The Role of Digital Therapy in Promoting Post-Secondary Student Mental Health

Abstract

Post-secondary mental health has reached crisis levels. Students attending post-secondary institutions such as universities, colleges, and trade schools are facing higher rates of negative mental health symptoms than before the pandemic, and have a higher prevalence of mental illnesses than found in the general population. Barriers to accessing mental health support prove to be a major obstacle for students—many of whom do not seek professional help when they need it. This mental health crisis is particularly poignant within marginalized student populations who face higher rates of mental illness as well as intersecting barriers to accessing support. Examples include cultural norms, chronic stress related to ongoing discrimination, and language barriers. Digital therapy presents a novel method of delivering mental health support and increasing accessibility to students in need. Mental health issues among post-secondary students, the barriers to care that they are facing, and specific digital mental health platforms to increase accessibility are outlined in this article.

Mental Health in the Student Population

The rates of mental illness among post-secondary students have reached crisis levels (Wiens et al., 2020). Within this population, mental illness is increasing in both prevalence and severity (Cohen et al., 2022; Linden, 2021; Prince, 2015; Rückert, 2015). Post-secondary students, though experiencing disproportionately high levels of mental health challenges, have a low rate of treatment-seeking: Fewer than 50% of students who need mental health services report actually receiving them (Blanco et al., 2008; Eisenberg et al., 2007, 2011). Moreover, for certain challenges such as substance abuse, post-secondary students are even less likely than their non-post-secondary attending peers to receive treatment (Blanco et al., 2008).

There are currently 16.9 million students in the United States who are enrolled in colleges and universities, and 2.17 million students enrolled in post-secondary institutions across Canada (Berg et al., 2023; Statista Research Department, 2022). Though mental disorders affect all ages, mental health concerns are a particularly prominent and growing issue for post-secondary students (Dunley & Papadopoulos, 2019; Skehan & Chan, 2022). In the last 15 years, the rates of mental illness among students have grown significantly, rising from 22% in 2013 to 37% in 2019 for women and from 12% to 21% for men (Linden et al., 2021). Some of the most current data on prevalence rates of mental health challenges among post-secondary students comes from the Healthy Minds Study (Eisenberg et al., 2022). The Healthy Minds Study is a large-scale, web-based survey that has been used to collect data from 96,000 U.S. post-secondary students across 133 campuses. According to the latest report from Healthy Minds, 44% of American post-secondary students reported experiencing depression, and 37% reported experiencing anxiety. Only 32% of students met the threshold for positive mental health, defined as self-perceived success in relationships, self-esteem, purpose, and optimism.

A common misconception exists that post-secondary students are a “privileged” population and, therefore, should be thriving; however, post-secondary students across the United States and Canada have been shown to have a prevalence of mental illness that is higher than that of the general population (Dunley & Papadopoulos, 2019). With this existing crisis being exacerbated by the COVID-19 pandemic and its aftermath, we are urged to take a serious look into national and global post-secondary mental health and ways that service providers can best provide support to students (Moghimi et al., 2023; Scherer et al., 2021). This article highlights current developments in the study of post-secondary mental illness and the role of digital mental health platforms in the treatment of mental health challenges, the promotion of help-seeking, and the prevention of the further development of this ongoing crisis.

Vulnerabilities and Outcomes for Students

There are a number of vulnerabilities unique to post-secondary students that help explain the high prevalence and severity of mental health challenges in this population—the first being age of onset. Globally, the onset of 75% of mental health disorders occurs before age 25, and over 80% of full-time undergraduates are under the age of 24 (Brown, 2016). Additionally, the beginning of post-secondary education is a time of major transition. In many cases, young people are required to leave their familiar home environments for the first time, face new financial burdens, have a flux in personal relationships, and assume new roles and responsibilities (Kadison & DiGeronimo, 2004). This period of adaptation is compounded by academic stressors that put students at additional risk of developing, or exacerbating, mental health challenges (Bohon et al., 2016; Larsson, 2022; Wei, 2022).

Among post-secondary students, academic and health outcomes and stress have been demonstrated to be directly impacted by mental health challenges (Linden, 2021; Moghimi et al., 2023). For example, 83% of American students felt that emotional or mental difficulties have hurt their academic performance in the past month (Eisenberg et al., 2022). Similarly, 64.5% of Canadian students reported that stress impeded their academic performance (American College Health Association, 2022). Additionally, U.K. students who report poor mental health experience less social contact with other students and professors, reduced satisfaction in school, and higher attrition rates (Papadatou-Pastou et al., 2017). Here, we can begin to see how a cyclical pattern of academic stress, poor mental health, and reduced academic performance can begin to form.

Suicide and self-injury among post-secondary students should also be acknowledged. Suicide is the second most common cause of death among young people worldwide (Brown, 2016; Wei, 2022). In Canada, 15% of post-secondary students report that they have contemplated suicide in the past year, and 28% have engaged in non-suicidal self-injury, such as intentionally cutting, bruising, or otherwise injuring themselves, whereas only 4% and 5% of the general population of Ontario adults, respectively, have done the same (Centre for Addictions and Mental Health, 2020; Eisenberg et al., 2022; Klonsky et al., 2011). In the United States, 14.2% of college students have contemplated suicide, and 25% have engaged in non-suicidal self-injury (Eisenberg et al., 2022). Put into perspective, this means that approximately 325,500 (15% of 2.17 million) Canadian and 979,800 (14.2% of 6.9 million) American post-secondary students have contemplated taking their own lives in any given year. These numbers make clear the present and growing issue of student mental health, and the importance of developing methods to prevent further risk.

Mental Health and Intersectionality in Post-Secondary Students

The mental health crisis among post-secondary students has particular relevance for students who have been marginalized and are situated at the intersection of compounding factors.

2SLGBTQIA+ Students

One group in particular is the 2SLGBTQIA+ (Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer and/or Questioning, Intersex, Asexual, and additional sexual orientations and gender identities) community, a group that has historically been a victim of prejudice and alienation, including from the mental health community. For example, homosexuality was declassified as a mental illness in the Diagnostic Statistics Manual (DSM) in 1974, and persistent and marked distress about one’s sexual orientation remained in the DSM until 2013. In addition, while “gender identity disorder” has been removed, “gender dysphoria”—a focus on the gender identity-related distress that certain transgender people experience—is still a diagnosable mental illness in the current version of the DSM (DSM-V).

The majority of American post-secondary students identify as heterosexual (79%), followed by 11% as bisexual, 3% as gay/lesbian, 3% as Queer, 3% as questioning, and 3% as another sexual orientation (Eisenberg et al., 2022). Non-gender conforming and transgender post-secondary students experience mental health challenges and impairment to a greater degree than cisgender students (American College Health Association, 2022). While 33.4% of cisgender Canadian students report serious psychological distress, this percentage increases to 54.3% for trans and non-gender conforming students. In the United States, 23% of 2SLGBTQIA+ post-secondary students have reported considering suicide, whereas the same is true for only 9% of their cisgender heterosexual counterparts (Eisenberg et al., 2022). Compared to 2.9% of cis-men and 2.4% of cis-women 11% of gay youth, 13% of lesbian youth, and 7.5% of trans and gender non-conforming students have attempted to die by suicide in the past year (American College Health Association, 2022; Trevor Project, 2022). This is not to minimize the significance of the mental health crisis among cisgender students, but rather to illuminate the heightened vulnerability of those who are 2SLGBTQIA+.

Racialized Students

Students from marginalized racial groups face additional challenges to their mental health, especially in the midst and aftermath of the COVID-19 pandemic. One group that has been disproportionately targeted throughout the pandemic consists of Asian and Asian-Pacific Islander students. Asian students in the United States have been forced to face increased racial prejudice due to COVID-19, with over a quarter of them experiencing racial or ethnic discrimination related to COVID-19 (Skehan & Chan, 2022; Zhou et al., 2021). This increase in prejudice and discrimination coupled with the social isolation resulting from the pandemic has led to significant mental health declines within Asian populations in the United States (Skehan & Chan, 2022; Zhou et al., 2021, 2023). A comparison of rates of mental health challenges in Asian-Pacific Islander students from Fall 2019 to Fall 2020 reveals a 17% increase in severe depression and a 30% increase in severe anxiety (Zhou et al., 2023).

The mental health of Black communities, and of Black students in particular, has, unfortunately, followed a similar trend in the United States and Canada. With pre-existing race-related inequalities concerning healthcare, Black communities were disproportionately vulnerable to COVID-19 and its accompanying mental health impacts (Kemei et al., 2023). As a result, Black students had significantly more negative mental health symptoms during the pandemic and reported higher levels of hopelessness, exhaustion, loneliness, depression, and anxiety than their White counterparts did (Wood et al., 2022).

The Indigenous population has been a victim of countless historical inequities and ongoing prejudice, especially in Canada. Mental health disparities between Indigenous and non-Indigenous populations in Canada have been well documented. In Canada, First Nations peoples and Métis are, respectively, three and two times more likely than their non-Indigenous counterparts to die by suicide (Statistics Canada, 2016). In the United States, the death rate from suicide for American Indian/Alaska Native adults is 20% higher than that for the non-Hispanic White population (Office of Minority Health, 2021). These disparities are linked to the intergenerational effects of colonialism and its continuing effects, the forced or threatened impositions on land and water rights, and gaps in mental health services (Redvers et al., 2022). In other words, this gap is due to both Indigenous peoples experiencing higher rates of mental health challenges while simultaneously having less access to help.

Indigenous individuals often deal with chronic stress associated with their marginalized social identities, as they face discrimination, prejudice, social isolation, and internalized stigma on a daily basis (Chai, 2023). These deeply rooted structural systems can lead to adverse mental health outcomes that require professional support (Beshai et al., 2023). Indigenous students in Canada experience high rates of anxiety and depression due primarily to the lasting effects of colonialism, racism, and discrimination (Beshai et al., 2023). Risk factors are compounded for Indigenous students, as they face these structural challenges while, at the same time, dealing with the demands of academic studies. Indigenous students were particularly at risk in the COVID-19 pandemic, where socioeconomic and health vulnerabilities functioned to exacerbate existing mental health challenges (Arriagada et al., 2020). The continuing psychological impacts of the pandemic are of particular concern, especially within historically under-supported communities such as Indigenous reserves.

Mental Health Need Versus Support

The research presented above highlights the growing need for mental health support to promote well-being within the post-secondary student population. The next logical questions seem to be, how many students are accessing mental health support, and how many are still in need?

The Healthy Minds Study indicated that in the past 12 months, 69% of post-secondary students stated that they needed help for emotional or mental health challenges (Eisenberg et al., 2022). However, only 37% of these students reported having received counseling or therapy for their mental health in the past 12 months. Here, we will explore factors that are preventing students from accessing therapy when they need it.

Barriers to Treatment

Post-secondary students struggling with mental health challenges face a multitude of barriers to accessing and seeking professional support. Barriers to treatment have been shown to exist at the institutional, sociocultural, and personal levels (Dunley & Papadopoulos, 2019). This concern for the mental well-being of post-secondary students and barriers to receiving treatment has been expressed at a global level (Cohen et al., 2022; Dunley & Papadopoulos, 2019; Rückert, 2015; Umubyeyi et al., 2016).

One of the most significant barriers to access and service delivery is the growth of the post-secondary student population. Research in the United States and Canada has revealed the substantial growth in student populations, which subsequently increases demand for counseling services (Cohen et al., 2022; Dunley & Papadopoulos, 2019). The number of American students with a serious mental illness has increased significantly in the past decade, leading to an increasing number of students seeking mental health support for increasingly severe concerns (Prince, 2015; Twenge et al., 2019). This greater need combined with the challenges outlined below leads to a delay in seeking support.

The most common reasons for American students not to seek mental health support were the belief that they have no need for services (33%), that they do not have enough time (25%), that they prefer to deal with challenges on their own or with support from family/friends (21%), and for financial reasons, such as therapy being too expensive or not covered by insurance (21%; Eisenberg et al., 2022). Rather than students truly believing that they have no need for mental health services, this number one reason is related to mental health literacy. Young people tend to have difficulty recognizing symptoms of mental health challenges, and even when these symptoms are recognized, they are often dismissed as not being severe enough to warrant seeking professional help, which is why many young people turn to their peers for support (Gulliver et al., 2010; Laidlaw et al., 2016). Students who did not seek help when they perceived that they needed it report greater financial difficulties (Nash et al., 2017). This is coupled with the fact that 30% of students do not know if their health insurance plan covers mental health support, and 9% of students are either not covered or do not think they are covered (Eisenberg et al., 2022).

Students have also noted inconvenient or unknown locations of mental health services as a main concern in accessing mental healthcare (Hadler et al., 2021). In fact, a third of students report not knowing the location of their school’s mental health supports (Flaherty, 2023). Not only do structural barriers such as waitlists, lack of time, and inconvenient locations barriers limit student access to mental healthcare, but they may also lead to a loss of motivation to continue therapy after the decision is made to seek support (Cohen et al., 2022). It is important to note that these factors do not exist in isolation but rather are part of a complex and shifting network that varies in relation to psychosocial factors such as previous trauma, location, personal and family circumstances, cultural norms and stigma, and health insurance coverage, to name a few (Dunley & Papadopoulos, 2019). It is, therefore, vital to understand student mental health challenges and barriers to access by using a holistic approach that considers personal and environmental circumstances.

Marginalized students face additional barriers at all levels when accessing and seeking support for mental health challenges, and these intersecting factors must be taken into account. In addition to a lack of access and transportation needs, the most commonly reported roadblocks include cultural and language barriers (Moghimi et al., 2023). The cultural stigma associated with help-seeking and mental health in general is part of the reason why students of color are less likely than those who are White to utilize mental health services (Hadler et al., 2021). Skehan and Chan (2022) indicate that White American students (46%) access mental health treatment more often than African American (26%), Latinx American (33%), or Asian American (23%) cohorts do.

In addition to cultural stigma surrounding mental health, students of color are more likely to seek help from their personal social network rather than professional help (Dunley & Papadopoulos, 2019). For example, it is common for members of Indigenous communities to go to their Elders for support (Redvers et al., 2022). Seeking support from culturally relevant services has unique strengths; in fact, help-seeking may be even more beneficial in this case, as these individuals may be able to develop a stronger therapeutic alliance, which is one of the most significant predictors of positive mental health outcomes (Meyer & Zane, 2013). Also, seeking help from alternative supports (e.g., friends and family) may minimize the stigma of asking for professional help (Hadler et al., 2021). However, it should be noted that seeking help from non-professionals within one’s community or personal network may limit success when one is dealing with more complex or severe mental health challenges.

Digital Therapy for Post-Secondary Students

Digital therapy is a relatively novel therapeutic method that has increased in use due to factors such as the advancement of technology and the convenience of meeting virtually. Notably, in-person services were shut down in the midst of the pandemic. Therefore, the vast majority of mental health services—including those on post-secondary campuses—were quickly forced to make the transition to digital platforms.

Digital Therapy: What Is It?

Digital therapy, also known as telemental health, refers to mental healthcare that is provided via electronic mediums such as a mobile phone, a tablet, or a computer (Hadler et al., 2021). With the continued advent of new technologies, digital therapy is constantly evolving and adapting as a current and effective method of mental health service delivery.

Allowing individuals the opportunity to seek help from any location, digital therapy has been of particular significance for those who are isolated or living in rural areas (Hadler et al., 2021). Post-pandemic, digital therapy continues to be an option for those facing accessibility barriers that prevent them from consistently attending traditional in-person therapy. Though certain individuals report hesitation to try digital therapy at first, overall satisfaction with online therapy sessions is generally high, especially for young adults (Batterham & Calear, 2017; Cohen et al., 2022; Hadler et al., 2021).

Young Adults and Digital Technology

Digital therapy has significant relevance for young adults, particularly the post-secondary student population. This form of therapy offers an accessible and familiar platform to students. Notably, over 90% of college students in the United States use the internet daily, and 86% of college students use a smartphone (Hadler et al., 2021). The availability of digital therapy platforms such as mobile phone apps provides a consistently accessible means for seeking mental health support.

The availability and accessibility of this digital form of therapy has the potential to reach a wider audience, maintain engagement between therapy sessions, and promote client awareness and feelings of responsibility—all of which function to enhance positive therapeutic outcomes (Broglia et al., 2016). Research on digital therapy among post-secondary students has demonstrated that this form of support is consistently accessible and available at their convenience, which is in stark contrast to the lengthy waitlists of traditional in-person therapy (Cohen et al., 2022; Hadler et al., 2021). Consistently accessible service from any location means that individuals can access help when they need it, from wherever they are. Consider, for example, a student in their dorm who is struggling with symptoms of depression. Along with their persistent low mood, the student may be feeling fatigued and lethargic, which makes getting out of bed difficult (World Health Organization, 2022). Though a person facing these symptoms would likely benefit from professional help, traveling to an in-person office can be a daunting (or even an impossible) task. The accessibility and availability of digital therapy can facilitate a greater number of individuals seeking help when they need it, with little delay.

Unique Therapeutic Challenges for Students

Historically, post-secondary students have unique needs that can make attending and remaining in therapy challenging. Services for students must be affordable, require therapeutic support for those with complex mental health challenges, and function within a student’s academic timetable (Broglia et al., 2016; Cohen et al., 2022; Holm-Hadulla & Koutsoukou-Argyraki, 2015). Consistently attending in-person therapy also becomes challenging when students are traveling between school and home. When having to choose between these two locations, a student can be away from their therapist’s office for weeks or months on end. It therefore becomes challenging for traditional in-person therapy to consistently meet the needs of students.

Positive Aspects of Digital Therapy for Students

Fortunately, digital therapy is a potentially positive alternative solution to traditional in-person therapy. Notably, it offers a new solution to meet the needs and promote the mental health of post-secondary students (Gatti et al., 2016; Harrer et al., 2019; Wong et al., 2021). Research has demonstrated the eagerness of American students to engage in digital methods of therapy, such as mental health apps, to manage their mental health challenges (Cohen et al., 2022; Kern et al., 2018). Digital therapy reduces the issue of fitting appointments into a course timetable, as it often provides more accessible hours and no commute time (Gatti et al., 2016). This therapeutic medium also means that a student can attend sessions from wherever they are located—school or home. Digital therapy has also been demonstrated to encourage self-disclosure in those seeking help, with the virtual platform fostering a sense of anonymity that facilitates vulnerability. This vulnerable disclosure helps to sustain the therapeutic alliance and facilitate client progress in therapy sessions. Additionally, it is often easier to sustain engagement in counseling when it is offered virtually, which reduces some of the social stigma that comes from physically seeking help in a professional’s office and taking the chance of “being seen” (Broglia et al., 2017). This element of anonymity has particular relevance for students from marginalized groups. Specifically, stigma is often a major barrier that prevents students from seeking professional help, as discussed previously (Hadler et al., 2021).

Post-secondary students in the United States have reported openness to digital therapy, expressing that it is convenient, accessible, easy to use, and helpful (Hadler et al., 2021). In fact, Hersch et al. (2024) found that during the pandemic, 90.2% of university students indicated that digital therapy services were as effective or more than traditional in-person services. Self-reports from students on the helpfulness of this form of therapy are echoed by empirical evidence, which highlights the positive impact of digital therapy services on post-secondary students (Cohen et al., 2022; Hadler et al., 2021; Larsson, 2022; Lattie, Adkins, et al., 2019). Studies have shown that digital therapy can effectively be used to treat depression, anxiety, sleep, stress, PTSD, and eating and alcohol use disorders in post-secondary students (Hadler et al., 2021; Harrer et al., 2019; Lattie, Adkins, et al., 2019). In a digital cognitive behavior therapy trial with post-secondary students in Canada, 54% reported large improvements in symptoms of depression and anxiety and small improvements in academic functioning after treatment, which were maintained at the 1- and 3-month follow-ups (Peynenburg et al., 2022).

In numerous studies where synchronous video-chatting and text message digital therapy formats were investigated, this counseling medium was shown to be as effective as a traditional face-to-face format (Harrer et al., 2019; Wong et al., 2021). A global systematic review of digital mental health programs indicated that these interventions were either effective, or partially so, in facilitating beneficial changes in psychological well-being and mental health (Lattie, Lipson, et al., 2019). Wong et al. (2021) conducted a qualitative study on the use of a digital therapy mobile app for university students in Canada. The majority of students in the study reported using the app as a tool for mental health support during times of need, such as when they were experiencing depression, anxiety, or other negative mental health symptoms (Wong et al., 2021). This echoes the work of Broglia et al. (2016) in the United Kingdom, indicating that digital mental health applications have the potential to promote self-awareness and responsibility for mental health among post-secondary students. With the help of digital therapy, students are able to seek help for regularly scheduled appointments, or can seek help immediately when they experience negative mental health symptoms.

This recent literature contends that digital therapy is an effective medium for the delivery of therapeutic services, with particular relevance for addressing the unique therapeutic needs of post-secondary students. Therefore, digital therapy demonstrates the capability of promoting positive mental health outcomes among post-secondary students and preventing further incidence of mental health challenges. However, despite showing significant therapeutic promise and favorability in student populations, digital therapy is not without limitations.

Limitations of Digital Therapy as a Modality

The main limitations of digital therapy include concerns surrounding therapeutic success for the treatment of severe mental health symptoms, the online client–therapist relationship, and client safety and privacy concerns.

In a systematic review of barriers to client engagement on digital mental health platforms, 20 of 208 articles indicated that severe mental health symptoms presented a barrier to engagement (Borghouts et al., 2021). The implicated articles reveal the complexity of addressing severe mental health concerns and their related symptoms and offer a preference for the use of face-to-face therapy in these situations. Though preliminary research demonstrates positive results globally for the use of digital therapy for symptoms in treating severe mental illnesses, at this point, insufficient evidence supports the use of digital therapies for individuals with schizophrenia spectrum disorders and bipolar disorder (Lawes-Wickwar et al., 2018; Tremain et al., 2020).

Research on the therapeutic alliance in digital versus face-to-face therapy is mixed. Certain studies have indicated student concern that moving from a face-to-face environment to a digital one will compromise the therapeutic relationship (e.g., Hadler et al., 2021). Additionally, certain therapists reported a preference for in-person therapy for reasons such as observing nonverbal cues and dealing with crisis situations (Leuchtenberg et al., 2023). Leuchtenberg et al. found that while clients do not report any differences in therapeutic bond, goal setting, or empathy in digital versus face-to-face settings, therapists prefer the latter therapy for setting goals and facilitating empathy. However, recent meta-analytic work by Seuling et al. (2024) indicates that there is no reported difference in therapeutic alliance by either client or therapist in video versus in-person therapy. As previously discussed, more research is needed to understand the nature of the digital therapeutic alliance for those with severe mental illnesses (Tremain et al., 2020).

Client safety is a responsibility that is at the forefront of all therapeutic relations, despite their specific modality. A concern expressed over digital therapy is the remoteness of the client and the possibility that they may enter a state of crisis during the therapy appointment. In this case, having a therapist in the same room as the client would prove beneficial as the therapist can monitor the client and their behaviors to best support their needs (Taylor et al., 2020). This situation becomes difficult in a virtual setting, where the client has the power to be immediately disconnected from the care provider. That being said, best practices have been developed to address client safety in digital crisis environments, including assessing the level of client agitation and keeping records of mental health professionals in the immediate area of the client (American Psychiatric Association, n.d.; Canadian Psychological Association, 2023).

Privacy, concerning both one’s physical environment and digital confidentiality, is another concern expressed by clients. While certain clients prefer digital therapy over the face-to-face version due to the option of attending therapy from a private home environment, other clients do not have access to a secluded environment at home (Borghouts et al., 2021). Those without access to a private environment feel that they can disclose more openly in a closed therapist office than in their own household and, therefore, prefer in-person therapy to digital modalities. Also, in situations where the home environment may be contributing to a mental health concern, disclosing the problematic details openly while within the home may prove challenging or even dangerous. Another facet of client privacy is digital confidentiality. Though a number of validated digital therapy platforms are compliant to the Health Insurance Portability and Accountability Act (HIPAA-compliant), concerns have been expressed about the security of personal information on these platforms (Taylor et al., 2020). Zoom, in particular, has become a topic of discussion for privacy and confidentiality concerns—including unnecessary data disclosure and leaked personal information—since its widespread adoption during the COVID-19 pandemic (Singer & Perlroth, 2020). Multiple studies have demonstrated that concerns about confidentiality can be a significant barrier to engagement in digital therapy platforms (Borghouts et al., 2021).

Though digital therapy is not without limitations, the recent literature surrounding this therapeutic modality continues to show the considerable promise that it demonstrates in promoting improvement in the mental health of students, especially those facing accessibility barriers.

The Issue of Non-Empirical App Development

Despite the fact that there are now multiple solutions that effectively target the post-secondary mental health crisis with a wide accessibility of services, a new issue has emerged. Empirical evidence suggests that of mental health applications, only 14% have been developed under supervision of healthcare professionals (Sedrati et al., 2016). This means that there is a significant lack of testing for efficacy, reliability, and accuracy within these mental health apps (Sedrati et al., 2016; Taylor et al., 2020). Though we are seeing an increase in digital therapy apps and platforms, the majority of them have yet to be proven effective. The solution to this problem is to rely on digital therapy platforms that are based on empirical data.

A Research-Based Solution: Digital Therapy Platform Case Example

In light of the demonstrated benefits of digital therapy and with attention to the factors reviewed in the present work and limitations of existing platforms, the authors have been involved in the development, implementation, and initial evaluation of a specific digital therapy platform known as Keel Mind. Several digital mental health platforms will be discussed in terms of features and utilization, but Keel Mind (2023) will be evaluated as the primary exemplar of a research-driven digital therapy platform based upon our knowledge of it and what is currently known about its benefits and limitations (Smith et al., 2023).

Keel Mind is a digital therapy platform that connects those in need of mental health support with a diverse range of mental health service providers through live audio or video sessions. In parallel, Keel Mind functions to provide clinical training and supervision to graduate-level students, who offer the therapeutic services to those seeking support. Keel Mind is fully funded by the Ministry of Colleges and Universities (MCU) in Ontario, Canada. It fits into the aforementioned 14% of applications developed under the supervision of mental health professionals and has undergone preliminary trials with samples of Canadian post-secondary students (Keel Mind, 2023; Sedrati et al., 2016).

Keel Mind was developed in 2021 with the goal of increasing the accessibility of mental health services for post-secondary students and promoting the training of high-level mental health professionals. It is an unfortunate fact that the demand for mental health services and practitioners outpaces their supply in all forms of mental health practice (Bethune, 2021). This means that those facing mental health challenges who have taken the first step to seek help by reaching out to a service provider are now often facing delays in actually receiving therapy. The driving force behind the MCU’s funding of Keel Mind is to support its method of simultaneous training of students and delivery of service.

In March of 2022, Keel Mind signed an agreement with the provincial government and the MCU to (a) allow graduate students in mental health programs to quickly and efficiently acquire supervised clinical hours while (b) providing mental health support to any student in a post-secondary institution in the province of Ontario. The goal of this agreement is not only to increase the graduation rates of students in mental health programs but also to increase significantly the immediate supply of mental health practitioners in Ontario. In promoting an increased supply of mental health practitioners, Keel Mind aims to offset the increased demand for mental health services.

Keel Mind is currently partnering with post-secondary institutions across Canada and the United States to offer free digital therapy to students. Connecting individuals in need of mental health services, especially those attending post-secondary institutions, with accessible mental healthcare has been a long-standing issue across Canada and the United States that was exacerbated by the COVID-19 pandemic (Canadian Mental Health Association, 2020; Eisenberg et al., 2022; Scherer et al., 2021). To combat these long-standing mental health challenges, Keel Mind strives to meet this growing demand by providing accessible, empirically based mental healthcare alongside accredited clinical supervision. Therapeutic service delivery facilitated by Keel Mind uniquely utilizes Artificial Intelligence (AI) within digital therapy sessions, which aims to support the therapeutic alliance and to provide a detailed analysis of therapeutic progress.

Therapeutic Features of Keel Mind

Keel Mind is an empirically based digital therapy platform, meaning that its features have been designed in line with previous research in supporting the therapeutic relationship and effective delivery of service. The team at Keel Mind includes various mental health professionals who oversee the development and implementation of the platform’s features.

A concern that post-secondary students express over digital therapy as opposed to in-person counseling is a possible lack of personalization that will compromise the therapeutic relationship (Hadler et al., 2021). Keel Mind is aware of and offers a solution for addressing this significant concern by facilitating a client–therapist matching algorithm, allowing clients to be paired with a therapist based on chosen demographic attributes. The self-selected matching ability utilized by the platform relates to the therapeutic alliance: When clients are matched on certain demographic factors, such as ethnicity, they have been shown to improve their responsiveness to therapy (Meyer & Zane, 2013). If they are well matched with a therapist, clients are more likely to fully engage in therapy more quickly, thereby shortening the duration of care required.

As a platform designed specifically for digital therapy delivery, Keel Mind contains progress features that allow practitioners to track client outcome measures across time. Therapists are able to send clients validated questionnaires directly within the Keel Mind platform, which allows for self-reported symptoms to be tracked. Each time a client completes a specific questionnaire, results are visually graphed, allowing the clinician to view progress across sessions. This self-reported symptom assessment functions as a secondary prevention technique, allowing for the detection of underlying symptoms of mental illness and for the personalization of the therapeutic experience moving forward. The detection of these symptoms leads to the tertiary prevention strategy of facilitating therapeutic sessions to reduce the severity of symptoms.

Notes are another central method for tracking client progress across time. Along with offering the ability to manually take notes in-session, Keel Mind contains a note assistant feature that uses session transcripts to automatically generate relevant notes from the session (for full description of feature, see Austin et al., 2024). This feature allows therapists to remain in the moment with clients rather than having to divide their attention between taking notes and actively listening. With the ability to track scores on symptom questionnaires across time, and through the use of the note assistant feature, Keel Mind aims to strengthen the therapist–client relationship, prevent further incidence of mental health challenges by detecting and reducing distressing symptoms, and promote positive mental health outcomes.

AI is a feature that has been utilized in recent years to personalize and to advance the world of healthcare (Palanica et al., 2020). AI analytics assist in the therapeutic process conducted on Keel Mind by providing clinical outcome data following therapeutic sessions. The platform utilizes natural language processing (NLP), which analyzes the full session transcript to provide assessments of variables such as rapport and empathy between therapist and client, feedback immediately following a session on the client’s level of inward and outward focus, authenticity, and cognitive load (Austin et al., 2024).

This process is accomplished through Linguistic Inquiry and Word Count (LIWC), which is based on the work of Dr. Pennebaker at the University of Texas at Austin. LIWC, the basis for Keel Mind’s NLP assessment, focuses on the creation of custom dictionaries built around word utilization to identify words that offer insights into the expression of certain emotions—for example, anger words, sad words, words that are tied to depression (Tausczik & Pennebaker, 2010). LIWC has been established as a valid method for measuring verbal expression of emotion (Kahn et al., 2007). This NLP data illuminates the therapeutic progress of the client and allows for clinician discretion if progress has come to a halt. If a client shows little improvement in clinical outcome measures, this data may be used to support the care provider’s decision to change the therapeutic approach or to allow a more compatible care provider to take over. Through the unique utilization of AI and NLP, Keel Mind aims to promote client well-being in demonstrating improvements in therapeutic alliance, rapport, and overall mental health.

As a digital therapy platform, Keel Mind strives to prevent mental health challenges within the post-secondary student population and to promote positive mental health moving forward. In addition to the secondary prevention utilized by the platform in detecting problematic symptoms of mental health challenges and the tertiary prevention methods of therapeutic sessions to reduce symptom prevalence and frequency, Keel Mind has recently incorporated primary prevention through the development of their Wellness Hub. This resource provides access to up-to-date information on post-secondary student mental health and includes resources that people can access if they find themselves beginning to struggle. In facilitating a psychoeducational resource that students can access at any point, especially prior to experiencing a mental health challenge, Keel Mind strives to reduce the incidence of distressing mental health symptoms and promote positive coping. Overall, Keel Mind is a digital therapy platform that provides preventative support to promote positive mental health in post-secondary students.

Alternative Digital Therapy Platforms

It is important to note that Keel Mind is among many high-quality digital therapy platforms, all of which have their own unique strengths. For example, Zoom Health™, Microsoft Teams™, and Certified Listener’s Society™ are three platforms that effectively facilitate digital mental healthcare delivery.

Perhaps the most similar platform to Keel Mind is Zoom Health, a sub-platform of Zoom™ that aims to be implemented directly in the healthcare realm. One unique aspect of Zoom Health is that it offers the option for live closed-captioning that the client and therapist can monitor and follow along. This accessibility feature, which is not yet available on Keel Mind, allows a larger population of individuals to seek mental health support virtually.

Many alternative digital therapy platforms offer a mental health approach that enables users to access care anonymously and episodically (e.g., Certified Listener’s Society). As stated earlier, a major barrier to accessing care is a fear of the stigma associated with seeking support (Gatti et al., 2016; Hadler et al., 2021). With care providers on scheduled and recurring platforms such as Keel Mind and Zoom Health, this fear of stigma may still present a barrier, as the care provider in these situations has access to the client’s name, mental health background, and progress over time. Certified Listener’s Society allows any individual the ability to seek anonymous emotional support from a trained individual immediately when they are in need. This is in contrast to platforms such as Keel Mind, where clients have an account that is linked with their health information and is accessible by their clinician. Although these episodic and immediately available platforms deliver an important service with meaningful applicability, it is important to note that this form of service delivery means that clinicians are unable to track progress of clients and assess the effectiveness of the program.

Current Impact and Future Goals of Keel Mind

In 2021, Keel Mind ran a pilot program with the Ontario Government, which resulted in a 98% retention rate for students receiving care and a 32% increase in student well-being over five sessions (Newswire, 2022). Since this initial success, Keel Mind has facilitated over 110,000 sessions between September 2022 and March 2024. These sessions are supported by 4,348 trainees and supervisors across 35 of the 46 publicly assisted institutions in Ontario.

Survey results from Ontario post-secondary students who utilized the Keel Mind (2023) platform showed that over 90% felt that the platform was easy to access and use, and over 83% have felt an improvement in their mental health and wellness since first use. Over 83% reported feeling more equipped to make positive changes in their daily life after receiving counseling on the platform. Based on the prevalence and severity of post-secondary mental health challenges (see Mental Health in the Student Population above), these reported numbers show promise in Keel Mind’s ability to prevent the continued escalation of incidence rates of mental health challenges and to promote positive mental health outcomes for post-secondary students across Canada and beyond.

In a case study by Smith et al. (2023), the Keel Mind platform was utilized to facilitate a virtual 8-week emotion-focused family therapy intervention for two parents during a marital separation. Results of the study indicated that a strong therapeutic alliance was formed using this method of service delivery. Parents reported improvements in family functioning; self-efficacy; psychopathology; and child depression, anger, and anxiety symptoms. This early work highlights the potential for the successful utilization of digital therapy platforms, such as Keel Mind, to promote the accessibility of effective clinical services for families. This form of therapy demonstrates particular relevance for families whose members reside in different homes or geographical locations.

Keel Mind is currently expanding the accessibility of the digital mental health platform to additional institutions across Canada and is broadening its reach to the United States. The platform also plans to work with and support at-risk populations, such as Veteran Affairs, first responders, and individuals living in remote locations such as Indigenous reserves. Once again, based on the author’s knowledge of the platform and its roles in development, Keel Mind has been selected as the primary exemplar of a research-based digital mental health platform. As many individuals continue to struggle with mental health challenges post-pandemic, Keel Mind and similar platforms aim to offer a research-driven platform designed to fit the needs of the diverse population.

The Future of Digital Therapy

As a rapidly developing therapeutic modality, digital therapy demonstrates the unique ability to increase service accessibility to diverse populations. Through the use of digital therapy, individuals are able to access service providers who are not physically accessible to them. For example, an individual who may have traditionally struggled to seek mental health support in their first language can now meet virtually with a service provider who communicates in a language with which they are comfortable and that they understand. Whether the care provider is minutes or hours away, this quality mental healthcare can be facilitated at anytime, anywhere.

As research and practice in the field of digital therapy continue to develop, digital mental health services will progress in their reach and accessibility. The additions of quickly developing technology such as assistive devices and AI analysis tools further facilitate the adoption of this method of service delivery. Further research should be used to assess the utilization of AI technology within digital therapy and to establish specific guidelines on the responsible use of digital therapeutic methods to assist in incidence reduction for the mental health challenges of post-secondary students.

Conclusions on Digital Therapy Platforms for Post-Secondary Mental Health

Growing in prevalence and severity, the post-secondary mental health crisis demands our attention. Mental health challenges affect post-secondary students worldwide and have particular relevance for students who have experienced marginalization and face intersecting barriers to accessing mental health support. However, the rapidly developing world of digital therapy presents a solution to post-secondary mental health challenges and demonstrates potential to prevent the further development of this crisis. Research-driven digital mental health platforms offer an innovative solution to meet the service and accessibility needs of post-secondary students and to promote positive mental health outcomes of young adults globally.