Using e-therapy to Service the Lower End of Need. 23 February 2017

Transcription

1 Using e-therapy to Service the Lower End of Need 23 February 2017

2 Agenda 1. Overview of the evidence and models of digital/e-therapies 2. What has been learnt from implementing a nationwide e- therapy program (the MindSpot Clinic)? 3. Summary

3 Overview: Evidence

4 Taxonomy e-mental Health Information Assessment and/or Treatment Website Website + Phone/Chat Self-Guided/Apps Guided mindhealth connect beyondblue Cost Free Cost Free ReachOut mycompass MoodGym This Way Up MindSpot Clinic OnTrack Hello Sunday Morning

5 Background: About DMHS o Definition DMHS o Mental health services delivered electronically. o Types of DMHS: 1. Apps (mainly standalone) 2. Information websites +/- chat/tel 3. Forums 4. Treatments o o Self-guided treatments Therapist-guided treatments ++ Greater accessibility ++ Lower cost - - More risk ++ Acceptability (no evidence) ++ More evidence ++ More integration Note: Absence of evidence does not necessarily indicate an absence of effect. But, referrers have (some) responsibility for the service they are referring to.

6 Background: DMHS: Evidence (Trials) o Apps: Most have not been evaluated (limited evidence of risk or benefits if unguided) (Larsen et al., 2016). o Self-Guided Treatments (Christensen et al., 2006; Klein et al., 2012) o <10% completion rates o Those who complete obtain moderate clinical benefits o Limited data on deterioration rates o Guided Treatments (Andersson & Titov, 2014; Titov et al., 2016) o >75% completion rates o Large clinical gains o Low deterioration rates o Improvements sustained + 1 year

7 DMHS: Evidence (Routine Care) 1. Self-Guided (fully-automated) o Australia: Mental Health Online (Klein et al., 2012) o Automated assessment o Choice of self and therapist-guided o 10% completion rate o Own outcome measures, moderate outcomes for completers, no data on deterioration, no recent results o Australia: Moodgym (Christensen et al., 2004) o No assessment o Completion rate 1-10% (Gilbody et al., 2015) o Moderate benefit for those who complete o Limited data on long-term outcomes, no data on deterioration, no recent results

8 DMHS: Evidence (Routine Care) 2. Therapist-Guided o Sweden: Karolinska Institute (Hedman et al, 2010). o GP referral, then F2F Psychiatry assessment o Large clinical benefits (short and long-term) o Low deterioration o High satisfaction o The Netherlands: Interapy (Ruwaard et al., 2010) o GP referral, then online/telephone interview o Large clinical benefits (short and long-term) o Low deterioration o High satisfaction

9 DMHS: Evidence (Routine Care) o Canada: Online Therapy Unit (Hadjistavropoulos et al, 2016) o GP referral then F2F or telephone screening o Treated by local mental health teams (across Saskatchewan), or via virtual Clinic o Large clinical benefits (short term) o High satisfaction o Low deterioration o Australia: MindSpot Clinic (Titov et al., 2015; 2016) o Self or GP referral o Screening assessment (online and/or telephone) o Large clinical benefits (short and medium) o High satisfaction o Low deterioration

10 DMHS: Evidence (Summary) 1. Therapist-guided > self-guided (1 st Gen) 2. Therapist-guided. In routine care: High completion rates (>65%); Large effect sizes (> 1.0) Results are sustained at follow-up High consumer satisfaction 3. Success factors Assessment/screening is essential (match patient to services) Treatment materials/content needs to improve over time Onboarding patients is essential (orientation, expectation management) Regular monitoring is essential (quality + suitability)

11 Learnings From the MindSpot Clinic (About Virtual Services)

12 Virtual Services 1. People Like Them! If properly introduced, consumers appear comfortable trialling e-mental health services, regardless of age or background. 2. People Don t Like Them! If they don t expect them. 3. Governance: These are mental health services. They require appropriate clinical and organisational governance. 4. Not a Panacea: Not suitable for everyone. But many people benefit. 5. Significant Demand: Demand is growing for online services. Success requires sustained focus on quality and safety.

13 Stepped Care and Low Intensity 1. Stepped Care: Is a model consumers understand and support. 2. Low Intensity: Refers to amount/type of therapist resource, not the amount of patient time (they may spend more time!). 3. Flexibility: Services need to allow patients to smoothly move between steps of care. Services need to be flexible. 4. Outcome Measurement: Regularly measurement of outcomes is essential, guides assessment and treatment. 5. Consumers: People vote with their mouse. Need to support consumers to make an informed decision.

14 HR and IT 1. Therapists: Require skilled professionals, at least for assessment, and for risk management. 2. Workforce Development: Challenges in professional registration and career development. This is specialised work, requiring careful training and supervision. 3. IT Design: Clinical processes should guide IT design, not the other way. There are no off-the-shelf solutions. 4. IT Workforce and Costs: Specialised, high risk, complex, and expensive area.

15 Challenges 1. Evolution: Field is rapidly evolving, still in early developmental stages 2. Evidence: Limited data from routine care, and little emphasis on quality assurance 3. Services: Duplication of services (duplication of risk, confusion) 4. Governance: No certification process (yet) 5. Treatment Options: Limited range of online interventions (mainly anxiety and depression) 6. Funding: Recent funding has occurred in 12 month cycles, undermining planning and development 7. Policy: Policy is evolving 8. Hype: Prone to hype and overstatement of results

16 e-mental Health Apps e-mental Health Services

17 Suggestions for PHNs When Considering Referrals to DMHS 1. Clinical Governance Evidence of clinical governance forums and processes, documented policies, procedures, alignment with guidelines and standards 2. Clinical Evidence from Routine Care Estimates of use; benefit; deterioration; acceptability; known risks 3. IT Governance Information Security Framework; Compliance with Australian Privacy legislation 4. Safety Protocols For: Triage, risk assessment, monitoring, escalation, reporting; complaints? 5. Referrals to DMHS Build a long term relationship; clarify duty of care; would you refer your own family member? Coroner s Court Test.

18 Summary

19 Summary Digital mental health services like MindSpot are not a panacea (they are not suitable for everyone). But, they have considerable potential to: 1. Provide screening and triage services. 2. Complement existing services by providing a step-up or step-down for consumers. 3. Be clinically and cost effective. 4. Highly acceptable and convenient. 5. Improve access for people who would not otherwise access care.

20 Recent Papers

21 Funding o Funding for the MindSpot Clinic is provided by the Australian Government Department of Health. o The development of the Wellbeing Course was enabled by funding from the Australian National Health and Medical Research Council Project Grant No o The development of the Wellbeing Plus Course and Mood Mechanic Course was enabled by funding from beyondblue: the national anxiety and depression initiative.

22 Thanks to Our Teams

23 o Thank you