A turning point for remote mental health care provision?

Dr Jeanne Wolstencroft on an essential instrument in the toolbox.

The current coronavirus pandemic has forced mental health outpatient services to close their doors and transition their practice to telephone or video consultations. Remote mental health interventions including telephone or video calls, and digital interventions such as computerised, web-based or app-based interventions have existed for some time. The private sector is pioneering the delivery of online video call consultations and commercial self-help applications such as ThriveTalk, Psychiatry UK and Headspace. However, the evidence base for many of these approaches is sparse. This is not to say that they are ineffective, rather their scientific evaluation is lagging behind. 

Our own research experience of conducting social skills training interventions with young people using a blended online/offline approach was very successful. We piloted our social skills group with girls who had a genetic disorder called Turner Syndrome (45,X). Due to the rarity of the disorder suitable candidates lived across the British Isles, so regular face-to-face groups were not feasible. Over the course of three months we met weekly and all but three of the sessions were delivered using virtual meeting rooms. Participants were very positive about the blended format and we found significant improvements on key outcome measures, which was surprising given the small group size. 

Like many, my presumption was that face-to-face sessions would be preferable to online ones. But this pilot project changed my mind. It’s important to consider the needs and preferences of the future generation of service users, who may feel more comfortable with digital interventions. Most psychopathology emerges in adolescence. When teenagers who have grown up with technology start to experience mental health problems, will they be more likely to seek mental health advice by contacting their GP or from an online source such as reddit or WebMD? Could digital access to services improve their experience and outcomes? More research is needed to understand the most inclusive pathways into care for young people. Integrating technology could make services more accessible and flexible for young people and those who can’t travel due to mental health problems, physical disabilities or sheer distance.  

In the future many innovative technology-based interventions will be pioneered (many are already in development), but until their efficacy has been demonstrated the next logical step would be to use the resources we have to hand more effectively. We have evidence-based therapies that work, and increasingly reliable digital communication platforms. Combining them may allow mental health support to reach more people. Some research evidence suggests that there may be a positive association between therapist involvement and participant retention in remote interventions. It may be that seeing a therapist on a video call is more engaging than speaking over the phone or instant message. Perhaps it should not be surprising that interventions with little or no therapist involvement require gamification or automated reminders to avoid dropout. Like most psychological treatment, the most important predictor of success in remote intervention is likely to be the therapeutic alliance. The good news is that the therapeutic alliance can be forged face-to-face or remotely. 

For better or for worse, coronavirus has obliged mental health services to engage with their service users in new ways. The integration of technology into mental health services will present new opportunities and challenges. Once security issues regarding client-therapist confidentiality are resolved, this approach has the potential to engage service users that might not otherwise be able to access treatment.  My hope is that remote communication platforms will soon be valued as an essential instrument in a psychologist’s toolbox. 

Dr Jeanne Wolstencroft

Research Fellow at UCL’s Great Ormond Street Institute of Child Health

Selected references

Hollis, C., Falconer, C. J., Martin, J. L., Whittington, C., Stockton, S., Glazebrook, C., & Davies, E. B. (2017). Annual Research Review: Digital health interventions for children and young people with mental health problems–a systematic and meta‐review. Journal of Child Psychology and Psychiatry58(4), 474-503. 

Wang, K., Varma, D. S., & Prosperi, M. (2018). A systematic review of the effectiveness of mobile apps for monitoring and management of mental health symptoms or disorders. Journal of psychiatric research107, 73-78.

Wolstencroft J, Mandy W and Skuse D. (2019). Protocol: New approaches to managing the social deficits of Turner Syndrome using the PEERS program [version 2; peer review: 2 approved]. F1000Research, 7:1864 

Wolstencroft, J., Kerry, E., Denyer, H., Watkins, A., Mandy, M., & Skuse, D. (2019) SOAR Study: New Approaches to Managing Social Skills Deficits in Turner Syndrome, ESPE Abstracts, 92 P1-375. http://abstracts.eurospe.org/hrp/0092/hrp0092p1-375

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