Information technology as the key to accelerating advances in mental health care

Introduction

Many major medical and scientific advances occur in association with technology. Cochlear implants, prosthetics and the human genome project have all come about because of investments in materials, electronics and biotechnologies, combined with medical and clinical knowledge. Computers, and indeed the Internet, are listed as some of the greatest inventions of all time, which have transformed medicine, the sciences and society. From the early 21st century, the Internet was seen to be transforming medicine, by improving communications between patients and clinicians, providing new devices, and facilitating information dissemination. Interestingly, papers written in the early 2000s in major journals such as the Journal of the American Medical Association now seem incredibly conservative in their predictions for Internet-enabled technologies and their use in health care (e.g. Baker et al., 2003).

In medicine, the recent NSW review chaired by Peter Wills (2012) and US-based reports on science highlight biotechnological developments as key drivers of innovation (Macilwain, 2010). However, information and communication technologies are just as likely to be as important as biotechnology, and particularly in population and mental health. Web 2.0 has quite literally ‘created’ the global village. The single largest website in the world is Facebook, which allows organisations and individuals across the globe to communicate (Owyang, 2012). Mental health research institutes have their own Facebook pages (e.g. Black Dog Institute). Access to specialised medical information has been democratised. This explosion in knowledge transfer and dissemination has, in part, been driven by the exponential rise in use of internet-enabled devices. More people own mobile phones than computers. In the developing world, mobile phones have overtaken laptops in volume, and provide the major source of communication technology. In Uganda alone, 10 million people, or about 30% of the population, own a mobile phone, a number that grows rapidly every year (Fox, 2011). Some 35% of the American population have ‘apps’ on their smartphones (Purcell et al., 2010) and tablet use is growing at a faster rate than smartphone devices (Online Publishers Association, 2012).

Mental health: qualitative leaps or just quantitative?

Within this context of medicine and technology, two questions have long interested researchers in mental health. The first is the extent to which mental health interventions have been transformed by technology (or what can we now do that we could not before?). The second relates to the extent to which the disciplines of mental health and psychiatry have especially benefitted relative to other disciplines such as medicine (or is technology especially useful in psychiatry and mental health?). In the remainder of this Debate, we address these two issues in turn, highlighting new ways that health professionals and health consumers can do things and how psychiatric and psychological treatment might particularly benefit from these innovations.

Can we do things we couldn’t do before?

The Internet has certainly made possible things that were nearly impossible before.

Dissemination, reach and acceleration of discovery

Contopoulos-Ioannidis et al. (2008) noted that the ‘translational lag’ for medical interventions took a median of 24 years. The Internet may allow this translation to occur much more quickly, and provide broader dissemination. This is uniquely the case where the intervention is a software application available online for download, allowing direct dissemination to the public. To illustrate, myCompass (Harrison et al., 2011), a mobile phone application offering cognitive behaviour therapy (CBT), took 4 years to develop and trial in a randomised controlled trial, but dissemination was immediate, with 8000 people taking up the application within 3 months of launch.

New roles in the workforce: The ‘barefoot psychologist’ and the ‘knowledge broker’

The role of the psychologist has changed with the introduction of interactive websites delivering ‘sophisticated’ therapies. Although manualised treatments have long been used to deliver CBT, the difference lies in the fidelity of the intervention that arises from ‘computerised delivery’. Current thinking suggests that programs guided by a non-professional are effective, comparable to clinician-administered variants (Titov et al., 2010), and better than self-help programs (Cuijpers et al., 2011), although the latter are also effective. New roles for ‘online barefoot psychologists’ will be created if evidence continues to support this position. Similarly, ‘knowledge brokers’ are newly created roles where health information available online is explained to populations in rural areas with low literacy.

Self-help and the empowered patient movement

The growth of self-help and the empowered patient movement has been created by the democratisation of the web. This movement promotes an equal relationship between patients and doctors, and advocated the use of online health information resources. A case could certainly be made that this movement would not be as influential today without the Internet allowing consumers to access health information directly and share it globally.

The whole is greater than the sum of its parts

By combining the Internet with other capabilities, the sum total extends the capabilities of both parts operating alone. This is indeed one of the most appealing qualities of websites, as they combine many sophisticated technologies. For example, some health-care sites pull together health databases, offer screening and ‘at-risk profiling’, and provide contact details for local health-care providers and route maps to these locations through tools such as Google maps. Mobile phones can link sophisticated bio-sensing technologies to self-report data, information and geographical location, which can be used to monitor behaviour and mood. These capabilities may facilitate identification of ‘at-risk’ individuals, assist referral and access to treatment, and improve management of mental disorders such as anxiety.

Can we do things especially better?

These changes in technologies have impacted all forms of health care. They may be particularly helpful for disorders that require chronic disease management strategies, such as obesity, because of their capacity to monitor and guide behaviour. However, there may be a number of features that make them especially likely to work for mental health. First, CBT, Interpersonal Psychotherapy and Problem Solving Therapy are therapies with a strong evidence base in psychiatry and psychology. Evidence from the last decade indicates that online versions of these programs are effective (Cuijpers et al., 2011). Thus, a major evidence-based treatment can be offered online in unique interactive formats, such as games or e-learning. This differentiates such mental health interventions from other medical disciplines where best treatment must be offered face-to-face to allow physical interventions to occur. Possibly more important than the capacity to deliver a major treatment in unique formats, is a second feature that may differentiate online interventions – which might be best described as ‘control and intimacy’. This is the need of consumers to have control over their own mental health, as it is so much a part of who they are. A third reason why the Internet is particularly important in mental health care is the greater availability of specialised medical knowledge and treatments, via the self-help movement, which increases mental health literacy, may reduce stigma and encourages help-seeking.

Conclusion

Because of space, other activities facilitated by technology cannot be described here. These include: the role of social media in promoting mental health; population-based approaches to understanding aspects of mental health, such as geospatial mapping of suicide clusters; and the great opportunity online dissemination has to improve T2 translation (Woolf et al., 2008). T2 is translation that seeks to improve access, develop higher quality clinical care, and help consumers. The impact of technological developments will become clearer over a very short time. In the meantime, we will continue to see transformations of all aspects of medical and psychological ‘transactions’, new infrastructure to manage interactions between patients / consumers and a broader range of providers, new devices and ‘apps’ which have the potential to extend, make more efficient and add value to mental health care.