Published: 02 August 2021
Online interventions that retain a personal touch can provide an important blend of open, inclusive and timely treatments but need rigorous testing, writes Dr Charlotte Hall, Clinical Trial Manager and Senior Research Fellow at the University of Nottingham, and Professor Chris Hollis, Director of the NIHR MindTech MedTech Co-operative and Professor of Child & Adolescent Psychiatry at the University of Nottingham.
Remote is not a dirty word
There has never been a greater need for research into children and young people’s (CYP) mental health. Recent evidence suggests a surge of mental health problems among the young, with one in six reporting issues in a NHS survey in July 2020, a significant rise from one in nine in 2017. Yet only about a quarter of those affected receive any treatment.
Timely access to evidence-based psychological interventions is essential to improving outcomes. The digital-era - and pandemic - has emphasised the importance of access to remotely delivered health therapies. Digital technologies, including online psychological interventions, have the potential to ease the current crisis in child and adolescent mental health service provision, where demand outstrips capacity.
Win over the online doubters
Online CYP interventions are attractive and potentially highly scalable, reducing some of the burdens of face-to-face therapy, such as the requirement to attend at a specific location and time, and associated costs such as travel. Children attending mental health clinics can face social stigma, and the waiting-room experience and having to discuss problems in person can also provoke anxiety. Furthermore, online delivery reduces the ‘postcode lottery’ around ease of access to care.
These factors and the need for innovation in CYP mental health interventions informed ORBIT, a randomised control trial (RCT) funded through the NIHR. The study led by our research team in Nottingham is investigating the clinical and cost effectiveness of remotely delivered, clinician-supported behavioural therapy for tics.
Yet that doesn’t mean digital interventions are a panacea. There is still mistrust of online services from both clinicians and families. Some view online therapy as second best to face-to-face, despite contrary evidence.
A prominent concern is patient safety, particularly where treatments are delivered without therapist support. Engagement with apps and online therapy can be low and could be due to technological barriers, lack of treatment credibility, or difficulties in building a ‘virtual’ rapport. More research on these issues and treatment efficacy can turn tentative steps down this digital path into confident strides.
The human touch in a digital age
One solution is a blended approach, where online treatment is supported by a clinician, and web therapy augments in-person sessions. Clinical contact may be face-to-face, delivered remotely in real-time (for example through a video call), or asynchronous (responding to messages). This flexibility means digital interventions have the potential to meet a range of service needs.
ORBIT is a good example of this blend in action. The trial has recruited more than 220 children and patients with excellent engagement rates, and findings corroborate the clinical effectiveness of this approach.
Time to update our methods
While research supports the effectiveness of remote interventions, many clinical evaluations fall short of the gold-standard RCT required to provide robust evidence of clinical efficacy and safety. Most studies use small sample sizes, have inadequate follow-ups, and offer insufficient comparator choice.
When you compare the significant time - and financial - outlay RCTs demand with the rapid evolution of digital tools, such as the release and update of mental health apps, you can see how studies fall out of sync. A significant proportion are developed without the input of clinicians or patients, undermining our quest for reliable real-world evidence.
While the therapeutic components of digital interventions demand rigorous testing, adaptations and updates would benefit from lighter-touch evaluations based on user metrics and clinical outcomes. Finally, more attention should be given to health economic analysis to give service providers evidence on efficiency and value for money to back these interventions.
Mind the gap
Even with solid evidence of online treatments’ efficacy, barriers remain to implementation and NHS adoption, including intellectual property and commercial partner engagement. Without the right backing, infrastructure or leadership, many digital interventions never bridge the gap from research into front-line services.
Teams should be planning and engaging in this process throughout their trial, consulting with commissioners, service providers and local support networks, such as the Academic Health Science Network. Crossing this 'valley of death' between research evidence and real-world adoption is the greatest challenge to be overcome if digital technologies are going to address mental health needs of children and young people. It’s heartening to see the new NIHR Invention for Innovation (i4i) Digital Health Technologies for CYP mental health call tackles this challenge head on.
Dr Charlotte Hall, is the ORBIT Trial Manager and Senior Research Fellow at the University of Nottingham; Professor Chris Hollis is Director of the NIHR MindTech MedTech Co-operative and Professor of Child & Adolescent Psychiatry at the University of Nottingham. He is the Chief Investigator of ORBIT