Are GPs 'reluctant' to prescribe digital mental health services?  

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.