Six reasons to integrate e-health into psychology practice

Professor David Kavanagh FAPS, Institute of Health and Biomedical  Innovation and School of Psychology and Counselling, Queensland University of  Technology

Over the last decade, Australia has seen an explosion of e-health programs and services and has become an international leader in e-health. These developments have not replaced existing psychological services, but have supplemented them, and made psychological interventions more available across the community. This is an exciting time for psychology: now, our treatments are reaching whole communities, and psychology has obtained a prominence and recognition that was difficult to imagine in the past.

Many psychologists are already using e-health programs and services in their practice, but others are yet to see how they can transform and benefit their work. As part of the Australian Government’s e-Mental Health Strategy, last year it funded a three-year tender to support the use of e-mental health in primary care – delivering training and mentoring to general practitioners, psychologists and allied health workers nationally, and even supporting workers in remote Indigenous communities to use it. The ePsychology group at the Queensland University of Technology is leading the overall project, called e-Mental Health in Practice (or eMHPrac), and the Centre for Mental Health Research at the Australian National University is leading the psychologist/allied health component. Between now and the middle of 2016, a range of workshops, webinars and resources for psychologists will be progressively released.

While the focus of eMHPrac is on mental health, e-health resources are available for a wide range of health and wellbeing issues. The issues and opportunities for practitioners are similar across e-health, and the mental health component is best seen in this wider context.

Why integrate e-health into psychological practice?

1. They are accessible, as-needed tools with fidelity and powerful functionality

   There is already a long history of psychologists using external resources such as self-help books to supplement their work, and cognitive-behavioural treatments have routinely used self-monitoring forms or written summaries of key concepts. Nor is adjunctive e-health a new phenomenon. Psychologists frequently deliver support by phone, or refer to telephone helplines for after-hours assistance with acute crises. Videos or audios are sometimes used to consolidate learning between sessions. A key strength of these approaches is that fidelity to the assessment or treatment is readily determined, and remains unchanged with repeated use. In contrast, therapists do not always implement procedures with high fidelity, so incorporating standardised elements can ensure that at least some aspects are always in place.
   
   E-health programs and resources extend existing methods using e-technologies in rapidly expanding and exciting ways. Web programs and phone apps typically incorporate engaging pictures, videos, audios or game features, and can tailor information and strategies to the person’s individual needs. Reminders for self-monitoring or strategy use can be timed to occur when most needed, and monitoring is time-stamped. Phone apps that collect and integrate automatically gathered data on movement, location, calls and even psychophysiological responses are progressively becoming available. Online fora or chat rooms can give peer support to model effective coping, address self-stigma and assist with problem solving, even in rare disorders or rural and remote areas, when face-to-face support would otherwise be difficult or impossible.
   
   Many e-health resources can be accessed at any time, allowing them to address issues as they occur. While online programs and services require web access, they otherwise are available anywhere, and increasingly are optimised for multiple devices. Phone and tablet apps take accessibility a step further, offering functionality offline. These features allow psychological interventions to support life changes as never before.

2. Many have robust evidence that they work

   As yet there are few trials on phone or tablet apps, but many web programs and online assessments now have substantial research support, both with adults and children. Examples of recent reviews are given in the online version of this article. The evidence is strongest for web programs addressing anxiety or depression than for other conditions, and give average effect sizes that are similar to standard face-to-face treatments. Positive results for a variety of other problems, including alcohol misuse and chronic physical disorders, are growing rapidly. While web interventions are usually recommended for milder conditions, severity does not reliably predict improvements.
   
   Effects of web programs for anxiety and depression are stronger when coaching is given, although the coaching need not be from a psychologist to achieve the effect (coaching from administrative staff has given comparable results). Coaching may need to focus on reinforcing program use and behaviour change and on using the program effectively, rather than undertaking other concurrent therapy, but more research on optimal support is needed.

3. They can increase a practice’s impact and cost-efficiency

   Electronic appointment reminders and informational materials on practice websites offer obvious advantages. However, e-health offers much more than this. While the number of sessions of Medicare-funded psychological services is restricted, clients frequently have multiple, complex issues requiring greater intervention. In cognitive-behavioural therapies, significant time is often taken in discussing basic concepts and their application. E-health interventions can do much of this work while clients are on waiting lists or between sessions, freeing practitioners to focus on other issues. Undertaking treatment segments via e-health can make practices more cost-efficient and able to have stronger and wider impacts on client issues.

4. When used in sessions, they can cue effective practice and refine psychologists’ skills

   Some e-health programs or applications can be used within sessions (e.g., by clients using programs under supervision). Those programs allow psychologists to address issues they may not otherwise feel confident in treating, using high-quality resources with a strong evidence base. Applying e-health elements in multiple sessions can consolidate these skills and confidence in using them.

5. Their innovative use can give a competitive edge to private practices

   Private practices are in a highly competitive environment. Those providing the best services and value for money have a competitive edge. It may not be cost-effective for most practices to develop and test complex e-health programs, and it would be difficult to match the quality of programs from large commercial or research groups. However, if practices fully integrate the best available e-health resources into their work and effectively use electronic media for marketing, this may give a significant advantage over those that do not.

6. Clients will use them, regardless

   Clients’ use of the web to search for information about health conditions and their treatment is now commonplace. The upside is that clients are more informed before they reach treatment; the downside is that this knowledge may not be correct. Being aware of the best sources of both information and interventions allows psychologists to give informed advice on the ones that are most accurate and well founded. While keeping abreast of emerging e-health resources is difficult, there are available tools that can help us with the task (see article on how mindhealthconnect and Beacon can assist).

Is there a good reason not to use e-health?

Particular e-health resources and interventions are not for all clients. Some people simply prefer just a standard face-to-face service, although most will accommodate at least some e-health elements. While many web programs only assume a limited reading ability, users are skewed towards people with more education. Some people may be more comfortable with telephone support or with an app that primarily uses pictorial icons. Some clients lack computer or web access, although the ubiquity of smartphones is rapidly addressing this issue. A few still lack confidence in using electronic devices, although even in older adults this is becoming less common, and rehearsal in sessions can build confidence. Finally, some users are concerned about privacy. While data transfer and storage do present risks, high-quality providers have strong data security systems, and many programs allow users to adopt an alias if they wish.

Any intervention can have a negative effect, but even in a stand-alone mode, the current research suggests that negative reactions from e-health resources are rare. A significant advantage of integrating them into psychological practice is that psychologists can monitor responses, to help clients make the most of their experience. Embedding e-health in regular practice also helps to address problems that can sometimes occur in sustaining engagement with stand-alone programs.

Conclusion

There is a quiet revolution going on. E-health is rapidly changing psychology practice, just as it is affecting every other area of our lives. It is a revolution that is here to stay. It presents challenges for psychological training and practice, but we need not be afraid. If we fully embrace e-health’s opportunities, we can offer the community a level of service and everyday support that has never before been possible.

The author can be contacted at david.[email protected]

Further reading

Depression/anxiety

• Andersson, G. (2012). Guided internet treatment for anxiety disorders. As effective as face-to-face therapies? Studies in Health Technology and Informatics, 181, 3-7.
• Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS ONE [Electronic Resource], 5(10), e13196.
• Calear, A. L., & Christensen, H. (2010). Review of internet-based prevention and treatment programs for anxiety and depression in children and adolescents. Medical Journal of Australia, 192(11 Suppl), S12-14.
• Cuijpers, P., Marks, I. M., van Straten, A., Cavanagh, K., Gega, L., & Andersson, G. (2009). Computer-aided psychotherapy for anxiety disorders: a meta-analytic review. Cognitive Behaviour Therapy, 38(2), 66-82.
• Foroushani, P. S., Schneider, J., & Assareh, N. (2011). Meta-review of the effectiveness of computerised CBT in treating depression. BMC Psychiatry, 11, 131.
• Griffiths, K. M., Farrer, L., & Christensen, H. (2010). The efficacy of internet interventions for depression and anxiety disorders: a review of randomised controlled trials. Medical Journal of Australia, 192(11 Suppl), S4-11.
• Johansson, R., & Andersson, G. (2012). Internet-based psychological treatments for depression. Expert Review of Neurotherapeutics, 12(7), 861-869; quiz 870.
• Richards, D., & Richardson, T. (2012). Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clinical Psychology Review, 32(4), 329-342.
• Titov, N. (2011). Internet-delivered psychotherapy for depression in adults. Current Opinion in Psychiatry, 24(1), 18-23.

Addictive disorders

• Cucciare, M. A., Weingardt, K. R., Greene, C. J., & Hoffman, J. (2012). Current trends in using Internet and mobile technology to support the treatment of substance use disorders. Current Drug Abuse Reviews, 5(3), 172-177.
• Gainsbury, S., & Blasczynski, A. (2011). A systematic review of Internet-based therapy for the treatment of addictions. Clinical Psychology Review, 31, 490-498.
• Khadjesari, Z., Murray, E., Hewitt, C., Hartley, S., & Godfrey, C. (2011). Can stand-alone computer-based interventions reduce alcohol consumption? A systematic review. Addiction, 106(2), 267-282.
• Riper, H., Spek, V., Boon, B., Conijn, B., Kramer, J., Martin-Abello, K., & Smit, F. (2011). Effectiveness of E-self-help interventions for curbing adult problem drinking: a meta-analysis. Journal of Medical Internet Research, 13(2), e42.
• Rooke, S., Thorsteinsson, E., Karpin, A., Copeland, J., & Allsop, D. (2010). Computer-delivered interventions for alcohol and tobacco use: a meta-analysis. Addiction, 105(8), 1381-1390.
• Tait, R. J., & Christensen, H. (2010). Internet-based interventions for young people with problematic substance use: a systematic review. Medical Journal of Australia, 192(11 Suppl), S15-21.
• Vernon, M. L. (2010). A review of computer-based alcohol problem services designed for the general public. Journal of Substance Abuse Treatment, 38(3), 203-211.

Health problems

• Cuijpers, P., van Strateen, A., & Andersson, G. (2008). Internet-administered cognitive behavior therapy for health problems : A systematic review. Journal of Behavioral Medicine, 31, 169-177.
• Stinson, J., & Yamada, J. (2009). A systematic review of Internet-based self-management interventions in youth with health conditions. Journal of Pediatric Psychology, 34, 495-510.

Positive psychology interventions

• Bolier, L., Haverman, M., Westerhof, G. J., Riper, H., Smit, F., & Bohlmeijer, E. (2013). Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health, 13, 119.

Online peer support

• Melling, B., & Houguet-Pincham, T. (2011). Online peer support for individuals with depression: a summary of current research and future considerations. Psychiatric Rehabilitation Journal, 34(3), 252-254.

Adherence issues

• Christensen, H., Griffiths, K. M., & Farrer, L. (2009). Adherence in internet interventions for anxiety and depression. Journal of Medical Internet Research, 11(2), e13.