Nii Lante Wallace-Davies and Sharon Harris, both head of business development of Ieso Digital Health, provide some insight into the current state of people’s mental health in the UK and what tools can be used to help manage it.
Over the past few months, the world as we once knew it has altered dramatically. It has been a time of change for everyone and, after many weeks of confinement at home, the extraordinary times we now live in will be taking their toll on many people’s mental health. However, as lockdown measures ease and people come to terms with this ‘newmality’, the transition period we are now in maybe the time when people will need mental healthcare the most.
Continuity and quality of mental health services has never been more crucial and, as a key priority for the NHS, IAPT has been working hard to keep mental healthcare services up, running and available during these uncertain times. During the COVID-19 crisis, many healthcare providers have put contingency plans and measures in place to support the ‘remain open’ directive, including:
- Adopting or increasing access / capacity to digital psychotherapy services as alternative approaches to face-to-face treatment delivery. For example, some NHS Trusts are deploying digital services like Ieso’s online CBT or working to extend already existing digital contracts in order to move more people into treatment quickly and reduce waiting times.
- Enabling clinicians with digital delivery methods so they can work more easily from home and continue to deliver treatment remotely. While there has been a period of adjustment, many clinicians have adapted to this approach with the help and support of increased training, knowhow sharing and useful self-help resources from service providers, the NHS, and associations like BABCP.
- Adopting digital communication and collaboration tools, such as Microsoft Teams and Zoom, which appear to have been embraced by GPs, NHS Trusts and patients alike as they continue to take appointments, triage patients and deliver treatments.
While many mental health services are still available and running as usual (albeit online) across much of the UK, in April and May mental health referrals to services appeared to experience a 30-60% drop off which is surprising during a collective crisis such as COVID-19. In recent weeks, referrals have begun to pick up again, but they are still not at pre-COVID-19 levels compared to the months prior the pandemic. This decrease in referrals could be for a number of reasons:
- During the early stages of lockdown, people didn’t know (and still don’t know) where to turn if their mental health is suffering. It may not be widely known that mental healthcare services are still available, and that by contacting your GP you can get referred to a service or self-refer online in some parts of he country. More details can be found on the NHS psychological services page.
- Members of the public are choosing not to risk going to hospitals, or are reluctant to reach out to their GP to avoid burdening the health service due to governmental messages about pressure on the NHS.
- People have been settling into lockdown living and, for some, this way of life is actually less stressful than before.
- GP’s have been referring less patients to mental health services, as they don’t know enough about them or what is up and running today. There has, however, been more education on remote access to services since the start of lockdown.
- As we move through lockdown phases, people are not coming forward for mental health support because they feel symptoms are normalized due to more people talking about their own distress.
- Mental health symptoms triggered by the current circumstances may not be presenting yet in people. Delayed onset of mental health conditions, symptomatic of wide-scale trauma, could result in a surge of new cases descending on the UK mental health system in the coming months.
The signs of delayed onset mental health issues
A recent report by the Royal College of Psychiatrists, which surveyed 1300 mental health doctors across the UK, also found that 45% of experts experienced a fall in routine appointments during the COVID-19 lockdown, with psychiatrists worried about a looming mental health crisis from problems stored up during lockdown. A report on the early warning signs of a mental health tsunami published by JMIR publications, also documented similar observations after speaking to multiple digital platform providers including the Ieso team. Its initial data indicated the onset of a mental health crisis and fears of a surge in demand as lockdown restrictions ease. The JMIR study also highlighted the complexity of, and change in mental health concerns witnessed by digital providers, notably the increased presentation of anxiety and loneliness, and a recurring observation that demand for digital support has risen.
At Ieso, we have interpreted our own mental health data in much the same way and expect a surge in the number of patients in need of treatment due to the delayed onset of symptoms. Initially we saw a significant increase in online CBT referrals in the weeks leading up to and just after lockdown started - an 84% usage increase in fact compared to the same period last year. This suggested that NHS mental health services had turned to digital delivery to help cope with demand and were sending more people our way. However, this surge soon saw a drop in health-seeking behaviour, suggesting the delayed onset response that has been observed in other critical incidents over time.
COVID-19 role in mental health difficulties today
The patterns of change in referral numbers, and particularly referral pathways (i.e. service vs self-referrals) are often complex and dynamic, and can be difficult to interpret or accurately predict what will happen next. However, Ieso has been observing the language used within therapy sessions and, while this is preliminary analysis on data collected, we have found a significant increase in worries about viruses including Coronavirus and COVID-19. With 20% to 30% of patients now mentioning COVID-19 in therapy, this does not necessarily indicate that patients are having mental health difficulties caused by the current crisis, but it does suggest that the current crisis is playing a substantial role in mental health difficulties for patients in therapy, and raises concerns about the long-term impact of the crisis on the mental health of the population.
This compares to approximately 40% of worries about family, and 5% of worries about finance, which seems to have remained stable during this period (April 2020).
A unique mental health situation
The COVID19 situation is pretty unique when compared to other modern times crisis. The virus has not been over a discrete point in time but instead prolonged over several weeks and months. It has caused trauma exposure at a global scale and at various levels with compounding sets of triggers for mental health conditions. On top of this, there is a lack of ability for people suffering from anxiety and depression to return to anything that remotely resembles “normal life”, which is usually the primary path to recovery.
We also expect that people may not be able to address the difficulties they are currently experiencing with their mental health due to other factors going on in their lives. However, as more people start to acknowledge symptoms due to factors such as isolation, family or financial distress or pressures, we believe they will start to seek help. Milder symptoms are usually detected in people in the immediate aftermath of a trauma, which become more severe with time. By intervening early we find that exposed individuals have better clinical outcomes. For those that don’t seek help we suspect this will lead to a rebound effect, where mental health difficulties increase as lockdown measures are lifted but life does not necessarily go back to normal.
Measures to move patients through treatment and prepare for a rise in mental healthcare cases
When this surge will hit no one really knows, but with generally lower numbers of referrals overall, we are seeing some healthcare service providers using the technology, time and budget they have to start to clear their waiting lists in preparation for any future disruption to healthcare services. Also, some NHS Trusts are taking steps to enhance their digital efforts further, by adopting services like Ieso’s online CBT, which can introduce more capacity and supplement NHS teams when workforces maybe depleted.
Ieso has already been helping with waiting list reduction programmes to clear pathways ready for the impending and expected surge in mental health cases. Keeping digital services up and running, and continuing to move people through treatment during a mental healthcare crisis is critical, particularly if healthcare professionals or therapists are re-prioritised to deliver frontline critical care or taken ill.
Digital services such as Ieso’s also offer patients the added benefit of flexibility and choice in terms of the time and location they receive therapy – so outside normal working hours and at home if they prefer. By utilising these more modern forms of digital communications, service providers can deliver much needed end-to-end care more immediately in times of emergency or crisis, meaning more people can get the treatment they need. People can seek treatment, continue to engage, and can also remain in touch if they need additional support, particularly as circumstances continue to change.
Digital therapy is the new ‘business as usual’
As the NHS Trust re-models for the expected ‘newmality’ and an increase in demand for mental health services, healthcare providers recognise that digital as a delivery method for therapy is here to stay. Digital delivery methods provide more flexibility for both therapists and patients, who are becoming more comfortable with these treatment platforms. GPs are also seeing the benefits in referring to online services to get people into treatment faster. With terms being used across the industry, such as ‘going back to better’, NHS Trusts are starting to invest more in tools like Ieso’s online CBT to enable remote and more flexible access to therapy for all. Digital delivery will be more embedded into working practice generally, and so for the most part, many NHS Trusts are being pragmatic and flexible in their approach and seeing digital as ‘business as usual’ until we all have more clarity on what will happen next.
As digital delivery methods become ‘newmailty’ in mental healthcare, we will continue to closely monitor the state of the UK’s mental health, and report back findings.
