The digital revolution
Advances in technology and particularly mobile digital information and
communication technology continue at an exponential rate, making it possible to
communicate, obtain information and access and buy goods and services in new
ways. In 2013, 36 million adults in the UK (73%) accessed the internet every
day and 72% of all adults bought goods or services online.
Access to the internet using a mobile phone more than doubled between
2010 and 2013 to 53%. In total, 51% of UK adults now own a smartphone (almost
doubled from 2011) and 24% own a tablet. Also, 43% of adults now use the
internet to seek health-related information, an increase from 18% in 2007.
Significant sections of society are becoming increasingly familiar and
comfortable with using technology for a wide range of transactions.
E-health and m-health (increasingly collectively referred to as ‘connected
health’, see Appendix) describe the
delivery of healthcare by electronic means via the internet using a variety of
devices including mobile phones, remote monitoring devices and other wireless
devices. These digital technologies can greatly improve access to mental
healthcare and treatment adherence by enabling services to be delivered more
flexibly and tailored to individual patient needs. Recent developments in
sensor technology, online psychological therapy and remote video consultation,
mobile applications (‘apps’) and gaming all present real opportunities to
engage and empower patients and create novel approaches to both assessment and
intervention for mental health problems.
The drivers for technological transformation in mental health
The growth in demand for mental healthcare exceeds available UK National Health
Service (NHS) resources, and this gap is likely to increase up to 2020. Cost
pressures require that more is done for less and providers therefore must find
innovative ways to deliver services. The UK Government’s mental health strategy
‘No health without mental health’
recommends the increased use of information and communication technology
(ICT) to improve care and access to services. UK Government initiatives such as
‘Digital First’ aim to reduce unnecessary face-to-face contact between patients
and healthcare professionals with NHS trusts encouraged to replace these
unnecessary face-to-face contacts with video-based remote consultations.
However, service users consistently report dissatisfaction with a ‘top–down’
one-size-fits-all approach. Connected health innovations have the potential to
offer great flexibility and to be more patient-centred.
Digital mental healthcare
E-mental health is not just about technology, but represents a cultural change
in mental healthcare by empowering patients to exercise greater choice and
control. For example, the provision of online psychological interventions,
potentially accessible 24 h a day, 7 days a week, is increasing rapidly using
synchronous video/voice or asynchronous text communication. Examples of
providers to the NHS include Xenzone (www.xenzone.com), PsychologyOnline (www.psychologyonline.co.uk) and Big White Wall (BWW) (www.bigwhitewall.com)
Mental health professionals have historically been reliant on face-to-face
consultations in clinic settings away from the normal lives of their patients.
Mobile apps are now available that allow patients to record their mood,
behaviour and activities in real-time using well-validated measures such as the
PHQ-9 depression scale.
Patients can track their condition using their own mobile device over
time and share this information with their clinician. Potential benefits to
patients include greater engagement in their care and earlier detection of
problems, more timely adjustment of treatment and shared decision-making.
Sensors such as accelerometers, gyroscopes, microphones and cameras, which are
now standard parts of smartphones and other mobile devices, mean that it will
be possible to continuously and passively collect objective data that can give
additional insight into a person’s behaviour and activities. For example,
detecting subtle changes in sleep and activity patterns constitute important
early warning signs of relapse and can prompt early intervention in depression
and bipolar disorder.
In mental healthcare, assessment and diagnosis is still largely based on
subjective clinical judgements about symptoms and behaviour. Technological
innovations have the potential to bring more objectivity and reliability to
these processes of assessment, diagnosis and monitoring. Affective computing is
a branch of computer science that aims to develop automated assessment of a
person’s mood by analysis of their facial expression, speech rate and tone of voice.
Automated analysis of facial expression has been shown to correspond
closely with clinical ratings of depression
and could potentially augment clinical assessment in the near
In addition, ICT can address issues such as social isolation and the relative
inaccessibility of mental health services to young people. The rapid increase
in popularity of social media platforms means that people are increasingly able
to access information and support from peers and professionals in new and
informal ways. Mental health problems disproportionately affect younger people,
and this group is also the biggest user of ICT; social media may widen access
for groups who find it difficult to access traditional services.
It is critical, however, to consider the challenges of introducing new
technology to mental healthcare. The so-called ‘digital divide’, describing a
gulf between those who have ready access to a computer and the internet and
those who do not, means that some groups of patients (for example, older
adults, people who are homeless and people with intellectual disabilities)
could experience barriers to accessing mental healthcare delivered using ICT. A
study of patients with mental health disorders found that their use of
technology (computers, mobile and smartphones) was similar to the general
population, with older people reporting less familiarity, access and confidence
with these technologies.
Older people experiencing psychosis report a significant desire to
increase their use of computers, suggesting that a cost and skills gap, rather
than indifference, is the reason for lower rates of computer usage.
Tailoring the device to the needs of the individual is particularly
important, as witnessed by the rapid uptake of tablet devices by older
Data protection, privacy and security: establishing public and patient
Maintaining public trust when handling and sharing personal health data is
paramount and this requires serious public engagement over issues of consent,
data security and privacy. There is an even greater need to address these
ethical issues in the field of mental healthcare as the data are often highly
sensitive personal information. Although technological developments hold great
promise, the lessons from the aborted initial roll out of
Care.data by NHS England
demonstrate that public acceptance and large-scale population
utilisation are unlikely unless steps are taken to safeguard the legal and
ethical rights of the public and patients.
The past 5 years have seen a rapid increase in the number of m-health apps,
including many targeted at mental health and well-being. Some of these are
aimed at healthcare professionals but the majority are targeted at the general
public, although many are developed without significant user (patient or
The majority of apps are sold via commercial marketplaces but the NHS
has also established a health apps library, which contains (as of 1 February
2015) 23 apps categorised under mental health, although the safety and efficacy
of many of these appears unproven.
The rapid emergence of apps combined with the relative low cost and speed with
which they can be developed and placed on the market, has resulted in the NHS
and regulatory bodies struggling to keep pace with the evolving field of
m-health. Guidance on the regulatory requirements for m-health apps was only
published by the Medicines and Healthcare products Regulatory Agency (MHRA) in
and NHS England is currently working with the US Food and Drug
Administration on a bilateral framework for regulation of m-health apps.
Evaluating the safety and efficacy of m-health interventions should be subject
to the same rigour as evaluations required for new drug or psychological
Some examples of apps that have been developed for mental health include
ClinTouch (www.clintouch.com), My Journey (www.sabp.nhs.uk/eiip/app), Buddy App (www.buddyapp.co.uk) and WellHappy (apps.nhs.uk/app/wellhappy/). Typically, these apps include a symptom
tracker and diary function, appointment and medication reminders and
motivational prompts. These examples have been developed with user and
clinician involvement and incorporate evidence-based principles of care (for
example, early intervention improves outcomes in psychosis). Although
early-stage pilot evaluations suggest that these apps are safe and their use is
acceptable to patients and clinicians, further research is needed to
demonstrate clinical and cost-effectiveness in routine NHS settings. The task
of building an evidence base and framework for evaluating the rapidly
increasing number of m-health apps and other digital products is being led by
NIHR MindTech Healthcare Technology Co-operative and should be a priority area
for NHS applied health research.
The ‘big data’ challenge for mental health
Digital health technologies, including, electronic medical records, imaging,
e-prescribing and the increasingly prevalent use of connected devices to
monitor health, have the potential to generate large amounts of data that could
be of considerable benefit to researchers and policymakers.
There are three processes required to achieve these benefits: unlocking value
in electronic medical records (EMRs); new forms of access that allow patients
direct control (patient health records, PHRs); and pervasive computing and
connected devices (m-health) to enable expansion of the ‘real-time’ patient
Increasingly, data accessed through the EMR is being used within clinical,
epidemiological and public health research. In each case use of the EMR enables
scaling of such studies; sometimes by orders of magnitude in both size and
speed. Challenges to the use of the EMR in such research are not trivial and
include technical (can data be accessed and linked in a format that enables
analysis from multiple data sources?), governance (security, privacy, access
control) and scientific (is the data of sufficient quality?); however, these
challenges are being met both for meta-data such as diagnosis and hospital
episodes, and for patient level-data including complex text or narrative data.
An example of the use of complex EMR data is the Clinical Record Interactive
Search (CRIS) system established by the Maudsley Biomedical Research Centre in London.
CRIS allows researchers to view de-identified records provided that
research studies are approved by an oversight committee with full user
engagement. The system has been used in many studies, an example being the
extraction of data from a single NHS trust to show substantially increased
mortality in people with serious mental illness.
Despite the clear potential of digital technology to connect people and health
data in new ways, there is currently insufficient evidence to suggest that this
potential is being fully realised, with uptake being limited and outcomes being
largely anecdotal and unpublished. There are a number of key challenges: first,
ensuring that patients and their needs remain at the centre of technology
development and implementation; second, rapidly increasing the evidence base
for the clinical effectiveness of digital technology; third, ensuring that the
opportunity provided by data sharing between patients, carers and clinicians
does not threaten privacy and undermine public trust. Finally, patients,
clinicians and NHS commissioners require an agreed framework to evaluate the
core features of new technologies including usability, content, safety,
clinical- and cost-effectiveness.
Definitions in digital healthcare
The transfer of health resources and healthcare by electronic means.
It encompasses three main areas:
(a) the delivery of health information, for health professionals
and health consumers, through the internet and
(b) using the power of information technology and e-commerce to
improve public health services, for example, through the
education and training of health workers;
(c) the use of e-commerce and e-business practices in health
Medical and public health practice supported by mobile devices, such
as mobile phones, patient-monitoring devices, personal digital
assistants and other wireless devices.
M-health involves the use and capitalisation on a mobile
phone’s core utility of voice and short messaging service (SMS) as
well as more complex functionalities and applications including
general packet radio service (GPRS), third-and fourth-generation
mobile telecommunications (3G and 4G systems), global positioning
system (GPS) and Bluetooth technology.
The use of ICT to support and improve mental health, including the use
of online resources, social media and smartphone applications. Two
types of e-mental health are commonly referred to: web interventions
and mobile applications.
A subset of telehealth that uses video-conferencing technology to
provide mental health services from a distance. It includes
telepsychology, telepsychiatry, telemental health nursing and
Ofcom. Communications Market Report 2013.
HM Government. No Health Without Mental
Health. Department of Health,
The PHQ-9: validity of a brief depression severity
measure. J Gen Intern Med
2001; 16: 606–13.
Towards personalised ambient monitoring of mental health via
mobile technologies. Technol Health Care
2010; 18: 275–84.
Bilakhia, S, et al.
AVEC 2013: The Continuous Audio/Visual Emotion and Depression
Recognition Challenge. Proceedings of the 3rd ACM International Workshop
on Audio/Visual Emotion Challenge.
Pandit, N, Wykes, T
Can't surf, won't surf: the digital divide in mental
health. J Ment Health
NHS Care.data information scheme
'mishandled'. BBC News
User requirements for the development of smartphone
self-reporting applications in healthcare. In
Human-Computer Interaction Applications and Services (ed.
M, Kurosu). Springer,
Denis, M, et al.
The South London and Maudsley NHS Foundation Trust Biomedical
Research Centre (SLAM BRC) case register: development and descriptive
data. BMC Psychiatry
2009; 9: 51.
Lee, WE, et al.
Life expectancy at birth for people with serious mental
illness and other major disorders from a secondary mental health care
case register in London. PLoS One
World Health Organization. mHealth New Horizons for
Health through Mobile Technologies. Global Observatory for eHealth Series
– Volume 3. WHO,