Online CBT is not a therapy substitute, but a step to help manage anxiety
Emotional disorders in young people are growing while NHS services are in crisis. Apps are not the cure but a stopgap
This article titled “Online CBT is not a therapy substitute, but a step to help manage anxiety” was written by Nihara Krause, for The Guardian on Sunday 30th December 2018 17.31 UTCAnxiety, one of the most common mental health problems, is a many-headed monster. Anxiety disorders include panic disorder, generalised anxiety disorder, phobias, social anxiety disorder, obsessive-compulsive disorder, separation-anxiety disorder and post-traumatic stress disorder. Anyone who experiences an anxiety disorder will tell you how acutely disabling it feels.
We all get anxious from time to time, particularly when we are about to do something we see as threatening or frightening. In the short term, anxiety is functional, making us feel alert while improving our performance. However, acute or chronic anxiety is unhelpful. It negatively affects our thinking, behaviour and emotional reactions, and can have a significant physical impact, leading to disorder. In addition, more than half of individuals with an anxiety disorder will have a coexisting diagnosis of depression.
Overall, 30% of Britons will experience an anxiety disorder during their lifetime. The Adult Psychiatric Morbidity Survey (APMS), published by NHS Digital in 2016, indicates that depression and anxiety disorders are the most common mental health problems, affecting one in six adults. More recent figures from NHS Digital confirmed that emotional disorders, which include depression and anxiety, are the most prevalent conditions in children and young people, affecting 8.1% of five-to-19-year-olds. Anxiety disorders reach a peak in girls between the ages of 17 and 19, affecting 20.9% of this age group.
However, even with such high prevalence and impact, anxiety disorders are under-diagnosed and under-treated in the UK. The NHS crisis in the provision of adequate mental health care is well publicised. Years of underfunding have left mental health services poorly resourced. This creates a bottleneck for treatment; the long wait for treatment is also likely to lead to more complex problems, which in turn necessitates more specialist and longer-term intervention. The NHS is at breaking point, especially so in child and adolescent mental health services (Camhs).
The recent survey by stem4, the youth mental health charity I founded, shows that 90% of GPs in the survey think mental health services for young people are inadequate, with nearly all (99%) fearing that children in their care could come to harm while waiting for specialist treatment.
In such circumstances the NHS has had to unofficially perform triage when it comes to crisis-level mental health conditions. As a result, people suffering from anxiety disorders lose out. Under current government funding proposals, new services to tackle rising mental ill health among children and young people are being developed, but the wait is long in the face of an urgent need for good-quality, comprehensive services. Even under these new funding proposals, it is unlikely that a robust programme for anxiety disorders will be rolled out in the near future. Anxiety disorders are very responsive to early intervention in the form of evidence-based treatments such as cognitive behavioural therapy (CBT), but in many local areas services of this kind have been cut, denying young people access to expert treatment.
Stem4 offers early detection through education in secondary schools and early digital intervention. Based on the requests made by many students, and on awareness of need observed in the course of my own clinical practice, I developed Calm Harm, a mobile phone app to help young people manage their urge to self-harm.Since its launch 18 months ago, Calm Harm has had close to 900,000 downloads. It is mainly used by young people under the age of 19, and 93% of them report that their urge to self-harm passed after each use of the app.
More recently I have developed Clear Fear, an app to help children and young people manage symptoms of anxiety using the principles of CBT. It aims to provide them with tools to help them negotiate some of the challenges they may face. It does this by offering them relaxation training, self-monitoring and ways of challenging negative thoughts and solving problems. It also harnesses the benefits of humour, feeds them inspirational quotes and examples of inspirational people, and helps them find the “grit” they need to keep going when the going gets tough.
Digital therapies should not be seen as a substitute for face-to-face engagement, assessment and treatment. But a handful of studies confirm that online CBT is as effective as face-to-face treatment for anxiety and depression. It therefore constitutes a first step in helping young people self-monitor and benefit from simple techniques for anxiety management.
Why are so many people anxious and are there common threats? Although digital connections are now flourishing, our relationships and community links are weaker. Our connection with nature is reduced, while an atmosphere of increased competition leads to less collaboration and unity. The world appears divided – a good example is the current state of UK politics. Fomo (fear of missing out) has become a prevalent term. In my opinion, the fear of being left behind is even higher. Social support is a vital contributor to recovery from major stress, and social connectivity is an essential factor in resilience. In addition to treating anxiety, perhaps we need to listen to the message it imparts and get to the heart of the problem.
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Dr Nihara Krause is a consultant clinical psychologist and the founder and CEO of stem4, a youth mental health charity
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