LAUSR

World Psychiatry 21:3 October 2022 be effective, but that higher-quality studies are necessary. A case in point is the March 2022 study comparing a proposed digital therapeutic app to a control app which was little more than a count-down timer. While the use of the proposed digital therapeutic app was associated with improved symptoms, the study found the surprising result that the use of the count-down timer was equally effective. Before creating new names, the field needs to do better science. Digital control groups may not make for an inspiring investor pitch, but they are the necessary and incremental work critical to improving the field. Building off the first two steps, digital mental health must be engaging. Metrics of patient interest in mental health apps or the number of potential users as measured by smartphones are no longer useful. Instead, the question must be around digital literacy and whether people have the knowledge, skills and confidence to equitably benefit from innovation. This question is too rarely asked until it is too late. The complexity of engagement and its challenges are exemplified by the city of Reno, Nevada, and the contract they signed with the digital mental health company Talkspace to provide remote therapy during the height of COVID-19 pandemic. While details are not public, news reports suggest that the actual use of Talkspace was so low that the contract was not renewed. A July 2021 interview with the founder of Talkspace suggests that, of the 55 million people who have access to the service, only ~0.1% (60,000) actively use it. This example serves to counter the notion that industry can solve health engagement challenges. The reality is that no one has solved this challenge and that it will require solutions beyond gamification or better design. The recent push for coaches to support digital mental technology is promising, but brings with it new risks that need to first be addressed under the first and second points of this framework (privacy/safety and evidence). Solutions such as task sharing suggested by Stein et al may also improve engagement, but the investment in such efforts only makes sense for tools that are truly effective and not, for example, digital clocks. The last step, data integration, also only makes sense in terms of the other three. How can the digital health data be used to improve outcomes or the treatment integrated into a complete management plan? The point is moot if users do not trust the tool, the tool generates nothing of clinical value, or users do not engage with it at all. But, assuming progress in these steps, digital integration presents a new frontier for psychiatry. Vast amounts of new patient data generated by technology, combined with constant care through synchronous and asynchronous telehealth, require new clinical workflows, practices and training for true integration. There is no artificial intelligence algorithm for retooling a field, but this investment in people expected to integrate and facilitate digital mental health may be the most valuable of all. While this step is often ignored with the assumption that high user engagement will make it unnecessary, now in 2022 it should be apparent that ignoring any of the above four steps is perilous. Just like Stein et al do not forecast any immediate paradigm shift but rather the need for incremental progress, digital mental health must follow the same route. Rather than a harbinger of a paradigm shift, there is an urgent need for iterative improvements around data privacy and safety, app effectiveness, user experience/adherence, and data integration. While this selective review took a purposely pessimistic view, focusing on harsh realities is necessary for a field where the hype is so amplified. These harsh realities also underscore how incremental progress can actually be transformational for digital health, and justify why we need to do the hard work instead of just the glamorous.