Asian Journal of Psychiatry 54 (2020) 102433

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Making mental health more accessible in light of COVID-19: Scalable digital

health with digital navigators in low and middle-income countries
Elena Rodriguez-Villa a, John Naslund b, *, Matcheri Keshavan a, Vikram Patel b, John Torous a
a
Division of Digital Psychiatry at the Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
b
Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, United States

A R T I C L E I N F O A B S T R A C T

Keywords: The rapid spread of COVID-19 and the devastating consequences to economies and healthcare systems around
COVID-19 the world has highlighted the exigent need for accessible mental health support. Increasing use of mobile devices
Telehealth in Lower Middle-Income Countries (LMIC) such as India offers novel opportunity to expand treatment options
Mobile
and reach underserved populations. Prior efforts have utilized technology to redistribute or supplement clinical
care but measurable outcomes of this research are limited. In this paper, we explain the structural barriers that
prevent access to care and build on prior research to demonstrate how technology can be utilized to offer
treatment if it is aided by education and technical support.

1. The need Understanding the growth and potential of technology augmented

The need for digital mental health tools to reduce the mental health
gap and increase access to care in low and middle-income countries
(LMIC) is clear (De Sousa et al., 2020). Even before the COVID 19
pandemic, the feasibility of solutions that utilized technology had been
well reviewed (Naslund et al., 2017). Reviews showed, however, that
despite tremendous research efforts devoted to innovative care, the
impact of digital mental health tools to date in LMIC remains limited or
unknown. In this paper, we explore barriers and opportunities, and,
using India as a case example, propose a new paradigm for studying and
implementing digital health to increase uptake and impact.
COVID-19 has heightened global awareness around the inaccessi­
bility of effective treatment and support for mental illness (Tandon,
2020) (Keshavan, 2020). On March 25th, 2020 India declared a
nationwide lockdown in an effort to prevent the spread of COVID19.
With a population that exceeds 1.3 billion, and close to 21 % of the
population living below the poverty line in the recent past (World Bank
Open Data, 2011), and only 10,000 psychiatrists serving the entire
country (Garg et al., 2019), access to care that was already limited
before the pandemic became nearly nonexistent. New initiatives such as
a telephone hotline and expanding online therapy programs at the Na­
tional Institute of Mental Health and Neuro-Sciences (NIMHANS) in
response to COVID-19 (Agrawal, 2020) are representative of how
technology can be rapidly employed to make treatment more accessible.
care, however, requires that it be understood within the unique cultural
context of a given population. A national effort to understand the
epidemiology of mental illness in India in 2015 revealed that 13.6 % of
the population experiences a mental disorder during their lifetime and
an estimated 86 % of these cases are untreated (Murthy, 2017). The
treatment gap in India has activated recent initiatives from its govern­
ment and garnered attention from international stakeholders. The
Mental Health Care Act, effective beginning in 2018, specifies protocol
for screening and treating mental illness and guarantees citizens medi­
cation and care, regardless of whether they can afford it (Duffy and
Kelly, 2019). Government spending on mental health care, however,
hovers near. 06 % of total healthcare spending (Mishra and Galhotra,
2018). The public sector is overwhelmed - it does not have the financial
capital or human capital to treat and support 176.8 million mentally ill
individuals. Even doubling the number of psychiatrists today would not
address the challenge, further highlighting the need for technology to
supplement and extend care as well as workforce development.
Mental healthcare infrastructure in India cannot meet the growing
demand for treatment. Mental illness doubled its contribution to the
total disease burden in India between 1990 and 2017 (Sagar et al., 2020)
and increasing isolation across the country to avoid coronavirus infec­
tion introduces a new barrier in delivering care. Although the paucity of
trained and licensed clinicians in India is consistent with other parts of
the world including the United States (Kohn et al., 2018), the burden on

* Corresponding author at: 330 Brookline Ave, Boston, MA, 02446, United States.
E-mail address: jtorous@bidmc.harvard.edu (J. Naslund).

https://doi.org/10.1016/j.ajp.2020.102433
Received 5 August 2020; Received in revised form 30 September 2020; Accepted 1 October 2020
Available online 28 October 2020
1876-2018/© 2020 Elsevier B.V. All rights reserved.
E. Rodriguez-Villa et al.
India’s population is intensified by its vast geography and how clinical
expertise is disproportionately clustered. Clinicians are where the
mental health hospitals are, concentrated in South and West India (Patel
et al., 2016). Patients were crossing state lines to reach mental health
care providers before the pandemic. Thus, there is imminent need to
build new systems and utilize different tools that draw on some of In­
dia’s strengths – its young, diverse, and rapidly growing population and
economy, and its propensity for building and adopting technologies – to
begin closing the mental health care treatment gap before it widens any
more (Fig. 1).
2. The basis for opportunity
Opportunities for technologies such as smartphones to augment
mental health care are clear – and the barriers that challenge imple­
mentation – are distinct in LMIC. Studies in India have shown that most
individuals surveyed with mental illness have access to a mobile phone
(Jain et al., 2015). Only a small percentage of these mobile phones,
however, are smartphones (Sreejith and Menon, 2019). These findings
are consistent with population-level statistics that estimate just under 1
in 4 Indians owns a smartphone (Pew, 2019a,b). Thus, while digital
resources such as smartphone apps will be able to serve millions of pa­
tients today, simpler technologies like text messaging can reach even
more. As smartphones become more affordable and prevalent around
the world, the opportunity for apps will only increase. Given the rapid
global adoption of smartphones, there is an opportunity to introduce
these devices to those first accessing them not only as communication
tools but also as health tools. The need to consider multiple types of
technology use and the constant evolution and upgrading towards
smartphones requires a multifaceted approach that is not dependent on
any one mode of technology but rather embraces this diversity as an
opportunity.
Delivering effective care in LMIC also means understanding the di­
versity of care that is necessary. Access to mental health care is varied
across India and highlights the complex needs any technology solution
must address. The District Mental Health Program (DMHP) was initiated
in 1990 to increase access to treatment at community levels but even by
2015 many states were not sufficiently supported by the program
Fig. 1. The Digital Navigator connects patients to appropriate technology and works with them to customize it. Patients use the technology with ongoing support and
teaching available from the Digital Navigator. The Digital Navigator modifies the technology with feedback from the patient so that it continues to meet their
evolving needs.
2
Asian Journal of Psychiatry 54 (2020) 102433
(Murthy, 2017). The number of districts in a state covered by the DMHP
ranged from 13.64 % in Punjab to 100 % in Kerala (Murthy, 2017). This
contrast highlights stark geographic patterns in inequality throughout
India. 6 states clustered around the northern and eastern regions of the
country - with a combined population of 56 million people – do not have
a single mental health hospital meanwhile other states in India, pri­
marily in the South, have several (Patel et al., 2016).
Already there is promising pilot data that technology-based solutions
can begin to address some of the mental health care disparities in LMIC.
Efforts to date have focused on offering high quality treatment at a
distance, largely using synchronous telehealth technologies such as
video and phone visits. By eliminating barriers physical distance pre­
sents, mobile devices can enable access to treatment (Ramalho et al.,
2020). A handful of studies have tested this hypothesis. Globally, tele­
therapy has proven an effective alternative to in-person therapy (Hubley
et al., 2016). Treatments such as cognitive-based therapy (CBT) and
motivational interviewing can be delivered successfully over the phone
by a mental health professional. While telehealth offers a means to in­
crease access to care (Torous et al., 2020), the unique opportunities and
challenges telehealth presents LMIC has not been evaluated in depth.
Efforts in India have been made to replicate the success of teletherapy,
including an initiative in Chennai that utilized local non-governmental
organizations (NGO) to set up telepsychiatry sites (Thara et al., 2008).
Helplines that offer one-off support and crisis prevention also leverage
mobile devices and enable remote support. However, these technologies
are only as effective and available as the voice on the other end of the
line. A survey of helpline volunteers in India demonstrated that the
demand for counseling exceeded their service capabilities and that
gender preferences and language requirements of callers could not be
met (Pendse et al., 2020). Telepsychiatry and helplines make mental
healthcare more accessible but to the extent there are sufficient human
resources to sustain it. The burden on clinical care providers has high­
lighted both the need and opportunity to redistribute work (Buttorff
et al., 2012).
It is possible to extend access to care through training non-clinical
professionals to support clinical work. Strong evidence shows that
non-medical workers can offer basic organizational and psychological
support at the community level (Patel et al., 2011). Several initiatives in
E. Rodriguez-Villa et al.
India and other lLMIC have provided education around identifying
mental illness and offered training in counseling (Shields-Zeeman et al.,
2017; Patel et al., 2017). Not only do these efforts make care more
accessible and regular, but they also help reduce stigma and falsify
common misconceptions of mental illness. In the absence of public
funding for mental health care, leadership from NGOs has contributed to
important findings on the feasibility and efficacy of task-sharing in India
through utilizing technology.
Technology offers an opportunity to aid task-sharing and can play a
key supporting role for non-medical workers (Raviola et al., 2019). At
their core, digital devices help make information more accessible and
communication more possible. Efforts that leverage technology to
expand the reach and capabilities of non-medical workers are increasing
in LMIC across medical fields (Joshi et al., 2014) but in most cases the
longevity and the extent of their effectiveness is unmeasured (Naslund
et al., 2019). Digital use cases related to mental health range from
performing clinical assessments on tablets (Maulik et al., 2017) to the
dissemination of maternal health videos that can be viewed on mobile
devices (Kumar and Anderson, 2015). Recently, a study in Madya Pra­
desh successfully utilized an online learning platform delivered on
tablets, laptops, and mobile phones to train Accredited Social Health
Activist (ASHA) workers in evidence-based treatment for depression
(Muke et al., 2019). These programs are representative of how tech­
nology can supplement caregiving and increase accessibility. Digital
devices are not poised to assume the responsibility of a clinician or
non-medical worker but they can help share it.
Successful use cases of digital technologies in LMIC must account for
the unique factors they are being asked to solve for. While increasing
access to care remains the underlying goal, addressing the heterogeneity
in languages, cultures, technologies, educational levels, and unique ex­
periences of mental illness across different regions of countries cannot
be ignored. Other factors such as maintenance and evolution of tech­
nology are constant across any country in the world and represent a
challenge that must also be considered in light of the unique infra­
structure present in LMIC, as well as clinical infrastructure (Ransing
et al., 2020).
Research in India on the acceptability of using mobile devices for
medical purposes favors the development of mobile health (mHealth)
technologies and programs to reduce the treatment gap. The majority of
patients and their family members are willing to use mobile phones
towards their personal health (Deb et al., 2018; DeSouza et al., 2014). A
randomized control trial (RCT) in Hunan, China demonstrated how
acceptability of mHealth can be leveraged to connect patients with
serious mental illness to treatment (Xu et al., 2019). The LEAN program
provided an intervention that combined medication adherence encour­
agement through regular text messages with support from non-medical
workers trained in counseling (Xu et al., 2019). Patients receiving the
intervention had greater medication adherence at the end of the study
and showed a smaller risk of relapse and rehospitalization (Xu et al.,
2019). These results highlight the potential of mobile devices, reinforced
by the support and organization of non-medical workers, to treat mental
illness.
3. The innovation
Building off prior research, we propose a hybrid solution that com­
bines adaptive technology with teaching and support. The solution
highlights the need and potential in India for the role of a Digital Nav­
igator– a non-medical worker who connects patients to technology that
is accessible and beneficial to them.
The Digital Navigator does not replace the role of a clinician or as­
sume their responsibilities. Instead, Digital Navigators educate patients
on available technologies and support them in accessing and using
relevant digital tools (Wisiewski and Torous, 2020). Ideally, they are
trusted members of the community who are already comfortable with
technology and willing to be trained in offering basic psychosocial
3
Asian Journal of Psychiatry 54 (2020) 102433
support and counseling. Instead of focusing on any one digital tool or
method, Digital Navigators consider all technologies –from text
messaging and voice calls that can be utilized from a basic mobile phone,
to apps and actigraphy sensors unique to smartphones – that can sup­
plement care. Different modalities offer aspects of the same treatment
protocol but the Digital Navigator works with users to determine and
optimize the mode that is most accessible to them. Digital Navigators
help individuals decide what communication mediums they are most
comfortable with and equip these individuals with the digital literacy
required to access that medium. In addition to connecting patients with
the right digital tools and offering treatment support, the Digital Navi­
gator works towards increasing access to smartphones through teaching
patients basic smartphone skills and helping them gain access to smart
technology. Given the utility of these tools to help patients partake in the
modern economy and access online only resources, digital literacy offers
increasing opportunity towards recovery and functional outcomes
(Hoffman et al., 2020).
The potential of the Digital Navigator to help individuals utilize
diverse digital tools is best understood in the context of current research
findings on mental health in India. The effectiveness of any technology
hinges on how accessible it is to the user. Before trust or engagement are
considerations, technology must be customized to meet the needs of its
user. In India, where several studies reveal a preference for voice mes­
sages over text messages (VA et al., 2010; Chandra et al., 2014;Sreejith
and Menon, 2019), short symptom surveys and medication reminders
can be delivered through voice menus and messages instead. Or, if a user
prefers text messages, they can opt in to automated texts that remind
them to take their medication, encourage them to complete a mood
survey using single digit responses, or provide them psychoeducation
tips. Engagement can also be measured through automated voice mes­
sages or text messages via simple responses prompted at the end of an
activity (e.g. “Dial 1 if you will take your medication today” or “Text 1 if
you found this tip helpful”). Given how easy it is to quantify patient
engagement with quantifiable data, it is subsequently also easy to gauge
the effectiveness of Digital Navigators and quantify their success.
Markers that indicate the efficacy of the Digital Navigator, the tech­
nology utilized, and the treatment the technology offers are outlined
below in Tables 1 and 2.
Anxiety disorders and depressive disorders contribute more than any
other mental illnesses to disability adjusted life years (DALYs) in India
(Sagar et al., 2020). Digital Navigators can play an influential role in
connecting untreated anxious and depressed individuals to mood
tracking and support that are clinically proven to relieve symptoms
(Torous et al., 2015) without involving a mental health care profes­
sional. While technology cannot obviate a nationwide deficit in mental
health care professionals and treatment options, it can help offer basic
treatment and information to those who would otherwise not receive it.
A customizable digital platform that can reach individuals via the mo­
dality of their choice with content unique to their condition offers un­
matched potential to increase access to care. The Digital Navigator is the
critical component in turning the potential of mental health technology
into a reality (Table 3).
4. The implementation
Digital Navigators can offer support out of a range of local settings
and medical institutions: primary health care facilities, community
health centers, NGO sites, inpatient hospitals, outpatient clinics, and
schools. This flexibility guarantees that Digital Navigators can deliver
care to individuals who need it in areas that are underserved. It also
means that they can integrate into established healthcare infrastructure
and trusted systems in place that are already treating patients effectively
but require more support. The role of the Digital Navigator is being
utilized successfully in an outpatient clinic at the Beth Israel Deaconess
Medical Center in Boston, MA (Rodriguez-Villa et al., 2020). Here, the
Digital Navigator works with patients to collect and interpret symptom
E. Rodriguez-Villa et al. Asian Journal of Psychiatry 54 (2020) 102433

Table 1
Challenges and opportunities in India parallel other LMIC and highlight the feasibility and scalability of training Digital Navigators in diverse settings.

will and should look different from that in another setting. Even within a
Table 2 region or community, users’ comfort levels with technology and per­
Goals and outcomes can be measured using metrics that reflect patient
sonal preferences will distinguish iterations and the support the tech­
engagement with technology. Through customization, teaching and offering
nology offers. The Digital Navigator plays an essential role in
support, Digital Navigators increase engagement with technology and improve
clinical outcomes. customizing the platform and utilizing the strengths of care systems in
place to engage the end user.
Goal Indicator of Success Measurement(s)
The private sector and NGOs are the lead providers of mental
Digital Navigator is Patient uses technology Patient responds to 1 healthcare in India (Patel et al., 2016). Both bodies are positioned to
effective teacher on their own survey
offer invaluable organizational support and resources. NGOs form a
Digital Navigator is Patient engages with 1. Patient responds to
customizing technology technology regularly >50 % of surveys given strong network of community-based sites that local programs can
to meet patient’s needs 2. Clinical outcomes operate out of. The successful ones build trust overtime and are inte­
Technology responds real- Technology switches Patient responds to grated into the community. In settings where private sector institutions
time to patient’s needs modality if it isn’t survey after technology and NGOs are already folded into local systems, they can facilitate the
utilized switches modality
Clinical outcomes for Patient’s symptoms Batteries administered to
utilization of Digital Navigators and supporting technology. From staff
patient related to anxiety and patient over technology who can help identify potential Digital Navigators in the community to
depression decrease lending physical space a Digital Navigator can meet with someone in,
the private sector and NGOs can provide structure, insight, and experi­
ence vital to the early stages of program implementation. Their influ­
and actigraphy data using mindLAMP, a digital platform with both a
ence and establishment within communities may significantly help to
smartphone app and dashboard component. mindLAMP is customized
increase uptake and engagement.
by the Digital Navigator, with input from the patient and their clinician,
To assess the degree to which a Digital Navigator and technology can
to track specific symptoms and offer psychoeducation relevant to their
meet and match the needs of a given setting, we propose a framework
unique condition. The utilization of mindLAMP at BIDMC was deter­
that accounts for measures in three distinct categories: 1) Mobile Con­
mined by factors unique to the hospital’s setting and the population it
nectivity 2) Population Demographics 3) Mental Health Infrastructure.
serves. Most patients own smartphones and wireless coverage in the
This framework is a holistic approach to helping identify the settings a
Boston area is ubiquitous, thus making it possible for most patients to
Digital Navigator can be most effective in and the technology it can
access the platform on a mobile app. For mindLAMP or another platform
utilize to best support care.
to support treatment in regions across India, it needs to be adapted based
on input and insight from the individuals who will be using it.
5. The implications
Successful innovations in technology and medicine require careful
consideration of the context they will be used in. Cultural relevance
The treatment gap in India and around the world will continue to
separates useful tools from ineffective ones. Implementation frame­
grow if mental health care infrastructure remains stagnant. In the next
works have not been researched in India to the extent that they have
10 years, the population of India is expected to become the largest in the
been reviewed and evaluated in other parts of the world (Ramaswamy
world (Pew, 2019a,b). This rapid growth, in conjunction with increased
et al., 2018). As such, approaches to initiating and sustaining clinical
social distancing measures related to COVID-19, is poised to strain re­
programs requires close collaboration with end users and infrastructure
sources that are already stretched thin. Increasing access to care in a
that is already in place. India’s economic, religious, and cultural di­
sustainable, scalable way will require innovation. Technology offers
versity – combined with the variance of mental health resources across
novel opportunity to reach infinite patients and connect them with care.
and within states – suggests that the platform one setting benefits from
Harnessing this potential and guaranteeing its efficacy, however, calls

Table 3
Several factors are taken into consideration to determine whether a Digital Navigator can increase access to care in a given setting and which technology they can help
patients utilize.
Mobile Connectivity Population Demographics Mental Health Infrastructure

Region % Mobile Phone % of area w/ Cost of % Mental Illness % Below Primary Care Provider Avg Distance from Clinician to
Ownership Network Wireless Prevalence Poverty Line (eg private/public/ mental health patient ratio
Connectivity Coverage NGO) facility

4
E. Rodriguez-Villa et al.
for an intermediary who can t integrate technology into treatment so
that it is relevant and impactful. The Digital Navigator ensures the utility
of digital tools and resources and is critical in implementing and
establishing new technology that meets the unique, distinct needs of a
patient and community. The pieces are in place to build and grow a
mental health care infrastructure that combines the support of a Digital
Navigator with the diverse capabilities of digital tools to deliver mean­
ingful care at unprecedented scale.
This paper focuses on the need and potential for a digital solution to
close the mental health care gap in India and help respond to the global
health needs during and post COVID-19. However, a combination of the
infrastructure challenges explained, increasing access to mobile devices,
and regional disparity of resources are true for many LMIC. The same
logic that highlights how technology can be adapted to meet the pref­
erences of individuals, aided by a Digital Navigator to support its use,
can be applied to designing and implementing programs around the
world. The implications for technology in mental health care are well
established. Going forward, the Digital Navigator can play a pivotal role
in realizing them.
Authors
All authors have reviewed this paper and agree to publication
Ethical statement
This paper did not involve human subjects and is exempt from IRB
approval.
Financial disclosure
None.
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgments
None.
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