Can Digital Psychiatry Meet Today’s Mental Health Crisis?

The evidence indicates it won’t solve this national epidemic but can serve as a valuable adjunct to professional therapy.

By John Halamka, M.D., president, Mayo Clinic Platform, and Paul Cerrato, senior research analyst and communications specialist, Mayo Clinic Platform

May is a mental health awareness month and it comes at the time when millions of Americans are seeking therapy, while venture capital and private equity firms are pouring billions in psychiatric platforms, digital health tools and apps. If you think the term mental health crisis exaggerates the situation we currently face, consider a few statistics: Among adolescents between 12 and 17 years of age, the percentage who have experienced at least one major depressive episode jumped about 60% between 2007 and 2017, from 8% ( 2 million) to 13% (3.2 million). Even more disturbing is the fact that among those between 10 and 24 years of age, suicide rates increased by more than 50% from 2000-2007 to 2018, according to a CDC report. Since then, the problem has not improved: “During February 21–March 20, 2021, suspected suicide attempt that resulted in ED visits were 50.6% higher among girls aged 12–17 years than during the same period in 2019; among boys aged 12–17 years, suspected suicide attempt ED visits increased 3.7%.” The numbers have prompted many thought leaders to refer to the problem as a devastating national emergency. A detailed analysis of the causes of this mental health crisis are beyond the scope of our blog, but it’s likely the isolation brought on by the COVID-19 pandemic and exposure to self-destructive content on social media both play a role.

What role might online mental health services and apps play in addressing the problem? John Torous, M.D., director of digital psychiatry at Beth Israel Deaconess Medical Center (BIDMC) and one of the world’s top authorities on the topic, provided a balanced view: “In general, mental health apps can help people gain insights into how their thoughts, feelings and actions interact with each other.” They may be helpful for patients with mild depression, assuming they are motivated enough to use them. But since anhedonia – a lack of motivation or the inability to experience pleasure – is one of the signposts of clinical depression, they will likely play a limited role. More importantly, the experts point out that anyone with moderate to severe depression is even less likely to benefit from these apps.

A closer look at mental health apps available in the Apple iOS and Google Play stores indicates that popularity is no substitution for value. Sarah Lagan and her colleagues at BIDMC recently analyzed 278 such apps to evaluate their accessibility, privacy and security, inputs and outputs, clinical foundation, features and engagement style, and interoperability. They found “app stars and downloads--even for the most popular apps by these metrics--did not correlate with more clinically relevant metrics related to privacy/security, effectiveness, and engagement.” That does not imply that mental health apps are useless. An in-depth review of smartphone apps by Dr Torous and his colleagues mentioned a large scale meta-analysis of randomized controlled trials of apps, including those designed to help with depression and anxiety among clinical and non-clinical populations. The analysis found that the apps helped users more than placebo controls like gaming apps or being given educational resources. Also encouraging was the observation that app interventions for anxiety “did not differ significantly from face-to-face or other computer-based interventions in terms of outcomes, although only a small number of studies were used in these comparisons.” On the other hand, when smartphone apps were used in conjunction with professional help, including phone calls and personalized therapy, effect sizes were larger, when compared to studies that didn’t involve professional help.

It's critically important to realize, however, that these studies were “watered down” by the fact that they included non-clinical participants, in other words, app users who probably did not have severe depression. As Torous et al point out: “The evidence to date suggests that smartphone apps could provide an accessible, scalable and low-cost mechanism to deliver
effective self-management interventions for symptoms of depression and anxiety, particularly to non-clinical populations and those who cannot access face-to-face services.”