LINDY ALEXANDER
Online mental health services, including self-guided tools and live therapy sessions, address problems of access for people in rural and remote areas as well as cost-effectiveness of treatment, writes Lindy Alexander.
Australia is a world leader in developing online mental health programs. NASA-funded researchers at Stony Brook University in the United States have begun a clinical trial of an Australian e-mental-health tool called myCompass, created by the Black Dog Institute, in order to determine whether it can relieve depression, anxiety and/or stress in astronauts.
Back on Earth, the director of the Black Dog Institute, Professor Helen Christensen, says there are about 600,000 people in Australia with mild to moderate levels of anxiety and depression who would potentially benefit from e-mental-health services. These services may come in the form of self-guided apps or programs, online peer support, interactive therapy or counselling via video calls or moderated groups.
Christensen says that despite evidence from a number of studies showing the efficacy of online psychological support, not everyone is yet convinced. “I think there is still opposition to the idea that you can get just as much psychological benefit from a computer than you can from face to face,” she says. “The evidence is that online and face to face are as effective as each other.”
Christensen is a co-author of an international meta-analysis, published in JAMA Psychiatry earlier this year, that found self-guided internet-based cognitive behavioural therapy (CBT) was effective in treating depressive symptoms. In particular, the authors proposed that online CBT might be a viable alternative as a first-step treatment for individuals reluctant to have any therapeutic contact. “This self-help form of CBT can provide treatment access at low cost to large numbers of individuals worldwide who have depressive symptoms,” the authors suggest.
The potential reach of online therapies is particularly appealing in a country such as Australia, where 29 per cent of the population live outside the major cities. “It means you can deliver these interventions with greater reach because they’re scalable, in that they can be consumed many times over without lacking any effect,” Christensen says. “This isn’t to say that it doesn’t cost anything, but it doesn’t cost as much as face to face.”
In addition to its cost-effectiveness, supporters say online psychological support is convenient, private and timely. Digital strategist and writer Anna SpargoRyan started looking into self-guided apps as a stopgap between sessions with her psychologist. “My therapist also records guided meditation and hypnosis to CD, but as technology has changed I found I needed something that would work better with my lifestyle,” she says. “I don’t own a CD player anymore except in my car, which is not an ideal place for hypnosis.”
Spargo-Ryan uses the apps to maintain her mental health as well as when she is in crisis. “They seem to work best when they’re used regularly, and this is what’s widely recommended,” she says. “But I’ve also found them effective for periods of extreme stress or anxiety. I had a family crisis earlier this year and found they were great for getting me out of bed when I couldn’t think of anything I wanted to do less.”
For communications professional Sophie Nolan, online access to her psychiatrist was crucial in managing her bipolar disorder. “During 2011-12, I saw my psychiatrist over Skype every few weeks,” she says. “We had already formed a face-to-face clinical relationship about seven months before I moved from Brisbane to Rockhampton.”
Nolan says the continuity of care was important for her, as well as the responsiveness her psychiatrist was able to offer. “If there was a crisis I could ring his rooms and they would grab him in between appointments and work me in to see him via Skype. It saved me an eight-hour drive or a one-and-a-half-hour flight,” Nolan says.
Regional areas typically have fewer local medical professionals – inner regional areas have access to just 37 per cent of the psychiatrists and 61 per cent of the psychologists major cities have. But changes to the Medicare Benefits Schedule this month mean that individuals can claim up to seven of their 10 Medicarecovered counselling sessions using online services, also known as telehealth. “Telehealth may not be as effective straight off the bat because you don’t have the rapport, but it’s better than nothing,” Nolan says. “It’s especially better than leaving people to languish in regional or rural areas.”
One such service, MindSpot, was launched in 2013 as an initiative of Macquarie University. Forty per cent of people who access MindSpot – a service for adults experiencing anxiety, stress, worry, chronic pain, sadness or depression – live outside major cities. “We describe MindSpot as a virtual clinic,” says project director Professor Nick Titov. “This means that we don’t see our patients face to face. Instead we contact people via technologies such as telephone, secure email and secure web-based portals.”
MindSpot serves about 20,000 Australians yearly. Most people register to learn more about their symptoms and treatment options, and about 25 per cent go on to enrol in one of the service’s seven free treatment courses. “They aim to teach people practical psychological skills which they use every day to help overcome their symptoms,” says Titov. During the eight-week courses, users are encouraged to log in weekly to learn more and have contact with the same therapist, who helps guide their recovery.
The courses have been evaluated in a large number of clinical trials at Macquarie University’s specialist research clinic, the eCentre Clinic. About 70 per cent of people complete treatment, and even those who withdraw early tend to make gains. “We see about a 50 per cent reduction in symptoms, which is sustained in most cases at three-month follow-up,” says Titov.
One in four young people experience a mental health condition, and online psychological support for this demographic is also being developed. The Moderated Online Social Therapy (MOST) project involves academics, researchers and creative professionals designing, building and testing a suite of digital and online technologies for young people with mental health conditions, as well as their parents and carers. It is a collaboration between the Orygen National Centre of Excellence in Youth Mental Health, the Australian Catholic University’s psychology school, the University of Melbourne School of Computing and Information Systems and its youth mental health centre.
Jia-Wern Toh, an online support worker with MOST, says: “My colleagues and I assist young people in navigating Horyzons, which is for young people recovering from psychosis, to brainstorm ideas on how to cope with mental health struggles and encourage them to try out the therapeutic tools available online. Young people were expressing a preference for online mental health services. They preferred to chat online with clinicians and seek support online, instead of attending face-to-face sessions.”
Toh can see the appeal. “Sometimes young adults can feel embarrassed or ashamed to access mental health services,” she says. “Maybe that’s why some of them are comfortable to access services online, where they can use a pseudonym or just chat to a clinician over a computer screen. They don’t have to worry about others seeing them walk into a mental health clinic and be judged. This is especially important in one’s teenage years because that’s when we feel most vulnerable and want to fit in with our peers.”
Penni Russon is an author of young adult fiction and a member of the MOST team. “A few years ago I was given the opportunity to join a multidisciplinary research team to write content for online therapy,” she says. “At first it was a fairly straightforward translation job of writing complex psychological and therapeutic concepts into youthspeak, but no matter how simply we wrote it, we found young people were just not reading it.”
In consultation with psychologists and young people, Russon and her team have published a range of comics and launched a new site called Generation, which is being trialled through youth mental health hotline eHeadspace. “The comics are about depression, self-compassion, mindfulness and using your strength,” Russon says. “They are part of a system of care that includes a moderated social network, extensive peer support through trained young people with lived experience, behavioural experiments and activities to apply the therapy to offline situations and various ways of tracking their progress.”
For Russon, what is significant is the engagement and creation of meaningful “human spaces” for online mental health. “It’s not about automatising therapy, but about meeting people where they are at.”