CPG Series: Making good on the promise of computerized therapy

Making good on the promise of computerized therapy

Can technology dismantle barriers to mental health treatment?

Licensed clinical social worker Josh Cutler has helped many navigate the mental health care system. The process, he says, can be frustrating, even more so because people seeking care for mental health issues may already be incredibly stressed. When they bump up against difficulty getting the help they need, they can become even more distressed or drop life-saving treatments.

“People might reach out to a hotline, and they’re given a list of counselors,” Cutler says. “Then they call 10 and sometimes no one calls back. The road to obtaining really good care is rife with difficulty and has great potential for exacerbating despair.”

Now, as manager of telebehavioral health at Seattle health care network Swedish, part of the Providence St. Joseph Health system, Cutler is helping change how primary care providers deliver mental health care to their patients. He’s building a team of clinicians who can offer virtual visits, blended therapy that happens both electronically and in person, and computerized screening tools that more efficiently pinpoint patients’ needs.

Mental health crisis

Approximately 44 million U.S. adults face mental illness. And yet six in 10 people with mental illness did not get treatment in the past year.

“We have not been able to bend the curve on morbidity and mortality from mental illness and give people the treatment they need,” says Dr. Arpan Waghray, chief medical officer at the Well Being Trust and system director for Telepsychiatry at Providence St. Joseph Health.

The most pressing reason for untreated mental illness is that many people simply lack access to mental health care providers. More than 6 in 10 U.S. counties don’t have a single psychiatrist. And many people don’t try to get care, or don’t talk to others about the care they are getting, because of negative attitudes about seeking mental health care and lack of support from family and friends.

Of those who are treated, not many are able to access the best, evidence-based care available. And the way the health care system works means patients’ medical, psychiatric and family-support needs are handled separately. For example, when a diabetes patient is also suffering from depression, their primary care physician may tell them to seek therapy. But the patient may not feel they got solid guidance from their physician or insurance company about where to get high quality therapy. This fragmentation can confuse patients and keep them from seeking or continuing care, leading them to do worse both from a physical and mental health perspective.

“Fragmentation just results in poor outcomes, people slipping through cracks,” says Eviatar Frankel, director of digital strategy at Providence St. Joseph Health.

Piloting solutions

Along with Waghray and Cutler, Frankel is looking at how to use technology to improve patient care, empower clinicians and better address the mental health crisis in the communities where Providence St. Joseph Health works.

To start, they turned to primary care physicians and patients to learn what is keeping patients from getting the care they need.

In one-on-one guided interviews, patients reported difficulty finding a psychiatrist who was a good fit and fitting appointments into their daily lives. They said they were unable to get questions answered, and they experienced “screening fatigue” from being asked to answer the same questions over and over. Often, they said, these obstacles kept them from completing treatment plans, and their depression or anxiety would come back.

Using that feedback, the Providence St. Joseph Health team chose two digital solutions — SilverCloud and myStrength — which they piloted for six months in primary care clinics in Washington and Oregon. The tools supplemented in-person doctors’ visits with computerized screening to measure patients’ depression and provided educational content to help patients  understand and cope with the condition. In addition, patients could undergo computerized cognitive behavioral therapy and mindfulness training, both shown to help people manage depression.

Because technology, in the form of a smartphone, is literally in the palm of many patients’ hands, digital mental health platforms like these have the potential to dramatically increase access, Waghray says.

“Patients don’t have to drive across town and take off time from work for therapy, and it’s not seven weeks from now,” he says.

In other words, mental health care no longer has to be confined to the clinic.

Right combination

Technology also has the potential to improve quality of mental health care by making it more uniform and measurable, as well as relieving some of the burden from primary care physicians, who deal with many competing priorities. And, with major improvements in artificial intelligence, computerized mental health screening and treatment can adapt to patients’ needs, eliminating screening fatigue and more quickly matching patients with the right therapies.

“We want to make it as easy for doctors to prescribe digital therapeutic tools that reduce the symptoms of depression as it is for them to prescribe antidepressants, so that patients can get the right combination of treatments for them,” Waghray says.

The team says so far 120 patients of the Oregon and Washington clinics have used the two solutions in the pilot.

“Now we’re working on, ‘How do we get this in hands of more patients, including through novel strategies that more effectively support busy doctors,’” Frankel says. “So much is going on in a primary care setting — finding a pathway to get as many patients on board as possible is our immediate next step.”