, because they are scalable. However, with purely self-guided digital interventions we stand at risk of losing the personal contact and flexibility of the intervention. If the intervention is merely a todo-list of exercises and modules, we would argue that it doesn’t enable the reflective building of understanding that can be achieved in more traditional discussion-based methods.

General or targeted?

Another noteworthy issue is that all the interventions reviewed by Lattie et. al seems to be targeted by themes or diagnoses. This means that the patient needs to know what their problem is before they can seek help by choosing the most suitable digital intervention. This either requires the patient to be able to reflect their own situation quite well or an evaluation and recommendation from a mental health professional. Either there is a risk of not choosing the best intervention or having the familiar bottleneck for effective treatment: an appointment with a mental health professional for reflecting, identifying and formulating the problem and making recommendations of the next steps.

For a good cause

As Lattie et al. put it, the goal is to genuinely improve the accessibility for mental health intervention, or to quote "To fully realize potential, interventions must be capable of eliminating, or at least narrowing, disparities in access to mental health care." 

This means that we need to consider the evaluation process as part of the intervention and ensure that digital solutions or DMHIs can assist in both evaluating the situation, formulating the issue that needs to be worked on and/or assist in the actual intervention.

Avoiding past mistakes

The final challenge to consider is to avoid a well-known pitfall of digital tools: incorporating and automatizing existing inflexibilities and biases. Nebeker et al. (2019) have provided a checklist for research into DMHIs and their ethical principles should also hold for clinical application of DMHIs: 1) Respect for persons, 2) Beneficence, 3) Justice and Respect for Law and 4) Public Interest. The principles  are adhered to in healthcare practice legislation. For clinical application of DMHIs we consider the first principle of respect to be the most challenging.  If the intervention is too structured and solution-focused, we risk that it reflects the values and assumptions of the designers. The challenge remains to build a digital intervention that works respectfully and builds genuine understanding together with the patient using it.

Lattie, E. G., Stiles-Shields, C., & Graham, A. K. (2022). An overview of and recommendations for more accessible digital mental health services. Nature Reviews Psychology, https://doi.org/10.1038/s44159-021-00003-1\ 

Nebeker, C., Ellis, R.B., Torous, J. (2019). Digital Health Checklist for Researchers (DHC_R) Accessed on November 7th 2022 from ReCODE Health https://recode.health/tools/