Market Review of Digital Health Technologies

TABLE OF CONTENTS

SECTION ONE: INTRODUCTION

1.1 What is digital health……………………………………………………....2

1.2 Why digital health is essential In the current health & care Landscape…………………….3

1.3 As at now…………………………………………………………………..3

1.4 The review………………………………………………………………………...4

SECTION TWO: THE CONTEXT……………………………………………...5

2.1 An overview of the mental health Condition - Schizophrenia…………………………….5

SECTION THREE: DIGITAL HEALTH PRODUCTS……………………..7

3.1 Digital health products for

Mental health condition- Schizophrenia………………………………........7

3.2 Prime………………………………………………………………………..8

3.3 Kooth………………………………………………………………………..9

3.4 SilverCloud…………………………………………………………………10

3.5 My possible self…………………………………………………………….11

SECTION FOUR: IMPLEMENTATION PATHWAY………………………16

4.1 The road to successful implementation………………………………….16

SECTION FIVE: CONCLUSIONS…………………………………………..18

REFERENCES…………………………………………………………………20

SECTION ONE: INTRODUCTION

1.1 What is digital health?

Digital health has been defined by many as the use of technology to address health-related issues. Tim (2016) reviews what exactly is digital health?, as a "Disruptive and transformational approach to the delivery of healthcare, with a focus on engaging and empowering patients, activating caregiver networks and understanding that patients are increasingly behaving as consumers of healthcare. Digital health provides us with a toolbox of technologies and techniques that support the development of new, innovative patient and caregiver-centered models of care, driving improved engagement, accessibility, quality, safety, efficiency, and sustainability into all corners of the health system." While Martin (2019) in his review about digital health says, "it is the use of information and communication technologies (ICT) to treat patients, conduct research, educate healthcare professionals, track diseases and monitor public health. While digital technologies (Teach with technologies, 2019) "...are electronic tools, systems, devices and resources that generate store or process data. Well, known examples include social media, online games, and multimedia and smart mobile phones."

1.2 Why digital health is essential in the current health and care landscape

The opportunity of interdisciplinary research that has encouraged the bringing of computer technology into the health sector has dramatically improved public health globally in the most unusual way.

Dhwani (2016) reviews the scope of digital health includes but not limited to categories such as health information technology (IT), mobile health (mHealth), wearable devices, telehealth and telemedicine, and personalized medicine. The benefits of digital health to stakeholders include:

• Reduce inefficiencies
• Trim down costs
• Improve access
• Increase quality
• Make medicine more personalized for patients

1.3 As at now

The success seen so far in the digital health spectrum has been made possible by some policies and strategies in place. Such as, but not limited to Acceptability & feasibility for clients and individuals – This has to deal with having a user-centered design of any digital health product, taking into consideration all aspects of the end-users concerns and limitations before any product goes into production. Also, Acceptability for health workers- they are critical stakeholders in the adoption of digital health products. Currently, we have seen them become part of the lifecycle of digital health products. (WHO, 2019)

1.4 The review

The purpose of this review is to identify/discuss some digital health products deployed in the delivery of healthcare to Mental Health patients, particularly Patients with Schizophrenia. Sheri (2014) reviews that Schizophrenia is characterized by hallucinations and delusions, with a pattern of thinking that usually leads to social withdrawal, difficulty maintaining a regular life, or a specific routine. Four digital health products were selected in this review; the reason these were selected is that they come very close to the management of Schizophrenia . They are Prime App, Kooth, SilverCloud App, and My Possible self. These digital health apps approach the management of mental health differently, although under what is referred to as Cognitive Behavioural Therapy (CBT).

SECTION TWO: THE CONTEXT

2.1 An overview of the mental health condition - Schizophrenia

Schizophrenia is a mental health condition that leads to severe changes in the biological functions of the brain, which in turn affects learning, thinking, and social relationships. Research has shown a biological factor, and often a genetic predisposition is the known cause of the illness (Sheri, 2014). According to available pieces of literature, there is no known cure for schizophrenia conditions. The symptoms of Schizophrenia are described as Positive and Negative, while positive symptoms include hallucinations and delusions; the negative symptoms include loss of a healthy way of thinking, feeling and motivations, social withdrawal, and loss of interest in life. Unlike the positive symptoms, the negative symptoms are not dramatic but challenging to cope with. If one living with Schizophrenia symptoms has become depressed, not getting treatment with less help from other people, such a person is prone to suicide (Schizophrenia, 2019).

Cognitive Behavioural Therapy (CBT)

This is one of such significant support that can be rendered to people with schizophrenia, and this therapy can be done by clinical psychologists, psychiatrists, or nurse therapists. Cognitive Behavioural Therapy (CBT) helps the patient concentrate on the problems they find most challenging, like thoughts, hallucinations, or feelings of being persecuted. Digital Health has recorded significant results in the management of mental health cases. It has helped improve access to therapies, reduced stigma, and provided other helpful services for people with mental health conditions through various applications. Between 8 and 20 sessions of CBT each lasting about an hour is the recommendation for patients with schizophrenia

From MQ - Transforming Mental Health through Research (2017), statistics show that 16 Million are living in the UK experience mental health-related illnesses; of this number, each year, one in four adults will experience mental illness. Such mental illness like Anxiety, depression, alcohol dependence, substance abuse, to mention a few. Furthermore, it shows that mental health conditions start from early childhood, with 10% of school children ages 516 having diagnosable mental health illness. Arising from this, a lack of early detection has resulted in the illness taken a stronghold on the child resulting in self-harm, they drop out of school or become violent, this is one of the leading causes of suicide between age 20-34.

Unfortunately, less than 30% of mental health research is focused on children, even though 75% of mental health illness begins from childhood. The wait time to receive treatment for mental health conditions has risen over time. This accounts for why about 75% of young adults with mental health conditions are not receiving treatment and to think of the fact that it takes approximately 10years to be treated with a mental health condition after the symptom is noticed for the first time. With digital health technology, issues like wait time can be resolved

SECTION THREE: Digital health products

3.1 Digital health products for mental health condition - Schizophrenia

Mental Health is a vast and varying condition that deals with issues like a personality disorder, Anxiety, depression, eating disorder, sleep disorder, psychosis, etc. All these cases that constitute what is referred to as mental health do not have the same symptoms or approach to addressing them; however, some of them have certain defining traits that can be seen in other cases of mental health (Schizophrenia, 2015). So you may not find a digital health product that fits only one case of mental health, nor will you find one product that fits all cases of mental health.

In this market review, four digital health products were identified in the management of mental health conditions. These include:

1. Prime (an acronym for Personalized Real-time Intervention for Motivational Enhancement)
2. Kooth
3. SilverCloud
4. My Possible Self

3.2 PRIME

Digital Technology: Mobile application

Name of Company: University of California- San Francisco

Search terms: Mental health app

Search Location: Google

Search Criteria: Top 25 Mental Health App for 2019

Description of Product

This digital health product is currently undergoing trial; it was put together by a Psychiatry Professor, Danielle Shlosser, at the University of California-San Francisco, U.S.A. She and her Drive Lab, a team of researchers using mobile technology to target a set of lesser-known schizophrenia symptoms, are seeking to improve the quality of life for people living with schizophrenia. They identified from research that patients with schizophrenia are susceptible to social isolation even after they are stable, which in turn kicks in and triggers social Anxiety. Traditional treatment regimens neglect this aspect of social Anxiety, but they make the condition of the patient worse, and it continues in a vicious cycle. The Prime app, which is an acronym for Personalized Real-time Intervention for Motivational Enhancement, provides on-demand counseling, a direct line to clinicians, which are referred to as "Coaches". Social networking tools to meet treatment goals such that the users can track, things they will like to accomplish or improve about themselves, they could post such accomplishments and share with others in their network. These goals are specially designed to help them battle their motivational deficits. Users of this app begin by creating their profile and indicating their interests and aspirations, based on their input, the app creates customized daily challenge goals for them (Michelle, 2018).

3.3 KOOTH

Digital Technology: Mobile application

Name of Company: XenZone

Search terms: Mental health app - NHS

Search Location: Google

Search Criteria: Mental Health App

Description of Product

Kooth is a product by XenZone. XenZone is one of the first companies that developed an online supportive and counseling community for people with mental health cases. It is on record that over 250,000 people have used or are using one of their services, one of such popular service is Kooth. Kooth, an NHS approved digital health app, is an online platform for children and young adults with mental health issues. It provides counseling and emotional support to its users. It is a confidential and anonymous platform. Some of the features of Kooth include Newsfeed, Live moderated forums, Online chat, Emotion status update, Feedback forms, and goal capture (https://xenzone.com/kooth/,2019)

3.4 SilverCloud

Digital Technology: Mobile Application

Name of Company: SilverCloud Health Limited

Search terms: Digital services and intervention for mental health

Search Location: Google

Search Criteria: Mental Health Apps - Scholarly Articles

Description of Product

SilverCloud is a Cognitive Behavioural online programme designed to help treat mental health cases like Anxiety, depression, and Stress. With SilverCloud, the user is expected to subscribe to it after a series of teaching on Cognitive Behaviour Therapy (CBT) as it relates to Anxiety, Depression, and Stress. Users are expected to undergo some teaching prior to subscribing; once the user is done with these teachings and subscribes, SilverCloud customizes a set of interactive modules for the user, which they can attend at their own pace. The programme irrespective of the user runs for 8-10 weeks with at least 30-40 minutes session once per week. The users are expected to complete some activities during the duration of the programme, which will be monitored by a dedicated supporter. These dedicated supporters are there to provide guidance to the users and respond to them more personally and confidentially. SilverCloud is a 24/7 service, and it is NHS approved. Users are given an activation code upon subscription to enable them gain access to the programme from anywhere, as well as a telephone number for support (https://www.silvercloudhealth.com/uk, 2019)

3.5 My Possible Self

Digital Technology: Mobile & Web application

Name of Company: My Possible Self Limited

Search terms: Digital services and intervention for mental health

Search Location: Google search

Search Criteria: Scholarly Articles

Description of Product

My Possible Self is an NHS approved mobile and web app designed for the improvement of mental health, improve the wellbeing of people living with stress as well as those living with Anxiety and low mood. The developers and promoters of this Mental Health App used contents by the Black Dog Institute, a world-renowned in e-mental health research. Their goal is to empower mental health patients to manage their conditions. This gained them a place in 2018 on the NHS digital health London Accelerator programme as one of the five selected digital health apps to speed up the adoption of technology in London's NHS services. Users of My Possible Self upon completion of a self- assessment are allowed to select learning modules from a list of 10 clinically proven methods recommended to them in Cognitive Behavioural Therapy and positive psychology. Any of the modules they select are aimed at helping them develop new skills in dealing with troubling thoughts and feelings (https://www.mypossibleself.com/history/, 2019).

Comparison

All the products in this review use Cognitive Behavioural Therapy (CBT) for the treatment of mental health conditions, which in itself cannot do much without the required medication. It is not a therapy alone or a medication alone; instead, to get the best outcome, it has to be a combination of both. This is why it is essential to involve clinicians in the mental health sector in developing products. SilverCloud has 70% clinical recovery as against the others like Kooth, Prime, and My Possible self. Silvercloud, has been in existence the same years with Kooth but has more evidence-based programmes than Kooth and the others, with a reach to 240 customer organizations and reporting on October 10th, 2019, of treating a total of 300,000 patients with mental health conditions (https://xenzone.com/kooth/,2019).

Silvercloud also has an Application Programme Interface (API), which makes it easy to synchronize with other external systems; this attribute is lacking in the others. SilverCloud has enjoyed significant partnership, one of such is that with Berkshire and very recently that with Microsoft lab in Oxford. Such collaborations are what digital health needs to achieve a massive milestone in healthcare delivery. Like My possible Self app, SilverCloud is not free, although it is free under NHS Services; not otherwise, this is where Kooth differs from them (https://www.silvercloudhealth.com/uk,2019).

Kooth is free and provides online counseling to its users every day for 10hours Monday – Friday and 4Hours Saturday-Sunday. Kooth is accredited by the British Association for Counselling & Psychotherapy (BACP) and has 1,500 logins every day plus 100 new registrations every day. Kooth has recorded 34,000 one to one online chat sessions in the last one year and has over 300,000 messages between young adults and Kooth Counsellors. Kooth, like Silvercloud enjoys a partnership with external bodies like Clinical Commissioning Groups (CCGs), Local authorities, and councils. Kooth is targeted at children, and young adults and 95% of its users would recommend Kooth to their peers, according to a survey conducted by Kooth

Confidentiality and anonymity, which are critical features in the use of Kooth, which is not evident in others, are some of the reasons its users are comfortable with the platform. However, Kooth does not have a broad reach, for instance on their sign up page; you are required to enter the place you live; incidentally, a place like Glasgow is not listed on the drop-down of places Kooth covers, this means someone in Glasgow cannot sign up to kooth. On https://xenzone.com/kooth/, a statement that reads, "18% of children and young people registering on Kooth identify as black, Asian or Minority ethnic" This statement may be seen by some quarters as offensive and racist because that is all it says about the percentage of children registering with them (https://xenzone.com/kooth/, 2019).

My Possible self app has been in operation for about 11years. It has ten programmes that users can benefit from, although not all of the programmes are free. My Possible self, like Kooth, SilverCloud addresses issues like Anxiety, Stress, Depression cases. They built their content from research conducted by Black dog institute, a medical research institute that ventures in mental health aspects like Bipolar, depression, and stress. Like Silvercloud, My Possible self would conduct an appraisal on the condition of the user to ascertain which of its programmes it can recommend to them; this way, the user is tailored to what he/she needs for their Cognitive Behavioural Therapy (CBT). Not much is known of the evidence-based success of My Possible self like Kooth and Silvercloud parades. My Possible self app shows no sign of interaction with external systems; this makes them more of a stand-alone system (https://www.mypossibleself.com/history/, 2019).

Personalized Real-time Intervention for Motivational Enhancement (PRIME) – This app is currently being developed specifically for Schizophrenia patients; unlike the others, it is specific in what mental health care it is addressing. Although much is not known of the look and feel of this product as it is currently undergoing trial, and maybe ready for commercial use sometimes next year. Prime gives the impression of detailed work-in-progress as it involved significant stakeholders such as patients with Schizophrenia, Psychiatrists, Academic researchers, and software developers (Coby, 2019), in its development, following the Integrate, design, assess, and share a pattern of system development (Sarah, et al. 2016). All the digital health products reviewed made Cognitive Behavioural Therapy (CBT) accessible to those who need it and for the purpose they need it from wherever they are, confidentially and in some cases, anonymously. The effect of therapy on a one-to-one meeting with a clinician in a physical clinic or hospital environment is by no means diminished by the use of any of the digital health products reviewed, rather it is said to have the same effect with the comfort of convenience.

Table 1: Shows the various digital health app reviewed against standard indicators

SECTION FOUR: Implementation pathway

4.1 The road to successful implementation

Jo (2004) reviews using the Promoting Action on Research Implementation in Health Services (PARiHS) Framework to consider the implementation pathways these various products adopted, apart from the Kooth app, they all followed to a reasonable extent the Evidence, Context, and Facilitation pattern. This pattern of implementation of a health service product proposes that for a successful implementation of evidence, there needs to be clarity about the nature of the evidence being used, the quality of context, and the type of facilitation needed to ensure a successful change process. Scientifically robust evidence that matches professional consensus and patients' preferences is the bedrock to a successful implementation of a digital health product. The primary barrier to the implementation of these technologies is resistance to change, but the support of clinicians facilitated this barrier. Most especially because these products maintained the same effectiveness as a one-to-one meeting, they were used to.

This review has observed that some of the digital health products that were considered have followed the user-centered pattern of product design. This kind of product design usually involves the users and other stakeholders in the lifecycle of product development. This, in part, explains the evidence-based success in the use of their products. For instance, KOOTH: The predominant Kooth users are young people, and a third of the 3,000 users surveyed, showed that the main reasons they use Kooth are because of its confidentiality and anonymity (https://xenzone.com/kooth/,2019).

SilverCloud, in partnership with Berkshire Healthcare, developed a digital health programme for mental health, which has over 300,000 people treated of various cases of mental health conditions. The success of this programme leads to 75% of NHS Improving Access to Psychological Therapies services signed up for it, incorporating in their treatment of mental health cases. The latest figures showed 1.1 Million hours of digital therapy had been delivered using this digital health technology, and the improvement rate is up to 65% of users. SilverCloud is also going into another partnership this time with Microsoft to explore the use of artificial intelligence to personalize care for mental health patients (: https://www.silvercloudhealth.com/uk, 2019).

PRIME app. has recorded successful trials in the past yet, they are modifying their product from users' feedback.

These digital health apps are not themselves treatment or cure to the illness, they simple provide the support that is necessary for the patient to get well.

There is no one size fits all technology. However, the underlining factors that make these products acceptable to users include their availability for different ages, flexible hours, therapeutic alliance, different levels of support, anonymity, and confidentiality, to mention a few (Michelle, 2018).

SECTION FIVE: Conclusions

Awareness of digital health products to patients who need them is very critical. It is essential to continue in the path of iterating these products with users as well as stakeholders. It has been observed that when clinicians are involved in the development process of any digital health product, they tend to help in creating awareness and need to use them.

Simon C. Matthews et al. (2019). suggests to a recent evaluation of 280 diabetes mobile applications that were tested on their effectiveness, the result was that only five of those apps were associated with clinically meaningful improvement. Furthermore, none were of high methodological quality. The article went further to state that a dearth of well-established value and impact-based business models for digital health was chiefly responsible for issues like this. There is, therefore, the need to put in place the right regulations since digital health technology is breaking limits and expanding to new frontiers.

Overall the idea of developing user-centered products in the digital health industry is becoming more of a front-burner discussion among the various stakeholders; these products we have just reviewed are a testimony to this fact. All the products we have seen are right, but it can be better if they are addressing specific mental health cases as against the generic approach some of them are currently using. For instance, if a product is tailored to address a couple of specific mental health issues, it would make it easier for the clinicians to recommend or for someone to refer a patient to it. These specifics can be categorized as it is clear that mental health conditions are a whole range of illnesses. Often the one with a mental health condition may not be aware that such a health challenge is before him/her.

Moreover, no one will gladly walk into a psychiatry hospital to have themselves evaluated for a mental health condition; this makes early detection of the illness a complex one. However, if two inputs can be added to what is already in existence, one will be the introduction of wearables to remind mental health patients to take their drugs. This is important because the digital health products without the patient taking their medications should, will not do much to improve their condition.

Also, the aspect of early detection for mental health patients is very critical. Much of what is seen is an aftermath of the issue when the symptoms have manifested, and the patient requires treatment; it is more reactive than a proactive approach. It would be nice to see gamification added to these technologies or a new technology altogether that will help in the early detection of any mental health condition. If more considerations are given to this, many people would not need to undergo prolonged therapy, be socially isolated, stigmatized, or suicidal. As the old saying goes, "prevention is better than cure."

6. References

1. Coby, M. (2019) Meet Prime, the new app that wants to help treat Schizophrenia. Available at:https://psmag.com/news/meet-prime-the-new-app-that-wants-to-help-treatschizophrenia

2. Dhwani, J. (2016) Digital health: improving lives. Available at: https://pharmeasy.in/blog/digital-health-improving-lives/(Accessed 15^th November,2019)

3. Jo, R.M (2004) 'The PARIHS Framework-a framework for guiding the implementation of evidence-based practice' Journal of Nursing Care Quality, 19 (4), pp 297-304

4. Kooth (2019) Available at: https://xenzone.com/kooth/(Accessed 21^st November,2019)

5. Michelle, H. and David, L (2018) 'Using digital technology in the treatment of Schizophrenia' Schizophrenia bulletin, 44 (5), pp 937-938.

6. My possible self (2019) Available at: https://www.mypossibleself.com/history/(Accessed 10^th November,2019)

7. Martin, C. (2019) About digital health. Available at: https://www.escardio.org/Education/Digital-Health-and-Cardiology/about-digital-health(Accessed 15^th November,2019)

8. Simon, C.M et al. (2019) 'Digital health: a path to validation'. Digital Medicine, 38 (2), pp1-2.

9. Sheri, J. (2014) what is Schizophrenia. Available at: https://www.harleytherapy.co.uk/counselling/schizophrenia.htm (Accessed 20th November, 2019)

10. Schizophrenia (2019) Available at: https://www.nhsinform.scot/illnesses-andconditions/mental-health/schizophrenia#introduction (Accessed 20^th November, 2019)

11. Schizophrenia (2015) Available at: https://www.rcpsych.ac.uk/mental-health/problemsdisorders/schizophrenia(Accessed 20th November, 2019)

12. SilverCloud (2019) Available at: https://www.silvercloudhealth.com/uk(Accessed 24th November, 2019)

13. Sarah, A.M. et al (2016) 'IDEAS (Integrate, Design, Assess and Share): A framework and Toolkit of strategies for the development of more effective digital interventions to change health behaviour' Journal of Medical Internet Research, 18 (12), pp317

14. Tim, B. (2016) what exactly is digital health?. Available at: http://semanticconsulting.com.au/2016/12/23/exactly-digital-health/ (Accessed: 15^th November, 2019)

15. Teach with digital technologies (2019) Available at: https://www.education.vic.gov.au/school/teachers/teachingresources/digital/Pages/teach.a spx (Accessed 15th November,2019)

16. What is digital health (2019) Available at:https://www.infoway-inforoute.ca/en/what-wedo/benefits-of-digital-health/what-is-digital-health (Accessed 15^th November,2019)

17. World Health Organization (2019) Recommendations on digital interventions for health system strengthening. Available at: https://www.who.int/publications-detail/who-guidelinerecommendations-on-digital-interventions-for-health-system-strengthening (Accessed 3^rd December,2019)

18. 12 Statistics to get you thinking about mental health in young people (2017) Available at: https://www.mqmentalhealth.org/posts/12-statistics (Accessed 20th November,2019)

7. Appendices