Digital Interventions

  • There are many different digital technologies that can be used at different points in a person’s life, from mental health promotion and prevention through to treatment and subsequent self-management.
  • Many digital technologies are designed to be used in adjunct to established mental health treatments, not to replace them.
  • A wide range of evidence-based digital interventions exist for children and young people, but it can be difficult for clinicians and the public to access these.
Dr. Bethan Davies
Dr. Bethan Davies

This topic guide has been written by Dr. Bethan Davies, a Research Fellow and Chartered Psychologist working within the NIHR MindTech MedTech Co-operative research group at the University of Nottingham. She works in projects relating to evaluating digital technologies for children and young people’s mental health. Currently Bethan is taking a lead role as a therapist in the ORBIT (‘Online Remote Behavioural Intervention for Tics’) study, which is evaluating two online interventions for children and young people with Tourettes and tic disorders.

  • Introduction

    Digital technologies and internet-enabled devices are an integral part of everyday life for many people, and serve many functions and purposes. Digital technologies reflect a broad range of hardware and electronic devices (such as smartwatches, virtual reality headsets, and smartphones), software (such as mobile applications, virtual reality packages) and internet-delivered services (e.g. online counselling).

    Children and young people are frequent, regular users of digital technologies such as games consoles, smartphones, laptops and tablets, with one recent survey reporting 93% of 15 yr olds had their own smartphone (Ofcom, 2016). The integration of online technologies and use of social media means they are part of everyday life, and there isn’t much differentiation between ‘online’ and ‘offline’ worlds. For children and young people who experience mental health problems, getting them to access appropriate treatment and support in a timely manner is important, as delays can lead to a worsening of mental health problems. Digital interventions are often mentioned as a way to help address this delay in receiving help, and to increase access to evidence-based treatment. Furthermore they can also be used as tools within the therapeutic process to compliment other treatments, or as part of ongoing management.

    There are a number of devices and mediums that come under the ‘digital technologies’ umbrella when applied to providing mental health treatment to children and young people – several of these are described below.

  • Online Programmes

    A vast number of online programs (often called ‘online interventions’) for a range of mental health problems have been developed and tested with children and young people. Their aim typically is to create positive change in attitudes, behaviour, thought patterns, or health status (Hollis et al., 2017); for example, to decrease anxiety (through identifying and changing thoughts, feelings, and behaviours) or improve coping skills. They are somewhat similar to what you might get in a self-help book, but in an online format accessed via a website – this means different types of multimedia and interactivity can be built into it to help the learning of new knowledge and skills.

    Online programmes are often done in a ‘modular’ format (i.e. divided into sections that build on each other) that the user works through. Sometimes, as part of the intervention, users might have someone to help remotely support them in completing the program: this could be a healthcare professional, trained ‘coach’, or a parent/carer. For children and young people, online programmes can be a more fun and engaging way to learn about mental health, and activities/tasks can be integrated into programs for the user to complete.

    One online programme that has received much attention is the adaption of cognitive behavioural therapy (CBT) into digital format: this is usually called computerised CBT (‘cCBT’ for short). For children and young people, many different cCBT programmes have been developed and tested for anxiety and depression.

  • Serious Games

    An offshoot of online programmes are Serious Games: this refers to using games to deliver an intervention – they have a purpose other than being fun. Gaming techniques are used to aid the users’ engagement and motivation, and to assist with learning, and changing the users’ attitudes, knowledge, and behaviour (Fleming et al., 2017). Serious Games are particularly used with children and young people, given the popularity of video games in this group, in order to provide an engaging platform for mental health prevention and treatment. Such games can be built using therapeutic theory, with the game aiming to provide a way to teach and apply therapeutic principles to children and young people. A similar but different change technique is called ‘gamification’ which relates to different elements of game playing that can be applied to, in this case, digital technologies. One example would be if there was some reward element for completing different sections of a CBT app.

  • Cognitive Training

    Computer-based cognitive training programmes typically involve a program designed to help children and young people in training aspects of their working memory, cognitive biases, and attention: you can read more about these in the Cognitive Training Topic Guide.

  • Virtual reality

    Virtual reality (VR) involves an interactive computer-generated experience simulating a specific environment or situation. It can be delivered through a number of devices, including headsets (like the Oculus Rift), computer-based virtual worlds that are populated with avatars (such as Second Life), projection-based VR displays (such as cave automatic virtual environments/‘CAVE’), and augmented reality (such as Pokemon Go) (Rehm et al., 2016; Rus-Calafell et al., 2017). These different VR devices have been used in several ways in mental health research. For example, headset-based VR has been used as part of exposure therapy (known as VRET for short) to simulate situations to provide an imitated environment for exposure (Valmaggia et al., 2016). This can help provide a ‘stepped’ approach to exposure, or where exposure to the feared object or situation isn’t possible. Examples of this include using VRET to help treat social anxiety, phobias such as fear of heights (Freeman et al., 2018) and social withdrawal and paranoia (Freeman et al., 2016).

  • Smartphone applications (‘apps’)

    Given the widespread uptake and use of smartphones and tablets in everyday society, alongside the hundreds of thousands of apps available, it’s no surprise that apps are often mentioned as a way to provide mental health interventions to a wide population. Apps are software programmes, downloaded via app stores onto your phone or tablet, and that have a variety of potential uses. When applied to mental health, apps can be used as a self-help tool, including to track and monitor symptoms and mood, educate the user about mental health, and to teach relaxation techniques (Grist et al., 2017).

  • Online peer support

    When we have a problem and decide to seek out help and support from someone else, we typically do so from peers or similar others– and young people often mention friends as a first line of mental health support. The internet can help us easily connect to similar others, especially if we don’t have anyone near us who’s also experiencing the same health issue. Young people are big users of social media, such as Facebook, Snapchat and Twitter, and are likely to have some experience in using and browsing similar online communities, such as online message boards, groups, and forums. Given their virtual nature, these online support groups are accessible regardless of time and geographical location (Griffiths, 2017). A person experiencing mental health problems can use the internet to (anonymously) participate in online communities in order to gain health information and advice, for emotional support, and to hear from others with first-hand experience of specific health conditions and treatment (Williams et al., 2018). Likewise their families can also use it in similar ways to gain support. This information and support gained through the virtual world can then have an impact on how they manage their mental health, e.g. increase their help-seeking behaviour (Griffiths, 2017).

  • Online counselling

    Online counselling involves dialogue between a qualified counsellor and user: this is often through synchronous online chat in real-time (similar to instant messaging) or through videoconferencing (e.g. Skype), but can also be asynchronous and delayed (e.g. through an email-type service) (Dowling & Rickwood, 2013). There are also other online emotional support services allowing users to synchronously chat to trained ‘listeners’ – one example is 7 Cups (Baumel, 2015). Young people may find it easier to disclose their thoughts and feelings online through typing rather than speaking (Glasheen et al., 2018).

  • What we know already

    Online programmes

    Online programmes have received a lot of attention in research with children and young people. There have been several systematic reviews and meta-analyses (i.e. pooling many studies together) examining of online interventions for children and young people: the majority of these focus on evaluating cCBT for depression and anxiety. In a meta-review of these reviews, Hollis and colleagues (2017) report that there are small-to-medium effects of cCBT interventions upon depression outcomes, with medium-to-larger effects reported for anxiety. Age is also an issue to consider, as meta-analyses have reported greater intervention effects for teenagers and young adults, compared to younger children (Hollis et al., 2017). A recent analysis involving 22 RCT studies of online interventions for young people with depression found short-term effects for improving depressive symptoms, but very few explored longer-term sustainability of the effects (Valimaki et al., 2018).

    It’s also important to think about where these interventions are delivered (e.g. at home, in school) and whether there’s a coach or other supportive adult to help the child/young person complete it (Hollis et al., 2017). Parents are often involved in delivery of online interventions to children and young people, particularly for younger children as they need more support in engaging with interventions and are more dependent on their caregivers, when compared to teenagers. Parents/caregivers may also be asked to complete their own online program that aligns with what their child is learning, and be asked to help support their child’s learning (e.g. support them in doing homework exercises or practices). Examples of these come from the Karolinska Institut in Sweden, where they have developed and tested several interventions that involve both the child and parent undertaking aligned online programmes. This includes cCBT for teenagers with OCD (Lenhard et al., 2017) and children with anxiety disorders (Vigerland et al., 2016).  Additionally the BRAVE program, an online cCBT for preventing anxiety and consists of programmes for both the child and parent, is now available for free to all young people and their parents in Australia. BRAVE has undergone a series of evaluations (Spence et al., 2011), demonstrating similar outcomes to face-to-face therapy in reducing anxiety (Spence et al., 2011). The most recent evaluation of BRAVE found it was associated with significant reductions in anxiety as they went through the intervention (March et al., 2018). However, as is a problem in these types of online programmes, usage of the intervention did taper off over time.

    Serious Games

    Several Serious Games have been developed and tested with children and young people (Fleming et al., 2017). SPARX is an online program for 12-19 yr olds developed by researchers at the University of Auckland: it looks like a game and the user is led by a virtual ‘Guide’ through several levels to learn different cognitive-behavioural skills (e.g. problem solving, challenging negative thoughts) for treating depression. You can find out more about SPARX through their website, and is freely available for New Zealand residents. SPARX has also been revised for different groups, including as SPARX-R (framed as a preventative intervention, rather than treatment; Perry et al., 2017), and Rainbow SPARX (for LGBT youth; Lucassen et al., 2015). SPARX has been evaluated in several RCTs and pre-post studies with adolescents at risk of depression (Merry et al., 2012; Fleming et al, 2012; Poppelaars et al, 2017; Perry et al 2017).  In general, findings from these evaluations have shown support for SPARX in improving depressive symptoms in teenagers aged 12-19 yrs and with greater improvements compared to comparator interventions (e.g. a school-based CBT intervention in Poppelaars et al., 2017) which have also shown improvements. However as with other online programmes, there is uncertainty about the long-term preventative effects of SPARX.

    Another example of a Serious Game is Champions of the Shengha, a game developed by BfB labs with children and young people that can help them to manage their frustration through a heart rate variability sensor that enables the game to respond to the child’s emotional state. Champions of the Shengha helps young people in learning and training their emotional regulation skills, which they can then use ‘offline’ to help reduce the physiological signs of stress.

    Virtual reality

    Much of the work exploring the application of VR into mental health treatment has been with adults; a recent systematic review found no evidence for these interventions with children (Valmaggia et al., 2016). A VR intervention for young people with social anxiety is currently being tested out at Nottingham Trent University. However, there has been some work with children in using computer-based virtual environments that involve avatars – these are digital representations of the person. Children and young people who are referred into CAMHS and other talking therapies may understandably find it difficult to talk about their mental health: they may have struggles with how to verbalise what they’ve been feeling and experiencing, and feel uncomfortable facing a clinician who isn’t known to them. Virtual worlds and avatars can be inserted into the therapeutic process; these aren’t replacing the therapy but rather working in adjunct to it as a therapeutic tool within the treatment – similar to aspects of play therapy (Rehm et al., 2016). In a pilot of ProReal (an avatar laptop-delivered software program) within school counselling services, young people (12-18 yrs) described how using the software helped them express themselves, helped to externally communicate their experience to their counsellor, and facilitated therapeutic change through developing insight of themselves (van Rijn et al., 2017; Cooper et al., 2018).  Such tools aren’t used to replace the therapeutic experience – rather to enhance it and facilitate communication and working with the clinician.

    Smartphone applications (‘apps’)

    A quick search of the app store will produce thousands of apps ‘designed’ for supporting mental health – but the majority aren’t tested, evaluated, or may not even be developed on sound theoretical underpinnings. Likewise, apps that are developed and evaluated as part of research projects may never see the light of day beyond a publication or report. Grist and colleagues’ (2017) recent systematic review of mental health apps for young people shows the limited evidence – particularly in relation to mental health outcomes – available regarding apps’ effectiveness, and so currently there isn’t evidence to support apps use for young people’s mental health. Their review discussed 15 apps: only two had been through a formal trial evaluation –which didn’t show an effect upon mental health outcomes – and another two different apps were publically available to access at the time of publication.

    A survey of 775 girls (11-16 yrs) found that while a third were experiencing elevated depression and/or anxiety symptoms, only a minority (15.6%) had used an app to help with their mental health (Grist et al., 2018). Even though young people may be receptive towards using apps for their mental health and can see many advantages – such as anonymity in accessing support, privacy, and availability – they can also see many disadvantages regarding their trustworthiness, how private they actually are in their use and security of their data (Grist et al., 2018).

    Online peer support

    There’s already a lot of concern from young people in using social media and the effects this has on their mental health and well-being (O’Reilly et al 2018). Likewise for online support groups, there have been concerns that they might be using them in a detrimental way: for example ‘pro-anorexia’ and ‘thin-spiration’ online communities have been known about for more than twenty years, and have continued to evolve and change alongside new developments in social media (Ging & Garvey, 2017; Wick & Harringer, 2018).

    Unlike many other digital interventions spoken about here, no RCTs have been done to explore online communities for young people’s mental health. Focusing on online support groups for young people’s mental health, the research available shows a mixed picture. In their review of 4 studies looking at online support groups for young people with depression, Rice and colleagues report that participating in online communities can help people access emotional support, provide an opportunity for knowledge exchange and to learn new coping skills (Rice et al., 2014).

    Online communities can provide an outlet for support that might not be available to young people face-to-face. Kooth is an UK-based online counselling service for young people but also hosts an online community for young people to chat with their peers (Prescott et al, 2017). Analysis of postings to this online community found users discussed a variety of mental health-related topics, and sought out emotional and informational support through asking others directly for advice, or disclosing their similar feelings in response to other users’ posts (Prescott et al, 2017). An analysis of six Facebook support groups for teenagers with depression shows how these groups are used to connect with others who have similar experiences: teenagers use them to self-disclose their feelings and experiences; to support others; and to offer and encourage help (Lerman et al. 2016).

    A recent report found more than a fifth of 14 yr olds stated they have self-harmed (Children’s Society, 2018), and teenagers may seek online support for self-harm. A survey of users (including teenagers) of an online self-harm support group described how it allowed them to contact others to gain support and feel less isolated; to learn more about self-harm and strategies they could use to help reduce self-harming behaviour; and provided an outlet to share their own and understand others’ experiences (Coulson et al., 2017). However they do carry disadvantages, including being ‘trolled’ or attacked, spreading of misinformation and harmful ideas, excessive reliance on online support, and responding to others’ negative comments (Kendal et al. 2017; Rice et al., 2014).

    Online counselling

    Dowling and Rickwood (2013) comment that the nature of online counselling means it differs from traditional face-to-face counselling: online counsellors have reported using rapport-building and information-gathering techniques to help make up for the lack of non-verbal cues. There are concerns that the therapeutic alliance between counsellor and client is more difficult to form in an online space, but findings suggest that this is possible to achieve (Hanley & Reynolds, 2009). There appears to be little published evidence regarding the effectiveness of synchronous chat online counselling, but the studies available do show promise in helping young people and show some equivalency to face-to-face counselling (Dowling & Rickwood, 2013). Kooth is one example of an online counselling service available for young people (11-25 yrs) in the UK, allowing young people to chat synchronously with an experienced counsellor (Prescott et al, 2017).  A small early evaluation of Kooth found that many reported a moderate working alliance with their online counsellor, felt it provided an anonymous and controlled place to disclose personal feelings, and provided an accessible way to access counselling (Hanley, 2009).

  • Areas of uncertainty

    As is often found in mental health research involving the evaluation of interventions, there are issues about implementation: are digital interventions that show effectiveness getting into real-world practice? Digital interventions can be developed, tested and evaluated through a process of ongoing testing and refinement – these evaluations may show effectiveness and promise, but then they may never make it out of trials and into the public (Hollis et al., 2017). However there are some digital interventions that have been implemented into clinical services or as part of public health systems. For example, SPARX is freely available in New Zealand, and BRAVE is available to children and their parents in Australia.

    Alongside implementation, there’s also debate about how exactly they should be evaluated and how/if they should be endorsed by healthcare professionals and organisations. The rigidity of randomised controlled trials, as the gold standard of evaluation, may not be practical given the rapid pace of development, re-design and obsolescence of digital technologies (Pham et al., 2016). In the NHS’s first attempt at building a library of recommended apps, many apps recommended did not have any evidence to support their claims of effectiveness (Leigh & Flatt, 2015). Furthermore, many apps in this initial NHS apps library didn’t meet data protection principles, showing a number of privacy risks in using these apps (Huckvale et al., 2015). The NHS has taken this into consideration and recently relaunched their Apps Library, which includes guidelines about how apps can be approved to be featured in this library.

    People often use interventions differently when they’re in a trial compared to in their ‘real-world’. Within a trial, a person may receive compensation or incentives for their participation and be sent reminders about using the intervention – and this might not occur in real-world delivery. In their review exploring uptake and dissemination of digital self-help interventions, Fleming et al. (2018) report on seven different interventions, showing great variability in how the public use such interventions and importantly finding that only a small number complete the whole digital intervention (Fleming et al., 2018). This finding makes us think how effective they are in non-trial situations. Think of it as similar to medication: are people receiving enough of the intervention to have an effect? Likewise, many trials will measure short-term outcomes but not consider whether any improvements in mental health outcomes are maintained over time – and so it can be difficult to look at how long these effects last.

    Digital technologies are ever changing and evolving, and interventions need to keep up pace with what’s available or what the public like. For example, websites may change and update to keep their appearance fresh and appealing. How can we make sure that digital interventions for mental health continue to be appealing and engaging for young people? Likewise, plans need to be in place to ensure such interventions are sustainable over time – for example, who is financially backing the intervention, and is this funding available for a long period of time.

    Accessibility is also an issue. The ‘digital divide’ exists – not everyone has good or reliable access to digital technology or not able to use it in the same way as others, whether for reasons of cost, infrastructure, impairment or even cultural norms. Those most at risk of experiencing mental health problems may not be able to get help (Robotham et al., 2016). Likewise, the services that deliver treatments may not be able to incorporate digital interventions into their services for many reasons, including issues around accessibility and affordability. Furthermore, smartphones regularly undergo operating system updates –there’s the likelihood that new updates aren’t compatible with apps, meaning people may suddenly no longer be able to use apps.

    It’s often said that digital interventions are more ‘cost-effective’ than currently available treatments – but it is difficult to confirm this given the lack of cost-effectiveness evidence in this field (Hollis et al. 2017). Some digital interventions include human support in their delivery, and this adds to the overall costs – and in turn is bound to affect sustainability and availability of such interventions.

    Something to think about is do children and teenagers actually want mental healthcare to be delivered digitally? As adults, we can all too easily think that because children and teenagers are big users of technologies and are so integrated into their everyday life, that this also means they’d be happy to have healthcare delivered through this manner too. In one survey asking teenagers (15-19 yrs) preferences for mental health help, over half (58.9%) had a preference for face-to-face help, compared to 16% who preferred online help – and 23.8% who preferred not to seek help at all (Bradford & Rickwood, 2014). We need to better understand children and young people’s preferences and ideas for mental health treatment and management.

    As with any intervention or treatment, digital interventions can be developed and made with the best of intentions, but in reality may not work as intended due to the intricacies of mental health. One example comes from BlueIce, an app developed by clinical psychologists and young people with lived experience of self-harm, and is used in conjunction with face-to-face therapies in CAMHS. This app is based on principles of CBT and DBT to help young people cope with the urge to self-harm and is currently being trialled. As part of its evaluation, interviews were conducted with 40 app users (Grist, Porter & Stallard, 2018). An important finding here is that for a small number of these users, the app was not helpful in reducing their self-harm as they were not at the stage where they wanted to change their self-harm behaviours. They also mentioned that there are points where the urge to self-harm is too intense and an app wouldn’t help them in such situations.

  • What’s in the pipeline?

    There’s already many online programmes, serious games, virtual reality and other digital interventions being developed, tested, and evaluated – potentially meaning the research field is becoming over-saturated with different interventions that aim to do the same thing. One way to move forward is to focus down on interventions that have showed effectiveness in one place, and then test them out with different populations and across countries. For example, SPARX has started to be tested out in other countries, such as the Netherlands and Ireland, and is currently being adapted and tested for Inuit youth in Canada. Additionally, the Karolinska Institut is collaborating with several UK universities to adapt and trial out their two programmes (one for OCD and the other for Tourette’s/tics) in the UK. These trials are currently underway.

    Implementation of digital interventions into the mental healthcare pathways may still take some years to achieve, and should be based on sound evidence. The NHS is continuing to try and put together a system for appraising apps, in order to create a library of apps that they can recommend to the public and clinicians: their new NHS apps library is now live. Work continues to try and figure out how best to evaluate the array of digital mental health interventions available.

    The James Lind Alliance brings patients, carers and clinicians together in Priority Setting Partnerships to identify and prioritise the Top 10 unanswered questions or evidence uncertainties that they agree are the most important. This was recently done for digital mental health to help identify what research questions are important to people with lived experience of mental health problems and the health and social care professionals who work with them. This has produced a ‘Top 10’ list of questions that future digital mental health research should aim to address (Hollis et al., 2018): these questions relate to the safety and effectiveness of digital interventions in comparison to face-to-face interventions, understanding how digital interventions cause therapeutic change, and how we can combine digital interventions with human support to be most effective.

    Co-design (intervention designers and end-users working together to design and create an intervention) is essential in the design of interventions in ensuring that such interventions are appropriate, suitable, and engaging to their target users. BfB Labs is one organisation that is currently working with young people, their parents, developers and clinicians in developing an app for anxiety.

    Chatbots have been on the scene for many years and are another type of digital service now being applied to mental health. Chatbots are automated agents, designed to engage in conversation with the user. These can be integrated into websites and messenger services. One example is Woebot, a chatbot accessed via Facebook messenger and uses cognitive behavioural methods to help the user ‘talk’ through their situation. The first RCT of Woebot was published in 2017 evaluating its effect upon depression symptoms, and did find a reduction in symptoms from two week use of Woebot (Fitzpatrick et al., 2017). Again, more work is needed to decipher who would benefit from these chatbot-based programmes, and to understand the potential harms in their use: for example, the BBC found chatbots failed to respond to sensitive information disclosed by users.

  • Useful organisations and resources

    NIHR MindTech Medtech Co-operative is a research group funded by the National Institute of Health Research, focussing on the development, adoption and evaluation of new technologies for mental healthcare and dementia.

    The University of Reading’s AnDY Research Unit is one of the UK’s leading research centres for depression and anxiety in young people, and runs its own clinic. It is currently developing its own online treatment program for childhood anxiety.

    BfB Labs are a London-based organisation that build digital mental health interventions for children and young people. They are currently developing an app for anxiety, and developed the Champions of the Shengha game – this is currently available to the public.

    mHabitat is an NHS-hosted organisation specialising in co-design, digital skills & inclusion, policy & strategy, and evaluation in health and social care. Their aim is to develop digital technologies to address real-world problems, including solutions for children and young people’s mental health.

    The Mental Elf provides daily blogs and reviews of newly published research and reports. It has a whole section dedicated to digital mental health.

    Kooth (from XenZone) is an online counselling and emotional well-being platform for children and young people, accessible through mobile, tablet and desktop and free at the point of use.

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