As children and young people (CYP) appear welded to their smartphones at all times of day and night, it seems obvious that when they face mental health difficulties they will turn first to digital health interventions (DHIs). But do young people really prefer DHIs to established services and are they clinically and cost effective?
At mHabitat our discovery work with young people has uncovered surprisingly mixed attitudes towards digital technologies, so I was interested to see how this new systematic and meta-review (Hollis et al, 2017) squares with what we have found in practice.
The researchers conducted a meta-review of scoping, narrative, systematic or meta-analytical reviews investigating the effectiveness of DHIs for mental health problems in CYP.
They also updated a systematic review of randomised controlled trials (RCTs) of DHIs for CYP published in the last three years.
- Twenty-one reviews were included in the meta-review
- Meta-analyses found support for the effectiveness of cCBT in CYP with:
- small-to-moderate effects (g = 0.16 to 0.62) on depression outcomes
- moderate-to-large effects (g = 0.53 to 1.41) for anxiety
- There were mixed results with regards to the importance of parental involvement in DHIs, but the evidence suggests that it may be particularly needed with younger children to support their engagement with the intervention
- DHIs seem to have a greater effect on 18-25 year olds compared to 12-17 year olds, but this may just be a reflection of higher baseline illness scores in the older group.
- The systematic review identified 30 new RCTs evaluating DHIs for attention deficit/hyperactivity disorder (ADHD), autism, anxiety, depression, psychosis, eating disorders and PTSD
- The benefits of DHIs in managing ADHD, autism, psychosis and eating disorders are uncertain
- Evidence is lacking regarding the cost-effectiveness of DHIs.
- High attrition rates were reported in some of the cCBT trials, most notably in the MoodGym trial (Lillevoll, 2014)
The paper includes a substantial summary and conclusion section which appraises the current evidence and makes suggestions for future development and evaluation of DHIs. There are a few stand out proposals that align to the grounded knowledge we have accumulated over the last three years which I highlight below:
The authors recommend that sustainability and cost effectiveness are considered at the beginning of DHI development. There are sparse examples of compelling models for sustaining DHIs over time and there is often a complete failure to consider the whole life cycle costs of a DHI and how they can be sustained. Sustainability is a critical factor in great ideas becoming adopted and embedded within healthcare.
Low cost and scalable (or not)
The authors challenge the view that DHIs are a low cost and scalable alternative to face-to-face services based on the evidence that more successful DHIs are blended with offline interventions. They found a prevailing view amongst practitioners that DHIs should be an adjunct rather than replacement to therapy. Young people agreed. This resonates with our experience at mHabitat that DHIs are most impactful as a means of enhancing and extended services rather than replacing them.
Are all young people digitally savvy with their health?
Whilst not explicitly addressing issues of digital inclusion, the authors argue that future research should aim to understand the characteristics of young people most likely to benefit from DHIs, and where in the care pathway this engagement is likely to happen. I would argue that further research is required to understand how young people are using not just DHIs but general digital tools to manage their mental health and what the impact of issues such as poverty and exclusion have on their take-up and use.
A taxonomy for Digital Health Interventions
I was interested in the case made in the review for a taxonomy of DHIs to be developed so that components can be identified and compared across studies. This precision and transparency would make it easier for patients and health practitioners to understand how DHIs are intended to have a positive impact and would make it easier for researchers to assess their efficacy.
Personalisation and privacy
The positive impact of personalising and tailoring DHIs (for example, changing features of an avatar) was notable and an interesting area for future research in terms of adherence and outcomes. It is often (wrongly) assumed that young people care less about their privacy, so it was striking to note that the authors found young people are very concerned about such issues and that transparency in use of data is a factor in take-up of DHIs. Issues of privacy come up without fail at every workshop we run with young people, so this was not a surprise.
Most interesting to me is the case made by the authors that the development and evaluation of DHIs requires a blend of interdisciplinary approaches drawing on engineering, computer science, human factors, human computer interaction, psychology and mental health services research. I would also suggest that a rounded approach to research would include humanities and address issues such as ethics and the development of DHIs in the context of a critical appraisal of government policy impacting on mental health services.
There were many more conclusions, but I’ve run out of space! You’ll have to read the paper (which unfortunately is not open access) if you’d like to find out more.
Strengths and limitations
The systematic review focused on evidence from randomised controlled trials (RCTs), which are problematic in their length and complexity when applied to DHIs that may change, evolve and become redundant within a short space of time. The focus on RCTs also narrowed the scope to largely computerised CBT and excluded more novel digital developments that are emerging at a rapid pace.
Whilst the case was made by the authors for interdisciplinary research, it is disappointing that the impact of participatory design with CYP in developing DHIs was not commented on in the paper. Our experience is that design and usability are key factors in DHI take-up and use that can only be addressed well through participatory processes and extensive user testing.
The wide variation in the types of studies reviewed means that the meta-review was unable to draw definitive conclusions about the effectiveness of DHIs in children and young people’s mental health. The review was also not able to comment on cost effectiveness of DHIs as it noted there is an absence of evidence in this regard. This is concerning given that DHIs are often promoted on the basis that they will save the NHS money.
Whilst not a methodological weakness, the review illustrates the paucity of research in the field of DHIs and CYP and the urgent need for research designs that fit with the fast paced development of digital in health.
Implications for practice
The review contains conclusions that are salient to both mental health practitioners and developers of DHIs as well as to ourselves at mHabitat:
- Firstly, the importance of building evaluation into the development of DHIs from the outset is critical and a taxonomy of DHIs would greatly assist comparability between studies
- Secondly, the importance of blended online and offline approaches to DHIs resonates with our experience. We would strongly advocate this way of working
- Lastly, we should all take seriously the importance of developing a nuanced understanding of CYP use of digital technologies, along with the implications of inclusion or exclusion for take-up and use of DHIs.
Hollis C, Falconer CJ, Martin JL, Whittington C, Stockton S, Glazebrook C, Davies EB. (2016) Annual Research Review: Digital health interventions for children and young people with mental health problems: a systematic and meta-review. J Child Psychol Psychiatr. doi:10.1111/jcpp.12663 [Abstract]
Lillevoll KR, Vangberg HCB, Griffiths KM, Waterloo K, Eisemann MR. (2014) Uptake and adherence of a selfdirected internet-based mental health intervention with tailored e-mail reminders in senior high schools in Norway. BMC Psychiatry, 14