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Are You Ready for the Annual Psychiatric Times World CME Conference? 

At the Annual Psychiatric Times World CME Conference, an all-star lineup of presenters will share their latest research. Check out this preview of the full agenda. 

The United States has been experiencing a critical shortage in access to mental health for years now. According to a 2018 study from the National Council for Mental Wellbeing, 38% of Americans seeking care had to wait longer than a week for necessary mental health treatments, and 46% either knew someone who had to drive an hour round trip to seek treatment or had experienced that challenge themselves.

These challenges go hand in hand with our ongoing national psychiatrist shortage. According to the National Council for Mental Wellbeing’s exhaustive 2017 report, by 2025, between 6090 and 15,600 additional psychiatrists would need to be added to the workforce to meet projected demand.

 Those statistics could paint an even more drastic picture when taking into account the national mental health crisis brought on by the COVID-19 pandemic—particularly its 

Current Inequities in High-Quality Care Access

The current state of behavioral health boils down to this: we are in a crisis of access to care. However, while demand for care exceeds workforce supply nationwide, there are communities and specific demographics that are disproportionately impacted by access issues. The National Council report on the shortage found that 55% of counties across the US had no current practicing psychiatrists, and 43 of 50 states experienced a severe shortage in psychiatrists specializing in child and adolescent care.

Currently, the system is so overwhelmed that patients have to wait months to access a clinician. While rural areas are still especially underserved, areas with an abundance of mental health practitioners have also been overwhelmed during the pandemic. This situation can be discouraging for families because when they do reach out for care, they do not get called back—or they do not know who to call.

COVID-19’s Impact on Children’s Mental Health

According to the American Academy of Pediatrics, 1 in 5 children or adolescents in the US have a diagnosable mental illness that requires some form of intervention or treatment. This situation has been highlighted and exacerbated during the pandemic, which introduced new, long-term stressors into the lives of many children and families. Whether due to socioeconomic losses during the pandemic, stressors of in-home schooling, or added stressors on caretakers trying to adjust to a new normal, 

COVID-19 magnified existing mental health vulnerabilities

Children have been particularly vulnerable in this environment because they 

. Suddenly, they did not have school counselors, teachers, or coaches available to them as a support system. The isolation resulting from this shift drastically increases the risk of depression and anxiety—even up to 9 years after the fact.

 Additionally, studies have found the duration of loneliness has a larger impact on children than the intensity, making the 14+ months of school closures a significant mental health challenge for children.

During 2020, we also experienced an increase in acuity of need among children. Many children and families are in crisis and are overwhelming pediatrician’s offices, or they are taking to emergency departments (EDs) as a last resort for treatment. According to the Centers for Disease Control and Prevention, mental health-related ED visits for children aged 5 to 11 and 12 to 17 increased by 24% and 31%, respectively.

It is also important to note that, even before the COVID-19 pandemic, 

depression and anxiety diagnoses for children

 have been on the rise—with the percentage of children aged 6 to 17 diagnosed with anxiety or depression growing from 5.4% in 2003 to 8.4% in 2012.

Telehealth is directly helping the access issue by reaching many of those underserved areas that do not have behavioral health providers available to support their demand. There are many areas that would be forced to go without providers if it were not for telehealth.

Now, as we move forward, more Americans not only have had direct experience with telehealth—but in many cases, they prefer it to in-person care. The American Psychiatric Association recently released a poll demonstrating that nearly 60% of Americans would use telehealth for mental health services.

 As a result of patients adapting to a more virtual world during COVID, telehealth (specifically for mental health) is more mainstream and comfortable for patients than ever before.

 for so many during the pandemic that providers now understand they can deliver high-quality care through this methodology. The opportunity is there for organizations to continue to recruit providers who can reach some of the underserved in this manner.

What Patients Can Expect From Telehealth Visits

Although more patients and families are familiar with telehealth now than ever before, it is important for providers to set parameters with the families first in terms of expectations for telehealth visits. In practice, telehealth appointments should operate as close to a standard in-person visit as possible. However, these are some best practices to ensure the visit is successful: 1) the appointment should be confidential and in a secure location, 2) providers should confirm the patient’s location and ensure they have a secondary plan in place if the telehealth connection is lost at any point during the appointment, and 3) providers should expect to spend more time building rapport with the child, particularly if it is an initial appointment.

Because of the pandemic, a lot of families are starting with the pediatrician’s office. Many pediatricians still have dedicated clinicians running telehealth appointments. There are also providers that patients and families can access through more dedicated mental health organizations, like Community Mental Health Centers (CMHCs) or Federally Qualified Health Centers (FQHCs) that have behavioral health programs. CMHCs and FQHCs also generally accept Medicare and Medicaid, so if a particular patient is not on private insurance, these organizations are good options for access to mental health services.

Potential Limitations for Using Telehealth for Children

While telehealth is as effective as in-person care in many cases, there are certain scenarios where it may not be the best fit for a patient or family.

For example, if the patient is younger than 6 years old, it may be more challenging to get them to engage virtually. Then, for some patients on the autism spectrum who need applied behavioral analysis as part of their treatment, telehealth may not be the best course of action.

For more rural communities that have persistent challenges with broadband, COVID-19 helped open up regulations around audio-only appointments as a lifesaving option (before COVID, many individuals in those communities would have to go without care). However, audio-only appointments can pose particular challenges with children, especially younger children, who are not able to verbalize their feelings and emotions effectively over the phone. That is where organizations or providers might see the advantage of having the virtual platform through a centralized location, like a pediatrician’s office or a clinic that has a well-established connection. In this case, telehealth can be an effective tool for organizations to hire psychiatrists who are not necessarily from their communities, but who can adequately serve their patient populations.

“Thomas” is a 10-year-old patient who experiences difficulties with depression and social isolation. As a native Spanish speaker in a rural Texas community, Thomas needed a bilingual psychiatrist with whom he could have regular appointments to build a relationship and get the treatment he needed.

Thomas and his family sought out a CMHC that covers 9 counties in central Texas. This CMHC had recently begun utilizing a telepsychiatry partner to expand its services. That partnership decreased their 9-month wait time for an appointment to 2 months, which allowed Thomas’s family to get their son the care he needed.

As we look forward to a future where telehealth plays a much more significant role in long-term mental health care, it is important to think creatively about where we can insert telehealth services to make the biggest impact on children. The next steps to building a better system through virtual care may include incorporating telepsychiatry appointments into schools; increased partnership between health care organizations and formal telepsychiatry organizations who can help them access nonlocal providers to address their community needs; and making referral resources readily available for patients and families looking to get their child seen by a high-quality psychiatrist.

The most important thing practitioners and health care organizations can do right now is continue thinking about ways to increase access. It is crucial that mental health services do not move backward and, instead, embrace virtual care as integral to their future operations. 

is a double-boarded psychiatrist with nearly 20 years’ experience and is currently the Medical Director of Outpatient Services at 

1. National Council for Mental Wellbeing. New study reveals lack of access as root cause for mental health crisis in America. News release. October 10, 2018. Accessed September 9, 2021. 

https://www.thenationalcouncil.org/press-releases/new-study-reveals-lack-of-access-as-root-cause-for-mental-health-crisis-in-america/

2. National Council for Mental Wellbeing, Medical Director Institute. The psychiatric shortage: causes and solutions. March 29, 2017. Accessed September 9, 2021. 

https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf

3. Loades ME, Chatburn E, Higson-Sweeney N, et al. 

Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. 

4. Leeb RT, Bitsko RH, Radhakrishnan L, et al. 

Mental health-related emergency department visits among children aged <18 years during the COVID-19 pandemic — United States, January 1–October 17, 2020.

5. Centers for Disease Control and Prevention. Data and statistics on children’s mental health. March 22, 2021. Accessed September 9, 2021. 

https://www.cdc.gov/childrensmentalhealth/data.html

6. American Psychiatric Association. New nationwide poll shows an increased popularity for telehealth services. May 27, 2021. Accessed September 9, 2021. 

https://www.psychiatry.org/newsroom/news-releases/New-Nationwide-Poll-Shows-an-Increased-Popularity-for-Telehealth-Services

43 of 50 states are experiencing a severe shortage in psychiatrists specializing in child and adolescent care. Telehealth may be able to help. 

Increasing Access to Quality Mental Health Care Through Telepsychiatry

Access to mental health and psychiatric services remains limited in the United States.

 Data shows 1 in 5 Americans will experience a diagnosable mental health condition in any given year,

 and early data suggests the COVID-19 pandemic likely increased the numbers of those needing care for a variety of clinical presentations.

 As the majority of health care systems pivoted toward virtual delivery during the pandemic, 

 provision and payment mechanisms expanded to address growing demand, with hopes this expansion will be made permanent.

 The surge in virtual care has also increased interest in digital mental health tools (DMHTs). Whether apps or online programs, DMHTs can augment clinical care by supporting skill-building and self-care techniques. They have the potential to provide symptom relief, enhance recovery, and build 

While the body of research on these tools is nascent and growing, DMHTs have been studied in over 100 randomized clinical trials and have been found effective.

 A recent Banbury Forum Consensus on digital mental health called for broader adoption of DHMTs in care delivery, including the establishment of associated reimbursement mechanisms to cover these tools as a standard of care.

 In April 2020, the US Food and Drug Administration issued a public guidance to increase the 

 as adjuncts to psychiatric care during the COVID-19 public health emergency.

 It would seem the time has arrived to “accelerate and bend the curve” on digital mental health.

Efforts to integrate mental health into primary care settings have increased over the past 2 decades.

 One recent development is an ecosystem approach, namely the ability to seamlessly connect all facets of mental health care to primary care. The ecosystem approach addresses 2 key barriers to real world utilization of DMHTs: 1) selective self-initiation of use (simply making apps available is not sufficient to ensure successful uptake), and 2) limited adherence to a digital intervention once begun. Indeed, research shows that app-based cognitive behavioral therapy (CBT) is more effective with an introduction, a referral from a clinician or health coach, and the right level of clinical guidance. 

 It explored the common treatment elements in self-guided CBT, such as cognitive restructuring, homework assignment, problem-solving, and social support activation, with varying levels of human support such as face-to-face care, personalized email, or telephone-based care. The goal was to determine the optimal ratio of techniques-to-support necessary to achieve positive outcomes.

 Findings showed that human support was an essential contributor to success; the degree of support measured in minutes was proportionally associated with several effective treatment elements. Support levels were broken into 3 categories; 1) no support (0 minutes), 2) brief support (1-119 minutes), and 3) more extended support (> 120 minutes), respectively. Given the growing prominence of team-based care, this review suggests that not all support needs to be delivered by doctors, and various team members can share this support role to ensure patients are pacing their CBT journey for optimal outcomes. An integrated approach toward synthesizing various modalities of treatment for patient access is therefore sorely needed in modern health care delivery systems.

Kaiser Permanente recently published a case study outlining the creation of a digital mental health ecosystem that includes digital mental health apps, patient-facing content, electronic medical record (EMR) functionality to support workflow integration, and clinician training in behavioral and primary care, including 562 clinicians.

 We found that this approach was not only feasible, but also widely embraced by patients and clinicians, who found it helpful for improving engagement and restoring daily function during treatment.

 Furthermore, patient use of DMHTs was 2 to 3 times the expected rate of similar apps downloaded from general app stores, and up to one-third of clinician-referred DMHT users were still actively using apps 3 months after initiation. A digital mental health ecosystem can therefore help target DMHT resources toward those patients and patient-clinician dyads who have the greatest need for them.

Kaiser Permanente leveraged human-centered design (HCD) methods and principles when creating their digital mental health ecosystem (

). HCD utilizes qualitative research methods and exploratory design techniques to better understand what patients value and need most in a specific situation or process, and then deploys iterative prototype testing cycles to build and refine services and product solutions to fulfill those needs. In this case, the need for an integrated approach to mental health care delivery, including the clinical value of DMHTs, presented the opportunity to develop and test a digital mental health ecosystem.

Leveraging HCD methods enabled the Kaiser Permanente team to design, build, and test iterative approaches with clinicians and patients before moving to scale, and to ensure that any rollout of the ecosystem would be able to solve immediate clinical needs rather than create any new inconveniences. This deployment, and other similar efforts at Beth Israel Deaconess and the Veterans Health Administration,

 illuminate several essential considerations when developing an ecosystem approach. These include 1) app selection, 2) workflow mapping, including EMR functionality, and 3) training for clinicians and staff with modules to build digital literacy.

While 97% of Americans own a phone, smartphone users make up 85% of total users, according to Pew Research.

 It would seem the delivery mechanism for apps is already in most patients’ hands. However, not all apps are created equal—many are low quality, and there are more than 10,000 digital mental health apps available to consumers.

 fall into 3 broad categories: 1) wellness apps that support skill building, 2) digital therapeutic apps that have translated the evidence base and reliably meet clinically benchmarked metrics such as reduction in PHQ9 through structured digital CBT or other treatment modalities, and 3) care platform apps that deliver virtual mental health treatment like talk or chat therapy.

A good starting place for app selection comes from the American Psychiatric Association’s App Evaluation Model.

 The model covers several important considerations (

 It is especially important to note that the app must be user friendly, as 95% of digital mental health apps users have stopped using apps by day 15.

Two credible go-to sources of app reviews currently exist, including 

 developed by the Digital Psychiatry Division of Beth Israel Deaconess Medical Center and Harvard Medical School,

Both app review databases allow users to filter by topic of interest, such as stress or anxiety, and offer transparent ratings for each solution based on available information. Both efforts update their databases regularly and share their methodology and scientific advisory boards transparently. These are helpful places to start when building a DMHT library component of an ecosystem.

Once the apps have been selected by the health care provider, team, or health care system, it is important to share the most salient app psychoeducational functionality that augments a care plan. In the Kaiser Permanente digital mental health ecosystem, the following functionalities—all part of the ecosystem—proved crucial for adoption: 1) patient- and clinician-facing web portals that enabled education about DMHTs and how they fit within a personalized care plan, and 2) a series of clinician-oriented brochures detailing key aspects of DMHT tools (eg, therapeutic orientation of skills taught, user journey overview, tear sheet, etc [

]). We found that providing clinicians with conceptualizations of DMHT usage that they could share with patients were particularly salient. These conceptualizations include similarities between using DMHTs and taking vitamins for preventive health, or ibuprofen for as-needed symptom relief.

If someone is having difficulty sleeping as part of their depressive episode, a mindfulness app may be helpful, or a course of CBTi to support sleep hygiene habits. How might this be discussed in a clinical visit? How would a clinician choose which app might be of most use at this time? Listening to needs of patients and clinicians can help ensure frictionless integration of DMHTs into clinic workflows, and developing EMR tools can help promote seamless digital referrals. Since digital mental health competencies do not yet exist in formal clinical training, efforts to close the knowledge gap and provide opportunities to gain experience, such as academic detailing or clinical support forums, are likely to be very useful.

 These opportunities can also help adapt DMHT uses to the needs of solo practice psychiatrists or those working in group practice models. 

Jane began struggling with anxiety and panic several months after starting her new job as a clinic receptionist. She felt stressed to the point that she would have trouble breathing as soon as she entered the office. 

“It was like being drenched by crashing waves of stress every day,” she said, “eventually, I just couldn’t go into work anymore.” She then isolated herself more from colleagues, followed by family and friends, until she was no longer answering phone calls or getting out of bed. “I just had no energy left for anything I needed to do,” she felt, “and then I started asking myself, what’s the point of living like this?”

Jane’s husband helped connect her to a nearby mental health clinic, through a direct phone call to the triage line. A social worker at the other end of the line began comforting Jane and providing supportive validation, then performed a rapid mental health assessment. She recommended Jane to start an intensive outpatient program at the clinic, which offered therapeutic group sessions and individual check-ins 4 times a week, with medication evaluation and management. Jane was booked for an intake appointment the next day. 

Over the following week, Jane began to feel more calmed. “I realized I wasn’t the only person feeling this way,” she noted, “and I started to learn more about these negative thoughts that kept coming back, and what I could do about them.” While she was making progress in her recovery, however, she felt that applying the skills she learned to real life challenges remained difficult. Her intensive outpatient therapist recommended she download an app from a digital mental health portal, so she could begin 

 and practicing skill modules she had just learned. 

“I found that the app made it easier to use tools my therapist taught me, like deep breathing exercises,” Jane said. “When I’m outside of sessions, I know I can reach the app anytime and those techniques are all there.” She also found that tracking her symptoms reinforced her progress over time. “I was actually having more good days than I believed,” she realized. Although it took some time to experience the benefit of the antidepressant she was prescribed, as expected, she did notice a steady relationship between her medication use and her symptoms. She soon felt stable enough to transition to outpatient therapy: “Even though I was going to see a new therapist, I knew I had my toolbox with me and that wouldn’t change.” 

She felt a positive connection to her new therapist, who encouraged her to continue using the app. Her symptoms soon resolved, and she was able to return to work. Although there were still occasional stressful moments on the job, she found the 

app’s exercises helpful to prevent panic from recurring

. “The app helped me see what I could be without anxiety, and showed me I could make good choices for myself and actually live my life.”

Real-world implementation of DMHTs is moving rapidly, and many health systems are leaning into building digital mental health ecosystems. While much work remains to ensure these tools are deployed optimally, the value to patients having access to on-demand psychoeducation and support is difficult to ignore, especially during times of growing demand for mental health care. Digital mental health ecosystems can play an important role in unleashing the potential of DMHTs effectively and safely in care delivery settings. Mental health as a discipline is undergoing tremendous innovation, and these instruments can be a valuable addition to our patients’ care plan.

is a Senior Principal Consultant of prevention, wellness, and digital health; and Director of the Weight Management Initiative at Kaiser Permanente Care Management Institute.

is a psychiatry specialist in San Jose, California for the Permanente Medical Group.

Senior Director of Innovation and Design at Kaiser Permanente Care Management Institute.

1. Alonso J, Liu Z, Evans-Lacko S, et al. 

Treatment gap for anxiety disorders is global: results of the World Mental Health surveys in 21 countries.

2. Substance Abuse and Mental Health Services Administration. Results from the 2017 National Survey on Drug Use and Health: Detailed Tables. September 7, 2018. Accessed September 7, 2021. 

https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdf

3. Hossain MM, Tasnim S, Sultana A, et al.

 Epidemiology of mental health problems in COVID-19: a review.

4. Federation of State Medical Boards. US states and territories modifying requirements for telehealth in response to COVID-19. Updated August 23, 2021. Accessed September 7, 2021. 

https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

5. Firth J, Torous J, Nicholas J, et al. 

The efficacy of smartphone-based mental health interventions for depressive symptoms: a meta-analysis of randomized controlled trials.

6. Mohr DC, Azocar F, Bertagnolli A, et al. 

Banbury Forum consensus statement on the path forward for digital mental health treatment.

7. US Food and Drug Administration. Enforcement policy for digital health devices for treating psychiatric disorders during the coronavirus disease 2019 (COVID-19) public health emergency. April 2020. Accessed September 7, 2021. 

https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-digital-health-devices-treating-psychiatric-disorders-during-coronavirus-disease

8. Torous J, Jän Myrick K, Rauseo-Ricupero N, Firth J. 

Digital mental health and COVID-19: using technology today to accelerate the curve on access and quality tomorrow.

9. University of Washington AIMS Center. Evidence base for CoCM. Updated February 1, 2021. Accessed September 7, 2021. 

https://aims.uw.edu/collaborative-care/evidence-base-cocm

Discovering common elements of empirically supported self-help interventions for depression in primary care: a systematic review.

11. Mordecai D, Histon T, Neuwirth E, et al. 

How Kaiser Permanente created a mental health and wellness digital ecosystem.

12. Connolly SL, Kuhn E, Possemato K, Torous J. 

Digital clinics and mobile technology implementation for mental health care.

13. Pew Research Center. Mobile fact sheet. April 7, 2021. Accessed September 7, 2021. 

https://www.pewresearch.org/internet/fact-sheet/mobile/

Needed innovation in digital health and smartphone applications for mental health: transparency and trust.

15. American Psychiatric Association. App Advisor. Accessed September 7, 2021. 

https://www.psychiatry.org/psychiatrists/practice/mental-health-apps

16. Henson P, David G, Albright K, Torous J. 

Deriving a practical framework for the evaluation of health apps.

17. Baumel A, Muench F, Edan S, Kane JM. 

Objective user engagement with mental health apps: systematic search and panel-based usage analysis.

18. The Division of Digital Psychiatry. Accessed September 7, 2021. 

19. One Mind Psyber Guide. Accessed September 7, 2021. 

20. Pote H, Rees A, Holloway-Biddle C, Griffith E. 

Workforce challenges in digital health implementation: How are clinical psychology training programmes developing digital competencies?

Here’s how a digital mental health ecosystem can seamlessly connect and support all facets of mental health care.

Delivering Health Care Through Digital Mental Health Ecosystems 

Paranoia, or fear of deliberate harm from others, is among the most common symptoms of schizophrenia-spectrum psychoses, and it also occurs in emotional disorders and other severe mental illnesses, placing 

 on the lives of patients and their families.

 Innovative therapeutic interventions are desperately needed to overcome paranoia and improve outcomes.

Existing therapies, whether pharmacological or psychotherapeutic, have widely recognized limitations in engagement, adherence, and effectiveness. Antipsychotic medication is the mainstay of treatment for most patients. However, distressing symptoms persist in 

 of those who take them, functional outcomes are frequently poor, and many discontinue treatment periodically or permanently, concerned about adverse effects, such as weight gain and metabolic syndrome.

 Psychological therapies, such as cognitive behavioral therapy for psychosis (CBTp), have been shown to improve psychotic symptoms, including paranoia, when added to treatment as usual in large clinical trials.

 But effects need to be improved, and implementation in routine care is poor. Individuals are often not willing or able to access and make use of therapy, particularly those from minoritized groups. There is a scarcity of trained therapists, with estimates suggesting only 0.3% of mental health consumers in the United States have access to CBTp.

A transformation in psychosis care is needed; digital technology has the potential to deliver it by improving the patient experience, therapy effectiveness, and 

 Digital interfaces can be designed to support personalization and accessibility, and they can assist engagement and adherence. Web and mobile technologies are also more readily scaled up than traditional interventions and can be designed to reduce training demands.

A New Frontier: Digital Therapeutics for Paranoia

To the best of our knowledge, metacognitive training (MCT), developed by Steffen Moritz, PhD, MSc, and colleagues, was the first psychological intervention for delusional beliefs that incorporated technology. It used desktop programming and presentation software to provide illustrative games and tasks. Group versions of this training approach were shown to have small to moderate effects on delusions, although it is important to note that patients with severe delusions were excluded and the basic digital materials were not personalized, limiting its ability to address challenges to therapy accessibility and adherence. More recently, individualized delivery of metacognitive therapy (MCT+) has been developed and evidence suggests it may have better effects on delusions, though there are only a few relatively

Building on this pioneering work, recent digital therapeutics for psychosis have sought to harness innovative technology such as virtual reality, social networking, mobile apps, and web-based therapies. Whilst preliminary findings are encouraging, few of these have been tested in large clinical trials, and those 

 In 1 of the largest trials to date, Depp et al (2019)

 investigated the effects of augmenting a single session of CBTp with an app, CBT2Go, compared to a single session of self-monitoring supported by an app or treatment as usual (TAU), in individuals with severe mental illness (N = 255). They found a small effect on general symptomatology favoring the CBT2Go and self-monitoring conditions over TAU. However, the impact on paranoia was not specifically examined, and the authors also note that baseline levels of psychosis symptoms were low. The FOCUS mobile app adopts a similar therapeutic approach, although it was investigated as a standalone app to support self-management in its most rigorous evaluation. Ben-Zeev et al (2019)

 compared FOCUS to a recovery group intervention in 163 patients with severe mental illness. They found no between-group differences on clinical outcomes, nor any within-group changes in psychosis symptoms.

These trials suggest that app-based technologies may safely and acceptably augment therapy for paranoia although, but they have yet to demonstrate meaningful clinical outcomes in robust designs. Crucially, there is little evidence that digital therapeutics have been designed to address healthcare inequalities. Indeed, emerging findings indicate digital therapies may actually exacerbate exclusion, with those from privileged demographic groups more likely to access and benefit from them.

In addressing the challenge of transforming psychosis care, we have developed SlowMo, an innovative digitally supported therapy for paranoia. SlowMo is based on the principles of CBTp and leverages technology to address health care inequalities, through enhancing therapy appeal and user friendliness for a 

 SlowMo therapy targets an evidence-based mechanism, or active ingredient, that we and others have shown can fuel paranoia.

 Drawing on the term popularized by Daniel Kahneman, PhD,

, comprising of a jumping to conclusions bias (forming rapid judgements using limited information) and belief inflexibility bias (reduced capacity for reflecting on one’s own beliefs, changing them in the light of new evidence, and considering alternatives). SlowMo is designed to help patients to slow down for a moment, encouraging awareness of a tendency to jump to conclusions and find new ways of feeling safer.

We followed human-centered design principles in the hopes of improving the user experience of therapy and radically enhancing engagement and adherence.

 Our multidisciplinary collaboration of individuals with lived experience, industrial designers, software developers, clinicians, and researchers developed SlowMo over 3 years through 7 cycles of prototyping. To address health care inequalities, we codesigned with stakeholders from diverse demographic backgrounds, who could identify therapy barriers and facilitators, and optimize the inclusivity of the design. SlowMo therapy consists of a web app delivered on a touchscreen laptop to support the delivery of face-to-face individual cognitive-behavioral therapy sessions, which is synchronized with a mobile app for use in daily life (

A Journey of Visualizing Thoughts and Thinking Habits

SlowMo uses new, responsive technologies to support the visualization of thoughts—as bubbles—and their associated thinking habits. This visual concept aims to enhance cognitive therapy by providing an appealing and tangible means of communicating subjective experience. The design minimizes the information processing demands, thereby lowering a significant barrier to engagement with traditional talking therapies. Patients interact with their personalized SlowMo thought bubbles using a touchscreen, altering speed, size, and transparency to reflect related thinking habits, distress, and conviction.

The SlowMo webapp used during sessions presents therapy as a journey, with interactive features including information, animated stories, and games. As well as tailoring worry and positive thought bubbles, patients record key learning points and future plans, with all content synchronized to the mobile phone app for access outside of sessions. The mobile app allows patients to notice their fears and thinking habits as they occur in daily life and helps them to find other ways of managing distressing experiences. It consists of a redesigned CBT thought record for managing paranoia and attempts to overcome the limitations of paper versions, which can be an inaccessible means of support during peak moments of distress. SlowMo uses a native mobile app with opt-in data transfer, addressing patients’ privacy concerns, which was a salient theme during the design research. The mobile app relies on user-initiated interaction and optional push notifications, to accommodate those who wish to have control over their data and find passive monitoring intrusive.

Delivering Evidence-Based Benefits for Recovery in Psychosis

SlowMo therapy has been iteratively developed over the past 10 years, with a number of studies demonstrating the efficacy of previous versions of the 

a large-scale randomized controlled trial

 with N = 362 participants recruited from United Kingdom (UK) clinical psychosis services (

, compared to the minimum 16 sessions recommended by the UK’s National Institute of Health and Care Excellence guidelines for schizophrenia treatment.

Remarkably, despite being half the minimum recommended length, SlowMo had a moderate effect on the measures of delusion severity commonly used in trials (Scales for Assessment of Positive Symptoms, SAPS

 and Psychotic Symptom Rating Scales, PSYRATS

)—for which meta-analyses have found only small effects.

 These positive effects sustained or grew over 6 months, with benefits cascading into other areas, including self-concept, wellbeing, and quality of life. Less consistent improvements were found for referential delusions, meaning that the Green Paranoid Thoughts Scale (GPTS)

 total, which is comprised of ideas of reference and persecution subscales, was not significant at 6 months. However, a psychometrically improved version of this measure, published whilst the trial was being conducted, did reach conventional levels of 

 Importantly, the SlowMo software design appeared to work as intended and was inclusive for a wide range of individuals. Whilst Black people and older patients were found to be less confident and less frequent users of mobile phones prior to doing SlowMo, these differences did not translate to their experience of the therapy, with paranoia outcomes, adherence, and patient experience comparable across groups.

 SlowMo is one of the first digital therapeutics for paranoia to overcome the digital divide associated with age and ethnicity.

The trial also had limitations. First, despite clear improvements in more severe persecutory delusions, consistent improvements were not found in milder referential delusions. One explanation is that SlowMo helped patients manage ideas of reference and their experiential components (eg, being watched by others), which prevented their elaboration into persecutory delusions (eg, being hunted by the mafia) but had less of an effect on directly modifying these underlying ideas of reference. This suggests that digital therapeutics for paranoia need to consider the broader phenomenological context fueling worries.

Accordingly, future versions of SlowMo will incorporate content on how to notice, understand, and manage the sensory-perceptual experiences (including altered salience and anomalous experiences) that are common obstacles to therapeutic change. The trial also did not control for effects of time with a therapist. TAU was chosen as the comparator condition because there is a low penetration of evidence-based psychological treatment in mental health care, thus the key question is whether SlowMo therapy confers benefits over and above standard care. Further, we had previously established the superiority of an earlier brief version of the intervention against an active control intervention, suggesting SlowMo’s positive effects are 

To illustrate SlowMo, Alex (name changed to protect their identity) has kindly agreed to us sharing their experience of therapy. Alex (a Black British Caribbean man in his late 20s) came to therapy reporting a strongly held distressing belief that he was being followed by a past acquaintance who intended to harm him and his family. In early sessions, he used the webapp to visualize these fears as personalized worry bubbles, and to build a picture of his fast thinking, including triggers and the impact on his life (

Alex could view and modify his personalized worry bubbles on the mobile app, which helped him develop an awareness of times when he thought fast. The SlowMo sessions then supported Alex to find ways to slow down for a moment and feel safer.

Alex connected with interactive stories of others discussing their own worries and tendency to jump to conclusions in everyday life. Reflecting on how these stories related to his own experiences, Alex audio-recorded messages to remind him how to slow down his worries. Using SlowMo tips, he created colorful, safer thought bubbles as he progressed through the therapy. Crucially, the synchronization of the web app with the mobile app meant that he could access this personalized helpful content (SlowMo strategies, messages and safer thoughts) when he needed them most. This helped him to consider alternative explanations when fast thoughts were triggered in daily life, for example recognizing that screams and laughter on the street could just be “people having fun” and not specifically related to him (see 

). Alex described how the principle of slowing down his thinking became “almost automatic” through early and regular use of the mobile app. By the end of therapy, Alex reported reduced fast thinking, distress, and conviction related to the fear of harm from others. He described how SlowMo therapy had helped him to “slow down…think different, act different, and feel different.”

As discussed in this article and exemplified by the SlowMo approach, therapy is likely to be most effective when it targets evidence-based processes that maintain distress (eg, fast thinking) whilst also being tailored to individual needs. Close attention to the patient experience of therapy is critical to deliver interventions that are accessible, engaging, and memorable.

A guiding principle of SlowMo is that assessment and intervention should include working with the patient in real-life environments, where fears of others are triggered (eg, public transport or crowded markets). This allows therapeutic targets to be understood in the broader context of the individual’s life, including relevant social factors such as experiences of poverty and discrimination.

It is crucial to promote and consolidate helpful learning and embed this into daily life, and digital tools represent a powerful method of achieving this. While SlowMo utilizes carefully designed digital tools, aspects reported by people as helpful (eg, recording and accessing helpful messages) may be replicated in simplified form using functions typically available on mobile devices.

Having found evidence for SlowMo’s efficacy and user friendliness, we are developing a new version for rollout in mental health services, which will build on its strengths while also addressing some of its limitations. We are encouraged by our findings to date, but the reality is that most digital therapeutics fail to be implemented outside of clinical contexts, due to organizational, provider, and consumer barriers.

 Further development is therefore required to deliver the benefits of SlowMo in routine care. Some challenges are beyond the direct control of developers and require governmental and provider intervention, such as access to hardware and data, and opportunities to acquire digital literacy skills. In line with these concerns, the next version of SlowMo will provide training on how to use the software, focus on a broader range of worries, and include additional tools to support therapists in providing evidence-based strategies to their patients. Implementation research is now required to establish whether efficacious digital therapeutics for paranoia can deliver on their promise of being a solution for transforming psychosis care.

is a professor of clinical psychology at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. She is one of the pioneers of cognitive-behavioural therapy for psychosis and has led evaluations of innovative digital therapeutics for psychosis, including AVATAR and SlowMo therapy. 

 is a clinical psychologist lecturer at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. She led on the development of SlowMo therapy and investigates the user experience of digital therapeutics. 

 is a research clinical psychologist at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. He is the therapy lead for the AVATAR and SlowMo therapy teams.

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A new digital therapeutic helps patients with psychosis to slow down and manage their fears.

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