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).