How mobile and Internet are changing mental health care

The Online Couch: how the Internet and mobile are changing mental and behavioral health care

June 16, 2012

by Jane Sarasohn-Kahn

Therapy is now a click away, whether on a computer, a smartphone or a tablet. Drs. Freud, Ellis and Beck, heads-up: the Internet is the new couch of psychiatry.

That is, at least for people with mild to moderate depression and those with anxiety, as I report in my latest paper for the California HealthCare Foundation, The Online Couch: Mental Health Care on the Web.

Many factors are aligning that make therapy online an effective extension of face-to-face therapy for the right patients at the right time in the U.S.:

• An undersupply of psychologists, psychiatrists, and other therapists, especially in rural and under-served areas
• Growing demand for services treating depression and anxiety, especially for people dealing in the post-recession economy, more kids diagnosed with depression and anxiety, and in the advent of U.S. soldiers returning from wars in Afghanistan and Iraq
• Sound clinical evidence from the U.K. and other countries proving the efficacy of computer-based therapy (notably, Beating the Blues from the U.K., a platform adopted in most primary care trusts in the National Health Service)
• Penetration of broadband and mobile networks in the U.S., with consumers using networks and novel communications platforms like Skype for daily living and, increasingly, for health care
• Health payment regimes moving from volume to value, for patient-centered medical homes and accountable care.

Therapy online is not a new-new thing. Dr. John Grohol, Founder of PsychCentral, and Dr. Peter Yellowlees of UC-Davis, were both pioneers in the field and shared their stories of what the earliest adoption was like. Over the past decade, enabling technology has vastly improved and proliferated health environments, at the same time as the price of technology falling and both health providers and consumers using mobile phones and computers in daily living and work. You can read more of these clinicians’ fascinating insights in the paper.

The paper outlines the forces shaping demand for online therapy, as well as the growing menu of services for people diagnosed and dealing with mild to moderate depression and anxiety, including:

• Computer-based cognitive behavioral therapy (CCBT)
• Online counseling via email, chat and video (THINK: the couch meets Skype)
• Online social networks
• Mobile platforms for self-tracking and support
• Games for behavioral health
• Virtual reality.

Of course, as with new technology meeting health care, there are barriers and challenges, from provider and consumer acceptance to aligning payment — always an obstacle when introducing new paradigms into health care workflows that disrupt entrenched practices.

But it’s clear that demand has grown for convenient, accessible, and cost-effective mental and behavioral health services. And with a growing evidence base, this is a market that is poised to gain traction in both the public and private health sectors in the U.S.

Health Populi’s  Hot Points: I have analyzed the intersection of technology and health for two decades, and from a health economics point of view, have never identified a market segment that’s as poised for development as tech-enabled mental/behavioral health. This is due to the huge amount of pent-up demand for services, the decline of funding at the state level (where Medicaid is the major payor for mental health services–set to grow with the absorption of uninsured Americans, goosing up demand even further), and a greater openness among consumers for whom the taboo of “being depressed” is eroding.

Furthermore, the growth of prescribing anti-depression medications is in the primary care practice (PCPs), where doctors have nil time nor expertise to counsel patients who are depressed. Furthermore, they’ve not had the bandwidth to diagnose patients segmented by mild to moderate depression versus severe cases. Thus, prescribing anti-depressants has become the modus operandi for some very busy physicians who haven’t created a workflow process to identify, segment, and refer patients to counseling.

In the U.K., the use of computer-based CBT systems has become a form of step therapy before patients receive anti-depressants. This strategy has been quite successful in helping a majority of Brits with mild to moderate depression avoid going onto these medications, and instead learning how to re-think daily challenges through employing the tools of cognitive behavioral therapy — recognized as the gold standard for therapy in this patient population.

The use of CCBT can scale to very large populations at relatively low-cost. It behooves health policymakers, keen to address health care costs, to look at technology-enabled mental health services — the Online Couch — as a way to expand services to populations under-served and needful of assistance — as well as aligning funding these services in primary care practice, which is where the vast bulk of health citizens will be diagnosed with depression and anxiety.