Delivering timely interventions: the impact of the internet on mental health

Innovative web services can overcome the barriers that block access to mental health care A range of factors have come together rapidly over the past decade to create a health services environment in which web-based technologies now offer one of the most promising opportunities for earlier and better management of common mental health problems. These factors include international recognition of the health burden attributable to anxiety, depression and substance misuse;1 epidemiological evidence that mental disorders largely commence before the age of 25 years;2,3 the development of highly interactive web-based technologies, and their widespread use in Australia (particularly among young people); and rapidly changing community attitudes towards help seeking for mental health problems.4-6 Sadly, the proportion of Australian adults with current mental health problems using traditional health care services has not increased (38% in 1997 v 35% in 2007).7 This is despite the apparent success of public awareness campaigns that have promoted help seeking4-6 and some substantial changes in primary care-based approaches to the provision of medical and psychological treatments.8,9 In reality, the structures, distribution and costs that currently underpin our primary and secondary care services make them relatively unavailable to many of those in need.10 Despite the strong arguments in favour of early intervention in youth mental health, it is this group who are most neglected by the current arrangements.11,12 By contrast, young people with difficulties are increasingly seeking informal and formal help online (see Burns et al). Recent work supported by the Australian Primary Health Care Research Institute has identified six successful models of e-health services.13 These include: stand-alone systems offering prevention, self-help and self-care approaches through websites; consumer-assisted care, offering early intervention and facilitated self-help delivered online through peer support from volunteers with lived experience of a mental disorder — these organisations are directed by individuals who have both lived experience and mental health professional qualifications; virtual clinics, providing early intervention and treatment using assisted professional care through the web, with telephone or email support; general practice models, where professionals offer e-treatment under various primary health care arrangements, including collaborative care approaches; and stepped care, which offers a range of integrated services from prevention, self-help and self-care through to assisted and professional care, and hospitalisation if required. The sixth model, common in the United States, is the development of packages of care that are offered in managed care environments by private organisations. Web-based mental health services have the capacity to not only overcome traditional geographical, attitudinal and financial barriers to access to care, but also to lower overall delivery costs and reduce demands on the clinical workforce. The 2006 Council of Australian Governments mental health reform package allocated $57 million for development of telephone counselling, self-help and web-based support programs.14 The new Fourth National Mental Health Plan15 suggests that better use should now be made of innovative web and telephone services. Very recently, a 10-year plan for the e-mental health sector in Australia has been drafted.16 It proposes a national e-health stepped-care service, a national access portal to all mental health services (see Christensen and Hickie), the establishment of consumer e-health records, and the development of a National Research and Development Collaborative Centre for Innovation in e-health. Australia has been a leader in the development of internet-based early treatment packages and prevention tools. At this critical stage, the articles in this Supplement present evidence concerning a number of key strategies and experiences to date. Several articles review the evidence for the effectiveness of internet interventions for anxiety and depression (Griffiths et al), adolescent alcohol use (Tait and Christensen), and management of high-prevalence disorders in young people (Calear and Christensen). The experiences of a range of online health service delivery models are also presented, including a stand-alone health promotion and social networking site for young people (Burns et al); self-help and prevention services (Bennett et al); an example of a virtual clinic (Andrews and Titov); and the use of an adjunctive e-health application delivering cognitive behaviour therapy for managing depression in primary care (Hickie et al). One report provides insights into the workings of a stepped-care program for e-mental health in the Netherlands (van Straten et al). Finally, a new health web portal — Beacon — is launched “in print” (Christensen et al). This web portal compiles all e-health intervention sites for anxiety and depression worldwide and rates them according to the quality of the scientific evidence of their effectiveness. Genuine health reform in Australia is slow and is likely to continue to neglect people with mental health problems.17,18 A significant national investment in e-mental health would not only give a real boost to prevention and early intervention, it would also address the fundamental lack of access to mental health services in this country. In doing this, we would finally orientate our efforts towards the long-term development of a more sustainable, equitable and patient-centric system that responds sensitively to the needs of those with difficulties.

Helen Christensen PhD, FASSA · Ian B Hickie AM, MD, FRANZCP, FASSA

Objective: To review the outcomes, nature and quality of published randomised controlled trials of preventive and treatment internet interventions for depression and anxiety disorders, and to document the availability of effective interventions.Data sources: Previous reviews of internet interventions for mental health and related conditions were updated using an extension of the original methodology. All studies included in the original reviews and more recent eligible trials (published before June 2009) were included, together with any trials identified from a search of the health intervention web portal Beacon and the Journal of Medical Internet Research.Study selection: A total of 29 reports describing 26 trials satisfied the inclusion criteria.Data synthesis: All trials employed a cognitive behaviour therapy intervention program. Of the 26 trials, 23 demonstrated some evidence of effectiveness relative to controls. Effect size differences ranged from 0.42 to 0.65 for depression interventions involving participants with clinically significant symptoms of depression, and 0.29 to 1.74 for anxiety interventions involving participants with a diagnosed anxiety disorder. Of the five effective English-language programs, three are available to the public without charge and two can be accessed at a small cost through health practitioner referral.Conclusion: Internet interventions for depression and anxiety disorders offer promise for use as self-help applications for consumers or as an adjunct to usual care.

Kathleen M Griffiths PhD · Louise Farrer BPsych(Hons) · Helen Christensen PhD

Objective: To identify and describe current internet-based prevention and treatment programs for anxiety and depression in children and adolescents.Data sources: Systematic search of the Cochrane Library, PsycINFO and PubMed databases conducted in June 2009.Study selection: Studies of internet-based programs that addressed anxiety or depression in children and adolescents. No restrictions were placed on study quality.Data synthesis: Eight studies of four intervention programs were identified. Programs were delivered via schools, in primary care, through mental health clinics or open access websites. Two were treatment programs, three offered universal prevention, two were indicated prevention programs, and one was a selective prevention program. Study quality was mixed, with three randomised controlled trials in which participants were randomly allocated to the intervention or control condition, one randomised uncontrolled trial, two controlled trials in which participants were not randomly assigned to conditions, and two uncontrolled pre–post evaluations. Two studies targeted anxiety in children, while the remainder addressed depression, or anxiety and depression, in adolescents. All the interventions were based on cognitive behaviour therapy, and six of the eight studies reported post-intervention reductions in symptoms of anxiety and/or depression or improvements in diagnostic ratings. Three of these studies also reported improvements at follow-up.Conclusion: Our findings provide early support for the effectiveness of internet-based programs for child and adolescent anxiety and depression. More extensive and rigorous research is needed to further establish the conditions through which effectiveness is enhanced, as well as to develop additional programs to address gaps in the field.

Alison L Calear PhD · Helen Christensen PhD

Objective: To conduct a systematic review of randomised trials of web-based interventions for problematic substance use by adolescents and young adults.Data sources: An extensive search conducted in February 2009 of computer databases (MEDLINE, PsycINFO, Current Contents) and manual searches of key references.Study selection: Randomised comparisons of fully automated web-based interventions specifically targeting adolescents and young adults (ie, typically school or tertiary students, ≤ 25 years old) versus other interventions.Data synthesis: 16 relevant studies were identified, and data were extracted from 13 of the 14 reporting on alcohol use by young adults. The alcohol interventions had a small effect overall (d = − 0.22) and for specific outcomes (level of alcohol consumption, d = − 0.12; binge or heavy drinking frequency, d = − 0.35; alcohol-related social problems, d = − 0.57). The interventions were not effective (d = − 0.001) in preventing subsequent development of alcohol-related problems among people who were non-drinkers at baseline. Due to methodological differences, data from the two studies reporting on tobacco interventions among adolescents were not combined.Conclusions: Based on findings largely from tertiary students, web interventions targeting alcohol-related problems have an effect about equivalent to brief in-person interventions, but with the advantage that they can be delivered to a far larger proportion of the target population. Web-based interventions to prevent the development of alcohol-related problems in those who do not currently drink appear to have minimal impact. There are currently insufficient data to assess the effectiveness of web-based interventions for tobacco use by adolescents.

Robert J Tait BSc(Hons), PhD · Helen Christensen PhD

Objective: To explore patterns of internet use by young people in Australia and assess the usefulness of online resources for mental health problems, exploring functionality that may be relevant in the development of online mental health services.Design and participants: Cross-sectional survey of a nationally representative sample of young people (2000 randomly selected participants aged 12–25 years), via telephone interview, conducted in January–March 2008.Main outcome measures: Patterns of internet use including type of use, social networking, sources of information about mental health, alcohol or other substance use problems and levels of satisfaction with the information, and type of information accessed via websites.Results: Young people reported using the internet to connect with other young people (76.9%; 1464/1905) and to seek information about a mental health problem, regardless of whether they had a problem themselves (38.8%; 735/1894). Twenty per cent of young people (398/1990) had personally experienced a mental health problem in the previous 5 years; when these people were asked about sources of information used for this problem, 30.8% (70/227) reported searching the internet. Patterns of internet use and types of resources used differed by age and sex.Conclusion: Our findings suggest that technology is important in the everyday lives of young people, and online mental health services that encompass promotion and prevention activities should include a variety of resources that appeal to all ages and both sexes, such as “question and answer” forums and email.

Jane M Burns PhD · Tracey A Davenport BA(Hons), eMBA · Lauren A Durkin PhD · Georgina M Luscombe Bsc(Hons), PhD · Ian B Hickie AM, MD, FRANZCP, FASSA

Reach Out Central (ROC) is a serious game drawing on the principles of cognitive behaviour theory that has been designed to improve the mental health and wellbeing of young people, particularly men. ROC was developed over a 3-year period from 2003 to 2006, in consultation with young people aged 16–25 years who use the Reach Out mental health website (http://www.reachout.com). ROC was launched online in September 2007. A traditional and viral awareness campaign was designed to engage young men, particularly “gamers”. In the first month after launch, ROC had 76 045 unique website visits, with 10 542 new members (52% male) joining Reach Out. An independent online evaluation involving 266 young people aged 18–25 years was conducted between August 2007 and February 2008 to examine psychological wellbeing, stigma and help seeking in ROC players. Overall results indicated that ROC was successful in attracting, engaging and educating young people. Young women reported reduced psychological distress and improved life satisfaction, problem solving and help seeking; however, no significant changes were observed for young men. Although ROC was successful in attracting young men, demonstrating that the concept resonates with them, the service failed to keep them engaged. Further research is needed to explore how (or what changes need to be made) to sustain young men’s engagement in the game.

Jane M Burns PhD · Marianne Webb BA · Lauren A Durkin PhD · Ian B Hickie AM, MD, FRANZCP, FASSA

Objective: To determine the feasibility of conducting a cluster randomised trial in Australia of the effectiveness of general practitioner-supported delivery of internet-based cognitive behaviour therapy (CBT) and enhanced psychological care.Design, setting and participants: Cluster randomised trial involving patients attending general practices in Australia. Participating practices were randomly allocated to interventions. The study was conducted between January 2004 and January 2007.Interventions: Enhanced GP care was delivered by doctors who had completed specific mental health training; the experimental condition consisted of enhanced GP care plus MoodGYM, an internet-based CBT intervention.Main outcome measures: Demographic and behavioural characteristics of patients, and demographic and practice characteristics of GPs; time to resolution of psychological symptoms for patients involved in the longitudinal phase of the trial.Results: 1571 patients attending 90 GPs from 84 general practices were identified as potentially suitable for recruitment. These patients had a mean age of 35 years, 76% were female, 84% had access to the internet for personal use, and 22% reported high or very high levels of psychological distress on the Kessler Psychological Distress Scale. The 90 GPs had a mean age of 49 years, 53% were female and 25% had completed formal mental health training. Of the 1571 screened patients, 340 reported high levels of psychological distress, but only 140 of these could be further assessed for eligibility in the trial. Of these 140, 83 patients with depression (attending 10 GPs in eight general practices) proceeded to randomisation. For these patients, the experimental intervention (enhanced GP care plus MoodGYM) tended to result in prompt and more sustained resolution of depressive symptoms.Conclusion: Our capacity to conduct a definitive trial was limited by available resources. Preliminary data suggest that primary care patients with depression may derive additional benefits from an internet-based CBT program delivered in conjunction with enhanced psychological care from GPs.

Ian B Hickie AM, MD, FRANZCP, FASSA · Tracey A Davenport BA(Hons), eMBA · Georgina M Luscombe BSc(Hons), PhD · Michael Moore MB BS, FRACGP, GradDipPH · Kathleen M Griffiths PhD · Helen Christensen PhD, FASSA

Stepped-care approaches may offer a solution to delivering accessible, effective and efficient services for individuals with depression. In stepped care, all patients commence with a low-intensity, low-cost treatment. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. We deliver a stepped-care model targeting patients with depression. The first step consists of “watchful waiting”, as half of all patients with a depressive episode recover spontaneously within 3 months. The second step, guided self-help, is the key element of the stepped-care model. Guided self-help, especially when offered through the internet, is effective and cost-efficient. The third step consists of brief face-to-face psychotherapy. Finally, in the fourth step, longer-term face-to-face psychotherapy and antidepressant medication might be considered. Patients are monitored by one person, a care manager, who is responsible for the decision to step up to the next treatment and for continuity of care. The different treatments within the stepped-care model are evidence-based. Data on cost-effectiveness of the full model are still scarce, but we recently demonstrated that the incidence of new cases of depression and anxiety could be halved by introducing stepped care. Effects of web-based guided self-help could be enhanced by incorporating them in a stepped-care model.

Annemieke van Straten PhD · Wike Seekles MSc · Nelleke J van ‘t Veer-Tazelaar MA · Aartjan T F Beekman MD, PhD · Pim Cuijpers PhD

Objective: To describe the Beacon web portal, which lists and rates quality health websites, collects user characteristics and publishes user feedback; and to report summary data on Beacon’s highest-rated (best evidence-based) sites for mental health.Data sources: A systematic search was undertaken in February 2009 for potentially relevant websites through a review of research papers and a recently published book, an internet search of Open Directory Project medical categories, a review of material on a high-profile mental health portal, and a survey of international researchers.Selection criteria: All sites were ranked on a 7-point scale from − 1 to 5, with negative scores indicating evidence of no effect and scores of 2 or more indicating evidence of efficacy based on reports in the scientific literature.Results: By March 2010, 183 sites had been identified, of which 122 focused on physical health or wellbeing, 40 targeted anxiety, and 23 targeted depression. Of the eight generalised anxiety disorder sites identified, four achieved ratings of 2 or above. Two social anxiety disorder sites achieved scores higher than 2. Ten panic disorder sites were identified, with three achieving ratings of 2 or above; and five post-traumatic stress disorder sites were identified, with two achieving ratings of 2 or above. Of the 23 identified depression sites, four achieved a rating of 2 or above.Conclusions: There are a number of high-quality mental health websites on the internet, and Beacon provides a portal to enable the wide dissemination of these resources.

Helen Christensen PhD · Kristen Murray BA, BSc(Hons) · Alison L Calear PhD · Kylie Bennett BA(Hons) · Anthony Bennett BAppSc · Kathleen M Griffiths PhD

Internet treatment programs for anxiety and depressive disorders are becoming available and offer cost-effective alternatives to face-to-face treatment with medication or cognitive behaviour therapy. The Clinical Research Unit for Anxiety and Depression at St Vincent’s Hospital, Sydney, offers internet treatment courses at the VirtualClinic (http://www.virtualclinic.org.au) for people who meet diagnostic criteria for major depression, social phobia, panic disorder and generalised anxiety disorder. These courses are free to people recruited for research. The results of VirtualClinic trials show a high level of patient adherence and strong reductions in symptoms, and that very little clinician time is required. The four treatment programs that have been successfully evaluated in the VirtualClinic have been made available on a not-for-profit basis ($5 service fee) at the CRUfADclinic (http://www.crufadclinic.org) for general practitioners and other clinicians to use with their patients. These programs could be the first level of treatment in a stepped-care environment, where patients who do not benefit sufficiently could then receive face-to-face treatment from their clinician or be referred for specialist treatment.

Gavin Andrews AO, MD · Nickolai Titov PhD

Self-help delivered through online websites has been found to be beneficial for people with mental health problems, and consumers find internet support groups helpful. The Australian National University e-hub group delivers automated web interventions (BluePages, MoodGYM, e-couch) and an online bulletin board (BlueBoard) to the public for mental health self-help. The evidence-based web interventions require no direct therapist or other human involvement, while the bulletin board is moderated by trained consumers under the supervision of a clinical psychologist. Users may contact the e-hub service by email. These web services are used by a large number of users, with and without clinical mental disorders, often over a long period of time. These services provide programs for prevention and early intervention and are particularly suited to people who prefer anonymous services, live in rural and remote areas, or have a preference for self-help methods, as well as for use in school and workplace settings. A range of best-practice measures have been developed and put in place to ensure high-quality service delivery. Evaluation and quality control are enabled by a database and associated software.

Kylie Bennett BA(Hons) · Julia Reynolds MPsych(Clin) · Helen Christensen PhD · Kathleen M Griffiths PhD

Traditional clinic-based service delivery systems remain inaccessible to many Australians with mental health problems. If we are to substantially reduce the burden of mental illness, we need to develop more accessible, empowering and sustainable models of mental health care. E-health technologies have specific efficiencies and advantages in the domains of health promotion, prevention, early intervention and prolonged treatment. It is timely to use the best features of these technologies to start to build a more responsive and efficient mental health care system.

Helen Christensen PhD, FASSA · Ian B Hickie AM, MD, FRANZCP, FASSA