In our first article in this series, we looked at how digital technology and mental health have a strained relationship and tackled the question: when it comes to youth mental health, is digital technology good, or bad?
Now, in part two, we explain the concept of ‘Stepped Care’ and introduce the use of digital technologies for the delivery of mental health services (also known as ‘e-mental health’).
Understanding the concept of stepped care.
When considering the best approach to mental health, there is widespread agreement among health, public health and social care bodies, that prevention and early intervention should be prioritised – through a ‘Stepped Care’ model.
In its simplest terms, Mental Health Stepped Care focuses on linking a person with the right level of support. Stepped Care is a recognised system of assessing, delivering and monitoring mental health treatments. Country specific models of stepped care vary, but the general concept remains the same. As the name suggests, patients receive treatment in different ‘steps’. The intensity and amount and type of treatment is designed to be appropriate to the patient.
Here we use the Australian model for stepped care as an example:
- Well population – focuses on prevention and promotion through public information and self-help resources.
- At risk groups – focuses on early identification and digital mental health services.
- Mild mental illness – low intensity services through a mixture of digital and face-to-face interactions.
- Moderate mental illness – mainly face-to-face primary care through more intensive clinical services.
- Severe mental illness – highly specialised services with wrap-around care for people with complex needs.
Offering a more person-centred approach, stepped care avoids a ‘one size fits all’ response and recognises the importance of the correct treatment level – avoiding under-treating or over-treating patients. Ultimately, if done effectively, stepped care is about having the right service, in the right place, at the right time, delivered by the right person.
Where does the stepped care approach to mental health encounter issues?
In theory, the stepped care model means more people can be treated. GPs and other medical specialists can spend the appropriate amount of time on each patient, meaning that when resources are limited, there’s a better chance of reaching everyone in need.
However, a recent survey by Young Minds reports that a lack of early support puts pressure on GPs.
This is described by Young Minds Activist, Ben.
“It was difficult to get support when I first looked for it and my anxiety got a lot worse.” says Ben “While I did eventually get support from CAMHS, it was inconsistent, so I turned to my GP because I had no other outlet for my worries. My GP would see me once a week and helped me get back to school. Staff at school were helpful too, but because they’re stretched it became harder to access support after a while. I know that if I had more consistent and ongoing support from early on, it would have helped me a lot.”
In fact, a lack of skilled provision between self help and professional care is a problem throughout the world. Research shows that mental health trusts are experiencing considerable workforce pressures – meaning they don’t even have time and resource to deal with the most severe cases. This is backed by analysis by the Education Policy Institute identifying workforce shortages as a major barrier to transforming children and young people’s mental health.
The rise in demand for mental health services has seen some governments start to act.
The Australian Government recently announced a number of youth mental health-related initiatives as part of the 2019 Federal Budget. This includes $373 million for additional services through headspace — formally the National Youth Mental Health Foundation — for service improvement, additional centres, and the extension of the Early Psychosis Youth Services program.
In the UK, the NHS long term plan was recently released. Mental health services was high on the agenda, as was access to digital health services.
Yet, according to the Education Policy Institute treatment rejection rates have remained unchanged despite additional investments. With EPI’s executive chairman, David Laws explaining:
“Young people continue to be deprived of access to specialist mental health treatment, despite the government claiming significant investment in mental health services over the past five years.”
So, how can these budgets be more effectively utilised to solve this increasing problem and, with the increasing funding making little to no difference, how can we think differently around the problem? How can we work towards a place where the majority of families with children with treatable conditions receive the support they need?
This is where digital technology can fit into the picture. In fact, the opportunities for specialists to utilise digital solutions can only make this more efficient and effective.
An introduction to e-mental health.
E-mental health refers to the use of the internet and related technologies to deliver or enhance mental health information and services.
From assessment and intervention, to support and information, e-mental health covers all services provided by the internet, mobile devices, phone or computers. In fact, the technologies involved are endless and new solutions are emerging daily.
E-mental health allows people to access mental health information and support at any time from any place. It also provides useful tools and resources for healthcare professionals to support and aid their delivery of mental health services.
In the UK in 2018, almost all people aged 16 to 34 years (99%) were recent internet users. It’s a core part of daily life. Smartphones are now in almost everyone’s pocket. For many, it’s the first thing they see when they wake up in the morning. And that’s even before they say ‘good morning’ to the person lying next to them. In the words of Elon Musk, “Your phone is already an extension of you. You’re already a cyborg, and most people don’t realise it.”
E-mental health, then, seems like an obvious idea; if internet and smartphone usage is so high, why restrict mental health services to face-to-face appointments, and instead, deliver treatments to people on their device? Most people seem to agree with this idea, which is why e-mental health is growing rapidly.
There are 5 main benefits to e-mental health:
1. It is cost effective. Online mental health interventions are substantially less costly to implement than conventional face-to-face therapies and programs.
2. It is accessible. With face-to-face services, there can be several barriers to overcome. One might be distance (someone lives in a rural area far from any suitable services). Another might be time (they cannot access services outside of school/work hours). Another might be availability (long waiting lists for a particular service). E-mental health helps to break down these barriers and ensures people can access a service anywhere, at any time.
3. It fills the gap in available resources. There is a worldwide lack of well-trained mental health practitioners – and a growing number of people suffering from mental health problems. E-mental health solutions can help to fill this gap. It can support professional by providing extra access to services. It can identify problems at much earlier stages in the process. And ultimately it can free up resources so that mental health practitioners can spend time with the people who need it most.
4. It helps to break down stigma. While stigma is reducing, it is still a huge barrier to individuals seeking mental health support. The fear of being identified as having a mental health disorder can cause significant delays in the critical step in someone’s journey: to seek help. The anonymity of some e-mental health solutions helps break down that barrier and give access to patients and professionals at a much earlier stage in the process, in a way that no other approach has been able to offer. If a patient doesn’t feel ready to talk to a GP, e-mental health is a great starting point.
5. It helps people take control. Empowerment is a huge part of the mental health journey. E-mental health solutions allow patients to take control of their own mental health and well-being. With e-mental health, people can choose their own treatment, control what happens in their care, monitor their progress, and have control over what information they share with health practitioners. Young people can now actively participate in their own recovery process, in cooperation (rather than passively) with their mental health practitioner.
E-mental health is still in its infancy in Australia and the UK. This is just the start. The future offers huge opportunities to advance and engage with patients and practitioners.
It’s not difficult to see how further technological advancements can develop to provide real opportunities to develop the quality and accessibility to care. Next week we progress this thought further – as we look at how digital technologies can be used to support stepped care in mental health.