The Digital Mental Health Paradox: Is Now the Time to Unlock the Potential?

John Torous

Abstract

The potential of digital mental health, whether offered through apps or video visits, to increase access to high-quality care is clear. Yet by all metrics, mental health outcomes continue to worsen. While the rise of social media and the impact of screen time is deleterious to some, its impact alone is not enough to explain the lack of benefit seen from digital mental health. Instead, concerns about privacy and lack of innovation have likely kept both clinicians and patients correctly skeptical about digital mental health offerings. But with new government initiatives to enforce digital health privacy and new innovations like ChatGPT highlighting what true innovation looks like, the stage may now be primed for actual innovation in digital mental health. The next generation of digital mental health tools will likely offer superior privacy and actual — instead of the illusion of — innovation that will help improve mental health outcomes for all.

 

Article

The digital mental health paradox is simple but stubborn. Despite over a decade of increasing access to smartphones, internet, apps, and even mental health care online, mental health outcomes have not improved. If anything, they continue to worsen, with February 2023 data from the Center for Disease Control and Prevention reporting a new nadir in sadness for teen girls.1

There are two leading theories to approach the digital mental health paradox. The displacement/harm hypothesis posits the negative influence of social media and the digital world on mental health. The illusion of innovation hypothesis maintains that we have not seen improvements because there has actually been little actual innovation. But now, in mid-2023, we may finally be approaching the point where the answer will become clear.

While there is no doubt that social media and the digital world can have deleterious effects on mental health, this point must be qualified with evidence that it also has a positive role as well. More recent and high-quality studies suggest that on average the impact of social media and screen time on mental health is minimal.2 The authors of this report claim that “including potatoes in your diet showed a similar association with adolescent well-being” to underscore their point. While less dramatic, numerous other reviews have found that there is no clear picture between technology use and mental health outcomes.3,4 That said, there are clear and well-documented extreme harms that social media has caused and the need to identify and help those at the highest risk is a priority.5,6 But in assessing the whole field, can social media and screen time be seen as the reason for worsening mental health across the entire population?

Exploring the other theory of illusory innovation, the question of what benefits have resulted from the plethora of mental health apps and online services is particularly salient. In one sense, there now is increased access, but the real question is access to what. Clinicians and patients have been skeptical of many digital offerings because of privacy and efficacy concerns.

Focusing first on privacy, for years, our team has cited the blatant privacy violations clear with both mental health apps and many online services.7 The violations were so clear that, in 2021, Consumer Reports wrote a report on the topic, and in 2022, the Mozilla Foundation conducted its own investigation to report on “how creepy” certain mental health apps are with regard to privacy.8 Even the suicide hotline service, Crisis Textline, was found to be sharing messages with a for-profit AI-driven chat service without users’ consent.9 Patient and clinician concerns about privacy thus appear to be well-founded and a good reason for low uptake.

Focusing on efficacy, whether or not these apps and services actually make people feel better is also in question. In 2022, we conducted a review of mental health app studies. We found that while many studies state they are a “randomized controlled trial” and thus offer impressive rigor, most of these were actually not rigorous. Instead of randomizing one app to the digital intervention and another to a digital placebo (e.g., mood tracking app or information app), most studies offered nothing at all to the non-intervention group. In other words, they randomized one group to an app and the other to nothing and then reported that something was better than nothing.10 Lack of strong evidence is sadly not new in the digital mental health space, and in 2020, the Institute of Clinical and Economic Review wrote a report about an FDA-approved mental health app noting “the authors present the results as positive, but the power calculations suggest that the primary outcome was the difference in mean weeks of continuous abstinence, which was not significant.”11 Looking across the literature, there is a lack of innovation in using methods like AI, NLP, digital phenotyping, and so forth to help people today.12,13 Our team hosts a website mindapps.org, that allows anyone to search through over 500 apps to assess the marketplaces themselves. This is not to deny there has been innovation, but the state of illusory innovation is well noted in a review of health-focused conversation agents (i.e., chatbots) that found 96% do not use AI or NLP and instead rely on simple decision trees.13

While the world of social media is hard to probe, given that data is rarely shared, there are major changes in the digital health world that will reshape approaches to innovation. In March 2023, the FTC fined an online mental health provider, Better Help, nearly 8 million dollars for violating users’ privacy and sending their data to social media companies.14 This represents a transformational point for the field. The government is sending a clear message: privacy matters. In early 2023, ChatGPT also blossomed and showed the world what true innovation looks like. When confronted with true innovation in AI and NLP, several mental health chatbot companies quickly changed their messaging realizing they could not stretch about their decision trees compared to ChatGPT. As we expect more innovation from ChatGPT and its competitors, the illusion of innovation for digital mental health will become untenable. Instead, these technologies will finally have to compete on actual innovation and outcomes proving their benefit. The age of conducting studies randomizing one group to treatment and the other to a control will finally come to an end. Sharing data with patients to help them recover, not secretly with social media companies, is poised to become the new normal.

As we enter a new phase of digital mental health innovation, will the new focus on privacy and clear sight of transformational technologies finally usher in an era of actual innovation? The timing and circumstances seem ideal. The digital mental health paradox may finally be about to change, and the timing could not be better.

 

About the Author

John Torous, MD, MBI is director of the digital psychiatry division in the Department of Psychiatry at Beth Israel Deaconess Medical Center, a Harvard Medical School affiliated teaching hospital, editor-in-chief for the journal JMIR Mental Health, web-editor for JAMA Psychiatry, and chair of the American Psychiatric Association’s Health IT Committee.

 

References

  1. CDC. U.S. Teen Girls Experiencing Increased Sadness and Violence [Internet]. Centers for Disease Control and Prevention. 2023 [cited 2023 Mar 5]. Available from: https://www.cdc.gov/media/releases/2023/p0213-yrbs.html
  2. Twenge JM, Haidt J, Joiner TE, Campbell WK. Underestimating digital media harm. Nat Hum Behav. 2020 Apr;4(4):346–8.
  3. Odgers CL, Jensen M. Adolescent Mental Health in the Digital Age: Facts, Fears and Future Directions. Journal of child psychology and psychiatry, and allied disciplines. 2020 Mar;61(3):336.
  4. Ritter D, Ray K, Keefe C. Social Media and Mental Health in Adolescents and Young Adults: A Systematic Review. Williams Honors College, Honors Research Projects [Internet]. 2021 Sep 14;1359. Available from: https://ideaexchange.uakron.edu/cgi/viewcontent.cgi?article=2712&context=honors_research_projects
  5. Russell I. Opinion | My daughter was driven to suicide by social media. It’s time for Facebook to stop monetizing misery. - The Washington Post [Internet]. [cited 2023 Mar 5]. Available from: https://www.washingtonpost.com/opinions/2021/10/25/facebook-frances-haugen-molly-russell-teen-suicide-social-media-uk/
  6. Orben A, Przybylski AK, Blakemore SJ, Kievit RA. Windows of developmental sensitivity to social media. Nat Commun. 2022 Mar 28;13(1):1649.
  7. Huckvale K, Torous J, Larsen ME. Assessment of the Data Sharing and Privacy Practices of Smartphone Apps for Depression and Smoking Cessation. JAMA Netw Open. 2019 Apr 5;2(4):e192542.
  8. *Privacy Not Included: A Buyer’s Guide for Connected Products [Internet]. Mozilla Foundation. [cited 2023 Mar 5]. Available from: https://foundation.mozilla.org/en/privacynotincluded/
  9. Levine AS. Suicide hotline shares data with for-profit spinoff, raising ethical questions - POLITICO [Internet]. 2022 Jan 28. Available from: https://www.politico.com/news/2022/01/28/suicide-hotline-silicon-valley-privacy-debates-00002617
  10. Goldberg SB, Lam SU, Simonsson O, Torous J, Sun S. Mobile phone-based interventions for mental health: A systematic meta-review of 14 meta-analyses of randomized controlled trials. PLOS Digital Health. 2022 Jan 18;1(1):e0000002.
  11. Opioid Epidemic: Digital Health Technologies [Internet]. ICER. 2020 [cited 2023 Mar 5]. Available from: https://icer.org/assessment/opioids-digital-apps-2020/
  12. Camacho E, Cohen A, Torous J. Assessment of Mental Health Services Available Through Smartphone Apps. JAMA Network Open. 2022 Dec 28;5(12):e2248784.
  13. Parmar P, Ryu J, Pandya S, Sedoc J, Agarwal S. Health-focused conversational agents in person-centered care: a review of apps. npj Digit Med. 2022 Feb 17;5(1):1–9.
  14. Fair L. FTC says online counseling service BetterHelp pushed people into handing over health information – and broke its privacy promises [Internet]. Federal Trade Commission. 2023 Mar 3. Available from: https://www.ftc.gov/business-guidance/blog/2023/03/ftc-says-online-counseling-service-betterhelp-pushed-people-handing-over-health-information-broke
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