Digital Psychotherapy As An Alternative To Remote Patient Treatment

Digital Psychotherapy

The United Nations International Labour Organization has extensively detailed the perennial challenges faced by regional, rural and remote communities worldwide in achieving both equitable access to health services and equivalent clinical outcomes compared with their metropolitan counterparts.

Individual living outside major metropolitan centers has worse outcomes across a broad range of health measures, including psychiatric variables. For example, in Australia, there is a 1.7-fold increased rate of suicide in rural communities; in developing or less urbanized societies, these discrepancies are even more pronounced. 

An important component of this disparity is likely the reduced availability of, and therefore utilization of, some healthcare services. In most rural and remote communities, mental healthcare is predominantly performed by general practitioners (GPs) or other primary health clinicians. 

Patients frequently have limited access to experienced psychiatrists or psychologists or face unacceptably long wait times before receiving therapy. The comparative paucity of mental health services in these areas leads to greater expectations for primary care providers to manage complex psychiatric presentations, often without sufficient specialist support. 

In 2008, the Kampala Declaration avowed that immediate action was required globally to enhance and rebalance the international healthcare workforce to ensure essential care could be delivered to all people, regardless of where they live.

This poses a daunting challenge, but also provides an opportunity for consideration of new treatment approaches to redress this gap. In mental healthcare, advances in digitally delivered psychological interventions are of particular interest. This novel treatment category has various names. 

But regardless of the terminology used, digital psychotherapy is defined as the delivery of a manualized psychotherapeutic intervention via electronic modules on a website or smartphone application. Essentially, it is the repackaging of a therapy initially validated in a face-to-face setting into a format where the patient actively engages with the material via their device without a therapist present. 

Therefore, it is distinct from other digital health interventions, such as the delivery of psychotherapy by a human therapist through a televisual link-up or the many useful e-health websites for patients that contain educational material to read. 

Generally, clinical practice guidelines recommend that digital psychotherapy should be delivered with the guidance of a suitably trained clinician to allow for (a) psychoeducation; (b) provision of support where required; and (c) monitoring of clinical response.

Objective input from an experienced, independent expert is considered important to provide tailored feedback for the patient and to ensure the intervention is being used as intended. However, this recommendation for clinician-guided digital therapy is based on principles of good medical practice rather than concerns that unguided programs are insufficient. Indeed, there is evidence that unguided digital psychotherapy still achieves good outcomes for patients. 

Digital psychotherapy has several inherent advantages. First, delivering psychotherapy online overcomes the barrier of having limited face-to-face practitioners in a local area because the therapy simply requires an Internet connection. 

This therapy is also more flexible than face-to-face psychotherapy because the patient can work on these modules at home and at any time that is convenient for them. Digital psychotherapy also reduces patient out-of-pocket costs. Many resources are free to access or charge a subscription fee that is lower than the cost of patient-funded psychiatry. 

Despite the many opportunities that digital delivery of treatment offers, there are also some potential challenges. Rural and remote communities may have reduced or patchy phone and Internet reception, limiting access to the resources. Even more problematic is that neither Internet connections nor personal devices are ubiquitous. 

Moreover, basic literacy and information technology skills are required, which may limit the usefulness of this mode of delivery as an intervention for patients without such skills. Another important consideration is that all current digital options are delivered using a predominantly Western paradigm, which may be less suitable for some culturally or linguistically diverse patients and communities. 

Finally, digital psychotherapy is less structured than face-to-face appointments and therefore requires a degree of self-motivation to regularly access the material and work through the modules. Patients with strong avoidance or avolition may require greater support from family or clinicians to maintain engagement. 

Appropriate training for GPs to support their patients while using these therapies is also important. Ideally, this would be produced by the developer of each online course and would be in the form of accredited training modules that contribute to GPs’ continuing professional development requirements. 

Moreover, there is an opportunity for rural and remote mental health services (both private psychologists and clinicians from public community mental health teams) to embrace a hybrid model whereby face-to-face sessions can be used to oversee therapeutic work done at home via online interfaces. 

Greater uptake of digital psychotherapy has the potential to increase the caseload capacity that an individual practitioner can support owing to the reduced frequency of face-to-face appointments. 

This may allow more judicious and cost-effective use of limited resources. Finally, specific future research investigating the application of digital psychotherapy in a rural and remote context would be instructive because much of the extant literature focuses predominantly on metropolitan populations.

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Weightman, M. (2020). Digital psychotherapy as an effective and timely treatment option for depression and anxiety disorders: Implications for rural and remote practice. Journal of international medical research, 48(6), 0300060520928686.

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