There is a preponderance of evidence that conventional approaches to the provision of mental health care do not meet the needs of a large portion of the population. Due to limitations of scale alone, there is an inherent misalignment between the number of individuals who can benefit from mental health assistance and the availability of traditional services.
Yet scale is not the only issue. Stigma, accessibility, and medical models of treatment are equal deterrents to seeking help. Poor mental health impacts us all and carries a huge socio-economic cost. Technology offers a solution and is already helping those experiencing depression, anxiety, and other such problems to lead healthier, more productive, happier lives.
Big White Wall (BWW)—a digital and behavioral health and well-being service facilitated by health care professionals—is one of these solutions. In the organization’s name, “big” recognizes the infinite nature of human emotion; “white” conveys the blank canvas the service provides; and, “wall” symbolizes shelter and support, as well as the barriers we sometimes need to break through to improve mental health.
We developed BWW in the United Kingdom in 2007, and in 2013, it was designated a High Impact Innovation by the National Health Service (NHS). In 2014, it became the first digital mental health service to receive Care Quality Commission registration, and in 2015, it was formally endorsed by the National Health Service (NHS) and promoted through NHS Choices.
Big White Wall expanded to Australasia in 2011, and to the United States in 2014. Our experience has shown that providing a wide range of behavioral health self-management services, anonymized peer support, and immediate access to evidence-based tools via a digital platform empowers people to seek assistance for their mental health challenges for the first time.
The Gap Between Mental Health Needs And Services
According to the National Survey on Drug Use and Health, one in every five adults in the United States—over 40 million people—experience some form of mental illness in any given year. These are mostly mild to moderate disorders, such as depression and anxiety, which can result in economic and social hardship as well as poor productivity at school or work.
Left untreated, these conditions can result in more significant problems, including incidences of disability. Indeed, serious mental illness, defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as resulting in serious functional impairment, affects nearly 10 million American adults each year.
Despite some of the known consequences of mental health disorders, the majority of these disorders go untreated. According to a report from the Centers for Disease Control and Prevention, only 35 percent of individuals with severe depressive symptoms reported seeing a mental health professional in the past year.
For the vast majority of those who do get treatment, it is via a primary care physician and mostly consists solely of medication. Access to broader support and treatment, such as evidence-based talking therapies, remains rare.
The Inherent Limitations Of The Mental Health Care Status Quo
Conventional approaches to mental health care are insufficient to deal with the magnitude of behavioral and emotional health needs when more than 40 million people face these challenges each year in the United States.
A study by Mental Health America found that there is one qualified mental health provider for every 790 citizens in the United States. Nearly 100 million Americans—and growing—live in an area where there is a shortage of mental health providers. But geographical access isn’t the only barrier to mental health services. A survey by SAMHSA found that individuals also do not seek assistance because of cost, lack of health insurance coverage for mental health care, fear of having others find out about mental health challenges, worries about job security, and general concerns about confidentiality. These mirror issues we find in the United Kingdom.
While the social stigma surrounding mental health has improved in recent years, it is still highly prevalent. Our determination that there was a need for the Big White Wall was, in part, founded in the knowledge that nine of every 10 individuals would not reveal their poor mental health to their employer for fear of discrimination. This fear makes it difficult for individuals with mental health issues to seek support and treatment as the risk of shame and exposure prevent them from reaching out.
Yet even if they do seek treatment, they are likely to have access issues. Most assistance for non-emergency mental health conditions is only available during a conventional nine-to-five workday schedule. However, stress, anxiety, and depression don’t always happen within office hours. Indeed our data show that people experiencing severe depression are often most troubled during the night. There may also be difficulties related to geography, physical disability, or the responsibility of caring for others. There are many reasons people simply cannot leave their homes to access mental health care. That is why digital systems, available 24 hours a day, are essential.
Expanding Mental Health Access Through The Digital Sphere
The Big White Wall concept was born from the realization that mental health services in the United Kingdom were woefully insufficient to meet the growing need. The challenge was threefold: First, address the capacity issue. How do you offer support and treatment to more than 20 percent of the population? Second, tackle the access problem. How do you extend mental health care to the 50 percent of those with poor mental health who do not reach out to primary care providers and whose struggles are often hardest outside of office hours? Third, how do you counter stigma?
The solution to all three of these challenges was a 24-hour digital service based around a safe and anonymous clinically facilitated peer community. Digital services, accessible from a personal computer or mobile device or tablet, provide both expanded access and a new level of privacy never before associated with these types of therapies.
The structure of Big White Wall reflects an understanding that those in need of mental health and well-being assistance have diverse needs. Where relatively unstructured self-guided therapy may work for some, others may find greater support from online connections with peers facing similar life challenges.
Big White Wall has been designed to offer personalized care pathways. When someone joins Big White Wall, they are offered pre-selected options, driven by machine learning algorithms which are most likely to improve their mental health and wellbeing. These may include:
- Self-expressive art therapy (also called “creating a brick”) where members use images, drawings, and words to tell their personal story. Some members find the creation of these bricks therapeutic in itself, while others wish to share and discuss them in a peer-supported setting.
- Anonymized peer support to break through feelings of isolation and openly share personal experiences. A wide array of topics allows members to connect with others who may, for example, be experiencing seasonal affective disorder or anxieties associated with work demands or the loss of a loved one.
- Online group courses on multiple mental health topics, led by trained, experienced professionals. These have been extremely useful not only in helping people better understand their feelings of depression and anxiety, but also in helping with health objectives such as positive thinking, mindfulness, or insomnia.
- A digital library of evidence-based resource materials to help members better understand and self-manage the conditions causing their psychological distress.
- One to one talk therapy with a credentialed therapist (this program—“BWW Connect”—is being launched in the US in 2015, and will offer the capability to conduct text, audio, whiteboard, and video sessions on a HIPAA secure platform).
Whatever the Big White Wall user’s needs, there are trained “Wall Guides” available 24 hours a day to provide assistance, answer questions and, perhaps most importantly, ensure that the member’s experiences are safe and welcoming. The Wall Guides, who are all masters level trained with degrees in social work, family and marriage therapy, and psychology (and report up to a doctoral level psychologist and psychiatrist), use a host of digital tools to help stratify users by risk, including groundbreaking data analytics that can deduct risk simply through the language someone uses when telling their story.
Members are also provided with self-measurement tools, such as the Patient Health Questionnaire (PHQ9), a widely used depression measure, and the Generalized Anxiety Disorder Screener (GAD7), a valid assessment tool for anxiety, so they can evaluate their own progress toward improved mental well-being.
Big White Wall operates as a standalone, end-to-end service as well as a wrap-around for those waiting for conventional care, to help with medication adherence and to prevent readmission for those leaving acute care. It complements and integrates with conventional care services. To date, BWW has been used by a broad array of payers and providers, including the military, insurers, employers, and colleges/universities. Among those who have used the service:
- 73 percent reported sharing a mental health issue for the first time in their lives.
- 95 percent reported an improved sense of well-being from using the service.
- 80 percent reported an improved ability to practice self-care.
Big White Wall has been particularly successful among those who serve their country in the Armed Forces. In the United Kingdom, approximately two thirds of Serving Personnel (68 percent), two thirds of Family Members (63 percent), and over a half of Veterans (55 percent) arrive with no previous treatment or support. Outcomes for these individuals include:
- average score reductions of six for PHQ9 and seven for GAD7 for Serving Personnel;
- average score reductions of six for PHQ9 and four for GAD7 for Family Members; and,
- average score reductions of five for PHQ9 and five for GAD7 for Veterans.
All of these results indicate significant improvement in symptoms and are correlated with improved function.
Extending The Wall To The United States
In 2014, Big White Wall extended its services to individuals in the United States. Just as in the United Kingdom, mental illness is exacting a tremendous societal and economic cost, with indirect mental illness costs totaling around $80 billion for U.S. employers annually, while health plans, accountable care organizations (ACOs), and others are calling for the integration of behavioral health into primary care.
Big White Wall is working with Kaiser Permanente Northwest—a large, nonprofit integrated delivery system in Oregon and Washington—providing the organization’s members with services that include innovative, emerging digital channels to supplement current mental health care.
Big White Wall is in the process of designing a unique program with a health plan in Texas, with expected implementation in early fall. The medical leadership of this plan views the BWW digital community platform as an innovative disruptor to traditional models of behavioral health and will use the program as an anchor for all aspects of its population health programs.
Another BWW customer, Mosaic Community Services in Maryland, through its community mental health centers, is working with BWW to provide its members with peer support and self-management tools. In addition, BWW has recently entered into a partnership discussion with Virtual Health Services, a subsidiary of Catholic Health Initiatives, to build upon and develop an enhanced digital engagement platform that incorporates medication education, promotes adherence, and enables pharmacist-directed interventions to members on BWW. If all goes to plan, BWW will be widely available in Texas, Massachusetts, California, and elsewhere by the end of 2015.
As health experts seek to integrate mental health into primary care, and patients themselves look for opportunities to take more control and have a greater say in their care, digital mental health solutions are taking root. A PricewaterhouseCoopers survey found that almost nine of every 10 clinicians in the United States believe mobile health applications will become essential for patient care over the next five years. It would stand to reason that these innovative approaches should also play a role in mental health policy discussions.
Better mental health is now just one click away.
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