How Can Digital Tools Solve the COVID Mental Health Crisis?


Even before the COVID-19 pandemic swept around the world, over 260 million people worldwide were suffering from depression, and nearly 130 million new cases of depression developed every year. As the pandemic forced billions of people into periods of isolation and raised stress levels over everything from personal relationships to job and food security, the state of worldwide mental health teetered on the brink between crisis and catastrophe. With traditional face-to-face treatment hindered by social distancing measures and a shortage  of trained professionals to deliver care, many governments and organizations turned to digital mental health interventions, low-intensity treatment options delivered through online platforms, mobile devices, or telephones.

On March 31, NYU Shanghai Professor of Global Public Health Brian J. Hall and Martin Vandendyck of the World Health Organization (WHO)’s Western Pacific Region brought together researchers and public health practitioners from eight countries spanning Asia, Europe, and Oceania to consider the promise and practice of digital mental health interventions, which not only meet many of the needs of the pandemic, but also address many barriers to care that have made mental health such an intractable global problem.

Dr. Ken Carswell of the WHO’s Department of Mental Health and Substance Abuse in Geneva, Switzerland and Professor of Clinical Psychology at Vrije Universiteit Amsterdam (Netherlands) Pim Cuijpers kicked off the conference with keynote addresses exploring digital interventions’ potential for depression and anxiety sufferers in places with less-developed mental health care infrastructure, especially in Asia.

Panelists Gan Yiqun of Peking University and Ren Zhihong of Central China Normal University in Wuhan were among 11 panelists from across the WHO’s Western Pacific Region who shared  their own innovative projects creating and delivering digital mental health interventions, particularly to young people who have been disproportionately affected by anxiety and depression during the pandemic.

For full recordings of the presentations by panelists, visit the conference website.

We sat down with Professor Hall to talk more about his own experience with digital mental health interventions, and to learn more about how this innovative approach can win back the millions of years of life lost to depression around the world.


Why is mental health such a difficult issue to address? Even in places where much of the stigma of seeking mental health care has been removed or mitigated, effectively treating mental health is still a big challenge. Why is that so?

A lot of people may not recognize that they are having a mental health issue. Unlike a broken bone, depression or anxiety might not reach the level of acute need for many people. This can leave many to suffer in silence. Some public mental health approaches are aimed at increasing mental health literacy for this reason -- if you don’t know the problem, you can’t adequately find solutions. But for many, even after identifying the need, there is still a resistance to seek care, whether that’s due to lack of knowledge about the treatment process, or whether they don’t want to admit that they need treatment. Cultural stigma against seeking mental health treatment can also discourage people from engaging in traditional face-to-face models of therapy.

Another issue is access to care. People may not be able to afford treatment, or there may not be a sufficient supply of treatment providers. There is a massive treatment gap across most of the world , especially among marginalized populations, primarily because of a limited number of treatment providers in the regions or communities in which these populations live. Mental disorders are among the leading causes of disability and morbidity globally, and it is widely recognized that physical health and mental health are intimately linked. So it is of paramount importance that we take a more systematic approach to addressing mental health globally.


Hall in his office at NYU Shanghai

Hall joined NYU Shanghai in fall 2020 from the University of Macau, where he led the Global and Community Mental Health Research Group.


So how does going digital help address a lot of these issues with mental health care?

The most important characteristic of evidence-based digital mental health interventions is that they are what we call “scalable,” so they are easy to offer to larger and larger populations quickly, without having to make substantial changes to the program and without having to train a lot of specialized caregivers. Since digital treatment programs rely less heavily on human resources, they can be cost-effective, sustainable alternatives to in-person care. They can also reduce the stigma of seeking mental health treatment because they can be used anytime, anywhere without signaling to others that someone is seeking treatment.

At the same time, it’s not a comprehensive solution to all mental health issues. Digital mental health interventions are part of an optimal mix of services that can help meet the needs of large populations of people with moderate mental health concerns. A smaller proportion of the population with more serious mental health concerns will need a combination of treatment options that may include digital interventions, but that will also likely include face-to-face treatment and perhaps medication-assisted management.

Right now I’m leading a project through the WHO that is developing a policy framework for addressing the mental health gap among marginalized populations in the Western Pacific Region [which includes East Asia, Oceania, and parts of Southeast Asia]. Digital mental health solutions are becoming an important part of WHO recommendations around the world, and these programs are going to play a strong role in my own project’s recommendations for this region.


Can you tell us more about your work delivering digital mental health interventions to real people who are suffering from poor mental health and depression?

Chinese young adults and Filipino migrant workers have been a part of my ongoing research program to expand access to needed mental health services in China. Roughly 1 in 4 Chinese young adults will experience a common mental disorder like depression, and the stress and pressures of academics and emerging into the workforce can be a significant burden. There are hundreds of thousands of Filipino migrant workers across Asia, and the prevalence of common mental disorders among this population is roughly 1 in 3. Both of these populations experience cultural stigma around seeking mental health treatment, and neither of these populations has robust treatment options available to them. We can really make a significant impact on mental health in our region by finding a culturally appropriate digital mental health solution for these populations, so we put a huge amount of effort into engaging these groups in co-creating digital applications to meet their specific needs.

My research teams used a WHO-developed digital mental health treatment program called Step-by-Step as the base intervention for both Filipino migrants and Chinese adolescents. Step-by-Step uses an illustrated story of a person who has learned ways to deal with their stress, anxiety, and depression to teach users behavioral activation and stress management strategies. Program users also receive 15-20 minutes of guidance per week over the phone or through chat messaging from an E-helper, who is a trained and supervised non-specialist. We spent several months working with focus groups of members from each population to adapt Step-by-Step’s content -- the story, visuals, and language -- and then we tested the two program adaptations with Filipino migrant workers and Chinese college-age users who were experiencing depression. We did qualitative interviews with the program users, both those who stayed with the program and those that dropped out, and we received a lot of positive feedback.


Illustrated panels show Filipino characters preparing care packages for relatives back home and Chinese characters enjoying social time with classmates

Hall and fellow researchers worked closely with focus groups, mental health care providers, illustrators, writers, and software developers to create adaptations of digital mental health intervention Step-by-Step for Filipino migrant workers (left) and Chinese young adults (right).


Why is it important to go beyond simply translating the intervention into the target users’ language? 

There is ample evidence to suggest that adapting all the visual and conceptual content of an intervention program improves the impact of that intervention. Culture shapes the motivations behind people’s life choices, so understanding culture helps us understand the pressures and stressors in the lives of the groups we work with. In digital mental health work, culture tells us the “why” behind people’s interest in seeking treatment: It tells us which social roles they feel they are having difficulty performing because of mental ill health.

For example, most Filipino migrants workers migrate in order to provide remittances to family members back home. Often migrant workers will neglect their own wellbeing in order to provide greater remittances. So when we adapted Step-by-Step for the Filipino migrant community, the underlying narrative was about making sacrifices to benefit loved ones at home, and also about seeking care in order to better serve their social role as providers. In the case of Chinese young adults, many of them experience stress related to academics because of a broader cultural expectation to perform well academically on behalf of their family members. So for Chinese youth, we adapted Step-by-Step’s narrative to focus on a school-related issue and its relationship to the fulfillment of this social role.


So what’s the next step for these programs?

From the clinical trials that we have done with both the adaptations, there is enough evidence to say that these interventions are effective. So the next step may simply be to find partner organizations or partner institutions like universities to scale up these programs and try to treat as many people as we can. But we also received feedback from some users of the program that they were interested in enhancements, like games or peer interactions, elements that are beyond the scope of the app platform that we have. So another possible next step could be working with the app developer to iterate some additions to the program, and we could then do trials to see which of those programs are more effective in terms of retention and symptom reduction.