Last May, 20-year-old Chloe saw her local GP in Grimsby, in the north-east of England, after a personal trauma pushed her to seek professional help. Chloe had been dealing with severe depression and anxiety on and off since she was 13, when she took her first overdose, so she knew she needed therapy to stop herself from deteriorating again.
“[My GP] asked me some questions and put me down on a waiting list for face-to-face counselling,” she said. But the help she needed was not forthcoming. “Over a year later, I’m still waiting for it.”
Until she turned 18, Chloe had been part of the Child and Adolescent Mental Health Service (CAMHS), the unit of the UK’s National Health Service that serves young people with mental health issues, under which she struggled with nine attempts at suicide. After her most recent trauma, she was no longer eligible for youth services and joined a long list of adults in her area waiting for counselling services.
While Chloe waited for a face-to-face counsellor, her GP introduced her to Kooth, a digital mental wellbeing platform for young people, which is available for free in parts of the UK. The British company, which was launched in 2004 for 11- to 25-year-olds, employs 40 trained therapists who provide text-based counselling, using a pluralistic approach, tailored individually to each patient.
Number of children and young people on the caseloads of NHS mental health services at any one time
The service is primarily paid for by about 100 clinical commissioning groups across the NHS that partner with the company. Last year, Kooth had 98,000 unique users, with roughly 17,000 log-ins to the service daily.
“[On Kooth] I’ve had the same person counselling me the whole way through,” Chloe said. “We would have an hour-long chat each week. I could decide what time and day.”
“[Compared with CAMHS], at Kooth I felt safer,” she added, “and I felt I knew that counsellor much more than the ones I saw face to face.”
The mental healthcare supply gap
Chloe’s 14-month wait is not uncommon for patients seeking mental healthcare through the NHS. Recent figures show that there are 240,000 children and young people on the caseloads of NHS mental health services at any one time.
“There is a really significant gap between the needs of people and availability of services. Depending on how you are looking at this, only roughly a third of people actually get the help they could do with,” said Paul Farmer, chief executive of the mental health charity Mind and the chair of the NHS’ independent mental health task force.
The NHS’s long-term plan, published earlier this year, listed mental health as a priority, recognising the need to expand access to hundreds of thousands of additional people, but a yawning supply gap remains. Official estimates say the NHS requires an extra 20,000 medical professionals to be in place by 2022 to meet the growing need for mental healthcare.
Digital services — including internet-facilitated therapy — are seen as an effective way to plug the gap, as a handful of platforms such as Kooth, are doing. These services, staffed by trained clinical therapists, are distinct from preventive mental wellness apps such as Headspace and Calm, and others that use automated therapeutic approaches.
“Our average wait time is 15 minutes,” says Zoë Blake, chief executive of Kooth. “Compared to the NHS, where, on average, 70 per cent of young people wait four weeks for an assessment, and up to a year before they start counselling, the immediacy of digital is remarkable, really, for them.”
Kooth is completely anonymous, allowing young people to book therapists through its website. It doesn’t have an app, because downloading apps often requires parental permissions or a credit card (even if free), and leaves a record. The service is publicised in available areas via Instagram, GP practices and by Kooth’s team of youth workers, who present the service in local school assemblies.
“Our son Archie was diagnosed at the age of 15 or 16 with OCD [obsessive compulsive disorder], which is an acutely punishing condition in its true form. The thought of Archie being in that assembly and hearing about a route you can take which can be anonymous and confidential, that could have been transformational for him,” said Norman Lamb, UK member of parliament, who was recently appointed head of Kooth’s independent advisory board.
Meanwhile, Ieso, another digital platform that connects adult patients to a network of 600 therapists, says its average wait time is five days. The company, which, like Kooth, is exclusively an NHS supplier, will treat 15,000 patients this year for moderate to severe mental illness, including depression and anxiety.
“A third of our patients are from rural areas. People don’t have to travel, they can continue to work, but have improved access to therapy,” said Nigel Pitchford, chief executive of Ieso.
‘We have to think creatively about how to meet need’
While better access to care is a clear advantage of digital platforms, academic research is now showing that online therapy is also equivalent to — or sometimes better than — face to face therapy, in terms of its clinical efficacy.
“We have a reasonably good evidence base that suggests talking to a therapist online is clinically effective, and has a clinical effectiveness that is akin to seeing somebody face to face, so there is clearly some benefit in making that more available,” Mr Farmer said.
Ieso claims its positive clinical outcomes are in the 60 per cent range, compared with the 50 per cent reported by the NHS for face-to-face therapy. “We also know that we require fewer sessions than we thought. Our average number of sessions in order to get people well is 6.3, in the NHS typically it is eight-plus sessions,” added Mr Pitchford.
Another advantage of text-based therapy is that the entire session between therapist and patient exists as text and can be analysed. “That is a pretty unique data asset so we have been able to explore some of the characteristics of therapy [and] what good therapy looks like,” said Mr Pitchford.
Ultimately, the anonymity and consistency of online therapy is what patients, particularly younger ones, are drawn to. “This isn’t a replacement for traditional therapy,” said Mr Lamb, “but we have got to think creatively about how to meet need in a more effective way.”