Stepped care and e-mental health tools: integration into general practice

In Australia in 2006 there were 2.1 million people with a 12-month mental health disorder who did not use any professional services for their mental health problems but perceived they had an unmet need.¹ In response, the Australian Government launched the Better Access to Mental Health Care initiative that enabled Australians with mental health problems to access Medicare benefits for psychological services as long as they were referred by a GP under a Mental Health Treatment Plan. This measure significantly changed the way mental health disorders were managed in general practice, making affordable psychological services available to all Australians. A formal evaluation of the Better Access program published in 2011 showed that the program had increased the treatment rates for individuals with mental illness from 35% in 2007 to 46% in 2010.²

Unfortunately, a significant proportion of the population still experience psychological distress but are unwilling or unable to access face-to-face care. Geographical and socioeconomic disadvantage remain a problem. Even when services are available, acceptable to the patient and appropriate to their needs, pressure on psychological services in some locations has led to long waiting times. The system is suffering in part because of the many people who might benefit from lower-intensity-interventions who are being referred to psychologists, just as once they may have been inappropriately treated with medications.

It is essential that GPs have a wide range of skill in mental health care. This includes knowing about options available other than medications and referral that can help their patients who are experiencing mild-to-moderate common mental health conditions. Australian evidence-based online resources can help GPs provide effective mental health care in their own practices without specialised training.

GPs and mental health care

Not all mental health conditions require face-to-face clinical interventions by specifically trained mental health professionals, and not every patient with a mental health condition wants to go beyond their GP for help. These factors put the responsibility for patient care firmly back onto the GP. 

Other important reasons why GPs need to know more about managing common mental health conditions are:

• 67% of GP consultations involve a mental health issue as part of the presentation.³ It has been estimated that since 2011 there has been a 4.7% annual increase in the number of GP consultations for mental health problems.⁴ The community expects GPs to know and care about their psychological wellbeing.
• GP services are often needed to exclude underlying physical causes for what appears to be a psychological presentation, a fact that is reflected in their ‘gatekeeper’ role for psychological services.
• Management of chronic physical illness also involves psychological care. People with anxiety or depression do not always take good care of themselves. The high rate of psychological distress in people with diabetes and the impact of that distress on their ability to manage their illness is a clear example of this.
• Of all health professionals, GPs are in the best possible position to identify patients who are vulnerable to developing mental health disorders. They can help their patients develop resilience before problems arise by encouraging them to learn skills for managing their psychological wellbeing.

What is stepped care in mental health?

The concept of stepped care in mental health is an important component of the Australian Federal Government’s Fifth National Plan for Mental Health and Suicide Prevention.⁵ At the outset, many members of the health care community were not sure what stepped care would mean for mental health care. There were fears it would force patients into treatment options they did not want to pursue.

These fears are unfounded. The stepped care model is as simple as matching the intensity of treatment to the severity of illness. It is something we do all the time in managing physical health problems. Patients remain free to choose their preferred option within the model.

In practice, stepped care means that those suffering from severe forms of mental illness receive the most intensive forms of therapy, whereas those at the other end of the severity spectrum, with subsyndromal or mild to moderate mental health conditions, receive lower-intensity interventions that are more appropriately matched to their conditions, provided those inter-ventions are acceptable to both patient and practitioner. Using these options can help patients achieve the optimal level of improvement efficiently, without added inconvenience, delay or expense. Low-intensity and self-help interventions can and should be included in treatment planning for all patients with mental health disorders, including those with more severe conditions, to support the development of a sense of self-efficacy in their management.

Stepped care in mental health requires that GPs make a reasonably accurate mental health diagnosis and assess severity carefully. It also asks that practitioners remember to recommend low-intensity interventions where appropriate and follow up their recommendations to ensure that outcomes have been good. It does not insist that these interventions be recommended.

What are low-intensity interventions?

Low-intensity interventions are, by definition, effective interventions that are brief and make more efficient use of the therapist’s time. They include group therapy, bibliotherapy, community-based counselling and online interventions. Online interventions, also known as e-mental health (eMH) interventions, are likely to be the most readily available and useful in the general practice environment.

eMH in Australia

Australia has been a world leader in the development of digital options in mental health care since the late 1990s. eMH includes websites for psychoeducation and apps that are mostly used for symptom management. Most importantly, it includes online or internet-based treatment in the form of self-help or guided self-help programs. These treatment programs can be used as standalone options but are also valuable when integrated into more broad-based patient care.

The first Australian online mental health treatment program, MoodGYM, was launched in 2001. It was developed by a team of researchers at the Australian National University to promote psychological resilience in adolescents.⁶ MoodGYM is a cognitive behavioural therapy (CBT)-based program. It has been used extensively in clinical and research environments worldwide. Subsequent research has shown that it not only helps develop good coping skills in young -people, but also works for adults, including those with mild-to-moderate anxiety and depression.⁷

eMH treatment programs such as MoodGYM have the advantages of being:

• available free of charge or at very low cost
• convenient both in terms of location (e.g. in the patient’s own home) and 24-hour availability
• a good introduction to the idea of therapy
• a reliable alternative to therapy for those unwilling to speak to someone face to face
• a useful adjunct to therapy
• a good way to teach mental health survival skills where absence of those skills has left people vulnerable to mental health problems.

Evidence to support the use of online treatment programs

The evidence to support the efficacy of online treatment for mental health conditions continues to grow. A 2007 meta-analysis looked at 12 randomised controlled trials and found that all the programs studied were effective but that effect sizes of internet-based interventions for symptoms of anxiety were larger than effect sizes for depressive symptoms.⁸

A 2018 meta-analysis concluded that the earlier evidence of efficacy for these programs was well supported and that iCBT (a term used to refer to CBT delivered via the internet) for anxiety and depressive disorders is ‘effective, acceptable and practical health care’.⁹

However, the studies of particular interest to GPs are likely to be those that look at the use of these programs in the clinical rather than the research environment. The results of a literature search of studies of therapist-guided iCBT in 2013 noted that of the four controlled trails and eight open studies of programs used in the clinical environment ‘all indicate that it is possible to transfer iCBT to clinical practice with sustained effects and moderate-to-large effect sizes’.¹⁰ Research articles about specific programs can be found on the programs’ websites and on the Beacon portal, an Australian site that rates available eMH programs according to the evidence (https://beacon.anu.edu.au).¹¹

Which patients should GPs refer to eMH programs?

There is potential benefit in eMH use for a wide range of patients. It is as important to consider which patients would not be suitable for eMH use as it is to consider those for whom it may be a good option.

To undertake eMH treatment, patients will need:

• adequate English literacy skills
• access to appropriate technology
• a reasonable level of comfort with using technology (or someone to help them use it).

Age is not necessarily a barrier. Older people may find online options less acceptable, but it is not safe to assume that is the case. Technological confidence and skill in older age groups is improving at a greater rate than in the young and there are programs that have been specially designed for use by older adults (e.g. the MindSpot Wellbeing Plus program from Macquarie University¹²).

Evidence about which candidates most benefit from online interventions is sparse.¹³ Most of the positive benefits shown in the research are for those at risk of developing mental health problems and those with mild-to-moderate anxiety and depression. Severity of illness can be assessed before referral both clinically and using instruments such as the Kessler Psychological Distress Scale (K10) or the Depression Anxiety  Stress Scales (DASS). Most treatment programs also assess severity regularly using these or other instruments, letting users know if they are deteriorating and advising them to seek other help.

Patients with severe and complex disorders may derive benefit from online programs used in conjunction with face-to-face therapy.¹⁴ Suicidality and self-harm require urgent attention but do not preclude the use of eMH resources in conjunction with face-to-face treatment to help treat the underlying conditions.

Characteristics of online treatment programs

MoodGYM and its sister program e-couch belong to a group of ‘transdiagnostic’ programs that deliver the same content irrespective of the user’s diagnosis. Diagnosis-specific programs are also available. Those from the THIS WAY UP and Mental Health Online suites of programs focus specifically on the various anxiety disorders and depression in separate courses (Table 1).^15,16

Most treatment programs are linear, working their way in a logical fashion through information about mental health conditions and the theoretical under-pinnings of cognitive behavioural strategies and then moving on to teaching the strategies themselves in an interactive and engaging way. The one exception among the evidence-based Australian programs is the Black Dog Institute’s myCompass program.¹⁷ MyCompass is a transdiagnostic program for mild-to-moderate anxiety, depression and stress. It consists of fourteen independent modules that can be completed in any order. This has the advantage for patients of allowing them to choose lessons that most meet their current needs, right from the time of registration.

Most online treatment programs are designed to be self-help; however, there are exceptions. THIS WAY UP offers guidance for its self-help programs at no extra cost if users have a referral (rather than a prescription) from their practitioner. Mental Health Online offers similar guidance if users would like to take advantage of it. One program, the MindSpot virtual clinic from Macquarie University, offers professional guidance as a necessary part of using the program.¹⁸ It offers four transdiagnostic programs targeting different population groups (adults, older people, adolescents and Indigenous people) and three diagnosis-specific programs (for post-traumatic stress disorder, obsessive-compulsive disorder and chronic pain management). When users register for these programs they are linked with a mental health professional at the clinic who contacts them either by phone or email and continues to do so after each of the five lessons in their course. This contact allows for discussion of course content and encouragement of continued engagement with the program. All Australian residents over 18 years of age can use MindSpot courses free of charge. No referral is required, but if a patient nominates their health practitioner the virtual clinic will contact the practitioner and let them know their patient is involved with the program and keep them apprised of their progress.

All but one of these Australian online treatment programs are available free of charge and without referral. The exception is THIS WAY UP, which requires both an online referral from a practitioner registered with THIS WAY UP and a payment of $60 by the user for access to each of the programs if the practitioner wishes to be involved in their patient’s use of the program. However, the body of evidence supporting the efficacy of this program, combined with the way it links the patient’s referring practitioner with the patient’s progress, is uniquely appealing and may influence the decision of many patients to use THIS WAY UP rather than a free program.

It is worth noting that some programs offer unique courses for specific purposes and population groups. Examples include the OnTrack courses for alcohol misuse and for depression combined with alcohol misuse, the veteran-specific courses for post-traumatic stress disorder available from the Department of Veterans' Affairs and the BRAVE program, an online course designed for children and adolescents experiencing anxiety.^19-21 There is also a range of resources for both men and women in the perinatal period including the ‘What were we thinking!’ program and app.²²

How to start using online resources in primary care

A team of researchers from the Australian National University has developed a framework for eMH use.²³ The framework consists of five models of use for eMH resources ranging from simply recommending the resources to integrating them into symptom-focused therapy or into comprehensive treatment. For GPs, the most appropriate models of use are the case-management and coaching models in which practitioners recommend and follow up their patients’ use of online resources or see patients regularly to guide them through their program use. The five models are summarised in Table 2.

Most clinicians who successfully use online resources agree that it is best in the first instance to familiarise yourself with one or two websites, apps or treatment programs that might be useful for your patients (see the case study in Box 1 and Box 2). Practise recommending these to patients who are open to the idea of learning mental health management skills online and learn from them about the obstacles and barriers and how to overcome them. Your patients will also be able to identify the things they find most valuable about their online experience, providing useful information for subsequent referrals. This communication can happen naturally as a result of following up your recommendations with at least one further appointment, something that most GPs would do irrespective of the treatment options chosen by their patients with mental health conditions.

It is an important and integral part of stepped care to ensure that follow-up occurs. It provides the practitioner with the opportunity to check that patients are receiving the intensity of treatment they require and that no deterioration is occurring.

Finding out more about eMH

In October 2017 the Australian Government launched an online portal, Head to Health, to provide information to the Australian community about digital mental health resources (https://headtohealth.gov.au).²⁴ The site is a useful starting point for GPs as well as members of the public to find out about mental health support available online. It contains a chatbot functionality that guides users inter-actively to the most suitable resources for their needs.

The government’s eMH in Practice Project (eMHPrac) has developed a range of resources to help GPs and other health professionals become familiar with the use of online resources. These include a six-module online learning program and a range of webinars and podcasts exploring various aspects of mental health and eMH. These resources can be found on the eMHPrac page of Black Dog Institute’s website (www.blackdoginstitute.org.au/emhprac).²⁵ The Royal Australian College of General Practitioners has also published a guideline for GPs on the use of eMH (www.racgp.org.au/your-practice/guidelines/e-mental-health).²⁶

Conclusion

Australian-made evidence-based online resources are a valuable addition to the GP’s toolbox for mental health care. They are useful both as low-intensity standalone treatment for mild-to-moderate mental health conditions and as preventive interventions for people who are vulnerable to developing mental health disorders. eMH resources and treatment programs can also serve as useful adjuncts to face-to-face care where their additional resources can enrich therapy and make therapy delivery more efficient and effective.     MT

References