August 29, 2019
By Sandra Bucci
#digitalta2019 was a symposium focusing on the relationship between patient and therapist as the field of mental health care evolves into a new era of digital mental health delivery. The symposium was hosted by the University of Melbourne on Wednesday 7th August 2019 and explored the impact of telehealth therapy consultations and mental health apps on the therapist–patient relationship, and users. Professor Sandra Bucci was the keynote speaker at the symposium and on the back of her thought-provoking keynote address, she shares some of her insights in the field of digital mental health.
Digital mental health isn’t a thing of the future – it is happening now! We no longer need to justify why we think digital technology has the potential to transform the quality and efficiency with which we deliver healthcare. Internet interventions, apps, social networking platforms, digital phenotyping, wearable devices, artificial intelligence are all part-and-parcel of what is becoming routine healthcare delivery. Innovations in mental health have historically lagged physical health treatments. But the pioneering work of researchers such as Inez Myin-Germeys and her group means that capturing distressing experiences in daily life allows us to more accurately and efficiently gain insights into the ebb and flow of distressing experiences, enabling the development of targeted interventions to be delivered at scale.
A recent paper by Cella and colleagues (2019) in the UK highlights the innovative work many groups across the world are engaging in regarding digital technology. Building on the ClinTouch psychosis and mood symptom monitoring app developed by Professor Lewis and colleagues at the University of Manchester, Cella and colleagues are blending both active (symptom monitoring via an app) and passive (wrist-worn device) digital methods in an attempt to monitor physiological and self-report symptom data in a small group of first episode psychosis service users. While these methods might not prevent relapse, they have the potential to enable early detection and intervention.
And there are others: Professor Andrew Gumley with collaborators across the UK and Australia are trialling a truly world-class, integrated approach to implementing digital monitoring and intervention in routine service delivery. The EMPOWER study involves people with experience of psychosis actively monitoring their wellbeing, including early signs of psychosis, for up to one year through the EMPOWER app. Participants use the app over an initial 28-day period to identify their baseline of typical variation in wellbeing. When a small deviation in wellbeing is noted, a tailored self-help message is sent via the app. When a larger deviation in wellbeing is noted, the community team is alerted and trained to respond accordingly. Publication of the results from this proof-of-concept study are imminent. SlowMo, developed by Garety and colleagues at King’s College London, is a blended digital therapy designed to slow down thinking in paranoia. It is one of the few blended digital therapies adopting the interventionist causal approach to targeting a clear psychological mechanism in psychosis.
There are alternatives to the blended approaches developed by Cello, Gumley and Garety. Developed by our group at the University of Manchester, the Actissist app is a standalone app informed by cognitive behaviour principles designed to target distressing psychotic experiences in daily life. Results from the proof-of-concept are promising, leading to the funding of a larger efficacy study currently underway.
Provided these digital systems are feasible, acceptable and effective, a palpable dilemma we in the field now face is implementing such systems into routine service delivery. Notable barriers have been highlighted by our group in a series of qualitative studies^. And, of course, we must not forget to closely monitor potential side effects of the digital systems and platforms we are developing. Dr Simon Bradstreet and colleagues highlight these issues in an important paper published in the Journal of Mental Health recently, showing that the mHealth for psychosis literature has largely neglected monitoring and reporting adverse events related to the technology developed. Finally, an issue on many minds is how we might conceptualise the role of the therapeutic alliance in the digital space – is it relevant? And how do we conceptualise digital therapeutic alliance when we potentially have different alliances with different systems and platforms? Such are the challenges of the field going forward.
Professor Sandra Bucci is Professor of Clinical Psychology at the University of Manchester, UK, and an Honorary Consultant Clinical Psychologist at Greater Manchester Mental Health NHS Foundation Trust, UK. Professor Bucci has 20 years experience in clinical research examining psychological processes involved in the development and maintenance of psychosis and developing interventions for psychosis. You can follow Sandra on Twitter @sbucci76
^ Series of qualitative studies
Bucci, S., Morris, R., Berry, K., Berry, N., Haddock, G., Barrowclough, C., Lewis, S. and Edge, D., 2018. Early psychosis service user views on digital technology: qualitative analysis. JMIR mental health, 5(4), p.e10091.
Berry, N., Bucci, S. and Lobban, F., 2017. Use of the internet and mobile phones for self-management of severe mental health problems: qualitative study of staff views. JMIR mental health, 4(4), p.e52.
Berry, N., Lobban, F. and Bucci, S., 2019. A qualitative exploration of service user views about using digital health interventions for self-management in severe mental health problems. BMC psychiatry, 19(1), p.35.
Bucci, S., Berry, N., Morris, R., Berry, K., Haddock, G., Lewis, S. and Edge, D., 2019. “They are not hard to reach clients. We have just got hard to reach services”. Staff views of digital health tools in specialist mental health services. Frontiers in psychiatry, 10, p.344.