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Dr Derek Richards, SilverCloud Health’s chief scientific officer, discusses the rise of ‘stealth science’ alongside his recent research on evidence- based frameworks in mental health apps.

The COVID-19 pandemic triggered an unprecedented rise in the number of people globally in need of mental health services. The current scale of need is at levels which constitute a pandemic. No country has the human resource capacity to meet the current mental health need; therefore, turning to digital solutions to deliver care is becoming a requirement. Digital Mental Health Interventions (DMHI) deliver in terms of both accessibility and affordability, offering patients real, tangible clinical benefits. However, it is important to be mindful that not all online mental health apps and platforms are backed with the same level of clinical validation.

Digital mental health platforms and programmes such as those designed by SilverCloud Health (NHS’s prime provider or digital mental health solutions) offer evidence-based treatments shown to be as effective as face-to-face delivery (Andersson et al, 2013). SilverCloud DMHIs are evidenced to provide clinical benefits post-treatment and to maintain these benefits in the long term (Richards et al., 2020, Palacios et al., 2022; Eilert et al., 2022). Many individuals report a preference for the convenience and ease of access, as well as the relative anonymity that internet-delivered services can offer (e.g. Boydell et al, 2014). 

Several global phenomena have contributed to the dramatic surge in digital mental health solutions

The demand-supply discrepancy in mental health care is widely recognised, often known as the treatment gap (Kohn, et al., 2004). Mental health care is an area calling out for innovative approaches to service delivery. Consistent with this, venture capital (VC) companies have in turn been pursuing digital mental health and wellness-oriented technologies with interest. A record-breaking $5.1 billion has been invested in mental health start-ups in 2021 by the VC industry – a fourfold increase when compared to 2019, and a tenfold increase since 2017 (Rock Health, Jan 2022).

With investment in digital mental health on the rise, there is a sense of optimism about current and future prospects in the field. The promising picture is reinforced by recent global phenomena, which cluster around three trends: 

1) Increasingly Mental health has broken through the taboos that once kept it locked away, and now there are open conversations around mental health and the need for access to care

2) Worldwide ownership of devices that facilitate internet access have been increasing rapidly; as of January 2021, there were 4.66 billion active internet users worldwide (Statista, 2021)

3) Infection prevention measures necessitated by COVID-19 have limited non-essential healthcare visits and encouraged physical distancing, further accelerating a fundamental shift to new ways of accessing healthcare including digital solutions. 

Collectively, these trends have led to giant steps in both the acceptance and adoption of technology-enabled mental healthcare in recent years. However, this surge has also produced a competitive landscape where DMHI are being created, marketed, and sold at a speed that does not always allow for robust clinical validation.  

The absence of scientific proof, however, has not prevented companies from using science to sell digital health solutions. A recent review of 293 apps for anxiety and depression found that only six per cent of the companies that claimed to use evidence-based frameworks in the descriptions of their products had published any evidence supporting their effectiveness (Marshall at al, 2020). The widespread growth of digital mental health apps launched without clinical validation could not only seriously jeopardise the reputation and future of the industry, but also expose risks to vulnerable end-users in need of mental health care.

Questions stakeholders should ask when evaluating the evidence base

It is concerning that so few of the commercially available DMHI are supported with published evidence. However, even when published research does exist, it is often of questionable quality (Byambasuren et al, 2018; Morley et al, 2021).

When reviewing evidence for claims in this area, there are certain important questions that should be asked to evaluate the reliability and validity: 

1. Is the product evidence based or simply evidence-informed? 

A large proportion of the DMHI available that claim to be evidence-based are in fact evidence-informed. In other words, they are extrapolating claims or making ‘evidentiary claims’ based on indirect evidence.

2. What level of research trial was employed? 

Stakeholders should be aware that well-designed random controlled trials with an adequately large number of participants who represent the target population, remain the gold-standard for generating evidence on DMHI.

3. Were the trial participants appropriately representative?

A foremost aim when conducting a research trial is to be able to draw valid inferences about a larger population of interest based on the results observed within a specific study sample. To maximise the validity of these inferences, the people that the study is carried out on must therefore be representative of those to whom the DMHI intervention will be provided to in real life.

4. Has the research been published in a peer-reviewed journal? 

Stakeholders should seek to establish that robust evidence of the DMHI’s effectiveness has been published in a reputable peer-reviewed journal.

5. Has there been an appropriate level of transparency about how outcome variables are defined? 

Stakeholders should ensure that clear definitions of outcome measures, as well as their respective sources have been provided, and should question the real-world value of the findings in instance where they have not.

These are just some of many examples that highlight why it is important to critically evaluate the quality of the research supporting any reported findings or claims.

It is our hope that this increased awareness will also, in turn, put pressure on the DMHI industry as a whole to improve standards of integrity, transparency and investment into robust clinical research.

Summary 

At SilverCloud Health, we are of the firm opinion that the capacity to harness the full potential of technology-enabled mental health care is contingent on building and sustaining a strong legacy of rigorous research and scientific inquiry. This is not an easy endeavour to prioritise, as the DMHI landscape is changing at lightning speed, and significant time, effort, and resources are required to conduct this research. But ultimately, as demand and competition continue to accelerate, we can be confident that our commitment to scientific rigour and clinically proven outcomes will have a lasting effect on how digital behavioural health interventions are implemented and used to treat and improve the quality of life for people across the world.

References

Andersson, G., Hesser, H., Veilord, A., Svedling, L., Andersson, F., Sleman, O., Mauritzson, L., Sarkohi, A., Claesson, E., Zetterqvist, V., Lamminen, M., Eriksson, T. and Carlbring, P., 2013. Randomised controlled non-inferiority trial with 3-year follow-up of internet-delivered versus face-to-face group cognitive behavioural therapy for depression. Journal of Affective Disorders, 151(3): 986-994.

Boydell KM, Hodgins M, Pignatiello A, Teshima J, Edwards H, Willis D., 2014. Using technology to deliver mental health services to children and youth: a scoping review. J Can Acad Child Adolesc Psychiatry, 23(2):87-99. 

Byambasuren, O., Sanders, S., Beller, E. and Glasziou, P., 2018. Prescribable mHealth apps identified from an overview of systematic reviews. npj Digital Medicine, 1(1).

Eilert, N., Wogan, R., Adegoke, A., Earley, C., Duffy, D., Enrique, A., Palacios, J., Timulak, L. and Richards, D., 2022. The relationship between posttherapeutic Cognitive Behavior Therapy skills usage and follow‐up outcomes of internet‐delivered Cognitive Behavior Therapy. Journal of Clinical Psychology,.

Kohn R, Saxena S, Levav I, Saraceno B., 2004. The treatment gap in mental health care. Bull World Health Organ. 82(11):858-66. 

Marshall, J., Dunstan, D. and Bartik, W., 2020. The role of digital mental health resources to treat trauma symptoms in Australia during COVID-19. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), pp.S269-S271.

Morley, J., Kinsey, L., Elhalal, A., Garcia, F., Ziosi, M. and Floridi, L., 2021. Operationalising AI ethics: barriers, enablers and next steps. AI & SOCIETY,.

Palacios, J., Enrique, A., Mooney, O., Farrell, S., Earley, C., Duffy, D., Eilert, N., Harty, S., Timulak, L. and Richards, D., 2022. Durability of treatment effects following internet‐delivered cognitive behavioural therapy for depression and anxiety delivered within a routine care setting. Clinical Psychology & Psychotherapy,.

Richards, D., Enrique, A., Eilert, N., Franklin, M., Palacios, J., Duffy, D., Earley, C., Chapman, J., Jell, G., Sollesse, S. and Timulak, L., 2020. A pragmatic randomized waitlist-controlled effectiveness and cost-effectiveness trial of digital interventions for depression and anxiety. npj Digital Medicine, 3(1).

Steven Aquino

This column has seen its fair share of coverage on various telemedicine startups over time—and for good reason. Long before the word “coronavirus” became a staple of the everyday vernacular, virtual services like remote doctor’s appointments have proven accessible to many people, particularly those with mobility impairments. It isn’t only that Covid has demanded the masses shelter-in-place as much as possible that has spurred adoption of so-called virtual visits. The fact is, remote doctor’s appointments—or anything else, for that matter—are godsends for those who cannot (or should not) travel outside the home to a community clinic or hospital. Disabled people have known about this forever; it may be a novel idea to abled people due to the pandemic, but that’s because the majority have been forced to confront accessibility-as-necessity for the first time.

Count Amwell as another company whose mission is to make medical care more accessible for everyone. Founded in 2006, Amwell focuses on building technology which “combines a delightful experience for patients with best-in-class workflows for providers” on a continuum ranging from urgent care to acute care, according to their website. The company boasts partnerships with over 55 health maintenance organizations, as well as more than 2,000 hospitals and healthcare systems. All told, 102,000 providers make use of Amwell’s technologies.

“We are committed to connecting and enabling the key players in healthcare to deliver greater access to more affordable, higher-quality care,” said Dr. Ido Schoenberg, Amwell’s chairman and chief executive officer, in a recent interview with me conducted over email. “We do this through our comprehensive, integrated digital care delivery platform [called] Converge, which is designed to support all digital health needs across the care continuum.”

Like those with other health-focused companies I’ve covered, Dr. Schoenberg is a true believer in technology’s power to revolutionize healthcare for the better. The journey has been, and still is, a slog. “Digital care finally has a seat at the table, but it wasn’t an easy road to get here,” he said. “When we started Amwell, no one knew what telemedicine was. We faced opposition and spent countless hours convincing people—particularly [those on] medical boards—that virtual care was an effective way to deliver healthcare. Covid changed the game. Now that there exists an understanding that some of our care will happen through technology, we’re focused on powering today’s new era of hybrid healthcare—which extends well beyond telehealth and combines physical, virtual, and automated interactions.”

However old hat digital-first services may feel to the disability community, there can be no denying the pandemic has been the accelerant for the fire of awareness. Dr. Schoenberg explained there’s a “pressing need” to improve the quality of patient outcomes and operational efficiencies, particularly as healthcare workers continue to face unprecedented levels of burnout and fatigue. He believes Amwell’s Converge technology is ideally suited to help drive innovation in this arena. To wit, Dr. Schoenberg cited a statistic from a 2020 New York Times report that some 8.6 million Americans live at least a half-hour from the nearest emergency room. That means critical healthcare is literally inaccessible for a not-insignificant swath of the population, disabled or not. Fixing such disconnection is the driving force behind Amwell’s (and its contemporaries) ethos.

“Today, the care experience is disjointed and disconnected. Virtual visits can be inconsistent and delayed with multiple logins and disparate portals made even more confusing by referrals to specialists,” he said of telehealth today. “Patients struggle with a lack of information on what is covered and how to follow up. With Converge, we’re enabling a seamless patient experience that is easy to navigate across the care continuum. Our platform provides an infrastructure that extends well beyond telehealth to connect care teams to one another, the information they need, and disparate tool sets throughout their organizations, driving new efficient workflows so that clinicians have more time to focus on their patients.”

Amwell’s focus on the infrastructure of telemedicine is “table stakes” for shaping a positive user experience, according to Dr. Schoenberg. Patients and clinicians alike should expect “fast, high-quality care experience no matter where and how they are connecting,” he said. The Converge technology is the facilitator of everything Dr. Schoenberg and team are trying to do. Its cloud-based nature means it’s readily available and easy to configure and customize. “Converge features fast and reliable video and audio connections and the ability to easily upgrade these core components over time, ensuring that clients have access to the best connectivity experience for the future,” he said. “The platform can be integrated with existing workflows, EHRs [electronic health records], patient portals, and consumer experiences to support the delivery of care no matter where the patient or provider originates and resulting in faster and easier deployment. The single platform approach means a unified identity system that enables a streamlined and regulatory compliant exchange of information and services across the ecosystem.”

Feedback, Dr. Schoenberg told me, has been positive thus far, with many commending Amwell’s design of Converge to be “highly reliable, faster, and more streamlined.” Looking towards the future, he told me Amwell’s goal in the near-term is to continue its buildout of Converge and work on iterating upon it. Everything points to a future where an ever-increasing amount of industry will be virtualized to great effect, where appropriate. What the pandemic has wrought for the masses is not merely a matter of public health; it’s accessibility awareness too. Over the last two-plus years, abled people have gotten the tiniest taste of some of the things disabled people have done forever to survive an inaccessible world.

For Dr. Schoenberg and Amwell, the work is truly just beginning.

“Telemedicine is only the tip of the iceberg. When we think about care delivery in the future, we believe the care of any one patient will be made up of a combination of in-person care, virtual care, and automated care,” he said. “It’s this hybrid model that we believe holds the greatest promise for transforming healthcare, improving patient engagement and outcomes, and making lives [better].”

As the COVID-19 pandemic is accelerating the use of digital health technologies, researchers are exploring the application of these technologies in the mental health space. In a recently published systematic review and individual patient data network meta-analysis (NMA), scientists found strong evidence that treating depression with guided internet-based cognitive behavioral therapy (iCBT) was associated with more effectiveness than unguided iCBT. But more importantly, they discovered that both iCBT modalities outperformed the treatment as usual (TAU) and waiting list regardless of depression severity.

These recent findings are phenomenal for the expansion of options available for the treatment of global mental health disorders such as depression. One major conclusion is that unguided iCBT can improve long-term outcomes when patients don’t have access to guided iCBT, for example in situations where patients have constrained economic and employer resources.

Depression: A Global Disability

About 322 million people—4.4% of the world’s population—are living with depression, according to the World Health Organization (WHO). Depression is a serious mood disorder that influences how patients feel, think, and deal with everyday activities like sleeping, eating, or working. It is the largest contributor to global disability and a major contributor to suicide deaths.

Traditional depression treatments typically include psychotherapy, pharmacotherapy, and adjunct interventions. However, psychotherapy is not available to most populations in the world because of costs, lack of trained clinicians, and stigma. Also, the COVID-19 pandemic has led to the displacement of many psychotherapy services that were available in the past.

Today, depression treatments, such as cognitive behavioral therapy (CBT), are increasingly delivered as online therapy for depression. According to Dr. Derek Richards, Chief Science Officer of Silvercloud Health, “In the last 12 months there has been a growing interest in the use of digital mental health interventions.”

Guided Versus Unguided Internet Cognitive Behavioral Therapy (iCBT)

In this systematic review, unguided iCBT was defined as CBT delivered via the internet where automated and technical support was permitted, but not support related to the therapeutic content.

Guided iCBT was defined as CBT delivered via the internet that involved therapeutic support, either synchronous or asynchronous, delivered by a professional or a paraprofessional (nonspecialists in mental health care but trained to deliver iCBT).

Investigating the Relative Efficacy of Guided Versus Unguided iCBT for depression

Below, we describe the key findings of this NMA that combined data from 36 studies about iCBTs for depression worldwide. There were 8107 participants with symptoms of depression from 12 countries.

The authors focused on the differential effects of the examined interventions on depression symptom severity on the Patient Health Questionnaire–9 (PHQ-9) at posttreatment. The PHQ-9 was the most commonly used scale across the eligible studies (available for 4703 participants across 15 studies). Other depression scales were converted into PHQ-9 scores using established conversion algorithms.

Key Findings:

The researchers found strong evidence that baseline depression severity was associated with effect sizes for guided and unguided iCBT, such that the higher the baseline severity, the larger the benefit of therapeutic guidance.

Also, using individual patient data (IPD), the researchers showed that treating depression with guided internet-based cognitive behavioral therapy (iCBT) was associated with more effectiveness than unguided iCBT.

Additionally, the benefits of guided iCBT were more substantial in individuals with moderate to severe depression. In individuals with mild/subthreshold depression, the effectiveness of guided and unguided iCBT was similar.

Interestingly, both iCBT modalities outperformed the treatment as usual (TAU) and waiting list regardless of depression severity.

Perhaps the most important discovery was that although guided iCBT was more effective than unguided iCBT, the differences between both treatments diminished over the long-term. This means that unguided iCBT can improve long-term outcomes when patients don’t have access to guided iCBT.

Conclusion

This NMA has shown that guided iCBT is associated with more effectiveness than unguided iCBT for individuals with moderate to severe depression. However, the authors established that unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. This means that many people living with depression may still benefit from iCBT without therapeutic guidance, expanding treatment coverage worldwide.

The results speak clearly to a “digital-first” approach that can encompass public mental health or population health interventions to target prevention and subthreshold symptoms and further the ability to step-up to a supported intervention if symptoms are moderate or severe. These results contribute to the growing research base that is supporting digital mental health interventions like Silvercloud Health.

Integrate Digital Mental Health Platforms like Silvercloud Health

Silvercloud Health is a global leader in developing and delivering mental health and wellbeing interventions. The adoption of digital mental health platforms like Silvercloud is supported by an increasing and robust empirical base supporting their effectiveness in the treatment and management of mental health and wellbeing.

Clinicians, health systems, and employers should choose digital mental health platforms like Silvercloud Health to target prevention and decrease mild/subthreshold symptoms of depression in the long term.

New international expert consensus statement reports key directions for DMHT.

The field of Digital Mental Health Treatment (DMHT) has exploded over the past decade. DMHT includes a wide range of technology-related interventions, such as internet-based Cognitive Behavioral Therapy (CBT), smartphone apps, virtual reality, therapeutic video games, and more recently treatments using artificial intelligence (e.g., therapist bots). Some estimate the number of mental health apps to be well over 10,000 available. DMHTs have the potential to disrupt the current model of mental healthcare, providing access to treatment for many more people, as well as augmenting existing treatments to make them more effective.

However, most of the DMHTs currently available are unlikely to improve mental health care. For example, in a 2016 review, researchers evaluated over 100 CBT smartphone apps (Huguet et
al., 2016); and only 10% actually included CBT principles. Moreover, most apps lacked privacy policies, and none had been tested in clinical trials to determine their efficacy and safety.

Another well-known issue is the difficulty in engaging users beyond the first download (see Torous et al., 2018). Keeping users engaged is hard, even in randomized controlled trials that include compensation and extra attention from research staff. Outside of tightly controlled research studies, app use dramatically falls off after initial download. Thus, there are significant challenges that must be addressed before the potential of DMHT can be realized. 

Europe and Australia have started to overcome these barriers and implement DMHTs in their healthcare systems, whereas the United States has not. A group of 23 international experts published a consensus statement this month outlining the future for DMHTs in the United States. In the “Banbury Forum Consensus Statement on the Path Forward for Digital Mental Health Treatment,” these experts reviewed the evidence base supporting DMHTs, as well as the barriers to wide adoption by healthcare systems in the United States.

Here are some of the highlights:

• DMHTs completed entirely as self-help are helpful; but only if people actually use them. Unfortunately, the evidence suggests that most people stop using DMHTs when they are delivered entirely on their own. 
• Guided DMHTs are effective. Guided means having some human connection, which could be a clinician or a trained layperson. The connection could be through phone calls or messaging. There is clear support from meta-analyses of randomized controlled trials that specific guided  DMHTs are effective for treating depression, anxiety, and PTSD. 
• Guided DMHTs are effective for all severity levels, from mild to severe.
• Guided DMHTs have been found effective for kids, adults, and older adults.
• Guided DMHTs are cost-effective.

They went on to make 3 specific recommendations:

• The United States health care system should adopt DMHTs and offer them to anyone with anxiety, depression, or PTSD.
• Reimbursement mechanisms (i.e., insurance coverage) are needed before DMHTs can be widely adopted.
• Ongoing evaluation of DMHTs effectiveness within the healthcare system is needed

The authors conclude: “Enabling reimbursement would allow health care organizations to make DMHTs broadly available, with evidence standards that would support the selection of DMHT products and services that are effective and can be sustainably implemented.” 

This consensus statement resonates with my personal experience developing and delivering DMHTs at McLean Hospital. For example, in our work we have observed that the coaching role is critical for keeping people engaged with the DMHT. Our coaches check in with users each week and provide support, accountability, and problem solving around app use.

Lack of reimbursement has also been a challenge. Without reimbursement, it is difficult to develop a sustainable system for delivering DMHTs.

As a researcher and clinician who values treatments that work, I especially appreciate the expert group’s third recommendation to conduct ongoing evaluation. DMHTs have rich data that can be explored, such as the number of times people open an app and how long they spend on specific components. We can use this data to determine how people are using these tools and patterns of use that are associated with clinical benefit. Developing an infrastructure for ongoing evaluation will help systems determine which tools are effective, for whom, and when.

Courtney Beard, Ph.D., is a licensed clinical psychologist with expertise in cognitive behavioral therapy for anxiety disorders. She is Director of the Cognition and Affect Research and Education (CARE) lab at McLean Hospital and an Associate Professor of Psychology at Harvard Medical School.

https://www.psychologytoday.com/ca

A group of stakeholders recommended developing reimbursement mechanisms and standards frameworks to help improve uptake of digital mental health tools in the U.S.

Since the start of the pandemic, more companies have adopted digital tools to give people access to mental healthcare. Investors poured a record amount into these tools, roughly $2 billion in equity funding, according to data from CBInsights. Startups got a boost when the Food and Drug Administration waived regulatory requirements that “computerized behavioral therapy devices” submit a 510(k) premarket notification.

Despite these changes, digital mental health tools still face significant challenges to adoption in the U.S. The lack of reimbursement or evidence standards are two big barriers to uptake.

In a paper published in Psychiatric Services, a group of stakeholders shared three recommendations for improving adoption in the U.S.

The group was led by Patricia Areán, a professor of psychiatry and behavioral sciences at the University of Washington, and David Mohr, director of Northwestern University’s Center for Behavioral Intervention Technologies. It included scientists from Optum, Kaiser Permanente, Microsoft, Talkspace and SilverCloud Health.

Offering digital mental health as a treatment
First, the group recommended offering guided digital mental health as a treatment option for patients experiencing anxiety, depression and PTSD. Citing a review of 66 clinical trials, they said that programs where patients received support from a clinician or coach were generally more effective than fully-automated tools, where patients were more likely to drop out of the study.

The authors of the report found that guided digital treatments for alcohol and substance use disorder showed “significant but more modest benefits.” There wasn’t as much efficacy data available on the effectiveness of digital health tools for serious mental illness, such as schizophrenia or bipolar disorder.

Making digital health reimbursable
They also recommended developing reimbursement mechanisms that fit into the current healthcare landscape. Kaiser Permanente recently began working to integrate digital health tools into physicians’ workflow to make it easier to “refer” patients, but for most fee-for-service providers, there’s little structure as to how to pay for digital health treatment.

Currently, most digital health tools don’t have billing codes, “making broad adoption of digital mental health treatment services financially unworkable in U.S. health care organizations,” the authors of the report noted.

Over the summer, the American Medical Association rolled out a set of new CPT codes for online evaluation and care management, as more care shifted to a virtual setting. These codes currently only apply to physicians, physician assistants and nurses, though they could be expanded to cover a broader range of practitioners, according to the report.

Building a standards framework
Finally, the group recommended building an evidence standards framework to help health plans and providers pick products that are effective, safe and equitable.

Most available mental health apps are not currently regulated by the FDA. For example, tools to chat with a therapist like Talkspace or to connect patients to online resources, like MyStrength, don’t fall under the agency’s purview. Even when digital health companies do seek FDA clearance, it doesn’t always address the information that payers and providers are looking for, such as the cost-effectiveness of services.

The authors of the paper suggested at least one well-powered, well-designed randomized clinical trial as the best practice standard for effectiveness. In some cases, tools could be compared to other, previously validated methods, though caution is needed.

For example, while there is strong evidence for the use of Internet-based cognitive-behavioral therapy (CBT), “… very few of the products that claim to be based on cognitive-behavioral therapy actually contain the CBT core elements,” they noted.

Privacy practices have also been a recurring concern with digital health tools. One study of 36 apps for depression and smoking cessation found that 29 transmitted data to services provided by Google or Facebook, but only 12 disclosed this in a privacy policy.

An evidence standard should ensure that all collected data is kept confidential, and privacy policies should clearly explain to patients how their data is stored and used.

To be effective, digital tools should be easy to use for as many people as possible. Screen readers should be able to parse content for users who are visually impaired, and effective tools should also consider whether users speak another language or have limited data usage on their smartphone plan, the authors noted.

A mental health platform is turning to A.I. to improve how it offers care.

DEPRESSION AFFECTS AN ESTIMATED 300 MILLION PEOPLE AROUND THE WORLD, according to the World Health Organization. While seeking care for mental health disorders has become more common and less stigmatized in many parts of the world, actually receiving care can be difficult. It can be expensive or inaccessible — especially during a pandemic. 

Video conferencing, telephone calls, and even text-messaging with a therapist have become more common in the past year but SilverCloud Health, an internet-based cognitive-behavioral therapy (iCBT) platform, offers a different solution. Their DIY health platforms enable patients seeking mental health tools to progress through care modules at their own pace with remote clinicians or coaches monitoring patient progress.

Now, thanks to a research partnership with Microsoft Research Cambridge, SilverCloud is exploring how machine learning can help clinicians understand the needs of their patients better than ever. The patterns found in the de-identified data of over 50,000 users could help create more effective and personalized mental health treatments.

WHAT IS SILVERCLOUD? — While apps like Headspace or Moodfit guide you through mindfulness or mental health exercises, SilverCloud is more similar to services like wayForward. It offers cognitive behavioral therapy (CBT) in the form of internet-delivered programs.

Derek Richards, SilverCloud’s chief science officer, tells Inverse that this platform is designed to offer affordable and accessible tools to people navigating mental health care.

“[This] is largely self-administered and then a human in the loop, the coach or supporter, is supporting asynchronously,” says Richards. Like a teacher reviewing online assignments, through SilverCloud, coaches or clinicians can log on and see what progress a patient has made and where they might be getting stuck.

THE FUTURE OF A.I. AND DIGITAL THERAPY

While Richards says that iCBT does have substantial clinical research to support its effectiveness, that doesn’t mean that all users necessarily benefit in the same way. 

To better figure out how people were interacting with their platform and what they were getting out of it, SilverCloud partnered with Microsoft Research to design a machine-learning algorithm to crunch over 3 million points of engagement data from SilverCloud users and uncover what makes them tick. The study’s results were published this July in the journal JAMA.

Over the course of this two-year study, the team trained a probabilistic machine learning algorithm to evaluate which modules users interacted with most (e.g. building a “worry tree” or completing quizzes about introspection) and how long they showed consistent interaction. While the team report that all users experienced some degree of clinical improvement, the improvement varied across five different engagement

Low engagers

Late engagers

High engagers with rapid disengagement

High engagers with a moderate decrease in engagement

Highest engagers

Danielle Belgrave, a lead author on the study and principal researcher at Microsoft Research, tells Inverse that these results demonstrated an opportunity for better-personalized forms of care.

“Through understanding these distinctions in how people engage, we may be able to better personalize interventions in the future by recommending resources that lead to better engagement, and therefore improve symptoms more effectively,” explains Belgrave.

Richards says that this information can be shared with clinicians or coaches supporting users on SilverCloud in order to help them better guide those who fall into these categories of engagement.

BEWARE OF YOUR BIAS — When it comes to distilling the complexity of mental health to variables and transcribing those to an algorithm, Richards admits that there are bound to be some limitations.

“Human behavior is extremely complex and the whole invention of using A.I. in healthcare is still very much debated,” says Richards. “There has been a lot of noise around it [because] it’s the new shiny thing, but really my view personally is we should use our A.I. intelligently. It should be I.A. — intelligent use of artificial means to enhance treatment.” 

And while Richards says they have yet to come across problems of algorithmic bias in their research, especially as demographic information like sex, race, or income was not included in this study, he tells Inverse that this is a dangerous precipice the team intends to approach with caution.

“… MY VIEW PERSONALLY IS WE SHOULD USE OUR A.I. INTELLIGENTLY. IT SHOULD BE I.A. — INTELLIGENT USE OF ARTIFICIAL MEANS TO ENHANCE TREATMENT.” 

Belgrave agrees and says they hope to address these kinds of problems early by designing machine learning systems that are human-first.

“[T]o achieve good A.I. that works for the person, we need to build A.I. tools that are based on a strong understanding of the person, and are carefully designed and developed for their benefit,” Belgrave says. “A foregrounding of such a human-centric approach to A.I. development will be crucial to the success and future evolution of digital therapy.”

Even with a more human-centered A.I. for iCBT, Richards says that SilverCloud is not attempting to replace teletherapy or therapy options. Instead, it should act as a complement to them: Both 1-on-1 support from a therapist and curated tools from a service like SilverCloud have a place in the overall improvement of a patients’ mental health, Richards says.

WHEN CAN YOU VISIT YOUR A.I. THERAPIST? — Going forward, Richards says they plan to begin incorporating more variables into their machine learning model, such as information about users’ sex, age, and history of mental illness, to build a richer picture of individuals. 

With more refined data, it may be possible for an A.I.-driven system like this to even make predictions about what a user’s clinical outcome might be based on their current path of engagement. This information would be communicated to a supporting clinician or caregiver who could then help correct their course towards a more beneficial outcome, even if that path took them off the service altogether and into in-person therapy instead.

Belgrave tells Inverse that she hopes innovations like these can be used to bring important services like mental health care to communities that need it most.

“Improving access to health and medical services is crucial to reducing health inequity globally,” says Belgrave. “Concepts like internet-based therapy are just one of a number of solutions that can improve access to care for people living in poverty or in underserved areas.”

https://www.inverse.com/innovation/microsoft-silvercloud-digital-therapy

16th June 2020

Digital mental health interventions can have a significant long-term impact on anxiety and depression recovery, newly published research undertaken in collaboration with the School of Psychology at Trinity College Dublin has found.

The study, published in the Nature partner journal Digital Medicine, involved more than 360 NHS service users in the UK. It was undertaken by SilverCloud Health, the world’s leading digital mental health company, with the School of Psychology at Trinity and health economics analysis from the University of Sheffield. As part of the study a treatment group was given eight weeks of supported digital mental health intervention to treat depression and anxiety, compared with a waiting list control group that did not receive the treatment initially.

Published at a time of increased anxiety and impact on mental health from the COVID-19 pandemic, the research emphasises how digital cognitive behavioural therapy (iCBT) as part of wider psychological care can deliver strong clinical improvements and recovery. In addition to patient self-reported outcomes, the study included a formal diagnosis of depression and anxiety and results show that more than half of those with a diagnosis of anxiety and/or depression recovered after three months.

Psychiatric interviews of participants at three months after treatment found that, overall, 56.4% no longer had a diagnosis of anxiety, depression or a joint diagnosis. A further significant decrease in symptom scores was seen after 12 months.

The findings come as mental health providers anticipate a significant increase in a range of disorders linked to anxiety and depression stemming from the pandemic and emerging as the lockdown continues to ease. The potential triggers include grief, job loss, and insecurity, loneliness and isolation. 

Dr Derek Richards, Chief Science Officer at SilverCloud Health and Co-Director of the E-Mental Health Research Group, Trinity College, said:

“This is an important, large-scale research that demonstrates how digitally-provided cognitive behavioural therapy can enhance a wider mental health therapy programme calibrated to an individual’s needs.

“Due to its results on long-term improvement, recovery and cost-effectiveness, at a time of increasing demand for psychological and behavioural healthcare, digital mental health care should be viewed as a standard part of psychological support and no longer simply as an innovative approach.

“As a result of the global pandemic, many individuals within communities are facing mental health challenges and iCBT can play an important part complementing current mental healthcare services, increasing their reach and capacity, and helping support and treat more people.” 

 Notes:  

E-mental health group, School of Psychology, Trinity College Dublin is a leading research group on digital mental health interventions.  The main aim of the group is to be a world leader in the science and practice of e-mental health interventions. The areas of research interest for the group include digital mental health interventions efficacy and effectiveness, qualitative experiences of service users and supporters, cultural adaptation and personalisation of interventions, Implementation science & practice, ??natural data analytics and data mining, performance and learning, and device integration and experimentation. The group are involved in a large and broad portfolio of projects across Europe and US and collaborate with leading academic and research institutions. https://www.ementalhealthgroup.com/

SilverCloud Health is the world’s leading digital mental health company, enabling healthcare organisations to deliver clinically validated digital health/therapeutic care that improves outcomes, increases access and scale while reducing costs. The company’s multi-award-winning digital mental health platform is a result of over 16 years of clinical research with leading academic institutions. Today, SilverCloud is being used by over 250 organisations globally to meet their populations’ mental health needs.  https://www.silvercloudhealth.com

Prior to COVID-19, mental and behavioral health was gaining momentum as a healthcare priority. Funding was starting to flow into mental health services and the technologies to support it. One of those technologies was telehealth – an effective way for patients to “visit” with their Psychiatrist. Another was digital cognitive behavior therapy solutions (digital therapeutics) which allow providers to treat more patients more effectively. Then the pandemic arrived and mental health became even more important.

Dr. Derek Richards, Chief Science Officer at SilverCloud Health, a company that creates internet-delivered cognitive behavioral therapy programs, was kind enough to answer a battery of questions in an email interview on the topic of digital mental health, cognitive therapy and digital therapeutics.

What is digital cognitive behavior therapy?

Generally speaking, digital therapy offers three benefits that are of high interest to healthcare providers who operate on the one-to-one therapy model: scalability, accessibility and affordability. Simply put, it allows them to increase the number of patients they see; the platform circumvents traditional barriers that prevent access to mental health therapy, and it dramatically decreases care delivery costs (91% reduction compared to face-to-face therapy). In the U.S., as many as 43.8 million adults will experience some form of behavioral or mental illness in a given year. In 2018, 56 percent of those wrestling with these mental difficulties did not receive care because of treatment barriers, including stigma, limited or exhausted budgets, and geographic remoteness – that’s over half the mental illness population.  Mental therapy is in need of a transformation, and digital therapeutics are a proven alternative.

Is digital therapy as effective as face-to-face?

SilverCloud’s platform is built on an extensive research base with over 30 peer reviewed clinical studies over nearly two decades. Through several randomized control trials (RCT), we have demonstrated that our programs are extremely effective and provide clinical outcomes that are equivalent to similar interventions delivered in face-to-face therapy. SilverCloud delivers structured brief interventions for the treatment of common mental health disorders including depression and anxiety.  They also have a suite of programs that address personal wellbeing and functioning such as stress management, sleep management, and resilience. These interventions are reflective of many types of interventions delivered in face-to-face services either in 1:1 formats or groups.  We have demonstrated equal effectiveness with similar evidence-based interventions delivered 1-to-1 and in group settings.

Is there any difference in the treatment received digitally? 

The treatments that are delivered online are identical to those that would be delivered in person.  Essentially as clinicians, we have a repertoire of empirically supported treatments that have been developed through research and practice over many decades.  They describe the treatment components and what works best for whom giving the presenting issues and difficulties.  It is from this repertoire that the active ingredients of treatment are composed and delivered for effective clinical outcomes. Therefore, apart from the mode of dissemination, we are delivering standard evidence-based psychological treatments.

What mental health services are most in-demand right now because of COVID-19?

At this current time, we are experiencing a pandemic like most have never witnessed before.  That alone raises the levels of distress and stress in the population. The various community initiatives to support the effective management of the COVID-19, including cocooning, social distancing, and the closure of many places of businesses and leisure pursuits will inevitably have its impact on people’s general wellbeing and their mental health.  These initiatives, while important and necessary, have a direct impact on our sense of selves, who we are, our social lives and also whether we are employed in meaningful and purposeful pursuits.

Stress management, resilience and sleep management have all been in high demand.

What is SilverCloud experiencing during this pandemic?

Due to the closure of mental health services, SilverCloud is being deployed more than ever before to maintain continuity of service provision.  This continuity helps to support those with serious and long-term mental health conditions that require ongoing management.  However, in addition and with the prospect of service doors remaining closed for the coming months, many health systems are leveraging SilverCloud to provide for the treatment of common mental health concerns such as depression and anxiety disorders. It is likely that these concerns will become more prevalent in the coming months as people face the ongoing consequences of loss and dislocation that we are experiencing.

One of the main advantages of digital is the ability to rapidly develop new content and deploy that at scale.  To that end, we have built new content specific to COVID-19.  The content is underpinned by the latest research in emergency psycho-social response that implicates the principles of mental health first aid.  The content builds on Hobfoll et al. (2007) 5 principles for intervention development during emergencies and mass violence: A sense of safety, a sense of calming, a sense of self-efficacy and collective efficacy, connectedness and hope.  We have delivered this globally, across our partnerships and networks, with particular emphasis on supporting frontline health care workers.

Is the growth that we are seeing in digital therapeutics and mental health services a blip or is it a sustained trend?

As it relates to COVID-19, we believe the heightened need for mental health therapy will sustain for quite some time for a variety of reasons. It is likely that the worsened socioeconomic conditions that will follow the crisis will have lasting effects on society, and consequently, it will be imperative that we have treatment options available to everyone who is in need. Digital therapeutics scales treatment beyond traditional one-to-one therapy models and bridges the gaps that healthcare providers and patients experience when trying to access mental health care. We believe the power and clinical outcomes of these programs will be realized even further after the COVID-19 dust settles, and we hope that those who are struggling with mental difficulties will continue to turn to digital therapeutics for treatment.  We have 20+ years of research supporting the effective and safe delivery of digital therapy for mental health, and the current circumstances only highlights how important it is that we have digital mental health solutions like SilverCloud available as part our treatment initiatives.

To learn more about SilverCloud Health, visit their website at https://www.silvercloudhealth.com/

This article is part of the #HealthIT100in100

Digital Therapeutics – Blip or Lasting Trend?

SilverCloud Health, the world’s leading digital mental health platform for providers, health plans and employers is to enhance its range of therapy programmes in the UK as part of expansion plans after securing $16m (~13m pounds sterling) funding from leading health investment groups. 

The new funding round will see the company further developing its innovative approaches to therapy, addressing the range of psychological conditions across all age groups. This will include the UK and Europe, and also further expand the geographical reach of its services in the US.

Founded in 2012, SilverCloud’s mental health programmes are used globally by more than 300 organisations including more than 70% of NHS mental health services. It offers more than 30 mental health programmes across the spectrum of mental health from wellness and resilience, through to severe mental health and chronic concerns.

“We are committed to providing truly impactful mental health support to all those with need,” said Ken Cahill, CEO of SilverCloud. “The need has never been greater than during this unprecedented global crisis. SilverCloud enables easier, earlier access to clinically validated mental health care that shows results equivalent to face-to-face care for the 1 in 5 people with a diagnosable mental health condition. With millions of people being asked to stay home and health systems needing to prioritise care, we recognise the heightened need for virtual support as the world copes with the COVID-19 pandemic. In response, SilverCloud is providing its clients, free of charge, expanded access to its platform to even more healthcare professionals, their families and patients to help make a difference for those in need in the current crisis.”

The new – Series B – funding round, led by MemorialCare Innovation Fund, and which included other US healthcare groups LRV Health, OSF Ventures and Unity Point Health Ventures, has helped raise the company’s total funding to more than $30 million and brings together a group of healthcare investors with extensive experience in the US healthcare market.

It will see the company, which has offices in Dublin, London and Boston, enhancing its current global portfolio, expanding availability of its programme offerings in the US and enabling additional research and clinical trials to be conducted. SilverCloud will also expand its presence in Europe, with new and existing partners like Thieme Telecare, part of the Thieme Group and one of the leading providers of integrated care in Germany. Existing investors ACT Venture Capital and B Capital Group, participated in the round as well.

The SilverCloud platform, used by more than 350,000 users and growing by more than 15,000 users per month, has demonstrated results on par with face-to-face therapy in multiple randomised controlled trials. Beyond its industry-leading results in clinical trials, its real-world evidence demonstrates that more than 65 percent of SilverCloud users have shown significant decreases in depression and anxiety symptoms.

SilverCloud’s programmes are evidence-based and involve clinical experts and users in the design and development of the mental and behavioural health interventions. Backed by over 17 years of research including partnerships with leading academic institutions, SilverCloud has seen exponential year-over-year growth since 2012.

Raj Ganguly, Co-founder and Partner, B Capital Group, said: “Our investment in SilverCloud Health is driven by our confidence in its team, its proven track record working with global health organisations and its esteemed partner network. This new capital will enable SilverCloud Health to continue to innovate, expand and broadly deploy its programmes to the millions of individuals who need them.”

The past year has seen some significant developments for SilverCloud. In October, it announced a research partnership with Microsoft to improve outcomes through artificial intelligence, based at Microsoft Labs in Cambridge, England. In December, it was announced that the SilverCloud platform would be included in digital health formulary of ExpressScripts, the largest independent manager of pharmacy benefits in the US.

This further shows how digital therapeutics solutions are becoming a critical component of mental health treatment and support, and how SilverCloud is determined to stay the leader in delivering outstanding outcomes. More than 94 percent of users of SilverCloud’s scalable and responsive platform said the programmes are helpful, relevant and supported them toward their goals. 

About SilverCloud Health

SilverCloud Health is the world’s leading digital mental health company, enabling providers, health plans and employers to deliver clinically validated digital health/therapeutic care that improves outcomes, increases access and scale while reducing costs. The company’s multi-award-winning digital mental health platform is a result of over 17 years of clinical research with leading academic institutions. Today, SilverCloud is being used by over 300 organizations globally to meet their populations’ mental health needs. Global experts have deeply validated the platform through full randomized control trials and real-world data from over 350,000 SilverCloud users. The platform continues to lead the industry with its effectiveness, engagement, and range of clinical programs that encompasses the spectrum of mental health needs.

About MemorialCare Innovation Fund

MemorialCare Innovation Fund (MCIF) brings strategic investment funding to accelerate the development of companies in the healthcare information technology, healthcare services, and medical device sectors that can advance high-quality, effective healthcare. MCIF is focused on companies offering innovative products, services and technologies which help healthcare systems significantly improve performance and outcomes and achieve their community missions.

About B Capital Group

B Capital Group is a global firm specializing in equity investing in venture and growth-stage companies that have achieved traction with customers. Through our extensive global network and exclusive partnership with The Boston Consulting Group, B Capital helps high growth start-ups navigate business challenges, raise capital and attract talented leadership at key points of their journeys to scale. With offices in San Francisco, New York, Los Angeles and Singapore, B Capital believes innovation can come from anywhere. Our unique multinational presence and deep industry knowledge have enabled us to build a portfolio of B2B and B2B2C start-ups that are transforming large traditional industries across borders and geographies. Portfolio companies include AImotive, Atomwise, Blackbuck, Bounce, Bright.md, CXA, Evidation Health, Icertis, INTURN, Plastiq, Ninja Van, Notable Labs and SilverCloud Health.

About LRVHealth

LRVHealth is the “Inside Healthcare” venture capital platform. LRVHealth’s investors include leading provider, payer, and vendor organizations, comprising a network that touches one in three healthcare consumers across the U.S. Together, this network collaborates to identify, invest in, and adopt innovative solutions to the industry’s most pressing needs. Founded in 2000 by an experienced team of healthcare investors, operators, and advisors, the LRVHealth team provides early stage capital, operating experience, and industry insights to build the next generation of great healthcare companies.

About OSF Ventures

OSF Ventures specializes in venture optimization, partnering financially and operationally in companies that improve patient outcomes and reduce costs to health care systems. OSF Ventures is a division of OSF HealthCare.

About Unity Point Health Ventures

Founded in 2019, UnityPoint Health Ventures makes direct investments in ideas and partners that provide an easier, more personal experience for patients and providers. As the venture capital arm of UnityPoint Health – one of the nation’s most integrated health systems – the firm invests in opportunities that improve patient outcomes and reduce the cost of health care. In addition to strategic investing, UnityPoint Health Ventures provides dedicated resources to accelerate portfolio company traction within UnityPoint Health and beyond. Through relationships with more than 315 physician clinics, 21 regional and 19 community network hospitals in metropolitan and rural communities and home care services throughout its 9 regions, UnityPoint Health provides care throughout Iowa, western Illinois and southern Wisconsin.

About Act Venture Capital

Act Venture Capital is one of the longest established VC firms based out of Ireland. We partner early with visionary founders and support them from inception to scale, and beyond. Act has raised €500m across multiple funds and this investment is made from its fifth expansion fund, Act V.

Digital mental health company SilverCloud Health has partnered with Microsoft Labs in Cambridge to explore how machine learning and artificial intelligence (AI) could be used to personalise mental healthcare.

Together, the companies are researching how digital therapeutics could be tailored to respond to each individual’s unique care needs.

This includes providing early interventions that ensure patients have access to the right support at the right time, and in the right context.

By applying machine learning and AI, Microsoft and SilverCloud hope to identify patterns of successful therapy that can be used to improve the effectiveness of digital therapeutics.

Christopher Bishop, lab director for Microsoft Research in Cambridge, said: “SilverCloud Health is one of the very few digital mental health platforms that has been deployed at scale in routine clinical care, and currently has the largest real-world patient user base of its kind.

“The aim of this project is very much aligned to our ambition to empower healthcare workers and patients through access to effective, intelligent technologies.”

SilverCloud Health offers more than 30 digital therapeutics programs.

Its digital mental health platform is used across 75% of NHS mental health services in IAPT (Improving Access to Psychological Therapies), and 250 organisations globally.

The platform is designed to remove the barriers that prevent patients from accessing mental health services.

These can include cost and clinical resources.

The company has been working with Microsoft Labs in Cambridge over the past 18 months as part of research that combines Microsoft’s machine learning and AI technologies with SilverCloud’s expertise in digital therapeutics.

The project will use data from more than one million hours of therapy delivered by SilverCloud since 2012, which it hopes will “change how online therapy is delivered for the NHS.”

Ken Cahill, CEO of SilverCloud Health, said: “Through this exciting research collaboration with Microsoft, SilverCloud Health will be able to leverage the latest in artificial intelligence and machine learning to further enhance our digital mental health platform.

“This truly is therapy for the 21st century; enabling more personalised treatment, earlier and easier access, and most importantly delivering ever increasing clinical outcomes.”

Digital therapeutics are increasingly being recognised for their effectiveness in improving access to mental health services.

In August, the University of Central Lancashire became the first UK university to offer digital therapy training as part of its curriculum.

This will be delivered in partnership with SilverCloud Health.