By Ciaran Pier Assoc MAPS, Britt Klein, David Austin, Joanna Mitchell, Litza Kiropoulos and Paul Ryan, Department of General Practice, Monash University
The New Year provides us with an ideal opportunity to reflect on how far we have come and what we would like to achieve in the future. For many in the psychology community 2005 was marred with the sad loss of our colleague, mentor and friend, Professor Jeff Richards. Amongst Jeff's many achievements was his pioneering role in the development of internet-delivered psychological interventions. This paper is inspired by the work of Jeff and his contemporaries and is intended to review progress, discuss the major clinical and research issues related to internet-based psychological interventions and explore some of the challenges that lie ahead.
The increasing use of the internet to deliver assessments and mental health interventions has created new opportunities and additional challenges to psychological practice. The unique clinical issues associated with internet therapy have only begun to be explored experimentally. Self-help and therapist-assisted programs have been delivered via a range of mediums, including desktop and palm-top computers, interactive voice response systems and helmets which generate a virtual environment. Some of the clinical disorders that have been treated via online therapy include panic disorder (e.g., Richards, Klein, & Austin in press,), phobias (e.g., Kenwright, Liness, & Marks, 2001), obsessive-compulsive disorder (Clark, Kirkby, Daniels, & Marks, 1998), post-traumatic stress symptoms (Lange, van de Ven & Shrieken, 2003) and depression (e.g., Christensen, Griffiths & Jorm, 2004).
These programs delivered via the internet (or other computerised applications) have involved the adaptation of evidence-based psychological interventions (e.g., cognitive behavioural therapy) and involve varying degrees of therapist contact. Some are pure self-help programs; others are predominantly self-help with therapist involvement restricted to diagnostic assessments and instruction in the use of the program. Some programs involve minimal contact therapy with communication occurring via email, whilst others are predominantly therapist administered interventions with regular email 'sessions' plus self-help materials.
These internet-delivered mental health interventions have, on occasion, been met with passionate resistance and indeed, all in the scientific community would encourage a healthy skepticism of any new mode or form of therapy. As with any novel development however, internet-delivered interventions must be subjected to rigorous experimental testing to establish efficacy. Recent reviews of controlled trials of internet-based interventions indicate that, despite some methodological limitations, most are equally effective or more effective than other forms of therapy for alleviating high prevalence psychological disorders (e.g., Griffiths & Christensen, in press).
Advantages of internet therapy
So, what are the perceived advantages of internet-based mental health interventions over other forms of mental health care delivery? One of the most significant advantages is the potential to provide far greater access to treatment than would otherwise be obtainable, thereby enabling greater numbers of people to receive mental health services. Recent Australian data (e.g., Andrews, Hall, Teeson, & Henderson, 1999) suggest that less than one third of people with an affective or anxiety disorder seek professional assistance and that only 10 per cent of these people consult a psychologist or psychiatrist for specialised mental health assistance. People outside of the major urban centres are particularly disadvantaged by having restricted access to specialist mental health services. By delivering therapy via the internet, greater access can be provided to those who are disadvantaged due to geographical isolation, physical impairment or other mobility, time and/or financial restrictions.
Another key advantage of internet-based interventions for common mental health problems is that they appear to be cost effective; with costs reduced to between one third and one sixth of other psychological treatments (e.g., Crone, et al., 2004). A recent analysis of the potential cost-effectiveness of the Monash University Panic Online program, a CBT-based treatment for panic disorder, revealed promising results. For example, the average health benefit associated with Panic Online compared favourably with usual care delivered by a general practitioner (Mihalopoulos, Kiropoulos, Shih, Gunn, Blashki & Meadows, 2005).
Clinical and research issues
While there are many other advantages to internet therapy, questions have been raised about the impact on clinical processes relative to face-to-face therapy. Contrary to popular belief, the research indicates that internet therapy can enhance some clinical processes. For example, internet interventions involving email correspondence between therapist and client provide both parties with a permanent record of the therapy. This can facilitate evaluation of the client's progress over time. Clients are able to re-visit the techniques previously used or guidelines on how to approach 'homework', set goals, etc.
There is also substantial evidence that the act of writing one's thoughts and emotions is itself therapeutic (Pennebaker, 2005) and that many clients are more candid in their responding via email or online than when speaking face-to-face (Fiegelson & Dwight, 2000). Furthermore, email therapy allows people to interact at their own convenience without the need for appointment times. Research continues into the impact of the internet on therapeutic process and whether certain people in the population are more suited to internet therapy than others.
Suitability / drop out rates
Despite these advantages however, high participant drop out rates are not uncommon in internet-based interventions. Drop out rates of over 30 per cent have been reported (e.g., Andersson, et al., 2002). However with the accumulation of research in this field, and therefore greater understanding and more sophisticated programs, recent research suggests that drop out rates are declining. Recent reports of controlled trials of internet-based interventions reveal drop out rates of well under 20 per cent (Klein et al., in press).
Our research group has conducted preliminary investigations to identify the factors affecting attrition. We have reviewed the data from two of our internet-based programs, Panic Online and Pace Heart Lifeskills (an intervention for reducing psychological risk factors for cardiovascular disease). Our findings suggest that certain factors, such as high stress levels, are related to attrition; and drop out rates appear to be lowest when responsive and relatively prompt therapist assistance is provided (Richards, Klein, & Carlbring, 2003). Receptive contact with a therapist therefore appears to be particularly significant.
Clearly it is important that research efforts seek to reliably identify predictors of suitability, compliance and completion of, internet-based therapy. By doing so, treatment providers will be able to identify which type of therapeutic delivery is likely to be most efficacious for each individual (e.g., internet-based and/or face to face), thereby maximising treatment outcome and cost effectiveness.
Treatment credibility and satisfaction
Other factors involved in participant compliance with internet-based interventions may include users' perceptions of the treatment's credibility and their satisfaction with the treatment. Establishing treatment credibility is an important aspect of therapy, particularly in the initial stages. Although treatment credibility of internet-based treatments has already been established in several studies (e.g., Klein et al., in press), more research is needed to identify why participants may or may not view internet-based treatments as credible and how this relates to their treatment outcome.
Participant engagement may also be influenced by how satisfied they feel about the treatment program. Although it is likely that treatment factors such as timely therapist contact influences treatment satisfaction, other factors will also play a role. A thorough investigation is required to identify the factors involved in internet therapy that establish treatment credibility and satisfaction. It may be that internet interventions can be made more engaging via multi-media applications, the use of graphics and greater participant interaction (Ritterband, et al., 2003).
Apart from compliance and suitability/drop out issues, another clinical issue for internet-based therapy is that of clinical assessment procedures. Assessment procedures have varied considerably in internet-based research studies. Some researchers have used face-to-face or telephone-based clinical assessments, while others used online-automated clinical assessments. There is also variation in the use of psychometric questionnaires (e.g., paper and pencil vs. online administrations).
The need for thorough diagnostic assessment is essential to make sure that people receive adequate and appropriate treatment. Without thorough assessment there is a risk that people will receive treatment for something other than their main presenting problem and that co-morbid conditions will interfere with treatment (Richards et al., 2003). In addition, diagnostic assessments are important due to the risk of suicide and other psychological crises. When face-to-face therapy is delivered, the therapist is better equipped to assess and manage crises, whereas people engaged in internet therapy are physically remote from the therapist. It is important, therefore, that users provide details of their primary care physician to be contacted if psychological crises occur (Richards et al., 2003).
Internet mental health interventions in primary care: Increasing access
A particular advantage of internet-based mental health treatments is that they lend themselves to a shared-care model of treatment delivery by involving general practitioners (GPs) and/or other allied health care providers. The Better Outcomes in Mental Health Care (BOiMHC) initiative now provides greater support to GPs to deliver psychological strategies. Internet-based CBT self-help programs or those with minimal therapist contact may provide an appropriate adjunct to routine GP care without substantially increasing consultation times, providing GPs are adequately trained.
Research into the efficacy of internet-based mental health interventions in primary care is accumulating. Our own research group is currently completing a controlled trial of the efficacy of Panic Online with GPs (who are trained to deliver focussed psychological strategies) providing the face-to-face component. Participants work through Panic Online with support from his/her GP (during regular consultations) and outcomes are compared to those who receive Panic Online plus email therapy with a psychologist over 12 weeks. Preliminary results indicate that both forms of delivery of Panic Online successfully alleviate panic and agoraphobic symptoms, with neither mode of delivery showing a clear advantage.
Given the large numbers of people with mental illnesses attending general practices, computerised mental health interventions in these settings could provide a large proportion of the population with access to psychological treatments. These interventions could become an important part of primary care mental heath services, providing a useful first step toward psychological care for some patients and a full treatment program for others. The availability of effective, affordable, computerised mental health interventions also has the potential to reduce costs and waiting lists, and increase mental health literacy.
The future of internet therapy
Demand for computerised and internet-based treatment has and will continue to increase over time. This demand raises important policy, implementation, and research issues. Dissemination of information on internet interventions is necessary to improve awareness of clinicians, consumers and policymakers. Clearly the development and integration of an internet mental health policy into the Australian health care system is needed to ensure that this treatment option is made widely available, without compromising quality of care (Christensen, Griffiths, & Evans, 2003). This challenge is largely a political and resource issue.
To facilitate the integration of internet-based mental health care, greater infrastructure and targeted research funding is required. Although it is clear that this is now being recognised by major research funding bodies such as beyondblue, there remains a need to increase the capacity of researchers to conduct computerised mental health interventions and assessments to ensure that evidence-based, effective treatments are available to address mental health needs.
Considerable evidence has accumulated to show that we have, and can, develop effective internet-based mental health treatments (e.g., Kaltehthaler, Parry, & Beverley, 2004). As suggested by Ritterband and colleagues (2003), it is not essential that internet-based treatments are more effective than face-to-face therapy, but that they provide comparable benefits and outcomes. The intention should not be to replace face-to-face CBT, which we know is one criterion for best-practice treatment. Rather, the aim should be to provide an alternative or adjunct to already well-established interventions administered by mental health professionals. The research to date demonstrates that internet treatments are economically viable and able to help reduce the significant burden of disease caused by mental health problems. There should be no delay in making effective internet interventions widely available to the Australian community.
The authors would like to thank the following funding bodies who make our research into e-mental health possible. beyondblue, Victorian Centre of Excellence in Depression and Related Disorders, Rotary Mental Health Research Fund, National Health and Medical Research Council, Australian Research Council and industry partner British Petroleum. The authors would also like to acknowledge the late Professor Jeffrey Richards, founder of several research projects discussed in this article.
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