When​ the​ therapist​ is​ a​ piece​ of​ software

A few years ago, Froedtert & the Medical College of Wisconsin health network saw that its behavioral health services weren't meeting local demand. Patients with mild-to-moderate mental health issues would receive a referral for one-on-one visits with a psychiatrist or psychologist and often faced a long wait for an appointment.

Froedtert also discovered many of their patients with multiple chronic conditions, which affect 1 in 2 adults and account for 86% of healthcare costs, have underlying mental or behavioral health conditions, which make them difficult to treat effectively.

So the system, which has three hospitals in eastern Wisconsin, looked into delivering cognitive behavioral therapy, or CBT, through digital technology.

Digital CBT works by asking primary-care patients who have been flagged for services to enroll in eight to 12 weeks of online sessions consisting of question-and-answer modules similar to what a patient might receive during a psychotherapy session.

Patients can move at their own pace, accessing the CBT module at any time by computer or smartphone. Once a week, a "supporter" checks a patient's progress and relays their assessment to a care team that can determine whether more intensive treatment is needed.

Relatively new to the U.S., digital CBT tools have been widely deployed in countries such as Australia, where online CBT programs are offered through the country's universal access healthcare system, and in the United Kingdom through its National Health Service.

They're getting more attention now from U.S. hospitals and health systems, which see them as a way to supplement their effort to integrate behavioral health into primary-care settings and overcome a shortage of specialists.

John Fryer, a senior consultant with the national healthcare provider consulting firm ECG Management Consultants, said CBT use among hospitals and systems has grown as a result of the move to value-based care.

Untreated depression and anxiety often leads to a higher likelihood that patients end up engaging in risky behaviors such as smoking, poor eating, lack of exercise, and alcohol and drug use. Those suffering from untreated depression are also less likely to adhere to their medication regimens, which makes manageable chronic conditions more severe and costlier to treat.

Many systems face difficulties in offering mental health services to such patients. Reimbursement is inadequate and there is a shortage of providers.

Froedtert will pilot an online CBT program at two primary-care clinics as part of its solution to address the growing need for outpatient behavioral health services. The online program will be offered to patients who screen positive for mild to moderate depression.

Studies show online CBT therapy can be as effective as an in-person visit with a mental health specialist. They can use the program at any time without cost, and it also goes a long way toward eliminating the stigma associated with visiting a therapist.

"It offers an opportunity to get help in a way that feels a little bit more comfortable for some patients," said Mark Stabingas, executive vice president at UPMC Enterprises. In February, UPMC's venture arm invested $17 million in the startup Lantern, which has developed an online CBT tool targeted at self-insured employers.

A major benefit of online CBT programs is that they are far less costly than hiring additional behavioral health specialists, who are in short supply.

Adoption of online CBT programs has been slow despite their promise and the growing interest among stakeholders. One particular challenge has been overcoming concerns that therapies offered through an online CBT program can provide the same quality of care as an in-person visit with a specialist.

Another roadblock is that healthcare providers are not reimbursed for using online CBT programs. Without that financial incentive, executives must decide whether the payback in terms of improved population health management is worth the cost of new technology and employee training.

"I don't remember if any of these apps or platforms have said 'Hey look, we saved $1 million in terms of preventing extra length of stay by implementing this program at a 500-bed hospital,' " said Dr. Steven Chan, a member of the American Psychiatric Association's Mental Health IT Committee. "They may have to produce studies like that or do it on a much wider scale if they already are trying to do these pilots."