e-Mental health is in demand – so how can GPs work best with it?

Australia’s rush to telehealth has seen soaring demand for mental health care delivered by phone or video.
 
With the flow-on effects of the pandemic affecting finances, work and relationships, many Australians are seeking help with their mental health for the first time – and that care has often been delivered remotely.
 
But this is only the tip of the iceberg for e-mental health, according to GP Dr Charlotte Middleton.
 
‘e-mental health is coming into its own,’ she told newsGP.
 
The growing field of e-mental health covers everything from online support groups, information websites, and assessment and diagnostic tools, through to blogs and podcasts, or even therapeutic gaming programs and the use of virtual reality for children with autism or panic disorders.
 
Dr Middleton, the Chief Medical Officer at Medical Director, recently facilitated a panel discussion on e-mental health with top mental health experts, including Beyond Blue clinical adviser Dr Grant Blashki, GP Dr Louise Stone, CrazySocks4Docs founder Dr Geoffrey Toogood, Black Dog Institute psychologist Dr Samineh Sanatkar, and headspace CEO Jason Threthowen.
 
Dr Blashki told the panel e-mental health has ‘huge potential’, with an explosion of different apps and websites aimed at everything from diagnosis to management and monitoring.
 
‘What’s happened with COVID is the whole community’s been shepherded into what was niche, and it’s gone mainstream because people have to be online now,’ he said.
 
‘It’s gone from this thing that your early adopters were into, to the same thing everyone’s into.’
 
But Dr Blashki cautioned the need to ensure e-mental health is evidence-based and links back to traditional mental health services.
 
‘People are going online, like it or not, for support and to try stuff out. We just want to make sure … it’s got some rigour,’ he said.
 
‘The word “integration” should not be lost because at the moment, there’s quite a bit of disconnect.’
 
Overall, the discussion showed there is a real need for work and training in the area, according to Dr Middleton.
 
‘This year, we’ve had to deliver medicine in a different way full stop. But in mental health, it’s been exponential because it’s been significantly worse of late,’ she said.
 
‘Around half of our patients have [had] some sort of mental health issue this year.
 
‘The bottom line is there’s been an explosion of mental health issues, from fires to floods to COVID – a triple whammy, with losses of jobs, concerns around infections and massive disruption to family life.’
 
Beyond Blue has seen between a 40–60% increase in demand for mental health this year compared to 2019, according to Dr Blashki, with three-quarters of the surging demand coming from Victoria.
 
He told the panel around half of their new patients accessing care through web-based chat were young people who had never previously sought support.
 
‘The bottom line is we can’t keep up with demand,’ Dr Middleton said in response. ‘We’re struggling to see everyone face-to-face, or deliver enough mental health care with the time constraints we have.
 
‘This is where there might be enormous benefits to some forms of e-mental health.’
 
In Dr Middleton’s clinical work, she will direct some patients with anxiety to websites containing exercises and information, with a follow-up consultation.
 
‘In future, we need better integration with general practice. Patients may well be using these tools anyway, so it would be great to alert GPs to that – with permission,’ she said.
 
Dr Stone told the panel that while there are benefits to e-mental health, building a therapeutic relationship is still essential.
 
‘There’s more evidence for the therapeutic relationship than there is for any individual techniques,’ she said.
 
‘So I think we are treading on dangerous ground removing a therapeutic relationship from the equation.’
 
Dr Stone told the panel that while natural disasters bring people together, pandemics drive people apart.
 
‘The hardest thing about pandemics is that people have difficulty connecting with others and that makes life incredibly challenging,’ she said.
 
‘We’ve had people who have normally managed life very well and even lived perhaps a life of generous privilege, and now that’s all turned on its head very, very quickly.
 
‘For those people, having mental health concerns is very unfamiliar, so they struggle to come into our door to talk.’
 
Dr Stone said people from lower socioeconomic backgrounds are experiencing the worst situations, and GPs need more support to provide care for these populations.
 
‘We know that the people with the highest income have five times less mental health problems and five times more services,’ she said.
 
‘We are not meeting the needs of that bottom quintile who have the most mental health services, the most mental health issues, the most risk, and by far the least access to anything.
 
‘And that’s where general practice is working, which is a terribly difficult space because we know they need caseworkers … accommodation [and] support and we can’t get it. 
 
‘That’s the part that causes the quite significant moral distress in GPs, that idea of wanting to do their best and being unable to do so because of a lack of resources available to them.’
 
Dr Stone also warned that common apps aimed at self-management or monitoring of mental health are aimed at people fluent in English and living in cities.
 
‘I do have a problem with this being the default go-to. I get a lot of referrals back from various services saying they’re unable to help my patients,’ she said. 
 
‘They do have e-mental health as though it’s this universal safety net. But just because it’s there doesn’t make it accessible. There are gates to get into e-mental health that people don’t often acknowledge. 
 
‘Particularly when you’ve got quite a significant mental illness, you’re cognitively slowed. Your reading age drops by a couple of years. I’ve been unable to find an e-mental health service that has a lower literacy than Great Expectations. So for a lot of my patients, it is inaccessible.’
 
Mr Threthowen and Dr Blashki agreed that there are many moving parts in e-mental health, making it less coherent and coordinated than desirable. 
 
The RACGP has guidelines available for use of e-mental health.
 
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