Of the 790 participants enrolled in the study, 572 (72.4%) provided complete case (CC) data on health care service use at baseline. To control for missingness, we assumed the item response was missing at random. Dr Rakesh Sharma, local GP and mental health clinical lead at NHS Blackburn with Darwen and NHS East Lancashire Clinical Commissioning Groups, said: After months of lockdown and measures now beginning to ease we are hearing more and more of people feeling isolated and lonely which can have a real negative impact on their mental health and wellbeing and lead to an increase in mental health conditions such as anxiety and depression. Additional international markets may be explored by replicating the Big White Wall model in other languages. These were completed on the web (though the study website) for approximately 20 to 30 minutes. Participants found all contact with the study remote and therefore not engaging. And for those who struggle to put how they feel into words, they can draw a brick to express the difficulties they are facing, which many people find quite therapeutic and relieving. The WHO estimates that depression will be the second largest cause of disability by the year 2020.1 As traditional approaches cannot be scaled up to meet this overwhelming need, new technologies are required to expand access and improve health outcomes at lower costs. We took out newspaper and magazine advertisements and also spoke on local radio programs dedicated to health matters. There exists a significant value for treating these individuals outside of the standard measures of health gain. Automated trials have sometimes failed to engage some populations [18,19], whereas others offering otherwise difficult to obtain structured psychological treatments have been more successful [20-22]. aParticipants were asked how they heard about the study. Nottingham, 73 percent reported sharing a mental health issue for the first time in their lives. Enter your email address below and we will send you the reset instructions. The Big White Wall is constantly monitored by wall guides who are on hand 24/7 and will intervene if members seem particularly low and at risk and provide personal support on a one-to-one basis. Online group courses on multiple mental health topics, led by trained, experienced professionals. Big White Wall chief executive Henry Jones said: Everyone has mental health and we believe everyone should be able to access support as and when they need it. Just as in the United Kingdom, mental illness is exacting a tremendous societal and economic cost, with indirect mental illness costs totaling around $80 billion for U.S. employers annually, while health plans, accountable care organizations (ACOs), and others are calling for the integration of behavioral health into primary care. We are delighted to form part of a joint strategy from NHS Fylde and Wyre and NHS Blackpool CCGs of delivering highly effective and easily accessible support for all Fylde Coast residents. While the social stigma surrounding mental health has improved in recent years, it is still highly prevalent. The https:// ensures that you are connecting to the The final model specification included variables for gender, WEMWBS, PHQ-9, age, education, and employment status alongside our outcomes of interest. People can also be referred and sign posted to Big White Wall by a variety of partners, including: Big White Wall is currently the subject of two randomised control trials: one on the SupportNetwork as a self-referral intervention at the Institute of Mental Health, University of Nottingham, UK, and one on LiveTherapy in IAPT (Improving Access to Psychological Therapies) at the Centre for Outcomes Research and Effectiveness, University College London. Worried or concerned about yourself or others. As a result, the trial lacked the power to demonstrate any differences in outcome between BWW and MZ. Of the 572 patients, no contact with any health service was reported by 271 (47.4%) patients of the CC sample. Proportions of participants completing the primary outcome measure were 14.5% (57/393) in the BWW intervention group and 18.6% (74/397) in the MZ control group. A review of methods to measure health-related productivity loss. An 18-month campaign was conducted across Nottinghamshire, the United Kingdom (target population 914,000) to advertise the trial directly to the public through general marketing, web-based and social media sources, health services, other public services, and third-sector groups. What does clinical commissioning mean for GPs and GP practices? In the US, Big White Wall augments our partners telemedicine and EAP programs. A restrictive approach to research ethics may have an undesirable effect in that research into digital interventions is not carried out in the most vulnerable manner, where there is arguably more room for beneficial effects and greater safety concerns [50,51]. Big White Wall is working with Kaiser Permanente Northwesta large, nonprofit integrated delivery system in Oregon and Washingtonproviding the organizations members with services that include innovative, emerging digital channels to supplement current mental health care. All members have access to the SupportNetwork and Guided Support, which are available 24/7. If the address matches an existing account you will receive an email with instructions to reset your password. United Kingdom, 6 bPrimary outcome of randomized controlled trial. Participants were able to access any part of the BWW site (apart from the option of personalized therapy or counseling sessions that have to be prescribed by a clinician, that is, not offered directly to the general public) and interact with other users within the boundaries of the sites house rules. Measuring Mental Health Needs. Kroenke K, Spitzer RL, Williams JB. We can all help each other through these uncertain times.. Patel S, Akhtar A, Malins S, Wright N, Rowley E, Young E, Sampson S, Morriss R. The Acceptability and Usability of Digital Health Interventions for Adults With Depression, Anxiety, and Somatoform Disorders: Qualitative Systematic Review and Meta-Synthesis. Baumel A, Edan S, Kane JM. These may include: Whatever the Big White Wall users needs, there are trained Wall Guides available 24 hours a day to provide assistance, answer questions and, perhaps most importantly, ensure that the members experiences are safe and welcoming. The new PMC design is here! No stratification or minimization was performed. Big White Wall has been designed to offer personalized care pathways. Of the 393 participants randomized to BWW, 225 (57.3%) registered to access BWW and 165 (42.5%) accessed it on more than one occasion. Learn more Big White Wall is a digital platform and community, which supports its members to self-manage their care with the collaboration and guidance of clinicians, caregivers and peers. As a result, any or all of our forward-looking statements in this post may turn out to be inaccurate. Feedback left by the first 50 participants suggested that they disliked the intrusiveness and length of some of the measures and assessments at baseline. The population reach of this campaign was examined by the number of people accessing the study website and self-registering to the study. As health experts seek to integrate mental health into primary care, and patients themselves look for opportunities to take more control and have a greater say in their care, digital mental health solutions are taking root. Where relatively unstructured self-guided therapy may work for some, others may find greater support from online connections with peers facing similar life challenges. A survey by SAMHSA found that individuals also do not seek assistance because of cost, lack of health insurance coverage for mental health care, fear of having others find out about mental health challenges, worries about job security, and general concerns about confidentiality. We were not allowed to recruit these participants by a research ethics committee because of the opinion that research on people with severe depression requires a greater duty of care than could be offered over the internet. Maheswaran H, Weich S, Powell J, Stewart-Brown S. Evaluating the responsiveness of the Warwick Edinburgh Mental Well-Being Scale (WEMWBS): group and individual level analysis. Weisel KK, Lehr D, Heber E, Zarski A, Berking M, Riper H, Ebert DD. HHS Vulnerability Disclosure, Help Of the 1510 eligible participants, 790 consented and were randomized, 393 to MZ and 397 to BWW. Big White Wall expanded to Australasia in 2011, and to the United States in 2014. Unit Costs of Health and Social Care 2018. Additional mental health support is available to all residents in Blackburn with Darwen and East Lancashire (Pennine Lancashire) thanks to a partnership between the local NHS and Big White Wall. Crisp D, Griffiths K, Mackinnon A, Bennett K, Christensen H. An online intervention for reducing depressive symptoms: secondary benefits for self-esteem, empowerment and quality of life. We recruited and randomized only 790 of 1510 (52.3%) of those who expressed interest and were eligible, despite a considerable amount of effort by the research team using traditional advertising, internet and social media, health services, other public services, and third-sector contacts. aOther use consisted of other specific National Health Service care, that is, phlebotomist or private health care, that is, physiotherapy and podiatry. Figures S2 and S3 (Multimedia Appendix 2) show recruitment by the geography of Nottinghamshire and in relation to the proximity of tram routes in the county, suggesting that proximity to tram routes in the City of Nottingham was associated with study enrollment. We targeted other health and social care workers, including educational establishments, such as universities, further education colleges, and those in contact with socially isolated groups, for example, social workers, health visitors, or those who work with mental health problems such as the Improving Access to Psychological Treatment program providing psychological treatments for depression and anxiety, private counselors and wellness in mind, and an NHS-funded public mental health signposting service. United Kingdom. In response to the pandemic, we have expanded our clinical and on-duty teams to effectively moderate increased activity across our community and manage risk. https://creativecommons.org/licenses/by/4.0/, J Med Internet Res. Yet even if they do seek treatment, they are likely to have access issues. Therefore, our data suggest that a process of interaction with a human or possibly a virtual human is required to ensure a full understanding of what the trial offered, fully informed consent, and commitment to the study, particularly when the digital interventions are not already well understood in the population being studied. It is vitally important at this time that people continue to follow Government guidance around social distancing and staying at home as much as possible. We extrapolated productivity losses using disease prevalence by gender to control for observed self-selection and the number of individuals between 18 and 64 years of age active in the labor market (employed or self-employed) in the United Kingdom. The primary outcome was the change in self-rated well-being at 6 weeks, measured using the Warwick-Edinburgh Mental Well-Being Scale. Using an adapted Community-based Sociotherapy approach to reduce depressive symptomology in Congolese refugees. Big White Wall aims to break down barriers to access by offering a scalable and integrated online service for community building, and connectedness - critical factors in supporting well-being, positive behavioral health, and engagement. Missing outcome values were investigated and imputed for all outcomes under the missing at random assumption with 100 data sets imputed for data analysis. However, we are committed to supporting people affected by their mental health in Pennine Lancashire by providing varied and high-quality services for them to access. McCall HC, Hadjistavropoulos HD, Loutzenhiser L. Reconsidering the ethics of exclusion criteria in research on digital mental health interventions. Department of Health and NHS England: Out-of-hours GP services in England. Griffiths KM, Mackinnon AJ, Crisp DA, Christensen H, Bennett K, Farrer L. The effectiveness of an online support group for members of the community with depression: a randomised controlled trial. If any Blackburn with Darwen or East Lancashire resident is experiencing heightened feelings of isolation, loneliness, stress or worry, I would encourage them to use Big White Wall for free to keep connected and receive support from our community. The withdrawal of the SF-12 instrument meant that we were unable to examine the health state utilities associated with mild-to-moderate depressive episodes and anxiety disorders. Harnessing Peer Support in an Online Intervention for Older Adults with Depression. Nottinghamshire Healthcare NHS Foundation Trust, The 95% bias-corrected CIs were derived from 1000-iteration bootstraps, and all health economics analyses were conducted in Stata/SE 16.1. Big White Wall (BWW)a digital and behavioral health and well-being service facilitated by health care professionalsis one of these solutions. Clarke J, Sanatkar S, Baldwin PA, Fletcher S, Gunn J, Wilhelm K, Campbell L, Zwar N, Harris M, Lapsley H, Hadzi-Pavlovic D, Christensen H, Proudfoot J. The structure of Big White Wall reflects an understanding that those in need of mental health and well-being assistance have diverse needs. Participants in employment took a mean 10.93 (95% CI 9.51-12.36) days of health-related time off work during the 3 months, which corresponded to a productivity loss of 1001.01 (95% CI 868.75-1133.27; US $1380.79, 95% CI 1198.35-1563.23), compared with 156.46 (95% CI 114.08-198.84; US $215.82, 95% CI 157.36-274.28) in direct-to-NHS costs per participant. However, the 6 most successful enrollment methods to the study (randomization) were through GPs, Facebook, trams, internet and social media, NHS acute hospitals, and leaflet door drop. Similar models were conducted on observed values to check the robustness of the treatment effect estimates sensitive to the influence of missingness. We recruited a largely female, White, and educated sample who were mostly currently in work or education. However, such patients access digital services on an everyday basis outside the research environment. Trifold leaflets (Figure S1 in Multimedia Appendix 1), posters, bus and tram adverts, and business cards with quick response codes were subsequently developed, and a marketing plan for distribution and dissemination across Nottinghamshire was created for the duration of the study. Institute of Mental Health, University of Nottingham, Jubilee Campus, Triumph Road, Nottingham, NG7 2TU, United Kingdom, Phone: 44 1158230427, peer support, digital mental health, depression, anxiety, population reach, productivity, mobile phone. Do the professionals get paid? Only 16.6% (131/790) participants completed the primary outcome assessment. There are other resources to help such as a range of online courses, for example to help sleep, anxiety and worry, and many more.. A core aim of providing digital mental health approaches to reach people who are not in contact with health services was achieved. Therefore, the website recommended nonparticipation for those who believed they were insufficiently proficient in the use of the English language. The scale of the problem suggests the need for effective, safe web-based public health services delivered directly to the public. Mattke S, Balakrishnan A, Bergamo G, Newberry SJ. 1211 Geneva 27 Approximately half of those enrolled were not in contact with any health service in the preceding 3 months. Nottingham, REALCOME and STATA 16 were used to impute missingness. Of 6483 visitors to the study website, 1510 (23.29%) were eligible. This fully automated trial was not successful in engaging or retaining participants because it did not recruit people with severe depression who most wanted these interventions and did not adequately explain how the digital interventions could provide personalized care and support. Well-being was measured at 3, 12, and 26 weeks using the WEMWBS. Careers, Reviewed by Simon Byrne and Sadhbh Byrne. We then analyzed this feedback thematically. Big White Wall also offers members the opportunity to take online tests to measure their anxiety or depression levels to set goals and track their progress. aNumber of individuals reported only when characteristics were not reported by all participants. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. United Kingdom, 4 Multiple imputation was inclusive of both trial arms to increase the sample size because neither arm had received treatment at baseline. Therefore, NHS mental health leads in Pennine Lancashire are encouraging residents to utilise free resources such as Big White Wall. The opportunities provided by BWW and MZ to use novel approaches to making choices about obtaining personal support and personalized care, particularly through BWW, which is designed to enable such choices to be made and provided almost immediately, were not made explicit and might have been explained better through initial human or virtual human contact. Table 2 shows that randomized study participants had a mean age of 38.0 (SD 13.8) years, 81.0% (640/790) were female, 93.4% (738/790) were White, everyone had educational qualifications with 45.0% (354/787) having a university degree, 4.3% (34/790) were retired, and 8.9% (70/790) were unemployed. Participants were ineligible for the trial because they scored in the severe range on the PHQ-9 or scored 2 or 3 on the suicide item of the PHQ-9. Big White Wall also offers members the opportunity to take online tests to measure their anxiety or depression levels to set goals and track their progress. Switzerland, London School of Hygiene and Tropical Medicine, To transform behavioral healthcare delivery by empowering consumers to play an active role in their care, Clinically-moderated interactive digital platform accessible 24/7 to increase access, improve member experience and outcomes. There is uncertainty about how to conduct fully automated RCTs of digital mental health interventions directly targeted at the public [14]. A wide array of topics allows members to connect with others who may, for example, be experiencing seasonal affective disorder or anxieties associated with work demands or the loss of a loved one. Table 5 shows that follow-up assessment rates were very low at each time point. PMC legacy view Nearly 100 million Americansand growinglive in an area where there is a shortage of mental health providers. Measuring the effects of work loss on productivity with team production. The These presentations were complemented by posters, cards, and leaflets that were displayed in every primary care waiting room in Nottinghamshire. 80 percent reported an improved ability to practice self-care. official website and that any information you provide is encrypted The Big White Wall concept was born from the realization that mental health services in the United Kingdom were woefully insufficient to meet the growing need. Their mean age was 38 (SD 13.8) years, 81.0% (640/790) were female, 93.4% (738/790) were White, and 47.4% (271/572) had no contact with health services in the previous 3 months. Other targeted approaches involved asking organizations and health professionals to hand out leaflets or spread the word to their community to patients in their preferred method. government site. Pounds sterling were converted to US dollars using the conversion rate published by the Federal Reserve as of March 26, 2021: 1 to US $1.38. There are many reasons people simply cannot leave their homes to access mental health care. Institute of Mental Health, Those eligible for participation were aged >16 years with probable mild-to-moderate depression or anxiety disorders. University of Bristol, sharing sensitive information, make sure youre on a federal The cost of implementing the service is dependent on the target population, the integration design, and reporting requirements. However, this change did not improve either recruitment or retention in the study. Dataset: Labour market statistics time series. Using UK NHS costs of treatment, our initial figures suggest that in the UK, Big White Wall can create up to 38,000 (US $54,800) in direct healthcare savings per 100 members with six month memberships. The primary outcome measure is change in self-rated well-being from baseline to 6 weeks after baseline using the 14-item Warwick-Edinburgh Mental Well-being Scale (WEMWBS) [28]. In addition to the blanket approach that was adopted for the general public, the recruitment team also targeted particular groups, such as those in areas of greater deprivation, through door drops. Is there a trial bias impacting user engagement with unguided e-mental health interventions? Implementation costs can vary, and the per member per month/year costs are driven based on population size. Depression and anxiety are, respectively, the first and sixth leading causes of years lived with disability globally among all health problems [1]. At Big White Wall we have seen activity and registrations across the service more than double, with 60 per cent of conversations over the past month discussing COVID-19. Massoudi B, Holvast F, Bockting CLH, Burger H, Blanker MH. We ran a public health campaign using these terms and offered the opportunity to take part in a study free of charge by comparing an information-giving website (MZ), which is a standard designed with and used within the NHS in the United Kingdom, with a web-based peer support site (BWW). Dr Neil Hartley-Smith, a Blackpool GP and clinical adviser to the CCGs, said: We are committed to supporting people living with mental health on the Fylde Coast by providing varied and high quality services for them to access. International cost-effectiveness assessments are ongoing. The sample size calculation and justification is outlined in detail in our protocol paper [24]. Project HOPE: The People-to-People Health Foundation, Inc. Self-expressive art therapy (also called creating a brick) where members use images, drawings, and words to tell their personal story. Big White Wall plans to scale its services to new settings and larger populations. 40,000+ members reached since 2007, 70% of enrolled members report improved wellbeing2, Recovery rates for BWW therapy services in the UK are 12% above national average, and 8% above national target, Big White Wall is estimated to create up to 38,000 (U$54,800) in direct healthcare savings per 100 members with six month memberships in the UK, Support through groups and on a one-on-one basis; talk forums, Tools for self-managing psychological distress and improving wellbeing, A range of self-help resources, information, and opportunities for visual and verbal self-expression, Ability to transfer relevant individual and aggregate assessment data, demographics and utilization data to key stakeholders, Key stakeholders willingness to embrace digital technology to increase access, and improve engagement and outcomes, Reduces unnecessary demand on healthcare and social services, Accessibility anytime, anywhere: laptop, smart phone, computer, Focus on both mental health and emotional well-being, Integration of physical and mental health concerns (for example in GuidedSupport programmes), as recommended by the UK National Health Services, Close alignment with government and local objectives for healthcare, Innovative methods of data collection, aligned to payer and provider requirements, Introducing a new concept to the healthcare market, Resistance from healthcare professionals, general practitioners, and family doctors (who may be more or less skeptical about digital services) of the value of digital health support, Demonstrating efficacy which we addressed, for example, through involvement in Randomised Control Trials, and building partnerships and obtaining funding to set up these clinical trials, Demonstrating safety and good governance in a framework designed for face to face services, for example through registration with the UK Care Quality Commission, Integrating as a complement rather than a challenge to existing face-to-face services, Primary care providers, mental and behavioral health specialists, Improving Access to Psychological Therapies (IAPT)referral workers (UK), Healthcare, military, university contracts (UK), Health plans, health systems, providers (US), 46% report sharing an issue for the first time, 58% recovery rate as a result of engagement in Big White Wall LiveTherapy, Over two thirds of logins are outside business hours, People with higher mental health need make more use of Big White Wall at night, when other services are less available. Digital services, accessible from a personal computer or mobile device or tablet, provide both expanded access and a new level of privacy never before associated with these types of therapies. That is why digital systems, available 24 hours a day, are essential. London, Zhang W, Sun H, Woodcock S, Anis AH. Exclusion criteria were as follows: patients (1) scored 21 on the PHQ-9 (severe depression); (2) scored 2 or 3 on PHQ-9 item thoughts that you would be better off dead or of hurting yourself in some way; and (3) scored 10 on PHQ-9 and GAD-7. Digital Exclusion Research Report, January 2019. Inclusion criteria were as follows: patients (1) aged 16 years; (2) reside in the county of Nottinghamshire; (3) scored between 10 and 20 on the 9-item Patient Health Questionnaire (PHQ-9) [25] or 10 or more on the 7-item Generalized Anxiety Disorder questionnaire (GAD-7) [26], indicating probable caseness for depression and anxiety, respectively, but not a definite diagnosis of depression or anxiety disorder; (4) had access to the internet through a computer, tablet, or smartphone (Windows, iOS, or Android) device and email address; and (5) were able and willing to give informed consent (through electronic consent). Therefore, during the recruitment of the first 50 participants, we decided to stop collecting questionnaires, namely the SF-12. And thanks to NHS Blackpool and NHS Fylde and Wyre Clinical Commissioning Groups (CCGs), the service is now available to all people with a Fylde Coast postcode. We followed up the excluded participants on one occasion. User's manual for the SF-12v2 Health Survey, 3rd ed. Brueton VC, Tierney JF, Stenning S, Meredith S, Harding S, Nazareth I, Rait G. Strategies to improve retention in randomised trials: a Cochrane systematic review and meta-analysis. A fully automated RCT recruiting directly from the public failed to recruit and retain sufficient participants to test the clinical effectiveness of this digital intervention, primarily because it did not personally engage participants and explain how these unfamiliar interventions might benefit them. Presentations were made by members of the research team to a range of GPs and primary care staff to raise awareness of the study across the county. This study aims to determine the reach, feasibility, acceptability, baseline costs, and outcomes of a public health campaign for an automated RCT of the BWW, providing digital peer support and information, compared with a standard website used by the National Health Service Moodzone (MZ), to people with probable mild-to-moderate depression and anxiety disorder. White IR, Royston P, Wood AM. It was founded by a service user because existing services did not provide support when it was needed and was first developed as a collaboration among service users, digital experts, and a National Health Service (NHS) organization providing mental health services in London. Potential participants from the county of Nottinghamshire self-referred to the study, and their eligibility was assessed by an automated digital program on the study website. Of these, 4125 were from Nottinghamshire, aged >16 years, and had continued access to the internet. In the organizations name, big recognizes the infinite nature of human emotion; white conveys the blank canvas the service provides; and, wall symbolizes shelter and support, as well as the barriers we sometimes need to break through to improve mental health. On Friday 1 July 2022 clinical commissioning groups (CCGs) across the country closed and were replaced by new NHS organisations known as integrated care boards. As all outcome scores were repeatedly measured at baseline and at 3, 6, 12, and 26 weeks, multilevel modeling was performed to quantify the treatment effect with participants as a level 2 unit and baseline, treatment arm, follow-up time, and interaction of armtime as a covariate. Dataset: Earnings and hours worked, all employees: ASHE Table 1. Mobile, Social, and Wearable Computing and the Evolution of Psychological Practice.