The pandemic-induced lockdowns lent fresh energy to teleconsultations for mental health, as clinic visits became impossible. A recent conference evaluated such digital solutions and explored the ways in which they can be finetuned to provide inclusive and culture-sensitive care.
The covid-19 pandemic underscored the impact of what is often among the most under-examined non-communicable diseases (NCDs)—mental illness. The World Health Organization (WHO) states nearly one billion people globally live with a mental disorder, with conditions like anxiety and depression climbing more than 25% in the first year of the pandemic alone.
Given these worrying numbers, the lack of clear and decisive strategies to address the issue is a significant problem. Technological solutions are increasingly helping fill this gap. Tools like mobile apps to record symptoms and correspond directly with clinicians as well as augmented reality platforms that offer people a way to process traumatic experiences are just a few examples. These kinds of innovations have increasingly entered mainstream discussions on treatment of NCDs.
The rise of telehealth services connected people to therapy and support at a time when the pandemic-induced shelter-in-place requirement kept many from in-person clinical visits, but flaws remained. The mental health apps, platforms, and tools that emerged during covid-19 were projected as democratising access; however, many among those at-risk had neither the technological nor economic resources to use these services.
Similarly, the one-size-fits-all approach of the technology-reliant interventions proved inadequate to address multi-dimensional, complex mental health issues across different cultures and communities. The innovations are many, but still more needs to be done.
Growing adoption of telepsychiatry
Recently, Re:solve Global Health, Dalberg, and Northwell Health convened 25 high-level executives across a wide range of disciplines to discuss how digital solutions can best help those living with NCDs—especially mental health issues—around the world.
Held during the 2022 United Nations General Assembly (UNGA) in New York City, the roundtable discussion brought together leaders from global health non-profits, non-governmental organisations (NGOs), private and public healthcare, startups, venture capital, and even film.
The discussions that emerged underscored some common themes. NCDs like depression, anxiety, and suicidality collectively mark a defining global issue of our time; many tech-focused solutions exist, but there is need for improved collaboration between stakeholders, including clinicians and policymakers.
“If we can seamlessly stitch the measurement, clinical decision support and intervention tools together, we are going to be able to make really important progress in making mental health care accessible to all.”
One of the tech solutions that gained prominence in the wake of the pandemic was telepsychiatry services. A 2022 report published in the Journal of Psychiatric Research revealed widespread adoption. Of 1,206 clinicians from 100 countries who were registered with WHO’s Global Clinical Practice Network (GCPN), just over 90% reported they “started or increased their telehealth services” between June 4 and July 7, 2020, right at the height of the pandemic.
In the US—ranked third in the world behind India and China in rates of mental illness, according to WHO—telehealth services for mental health consultations increasingly became the norm rather than an exception. A 2022 study in JAMA Network Open showed that US clinicians were readily approving of and utilising telehealth services for mental health care.
During a panel discussion at the UNGA event, John Young, who leads the departments of psychiatry at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Zucker Hillside Hospital, mentioned that the pandemic saw a “rapid adoption of telepsychiatry” services across the US.
Young, who also oversees behavioural health at Northwell Health, says the pandemic brought about the realisation that “we could immediately use remote technology to increase support to our global mental health partners”. Citing Northwell Health’s ongoing work in Ecuador, he says virtual mental health services “enabled more trainees to have direct experiences in global mental health”.
“Trainees long for these opportunities,” Young says. “They want meaning, purpose, passion in their careers. These experiences will build a deeper engagement by our next generation of mental health clinicians.”
At the same panel discussion, Tanzeem Choudhury, the Roger and Joelle Burnell chair in integrated health and technology at Cornell Tech, said that digital solutions for mental health care were largely “fragmented and direct-to-consumer focused”.
“We need to consider how a clinician would use them. With the pandemic, we have seen that telepsychiatry works. The acceptance of virtual care combined with information from powerful measurement devices that people carry all the time [such as smartphones, mobile apps and wearables] makes me optimistic about the future of mental health care,” she says. “If we can seamlessly stitch the measurement, clinical decision support and intervention tools together, we are going to be able to make really important progress in making mental health care accessible to all.”
Choudhury, who is also senior vice president of digital signals, therapeutics, and mental health at Optum Labs at UnitedHealth Group, says collaboration between technologists, clinical practitioners, and care delivery organisations is needed to “take digital technology for mental health from a predominantly consumer space to a clinical-care space”.
This involves what she calls a ‘de-siloing’ of mental health care from physical health care; they have to be part of a greater whole. “In integrated care models, physical and mental health are treated jointly. Digital solutions can scale and amplify integrated care models, especially in resource-constrained settings,” Choudhury says.
“Digital measurement and AI-based predictive models can enable a virtual psychiatrist to support multiple clinics remotely and increase their capacity. Digital tools for measurement, clinical support, and intervention delivery become important in making integrated mental and physical health care more accessible.”
Towards culturally sensitive solutions
Crafting tech solutions for mental health care also requires cultural inclusivity and sensitivity. A common theme surfacing at the event was that technology—whether an app or a telehealth service—designed to address these concerns must be geared to resonate with specific communities. Just as mental health is an umbrella term for a multitude of experiences and diagnoses, the care and treatment too varies culture-to-culture, across nations and socioeconomic statuses.
"In the absence of access to clinical support, we believe it is important to ask communities for their suggestions and advice on making mental health [care] accessible."
During the panel discussion, Celina de Sola, co-founder and president of Glasswing International, a non-profit that works directly with communities across Latin America, pinpointed the need for greater cultural awareness and sensitivity when developing digital solutions for mental health care and interventions.
She highlighted the fact that many Indigenous communities around the world have a much more "integrated approach" to wellbeing and mental health. How do we merge digital solutions with existing integrative practices that have always been a part of a community's approach to healthcare?
When reflecting on the panel discussion later, de Sola said that those in global health "should be cognizant about the use of technology in different cultural contexts".
"We should take into consideration how some people may feel about these new technologies. For example, we don't want to lose sight of the value of millennial practices of collective healing; of ways people approach mental health in both clinical and non-clinical ways," she says. "In the absence of access to clinical support, we believe it is important to ask communities for their suggestions and advice on making mental health [care] accessible."
She emphasised that global health approaches always face the challenge of leveraging technology while retaining cultural markers and traditions.
"What are we sacrificing in scaling to technology that we might regret later when it comes to trauma and healing, to mental health? The virtual space is definitely important for mental health access. However, if we make all, or most, services online, we miss the opportunity for person-to-person connection that is so important for healing—especially for 'non-clinical' and group interventions that may draw from traditional wisdom and practices," de Sola explains.
She adds that there are "many layers and facets of personal experience" that affect how we deliver and receive healthcare. "If we don't pay attention to the wellbeing of care providers themselves—clinicians, providers, and community leaders who work directly with communities—we will be negatively impacting the quality of care. It is hard to pour from an empty cup."
Addressing NCDs amid crisis
Olga Berg, executive director of Ukraine Medical Consortium, has been working on support in Ukraine since the beginning of the war, coordinating training for doctors, in-kind donations distribution, equipment procurement, and partner collaboration. The organisation serves as a liaison between those contributing to Ukranian relief right now—Ukranian and Polish NGOs, volunteers, hospitals in Ukraine, the nation's government, and international donors. During the panel discussion, she focused on digital solutions to address mental health during the ongoing conflict.
These include training mobile volunteers on the ground in Trauma Risk Incident Protocol (TRIM) in collaboration with King’s College London Centre for Military Health Research, and using messaging app Telegram to share interactive training in tactical medicine, mental health, and other crucial resources.
She says there are “no perfect solutions” for addressing mental health in the middle of war. “Every culture has their way of healing,” Berg says, and, as a result, when coordinating mental health support during a crisis, like the current war, cultural competency has to be prioritised.
International war efforts have a long, chequered history in which foreign governments and NGOs swoop into a country, lacking the cultural awareness needed to answer the specific needs of the communities they are pledging to help. One culture’s approach to mental health might not make sense to another.
In the fog of war, when communities are under attack, the negative effects of NCDs like mental health issues can coalesce for those on the ground to an intimidating, nearly unmanageable degree. Berg says volunteers in Ukraine—and the people they are helping—are facing incredibly high levels of persistent trauma. They need support in real time as there's no luxury of meetings or scheduled consultations. These are problems that need immediate action.
For those looking to address mental health during an international crisis, Berg says it’s crucial to understand the culture-specific needs of the people affected—in this case, the people of Ukraine.
“When we do training—currently we provide ultrasound, tactical medicine, and mental health—we always look for capable local experts with a good reputation who need support. Frequently, they have already established practices that have proven effective in their environment. We try to integrate with existing formats and provide additional tools,” she says.
“For example, some of the local groups supporting military and mental health goals… stay with the troops, cook and sing together, to create rapport and create an open environment for conversations with soldiers. Now they will be also bringing TRIM protocol training for officers as a part of the ongoing programme.
"It is about supporting the local systems that already exist and doing the best job we can.”
Breaking through stigma
Giving mental health equal importance as physical health involves tackling multiple levels of stigma, which perhaps forms the biggest obstacle in the treatment of such NCDs. There is the cultural stigma of society at large unwilling to acknowledge the realities of mental health conditions, which are often invisible. They affect people in some of their most private, intimate, and vulnerable moments. There is also the political reluctance to break through the stigma and engage with the complex issue head-on through policymaking.
Physician and public health expert Howard Zucker witnessed the challenges of overcoming these hurdles during his tenure as Commissioner for the New York State Department of Health, a role he left in November 2021.
“When I entered state government, I said that two of the biggest health issues facing America today are, one, ageing and the elderly population. And the other is mental health issues,” Zucker said during the event. “These are two complex issues and consume many resources.”
Zucker says “everything has politics involved”. “Some of these issues, especially mental health issues, do not have easy solutions and often the solutions take years. Such timelines are not ideal for politicians who see things in two- or four-year cycles.”
This can create a bottleneck effect—with the pressing need to address mental health care at the policy level building up while other political concerns take precedence.
Zucker, who is a visiting professor at New York University, says part of the challenge is in getting policymakers and stakeholders to understand the urgency needed in addressing the global mental health crisis. It is an ongoing issue that calls for forward-looking solutions and patience.
“Stigma is a really big issue. There is stigma attached to behavioural health issues and we haven’t handled that as well as we could or should,” Zucker explains. “That was true of other health issues where, decades ago, we would ‘whisper’ the words ‘cancer,’ ‘HIV,’ but that is no longer the case. We need to achieve similar successes with behavioural health as well.”
When dealing with issues like depression or anxiety, a big piece of the puzzle is breaking through the societal stigma attached to mental health. “Once we figure out how to remove stigma, we will be one step closer to overcoming some of the challenges regarding behavioural health and finding solutions,” Zucker says.
Collaboration as a platform for solutions
One big avenue for affecting change is collaboration. Young, of Northwell Health, says the way forward is to bring together leaders and innovators across backgrounds to find out how technology can address global health issues as complicated as mental health.
"I think this is actually the future of solutions… It involves teams consisting of people with different expertise, but then de-siloing to solve problems in a way that is integrated."
"It's remarkable, the human capital in this room—just the different perspectives around the table, from public health to finance to technology to medicine,” he remarked after the event. “I think this is actually the future of solutions… It involves teams consisting of people with different expertise, but then de-siloing to solve problems in a way that is integrated.
“From my experience in global mental health, when you have these [multi-disciplinary] teams, it's amazing what you can accomplish.”