Technology is essential for the Australian mental health system

Australia is the global leader in the Research and Development of mental health technological solutions. Based on economic modelling, global wealth management specialists EY Australia finds that the only way Australia can financially meet its demand for mental health support is if the Australian mental health system is restructured as a stepped care system, where the intensity of resourcing is scaled according to the level of complexity of mental health conditions.

Within this stepped care system, online self-service education (e.g. the This Way Up suite of courses) as well as anonymous peer support forums (e.g. ReachOut.com, the SANE Australia Lifeline forums, and the BeyondBlue forums) and groups (e.g. eGrow) are established low intensity resources for 80% of the Australian population.

Among the highest intensity resources, universal 24/7 crisis support by phone, instant messaging, and SMS is delivered by Lifeline accredited volunteers who have completed a minimum of 170 hours of extensive training, including 21 hours of e-learning and 72 hours of calls over 12 months. In specialist mental healthcare, patients can claim Medicare rebates for telepsychiatry by videoconferencing, if they are located in a rural or remote area more than 15km from the psychiatrist, live in residential care, or access care through an Aboriginal Medical Service or an Aboriginal Community Controlled Health Service.

How technology for mental health applies to diverse stakeholders

Information and evidence about technology for mental health are substantial, growing, and available. More than 200 journal articles on technology for mental health have been published in the past five years, and online access to the full papers is free, courtesy of the State Library of Victoria in Australia and the US National Library of Medicine.

Technology enables a universal mental health service

Supported by recurring funding from the Australian Government’s eMental Health strategy and free to end users, the MindSpot clinic received registrations from over 80,000 people, with over 16,000 patients opting to receive Internet delivered Cognitive Behaviour Therapy (ICBT), in the five year period from January 2013 (when the clinic first opened) to December 2017. MindSpot assessed over 20,000 people in 2017. A wide age range of people (including older adults) engage with MindSpot, 30% of patients do not live in a metropolitan area, and therapists are rostered to deliver services across Australia’s three time zones. The MindSpot clinic and similar clinics in Sweden, Norway, Denmark, and Canada have established the following global benchmarks by example:

• Online/phone registration and validated clinical assessment online
• Interview with a therapist in person or by videoconference/telephone/secure text messaging
• Registrants opt for information, referral, or from a range of ICBT courses that are validated and administered with fidelity. MindSpot also delivers CBT by post, in response to some participants’ limited Internet access and preferences.
• Automated and individualised messages increase treatment adherence and engagement
• Clinicians spend 10-20 minutes per week checking in with each patient by secure messaging or telephone
• Homework submission, therapist review, and validated clinical outcome measurement and monitoring before therapists give patients access to the next module of an ICBT course
• Follow-up outcomes measurement at three or six months post-treatment
• Strong clinical, IT, and organisational governance
• Scaling from pilot to permanent services sustained by recurring public funding
• Information sharing with other members of the patient’s healthcare team and integration with local health services. Collaboration with university resources the training of therapists and facilitates the translation of treatment advances to routine practice.

Technological challenges and solutions for mental health in rural and remote communities

Mental health in rural and remote Australia, such as the Murray Darling Basin in New South Wales, are likely to experience distinctive challenges that call for specific technological solutions:

Challenges

• In community mental health, there are few psychiatrists, so mental health practitioners must refer service users to hospital to access psychiatrists.
• Rural and remote communities that are closely interdependent can offer mental health support, but may find it challenging to protect service users’ privacy.
• When practitioners travel long distances to provide mental health outreach to isolated individuals, it may be challenging to coordinate:
  • Practitioner and service user schedules
  • Outreach services with the individual’s local services, especially when practitioners cannot keep up to date with regular changes in services

Technological solutions

• A user can use telepsychiatry to connect to specialist care from a base within the community. However, this base must be connected at a threshold level of network speed and reliability to support synchronous videoconferencing
• Community centres can protect privacy by establishing and maintaining closed kiosks where individuals can securely access a range of resources for purposes including but not limited to mental health
• Integration and responsiveness in:
  • Information about services
  • Communication among practitioners and users of outreach and local services
  • The collection and documentation of clinical data

  Can be facilitated by:

  • The use of secure and connected mobile devices and GPS
  • The development, maintenance, and use of a searchable, interactive map of local mental health services Australia-wide

Culturally appropriate technologies for young people, Indigenous people, and people with disability

The Australian government has been funding the established Mindframe guidance and training for media students, professionals, and sources (e.g. people with lived experience of mental ill-health, mental health sector and community stakeholders) on how to communicate safely about mental ill-health in news and fiction (e.g. print, broadcast, cinema, online streaming, social media, theatre).

In addition, Australian researchers have used the Delphi expert consensus method to develop the #chatsafe guidelines to help young people keep themselves safe when exchanging suicide-related content on social media. #chatsafe has been developed based on high quality literature and the feedback of suicide prevention experts, media and communications specialists, and young mental health advisors. In the context of youth as a distinctive process of cognitive, emotional, and social development, #chatsafe encourages young people to choose whether or not to communicate about suicide, to monitor their own internal experience and resources, and to manage distress.

An app such as iBobbly can be downloaded for ongoing offline use. Federal, state, and local government, business, not-for-profit, and academic organisations have been collaborating to develop and trial iBobbly across Australia’s diverse Indigenous youth population. Designed specifically to address the social and emotional wellbeing of Indigenous youth, iBobbly’s culturally significant metaphors, images, and stories intend to Close the Gap with technology. Whereas iBobbly is designed for Indigenous youth, Aboriginal and Torres Strait Islander adults aged 18 years and over can participate in the free MindSpot Indigenous Wellbeing skills training course with weekly or PRN support from an Indigenous mental health professional at MindSpot.

A Queensland trial highlights the need to consider the accessibility of technology for mental health for people with disability such as post-stroke aphasia. Content creators can use standard readability tests in Microsoft Word to check how easy it is for readers to understand a text. Developing a mobile app version of mental health resources is another way to improve accessibility, since users with disability related to vision and mobility can use the VoiceOver, predictive text, and Switch Control features of touch interfaces.

Developers of mental health software must comply with law

Australia is a core contributor to the international regulation of Software as a Medical Device. If a vendor intends for people to use their device or software to diagnose, manage, or treat mental illness, the device or software must be on the Australian Register of Therapeutic Goods before it can be legally supplied in Australia.

For example, the Synergy Online System is an integrated suite of technological products that advance users from mental health promotion, through prevention, early intervention, and treatment, to relapse prevention. Aligned with users’ engagement with mainstream consumer technologies, Synergy features a portal of wellbeing apps, a system for user-generated rating, recommendation, and storytelling, automated triage and support, functionality for biofeedback and self monitoring, as well as tablet screening and care plan generation for use with mental health professionals. More details are available in this journal article and the mapping of these products with reference to one another is illustrated in the diagram on page 10 of the journal article.

Even if the mental health software is not a medical device, it is regulated by, and must comply with, privacy, content, and consumer legislation. The University of Sydney and the Australian Communications Consumer Action Network have produced and freely distributed a precise guide for developers of mental health apps. For example:

• If the app records a person’s health information, it must comply with privacy legislation.
• Any app must have an appropriate age-classification and comply with content legislation on themes, violence, language, and drug use. The developer cannot distribute offensive content and must remove all offensive third party content related to the app (e.g. user reviews and social media comments). If an app is likely to be classified as MA15+, the developer must ensure that access to the app and any content about the app (e.g. on a website or social media) is restricted to users aged 15 years and above.
• Developers should limit in-app purchases by vulnerable users such as children and people living with mental illness.

What step can you take next?

Human-Technology Interaction researchers in the Netherlands have developed a Levels of Adoption of eMental Health Model based on their interviews with clinical psychologists. I have mnemonically renamed these levels with concepts that all begin with the letter E. Which level of adoption are you at?

Level 1: Exposure

You are unaware of the value of technology for mental health, and you do not like or want to use technology for mental health. I encourage you to:

• Take less than two and a half minutes to watch this video on Head to Health, the Australian government’s publicly funded suite of digital mental health resources
• Access the Black Dog Institute’s free accredited E-Mental Health in Practice (eMHPrac) suite of resources

Level 2: Experience

You know and believe in the value of technology for mental health, but you are not motivated to integrate technology for mental health into routine practice. I encourage you to use a free app like Headspace or Calm that guides you to meditate for three minutes a day and sends you supportive messages.

Level 3: Evidence

You are experiencing the value of technology for mental health, but are only using technological solutions that are easy to access. I encourage you to:

• Use the multiple choice questions in the American Psychiatric Association’s App Evaluation Model to assess the efficacy, safety, usability, and interoperability of the mental health apps you are using
• Try the other mental health websites, apps, and online support groups that have been assessed in the Beacon directory and in the NHS Apps Library

Level 4: Exploration

You are expanding the range of technologies you use for mental health to include emerging solutions, but you do not have much support from other professionals. I encourage you to join professional networks such as:

• The Australian Psychological Society ePsychology Interest Group
• The American Medical Informatics Association Mental Health Informatics Working Group
• The American Telemedicine Association Telemental Health Special Interest Group
• The Mental Health, Technology and Community LinkedIn group

Level 5: Entrepreneurship

You are creating new ways of using technology for mental health. I encourage you to:

• Support, collaborate with, and contribute to top quality mental health journalism, such as the news, documentary, fiction, audio, and digital media by journalism professionals and students recognised in the annual Mind Media Awards and the following Ossie Award categories: Dart Centre for Journalism and Trauma - Asia Pacific, Mindframe, and Our Watch
• Publish your work in a top quality, peer-reviewed, open access journal such as the Journal of Medical Internet Research Mental Health or PLOS ONE

Author Bio

Dr Esther Chin (Twitter: @estherchinmedia) is an independent researcher writing a book on technology for mental health in Australia, under contract with Springer Nature. Building on her PhD, Esther was employed in a full-time permanent position as a University Lecturer in Media and Communications, before pivoting to her current role as Research, Evaluation, and Engagement Consultant at Socialsuite, an Australian global technology business that develops impact management software for diverse organisations. Esther volunteers as a moderator of an online support group for people who experience Borderline Personality Disorder (BPD), a complex mental health condition (view an extensive collection of videos on BPD by the clinician-academics who pioneered the various treatments for and research on BPD here).