Right now we are in the midst of a digital revolution that presents us with new opportunities as well as new challenges to enhance the quality, accessibility and efficiency of care.
It's an "era that may provide new knowledge and evidence-based tools to better promote mental health; and help with diagnosis, treatment, rehabilitation and recovery"[4].
While technology offers the potential for cost-effective scaleable mental health support, it cannot be used as a substitute for access to high-quality individualised services. It is another option in the continuum of mental health care and support, and a toolf or better integration of mental health services, if done correctly.
This is the text of a speech delivered by Commissioner Ivan Frkovic at the Australian Telehealth Conference in Brisbane on 3 April 2019.
Established and familiar technologies
Tele-mental health has long been an established part of the health system—with evidence confirming it as effective as face-to-face service provision.
Currently we are using somewhat familiar technologies as enablers of the mental health system—for example online mental health information, telephone counselling, video-based telepsychiatry, peer chat rooms and mental health apps.
Telephone services such Lifeline and Kids Helpline are familiar examples of this, while websites provide static information—but also increasingly offer multi-channel counselling via phone, online chat and video chat.
Lifeline, the Suicide Call Back Service and eHeadspace are well-known as providers of these kinds of multi-channel service options, where people can quickly and easily access professional suicide prevention counsellors by phone or online.
Telepsychiatry via video link is also an established method of service delivery — again with evidence to show its acceptance by users and its effectiveness as a treatment option.
The Commission has itself invested in Chats for Life, a mental health and suicide prevention App for young people developed with the University of the Sunshine Coast.
Evidence shows, when experiencing mental health problems and thoughts of self-harm, young people look online and through social media for answers.The App also recognises that young people often approach a friend or family member for support rather than formal services when experiencing mental health difficulties.
The app provides a free, step-by-step resource to allow young people to plan a conversation to help someone at risk of suicide or experiencing personal or social pressures — and emphasises the importance of seeking professional support.
There is a consistent theme among these technologies, that is: they enable connection with a human at the other end for advice and support, or assessment and referral, as required.
These treatment channels are an essential part of the mental health system today, but they are generally an adjunct to face-to-face clinical care.
The future
It is imperative that we look to the current and emerging capabilities, challenges and opportunities that technology brings to the mental health system[i].
Right now we are in the midst of a digital revolution that presents us with new opportunities as well as new challenges to enhance the quality, accessibility and efficiency of care.
Increasingly we are seeing the rise of technology not just as an enabler of connection, but as an enhancer of mental health practice and outcomes.
Some of the digital mental health initiatives I will mention may seem far-off and futuristic, even far-fetched — but all are already in use overseas, and will, in fact, be upon us in the near future.
We need to be ready for this digital revolution, but we also need to be cautious and shape technology to best meet the needs of people with lived experience, and the system as a whole.
A smart world
The 21st century is a digital world. Most of us carry in our pockets powerful technology that 60 years ago would fill a large room.
Today our smart phones can:
- track our movement and location via global positioning satellite
- take biometric data by fingerprint, voice, eye or facial recognition
- tap into a digital assistant
- make payments
- connect with others via video, text, email and social media
- take pictures and store personal data
- monitor and manage our time, exercise, diet and heart rate — and countless other things,
- entertain us, and find any information we want.
We have vast capability, literally at our fingertips.
It is predicted by the tech industry that “by 2022 your personal device will know more about your emotional state than your own family” … and “artificial intelligence systems and devices soon will recognise, interpret, process and simulate emotions through a combination of facial analysis, voice pattern analysis and deep learning” [2].
We are also increasingly connected in the digital world:
- 87% of the Australian population own a smart phone
- 84% have a laptop or desktop computer; and
- we spend a lot of time with our devices — on average five-and-a-half hours each day on the internet[3].
The digital mental health revolution
"We are at the beginning of an era that may provide new knowledge and evidence-based tools to better promote mental health; and help with diagnosis, treatment, rehabilitation and recovery"[4].
It is predicted that “digital health platforms and tools may significantly improve mental health services and, in turn, the quality of life and social inclusion”[5] of people with mental health problems and their families and carers.
We have the opportunity of combining technology with mainstream clinical care, empowering person-centred care through digital platforms, and monitoring mental health at the population level[6].
There has been a proliferation of mental health services being delivered by new modalities such as text/sms, Apps and even by gaming technology — and the rise of artificial intelligence systems which offer and enhance diagnostic and treatment capabilities.
As examples of the kind of technology that’s already in use overseas, let me introduce you to Tess and Sleepio.
Tess
Tess is a psychological artificial intelligence chatbot offering internet CBT.
Her developers say she coaches 8 million people experiencing depression, anxiety and stress to build resilience, and is delivered through unlimited text or Facebook messager conversations, on-demand, 24/7 [7] [8].
Tess’s content is developed by psychologists and her emotion and conversation algorithms mean that she is improving with each interaction. As a machine she never has a bad day, is consistent, but also remembers each individual, and can track changes in their mood.
Her algorithms can process metaphors, such as ‘I don’t want to wake up anymore’, to identify a crisis or emergency, which she escalates to a live psychologist for intervention[9].
Her creators describe her as a therapeutic assistant, which means they offer help and support rather than treatment — an important legal and ethical distinction.
The same company has also developed Karim — an Arabic speaking psychotherapy bot assisting Syrian refugees, enabling scalability without the difficulty of placing therapists in a crisis area.
The United Nations World Food Program have reportedly expressed interest in running larger pilot programs using Karim[10]
Sleepio
It is well known that improving sleep improves mental health.
The Sleepio App, developed in the UK, is a prescription only iCBT six week treatment for chronic insomnia with demonstrated success in replacing sleeping pills.
More than 70 percent of participants who completed Sleepio’s online CBT had healthy sleep eight weeks after completing the program, compared with less than 30 percent of those who received visualisation exercises.
Sleepio is so successful in treating insomnia that guidelines from the American College of Physicians indicate iCBT should be first-line treatment for people with chronic insomnia.
As Sleepio’s co-founder and chief medical officer Professor Colin Espie said: “Anyone … can go to the doctor and get a sleeping pill, but they very seldom have access to CBT… digital medicine can replace sleeping pills”.[11]
Severe mental illness
Various studies have demonstrated the potential for enhancing treatment of severe, complex and enduring mental illness.
For example, university students with eating disorders which may require a higher level of care were more likely to seek support after participating in a digital body-image program and working with a coach via messaging. The high frequency of messaging was seen as beneficial by study participants[12].
Electronic, web and mobile apps have also demonstrated potential to provide valuable self-management strategies for people with bipolar disorder and people with substance use disorders.
People participating in CBT for psychosis showed significant increases in social functioning, symptom management and recovery.
Digital technology is also useful in the treatment of substance use. There is a mobile phone App currently available in the US called reSET for outpatient treatment of alcohol, cocaine and marijuana addiction.
reSET has undergone US Food and Drug Administration evaluation and approval as a medical device and requires a medical prescription to access it. It is designed as an outpatient therapy to “track substance use, cravings and triggers such as social pressure and loneliness” and is iCBT based.
This means the App can offer the more time intensive and repetitive aspects of treatment, and the clinician is freed to focus on the areas where people are struggling. reSET has a cousin for opiod addiction that is currently undergoing FDA approval, which combines the App with prescribed medication.[13]
In the US, there are gaming platforms already in use that provide virtual reality exposure therapy, guided by a trained therapist, to assist veterans with post-traumatic stress.
There is also the virtual patient, which trains clinicians in interpersonal areas such as rapport, interviewing and diagnosis. This system also has a variety of avatars to enhance training, including for the elderly, young people, and people with different cultural backgrounds.
Benefits
Many of the platforms themselves are careful to emphasise that they are not a replacement of face-to-face clinical treatment.
However, some studies have found online therapy to be as effective in reducing symptoms as therapies delivered face-to-face by a clinician.
The evidence is strongest for treating depression, stress and anxiety. One study found people accessing iCBT for depression had better outcomes and stuck to their treatment[14].
These indicate that iCBT is a viable option as a first-step assessment and treatment, enabling the user to track progress via a digital dashboard over time and seek assistance if their condition deteriorates.
Guided digital platforms can aid recovery and assist in monitoring and maintaining mental health on a daily basis. This also means their therapist can also track progress and symptoms and intervene early if necessary.
The potential benefits of digital mental health include:
- availability and accessibility
- reducing barriers to help-seeking
- enabling peer supports and access to networks
- mental health triage
- referral pathways
- scalability, and
- cost effectiveness.
Digital mental health may also help close a treatment gap and reach those who currently go untreated and reach traditionally under-serviced groups— those who are disadvantaged economically, socially and geographically[15].
For example, recently the NQ Connect phone counselling and support service was able to be rapidly deployed to reach people distressed and isolated in flood affected areas, offering free mental health counselling and support.
At the back-end we also have access to big data, and for the first time in human evolution, the capability to map and understand the population-wide human context, in real time.
Not a panacea
Despite the promise of the digital mental health revolution, there are just as many challenges.
Firstly, we need to step back and look strategically at technology in mental health to determine where it can best enhance individual, practitioner and system outcomes. This is on the national agenda.
Secondly, this is an area that needs regulatory oversight.
The Australian Government is currently leading and developing a national certification framework to assure the safety and quality of digital mental health services.
For every evidence-based, clinician guided model, there are several more developed without evidence, clinical standards or appropriate oversight. 0It is especially important to quality-assure these services, because of their reach, but also the potential for real harm if not done right.
This means building strategic collaborations with the tech sector, which is increasingly driving reform in health service delivery. My Health Record, and TMR, the Princess Alexandra Hospital are examples of digital advances in health care.
We also need robust clinical studies and research to build solutions that are evidence-based. In the US, some developers are electing to undergo an R&D process more like drug development[16], involving clinical trials and rigorous evaluation.
While AI is advancing quickly, there are still limitations to algorithms built by humans, including the restrictions of pre-set scripts, and in-built bias from those building and teaching the computers.
The Karim app had some early failures due to cultural issues, including the original name of the app and the visual representation of ‘Karim’. So, we also need to be mindful to address culture, age and gender differences to best match digital services with real-world diversity.
We also need to consider workforce capability, not just in developing and using technology, but recognising when a digital solution may or may not meet a person’s needs.
Privacy and data security are critical areas that we have to get right if we are to employ technology in mental health care. Privacy and confidentiality are critical elements of success for people with lived experience.
I think while technology offers the potential for cost-effective, scaleable mental health support, it “should not be viewed as a solution to chronic under-staffing or under-funding”[17] of face-to-face services. Nor can it be used as a substitute for access to high-quality individualised services.
Lived experience perspective
Finally, I think lived experience perspectives are vital to this discussion, and a study the Commission undertook into telepsychiatry in 2015 provides useful insight.
People with lived experience said telepsychiatry was a valued and necessary component of mental health care in rural and remote Queensland.
They reported it as beneficial for:
- prevention and early intervention, as well as acute and emergency situations
- enabling service integration, particularly with local services
- supporting community-based recovery
- supporting family and carers
- as a back-up service
- for clinics such as clozapine clinics, and
- for hearings of the Mental Health Review Tribunal.
Patients liked the accessibility of the service at a time and place convenient to them, and valued the immediacy and timeliness of access to specialist practitioners.
However, they wanted to exercise choice over whether telepsychiatry was part of their treatment, had concerns over continuity of care, privacy and confidentiality, technical glitches, and language and culture barriers.
Over everything else, establishing a positive relationship with their practitioner and broader support team was the most valuable feature.
In conclusion
I think the voice of lived experience should be the final word.
If overseas patterns are replicated here, we can expect digital mental health to have a growing role in mental health treatment and recovery in Australia.
We cannot ignore the significant impact of technology on mental health care, but it is not a panacea.
It is another option in the continuum of mental health care and support. It can also be a tool for better integration of a variety of mental health responses if done correctly.
[1] Luxton, D. (2015). Artificial Intelligence in Behavioral and Mental Health Care. Academic Press. London.
[2] Kleber, S. (25 August 2018). Artificial intelligence is gearing up to have greater emotional impact. The Australian. Retrieved from https://www.theaustralian.com.au/business/careers/artificial-intelligence-is-gearing-up-to-have-greater-emotional-impact/news-story/7815ea05586cea1520daa5298d7f39e5
[3] We are social. 2018 Digital Report – Australia. Retrieved from https://wearesocial.com/au/blog/2018/02/2018-digital-report-australia
[4] Tal, A. and Torous J. (2017). The Digital Mental Health Revolution: Opportunities and Risks. American Psychological Association
[5] Ibid.
[6] Ibid.
[7] Retrieved from https://www.x2ai.com/
[8] Rucker, M. (19 November 2018). Using Artificial Intelligence for Mental Health: Your Virtual Counsellor Will See You Now. Retrieved from https://www.verywellmind.com/using-artificial-intelligence-for-mental-health-4144239
[9] Berman. A.E. (10 October 2016). Bridging the Mental Healthcare Gap with Artificial Intelligence. Singularity Hub. Retrieved from https://singularityhub.com/2016/10/10/bridging-the-mental-healthcare-gap-with-artificial-intelligence/#sm.001s056bz4d4ekz10ws244vm954ww
[10] Romeo, N. (25 December 2016). The chatbot will see you now. The New Yorker. Retrieved from https://www.newyorker.com/tech/annals-of-technology/the-chatbot-will-see-you-now
[11] Weir, K. (November 2018). The ascent of digital therapies. American Psychological Association. Retrieved from https://www.apa.org/monitor/2018/11/cover-digital-therapies
[12] Novotney, A. (February 2017). A growing wave of online therapy. American Psychological Association. Retrieved from https://www.apa.org/monitor/2017/02/online-therapy
[13] Weir. K. (November 2018)
[14] Rosenberg, S. and Hickie, I. (5 March 2019). Online therapies can improve mental health, and there are no barriers to accessing them. The Conversation. Retrieved from https://theconversation.com/online-therapies-can-improve-mental-health-and-there-are-no-barriers-to-accessing-them-111357
[15] Ibid.
[16] Weir. K. (November 2018)
[17] Banerjee, R. (25 November 2018). Can AI Help solve the mental health crisis? The New Statesman. Retrieved from https://www.newstatesman.com/spotlight/healthcare/2018/11/can-ai-help-solve-mental-health-crisis
