At our HTN Now event focusing on digital mental health, we welcomed Dr Joseph Firth, senior research fellow at the University of Manchester and honorary fellow at Greater Manchester Mental Health NHS Foundation Trust and Western Sydney University. Joe is currently undertaking a UKRI-funded programme of research on digital lifestyle interventions in mental healthcare, and joined us to share some of the key findings from his research, and provide some general discussion on how his team are involving clinicians, patients and public feedback in their design and delivery of digital health interventions.
Joe began by providing some background to his research, highlighting the ‘healthy body, healthy mind’ line of thinking and asking: “What is the actual evidence for using lifestyle approaches in psychiatry and in the treatment of psychiatric conditions? This was a question put to my research team by World Psychiatry, which is the highest ranking journal in psychology and psychiatry. They asked us to bring together all the medical evidence around the idea of using things like exercise, diet, smoking cessation and sleep in the prevention and treatment of mental disorders.” The full review is available online.
Joe noted that the review provided his team with insight into where the evidence lies. “Physical activity, for example, is really widely-researched to show beneficial effects in both the prevention of mental health conditions arising and also at the time effective when used as treatment, with lots of studies showing that conditions can benefit clinically from receiving exercise interventions,” he explained. “That’s where much of the evidence lies at the minute and it’s been a big field of research across my entire career. On the other side, there isn’t as much evidence for how diet can play a role in mental health care – that’s not to say that it doesn’t have potential as a lifestyle factor, just that there isn’t all that much evidence in that area yet.”
Where is the implementation?
“The way our services are set up tend to divide the body and the mind,” Joe commented. “They’re often not treated together, and despite the research, lifestyle interventions are not a mainstream part of many mental health care services. People with mental illness have far worse physical health outcomes in general, and this inequality is something that is coming to light a lot more these days. For example, the New York Times ran an article highlighting statistics that indicate how Americans with serious mental illnesses die 15-30 years earlier than those without, due to increased excess mortality from physical diseases.”
In ‘The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness’, Joe and his team highlighted key issues and suggested actions for tackling fragmented and inaccessible physical health care for people with mental illness.
“We were recommending the use of digital technologies for promoting physical health and trying to find a way to integrate them in mental health care,” he explained.
This formed the idea for Joe’s UKRI funding. “There are so many studies looking at how we can use digital technologies to improve mental health, from therapy apps to chatbots. At the same time, we’re seeing massive developments in the general population on using digital for physical health and fitness. But there’s not much attention paid to how we can use digital technologies in order to support and improve physical lifestyle interventions for people living with mental health conditions – addressing the physical to support the mental. If we don’t look at that, again, mental health services will get left behind and the extent of the inequalities will increase further.”
Joe shared how he and his fellow researchers have been looking at various studies to explore ways in which existing technologies can be used in this space and potentially redesigned to support access.
Gathering clinician feedback…
“One of the first things we did was a clinician implementation study, because clinicians working in healthcare services are essentially gatekeepers to the type of care that people receive. As good as their intentions may be, there are barriers to clinicians making use of digital tools to improve patient outcomes. We’ve done a big survey across a number of sites in the UK, getting clinicians’ feedback on how they’d like to use digital health approaches for improving physical health. We’ve also conducted a number of in-depth qualitative interviews with clinicians working across various NHS mental health trusts.” The first study has been published and can be found here.
The results showed a “massive positive favouring towards using these technologies,” Joe stated. Across the different lifestyle interventions respondents were asked about – physical activity and exercise, healthy eating and diet, smoking and tobacco use, sleep and alcohol – the “vast majority” of clinicians responding to the survey felt that digital technologies would be useful. “They’re asking for these digital tools to be used, but they don’t always know where to start,” he commented.
Looking at the results of the qualitative interviews, Joe highlighted some of the key words that were brought up during conversations, such as healthy eating, weight management, water intake, alcohol and sleep. “The mental health practitioners were interested in learning how digital tools could support with these general day-to-day healthy living factors.”
Joe continued: “Across all the interviews and data, including the surveys, we found that clinicians were overall very optimistic and positive about taking on board these digital approaches. There was some tech hesitancy, both in terms of their own learning and how comfortable they feel as well as with patients. There was also a desire for training, for them to develop their knowledge of the evidence base, of what actually works. They want to have confidence in what they are prescribing.”
… and the patient perspective
“We’ve also done a big exercise gathering patient perspectives, going over these digital technologies with over 500 young people with diagnosed mental illness across more than 20 NHS mental health sites in the UK,” Joe shared. “We asked what, if any, apps they were already using – a minority were using them, with the most popular ones were the apps we’d expect to see from the general population too – things like Fitbit, MyFitnessPal or Couch to 5k. Most of them were around fitness, with a few around healthy eating and sleep. There wasn’t much use of apps around alcohol or drug use cessation.”
The researchers highlighted four types of app-based approaches with the young people to see what they would be interested in using. The four approaches were tracking (for example tracking sleep or steps), health coaching to get feedback on their lifestyle, instructional videos (such as healthy cooking classes or exercise support), and health connections (using digital technology to connect people to health opportunities in their local communities).
The key findings showed that there was a significant level of interest in all four approaches from the young people – when asked to rate their interest between one (not at all) and five (very interested), each approached scored higher than a three. Instructional videos were the most popular, followed by health coaching, then health tracking and finally health connections.
“We delved further into each approach to look at how people would want these apps to be set up, to be used, what they’d want them to be used for.” Looking at health tracking as an example, Joe demonstrated how the most popular choice was to track physical activity and exercise, followed by their sleep and then their diet.
Regarding how they would want the tracking apps to be used, the most popular idea was around “not only using these technologies for physical health but for mental health too. They were interested in finding out how their lifestyle behaviours such as exercise and diet impact on their mental health experience on a day-to-day basis. The least popular option was for these apps to share their healthcare data. The results indicate that patients are not as interested in setting up a system where they track their health and their clinician receives that data, which is somewhat at odds with what healthcare services might want to provide.
With health coaching, people liked the idea of getting feedback on questions that they may have around managing their health via a chat with a lifestyle coach. By contrast, using video or phone calls to talk to a health coach was one of the least popular options.
However, Joe said, whilst there were preferred options, there was generally “quite good positively across all of the applications we suggested”.
What is happening with this data?
“As I mentioned, the most popular approach was instructional videos. So we’re setting up and about to start a trial of live workouts for young adults with mental health conditions. We’ll be livestreaming these workouts and giving everybody who joins the group a FitBit to help them support their own health tracking in their own time, without needing to share the data with us.”
In addition, young people receiving in early intervention from mental health services will be invited to the the online fitness sessions, which will be delivered two to three times a week across Greater Manchester.
“We’re testing the approach – I’ve done a lot in my career around trying to use physical activity to help mental health, even taking people to gyms and setting up exercise support within the services themselves. People with mental health conditions benefit from those approaches, but it’s hard to keep that support alive for long without moderate backing from commissioners. But with digital, once we record and set up online fitness sessions for people with mental health conditions, it’s something that can be scaled and sustained.”
The researchers are also taking the recommendations from their studies into account with a trial of the Smoke Free app, an evidence-based smoking cessation app in the UK. The app combines the approaches, offering health tracking and health coaching. The trial has seen the app tested out again in the context of young adults with mental illness who are looking to quit smoking, to see how they respond to the different features.
Joe concluded his session by sharing his email address (email@example.com) and encouraging people to get in touch. Particularly, Joe is more than happy to hear from anyone who is interested in:
(1) involving patients/consumers in the development and delivery of digital health interventions,
(2) building new solutions for improving physical-mental health outcomes in underserved populations, and/or
(3) researching the barriers and benefits of adoption of digital health tech in real-world settings.
Many thanks to Joe for joining us.