Psychotherapy access barriers and interest in internet-based mental health interventions: Survey of adults with treatment need (Preprint)

Abstract

BACKGROUND Low-intensity treatments (LITs) such as digital mental health interventions, internet-based cognitive behavioral therapy (i-CBT), and guided self-help (GSH) may be a promising way to reduce the public health burden of mental illness. These interventions are efficacious, can provide evidence-based treatment at low cost, and may circumvent structural barriers (e.g., cost) to traditional psychotherapy (i.e., individual face-to-face treatment with professional providers). There is great excitement regarding the resulting potential of LITs to expand treatment access to those currently facing structural barriers. However, this claim relies upon the largely untested assumption that individuals who cannot or do not access psychotherapy want and would use LITs, often without consideration of the influence of attitudinal barriers to psychotherapy access, which at least equally as common as structural barriers. OBJECTIVE The current study evaluates the assumption that LITs will reach individuals with unmet treatment needs by circumventing structural barriers. We investigated the relationship between 1) structural barriers to traditional psychotherapy access and 2) attitudinal barriers to traditional psychotherapy access with indicators of potential GSH use. METHODS We collected survey data from N=971 U.S. adults who were recruited online via Prolific and screened for the presence of internalizing distress. Participants provided information about demographic characteristics, current symptoms, and use of psychotherapy in the past year. Those without past-year psychotherapy use answered questions about perceived barriers to psychotherapy access, selecting all contributing barriers to not using psychotherapy and a primary barrier. All participants also read detailed information about a GSH intervention. Primary outcomes were participants’ self-reported interest in the GSH intervention and self-reported likelihood of using the intervention if it were offered to them. RESULTS Individuals who had used psychotherapy in the past year had much greater interest in GSH than those who had not (OR=2.38; 95% CI 1.86, 3.06; P<.001) and much greater self-reported likelihood of using GSH (OR=2.25; 95% CI 1.71, 2.96; P<.001). Among those without past-year psychotherapy use, the most commonly reported barriers were lack of perceived need for treatment (206/640, 32.19%) and issues with money or insurance (170/640, 26.56%). When participants’ primary barriers to psychotherapy access were sorted into categories, attitudinal primary barriers (e.g., lack of perceived need, wanting to handle the problem on one’s own; 336/640, 52.5%) were more common than structural primary barriers (e.g., money or insurance, lacking transportation; 244/640, 38.12%). Relative to endorsing a structural primary barrier, endorsing an attitudinal primary barrier was associated with lower interest in GSH (OR=0.44; 95% CI 0.32, 0.6) and lower self-reported likelihood of using GSH (OR=0.61; 95% CI 0.43, 0.87). CONCLUSIONS Our findings suggest that attitudinal barriers to traditional psychotherapy use may also serve as barriers to LIT use, challenging assumptions about the potential of LITs to expand treatment access by circumventing structural barriers alone. Future research should seek to further understand attitudinal barriers to LIT access, their relationship with barriers to traditional psychotherapy access, and potential LIT design adaptations and dissemination strategies that might counter these barriers.