This week is Depression Awareness Week, and it is a good moment to take stock of how we support people with common mental illnesses.
The good news is that, in the UK at least, thousands of people recover from depression every year with the help of talking therapies prescribed by the NHS. The bad news is that most of them sit on a waiting list for weeks or months before they get that therapy. The even worse news is that there is a large group of ill people that never get on to the waiting list at all, because they do not come forward for treatment.
This group has come to be called "the silent waiting list" and although it is impossible to put an exact figure on it, we know it is big. Consider NHS England's target to make talking therapy available to just 15% of those "with relevant disorders". This shows how tiny the numbers getting help are compared to the numbers who need it. Consider too that fewer than one in six older people even talk to their GP if they have depression, according to 2014 guidance from the Royal College of GPs.
So what stops this "invisible" group from seeking help?
Depression is often accompanied by shame, and people try to hide their symptoms. We know from statistics that men find it harder to admit to depression or anxiety, which is why three times more men commit suicide than women. Older and younger people, black and ethnic minority people, and people with chronic physical illness also find it hard to ask for help.
The practicalities of having therapy can be off-putting, too. Appointments are normally at a clinic during office hours because that is how the NHS works. If you have a job, how do you explain this to your boss? If you have a baby, who is going to look after it? If you have mobility problems - arthritis, for example - how will you travel to your appointment?
The silent waiting list is an unenviable place to be. People who recover and learn to manage their psychological symptoms can end up feeling stronger and happier than ever before. But invisible sufferers never get that chance. Some will get better with no help, but many will not, and a significant number will get worse.
By the way, we are not talking about severe mental illness, we are talking about the common variety, which one in four of us will experience at one point. This includes depression, anxiety, phobia and the aftermath of trauma.
Often these people present to their GP with physical ailments, when what they really need is psychological support. As well as prolonging individual suffering, this places further strain on an already stretched health budget.
So what is the answer? Clinical evidence shows people with these common illnesses respond well to talking therapies, including face-to-face cognitive behavioural therapy (CBT), the type the NHS is most likely to prescribe.
Unfortunately, the face-to-face CBT service is unlikely to solve the current scale of unmet need. It is already struggling to treat 15% of patients with mood disorders and it is not attractive to people who are reluctant to identify themselves as ill in the first place.
However, there is a way to reach this locked-out demographic, and it involves technology. For example, Ieso Digital Health's online therapy service allows patients to have CBT with accredited therapists over the internet, using written communication. It is delivered as a free NHS service in 26 areas in England, and as a paid-for service elsewhere.
The service is accessible on computer, tablet or smartphone. You can use it at a time and place of your choice - on the sofa after the evening news, or after the baby has gone to bed. No need to find childcare, explain to your boss, or overcome your mobility problems. And people can self-refer - so you do not even have to speak to your GP.
Another advantage of the service is its speed. It can take months to get your first face-to-face therapy appointment, but with online therapy you can be allocated a therapist within hours, and have your first session within days.
Intriguingly, clinical results suggest online CBT is just as effective - perhaps even slightly more so - than the face-to-face kind. On average 52% of Ieso Digital Health patients recover compared to 45% for talking therapies nationally.
This is partly because it is easier to open up online, speeding up the process of recovery.
It is by definition impossible to quantify the silent waiting list. But when Ieso Digital Health leafleted 80,000 households in West Kent about the availability of its service via self-referral, the numbers of patients coming to us soared by 400%. This gives a sobering indication of the numbers who may be suffering in silence.
One patient made a comment that summed up the power of our approach for people on the silent waiting list.
She said: "I couldn't imagine sitting in a room with a stranger and them looking at me whilst I'm discussing my most personal thoughts and feelings. I don't like social situations and that alone has stopped me from pursuing help in the past. You have no idea the sense of relief I felt when a leaflet arrived through my door today telling me about online therapy. I dropped everything and ran upstairs to register! I hope I can finally start to heal."