Patricio V Marquez

                                            March 18, 2024

In a recent post, I delved into the mental health and wellbeing-related risks of our growing attachment to digital and social media, particularly among children and adolescents.  Here I explore the notion that while extensive usage of these technologies presents risks, it is important to also recognize their potential social benefits.  Digital and mobile technologies are not just revolutionizing communication, social interaction, and community-building across boundaries of time, place, and social context, but are contributing to enhance the delivery of essential services, such as healthcare services, benefiting the entire population.

Digital Interventions, Services, and Applications in Health

Digital health refers to the use of information and communication technologies, computer science, and data to help individuals, health workers, and health systems make informed decisions to enhance resilience against diseases and promote overall health and wellness.

The World Health Organization (WHO) classifies digital interventions, services, and applications in health according to the different ways in which digital and mobile technologies are used to support individuals and address health system challenges.

Digital health interventions refer to a discrete technology functionality or capability designed to achieve a specific objective addressing a health system challenge.  These are organized into four overarching groups: 

• Digital Interventions for Persons. This group describes the capabilities of digital technology that can be implemented to achieve objectives that are targeted toward potential or current users of health services and caregivers of individuals receiving health services, including targeted and untargeted communication to persons, person to person communication, personal health tracking, person-based reporting, on demand communication with persons, person-centered financial transactions, and person-centered consent management.
• Digital Interventions for Healthcare Providers. This group describes the capabilities of digital technology that assist healthcare providers to deliver health interventions, including identification and registration of persons, person-centered health records, health care provider decision support, telemedicine, healthcare provider communication, referral coordination, scheduling and activity planning for healthcare providers, healthcare provider training, prescription and medication management, laboratory and diagnostics imaging management, and healthcare provider financial transactions.
• Digital Interventions for Health Management and Support Personnel. This group describes the capabilities of digital technology that can be implemented to achieve objectives that are targeted toward health management and support, including human resource management, supply chain management, public health event notification, civil registration and vital statistics, health system financial management, equipment and asset management, facility management, and person-centered health certificate management.
• Digital Interventions for Data Services. This consists of crosscutting functionality to support a wide range of activities related to data management, use, and data governance compliance.

Digital services and applications are the types of software, information, and communications technology systems and services or communication channels that deliver or execute digital health interventions and health content. These services and applications are categorized into five distinct groups:

• Point of Service Applications.  These systems facilitate the provision and delivery of healthcare services to persons at the point of care, including software capabilities that enable healthcare providers to access, record, and update individuals’ health information as well as interactively communicate with them.
• Health System/ Provider Administration. These systems facilitate the administrative and clinical management aspects of health systems, providing software capabilities or services to healthcare that may be leveraged by other applications across the digital health enterprise.
• Registries and Directories. Systems that serve as a central authority for maintaining specific sets of data, and that provide software capabilities or services that are canonical/master lists, which are enforced by specific governance mechanisms. 
• Data Management Services. Systems that serve as a repository containing data that have been validated, providing capabilities to store, process, retrieve and analyze data held within such systems.
• Surveillance and Response Systems. These systems support the continuous, systematic collection, analysis, and interpretation of data for use in health contexts, providing software capabilities that utilize protocols to generate information.

Overall, digital technologies and their application and use offer new opportunities for delivering healthcare. As such, they have the potential to transform healthcare services, addressing the challenges faced in health systems and improving performance to achieve health system goals.

Application of Digital Health for Scaling up the Delivery of Mental Health Care Services

The impact of digitalization of health services has been profound and is expected to accelerate in the future with the rapid and constant pace of technological development and diffusion. Digital and social media, and the growing popularity and use of mobile devices to access them, can improve access to care and help reach vulnerable populations, particularly in low-income settings where healthcare delivery systems face severe limitations and constraints.

While digital health was used to support mental health services before the COVID-19 pandemic, the service delivery challenges experienced during this period led to the widespread adoption of web-based and mobile-based platforms.  Digital interventions and applications proved to be particularly effective in scaling up service access, offering online consultations, and remote support. Clinician or counsellor-based virtual care replaced traditional in-person office visits with synchronous or same time video or audio visits or with text messaging that allowed patients to communicate with a clinician or a counsellor at any time and get a response later.

Digital care options through teletherapy and new applications offer now alternative service delivery and data collection models for monitoring and evaluation that can help overcome obstacles that hinder access to care, such as stigma associated with using mental health services, transportation barriers, shortages of healthcare personnel, and high costs. These platforms, especially in mobile formats, can facilitate remote screening, diagnosis, monitoring, and treatment, as well as remote training for non-specialist health care workers and can enhance online peer-to-peer support and self-care.

Given the lack of or limited availability of mental health resources in low-and middle-income countries, the development and usage of mental health apps can help address unmet needs. For example, the Philippines Department of Health, backed by the USAID RenewHealth project, created the Lusog-Isip mobile app to offer evidence-based methods for enhancing well-being and coping mechanisms, along with a directory of mental health service providers. Although not a substitute for clinical services, a randomized control trial assessing the app's effectiveness found that both app and workbook users experienced improved psychological well-being and cognitive reappraisal skills. Additionally, the app users reported better outcomes in emotional release compared to workbook users.  Likewise, the findings of a scoping review of the characteristics and effectiveness of digital interventions that were employed to improve mental health in the real context of COVID-19 pandemic suggested positive effects of digital technologies, either on improving general mental and emotional well-being or addressing specific conditions (e.g., depression, stress, and anxiety).

Mobile devices like smartphones also give the public, service providers, and researchers new ways to access help, monitor progress, and increase understanding of mental wellbeing. For example, in the United States, anyone with a phone or computer can call, text, or chat the 988 Suicide and Crisis Lifeline. Also, new technology can also be packaged into an extremely sophisticated app for smartphones or tablets that can use the device’s built-in sensors to collect information on a user’s typical behavior patterns, including detecting a change in behavior, and provide a signal that help is needed before a crisis occurs.  

Social media platforms are seen as venues that offer a significant opportunity for promoting mental healthcare due to their vast influence and reach. The extensive time users spend on these platforms, combined with the platforms' ability to provide accessible and easily comprehensible information, makes them an effective medium for disseminating health information. This can help in raising awareness and understanding about mental health issues, potentially leading to improved mental healthcare for various populations.  However, as pointed in a study, social media can have both positive and negative impacts on mental health. On the positive side, it can enhance connections with others, boost self-esteem, and foster a sense of belonging, all of which can benefit mental health. However, the negative aspects include causing stress, creating pressure to compare oneself to others, and potentially leading to increased feelings of sadness and isolation.

Non-clinician based digital mental health services, such as chatbots, video and written content, and gamified user exercises, are a good complement to clinician-based virtual care, allowing 24/7 access for those with less intensive needs. Artificial intelligence (AI) chatbots, for instance, can help patients practice cognitive behavioral therapy (CBT) to become aware of inaccurate or negative thinking so that they can view challenging situations clearly and respond to them effectively.  This support can be simple but effective.  A systematic review and meta-analysis found that brief interventions, such as computer-assisted CBT delivered through mobile devices, improved people’s psychological well-being and reduced reported symptoms of depression and anxiety. 

As examined in a World Economic Forum article, there are also a range of apps that aim to boost mental wellbeing, and some research indicates that cognitive training carried out using apps can improve brain health. Other tech innovations include prescription video games, that challenge children aged 8 to 12 with Attention-Deficit/Hyperactivity Disorder (ADHD) to focus on multiple tasks simultaneously within the game environment. Further, online symptom tracking apps prompt patients to share data daily which are analyzed with an AI algorithm to identify patterns and alert providers in real time of any warning signs.

Additionally, digital media can facilitate education and life-long learning to build skills of the future, contributing to human capital development in countries. Several initiatives deal with scarcity or lack of providers needed to reach people in need. For example, the World Health Organization Academy provides digital learning to health workers across the world on a range of topics, including mental health. EMPOWER, a Harvard Medical School initiative, provides digital training to support delivery of psychosocial interventions. And UNICEF’s Caring for the Caregiver program targets community workers using online and in-person training.

Overall, as highlighted in a National Institutes of Health (NIH) article, mental health apps and technology offer significant benefits for both individuals seeking mental healthcare and professionals providing such services. Key advantages include:

• Convenience: These technologies enable treatment at any time and place, such as at home or during a commute, which is especially beneficial for those who find it challenging to attend in-person appointments.
• Anonymity: Users can receive treatment privately and anonymously from their homes, offering comfort and privacy.
• Introduction to Care: For those hesitant about seeking mental healthcare, these apps and technologies serve as an accessible first step.
• Lower Cost: Many apps offer free or more affordable options compared to traditional in-person care, making mental health services more accessible financially.
• Greater Outreach: These technologies allow mental health professionals to reach people in remote areas or to respond quickly to large groups in need, such as during natural disasters or traumatic events.
• Interest: By making care more appealing and accessible, these tools can motivate people to continue with their therapy compared to conventional methods.
• 24-Hour Service: They provide continuous monitoring or support, which is not typically available with in-person therapy.
• Consistency: Everyone has access to the same treatment programs, ensuring a uniform approach to care.
• Support: These technologies complement traditional therapy by extending its benefits, reinforcing new skills, and offering ongoing support and monitoring.
• Data Collection: They can gather various data such as location, movement, and phone usage, which can be useful for personalized care and understanding patterns related to mental health.

Although digital technologies have the potential to bridging the mental health-care gap, and apps are becoming more appealing and user-friendly, there is need for more information on their effectiveness and their sustained impact.

Takeaways

Digital health, as discussed above, is transforming healthcare delivery. The adoption of digital technologies and mobile applications in mental healthcare, particularly during the COVID-19 pandemic, has accelerated, offering innovative solutions to health system challenges like online consultations and remote support. This shift has been crucial in addressing the global shortage of mental health services, making care more accessible through teletherapy, mobile applications, and remote training for non-specialist health workers. Mobile devices, social media platforms, and AI technology are playing a significant role in expanding access to care, providing real-time monitoring, and facilitating peer support and self-care. Furthermore, digital media is proving instrumental to train health workers worldwide.

The advantages of digital mental health services are numerous, including convenience, anonymity, affordability, greater outreach, and 24-hour support. These technologies not only enhance traditional therapy but also provide valuable data for personalized care. Going forward, however, there is a recognized need for more research into the effectiveness of these apps and technologies.

Source of Image: 

First Image:  Photo taken by the author of painting Signo I (2003), by Pablo Palazuelo (Madrid 1916-Madrid 2007), at exhibition held at the Guggenheim Bilbao Museoa, Spain, on October 4, 2023.