The U.S. has long suffered from a severe shortage of mental health care services. The pandemic has put a spotlight on the effectiveness and wide availability of digital and virtual mental health care, and by doing so might have thrown a lifeline to our mental health system.
We have a crisis in mental health care in the United States. Sixty percent of young people with major depression received no mental health treatment in 2017-2018, and one quarter of adults with mental illness reported an unmet need for treatment. In the U.S., 55% of counties have no psychiatrist, psychologist or social worker, and 70% don’t have a single child psychiatrist. Queues for substance abuse care can be weeks long; 70% of those who needed substance use treatment in 2017 did not receive it. To make it worse, many practices have closed or reduced their capacity in response to pandemic health concerns.
Because of the pandemic, virtual care and other digital tools are more important than ever in supporting existing care, providing scale and increasing capacity. Clinician-based virtual care replaces traditional in-person office visits with synchronous video or audio visits or with asynchronous text messaging. This provides alternatives to the traditional 50-minute therapy hour and allows for a better match of supply and demand across times of day and geographies. Asynchronous messaging, for example, lets patients text a clinician or coach at any time and get a response later.
Non-clinician based digital mental health services, such as chatbots, video and written content, gamified user exercises and digital cognitive behavioral therapy (CBT) programs, are a good adjunct to clinician-based virtual care, allowing 24/7 access for those with less intensive needs.
Increasingly, innovative mental health vendors are combining digital tools and virtual care to create a robust ecosystem for end-to-end patient care, including steering patients to in-person care when needed. This combination of tools provides the mental health care system with scalable solutions and increased flexibility while improving access and convenience for consumers. Because of these benefits, the majority of employer-sponsored health plans now offer virtual and digital options for mental health care.
How well do digital services and virtual care work? A 2016 metanalysis of 452 studies of telepsychiatry found high patient satisfaction and quality equivalent to in-person care. And a 2020 Veterans Administration study found that video telepsychotherapy was as effective as in-person office-based care for treating depression and post-traumatic stress disorder. Overall, most published studies show telephonic mental health care is as effective as in-person care in treating depression, anxiety and obsessive-compulsive disorder.
Similar results have been generated by digital tools that provide animated and/or human video instruction, content libraries and exercises. Digital CBT programs have proven as effective as in-person CBT in treating anxiety and depression and insomnia. One randomized, placebo-controlled trial of web-based CBT for insomnia demonstrated improvements in sleep quality and wakefulness. That technology, marketed today as Sleepio, has been implemented by many large employers. A chatbot developed by Woebot which provides CBT, DBT (dialectical behavior therapy) and mindfulness support led to significant improvement in young adults’ anxiety and depression in randomized clinical trials. And meQuilibrium, a stress and resilience app and program now available through many employers, showed a significant positive dose-response effect on stress and related symptoms in enrollees in a digitally administered resilience program.
Each of these types of care solutions can be delivered in a HIPAA-compliant manner with appropriate privacy protections.
Scalability and Access
Ginger is an on-demand support program that guides users in addressing low-acuity mental health care needs, such as mild depression or anxiety, through secure asynchronous texting with trained coaches supervised by therapists and supported by artificial intelligence. (Many virtual care platforms use algorithms to match users to providers; there’s some evidence this can increase patient satisfaction and even clinical efficacy.) With Ginger, patients are escalated to a therapist or physician if they request it, or if the AI or coach recognizes the need for escalation. Coaches focus on needs including stress management, goal attainment, and recovering from loss using tools such as motivational interviewing and app-delivered content. By addressing less acute issues directly and triaging people to therapists or physicians as needed, the program provides scalable, cost-effective support. Ginger is offered directly by many employers, is in-network with several health plans, and counts Cigna and Kaiser Permanente among its investors. Vendors, including Spring Health, Lyra and Modern Health, likewise provide a continuum of care from addressing low-acuity needs to triaging users to more advanced care.
Talkspace, a platform with more than a million users, also scales access as it connects users to licensed providers. Members or employers pay a subscription fee for unlimited 24/7 access to therapists via texts, voice messages and/or videos within their secure application. Members or employees can also schedule video or phone sessions with a therapist as needed. While traditional 50-minute sessions are available, much care is delivered in small bites, allowing therapists to care for more patients and have more flexible schedules.
In addition to the scheduling flexibility and efficiency of therapy such platforms offer both patients and providers, these digital solutions have the potential to lower practitioners’ overhead. (They needn’t have an office.) They also broadly increase access at potentially lower cost to patients and employers than the cost of providing traditional face-to-face care to the same population.
The Path Ahead
The Covid-19 pandemic led to a dramatic increase in the use of virtual and digital mental health services. The pandemic and associated lockdowns left more patients in need with little choice but to move away from in-person care. Clinicians who had resisted virtual visits faced devastating loss of income, and they, too, moved online. However, maintaining and building on the gains in access to care will be key. Many users and clinicians have had good experiences with digital tools and virtual care, and their availability and use can help us meet our mental health needs as the pandemic recedes.
Clearly, virtual and digital care isn’t for everyone, and is inappropriate in some cases – for instance in most emergency situations. But virtual and digital care can improve affordability and provide critical additional access for those in need. In a study on virtual care, Accenture reported that 46% of patients “would choose to receive mental health appointments virtually.” Those in Gen Z (born in 1997 or later) were more than four times more likely than Baby Boomers to prefer virtual care to in person care. In addition, some communities which have historically faced stigma and discrimination may prefer virtual or digital care.
The pandemic has put a spotlight on the value of digital and virtual mental health care, and by doing so might have thrown a lifeline to our mental health system. If we can harness learnings from the pandemic to drive increased, appropriate use of digital tools and virtual care, we can significantly improve the long-standing problems of inadequate access to mental health services. Critically, digital tools and virtual care will allow us to effectively meet the mental health needs of more Americans than ever before.