With mental health problems affecting a substantial proportion of the population, digital platforms are increasingly commonly used for mental healthcare in the modern world. The National Institute for Health and Care Excellence (NICE, 2023) has now issued conditional recommendations on technologies that can be used.
Globally, around one in five people will experience some type of mental disorder (meeting the criteria for a diagnosis) over a 12-month period, and nearly a third of adults will experience mental ill health at least once during their lifetime (Steel et al, 2014). These problems are a major burden for individuals and for society, leading to reduced quality of life, relationship difficulties, impaired occupational and educational performance and an elevated risk of mortality. Mental health problems are also strongly associated with physical illnesses, such as cardiovascular diseases, chronic pain, diabetes mellitus and asthma.
In the general population, around 5% of people experience either depression or anxiety at a severity that warrants clinical diagnosis, while substantially larger proportions have been identified in studies using self-report scales (Bromet et al, 2011; McManus et al, 2016). In women who are pregnant or have recently given birth, mental health problems affect one in five women in the perinatal period (NICE, 2019). These issues can continue affecting women for up to 1 year after birth, and include include perinatal depression, anxiety, obsessive compulsive disorder, postpartum psychosis and postpartum post-traumatic stress disorder (Mind, 2020).
Midwives themselves may also experience mental health issues, with a systematic review of 100 studies in the UK finding that nurses and midwives are at ‘considerable risk of work-related stress, burnout and mental health problems’ (Kinman et al, 2020). The review found increasing rates of poor mental health among nurses and midwives in the UK, as a result of staffing shortages, lack of resources and increasing demands on the workforce, particularly in light of the COVID-19 pandemic (Kinman et al, 2020).
Capacity issues in NHS mental health services
The prevalence of mental health problems has been increasing in the UK. Evidence from population-wide surveys indicates that the rate of severe symptoms of common mental disorders increased from 6.9% in 1993 to 8.5% in 2007 and to 9.3% in 2014 (McManus et al, 2016). Other evidence shows more recent increases, with 10% of adults experiencing moderate to severe depressive symptoms in the pre-pandemic period of 2019–2020, increasing to 16% in autumn 2022 (Office for National Statistics, 2022).
For many, mental health problems have been precipitated or exacerbated by the effects of the COVID-19 pandemic and/or the cost of living crisis. For pregnant women, evidence from a sample of 150 pregnant women in the UK shows that the pandemic led to high rates of mental health problems, with findings based on validated self-report scales showing around 40–60% reporting symptoms of depression, anxiety and post-traumatic stress disorder (Filippetti et al, 2022). Women who were more highly impacted by the pandemic being more likely to experience depressive and anxiety symptoms (Filippetti et al, 2022). Similarly, Hessami et al (2020) noted significantly higher rates of depression and anxiety in perinatal women comapred to pre-pandemic levels, in their systematic review and meta-analysis. This increase in women experiencing mental health problems has undoubtedly impacted those who provide maternity services and mental health support for pregnant and postpartum women.
Management of mental ill health
A range of treatment approaches may be appropriate for people experiencing common mental health problems, with management based on both severity and patient choice. As with many common physical health problems, the mainstay of management involves primary care and self-care. In the UK, people experiencing depression or anxiety (or a combination of these problems) will usually consult a GP, but may also refer themselves directly to NHS talking therapy services.
Assessment, support and management for mental health problems should be guided by high-quality systematic review evidence, such as relevant NICE guidelines. Treatments typically involve lifestyle changes, psychological interventions and medication, with management decisions based on the individual's symptom severity, medical history, circumstances and preferences.
Midwives can refer pregnant women to mental health support via their GP or NHS talking therapy services. Talking therapy services are particularly suited for (and have been developed to address) the needs of people with common mental health problems, such as depression and anxiety disorders (including panic and phobias, post-traumatic stress disorder and obsessive compulsive disorder). Self-help and guided self-help is a key part of the service delivery model for NHS talking therapy services.
Evidence-based psychological treatments are often delivered using digital platforms. The widespread use of digital technology has enabled NHS talking therapy services to continue meeting their waiting time targets, despite the increasing prevalence of mental health difficulties in the population. Although waiting times vary between settings and over time, records of service data for June 2021 to June 2022 show that 89% of patients entered treatment within 6 weeks of referral (NHS Digital, 2022).
Digital self-help
Digital platforms can be a useful tool for talking therapy services. These platforms can host ‘pure’ self-help or facilitate a collaborative treatment approach, with a variable amount of therapy work being linked to online materials. The latter is complemented by engagement with a health professional (typically a psychological wellbeing practitioner), which can occur in person, online, via video call or by instant messaging.
These programmes can be used in a flexible way, based on an initial assessment, discussion and agreement between the therapist and service user. Digital approaches may be used as an adjunct or alternative to traditional individual or group therapy sessions (which usually deliver cognitive behavioural therapy, behavioural activation or counselling), or as a means of support while the patient waits for these to become available. This use of technology to deliver evidence-based psychological treatment enables a much more rapid provision of support; importantly, this addresses some of the distress and worry that waiting times may cause, as well as allowing mental health service resources to be used more effectively, helping to ease capacity issues.
For common mental health problems, such as depression and anxiety, the most effective and least intrusive treatment should initially be offered. This typically involves psychoeducation, support for lifestyle change and self-help measures, which may be guided or facilitated by a professional (NICE, 2020; 2022). This approach may sometimes be used for more severe depression or anxiety, although a combination of medication and individual psychological treatment is usually recommended in these cases.
Self-help has a long history, first involving book-based provision of psycho-education and structured self-help treatment, before the development of commercially produced digital programmes in the early 2000s. The latter deliver mental health treatments based on structured techniques, such as cognitive behavioural therapy. These programmes can include educational components, interactive exercises and modules that teach coping skills and relaxation techniques. An early example of a digital self-help programme is ‘Beating the Blues’, which provides online cognitive behavioural therapy courses and has been supported by randomised controlled trials (Proudfoot et al, 2003; 2004). As technology has developed, these programmes now include apps and virtual reality systems, as well as more advanced and interactive online platforms.
The benefits of digital approaches to mental health
The digital approach to mental healthcare has a number of important benefits, including the provision of a faster and more accessible route to effective treatment. Online delivery removes the need to travel for treatment, which may be useful for people with work commitments, caring responsibilities or other time constraints that could make in-person talking therapy inaccessible. It may also be useful for individuals with disabilities that make it harder to travel, those who are particularly vulnerable to catching infections such as COVID-19 or those experiencing financial hardship that would cause difficulties with travel costs.
Online delivery also allows for more discrete access, potentially without the knowledge of family, work or the community, which can be particularly important for those who might otherwise avoid therapy from fear of stigma. It has the potential for users to receive the programme in their first language, reducing language barriers and the need for interpreters. Additionally, digital programmes offer the ability to access care outside of standard treatment times, reducing disruption to work routines or caring responsibilities.
However, NICE (2023) have only recommended a handful of digital-enabled therapies for helping adults that address depression and anxiety disorders; six are recommended for anxiety: Perspectives, Beating the Blues, SilverCloud, iCT-PTSD, Spring and iCT-SAD, and three for depression: Beating the Blues, Deprexis and SilverCloud. These programmes are already widely known and used by many mental health professionals, particularly those working in services set up for common mental health problems. SilverCloud for example, is widely used in adult NHS talking therapies to provide online therapy in what are typically known as ‘virtual clinics’, to which patients can self-refer.
However, in specialist mental health teams, services tend to differ considerably, as these teams are set up to provide multidisciplinary care for people experiencing more complex and severe mental health problems, such as severe depression or psychosis. These patients' needs are often very different from those of people with less severe, more common mental health problems, so there will be less use of digital therapy tools in these services, with less knowledge and experience of their potential application among staff. There may be opportunities for online and guided self-help programmes to be used more widely in these areas.
Are digital programmes evidence-based?
As digital programmes are part of wider self-help options for mental health treatment, support for their use can be drawn from evidence for self-help interventions in general, regardless of their delivery modality. For example, Bennett et al (2019) synthesised the findings of 50 studies on the effects of guided and non-guided self-help for common mental health problems among children and adolescents, with results showing moderate positive effects when compared to a control group with no intervention. A review of 21 studies by Cuijpers et al (2010) looked at guided self-help for the treatment of depression and anxiety in adults, and found that it was just as effective as in-person therapy at follow-up periods of up to 1 year. There were also no differences in drop-out rates between the two types of intervention. Similarly, Van't Hof et al (2009) found that self-help methods were effective across a range of common mental health problems, including depression and anxiety disorders, regardless of the type of self-help or the mode of delivery.
NICE (2022) conducted one of the most rigorous analyses of relevant evidence for the treatment of a new episode of less severe depression. This found that a wide range of treatments were associated with potential benefits for key outcomes (such as wellbeing improvement, symptom changes and remission), although there remains considerable uncertainty about effects for depression at this milder level of severity.
There is an emerging field of evidence specifically for digital mental health programmes and self-help platforms, although these studies vary in quality. A high-quality meta-analysis (Karyotaki et al, 2021) found that internet-based guided cognitive behavioural therapy was effective in treating depression, with the most substantial benefits seen in individuals with moderate to severe symptoms. For individuals with mild or sub-clinical depression, unguided online cognitive behavioural therapy was also effective, leading the authors to conclude that personalised treatment selection was key to ensuring appropriate use of treatment resources (Karyotaki et al, 2021). Similarly, Gratzer and Khalid-Khan (2016) noted that although early studies in this area often lacked methodological rigour, more recent studies have provided better-quality evidence. This review indicated that there was strong evidence for integrating online cognitive behavioural therapy into mental health services, particularly for patients with depression, anxiety disorders and those experiencing emotional distress secondary to physical illness, such as diabetes mellitus and cancer (Gratzer and Khalid-Khan, 2016).
For pregnant women experiencing perinatal mental health issues, the evidence of the effect of digital delivery of mental health programmes is more limited. A review of technology-based approaches to supporting perinatal mental health by Novick et al (2022) found that although the available evidence for the use of technologies such as electronic consultations and internet-based cognitive behavioural therapy was almost uniformly positive, ‘evidence for use in [perinatal mood and anxiety disorders] was limited compared to that in general mental health populations.
However, there is evidence to support the use of interventions used by NHS talking therapies. Richards et al (2020) randomised adult patients who had been referred for depression and/or anxiety symptoms (n=361) into an online therapy course (delivered by SilverCloud) or waiting list control group. In the former group, 63.4% of participants showed reliable improvement after 8 weeks, compared to 34.4% in the control group. These improvements were sustained or increased at the 12-month follow-up point.
Conclusions
Mental health problems are increasingly common, both in the general population and among women in the perinatal period. The COVID-19 pandemic exacerbated these issues, particularly among vulnerable groups such as pregnant women. Digital mental health platforms can provide mental healthcare that is more accessible to many, helping to offset issues such as accessibility, long waiting times and staff shortages.
Although more evidence is needed for the effectiveness of these platforms specifically in the pregnant population, research shows that online delivery is an effective tool to help provide self-care and professional therapy to those experiencing mental health problems such as depression, anxiety and stress.