Virtual Mental Health in Our Post-Pandemic World -

As demand for mental health resources increases in the wake of the COVID-19 pandemic, supply is increasing in the form of virtual face to face therapy appointments. This growing sector has the benefits of accessibility and flexibility, but misses out on the human connection and therapeutic space of in-person sessions. The balance between online and in-person may come in the form of blended virtual/in-person therapy models, providing providers and patients with a more integrated approach to therapy.

Though the COVID-19 pandemic is not yet over, there’s a “second pandemic” already looming large in the form of a mental health crisis. The Centre for Mental Health predicts 500,000 more people in the UK will experience mental health problems post-pandemic, with depression anticipated to be the most common diagnosis, disproportionately affecting high-risk groups. This unequal distribution will exacerbate existing healthcare inequalities, including access to care. Several groups have already been affected, such as healthcare workers, pregnant women, those with addiction problems and eating disorders.

Using the ONS and Mind’s estimate of 5.34 million Britons already struggling with depression, a hike of 500,000 individuals with mental health challenges translates to close to a 10% surge. During the course of the COVID-19 pandemic, a Mind survey found that a staggering 22% of mental health patients had their appointments cancelled and 25% could not access help. These statistics showcase a crippling increase in demand for services in an already strained system of mental support resources. Moreover, the burden of this need would largely fall on the young, with 80,226 more under-18 year olds making 999 calls in 2020 than 2019.

Previously, the BMA had documented a lack of adequate resources in mental health care across the UK. While the NHS has earmarked £2.3 billion in additional mental health spend by 2023/2024, at best this incentive still represents a 3 year lag between supply and demand. Underscoring the immediacy of this need, the BMA found an increase in suicide rates across previous public health crises, documented in the 2003 SARS pandemic in Hong Kong.

As COVID-19 assumed priority in healthcare centers nationwide, other health concerns went untreated, resulting in a decrease in availability of mental health resources with 2 million fewer GP appointments booked in 2020 compared to 2019. According to a Lancet study on resource allocation, there was an initial contraction in outreach for mental health issues, with the greatest decrease in depression, self-harm, anxiety, and obsessive-compulsive disorder complaints between March- August 2020. This number steadily rose as the pandemic wore on, resulting in double the number of daily calls to Mind’s Infoline in October 2020 compared to 2019. With in-person community resources curtailed, options for receiving mental health support remain scarce in the wake of the pandemic. Compounding this scarcity, as physical health issues went untreated, emotional wellbeing further declined, not to mention post-COVID PTSD, grief, and long COVID.

One sector that rose in prominence during this past year has been online therapy. As the rest of the world transitioned from in-person to virtual service offerings, psychological therapy was able to join this trend and similarly expand within existing technological capabilities. With the advent of more online therapy, patients in growing need were able to access practical solutions.

Google trends shows a 400% increase in “online therapy” searches from the start of 2020, and one smart phone based therapy app estimates a 500% increase in companies interested in providing mental health care for their employees. Further to this increase in digital demand, one Dutch study found that over 80% of practitioners made use of digital tools since May 2020. As such, it makes sense that more online therapy companies are entering the market, aiming to provide much needed relief for strained resources.

As with any new frontier, the limitations of virtual mental health therapy are still largely in question. The new entrants in this market have been of varying quality, with several publications outlining concerns about whether clients are being exploited by unaccredited online counselling. As traditional providers create an online presence, they may be hindered by poor technological infrastructure, leading to a disjointed patient-provider relationship and confusing service navigation. For example, recently trying to access a free CBT online therapy service led to a “page not found” message. These providers may struggle to adapt to an online format, and are competing in an unregulated marketplace that further obscures the ability to discern quality.

Non-professional enterprising individuals may also sense an opportunity, leading them to create virtual therapy companies. These founders may create online profiles while having little to no personal experience in clinical psychology, capitalising on a gap in the market but not fully understanding the landscape. These virtual therapy matching services can use the pressing demand for therapists to their advantage, charging unclear fees, advertising therapists with unknown or overstated credentials.

In addition to unclear quality controls, these private services may offer services by therapists at various levels of training, perhaps unclear to the user. For example, a “psychologist” is not a legally protected term in the UK, so can be used by individuals with a variety of levels of experience and training. Psychologists then require further training and a doctorate degree, as well as registration with the Health and Care Professions Council (HCPC), to use restricted titles such as “clinical” or “counselling” psychologist. This legal protection is different to psychotherapists, which is not a legally protected title. Psychotherapists who are registered or accredited with a professional body are verified to have completed substantial training, often specialising in a particular type of therapy – such as psychodynamic or cognitive behavioural. Finally, counsellors are not a legally protected title and users must do their own research to verify the counsellor’s credentials.

Aside from logistical hurdles, there are inherent adaptations necessary to engage in virtual face to face therapy. These considerations include patient privacy, decreased engagement, and the loss of disinhibition that occurs in a dedicated therapeutic space. Some individuals do not have dedicated space at home for therapy, and many a session has taken place from parked vehicles. Therapists are learning to adapt to tracking nonverbal cues over screens, and patients are more involved in creating their own therapy environment. Finally, connectivity issues can interrupt a therapy session or limit patient access.

Offsetting these considerations are the upsides to an increase in online therapy options: increased access, particularly to regions and individuals who have historically and/or continue to struggle to attend in-person appointments, increased flexibility in the patient-therapist relationship, and increased reach as providers are no longer limited to their geographical region. Furthermore, a 2018 study published in the Journal of Affective Disorders found that cognitive behavioural therapy (CBT), a mainstay treatment in mental disorders, was just as effective online as in-person for major depressive disorder and generalised anxiety disorder, among others. In addition to the added possible benefit of speaking from the home environment, unofficial reports have stated that family pets have been assisting with therapy. In an evermore virtual world, the trend is here to stay – albeit as an evolving service modality.

While it is clear that online therapy is here to stay, the balance between in-person and online is still in flux. The nature of therapy delivery will pan out over the coming months as the world slowly wakes up from the virtual realm. One option is a dominance of new blended therapy models, offering integrated online and in-person therapy sessions with self-improvement tools, transparent pricing and flexibility in insurance versus self-pay.

Companies such as My Therapy Assistant (MTA) or Private Therapy Clinic in this online therapy space can be viewed as part of this new sector creating blended virtual/in-person mental health clinics. These companies’ extensive services and in-house software platforms create an ecosystem for the patient, transitioning care from in-person to virtual and blurring the personal with interpersonal. As virtual mental health appointments gain popularity, it is critical to establish reputable brands that keep therapy delivery outcomes in mind while maximising ease of access.

One step at a time, virtual mental health services are stepping up to fill the need gap left by the COVID-19 pandemic. After all, if we could provide more people with mental health resources, we can all ride out the rest of this pandemic with a little bit more ease.