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GMH Newsletter Featured Topics – May 2020

Digital Solutions to Mental Health Needs in the United States

Mental Health in the Digital Age

Videoconferencing with a psychiatrist, a pill that is tracked by a smartphone app when swallowed, and virtual reality treatments are all ways in which technology is rapidly transforming mental healthcare. Digital health is a booming sector that helps close the gaps in many high-income countries and low- or middle-income countries alike, and the focus on mental health in particular has exploded in recent years. In the United States, researchers and program developers hope involving the technology sector can help to close the gaps in access to mental healthcare while providing financial gains for investors. More than 75% of Americans own a smartphone and even more have access to the internet, giving app developers and healthcare innovators an opportunity to expand mental healthcare treatment outside of the provider’s office.1 As the number of new technologies to improve mental healthcare explodes, providers, patients, researchers, and policy-makers alike face challenges at understanding the solutions available and how to pay for them.

A Rapidly Changing Environment

Digital mental health solutions can take many forms. Some platforms work directly with healthcare providers to ease the process of referring a patient to mental or behavioral healthcare service while others help users themselves find and connect with a provider. Some apps provide access to therapists or psychiatrist through a user’s computer or smartphone, and others provide users with mindfulness guidance or other mental wellness-related programming that does not involve engaging with a trained clinician. Figure 1 demonstrates the saturation of mental health apps in app stores and the difficulty that consumers may face in determining which apps are evidence-based or best for their particular needs. Many healthcare providers see an advantage to those digital solutions known broadly as “blended treatments”, or when self-service and/or automated technology assists healthcare providers.2 Virtual reality experiences during treatment sessions have been used to help patients address phobias or depression, and other technologies simply help keep patients connected with their providers outside of appointment times.2 The University of Washington’s Dr. Dror Ben-Zeev and the University of Washington’s BRiTE Center developed the Focus app, which targets mood or depression, hearing voices,  sleep issues, social functioning, and medication use. The Focus app provides written or video suggestions from medical professionals for solutions to problems the user might be experiencing, and although use of the app is self-directed, Focus sends the user several prompts daily to address the main issues they may be experiencing.

Figure 1: Larsen, et. al. (22 March 2019). Using science to sell apps: Evaluation of mental health app store quality aims. npj Digital Medicine. 2(18).

In the United States, many insurance plans allow patients to engage with a mental health professional remotely in what is known as “telemental health”, but coverage of videoconferencing and other digital solutions varies widely by plan.5 In the University of Washington’s Department of Psychiatry, videoconferencing allows individuals to consult with a psychiatrist without attending an in-person appointment. Under current pandemic conditions in the United States, many healthcare providers are increasing offerings for individuals to engage with mental health professionals remotely through phone or video appointments.

 An estimated 1 in 5 Americans uses a smart watch or activity tracker, and companies are capitalizing on this ubiquity in their interventions for mental health. Abilify MyCite is a partnership between the technology company Proteus Digital Health and the pharmaceutical developer Otsuka America and has developed a way to track medication adherence.1 When their medication for schizophrenia or bipolar disorder is ingested, a sensor in the pill communicates with a patch worn by the patient to indicate that they have taken their medication that day. This health information is then reported to an app on the patient’s smartphone and transmitted to the patient’s physician.1 An estimated 75% of people with schizophrenia have difficulty adhering to their medication, and innovative technologies could improve adherence to care and the lives of patients.2

As the number of digital interventions increases, so does the number of evaluative research studies seeking to understand their true impact on health. By 2014, over 126 research studies had evaluated technological mental health interventions for children and adolescents, and a search for studies of evaluations of digital mental health interventions produces over 16,000 results from 2019 alone.3 Evaluative studies tend to report satisfaction among providers and users of telemental health solutions. Studies are also beginning to show that telepsychiatry and other video conferencing interventions are effective at helping patients reduce symptoms of mental disorders like anxiety and depression.3 The number of technological strategies to treat mental disorders and improve mental well being is growing exponentially, which makes it difficult for the research community to keep up. Convincing health providers and health systems to use new technologies and showing that they are effective is increasingly difficult for developers and researchers as the market becomes more saturated with digital mental health solutions. Over time and with increased focus on evaluating these technologies, perhaps providers, health systems, and users can make informed decisions about which interventions will be most effective for their purposes.

Political Contexts

These innovations are exhilarating for those seeking to improve the delivery of mental health care in the United States and around the globe but engaging in mental health care in the United States can be costly or complicated by the insurance landscape. Many low-income and/or under-insured individuals who might need services may not be able to take advantage of some of these innovative solutions if consultation costs or user fees are not covered by insurance. In February 2019, Massachusetts became the last state to provide Medicaid fee-for-service coverage for telemental health solutions.4 However, the types of services covered and amount of coverage vary in many states for Medicaid patients, so many of these new technologies are not accessible. 39 states and Washington D.C. also have laws known as mental health parity laws, which require insurance payers to cover telemental health services similarly to their coverage of in-person services.5 Although this may seem like telemental health services are available to those who need it most, there are many complications that make this untrue. Some states only require commercial insurance payers to cover telemental health solutions, but in others even Medicaid is required to provide coverage of these services.5 Proof of medical necessity also complicates this coverage in some states. Understanding what technologies are available, whether they are effective, and whether they are covered by insurance may be difficult for individuals looking for digital mental health solutions.

Looking Forward

New technologies provide exciting solutions for mental health treatment but are also collecting enormous amounts of digital health data that has potential for use in research and policy development. The deployment of these technologies also warrants careful consideration of privacy protection and protection from discrimination. Some researchers compare the collection of digital information from patients using digital mental health platforms to biomarkers such as cholesterol that are routinely used in diagnosis. Mental healthcare has historically relied on written notes from providers, but technology could analyze voice or engagement with mobile devices, social media content, and other behaviors to provide insight into a user’s mental wellbeing.1

Figure 2: Interconnectedness of policy, technological innovation, practice, and research in the mental health technology field

As the digital mental health space continues to expand with new technologies in the United States, there is significant opportunity for policy-makers and researchers to take advantage of these developments and facilitate their use by providers and patients. State policy development is slow, and several states (including Massachusetts) have had difficulty passing parity laws that could improve coverage of digital solutions.4 Continued advocacy for these policy changes may improve coverage of mental health technologies over time, but research advances and advocacy from developers, providers, and patients must occur concurrently. Evaluation of the effectiveness of new technologies can improve their legitimacy, improving the likelihood that policy-makers and insurance providers will take note and make them more accessible. Completing the feedback loop shown in Figure 2, patient and provider use of these new technologies can encourage research institutions to invest in evaluating their effectiveness. With these actors working in tandem, the emerging mental health technology sector provides exciting opportunities for the future of mental health service delivery in the United States.


  1. O’Hara D. (6 June 2019). Wearable technology for mental health. American Psychology Association.
  2. Mathieson SM. (15 May 2019). How technology is transforming mental health treatment. The Guardian.
  3. Boydell KM, Hodgins M, Pignatiello A, Teshima J, Edwards H, Willis D. (May 2014). Using technology to deliver mental health services to children and youth: A scoping review. J Can Acad Child Adolesc Psychiatry. 23(2): 87-99.
  4. Wicklund E. (15 Feb 2019). Massachusetts embraces telemental health for Medicaid members. mHealth Intelligence.
  5. Epstein Becker Green. (2019). Telemental Health Laws Survey. (2019 Update).
  6. Shiffman J, Smith J. (2007). Generation of political priority for global health initiatives: a framework and case study of maternal mortality. The Lancet, 370: 1370–79

Spotlight: PHI COVID Awards and Mental Health

The Population Health Initiative has launched a COVID-19 rapid response funding call to support the University of Washington research community in quickly responding to the vast array of population health-related challenges created by the COVID-19 pandemic. This spotlight will feature two of the winners of PHI COVID Awards who are investigating the impact COVID-19 has on the mental health of vulnerable populations.

COVID-19 and Pregnancy

Principal Investigator:

Kristina Adams Waldorf, M.D. is a Professor in the Department of Obstetrics and Gynecology and Adjunct Professor in Global Health at the University of Washington School of Medicine. She is an actively practicing obstetrician-gynecologist with research interests in pregnancy infections, preterm birth and fetal injury related to Group B Streptococcus, E. coli and more recently, the zika virus.



Amritha Bhat, MBBS, M.D., MPH is a psychiatrist trained in both India and the United States. Dr. Bhat is currently an assistant professor in the University of Washington Department of Psychiatry and Behavioral Sciences. She established the perinatal psychiatry clinic at the University of Washington Medical Center and has also implemented screening for depression in mothers whose babies are admitted to the neonatal intensive care unit. In addition, Dr. Bhat is actively involved in projects that make collaborative care for depression available to women during pregnancy and postpartum.

Full co-investigator list

Q: How have you seen the COVID-19 epidemic affect the mental health of your patients?

Dr. Amritha Bhat: The pandemic has several implications for pregnant people, disrupting their plans for baby showers, forcing them to change their birthing plans and causing anxiety and distress about the possibility of having to deliver without their support person, about transmission of the infection to their babies, or having to be separated from their baby for up to 2 weeks. We know from previous natural disasters and epidemics that pregnant women are at higher risk for depression, anxiety and post-traumatic stress, so it is critical that we closely monitor and support the mental health of pregnant and postpartum people during this pandemic. In clinical practice we have seen an increase in depression anxiety and post-traumatic stress disorder especially in those already at higher risk of these conditions. On the other hand, we have also seen some people who are doing better and have had more time to connect virtually with their loved ones, and have found that having their partner home has provided them with additional support.

Q: Please tell us a little about the project you are conducting with the PHI COVID award.

Kristina Adams Waldorf: The PHI COVID Award will enable us to build upon and expand the Washington State COVID-19 in Pregnancy Collaborative, which is a network of obstetrical providers in Washington State that currently represent sites with 40% of all births in the state. Through this network, we can capture outcomes related to maternal and newborn health impacted by COVID-19, including the mother’s mental health. The award will enable us to add partners and sites to cover 80-90% of all state births, as well as, launch studies of maternal mental during pregnancy and postpartum. The scope of our population-based study is unique to the U.S.

Q: Can you also tell us about the work you’re doing around mental health in this award?

Dr. Amritha Bhat: We are planning to collect information on symptoms of depression, anxiety stress, and presence of intimate partner violence where available, from the charts that we are reviewing. We also plan to initiate a follow-up study tracking mental health symptoms in the postpartum period.

Q: How could this research be translated to other populations around the world?

Kristina Adams Waldorf: Seattle was a “canary in the coal mine” for the United States with identification of the first case and community transmission of COVID-19. The actions by UW Medicine and the Washington State Department of Health not only saved lives in our region, but also made their protocols available publicly and in real time. Our goal is now to translate our data into public health interventions that can make an immediate impact on mother-child health in Washington State. Making our protocols and public health messaging widely available would help to make this work have a wider global impact.

COVID-19 and the Latina Immigrant Community

Principal Investigator:

India Ornelas, PhD, MPH, Associate Professor, Health Services


Deepa Rao, PhD, Professor, Global Health

Jen Balkus, PhD, Assistant Professor, Epidemiology

Georgina Perez, LICSW: Georgina Perez, LICSW is a clinical social worker and public health researcher. Georgina is a part of the team implementing Amigas Latinas Motivando el Alma (ALMA), a mindfulness program aimed at building coping skills to reduce rates of anxiety and depression among Latina immigrant women. Georgina’s research interests lie in mental health among Latina Immigrants and intervention strategies to improve mental health among this population.

Q: How have you seen the COVID-19 epidemic affect the mental health of the Latino immigrants in King County?

Georgina Perez: Recent public health data suggests that Latinos are at increased risk of poor outcomes from COVID-19 in Washington state when compared to non-Latinos. This may be due to underlying social determinants of health such as housing, transportation, employment, and immigration policies. In our experience speaking with ALMA participants and our community partners, they have shared that women are facing challenging emotions; have concerns about finances; and are worried about COVID-19. These concerns include whether they will be able to continue to work or have the appropriate personal protective equipment and how to cohabitate and care for someone that has COVID-19. Some have concerns about people that are already in detention centers being at risk for getting COVID-19. All these factors can impact the mental health of this population and emphasize the importance of research in this area.

Q: Please tell us a little about the project you are conducting with the PHI COVID award. Can you also tell us about the work you’re doing around mental health in this award?

Georgina Perez: Our current study assesses the impact of the Amigas Latinas Motivando el Alma (ALMA) intervention to reduce stress, depression, and anxiety among Latina immigrant women. We have already conducted surveys on mental health, stress and demographic factors with over 150 Latina immigrant women in King County. In our new study, we will collect additional data from these women to assess the impact of COVID-19 outbreak on their households, including exposure to COVID-19, disease severity, access to testing, and health care seeking. We will also ask about the mental health, economic and social impacts of the outbreak. In addition, we plan to develop and pilot test online sessions that are similar to the ALMA intervention. We will direct participants in need of services to local resources and our pilot intervention has the potential to reduce the mental health impacts of the outbreak. We will also share data with state and local agencies coordinating the COVID-19 response.

Q: How could this research be translated to other populations around the world?

Georgina Perez: Given the current situation and the growth of the Latina immigrant population in the United States, developing interventions that reduce mental health disparities in this population can have a significant public health impact. Our work with ALMA, both before and especially during the COVID-19 pandemic, has encouraged us to find innovative ways to connect with participants including Facebook live, Zoom, and WhatsApp. We hope that our research is useful to other communities experiencing similar COVID-19 related disparities.