and advisor to The Healthcare Improvement Studies Institute

Dr Amlan Basu FRCPsych

The worlds of digital and mental health do not make for easy bedfellows. The generation born between 1995 and 2012 (iGen or Gen Z) experience far higher rates of anxiety and depression than the generation preceding it.For girls in the US and Canada, hospital admission rates for self-harm have increased significantly, as have suicide rates. Convincing analysis suggests that this rise correlates directly with the frequent use of smartphones and other electronic devices. In the UK, around 1 in 5 children as young as 10 to 15 have experienced online bullying. Yet the excitement about the potential for technology to help, not hinder, our mental health is at fever pitch. Investment in mental health technology reached £578m in 2019 and is projected to reach £1,429m in 2020. Can technology really be the cure rather than the pathogen? There are plenty of reasons to be hopeful, but cautious.

Investors may be forgiven for being the proverbial children in a sweet shop; the number of possibilities, each with their own raft of claims, seems endless and overwhelming. Wearable devices (e.g., smartwatches and activity trackers) that monitor the physiology of anxiety, pre-empting the next panic attack, apps that allow someone to carry their entire personal health record (PHR) with them at all times or participate in research by sharing their real-time personal data, telehealth (e.g. including evidence that even simple text-based CBT may be more effective than face to face), virtual reality (e.g. simulating various environments for graded exposure therapy), and artificial intelligence (e.g. to aid diagnosis) all occupy shelves at eye-level. Look lower or higher and even more opportunities present themselves: home kits for electroencephalography (EEG), galvanic skin responses, electrooculography (EOG), and electromyography (EMG), an entire suite of biofeedback technology. Even the way in which we interact with our phones (how fast we scroll, how many errors we make as we type, what images we are transfixed by) may provide valuable insights into our mental states, providing the opportunity to warn us if we are about to take a turn for the worse.

The more we desire from technology, the greater the need for high specification and reliable infrastructure, not just the capability of the hardware to run software tools, but crucially the connectivity between digital devices and hubs. 5G offers high bandwidth, high speed, high capacity and low latency networks that has the potential to revolutionise what is possible: immersive augmented or virtual reality can be delivered faster than the human visual reaction time, allowing for remote surgery and cloud robotics, but as yet the outcomes for mental health still appear obscure. Even though in most areas of the world 5G continues to be more of a promise than a reality, talk of 6G has already begun.

Financial investors need to consider more than the usual factors such as the rate of return, the diversification of their portfolios, the dynamic market opportunity (undoubtedly large), commercial traction, the team’s execution capability and the exit strategy. The current market is ‘a thousand flowers blooming’ and some consolidation of the sector is almost certain, so whether you are investing your time or your money here are some golden rules:

• Just because we can does not mean that we should. As well as significant ethical dilemmas (e.g. around genuinely informed consent), user outcomes have to come first. As engaging as an experience might be, it will be short-lived if it does not provide any tangible benefits.

• Engage experts – both clinical and by experience – before making assumptions. A common assumption is that the more a clinician can be freed from routine administrative tasks, the more time they will spend with patients and outcomes will improve. Outcomes may indeed improve, but perhaps because the clinician chose to use this time to engage in continuing professional development or peer support to prevent themselves from burning out.

• Focus on peer-reviewed published data, be wary of company ‘internal’ data.

• Consider the regulatory environment, e.g., the need to position a device as medical rather than side-stepping these requirements by marketing it as a ‘health or wellness device’.

• Think broadly when assessing the wider impact. For example, in relation to devices, too many alerts about impending crises risk being totally ignored after a few days, or alternatively risk turning us into a hypochondriacal frenzy, ready to medicalise the slightest psychological discomfort. Bad feelings have good evolutionary reasons for their existence and do not all need to be ‘treated’.

What was once science fiction is now science fact, and it would be churlish not to be hugely excited. Some of the risks and mitigations have been mentioned already, but perhaps the biggest relates to digital inclusion, or rather exclusion. For many, these developments do not trigger awe or wonder, but dread. Whether they be patients or healthcare staff, the pace of technological advancement is deeply anxiety provoking for some. Even in countries that do their best to offer a single tier standardised healthcare provision, blind to financial means, technological advances have the potential to create deep divisions between those that have and those that do not. We must, above all else, ensure that the enthusiasm for technological advancement does not come at the cost of increasing wider health inequalities.