E-mental health: a new era in delivery of mental health services

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.