Digital interventions in mental healthcare: the road ahead

On 21 June 2023, NHS leaders and health experts convened at the SilverCloud® by Amwell® Digital Mindset conference to address the present and future challenges facing the UK’s mental health services.

Hosted at The King’s Fund in London, the conference explored the role of technology in alleviating pressures on NHS services, as well as in tackling the wider issues around access to care and mental health waiting lists.

Data from the National Audit Office indicates that the proportion of talking therapy sessions conducted over the phone increased from 21 per cent to 60 per cent between 2019 and 2022, while video sessions increased from 2 per cent to 26 per cent.

With these figures in mind, speakers at the Digital Mindset conference discussed whether digital interventions, introduced in the appropriate context and setting, could take the pressure off NHS services by helping people stay healthy, thus requiring less in-person treatment.

Much of the discussion focused on the role of digital mental healthcare against the backdrop of the pandemic. With covid-19 having prompted more care providers to adopt digital services, the conference heard from healthcare professionals, community providers, charities and business leaders on how they were using digital interventions to promote and improve mental wellbeing among patients and service users.

The conference also addressed more pressing challenges facing the UK’s mental health landscape. To what extent, for instance, can digital interventions support the treatment of people who are referred to children and adolescent mental health services (CAMHS)? Likewise, what are the opportunities for moving mental health support outside of healthcare settings and reframing the conversation to focus on prevention and self-care, as opposed to treatment?

A prevailing consensus among conference attendees was that integrating digital tools into the mental health service chain was not merely an option for the future, but an imperative for the present. If that’s the case, advocating the use of technology in mental healthcare isn’t just about promoting innovation: it’s about supporting the entire healthcare system and its users.

While recent advancements provide a promising foundation, the integration of digital interventions into existing NHS mental health services is a complex and ongoing process

Digital health interventions became a lifeline for NHS services and their users during the initial waves of the covid-19 pandemic, which put mental health services under strain during a decisively challenging period.

The impact has been dichotomous. While digital solutions have become more common and accepted in parts of the NHS than they were prior to 2020, they have also introduced new challenges into the mix, both from an IT standpoint as well as in the provision of care itself.

Sean Duggan, chief executive, Mental Health Network at NHS Confederation, recognised the benefits of digital innovation in the healthcare system, but acknowledged the NHS’s ongoing struggle to do “imaginative and progressive things with digital” due to outdated infrastructure.

“By and large, it’s clunky old systems that we’ve had within the NHS,” Mr Duggan said in his opening address.

“Alongside that, the regulation will have to improve, we have to have investment, and we have to support all you guys coming up with all the innovation.”

Funding presents a particularly stubborn sticking point, said Mr Duggan, who reflected that mental health rarely took precedence when money was available: a subject he said he was “sore about”.

“In order for us to really tackle this and catch up, we do need some capital, and of course, every time there’s any capital, mental health doesn’t fare very well.”

Despite these complexities, many argue that technology can help meet the level of mental health need currently being seen, while also addressing the complex and often highly personal nuances of mental healthcare.

A session about mental health in work settings explored the concept of “digital touchpoints” as a means of engaging with people who might struggle to engage with face-to-face therapy, either a result of their socioeconomic situation or the nature of their work commitments, or because of the nature of their mental health issues.

Laura Rodger, lead senior health practitioner, work and health programme at Ingeus, told the story of a young woman whose anxiety prevented her from leaving the home to meet a therapist in person, but was eventually able to engage in treatment after enrolling in a digital programme offered by SilverCloud® by Amwell®.

Not only did this mean she was able to access mental health support, but it also significantly improved her employment prospects. “This is somebody who really struggled with getting to the offices to attend her appointments; she had to be accompanied on public transport and to her appointments,” Ms Rodger said.

Mr Duggan expressed his belief in the potential of digital solutions to help with more immediate NHS targets, including the reduction of waiting times for mental health services. “Good digital mental health solutions help with that, and they help with it in practice: it’s happening now,” he said.

The journey ahead calls for an understanding of the complexities of the digital mental health landscape, underpinned by solid data, active clinical involvement, and a clear alignment with the overarching goals of the NHS

Mr Duggan also voiced optimism about recent financial commitments towards digital mental health from NHS England and the government.

However, he raised concerns about the lack of coordination in planning and spending and highlighted what he viewed as a key problem in the mental health sector – a lack of centralised data.

“We come across this time and time again: you go into an organisation and they’ve got good data themselves… but that is not centralised, that is not controlled centrally,” he said.

“We’ve got to share good practice so that we can get some consistent, good practice right across the country… We need to coordinate it and make it part of the fabric, the DNA going forward.”

A similar sentiment was shared by Steve Skinner, service development lead, adult mental health community division at Lincolnshire Partnership Foundation Trust, who said one of the biggest challenges was the complexity of sharing information consistently between care settings.

“I think the elephant in the room is around information sharing and governance as a whole,” said Mr Skinner. “It’s been a big thing across Talking Therapies services [formerly IAPT], where there’s multiple providers… That [issue] won’t go away, and we need to work on it.”

The question that remains is how quickly digital interventions can be mobilised at scale. Mr Duggan noted the current disparity in speed between rapidly-evolving digital companies and the NHS, which is trying to keep pace.

“What I see is brilliant innovation, creativity, and good, evidence-based solutions on the digital side,” he said.

“I’m just a little bit worried that we’ve got digital companies that are really good at moving at speed, while the NHS and social care are playing a bit of catch up.”

Indeed, the journey ahead calls for an understanding of the complexities of the digital mental health landscape, underpinned by solid data, active clinical involvement, and a clear alignment with the overarching goals of the NHS.

The challenges that stand in the way – unforeseen costs, protracted implementation timelines, and requisite cultural shifts – are undeniably daunting. Yet the consensus is clear: abandoning digital solutions is not an option. Persistence, in spite of these challenges, is the only way forward.

Digital mental health interventions can offer flexible and familiar support environments that meet the needs of a tech-native generation

While research is ongoing, early evidence suggests that digital therapies can be an effective tool in supporting children and young people with symptoms of anxiety and low mood.

Helen McGlinchey, head of service and clinical lead at Yorkshire-based mental healthcare provider Northpoint, shared an example of a Year 6 boy who suffered from anxiety that intensified during lockdown. Once he started Year 7 at a new school, he felt unable to leave his home.

“We offered various options and support in terms of face-to-face therapy in alternative venues to the school, and he just felt unable to access that,” said Ms McGlinchey.

“But when we had the digital option, with the support of a therapist, he was really open to that, and that then enabled him to get back into school and into therapy.”

SilverCloud® by Amwell® programmes are designed to support the NHS’s Stepped Care model, offering patients self-management tools and interactive modules that can be used while they’re waiting for face-to-face treatment, in-between therapy sessions, or as a post-treatment continuation of their care.

Since introducing SilverCloud into its services in 2019, Northpoint has supported more than 1,500 children and young people, according to Ms McGlinchey. Its school-based therapy service currently has 640 children and young people in treatment, 20 per cent of whom are receiving digital treatment options.

“As an intervention, it’s proven to be really beneficial,” she said. “It can be offered as an intervention or as holding support whilst a child or young person is waiting for face-to-face therapy treatment. It can also be offered following that to really help sustain strategies.”

Laura Artis, clinical lead at CAMHS gateway, Dorset HealthCare University FT, shared similar sentiments on the benefits of digital mental health interventions.

She detailed the experience in Dorset, a large and geographically varied county where many isolated rural communities have struggled to access in-person services.

“One of the things that it really brings is that ability to access services from home that some young people and families would really struggle to access otherwise,” she explained.

“Equally, for some of the young people, it’s about accessing it as and when they want. They’re able to pick it up when they feel ready to tackle it, rather than having a set time that’s set by the service and the therapist availability.”

Therapy on their terms

The flexibility of digital interventions was viewed as a key component in the ability to reach children and young people who are innately connected to the digital world.

John Church, chief executive of the Irish Society for the Prevention of Cruelty to Children, said it was a “no-brainer” that children and adolescents would be more open to engaging with mental health support in a familiar, digital setting.

“Being online, it’s just so much part of what they do anyway,” said Mr Church, while discussing the ISPCC’s adoption of the SilverCloud Anxiety programme.

“Why wouldn’t we operate in their ’hood on their terms?”

One area that panellists agreed warranted further research was the efficacy of digital mental health interventions in children and young people who are neurodivergent – a fact highlighted in an assessment by NICE in February 2023.

Dorset’s Laura Artis acknowledged that this gap in evidence “needs looking into”; however, she argued that her own experience suggested that technology could play an important role in supporting young, neurodivergent populations.

“From my experience clinically, the platform is something that is accessible to people who have that neurodivergent profile… It’s a way of them being able to access information that doesn’t involve busy journeys to get somewhere at a particular time, and then having to sit in a small and potentially stuffy room with somebody else.”

Perhaps most important is that digital interventions could potentially stop children and young people presenting in CAMHS to begin with

She noted that cultural buy-in from staff was critical to ensuring a positive response to digital therapies. “No young person is going to want to sign up to [a digital intervention] if they’re getting the impression that the clinician they’re talking to doesn’t value it,” she said.

Meanwhile, Mr Church stressed that digital tools should not be seen as a replacement for traditional therapy services. “It’s not an exclusive intervention in itself: it’s part of a series of options, and I think that’s an important distinction,” he said.

Perhaps most important is that digital interventions could potentially stop children and young people presenting in CAMHS to begin with. “We’ve put a significant number of children through the [SilverCloud] programme,” said Mr Church.

“Of the 500-odd referrals, 231 of them were on the CAMHS waiting list. Hand on heart, we can say the vast majority, if not all, should never have been there in the first place.”

At Northpoint, digital interventions appear to be serving their purpose.

Said Ms McGlinchey: “Because it has a digital offer, we’ve been able to bring our overall wait times down to five and a half weeks. Which, again, is significant.”

Expanding support beyond traditional care settings requires careful consideration of user needs and circumstances

Done properly, the integration of technology with mental health services can provide a blended and personalised approach to care that supports diverse needs, and gives individuals the tools to take greater control of their own wellbeing.

Done incorrectly, however, care providers risk exacerbating the very issues they seek to address, creating service duplication, a fragmented system of care, and potentially alienating those who are less inclined or unable to engage with mental health services.

This nuanced approach to mental health support was discussed by Laura Rodger, a senior health practitioner for Ingeus’ work and health programme. At Ingeus, a health team sits within an employment service – a unique combination, by her own admission.

Ingeus’ model of supporting unemployed individuals with health conditions involves an initial face-to-face meeting, followed by digital resources and intensive case management. Digital pathways are integral to the services it offers, said Ms Rodger; however, a fully virtual approach is rarely feasible due to the complexity and varying needs of service users.

“A lot of our clients are lacking routine; they’ve got a lot of other complexities going on in their life. They just don’t stay focused on a completely virtual programme,” she said.

“We end up having touchpoints on the phone or face to face to make sure that they’re engaging with the programme, to check on progress and to find out what the barriers to engaging are.”

Bertrand Stern-Gillet, CEO at employee assistance programme provider Health Assured, emphasised the increasing demand for digital support.

Mr Stern-Gillet explained that, while traditional counselling methods were still widely used at Health Assured, there was a growing demand for digital options among its client base of some 70,000 organisations.

“We need to provide for people who don’t want to phone [or] aren’t ready to pick up the phone,” he said. “They want something that’s more digital.”

Providing support for those who don’t seek it

Mr Stern-Gillet discussed a case in which a person initially contacted Health Assured for financial advice due to severe debt problems.

Through their interaction, the financial wellbeing adviser – trained to identify ancillary issues like potential mental health concerns – recognised the need for additional support and arranged a transfer to a counsellor.

Mr Stern-Gillet said the case illustrated the potential to reach people with appropriate mental health support even if they have not actively sought it, and how digital tools could be used as “an access route for people who otherwise would be disenfranchised from support full stop”.

He also presented the concept of “digital homework”, whereby patients are directed towards resources they can use after traditional counselling comes to an end.

“With face-to-face therapy, you have six or eight sessions that are done in six or eight weeks. If you have access to a digital CBT [cognitive behavioural therapy] session, you typically have access to that for 12 months, and we find that a high percentage of people will use that access,” Mr Stern-Gillet said.

“You’ve got to take a little bit of control yourself of your own journey, and we all need help in doing so.”

Perhaps one of the most powerful motivators for digital mental health interventions is the ability to promote mental wellness through self-care, enabling individuals to take control of their mental wellbeing and stop them from becoming patients to begin with.

Faris Al-Ramadani, GP and clinical director at Warwickshire East Primary Care Network, said the need for preventive interventions was highlighted during the early stages of the pandemic, when people seeking treatment for mental health concerns were referred to NHS Talking Therapies.

“The difficulty we were having was that there was nowhere to go. [Patients] would see the GP, they’d be referred to NHS Talking Therapies, or at least told to self-refer to NHS Talking Therapies, and we knew there was going to be a long wait,” Dr Al-Ramadani explained.

“It didn’t feel comfortable… My job is to try and make people better, and try to give them the tools they need to get better.”

The solution being piloted within Warwickshire East PCN focuses on the use of “supported self-help” through the PCN’s infrastructure, assisted by the SilverCloud® Tools for Therapy programme by Amwell® and using care coordinators to guide people towards suitable methods of care.

“We know that the model, in principle, should work, because we’ve got people using it who are getting a benefit,” said Dr Al-Ramadani.

“They can do it in their own time, they can do it at weekends, they can do it at night-time, so it’s perhaps not as confined as more traditional methods.”

Equally significant, said Dr Al-Ramadani, was the potential for digital interventions to help reframe the narrative on mental health. “This is not just mental health or illness – it should be about mental wellness,” he said.

“If you open the subject up to mental wellness, there’s no one in this room who that doesn’t apply to. Mental wellness affects everybody.”