Evaluating the Feasibility and Accessibility of Digital Technology Interventions for Global Mental Health

At the moment, there is a lot of enthusiasm for using mobile devices to treat mental health disorders because mobile technology is embedded in the way we communicate, not just here in America, but worldwide. Though not considered as a replacement for face-to-face mental health care, mobile devices are thought to have the potential to extend the reach of the limited number of mental health care providers in low- and middle-income countries.

A paper published in the April 19 issue of Lancet Psychiatry evaluates an array of studies about this issue and summarizes the demonstrated potential effectiveness of digital technology for treating and preventing mental and substance use disorders in low- and middle-income countries.

Lead author John A. Naslund, MPH, a doctoral candidate at The Dartmouth Institute for Health Policy and Clinical Practice, and an affiliate of Dartmouth's Center for Technology and Behavioral Health, wrote the paper along with colleagues at Dartmouth, the London School of Hygiene and Tropical Medicine, the Public Health Foundation of India, and the University of Washington. Though he believes technology has the potential to positively affect the treatment of mental disorders, he admits it is not a panacea, but rather a valuable tool whose use should be based on evidence.

John Naslund, MPH

Naslund identified 49 studies, mostly centered on preliminary evaluations of feasibility and acceptability. He and his colleagues then reviewed evidence cited by those studies on the use of digital technologies for treatment and prevention of mental disorders in low- and middle-income countries. Naslund says they found promising findings demonstrating the potential effectiveness of online, text messaging, and telephone support interventions.

“One of the major motivating factors for conducting this review is because the tremendous burden of mental disorders worldwide, which range from depression to serious mental illnesses such as schizophrenia to a broad range of trauma disorders, is greater in low-income countries,” he says. “Our goal was to summarize the state of the evidence on using digital technology, including mobile, online, and other remote technologies, for better understanding how we can make evidence-based mental health care available to the millions of people in need in low- and middle-income countries.”

Naslund describes the work as, “A call to action and something we should be seriously thinking about—creating innovative approaches to treating mental health disorders.”

Accessing the web through mobile technology has spread rapidly to significant portions of the global population—nearly 40 percent of the world’s web traffic stems from mobile devices—and while there are many gaps in both mobile and online connectivity, this rapid growth in mobile telecommunications may offer new opportunities to reach, support, and treat individuals living with mental disorders.

“In some countries less than 10 percent of people with mental illness receive any treatment and even in high-income countries such as the US, fewer than half of people with mental illness ever receive treatment,” Naslund explains. “In a country such as India or in many countries in sub-Saharan Africa, fewer than 10 percent of people receive treatment for mental health issues. The gap in treatment is huge. But what’s most striking when thinking about mental disorders is that there are effective and inexpensive ways to treat them.

“It’s quite amazing how many people have access to mobile devices. For example, we’ve seen mobile phone subscriptions reach more than 80 percent of the population in low-income countries in Africa and South Asia—a large portion of the world’s web traffic is actually coming off of mobile devices,” he says. “In a country like Nigeria, it’s over 80 percent. This tells us that people are accessing the Internet over their phone—and we can reach them.”

Yet in the face of this access, treatment gaps remain. Globally, women have much lower access to mobile devices compared to men, and social and structural barriers make it difficult for them to access online mental health support. And when rural poverty is added to that equation access becomes more limited.

For Naslund and his colleagues this is an exciting opportunity, “because we know there are meaningful ways to help treat people with mental illness and substance use.” What’s critical, they say, is getting the right treatment to the right people and getting it early on, “It can have a big impact, but the question is how do you get the right tools to the right people and we don’t have a good answer for that yet.”

Reaching vulnerable populations requires creative thinking.

“We need to think about the challenges that exist within different societies and the structural barriers that may make it difficult to access digital technologies and think of new ways to support people in need of mental health care,” he says. “And along with that, we also need to think carefully about risks, such as confidentiality or safety, when people access mental health care through a mobile device—right now a lot remains largely unknown.”

Because the number of mental health care providers is limited, Naslund says part of any discussion around treating mental disorders must include methods on how to scale up care by facilitating the supervision and mentoring of non-medical health workers while supporting professional development opportunities that promote workforce retention and satisfaction to bridge the treatment gap, “There will never be enough providers—psychiatrists, psychiatric nurses, and others—to meet the treatment demand.

“Shoring up this disparity is closely aligned with exploring how we can use a variety of digital technologies, such as online social networks, Facebook or Twitter, mobile devices, smartphone applications, or wearable devices to improve the quality and effectiveness of mental health care and to make these services more widely accessible to those in need,” Naslund says.

Though preliminary findings are positive, it is still early in using technology for helping those with mental health disorders in low-income countries and rural areas, and there is a caveat—the lack of strong data showing digital technology’s effectiveness.

“I think we need to try to move ahead and build off this preliminary work,” Naslund says. “But there haven’t been a large number of rigorous studies evaluating it, and that’s the other thing highlighted in this paper—the need for strong data showing its effectiveness.

“So yes, we need to understand this better, but what is remarkable is that digital devices, particularly the mobile phone is part of every culture in many parts of the world,” he explains. “It’s become second nature—it has changed the way we communicate and access information and it has the potential to change the way we access mental health care.”