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By Adrian Aguilera
Dr. Aguilera is a professor in the School of Social Welfare at the University of California, Berkeley, and a professor in the department of psychiatry and behavioral sciences at the University of California, San Francisco/Zuckerberg San Francisco General Hospital.
The way Americans receive mental health care has never changed as quickly as it has since the spring of 2020. When the Covid pandemic forced so many of us into our homes and onto Zoom, psychiatrists, psychotherapists and social workers followed. What started as a short-term fix is now becoming permanent. Today, nearly 40 percent of mental health and substance use outpatient treatment visits at hospitals and clinics are offered remotely, compared with just 1 percent in 2019.
This estimate is probably even higher for private psychotherapy practice visits. According to a survey conducted by the American Psychological Association last year, 96 percent of clinical psychologists reported offering at least some services remotely. For millions of people, getting treatment for anxiety, depression or post-traumatic stress disorder can now be done from the comfort and privacy of home. No more bus rides across town or awkward waiting-room encounters.
It’s not just telehealth. While many existed before the pandemic, existing start-ups grew rapidly and dozens of new ones have emerged since, offering to make your smartphone a partner in your mental health care. There are A.I.-informed chatbot therapists; direct-to-consumer therapy via chat and text apps; and smartphone-based cognitive behavioral therapy programs. Companies providing these types of services raised over $5 billion globally in 2021 alone — an increase of 139 percent from the previous year.
So is this good news for America’s collective mental health? Does this proliferation of digital technology really mean that therapy is more accessible than ever before? Well, it depends. America’s mental health industry faces a stark choice: take advantage of this moment to get help to the millions who need it — including, especially, poor Americans and immigrants — or allow the inequalities that already exist to deepen.
Ever since Sigmund Freud drew his first patients primarily from among Vienna’s upper class, psychotherapy has had an inequality problem. These days, advances in psychotherapy and clinical trials typically occur in universities and academic medical centers. Therapy has been most accessible to those who can afford it — which also means it is often least accessible to those who most need it: Over half of people with a diagnosable mental health condition in America go untreated. These numbers are higher for Black, Latino and Asian Americans. When they do receive care, it is often of lower quality compared with care received by white and higher-income people.
There is a real danger that the innovations in teletherapy and other new technology will exacerbate these inequalities, rather than reduce them. If technologies are not designed with underserved communities in mind — and with their participation — we may find that low-income populations and ethnic minorities have an even harder time getting the treatment that they need.
At a basic level, people have varied access to internet, broadband and mobile phone data plans, which can hinder access. At the public clinics where I conduct research and practice, most Spanish-speaking patients are receiving care via telephone calls because of limited access to internet or data plans, as well as a lack of digital literacy. We’ve sometimes addressed this by training patients to use technology tools and even subsidized, via research grants, mobile phone data plans. But that’s not going to work in every case.
As technologies advance, the potential benefits increase but so do potentials for further inequity. For example, A.I. algorithms can improve efficiency and decision-making when it comes to getting people care, but the data that undergirds them are also subject to human biases. Imagine, for example, an A.I. algorithm designed to suggest enjoyable activities to break out of a depressive state. Seems like a good idea, right? But what happens if all of its suggestions cost money (“go to a movie”) or require certain amenities (“take a bath”)? Unfortunately, this is already happening. The latest digital mental health interventions are not adequately including high-burden and high-need populations in their development and testing.
It doesn’t have to be this way. The revolution in mental health care that is underway could be an opportunity to fix this country’s longstanding problems with access to therapy and other forms of mental health care. In other areas, such as the targeting of chronic disease, new digital developments are increasingly taking equity into account. Unfortunately, the same isn’t happening as urgently with mental health.
But there are signs of progress.
I have been part of one such experiment: My research lab recently developed MoodText. It is a low-tech way to reach people who may not have access to home computers or endless phone data and help them to make the most of their group cognitive behavioral therapy sessions for depression. After sessions, MoodText will send automated messages to track patients’ moods and remind them of lessons that they learned in their sessions. We have found that the addition of the texting program doubled the number of sessions attended from three (nontexters) to six (texters) and greatly increased the number of weeks that patients stayed in treatment, from three to 13 out of a 16-week treatment. This type of intervention could be crucial since the dropout rate for therapy ranges from 20 percent to 60 percent and is especially high among low-income patients with competing life demands.
There have also been successes with app-based programs that focus on less stigmatizing approaches to improving mental health, such as those that encourage exercise. Physical activity can benefit a variety of health conditions, including mental health and depression symptoms via what we call “behavioral activation” or more plainly stated, improving mood by reducing isolation and increasing the chances of social interaction. That’s why a team of researchers that I have been working with developed and is testing Diamante, a machine-learning algorithm to personalize text messages to people, which they receive to encourage physical activity like walking. Importantly, this program is targeting English and Spanish speakers in a public sector clinic — the kind of place that is not typically the source of data for most machine learning and artificial intelligence algorithms.
Or look at [email protected], an initiative in California that — thanks to funds provided by the Mental Health Services Act — pays for mental-health services apps like Headspace, Mindstrong and iPrevail for people in underserved communities who might otherwise not be able to afford as much as $70 a year, which is how much Headspace costs. Additionally, the [email protected] initiative integrates feedback from patients and consumers of public mental health services to ensure that the apps are relevant to their lives.
To be sure, technology alone is not going to be a substitute for the more robust and equitable mental health care system that the United States needs. Our country needs to train more providers, particularly from communities with the least access to care. But that will take time. And even if we train providers, there will still not be enough to meet the needs of everyone, especially if the focus remains on traditional one-on-one psychotherapy. Digital technology can help increase access to mental health services. But only if we do it right.
Adrian Aguilera (@draguilera) is a professor in the School of Social Welfare at the University of California, Berkeley, where he directs the Digital Health Equity and Access Lab. He is also a professor in the department of psychiatry and behavioral sciences at the University of California, San Francisco/Zuckerberg San Francisco General Hospital, where he directs the Latino Mental Health Research Program and coleads SOLVE Health Tech.
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