Sponsored CPD: Key questions on digital mental health technologies

GP mental health lead Dr Peter Bagshaw explains the principles and evidence behind digital mental health technologies, their current place in psychological therapy and what future developments may be on the horizon.

Learning objectives

This module will enable you to improve your understanding of:

• What digital mental health technologies are and which digital versions of psychological therapy are currently available for use in the NHS
• Evidence for the use of this technology in common mental health problems in adults, particularly the use of internet-delivered cognitive behavioural therapy (iCBT) in depression and anxiety
• Where iCBT sits within the range of recommended treatments for depression and anxiety in adults
• What the iCBT platforms involve including the user’s journey and how GPs can support patients to access them where appropriate
• Future developments in iCBT and other digital mental health technologies in managing common mental health problems

Q1. What are digital mental health technologies and which ones have NICE approval?

A. Digital mental health technologies can refer to any use of technology to help in mental health, and some of these will be covered at the end of this article. However, in the following questions we will focus on the main technology now being used in the NHS, which is internet-delivered cognitive behaviour therapy (iCBT), and how this compares to traditional talking therapies.

There is a range of talking therapies which show benefit, but one of the most common and most evidence-based is CBT. This is a goal-oriented psychotherapy focused toward educating patients in skills to alter dysfunctional thinking. The structured nature of CBT makes it especially suitable for online self-teaching in a way that other more flexible talking therapies may not be.

iCBT for depression and anxiety has been found to significantly reduce symptoms and produce medium to large improvements, with effects maintained at long-term (12-month) follow-up.¹ Several reports have also indicated positive outcomes for the delivery of internet-delivered interventions to address the behavioural health aspects of chronic and somatic conditions, eg, chronic pain, headache, tinnitus, irritable bowel syndrome and diabetes.

In March 2023 NICE gave provisional approval under its rapid assessment process to the following online therapies for adults:²

• SilverCloud® by Amwell® Depression and Anxiety Programmes, therapies for depression and generalised anxiety symptoms respectively, with support provided by a psychological wellbeing practitioner.
• Beating the Blues, a therapy for depression and generalized anxiety symptoms. (NICE has since announced this technology is no longer available.)
• Deprexis, a practitioner-supported treatment for depression, based on similar principles.
• Perspectives for body dysmorphic disorder (BDD), with support provided by a high intensity therapist trained in treating BDD.
• iCT-PTSD (OxCADAT) and Spring for post-traumatic stress disorder (PTSD) with support from a high intensity therapist trained in treating PTSD.
• iCT-SAD (OxCADAT) for social anxiety disorder with support provided by a high intensity therapist who is trained in treating social anxiety disorder.

As approval is provisional, with NICE collecting data on effectiveness, this list is likely to be amended and added to over time.  In addition to NICE approval the therapies all require approval for use in the NHS under the Digitally Enabled Therapy Assessment Criteria. This is ongoing, but at the time of writing the SilverCloud® by Amwell®Depression Programme has been found to be fully compliant.

The critical issue for GPs is that we can be confident that iCBT offered by our local talking therapies will be NICE-compliant and supported by therapists.

While this article will focus on iCBT in adults, it is worth noting that the technology is also being trialled in children and young people and NICE has also approved the following under the same evaluation scheme:

• SilverCloud® by Amwell® Anxiety for Teens, Low Mood for Teens, Low Mood and Anxiety for Teens Programmes aimed at teenagers with anxiety or low mood but can also be used for younger children. There is online support from psychologists and online cognitive behavioural therapy co-ordinators.
•  Lumi Nova, a therapeutic intervention in the form of a game for children and between 7 and 12 with symptoms of mild to moderate anxiety.  
• Online support and intervention for child anxiety (OSI), an internet based, parent-led and therapist supported psychological intervention for children aged 5 to 12 years old with symptoms of anxiety.  It has three components: a parent’s website, a clinician case management website and an optional game app and interactive worksheets, videos and quizzes.    
• Online Social anxiety Cognitive therapy for Adolescents (OSCA) a programme of therapy for social anxiety in adolescents aged 14 to 18 years old. All users receive a core set of modules to work through which is then individualised.  
• ThinkNinja intended for children and young people aged 11 years and older with anxiety or low mood, and related problems. It is an app with wrap-around clinician support in the form of text messaging in the app and video calls via a secure platform on the computer or tablet.  

Q2. How are these technologies accessed? Do they require referral from a GP or NHS Talking Therapies service, or can patients self-refer? And, depending on route of access, are patients charged for their use of the service?

A. Within the NHS, iCBT for adults is available in most trusts offering the NHS Talking Therapies service (formerly known as Improving Access to Psychological Therapies, or IAPT). Services vary between different parts of the country, but in most areas self-referral is possible, or even encouraged, in addition to traditional GP referral.

An initial assessment by a practitioner within the NHS Talking Therapies service will decide if iCBT is appropriate; issues that would make it suitable might include the ability of the client to read and understand English (hopefully iCBT for non-English-speakers will become available in the future), absence of cognitive impairment, mild-to-moderate depression (now termed ‘less severe’ depression in NICE guidance) and / or anxiety with no suicidal risk, no psychotic disorders, and a willingness to use the internet as a treatment option. In some areas, waiting times for traditional talking therapies might be another incentive for choosing a digital solution.

Note that the NICE guidelines for depression recommend use of iCBT (under ‘guided self-help’) as an option for less severe (mild-to-moderate) depression; it can be used first-line or as an alternative if the patient has tried other treatment options.³ NICE does also recommend iCBT as an option in more severe depression, although in this case it says other treatments with more therapist contact ‘should be carefully considered first’.  

The therapy is obviously only possible for those able to access the internet through a mobile phone or other device, and some concerns have been raised about those living in ‘digital poverty’. However, there are ways round this in most cases (in our area, for instance, libraries can provide internet access) and the nature of the programmes mean that physical access is not an issue, as it often is in remote or rural areas. In addition, the self-directed nature of iCBT means that it can be accessed at whatever time is convenient, overcoming blocks that can be an issue for traditional therapies, particularly when people are unable to get time off work to attend therapy.

Assessment is carried out in the same way as for other talking therapies; the standardised nature of such therapies and accepted outcome measures such as PHQ-9 and GAD7 have made assessment of effectiveness relatively straightforward, and NICE have looked at the widespread published data in deciding which therapies to approve.

Although private iCBT is available, there is no charge for people referred through the NHS Talking Therapies service.

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Dr Peter Bagshaw is a GP and clinical lead for mental health at NHS Somerset ICB