“E-mental health applications are proliferating and hold [the] promise to expand access to care,” concluded Shalini Lal, Ph.D., and Carol Adair, Ph.D., in a study of this technological tool published in the January Psychiatric Services. They evaluated 115 studies published from 2005 to 2010 that focused on e-mental health services, over three-quarters of which originated in the United States, Australia, or the Netherlands. They noted that 94 percent of the studies related to e-mental health were peer reviewed, while 51 percent reported empirical findings. The studies were obtained from keyword searches of the MEDLINE site and the Internet.
E-mental health services, or applications, encompass more than traditional telehealth and telemedicine by incorporating more than just the phone or videoconferencing. They include the use of streamed video; web applications, like flash animation; social-networking sites; and different combinations of these technologies to deliver mental health care services. Further, these applications have grown more prevalent as webpages become more dynamic and interactive and less static.
MoodGYM, for example, is a website based in Australia that was highlighted by Lal and Adair. Its homepage boasts 600,000 registered users, and its newest program, e-couch, leaves the user with no doubt that these services are being offered with the promise of free access and anonymity for the user. These two attributes are acknowledged as being two of the largest benefits of e-mental health services overall; although Lal told Psychiatric News, “We don’t have enough cost-effectiveness research to clearly indicate the level of savings achieved or expected.”
As for whether the literature shows the extent to which these e-mental health websites are being used and if they are effective, the answer is a qualified yes. For example, one of the studies the authors reviewed that focused on respondents in Australia reported that 77 percent of them expressed a preference for face-to-face services; however, fewer than 10 percent reported that they had no interest in using e-mental health services. Lal cautioned against reading too much into this, however, because the information in the study was collected prior to the article’s 2010 publication date “and things have changed quite importantly in terms of access and use of technology” in the last several years.
Also, of the empirical studies, none focused on treatment for patients with comorbid substance use and other mental disorders, opting instead to target one disorder or treatment. The authors noted this reflects traditional treatment paradigms, even though many people experience more than one mental health issue. They go on to say “effect sizes are comparable to those observed in similar interventions delivered in person,” in terms of treating anxiety and depression disorders. There is also preliminary evidence that these new tools are effective in treating substance abuse, insomnia, and stress.
Still, psychiatrists and other mental health professionals may be reluctant to use e-mental health applications, thus limiting their usefulness or prevalence. Lal told Psychiatric News that “a clinician said to me, ‘In our organization, we don’t even use email or texting to communicate with our patients.’ ”
There are good reasons psychiatrists and mental health professionals may make that choice. Lal and Adair reported that the literature they reviewed documents privacy and security concerns. Other potential hazards cited in the review were publication bias on the part of developers and researchers, lack of quality control and care standards, and the limited evidence base for interventions.
To address some of these concerns, organizations like the International Society for Mental Health Online created frameworks that help set appropriate standards, and in Australia, the Beacon website uses expert reviews and user comments to rate e-mental health services. John Luo, M.D., told Psychiatric Newsthat in the United States, applications, like DoctorBase, and electronic medical record vendors, like Epic, are now offering secure communications between patients and providers. “While security and privacy are significant issues,” he said, “the culture is somewhat changing. The younger generation [is] not so concerned about security, as access trumps their concerns.”
One of the great promises of e-mental health is its ability to expand and deliver psychiatric as well as a wide spectrum of other medical resources to hard-to-reach groups, like adolescents or underserved communities. Lal and Adair singled out a study by Guy Diamond, Ph.D., which documented a free online self-assessment tool that targeted young people, was automatically scored, allowed for results to be integrated into an e-record, and was easy to complete as an example of this reach.
At the time of Lal and Adair’s review, 68 percent of the empirical studies were geared toward adults and 19 percent were designed for adolescents or young adults. But one study of 2,000 people aged 12 to 25 that the authors cited found that “77 percent [of respondents sought] information about mental health problems whether or not they had the problem themselves.”
Lal told Psychiatric News that young people “are already going online searching for mental health information and support. So, I do believe this is a snapshot for the future.”
She added that she did not think that e-mental health services would ever replace traditional services. Instead, they will act as an on-ramp for those seeking treatment. ■