With mental health workers in short supply across rural Kansas, a program that allows people suffering from depression to receive help online is being launched and studied for effectiveness.

The Program in Digital Mental Health is a joint effort between the KU School of Medicine-Wichita Department of Psychiatry & Behavioral Sciences and the KU Center for Telemedicine & Telehealth, directed by Shawna Wright, Ph.D., in Kansas City.

“It is primarily an effort to increase access to effective mental health supports in rural Kansas,” said Matt Byerly, M.D., who is program director and holds several faculty positions at KU Wichita. “And because there’s so much challenge in having available a mental health workforce in rural regions, this becomes a partial solution for that challenge.”

Earlier this year, Byerly secured a five-year, $28 million grant from the federal Rural Health Transformation Program to fund the effort.

“Our ultimate goal is to provide widespread access to people over the five-year grant,” he said.

The first phase of the initiative will introduce rural residents who may be experiencing depression to a self-administered, interactive cognitive behavioral therapy platform called Thrive. Cognitive behavior therapy is usually described as a method of reducing mental health problems by teaching people different ways to think, behave and feel.

Thrive isn’t meant to replace trained mental health professionals, but it is an acknowledgement that their current supply can’t meet the demand. And, Byerly thinks Thrive may actually offer some advantages. 

For one, he said, “It’s better for overcoming the stigma (associated) with going to see a mental health professional in person in a rural setting. Rural residents have more concern about that than non-rural residents.”

For another, he said, “People can do it at any time and any setting of their choosing. That’s really helpful for people who are working. It’s immediate and flexible.”

And finally, he noted, “It’s going to be free of cost to them.”

The focus on depression is based on its prevalence. Estimates are that one in five Americans experience depression at some point in their lives, often with devastating consequences for themselves, their careers and the people around them.

“Depression is the most disabling of all health conditions, not just mental health” conditions, Byerly said. According to several reports, at least 85 of Kansas’ 105 counties have a shortage of mental health professionals — basically, everything outside Sedgwick County, north-central Kansas and northeast Kansas.

Thrive was created by a Seattle-based Waypoint Health Innovations and has been around about a decade, Byerly said. It employs a combination of videos and interactive tools to guide users through cognitive behavior therapy sessions.

When users first log in to Thrive, they are shown an introductory video, then answer questions about themselves that determine which of three intervention modules they start with. Each module starts with a brief testimonial about cognitive behavior therapy, Byerly said. “That’s absolutely critical because it tries to address questions they might have, like ‘Is this brain washing?’ and ‘Can I trust this?’ That’s meant to address worries and also gain investment and buy-in.”

A series of videos then guide users through steps of cognitive behavior therapy designed to lessen depression, and they’re given homework to focus on before their next session. When they log back in and share what they’ve experienced, they are directed to more cognitive behavior therapy exercises. Each module consists of 10 sessions with multiple videos lasting several minutes each. If a user desires, his or her progress can be monitored by a mental health professional or their primary care provider.

Byerly said the entire Thrive video library consists of more than 300 videos, which allows the sessions to be individually tailored to users based on their interaction with the program. The videos are sorted into three modules or categories focusing on cognitive restructuring, which is the addressing of inaccurate or negative thoughts; rewarding activities; and assertive communications.

New version, new feel 

Byerly’s work in digital mental health includes two studies involving Thrive. In the first, rural residents praised the program’s easy accessibility, ability to avoid stigma and other benefits, but said it “needed to have a rural feel.”

“They loved all the positives I mentioned of easy accessibility, ability to avoid stigma and so forth,” Byerly said. “But they said, ‘We think it could look and sound and relate to us more like our experiences than it does.’”

In response, the research team, consisting of KU faculty and the owner of Thrive, culturally adapted Thrive, including shooting new videos. A subsequent study found that the adapted program was effective in reducing depression and anxiety symptoms and improving functioning and resilience among a mostly rural population, with effects generally larger than those reported for other fully automated online cognitive behavioral therapy interventions.

Thrive isn’t available to the general public but is used by some healthcare systems such as Kaiser, based in California, and the Henry Ford Health system, headquartered in Detroit. In rural Kansas, Byerly said, “We will be the ones supporting access to the service.”

Byerly said Thrive will be promoted through rural clinicians, social media and other engagement avenues, and community partners such as churches, employers and insurers. No prescription is needed.

“We’ll be building bridges along all those pathways to help people become aware that Thrive exists, that it’s effective and this is how you access it,” Byerly said.

Byerly is professor, chair of the Department of Psychiatry & Behavioral Sciences, and associate dean for research at KU School of Medicine-Wichita. He directs the Program in Digital Mental Health, with Frank Materia, Ph.D., serving as associate director. The initiative also includes two KU School of Medicine-Kansas City teams with expertise in community health worker-supported interventions (Sarah Kessler, Ph.D., MPH, and Allen Greiner, M.D., MPH) and health communication (Ayo Olagoke, Ph.D., MPH), as well as an implementation evaluation team from the University of Wisconsin led by Shellie Ellis, Ph.D.

“We’ll be continually learning and testing and refining our approach to create more reach and more support for people using it,” Byerly said.

He believes Thrive can supplement antidepressant medications that an estimated 13% of Americans now take, a market supported by “billions” on marketing spent by pharmaceutical firms.

“That’s what it takes to get the word out,” he said. “These (digital) interventions are at least as effective as antidepressants but they’ve had no advocates and they’ve also had no payer. That’s why we’re here and that’s the significant resource that’s needed.”