MindSpot: a valuable service that raises questions

Abstract

Nickolai Titov and colleagues1Titov N Dear BF Nielssen O et al.User characteristics and outcomes from a national digital mental health service: an observational study of registrants of the Australian MindSpot Clinic.Lancet Digit Health. 2020; 2: e582-e593Summary Full Text Full Text PDF Scopus (10) Google Scholar report outcomes from 7 years of operation of the MindSpot Clinic, a digital and therapist-supported mental health service available to all Australians since December, 2012. MindSpot is an innovative service and part of a suite of world-leading digital mental health services developed in Australia over the past two decades. Australia has a combination of private and public mental health services distributed in uneven clusters across the country, with gaps in care for rural, remote, and indigenous communities, despite the fact that Australia is a high-income country. Titov and colleagues report that only 18·9% of those registering with MindSpot are from rural and remote regions, where around 29% of the Australian population live.2Australian Institute of Health and WelfareAustralia's health 2018.https://www.aihw.gov.au/getmedia/7c42913d-295f-4bc9-9c24-4e44eff4a04a/aihw-aus-221.pdfDate: 2018Date accessed: September 29, 2020Google Scholar Possible explanations include the limited and unreliable internet access in some rural and remote regions and poor awareness of MindSpot among local health-care providers and the public. In Australia, few people who have clinically significant symptoms seek or successfully connect with some form of intervention. For the majority of people who registered on MindSpot, their main purpose was to take the initial assessment (52·6% of registrants in 2013, increasing to 66·7% in 2019), rather than enrol in a treatment course (42·6% in 2013, decreasing to 26·7% in 2019). Assessment is an important and legitimate function provided by MindSpot. A question not addressed is why did the proportions of people who registered and sought treatment decrease substantially over the reporting period? A possible explanation is that use of terms such as “wellbeing”, which would appear to destigmatise mental distress, might be having the opposite effect. Participants might in fact prefer or need condition-specific, tailored psychological treatments for anxiety and depression. Additionally, what happened to the large proportions of participants who did not progress to treatment? The Australian federal government has invested billions of dollars in expanded mental health services since 2006, including the Better Access initiative (offering up to 10 sessions per year with an allied mental health professional to people referred by their general practitioner), digital services such as MindSpot, and subsidised a marked increase in the use of antidepressants without any improvement in community psychological distress or suicide rates,3National Mental Health CommissionContributing lives, thriving communities—report of the national review of mental health programmes and services.https://www.mentalhealthcommission.gov.au/Monitoring-and-Reporting/national-reports/2014-Contributing-Lives-ReviewDate: Dec 1, 2014Date accessed: September 30, 2020Google Scholar with similar findings in the UK.4Bastiampillai TJ Allison S Harford P Perry SW Wong M-L Has the UK Improving Access to Psychological Therapies programme and rising antidepressant use had a public health impact?.Lancet Psychiatry. 2019; 6: e8-e9Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar Men, who are 3 times more at risk of suicide than women in Australia across all age groups (age >15 years),5Australian Institute of Health and WelfareSuicide and intentional self-harm.https://www.aihw.gov.au/reports/australias-health/suicide-and-intentional-self-harmDate: Jul 23, 2020Date accessed: September 29, 2020Google Scholar consistently represented less than 30% of users of MindSpot. The Australian NewAccess demonstration project, based on the UK's Improving Access to Psychological Therapies (IAPT) service,6Clark DM Layard R Smithies R Richards DA Suckling R Wright B Improving access to psychological therapy: initial evaluation of two UK demonstration sites.Behav Res Ther. 2009; 47: 910-920Crossref PubMed Scopus (384) Google Scholar applied social media and advertising strategies to achieve an enrolment rate in men of 40%.7Baigent M Smith D Battersby M Lawn S Redpath P McCoy A The Australian version of IAPT: clinical outcomes of the multi-site cohort study of NewAccess.J Ment Health. 2020; (published online May 12.)https://doi.org/10.1080/09638237(2020)1760224Crossref PubMed Scopus (5) Google Scholar Where does MindSpot sit in relation to similar services internationally? No agreed benchmarks, internationally nor in Australia, are available to compare outcomes of therapist-assisted digital services. In the UK, from 2009, use of so-called low-intensity, phone-delivered cognitive behavioural therapy (CBT) IAPT services for the treatment of anxiety and depression6Clark DM Layard R Smithies R Richards DA Suckling R Wright B Improving access to psychological therapy: initial evaluation of two UK demonstration sites.Behav Res Ther. 2009; 47: 910-920Crossref PubMed Scopus (384) Google Scholar led to a national roll out of IAPT, which is now accessed by more than 1 million people per year. Research shows that use of online CBT modules has equivalent outcomes to face-to-face interventions.8Carlbring P Andersson G Cuijpers P Riper H Hedman-Lagerlöf E Internet-based vs face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis.Cogn Behav Ther. 2018; 47: 1-18Crossref PubMed Scopus (332) Google Scholar MindSpot is such an example with an emphasis on the digital entry point. In comparison, IAPT and the Australian equivalent NewAccess, which has been expanded nationally, has telephone-based contact as an entry point and a phone contact at each therapy session, with use of online workbooks. MindSpot therapists are psychologists and other mental health professionals. IAPT in the UK and NewAccess in Australia have seen the training and deployment of a new, qualified workforce who provide safe, evidence-informed care. NewAccess low-intensity coaches are often community members who receive 12 months of specific training in low-intensity CBT, social prescribing, and community signposting. Low-intensity coaches or, in the UK, psychological wellbeing practitioners, produce equivalent outcomes to masters-level clinical psychologists when supported and supervised in a structured IAPT system of care.6Clark DM Layard R Smithies R Richards DA Suckling R Wright B Improving access to psychological therapy: initial evaluation of two UK demonstration sites.Behav Res Ther. 2009; 47: 910-920Crossref PubMed Scopus (384) Google Scholar Such outcomes rely on the option to step up participants to high-intensity services provided by clinical psychologists or psychiatrists. MindSpot could consider employing such a workforce, as could others in rural and remote mental health services, to provide tailored psychological treatments. Australian psychological therapy services are funded without the requirement for measured clinical outcomes. A strength of MindSpot is the collection of outcome data routinely at each session and the publication of service outcomes. For benchmarking, we would recommend use of the service and outcome measures of Clark and colleagues,9Clark DM Canvin L Green J Layard R Pilling S Janecka M Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data.Lancet. 2018; 391: 679-686Summary Full Text Full Text PDF PubMed Scopus (103) Google Scholar such as reliable improvement and reliable recovery as measured by the Generalized Anxiety Disorder 7-item and Patient Health Questionnaire-9 scales. Reliable recovery was 59% in MindSpot over 7 years, 51% in the national UK IAPT over 10 years,10Clark DM IAPT at 10: achievements and challenges.https://www.england.nhs.uk/blog/iapt-at-10-achievements-and-challenges/Date: Feb 13, 2019Date accessed: September 29, 2020Google Scholar and 68% in NewAccess over 3 years.7Baigent M Smith D Battersby M Lawn S Redpath P McCoy A The Australian version of IAPT: clinical outcomes of the multi-site cohort study of NewAccess.J Ment Health. 2020; (published online May 12.)https://doi.org/10.1080/09638237(2020)1760224Crossref PubMed Scopus (5) Google Scholar These differences in recovery rates might reflect variations in fidelity and scale. The UK IAPT services have a broad and large reach, with variable fidelity to the model of care and variable supervision. Higher recovery rates would be expected from a single service like MindSpot with an ability to monitor therapist competency and fidelity. For NewAccess, in the demonstration project at three sites,7Baigent M Smith D Battersby M Lawn S Redpath P McCoy A The Australian version of IAPT: clinical outcomes of the multi-site cohort study of NewAccess.J Ment Health. 2020; (published online May 12.)https://doi.org/10.1080/09638237(2020)1760224Crossref PubMed Scopus (5) Google Scholar a key focus was on fidelity to the model of care via training and online supervision of coaches, provided remotely by a team of experienced CBT practitioners from one site. However, given these studies used different samples and study designs, they cannot be directly compared. We also recommend the addition of attempted and completed suicide data within a defined period of contact, given most countries have or are developing suicide registries. Common datasets will allow comparison between services and ultimately create an international exchange system of mental health outcome statistics to ask significant research questions and share cost-effectiveness data. The Article also exposes the need for an international taxonomy of service descriptors that go beyond stepped care. MindSpot is described as a digital mental health service, but includes phone counselling, and provides a range of services including education, assessment, and, for treatment, transdiagnostic wellbeing and some condition-specific courses. These broad descriptions might cause confusion for the public and health professionals as to what information and therapy options are available. Clarification is needed on what hybrid, low-intensity, or digital services are called, what their purpose is, their population target group, and where they fit into the wide variety of self-care, stepped care, and mainstream mental health services, and other public and private non-governmental and educational services. Finally, Australia needs to redevelop its health delivery framework, and take on a wider vision of integrated mental health services, rather than a select assortment of offerings. An advantage of the UK establishing stepped mental health interventions was its integration of low-intensity and high-intensity services from the outset. In Australia, digital and low-intensity stepped-care services have evolved gradually and are now struggling for a place in the therapeutic landscape of private and public services. MFB was the Clinical Advisor then a Board Director at Beyond Blue between 2011 to 2020 and in this role received an honorarium. The Beyond Blue Board oversaw the commissioning, implementation, and evaluation of the NewAccess demonstration project in Australia. MWB in his role at Flinders University received a grant by competitive tender from Beyond Blue, to provide training and supervision for the low-intensity coaches in the NewAccess demonstration project. Since the NewAccess demonstration project, PR has received grants from Primary Health Networks (Australian Department of Health) in her role at Flinders University to provide training and supervision of low-intensity coaches at newly commissioned NewAccess services and led the training, development, and evaluation of low-intensity cognitive behavioural therapy programmes including MindStep, and other step two and three services throughout Australia. User characteristics and outcomes from a national digital mental health service: an observational study of registrants of the Australian MindSpot ClinicOur findings indicate improvement in psychological symptoms and positive reception among patients receiving online mental health treatment. These results support the addition of digital services such as MindSpot as a component in contemporary national mental health systems. Full-Text PDF Open Access

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