For decades, mental health and wellbeing was something that was ‘just not spoken about’. Now – belatedly – it appears finally to be becoming a more prominent part of the public discourse around Australia’s health, our people (particular our young people) and our future.
Sadly, part of the reason for that may well be because the problem is now too big to ignore. We have been described being in the midst of a “crisis in mental health care”, with an increase in the prevalence of mental health conditions being exacerbated by ever-greater pressures on public healthcare budgets, and by continued barriers to patients accessing the treatment they need.
There are no easy answers to these challenges, and no silver bullets. Increasingly, however, smartphone-based apps and other ‘digital’ solutions are being looked to as a potentially important part of how we approach mental health care and treatment in the future.
The question therefore is this. Can we really swipe our way to a healthier future?
Mental health: an issue that affects us all
In a 2014-15 study, four million Australians – some 17.5% of the population - reported having a mental or behavioural condition. It is estimated that over half of us will suffer from mental ill health in our lifetime. Tragically, eight Australians take their own life every single day.
The statistics are equally stark when looked at from a condition-specific perspective. In the same study, over two-and-a-half million– one in nine of us – reported suffering from an anxiety-related condition, and almost one in ten were affected by mood (affective) disorders such as depression. It’s also been found that certain sections of our society are at greater risk than others, including Indigenous Australians, those returning from war and conflict, and members of the LGBTIQA+ community.
Sobering as all these figures are, as we look forward it is the statistics on young people that should give us even greater pause. One in seven under 18s have experienced a mental illness and, at any given time, it is estimated that over a quarter of Australian young adults (those aged 16-24) are experiencing a mental illness. For many of the adults who currently live with a mental health condition, their symptoms will first have emerged during adolescence.
Amplifying the problem: barriers to accessing care
The impact of such mental illness is considerable, and extends far beyond the severe burden on sufferers themselves. It is felt equally by their families, friends and employers. Those with a mental health condition are twice as likely to be out of work as those without. The cost for the Australian economy of untreated mental illness in the workplace is thought to be hundreds of millions of dollars a year.
The problem is amplified, however, by the fact that many of those living with a mental health condition – whether diagnosed or undiagnosed – find it difficult or impossible to access treatment they need.
As support organization Australians for Mental Health put it: “Australia’s mental health services are fragmented, underfunded, hard to access, and of poor quality. People who need help can’t get the care they require.”
The causes of this are myriad. Inevitably, many are broad political or economic issues regarding the way in which public services are funded and delivered. But there are also a range of factors at an individual level which inhibit those with mental health issues from accessing vital care.
A person might lack the time or the familial support to visit a doctor. They may be scared or embarrassed to confide in doctors or family members due to the stigma that is still sadly attached to mental health – a survey for insurers Bupa found that 72% of people listed “shame and embarrassment” as the primary barrier to them getting help. Or they might simply not know where to start. Navigating the healthcare system is complex (the Bupa study also found 55% of Australians don’t understand and navigate the mental healthcare system, to the extent they can’t look after themselves) and those with mental health conditions are significantly more likely to face barriers to doing so.
Other factors may also play a part: things like the cost of treatment, or geographical remoteness. According to mental health charity SANE, while mental illness is not statistically more prevalent in rural and remote areas, rates of suicide are much higher, which may be in part the result of services being harder to access and a stigma around mental illness being greater in those areas.
When all these factors are added together, it is clear that more needs to be done to ensure people are getting the treatment they need.
It is against this backdrop that a possible solution has emerged. And in some ways from an unlikely source.
For understandable reasons, there has been particular recent focus on the potentially negative effects of new digital technologies, and social networks in particular, on the mental health of young Australians. But there is growing evidence that such digital technologies – and specifically smartphone apps – can be a cost-effective, scalable solution to some of the informational and access problems that those suffering from mental ill health face.
It is not hard to see why. We carry smartphones with us all day, creating the potential to enable 24/7 access to information and support, wherever in the country we may be. Whether used for long-term monitoring of symptoms and risk factors, or as an urgent ‘safety net’ to providing short-term ‘bridging’ care while a patient waits for access to formal medical services, the ‘always on’ convenience of smartphones could help democratize and ‘even out’ access to care in ways not before seen.
Particularly for young people – so used to communicating and conducting their lives through digital devices (and as we’ve seen, especially susceptible to mental ill health) – apps may well be a far more accessible, more understandable and less daunting means of information and support than going to a doctor.
Moreover, insofar as mental health issues often first manifest themselves during adolescence, facilitating access to effective care at those early stages of the illness could have not just remedial, but also preventative effects.
There are benefits for clinicians too. Such apps could, for example, aid more accurate, cost effective treatment and monitoring of their patients’ health – rather than having to ask patients to visit the surgery periodically to complete a survey, a doctor could provide patients with an app that allows real-time recording of the patients’ feelings and symptoms. As well as freeing up the clinician’s time for other appointments, such higher-quality, real-time data could also enable more accurate diagnoses and more effective, personalized support and treatment.
In many ways, while it is arguably still in its infancy, it is clear that this ‘app-based’ future for mental health care is already upon us.
A survey by the World Health Organization in 2015, for example, found that 29% of the 15,000 health-related apps examined focused on mental health.
Or, somewhat less scientifically, a simple search for “mental health apps” in the Apple or Android apps stores reveals a huge number of apps available for instant (and often free) download, covering various conditions and all stages of care, from urgent crisis intervention to post-treatment condition management, via prevention, diagnosis and both primary and supplementary treatment
In order to try to classify the plethora of products available, the US National Institute of Mental Health (NIMH) has adopted a broad, function-based taxonomy comprising the following six categories: self-management, cognition improvement, skills-training, social support, symptom tracking, and passive data collection.
Given how nascent the market is, there remain relatively few formal studies into the efficacy of mobile apps. However, studies that have been undertaken have found that apps can have demonstrable benefits for those with mild to moderate depression and, when paired with face-to-face treatment, those with anxiety. And for those patients unable or unwilling to access help through traditional channels, such apps can provide a vital gateway to support at moments when it’s needed most.
Evidently, among the thousands of apps available, there will be significant variations in quality, and care is evidently needed in designing, marketing and using apps.
Given in particular how vulnerable those with mental health issues may be for, it is vital for example, that apps have been verified or designed in conjunction with qualified experts in mental health, so as to ensure that their effectiveness and effects on patients are properly understood. Beyond these fundamental parameters, however, further evidence is emerging as to the factors liable to make mental health apps more effective. One 2018 paper, for example, identifies four simple, but, key characteristics common to the most effective mobile solutions:
a) High patient engagement – apps will be more effective when patients are motivated to engage with them – without a doctor on hand to monitor a patient’s usage, it will typically be down to the patient themselves to continue to use the app. For those suffering from mental health conditions which often manifest themselves in feelings of hopelessness or lethargy, this can be a particular challenge.
b) A simple user interface and experience – against that backdrop, an app’s success will often rest on whether it is able to provide a low-effort, comprehensible user experience, not least as some patients may be experiencing cognitive impairment as a result of their illness.
c) Transdiagnostic capabilities – many of the apps currently available on the market focus on a single, narrow mental health condition. However, as the effective interventions for related conditions are often quite similar, apps that can harness this, and provide broad-spectrum solutions (and thus eliminate the need for patients to engage with several apps at once) are likely to be of particular value.
d) Self monitoring features – finally, apps that involve users self-monitoring their mood have been found to be particularly effective in increasing emotional self-awareness, which has been shown to alleviate symptoms and improve coping skills for those suffering from certain mental health conditions.
All of this shows that there is huge potential for mobile apps to provide ever-more effective and personalized mental health treatment and support, especially for those patients that are currently excluded from traditional mental health services. But for that potential to be fully realized, it is vital that those apps are well-designed and user-oriented and are, as far as possible, integrated into and consistent with traditional treatment pathways.
One company that is taking on those lessons is AlexGunnOnline Technology, a new Australian start up that will partner with health industry professionals, app developers and entrepreneurs to create the next generation of mental health apps. By bringing together medical expertise and technological know-how, the company aims to create apps that not only provide functionality and usability, but also provide health support that is clinically safe and effective. And by providing access to sustainable sources of capital, AlexGunnOnline Technology will help remove the funding hurdle at which too many of the most innovative and potentially revolutionary ideas fall. The company will be providing updates in coming months on new developments in this area.
Mental health issues have been under-reported and under-addressed for too long. While that is now slowly changing, barriers to effective treatment remain. By harnessing the potential of new technologies, and combining these with our ever-deepening appreciation and understanding of mental health conditions and therapies, the opportunity undoubtedly exist to accelerate that change and to deliver a step-change in the way in which, as a nation, we treat mental health.