For Mental Health Awareness Week 2019, we are exploring how the University of Oxford has been researching the potential of online psychological treatments to support better mental health care.
The effects of the internet revolution over the past decade alone has been astounding. From the palm of our hand, the top of our desks and in our pockets, we have drastically altered the way we conduct our everyday lives and enhanced our capabilities.
The scale of internet use alone is evidence enough of its effects. According to the Office for National Statistics, 90% of adults in the UK reported being regular internet users and virtually all adults aged 16 to 34 reported being recent internet users (99% in 2018 compared to 44% of adults aged over 75).
Internet driven technologies have enhanced most aspects of our everyday existence, but what’s the potential for harnessing this capability for better health and care? We are seeing both national and local policies that are emphasising the need for embracing a spectrum of internet driven technologies to support professionals and patients alike.
But what about mental health? This Mental Health Awareness Week, the scale of the mental health challenge is serving as an urgent reminder as to why we should be embracing innovation in tackling it.
One in four of us at some point will face a mental health problem each year. 300,000 people leave the work place each year because of mental health issues and it accounts for 15.4 million sick days.
It presents one of the most burning social and economic issues facing the world today.
Some of the most common disorders seen by mental health professionals are Social Anxiety Disorder (SAD) and Post Traumatic Stress Disorder (PTSD). SAD normally starts in childhood or adolescence and is one of the most persistent disorders when not treated. PTSD is a common problem that can occur after a traumatic event and can lead to chronic disability and high healthcare costs if left untreated.
Both of these conditions normally respond well to psychological interventions such as cognitive behavioural therapies (CBT). Specific CBT interventions for these problems were developed by researchers at the University of Oxford at the Oxford Centre for Anxiety Disorders and Trauma (OxCADAT). These treatments are now widely used within the NHS and beyond, and are recommended by the National Institute for Health and Care Excellence (NICE).
While CBT can effectively treat these two common conditions, like any medical intervention, it comes with its own unique set of challenges. Common across mental health services, patients can face difficulties in accessing treatment given the high demand and limited number of therapists.
In the light of these problems and the scale of internet use, one potential solution that is receiving attention here at the University of Oxford is the use of internet-based versions of effective psychological therapies that have traditionally been delivered face-to-face.
OxCADAT have been investigating therapist-guided, internet-based forms of their previously developed CBT programmes for SAD and PTSD and assessing their effectiveness and potential.
The early research has shown some promising results.
The clinical outcomes of these early studies have suggested that internet-delivered CBT may be just as effective as face-to-face therapy sessions. Crucially, good outcomes have been achieved with a drastically reduced workload for the therapists compared to face-to-face clinical settings: 20% for SAD and 25% for PTSD treatment.
As well as being less resource intensive, the early results have indicated that patients may find online-delivered therapies just as acceptable as traditional face-to-face therapies. The early pilots have shown that patients reported greater control over their treatment and greater convenience when undertaking therapy online. In patients suffering with common mental health disorders, this has the potential to attract a greater number of people seeking treatment.
Therapy for common mental health disorders going online has the potential to transform and improve the mental health treatment offering. There could be reduced waiting lists, greater successful turnover of patients, more patients being able to access treatment even if they cannot attend face-to-face therapy and a reduction in the societal and economic burden of mental health problems.
What the key focus is now here at Oxford is examining these treatments further and building the evidence base. Oxford has been a world leader in the development of face-to-face psychological therapies, which are now mainstream throughout the NHS. It is hoped that online CBT can reach the same level of success.
Furthermore, there is also ongoing research adapting internet therapies for global use. Online solutions to these conditions could make a big difference to the global mental health crisis, if we can find effective methods to transport and adapt these programmes for use around the world.
Although these are early days, the results are indeed encouraging. If further research is just as promising, Oxford would be building on its proud legacy in leading some of the greatest evolutions in mental health treatment.
In a series of videos launching The Mathematical Observer, a new YouTube channel showcasing the research performed in the Oxford Mathematics Observatory, Oxford Mathematician Michael Gomez (in collaboration with Derek Moulton and Dominic Vella) investigates the science behind the jumping popper toy.
Snap-through buckling is a type of instability in which an elastic object rapidly jumps from one state to another. Such instabilities are familiar from everyday life: you have probably been soaked by an umbrella flipping upwards in high winds, while snap-through is harnessed to generate fast motions in applications ranging from soft robotics to artificial heart valves. In biology, snap-through has long been exploited to convert energy stored slowly into explosive movements: both the leaf of the Venus flytrap and the beak of the hummingbird snap-through to catch prey unawares.
Despite the ubiquity of snap-through in nature and engineering, how fast snap-through occurs (i.e. its dynamics) is generally not well understood, with many instances reported of delay phenomena in which snap-through occurs extremely slowly. A striking example is a children’s ‘jumping popper’ toy, which resembles a rubber spherical cap that can be turned inside-out. The inside-out shape remains stable while the cap is held at its edges, but leaving the popper on a surface causes it to snap back to its natural shape and leap upwards. The snap back is not immediate: a time delay is observed during which the popper moves very slowly before rapidly accelerating.
The delay can be several tens of seconds in duration — much slower than the millisecond or so that would be expected for an elastic instability. Playing around further reveals other unusual features: holding the popper toy for longer before placing it down generally causes a slower snap-back, and the amount of delay is highly unpredictable, varying greatly with each attempt.
By Shamit Shrivastava and Robin Cleveland
Ultrasound has long been an important tool for medical imaging. Recently, medical researchers have demonstrated that focused ultrasound waves can also improve the delivery of therapeutic agents such as drugs and genetic material. The waves form bubbles that make cell membranes - as well as synthetic membranes enclosing drug-carrying vesicles - more permeable. However, the bubble-membrane interaction is not well understood.
Soft lipid shells, insoluble in water, are a key component of the barrier that surrounds cells. They are also used as drug nanocarriers: nanometer size particles of fat or lipid molecules that carry the drug to be delivered locally at the diseased organ or location, and which can be injected inside the body.
The lipid shell can be “popped” by soundwaves, which can be focused to a spot around the size of a grain of rice, resulting in a highly localized opening of barriers potentially overcoming major challenges in drug delivery.
However, the understanding of such interactions is very limited which is a major hurdle in biomedical applications of ultrasound. Lipid shells can melt from a gel to a fluid-like material depending on environmental conditions.
By observing the nanoscopic changes in lipid shells in real time as they are exposed to soundwaves, our research has shown that lipid shells are easiest to pop when they’re close to melting. We also show that after rupture, a cavity forms and the lipids at the interface experience “evaporative cooling” - the same process by which sweat cools our body - which can locally freeze the lipids, or even water, at the interface. This research advances the fundamental understanding of the interaction of sound waves and lipid shells with applications in drug delivery.
We performed ultrasound experiments on an aqueous solution containing a variety of lipid membranes, which are similar to cellular membranes. We tagged the membranes with fluorescent markers whose light emission provided information about the molecular ordering within the membranes. We then fired ultrasound pulses into the solution and watched for bubbles. The bubbles began to form at lower acoustic energy when the membranes were transitioning from a gel state to a more liquid-like state. The bubbles also lasted longer during this phase transition.
We explained these observed effects with a model that — unlike previous models — account for heat flow between the membranes and the surrounding fluid.
Future work may be able to use this model of membrane thermodynamics to optimize drug-carrying vehicles with membranes that go through a phase transition at the desired moment during an ultrasound procedure.
Read the full study - 'Thermodynamic state of the interface during acoustic cavitation in lipid suspensions' - in Physical Review Materials
Find out more about Dr Shamit Shrivastava
Find out more about Robin O. Cleveland
The 25 of April is World Malaria Day - a good time to take stock of progress towards dealing with one of the great historical global scourges.
Malaria is caused by a tiny parasite transmitted to humans by the bite of certain sorts of (Anopheline) mosquitos. It occurs though the tropics and subtropics. Historically is has caused so many deaths that it has been one of the most powerful selective forces acting on human evolution.
At the turn of this century malaria was rightly described by many as a ‘disaster’: resistance to drugs used in treatment was widespread and estimates of deaths were in millions a year. There was a sense of national and international paralysis. In response to this dire situation came a whole set of initiatives, including declarations by heads of states the initiation of new public private partnerships and the launch of the Global Fund to fight AIDS, TB and malaria. Often such efforts are greeted with a certain amount of scepticism but in this case they marked the beginning of a log order rise in global investment in malaria control and a truly remarkable change in the global malaria situation.
Over the next 15 years malaria reduced dramatically in almost all parts of the world accompanied by an incredible 60% reduction in malaria death rates. In large part this was due to the widespread deployment of effective new drugs, the so called artemisinin combinations and the use of bed nets impregnated with insecticide Encouraged by the possibilities many began to call for a new campaign of global malaria eradication. Others were concerned that this was hubristic, given the biological and social complexity of malaria. The WHO set out in 2015 a Global Technical Strategy, which while disappointing some by not calling for eradication in any short time frame, was in fact very ambitious in aiming at a 90% reduction in malaria deaths by 2030 and at least 35 countries to have achieved elimination.
Over the last few years we have come to a more realistic and nuanced appreciation of the global position. In areas of lower transmission progress toward the elimination targets is on track but at the other end of the spectrum malaria remains a major cause of death in high burden countries. 75% of the worlds estimated 435,000 deaths each year occur in just 11 countries, ten of them in Africa and the eleventh being India. Here progress is in danger of stalling without concerted political and societal action. Against this background there is also concern about emerging drug and insecticide resistance and static levels of international funding. On the more optimistic side there is exciting progress towards potential new tools including drugs, vaccines and ways of genetically modifying mosquito populations.
So on malaria day 2019 we can reflect both on the massive progress over the last 19 years and but also on the considerable challenges ahead. It is a matter of pride that researchers from many parts of Oxford University and especially the major overseas collaborating programmes in south East Asia and Africa have played a central role in the many of the developments that have contributed to the progress described above.
Search online for ‘climate change’ and ‘tipping points’, and you will find some scary results. Melting Ice-sheets, the collapse of the Atlantic thermohaline circulation, the permafrost methane ‘time bomb’ and the dieback of the Amazon that threaten to exacerbate the climate crisis and cause global warming spiralling out of control.
But what if we could leverage similar tipping point dynamics to solve the climate problem? Like physical or environmental systems, socioeconomic and political systems can also exhibit nonlinear dynamics. Memes on the internet can go viral, loan defaults can cascade into financial crises, and public opinion can shift in rapid and radical ways.
Research into such positive socio-economic tipping points is underway at the Institute for New Economic Thinking for the Oxford Martin School Post-Carbon Transitions Programme, headed by Professors Doyne Farmer and Cameron Hepburn. In an article just published in Science, the team outline a new approach to climate change that seeks to identify areas in socio-economic and political systems that are ‘sensitive’ - where a modest, but well-timed intervention can generate outsized impacts and accelerate progress towards a post-carbon world.
Sensitive Intervention Points (SIPs)
These “Sensitive Intervention Points” – or SIPs – could trigger self-reinforcing feedback loops, which can amplify small changes to produce outsized effects. Take, for example, solar photovoltaics. As more solar panels are produced and deployed, costs fall through “learning-by-doing” as practice, market testing and incremental innovation make the whole process cheaper.
Cost reductions lead to greater demand, further deployment, more learning-by-doing, more cost reductions and so on. However, the spread of renewables isn’t just dependent on technology and cost improvements. Social dynamics can also play a major role. As people observe their neighbours installing rooftop solar panels they might be more inclined to do so themselves. This effect could cause a shift in cultural and social norms.
Financial markets are another key area where SIPs could help accelerate the transition to post-carbon societies. Many companies are currently failing to disclose and account for climate risks associated with assets on their balance sheet. Climate risk can entail physical risks, caused by extreme weather or flooding. They can also entail the risk of assets such as fossil fuel reserves becoming stranded as economies transition to limit warming to 1.5℃ or 2℃, when such resources are no longer valuable.
Most of the world’s current fossil fuel reserves can’t be used if the world is to limit warming and they become effectively worthless once this is acknowledged. By not accounting for these risks to fossil fuel assets, high-emission industries are effectively given an advantage over low-carbon alternatives that shouldn’t exist. Relatively modest changes to accounting and disclosure guidelines could make a significant difference.
If companies are required to disclose information about the climate risks associated with their assets – and if such disclosure is consistent and comparable across companies – investors can make more informed decisions and the implicit subsidy enjoyed by high-emission industries is likely to rapidly disappear.
Opportunities for triggering SIPs in a given system can also change over time. Sometimes “windows of opportunity” open up, where very unlikely changes become possible. A key example in the UK was the political climate in 2007-2008 which enabled the 2008 UK Climate Change Act to pass with near unanimous support. This national legislation was the first of its kind and committed the UK to reducing greenhouse gas emissions by 80% relative to 1990 levels by 2050.
The act also created a regular ratcheting cycle which encourages more ambitious future climate action. Since 2008, emissions in the UK have fallen dramatically. However, the UK Climate Change Act’s influence beyond the UK is also significant as it encouraged similar legislation in other countries, including the Paris Agreement, which contains the same self-reinforcing ratcheting mechanism.
Using SIPs for rapid change
Thinking about SIPs in policy and business could accelerate the post-carbon transition – but much work lies ahead. The first step is to systematically identify potential SIPs and the mechanisms by which they can be amplified.
These new methods could provide more accurate insights into the costs, benefits and possibilities of SIPs for addressing climate change. As SIPs could be present in all spheres of life, experts in social and natural sciences will need to work together.
The window to avert catastrophic climate change is closing fast, but with intelligent interventions at sensitive points in the system, we believe success is still possible. Since the stakes are so high – and the time frame so limited – it is not possible to chase every seemingly promising idea. But with a smart, strategic approach to unleashing feedback mechanisms and exploiting critical windows of opportunity in systems that are ripe for change, we may just be able to tip the planet onto a post-carbon trajectory.
A version of this article originally appeared in The Conversation.