A call for better mental health: How modern technology may improve access to ADHD services

Masai mobile

Kenya, Kajiado district. Isaac Mkalia (20), a Maasai and a teacher by profession, checks his mobile phone while guarding a flock of cattle. © Sven Torfinn

According to a UN report more people now have mobile phones than toilets: Of the world’s 7.5 billion people, only around 3 billion have safely managed sanitation, but there are 3.7 billion Internet users and over 5 billion unique mobile phone users in the world in 2017. One day this week, whilst bemoaning the apparent global sanitation crisis, I started to ponder what promises the widespread use of mobile and Internet technology nonetheless might hold, particularly with regards to mental health and more specifically ADHD.

Access to mental health services and evidence-based treatment can be poor in rural areas, with lower availability of services and greater distances to specialist care. In addition, psychosocial factors (e.g. stigma), financial constraints and a lack of human resources (i.e. clinicians and practitioners) may create barriers to treatment, and long waiting times, in both rural and urban areas. E-mental health could be key to tackling these problems.

E–mental health can be defined as the “use of digital technologies and new media for the delivery of screening, health promotion, prevention, early intervention, treatment, or relapse prevention, as well as for improvement of health care delivery (e.g. electronic patient files), professional education (E-learning), and online research in the field of mental health” (Riper et al., 2010). This means that e-mental health has the capacity to aid with anything from prevention and early diagnosis to behaviour management and high-quality treatment.

Online therapies have emerged as a valuable and effective approach to delivering evidenced-based care via the Internet. These types of therapies can comprise electronic modules patients can work through in their own time, (recorded or real-time) videoconferencing to conduct mental health visits within the patient’s home, or a combination of the two. One example of an evidenced-based self-administered programme is the Triple P (Positive Parenting Program) Online (Sanders, Kirby, Tellegen & Day, 2014), which provides support for parents of children with disruptive behaviour in eight self-paced modules.

Research into videoconferencing for ADHD is still in its infancy. A preliminary study recently found that, despite minor technological glitches, ADHD symptoms decreased in 20 children with ADHD at a similar rate to face-to-face sessions (Sibley, Comer & Gonzalez, 2017). Given the scarcity of mental health providers, the distance to services and problems with transportation access, especially in remote areas, as well as scheduling conflicts and long waiting times, online therapies may prove to be a useful tool to improve cost-effectiveness and access to evidenced-based treatment in underserved areas. Online therapies may also be more attractive to patients who are reluctant to seek face-to-face care due to stigma or other concerns (Christensen & Hickie, 2010).

An even more comprehensive way of employing the Internet for medical practice is the use of web portals, which can address several key aspects of healthcare, including screening, symptom tracking, patient registries and online communication between patients and their clinicians. One example of an ADHD web portal is myADHDportal.com, developed by Cincinnati Children’s Hospital Medical Center (Epstein, Langberg, Lichtenstein, Kolb, Altaye & Simon, 2011). The myADHDportal.com web portal consists of online training for community-based practitioners, ADHD assessment as well as treatment for children with ADHD. Parents and teachers can complete ADHD rating scales about patients online and rating scales are automatically scored and summarized to aid the clinician in diagnosis and treatment monitoring. The ADHD web portal also allows parents, teachers, and clinicians to communicate with each other and with other mental health professionals during assessment and treatment via an online emailing system. Although ADHD web portals can have high clinical utility, their implementation may be burdensome for healthcare professionals because these portals usually exist outside of official electronic health records and information has to be transferred between the two.

Smartphones provide considerable healthcare-related opportunities. Since their inception, the development of smartphone applications, so-called apps, has skyrocketed. In 2016, an estimated 150 billion apps were downloaded worldwide. As smartphones and apps become ever more integral to the lives of many people around the world, these technologies offer great possibilities for improving the provision of mental health services and encouraging healthy behaviours. Apps can, for instance, help with behavioural change, goal setting and education by providing both training (repeated exposure to a task to improve ability) and support (facilitation of a skill while the technology is in use). Available apps related to ADHD may improve organizational skills by employing push notifications, reminders and timers. They can also help to reduce stress and track behaviour, as well as making use of positive reinforcement through the ‘gamification’ (using badges or phrases to reward participants for meeting their goals) of arduous tasks. The CoCA-PROUD project is currently piloting an app, which monitors physical activity and light exposure, analyses the behaviour in real-time and provides encouraging feedback to the user to improve motivation in order to provide new insights into the potential of smartphones to improve ADHD symptomatology and comorbidities such as obesity and depression. Moreover, this list includes some useful examples of apps that may be beneficial to individuals with ADHD. However, some users may rightly raise concerns about digital privacy and security. Few apps to-date are supported by an evidence base, and there is currently no governing body responsible for quality control. The American Psychiatric Association has therefore developed a hierarchical model to assess health apps to guide clinicians and service users in their decision-making.

While overall more evidence for the efficacy of E-mental health services is still required, the widespread use of smartphone and Internet technology holds immense promise for the future with the lauded benefits including cost-effectiveness, geographic and temporal flexibility, the reduction in therapist time, stigma and waiting time for treatment, as well as the increase in help-seeking behaviours and treatment satisfaction (Musiat & Tarrier, 2014).

Sweet dreams – The interrelatedness of ADHD, sleep, mood and obesity


Image by NaBHaN

The risk for obesity and depression co-occurring with attention-deficit/hyperactivity disorder (ADHD) is increased in adolescents and adults with ADHD. Moreover, ADHD in adolescence predicts obesity and depression in later life. Sleep disorders such as a not being able to fall asleep, shorter sleep and a shifted day-night cycle (circadian rhythm) are also common among individuals with ADHD. In turn, sleep problems have been linked to obesity.

In a series of papers, a research group from the Netherlands tried to make sense of these findings, suggesting a connection between ADHD symptoms, depression, sleep disturbances and weight. The first study1 investigated the associations between ADHD, sleep problems and depression by obtaining self-reported sleep/wake characteristics, lifestyle factors and information on physical and mental health from 202 adults with ADHD and 189 control participants. The second study2 extended the first by adding a group of 114 adults with obesity to examine whether sleep problems and unstable eating patterns (circadian rhythm disruptions) may be the mechanism linking ADHD to obesity.

Individuals with ADHD reported problems sleeping, including shorter sleep and difficulties falling asleep. Shorter and later sleep was further associated with hyperactivity symptoms and depression, as well as with higher Body Mass Index (BMI). The authors, therefore, propose common origin for the sleeping problems and ADHD symptoms, which may lead to depressive symptoms. Moreover, both sleep duration and unstable eating patterns mediated the association between ADHD symptoms and BMI. This means that higher ADHD symptoms increased the risk for worse sleep and unstable eating patterns, leading to an increased risk for a higher BMI. These results support the idea that circadian rhythm disruption is a mechanism linking ADHD symptoms to obesity.

While these are interesting and important findings, the studies also suffered a few methodological shortcomings. Firstly, cross-sectional studies like these do not allow strong conclusions about cause and effect. Secondly, the data are based on self-report measures, which have not been extensively validated. Thirdly, due to the high proportion of young, better-educated females and the high levels of depressive symptoms in the control group, the sample may not be representative of the general population. Lastly, confounding diagnoses such as mood, anxiety and substance use disorders, were not assessed comprehensively, despite findings from the initial analysis suggesting a relationship between ADHD, sleep problems and depression.

These thought-provoking initial results, therefore, require replication using a longitudinal design, as well as more validated and objective measures, in representative samples. The European collaborative study CoCA (Comorbid conditions of ADHD) aims to investigate major comorbid conditions in ADHD, including depression and obesity, using diagnostic interviews and physical examinations. In addition, CoCA will examine sleep and physical activity in adolescents and adults with ADHD using objective light sensors and accelerometers. To establish whether therapies combining ADHD treatment and treatment of the circadian rhythm disruptions are effective in treating and preventing obesity and depression in patients with ADHD, CoCA will test two potential interventions, namely bright light therapy and exercise, in a 10-week trial. While bright light therapy is proposed to have an effect on the circadian rhythm and is an established therapy for major depression in adolescents and adults, exercise prevents and reduces obesity in adolescents and adults, and may also improves depressive symptoms.

  1. Bijlenga, D. et al. Associations Between Sleep Characteristics, Seasonal Depressive Symptoms, Lifestyle, and ADHD Symptoms in Adults. J. Atten. Disord. 17, 261–275 (2013).
  2. Vogel, S. W. N. et al. Circadian rhythm disruption as a link between Attention-Deficit/Hyperactivity Disorder and obesity? J. Psychosom. Res. 79, 443–450 (2015).