Two and a half years since the start of the Covid-19 pandemic, we are still dealing with the fallout – not least the effect on youth mental health. For many children and young people, the repeated lockdowns, social isolation, and climate of uncertainty, proved to be deeply distressing. Searches for apps for mental health problems are rising considerably.
“Young people are at the very point in their lives when socialising with their peers is a way to discover their independence and learn how to interact in the world as young adults,” says Dr Lloyd Humphreys, clinical psychologist and managing director of ORCHA (the Organisation for the Review of Care and Health Apps). “We now know that areas with a higher concentration of younger people (aged 16-24) tended to have higher rates of loneliness during the pandemic.”
Of course, these kinds of impacts were felt population-wide. Around 1.4 million UK residents are currently waiting for specialist NHS mental health treatment, and there are thought to be another eight million who would benefit from support.
However, young people were more susceptible than most. According to a 2021 review paper, rates of depression and anxiety increased, while many children and adolescents experienced Covid-related fear. This applied above all to older teenagers, girls, and those living with neurodiversities or chronic health conditions.
Another study found that pandemic-related distress was correlated with other hardships. Young people living in challenging circumstances (such as poor housing or financial instability), and other vulnerable or marginalised groups were most at risk.
Why digital health tools are needed
Against this backdrop, mental health services came under an unprecedented strain. More young people than ever required support, at a time when provisions weren’t available in person. Digital services, ranging from virtual therapy sessions to mental health apps, emerged to fill the gap.
“There isn’t a one-size-fits-all approach to mental healthcare,” says Tim Barker, CEO of digital mental health platform Kooth. “There is an increasing recognition of the value that digital services bring, from a logistical as well as a choice perspective.”
An anonymous platform for young people aged 10-25, Kooth is the UK’s largest and most established digital mental healthcare provider. It provides a safe, confidential space for users to seek help, be that in the form of professional counseling (via text-based chat), therapeutic self-help activities, or peer-to-peer support. There are no waiting lists, it’s free for the end-user, and referrals are not required.
Although the platform has been going strong since 2001, the pandemic truly underscored the need for provisions of this kind. According to the Kooth Pulse 2021 report, Kooth saw a 42% uptick in young users, as well as a 25% increase in students pursuing counseling. There was a particular spike in the proportion of users presenting with suicidal ideation, eating difficulties or self-harm.
“Children and young people experienced an increase in presenting issues including sadness, concerns about family relationships, sleep difficulties and loss of aspiration and motivation,” says Barker. “Throughout the pandemic, Kooth demonstrated that providing consistent and readily available support was critical to the most vulnerable children and young people.”
The advantage of digital health services, he adds, is that they can provide an immediate alternative for those who don’t (or can’t) engage with more structured services. That might be because they don’t meet NHS eligibility criteria, because they’re stuck on a waiting list, because they’ve recently been discharged, or because of deeper factors like shame and stigma.
“They ensure that people have easy access to a choice of care that is right for them, on their own terms, and available when they need it,” says Barker. “Leaving concerns unchecked puts young people at risk of developing more serious mental health problems throughout adolescence and early adulthood.”
The platform is currently accessible to 7.1 million children and young people across the UK. Although it operates autonomously, it is NICE-compliant and aligned with the NHS Thrive Framework, and many users get there through a GP recommendation. In 2021, Kooth had over 218,000 unique users and just over 1.3 million logins.
The pros and cons
Clearly, services of this nature fulfill a vital role – especially when it comes to early intervention and prevention. At a time when waiting lists are growing and NHS therapists are in short supply, technology has been shown to alleviate some of the burden on the system.
“Technology-enabled care can augment, complement and enhance what we do as professionals in this space,” says Humphreys. “For example, it can support those waiting for face-to-face therapy and reinforce what they’ve learned after the sessions have ended. Self-help apps can also be used to free up therapists to deal with clients who need their highly trained skills.”
However, it would be remiss to suggest that traditional pathways could ever be fully supplanted by digital ones. For the time being, relatively few digital health technologies show robust evidence of effectiveness.
“Face-to-face services are, in the main, tried, tested and trusted,” says Barker. “It is important that the same amount of rigour and governance is applied to digital initiatives, and ‘digital’ is not seen as a quick and easy fix. Setting up systems that are effective, easy to navigate and above all safe is challenging and takes time.”
Humphreys adds that, while there are exceptional digital health tools available, there are just as many that don’t reach expected levels of professional assurance. As the UK’s independent health app review service, ORCHA has reviewed over 17,000 digital health products to date. It has found that some apps offer poor levels of data privacy, while others lack sufficient clinical backing or are hard to use.
“ORCHA recently assessed 1,300 mental health apps and rejected 52% as being unsuitable for its digital health libraries,” he says. “It’s essential these apps are tested against consistent, demanding standards – and we encourage users to get recommendations from healthcare professionals rather than taking potluck on a commercially-available app store.”
Apps that get it right
Since youth mental health apps support a diverse range of conditions, it’s imperative to match the right app to the right person at the right time. For instance, young people on the autism spectrum may benefit from apps like Brain in Hand, which combines planning tools with human support. Apps are also available to support young people through bereavement, eating disorder management, suicidal thoughts and self-harm.
Then there are more general-purpose options such as Wysa, the ‘therapy chatbot’ for everyday mental health. One of ORCHA’s top-scoring apps, the chatbot uses cognitive behavioral techniques to ensure that patients feel heard.
“The app’s conversational coaching tools allow users to express their feelings confidently and anonymously,” says Humphreys. “Another top scorer, SilverCloud, which is available via NHS referral, has a range of self-guided or supported programmes, whereby a user can gain feedback from a psychological wellbeing practitioner or therapist.”
He would also recommend Tellmi, a confidential app that allows users to share their struggles and receive peer support. While the app has a social media-type layout, all sessions are carefully moderated to create a truly safe space online.
According to independent research commissioned by ORCHA, young people are finding these apps via a mix of self-referral and professional recommendation.
“In the 18-24 age group, 17% of users were finding apps themselves. GPs had made the recommendation in 7% of cases and nurses in 8%,” says Humphreys. “We expect to see the number of referrals coming from healthcare professionals increase as access to digital health training improves and doctors and nurses become more familiar with the technologies now available.” ORCHA saw a 6,500% increase in healthcare professionals recommending technologies to their patients throughout the pandemic.
Unfortunately, the pressures on NHS mental health services are unlikely to ease any time soon. The UK has made some progress in this regard – its Five Year Forward View has expanded access to services, despite facing some setbacks during the pandemic. However, the system has serious capacity limitations, leaving many young people unable to access support in a timely manner. And as the cost of living crisis starts to bite, the impact on mental health remains to be seen.
“Despite a £2.3 billion increase in NHS mental health support since 2019, demand has continued to massively outstrip support,” says Barker. “The status quo is unsustainable. The only way to tackle the growing mental health crisis is to focus ‘upstream’ on providing fast and early help to reduce the number of people needing acute care.” Digital tools, then, could end up being a big part of the solution. Ideally, these tools should be properly vetted and integrated with more traditional services, giving young people more options for accessing care.