Source [[Book - Digital Therapeutics for Mental Health and Addiction]] 5.5.2 Value of blended care The motivation to develop and implement BC interventions is multifaceted. For many evidence-based interventions, outcomes have much room for improvement that could potentially be enhanced with digital tools. Notably, access to treatment within the US and many other countries is poor. BC provides one possible solution to improving healthcare access for MHD and SUD across various phases of treatment and recovery. For instance, low-threshold iCBT has been implemented as an early step to bridge waiting times for subsequent face-to-face treatment (Erbe et al., 2017). BC combines strengths from traditional person-to-person psychotherapy and digital interventions while overcoming many limitations inherent with standalone models, and thus offers multiple potential benefits to clients, providers, and health systems. 5.5.2.1 Benefits to clients and healthcare providers Clients: BC can offer clients up to 24/7 access to certain types of treatment support (Carlbring & Andersson, 2006) and reduces the impact of a variety of traditional treatment barriers (e.g., transportation, childcare, availability). The digital components of BC can also provide greater opportunity for clients to work at their own pace throughout the course of treatment (Erbe et al., 2017). Such interventions have been shown to lower client dropout (Campbell et al., 2014) and enhance motivation/engagement (Walters, Vader, & Harris, 2007), which may encourage self-mastery and empowerment, key factors in long-term positive outcomes (Wentzel et al., 2016). BC can expand treatment options for individuals with chronic mental health conditions by maintaining therapeutic relationships, contributing to more comprehensive aftercare or long-term support following more intensive face-to-face therapy (Erbe et al., 2017). Research suggests that clients are accepting of digital treatment components (Materia & Smyth, 2021; Wright & Wright, 1997). Clients benefit from the convenience of accessing portions of their treatment remotely and from tracking their progress. That said, the digital components of BC may not be attractive to all clients, with some concerns centering around data security, access to suitable technology devices, or simply the preference of traditional psychotherapy. Healthcare providers: BC can increase the frequency, intensity, or “dose” of an intervention while offering substantial digital options and greater flexibility for providers. BC can potentially reduce the number of person-to-person therapy sessions by implementing some psychotherapeutic techniques digitally, increasing time and availability of providers to serve more clients (Budney, Borodovsky, Marsch, & Lord, 2019). Provider time can be more focused on clients with greater clinical needs that may require weekly person-to-person sessions, such as clients in crisis (e.g., suicidality, homicidality) and/or with complex comorbidities (e.g., cognitive impairments). Providers can adapt or augment digital components of treatment to meet the individual care needs of clients. For instance, providers might ask clients to monitor targeted thoughts, emotions, and/or behaviors between sessions via a smartphone app. Mobile technology allows for the collection of real- time client data (e.g., environmental, physiological) via passive sensing or ecological momentary assessments which could provide individualized just-in-time adaptive interventions (JITAIs) or skills to practice when high-risk situations or behaviors emerge (Nahum-Shani et al., 2018). Alternatively, supportive digital messaging could be utilized to enhance motivation or in response to detected stressors to assist with coping. Finally, BC can tailor to a wider variety of learning styles (e.g., visual/auditory aides), cultural considerations, and treatment preferences (Milward, Drummond, Fincham-Campbell, & Deluca, 2018). Since BC is a relatively new form of treatment, it is not surprising that there are also still multiple barriers for providers related to training, equipment, and processes, which are discussed in more detail later in this chapter. 5.5.2.2 Benefits to mental health services While a wide range of BC models exist, one commonality is that BC provides the opportunity of collecting data as part of therapy. Better data in turn promises to help clients and providers in several ways. For instance, collecting outcome measures and documenting in-between session tasks allow clients and providers to better understand progress in therapy and can facilitate adjustments to processes or goals. For example, services may use aggregated data to alter the type of therapy offered to specific client populations, to offer additional training to providers, and more. Advances in digital assessment, including performance tests and self-report measures, offer providers more options in BC models. Several standardized assessment protocols, often associated with high cost and training via face-to-face administration, have been programmed digitally (Bultler et al., 2001). Passive sensing and ecological momentary assessment options have also expanded with mobile advancement (e.g., smartphone apps, smartwatches) allowing for continuous physical and/or behavioral data collection that can facilitate JITAIs via less intrusive means. For example, digital methods can be used to increase the accuracy of the assessment of social anxiety symptoms, which tend to be underreported in traditional assessment (Jacobson, Summers, & Wilhelm, 2020) and other mental health conditions (Jacobson & Chung, 2020). A recent meta-analysis reported benefits of passive sensing including behavioral and client status change detection (Cornet & Holden, 2018). Further, virtual reality has shown promise as another novel approach to assessment (Parsons & Carlew, 2016; Parsons, Bowerly, Buckwalter, & Rizzo, 2007). Studies have found greater discloser of risky behaviors, including suicide and substance use, via digital tools (Butler, Villapiano, & Malinow, 2009; Proudfoot et al., 2003), lending support to their use in screening/monitoring. Within health systems, reducing the number of face-to-face contacts lowers treatment costs (Budney et al., 2019; Erbe et al., 2017). BC may also enhance the quality of care delivered in that digital interventions validated in controlled trials can be delivered in places where such interventions are not available, including non-specialty clinics or primary care settings. An ancillary consequence of such availability is reduced burden on the health system by lessening the need for highly trained mental health providers within these settings. Supportive person-to-person contact from non-specialty providers in BC models provides benefit when evidence-based components are delivered digitally (Budney et al., 2019). Last, digital delivery of evidence-based interventions provides high treatment integrity and fidelity, which is not always the case with face-to-face delivery of these interventions (Moller et al., 2017). In sum, by combining strengths from traditional face-to-face therapy and digital technology, BC holds promise of value. For clients, BC may strengthen outcomes of traditional psychotherapy while enhancing treatment access across different treatment phases for individuals with a variety of mental health concerns. BC has the potential to improve client motivation, engagement, and adherence (Figueroa, DeMasi, Hernandez-Ramos, & Aguilera, 2021) and feelings of self-mastery (Wentzel et al., 2016) while enhancing the frequency and intensity of high-fidelity evidence-based interventions. Providers can harness digital advances to augment therapy or assessment in a variety of ways to meet individualized client needs, while reducing client burden and cost of treatment delivery. Further, technology offers novel approaches to assessment that improve accuracy and frequency of status tracking over time. Last, BC models may offer a means to reduce treatment costs while improving access to high fidelity care, particularly in non-specialty clinics.