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The COVID-19 pandemic: The ‘black swan’ for mental health care and a turning point for e-health

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The COVID-19 pandemic: The ‘black swan’ for mental health
care and a turning point for e-health
Tim R. Wind, Marleen Rijkeboer, Gerhard Andersson, Heleen
Riper
PII: S2214-7829(20)30046-4
DOI: https://doi.org/10.1016/j.invent.2020.100317
Reference: INVENT 100317
To appear in: Internet Interventions
Received date: 17 March 2020
Revised date: 18 March 2020
Accepted date: 18 March 2020
Please cite this article as: T.R. Wind, M. Rijkeboer, G. Andersson, et al., The COVID-19
pandemic: The ‘black swan’ for mental health care and a turning point for e-health,
Internet Interventions (2020), https://doi.org/10.1016/j.invent.2020.100317
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The COVID-19 pandemic: The black swan for mental health care and a turning point for e-
health
Tim R. Wind, PhD1, Marleen Rijkeboer, PhD2 Gerhard Andersson, PhD3, & Heleen Riper,
PhD 4 5
1Foundation Centrum '45, Oegstgeest, The Netherlands | partner in Arq Psychotrauma Expert
Group, Nienoord 5, 1112 XE Diemen, The Netherlands
2Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience,
Maastricht University, The Netherlands
3Department of Behavioural Science and Learning, Linköping University, Linköping, Sweden
and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
4Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit,
Amsterdam, The Netherlands
5 Department of Research and Innovation, GGZ in Geest/Amsterdam University Medical
Center, VU University Medical Center, Amsterdam, Netherlands
In February 2020, Duan and Zhu (2020) stressed the need for a solid Chinese evidence-based
mental health care system in times of public health emergencies such as the outbreak of the
Coronavirus disease-2019 (COVID-19). That would enable treatment of people who suffer
from mental health problems in relation to the epidemic. The WHO has meanwhile labelled
the Coronavirus a pandemic, and it is now hitting Europe, the USA, and Australia hard as
well. In an attempt to reduce the risk of infections, many mental health care providers in
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afflicted countries are currently closing their doors for patients who need ambulatory face-to-
face therapy. They are simultaneously trying to replace some of these contacts with digital
therapies. Most probably, European mental health care institutions have yet to experience the
full impact of the coronavirus crisis. At the same time, the demand for mental health care
among infected patients and their relatives is expected to rise (Blumenstyk, 2020). Levels of
anxiety will increase, both through direct causes including fears of contamination, stress,
grief, and depression triggered by exposure to the virus, and through influences from the
consequences of the social and economic mayhem that is occurring on individual and societal
levels. We expect that this "black swan" moment (Blumenstyk, 2020) - an unforeseen event
that changes everything - will lead to a partly, though robust, shift in mental health care
provision towards online prevention, treatment, and care in the near future. We also need to
consider the role of psychological processes and fear that may cause further harm on top of
the pandemic (Asmundson, & Taylor, 2020).
The obvious solution to continue mental health care within a pandemic is to provide mental
health care at a „warm‟ distance by video-conferencing psychotherapy and internet
interventions. A systematic review showed that videoconferencing psychotherapy show
promising results for anxiety and mood disorders (Berryhill et al., 2019), and the evidence-
base for therapist-guided internet interventions is even stronger (Andersson, 2016; ). Yet,
despite two decades of evidence-based e-mental health services, numerous barriers have
stalled the overall implementation in routine care thus far (Vis et al., 2018; Tuerk et al.,
2019). One of the most important barriers highlighted, however, has been that e-mental health
has not been integrated as a normal part of routine care practice due to the lack of acceptance
by health professionals themselves (Topocoo et al., 2017). Myths on telehealth such as “the
therapeutic alliance can only be established face-to-face” have dominated the field, in spite of
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research showing the opposite (Berger, 2017). In that sense, learning curves in the adoption of
new e-mental health technologies by both patients and psychologists have progressed far
more slowly than initially expected, thus tallying with the estimate that it takes on average16
years for a health care innovation to be implemented (Rogers et al., 2017). There are however
exceptions in the world but progress is still slow.
In the Netherlands and elsewhere, we are now witnessing a phenomenon whereby the
outbreak of COVID-19 is hastening managers, ICT-staff, and clinicians to overcome all such
barriers overnight, from a pragmatic standpoint seldom seen before. The virus seems a
greater catalyst for the implementation of online therapy and e-health tools in routine practice
than two decades of many brilliant, but failed, attempts in this domain (Mohr et al., 2018).
After all, since predictions about COVID-19 are largely unclear as of yet, it is now time to
create a longer-term solution to the problem of heterogeneous patient populations, such as
those still active in the community and those that are house-bound or isolated in hospitals.
Videoconferencing and internet interventions could therefore be very helpful in mental health
care, as well as in physical care and can be easily upscaled to serve isolated regions and reach
across borders.
Thus, the “black swan virus” has already enabled wide-scale acceptance of videoconferencing
by health professionals and patients alike creating a win-win situation for both. We should
stress that e-mental health applications hold value far beyond the provision of
videoconferencing psychotherapy in the current situation of crisis. Countries hit by the
Corona virus may also consider adopting a wider public e-mental health approach, which
would focus additionally on prevention and on reaching people at risk for mental health
disorders. In this respect, not only guided but also fully self-guided interventions, such as self-
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help apps or online therapeutic modules, could also be applied in settings and countries with
scarce mental health resources (Christiani & Setiawan, 2018). We should also consider the
need for treatment development (for the psychological problems caused by corona virus
isolation), which is by far more rapid in the field of internet interventions than in traditional
psychotherapy (Andersson et al., 2019).
It is likely that the response to this emergency will be more than a temporary increase in
online work (Blumenstyk, 2020). Once mental health care institutions have developed the
capabilities of serving their patients via videoconferencing and other digital technologies,
there is little reason for them to give these up, in view of the many advantages (Blumenstyk,
2020; Tuerk et al., 2019).This black swan should be a call for action by encouraging providers
to move more rapidly towards blended care models (van der Vaart et al., 2014; Kooistra et al
2019). Agility, flexibility, and resilience are essential skills for 21-st-century institutions,
particularly when unforeseen disruptive viruses and devastating events driven by climate
change are likely to be increasingly common (Blumenstyk, 2020). We urge practitioners to
promptly start adopting e-mental health care applications, both as methods to continue their
care to current patients in need and as interventions to cope with the imminent upsurge in
mental health symptoms due to the coronavirus.
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Digital mental health (DMH) interventions have promised to revolutionize mental health care by increasing its accessibility, availability, attractiveness, and cost-effectiveness. The first generation of web-based DMH interventions have consistently been found to be clinically effective for common mental disorders, such as depression and anxiety, in more than 100 randomized clinical trials (RCTs) and meta-analyses, particularly when accompanied by low-intensity coaching.¹ Inspired by this research, numerous health care systems have attempted to implement DMH interventions to address the large burden of mental health. However, these real-world implementation efforts have failed, often because they are not used by patients or therapists. This large research to practice gap suggests failures at many points, including DMH intervention design, research methods, and implementation approaches. The promised revolution in mental health will require a paradigm shift that addresses all 3 components to overcome the design, research, and routine care chasms.
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This review summarizes six decades of clinical outcome research relevant to evidence-based practices for depression and anxiety delivered via clinical videoconferencing. The authors conducted a literature search of previous systematic reviews and an updated search of publications specific to anxiety and depression. Overall, strong evidence supports the safety and clinical effectiveness of administering evidence-based psychotherapy for anxiety and depression via clinical videoconferencing among heterogeneous populations and age ranges, and in multiple care settings, with similar outcomes to in-person care. Despite the overall clinical effectiveness of the modality, the authors discuss common logistical and institutional barriers to long-term effective implementation. Future systems-level research is required to investigate replicable and sustainable models for implementing and expanding access to evidence-based psychotherapies via clinical videoconferencing.
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Background: Cognitive behavioral therapy (CBT) is an effective treatment, but access is often restricted due to costs and limited availability of trained therapists. Blending online and face-to-face CBT for depression might improve cost-effectiveness and treatment availability. Objective: This pilot study aimed to examine the costs and effectiveness of blended CBT compared with standard CBT for depressed patients in specialized mental health care to guide further research and development of blended CBT. Methods: Patients were randomly allocated to blended CBT (n=53) or standard CBT (n=49). Blended CBT consisted of 10 weekly face-to-face sessions and 9 Web-based sessions. Standard CBT consisted of 15 to 20 weekly face-to-face sessions. At baseline and 10, 20, and 30 weeks after start of treatment, self-assessed depression severity, quality-adjusted life-years (QALYs), and costs were measured. Clinicians, blinded to treatment allocation, assessed psychopathology at all time points. Data were analyzed using linear mixed models. Uncertainty intervals around cost and effect estimates were estimated with 5000 Monte Carlo simulations. Results: Blended CBT treatment duration was mean 19.0 (SD 12.6) weeks versus mean 33.2 (SD 23.0) weeks in standard CBT (P<.001). No significant differences were found between groups for depressive episodes (risk difference [RD] 0.06, 95% CI -0.05 to 0.19), response to treatment (RD 0.03, 95% CI -0.10 to 0.15), and QALYs (mean difference 0.01, 95% CI -0.03 to 0.04). Mean societal costs for blended CBT were €1183 higher than standard CBT. This difference was not significant (95% CI -399 to 2765). Blended CBT had a probability of being cost-effective compared with standard CBT of 0.02 per extra QALY and 0.37 for an additional treatment response, at a ceiling ratio of €25,000. For health care providers, mean costs for blended CBT were €176 lower than standard CBT. This difference was not significant (95% CI -659 to 343). At €0 per additional unit of effect, the probability of blended CBT being cost-effective compared with standard CBT was 0.75. The probability increased to 0.88 at a ceiling ratio of €5000 for an added treatment response, and to 0.85 at €10,000 per QALY gained. For avoiding new depressive episodes, blended CBT was deemed not cost-effective compared with standard CBT because the increase in costs was associated with negative effects. Conclusions: This pilot study shows that blended CBT might be a promising way to engage depressed patients in specialized mental health care. Compared with standard CBT, blended CBT was not considered cost-effective from a societal perspective but had an acceptable probability of being cost-effective from the health care provider perspective. Results should be carefully interpreted due to the small sample size. Further research in larger replication studies focused on optimizing the clinical effects of blended CBT and its budget impact is warranted. Trial registration: Netherlands Trial Register NTR4650; https://www.trialregister.nl/trial/4408. International registered report identifier (irrid): RR2-10.1186/s12888-014-0290-z.
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Internet interventions, and in particular Internet‐delivered cognitive behaviour therapy (ICBT), have existed for at least 20 years. Here we review the treatment approach and the evidence base, arguing that ICBT can be viewed as a vehicle for innovation. ICBT has been developed and tested for several psychiatric and somatic conditions, and direct comparative studies suggest that therapist‐guided ICBT is more effective than a waiting list for anxiety disorders and depression, and tends to be as effective as face‐to‐face CBT. Studies on the possible harmful effects of ICBT are also reviewed: a significant minority of people do experience negative effects, although rates of deterioration appear similar to those reported for face‐to‐face treatments and lower than for control conditions. We further review studies on change mechanisms and conclude that few, if any, consistent moderators and mediators of change have been identified. A recent trend to focus on knowledge acquisition is considered, and a discussion on the possibilities and hurdles of implementing ICBT is presented. The latter includes findings suggesting that attitudes toward ICBT may not be as positive as when using modern information technology as an adjunct to face‐to‐face therapy (i.e., blended treatment). Finally, we discuss future directions, including the role played by technology and machine learning, blended treatment, adaptation of treatment for minorities and non‐Western settings, other therapeutic approaches than ICBT (including Internet‐delivered psychodynamic and interpersonal psychotherapy as well as acceptance and commitment therapy), emerging regulations, and the importance of reporting failed trials.