Digital mental health services in general practice

INTRODUCTION

The NHS has recently announced plans to kitemark the best health apps so they can be recommended to patients, and to accelerate the development of digital mental health services. There is considerable demand for mental health support delivered this way, in line with rising internet and smartphone use. We describe the types of services available, and consider when a GP might consider referring patients to them, in terms of the characteristics of the patient and the attributes of the service.

POLICY INTO PRACTICE

When patients present at surgeries with mental health problems there is a good chance they will already have sought help and information online. NHS Choices recorded more than 2 million visits to its mental health pages in April 2014 alone (the last month for which figures are available)¹ and Mind reported 5.8 million website hits in 2012–2013.² Many of these patients will also be using, or would be interested in using, digital services to improve their mental health, ranging from apps to support mindfulness to therapy delivered online.

Until recently, central NHS organisations have paid relatively scant attention to digital mental health, although clinical commissioning groups (CCGs) and mental health trusts often commission such services locally. The National Institute for Health and Care Excellence (NICE) has approved some digital services for mild-to-moderate mental health problems, but the length and complexity of the application process means that this is an option for only a few of the many providers in the field. The Medicines and Healthcare products Regulatory Authority (MHRA) has some powers over the sale of ‘medical software’, which includes some apps, but in practice their activity is fairly limited, their public profile low and their rules complicated.

This changed with the publication of the National Information Board’s (NIB) Personalised Health and Care 2020, which promises ‘a framework for action’ on the use of data and technology in the NHS, and was heavily promoted in Simon Stevens’ NHS Five Year Forward View.³ Media attention for the report was largely focused on giving patients online access to their data, but it also marks a step change in the NHS’s attitude to digital healthcare, particularly for mental health. The NIB promises that by the end of 2015 good health apps will be kitemarked, allowed to use NHS branding and available through NHS Choices. Mental health services, which are struggling to meet rising demand, and often well-suited to remote delivery, are in focus, with the launch of an apps innovation prize to encourage the rapid development of user-friendly, personalised cognitive behavioural therapy (CBT) apps.

KITEMARKING AND REFERRING

This is encouraging for patients and GPs frustrated by the NHS’s slow adoption of consumer-facing technologies, but significant unanswered questions remain. If apps are to be kitemarked by the end of this year, evidence on safety and efficacy will need to be gathered fast. While there is a broad consensus in the field that traditional randomised controlled trials are not fit for purpose with digital interventions (largely because services develop and expectations change faster than trials can be run) the NHS has little experience of approving new technologies outside the work of NICE and MHRA. Set the standards of evidence required too low and you risk undermining your system with poor quality products, or even negative outcomes for patients. Set them too high and you risk patient trust by excluding popular and helpful services.

In general practice, the question is more immediate: how to help patients who present with mental health problems and could benefit from digital interventions right now? What should be recommended and to whom? The variety of digital mental health services available makes it hard to generalise about the people who use them and much will depend on individual need. In broad terms, digital services may be helpful for people who find it difficult to talk about their mental health problems. They may also be beneficial for people who are unable to access traditional services due to time constraints; this may include people who work long or antisocial hours, or full-time carers.

WHO USES DIGITAL MENTAL HEALTH SERVICES?

Not engaging with the field is probably not an option. Many patients expect to be able to find help online, and if they are not signposted to high quality, evidence-based services there is a danger that search engines will lead them to places that are unhelpful or even dangerous. Digital mental health services are often assumed to appeal to fairly young people, but data suggest that they are popular for a fairly wide range of ages, consistent with the increasing average age of internet users over the past few years. The average age of members using Big White Wall, a UK digital mental health service focusing on peer support for adults, was 37 years and 8 months during 2012–2013, with a fairly wide age range (standard deviation of 13 years). Just 18% of members were aged 16 to 24 years. This represents a significant change from 2009, when 49% of Big White Wall members were in this age range and just 14% were >45 years (unpublished data Big White Wall: taken from self-reported member date of birth, given during sign up; contact author for further details).

GPs and therapists are often worried that digital tools exclude older and poorer people. This is a real concern and a major area for policy development. How can we help more people benefit from all the services available online? However there is a risk that these concerns can actually prevent people from getting the help they need. Data from the US suggest that 70% of young homeless people use Facebook.⁴ This is perhaps surprising at first sight, but many services for homeless people offer internet access, friends offer computer time, and if you don’t have a physical address or a phone number, staying in contact with friends and finding the support you need online makes a lot of sense.

Furthermore, the profile of internet users is changing fast. Use of the internet by people with no educational qualifications at all is rising faster than for any other group, and stands at 40%, while 58% of people in the lowest household income group (less than £12 500 a year) are now online.⁵ Perhaps due to some misconceptions about who makes use of digital services, GP referrals to Big White Wall are, on average, 3 years younger compared to the age profile of those who found the service through another route; this points, potentially, to under-referral among those aged >35 years.

SUPPORTING PATIENTS NOW

Broadly, digital mental health services fall into four major categories: information and advice, such as that provided by NHS Choices or the big mental health charities; one-to-one therapy, delivered online via video calling or live chat; guided self-help, generally based on CBT or mindfulness; and peer support delivered online through discussion forums. Some services, especially for teenagers, use gaming elements. Many will offer a combination of these aspects. They may be designed for children or teenagers, the general adult population, or specific groups such as students, carers, or people with long-term conditions. The evidence is currently strongest for structured CBT-type interventions, but the field is evolving rapidly with new reviews published almost every week.

Key considerations about services offered include how they ensure patient safety, and whether they have a defined recovery model that supports self-management and personalised care. Services that offer interwoven physical health and lifestyle interventions may be particularly attractive, as they can help to achieve parity of outcomes for people experiencing mental illness. Until the promised kitemarking system comes online, or until more NHS services develop local apps, the best course of action for GPs is likely to be either to find out what digital services are available and recommended by their CCG or local mental health service, or to use the existing NHS Health Apps Library as a starting point to look for apps which could support their patients.

Provenance

Freely submitted; not externally peer reviewed.