Aislinn Enright and Mark Wallin represent SilverCloud Health in the UK and US respectively. As leaders in their field, producing and promoting engaging online health and wellness solutions, their roles require them to stay abreast of industry relevant matters. However, their geographic localities each present different issues and priorities, and occasionally divergent perspectives.
A View from the US
Mark Wallin, SVP, SilverCloud Health Inc.
Mark has U.S. and international experience with corporate healthcare and eHealth organizations, such as Aetna, WebMD and ICW AG. Driven by a passion for quality health outcomes, Mark has successfully operated or engaged in multiple entrepreneurial start-up and turnaround opportunities in healthcare technology.
Behavioural health in the US
In the United States, the burden of the cost of behavioural health care has traditionally fallen primarily to the patient and their families. Over the past twenty years, that has slowly begun to change, and more recently, in November 2013, ‘The Mental Health Parity and Addiction Equity Act of 2008’ (MHPAEA) legislation received the approval of Final Rules. 
The MHPAEA represents substantive change in coverage and reimbursement requirements. However, amid the evolving healthcare landscape in the U.S., the impact of this legislation may not be fully known until real-world tested, fully implemented and perhaps litigated.
Progress through technology
Progress is being made however! Behavioral health care in the US is beginning to more thoughtfully address matters of stigma, access and cost. Additionally, delivery of appropriate, timely, efficient and effective behavioral health care is being addressed through adaptive innovation and advances in the unique application of technologies.
For the last 15-20 years, online therapies have delivered basic levels of support with mixed results. More recently, highly creative strategies that engage the user and the therapist in an online therapeutic space have evolved. This blended approach provides care and support, combining human engagement with technology. These innovations can be used to extend clinical services, rather than attempt to replace them and offer clients with broader, easy-to-access options.
Such a breakthrough is well timed for the US healthcare market as it tackles the issues of cost and quality. In addition to providing low barrier access and quality outcomes on par with traditional therapeutic methods, these guided online health and wellness solutions are set to support and help stabilize the expanding behavioral health costs of health care in the United States.
1. United States Department of Labor, Employee Benefits Security Administration, http://www.dol.gov/ebsa/mentalhealthparity/
A view from the UK
Aislinn Enright, UK Director, SilverCloud Health
Aislinn worked within the NHS for 13 years as both a clinician and project manager, and more recently she has worked in private and non-profit organisations, within the mental health and primary care field. She has vast experience developing and implementing talking therapy services, primary care and long-term condition motivational services.
Mental health care in the UK
In health care, never have the concepts of effectiveness, efficiency and value for money been so important.
Apparently in response to the Quality, Innovation, and Prevention (QIPP) program’s aim to save £20bn by 2013/14, the UK government is now demonstrating commitment to telemedicine.
Telemedicine (or telepsychiatry as it is known in mental health) provides maximum benefit in terms of patient access, value for money and efficient use of resources. The 2011 Department of Health (DH) report; ‘Whole Systems Demonstrator Programme: Headline Findings’, suggested that 3 million people could benefit from telemedicine/telecare over five years.
Improving Access to Psychological Therapies
In the UK, the Department of Health developed an initiative called the Improving Access to Psychological Therapies (IAPT), now known as Talking Therapies, for adults aged 18-65 years with common mental illness such as depression and anxiety. IAPT offers patients fast access to a choice of psychological therapies in addition to ‘care as usual’. The service is provided in a step care approach, as recommended by the National Institute of Clinical Excellence (NICE) guidelines for depression and anxiety (DH 2004, amended 2007).
While the option for paid services is always available, anyone entering the IAPT service will receive free care through the National Health Service (NHS), depending on their need. However, many of these NHS Trust services are struggling to cope with capacity, often ending up with long waiting lists. Telehealth offers clinicians a solution that is both cost effective and resource-friendly and clients with an effective and easily accessible health and wellness solution.
A Clinical and Technological view
Derek Richards, Clinical Research Director
Derek Richards was responsible for pioneering the first online mental health community for students in conjunction with the Centre for Research in IT in Education (CRITE). Now, as Director of Clinical Research & Innovation at SilverCloud Health, Derek is very interested in the development, implementation and clinical research of technology delivered interventions for mental health problems. In particular interventions for high prevalence disorders such as depression and anxiety.
The future of technology evolves
In the last 15 years or so, the use of technology as a solution to meeting the needs of health and mental healthcare organisations has grown exponentially. It is a real privilege to be part of that history, and I continue to enjoy being witness to this blossoming field.
Cognitive Behavior Therapy protocols for the treatment of various mental health difficulties have predominated, especially in the delivery of interventions online. However, I recently came across some new research that uses psychodynamic psychotherapy for the treatment of depression and anxiety. This work originates from a highly reputable group in Sweden; Andersson, Carlbring, Johansson and their colleagues, from whom we are becoming used to seeing great things. This current work is based on a particular model of psychodynamic psychotherapy called ‘affect-focused’.
Affect-focused psychodynamic psychotherapy presents to clients a psychodynamic understanding of depression. The treatment seeks to help uncover unconscious patterns that contribute to emotional difficulties that may be interfering with different areas of one’s life, such as work and personal relationships. Once a client comes to understand these unhelpful patterns, they can learn to break them. The treatment includes provision of tools to prevent relapse.
The Swedish group has published three randomized trials of the treatment and has reported significant outcomes for participants (see reading list).
In my opinion this work, that began 15-20 years ago, was only a beginning. From the firmly grounded foundations of this valuable learning, inspiration comes from the significant technological advances that continue today… stimulating ideas for creative ventures of the future.
Watch this space!
The question of engagement
Technology has certainly advanced!
Treatments for various mental health problems are being delivered online and, for the most part, their clinical utility need not be questioned as the content is based on well-established behavioural and cognitive interventions. Also, if these interventions are supported, to allow something of the therapeutic alliance to feature in the treatment, outcomes improve.
Nothing surprising or new there … But what about the problem of dropout? Or, to turn it on its head; the question of engagement?
I think we can improve on the clinical utility of current technology to enable better client management, meet the needs of non-responders and ultimately improve outcomes.
We have the technological capability to include, as part of any platform, several ways of monitoring clients. This can be done simply, through the analysis of psychometrics collected routinely, or by flagging risk factors for any given client. For example, if client x has had a previous episode of depression. Monitoring can also involve tracking and comparing clients’ use of programme elements from week to week.
The automated tracking and easy reporting of simple online acts has enormous implications for understanding engagement and facilitating more accurate and timely support. The resulting feedback loop enables mapping of the clinical path most suitable for individual clients, including the possibility of removing the client from the programme and offering a more suitable solution if necessary.
Client monitoring has always been a central feature of the therapeutic endeavor. Not least for informing the appropriate clinical path for a client. It should not be lost when delivering interventions online and modern technology can, and should, promote this goal.
Johansson, R., Björklund, M., Hornborg, C., Karlsson, S., Hesser, H., Ljótsson, B., . . . Andersson, G. (2013). Affect-focused psychodynamic psychotherapy for depression and anxiety through the Internet: a randomized controlled trial. PeerJ, 1, e102. doi: 10.7717/peerj.102
Johansson, R., Ekbladh, S., Hebert, A., Lindström, M., Möller, S., Petitt, E., . . . Andersson, G. (2012). Psychodynamic Guided Self-Help for Adult Depression through the Internet: A Randomised Controlled Trial. PLoS ONE, 7(5), e38021. doi: 10.1371/journal.pone.0038021
Johansson, R., Nyblom, A., Carlbring, P., Cuijpers, P., & Andersson, G. (2013). Choosing between Internet-based psychodynamic versus cognitive behavioral therapy for depression: a pilot preference study. BMC Psychiatry, 13(1), 268.
This article first appeared in the Winter 2014 issue of TILT Magazine ~ Therapeutic Innovations in Light of Technology.
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