e-Mental Health – What is it and why do we need it?

e-Mental Health – What is it and why do we need it?

Dr Jan Orman MBBS MPsychMed GP Services Consultant, Black Dog Institute

I want to declare upfront that I am old (born in the year of the Chico Roll) and until recently relatively technophobic.  I am an urban GP, despite my adolescent plan to return to the country town I grew up in to save lives in dramatic ways, and my interest and postgraduate training is in mental health.

I have worked as a GP educator in mental health for the Black Dog Institute for over 10 years but, given what I’ve already said, imagine my surprise and trepidation when I was asked to lead the content development for the GP arm of the e-mental health in practice (eMHPrac) project for the Black Dog Institute. The project  is about using technology for heaven’s sake! And in an area that I take pride in being able to manage myself!

I’ve learnt a lot in the last 18 months. I’ve learnt (from the focus groups I ran) that in late 2013 and early 2014 in places as diverse as Randwick and Ulverstone,  very few GPs knew anything at all about eMH,  even fewer had experience with using eMH resources. Many didn’t even know what eMH meant.

At that time some people had heard of MoodGYM, an internationally respected online CBT program developed by Helen Christensen’s team at ANU and launched in 2001. Some GPs had also heard of This Way Up, the online programs developed by the WHO’s Clinical  Research Unit for Anxiety Disorder (CRUfAD) based a St Vincent’s Hospital in Sydney. But no-one had much of an idea about how these things could be used in general practice.

Clearly there has been a lot of work to do since then, and I’m thinking there is a lot more work needed still to get GPs knowing about and feeling confident in using online resources, including online treatment programs, in the care of patients with mental health problems. I’m not giving up yet!

Why do GPs need to know about this?

In 2014, according to the BEACH study, 12% of general practice presentations were for mental health issues (and of chronic conditions 26.6% were psychological problems).  I think that may well be an underestimate – it obviously is judging by my experience as someone known to be interested in mental health, but many GPs I meet tell me they think so too. What if we counted the consultations that had a “mental health component”? Would that better reflect what we are really seeing?

Even if 12% is the true figure it’s still a lot of consultations and a lot of distressed people.

And what about the GPs who say they have no interest in mental health? What do they do with these “problem” patients?

The 2014 AIHW Report on Mental Health Services in Australia http://mhsa.aihw.gov.au/home/ estimated that only 70% of Australians with mental health problems received any professional help for those problems. Admittedly its better than the previous report,  from just after the Better Outcomes in Mental Health Initiative began, when the figure was less than 50%, but still, with psychologists available on Medicare and Focussed Psychological Strategy item numbers available for appropriately trained GPs, we are missing 30% of the people who need mental health care. Maybe if we (or the patients) knew more about the kinds of help available online more people would be able to access the help they need. Maybe we could even help prevent some of the distress we are seeing by using resources that are designed to help build resilience and reduce vulnerability!

What is there online?

Online there are portals to internet based resources developed by the federal government (www.mindhealthconnect.org.au) and the Australian National University (ANU) (www.beacon.anu.edu.org ).  These portals have filters which guide users to reliable resources to suit their disorder and their demographic. The Beacon website also rates the resources according to the evidence available to support their use. As a GP you can help your patients by telling them about the portals or even showing them how to use them to find what they need.

There are lots of unhelpful websites out there in cyberpace but there are a number of reliable Australian websites for information and psychoeducation. www.blackdoginstitute.org.au and www.beyondblue.org.au are just two examples. Another website worth looking at is www.biteback.org.au  a positive psychology based website developed by a young team at the Black Dog Institute for young people aged 12-18 years old. And don’t forget www.eheadspace.org.au which offers support and counselling for young people as well as information and advice.

And then there is online therapy. There are many options to choose from as Australia is a world leader in online therapy development. There is plenty of evidence that online therapy can be as effective as face to face therapy for the right people (people who like doing things online) and the right conditions (mild to moderate anxiety and depression) and it is certainly lot better than no therapy at all. Some of that evidence can be found in the reviews and meta-analyses mentioned in the reference list below.

Online therapy in Australia is mostly free and mostly available without referral (the exception to both these is This Way Up which also happens to be supported by the biggest body of evidence.  It is usually CBT (cognitive behavioural therapy) based, often with a dash of IPT (interpersonal therapy), Positive Psychology and Mindfulness for good measure. It is delivered in a modular fashion that resembles “sessions” with a psychologist and involves homework tasks and interactive activities.

What do you do with online therapy as a GP?

You can:

  • Recommend it as a self-help tool (preferably with knowledge and enthusiasm and by showing it to your patients on your desk top as you recommend it, all of which is likely to increase their compliance and adherence)
  • Incorporate it into your usual general practice care by routinely following patients that are using it just as you would someone for whom you had prescribed antidepressant medications
  • Act as a coach or guide as patients work their way through a program
  • Use it to introduce reluctant patients to the idea of face to face therapy or to fill the gap while they wait to see a psychologist

So what’s out there? Here’s a sample of the best:

 Examples of Reliable Australian-developed Online Mental Health Treatment Programs  
Program and Provider Indication Cost and Access Additional Comments
myCompasswww.mycompass.org.auBlack Dog Institute Older adolescents and adults with mild to moderate stress, depression and anxiety Free of chargeNo referral required Smart phone tracking
Moodgymwww.moodgym.anu.edu.auAustralian National University Older adolescents and adults vulnerable to depression and anxiety as well as those with mild to moderate conditions Free of chargeNo referral required Available in 5 languages:Mandarin, Suomi, Norsk, Nederlands as well as English
e-Couchwww.ecouch.anu.edu.auAustralian National University Adults with mild to moderate anxiety, depression and specific anxiety disorders. Free of chargeNo referral required Linked to blueboard www.blueboard.anu.edu.au a moderated forum for mental health support
This Way Upwww.thiswayup.org.auCRUfAD/UNSW/St Vincent’s Hospital Adults and older adolescents.Disorder specific programs for panic, GAD, depression, social anxiety, anxiety and depression  together and OCD Currently $55.00 for 90 days accessGP referral required Program maintains contact with referring GP
OnTrackwww.ontrack.org.auQueensland University of Technology Adults with depression, alcohol use disorders and depression and alcohol use problems together Free of chargeNo referral required Unique programs include support for family and friends and help with early psychotic symptoms
Mental Health Onlinewww.mentalhealthonline.org.auSwinburne University of Technology Disorder specific programs for adults with panic, GAD, SAD,PTSD, OCD and depression Free of charge or $120 if therapist guidance requiredNo referral required
Mindspot Clinicwww.mindspot.org.auMacquarie University Trans-diagnostic “Wellbeing” programs for adults with anxiety depression and stressDisorder specific programs for OCD and PTSD Free of chargeReferral optionalContact made with GP if user desires “Virtual clinic” format provides regular “human contact” with user by therapist at Mindspot ClinicIndigenous wellbeing program and program designed for adults over 60 available

 

 

If this looks overwhelming think about it as you would a new class of drugs. Learn about them all in a general way, become very familiar with a few that are relevant to your patient group and learn the right way to use them then prescribe them confidently. Follow your patients up and if the programs aren’t helpful or are unacceptable find another way.

For more help or information go to www.blackdoginstitute.org.au . While you’re there you can watch a recorded webinar, sign up for a live webinar , read the research or join the eMHPrac online community.

It really is time to let good online resources help in patient management

 

References

  • Australian Institute of Health and Welfare Report on Mental Health Services in Australia 2014 https://mhsa.aihw.gov.au/services/general-practice/
  • BEACH General Practice Activity in Australia 2014 http://ses.library.usyd.edu.au/bitstream/2123/11882/4/9781743324226_ONLINE.pdf
  • BEACH 2014 The prevalence of common chronic conditions in patients at general practice encounters 2012 – 14 http://sydney.edu.au/medicine/fmrc/publications/sand-abstracts/212-Prevalence_of_chronic_conditions.pdf
  • Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N (2010) Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-Analysis. PLoS ONE 5(10): e13196. doi:10.1371/journal.pone.0013196.
  • Andersson, G. & Hedman, E. (2013) Effectiveness of Guided Internet-Based Cognitive Behavior Therapy in Regular Clinical Settings. Verhaltenstherapie. 23:140-148
  • Griffiths, K.M., Farrer, L., & Christensen, H. The efficacy of internet interventions for depression and anxiety disorders: a review of randomised controlled trials. MJA 2010; 192: S4–S11
  • Proudfoot, J., Clarke, J., Birch, M., Whitton, A.E., Parker, G., Manicavasagar, V., Harrison, V., Christensen, H., and Hadzi-Pavlovic, D. Impact of a mobile phone and web program on symptom and functional outcomes for people with mild to-moderate depression, anxiety and stress: a randomised controlled trial. BMC Psychiatry 2013 13:312.
  • Spek, V., Cuijper, P., Nyklick, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychological Medicine, 37, 319–328

Declaration of Interest

I am paid by the eMHPrac project to educate general practitioners about eMH programs and resources

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3 thoughts on “e-Mental Health – What is it and why do we need it?

  1. You are addressing a very under served issue in the General Practice area of Medicine. I have witnessed two cases, both falling into the crack between physical health & mental health. In one case, the person seeking care became dangerously suicidal when the GP & ER doctor failed to either recognize the problem or deal with it on any level. The area these people live in has somewhat limited psychiatric services. One of the people I am describing in this communication, finally got to see a Psycholgist in conjunction with a Psychiatrist. The options this office offered were limited. As a very busy office, the patients could only talk to or see either the doctor or the psychologist during scheduled appointments. When patient was having, what I term as a meltdown, & too upset to drive to their appointment, he asked if he could have session or even a brief conversation via telephone. The Secretary asked the psychologist, as requested by patient, who was shaking & crying ( unusual for this person ) for the connect. She returned to the phone with a definite “NO”. What do you do in a circumstance when hospitalization is not necessary, but communication is. The Patient, probably disallusioned with the response, told the secretary to cancel any future appointments. I understand that this was done while sobbing hysterically. Neither the Psychologist or anyone in that office made a followup call. This office ran a lot like a business, which I suppose it is. However, someone should have responded to this desperate cry for help. I’d like to see a situation where offices have a social worker on site able to respond & deal with problems of this type, ones that could easily end in suicide. The patient in this scenario, had an appoinent at the time this was all happening. Availability was not the problem. Willingness was. It would be my best guess that office could not bill for a phone session. What do you do in a case where they are almost no choices for mental health care from a doctor? It would be good if the patient had somewhere to turn for help, perhaps to the family doctor who could make recommendations. Thank you for reading this.

    • Dear Bonnie
      This is a terrible situation and I am sorry to hear about it. It reflects the complexities for the psychologist of trying to work in an environment that is driven by rigid attitudes to boundaries as well as the inappropriateness of providing human services in primary care (including allied health) using a strict business model. It really is inexcusable.
      I figure that as referring GPs part of our role is to pick up the pieces in situations like this.
      I can’t tell psychologists how to run their businesses but I would certainly be very keen to talk to them personally about that situation if it were affecting my patients. If I had no choice other than to refer patients to them again (because there was noone else) I would also be careful to warn the patients that I refer that these psychologists they were not useful in crisis situations and provide them with other options. (eg Lifeline, access to urgent appointments with me.)
      Unfortunately in crises such as this the online world cannot offer much help beyond crisis lines like lifeline and chat rooms like blue board (www.blueboard.anu.edu.au ). Severe distress needs human contact.
      Online help works best before such a crisis in order to avert it or after a crisis to prevent further problems and in someone so unwell it needs to be used in conjunction with face to face therapy.
      If you have no acceptable face to face option for your patients maybe learning to coach them through online treatment programs might increase your effectiveness and confidence.

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