Globally, mood and anxiety disorders affect more than 700 million people each year and are associated with considerable burden and disability [1
]. However, in a 12-month period, fewer than half of those affected seek or receive evidence-based treatments [3
] for reasons that include cost, limited availability of services in many areas, limited awareness of both illness and the potential benefit of treatment, stigma and preference to self-manage [6
Delivering psychological services via the internet is one way of increasing access to care. A large number of randomised controlled trials have demonstrated that internet-delivered cognitive behavioural therapy (ICBT) is effective at treating anxiety and depression [7
]. However, attempts to extend ICBT to routine care have produced mixed results. Several attempts at implementation have either been unsuccessful [11
] or were not found to have added value to existing face to face services [12
], which has raised doubt as to whether internet-delivered psychological services can be implemented successfully in typical health care settings [13
]. Notwithstanding the challenges, the successful use of ICBT as part of routine clinical care has been reported in Sweden [14
], the Netherlands [18
], Norway, Denmark [20
], Canada [22
], and Australia [26
]. In addition to reports of outcomes from individual clinics, and reflecting the maturing state of the field, there is now an increasing number of studies describing barriers [20
], guidelines for implementation [33
], and comparisons of clinics across different countries [35
]. The successful clinics typically deliver ICBT interventions via so-called virtual or digital mental health services (DMHS). Common features of the successful clinics include high standards of both clinical and organisational governance, and robust systems for staff training and supervision [35
This paper describes key lessons learned during our own efforts to develop and deliver DMHS. The MindSpot Clinic, Australia, and the Online Therapy Unit (OTU) in the province of Saskatchewan, Canada accept referrals directly from consumers as well as via general practitioners. Together, these DMHS have provided assessments to more than 100,000 people and treatment to more than 30,000 people. The authors have worked closely together for several years and have served on advisory bodies to each other’s services. The lessons we describe draw on our shared experiences in service development, delivery and collaboration.
We narrowed down our experience to ten key lessons that were not fully described in other papers. These lessons were not immediately apparent to us when we set about translating our research findings to routine care but have been of fundamental importance in how we developed and now operate our DMHS. Hence, we anticipate that these lessons may help those launching similar clinics.
We intentionally avoided specific frameworks of reporting [36
], because an aim of this paper was to describe the experiences of operating mature services, rather than just the implementation phase. We also acknowledge that some of these lessons overlap, may not apply in other jurisdictions or even to other DMHS within our own countries.
We chose to organise our lessons according to the model shown in Table 1
, which represents the lessons learned from working with (1) consumers, (2) therapists, (3) operating DMHS, and (4) when operating in the broader health systems, including when engaging with funders and policy makers.
Before further describing the lessons learned, key aspects of the MindSpot Clinic and OTU are summarised below.
2.1. The MindSpot Clinic, Sydney, Australia
MindSpot was launched in 2013 and operates from Macquarie University, Sydney. MindSpot is funded by the Australian Government Department of Health, with funding initially provided for a 3-year period as a result of the competitive tender process. MindSpot aims to improve access to evidence-based education, triage, assessment, referral, and treatment services throughout Australia to adults with symptoms of depression and anxiety [28
]. Clinic services are provided free of charge.
Patients can either self-refer after learning about MindSpot via the website (mindspot.org.au), online advertising, links from other mental health websites, recommendations by previous users or can take up referrals from health professionals. Patients first register online or via telephone and complete a detailed assessment questionnaire followed by telephone or secure email contact with a therapist to discuss symptoms and treatment options. Patients then choose between information to assist with self-management, referral to another service or ICBT. The clinic offers seven ICBT programs that have been validated in clinical trials, including transdiagnostic treatments designed to treat symptoms of anxiety and depression in several age groups [24
] and disorder-specific treatments for obsessive compulsive disorder [48
], post-traumatic stress disorder [50
], and chronic pain [51
]. All the treatment programs comprise of five lessons which provide the core information, delivered over eight-weeks. Additional resources targeting specific symptoms or difficulties are made available during treatment to assist patients tailor treatment to their own needs. Outcomes are measured using validated symptom scales that are administered weekly during treatment, on completion, and at a three-month follow-up. The therapists are all registered or provisionally registered mental health professionals who contact and monitor participants weekly during treatment via a secure email system or by telephone. The treatment patients are enrolled in cohorts every two weeks, with therapists each responsible for 50 or so patients. To date, more than 100,000 people have registered to use the clinic, and 25,000 have opted to receive ICBT.
2.2. Online Therapy Unit, Canada
The OTU has operated from the University of Regina in Saskatchewan since October 2010. Initial funding was provided by a federal research grant, but since 2015, the OTU has received stable funding from the Saskatchewan Ministry of Health. The OTU aims to provide therapist-guided ICBT for depression and anxiety and to educate providers of mental health care and conduct research on ICBT in routine practice [25
]. Clinic services are also provided to patients free of charge.
The OTU promotes services to patients via word of mouth primarily from health care providers, media reports, and both digital and print communication. Patients are encouraged to visit the clinic online (onlinetherapyuser.ca) and can either self-refer or are referred by a health professional. Patients first complete an online screening followed by telephone assessment.
The OTU delivers several ICBT programs including an adaptation of the Wellbeing course developed at Macquarie University and used at the MindSpot Clinic [44
]. Clinically validated patient reported outcome measures (PROMS) of anxiety and depression are administered regularly during treatment, at post-treatment, and at three-month follow-up. Therapists are registered mental health professionals or graduate students under supervision employed by the clinic or by publicly funded community clinics located in other parts of Saskatchewan. During treatment, patients receive weekly therapist contact primarily via secure email or by telephone to assist in applying the skills taught during treatment. Since October 2010, the clinic had assessed more than 5400 patients, 4200 of whom have received ICBT [23
4. General Discussion
This paper aimed to assist other emerging DMHS by sharing ten lessons we learned from successfully delivering DMHS to very large numbers of consumers. Some of these lessons might seem obvious, but their importance was not always apparent when we started our services. Several key themes are discussed below, followed by recommendations.
One theme is that we expect that demand for this service model will grow. The number of patients treated using ICBT in the OTU has more than doubled in the past four years. The threshold for accessing this model of care is significantly lower than traditional face-to-face services and consumers are becoming increasingly comfortable with using technology to access a broad range of services, including health services. Along with a growth in numbers, we expect that existing DMHS will become more tailored to different populations, for example, people in certain occupations, different cultures, or who have been referred from different pathways, although our experience is that the extent to which the treatment course materials need to be customised is considerably less than expected [56
A second theme is that the workforce requires specialised training, clinical supervision and support. This raises broader issues about workforce planning and training programs. We note that many professional bodies have recognised the importance of education and training of mental health professionals and standards in this model of care [79
] but that few training programs in any mental health discipline offer courses or training opportunities specifically for digital mental health. The absence of such training opportunities poses significant risks for the future sustainability and quality of the field.
A third theme is that the delivery of DMHS requires specialist skills in both clinical and operational domains. We also note that although the costs to entry of developing a DMHS, especially a low volume service, might be relatively low, the costs of maintaining quality services can be high. Inadequate funding and inadequate organisational governance can affect the reputation, credibility, and therefore, the potential of the emerging field of DMHS [83
]. Hence, we strongly encourage anyone seeking to launch a DMHS to carefully consider the governance frameworks that will ensure the safe and sustainable delivery of services, or to consider licensing their interventions to groups who have proven success in implementing similar services.
Another theme is that the field of DMHS is rapidly evolving. We encourage those seeking to start a DMHS to consider trialing different models of care to those currently used by existing DMHS, including testing different levels of therapist support [24
] and testing care which combines both face-to-face and online delivery. We note the important work conducted by our European colleagues on blended care [70
] and by others on mobile services [13
] and encourage collaboration in order to collectively develop the most effective models of care.
Our final theme relates to recognising the true value proposition of DMHS. We maintain that they are not a panacea but instead serve several valuable functions, including as a useful complement to existing services, as a way of improving equity of access to mental health care for common psychological disorders, and as a stepping stone to other services. Over-promising may increase the likelihood of short-term funding, but poorly designed and delivered services might harm consumers, disappoint stakeholders and risk the future of DMHS.
These observations lead to several recommendations which we encourage those contemplating developing DMHS to consider. First, we recommend that new DMHS recruit not only appropriately skilled therapists, but also people with commercial and professional skills, ideally with experience in digital service delivery. Second, given the unique challenges of DMHS, we recommend the development of both thorough initial training of therapists, as well as of systems for ongoing training and supervision. Third, given the likelihood that demand for DMHS will grow, we strongly encourage that organisations involved in training and certification of mental health professionals add content and training opportunities relevant to the competencies required in DMHS.
Fourth, we recommend that emerging DMHS measure and publish their outcomes, including disappointing and negative effects outcomes [84
]. We also encourage DMHS to engage with policy makers and funders to develop mental health policy grounded in evidence rather than in opinion. Finally, we strongly encourage DMHS to engage with their consumers in appropriate co-design and evaluation activities to ensure services are not only effective but acceptable to consumers.
4.2. Strengths and Limitations
We believe that the main strength of this paper stems from the authors’ shared experience in launching and steadily improving successful high volume DMHS. However, we acknowledge several weaknesses, including that the list of lessons is non-exhaustive and did not include some of the significant challenges associated with managing funding insecurity or bureaucratic and professional challenges within the field of mental health, topics we will return to in a subsequent publication. We also acknowledge that our experiences may not reflect those of other DMHS.
This paper described ten key lessons learned by the authors when developing, delivering, and evaluating DMHS. Despite the challenges, provided they are delivered safely, effectively and with strong clinical, operational and organisational governance, we remain highly optimistic about the potential of DMHS to reduce the global burden of the high prevalence of mental disorders.