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Benefits of e-mental health treatments and interventions

Position statement Last updated: Oct 2023 Published in Australia Reference: PS #98

E-mental health tools may provide affordable and equitable access to complementary forms of care and support but also bring challenges.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) supports e-mental health tools to deliver affordable, equitable and accessible mental health services and has developed this Position Statement to provide an overview of its associated benefits and challenges. 

Key messages

  • E-mental health tools encompass a broad range of digital resources, services or programs, delivered via online, mobile or phone-based platforms.
  • E-mental health tools have the potential to fill gaps in service provision and reach hard-to-access consumers, 
  • E-mental tools can bring issues surrounding privacy, quality, supervision.
  • Sustained research and oversight are required to ensure psychiatrists are informed on the ever-changing benefits and challenges with particular e-mental health services.
  • When recommending e-mental health services, mental health professionals should be familiar with the tools and the evidence for their effectiveness.

Definition

E-mental health tools encompass a broad range of digital resources, services or programmes which offer support to people affected by mental health issues, including consumers, families/whānau[a], carers[b] and communities. E-mental health tools may include services such as online resources, social media, smartphone apps, personalised messaging, immersive virtual and augmented reality tools, wearable monitoring technologies to enhance real time diagnostics and care, telehealth services and social support. 

Background

Digital health has yielded significant data availability, decision support and clinical informatics benefits.[1] Through a variety of technology enabled communication channels e-mental health can deliver health literacy, prevention, intervention, assessment, therapy, administrative support, or a combination of these, and target specific populations or conditions of mild to moderate severity. The use of these tools was accelerated by the COVID-19 pandemic.[2-3] 

Not all e-mental health tools will suit every condition or consumer, and there is a need to be aware of false claims made by manufacturers of e-health products relating to their effectiveness. Whilst the more established approaches have a strong evidence base, ongoing research is steadily building an evidence base for a fast-developing range of other tools.[4] It is therefore imperative that the mental health professionals, including psychiatrists are well informed of risks, to communicate with, and empower consumers as they direct their own e-mental health care. 

Benefits of e-mental health

E-mental health tools are a creative and potentially more affordable way of meeting the mental health needs of the community.[5] To experience the benefits of e-mental health, individuals will require a reliable internet connection and access to a compatible device. In 2023, 96.2% of Australians had access to a stable internet connection.[6] In 2022, 94.9% of Aotearoa New Zealanders had access to a stable internet connection.[7] Servicing the remaining five per cent that do not have regular access to an internet connection and therefore access to e-mental health tools lies outside the scope of this position statement. 

E-mental health tools have the potential to increase access to and improve the quality of mental health care by:

  • Improving access to care

By providing another means of early access to services, e-mental health allows for quicker identification of conditions, reduced duration of untreated illness, and the potential for less intensive treatment and faster recovery. 

  • Improving efficiency

For some consumers, online information, self-management and e-therapy programs are sufficient to alleviate symptoms at a minimal cost and without clinical support, enabling mental health professionals (including psychiatrists) to focus on people who are in most need. 

  • Providing more equitable access to care

E-mental health tools can improve access to care, particularly for those in rural and remote areas.[5, 8] It can also improve access for individuals who are concerned with confidentiality and are not currently seeking help from traditional services as individuals have the option to remain anonymous while accessing these services.[9] Studies have also shown that young people are receptive to using mobile apps and online resources for mental health.[8,9] E-mental health tools can also benefit Aboriginal, Torres Strait Islander, and Māori people and support wellbeing and culture.[12-15]

  • Increasing outpatient engagement

E-mental health tools such as 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. 

Challenges and considerations for e-mental health

There are several considerations to be made for e-mental health tools to be fully and effectively integrated into Australian and New Zealand mental health care services, including: 

  • Confidentiality and record keeping  

Irrespective of the care setting, including virtual settings, consumers’ personal information is to be treated confidentially and held in accordance with the relevant legislation. This includes the Australian Privacy Principles (contained within the Privacy Amendment (Enhancing Privacy Protection) Act 2012) and the New Zealand Health Privacy Principles (contained within the Privacy Act 2020). This is pertinent for people living with mental illness, who often face social barriers and stigma when seeking help. Whānau/carers must also be informed of privacy and confidentiality practices concerning e-mental health. 

Government and national associations can prioritise privacy and security standards by co-designing and maintaining clear guidance surrounding e-mental health tools and relevant privacy regulations. Ongoing review is relevant due to the fast-moving nature of the e-mental health sector. Monitoring these tools through medical regulators would also contribute to reducing patient risk. Mental health professional (including psychiatrists), patients and families should aim to be aware of privacy obligations and the challenges with this and e-health tools. 

  • Clinical risk 

The recommendation of a particular e-mental health tool carries clinical risk. The psychiatrist should be familiar with any recommended tool and the evidence for its effectiveness. This includes consideration of risks and benefits regarding treatment effectiveness and adherence.[5] Caution is urged when using new technologies that lack guidance and regulation in treatment. E-mental health tools are to be trialled within current mental health care services along a continuum of care where possible.

Face-to-face therapies are the optimal method of treatment, with e-mental health services used to complement rather than substitute for these therapies, especially in the diagnosis and treatment of severe mental health conditions. If e-mental health tools are chosen, the same care standards apply with online or remote assessments as with face-to-face assessments, complying with relevant clinical guidance and with clinician involvement.

  • Training in e-mental health

Lack of awareness of relevant e-mental health tools and/or the necessary IT proficiency for their use, can be a key impediment to implementation. This is worsened by the great number of e-mental health tools on offer.[5,16,17] Implementation of e-mental health tools that are relevant to the consumer is dependent on service providers’ understanding of them, and their space within the respective organisation’s practice.[18,19] Mental health practitioners, including psychiatrists, should familiarise themselves with e-mental health tools to advise the community on the appropriate choice of tool. To support the psychiatrist’s choice of e-mental tool and evaluation of its efficacy (associated risks and benefits), routine provision of training is required. This includes consideration of, as with any in-person assessment, the best interest of the health consumer and compliance with jurisdictional policies on medical standards.

  • Health care planning and governance 

Despite a growing evidence base for e-mental health tools, many technologies are relatively new, and quality of research is limited.[20] Investment in good quality research, informed by those with lived experience in the delivery and reception of e-mental health care, is required to inform the development of interventions and to improve e-mental health quality and effectiveness. 

The market for e-mental health tools is expected to continue to increase and global spending rise at an annual growth rate of 20%.[21] Anticipated cost savings from e-mental health must not be used to reduce spending on mental healthcare services.

Existing e-mental health tool strategies, frameworks and guidelines (see resources) across Australia and New Zealand provide an overview for clinicians, and should be adhered to when implementing, or deciding to implement, e-mental health tools. To maintain this overview within a fast-moving sector, such resources must be regularly updated to provide current and clear guidance on person-centred online assessment and referral to other clinical and non-clinical treatments.[22] These resources may also consider appropriate practice for groups with complex treatment needs.

Given its broad application, e-mental health tools should be designed to ensure it has flexibility to meet diverse needs in areas including language, content, design and accessibility to improve care for diverse population groups.[23] These include consumers from culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander people or Māori people, and people with severe mental illness. 

Public funding for e-mental health services in Australia and New Zealand is required to ensure barriers to the adoption of e-mental health tools are minimised. Funding for mental health interventions should be evidence based, considering the service’s effectiveness for consumers, particularly those with pre-existing access issues.

  • Establishing care boundaries

It is important that a professional balance is achieved between accessibility and treatment boundaries when e-mental health tools are employed, particularly on social platforms. Clear communication is an important part of appropriately incorporating e-mental health into care. Individual psychiatrists should outline their boundaries around e-mental health tool engagement and oversight to their mental health consumers and clarify what they are available to do.[24] 

Recommendations

The RANZCP recommends that:       

  • Training of psychiatrists addresses skills and competencies in the targeted use of e-health tools for assessment, management and treatment monitoring. 
  • E-mental health tools are implemented within current mental health care services along a continuum of care where possible.
  • More research is conducted to support clinical practice and better inform patients and/or carers of the associated benefits and risks of e-mental health tools.
  • Oversight is maintained across New Zealand and Australia over the claims and effectiveness of the growing number of e-mental health tools available.
  • Greater government funding ensures all Australians and New Zealanders have equal access to the technology required to utilise e-mental health tools.

Resources

[a] Whānau (pronunciation: fa:no) is a Māori word used to describe an extended family group spanning three to four generations. The whānau continues to form the basic unit of Māori society (Rāwiri Taonui).

[b] The terms ‘carer’ and ‘consumer’ are used where differentiation is required for the purposes of document clarity. The RANZCP acknowledges that both carers and consumers have a lived experience and that the roles are not mutually exclusive. The RANZCP also acknowledges that ‘carer’ and ‘consumer’ may not be the preferred terms of individuals.

References

  1. Canfell OJ, Littlewood R, Burton-Jones A, Sullivan C. Digital health and precision prevention: shifting from disease-centred care to consumer-centred health. Australian Health Review. 2021.
  2. Shalini L, Adair C. E-mental health: A rapid review of the literature. Psychiatric Services. 2014;65(1):24-32.
  3. Ellis LA, Meulenbroeks I, Churruca K, Pomare C, Hatem S, Harrison R, Zurynski Y, Braithwaite J. The Application of e-Mental Health in Response to COVID-19: Scoping Review and Bibliometric Analysis. JMIR Mental Health. 2021;8(12).
  4. Australian Bureau of Statistics. First insights from the National Study of Mental Health and Wellbeing: 2020-21. 2021.
  5. Meurk C, Leung J, Hall W, Head BW, Whiteford H. Establishing and governing e-mental health care in Australia: a systematic review of challenges and a call for policy-focussed research. J Med Internet Res. 2016;18(1).
  6. Kemp S. Digital 2023: Australia. DataReportal, Digital 2023: Australia — DataReportal – Global Digital Insights. (2023).
  7. Kemp S. Digital 2022: New Zealand. DataReportal, https://datareportal.com/reports/digital-2022-new-zealand (2022).
  8. Stigma-Free Society. E-Mental Health: Digital Alternatives to Mental Health Support in Rural Communities. Rural Mental Wellness Toolkit 2022. https://ruralmentalwellness.com/e-mental-health-digital-alternatives-to-mental-health-support-in-rural-communities/ 
  9. Garrido S, Oliver E, Chmiel A, Doran B, Boydell K. Encouraging help-seeking and engagement in a mental health app: What young people want. Front Digit Health 2022;4:1045765. https://doi.org/10.3389/fdgth.2022.1045765 
  10. Montague A, Varcin K, Simmons M, Parker A. Putting technology into youth mental health practice: young people’s perspectives. SAGE Open. 2015;5:1–10.
  11. Struthers A, Charett C, Bapuji S, Winters S, Ye Z, Metge C, Kreindler S, Raynard M, Lemaire J, Synyshyn M, Sutherland K. The acceptability of e-mental health services for children, adolescents, and young adults: a systematic search and review. Canadian Journal of Community Mental Health. 2015; 34:1–21.
  12. Rice ES, Haynes E, Royce P & Thompson SC. Social media and digital technology use among Indigenous young people in Australia: a literature review. Int J Equity Health. 2016;25(15):81.
  13. Puszka S, Dingwall K, Sweet M, Nagel T. E-mental health innovations for Aboriginal and Torres Strait Islander Australians: A Qualitative Study of Implementation needs in health services. Journal of Medical Internet Research - Mental Health. 2016;3(3).
  14. Povey J, Mills PP, Dingwall KM, Lowell A, Singer J, Rotumah D, Bennett-Levy J, Nagel T. Acceptability of Mental Health Apps for Aboriginal and Torres Strait Islander Australians: A Qualitative Study. Journal of Medical Internet Research. 2016;18(3).
  15. Caffery LJ, Bradford NK, Wickramasinghe SI, Hayman N, Smith AC. Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: a systematic review. Aust N Z J Public Health. 2017;41(1):48-53. 
  16. Raphiphatthana B, Sweet M, Puszka S, Whitty M, Dingwall K, Nagel T. Evaluation of Electronic Mental Health Implementation in Northern Territory Services Using the Integrated "Promoting Action on Research Implementation in Health Services" Framework: Qualitative Study. JMIR mental health. 2020;7(5).
  17. Bennett-Levy J, Singer J, DuBois S, Hyde K. Translating e-mental health into practice: what are the barriers and enablers to e-mental health implementation by Aboriginal and Torres Strait Islander health professionals?. J Med Internet Res. 2017;19(1).
  18. Ross J, Stevenson F, Lau R, Murray E. Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update). Implement Sci. 2016;11(1):146.
  19. Vis C, Mol M, Kleiboer A, Bührmann L, Finch T, Smit J, Riper H. Improving implementation of emental health for mood disorders in routine practice: systematic review of barriers and facilitating factors. JMIR Ment Health 2018;5(1).
  20. e-Mental Health Alliance. E-mental health services in Australia 2014: current and future. e-Mental Health Alliance. 2014.
  21. Auxier B, Bucaille A, Westcott K. Mental health goes mobile: The mental health app market will keep on growing. Deloitte Insights, https://www2.deloitte.com/us/en/insights/industry/technology/technology-media-and-telecom-predictions/2022/mental-health-app-market.html (2021).
  22. Torous J, Andersson G, Bertagnoli A, Christensen H, Cuijpers P, Firth J Haim A, Hsin H, Hollis C, Lewis S, Mohr DC, Pratap A, Roux S, Sherrill J, Arean PA. Towards a consensus around standards for smartphone apps and digital mental health. World Psychiatry. 2019;18:97-98.
  23. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Digital Mental  Health Standards – Guide for service providers 2022.
  24. Hilty DM, Chan S, Hwang T, et al. Advances in Mobile Mental Health: Opportunities and Implications for the Spectrum of E-Mental Health Services. FOC 2018; 16: 314–327.