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In part 1 of this series, Dr Louise Stone examines current national policies and digital mental health frameworks.
Mental health services have never been more heavily funded, but despite substantial increases in investment, the demand for mental health services continues to outstrip supply. Digital mental health services have been proposed as one solution to the crisis in mental health and mental health workforce. The Australian Government has heavily endorsed these interventions, making substantial financial commitments to subsidised education, policy drivers, research grants and service delivery models to ensure digital mental health solutions are used. Digital mental health solutions are presented in policy documents and media releases as cheap, effective, patient-centred, evidence-based solutions that are accessible to patients with a variety of mild to moderate mental illnesses.
However, uptake of these services remains low, despite substantial investment in developing, marketing and subsidising digital products. In this series of articles, I address the concerns expressed by politicians, policy makers, opinion leaders and advocates of digital mental health services, who claim GP reluctance to recommend digital health solutions is creating a substantial barrier to positive change.
This article focuses on the marketing of digital mental health transformation, and some of the policy drivers for their use in primary care. The second article focuses on concerns around the safety and cost digital mental health solutions and the third examines the accessibility, effectiveness and ethics of digital transformation in mental health care.
What are digital mental health services?
Digital mental health services generally fall into seven categories:
- technology-enabled consultations, such as phone and video consultations with a clinician;
- helplines, including Lifeline and Kids Helpline;
- patient education, including websites such as the Black Dog Institute or Beyond Blue;
- peer support, including forums that may or may not be moderated;
- clinician support tools, such as clinical guidelines, templates and assessment tools;
- online therapy with or without clinician support, such as This Way Up, MindSpot and Phoenix Australia;
- assessment, referral and monitoring platforms, which aim to assess participants, connect them with appropriate services and provide analytics for providers to better understand their cohort.
Different services may combine different elements, and have a number of complementary goals. In this article, I’ll focus on programs with therapeutic intent, which include online therapy programs and care coordination platforms.
Driving a greater reliance on digital solutions through policy
The National Digital Mental Health Framework (the Framework) is quite open about the government’s agenda, using incentives to drive “reluctant” clinicians into using and recommending digital mental health products. Interestingly, it is not only clinicians who are seen as reluctant, with similar comments in the literature about “reluctant” consumers, who need to be “persuaded” of the value of the tools.
The Framework recommends using “bundled and outcomes-driven funding models [to] drive willingness to adopt hybrid or blended models of mental health care into existing services.” It also asserts that health professionals should view digital mental health tools “as being essential to the delivery of mental health care”.
There are a number of reviews that underpin the Framework, including the Scoping and development of a National Digital Mental Health Framework, The Productivity Commission’s Mental Health Inquiry and the Strategies for adopting and strengthening e-mental health article by the Sax Institute. Although they claim a strong commitment to consultation across a wide range of stakeholders, the documents themselves demonstrate a strong bias towards using digital tools to replace GPs as “gatekeepers” to mental health services.
The Productivity Commission report has disturbing errors of fact around general practice. They write on page 26:
“most GPs receive minimal training in mental healthcare when qualifying as a GP” and recommend:
- “more rigorous approaches to assessing mental health (including consideration of cultural influences, relationships and trauma);
- inclusion of carers and family in diagnosis and treatment discussions;
- attitudes to peer workers;
- buy-in to a person-centred ethos; and
- adherence to evidence-based clinical practices (including the clinical appropriateness of GPs prescribing practices for mental health medication, management of medication side effects and de-prescribing)”.
Every suggestion is already included in the curriculums of the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM), assessed throughout training and heavily weighted in fellowship examinations.
The Productivity Commission also states that GPs are financially incentivised to do shorter consultations, are not culturally competent across the entire range of cultural contexts in which they work, and lack understanding of available services. Their solution is to suggest providing a digital platform to bypass the GP “gatekeeping” of services. There are 160 references to this platform in the document, with the claim that it will “ensure people would be assured they are receiving an assessment that is rigorous and treatment recommendations that are evidence-based and match their needs.” The report suggests replacing mental health treatment plans with this digital assessment. There is little evidence for digital assessment, and even less for the capacity of digital tools to be “culturally competent”.
Nevertheless, this idea of a digital platform that will bypass GP “gatekeeping” occurs across all the review documents. There is also a strong suggestion that young people prefer online forms of information gathering and treatment. Although this would seem to be an intuitive conclusion, the evidence from the National Study of Mental Health and Wellbeing suggests this may not be the case. For young people aged 16-34 years, 30% of women and 16% of men accessed a health professional, while 11% of women and 3.5% men used a digital service (including helplines). Only 2% of young people used an online assessment or treatment service.
Despite several decades of heavy investment in research and implementation of digital solutions to the growing mental health crisis in Australia, uptake of digital mental health services remains low, with only 4.8% of Australians accessing care through digitally enabled services (including helplines, apps, forums, online programs and educational content). The reasons for low uptake are often cast as a lack of GP motivation to recommend the products. However, there may be other concerns influencing this behaviour.
In the next two articles, I will discuss the evidence behind the common view that digital mental health services are cheap, safe, accessible and effective. The Fifth National Mental Health and Suicide Prevention Plan calls for strategies to improve the use and uptake of digital mental health services, by “nudging” GPs towards recommending these services. We all agree that we are experiencing a mental health crisis. However, as a GP, it is important that my recommendations for care do not come ahead of the evidence for the safety and efficacy of any intervention, including digital mental health tools.
Dr Louise Stone is a Canberra GP with clinical, research, teaching and policy expertise in mental health. She is an associate professor in the Social Foundations of Medicine group, Australian National University Medical School.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Thankyou, Professor Louise Stone, and all other later comments, subsequent her article, and, all of which I found of interest, and of much value .
I note an article in the most recent edition of MJA, which, I think, may be of also pertinence:-
https://www.mja.com.au/journal/2024/220/9/mental-health-crisis-needs-more-increased-investment-mental-health-system
Here, and now aged 73, and still going (though, well strongly considering a retirement in the next twelve months or so, due, not only my age, though also from time to time oft having the abusive calls that we often have here.. often, too, that I I note, in general practice, these days), in one of the NSW government funded, mental health triaging and accessing services, known generally, I think, as the Mental Health line, telephone 1800011511, and exceptionally busy at the very best of times, manned by mental health clinicians, all with a degree, often with a post grad degree, relevant the field of practice, this post, with thanks, I will also forward my colleagues.
Best wishes, all,
Kaete
I give a list of Online resources to every MH patient I see, over the past 10 years less than 1% have utilised the services, the rest all wanting to have contact with a real person.
Bypassing GPs is also going to further fragment our patient’s care, turning up to see us much further down the line and more unwell due to failed digital management.
It is the way things are going and Mr Butler’s over $500 million to run digital MH services is about to happen now.
Now there are the baby boomers entering old age making up a large share of potential MH patients.
Not all are au faux with technology and are not interested in anything that doesn’t look like a “traditional” personal consult.
How do GPs in care facilities reconcile geriatrics with psychiatric care 🤔
One of the problems with discussions about digital resources is that they are all lumped together under one heading and the discussion gets confused.
Using an app for symptom managment or consulting a website for information about mental health and perhaps even peer support is not the same thing as enrolling in a digital treatment program or, for that matter, using an AI platform that provides advice about diagnosis and treatment options. Those things are worlds apart.
Nonetheless it doesn’t matter which kind of digital mental health resources we are discussing there is value in our knowing about them and using them in the context of our practices.
If we close our minds to digital resources we will lose the opportunity to enrich patient care. These resources, even the treatment programs, are best used when incoorporated into broader patient care, to augmetn therapy and close up any holes in our own knowledge.
And no, digital mental health resources are not for everyone. (Anonymous i think your 30% uptake figure is fantastic)
In my experience judiciously chosen elements of digital resources can be beneficial to most people in the context of their therapy. They need to be recommended with commitment and enthusiasm and the recommendations need to be followed up or it will seem to your patients like a strategy for fobbing them off and they will miss out on the value these resources can bring.
As to spending $588 million on a new digital platform – well that’s a different thing altogether adn a whole other discussion.
Great article @Louise. As GPs, our reluctance should not be about resisting change but ensuring patient safety and efficacy, much like the rigorous quality assurance we’ve been dealing with in the pharmaceutical industry for over 100 years.
Just as new medications undergo stringent testing and evaluation before they reach patients, therapeutics /Software as a Medical Devices (SaMD), DTx inclyding digital mental health tools need the same level of scrutiny. Our cautious approach stems from a commitment to evidence-based practice, ensuring that any recommended intervention—digital or otherwise—meets the highest standards of care.
This is a useful update:
https://www.tga.gov.au/how-we-regulate/manufacturing/medical-devices/manufacturer-guidance-specific-types-medical-devices/regulation-software-based-medical-devices
Thanks Dr Jayne Ingham : “As for referral to a psychiatrist there aren’t any available and the cases are usually too complex for them”.
I am glad that I still wear a mask at work , it stops my jaw dropping on the floor when a Registrar approaches me with the same experience.
We refer to this as “the Dr. John West phenomenon”-“your referral has been rejected” .I have had complex patients “dumped by text” informing them that the referral was declined.
90% of Psychologist appear to have adopted Telehealth for its benefits of low -rent and personal safety (who could blame them).
We are qualified , we are available in person , bill accordingly . We are no good to patients if practices become non-viable or if running them becomes so stressful that we burn out.
Thanks Prof Louise Stone, for highlighting the shortfall in our mental health services and the somewhat inward-looking and self serving digital platforms that are on offer. Most of my rural patients comment that they are once again being fobbed off by telehealth coming from junior staff within the hospitals. THey comment that they really need to see a real doctor most of the time- and that the doctor really needs to see where they actually come from.
And that they aren’t keen on being fobbed off with yet another app or being sent to chat with a chatbot.
They would like a real service, with real people, please, not a blasted phone call!
“Despite all the technological advances of recent decades, caring, compassionate, healing doctors remain the best therapeutic tool in medicine.”
“Guerir quelquefois, soulager souvent, consoler toujour (To cure sometimes, to relieve often, to comfort always)”
I just need to be convinced that a digital platform, even one driven by modern Artificial intelligence, with be capable and competent at the caring and compassion that is so needed in mental health care and indeed, in all care.
It’s not spreading virally because it’s just not that good. Not yet.
I do not doubt the Productivity Commission’s observation that fee structures incentivise shorter consultations. Activities and behaviours that our community invests most heavily in, are what we get most of.
How about we chance an investment in caring, compassion and comfort?
It comes down to the basics of mental unwellness. There have been so many studies on the causes of mental health issues especially from early child hood not having a circle of security not having the basics in life housing food being exposed to physical sexual and emotional trauma.
The productivity commission would have better out comes if it looked at these issues.
GPS are in a unique position to see the family and cultural circumstances. If you don’t ask the question about trauma you won’t know. How are these digital programs going to provide ongoing support even if they do ask the difficult questions.
I find it very difficult finding a suitable psychologist to deal with these issues especially if the gap payment is about $130. As for referral to a psychiatrist there aren’t any available and the cases are usually too complex for them. As a GP we are in the position to support these people in the long term.
Unfortunately obviously the Productivity commission isn’t aware of this. I have started billing more mental health consultations as this is the only way data can show what we are GPS do.
Maybe, just maybe, our world ( and the people in it ) do not suffer from access to digital information and help but from lack of contact with another human being….. but surely it could not be that simple, could it. ( and oh my, what will this cost …. , digital access is soooo much cheaper …. maybe therefore the pressure …. )
Surely the young people of this world are fine in their loneliness scrolling through a digital help app – what could go wrong. oops. Funny that with all this on offer, young people’s MH gets worse.
Excellent article .
One corrigendum :
“”The Productivity Commission report has disturbing errors of fact around general practice. They write on page 26:”
The quote is on page 34.
However , we now have insight into the report which informs the MH WIP to exclude 90% of the work we do from being counted as mental health.
45minutes safety netting and transferring an acutely disturbed suicidal patient -not counted .
40 minutes FPS -counted. Which is the higher skillset ????
MH work is pervasive in General practice .
In today’s world of computers, smart phones and social media, people are yearning for real human connection. In the past decades of availability of eMental Health modules, which I have recommended to many, many patients, uptake has been extremely poor. I believe this is because people instinctively know that their mental health will not be improved by further screen time, but by real human connection. My patients are thirsty for time spent in deep conversation, and with that, they heal.
In theory, digital mental health resources, such as Head to Health, Beyond Blue, Mindspot, etc can be an excellent adjunct to mental health care, particularly in remote areas where face to face psychology are limited. Given the limited face to face psychology in our remote area, I rutinely recommending digital online options during mental health care plans and mental health consults, including providing physical handouts as well as registering patients electronically. Unfortunately, despite this, I have not yet had a single patient (including health and IT literate young patients) access digital mental health services.
The first step is understanding the patients story or narrative and then formulation to embark upon a person centred journey taking account of the context – attending to processes of change with transparency of progress, results and impact.
Thanks you Louise.
I agree entirely that many seem to have gotten onto the hype train and perhaps have lost sense of the difference of what they wish things to be like, compared to what things are actually like. One of the amazing things when we live in a relatively free (as in liberty) world when it comes to health is that genuinely appropriate, acceptable, and effective interventions and treatments have rapid uptake from both clinicians (e.g., GPs) and consumers. Things go “viral” because the demand for that thing breaks through boundaries.
That GPs are cast as professional luddites is a ludicrous worldview. GP uptake of a variety of digital technologies (medical records, prescribing, referral, consulting) is very high in clinical practice, and typically outpace that of hospitals, sometimes by over a decade.
The issue is one of pragmatics and a recognition that the health system is a complex and adaptive system. When neither clinicians nor consumers embrace a digital service en masse in the digitally connected world of 2024, the most obvious reason that should be assumed is that the digital service just isn’t very good as it is delivered in the real world. Framing GPs as the scapegoats for ineffective policy is an extraordinary misattribution of causality.
i give every patient i do a MH plan for psychologist referral an electronic this way up prescription to do whilst they wait for an appt in person. perhaps 30% enrol