Benefits of e-mental health treatments and interventions
E-mental health tools and resources have the potential to fill gaps in service provision and reach hard-to-access consumers, however, privacy concerns, quality, supervision and the lack of evidence remain issues to address.
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises that mental health services are increasingly being delivered online in Australia and New Zealand. The RANZCP welcomes this development and recognises the potential for technology to deliver effective, affordable and accessible services as a useful complement to other forms of care and support. However, it must be acknowledged that e-mental health also brings with it substantial risks and issues.
This position statement aims to provide an overview of the benefits and issues associated with e-mental health, and to ensure that technology is used wherever possible and appropriate in psychiatry, noting the role psychiatrists play in guiding consumers in this field. This document has been adapted with permission from the World Psychiatric Association (WPA) position statement on e-mental health (WPA, 2016).
Please note this area is developing faster than the evidence-based research in the field and e-mental health tools are already being used in practice. It is therefore imperative to have open communication about what e-mental health tools are being used, ensuring that consumers and patients are informed of the risks as much as possible. Ideally we want patients to have an open dialogue with their medical professional and feel comfortable to discuss these matters with their psychiatrist.
- E-mental health refers to the broad range of digital resources, services or programs, delivered via online, mobile or phone based platforms.
- There are many benefits associated with the use of e-mental health tools and resources, which have potential to fill gaps in service provision and reach hard-to-access consumers. However privacy concerns, quality, supervision and the lack of evidence remain issues to address.
- Psychiatrists are well placed to help consumers use and engage with a range of e-mental health tools and resources. Clinicians should be informed of the benefits and issues associated with e-mental health applications and tools, and understand how to incorporate them into practice.
- Further research and greater oversight is needed to ensure e-mental health tools are evaluated and employed based on valid evidence.
- Conflict of interest should be considered if psychiatrists are involved in the development or trial of e-mental health services, including the development of applications. Recommendations to consumers by mental health professionals should be made on the basis of evidence and accompanied by declaration of any conflicts of interest.
E-mental health refers to the broad range of digital resources, services or programs, delivered via online, mobile or phone based platforms, which offer support to people affected by mental health issues, including consumers, families/whānau, carers and communities. E-mental health may deliver health literacy, prevention, intervention, assessment or support, or a combination of these, and usually target conditions of mild to moderate severity.
A broad range of approaches may be utilised, from administrative support through to the delivery of therapy through a variety of technology enabled communication channels. This can include access to online resources, use of social media, smartphone apps to create tailored engagement, personalised messaging, immersive virtual and augmented reality tools, wearable monitoring technologies to enhance real time diagnostics and care, telehealth services and social support. The more established approaches often have a stronger evidence base, however ongoing research is steadily building an evidence base for a range of tools and resources (Shalini and Adair, 2014).
E-mental health tools are typically developed for a specific purpose or population, and not all e-mental health tools and resources will suit every condition or consumer. There is a need to be aware of false claims made by providers of e-health technologies, such as videogames and other e-platforms, relating to their effectiveness. It is important that consumers are empowered to direct their own e-mental health care, and psychiatrists are well placed to guide consumers in this field.
Benefits of E-Mental Health
E-mental health services can offer creative and cost-effective ways of meeting some of the mental health needs of the community, in particular, those groups and individuals that do not currently seek help from current service providers. The Australian National Survey of Mental Health and Well-being in 2007 found that only 35% of people with a mental illness had used a health service within the survey period (ABS, 2007). E-mental health tools and resources have the potential to increase access to, and improve the quality of care, as follows:
- Improving access to early diagnosis, intervention and care: By providing another means of early access to services, e-mental health allows for reduced duration of untreated illness, and potential for less intensive treatment and faster recovery.
- Improving efficiency: For some people, online information, self-management and e-therapy programs may be sufficient to alleviate symptoms at a minimal cost and without clinical support. Telepsychiatry services can provide more flexible access to person-to-person contact with a mental health professional. E-mental health technology provides for quicker identification of more serious conditions, and/or access to emergency support, enabling clinicians to focus on people who are in most need.
- Helping to improve continuity of care: E-mental health technology can facilitate collaboration between primary and secondary care, and other agencies, and help to support ongoing decision-making with patients. This can include established health information systems such as the My Health Record system in Australia, where consumers have control of their health information and share data with medical professionals.
- Providing more equitable access to care: For people on low incomes, e-mental health is typically lower in cost, more affordable, and with reduced travel and wait times. However, limited access to the technology itself may be a barrier for some population groups. Fear of stigma is also barrier for many people in seeking help for mental health problems. E-mental health support can be sought on an anonymous basis which can alleviate this problem.
- Helping promote mental health and prevent mental illness: By enabling quick access to online information and self-management programs, e-mental health options can encourage people to take control of their own mental health, and seek help if they need to.
- Increasing outpatient engagement: Mobile phone applications are available for reminding people of appointments, recording and self-monitoring mental health conditions and unhealthy addictive behaviours, and communication with clinicians in between sessions.
- Providing greater support for telehealth: Telehealth is one of the most widely used e-mental health services in Australia and New Zealand, and can greatly improve access to psychiatric services. The use of telehealth in psychiatry is discussed further on the RANZCP web page on telepsychiatry.
E-mental health may also offer particular benefits for certain groups in Australia and New Zealand, such as young people, rural and remote communities, and those who do not access traditional services. Studies have shown that young people feel favourably towards the use of mobile phone applications and online resources for mental health care (Montague et al, 2015; Struthers et al, 2015). Studies suggest e-mental health interventions can be effectively used to support or extend existing health services for Aboriginal and Torres Strait Islander people (Puszka et al., 2016; Povey et al., 2016).
For Māori, a number of e-mental health tools are available based on a holistic model of Māori health, incorporating spiritual, mental, physical and family dimensions. Examples in this field include SPARX, which is a self-help e-therapy tool in a game format, and Whaiora Online, an interactive web-based tool that allows individuals to set their own goals and monitor their progress (New Zealand Government, 2016).
Challenges and Considerations for E-Mental Health
Australia and New Zealand have encouraged the research and development of e-mental health with government investment and support. There are, however, a number of considerations that need to be managed for e-mental health tools to be fully and effectively integrated into Australian and New Zealand mental health care services. Key considerations, identified by WPA, have been adopted by the RANZCP below:
- Training in e-Mental Health
Studies have identified a lack of awareness in the use of e-mental health as a key impediment to implementation (Puszka et al., 2016; Meurk et al., 2016). Mental health staff, including psychiatrists, should familiarise themselves with e-based mental health tools so that they can advise the community on the appropriate use of e-mental health, and explain limitations. Consideration should be given to online portals that have been developed for consumers and health professionals to guide their selection and use of evidenced based e-mental health tools (e.g. Beacon, e-hub Mental Health and Head to Health). It is important that institutions responsible for training doctors and specialists equip them to use new technology.
Patients should expect their personal information to be treated confidentially and with respect. Personal information should be held in accordance with the relevant legislation, including the Australian Privacy Principles (contained within the Privacy Act 1988) and the New Zealand Health Privacy Principles (contained within the Privacy Act 1993), as well as the New Zealand Information Security Framework and Health Information Governance Guidelines. The protection of patients’ information must be properly managed irrespective of the care setting, including virtual settings. This is particularly important for people living with mental illness, who often face social barriers and stigma when seeking help. The RANZCP encourages clarity around mechanisms to ensure the privacy of individuals should be a priority of government and those developing e-mental health tools. These issues will need to be monitored carefully by regulators and medical professionals.
- Record keeping
The same requirements to preserve information and secure it against unauthorised access or distribution should apply to all patient data, regardless of how it is stored. Records must be kept safe and secure whether they are paper-based or electronic health records, such as the Australian My Health Record scheme. The Australian and New Zealand governments need to manage criteria and regulations for data collection by digital interventions and conduct ongoing reviews of data collection requirements. Storage of data on personal computers and mobile instruments carries risk of data breach and potential use for commercial purposes. In cooperation with governments and policymakers we urge national associations to create regulations for standard setting and reducing risks.
- Clinical Risk
E-mental health may be able to enhance quality of care and support self-management in a number of consumers. However, the RANZCP would like to emphasise that the same standards of care should apply with online or remote assessments as with face-to-face assessments, and care must comply with relevant clinical guidance. Building ethical and evidence-based practice is core to healthcare delivery and to the development of e-mental health.
All new interventions should be considered in terms of potential risks and benefits, treatment effectiveness, equitable utilisation and prioritisation of limited resources. In particular, consideration should be given to treatment adherence, as some studies highlight issues around completion rates for e-mental health interventions (Meurk et al., 2016). On this basis face-to-face therapies are still the preferred method of treatment. It is also important to note that clinician involvement is important to the effectiveness of e-mental health interventions. Although the evidence is advancing in this field, caution is urged when using new technologies that lack guidance and regulation, such as video games, in treatment. The RANZCP recognises that e-mental health can be used to complement, rather than substitute for face-to-face care, especially in the diagnosis and treatment of severe mental health conditions.
- Health Care Planning
There is a growing evidence base for e-mental health resources and tools, however many technologies are relatively new and the quality of research is limited (E-Mental Health Alliance, 2014). Investment in good quality research alongside the development of interventions is important to refine and improve e-mental health quality and effectiveness. The cost of developing digital systems across the care continuum and incorporating e-mental health into health care systems need to be adequately estimated, with provision of sufficient budget. Robust economic analysis based on sound evidence for effectiveness is needed. Until there is much better information, anticipated cost savings from e-mental health must not be used to reduce spending on mental healthcare services.
The gains from e-mental health can only be realised if barriers to its adoption are minimised. Funding for mental health interventions should be made on the basis of whether a service is effective for people in need, not solely on the basis of whether it is delivered face-to-face by a clinician. Support under publically funded health services in Australia and New Zealand is required to ensure barriers to the adoption of e-mental health tools are minimised. The RANZCP acknowledges that several items under the MBS can be used for teleconferences and consultations and these should be maintained and extended as technology expands.
- Establishing Care Boundaries
It is important that a professional balance be achieved between accessibility and treatment boundaries when e-mental health tools are employed, particularly when social platforms are used. Individual psychiatrists should make it clear with their patients what the boundaries are around e-mental health engagement, and they should make it clear what they are or are not prepared to do. Clear communication is an important part of effectively and appropriately incorporating e-mental health into care.
The changes brought to mental health care by the development of e-mental health tools are substantial and ongoing. New technology and approaches bring benefits, but also challenges and risks. These recommendations are made in light of this knowledge and with an understanding that they will need regular review. The RANZCP recommends that:
- E-mental health tools be trialled within current mental health care services in line with the ‘stepped care’ model where appropriate. This may involve e-mental health tools being offered to those with mild to moderate mental illness as an initial and ongoing option for support, information and assistance. As part of this integrated approach, psychiatrists should ensure their consumers are aware of relevant e-mental health tools, and should, where appropriate, guide their consumers in the use of such tools.
- Training of psychiatrists should address skills and competencies in the targeted use of e-health resources in psychoeducation and as adjuncts to assessment, management and treatment monitoring. Psychiatrists must also remain aware of and up to date with available e-mental health tools where possible. The RANZCP acknowledges that the great number of e-mental health tools may make this challenging, however a number of online portals exist that allow for easier evaluation and use of a number of e-mental health tools (e.g. Beacon, e-hub Mental Health and Head to Health).
- Greater government funding to ensure that all Australians and New Zealanders have equal access to adequate infrastructure for the use of e-mental health tools (e.g. reliable and fast internet connections) will help to encourage use of such tools and offer greater potential for those who might find it difficult to attend appointments face-to-face.
- The Australian and New Zealand governments should have greater oversight of the claims and effectiveness of the growing number of e-mental health resources available.
- Parents, carers and those working in the mental health system should be made aware of the benefits and potential issues associated with e-mental health tools. They should be encouraged to educate themselves about these topics where they feel lacking in knowledge and empowered to help others to use e-mental health resources.
- More research is needed to distinguish between valuable and ineffective resources. Ongoing support should be provided to online portals that evaluate and recommend certain e-mental health tools on the basis of evidence. It is also particularly important that appropriate use and populations for e-mental health resources be identified.
- Ministry of Health (2015) Youth mental health project (New Zealand Government).
- Department of Health (2012) e-mental Health Strategy for Australia (Commonwealth Government).
- Australian Government (2018) eMHPrac (Commonwealth Government)
- e-Mental Health Alliance (2014) e-mental health services in Australia 2014: current and future.
- Royal Australian College of General Practitioners (2015) e-Mental health: A guide for GPs.
- Special Issue: e-Mental Health (2013) Australian and New Zealand Journal of Psychiatry 47(2).
- Andrews G, Titov N (2010) Is internet treatment for depressive and anxiety disorders ready for prime time? Medical Journal of Australia 192(11 Suppl): S45–S47.
- Department of Health (2018) Head to Health (Commonwealth Government)
- Office of the eSafety Commissioner (2018) eSafety Resources (Commonwealth Government)
- Netsafe (2018) Online Safety for New Zealand (New Zealand Government)
- Royal Australian and New Zealand College of Psychiatrists (2011) The impact of media on vulnerable children and adolescents.
Responsible committee: Committee for Evidence-Based Practice
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Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.