Dr. Heleen Riper, Full Professor eMental-Health, VU University Amsterdam, is the guest columnist of the 5th issue of Smart Health. Dr Riper considers eMental-health may contribute to improve access to psychological treatments.
One out of every four adults worldwide will experience a mental disorder like depression, anxiety or substance misuse during their lifetime. It is estimated that in 2030 five mental disorders rank among the top ten diseases with the highest disease burden in terms of Disability Adjusted Life Years (DALY’s) both in developed and less developed countries. Mental disorders are also a well-known risk factor for premature morbidity and mortality including suicide. They thus have a severe negative impact on the quality of life of those affected and their families. In addition, these disorders are notorious for their high economic costs which entail both health care delivery costs and costs related to absenteeism of work.
The good news is that there are several effective therapeutic regimes available to prevent and treat mental disorders ranging from pharmacological interventions to psychotherapies. Patients however often prefer the latter, especially those who suffer from common mental disorders.
The bad news is that access to mental health care services is far from optimum and globally unevenly distributed. For example, there are countries were these services almost do not exists while in Europe half of the population in need of psychological treatment do not have access to evidence based therapies either. Even when these psychotherapies are available there often exist long waiting list and for many these are not affordable. For all count an underestimation of the rich potential of prevention instead of treatment only. Several studies have shown that full-blown DSM V disorders may be decreased by 25% through early screening and preventative interventions. There is thus ample room to improve access to psychological treatments, to ameliorate their clinical and cost-effectiveness and to implement these effectively in existing routine care services.
The good news is that eMental-health, defined as the smart use of innovative technologies for mental disorders, may contribute to these needs for improvement. The already high and growing penetration grade of PCs, tablets and especially mobile phones globally strengthens the preconditions necessary for improving prevention and treatment of mental disorders among all age and economic groups.
This digitalisation of the treatment of mental disorders such as depression and anxiety has gained momentum over the last two decades as can be illustrated by the work of research groups in the Netherlands, Sweden, UK, Spain and Australia. With ample studies these groups have shown that online prevention and treatment, for example by means of cognitive behavioural therapy, is feasible, acceptable and (cost) effective. These interventions may persuade depressed persons to seek appropriate treatment at an early stage and contribute to overcome health inequalities due to their potential to reach out to underserved groups especially with unguided evidence based interventions. The application of mobile devices that support virtual and augmented realities, sensors, and gaming will become an integral component of these interventions in the near future. All these enable a more personalized approach of mental disorders by patients and therapists alike. However, research also indicates that eHealth is not effective for everyone but yet we do not know for whom it works best or not and yet it has still to be proven that it works even better than face-to-face therapies. In addition, eMental-health has not led yet to a disruptive innovation of mental health care delivery as implementation levels in routine practice are still low. One could argue that this is due to a question of time as it takes long time to implement innovations in routine care. A different line of reasoning may hold promise as well namely that we need not only to innovate our treatments but also, under the umbrella of an ‘agile science’ approach, our scientific methods for the development (‘co-creation’), evaluation (‘beyond RCT’s only’) and implementation (‘evidence based implementation strategies’) of digital interventions. The availability of wireless devices and sensors, which are able to measure subjective and more objective parameters by patient themselves in their natural habitat, provide the necessary context for such a ‘personalisation’ approach.
Currently these challenges are addressed in a number of large scale EU projects such as the European Comparative Effectiveness Research on Internet-based Treatment for Depression (E-COMPARED project, www.ecompared.eu) in which the clinical and cost-effectiveness of blended CBT treatment for depression is compared to face to face CBT for depression. The issues of up-scaling and shared knowledge exchange between high and low experienced eMental-health countries is addressed in another EU project named MasterMind. Applying eMental-health for more complex disorders like bipolar disorder and how to make these devices commercially successful is investigated in an Ambient Assisted Living project in collaboration with Dutch, Norwegian and UK partners. The potential of early intervention and screening for a range of behavioural disorders by means of trans-diagnostic interventions and a shared intervention platform is studied in the iCARE project. All these initiatives stress the importance of smart ICT solutions for healthcare delivery with a strong focus on prevention and treatment, and on patient and therapist ‘engagement’ in the development and evaluation of digital health, all with the aim to improve the mental wellbeing of individuals worldwide.