Mental health’s digital first-line treatment

After a long week at work, you sit down in your lawn chair excited to soak in some sunshine at your child’s soccer game. Unfortunately, three minutes into the game they break their leg. You run onto the field and rush them to the family doctor. The doctor calmly states that medication and a smile are all your child needs to recover.

Not offering additional care options for your kid’s broken leg, such as a cast, crutches, surgery, or physical therapy may seem absurd, but this kind of health care experience is all too common for people who suffer from a mental health condition. Due to a shortage of trained psychotherapists, 83% of people with mental health concerns consult their primary care physician, and 82% of those people receive medication.

Despite the majority of people receiving psychiatric medication, it’s not the recommended first-line treatment for most common mental health conditions such as insomnia, anxiety disorders, and depression. In fact, the recommended first-line treatment for these conditions is cognitive behavioral therapy, or CBT. That means most people receive insufficient care when proven, effective alternatives exist. So the question becomes, how can we break this cycle so that people receive the best available care in a format that’s as scalable and consistent as medications?

First-line treatment, explained

First-line treatments are the ‘gold-standard’ intervention for a given health condition. Selected primarily on their proven effectiveness, they are the first treatment option that a provider should offer a patient to achieve the best outcome. However, effectiveness alone is not sufficient for a treatment to be the first-line recommendation. Side effects are also critical.

For example, a treatment can be incredibly effective at addressing a specific symptom, but if it comes with a tidal wave of unwanted side effects it won’t be a first-line recommendation. With this in mind, first-line treatments are interventions that are expected to provide the best outcome for the patient with the fewest side effects.

Who decides what the first-line treatment is?

As you can imagine, there are numerous mental and physical health conditions that someone can experience — each of which is associated with a hierarchy of recommended treatments. That’s an unrealistic amount of (very important) information for providers to keep on top of. Which is why treatment guidelines exist. They distill this information into short, easily digestible recommendations for each condition, including a suggested sequence of treatment options. For example, if the first option does not lead to significant improvement, they can move on to the next one.

Third-party organizations such as the National institute of Clinical Excellence (NICE) in the UK, or the American College of Physicians (ACP) (amongst others) in the US create, manage, and distribute these guidelines using all available clinical research.

What is the first-line treatment for mental health?

Cognitive behavioral therapy (CBT) is considered the first-line treatment for most mental health conditions and insomnia. CBT has been proven effective in reducing symptoms of anxiety, depression and improving chronic poor sleep. Traditionally delivered by a trained mental health clinician in an individual or group setting, the aim of CBT is to change the thoughts and behaviors that perpetuate a mental health condition.

By tackling the root of poor mental health, CBT has been shown to have long-lasting results and comes with fewer side effects than medication. While medications still have a place in mental health care, they shouldn’t be the first or only option available to patients.  

For example, the American College of Physicians (ACP) guideline recommend the following steps for insomnia treatment:

• Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence)
• Recommendation 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (Grade: weak recommendation, low-quality evidence)

Mental health care, reimagined

Let’s circle back to the question posed at the start of the blog: How can we offer first-line interventions to patients in a format that’s as scalable and consistent as medications?

CBT-based digital therapeutics (DTx), with established effectiveness, are one great option. They allow providers to offer first-line treatment via safe and effective non-drug alternatives, when in-person therapy is inaccessible. Because DTx are fully automated, they don’t require a provider to teach patients CBT skills — thus eliminating long therapy wait times and the challenges of finding a mental health provider. In addition, patients have the ability to access the therapeutic anytime, anywhere.

Software is also incredibly flexible, allowing digital therapeutics to provide an experience tailored to each individual’s needs and pace. And most importantly, digital therapeutics by definition are clinically evaluated, and thus shown to be effective in gold-standard, peer-reviewed clinical studies. For example, large randomized controlled trials (RCTs) of Sleepio and Daylight — digital therapeutics for insomnia and anxiety — demonstrated a remission rate of over 70% for participants.

Everyone deserves access to high-quality care — not just what’s most convenient. With applied creativity and innovation, first-line treatments can be made available to the masses. Digital therapeutics offer an immediate way forward.