Mental health in Australia1Approximately 17.2 per cent or 3.8 million Australians are estimated to be affected by mental illness in any one year – meaning that they experience symptoms at diagnostic levels, for either brief or extended periods. This estimate excludes dementia and alcohol/drug-related disorders, except where these are concurrent with a mental disorder. The figure rises to about 20 per cent, or 4.4 million people, when alcohol and drug-related conditions are included.
A further 15 per cent of the population have experienced a mental disorder previously in their lives but not had symptoms over the past 12 months at a level that would warrant a formal diagnosis. In total, approximately one in three (32 per cent) of Australians will experience a mental illness during their lives. When alcohol and drug use disorders are included, this figure rises to 45 per cent of the population.
Anxiety disorders and depression are the most common disorders, affecting approximately 9 per cent and 7 per cent, respectively, of the adult population each year. Collectively referred to as 'high prevalence' illnesses, these disorders include diverse conditions (for example, post traumatic stress disorder, panic disorder, agoraphobia, obsessive compulsive disorder and depression), with differing treatment requirements and outcomes. It is these disorders, in mild to moderate severity, that the evidence shows can be effectively treated through online programs.
Mental illness also includes other less common or 'low prevalence' conditions such as schizophrenia and bipolar disorder. Together, these two disorders affect approximately 1 per cent of the adult population in any one year, and 2 per cent over the course of a lifetime. Prevalence rates vary across the lifespan and are highest in the early adult years, the period during which people are usually completing education, and establishing families and independent working lives.
The diagram below summarises the national picture of prevalence of mental disorders in the population showing the splits by severity levels.
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12-month prevalence estimates of mental illness in the population by severity level, based on diagnosis, disability and chronicity
Source: COAG National Action Plan on Mental Health 2006-2011 Third progress report June 2011.
Text version of DiagramThe diagram demonstrates that 2-3% of the population have a severe mental illness (approximately 600,000 Australians). 4-6% of the population have a mental illness that is considered to be of moderate severity (approximately 1 million Australians). 9-12% of the population have a mental illness that is considered to be mild (approximately 2 million Australians). In addition, a further 25% of the population will experience a mental illness at some point in their lives. 80% of the general population currently have no mental illness.
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Overview of e-mental healthAs technological efficiency develops, we increasingly conduct our business over the telephone or online. We do this because it is efficient and convenient. In recent years, these benefits have been transferred to the health sector with many medical and general health services now conducted through digital platforms such as internet and mobile based services. Health services for people with mental health disorders have increasingly expanded into online environments leading to the development of formal e-health services.
E-health services provide treatment and support to people with mental health disorders through telephone, mobile phone, computer and online applications, and can range from the provision of information, peer support services, virtual applications and games, through to real time interaction with trained clinicians. The treatment of mental health disorders through traditional techniques such as cognitive behavioural therapy has been shown to be effective in an online environment for high prevalence conditions.
In 2006, the Australian Government invested in e-mental health support through the development of a number of projects funded by the Australian Government under the Telephone Counselling, Self Help and Web-based Support Programme. Australia's universities, the non-government sector and the private sector, to a lesser extent, have been trialling e-mental health services. A list of the primary e-mental health projects funded by the Australian Government is at appendix A.
A recent review of the Telephone Counselling, Self Help and Web-based Support Programme has confirmed the value and importance of e-mental health. Early work in e-mental health by a group of Australian academics and non-government sector leaders, has strongly advocated for a structured approach to the development of this new e-mental health sector. The E-Mental Health: A 2020 Vision and Strategy for Australia2 identifies many of the key components of a fully developed e-mental health system.
Given the importance of the e-mental health sector and the range of stakeholders with an interest in its successful development, the Government has established an E-Mental Health Expert Advisory Committee. The Committee provides advice to the Department of Health and Ageing on the design and development of a national e-mental health portal and this Strategy. The Committee comprises experts involved with existing e-mental health services, including some of the authors of the "2020 Vision" paper and consumer and carer representatives. The membership of the Committee is at appendix B.
The Government's E-Mental Health Strategy for Australia builds on work already undertaken in the area of online mental health services and sets out key elements of the Australian Government's approach to future planning and development of these services. Improved e-mental health services lead to improved mental health outcomes. Through the scaling up of existing services and the utilisation of new technologies, a mature e-mental health system can be developed, offering high quality services to consumers and carers in a timely and efficient fashion, integrated into the broader primary health care system.
The e-mental health system will also be closely integrated with wider health services, including Personally Controlled Electronic Health Records. As a consumer-centred system, responsive to input from users, the e-mental health system will be adaptive and innovative and ensure that the support and well-being of consumers remains a priority. Taking advantage of the National Broadband Network and the convergence of various platforms (fixed line, mobile and wireless), to deliver a multifaceted service, the e-mental health system will also include provision to monitor and provide feedback on the usefulness of this Strategy to consumers.
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Strategic contextThe Australian Government has embarked on a planned approach to improving access to services in e-mental health with a view to increasing availability in the community. The Government is committed to ensuring that evidence based, e-mental health services are available for people with a mental health disorder. It is essential that consumers are assured of the capacity of online and telephone e-mental health services to maintain confidentiality and offer a secure, therapeutic environment while providing an opportunity for consumers to share information with other treating professionals as needed. It is also important that these services are linked with the wider health services available in the community, that health workers involved in providing face-to-face health services are aware of and are trained to work alongside online services, and that training is given to health providers working within these online services.
The value of e-mental health – Who is it for?E-mental health services are aimed at people experiencing mild to moderate symptoms of mental illness, particularly those who are experiencing stress, anxiety or depression. Research shows that e-mental health interventions are effective for this group of people. E-mental health services are designed to complement, rather than replace established mental health services. Many consumers will continue to receive support through traditional clinician led services, and online services users who are identified as requiring a higher level of support will be directed to appropriate face-to-face services.
E-mental health provides a platform to reach people experiencing mental illness and has the potential to address the low take-up rate in mental health. It is estimated that, even with improvements in access resulting from the Better Access initiative, only about 46 per cent of people with a mental health disorder accessed treatment in 2010.3
The major advantage of e-mental health services for those who do not require a clinician or real time help is convenience. People can access services from home at a time that is suitable for them. There is no need to take time off work or other commitments. Furthermore, the potentially anonymous nature of online services, and the high household use of the internet in Australia, makes e-mental health options ideal for people who would rather access services at a distance, or who are reluctant to use face-to-face mental health services for reasons of stigma or preference.
It is also particularly advantageous for those who have transport difficulties, who live in more remote locations or experience social isolation. In addition, research studies suggest that the outcomes for those who participate in online cognitive behavioural therapy are comparable to outcomes from face to face services using the same approach particularly for the high prevalence disorders such as anxiety and depression.4
Importantly, e-mental health is cost-effective and can reduce some of the workforce issues that are faced in training a workforce that has been limited to face-to-face methods of delivery. Consumers can be assisted through this low cost but effective mechanism. As it can be used in a "stepped" approach, it can facilitate access for those who have more complex or immediate needs for whom more intensive face-to-face services may be appropriate. E-mental health is expected to form an additional layer of service in the health system. It will be the first point of contact for many and will respond to low to medium intensity needs which might otherwise be the concern of face-to-face services. This will complement existing mental health services by freeing up clinician resources to focus on assisting those with high intensity needs.
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Health reform agendaE-mental health services operate in a wider health system which itself is undergoing change. The National Health Reform Agreement 2011 provides for a range of important reforms in public hospital funding and a strengthened primary health care system, including expansion of Medicare Locals. The Government is also committed to significant further investment under National Mental Health Reform in the 2011-12 Budget. This provides additional services for people with complex needs, further support for employment participation for people with mental illness and additional services for family mental health support and for youth mental health centres (headspace) among other investments.
The Australian Government's plan to develop the e-mental health sector will take account of these changes. In particular, e-mental health needs to be closely integrated with new and expanded primary care and specialist mental health services, as well as with the existing network of providers who come in contact with people experiencing mental illness, such as general practitioners and psychologists, not-for-profit mental health and substance abuse services, and homeless support service providers. Establishing links in these areas will ensure that e-mental health is entrenched in health professionals' thinking so that they refer consumers to e-mental health services where appropriate. It will also mean that people who are using e-mental health services can readily find their way to the face-to-face services they need, when they need them.
In planning the future of e-mental health, there are also opportunities to anticipate the convergence of other electronic technologies and e-services. Important developments in this area include electronic health records and the National Broadband Network.
Personally Controlled Electronic Health Records are expected to be implemented progressively from 2012-13 and be available for those Australians who choose to opt in. This initiative will build on the introduction of the Individual Health Care Identifiers measure which will provide every Australian with a 16-digit electronic health number. Personally controlled electronic health records will include summaries of consumers' health information including medications, immunisations and medical test results, and will provide secure access for consumers and health care providers.
It will be important for e-mental health services to plan for the implementation of electronic health records in the design of services so as to allow for easy transfer of mental health information to electronic health records, should that be agreed in the future. E-health services also offer the opportunity to provide information on online mental health service outcomes for consumers and government. Designed well, and with appropriate safeguards concerning the privacy of personal information, information about the effectiveness of services can be collected as part of service delivery.
The National Broadband Network, as it is rolled out across the country, will provide fast and reliable services that will support existing e-mental health services. These services include online chat or web counselling - that is, real time, text-based conversation with a worker associated with the e-mental health service, as well as automated interactive programs that are tailored to individuals. Voice interaction will also be available, but video counselling will initially be limited. Fast and reliable broadband will make it easier to offer higher level services where these are found to be useful: including real-time video conferencing with a mental health clinician should a consumer require this kind of assistance.
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Building blocks for e-mental health servicesIn Australia the e-mental health system has developed within a research framework which has led to variations in the way services have evolved. As a result, important online building blocks such as user privacy and the security of personal information have been developed inconsistently. A well developed e-mental health system requires the establishment of agreed standards for user privacy and security of personal information which must also be compatible with wider developments in e-health. This involves leveraging the work undertaken by the National E-Health Transition Authority regarding overall security and access principles for e-health. Further to this, there is an opportunity to plan for future inter-operability with the personally controlled electronic health records system, giving consumers the opportunity to include e-mental health service interactions on their personal health records.
Quality and safety are related to issues of privacy and security. Users of any health service need to be assured that services adhere to basic standards of quality and safety and users of e-mental health services are no different. Within the current community of practice there have been calls for guidelines to be developed and a reference group to be established to review and ratify online services. A quality assurance framework to address these issues is essential for e-mental health services.
Vision and future directionIt is expected that e-mental health services will play an increasingly significant role in mental health care in Australia. E-mental health services are uniquely placed to reach those people who are currently not accessing services, overcoming issues of distance, cost and stigma. It is expected that e-mental health will make a major contribution by utilising evidence-based online interventions and complement face-to-face services to improve health outcomes.
To achieve this purpose, there will need to be a vibrant e-mental health community of practitioners and availability of access for consumers and carers, to high quality, trusted services. It is envisioned that with investment, these services will evolve and grow in concert with emerging communications technologies.
A successful and mature e-mental health system will also need to be supported by structures designed to promote good governance, marketing, training, research, quality assurance and the integration of e-mental health within the primary health care sector. This also requires investment.
1 Information Paper 1: Clinical Categorisation of Mental Illness, Department of Health and Ageing November 2011.
2 E-Mental Health: A 2020 Vision and Strategy for Australia. PDF available on the Australian National University website (www.anu.edu.au)
3 National Mental Health Reform 2011-12: Strengthening primary mental health care services. Available on the Department of Health and Ageing website (www.health.gov.au)
4 See, for example, Andrews G and Titov N, "Is internet treatment for depressive an
d anxiety disorders ready for prime time?" 2010 Medical Journal of Australia Supplement 7 June 2010 Volume 192 Number 11 S45-S52