A new model of mental health care services in Australia is providing no cost, exclusively virtual assessments and treatments. The outcomes are promising—some 30,000 people have signed up, and most participants report a reduction in symptoms of anxiety and/or depression. Can this online model of care improve access to the many millions of people worldwide with mental health conditions who are not currently receiving care?
The MindSpot Clinic: Free Online Mental Health Treatment
In late 2012, our team launched an innovative online model of mental health care for people with anxiety and depression called the MindSpot Clinic. The service provides entirely virtual assessments and treatment for adults across Australia, with the aim of improving access to evidence-based care. Similar to the situation in many other countries, Australia recognizes that fewer than half of those with clinical levels of anxiety and depression access traditional mental health services. Consequently, many Australians are burdened with symptoms that should be, but are not, treated.
The reasons for this burden-service gap are complex, but include the financial costs of treatment, the limited number of health professionals outside of cities, and barriers related to stigma and shame. By providing a service model that is online and free to consumers, that is, publicly funded, and by using online treatments carefully evaluated in a large number of clinical trials, the MindSpot Clinic attempts to improve access to high quality care. Our guiding principle has been to build a clinical service that we would refer our own family and friends to.
Our learning curve has been steep. We would like to share these learning experiences to help consumers, therapists, and funders of mental health services avoid some of the challenges we experienced. We hope that this information will assist in further developing high quality and affordable mental health care worldwide.
The Demand for Online Mental Health Care is Massive
Our first lesson learned was that the potential demand for online mental health care is massive. Despite minimal advertising, in the first two years of launching our service, www.mindspot.org.au, more than 30,000 people have registered to use the clinic. People found us directly, using Internet search engines, and by clicking on our online ads.
In addition, a growing number of participants have been referred by family, friends, and healthcare professionals. We initially handled 50 new participants per week. But this number has increased steadily, and more than 1,600 new people are now using our service each month. We expect this growth to continue as more people learn about MindSpot.
Online Participants Have Anxiety and Depression, but No History of Treatment
The second lesson we learned is that people using the MindSpot Clinic have non-trivial symptoms. Many have struggled with highly distressing symptoms of anxiety and depression for years, if not decades. Unfortunately, many of these individuals will not or cannot access existing mental health services. More than one-third of people using MindSpot have never spoken to a health professional; almost half will not access face-to-face care for reasons related to stigma or shame.
While a significant number of participants come from rural and remote regions of Australia, many live in cities, and some even live near traditional face-to-face services. Their symptoms and self-consciousness sabotage their attempts to reach out for help. Thus, our virtual model is increasing access to care to those who would not otherwise seek it.
Majority of Online Patients Have Positive Outcomes, Recommend Virtual Service
We have also found that our clinical outcomes are strong and robust. On average, people using MindSpot online treatments experience at least a 50% reduction in symptoms. Moreover, outcomes are similar regardless of age, location (rural versus urban), or ethnicity.
For example, we have learned that older adults using MindSpot get at least as much benefit from the clinic as younger adults – unsurprising considering the older population is now using the internet for a plethora of activities. Satisfaction with the clinic is also high, with ≥95% of participants reporting that they would refer a friend.
Some Patients Prefer Online Treatment without a Therapist or No Treatment
We have also learned an enormous amount about developing and operating an online national mental health service. The experience of delivering online treatment fundamentally challenges many of the core assumptions about psychological treatment held by therapists. We are proud to employ a highly motivated and talented group of therapists, all of whom are experienced in delivering high-intensity face-to-face treatments.
They have all been surprised to learn that approximately one-third of the people who access our online treatments do not want to speak to a therapist, but instead prefer to use the treatment materials and only contact the therapist if and when they need to. Our therapists have also been surprised to learn that our participants who use treatment materials without speaking to a therapist obtain excellent clinical outcomes.
These findings challenge therapists’ expectations and beliefs about the role of the therapist. We believe these challenges are healthy, and are helping us to develop and deliver models of healthcare that empower consumers to play a greater and more active role in their own recovery. Fundamentally, we also believe that the more our consumers can do during treatment, the better their long-term outcomes will be.
Further, we have learned that not everyone wants to receive treatment. In fact, about half of those using our service report the main reason they registered was to obtain a screening assessment to help them better understand their symptoms and learn about treatment options. This finding speaks to the potential role of online services to help people to learn more about their health and treatment options, even if some of the participants don’t necessarily seek care.
Virtual Model Allows Therapists to Measures Outcomes
The MindSpot model of practice has also increased visibility about the quality of care provided by each individual therapist. While many therapists talk about providing evidence-based care, the reality is that few regularly administer outcome measures that monitor change during therapy, and even fewer use such measures to improve their practice.
At MindSpot, participants complete validated clinical questionnaires weekly, measuring symptoms and the severity of their anxiety and depression, and answer questions about safety and satisfaction with therapy. This information not only helps therapists monitor trajectory and progress, but it also alerts our team to a person who is struggling and needs support, thus mobilizing resources before a crisis occurs.
Also, our therapists can benchmark their clinical outcomes with the overall benchmarks and targets of the clinic, which motivates therapists to strive for improvements. Combined with systems for assessing core clinical competencies, this feature provides our therapists with rich opportunities for professional training and development.
The Start-Up Phase of the Virtual Care Model
The experience of developing and delivering an online mental health service has been humbling. Prior to launching the MindSpot Clinic, the authors had worked as clinical psychologists for many years and had conducted a large number of clinical trials of online treatments. Regardless, the magnitude of MindSpot has become a world apart from our previous experiences.
We were lucky to attract and assemble a clinical team with high levels of passion and commitment, but it quickly became obvious that these characteristics were not sufficient to sustainably develop and operate a safe, effective, and high-volume online clinical service. Our preliminary plans about how to best deploy and manage the IT infrastructure and systems, including systems of security, back-up, recovery, and redundancy revealed the need for specific skill sets and resources that we had not previously required.
We have had to overcome additional challenges that occurred simultaneously. For example, during most of the first 24 months that our service was available, we were enormously busy recruiting, inducting, training, and supervising an ever growing team of therapists. At the same time, we were developing our clinical procedures and systems for assessing and managing safety and risk of our participants. In addition, we were also learning how to promote our service, fully aware that too much demand for our service could compromise our ability to safely manage and support the inevitably large numbers of people desperate for care.
These challenges offered multiple opportunities for team building, but also put enormous pressure on the team, who were providing services to an ever increasing number of patients. At the same time, we were inundated with messages of gratitude from those using our clinic, many of whom had never before contacted a health professional about their symptoms. This positive feedback helped sustain our enthusiasm and motivation, even through the most challenging of times.
What’s Next for Our Internet Model of Mental Health Care
We are pleased to report that the start-up phase of the MindSpot Clinic is over, and we are now focused on improving what we do and how we do it. We have developed an online treatment for indigenous Australians, and are translating some of our treatment materials into other languages. Our other foci include engaging more with other service providers as we strive to develop a model of virtual clinic that works with, rather than independently of, existing service providers in other medical specialities.
Our experience of operating the MindSpot Clinic has been enormously positive. But, we do not believe that online treatments are a panacea (they aren’t). Nor do we imply that online treatments should replace existing traditional services (they shouldn’t). As our virtual service grows, the field of mental health care is likely to face numerous and significant challenges, including how we ensure that mental health services remain accountable to the people we serve. Notwithstanding, we remain excited about the potential of the MindSpot Clinic to improve the quality of life for the many millions around the globe affected by anxiety and depression.
Blake Dear, Ph.D., is a National Health and Medical Research Council (NHMRC) Australian Public Health Fellow and Clinical Psychologist. He is also a Director of the eCentreClinic and on the senior management team of the MindSpot Clinic.
The MindSpot Clinic is a free and national online and telephone delivered assessment and treatment service for Australian’s with anxiety and depression, which is funded by the Federal Government. The eCentreClinic is a not-for-profit research unit that develops and evaluates innovative psychological treatment programs, which aim to improve access, for both clinicians and consumers, to evidence-based care.
Dr. Dear’s research is pragmatic and has the goal of creating clinically optimally effective, safe, efficient and convenient treatment programs that are highly acceptable. He has a special interest in transdiagnostic approaches to psychological treatment as well as the internet-delivery of self-management programs for common chronic physical conditions, such chronic pain.
Nick Titov Ph.D., is a Professor of Psychology at Macquarie University, Clinical Psychologist, Co-Director of the eCentreClinic and Project Director of the MindSpot Clinic He is a graduate of the University of Otago, New Zealand, Clinical Psychology programme.
Professor Titov leads a team who have developed and operate a national online and telephone delivered assessment and treatment service for Australian adults with anxiety and depression. This clinic provided services to more than 35,000 adults in the first 30 months of operations. Professor Titov is also Co-Director of an online research clinic, which develops and evaluates innovative psychological treatment programs for a range of everyday mental health problems and chronic health conditions.
Professor Titov is committed to developing innovative and effective psychological interventions and delivery mechanisms that are safe, clinically effective, acceptable to consumers, and increase access to high quality care. He has publications in multiple journals including the Lancet, General Hospital Psychiatry, PLoS ONE, and Psychiatric Services. Professor Titov serves on the New South Wales Board of the Psychology Board of Australia, and on the Mental Health Expert Reference Group for the Australian Government Department of Health (2015).
