Digital interventions for young people: addressing the gap between development and implementation

Bethany Cliffe
First-year PhD student at the University of Bath, researching a smartphone app for self-harm in university students.

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Abstract

Smartphone apps and other digital mental health interventions can increase access to support for young people struggling with their mental health. While young people are very engaged with technology and there are plenty of apps available to choose from, uptake is still low.

Valid concerns around their reliability and safety have been raised by both young people and clinicians and so, moving forward, we need to think about how to address these in order to close the gap between development and implementation of digital interventions.

Background

Young people today are fully immersed in the digital world with 99% of 12-15 year olds in the UK having access to the internet, spending an average of 20 hours a week online. This is compared to 8 hours a week in 2005, showing a 150% increase in the past 14 years (Ofcom, 2019). Similarly, 83% of 12-15 year olds now own their own smartphone compared to 41% in 2011, showing a 102% increase in the past 8 years (Ofcom, 2011).

One benefit to ubiquitous technology use is the opportunity to seek mental health support digitally. This can take many forms, such as online support groups, forums, podcasts, or smartphone apps. Apps for mental health can provide a solution to some of the barriers that young people face when accessing face-to-face support. It is estimated that 1 in 8 young people now struggle with mental health difficulties (NHS Digital, 2018), yet less than one quarter of those are able to access treatment (Ford et al., 2007). Smartphone apps can be available immediately, 24/7, and without limits on provision capabilities.

Few young people are able to access face-to-face treatment

What is happening now

Despite the advantages that smartphone apps can offer, it seems that young people are not necessarily engaging with mental health apps as much as perhaps would be assumed. A survey conducted with adolescent girls identified that only 15-17% of those with raised mental health symptoms had used apps for their mental health (Grist et al., 2018). The sample were split roughly 50/50 on whether they would consider using mental health apps in the future, and also on their preference for face-to-face or digital interventions. While advantages of apps were identified, such as their accessibility, availability and anonymity, concerns over the trustworthiness of the app and the accuracy of the information provided through the app were also highlighted. This is a very valid concern.

The market for mental health apps has become incredibly saturated, with 1,435 mental health apps having been identified so far (Larsen et al., 2019). Despite this, one review found that only 3.4% of apps available had any evidence base (Marshall et al., 2019).

For young people attending a face-to-face service for mental health support, their engagement with smartphone apps can be mediated by their clinician’s attitude towards apps (Hollis et al., 2017); given the saturation of the market many young people may rely on their clinician for guidance around what to use. Based on this, we conducted a survey with CAMHS clinicians working in Oxford Health NHS Trust – it should be noted that this trust is a mental health Global Digital Exemplar identified as a digitally advanced mental health trust, so responses may not mirror the wider community.

Respondents to the survey suggested that incorporating digital tools into their clinical practice was helpful and appealing to young people, but the majority also indicated that they did not know what resources were available. We found that 70% used or recommended smartphone apps in their clinical practice with young people at least monthly, while 20% never used them (Cliffe et al., 2019). Again, it is important to note that this trust has been a trial site for several mental health apps.

When assessing their attitudes, it was identified that many clinicians were unsure about the privacy, security, safety, reliability and risk associated with digital mental health tools. This reflects the concerns raised by young people in the study mentioned above. This provides further evidence for a barrier to young people accessing mental health smartphone apps, relating to the trustworthiness of the apps available.

Young people and their clinicians are concerned about the reliability and safety of apps

 

Moving forward

Smartphones have the power to put support in the pockets of young people struggling with their mental health. App developers have jumped at this opportunity meaning users have plenty of options to choose from, perhaps too many. Despite the abundance of apps available, uptake remains relatively low. Both young people and clinicians have expressed an interest in using smartphone apps and other digital mental health interventions, but both have some reservations about engaging with them, leaving a gap between app development and implementation.

So, the question moving forward is, how can we help guide people who wish to engage with them?

While clinicians seem eager to incorporate technology into their practice, we found that a majority are unaware of what resources are available, and are safe to use. A suggestion following this piece of research was to provide training and workshops for clinicians around evidence-based digital resources where they can be explained and demonstrated. This might help them to feel more confident in using them with, or recommending them to, young people as an adjunct to any therapy that they are providing. Similarly, GPs and other first points of contact, for example in schools, may also benefit from similar training to help guide young people in making informed choices about which apps to engage with.

Further, the NHS has developed an app library to try and help the public identify apps that are trustworthy, safe to use and that meet certain standards; there are currently 20 mental health apps listed on the library. In order to be included, apps are assessed for: any available evidence; clinical safety; data protection; security; usability and acceptability; interoperability; and technical stability. This can provide some comfort given the concerns raised in the above studies. It can also help users save time by avoiding having to sift through the overwhelming number of options available on the app store.

The NHS Apps library* provides a great database of apps that meet a certain standard of assessment, however, speaking anecdotally, not many clinicians or young people seem to be aware of it. This could be an important resource to highlight in any training or workshop, and to encourage clinicians and first points of contact to flag up with any young people they are working with.

Finally, half of the girls in the above study suggested they would be interested in using digital tools for their mental health, and half didn’t. Research that could further clarify preferences towards digital mental health support may be beneficial as this could help to effectively target services towards those who are more receptive to it.

*The NHS apps library may help to alleviate some concerns around using apps.

Conclusion

The take home message is that concerns around using digital interventions need to be addressed before young people or clinicians will be comfortable fully engaging with them. This could involve training, distributing helpful resources, and further developing the evidence base around apps and who engages with them.

It is important to remember that some young people do express a preference for digital interventions, while some express a preference for face-to-face interventions – it is not a one size fits all solution.

Conflicts of interest

I was involved in both of the main studies discussed above and have worked with the other researchers involved on other projects. I have no financial interests in the work.

Links

NHS Apps Library 

References

Cliffe, B., Croker, A., Denne, M., & Stallard, P. (2019). Clinicians’ use of and attitudes towards technology to provide and support interventions in child and adolescent mental health services. Child and Adolescent Mental Health, n/a(n/a).

Ford, T., Hamilton, H., Meltzer, H., & Goodman, R. (2007). Child Mental Health is Everybody’s Business: The Prevalence of Contact with Public Sector Services by Type of Disorder Among British School Children in a Three-Year Period. Child and Adolescent Mental Health, 12(1), 13–20.

Grist, R., Cliffe, B., Denne, M., Croker, A., & Stallard, P. (2018). An online survey of young adolescent girls’ use of the internet and smartphone apps for mental health support. BJPsych Open, 4(4), 302–306.

Hollis, C., Falconer, C. J., Martin, J. L., Whittington, C., Stockton, S., Glazebrook, C., & Davies, E. B. (2017). Annual Research Review: Digital health interventions for children and young people with mental health problems – a systematic and meta-review. Journal of Child Psychology and Psychiatry, 58(4), 474–503.

Larsen, M. E., Huckvale, K., Nicholas, J., Torous, J., Birrell, L., Li, E., & Reda, B. (2019). Using science to sell apps: Evaluation of mental health app store quality claims. Npj Digital Medicine, 2(1), 1–6.

Marshall, J. M., Dunstan, D. A., & Bartik, W. (2019). The Digital Psychiatrist: In Search of Evidence-Based Apps for Anxiety and Depression. Frontiers in Psychiatry, 10.

NHS Digital. (2018). Mental Health of Children and Young People in England.

Odgers, C. L. (2018). Smartphones are bad for some adolescents, not all. Nature, 554(7693), 432–434.

Ofcom. (2011). UK children’s media literacy.

Ofcom. (2019). Children and parents: Media use and attitudes report 2018.

Soni, R., Upadhyay, R. K., & Jain, M. (2017). Prevalence of smart phone addiction, sleep quality and associated behaviour problems in adolescents.

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